PNHP

“Plan for a Healthy America”

“Plan for a Healthy America”

Health Affairs
March 23, 2005
Change In Challenging Times:
A Plan For Extending And Improving Health Coverage

Health care for every American may be the current test of the strength of our convictions, as civil rights was in the 1960s.

By Jeanne M. Lambrew, John D. Podesta, and Teresa L. Shaw (from the Center for American Progress)

As veterans of previous policy battles, we do not underestimate the political challenge involved in making the U.S. health system accessible to all. Nor do we disagree with the assessment that moral conviction has been lacking in past health policy debates. However, we reject the claims that health reform is doomed by political paralysis and an incapacity for Americans to sacrifice for the greater good. At opportune points in U.S. history, pragmatic ideas have overcome seemingly impossible political odds and become policy. We also believe that the perceived disconnect between values and health reform reflects not a lack of conviction but a failure to express that conviction in a policy environment. In most faiths and value systems, it is wrong to tolerate pain, suffering, and even death that could be prevented with different policy choices. The challenge is to translate these deeply held values into action that ensures a better system and healthier nation.

Abstract:

Some speculate that Americans are neither politically capable of nor morally committed to solving the health system problems. We disagree. We propose a plan that insures all and improves the value and cost-effectiveness of health care by knitting together employer-sponsored insurance and Medicaid; promoting prevention, research, and information technology; and financing its investments through a dedicated value-added tax. By prioritizing practicality, fairness, and responsibility, the plan aims to avoid ideological battles and prevent fear of major change. By emphasizing the moral imperative for change, especially relative to other options on the policy agenda, it aims to create momentum for expanding and improving health coverage for all.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.119

Comment: The leadership of the Center for American Progress is to be commended for challenging the notion that “major change is politically infeasible.” They present very convincing arguments that now is the time to
move forward with a program that would provide comprehensive health insurance coverage for everyone.

Somewhat reminiscent of the Clinton attempt at reform, they have patched together a model that they believe would cross the political divide and receive the support of the various vested interests. The Clinton effort pleased no one.

As we look at a few of the features of this “politically feasible” model, please keep in mind that a critique of their model should not in any way deter us from our efforts to move forward with comprehensive reform. The selected and incomplete comments below about some of the features relate only to whether Center for American Progress has produced the definitive model for reform.

* Employer-sponsored coverage would be left in place, with current tax incentives that would encourage the continued participation of employers

Problem – Funding is regressive, providing a greater tax subsidy for higher income individuals. And this leaves in place our flawed, expensive, administratively inefficient system of funding care

* The Federal Employees Health Benefits Program (FEHBP) would supplement the employer system for those without options for group coverage (Healthy America pool)

Problem – Most FEHBP plans have cost sharing that would impair affordable access for those with modest or low incomes. And it still leaves the private health plans in place

* Medicaid would serve as a safety net for low-income people

Problem – Medicaid is chronically underfunded, reducing the number of willing providers, and that will not change when it continues to be perceived as a welfare program for the poor

* Reinsurance would be used to cover high-cost people

Problem – 20% of people use 80% of health care. Reinsurance would remove this major portion of health care spending from the risk pools of the private insurers and transfer it to the taxpayers. Why leave in place this highly flawed, expensive and wasteful system of private insurers when the taxpayer would be footing much of the bill?

* Refundable, means-tested tax credits would be used to help fund coverage for lower-income individuals

Problem – Unless the tax credit approached 100% of the premium, very few low-income individuals could participate. If the full premium is provided then, once again, why leave in place the superfluous, wasteful private plans?

* Individuals who fail to enroll in one of the programs would pay an income-related assessment and Medicaid would be the default payer

Problem – 80% of the uninsured do not have access to affordable employer-sponsored plans nor the funds to purchase insurance in the individual market. Enacting an individual mandate with the threat of financial penalties for individuals with very little if any disposable income can impact their ability to pay for other essential needs such as food and housing. Higher-income free riders utilize only a very small portion of total health care costs, and it would be more effective to have them contribute their equitable portion through a single, universal system.

* New funding would be through a value added tax (VAT)

Problem – A VAT is administratively complex and expensive to administer, but, much worse, it is highly regressive, shifting even more of the tax burden from the wealthy to the masses

The Center for American Progress proposal also includes recommendations for an emphasis on disease prevention and health promotion, developing better information about high-quality care, and utilizing the benefits of information technology. These are certainly fine. But their proposal fails to seriously address some of the major issues such as the profound administrative waste of our fragmented system of funding care, the costly and ineffective high-tech excesses related to excess capacity, the failure to negotiate excess prices, and the failure to ensure an adequate primary care infrastructure.

There is another model that would ensure that everyone would have access to comprehensive health care that would be funded equitably and that would return the health care decision-making process to the patient and his or her health care professionals. But then the single payer model is designed to spend our health care dollars on patient care rather than on the other vested interests.

The Medicare legislation demonstrated that the only way that we can please the insurance industry is to give them more money than a public system (Medicare) actually costs. Maybe it really is time to give up on bending over backwards in trying to please the insurers and get on with the important task of trying to take care of the needs of patients.

