Chapter – Page 1075

The safety net is tattered

Kaiser Commission on Medicaid and the Uninsured
November 4, 2005

Covering the Uninsured – Growing Need, Strained Resources

In 2004, America’s 46 million uninsured received about $41 billion dollars in uncompensated care – care that was not paid for either by the uninsured themselves or by another identifiable source. Most of the care received by the uninsured is provided through the informal network of hospitals, clinics, and health centers, referred to as the “safety net,” which is supported by federal, state, and local government as well as private sources. About half of all safety net funds come from the federal government, but they still comprise less than one percent of overall federal spending.

After adjusting for medical inflation and using constant 2004 dollars, total federal spending on the safety net increased by only slightly more than one percent between 2001 and 2004. Because the number of uninsured grew by nearly 5 million people, federal spending actually decreased from $546 to $498 per uninsured person over this time – a decline of 8.9%.

The federal commitment to the health care safety net has not kept pace with the growth in the uninsured, and future federal funding appears unlikely to reverse this trend. Most federal safety net spending flows through Medicare and Medicaid, both of which are under severe budgetary pressures. If safety net resources continue to decrease as the number of uninsured increases, the amount of care provided to the uninsured will be jeopardized, with further consequences on their health and the health of the country.

http://www.kff.org/uninsured/upload/Covering-the-Uninsured-Growing-Need-Strained-Resources-Fact-Sheet.pdf

The Uninsured and Their Access to Health Care

Charitable physicians and the safety net of community clinics and public hospitals do not fully substitute for health insurance. Lack of health coverage matters for millions of uninsured Americans – affecting their access to care, health status, job decisions, and financial security, as well as exacting an indirect toll on society in terms of more disability, lower productivity, and increased burden on the health care system.

http://www.kff.org/uninsured/upload/The-Uninsured-and-Their-Access-to-Health-Care-Fact-Sheet-6.pdf

Five New Reports Profile the Growing Uninsured Population and Portray the Health Care Safety Net as Increasingly Strained:
http://www.kff.org/uninsured/kcmu110405pkg.cfm

Comment: Lacking the “insurance ticket” that authorizes access to the private health care delivery system, the uninsured must depend on the safety net. When you consider that premiums for employer-based coverage for an individual averaged $3481 in 2003, it is difficult to imagine that the current safety net federal spending of $498 will pay for much care for the uninsured who typically have greater needs than the higher-income, healthier work force.

Since programs for safety net funding are considered to be welfare programs, the weak political voice for the uninsured is always drowned out by the strong political voices calling for fiscal restraint. Safety net institutions will never receive adequate funding until they are included in a single, universal risk pool.

We will always need community health centers and public hospitals. But to fund them adequately we will need to establish a program of comprehensive, universal health insurance, with everybody in, nobody out.

Health systems provide mediocrity for sicker adults

Taking The Pulse Of Health Care Systems: Experiences Of Patients With Health Problems In Six Countries
By Cathy Schoen, Robin Osborn, Phuong Trang Huynh, Michelle Doty, Kinga Zapert, Jordan Peugh, Karen Davis
Health Affairs
November 3, 2005

This paper reports on a 2005 survey of sicker adults in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States. Sizable shares of patients in all six countries report safety risks, poor care coordination, and deficiencies in care for chronic conditions. The United States often stands out for inefficient care and errors and is an outlier on access/cost barriers.

As found in past surveys, the United States is an outlier for financial burdens on patients and patients forgoing care because of costs. Half of sicker adults in the United States said that they did not see a doctor when sick, did not get recommended treatment, or did not fill a prescription because of cost. On each access/cost question, the U.S. rate was 1.5 to double the forgone care rates reported in the next-highest country.

Moreover, the percentage of U.S. sicker adults forgoing care because of costs was much higher on all three indicators compared with the 2002 survey of sicker adults. Despite these high rates of care forgone, one-third of U.S. patients spent more than $1,000 out of pocket in the past year, a level rare in the other countries. Insured and uninsured U.S. patients were about equally likely to report expenditures this high (34 percent insured and 32 percent uninsured).

Symptoms of inadequate insurance coverage and more fragmented care in the United States emerged throughout the survey. The United States outspends the other countries, spending 14.6 percent of national income compared with Germany’s 10.9 percent, Canada’s 9.6 percent, Australia’s 9.1 percent, New Zealand’s 8.5 percent, and the United Kingdom’s 7.7 percent. Yet the United States often ranks last or tied for last for safety, efficiency, and access.

With one-third of U.S. patients reporting medical, medication, or lab errors and a similar share citing duplicate tests or medical record delays, our findings indicate widespread performance deficiencies that put patients at risk and undermine care. Moreover, a recent study finds that the United States is not systematically a leader in clinical outcomes.

Confirming spending data from the Organization for Economic Cooperation and Development (OECD), the United States also stands out for its patient cost burdens, with consequences for access. U.S. physician visit rates are already low by OECD standards. To the extent that U.S. insurance continues to move toward higher front-end patient deductibles, these rates could go up, as increasing numbers of insured patients become “underinsured,” lacking access or adequate financial protection. Contrasts between the United States and Germany, in particular, indicate that it is possible to organize care and insurance to achieve timely access without queues, while ensuring that care is affordable at the point of service. There are clear opportunities for the United States to learn from other countries’ insurance systems.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.509v1

Release from The Commonwealth Fund:
http://www.cmwf.org/publications/publications_show.htm?doc_id=313012&#doc313012

Comment: This is yet another report that confirms that the United States does not have “the greatest health care system on earth,” even though we are paying enough such that we should have it. Our lowest ratings in these international comparisons stem from our fragmented system of funding care.

We can learn much from other countries’ insurance systems. Combining optimal insurance policies with our great resources should provide the first giant step toward providing us with what would truly be the greatest health care system on earth.

Working-Age Americans Bear Brunt of Medical Debt

Health Care Economics
By Rich Daly
Psychiatric News
October 21, 2005
Volume 40, Number 20, page 16
© 2005 American Psychiatric Association

A study finds the largest number yet of Americans struggling with medical bills and medical debt. The burden deters many from seeking preventive care and chronic disease treatment.

