Tuesday, July 26, 2005
By Alana Semuels
Pittsburgh Post-Gazette

Although her husband is employed, 30-year-old Pamela Ramirez still pays her health bills the same way many immigrants do — out of her savings account.

Ramirez, of the South Side, moved here from Argentina more than four years ago. She’s typical in that she costs less to the health care system than do native-born residents, according to a study published yesterday in the American Journal of Public Health.

The study found that immigrants use 55 percent less health care than non-immigrants, and that both insured and non-insured immigrants use less services than the native born.

Immigrants actually subsidize care for the rest of the population, according to the study, because they pay Medicare payroll taxes and health insurance premiums, but do not reap all the benefits of these services.

“This ought to explode the myth that health care costs are due to immigrants,” said Dr. Steffie Woolhandler, an associate professor of medicine at Harvard Medical School and one of the authors of the study.

In dollar terms, per capita health expenditures were around $1,139 per immigrant, versus $2,564 for non-immigrants.

This is the first national study of immigrants’ health care expenditures. It looked at data from 21,241 people in the Agency for Healthcare Research and Quality’s 1998 Medical Expenditure Panel Survey, counting anyone born outside the country as an immigrant. The data is the most recent available, Woolhandler said, and the problems it highlights — such as immigrants’ fear of seeking treatment — have probably been exacerbated in the post-9/11 world.

Woolhandler argues that it highlights the need for a national health insurance program, which is the goal of the organization she co-founded, Physicians for a National Health Program.

But a think tank that supports tighter controls on immigration said that the study shows only that immigrants are poorer than non-immigrants, and are thus less able to afford health care.

“To the extent there’s an immigration policy conclusion, it would be that we’re taking in too many poor immigrants,” said Mark Krikorian, executive director of the Center for Immigration Studies in Washington, D.C.

One of the most striking pieces of the study found that immigrant children receive very low levels of care. They got 71 percent less care in doctors’ offices, and 72 percent fewer prescription medications than native-born children. The cost of their emergency room visits was the only expenditure that was higher — three times greater than those of native-born children — implying that parents wait until their children are very ill before seeking care.

“There’s widespread agreement that young children need to see a doctor on a regular basis,” said Woolhandler. “There’s very strong evidence that there was under-use of services in immigrant children.”

Although many of Pittsburgh’s immigrants are better-educated than those in other cities, children and elderly immigrants who don’t qualify for services are particularly vulnerable, said Dr. Vish Nimgaonkar, a professor of psychiatry at the University of Pittsburgh School of Medicine and a member of Woolhandler’s nonprofit group.

Local doctors have tried to help immigrant children obtain health care by running a bilingual clinic every week at Children’s Hospital and a monthly clinic on the South Side for uninsured children.

Lack of insurance, language barriers, and cultural differences are three of the main reasons preventing immigrants in Pittsburgh from seeking care, said Dr. Diego Chaves-Gnecco, a pediatric resident at Pitt who founded the local clinics. Many Latinos he treats would rather use traditional remedies than try to navigate a health care system that doesn’t speak their language.

Latino immigrants were found to utilize half as much health care as U.S.-born Latinos, and 70 percent less than U.S.-born whites, according to the study.

“We’re overcoming those barriers,” he said. The clinics have now had more than 1,000 visits — a significant number for a city with a small Latino population.

Ramirez takes her Pittsburgh-born daughter to Chaves-Gnecco’s clinic. But she and her husband don’t have a similar outlet to seek care for themselves.

“The ideal situation is when you don’t have to overcome all the barriers we have mentioned,” she said. “Immigration status shouldn’t affect health care.”

Alana Semuels can be reached at asemuels@post-gazette.com or 412-263-1928.

Existing health services are being deliberately destabilised to pave the way for an ideologically driven privatisation programme
By John Lister
Wednesday July 20 2005
The Guardian

How is it that with spending on the NHS now running at double the level of 1997, the service is running into an autumn crisis, with debts totalling at least 750m pounds, bed closures, theatres closed, services cut and estimates of 8,000 or more redundancies?

The answer lies in the breakneck process of “modernisation”, under which existing services are being deliberately destabilised to establish a competitive market system incorporating for-profit private providers, in place of a planned system of public healthcare.

Under John Major the NHS was buying less than 200m pounds worth of treatment from private hospitals a year. This will have increased 10-fold by 2007. Up to 15% of elective surgery will be hived off to private hospitals, leaving NHS trusts to cover the remainder.