Let’s act on the Center for American Progress’s clarion call to “translate these deeply held values into action that ensures a better system and healthier nation.” But let’s make sure that all options are on the table so that there is no doubt that we are selecting the model that is best for America.

New York needs a single-payer health care system

Albany Times-Union
New York needs a single-payer health care system
By Paul Sorum

It is shameful that residents of New York do not have easy access to needed health care. The best way to do this — indeed, the only way to do it efficiently and justly — is to institute a single-payer health care system.A single-payer system in New York would be like Medicare for all on the state level. A single board, composed of representatives of the various stake holders, would administer the system. The board would decide what goods and services would be covered, would negotiate with providers and would contract with private companies to process claims and monitor quality.

The money used by the board to pay providers would come from a variety of sources: the federal Medicare and Medicaid funds currently spent on New York residents and a combination of payroll levies and state income taxes voted by the state Legislature. Medicaid would disappear as a separate program and would no longer burden county property taxpayers.

In a single-payer system, you would come to my office, show your health card and receive the same care no matter what your profession or income, and I would, without hassle, get the same reimbursement for the same service –simple, efficient and just!

The key is that a single-payer system eliminates most of our huge, rapidly growing and enormously expensive health care bureaucracy. You — or your employers — wouldn’t need multiple insurance companies and multiple plans to choose from. Your needs and wants are, fundamentally, the same as everyone else’s: You want to be able to receive appropriate and effective care when you are sick and to receive the preventive care shown to keep people like you from getting sick.

By eliminating all these health insurance companies, everyone (except them) wins. My staff and I win because we don’t have to deal with myriad insurance companies and their regulations and regulators. I can spend my time taking care of you, rather than taking care of your insurance company.

Your employers win because they can get out of the business of providing — or not providing — you with health insurance, and because they no longer have to foot the bill for all these superfluous administrators.

You win because you are equal to everyone else in your access to care. You can receive care from the doctor and other provider of your choice. You can choose based on quality, not cost. You do not have to fear losing your health coverage or your doctor if you change jobs, are laid off or don’t have a job.

Society wins because the huge savings in administrative costs allows us to provide universal access to health care — allows us to become a more just society — while not increasing overall health care costs.

What can you do to make a single-payer system a reality in New York state? First, you can tell your state legislators to support the bill recently introduced by Assemblyman Gottfried to establish a commission to study ways to achieve universal access to health care in New York. Second, you can tell them that the most efficient and just way of achieving universal access is through a single-payer health care system.

Paying for single payer in Taiwan

Taipei Times
Mar 19, 2005
Experts call for health premium hikes
By Wang Hsiao-wen

Although the rest of the world envies Taiwan for its success in providing easy, affordable and universal healthcare, Taiwan’s NHI is suffering from a recurrent financial crisis that also besets other nations like the UK, US, Germany and South Korea. As in these countries, health insurance is a highly politicized issue in Taiwan.

“Taiwan NHI’s financial problems stem from two factors: people’s mindset and
politicians’ intervention,” said William Hsiao, a professor of economics at
Harvard University who helped design the NHI a decade ago.

“Taiwanese people think that they don’t need to pay more since they’ve got NHI. In fact, the rise of insurance rates is an inevitable trend as the society grows older, richer and demands more medical care,” Hsiao said.

As Taiwan matures from a one-party state to a vibrant democracy, the insurance rate has increasingly become a bargaining chip in party politics, according to Hsiao. When the financing of the NHI was legislated under an authoritarian system, the executive branch was empowered to raise the premium rate whenever the program faces a deficit. But when faced with the opposition-dominated Legislative Yuan that now exists, the executive branch has lost its power and political conflicts flare up.

“The solution is to revise the law to allow insurance rates to edge up automatically,” Hsiao said.

Although politicians usually follow the “no premium raise” mantra to pander to potential voters, experts from other countries suggested that a fare hike, if well managed, would not trigger strong opposition from consumers.

Uwe Reinhardt, a professor of political economy at Princeton University, agreed that a premium increase would be a good way to sustain the universal insurance plan.

“Taiwanese could pay twice the fee now without hurting its macroeconomics,”
Reinhardt said.

Official figures showed that Taiwanese people pay 15.4 visits to physicians per year and that the country spends about 6 percent of GDP on healthcare —
a relatively low figure compared to the US’ 15 percent.

Reinhardt said that the real issue is to share the insurance burden and foster a spirit of fraternity.

“While 80 percent of health spending is used on 20 percent of the population who are severely or chronically ill, it is only natural that not every one feels their money is fully spent on their own health,” he noted. On the sideline of the NHI’s financial difficulties, Reinhardt advised Taiwan to steer away from the US example where many families go bankrupt because of health costs.

