PNHP

DrSteveB's single payer blog on Daily Kos

DrSteveB's single payer blog on Daily Kos

Single Payer National Health Insurance

Part I – Introduction
Blog by DrSteveB
Daily Kos
November 27, 2006

This is the beginning of a series of diaries to explain what single payer national health insurance is, and what it is not.

In discussing this issue, the most important piece of information to hold on to, is that:

EVERY OTHER DEVELOPED COUNTRY IN THE WORLD ALL THE OTHER WESTERN CAPITALIST DEMOCRACIES EVERY SINGLE ONE

…has SOME form of universal health coverage for their citizens. Only the United States does not.

They differ from each other in how they do this, and the mechanisms and details do matter… Canada is different from the U.K., is different from France is different from Germany, Japan, Austalia, Taiwan, etc… But only the United States does not have something. Remember that whenever somebody says, “yes… but…”

http://www.dailykos.com/story/2006/11/27/114614/15

Comment:

By Don McCanne, MD

Many have suggested that we need a blog on single payer health care reform. Well, it’s here.

DrSteveB, a single payer supporter, has established a health care blog on Daily Kos, the largest center-left political blog in the United States.

Although you won’t be able to read it in detail now (at this posting there were 432 comments), you should glance at it and save the link for future reference. Whether or not you have an interest in blogs, it is important to be aware of DrSteveB’s efforts and be able to direct to his site others who do want to see a single payer-friendly blog.

Rep. Dennis Kucinich Tackles Health Care

By Joshua Scheer

Rep. Dennis Kucinich speaks with Truthdig contributor Joshua Scheer* about the state of health care in America, his bill with Rep. John Conyers to provide universal coverage and why progress is inevitable.

Edited Transcript:

Truthdig: What kind of healthcare [do] congressmen get – what kind of healthcare do you have?


AP Photo / Robert F. Bukaty
Rep. Dennis Kucinich, D-Ohio, gestures during his speech to the
Democratic National Convention at the FleetCenter in Boston
Wednesday, July 28, 2004.

Kucinich: Well, we pay for our health care. I mean, our health care is deducted from our salary. You know, we can opt for what kind of plan we want. The more comprehensive coverage you have, the more you pay. The solution to the nation’s health care problem is not to deny members of Congress health care coverage. It’s to make sure every American has the access to quality health care, and the only way to do that is for Congress to pass a bill that would provide for universal not-for-profit health care for all Americans. There’s a bill called “Medicare for all,” and this bill in this current Congress is HR-676 – the Conyers/Kucinich bill.

Truthdig: That bill – it’s Conyers and you? Do you think it’s going to pass?

Kucinich: There are 75 members of Congress signed on in support of the bill. We recognize that there are 46 million Americans who don’t have health insurance, and there are another 50 million Americans who are under-insured; that the cost of healthcare has gone out of the reach of a large number of Americans, and so there’s only one real solution, and that is to make health care not-for-profit. I mean health care should be established as a basic right in a democratic society. Every industrialized democracy has health care for its people…You know when I traveled the country as a candidate for president, the two issues that came up most consistently were health care and the integrity of the election process. Health care is one issue that unites Americans across party lines, across income lines. Because every person realizes that a single illness in a family can wipe out that family financially. So health care and the accessibility and affordability of health care is central to the government’s responsibility to provide – to promote the general welfare.

When you look at the fact that there are 46 million Americans without health insurance – another 50 million under-insured – when you see that businesses are cutting back sharply on health care benefits – at the bargaining table labor is faced with giving up their hard-fought health care benefits, when you see that trade, meaning in this case jobs that move out of our country – there is an acceleration of jobs going out of the country because workers not paid benefits in a number of countries where the jobs move to. Chief among those benefits is health care. Health care is central – it’s a central question – and it defines who we are as a nation and what we can become as a nation. We are already paying for a universal system of care, we’re just not getting it…Close to two trillion dollars a year is spent for health care in America, but one out of every four dollars goes for the activities of the for-profit system: corporate profits, executive salaries, advertising, marketing, the cost of paperwork – anywhere from 15-30 percent as compared to Medicare’s 3 percent. And so a for-profit health care system is crushing everyone, except the insurance companies. It’s crushing workers, who may actually be working 40 hours a week and not have health care coverage. It’s crushing businesses, particularly small businesses, who are finding that they cannot afford health care for their employees. It’s causing major manufacturers to renege on commitments they made to their workers years ago and to retirees years ago for health care.

The high cost of health care and health care for profit has transformed American society and has been a powerful engine for accelerating the wealth of the nation upwards. And so what I’ve advocated with John Conyers is HR-676: universal single-payer not-for-profit health care, which provides that everyone’s covered for everything and we’re already paying for a universal standard of care, we’re just not getting because – if you took that almost $500 billion a year and put it into health care in the form of a universal system, we would have enough money for all basic medical care, plus dental care, vision care, mental health care, long term care, prescription drugs and even broader coverage. We’re already paying for this. We’re not getting it. We need to have the end of health care for profit in the United States, and the beginning of a health care system which helps those who don’t work or can’t work, which helps workers, small businesses, manufacturers – this could be – this single move towards health care for all can bring about a dramatic shift in the American economy and in the lives of every man, woman and child in the United States.

Truthdig: If I’m interested in the plan and I want to know more and make my voice heard, how do you suggest going about that?

