The Business Review (Albany)
September 8, 2006

As chief executive officer of Albany Medical Center, James Barba has a unique perspective on the health care industry both regionally and nationally. What he sees is a broken system in which costs are rising and competition is increasing, with no cure in sight.

That has led Barba to the conclusion–unpopular with many–that universal, government-run health care is the only solution.

Barba recently sat down with Business Review reporter Barbara Pinckney to share his thoughts and ideas on the future of health care.

What is your general view of the health care system?

There is no American health care system. What we have, at best, is a loose configuration of various interest groups who even when they operate in absolute good faith–and I think, for the most part, they do–cannot bring sense, order or rationality to what we call American health care and what I refuse to call an American health care system. You can’t make it a system. I think that’s the bottom line.

What’s the answer?

Well, I think the answer lies in understanding the problems. And even once one does that analysis, I’m certain that many will not agree with where I come out on it, because I think you can come out in a couple different places. But I think, after you analyze the problems, I break them into two convenient categories: the problems of cost and the problems of constituencies. Why can’t we control the costs? Why are the costs running away? Two trillion dollars in 2005. And who are the constituencies of American health care and why have we not been able to align their interests and their goals?

I come out and say that what we have now is a market-driven system and it has failed us terribly. And the opposite of that is what I think we will inevitably move toward, and that is a regulated system. So once I make that leap–based, I hope, on decent analysis–the answer is you have to look at the government and say “What is its track record in delivering health care? What might we reasonably expect in the future? And can it work?”

Is universal health care a realistic possibility?

Is it realistic that we might have a government-run system? It is. In the end, I think it’s going to be the only practical answer.

I always like to start an explanation of that answer by pointing to the Medicare system. Medicare has been around for 40 years now. It is, I think, universally regarded as a good system for delivering health care to people 65 and older. Not perfect, but we’ll never have a perfect system. The cost for administering the program is 3 percent–the cheapest administrative cost of any health care payer in the nation. So the federal government–the bureaucracy, if you can believe it–spends 3 cents on administering Medicare and 97 cents on actually delivering health care, both in the hospital and through physician payments. That’s extraordinarily efficient. If we could replicate that efficiency in a system that was national, I think we would have achieved something. We actually will have created an American health care system.

What’s kind of interesting to me–and I like to just sometimes theorize about what we could have done and what we can still do, I guess–we have this Medicare system which covers everyone 65 and older. We have in New York state Child Health Plus, but there’s a similar program in virtually every state of the union which covers those 18 and younger whose families meet certain income criteria. If we had started, let’s say, 15 years ago when the Clintons were trying to “reform” health care, to “up-age” Child Health Plus and “down-age” Medicare [and had] taken off two years in each direction in each of the last 14 years, we’d be there by now.

And I guess once I get to that point I say well, OK, the last 15 years have not been wasted; they’ve just taught us, I think that we are not going to solve the problems of costs and constituencies by doing more of the same. It only gets worse. So why don’t we start now and start “up-aging” Child Health Plus and “down-aging” Medicare and see when they meet in the middle, and that analysis will be a matter of how much we can afford it.

Would you like to see the whole private payer system–the Blues, the HMOs–done away with?

Well, they’re going. I don’t know how we can justify a payer system with hundreds, if not thousands, of insurance companies, each one of which has a completely different set of rules for what it will pay, and who it will pay, and how it will pay, and when it will pay, and why it will pay, etc. That replication in and of itself costs hundreds of billions of dollars every year. If we could do away with it all, all of that waste, and just concentrate on a single payer with a single set of rules, and everyone understood what they are and knew what was covered and what wasn’t, some experts estimate that we could save between $300 billion and $400 billion. That’s a lot of money!

As I’ve thought about it, the best I can come up with is transitional roles for [the insurers], having them continue to serve the role that they serve as we go to a single-payer system. We’re struggling under the weight of all these extraneous costs. I don’t want to leave myself, the hospitals, out because hospitals add to it as well. We just happen to be talking about the HMOs right now. But, ultimately, I don’t see any role for them. I know that’s not a popular position but my prediction is it is one that we’ll get to.

