Insurance is enough to make you sick

Private health insurance is a drag on the economy the government must fix.

By Patt Morrison
Los Angeles Times
January 4, 2007

It’s a good thing I have health insurance, because I thought my ticker was going to give out when I read this: Health insurance companies will not sell policies, at any price, to hale and healthy people who have, or had, some pretty trifling ailments. Hemorrhoids. Varicose veins.

A woman who’d gone to a psychologist after breaking up with her honey was denied. So was a guy with jock itch, and a 40-year-old man with asthma.

Lisa Girion’s front-page Times article the last day of 2006 leaped off the page and grabbed me by the throat, which is pretty much what health insurers are doing to millions of Americans — strangling them. If they don’t work for a company with health benefits and they want individual health policies, they pay huge premiums for skimpy benefits, if they can get a policy at all. For health insurers, it’s a seller’s market, and they ain’t selling.

Business, which has a firm grip on the legislative joystick, hits the panic button at talk of single-payer healthcare or universal healthcare, and it hauls out its own boogeyman phrases, such as “job-killer” and “drag on the economy.”

I’ll tell you what’s a drag on the economy. Healthcare insurance that’s impossibly expensive, or impossible to get. If the United States wants a vital economy of personal enterprise and risk-taking, then it needs to guarantee health coverage, period. Americans are willing to take chances in business and careers, but not with their families’ health, or their own.

Dan Luke is an Oregon insurance broker. He told me that he runs into this “all the time — people staying in jobs they don’t like. People have dreams about going into business for themselves that they can’t fulfill because they don’t want to lose medical coverage, and they can’t pay a lot of money for [individual policies] even if they are healthy.”

I gave him a professional for instance: Say there’s a man who wants to switch careers, start something on his own. He’s 59, married, four kids, comes to you for health insurance. He smokes cigars. (“Mmmmm,” I heard Luke say.) And he had heart-valve surgery almost 10 years ago.

Luke stopped me right there. The man would never get coverage. I didn’t even get to ask Luke about the risk factors of riding motorcycles and skiing.

My “for instance” is Arnold Schwarzenegger. If the governor weren’t a rich man, if he were just a guy with a bold idea who wanted to give it a shot, as Schwarzenegger did when he abandoned acting for governing, he couldn’t get health insurance. He’d be stuck in his old job instead of bringing something new to the economy and to his life.

A 2004 health industry survey Girion cited said 12% of applicants for individual policies were turned down. Luke believes it’s closer to 40%. “I can’t think of any other business,” he said, “where people have money in their hand to buy a product, and you can’t sell it to them.”

Schwarzenegger — on crutches because of his broken leg — gives his State of the State speech Tuesday. In October, at a meeting at The Times, I asked him what he’d do in a new term, and what he said then is what, it turns out, he’ll be promoting next week: “Find a way of providing healthcare for the people of California.” Now, with screws and cables holding his leg together, he can contemplate the pickle he’d be in if he were just Arnie S., a desk jockey dreaming of making something more of himself — and uninsurable at any price.

http://www.latimes.com/news/printedition/opinion/la-oe-morrison4jan04,1,2915046.column?coll=la-news-comment

And…

Kaiser to push for standards on health plans

The move comes amid a growing controversy over the insurance industry’s cancellation of individual policies for medical coverage.

By Lisa Girion
Los Angeles Times
January 3, 2007

Kaiser Foundation Health Plan Inc. said Tuesday that it was working with state regulators to develop standards to protect its members from unfair cancellations of health insurance, a move that the state’s largest HMO hopes could lead to industrywide reforms.

Kaiser’s move comes as it was being fined $100,000 by state regulators for dropping a policyholder it accused of concealing his epilepsy when he applied for coverage, even though the condition had never been diagnosed by a physician.

Also, the policyholder was unaware of his seizures because they were accompanied by amnesia.