Kucinich: You have to start by talking to people in your family and your neighbors, because everybody is affected by this. I mean this is a moral question. Martin Luther King says of all the forms of inequality, injustice in health care is the most shocking and inhumane. And when you have – I think it was 82 million people spent part of 2002 and 2003 without health insurance, and when you understand that the uninsured include – half of the uninsured are people who are employed…certainly people have to talk to their congressman, but already there are over 14,000 physicians for national health care who are advocating this plan. The American manufacturers are starting to take a more careful look at how health care can benefit their industries, when you see that Canada, for example, has long maintained a competitive advantage in various manufacturing sectors vis a vis the United States because they provide health care. And all of Europe has had a competitive advantage against the United States because they provide health care. When you understand that, for example, you remember General Motors? They had a big big debate a few years ago about their health care costs – they spent five billion dollars in 2003 for health care – that was like $1,200 per car, and when you see how GM has gotten into financial trouble, one of the reasons is their health care costs. And all these Americans…don’t have health insurance because their employer either dropped their coverage or people can’t afford the insurance.

And you look at medical bankruptcies, Josh, there are millions of bankruptcies in America now and about half of them are related to the cost of medical care. And people are filing bankruptcy – I think it was in 2001, there was a study that three-quarters of those who filed [for] medical bankruptcy had health insurance at the start of – at the onset of the illness. This is a huge problem for middle class families because people are postponing needed care, they’re having trouble paying their bills, they aren’t getting the drugs they need, the collection agencies are on top of people…A lack of access to health care is one of the reasons why the United States has had higher infant mortality rates as compared to Germany and Australia, Norway, Sweden and Canada, you know, lower life expectancy, less continuity of care.

People are having difficulty getting needed care. I mean think about this, life expectancy in Sweden and Italy and Canada and France and Germany and the UK – it’s all higher than the US. And this despite the fact that we spend over $2 trillion a year. So…throughout my district, I’ve been holding town hall meetings on the issue of health care and discussing this with people, my constituents…As a candidate I was promoting this, and we had some real challenges that have to be overcome in the congress in order to make it possible for people to get the care that they need…This really is the single most important economic issue confronting the United States right now.

Truthdig: You’ve said the money’s already there…there’s not going to be a problem paying for this…

Kucinich: Well yes, now here, a woman whose name is Dr. Marcia Angell…a few years ago…when Conyers and I introduced our bill, she said that – and this is a woman who was the editor of “the New England Journal of Medicine” – she said that she’d estimate that no more than fifty cents of the health care dollar actually reaches the providers. So if you’re talking about a little more than $2 trillion, where does the rest of the money go? And where it goes is to, you know, you look at some of the executive compensation where people running these health care companies are making tens of millions of dollars a year, when you look at the fraud that’s involved in the system, the drug company profits, how people are paying so much more for drugs than they should be – look at the crooked deal that resulted in…Medicare being strapped with a law that forces them to pay whatever the drug companies ask for for drugs…the Medicare part D drug plan forbids the government from negotiating lower prices with the drug companies, and it banned the Canadian import of drugs and it paid only 30% of that first fifty-one-hundred dollars – the so-called “doughnut hole” – and forced coverage through private plans.

It resulted in windfalls, subsidies and profits for private plans and managers and – I mean there are so many things wrong with it, but [the worst] part of it was it guaranteed $150 billion in drug company profits. And, of course, it was not a surprise that the drug companies turned around and rewarded Congress handsomely with big contributions during election cycles. And you know any time you’re talking about a for-profit system, the costs are higher, there’s fraud, there’s higher overhead, there’s fewer nurses, the quality is worse, death rates are higher, you get more citations on poor quality and as far as the doctors – more and more doctors are favoring the approach that I’m talking about because they don’t want the insurance companies to be making the decisions – about the doctors, about the tests, about procedure, about length of stay, about medication – and what we’ve seen in health care has been a tremendous increase in administrators as opposed to physicians over a period of about twenty years. So, I see this change coming. It is going to happen, because there is an awareness that government has failed the American people in this regard, and it’s an economic issue, it’s a moral issue, and it’s central to who we are as a nation.

Truthdig: So for-profit medical companies have as much bureaucracy as…the government run [program]?

Kucinich: It’s not just the bureaucracy, Josh, it’s the amount of profits they make with their product. The V.A. negotiates a price for drugs with the drug companies. Under the Conyers/Kucinich bill, the government can negotiate for all the people in this country with the drug companies and benefit from high volume. I mean, if the drug companies don’t want to negotiate, the government could start making its own generic brands if it wants to, but we shouldn’t have to do that. The drug companies already negotiate with the V.A., but in Medicare part D, in order to protect over $100 million in drug company profits, the administration saw to it that cost controls were taken off. So you have to go back to: what is it the people want with health care? They want guaranteed access. They want freedom of choice as far as their doctor. They want high quality and affordability. They want to be able trust the system. And that’s not what they’re getting right now. So what I’ve been doing – John Conyers is the senior member whose name is first on the bill, but John and I have been working together and I’ve been organizing members of Congress on this, to get people to be involved in supporting this universal single-payer not-for-profit health care system and this is really an idea whose time has come, and one for which there’s broad support.

I’ve got one more thing to say about it if I may, and that is – I went to the Democratic platform committee in 2000 with Lila Garrett, Tom Hayden [and Gloria Allred] where I offered a presentation that the Democratic party take a strong stand on universal health care. My proposal, unfortunately, was rejected. I brought the same proposal embodied in the Conyers/Kucinich bill to the Democratic platform committee in 2004. Once again, the plan was rejected. Both times the plan was rejected because of the unfortunate influence of corporate interests upon the Democratic party hierarchy. And so it is urgent that the American people are aware that our political system has frustrated the emergence of health care for all because of the tremendous influence which the insurance companies and the drug companies have on our political process. It doesn’t mean that this influence is fatal, but people need to know that it exists.

Truthdig: You’ve just said it’s not fatal, but do you think this is going to hinder the Conyers/Kucinich plan this time? Or do you think you have enough support now that the Democrats are in power and they won on these kinds of issues like health care, the minimum wage and the war?