“Privatization of health insurance won’t solve the financial deficit. It just sweeps the problem under the rug,” he said. “The competition between insurance companies only makes programs less affordable, [and] over 46 million Americans are not covered.”

http://www.taipeitimes.com/News/taiwan/archives/2005/03/19/2003246881

Comment: So funding of a single payer system is political. But imagine debating whether 6% of the GDP is an appropriate level of funding for an established, comprehensive national health insurance program. Contrast that with 15% of the GDP being used for a deficient, fragmented program that sweeps the problems under the rug.

The current political debate over Social Security is instructive. When the people really understand the issues, they’ll support solidarity. Now they merely need to understand single payer national health insurance. And it’s our job to make sure that they do.

Never have so many paid so much for so little

The Santa Barbara Independent
March 10, 2005
Healthcare for All
By Peter Conn, Chairperson of the S.B. chapter of Healthcare for All

The present healthcare system in this country is in dire need of extensive rehabilitation. It bankrupts the sick – even those with insurance – as well as hospitals. Our healthcare system has an unsustainable inflation rate and is burdened by administrative waste and inefficiency. It fails to deliver proper care almost half the time and is unavailable to ever larger numbers of people. Your “choice” of plan or doctor depends on who you work for and how much you can afford. This non-system has had over 40 years to get it right. It was supposed to hold down costs through competition and give us “choice.” Yet never have so many paid so much for so little.

http://www.independent.com/opinions/voices955.htm

Comment: Simply repeating, “…never have so many paid so much for so little.” The article does then proceed with an excellent description of CHIRA, the single payer bill introduced by Sen. Sheila Kuehl.

(My selection of today’s quote is admittedly biased since we just spent four fantastic days camping with the author, Peter Conn, and his wife Paulina in California’s Anza-Borrego desert, now painted with a spectacular bloom of wildflowers.)
——————————————————————————
Message: 2
Subject: qotd: Confusion over “single-payer”

The Berkshire Eagle
March 16, 2005
Insurance plan tries to promote healthy lifestyle
By Carrie Saldo

The Berkshire Health Group — whose members include municipalities such as Lenox, Great Barrington and Adams, as well as school districts like Mount Greylock Regional School District and Central Berkshire — recently approved
adopting a “consumer-driven health plan.”

Availability of a consumer-driven health plan is subject to approval by the Selectmen and various unions, said (Town Manager Gregory) Federspiel. Enrollment would be voluntary and could begin as soon as July; the traditional plans would still be available.

Federspiel said it is up to each person to weigh the pros and cons of both the available single-payer plan and the proposed consumer-driven plan, and to decide which is right for their health care needs.

http://www.berkshireeagle.com/Stories/0,1413,101~7514~2764913,00.html

Comment: In this article, the term “single-payer” is being used to refer to Blue Cross/Blue Shield coverage. It is gratifying to see that “single-payer” has now become part of the standard rhetoric about our health care system. But confusing single-payer with Blue Cross/Blue Shield indicates that we must press on ever more energetically with our education campaign.

(For those who object to the “single payer” label, please keep in mind that this is now the standard term in the health policy literature for a precisely defined model of public financing of health care. For those who prefer other terms, an effort must be made to define your model. If it is single payer, then you should state so, at least parenthetically, to clarify that we are all out there with the same message. For those who prefer other models of reform, at least you’ll understand exactly what we mean when we say “single payer.”)

Baltimore City Council Endorses HR 676 Single Payer Healthcare

Eighth Day
Fourth Councilmanic Year- Session Of 1999-2004
Journal
City Council Of Baltimore
March 17, 2003

http://www.baltimorecitycouncil.com/Council_Journal/03-03-17_8th.pdf

In Support of Federal Legislation – (HR 676) The United States National Health Insurance Act (“Expanded and Improved Medicare For All”)

FOR the purpose of expressing support for Representative John Conyers, Jr.’s legislation that seeks to ensure that all Americans, guaranteed by law, will have access to the highest quality, cost effective, health care regardless of an individual’s employment, income, or health care status; and urging the Maryland State Delegation to the 108 th Congress to secure final passage of the legislation.

Recitals

The United States National Insurance Act establishes a national health insurance program by creating a single payer health care system. The bill creates a publicly financed, privately delivered health care program that expands and improves upon the existing Medicare program and makes it available to all residents of the United States and the U.S. territories. Persons enrolled in the program would not be subject to co-pays or deductibles.

The legislation addresses the needs of the over 42 million uninsured and over 40 million under-insured Americans who do not benefit from the current inefficient, costly, and fragmented health care delivery system. It is expected that the United States National Health Insurance Act will reduce overall annual health care spending by $109 billion – the average cost to an employer for an employee earning $35,000 per year will be reduced to less than $100 a month and a family who pays $5-7,000 a year in health insurance will pay less than $50 a month. Total household expenditures would drop from $326.7 billion to $65.9 billion annually.

National Health Insurance will cover all medically necessary services, including primary care, in-patient care, out-patient care, emergency room care, prescription drugs, durable medical equipment, long term care, mental health services, dentistry, eye care, chiropractic, and substance abuse treatment. Patients will have their choice of physicians, health care providers, hospitals, clinics, and group practices.