Oakland-based Kaiser said its proposed standards would include the requirement that it consult with policyholders before deciding whether to rescind their coverage. Such a consultation would help the HMO determine whether policyholders intentionally submitted inaccurate information about their health conditions in order to obtain coverage.

Other health plans, including Blue Cross of California and its rival Blue Shield, are fighting regulators and former policyholders for the right to rescind coverage when medical information relevant to the policy-granting decision is left out of an application — even if the omission is an honest mistake or the result of a foggy memory or poorly worded question.

Amy Dobberteen, enforcement chief for the Department of Managed Health Care, said Kaiser’s plan to talk to policyholders first was a shift in the right direction.

“Other plans have pointed out to us endlessly that that’s not required by law,” Dobberteen said. “For goodness sake, if you are consumer-friendly, why wouldn’t you contact the consumer? … A health plan does have the moral responsibility to pursue [this information] when they are about to wipe out from under them their entire health security blanket.”

Cindy Ehnes, director of the managed care agency, has called a Jan. 29 hearing in Los Angeles to gather suggestions for regulations she is developing that would clarify the law and enhance consumer protections against unfair cancellations.

http://www.latimes.com/business/la-fi-kaiser3jan03,1,417514,full.story?coll=la-headlines-business

Comment:

By Don McCanne, MD

The first step in problem solving is to define the problem.

Let’s see. Hundreds of thousands or even millions of people nationally are denied health insurance coverage because of their prior medical histories, even for trivial disorders. That seems like a problem.

So what solution is California considering? They are attempting to establish specific guidelines for the insurers in order to protect them from penalties when they rescind coverage for individuals who successfully negotiated their underwriting process, but then obtained care for injuries or illnesses often unrelated to any preexisting problem.

What?! We do have real problems in health care. Let’s address those!

Protecting and nurturing the private insurers should be the very last priority of our public stewards, especially since the private insurers have continued to refuse to protect and nurture those with health care needs.

The private insurers are the greatest problem in health care financing today. Let’s throw them out and establish our own public single payer system. That would benefit the health of all of us. Oh, and our economy too!

Health Care Spending in the United States and OECD Countries

Kaiser Family Foundation
January 2007

After a brief respite in the mid-1990s, significant annual increases in health care spending over the past few years have refocused U.S. policymakers on the impacts that rising health care costs have on businesses and individuals and on federal and state budgets. Compared to other developed nations, the U.S. spends more on health care per capita and devotes a greater share of its GDP to health. Since 1980, the U.S. also has had among the highest average annual growth rates in per capita spending on health care. Despite this relatively high level of spending, the U.S. does not appear to provide substantially greater health resources to its citizens, or achieve substantially better health benchmarks, compared to other developed countries. This growing gap between health spending in the U.S. and that of other developed countries may encourage policymakers to look more closely at what people in the U.S. are getting for their far higher and faster growing spending on health care.

http://www.kff.org/insurance/snapshot/chcm010307oth.cfm

Comment:

By Don McCanne, MD

For policy analysts, the most important exhibit in this report demonstrates that the United States has not only had the highest percentage of GDP devoted to health care, but we also continue to have the highest percentage point increase in total health expenditures as a share of GDP. Although there has been some slowing of the rate of increase since 1990, ours is still the highest. The highest percentage point increase in the highest spending system has brought us neither better health benchmarks, nor, astonishingly, greater health resources for our citizens.

Our fragmented system of private plans and public programs is not working. It needs to be changed. So what are the current proposals? More of the same… but worse! Instead of fixing our system, our policymakers are supporting laws requiring individuals and/or businesses to pay the outrageous tab through mandates to purchase ever-less-effective private insurance plans.

Talk about irresponsible! Now that insurance rates and health care are truly unaffordable for average-income Americans, they are no longer simply telling us to live with it, they are ordering us to foot the bill that we can no longer pay (as long as we depend on the private insurance industry to finance health care for the majority of us).

Every policymaker knows that we can slow the rate of increase while dramatically improving the allocation of our current health care resources simply by jettisoning our highly dysfunctional system of health care financing and adopting a single-payer national health insurance program.

