PNHP

Memo on reform from a Medical Economics staff member

Memo on reform from a Medical Economics staff member

Medical Economics
November 5, 2004
Memo from the Staff

A crisis too loud to ignore
By Robert Lowes

I began writing this in a hotel bathroom in San Francisco. Only there could I escape the racket of a picket line 20 floors below and hear myself think: Maybe doctors shouldn’t view national health insurance as a dirty idea. I had a window on this war from my room at the Renaissance Parc 55. Its workers weren’t striking, but I could see picketers across the street at the Hilton. Some carried signs reading “Healthcare is a Right” while others drummed buckets, blew whistles, and chanted from 7 a.m. to 10 p.m., the limits set for noise-making. A renegade drummer woke me up at 2 a.m.

Earplugs courtesy of the hotel were useless. The din was unnerving but understandable. A proposed contract would increase a worker’s health in-insurance premium from $10 a month, an unbelievably low amount, to $273.42 a month in five years, an unbelievably high amount. That’s more than my premium, and I make more than they do.

Nationwide, millions of laid-off workers have lost insurance coverage. Millions more who’ve kept their jobs find it costlier. So what’s the systemic solution? “We don’t have national health insurance,” said Tim Miller, a waiter turned picket captain. “Shame on America.”

Maybe national health insurance strikes you as socialized medicine. But our society must replace the current system with something that’s fairer and more compassionate. I was heartened by the report of a surgeon who grabbed a
sign and joined the hotel strikers. If anybody has the moral authority to provide leadership on this issue, it’s the healing profession.

The presidential election is over, but the crisis remains. Whatever we do, we can’t succumb to the temptation to stick in earplugs. Otherwise, the drumming will only get louder.

http://www.memag.com/memag/article/articleDetail.jsp?id=130910

Comment: The message is familiar. What is notable is the source: Medical
Economics. The rationale of national health insurance has not escaped anyone. The anti-government ideologues are becoming more shrill in their response.
But the good news is that concerned individuals of sound mind across the political spectrum now agree that we must have comprehensive reform. And they realize that options other than national health insurance do fall short of our goal of affordable, comprehensive coverage for everyone.

The drumming is growing ever louder.

Flu shot shortage: Health care woes in a nutshell

By Ellen Goodman 
The Boston Globe, 11/15/04

BOSTON — Toward the end of the campaign, President Bush offered his small variation on JFK’s famous line: Ask not what your country can do for you, ask what you can not do for your country:
“My call to our fellow Americans is, if you’re healthy, if you’re younger, don’t get a flu shot this year.”

I have followed the patriotic edict to go unarmed into this flu season. In fact, unlike certain members of the Congress who shall remain nameless, I have no choice but to follow it. At the same time, I have been collecting various little anecdotes for the Flu Story 2004.

First is the tale of a New York friend who had to go to Toronto for work. She found the name of a doctor through the Canadian sister of a friend of a friend. Then, feeling vaguely like a mule in some illegal drug operation, she got her shot, wrapped the rest of the vial in ice and smuggled it back to her stateside doctor for distribution to seven high-risk patients.

There is another friend, a certified member of the greatest generation living in the capital of the free world, who ended up at 5:30 one morning in a drug-store line in search of a shot. Then there is a department store Santa, Nick Pallotto, 62,
of Denver, who couldn’t get the vaccine despite the fact that about 10,000 children will pass across his lap.

If we are lucky, if the flu season is mild and the crick don’t rise, this may not be a disaster. But for the moment, we have the Centers for Disease Control and Prevention rationing the last 10 million doses and we have New York City independently ordering its own vaccine.

In short, every American is getting a chance to see what life’s like for people without health care insurance and just how precarious the health care system really is. The strain of flu that is coming our way has been dubbed by one reporter as the Free Market Flu. This shortage is not, after all, a natural phenomenon, like say, a shortage in pomegranates or pineapples.

The entire debacle comes from the fact that preventing the flu isn’t as profitable as, say, treating erectile dysfunction.The major U.S. drug companies, who continuously tell us that their profits are for our benefit, don’t do flu anymore.
For some years, flu prevention has been outsourced without oversight. Chiron Corp., one of the vaccine manufacturers, had worried the FDA as long ago as 1999, but it was the Brits who blew the whistle on them in October when this year’s batch of vaccines was contaminated. We were left dependent — mon dieu! —
on a French company, Aventis Pasteur.