Nearly one-third of working-age Americans struggle to pay their medical bills, according to a recent report, with African Americans and women the most financially strained.

A recently released analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey concluded that an estimated 77 million adult Americans-both insured and uninsured-have difficulty paying medical bills, have accrued medical debt, or both. The latest findings support the conclusions of earlier studies that have found medical debt to be a significant problem, even for those with health insurance (Psychiatric News, March 18).

“Medical bill and debt problems not only create financial hardship but can deter people from seeking further health care,” said Michelle McEvoy Doty, Ph.D., a study author and senior analyst at the Commonwealth Fund. “In the long run that situation puts a bigger burden on the health care system because you are missing out on preventive medicine and not managing chronic conditions.”

Working-age adults are much more likely to face medical bill problems than Americans aged 65 and older, since pensions and Medicare offer protections for older Americans. The survey found that nearly one-third of the working-age respondents (32 percent) reported struggles with medical bills, while just 14 percent of elderly respondents reported the same. Medical debt was reported by 16 percent of working-age adults compared with 4 percent among adults over 64 years old.

Doty said the larger impact of medical bills on working-age adults stems from private insurers’ “much more fragmented” approach to coverage, compared with Medicare’s “very reliable” assistance in paying medical bills.

The challenge for working adults trying to pay for health care was even greater than for seniors among those with low incomes. The report found that 48 percent of low-income, working-age adults reported medical bill problems in the 12 months prior to the survey, while only 20 percent of low-income seniors reported such problems.

Working-age women were strongly impacted by the cost of medical care, and 39 percent reported medical bill problems, compared with 25 percent of men.

The survey found that 52 percent of African Americans reported medical bill problems, in contrast to 34 percent of Hispanics and 28 percent of whites, according to the report.

The data stem from a national telephone survey conducted from September 3, 2003, through January 4, 2004, among a random, nationally representative sample of 4,052 U.S. adults. The survey had a 50 percent response rate.

Access Under Increasing Threat

Health care reform advocates, such as Physicians for a National Health Program (PNHP), said the data support long-held beliefs that the rising cost of health care reduces access to that care, especially among working-age Americans, who lack the Medicare or pension coverage that buffers costs for older Americans.

“Though some protection for the retired is afforded by pension funds, the much larger incomes of the workforce are not adequate to compensate for the deficiencies of private coverage,” according to a statement on the results issued by PNHP, which advocates a national, single-payer health system. “Obviously a universal Medicare program with expanded benefits would be much more effective in preventing medical debt.”

Crisis Acute for Uninsured

Those without health insurance coverage during the study period had significantly higher rates of medical bill problems and debt (60 percent) than did the continuously insured (35 percent).

Rates of medical bill problems for the uninsured were more than twice those of the insured, with 35 percent of those without insurance at some point in the year contacted by collection agents compared with 15 percent of the continuously insured.

However, the possession of health insurance was not enough to prevent large numbers of Americans from incurring a large burden of medical debt. Researchers found that 57 percent of adults with medical bill problems and 70 percent with medical debt were insured at the time their financial obligation was incurred.

“As employers continue to pass on health care costs to their employees, you are going to see more people struggling with their medical bills and accruing debt,” Doty said.

A survey of 1,800 firms released in September by Mercer Human Resources Consulting found more employers are struggling with ways to cover what is expected to be a nearly 10 percent increase in health insurance costs for 2006 and plan to shift more of the burden of paying for medical care to their employees. Despite the expected 10 percent increase, employers polled plan to increase their spending by only 6.4 percent and have their employees make up the difference.

Medical bill problems and inadequate insurance, said the Commonwealth survey analysis, were also linked by inadequate or absent prescription drug coverage. Nearly half of working-age adults without prescription coverage in their insurance plan had problems covering the medical costs, compared with one-third who did have prescription drug benefits.

The study also found that medical bill burdens and medical debt reduced Americans’ access to health care, with 63 percent of adults with medical debt problems forgoing needed care within the preceding year due to cost. Only 19 percent of adults without medical bill challenges avoided seeking needed health care.

The study found 43 percent of workingage adults experiencing medical bill or debt problems failed to fill a prescription because of cost, compared with just 9 percent of adults not enduring such problems.

Even after adjusting for insurance coverage, income, health status, and other variables, the researchers found that Americans with problems paying health care bills were much more likely to leave a prescription unfilled, forgo a needed physician’s visit, or skip recommended tests or follow-up visits than were adults less challenged by medical costs.

The study found as well that 23 percent of those struggling to pay medical bills did not see a specialist when needed, compared with 6 percent without such bill-paying challenges. Thirty-seven percent with medical bill problems skipped medical tests, treatment, or follow-up, while only 6 percent of those without bill problems did so.

Additionally, 42 percent of those with daunting medical bills had a medical problem but did not visit a physician or clinic for treatment, far more than the 8 percent without difficult medical bills and did not seek needed assistance.

“People who have bills and debt are more likely to have health care access problems,” Doty said.

Lack of health insurance kills

By Kay Lapp James
November 2, 2005
Wisconsin Dells

Being without health insurance can kill you, say Drs. Linda and Gene Farley, and access to medical care should be a right, not a privilege.

The two doctors spoke on the health care crisis and the need for a national health care plan at a meeting Thursday of the Dells Progressive Voices. About 20 people heard the Farleys describe with numbers and anecdotes the plight of the uninsured in America.

The two retired University of Wisconsin-Madison Medical School faculty members also were once family practice doctors and believe the country can afford to provide medical care to everyone.

Gene Farley asked anyone who does not believe health care is a right to say on whose doorstep the uninsured will die.

The uninsured die because they don’t have insurance, said Linda Farley. In 2002, 18,314 adults died because they did not have insurance and could not afford medical care.

U.S. taxpayers pay the health care bill for about 50 percent of the U.S. population through Medicare for seniors, veterans, Native Americans, Medicaid for the disabled, children and the poor elderly, and for public employees on the local, state and national level. Of the rest of the population, 45 million don’t have any insurance. Of those without insurance, 50 percent are employed and 25 percent are children.