It’s the private plans, stupid!

Freedom in economic arrangements is itself a component of freedom broadly understood, so economic freedom is an end in itself…. Economic freedom is also an indispensable means toward the achievement of political freedom.
Milton Friedman
Capitalism and Freedom (1962)

Practical men, who believe themselves to be quite exempt from any intellectual influences, are usually the slaves of some defunct economist. Madmen in authority, who hear voices in the air, are distilling their frenzy from some academic scribbler of a few years back.
John Maynard Keynes
The General Theory of Employment, Interest and Money (1936)

The test of our progress is not whether we add more to the abundance of those who have so much; it is whether we provide enough for those who have too little.
Franklin Delano Roosevelt
Second Inaugural Address (1937)

Perhaps it is this specter that most haunts working men and women: the planned obsolescence of people that is of a piece with the planned obsolescence of they things they make. Or sell.
Studs (Louis) Terkel
Working (1972)

Comment:

By Don McCanne, MD

Wise lessons for 2007… and beyond.

Single-Payer Is Feasible

Letter to the Editor
The Washington Post
December 28, 2006

The Dec. 13 editorial “Inequality and Health Care” was right on the mark in its diagnosis of America’s health-care problem.

Your continued dismissal of a single-payer solution as “politically infeasible” is less persuasive. Media misrepresentation may give the impression of infeasibility. Yet Medicare is a single-payer system, and it’s enormously popular and economical.

A Dec. 1 Washington in Brief item reported that a study has found that “private health-care plans for the elderly cost the U.S. government $5.2 billion more last year than traditional Medicare coverage.”

Besides, Medicare covers the expensive populations — the elderly and disabled — leaving the young and healthy to the insurance companies, which still decline to make coverage affordable to middle-income families.

It would seem, therefore, that Medicare for All would be a more economical way to provide affordable health care to everyone than would subsidizing private insurance coverage.

Mary Von Euler
Bethesda

http://www.washingtonpost.com/wp-dyn/content/article/2006/12/27/AR2006122701496.html

The Dec. 13 Washington Post editorial, “Inequality and Health Care:”
http://www.washingtonpost.com/wp-dyn/content/article/2006/12/12/AR2006121201436.html

Comment:

By Don McCanne, MD

The significance of the publication of this letter and the editorial on which it is based cannot be understated. Although very subtle, the national dialogue on reform has changed.

In their editorial, The Washington Post stated, “switching to an entirely tax-financed system (euphemistically known as ‘single-payer’) may be politically infeasible at this point.” Please note that “…may be politically infeasible…” is a far different position from “…is not politically feasible…” It is a clear acknowledgment that the lack of political feasibility is no longer an absolute given.

The fact that they published a letter in response that expands on this point is further confirmation that The Washington Post believes that single payer has a legitimate position in our national dialogue on reform.

That’s a giant step forward. An honest debate of all policy options should be the primary determinant of political feasibility.

Bupa health pulls out of Ireland

Health insurer Bupa has said it will close operations in Ireland to avoid making payments to a main rival.
BBC News
December 14, 2006

The Irish High Court ordered Bupa to make “risk equalisation” payments to state health insurer VHI, which has older policyholders.

The payments are meant to limit VHI’s costs and cut premiums, thus supporting the government policy of charging clients the same for health insurance.

Under the process of risk equalisation, insurers with a higher number of elderly customers – which tend to make more claims – are compensated by insurers with younger clients.

“Irish consumers are the real losers as the market will be restored to a virtual monopoly,” said Martin O’Rourke, managing director of Bupa’s Irish operations.

http://news.bbc.co.uk/1/hi/business/6180279.stm

Comment:

By Don McCanne, MD

What is the primary function of health insurance? Pooling risk. All participants make an equitable contribution into the pool of funds that pay for health care for everyone. Disease and injury can never be equitably distributed, but the financial consequences can be.