Kucinich: I see health care as being the defining domestic issue in 2008. It transcends every other issue. It relates to quality of life, it relates to economic productivity, it relates to wages, it relates to trade, it relates to our ability to have a government we can call our own. It relates to the foundational purposes of the United States of America as outlined in the very preamble to the Constitution. This really is a great cause that we should all be involved in. And so my commitment on this has been very strong, and I think that when you go out across the country as I have, and you hear from the people and you see the amount of economic jeopardy which exists because of a lack of – either a lack of access to or affordability – then you know that one must take a stand – that health care is a right, and that the current health care system is not adequate, and that we have to fulfill the purpose of our nation to promote the general welfare.

http://www.truthdig.com/interview/item/20061128_rep_dennis_kucinich_tackles_health_care/

*Interviewer Scheer worked as an entry-level staffer on Kucinich’s state Senate campaign, and was later a summer associate in his congressional office. In this weekly interview series, Rep. Kucinich gives his take on the goings-on in Congress in the wake of the Democrats’ victory.

Cigna sticks it to entertainers

Healthcare premiums to soar for entertainers

By Lisa Girion
Los Angeles Times
November 23, 2006

Hundreds of actors, artists, musicians and writers in California are facing massive increases in their health insurance premiums — a situation that could face other consumers who don’t have employer-sponsored health plans, advocates and lawmakers said.

Cigna Corp., which has sold insurance to members of the entertainment industry through their professional associations for 25 years, is raising premiums for actors and others by an average of 82%, with some hikes as high as 254%.

Under the Cigna increases, premiums on its point-of-service plan will rise to $1,022 a month for single members in the Los Angeles area beginning Jan. 1. Family point-of-service coverage would jump to
$2,485 a month.

State Sen. Sheila Kuehl (D-Los Angeles), a proponent of single-payer universal coverage, said the entertainers’ plight illustrates the vulnerability of consumers under the current “fragmented” system that is largely based on employment.

“Everyone is at risk now,” she said. “People believe that they are secure because they have a job. But, in an employer-based system, you lose your job, you lose your insurance. And even those who are paying a significant premium on their own have no guarantee this won’t happen to them in terms of their premiums being jacked up to an unaffordable place.”

Insurers disagree, saying that competition remains robust.

http://www.latimes.com/business/la-fi-insure23nov23,1,5705270,full.story?coll=la-headlines-business

Comment:

By Don McCanne, MD

A $29,820 annual premium for family coverage!? And we have “robust competition” to thank for this?

This insanity would end if only we would all agree to establish a single risk pool, covering everyone, and fund it equitably. But then there wouldn’t be a place for the robust competitors.

Will Congress reform health care?

Uninsured Americans and the new Democratic Congress Is universal coverage now more likely?

By Uwe E Reinhardt
BMJ | November 23, 2006
Editorial

In August 2003 I published a paper entitled “Is there hope for the uninsured?” My answer then was “most probably not.” As economic forecasts go, this one has been accurate so far. The question now is whether the Democrats’ ascendancy to power in Congress requires a recalibration of that dire forecast, especially in light of the recent unveiling of a proposal for universal coverage by America’s Health Insurance Plans, the national association of private health insurers in the US. My revised answer is “probably not,” although I would love to be proved wrong by subsequent events.

It is not for want of attention that so many uninsured Americans find themselves in their predicament. Their plight has been explored in a decades’ old series of conferences, town hall meetings, workshops, public hearings before Congress and state legislatures, television talk shows, and even, in recent years, exuberant nationwide observances of “cover the uninsured week.” An entire industry has sprung up in the health services research community, dedicated annually to counting and categorising the number of uninsured people, arguing over the accuracy of the various counts, and debating whether uninsured people are worse off for their lack of coverage.

An equally energetic research enterprise has sprung up to create health reform proposals designed to bring universal coverage to the US. Although some of these proposals have been crafted with scholarly detachment, they mostly embody distinct political ideologies or the pecuniary interests of groups who profit from health care. The previously mentioned health insurance proposal unveiled by the health insurance industry on 13 November 2006 is a classic example of this genre. Although America’s Health Insurance Plans would tolerate a modest expansion of government insurance programmes for poor Americans, for the most part the plan calls for federal subsidies towards the purchase of the private health insurance policies the association’s members sell. It is, like all such plans, designed to allow the originator to do well by doing good.

It may be asked why, during more than a century with so many health reform proposals on the table at any time, not one has become the law of the land, if only by accident. The answer seems to be twofold.

Firstly, unlike Europeans, Americans tend to believe that poverty is the product of free choice rather than lineage and bad luck. The persistence of that myth, despite empirical evidence to the contrary, has made it difficult to raise taxes for universal health insurance, even though the US has the lowest ratio of taxes to gross domestic product in the Organisation for Economic Cooperation and Development.

However, a more important obstacle to universal health insurance in America is that, although all politically powerful interest groups have their own preferred strategy for universal coverage, these groups always prefer the status quo as the alternative — a phenomenon known as Altman’s law (after Brandeis University economist Stuart H Altman). Because no single plan has garnered the support of a political majority, we always revert to the current non-system mix of employer, government, and self coverage or no coverage. And Altman’s law holds.

The Democrats’ ascendancy to congressional power will probably trigger another national conversation on the plight of uninsured people. But even if the Democrats mustered the courage and the votes to raise taxes or enlarge the nation’s already huge deficit for the sake of universal coverage, President Bush’s veto pen would undoubtedly nip that idea in the bud, ironically appealing to the very budget deficit for which he is largely responsible.