Would the role of the hospitals change?

I think in terms of hospitals, we have to take a hard look at ourselves and ask a couple of fairly fundamental questions. One, do we need as many hospitals as we currently have? And the answer to that is “No, we do not need as many hospitals as we have currently throughout the country.”

And second, is there a way to more intelligently design a hospital delivery system than the way we’ve designed it now? Why is it that hospitals in any given region–and I’ll use this one because this is the one with which I’m most familiar–why is it that we’re engaged in an arms race, for example, a technology arms race? [Albany Med makes a purchase and] predictably that will set off in the board rooms and CEO offices of other hospitals in the region the conversation that says “Do we need a new X type of scan or Y type of scan? Albany Medical Center is going to do that and they’ll get ahead of us competitively.” All of that adds unnecessarily and wastefully to costs.

Now, why can’t I just sit down with my fellow CEOs and agree to divide up the market so we don’t do it that way? Albany Med does one thing and St. Peter’s does another? The answer is because we’d all go to jail. That violates the federal anti-trust laws. We cannot do it and so, there again, if hospitals are to be reformed we’re going to need some guidance from the federal government as to how we can intelligently design the services that are being offered. We can’t do it without some help from Congress because it’s all illegal otherwise.

On a statewide level, what are you hoping to see from the Commission on Health Care Facilities for the 21st Century?

I’m hoping to see a sober, analytic document that speaks about what we should be doing vis-à-vis the hospitals in the state. Apparently, from what I read, if the next governor is Eliot Spitzer–and it appears sitting here today it’s going to be–he’s made some statement, I believe, that he’s not going to be bound by that report, and that’s understandable. The question is, can the report in and of itself have sufficient gravitas, or weight, so that even a new governor and a new administration will have to say, “This is pretty important stuff and while we may not want to implement every last recommendation, we have to take it seriously because serious people spent a lot of time thinking and listening and analyzing and came up with these conclusions.” So I think that’s the best thing we’re going to get out of the commission’s report.

What keeps you awake at night?

There is one thing I worry about. As I think most of the country now understands and appreciates, we’ve been working with a nursing shortage for at least a half-dozen years. But I don’t think the public is yet appreciating that there is an impending physician shortage and that shortage is going to happen at the worst possible time in the history of this country, namely at a time when that huge demographic–the baby boomer generation–is moving into an age when they are going to require more and more medical assistance.

The Association of American Medical Colleges for quite a few years was saying that it did not see a physician shortage coming and then, maybe six months ago, it just changed its mind and said, “Yes, in fact, it is going to happen and we’re asking the 125 medical colleges over the next 10 years to increase their enrollment by 30 percent.” Leaving aside the virtual impossibility of just overnight increasing class size by 30 percent, the underlying issue–a physician shortage at a time of enhanced demand–is going to be something that could cause some real dislocation in American health care and it provides another reason for us to try to create something more rational than what we have currently.

What in the health care system gives you the most hope?

There are tremendous bright spots. Look at this medical center. We call it an academic health sciences center–the only one in the region. Ten years ago when I became CEO, I said–and I think people thought I was exaggerating–“This is a place where miracles are performed every day.” I wasn’t exaggerating then and I’m not exaggerating today. I think the statement is more pertinent and more accurate today than it was 10 years ago.

We do wonderful things with science and with medicine to treat conditions that were either totally untreatable and terminal only a decade ago, or that were chronic and wasteful and now they are no longer.

Take a look at the work, for example, that we’ve done with AIDS. I’m very, very proud of the role this specific institution has played with that particular disease. We worked with the science a dozen or more years ago–the protease inhibitors–and now, by and large, these new medications and the treatments that were developed here and elsewhere, and delivered here, are turning what was an absolute death sentence, by and large, into a chronic disease.

We could go down the list: Look at the transplant programs, look at the advances in childhood cancer; those are all good-news stories.

Editorial: Socialized bogeyman

Government has real role in providing health care solutions for residents
Sacramento Bee
10-SEP-06

Careful, Gov. Arnold Schwarzenegger. Your ghostwriter seems to have just made you an opponent of Medicare.