To ensure conversion to a non-profit health care system, private health insurers will be prohibited from selling coverage that duplicates the benefits of the National Health Insurance program. They will not, however, be prohibited from selling coverage for any additional benefits not covered by the Act such as cosmetic surgery and other elective and medically unnecessary surgery and treatments.

The National Health Insurance Act will set annual reimbursement rates and provide an annual lump sum allotment to each existing Medicare region that will then administer the program. Payments to health care providers will include fee for service and global budgets. The conversion to this not-for-profit health care system is expected to take place over a 15 year period and will be financed through the sale of U.S. Treasury bonds.

The United States Congress will establish annual funding appropriations for basic operating costs of the program that will operate under the auspices of the Department of Health and Human Services and be administered by the former Medicare offices. All current expenditures for public health insurance programs will be enveloped by the National Health Insurance program. Other funding for the program will come from modest payroll taxes on employers and employees and a higher health income tax on the wealthiest 5% of Americans.

There is no reason for anyone in this country to go without the basic health care coverage that sustains life when the industry has evolved to the point that vanity-driven, elective, medical procedures have become the lunchtime indulgence of middle-class America.

NOW, THEREFORE, BE IT RESOLVED BY THE CITY COUNCIL OF BALTIMORE, That this Body supports Representative John Conyers, Jr.’s legislation that seeks to ensure that all Americans, guaranteed by law, will have access to the highest quality, cost effective, health care regardless of an individual’s employment, income, or health care status; and urges the Maryland State Delegation to the 108 th United States Congress to secure final passage of HR 676.

AND BE IT FURTHER RESOLVED, That a copy of this Resolution be sent to the Mayor, the members of the Maryland State Delegation to the 108 th United States Congress, the members of the Baltimore City Delegation to the 2003 Maryland General Assembly, the Baltimore City Health Commissioner, and the Mayor’s Legislative Liaison to the City Council.

Councilmember Holton made a motion, which was duly seconded, that the Rules be suspended.

The roll was called on the motion, resulting as follows:

Yeas – President and Councilmembers Cain, Garey, Branch, Carter, Young,

Curran, Harris, Mitchell, Pugh, Welch, Holton, Rawlings Blake, Spector, Abayomi, Reisinger,

Stukes – Total 17.

Nays – Councilmember Stancil – Total 1.

Out of Chambers – Councilmember D’Adamo – Total 1.

The President declared the Rules “Suspended”.

Then Councilmember Holton made a motion, which was duly seconded, that the Resolution be adopted.

The roll was called on the motion, resulting as follows:

Yeas – President and Councilmembers Cain, Garey, Branch, Carter, Young,

Curran, Harris, Mitchell, Pugh, Welch, Holton, Rawlings Blake, Spector, Abayomi, Reisinger,

Stukes – Total 17.

Nays – Councilmember Stancil – Total 1.

Out of Chambers – Copuncilmember D’Adamo – Total 1.

The President declared the Resolution “Adopted”.

Canada a mix of U.S., European sensibilities

By Gwendolyn Owens
Special to the Sentinel
March 13, 2005

MONTREAL — There was a joke making the rounds here a few years ago that went like this:
Question: What’s a Canadian?
Answer: An American with a health-care card and no gun. The way Canadians view the United States is a much more complicated matter — roughly analogous to how one might view a rich, overbearing cousin.

Canada sits on the United States’ northern border with a population roughly twice that of Florida, but with a culture and mentality that melds together Europe and the United States.

Having lived in Canada since 1991, I spend a lot of time explaining the differences and similarities to my neighbors here and to friends at home. My professor husband and I moved our family to France for the 2003-04 academic year, and one byproduct was a new perspective on the differences and similarities of the United States, Canada and Europe.

Canada looks more like the United States than it does Europe. Cities in Canada often resemble those to the south that date from the same era: Montreal looks a lot like New York; Toronto looks Midwestern, almost like Chicago. Vancouver, British Columbiais a lot like Seattle, and Calgary, an energy center in the West, has been compared to Dallas with snow.

Everywhere the roads are filled with fast-driving Canadians, largely in trucks and sport utility vehicles, far larger and less energy efficient than those peppy little European cars.

However, in every one of those big cars will be a person with a health-care card entitling him or her to government-paid health care from the doctor of his or her choice. Canada, like European countries, is facing tough choices about how to manage the spiraling costs.

The system itself is a matter of pride. In Quebec, where they are discussing user fees, a friend told me that though she would have no problem financially paying a fee, she resents the idea because that’s not what health care should be about.

The greatest Canadian

Just how dear this system is to Canadian hearts was brought out last fall when the Canadian Broadcasting Corp., the public television of Canada, held a contest for the greatest Canadian. Tommy Douglas (1904-86), the “father” of the Canadian Health Care Act, won.

Though the belief in a public-health system unites Canadians, it is a nation that is often described not as a melting pot of immigrants, but a patchwork. New Canadians are expected to learn French or English — preferably both — but they are encouraged not to forget their roots, their customs and their language; they don’t have to give up their other citizenship.