Our policymakers continue to reject the most effective model of pooling risk – single payer – with the convenient but dubious claim that it is not politically feasible. The policy recommendations currently in vogue – employer mandate, individual mandate, high-deductible plans, association health plans, etc. – all use private insurers. The policymakers give the private plans credibility by citing their use in many other nations with universal systems of health care.

It is very important to understand how these more egalitarian systems pool risk. One of the most difficult tasks is to be certain that no insurer risks insolvency due to adverse selection – having to pay out more in benefits because of a less healthy, higher cost clientele. Likewise, it is important that other insurers do not unfairly benefit from favorable selection – increasing profit by successful selective marketing to a lower cost, healthier segment of the population. Adverse selection and favorable selection defeat the crucial function of equitably pooling risk.

So how do they do it? These egalitarian systems use sickness funds or transfer funds to adjust for the inevitable selection problems, whether inadvertent or deliberate. They either draw from a common pool, or they transfer funds between their respective pools based on the actual claims experiences. Thus when we talk about private insurance in other nations, we have to acknowledge that their version has almost no resemblance to our concept of private plans in the marketplace.

Our private insurance companies are absolutely dependent on favorable selection to produce the returns that we have come to expect of them (admired by Wall Street and reviled by reform activists). The insurers have skimmed off the nation’s employees and their healthy families, plus the healthy sector of the individual insurance market. By leaving out the less healthy, higher cost sectors of our society, they have totally defeated the purpose of pooling risk.

Suppose we did mandate universal coverage, using the private insurers. Obviously, the insurers’ risks would dramatically increase once they included high cost patients, and that risk would not be evenly distributed between insurers. Suppose claims experience resulted in record profits for Wellpoint, and Cigna was insolvent at the end of the year. The egalitarian systems would require Wellpoint to transfer funds to Cigna.

Could you imagine, with our market mentality, expecting Wellpoint to transfer perhaps tens of billions of dollars to competitors? Or could you imagine a private Medicare Advantage plan transferring funds to the traditional Medicare program only because the private plan performed well through its favorable selection marketing? The private Medicare + Choice plans once walked away for much less.

And that is what just happened in Ireland. Bupa practiced favorable selection by insuring the young and healthy, and the Irish High Court required that they transfer “risk equalisation” payments to the state health insurer. Bupa walked away.

This demonstrates why our policymakers are wrong when they insist that we must use the private insurance industry to expand coverage to everyone. We must begin with the principle that funds must be pooled, and the pool needs to be funded equitably. Private insurers cover two-thirds of us but only pay one-third of our total health care costs. With an effective, egalitarian method of pooling, they would have to pay two-thirds of the costs (adjusted for the expansion to universal coverage). That would double the premiums that we are paying. Yet employers and individuals are already bailing out because they can’t afford our current premiums.

If we are serious about providing everyone with insurance that really works and is affordable, we are going to have to abandon the idea of separate private insurer risk pools. By design, a single payer system would establish a single risk pool covering everyone, and it would be funded in the only equitable manner that’s reasonable – through progressive tax policies that shift funds from the healthy to the sick and from the wealthy to those not so wealthy who need health care.

An egalitarian America? Did I just hear, “Bah, Humbug!”

Filet Mignon, Pinot Noir and an MRI

By John R. Graham
The Washington Post
December 21, 2006

Your other patrons are a mixed blessing… purchasing the most expensive bottles of wine, ordering filet mignon instead of flank steak and always sticking around for dessert and coffee — they pick up only around one-eighth of their tab. The rest of the check is covered by one of several food insurance companies. But to get paid by the insurers, you must spend endless hours filling out paperwork.

You also waste a lot of time deciphering the confusing reimbursement policies of the insurance companies. Merlot and cabernet sauvignon, for example, are covered without question, but if a patron orders pinot noir without first trying the shiraz, many insurance companies won’t pay the bill unless you can justify the patron’s selection.