While Americans may brag about the quality of care here, Linda Farley pointed to comparisons showing that the United States had poorer life outcomes than countries with national health care plans.

The U.S. had the highest infant mortality rate in 1999 (7.1 babies per 1,000 births)among a group of developed countries, that comprises Australia, Canada, Italy, Germany, France and Sweden.

In that same year and among those same countries, women lived fewer years in the United States. Here women can expect to live an average of 79 years, while in France they can live an average of about four more years.

“Every other industrialized nation (except the United States) has a healthcare system that assures medical care for all,” said Linda Farley.

Those countries also spend less than the United States does per person. Most spend less than half what the U.S. does, she said.

Besides the lower death rates, those countries also have more accountability for care and higher satisfaction with care, she said.

The way to cut costs and to insure everyone is to go with a one-payer health care system, the couple said. That eliminates the most costly feature of the U.S. health care system half the multiple payers: insurance companies, HMOs, PPOs and the government.

As an example of the savings that could be achieved, the Farleys compared the same size hospitals in the United States and in Canada. In the U.S., a patient bill must cover the costs of 356 people in the billing department, which adds about $372 to each bill. In Canada, the same size hospital needs just nine people in its billing department and billing adds $68 to a patient’s bill.

In addition to a more cumbersome billing process, hospitals and other medical facilities have been adding administrators. Since the 1970s, the number of administrators has grown by 2,500 percent while the number of registered nurses in hospitals has hardly grown. The growth of the clerical staff has spawned the increase in administration.

Linda Farley also pointed to the salaries of the CEOs of health insurance and managed care companies. The salaries start around $1 million and the highest, $5 million, goes to the CEO of Cigna, Wilson Taylor. Those salaries don’t include the stocks the CEOs also receive. Taylor also receives $64.2 million in stock.

The Farleys also cited drug manufacturers as contributing the high cost of health care. In a chart, they showed that drug companies spend 27 percent of their income on manufacturing, 35 percent on administration and marketing, 7 percent on taxes and only 13 percent on research and development. A drug manufacturer has profits of about 18 percent, Linda Farley said, which was much more than the average Fortune 500 company. It makes about 5 percent profit.

Doctors’ salaries are less of a problem, although some who have become partners in hospitals, clinics and insurance organizations have become millionaires. Gene Farley noted that when Medicare began in the 1960s, doctors’ incomes began to rise. Prior to that time, health care was considered a charity and doctors often weren’t paid for the care they provided. With Medicare, doctors could count on being paid.

“People say we can’t afford universal care, but we’re already paying for it,” Gene Farley said.

Bills to set up a universal or single-payer system in Wisconsin have been introduced in the state Legislature. Under such a system, the Farleys said the state could save money. In 2003, spending here for health administration totaled $7.72 billion. They say that a single-payer health insurance would have saved $5.52 billion or enough to provide $13,513 for each of the 409,000 uninsured people in the state.

Gene Farley said he does not understand why businesses here do not support a single-payer, universal health care system. Canadian businesses have cheaper operating costs because of the universal system there and support it. In Canada, every business has to pay into the system.

The United States or even Wisconsin won’t get a single-payer system unless people demand it, Gene Farley said. He urged people to be noisy and contact their legislators. He also urged everyone to vote, noting that poor people who pay the steepest price for health care (they get no discounts like the government and HMOs or PPOs get) don’t vote.

“It won’t get any better until people speak up,” said Gene Farley.

International Survey: U.S. Leads In Medical Errors

PRESS RELEASE

EMBARGOED UNTIL
Thursday, November 3, 2005, 9:00 A.M. EST (Washington and Ottawa) Thursday, November 3, 2005, 2:00 P.M. GMT (London) Thursday, November 3, 2005, 3:00 P.M. CET (Berlin) Friday, November 4, 2005, 1:00 A.M. (Canberra) Friday, November 4, 2005, 3:00 A.M. (Wellington)

For further information, contact:
Mary Mahon, (212) 606-3853 or (917) 225-2314, mm@cmwf.org, or Monika Ellis, (301) 652-1558, mellis@burnesscommunications.com

International Survey: U.S. Leads In Medical Errors

Patients in Six Nations Report High Error Rates, Lapses In Hospital Discharge Planning, And Lack Of Care Coordination

U.S. Has Highest Out-Of-Pocket Expenses And Rates Of Forgone Care Due To Costs

Bethesda, MD — One-third of patients with health problems in the United States report experiencing medical, medication, or test errors, the highest rate of any nation in a new Commonwealth Fund international survey. Assessing health care access, safety, and care coordination in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States, the survey found that while no one nation was best or worst overall, the United States stood out for high error rates, inefficient coordination of care, and high out-of-pocket costs leading to barriers to access to care.

The findings are published today in a Health Affairs article, “Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries,” whose lead author is Commonwealth Fund senior vice president Cathy Schoen.

You can read the article at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.509.

“While the consistently high error rates and lack of coordination are disturbing, the findings also highlight the potential for each country to improve,” said Commonwealth Fund president Karen Davis. “Some countries have been able to achieve timely access to needed care while reducing financial barriers. Each country could also gain through strategies to improve the quality and efficiency of care, such as implementing modern information technology systems, supporting patient engagement in care, and improving management of chronic conditions.”

The 2005 survey of adults with health problems is the eighth in an annual series of cross-national surveys conducted by Harris Interactive for the Commonwealth Fund.

One-third (34 percent) of U.S. survey participants reported at least one of four types of errors: They believed that they experienced a medical mistake in treatment or care, were given the wrong medication or dose, were given incorrect results for a test, or experienced delays in being notified about abnormal test results. Three of ten Canadian respondents reported at least one of these errors, as did one-fifth or more of patients in Australia (27 percent), New Zealand (25 percent), Germany (23 percent), and the United Kingdom (22 percent).

U.S. patients who saw four or more doctors in the past two years were especially vulnerable, with about half reporting at least one of these errors; this points toward lapses in communication during care transitions.