Thus, it is a safe bet that any flurry of activity on uninsurance will be just another instalment in the never ending series of America’s national conversations on the topic — a conversation that resembles nothing so much as the rambling of a drunken lover at a bar — big talk, little action. In health care it has become “the American way.”

http://www.bmj.com/cgi/rapidpdf/bmj.39042.375544.BEv1?hrss=1

And…

Health reform looks to the states

Bipartisan support increases for ‘test labs’ around the nation
By Guy Boulton
Milwaukee Journal Sentinel
Nov. 26, 2006

(Liberal Rep. Tammy Baldwin and conservative Rep. Tom Price) are part of a group of lawmakers and policy analysts that would use states as laboratories to test different approaches for expanding insurance coverage, improving quality and controlling costs.

The idea appeals to conservatives and liberals alike. It recognizes that states have taken the lead in health care reform. And it acknowledges that there may not be one sweeping solution that works equally well in states as dissimilar as Massachusetts and Mississippi.

It also concedes that Congress – mired in the debate over whether the solution is more government involvement or less – is unlikely to agree on the best way to reform the health care system.

The (three) bills all differ slightly. But each would encourage states to come up with ways to make the health care system work better. The proposals would be reviewed by a commission or task force. The most promising ones would be sent to Congress for fast- track approval.

The idea is for the proposals to cross the political spectrum. And, in this, the idea implicitly acknowledges one of the realities of health care reform: No one really knows the best way to expand coverage, control costs and improve quality.

“You can’t possibly know the right solution,” said Stuart Butler, a health care economist with the Heritage Foundation, a conservative policy research organization.

“You may be half right,” he said. “But it’s only by trying these ideas in practice – modifying them based on experience – that you gravitate to a right answer.”

“When you think about what it is going to take to get health care reform,” Butler added, “a key part of this is going to be trust and the ability to work together.”

Everybody’s first choice still is for everyone else to agree with them.

“But that,” he said, “isn’t going to happen.”

http://www.jsonline.com/story/index.aspx?id=535435

Comment:

By Don McCanne, MD

Is covering everyone an idea that is only half right? Is funding health care equitably so that it is affordable for each individual an idea that is only half right? Is improving efficiency by reducing administrative waste an idea that is only half right? If the right solution means that we fix the financing of health care so that it works for everyone, then we really do understand how to do that.

Apparently the Next Big Thing in health care reform is for Congress to grant the states the opportunity to achieve universal coverage. It is not as if the states haven’t been actively involved in this process. In fact, the federal government already has been giving states budget-neutral permission slips to experiment with various reforms.

Of the fifty states, after a half century of efforts, how many of them have achieved universal, affordable health care coverage? None, of course. They are busy struggling with funding issues, high-risk pools, Medicaid, regulatory oversight of private insurers, and many other policy issues that inevitably fall short on reform goals. When we already know how to fix the system, why would we insist on continuing with fifty different state laboratories to experiment further with well understood health policy science?

This is simply a process designed to further fragment our public and private insurance systems, and prevent us from ever having a universal program of social insurance such as Medicare for All. It is not a process designed to establish trust so we can work together. Rather it is a process designed to deceive. It is a decoy set up by the conservative/libertarian faction that has lured the centrists and the progressive/liberal factions.

As long as those in the center and on the left, with a false sense of compromise, sing the praises of those on the right who would constrain and limit government at the cost of a modicum of egalitarianism, we will be unable to prove wrong Uwe Reinhardt’s prophecy.

Canada's Health Care Lauded by One Who Knows

by Sol Littman
Arizona Daily Star

Ever since my wife and I chose to leave Canada and settle in Tucson, we have been amazed and angered by the distortions and misrepresentations in the American media of Canada’s government-funded, one-payer medical system. Among them is the recent op-ed article in the Arizona Daily Star by Dr. Jane M. Orient.

For most of my adult life, I worked as a journalist in Canada and took full advantage of Canada’s health-care system. My wife, daughter and grandchildren were free to choose their own primary doctors and specialists. Service was consistently kindly, prompt and concerned. If something serious was suspected, we were tested, X-rayed and examined in a matter of days. Our physicians were highly trained and the hospital facilities modem and pleasant.

Thirty years ago, I had my gall bladder removed and had to spend three or four days in hospital. When I was discharged, I was presented with the bill — a total of $5.50 for the use of the television set in my semi-private room. The Ontario Hospital Insurance Plan paid the rest.

It is important for Americans to know that people in Canada tend to live a couple of years longer than their U.S. counterparts and that Canada’s infant mortality rate is lower. This is attributed to the fact that everyone — young, old, working or unemployed — is covered for basic hospital and medical care in Canada without co-insurance or deductibles. This is in contrast to the United States, where there are more uninsured people (over 40 million) than Canadian inhabitants.

American critics of Canada’s health care are quick to cite the fact that there are lengthy waiting lists for non-emergency medical procedures. It is also true that there is considerable overcrowding in some hospitals, but this is due to the fact that emergencies are treated immediately even if it means a lineup of gurneys in the hospital corridor — a situation I have found exists in American emergency wards as well.

The Canadian system does not rely on private insurance companies. The system is run by 10 provinces and two territories. They pay the bills and set the rules. Medicare, which services the American elderly, is the closest approximation to the Canadian one-payer system, but there are important differences.
In the United States, the government pays the bills but private insurance companies that are more wasteful than the government run the system. In addition, some of our American health-care dollars go to make the insurance companies rich and play no role in actual health care.

The waiting times for some procedures are longer in Canada than in the United States, but this problem is being actively tackled by the government in the wake of a Canada Supreme Court decision that “access to a waiting list is not access to health care.” However, the decision did not abolish the one-payer system — in fact, it reinforced it by giving the Quebec government, which was the chief object of the lawsuit, 12 months to remedy the situation.

As a result, Quebec is working hard to catch up with the rest of Canada. The average wait for a hip replacement has been reduced to four to five weeks, and knee replacements usually take six to seven weeks. This may still be too long, but if you happen to be one of the 40 million uninsured Americans, you might have to wait forever.