You’re angry about the uninsured, because many of them could have afforded to pay for their own meals, particularly if they’d purchased groceries at the supermarket instead of dining out. So, together with other restaurant owners and food insurers, you’re working to convince your lawmakers to pass a bill requiring mandatory food insurance.

Crazy? Of course. But not if you substitute “health care” for “food.”

…the nation would be better served if America’s lawmakers stopping piling more regulations onto a system that’s already absurdly overregulated. Far better to deregulate health insurance and hospitals than to force us into a system that doesn’t serve our needs. Then we could shop for the precise care we need, which would improve quality while lowering costs.

After all, mandatory food insurance might provide everyone with sustenance for a while. But eventually, we’d all be worse off. No one would learn to grocery shop or cook. And the entire nation would eat out for every single meal — breakfast, lunch, dinner — until we all went broke.

Health insurance is no different. The system needs more choice, not more coercion.

Reader comments:

By don / Dec 21, 2006

A bottle of shiraz has absolutely nothing in common with an expensive antibiotic that could successfully treat a child’s meningitis. This silly food analogy displays crass insensitivity over a crisis in health care coverage that is resulting in suffering and death for tens of thousands of Americans. But perhaps the greatest insensitivity is demonstrated by our policymakers who insist on continuing to support a superfluous private insurance industry that covers two-thirds of us, but evades paying for two-thirds of our healthcare costs. If we all had Medicare, none of us would expect it to cover shiraz as we recovered from a heart attack, but we would expect it to prevent financial hardship from becoming an additional burden to our unwelcome rendezvous with disease or injury. Rather than giving private insurers the freedom to expand their abusive practices, we need to dismiss them and establish our own public program that would remove financial barriers to beneficial health care services.

http://www.washingtonpost.com/wp-dyn/content/article/2006/12/20/AR2006122001327.html

Comment:

By Don McCanne, MD

How many times have you heard this ridiculous food insurance argument? Though it makes most of us angry, the opponents of reform keep bringing it up. Let’s review the lessons from yesterday’s message on framing.

Do not let the opponents frame the debate: health insurance is as silly as food insurance!?

Destroy their frame by exposing their lack of credibility: it is clearly a falsehood that gourmet dining can serve as a surrogate for health care.

Establish framing that accurately communicates the principles: the problem to be addressed is financial hardship, suffering and death for those without adequate insurance.

Maintain credibility: use irrefutable facts about the inadequacies of our private insurance programs and the financial and health consequences of our failure to enact an effective, universal insurance program.

The Way I see It: The author makes a case for a shift to a consumer-driven system.

By Jordan L. Geller, MD
Medical Economics
December 15, 2006

There’s another problem with calling healthcare a right. It imposes an obligation on the government to fulfill that right–something our government is neither economically nor functionally equipped to do. In contrast, the Bush administration reform plan would shift at least part of the healthcare burden from employers and government back to the consumer. By coupling a high-deductible policy with a tax-free health savings account, policy makers believe that Americans will become more efficient and discerning consumers of healthcare.

The devil is in the details, of course. Still, if the current plan accomplishes anything, it will almost certainly raise anew the question of health and individual responsibility. This is crucial for progress in the area of healthcare reform, since, to date, the bad effects on health of certain lifestyle choices–poor diet, overeating, smoking–have done little to alter peoples’ behavior. If, on the other hand, consumers were forced to shoulder more of the financial burden of their lifestyle choices, finally, perhaps, they’d be motivated to pursue healthier choices.

Comments from our readers:

dmccanne / San Juan Capistrano, CA
Posted Dec 15 2006

The wealthiest nation of all is not financially equipped to do what all other industrialized nations have – insuring everyone? And the fear of spending money from a health savings account is a greater incentive to quit smoking than the fear of cancer, heart disease or emphysema? Get real! We each have a personal responsibility to take care of ourselves, but we also have an egalitarian responsibility to our fellow Americans to see that financial hardship does not compound the misfortune of illness or injury.

http://www.memag.com/memag/article/articleDetail.jsp?id=390156

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And…

Building on the Progressive Victory

By George Lakoff
Rockridge Institute
December 15, 2006

What is a progressive worldview? It’s simple: You have empathy for others, and you act responsibly on that empathy, being both responsible for yourself and socially responsible as well. Progressives say, “We’re all in this together” while conservatives say,” You’re on your own.” It was running on those progressive values that won the election for the Democrats.