Although attention to patient safety has focused chiefly on care in hospitals, a majority of patients (60 percent or more) in each country who reported medical mistakes or medical errors said that these errors occurred outside the hospital, which highlights the need for policies to improve patient safety in ambulatory care settings.

“There were many symptoms of poorly coordinated care in every country, regardless of the type of delivery or financing system,” said Schoen. “Shortfalls were particularly evident for people when discharged from the hospital, and for patients seeing multiple physicians. Improved care coordination during transitions across sites of care and providers offer opportunities for significant improvement. These patients are the ‘canary in the coal mine’ of any health system.”

In all six countries, one-third or more of recently hospitalized patients reported failures to coordinate care during hospital discharge. Germany had the highest rate of patients reporting lack of follow-up care, with three-fifths (60 percent) saying that the hospital did not make arrangements for follow-up visits with a doctor or other health professional or otherwise give instructions about posthospital care, such as symptoms to watch for and when to seek further care.

The United States had the highest rate of patients reporting coordination-of-care problems that reflected inefficient care during doctor visits. One-third of U.S. respondents said that within the past two years, either their test results or records were not available at the time of a doctor’s appointment, or that a doctor had ordered a test that had already been done. Rates of care-coordination problems in the United States were higher than those in the other five countries, which ranged between about one-fifth to one-quarter reporting coordination problems.

Patients with chronic diseases in all of the countries often did not receive the care recommended to manage their condition. At best, about half of diabetics reported receiving all four recommended screening exams to manage their condition. Patients who had supports such as a self-management plan or a nurse included as part of their care management team were more likely than others to have received recommended care.

The United States was an outlier for its financial burdens on patients:
• Half of U.S. adults reported that they had gone without care because of costs in the past year
• In contrast, just thirteen percent of U.K. adults reported not getting needed care because of cost
• One-third of U.S. patients reported out-of-pocket expenses greater than $1,000 in the past year
• U.K. patients were the most protected from high cost burdens, with two-thirds having no out-of-pocket expenses. The variations were notable given the study’s design focus on sicker adults with recent intensive use of medical care.

Access—including after-hours access—and waiting times to see a doctor when sick differed markedly across the countries:
• Canadian and U.S. adults who needed medical care were the least likely to report fast access (same day) to doctors (30 percent or fewer of U.S. or Canadian patients)
• In contrast, majorities of patients in New Zealand (58 percent) and Germany (56 percent) reported that they were able to get same-day appointments, as did nearly half of patients in Australia (49 percent) and the United Kingdom (45 percent)
• Majorities of patients in Germany (72 percent), New Zealand (70 percent), and the United Kingdom (57 percent) also reported easy after-hours (nights, weekends, or holidays) access to a doctor
• In contrast, majorities of patients in the United States (60 percent), Australia (58 percent), and Canada (53 percent) said that it was very or somewhat difficult to get after-hours care
• The four countries with comparatively more rapid access to physicians—Australia, Germany, New Zealand, and the United Kingdom—also had lower rates of emergency room use, with Germany having the lowest rates
• One-fifth of Canadians and one-fourth of U.S. patients who reported going to the ER said that it was for a condition that could have been treated by their regular doctor if available

The findings highlight the need for improved access as well as coordination of care. The authors conclude that “these findings suggest that many of the problems with which policy leaders are grappling transcend specific payment or delivery systems and will require more fundamental transformation.”

The Commonwealth Fund is a private foundation supporting independent research on health care issues and making grants to improve health care practice and policy.

Health Affairs , published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org. The full text of each Health Affairs Web Exclusive is available free of charge to all Web site visitors for a two-week period following posting, after which it will switch to pay-per-view for nonsubscribers. The abstracts of all articles are free in perpetuity. Web Exclusives are supported in part by a grant from the Commonwealth Fund.

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Unintended over-utilization by ethical physicians

Variation in the Tendency of Primary Care Physicians to Intervene
By Brenda E. Sirovich, MD, MS; Daniel J. Gottlieb, MS; H. Gilbert Welch, MD, MPH; Elliott S. Fisher, MD, MPH
Archives of Internal Medicine
October 24, 2005

There is widespread recognition that health care spending varies widely across the United States. Per capita Medicare expenditure in the areas of highest spending is double that in the lowest-spending areas, even though in some cases these represent neighboring areas. Because higher spending does not appear to result in better outcomes or quality of care, there is intense interest in understanding the reasons for the wide variation in utilization of services. Average illness severity varies little across regions; therefore, attention has focused increasingly on the role of physicians who, through their actions and recommendations, control most health care resources and thereby direct most health care spending.

There are, however, competing explanations of how physicians might contribute to higher health care spending. On the one hand, high-spending areas have more physicians per capita, and on average, patients in these areas each see a greater number of physicians. Even if each physician’s shared ordering pattern is identical to those in lower-spending areas, utilization (and spending) per capita would be higher in areas with a greater number of physicians. On the other hand, physicians in high- and low-spending regions may have entirely different ordering patterns.

Specifically, physicians in high-spending areas may be more prone to intervene – to order tests, referrals, and treatments – for individual patients.

We sought to determine whether physician behavior is at least in part responsible for widely varying spending and utilization patterns across the United States – that is, to what extent individual physicians in high-spending regions have a greater tendency to intervene for individual patients.

The sample of primary care physicians consisted of both family/general practitioners (57%) and general internists (43%). Regions in the quintile of highest spending averaged $8325 per capita in annual Medicare spending and
242 physicians per 100,000 persons compared with $6087 per capita and 193 physicians per 100,000 in moderate-spending regions and $4911 per capita and 185 physicians per 100,000 in regions of low spending. The supply of hospital beds and physicians of all specialties was more abundant in regions of higher spending, with the exception of family practitioners, whose numbers declined as local spending increased.

This study shows that widely differing levels of health care spending across the United States reflect the tendency of local physicians to recommend interventions for patients. In high-spending areas, physicians would order further evaluation or treatment for approximately 10 additional patients of every 100 patients seen compared with physicians in low-spending areas.