For business, it is a positive attribute; you can find people who speak the language to help you to do business in just about any part of the world.

A union of many nations

It also makes for wonderful ethnic food as immigrants open businesses, not just to cater to people looking for exotic food, but for people from their own community who want to eat just like they did at home in, for example, India, Morocco or Peru. It is as if the country is a kind of union of many nations, not unlike the new European Union or a small United Nations.

When it comes to sports, Canadians love their homegrown sport, hockey, but they also love the American sports of football, basketball and baseball, even if the Montreal Expos had few real fans left in the end.

The wardrobe malfunction of last year’s Super Bowl, seen by millions of Canadians as well as Americans, was not a big story; the story was the U.S. outrage about the malfunction.

In the subway in downtown Montreal is a billboard advertising a DVD with a photograph showing a dancer in a similar state of undress as Janet Jackson, and no one seems to mind or even notice, although in some more conservative parts of the country, it might raise some eyebrows.

Canadians eat fast food like their southern neighbors do, but the concept of a private college or university for students getting a college degree does not really exist in Canada.

Labor unions are stronger here than across the border — just ask Wal-Mart, which is trying to close a store outside Montreal in which the employees voted to unionize, and is facing unionization, which Wal-Mart regards as a threat, in several other Quebec stores.

Country without a revolution

What’s at the root of Canada’s position as a middle ground? Canada never had a revolution or broke forcibly away from Great Britain as did the United States. It became a confederation in 1867, but it was not until 1982 that Canada got its own constitution with its own powerful version of the Bill of Rights, called the

Charter of Rights and Freedoms.

This is not a country made up of rebels, which is most likely where the jokes come about Canadians being law-abiding. Quebec was allowed by the conquering English in 1759 to stay French-speaking, and while tension has risen and fallen through the years about the place of French in Canadian life, the decision in the first place to let French colonists keep their language now seems very Canadian: It was a decision, while political on the part of Great Britain, that allowed for the beginnings of acceptable differences, the patchwork model.

Geography has had a lot of influence on how Canada works. In a country so vast with relatively few people, delivery of services is a more complex problem. So the government, on the provincial and federal level, has always had a more visible hand in setting up and providing for citizens far afield from one another.

In bed with an elephant

Former Canadian Prime Minister Pierre Trudeau described living next to the United States as being like sleeping in the same bed as an elephant: You cannot avoid knowing that the elephant is there, even if the elephant is being very quiet.
So to give Canadian artists, singers, writers, publishers, et cetera, a chance to be heard and seen, the Canadian government supports the arts in Canada and promotes including Canadian content with rules governing the number of cable channels that must be offered with Canadian content and how many songs an hour on the pop stations should be Canadian.

About 35 percent of the music on the radio and 60 percent of the programs on television are required to be Canadian, but there are no such rules for movies in theaters. However, the Canadian government provides generous tax credits to Canadian film producers to encourage the homegrown film industry.

Americans still welcome

In discussions since 2001, the question of whether Americans are being singled out for bad treatment abroad usually comes up. Our experience, in Canada and Europe, has been positive; outside the United States, American foreign policy is often seen as misguided or downright wrong, but individual Americans still welcome visitors to Canada, France and the other places we have visited in the past year.

Are Americans ready to be as welcoming to people from abroad? Many people we met in Europe were planning to visit North America — not the United States, only Canada — just because they were not sure how they would be treated. They felt comfortable about coming to Canada; it was not as different, not as far a trip metaphorically as the United States.

Originally from Baltimore, Gwendolyn Owens is a writer and historian of American art who lives in Montreal.

Stanford Dean Pizzo supports single payer

Stanford School of Medicine
Stanford Medicine Magazine
Winter 2005
Letter from the Dean

It’s hard to fathom why our nation, with its great financial and intellectual capital, has a health-care system that’s so far from world class. Much of the trouble comes from the belief that health care must be run like a business – as if personal health were a commodity. This notion, promoted over the past two decades by our leaders in Washington, posits that the free market will restrain costs and bring high-quality care to all. Obviously, this strategy has failed miserably.

I do not believe that modifications around the edges of our health-care quagmire are going to do it. We need sweeping change. I personally favor a single-payer model incorporating support for medical training, innovation and discovery. But I’m not convinced that our political leaders can muster the will to overcome the obstacles from special interests with stakes in supporting the status quo.

Philip A. Pizzo, MD
Dean, Stanford University School of Medicine

http://mednews.stanford.edu/stanmed/2005winter/letter.html

Universal Health Care System Has Local Support

Store Owner Pleads For It
By Gary E. Lindsley, Staff Writer

ST. JOHNSBURY — His voice quivering, businessman Tom Hurst pleaded Monday for the creation of a universal health care system.

Hurst, who is his family’s fifth generation to run Willey’s Store in Greensboro, asked state Rep. Steve Larrabee, R-Danville, to push for such a system for all Vermonters.

He made his plea during a special meeting called by the National Federation of Independent Business Monday afternoon at the Comfort Inn & Suites in St. Johnsbury.