Progressive values-based reframing has begun to work, because it has been paired with authenticity (saying what you believe) and with framing that highlights the very real traumas affecting the nation.

The role of the progressive activists, grassroots, and netroots is to promote progressive values to biconceptuals both within and outside the Democratic party — to activate the progressive beliefs they already have and to extend them further by speaking a progressive language and using progressive values, ideas, and arguments. The goal is not just to move the Democrats in a more progressive direction, but to move Republicans and independents in that direction as well. The idea is to benefit the nation, not just the party.

And conservative values and practices, when they lead to people getting hurt and our democracy undermined, have to be attacked overtly.

This election marked a progressive victory and a victory for progressive efforts at factually accurate, values-based framing.

http://www.rockridgeinstitute.org/research/lakoff/building-on-the-progressive-victory

Comment:

By Don McCanne, MD

Berkeley linguistics professor George Lakoff has taught us much about framing. In the example from Medical Economics, I have applied some of his concepts:

1) Do not let the opponents frame the debate.

2) Establish your own framing that accurately communicates the principles you wish to express.

3) Be meticulous in maintaining the credibility of your framing.

4) When the opponents’ framing is not credible, do not hesitate to briefly expose their lack of credibility for the purpose of destroying their frame.

In the example, Dr. Geller has linked together, in a single frame, dismissing the role of government in health financing and relying on individual responsibility. Without entering his framing of rights and responsibilities, we have destroyed his credibility by exposing his fallacies – that the United States is not “economically equipped” for the task, and that personally assuming the financial burden of health care incredibly improves health, when all of the data is to the contrary.

Our framing much more credibly establishes two separate frames – one for personal responsibility, and the other for egalitarian responsibility.

Although Professor Lakoff’s message has been a call for progressives to catch up with the conservatives on framing, it is also a nonpartisan message. Let’s establish a highly credible frame for the health care reform debate within which we can all communicate. And let’s overtly attack those who would undermine the process.

For more on George Lakoff and the Rockridge Institute:
http://www.rockridgeinstitute.org/people/lakoff

Health Reform Interrupted: The Unraveling Of The Oregon Health Plan

by Jonathan Oberlander
Health Affairs
December 19, 2006

Abstract:

The Oregon Health Plan (OHP) has received national and international attention for rationing medical care based on explicit priorities. However, in recent years OHP has lost substantial enrollment and struggled to live up to its core principles. This paper explores what went wrong in OHP and the implications of Oregon’s experience for state-led health reform.

Lessons for state health reform (excerpt):

The strongest challenge to sustainability, though, may come from rising medical costs. As medical inflation increases, and with it the number of uninsured people who lose employer-sponsored coverage and qualify for public insurance, the price tag for maintaining–let alone broadening–coverage expansions also increases, and retrenchment may supplant activism on the agenda. And as Medicaid spending consumes a higher percentage of state budgets, outpacing revenue growth and threatening to crowd out spending for education and other politically popular priorities, ambitious plans to cover the uninsured become more difficult to fulfill. Economic downturns exacerbate these pressures, especially since states must live with balanced budget requirements. Cost control, which triggers intense opposition from medical-industry interests that profit from the status quo, requires much more political will to impose than insurance expansions do. Avoiding cost control and gaining the support of system stakeholders is perhaps the key to short-term political success. However, its absence may be, in the long run, the Achilles’ heel of state-led health reforms that seek to move toward universal coverage without serious mechanisms to control spending in their own programs and without limits on medical care inflation in the broader health system.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.1.w96

Comment:

By Don McCanne, MD

There are many factors involved in the unraveling of the Oregon Health Plan that will not be discussed here, but most are of importance to other states. Nonsubscribers can download this article free of charge for the next two weeks and should do so to learn these other important lessons from Oregon. Only one factor will be discussed here.