Why have my wife and I chosen to spend our retirement years in Tucson? We did, in fact, worry about leaving behind our Canadian health care, but climate, the availability of year-round golf and relatively good health persuaded us to take the chance.

We have found medical services in Tucson excellent, but expensive and complicated. We don’t like being at the mercy of an HMO and have yet to decipher the ins and outs of the new drug plan. We continue to long for the simplicity and efficiency of Canada’s single-payer system.

Sol Littman is a former Canadian journalist living in Tucson with his wife, Mildred.

Medicaid coverage worse than private insurance?

Insurance Coverage and Care of Patients with Non-ST-Segment Elevation Acute Coronary Syndromes

By James E. Calvin, MD; Matthew T. Roe, MD, MHS; Anita Y. Chen, MS; Rajendra H. Mehta, MD, MS; Gerard X. Brogan, Jr., MD; Elizabeth R. DeLong, PhD; Dan J. Fintel, MD; W. Brian Gibler, MD; E. Magnus Ohman, MD; Sidney C. Smith, Jr., MD; and Eric D. Peterson, MD, MPH
Annals of Internal Medicine
21 November 2006

Background: The impact of insurance coverage on the care of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unclear.

Objective: To compare NSTE ACS care patterns by insurance type.

Design: Comparison of Medicaid patients younger than 65 years of age and Medicare patients 65 years of age or older with patients of similar age who have health maintenance organization (HMO) or private insurance coverage.

Setting: 521 U.S. hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC [American College of Cardiology]/AHA [American Heart Association] Guidelines) quality improvement initiative from January 2001 through March 2005.

Patients: 37,345 NSTE ACS patients younger than 65 years of age and 59,550 patients 65 years of age or older.

Measurements: Guideline-recommended treatments, and in-hospital outcomes.

Results: Medicaid was the primary payer for 18.7% (6999 of 37,345) of patients younger than age 65 years, whereas Medicare was the primary payer for 67.5% (40,199 of 59,550) of patients age 65 years or older. Medicaid patients were statistically significantly less likely to receive short-term (less than 24 hours) medications and to undergo invasive cardiac procedures than patients covered by HMO and private insurance. They also had higher mortality rates (2.9% vs. 1.2%; adjusted odds ratio, 1.33; 95% CI, 1.08 to 1.63). Medications and invasive procedures were used to a similar extent in patients with Medicare and HMO or private insurance, and respective mortality rates were not significantly different (6.2% vs. 5.6%; adjusted odds ratio, 1.08; 95% CI, 0.99 to 1.18).

Limitations: Self-pay patients and patients without insurance were not assessed.

Conclusions: NSTE ACS patients with Medicaid (but not Medicare) as the primary payer were less likely to receive evidence-based therapies and had worse outcomes than patients with HMO or private insurance as the primary payer. The causes of these treatment differences and solutions for narrowing the gaps in quality require further investigation.

Grant Support: CRUSADE is funded by Schering-Plough Corporation. Bristol-Myers Squibb/Sanofi-Aventis Pharmaceuticals Partnership provides additional funding support. Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, also provided funding for this research.

Potential Financial Conflicts of Interest: Consultancies: M.T. Roe (Schering-Plough, Bristol-Myers Squibb, Sanofi), E.M. Ohman (Savacor, Liposcience, Responsible Biomedical, The Medicines Company, Inovise): Honoraria: J.E. Calvin (Millenium Speaker’s Bureau), M.T. Roe (Sanofi, Bristol-Myers Squibb, Schering-Plough); Stock ownership or options (other than mutual funds): E.M. Ohman (Inovise, Savacor, Medtronics Inc.); Grants received: M.T. Roe (Schering-Plough, Bristol-Myers Squibb), W.B. Gibler (Schering-Plough, Bristol-Myers Squibb, Sanofi-Aventis), E.M. Ohman (Bristol-Myers Squibb, Sanofi-Aventis, Schering-Plough, Millenium Pharmaceuticals, Eli Lilly Inc., Berlex).

http://www.annals.org/cgi/content/abstract/145/10/739

Comment:

By Don McCanne, MD

It is important to understand this study because it will be used by the opponents of government health insurance programs to “prove” that private plans provide higher quality care and improved health care outcomes compared to government programs.

Perhaps the most important point to note is that private plans were contrasted with two different government programs – Medicaid and Medicare – and the conclusions were that only Medicaid was associated with worse outcomes, and Medicare was not.

As an insurance program, Medicaid has more comprehensive benefits and much lower out-of-pocket spending than do the private plans or Medicare.

Therefore the difference cannot possibly be explained by a greater ability of private plans to eliminate financial barriers to health care, a crucial function of insurance. Unfavorable socioeconomic factors undoubtedly play a significant role. The Medicaid program is chronically underfunded, which reduces the financial incentives for physicians and hospitals to care for these patients. Also, many physicians strive to create a practice with a classier clientele. Anyone who has spent any time in the doctors’ dining room has heard countless complaints from physicians who have had another (censored) Medicaid patient dumped on them by the ER (while the more dedicated physicians at the table lose their appetite and become silent). You do not need hard data to surmise that an angry physician who wants to rid himself of his welfare patient would not be as compulsive about a checklist for ACC/AHA compliance.

The other government program studied, Medicare, rather than being a welfare program for the poor, is a program of social insurance in which almost everyone over 65 participates. Medicare patients are largely welcomed by physicians and should and do receive at least the same level of care as privately insured patients. If anything, the conclusion that should be reached based on this study alone is that private plans did not provide any advantage over Medicare even though private Medicare Advantage plans are paid on average 15 percent more than is spent on patients in the traditional Medicare program. Even though quality and outcomes on these limited measures were the same, value provided by the private plans was worse because it cost more for the same outcomes.