While we have shown that physicians who practice in areas of higher local health care spending are more prone to intervene, we are unable to distinguish among 3 potential explanations: (1) more aggressive physicians may be attracted to certain areas; (2) physicians may adopt the practice style (or standard of practice) of the community where they locate; or (3) characteristics of the market itself, such as greater difficulty maintaining target incomes in a more competitive marketplace, could lead to a lower threshold for referral and test ordering.

It is unlikely that physician behavior is the sole explanation for higher levels of spending in some areas. Having more specialists or more hospital beds in an area, for example, likely plays a role in higher levels of local spending. It is also possible that – notwithstanding similar end-of-life preferences – differences in patient expectations and demands across different regions impact the level of local health care spending via direct influence on physician decision making. However, in the present study we have been able to show that, when faced with the same patients, physicians in higher-spending areas are more likely to intervene, and this undoubtedly accounts for some portion of the higher spending seen in some US regions.

http://archinte.ama-assn.org/cgi/content/abstract/165/19/2252

Comment: We already know that there is a wide variation in spending in different locations, and that the differences are not explained by the relative health of the populations served. We know that the higher level of spending does not result in higher quality nor does it improve health outcomes. We know that regions with higher spending have excess capacity and an excess concentration of specialists. This study adds to others which demonstrate that physician behavior also drives up spending in high-cost areas.

The design of this study makes it very likely that these physicians believe that they are making optimal choices for their patients’ care. As we consider policy changes that would reduce excess spending in high-cost areas, it is a relief to know that not much attention needs to be directed to efforts to reduce fraud and abuse (except for the rare provider who clearly churns or submits fraudulent claims).

A single payer system can be beneficial because, as a monopsonistic purchaser, it can favorably alter the practice environment. Excess capacity of health care facilities can be controlled through budgeting of capital improvements. Excess concentration of specialists can be controlled by offering differential compensation based on regional needs.

Controlling excess capacity runs the risk of creating excessive queues. Continual monitoring with appropriate adjustments as needed would be required. Not only would we benefit by reducing the waste of over-utilization, but we would also improve access in regions with deficient capacity.

Those who are uncomfortable with a publicly administered process should keep in mind that currently the marketplace is failing to provide the oversight and adjustments that need to be made. We want to continue to spend nearly the same amount on health care, but we want to spend it much better.

Kentucky AFL-CIO Endorses Conyers' Single Payer HR 676

Adopted by the Kentucky State AFL-CIO Convention, October, 2005
RESOLUTION CALLING FOR THE KENTUCKY STATE AFL-CIO CONVENTION TO ENDORSE HR 676, SINGLE-PAYER UNIVERSAL HEALTH CARE

Workers, their families and their union are waging an increasingly difficult struggle to win or keep good health care coverage. Almost very union at every contract deadline must battle and sacrifice merely to sustain health care benefits. The rising costs of health insurance are blocking workers’ progress in wages and other areas. All of our unions face a health care crisis.

But the crisis extends far beyond union members. More than 45 million people in the U.S. are currently without health care insurance. More than 75 million went without for some length of time within the last two (2) years; and millions more have inadequate coverage or are at risk of losing their coverage. Women, people of color and immigrants are denied care at disproportionate rates, while the elderly and many others must choose between the necessities and life sustaining drugs and care. Unorganized employers, such as Wal-Mart dump their responsibilities for health care onto public programs.

The U.S. health system continues to treat health care as a commodity distributed according to the ability to pay, rather than a social service to be distributed according to human need. Insurance companies and HMOs compete not by increasing quality or lowering costs, but by avoiding covering those with the greatest need.

Economic necessity and moral conscience compel us to seek a better way. Therefore, be it resolved that: A single payer program as provided for in Congressman John Conyers’ bill HR 676, ‘Expanded and Improved Medicare for All,’ a single payer health care program is the only affordable option for universal, comprehensive coverage.

That the Kentucky State AFL-CIO will work with unions and community groups to build a groundswell of popular support and action for single payer universal health care and HR 676 until we make what is morally right for our nation into what is also politically possible.

That the Kentucky State AFL-CIO will send a copy of this resolution to Congressman Conyers, to all the Kentucky members of the U.S. House and Senate, to the AFL-CIO Executive Committee, and to the news media.

Respectfully submitted by,

AFSCME Local 2629

Sheila Wade, President

Kentucky AFL-CIO Endorses Conyers’ Single Payer HR 676

Adopted by the Kentucky State AFL-CIO Convention, October, 2005
RESOLUTION CALLING FOR THE KENTUCKY STATE AFL-CIO CONVENTION TO ENDORSE HR 676, SINGLE-PAYER UNIVERSAL HEALTH CARE

Respectfully submitted by,

AFSCME Local 2629

Sheila Wade, President

Increase in uninsured will save our economy

Changes In Economic Conditions And Health Insurance Coverage, 2000-2004
By John Holahan and Allison Cook
Health Affairs
November 1, 2005

Between 2000 and 2004, the number of uninsured Americans increased by six million, primarily because of a decline in employer-sponsored insurance. All of the increase occurred among adults, for whom the drop in employer coverage was not offset by an increase in public coverage. The number of uninsured children fell slightly. About two-thirds of the growth in the uninsured was among Americans below 200 percent of the federal poverty level. Coverage rates have also fallen among higher-income Americans. About half of the growth in the uninsured was among young adults ages 19-34, about 55 percent among whites, and 73 percent among native-born citizens.

The decline in employer coverage is likely to continue. Increases in health care costs, and thus health insurance premiums, are likely to continue to grow faster than workers’ earnings. The decline in employer coverage will be further exacerbated if the shift from working in large and midsize firms to small firms and self-employment and from high- to low-coverage industries continues. The problem of the uninsured can be addressed in many different ways, such as tax credits or public program expansions, but doing so is likely to prove very difficult. Federal budget deficits are large, which will limit the federal government’s ability to act for the foreseeable future, and all indications are that the government will pursue spending cuts to address the huge cost of hurricane recovery in the coming years.