NFIB representatives were in town to urge business owners to get engaged in debates regarding health care, energy and minimum wage.

The purpose of the “Act Now or Pay Later” meeting was to highlight the “anti-small-business legislation” making its way through the Legislature, according to NFIB information.

Hurst focused on health care.

“I’ve got two four-hour periods a day I can function,” he said, his left hand shaking. “The rest of the time my arms don’t work. The rest of the time I am unable to help.”

Sitting with a number of prescription bottles and two piles of money in front of him, he spoke about how he is suffering with a serious illness. He declined to reveal what the illness is.

“I am unable to hug my daughter,” Hurst said, “but she hugs me.”

He offered $1 and $5 bills to Larrabee and others who might be able to muster a universal health care system through the state Legislature.

“Take $1 because tonight I will not be able to use my hand,” Hurst said. “Please take a $5 bill so you can say I bribed you to really consider universal health care.”

He said his store provides his 17 employees 100 percent health insurance coverage. The employees’ family members are also covered. This year, the store’s health insurance premium went up $20,000, he said.

“Now we are in financial trouble,” he said. “So Steve, I want you to become a person behind universal health care.”

He spoke about how his grandfather Robert Willey had first been a Greensboro state representative and later a state senator.

“He had a passion for education,” he said. “Steve, I would like you to work on health care.”

George Pratt of Bradford Oil said he also would like to see NFIB officials back a universal health care system.

“I don’t understand why they are not,” Pratt said.

Hurst bemoaned the fact that having health insurance coverage is dependent on being employed.

“It favors the wealthy,” he said. “Health care should be like education. It should not be just for full-time [employees].”

Mary Grant, executive director of Rural Community Transportation Inc., agreed.

Grant said she believes everyone should have access to health care. And she believes there should be a universal health care system. She said her son cannot afford to buy health insurance for himself and his family because it would cost about $1,200 a month.

“Our state has to look at the true costs,” Grant said. “Vermont is small enough. We are always doing new stuff. Why not?”

Jim Harrison, president of the Vermont Grocers’ Association, said it is very important for business owners to get involved as well as to learn about the issues. He said there are a lot of business owners interested in the universal health care issue because they cannot afford 20 percent increases in their health insurance costs each year.

He also said individuals are interested as well because they cannot afford co-pays and deductibles.

“We encourage you to get engaged,” Harrison said. “It’s a huge, huge issue.”

Shawn Banfield, state director of NFIB, said the health care issue has been “percolating” since the beginning of the current Legislative session.

Banfield believes there is a lot of momentum behind establishing a single-payer system.

“The business community for the most part has not taken the bull by the horns,” she said. “There’s a lot of dollars at stake.”

Should reducing the uninsured rate by half be our goal?

The Commonwealth Fund
March 8, 2005
News Release
New Health Care Opinion Leaders Survey: Uninsured Rate Could Be Reduced
by Half in Ten Years

The proportion of Americans without health insurance can and should be reduced to 8 percent in ten years, less than half the current rate, according to the Commonwealth Fund Health Care Opinion Leaders survey, an online survey of widely-recognized experts in health care practice and policy.

Three-quarters (75%) of respondents say that employer-sponsored insurance should not be permitted to decline. There was also wide support from respondents for a range of policy efforts to improve coverage. About four-fifths (82%) favor incentives for employers to provide insurance that meets minimum standards, and tax credits or other subsidies for low-wage workers (79%). Other popular policy options included requiring employers who do not provide health benefits to pay into a fund to insure workers and their families (70%), allowing employers to buy into Medicaid or CHIP for their employees (60%), and employer mandates to help finance benefits (52%).

Respondents expressed lower rates of support for replacing employer coverage with a single-payer plan, with about two-fifths supporting (42%) or opposing (40%) this policy.

In contrast, three-fifths (62%) of respondents oppose making HSAs the centerpiece of efforts to cut health care costs (combined with making high- deductible plan coverage more widely available).

http://www.cmwf.org/usr_doc/HCOL_survey2_release.pdf

The survey questions and results:
http://www.cmwf.org/usr_doc/HCOL_survey2_topline.pdf

Comment: The good news about this survey is that health care opinion leaders support protecting the coverage that we do have, and they support improving coverage. The bad news is that this survey was designed to support the current path of incrementalism, an approach that has been ineffective in expanding coverage.

As an example, the very first question: “Health care costs, market pressures, and public and private policies are changing insurance coverage in the U.S. For each of the following, please indicate what you would see as both an achievable and a desirable target or goal for policy action for the next ten years: (1) The proportion of under-65 population that has no health insurance (now about 18%).”

The median answer given was a goal of 8% without insurance. Thus the survey begins with a concession on the part of the respondents that 100% coverage is not an achievable goal. Obviously that makes it very easy to reject 100% solutions as lacking political feasibility.