The opinion piece in question was designed to detail your reasons for vetoing Senate Bill 840 by Sheila Kuehl, D-Santa Monica. SB 840 would have revolutionized the state’s health care system. Private insurers would have gone out of business. The state would have started paying directly for the health care of millions of Californians.

“I cannot support a government-run health care system,” you wrote (or, more accurately, someone wrote for you).

Hmm. So what exactly is Medicare? Or, more important, what are Republicans and Democrats really fighting about when it comes to providing affordable health care to more Californians, and how can anyone find the elusive political compromise?

SB 840 sought to create one payer of health care _ the state _ for residents of California. That would be the so-called “single-payer”
solution to our health care ills. The very term “single payer” tends to create political divides. And along those divides, the very real role of government in health care gets misunderstood.

“Socialized medicine is not the solution to our state’s health care problems,” wrote Schwarzenegger in vetoing SB 840. Actually, socialized medicine is as American as apple pie. No greater example is Medicare.

Medicare is essentially a single-payer form of health care. One payer _ the federal government _ provides the bulk of the funds to hospitals and doctors for the necessary care of millions of senior citizens.

Yes, those over the age of 65 pay part of the cost. Some can join HMOs as an alternative. But the federal government “runs” Medicare. And it also “runs” Medicaid (known as Medi-Cal in California), the single-payer program that underwrites care to the poor and disabled.

The political mainstream isn’t clamoring to get rid of those established forms of socialized U.S. medicine. So why do hard philosophical viewpoints suddenly emerge when the same solution is discussed for working Americans and their children?

Our problem with SB 840 was how the Democrats dangled it as veto bait from the get-go. No quest for common ground ever appeared evident, either by Democrats or Schwarzenegger. It was all about Democrats embracing government as the solution and Republicans denouncing it. In vetoing SB 840, Schwarzenegger followed the script.

Real progress in lowering health care costs and insuring more Californians will take a far more serious effort than the theater surrounding SB 840. It will start with the recognition that government is not the bad guy, and that government has an indispensable role in any solution.

By ROBERT PEAR
New York Times
September 11, 2006

WASHINGTON, Sept. 9 — Higher-income people will have to pay higher Medicare premiums than other beneficiaries next year, as the government takes a small but significant step to help the financially ailing program remain viable over the long term.

The surcharge is a major departure from the traditional arrangement under which seniors have generally paid the same premium.

It is expected to affect one million to two million beneficiaries: individuals with incomes exceeding $80,000 and married couples with more than $160,000 of income. For individuals with incomes over $200,000, the premium, now $88.50 a month, is expected to quadruple by 2009.

The surcharge was established under a little-noticed provision of the 2003 law that added a prescription drug benefit to Medicare.

Supporters of the surcharge say it makes sense for wealthy people to pay more at a time when Medicare costs are soaring. But some Medicare experts worry that wealthy retirees will abandon the program and rely on private insurance instead, leaving poorer, sicker people in Medicare.

The premium in question is for Part B of Medicare, a voluntary program that covers doctors’ services, diagnostic tests and outpatient hospital care.

“The higher premiums could drive people with higher incomes out of Medicare,” said Samuel M. Goodman, a 73-year-old retiree in Derwood, Md. “Medicare would then become a welfare program, rather than a universal social insurance program, and it would be easier to attack.”

Federal officials have repeatedly said that Medicare is financially unsustainable in its current form.

Congress said the surcharge would “begin to address fiscal challenges facing the program.”

Joanne S. Shulman, who worked at the Social Security Administration for 35 years, said, “The surcharge will come as a shock to many people because they have not received any warning.”

Most beneficiaries now pay the same premium for Part B of Medicare. That amount has been increasing rapidly even without a surcharge. The standard premium has shot up an average of 12 percent a year since 2001, when it was $50 a month.

The premium is set each year to cover about 25 percent of projected spending under Part B of Medicare, which has been growing because of increases in the number and complexity of doctors’ services. General tax revenues pay 75 percent of the cost.