Why were these data pulled out of the CRUSADE study? Why were the uninsured excluded from this subset of data? Did the authors really wish to prove that Medicare could produce the same results at a lower cost?

Several of the authors have alliances with the pharmaceutical industry, and the CRUSADE study was supported by pharmaceutical company grants. The pharmaceutical industry is currently partners with the private insurance industry in combating a move toward publicly-funded and publicly-administered universal health insurance.

A cavalier quote by James Calvin, the lead author, is revealing: “On the surface, people may conclude that doctors have a bias against poor people. However, it doesn’t cost a thing to tell someone to watch the salt in their diet or to quit smoking, which is really good advice to reduce heart problems.” (http://www.southcoasttoday.com/daily/11-06/11-21-06/01health.htm)

What is that line? When they say it’s not about the money, it’s about the money.

The catastrophe of cancer – money or health?

USA Today/Kaiser Family Foundation/Harvard School of Public Health National Survey of Households Affected by Cancer

Kaiser Family Foundation
November 20, 2006

Survey of Families Affected by Cancer Shows People With and Without Health Insurance Often Suffer Serious Financial Hardships

A major national survey of people affected by cancer provides an in-depth examination of how families cope with cancer and highlights problems of health insurance and health care costs through the lens of those who have experienced this major illness. The results show how health care and health insurance systems can fail to protect people when they are most in need.

The survey found that one in four families affected by cancer say the experience led the person with the disease to use up all or most of their savings, and one in eight say they borrowed money from relatives. The illness also made it harder for some to find and keep health insurance – with about one in 10 saying they couldn’t buy health insurance because they had been diagnosed with cancer, and 6% saying they lost their coverage as a result of the disease.

Having health insurance at all times during treatment helped to limit the financial consequences of a cancer diagnosis, but even those with consistent coverage faced difficulties – one in five used up all or most of their savings, one in 10 borrowed money from relatives and 9% were contacted by a collection agency.

Among those who did not have health insurance consistently during their illness, the financial burden was even greater. More than one in four said that they delayed or decided not to get treatment because of its cost – five times the rate reported by those who had health insurance consistently. Nearly half used all or most of their savings; four in 10 were unable to pay for basic necessities; one in three sought the aid of a charity or public assistance program; and 6% filed for personal bankruptcy.

“This is one of the most disturbing of the hundreds of surveys we have done,” said Kaiser Family Foundation President and CEO Drew E. Altman, Ph.D. “When people with cancer are deferring care and experiencing such serious financial hardships because of inadequate insurance or because they have no health insurance, it casts a new light on the need to address our nation’s health insurance problems.”

http://www.kff.org/kaiserpolls/pomr112006pkg.cfm

Comment:

By Don McCanne, MD

How many times have you heard the opponents of health reform say that insurance should not pay for an oil change for your automobile, nor for a bag of potato chips at the supermarket? They contend that the only purpose of insurance is to indemnify an individual against catastrophic financial loss.

When a biopsy is not obtained in a timely manner because of financial limitations, doesn’t that result in a catastrophic loss? When potentially curable interventions are declined because of financial considerations, doesn’t that result in a catastrophic loss? When a victim of cancer decides to decline care in order to protect his or her limited assets in order to help pay for food and shelter for the surviving children, doesn’t that result in a catastrophic loss? Admittedly these questions redefine catastrophic loss as a loss of health or life, and not merely a loss of a large amount of personal funds. But, really, which is more important?

It is truly tragic that both the uninsured and the insured potentially face catastrophic losses. Our national policies are currently aimed at expanding coverage to the uninsured by exposing those insured to greater risks. Instead, we should be adopting policies that improve access to care by removing financial barriers for both the insured and uninsured.

This is certainly “one of the most disturbing of the hundreds of surveys” that KFF has done. What is particularly disturbing is that we understand the policy options that would allow us to remove the financial barriers without increasing health care spending. A single payer system does precisely that, by design.

For those who would prefer to accept the status quo simply because they’re healthy and their employers provide them with insurance, we should not wish that they would be the next to face the tragedy of cancer in their families. But we can grieve in the realization that our fellow Americans do not have the decency to support policies that would help protect other individuals and families (and possibly even their own!) against these tragedies.

It is not a matter of spending more money, because we don’t have to. It’s a matter of egalitarianism – apparently a foreign concept for Americans.

AHIP's welfare plan for private insurers

We Believe Every American Should Have Access to Affordable Health Care Coverage A Vision for Reform

America’s Health Insurance Plans (AHIP)

Our proposal to expand access to health insurance coverage is built upon five principles that are designed to clearly delineate the responsibilities of the private and public sectors, avoiding duplication, providing a framework for complementary strategies, and maximizing the effectiveness of a system-wide effort to improve quality and reduce costs.

Principle 1: The federal government should provide incentives to states to develop strategies that lead to – and sustain – coverage of children within three years and adults within 10 years.

Principle 2: The federal government should establish incentives for states to provide coverage through the Medicaid program for all adults with incomes

under 100 percent of the federal poverty level (FPL), including single adults, and through the State Children’s Health Insurance Program (SCHIP) for children under 200 percent of the federal poverty level. States should have the option to exceed these levels for SCHIP to the extent necessary to maintain enrollment of existing populations.

Principle 3: The federal government should provide subsidies for the purchase of private coverage to individuals and families with incomes under 400 percent of the FPL. Individuals with incomes under 300 percent of the FPL should receive proportionally greater assistance, with assistance levels phasing down for individuals with incomes approaching 400 percent of the FPL. Individuals who are eligible for premium subsidies should be encouraged to purchase coverage through existing market mechanisms. Employed individuals who are eligible for employer-sponsored coverage should be encouraged to use their premium subsidies to enroll in such coverage.