As James Morone, a political scientist and co-author of the upcoming “Healthy, Wealthy and Fair,” says, “When one company in England runs into trouble, the whole thing collapses. Private markets are as only as good as the public health system overseeing them. If there were a sudden run on watches or sofas it wouldn’t be a problem, but health care can’t work that way.”

Instead of sofas and watches, it might be life and death. About 36,000 people died from the flu last year and that was when vaccine was available. After Sept. 11 — with all the talk of bioterrorism, anthrax and smallpox — there was the beginning of a dialogue about strengthening the public health system. But today we rarely talk about the basics, such as vaccines, as a public good.

Americans have long been told that national health care would mean long lines, rationing and g second-class medicine. Despite spending more of our gross national product on health care than any other country, we rank 29th in life expectancy, right between Slovenia and Portugal. And what do we have? Long
lines and rationing. Not to mention lotteries, and a shot in the arm for Canadian tourism.

Maybe it takes the Free Market Flu to remind us that sometimes we need a public health system as much as we need a fire department or a military. For the moment, however, a casino in Las Vegas has generously donated its 5,000 doses to the local health department. A retirement home has given the Denver Santa his shot.

Meanwhile back home, I think I will tie a yellow ribbon around a great big pot of chicken soup.

Ellen Goodman (ellengoodman@globe.com) is an associate editor and columnist for The Boston Globe.

Honoring our troops

Berkshire Eagle, Lenox, MA
Monday, November 15, 2004
Honoring our troops
By Suzanne L. King M.D.

Last Week we celebrated Veterans’ Day. Parades and services honored veterans from past wars, even as American troops pushed forward against the Fallujah insurgency. Soldiers continue to die, and many more have been wounded as they fight in the current war in Iraq.

Meanwhile, a quiet and less publicized battle is being fought at home: the fight for health care by veterans of both the Vietnam and the Persian Gulf wars. A Harvard Medical School study recently reported that almost 1.7 million American veterans were uninsured in 2003. That means they did not have health insurance, and they were not able to receive care at Veterans Health Administration (VHA) hospitals or clinics.

The Bush administration halted VHA enrollment for middle income veterans last year if their yearly income was above $25,000. In addition, veterans who did qualify for VHA benefits often could not obtain VHA care because of waiting lists, unaffordable co-payments, or lack of access to VHA facilities. (Veterans of World War II and the Korean War are covered by Medicare because of their age, and therefore have access to America’s single payer health care system for the elderly).

Twelve percent of all veterans were uninsured in 2003. Younger veterans were least likely to have health insurance, with more than one-third of veterans under 25 years of age uninsured, and one in seven aged 25-44 years without insurance. Of course, their families did not have insurance coverage either. Many of these veterans have major health problems, often related to their war duty; less than a quarter indicated they were in excellent health.

On television last night, a grateful father talked of his son’s return home from Iraq, a son whose skull had been broken into 500 pieces, and who lay in a coma, hospitalized for five months. He is slowly recovering, and feels guilty that he is safe at home and his friends are still fighting and in danger. With courage and dedication, he has risked his life for his country; will his health care needs be forgotten 10 years from now?

The Berkshire Eagle recently published an article about the thousands of Gulf War veterans who have been ill with a mysterious syndrome that includes chronic fatigue, dizziness, loss of muscle control and balance, memory problems, and gastrointestinal symptoms. Originally attributed to “stress,” current VA studies are focussing on the possibility the symptoms are secondary to neurotoxins like pesticides or nerve gases used in the war. Thirteen years later, these veterans are still having symptoms related to their war experience. They have sacrificed their health; how can we not provide health care for all of them?

Uninsured veterans are not nursing their wounds; 86 percent of them worked
within the last year. They had as much trouble getting medical care as other uninsured people, most of whom are also employed. Dr. David Himmelstein, a professor at Harvard Medical School and an author of the study, commented, “This administration professes great concern for veterans, but it’s all talk and no action. Since President Bush took office the number of uninsured vets has skyrocketed, and he’s cut VA eligibility, barring hundreds of thousands of veterans from care. Our president has put troops in harm’s way overseas and abandons them and their families once they get home.”

What is the solution for these uninsured veterans? It’s the same solution that everyone in our country, including 45 million uninsured Americans, needs: a universal single payer national health insurance program, funded and administered by the government (i.e., Medicare for everyone). How can we ask our soldiers to risk their lives, lose limbs, develop chronic illnesses, suffer post-traumatic stress disorders, and then not care for them when they return home? And how can we not provide health care for every citizen of the United States, a country founded to provide “life, liberty and the pursuit of happiness” for everyone? Other industrialized countries, all of whom have national health insurance, manage to provide universal health care at half the cost we pay for health care per person. The problems of rising health care costs and lack of
access to health care in America cannot be solved by incremental change and
continued reliance on market-based strategies. We need to change the system
itself. We need universal single payer health care. Then we can truly honor
our troops.