The Bush administration plans to announce the standard premium for 2007 later this month. In July, Medicare officials estimated that it would be $98.40 a month. The surcharge will be phased in from 2007 to 2009.

Here is how it will work: The surcharge for 2007 will be computed by the Social Security Administration, using income data obtained by the Internal Revenue Service from tax returns for 2005. If an individual has modified adjusted gross income of $80,000 to $100,000, the surcharge will be 13.3 percent, which adds about $13 to the monthly premium, for a total of about $111.50. For a single person with income of more than $200,000, the surcharge will be 73.3 percent, or about $72 a month, for a total premium of about $170.50.

When the transition is complete in January 2009, according to Medicare actuaries, the total premium for a person with income of $80,000 to $100,000 will be 1.4 times the standard premium. A person with income of $100,000 to 150,000 will pay twice the standard premium. A person with income of $150,000 to $200,000 will pay 2.6 times the standard premium, and a beneficiary with more than $200,000 of income will pay 3.2 times the standard amount.

If the basic premium rises 10 percent a year — a relatively conservative forecast — the most affluent beneficiaries will be paying premiums of more than $375 a month in 2009.

Under current law, the $80,000 threshold and the income brackets will be adjusted each year to keep pace with inflation, as measured by the Consumer Price Index.

President Bush recently proposed eliminating these annual adjustments, so that more people would pay a surcharge. “This change gives beneficiaries increased participation in their health care,” he said.

More than 40 million people are in Part B. Medicare officials estimate that 2 percent of them will have to pay a surcharge next year. The Congressional Budget Office says 5 percent of beneficiaries will be affected. The Social Security Administration puts the figure at 4 percent to 5 percent. Most people have their premiums deducted from monthly Social Security checks.

Fiscally conservative Republicans supported the surcharge. But so did some Democrats, who saw it as a progressive way to finance Medicare without cutting benefits or raising payroll taxes.

Senator Dianne Feinstein, Democrat of California, argued that “high-income beneficiaries can afford to pay a larger share of Medicare’s costs,” in part because Congress has cut their taxes in recent years.

The Congressional Budget Office estimates that the surcharge will raise $15 billion from 2007 to 2013.

Representative Nita M. Lowey, Democrat of New York, recently introduced a bill to repeal the surcharge, which she says will hit “more and more middle-class seniors.” Some advocates for older Americans, including the Senior Citizens League, with 1.2 million members, are lobbying for repeal.

A beneficiary can obtain relief from the surcharge by showing that the I.R.S. data was incorrect or that the person’s income declined because of a “major life-changing event” like the death of a spouse or the loss of pension benefits.

Theodore R. Marmor, a professor of political science at Yale, said the surcharge was more important for the politics of Medicare than for the financing of the program.

“The new income-related premium is fundamentally at odds with the premises of social insurance,” Mr. Marmor said. “Large numbers of upper-income people will eventually want to find alternatives to Part B of Medicare and will no longer be in the same pool with other people who are 65 and older or disabled. Congress will then have less reluctance to cut the program.”

Submits Resolution to State AFL-CIO Convention

Montpelier, VT The Washington-Orange-Lamoille Labor Council became the first in Vermont to endorse HR 676, single payer universal health care legislation introduced by Congressman John Conyers (D-MI). Representative Bernie Sanders, that state’s only member of the US House of Representatives, is among the 75 co-sponsors of HR 676.

The council’s resolution will be submitted to the state AFL-CIO convention which meets in mid September. Representative Sanders is expected to address the convention.

Currently, Sanders is running for the U.S. Senate. Single payer advocates in Vermont are working to persuade Sanders, who is leading in the polls, to agree to introduce a companion bill to HR 676 in the Senate once he is elected to that new position.

###

HR 676 now has 75 congressional co-sponsors in addition to John Conyers. It would institute a single payer health care system in the U.S. by expanding a greatly improved Medicare system to every resident.

HR 676 would cover every person in the U. S. for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care, chiropractic and long term care. HR 676 ends deductibles and co-payments. HR 676 would save billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.

HR 676 has been endorsed by 175 union organizations including 39 Central Labor Councils and Area Labor Federations and seven state AFL-CIO’s (KY, PA, CT, OH, DE, ND & WA).