The third question: “About 160 million Americans get health insurance coverage through their employers who spend more than $400 billion on such benefits. Would you favor or oppose each of the following options for such coverage in the future? Please consider each option in isolation.” (Seven options are offered, in randomized order.) One option: “Employer coverage should be replaced with a single-payer plan, with current employer premium contributions redirected to help pay for coverage.”

Results: 42% in favor, 40% opposed, and 17% not sure. But this was not a question about abolishing the current fragmented system of funding care, including employer-sponsored coverage, and replacing it with a single,
publicly-administered program. Instead, this was a question about preference for a universal insurance program in which employers must bear much of the burden of the funding of health care for everyone. It makes the assumption that employer sponsorship would continue to be the mainstay of health care funding, thereby losing the support that much of the business community would have for a single payer system.

The political consequences of rejecting a 100% solution before beginning negotiations are exemplified by the comments of Charles Kahn in an accompanying commentary. He is the president of the Federation of American Hospitals, an advocacy organization for investor-owned hospitals. He is also the “strange bedfellow” of Ron Pollack, the executive director of Families USA. Although of different ideological persuasions, they had joined together to drive consensus on the development of public policy to address the problem of the uninsured.

Kahn’s comments:

“Up to this point, it has been my belief that the best way to proceed on this front is to bring together people with varying ideas about health policy and to work within the current context.”

“I still have great hope for this approach… But after many years of coalition building and consensus development, the number of uninsured Americans continues to grow, dramatically. Rather than risk inactivity and allow this number to escalate, perhaps we should adapt this approach to better reflect current political reality.”

“Republicans, who control the White House and both Houses of Congress, dominate the current political landscape. Therefore, if health policy advocates want to see progress on the uninsured, we have to look to President Bush and the GOP majority to take the lead.”

“Rather than trying to achieve a sufficiently broad consensus, there is a compelling argument to be made that, to begin reducing the number of uninsured Americans, we instead ought to reach for what is already within our grasp.”

“I recognize that tax credits and expanded health savings accounts are not the preferred policy approaches for some members of our ‘strange bedfellows’ coalition. However, these are the approaches most likely to be approved by Congress. Given the rising number of uninsured Americans, we owe it to them, and to ourselves, to work to pass what can be passed, and then allow these approaches sufficient time to work.”

http://www.cmwf.org/publications/publications_show.htm?doc_id=262376

Further comment: When you wake up in the morning and find your bedfellow gone, you suddenly realize that your self-esteem left with him. But all is not lost. There is no better way to recover your self-respect than to pick yourself up, reject the siren song of incrementalism, and move forward with great certitude toward a fully achievable 100% solution in health care.

Fortunately, we can find more inspirational guidance in another commentary by Michael Rodgers, interim president of the Catholic Health Association:

“Most important, those working to amplify the voice of the uninsured and the marginalized are well served to remember that the cause for which they fight is nothing short of a moral imperative.

“We are a fortunate nation with plentiful resources and a community spirit rooted in equality and fairness. Now it is our monumental but unavoidable task to express the need for change, to mobilize the nation behind it, and to once and for all meet our obligation not just to the sick specifically, but to one another generally.”

http://www.cmwf.org/publications/publications_show.htm?doc_id=260394

Frist and Kennedy on health disparities

Health Affairs
March/April 2005
Overcoming Disparities In U.S. Health Care
By William H. Frist

…the best way to eliminate health disparities is through improvements in the care we deliver to each patient, emphasizing patient dignity and empowerment.

Patients must be central to our efforts to improve health care. For instance, a person with a chronic illness such as diabetes must essentially “own” that illness if he or she is to have any hope of effectively managing it. Providers can help with high-quality treatment and the best recommendations, but patients must act on those recommendations. They must stop smoking, eat right, exercise, take their medication, and monitor their blood sugar, based on their own volition and usually outside of the clinical setting. Public policies must encourage patients to embrace personal responsibility.

Policies that promote dignity and personal responsibility will help decrease individuals’ risky behavior. The major causes of death among African Americans, for instance, are heart disease, cancer, stroke, accidents, and diabetes. Most of these are chronic diseases rather than acute illnesses, and all of these causes of death are at least arguably preventable.

Further, the top three can be reduced by decreasing tobacco use alone. We must
promote policies that help people address individual behavior, such as smoking.
Some have voiced concerns that health care is somehow different: that the
therapeutic relationship between doctor and patient should not be subject to
competitive forces. Further, many argue that quality chasms and health disparities cannot be fixed by fostering competition. Certainly, competition does not provide all of the answers. We will need a strong safety net and vigorous attention to vulnerable populations. But all of our immediate health care system problems-rising costs, questionable quality, patient safety, rising numbers of uninsured people, and, yes, health disparities-are interrelated and can be improved by empowering patients and providers.