AMA members' opinions on reform

American Medical Association
Division of Market Research and Analysis
September 2004

2004 AMA Advocacy Agenda Setting Survey
(The survey was sent to all 202,777 members of the AMA. 8,323
responded, either by mail or online.)

Members’ Opinions of Approaches to Increase Health Insurance Coverage to the
Uninsured % Favor
(The first number is the percent of physicians in favor, and the second is the percent of medical students and resident physicians in favor. Multiple responses are possible.)

53/50 – Use of tax credits
38/49 – Expanding eligibility for public programs
41/40 – National single payer system
24/34 – Employer mandates
27/26 – Individual mandates
53/44 – Government-sponsored catastrophic coverage

Office-based physicians (56%) are more likely than administrative physicians
(49%), hospital-based physicians (45%), and physicians in medical teaching/
research (45%) to favor the use of tax credits. Psychiatrists (58%) are the
most likely and anesthesiologists (30%) are the least likely of all specialties to favor a national single payer system. Physicians in medical teaching/ research (57%), administrative physicians (52%) and hospital-based physicians (49%) are more likely than office based physicians (38%) to favor a national single payer system. Physicians 40 years of age or more (43%) are more likely than physicians less than 40 years of age (35%) to favor a national single payer system.

http://www.ama-assn.org/ama1/x-ama/upload/mm/363/agendasurvhighlights.pdf

Comment: The AMA’s conclusion: “AMA members are divided on the approaches
they favor to increase health insurance coverage to the uninsured.” That is true. But some aspects of this survey are worthy of comment.

Many physicians with progressive views have dropped out of the AMA, partly
because of a perception that it is controlled by relatively conservative physicians. There is some basis for this perception as is exemplified by the fact that 75% of AMA PAC contributions for the recent election went to Republican candidates. Also, the health reform policies supported by the AMA House of Delegates are very similar to those supported by President Bush. So the survey likely is heighted toward the conservative physicians in the United States.

It has been said that there are three primary models of universal coverage:
universal single payer, an employer mandate with a backup public program,
and an individual mandate with a backup public program. It is quite remarkable that, of these three choices, a national single payer system has the strongest support. There is even greater support for government-sponsored catastrophic coverage, which would have some features of the single payer model, albeit with a high deductible requirement.

Tax credits received high support, but they are not insurance models. They are
merely a mechanism of funding insurance.

The employer mandate and individual mandate leave in place our current private insurance programs. They have the least support in this survey. All other options involve government funding and government administration, and all of them received greater support from the physicians responding.

It may be a stretch to say that the conservative physicians of our nation prefer a government-run, taxpayer-financed health insurance program. But it’s not far from the truth.

The AMA and PNHP should sit down together and discuss health policy, devoid
of partisanship. We may not be as far apart as it would otherwise seem.

Headaches For All

Everybody knows it will take a lot more than diet and exercise to fix America’s health

AMERICANS are constantly told that their health care is the best in the world. In terms of research, technology and advances in surgery, the boast is undoubtedly true. In other ways, it is hard to justify. At any one time, more than 43m Americans under the age of 65 have no health insurance (the elderly are covered by Medicare, a federal insurance programme). The infant mortality rate for black Americans runs at 14 per 1,000 live births, double the rate for white Americans and over four times the rate in Japan. Indeed, in a 2000 study of the effectiveness of health-care systems around the world, the World Health Organisation ranked America only 37th (France came top).

If all that speaks ill of the nation as a whole–over half of America’s uninsured in 2002-03 were without cover for at least nine months–the situation in some states is far worse. Families USA, a health-consumer organisation, notes that in Texas–the state that George Bush likes to call home–some 43.4% of the “non-elderly” population were without health insurance for all or part of 2002 and 2003. In California the rate was 37.1%; in Florida 34.6%. The Kaiser Family Foundation (KFF) notes that infant-death rates across the South, from Arkansas to the Carolinas, are far higher than in the western states.

This is a poor reward for spending more on health than any other country. Health care accounts for almost 15% of America’s gross domestic product, compared with less than 8% for Japan and Britain. Moreover, where other countries pay for their health care mostly out of taxation (the OECD average in 2001 was 72%), over half of America’s spending is accounted for by private insurance–normally provided by an employer–and out-of-pocket payments. Indeed,America is the only industrialised democracy without publicly funded universal health cover.