For further information, a complete list of union endorsers, or a sample endorsement resolution, contact:

Kay Tillow
All Unions Committee For Single Payer Health Care-HR 676
c/o Nurses Professional Organization (NPO)
1169 Eastern Parkway, Suite 2218
Louisville, KY 40217
(502) 636 1551, (502) 459-3393
Email: nursenpo@aol.com

By Susanne L. King, M.D.
Berkshire Eagle,
Thursday, August 31

POWERFUL FORCES have been shaping the new mandated health care insurance bill being developed in the Statehouse in Massachusetts. I was reading a news article this week about health care lobbying in our state legislature, and was astounded by the sums of money being spent by special interest groups to ensure that the new bill will protect their specific interests; i.e. their profits.

For example, Blue Cross Blue Shield of Massachusetts spent $507,056 this year on lobbying, and the Harvard Pilgrim health insurance company was not far behind with $392,631. Other big spenders included Associated Industries of Massachusetts, and Partners Healthcare, the Boston hospital conglomerate.

But who lobbies for patients? Who lobbies for the policemen, firemen, and other essential city employees who are paying more and more for their health care, so that cost of living wage increases are being canceled out? Who lobbies for the increasing numbers of workers who pay for their own insurance premiums, as fewer employers offer health care benefits (down to 60 percent of employers in 2005, from 69 percent in 2000)? And who lobbies for those of us who pay our own health insurance premiums, and have watched them rise by double digits each year for the past five years?

The new mandated health insurance bill will be helpful to those who earn the least — $9,800 per year for an individual and $13,200 for a family, the federal poverty line. And if you earn up to three times the poverty line, you will qualify for a sliding scale subsidy from the government. However, whether the payments will be affordable for poor families, and what will be affordable for Massachusetts, is now the focus of intense debate within the Commonwealth Health Connector Authority board (a new state agency that will add yet more administrative cost to the health care system).

The state has budgeted $160 million for this mandated health care plan. Tapping into the free care pool fund has been suggested when this budget runs out, which is sure to happen. This means that hospitals, which rely on the free care pool for compensation for patients who don’t pay their hospital bills, will just have to make do or fold. This does not bode well for community hospitals, which don’t have the lobbying power of the large hospital conglomerates.

Meanwhile, we spend over $1 billion per week for health care in Massachusetts. That is $62.1 billion per year, 33 percent more than our national average, and more than other state or country in the world.

Where is all that money going? Certainly the health insurance industry’s expenditures for lobbying, paid for with our insurance dollars, increase administrative costs (which are 10 times higher than with the government-administered Medicare). And there are of course, the multi-million dollar salaries for CEOs, also paid for with our premiums. Health care lobbying not only drains our health care dollars, but also ensures that business as usual reigns in the health care world: powerful vested interests are trying to maintain an unsustainable status quo.

Fundamental change in the health care insurance system must occur. Single-payer health care would eliminate profits and the need for lobbying for those profits. (“Single-payer” means that health insurance is administered by the state government instead of multiple for-profit insurance companies). In addition to eliminating the profits of insurance companies, which are increasing the wealth of a few at the expense of the health of many, single-payer health care insurance would also eliminate the other administrative costs that make this system so much more expensive than Medicare.

With single-payer health care, for-profit insurance companies would not exist. Businesses would not have to support health insurance companies with their own hard-earned income, nor worry about health insurance expenditures for their employees. As a result, they could be more competitive in a world where every other industrialized country has single-payer, universal, government-administered health care, and doesn’t rely on employer benefits.

Every patient in a single-payer system — rich or poor, old or young, employed or unemployed, sick or well — would have comprehensive health care coverage, and would not have to worry about rising premiums, deductibles, and co-payments. Doctors would love the simplified paperwork, and have more time to spend with their patients, instead of dealing with insurance-related administrative tasks.

The new mandated health insurance bill is an attempt to provide universal coverage, but it does not address affordability, nor is it sustainable, either for the individual or for our state. And vested interests, which will profit from this bill, have helped to craft it through their lobbying efforts. If you are one of the many patients for whom no one is lobbying, you should call your legislator and let him know how the current mandated health care bill will affect you, and whether it represents progress in addressing your rising health care costs.