Hospital buildings have also been privatised: private finance initiative schemes worth more than 5bn pounds have been completed since 1997 or are being built, and another 12bn pounds of projects are under negotiation – all of them locking trusts into costly, long-term leasehold deals.

But while New Labour ministers press relentlessly on, opposition is starting to coalesce. Last week in London a group of consultants, academics, MPs and trade-union officials met to plan a “save our NHS” coalition against these “stealth reforms”, which have little public support – a recent poll showed 89% against private provision of NHS care – and are little reported or discussed.

That is likely to change in the autumn as huge, unprecedented budget deficits – and cuts in services – begin to take shape alongside the new competitive health market.

Soon all patients must be allowed to “choose and book” elective treatment from a list including both NHS and private providers. Millions will be siphoned out of trust budgets into private-sector treatment centres: Brighton and Sussex University Hospitals NHS Trust stands to lose 85% of its elective orthopaedic work, worth 15m pounds.

The attempt by the health secretary, Patricia Hewitt, to claim the mantle of Nye Bevan in her defence of New Labour’s NHS reforms earlier this month – arguing that even Bevan “saw a role for the private sector” – should have drawn a gasp.

When Bevan nationalised the flagging network of voluntary and municipal hospitals in 1948 he made compromises that left some relics of the pre-NHS private sector intact – pay beds and private practice for consultants, and allowing GPs to remain as “independent contractors”.

But what for Bevan were concessions, to ensure the passage of ground-breaking changes, have for Hewitt become a point of principle. Billions are now diverted from NHS budgets to create a new, expanding private sector, which will now be free to poach staff from NHS hospitals. Hewitt’s first announcement in her new job was that another 3bn pounds was to be spent on services exclusively from private providers – with NHS hospitals forbidden to bid. Two modern NHS treatment centres are to be privatised, reversing Bevan’s modernisation. This is neither expanding capacity nor supporting patient choice, since existing high-quality NHS services will no longer be available in these areas.

Hewitt is also creating a new private sector in primary-care services, while GPs are encouraged to act more like businesses, and allowed to retain unspent surpluses from “practice-based commissioning”.

A survey of more than 40 countries shows that for 15 years England has gone furthest and fastest down the road of market-style reforms; but there is no evidence that these reforms improve efficiency or cut costs.

Thatcher’s 1990s marketising reforms, by fragmenting the NHS into purchasers (health authorities and GP fundholders) and providers (trusts), massively increased administrative costs and boosted the number of senior managers.

Throughout Europe and around the world, insurance-based systems with separate purchasers and providers cost more to administer than the NHS: admin costs in France and Germany are over 20% of health spending, while in the US almost a third of the $1.4 trillion spent on health goes on administration.

New Labour came to office pledging to scrap the costly internal-market system, and began to do so – only to turn rapidly back towards the current policy, creating a market in which the NHS competes on unequal terms with a private sector free to cherry-pick the most profitable specialities and treatments.

NHS productivity has been hampered by soaring costs of goods and services from the private sector. For every £1 spent on NHS staff in 1995, according to the Office for National Statistics, 71p was spent on procurement of goods and services from the private sector; by 2003 the figure was 1.15 pounds for every 1 pound on staff.

Hewitt’s plans to spend billions on buying in treatment from private hospitals and treatment centres will therefore increase costs – just as private-sector care, especially for-profit care, costs more in almost every country where it is purchased alongside public provision.

New Labour’s ideologically driven modernisation reinvents failed policies and ignores the evidence. Competition, which brought fragmentation, dislocation and widened inequalities under the Tories, is coming back as “payment by results” from next April; it is already destabilising local NHS hospitals, and will bring more closures. Foundation Trusts ape failed experiments that were dropped in Spain, brought soaring debts in New Zealand, and led to outright privatisation in Stockholm.

In Britain, what is called modernisation has already increased costs and overheads, demoralised and alienated staff, undermined planning – and done nothing to ensure equal access to local care. It cannot continue to go unchallenged.

John Lister is the information director of London Health Emergency, and lectures in health policy and journalism at Coventry University; his book Health Policy Reform – Driving the Wrong Way? is published this month.

Copyright Guardian Newspapers Limited

By Ceci Connolly
Washington Post Staff Writer
Tuesday, July 26, 2005; Page A11

Regardless of age, legal status or insurance coverage, immigrants, on average, receive about half the health care services provided to native-born Americans, according to findings released yesterday that immediately fueled the debate over tightening immigration policies.