The most difficult problem that Oregon and all other states have faced is the continuing escalation of medical costs. Now that there seems to be a growing political consensus that comprehensive reform must occur at the state level, we need to ask whether the states would be capable of stabilizing the system by controlling costs.

We can’t discuss controlling costs without understanding some of the more important reasons for our high costs. Amongst them are deterioration of our primary care infrastructure, high prices, profound administrative inefficiencies, and an excess of non-beneficial high-tech services.

Innumerable studies have demonstrated that a strong primary care infrastructure ensures the delivery of higher quality care at a lower cost. Could any state build that infrastructure independently? It would require a transformation of both our medical education and health care delivery systems to achieve that mission. It is unlikely that any one state would be capable of that intrinsically, not to mention the fact some states might expropriate the products of the efforts made by other states. We will not have an effective primary care infrastructure until we have made it a national policy that all concerned individuals and institutions cooperate in efforts to build the primary care system we need.

Our health care pricing is the highest of all nations. Could any one state independently control prices, whether through markets or by government control? Both government and private insurance programs already set rates, yet health care costs continue to escalate. Prices need to be set based on legitimate costs and fair profits. The most efficient and equitable method would be through negotiation. If one or two states acted independently without other states involved in a similar process, cost shifting and unfair pricing would be inevitable with the possible consequence of instability in the health care delivery infrastructure. We need national policies to establish a system of pricing that is fair for all.

Much of the administrative waste that characterizes the health care system in the United States is due to the fragmented financing system of public programs and a multitude of private plans. Could a state independently establish an efficient, coordinated system of health care financing, such as a single payer system? It would be impossible without federal involvement. The state would require funds that are currently financing Medicare, Medicaid, SCHIP, and innumerable other programs that have designated revenues flowing to the states. Even though administration would be more efficient on a state or regional basis, only the federal tax system has the size and stability to ensure that state programs remain adequately funded. We need federal policies to be sure that adequate public funds would always be available for an administratively efficient financing system.

Can states control the high-tech excesses? Once again, that would require a coordinated effort between our medical education and health care delivery systems. Only a national resource such as the National Institutes of Health would be capable of providing the parameters to guide this process. We need federal policies to support national programs that would identify value in all health care services, not just high-tech, so that we receive greater relative benefit from our health care expenditures.

The Democrats have indicated that they intend to merely tweak our system. Many are advancing programs to shift responsibility to the states to allow them to adopt “politically feasible” programs that have been designed by the conservatives. (One important factor in Oregon’s unraveling was the introduction of “personal responsibility” through decreased benefits and greater cost sharing.)

Oregon, and every other state for that matter, have provided us with an important lesson. The states cannot act alone. It must be national policy that everyone has access to comprehensive, high quality, affordable health care.

All state programs have fallen short. Why do we continue these experiments with state laboratories when a simpler, single national health insurance program will do it?

The Press-Enterprise
December 17, 2006

The perspective of Don McCanne, senior health policy fellow, and Nicholas Skala, research associate, Physicians for a National Health Program

Compared to other advanced nations, the United States spends far more on health care but achieves only mediocre results. Though the World Health Organization has ranked us first in spending, we are ranked 37th in performance–well behind Canada and all Western European nations. What do these countries know that we don’t?

Universal coverage is public policy in the rest of the industrialized world, but it is not in the United States. We leave nearly 47 million without any insurance at all. Even the insured are finding that increasingly inadequate private insurance policies are leaving them exposed to insurmountable costs.

Although unheard-of in other nations, illness and medical bills contribute to half of personal bankruptcies here, and 75 percent of those with medical debt had coverage when they got sick.

How do other nations insure everyone, protect their personal assets from medical debt and do it at a much lower cost than that of the United States? Although no two nations have identical programs, none has adopted the disorganized, wasteful, fragmented insurance payment system that we have in America.