To counteract the costs of medical advances and malpractice suits,insurance premiums have been rising by more than 10% a year. In 1998 the average health-care cost per employee for a private-sector company was $1 an hour; by last year, it had risen to $1.50. This has a perverse effect: employers either tend to cut or eliminate their workers’ coverage–thereby adding to the uninsured–or try not to hire new workers. With the cost of insuring a single worker now running at around $3,000 a year, the proportion of workers covered by a company health plan has fallen to 61% in 2004, according to KFF, compared with around 65% in 2001.

The Search For A Cure
Clearly, reform is needed. One reason is pressure from voters. Health care is consistently near the top of their concerns, especially if they are old; old people are both sicker, and vote more, than the average American. They note that many of their drugs are much cheaper in Canada than in the United States, and ask why the federal authorities are refusing to legalise imports from across the northern border. (In defiance of the Food and Drug Administration, Illinois has recently approved the importation of drugs from Canada; Vermont is suing the
FDA.) Seizing the moment, John Kerry says he backs such imports.

A second reason for reform is the inexorable pressure of demography. As baby-boomers retire, they will add to the burden of health care in general and Medicare in particular. Indeed, America’s total expenditure on health care is expected to rise from just under $2 trillion a year now to almost $3 trillion by the end of the decade.

So the question is not so much whether to reform, but how. The Clinton plan a decade ago for universal coverage was defeated by doctors and insurance companies, as well as by Republicans. In its place came health-maintenance organisations (HMOs), health-care-management companies that contract with doctors and hospitals to manage treatment and costs. The proportion of employees with employer-provided care enrolled in managed health-care plans rose from 27% in 1988 to 92% in 2000.

But HMOs succeeded only for a time in slowing the rise in health-care costs. Some politicians, such as the former Democratic presidential candidate, Dennis Kucinich, believe the only workable solution is to replace the private-sector insurance companies with a government-run “single-payer” system, as in Canada. This, however, would guarantee the same lobbying that defeated Mr Clinton–which is why neither Mr Kerry nor Mr Bush is talking about dramatic change.

Mr Bush’s remedy is particularly modest. He proposes extending the new Health Savings Accounts to allow individuals to deduct from their taxes the cost of premiums for major medical coverage. According to the Treasury Department, this would extend insurance to an extra 1m Americans. Similarly, there are tax credits to help workers laid off “due to international trade” to find insurance; other credits would make insurance affordable for around 4.5m workers with no employer-provided or public insurance. Meanwhile, a five-year plan is already under way to fund 1,200 new or expanded community health centres to serve an additional 6.1m people, and association Health Plans are proposed to allow small businesses to band together to provide cover to another 600,000.

The centrepiece of the president’s reform, however, is to make prescription drugs available to the 40m elderly and disabled Americans covered by Medicare. From 2006 (a discount card will in the meantime offer savings off retail prices), a Medicare recipient will pay the first $250 in a year, Medicare most of the next $2,000 and the recipient the next $2,850 (after which Medicare will again pick up the tab). The plan is both complicated and expensive: over $570 billion, according to the latest estimates, over ten years. Embarrassingly for the president, the price tab is rising not just for the government but also for Medicare recipients: their premiums are set to rise by 17% in 2005.

These are not the only problems with Mr Bush’s proposals. The tax credits, aimed at helping the poor and worth some $90.5 billion over ten years, would actually benefit the rich, who need no help, and would be little help to the low-paid, who pay little or no tax and are most at risk of losing insurance. As for Medicare reform, the congressional Budget Office reckons that, as an unintended side-effect, a third of retired people whose drugs are now covered by their former employers will lose that coverage (why should the bosses pay if the government will pick up the tab?) and be forced to accept inferior cover from Medicare. The most damning criticism of the proposals, however, is that their impact will be too limited: according to the Kaiser Family Foundation, the ranks of the uninsured will fall by just 1.8m.

THE 95% SOLUTION
By contrast, Mr Kerry aims to reduce the number of uninsured by 26.7m and so bring health insurance to 95% of America’s population. That ambition carries a hefty price-tag of $653 billion over nine years, which a President Kerry would finance mainly by repealing Mr Bush’s tax cuts for Americans earning over $200,000. In the Kerry vision, all Americans would have the right to the same health plans as their congressmen and some 9m federal employees and their dependents. Tax credits would help find cover for 55-64-year-olds, who are too old to be good insurance risks for an employer but too young to qualify for Medicare. To help poor families, Mr Kerry would make the government assume all the costs of the 20m children who now benefit from state Medicaid plans. In return, the states would have to expand insurance to those poor families who do not qualify for Medicaid.