Principle 4: The 6 million uninsured Americans with incomes over 400 percent of the FPL should be encouraged to purchase coverage. This proposal sets out a range of options states should consider to achieve this goal. To help create a level playing field for individuals purchasing coverage on their own and for those who have employer coverage, full tax deductibility of premiums purchased in the individual market should be granted.

Principle 5: Employers should be encouraged to facilitate, provide, and maintain coverage for their employees. This proposal sets out a range of options states should consider to achieve this goal. In addition, the federal government should not disrupt employer coverage by changing the current tax treatment of employer-provided coverage.

http://www.ahipbelieves.com/Portals/0/docs/vision_of_reform.pdf

HealthCast video of AHIP’s release of the proposal:
http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=1974

Comment:

By Don McCanne, MD

AHIP, representing the nation’s private insurers, is currently being lauded for taking a leadership role in promoting policies encouraging universal access to affordable health care coverage. Are the accolades warranted?

The proposals do seem to meet what many consider to be the political common ground for reform. The expansion of coverage is incremental, beginning with children. The goal is universal coverage that is affordable for everyone.
The process builds on the current system rather than replacing it with a single, government-run program. Though politically expedient, is this the common ground where we really want to be?

AHIP’s primary mission is to protect the interests of the private insurers. They want to continue to market affordable plans to healthy populations that have a source to pay for the insurers’ products. Most employed individuals and their families are healthy and have, through their employment, the resources to purchase insurance. The insurance industry wants to retain that market. Many of the uninsured are also employed and healthy, but lack the resources to pay for coverage. The insurance industry also would like to have this market, and so they have proposed government subsidies to help pay for that coverage. They also propose subsidies for the higher-income uninsured in order to entice them as well to buy their products.

Individuals living in poverty have poor employment records and have a high incidence of chronic problems, especially socio-economic difficulties. The insurance industry does not want to cover this market since there is very little profit incentive in including these less fortunate individuals. Thus AHIP recommends turning these individuals over to a government welfare program, Medicaid, thereby sparing the industry of this burden.

What a great program for the insurers. They cover the healthy with well funded plans, and turn the problem sectors over to the government and the taxpayers.

Besides being extremely self-serving, there are serious deficiencies in their proposals. They are supporting affordable coverage, but not affordable health care. Reading the specifics of their proposals, it is clear that they have no mechanism for slowing health care inflation. Instead, they support proposals that shift more costs to individuals, making access less affordable. Rather than reducing the profound administrative waste in our system, they increase administrative inefficiencies, further adding to health care costs. They have no proposal to pay for the increased government spending, knowing that a massive tax increase, without an offset in reduced private spending, would blow a crater in a common ground on reform. Also, their program cannot possibly achieve 100 percent coverage since much of it requires voluntary participation.

The greatest flaw of all is that their plans are made affordable by increasing financially burdensome cost sharing, by reduction in benefits covered, and by excluding those with health care needs. If these patterns were reversed, then coverage would not be affordable. The private insurance model is an anachronism.

The political common ground for reform should be on policies that ensure that everyone has affordable access to comprehensive health care, rather than on policies that increase wasteful spending through a government program designed for the welfare of private plans. It’s time for taxpayer/patients, providers, and politicians to join together on a common ground to fix our system. But we do need to acknowledge that AHIP and the private insurers have disqualified themselves from being legitimate participants in that process.

Humana's flagrant cherry-picking,cream-skimming HealthMiles Plus program

Gathering focuses on state's health insurance woes Local leaders and national experts on healthcare met in Fort Lauderdale to discuss the growing problem of Floridians without health insurance.

By Bridget Carey
The Miami Herald
Nov. 10, 2006

Imagine getting frequent-flier miles for walking your dog.

Humana has recently made it a reality as part of a new way to encourage the growing number of Americans without health insurance to buy coverage.

It’s called HealthMiles Plus, and the more customers stay active, the more points they earn to turn into cash or miles with Humana’s partner, Virgin Atlantic Airways.

Elizabeth Bierbower, vice president of product innovation for Humana, showcased the recently launched GoZone, a device that plan holders wear to record how active they are. The information is then posted online, adding points to the person’s account.

The creation was designed to “attract people from the uninsured pool and try to give people back something who are purchasing health insurance,”
Bierbower said.

http://www.miami.com/mld/miamiherald/business/15975233.htm

Comment:

By Don McCanne, MD

Insurers do not market their products to the majority of the uninsured since most of them are not able to pay the premiums and many of them have preexisting disorders which would have an adverse effect on their risk pools and result in an upward pressure on their premiums. A small minority of the uninsured have above average incomes and are healthy. Insurers are interested in mining this population to select out these few who are healthy and can afford insurance.

Humana has now introduced the ultimate in cherry-picking and cream-skimming products. They are selling HealthMiles Plus to healthy individuals who not only claim to exercise regularly but are willing to prove it by wearing the GoZone physical activity recorder. Those who are not in great shape and do not have the income to pay the premiums need not apply.

In a remarkable show of chutzpah, this vice president of Humana has the gall to present a blatant cherry-picking program to a conference on addressing the problem of the uninsured, as if it were a solution.

We continue with policies that allow the private insurance industry to skim off the healthy who can pay the premiums, while we concentrate those with higher costs and fewer assets into the giant risk pool of the uninsured. This greatly compounds the difficulty of providing affordable, comprehensive coverage for the uninsured.

It is utterly absurd to continue to support policies that take care of the private insurers while rejecting policies that take care of those with health care needs. Private insurers do not want that business. Why should we let them continue to skim off the majority who are healthy and can afford their premiums?

The fundamental function of health insurance is to shift the costs of the few with needs to the many who are healthy, making health care affordable for everyone. Since the private insurers refuse to provide that service, we need to dismiss them and establish our own public, universal risk pool that would do precisely that.