We simply cannot afford to forgo the lower costs and increased quality and value that the right kind of competition will drive.
http://content.healthaffairs.org/cgi/content/abstract/24/2/445

Health Affairs
March/April 2005
The Role Of The Federal Government In Eliminating Health Disparities
By Edward M. Kennedy

The state of U.S. minority health is an embarrassment to the nation. Minority communities are struggling with rising numbers of uninsured citizens, festering epidemics, and lower health care quality, all of which mean increased rates of diseases and preventable deaths. To end the minority health crisis, Congress and the Bush administration need to step up to the plate by increasing health insurance coverage and investing in cultural competence, workforce diversity, minority data collection and reporting, and overall public health. Greater resources should be given to the HHS Office for Civil Rights and Office of Minority Health, both of which lead the fight to reduce disparities. All of these efforts must be integrated into the larger effort to increase access and improve quality of care, since we face not only a minority problem, but a national problem. In addition, the country must be mindful that health is inextricably tied to educational opportunities for children, job security and living wages for families,
safe and affordable community housing, and pension stability and social security
for seniors. Elimination of disparities in health depends in part on progress in each of these critical areas.

Health insurance for all is still my overarching goal, so that the basic right to health care can become a reality for all citizens.
http://content.healthaffairs.org/cgi/content/abstract/24/2/452

Comment: Perhaps the most appropriate comment comes from an article in this
same issue of Health Affairs: The Role Of Health Insurance Coverage In Reducing Racial/Ethnic Disparities In Health Care, by Marsha Lillie-Blanton and Catherine Hoffman:

“To assess whether insurance expansions could be expected to reduce racial/ethnic disparities in access to care, this paper reviews evidence from studies specifically designed to quantify the contribution of health insurance to racial/ethnic disparities in access. The studies provide evidence that a sizable share of the differences in whether a person has a regular source of care could be reduced if Hispanics and African Americans were insured at levels comparable to those of whites.”

http://content.healthaffairs.org/cgi/content/abstract/24/2/398

Philip Morris helps us frame the debate on reform

Pediatrics
March 2005
Changing Conclusions on Secondhand Smoke in a Sudden Infant Death
Syndrome
Review Funded by the Tobacco Industry
By Elisa K. Tong, MD; Lucinda England, MD; and Stanton A. Glantz, PhD

Prenatal and postnatal exposure to tobacco smoke adversely affects maternal and child health. Secondhand smoke (SHS) has been linked causally with sudden infant death syndrome (SIDS) in major health reports.

In 1997, PM (Philip Morris) commissioned a consultant, Frank Sullivan, to write a review, with coauthor Susan Barlow, of all possible risk factors for SIDS. The first draft concluded that prenatal and postnatal smoking exposures are both independent risk factors for SIDS. After receiving comments and meeting with PM scientific executives, Sullivan changed his original conclusions on smoking and SIDS. The final draft was changed to emphasize the effects of prenatal maternal smoking and to conclude that postnatal SHS effects were “less well established.”

Clinicians, parents, and public health officials are most vulnerable to the changed conclusions of the SIDS review. The national SIDS “Back to Sleep” campaign has been very successful in reducing SIDS rates. However, estimates of SIDS risk from SHS (odds ratios range from 1.4 to 5.1) have considerable overlap with estimates of risk from prone sleep positioning (odds ratios range from 1.7 to 12.9). With the Back to Sleep campaign well underway, efforts to address parental smoking behavior in both the prenatal and postnatal periods should be intensified.

http://pediatrics.aappublications.org/cgi/content/abstract/115/3/e356

Comment: What does the malfeasance of toxicologist consultant Frank Sullivan have to do with national health insurance? My response may be a stretch, but the issues are fundamental.

The opponents of national health insurance have framed the debate as the efficiency of the private marketplace in providing higher quality and greater value versus the inefficiency and poor value wrought by government bureaucracies. But the overwhelming preponderance of health policy literature indicates that this framing of the ideological divide is incorrect. In the financing of health care, the private bureaucracy has been profoundly inefficient, and the failure to provide adequate coverage has negatively impacted quality by leaving in place financial barriers to care.

In contrast, government bureaucracies have been much more effective in ensuring affordable access to care with greater efficiency through streamlined administration.

If the framing of the ideological divide as efficient markets versus inefficient government bureaucracies is incorrect, then how should this ideological divide be framed? One does not need to be an astute observer to recognize that the divide is between those who support freedom in the marketplace as a means to achieve maximum personal wealth versus those who support solidarity through government action to be certain that all of us have our most basic needs met first before we enjoy our hedonistic pursuits in the marketplace. This reframing of the debate over the ideological divide is not merely rhetorical, but it is fundamental because it places the issue of solidarity ahead of money in our society.

And today’s quote? The medical literature has been used in an attempt to preserve profits of the tobacco industry at a cost of loss of lives due to SIDS. What could be more fundamental than that? We have enough solidarity to be outraged by these individuals who would sacrifice infants’ lives for personal greed.

But do we have enough solidarity to act to save the lives of the 18,000 young adults who die prematurely each year due to lack of health insurance? Or is it more important to maximize the wealth of those who have learned the ways of success in the health care marketplace? This is really the way that we need to frame the debate.

Efficient free markets versus oppressive government bureaucracies? Balderdash! Let’s quit debating their ideology and start debating polices that save lives!