Immigrants received an average of $1,139 worth of care, compared with $2,564 for non-immigrants, according to the analysis, published in the August issue of the American Journal of Public Health. The gap was especially pronounced among immigrant children, who received one-quarter the care given to U.S.-born youngsters.

“Our study lays to rest the myth that expensive care for immigrants is responsible for our nation’s high health costs,” said co-author Sarita Mohanty, an assistant professor of medicine at the University of Southern California. “The truth is, immigrants get far less care than other Americans.”

The report is based on government data that tabulated health spending for 21,000 people in 1998, the most recent year for which figures were available. The analysis includes legal and illegal immigrants.

“If we think our high health care costs are due to immigrants flocking to our shores, we’re wrong,” said co-author David Himmelstein of Harvard Medical School. Although immigrants accounted for 10 percent of the population, they consumed 8 percent of total health services, the study found.

Some immigration experts, however, said that tracking per capita spending ignores the larger societal costs of a growing immigrant population that is far less likely to have health insurance.

“The fact that immigrants, when uninsured, might use 27 percent less medical care doesn’t change the fact that they’re 200 percent more likely to be uninsured in the first place,” said Steven Camarota, research director at the Center for Immigration Studies, a Washington think tank that favors strict controls on immigration. “Why have a system that allows in so many people who aren’t self-sufficient?”

Immigrants account for 18 percent of the costs associated with the uninsured — expenses likely to be borne by taxpayers and charities, Camarota said.

Both sides said financial, cultural and language differences all make it hard for immigrants to afford care, understand medical advice or embrace recommendations from American doctors and nurses.

A much higher percentage of adult immigrants lack a high school education, which makes it difficult for them to navigate the health care system, said Elena Rios, president of the National Hispanic Medical Association.

“They don’t understand the lingo,” such as what a cholesterol reading signifies, she said. “Because of limited education levels, you can’t connect the dots and think about what prevention like physical exercise means in terms of the future and things like heart disease and cancer.”

Immigrants often live in low-income neighborhoods with fewer hospitals, clinics, physicians and pharmacies, she said. And many Latin Americans, coming from countries with government-run health systems, are unfamiliar with the concept of buying insurance.

In addition, many immigrants do not qualify for government health programs that are targeted at specific groups such as retirees, American Indians and veterans, Camarota said.

Over the long term, Himmelstein said, the potential ramifications for children are most alarming. The data showed immigrant children had fewer doctor visits, took less medication and made fewer trips to the emergency room. But their emergency room costs were nearly triple those for non-immigrant children, suggesting that immigrant families missed routine checkups and waited until a condition was more serious before seeking treatment, Himmelstein said.

It is far more likely, he said, that immigrant children do not receive standard vaccinations and let chronic problems such as asthma go untreated.

Even better-educated, insured immigrants — and U.S.-born minorities — received less care, probably because of racism and cultural differences, Mohanty said.

The paper’s authors, who are active in the liberal Physicians for a National Health Program, said one solution would be to provide everyone with basic health coverage. Short of that, they advocated lifting restrictions on government health programs and easing entry into employer-provided health plans.

Camarota, who agreed that legal immigrants should have greater access to care, said lawmakers need to take a more critical look at who is allowed into the United States. He said, “The solution to the problem is make them go home or not let them in in the first place.”

© 2005 The Washington Post Company

Dear Colleague:

This summer marks the 40th year since the enactment of Medicare, the landmark health care program for the nation’s most vulnerable—the elderly, frail, and disabled. For the past decade, the Fund’s Program on Medicare’s Future has focused on the experience of beneficiaries, evaluating how new policies or emerging trends affect their coverage and access to care. In conjunction with the program’s anniversary, we are pleased to offer a new Medicare Resources page, a collection of selected Fund research on some of the program’s current challenges, including implementation of the new drug benefit, a restructured managed care program, and growing pressure to improve the quality of care while controlling costs.

Check this page again next week for a link to a webcast of a July 26th event at the Henry J. Kaiser Family Foundation conference center in Washington, D.C., noting the 40th anniversary of enactment of the laws establishing both Medicare and Medicaid, the jointly funded federal-state program that helps states provide medical assistance to low-income individuals and families. This historic event will include remarks from a half-dozen former Health Care Financing Administration (HCFA)/Centers for Medicare and Medicaid Services (CMS) administrators, former Health, Education, and Welfare Secretary Joseph A. Califano, Jr., and other health policy experts, including Kaiser President Drew Altman and Fund President Karen Davis. Also on the 26th, Health Affairs, in collaboration with the event’s co-sponsors, will publish several perspective articles by former HCFA/CMS administrators.