Of the candidates for the upcoming Democratic primary election for state Senator Nuciforo’s position, Chris Hodgkins is the long-time supporter of single-payer health care, and has promised he will work to make it a reality. He understands that single-payer health care is not just a single issue that benefits individual lives and livelihoods, but that it also would decrease the cost of doing business in our state and benefit our economy. Vote in the Democratic primary on Sept. 19 with this in mind!

Editorial

Rutland Herald, VT
September 3, 2006

A single-payer health care system would save the state $51 million a year, according to a new study carried out for the Legislature and released last week. It would achieve these savings by reducing the wasteful administrative costs that burden the present system.

The Legislature’s study provides welcome information, but it ran into immediate criticism from the business community and from the office of Gov. James Douglas. The hostile response by officials ready to denounce the idea of a single-payer system is an indication of the difficulties facing any proposal to put such a plan into effect.

Democratic proponents of health care reform are not ready to embrace a single-payer system. They understand the political difficulties and the economic uncertainties that remain. But at least, they are not closed-minded. The principles underlying a single-payer system are important to understand because they help set a direction toward the goal of universal access and cost-containment.

One of the important principles is shared risk. That is the principle behind all insurance, and it applies to health coverage that might be provided by the state. Shared risk means that the cost of health care is shared because we recognize that for most individuals the high costs incurred by most medical procedures are not affordable.

It is the same principle behind auto insurance. The high cost of an auto accident is likely to be unaffordable to an individual driver, so through a system of insurance we share the risk, knowing the driver having the accident may some day be any one of us.

At present the risk pool is limited to those with insurance, who pay high costs because their insurance premiums must incorporate the costs of care provided, often in haphazard fashion, to those without insurance. In a single-payer system, everyone would pitch in, and everyone would be covered.

Another advantage of a single-payer system would be its efficiency. As much as a third of medical costs at present go to the complex, wasteful process of tracking down insurance payments and fighting insurance companies who make their money by finding reasons not to pay.

Sharing the risk broadly would mean that those now enjoying a free ride would have to begin paying for health care. Many small businesses in Vermont do not offer health insurance, and paying the payroll tax needed to fund a single-payer system would be a significant new cost for them and their employees. On the other hand, employers who now offer insurance and their employees would see their costs fall when their present health insurance plans were replaced by a new payroll tax.

The study conducted by the Legislature by consultant Kenneth Thorpe describes this system, but legislative leaders know the state is far from adopting it. It would have its complications. It could not supplant Medicare and Medicaid, the federal programs for the elderly and the needy, and it would have to recognize the private plans of people from out of state receiving care in Vermont.

And there is the political resistance. As soon as the Thorpe plan was released, the Vermont Chamber of Commerce jumped on it, saying that it would “drown” the state in new taxes. Not mentioned was the elimination of the cost of health care premiums, which would actually save money for many businesses and individuals. A spokesman for Douglas also took a potshot at the Legislature, accusing it of looking for ways to raise the payroll tax.

It is apparent to Democratic legislators that paranoia about raising taxes, even if costs to businesses and individuals are lowered, is a political fact of life. Resistance to a single-payer system from the insurance industry and from businesses seeking to prolong their free ride will continue to be tenacious.

But it is useful to remind ourselves of the principles underlying a single-payer system as we move ahead with the reforms associated with the new Catamount Health plan. One question that emerged last week was whether people who leave jobs voluntarily would be eligible for the state-backed Catamount plan without a year’s wait. The state is arguing that barring them for a year was necessary to protect the solvency of the system. Legislators countered that covering them was essential to provide the seamless coverage that is the goal of Catamount Health.

Broad, seamless coverage is what a single-payer system is all about, and it ought to be a goal of less sweeping reforms as well. Locking people in unproductive jobs because they fear to go without health insurance is damaging to individual enterprise and to the state’s economy. Let’s cover everyone. Let’s eliminate unnecessary barriers to the health care that everyone deserves.