States also face serious budget problems in part because increases in health care spending outpace the growth in state revenues, a trend that is likely to continue. As a result, it is difficult to envision a reversal of the trends we have described in this paper.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.498v1

Comment: So employment-based coverage is declining, and the increases in the numbers of uninsured cannot be addressed because federal and state spending must be cut. What? Why is that last statement presented as if it were an immutable given?

We do have the option of moving health care spending from private ledgers to public budgets. Yes, there would be challenges in a publicly-budgeted system. In using public funds we would have to be certain that everyone was covered, and that access and funding would be on an equitable basis. But that really wouldn’t be much of a challenge for a single payer system since it would achieve precisely those goals by design.

As the problem gets worse, tens of thousands more will die. Yet we do nothing because one individual says, “No new taxes.” Isn’t there a higher ethical principle that should guide us?

The danger of consumer-driven health care

The Danger of Consumer-Driven Health Care Crash Course
by Jonathan Cohn
The New Republic
Nov. 7, 2005

Health care operates by what economists commonly call an “80/20” rule. In any given year, most of the money being spent on medical care in the United States (about 80 percent of the total) is for the relatively small portion of Americans (about 20 percent of the population) recovering from severe accidents, fighting off a life-threatening disease like cancer, or struggling with a serious chronic condition like diabetes.

… traditional health insurance spreads the financial burden, using premiums paid by people who don’t use many medical services to help pay the bills of those who do. The trouble with HSAs is that they change the equation, dramatically, allowing people in relatively good health to keep much more of their own money. “One hundred percent of the time it makes sense for a healthy person to take the savings account,” one benefits consultant explained in The Tampa Tribune. “That’s a no-brainer.” But, once that happens, there’s less money to subsidize care for the people with high medical bills–which means those people must either make up the difference themselves or simply go without care. “A wholesale switch to [HSAs] would redistribute the nation’s overall financial burden of health care from the budgets of chronically healthy families to those of chronically ill families,” Princeton economist Uwe Reinhardt has written. “One should simply not brush these ethical issues aside.”

…we need to go back to the guiding principle of group health care–that the way to both lower costs and serve as many Americans as possible is to broaden, rather than shrink, the patient pool. One way to do this is through the plan we’ve been flirting with since the Progressive era–universal health coverage. These days, the case for it seems stronger than ever.

Depending on how it’s structured, universal health care would either limit or eliminate altogether the employers’ responsibility for their workers’ health bills, by transferring greater financial responsibility to an even broader base: the entire population, through some combination of taxes and premiums.

(Jonathan Cohn is a senior editor at The New Republic. He is currently writing a book on the U.S. health-care system.)

http://www.tnr.com/user/nregi.mhtml?i=20051107&s=cohn110705&pt=5%2FcM70%2FKqHd9828cDSfJPW%3D%3D

Comment: The full article is well worth reading for those who want an excellent crash course on the danger of consumer-directed health care.

We are looking forward to the publication of Jonathan Cohn’s new book on the U.S. health-care system. Now, more than ever, there is a greater need for more light and less heat on the subject.

Medicare catastrophic drug coverage is a catastrophe

Medicare Drug Benefit May Expand ‘Catastrophic’ Protection
By Karen Pallarito
Forbes.com
Oct. 26, 2005

The number of seniors protected against formidably high drug costs will increase sharply under the new Medicare prescription drug program, a new analysis finds.

The study focused on the 1.5 million Medicare beneficiaries in the United States who spend more than $4,000 annually on prescription drugs and who lack coverage for so-called “catastrophic” drug costs. These people include individuals who do not have supplemental drug coverage or whose “medigap” insurance does not pay for prescription drugs

“There’s no question of the impact this benefit will have on the lives of those who are dealing with serious illness and their accompanying prescription drug costs,” said Mary R. Grealy, who chairs the Medicare Today partnership. “Our task is simply to get the word out.”

But Robert M. Hayes, president of the Medicare Rights Center, a New York City-based information and consumer advocacy group, said the numbers are somewhat misleading.

“The point of a real Medicare drug benefit would be to assist folks who go without that medication because they cannot afford the $4,000,” he said.

http://www.forbes.com/lifestyle/health/feeds/hscout/
2005/10/26/hscout528779.html

And…

Medicare Prescription Drug Benefit Calculator
The Lewin Group

(The following is an example entered by The Lewin Group to demonstrate the use of the calculator, but you must click “calculate” to get correct results for the example entered.)

Information entered:
$6,000 – Your individual annual drug costs $25,000 – Your annual household income Single – Marital status

Calculated results:
$1,200 – Estimated savings due to Rx plan’s buying discounts $1,500 – Medicare Rx plan’s share of drug costs $3,300 – Your out-of-pocket costs under the new benefit $3,720 – Your costs including estimated premium

The calculator assumes savings to beneficiaries of 20% resulting from bulk purchasing of prescription drugs, compared to the retail prices many seniors face today as individual cash purchasers.

http://webstudies.lewin.com/pdb/medicare2.htm

Comment: Wow! $2,280 savings for $6,000 worth of drugs. Who could ever complain about that?

Before looking closer at these numbers, it’s important to understand that the Medicare drug benefit was carefully designed to advance the conservative agenda of privatizing Medicare. They wanted to allow drug coverage only under the private Medicare Advantage plans to give them a competitive advantage over the traditional Medicare program. But political realities were such that they had to develop some sort of a Medicare D option to provide drug coverage for those remaining in the traditional Medicare program. Otherwise, the Medicare privatization legislation was doomed to certain defeat.

In order to embed the privatization agenda into the public Medicare D program, the conservatives required that the program be administered privately, through insurers and pharmacy benefit managers. They recognized that this private sector drug bureaucracy would consume much of the negotiated discounts because of their very high administrative costs. If Medicare were allowed to negotiate the same discounts, then the entire scheme would fall apart because Medicare would have been granted an “unfair” competitive advantage because of its greater efficiency. Consequently, the conservatives inserted into the legislation a prohibition against government-negotiated drug discounts. Now, let’s look at the numbers.