Mr Kerry’s biggest claim is that he can cut insurance costs by up to two-thirds for small businesses: the federal government would act as a reinsurer, reimbursing employee health plans for 75% of costs above $50,000. This alone would lower employee premiums by 10%. In addition, there would be tax credits of up to 50% of the cost of covering employees, and employers would profit from buying into the federal worker-insurance programme. Meanwhile, everyone–firms, employees and states–would benefit from discounts gained by the bulk purchasing of drugs. (At the moment, the drug companies are loth to co-operate with any buyer except Medicaid, the federal/state programme for the poor.)

Add in a “quality bonus” to give hospitals a financial incentive to reduce medical errors; add, too, a “technology bonus” to favour computerisation and so cut non-medical costs (now running at $350 billion a year) from $12-25 per health-care transaction to less than a cent. The result is a health plan which the 35m-strong AARP, the formidable lobby group for the elderly–which supported Mr Bush’s Medicare scheme–finds much more convincing than the president’s.

That does not mean it is without problems. Mr Bush’s team notes that while Mr Kerry claims it will be harder to bring undeserving malpractice suits, he refuses to cap the awards–even though the Bush camp says that the “broken medical liability system” drives up costs by at least $28 billion a year for the federal government alone. (It certainly pushes up the cost of doctors’ malpractice insurance.)

The Bush team also attacks Mr Kerry for adding to the burden of regulation. Small businesses would have to offer costly benefits in order to join the federal employees’ health-benefits programme. Overall, say the Republicans, the Kerry plan simply shifts the burden to the taxpayer. But given the unpopularity of the present system, this is a burden that taxpayers sometimes seem ready to bear.

Greetings From The Disunited “United States Of Canada”

November 14, 2004
WASHINGTON — I pledge allegiance to the flag of the disunited states of America.

Now is the winter of some people’s discontent following the stormy election of President Bush. The Internet is all abuzz with residue resentment. Canada’s immigration Web site reports a sharp increase in inquiries from Americans seeking information on how they can defect to our chilly neighbor. Other Webheads are offering a “Boycott Ohio” petition.

That in particular saddens me, since I grew up in Ohio and still have friends and relatives living behind the Buckeye curtain.

But the wackiest idea I have run across so far is the option offered by Web sites that are calling for secession.

That’s right. Secession, you may recall, didn’t work out very well the last time it was tried in this country. (For the benefit of those of you who snoozed through history class, I point out that secession resulted in the Civil War.)

Nevertheless, several Web sites are offering color maps of a new North American political landscape in which the so-called “blue states” that voted for Democratic Sen. John Kerry are joined to our northerly neighbor in a new, blue country called the “United States of Canada.”

The remaining states–the “red states” that voted for Bush–are renamed “Jesusland,” which sounds like a good name for some televangelist’s Christian amusement park.

Well, count me out.

I think the best revenge for blue-state Americans is to continue to stand with our red-state brothers and sisters to hold Washington accountable, no matter which party happens to be in charge.

Besides, as much as I like to visit Canada, I don’t see much advantage to having Canada permanently visit me–except maybe national health insurance.

That’s not a small thing. As you may have heard Kerry mention repeatedly during the recent presidential campaign, an estimated 45 million Americans in this, the world’s most powerful and prosperous country, lack health insurance.

Back in the early 1990s, only about 30 million Americans lacked health insurance and President Bill Clinton and First Lady Hillary Clinton took a stab at trying to close that gap.

Their push for universal coverage was beaten back quite impressively by the health insurance industry’s “Harry and Louise” ads.

Those scary little attack ads painted horror scenarios of skyrocketing costs, shrinking coverage and Americans no longer able to choose their own doctors.

A decade later? Surprise, surprise. We have the higher costs and shrinking coverage that “Harry and Louise” warned us about, except that we also have even more uninsured patients.

Now the same insurance industry tells us scary stories about Canadians rushing to the U.S. for elective surgery and other procedures they can’t get quickly enough in Canada. You have to turn to the news to hear the other side of that story, like the Americans now turning to Canada to get their flu shots or to find cheaper prices for American-made pharmaceuticals.