No happiness with health policy

Conference leans toward national health care. Participants say crisis coming without changes.

By ANTHONY SALAMONE
The New Jersey Express-Times
Friday, October 20, 206

BETHLEHEM TWP., Pa. | The slide showed excerpts from a 2005 story about Toyota hiring automotive workers in Ontario, with the company citing the quality of the Canadian province’s work force.

“Everyone knows it’s crap,” said Dr. Walter Tsou. “The reason why they chose Ontario is because they don’t have to deal with the enormous health-care burden (compared with costs in the U.S.)”

Tsou joined two other guest speakers Thursday during Lehigh Valley Business Conference on Health Care’s 26th annual meeting at Candlelight Inn & Conference Center.

The meeting focused on national health insurance, and while many opinions arose during the meeting, which drew about 75 people, no one remedy emerged.

“That wasn’t the purpose,” said Kitty Gallagher, the organization’s president. “The purpose was to begin the discussion (locally).

“This is an issue that needs to be discussed; we can’t go on the way we are.”

Tsou’s, whose group, Physicians for a National Health Plan, supports a national insurance program, laid out how the current situation has left some 46 million people go uncovered.

Many businesses, including the former Bethlehem Steel Corp., have stopped subsidizing retirees’ benefits. Agere Systems Inc. plans to stop paying coverage beginning in 2008.

Tsou predicted more people will lose insurance and the system will worsen, unless businesspeople exert more influence in which way things should head.

He also said a national plan would foster competition.

“It gives the customer what he wants, and I believe the customer wants quality, affordable health care, ” said Tsou.

Jim Bentley with the American Hospital Association said the group also supports universal coverage with standards for determining what is “medically necessary,” among other factors.

Bentley and John Parker of Blue Cross and Blue Shield Association agreed serious problems exist, but opportunities have surfaced to build on some current programs. They include health savings accounts, which help individuals save for qualified medical and retiree health expenses tax-free.

Bentley also said since most people are healthy, they don’t comprehend the crisis, controversy or complication of health insurance.

“We have to help society understand what the current system is like, what the options are for the future, and what the trade-offs are,” said Bentley.

Anthony Salamone can be reached at 610-258-7171 or by e-mail at tsalamone@express-times.com.

As I see it: Act now to fix ailing health care system

By DR. COSIMO STORNIOLO
Gazette-Times
November 13, 2006

Everyone agrees that the health care system is broken. Almost 50 million Americans are uninsured; more than 600,000 of them in Oregon. Those who are insured pay higher premiums and deductibles and drug costs. Unpaid medical bills are the number-one cause of personal bankruptcy.

An under-funded Medicare entitlement program (with a new irrational prescription drug plan) will become insolvent in 2018; it will create unprecedented deficits this century. U.S. health indicators — such as infant mortality and life expectancy — fall far below other industrialized nations, despite the fact that we are spending more than 40 percent more per capita than any other country.

I witness this crisis on a weekly basis while working at Community Outreach’s free medical clinic for the uninsured. At every clinic, I see examples of acute and chronic illnesses left unattended by patients who cannot afford or access the health care system. This leads to unnecessary and costly complications.

More than that, I experience how the system is a dehumanizing social injustice and a shameful embarrassment for the most affluent nation on this globe. I have worked in some of the poorest areas of Africa and Latin America that, while lacking resources, still espouse a stronger public health approach and universal human right to health care.

The solution is government-administered national health insurance. Successful models of such a plan abound in countries such as Canada, Britain, New Zealand, Australia and Taiwan.

A single non-profit insurance plan would eliminate our current market-based and employer-based system, which squanders 30 percent of health care dollars on administrative costs, and only profits investors. These systems offer universal coverage, improved access, portability regardless of employment status or medical circumstance, and fewer barriers to choice of physician or hospital.

The health care delivery system that we are used to — your personal provider and hospital and pharmacy — would not change, only the way everyone was paid. Polls show that a majority of Americans and more than 40 percent of physicians support some form of a single-payer system.

So how can we afford it? Every reputable group that has examined the economics of a single-payer system — from the Government Accountability Office to the Congressional Budget Office to independent investigators — has concluded that the money saved from curtailing administrative waste and profits more than offsets the costs of expanding coverage to the uninsured.

What can we do locally?

• Support the Archimedes Movement, a program spearheaded by former Gov. John Kitzhaber. It aims to create public debate and to place a proposal before the 2007 Legislature in January.

• Join the Mid-Valley Health Care Advocates, our branch of Oregon’s “Health Care for All” program.

• Lobby your state and national representatives. There currently are proposals in Washington, D.C.; a new proposal by the Oregon Senate Commission and a plan by the governor’s Oregon Health Policy Commission.

• Read more from the Physicians for a National Health Program at www.pnhp.org, a group of concerned physicians with years of experience promoting single-payer national health care.

• Talk about it in the workplace, in the doctor’s office — to the newspaper.

The elections are over. Let’s turn our attention away from war and terror to a real social and ethical crisis in our country. Let’s put affordable and accessible health care at the top of our state and national agendas.

Cosimo Storniolo is a Corvallis physician.

Dr. Oliver Fein on healthcare costs and how to contain them

NJAFP Podcast #4, Healthcare costs and how to contain them, Dr. Oliver Fein 6/22/2006

This podcast is NJAFP Podcast #4, an excerpt of a recording of a panel discussion on healthcare costs and healthcare reform, sponsored by the New Jersey Academy of Family Physicians. This program was recorded June 22, 2006. The program is introduced by Ray Saputelli, executive vice president of the New Jersey Academy of Family Physicians.

Download the podcast file here (16.4mb mono MP3 file, 00:20:00 length). This podcast includes the presentation by Dr. Oliver Fein