Suppose Medicare had been allowed to negotiate discounts. The amount of the discount should be greater since the much higher volume of drug utilization would increase drug costs by only the marginal costs of increasing manufacturing volume, a very small percentage of the overall costs for the pharmaceutical industry. But lets ignore this additional savings and assume that Medicare would receive the same discount as the private pharmacy benefit managers, estimated by The Lewin Group to be 20%.

In the example provided by The Lewin Group, the beneficiary pays the first $250, plus 25% of the next $2,000 ($500), plus the full amount between $2,250 and the discounted total of $4,800 ($2,550), and a premium of $35/month ($420), for a total of $3,720. Medicare pays 75% of the amount between $250 and $2,250, or $1500. Since the Medicare portion is paid from tax funds, it is really an allocated portion of pooled consumer funds and, thus, a portion of the costs paid indirectly on behalf of the Medicare beneficiary. So the full amount paid by the beneficiary, directly and indirectly, is $5,220 ($3,720 plus $1,500).

Wait a minute. If Medicare didn’t even set up a drug program but merely negotiated a 20% discount, the cost would have been $4,800. Thus an extra $420 ($5,220 minus $4,800) is the penalty assessed because we prohibited Medicare from negotiating the same discount that the pharmacy benefit managers receive.

This example assumes only a negotiated drug discount for Medicare and nothing else. But suppose that Congress were to authorize a bona fide Medicare drug benefit. We would receive not only the discounts, but also the tremendous power of spreading the risk through an equitable system of funding the program. By expanding the program into a Medicare for All, we would further dilute the costs per beneficiary by including younger, healthier individuals who have little need for drugs now, but who want to have affordable access when they are older and in poorer health.

Privatize Medicare? No way! We need a single payer, national health insurance program. How about Medicare for All?

The Chaoulli Case: A Two-Tier Magna Carta?

By Gregory P. Marchildon
Healthcare Quarterly
Vol 8, No 4, 2005

Abstract:
There has been considerable speculation about the potential impact of the Supreme Court of Canada’s judgment in Chaoulli v. Quebec. Even if those who are most friendly – or most hostile – to Canadian medicare are exaggerating the impact of the decision, its impact will be large. While the decision does not strike down any existing single-payer medicare system in any province, including Quebec’s single-payer system, it is certainly capable of becoming the Magna Carta for two-tier medicare through future judicial interpretation and extension. In any event, it has already become the battering ram of choice for medicare’s most tenacious opponents.

In recent years, the critics of medicare have become more vocal about what they invariably describe as the monopoly of single-payer health care, often comparing Canadian healthcare to the command economy of the former Soviet Union. This perception is not only misleading – it is fundamentally wrong on a number of counts.

In the first place, Canadians are awash in choices when it comes to medicare. We have the freedom to choose our physician. Within our respective provinces and territories, we are free to choose our health institutions – one hospital over another, one clinic over another, depending on our personal preferences. And in contrast to the imagery of a single government bureaucracy perpetuated by the critics of medicare, almost all of our physicians are independent professionals working on fee schedules or contracts freely negotiated with provincial and territorial governments. Many of our clinics are private (not-for-profit as well as for-profit) and the majority of our hospitals are either private not-for-profit institutions or part of regional health authorities that have varying degrees of managerial autonomy from government. This contrasts sharply with the history of the National Health Service in Britain, in which hospitals and their employees all became part of a central government bureaucracy.

In the second place, medicare refers to a quite narrow range of health services – mainly hospital, diagnostic and physician services that are provided on a universal basis and without direct payment by the patient. These services constitute about 43 per cent of total healthcare expenditures in the country. Almost all other healthcare, including home care, nursing home care, prescription drugs, vision care and alternative medicines, are outside the medicare basket. In other words, the so-called monopoly covers less than one-half of Canadian healthcare and does not at all apply to mixed and private sectors of healthcare – sectors in which private insurance, user fees and direct payment are the rule rather than the exception. Moreover, the mixed and private sectors – comprising over 50 per cent of health expenditures – have contributed far more than the public sector to the high rate of growth in healthcare expenditures over the last decades.

Finally, we have always permitted two small exceptions to our single-payer medicare regimes – one private, the other public. On the private side, no one is prohibited from purchasing private health services as long as they pay out-of-pocket for those services from providers who have chosen to be non-participating members of a provincial medicare scheme. On the public side, workers’ compensation health benefits predate medicare and were legally excluded from the operation of the Canada Health Act and provincial medicare laws. Of the two, at least until the Chaoulli decision, the public tier of workers’ compensation has been more problematic in terms of its damage to the principle of universality by allowing a segment of the population preferential access to medicare services, occasionally through non-participating physicians and private facilities.

In contrast, the private exception based upon private payment never really developed in Canada for a number of complex reasons, particularly the refusal of provincial and territorial governments to subsidize private care or encourage physicians to work both sides of the public-private street at the same time. Although I know it is contentious to do so, I would add that the generally high quality of Canadian medicare has also prevented a large private market from developing. At any rate, the very few Canadians who have wanted such services have always been free to purchase them in the United States, where a ready market for privately purchased services has always existed because of the truncated nature of public health insurance in that country.

This brings us to the nub of the Supreme Court’s decision. Despite the lack of evidence, opponents of Canadian-style medicare, including Dr. Jacques Chaoulli, have long argued that the inability to purchase private insurance for medically necessary health services has been the key factor in preventing a viable second tier from emerging capable of competing with publicly administered medicare for customers (Coffey and Chaoulli 2001). They often point to examples such as Australia, where public and private hospital and physician services co-exist. Of course, they conveniently ignore the fact that the Australian government has had to provide a huge public subsidy in the form of a 30 per cent deduction for private insurance premiums to keep the private system in business, an experience that seems common in countries with such two-tier systems. In other words, public funds are often diverted to the wealthier members of society in order to prop up the private tier where it exists.