In nations such as the United Kingdom, the government owns the health care delivery system, and it is the direct provider of care. Other nations use a social insurance model in which care is paid for either
directly through the government or via tightly organized and regulated nonprofit companies, while doctors and hospitals remain independent.

These social insurance programs cover everyone, protect against financial losses, more effectively pool risks and fund the entire system much more equitably than we do in the United States.

This egalitarian social insurance model of other nations contrasts sharply with the market model of private plans that we have here. Private insurance companies erect massive bureaucracies for the purpose of fighting claims, issuing denials and screening out the sick from coverage.

Their principal product is an excess of administrative services with its resulting headaches. Doctors, hospitals and businesses must react by employing armies of administrators to deal with this massive private bureaucracy.

Health-care administration consumes a mind-boggling 31 percent of our health spending. Some $350 billion of this waste could be recovered and is enough to extend good coverage to all Americans. Americans are already paying for national health insurance — we just aren’t getting it. Two-thirds of our health-care system already is funded through the tax system.

Although it works well for our armed forces and veterans, Americans may have difficulty accepting a government-operated medicine system similar to the U.K.’s. But we are already comfortable with the concept of social insurance: Our Medicare and Social Security programs are familiar examples.

The public’s response to recent threats of privatization has shown just how protective we are of these programs, even though they are government programs. A national health-insurance system for the United States — in essence “Medicare for All” — would likewise be successful and popular.

Medicare is not perfect. It requires continual oversight and maintenance. But with appropriate revisions, it can serve as an American model of comprehensive coverage for everyone.

While making funding more equitable, the system can assure care will remain affordable. Even though the Europeans provided us with the health-policy science, we can take pride in the fact that Medicare is our own, made-in-America idea.

http://www.pe.com/localnews/opinion/localviews/stories/PE_OpEd_Opinion_D_op_1217_mccanne_loc.c79484.html#

The opposing view, “Beware massive costs, rationing, loss of freedom,” was written by Grace-Marie Turner of the Galen Institute and Robert E. Moffit of The Heritage Foundation. Their op-ed was not posted on The Press-Enterprise website, but an unedited version is available from Galen:
http://www.galen.org/healthabroad.asp?docID=950

The opposing view that was posted on The Press-Enterprise website, “Government-run systems restrict care,” was written by Merrill Matthews of the Council for Affordable Health Insurance:
http://www.pe.com/localnews/opinion/localviews/stories/PE_OpEd_Opinion_D_op_1217_matthews_loc.c79387.html

Comment:

By Don McCanne, MD

Would Europe’s health-care-for-all model work here? Since no two European nations have the same model, the question really is whether an insurance program that covers everyone would work in the United States. Since we already spend far more per capita on health care than the European nations, there is absolutely no doubt that a properly designed universal insurance program would work as a “health-care-for-all” model (or Medicare for All).

Grace-Marie Turner, Robert Moffit, and, separately, Merrill Matthews didn’t answer that question, but, in their usual reframing of the debate, they changed the topic to rationing. So their question is whether the level of rationing that would take place in the United States would be so severe that we should not attempt to cover everyone with effective insurance. In their response they ignored two crucial points.

Those European nations that have been attentive to capacity and have practiced queue management do not have significant problems with excessive queues. At our level of spending, there would be no need to ration reasonable, beneficial health services, though we should reduce funding for non-beneficial or detrimental services. But that is not rationing; that is value purchasing – a feature of well functioning health systems.

The other point is that they remain silent on the nation with the worst rationing of all – the United States. We ration care for tens of millions of Americans based strictly on their ability to pay. A national health insurance program would eliminate that inhumane basis for rationing.

In our debate over health care reform we don’t need more anecdotes about C-T scans for dogs, or ideological discussions about freedom to pay for your own health care. We need serious discussions about policies that will work. Unless the opponents come up with something better than national health insurance, they should get out of our way and let us heal our very, very sick system.