Proponents of medicare have long argued that to preserve the universality of a system, with access based solely on need, government needs to discourage the emergence of a separate “upper” tier of care based on ability to pay. Most governments in Canada have done so because they wanted to prevent major exceptions to the principle that access should be based on urgency of need. They have also done so to prevent a parallel private system from robbing the financial and human resources needed to run a top-notch public system. To protect their single-payer systems, different provinces have selected different and various means to discourage a second private tier. These means include: not allowing non-participating physicians to charge more than the medicare fee schedule; refunding patients only the medicare portion of fees paid to non-participating physicians; and in the case of six provinces (British Columbia, Alberta, Manitoba, Ontario, Quebec and Prince Edward Island) prohibiting private health insurance for medicare services.

In Chaoulli, the Supreme Court decided that Quebec’s prohibition on private health insurance is contrary to the Quebec Charter of Human Rights and Freedoms when an individual’s lengthy wait for medicare services seriously compromises the health of that individual. The court provided little guidance, however, in helping governments, health organizations and physicians know at what point a waiting time is too long. Moreover, little or no consideration was given to the fact that many provincial governments and health organizations, through initiatives such as the Western Canada Wait List Project and the Saskatchewan Surgical Care Network, have focused their efforts at understanding and shortening wait lists. Indeed, while the degree of success varies across and within provinces, there has been considerable progress in reducing waiting times in many parts of the country in the last couple of years.

Contrary to the majority view of the court, which seemed to swallow the monolithic, monopoly view of the world, medicare is actually a highly local system depending on the management and decisions of individual physicians, hospitals and regional health authorities. It is up to these organizations, under a publicly administered framework provided by the provincial government, to balance the many priorities, from urgent to elective care, and from sickness care to illness prevention and health promotion. We must ask ourselves whether the court’s concern with one waiting list problem in one city in one province is going to end up dictating the priorities of health organizations and governments throughout Canada, even further tipping the balance in favour of downstream illness care and away from prevention and promotion efforts that will keep us all healthier (and at less cost) in the long run.

So, what next?

In the face of this decision, those governments that support medicare should act now rather than waiting for the inevitable offensive driven by the powerful interests supporting the radical privatization of Canadian medicare. Individuals and groups within those provinces can strengthen the resolve of these governments by expressing their support for universal medicare, their opposition to allowing a private upper-tier of care, and initiating their own litigation to support the principles of medicare.

Those provinces that have prohibited private insurance should consider amendments that clarify the reasons for prohibition and the merits of a single-tier system of medicare. The legislative debates will force everyone to make their positions and assumptions clear and will provide an opportunity for medicare-friendly governments to set out the evidence supporting a single-tier system. Once enshrined in law, each government’s legislative intent will have to be taken into consideration in future court rulings.

The provinces that have not previously prohibited private insurance have at least two options open to them. They can re-examine the combination of measures they have used in place of an outright prohibition on private health insurance to protect the integrity of their single-payer systems, and the extent to which their circumstances may be similar to, or different from, the provinces with express prohibitions. They can then amend their own medicare laws to make clear their legislative intent to continue to preserve the integrity of their single-payer systems.

Although unlikely because of the inherent cautiousness of the advice given by health bureaucracies to their political masters, it would be interesting to see at least one provincial jurisdiction carefully draft a new law prohibiting private health insurance for the express purpose of having it tested in the courts, perhaps through a reference case. I am quite sure that it would be relatively easy in such a case to demonstrate the broader point that the policy measures relied upon by any government to protect medicare are better determined by governments accountable to the public through the democratic process than by the courts.

The federal government could also take some long overdue action to enforce the Canada Health Act. There is a reason that Montreal has the largest number of private MRI clinics in the country – a market has been created because of the extremely long waiting lists in the public sector and the willingness of participating physicians to encourage their more well-off patients to jump the medicare queue by getting a private MRI. If the federal government had forced this issue into the public domain years ago through a (temporary) reduction in its transfer payments, the Quebec government might have better ensured timeliness of care through the public system and not relied so surreptitiously on its private release valve. In more general terms, while it is up to individual provinces to decide on how best to administer (and protect) their respective single-payer systems, the federal government needs to continue to ensure that it is effectively discouraging major exceptions to the fundamental principles of public administration, universality, comprehensiveness, portability and accessibility.

Finally, I would like to offer some unsolicited advice to Premier Klein of Alberta, given his comments following the Chaoulli decision. If he truly believes that the founding principles of medicare are fundamentally flawed, then this court decision should finally give him the courage of his convictions. If he truly believes that Albertans endorse his vision, then he should immediately introduce a two-tier system. He can bypass the Canada Health Act by simply refusing federal health transfers in the future. If Saskatchewan was able to go it alone for years when it first introduced medicare, then surely oil-rich Alberta can now afford to go it alone. Albertans could then pay directly out-of-pocket or indirectly through private health insurance for a portion of their medicare services. Access for the majority would be based mainly on “ability to pay,” while access for the very poor (often defined as those on welfare) would be determined by a safety net type medicare program. Where the working poor fit into this picture is a little harder to determine but all Canadians outside Alberta would have a home-grown point of comparison on how the systems stack up against each other.

In the 1960s, this option was called Manningcare because Premier Ernest Manning was convinced of its merits compared to the universal medicare model. Personally, I would be confident that single-tier medicare would prove itself more efficient, effective and equitable in the comparison, just as it has done so relative to the American system. Whether a majority of Albertans would willingly go along with Premier Klein on this trip back to the past is highly questionable. Indeed, I suspect the majority of Albertans remains as opposed to a two-tier system as all other Canadians, a stubborn fact that explains the gap separating Klein’s bravado from his government’s timid actions on the ground.

We all know that the demand for healthcare services is potentially limitless. After protracted debates almost a half century ago, we decided that, at least for medicare services, rationing should be based upon urgency of need rather than ability to pay. Though the majority of Canadians continue to support that democratic decision and the founding principles of medicare, the Supreme Court through its Chaoulli Magna Carta is doing its best to force us back to the drawing board again.

About the Author
Gregory P. Marchildon, is Canada Research Chair and Professor Graduate School of Public Policy, University of Regina and Fellow, School of Policy Studies, Queen’s University. Email: greg.marchildon@uregina.ca.

References
Coffey, J. Edwin and J. Chaoulli. 2001. Universal Private Choice: Medicare Plus. Montreal: Montreal Economic Institute.

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