And you also might hear in the news about how Americans are more dissatisfied than citizens of other major industrial nations with their basic health care even while paying more of their own money for treatment, according to a recent five-nation survey by the non-profit Commonwealth Fund.

One-third of Americans told the pollsters that the U.S. health-care system should be completely rebuilt, which was far more than residents of Australia, Canada, New Zealand, or the United Kingdom. Just 16 percent of Americans said that the U.S. health-care system needs only minor changes, the lowest number expressing approval among the countries surveyed.

Want to see President Bush’s plan for insuring the uninsured? Hold up a blank sheet of paper.

Well, OK, it’s not quite that bad, but it’s close. He has offered tax-free health savings accounts for those who can afford to put money aside for their health-care costs. The business-oriented Bush seems never to have witnessed a social problem that cannot be solved with a tax break.

But what if you’re a minimum-wage waitress with kids, and you can’t afford to put money aside for health-care costs? Well, I guess there’s always prayer.

Of course, no country’s health-care system is perfect, and America does offer the best health care that money can buy, if you can afford it. The problems come when you can’t afford it.

We’re problem solvers. That’s the American way. We can build a better system, if we want to. The first step is to demand what we have not had, a fair and balanced national health-care debate, not just dueling campaign ads.

AMA members’ opinions on reform

American Medical Association
Division of Market Research and Analysis
September 2004

2004 AMA Advocacy Agenda Setting Survey
(The survey was sent to all 202,777 members of the AMA. 8,323
responded, either by mail or online.)

Members’ Opinions of Approaches to Increase Health Insurance Coverage to the
Uninsured % Favor
(The first number is the percent of physicians in favor, and the second is the percent of medical students and resident physicians in favor. Multiple responses are possible.)

53/50 – Use of tax credits
38/49 – Expanding eligibility for public programs
41/40 – National single payer system
24/34 – Employer mandates
27/26 – Individual mandates
53/44 – Government-sponsored catastrophic coverage

Office-based physicians (56%) are more likely than administrative physicians
(49%), hospital-based physicians (45%), and physicians in medical teaching/
research (45%) to favor the use of tax credits. Psychiatrists (58%) are the
most likely and anesthesiologists (30%) are the least likely of all specialties to favor a national single payer system. Physicians in medical teaching/ research (57%), administrative physicians (52%) and hospital-based physicians (49%) are more likely than office based physicians (38%) to favor a national single payer system. Physicians 40 years of age or more (43%) are more likely than physicians less than 40 years of age (35%) to favor a national single payer system.

http://www.ama-assn.org/ama1/x-ama/upload/mm/363/agendasurvhighlights.pdf

Comment: The AMA’s conclusion: “AMA members are divided on the approaches
they favor to increase health insurance coverage to the uninsured.” That is true. But some aspects of this survey are worthy of comment.

Many physicians with progressive views have dropped out of the AMA, partly
because of a perception that it is controlled by relatively conservative physicians. There is some basis for this perception as is exemplified by the fact that 75% of AMA PAC contributions for the recent election went to Republican candidates. Also, the health reform policies supported by the AMA House of Delegates are very similar to those supported by President Bush. So the survey likely is heighted toward the conservative physicians in the United States.

It has been said that there are three primary models of universal coverage:
universal single payer, an employer mandate with a backup public program,
and an individual mandate with a backup public program. It is quite remarkable that, of these three choices, a national single payer system has the strongest support. There is even greater support for government-sponsored catastrophic coverage, which would have some features of the single payer model, albeit with a high deductible requirement.

Tax credits received high support, but they are not insurance models. They are
merely a mechanism of funding insurance.

The employer mandate and individual mandate leave in place our current private insurance programs. They have the least support in this survey. All other options involve government funding and government administration, and all of them received greater support from the physicians responding.

It may be a stretch to say that the conservative physicians of our nation prefer a government-run, taxpayer-financed health insurance program. But it’s not far from the truth.

The AMA and PNHP should sit down together and discuss health policy, devoid
of partisanship. We may not be as far apart as it would otherwise seem.

AARP continues its attack on social insurance

The New York Times
November 12, 2004
AARP Opposes Bush Plan to Replace Social Security With Private Accounts
By Robert Pear

Gearing up for battle over the future of Social Security, AARP, the influential lobby for older Americans, said Thursday that it opposed President Bush’s plan to divert some payroll taxes into private retirement accounts. But it supports new incentives for private accounts that supplement Social Security.

Working closely with Congress and the White House, AARP helped shape legislation adding drug benefits to Medicare last year. Social Security is an even bigger issue, politically and financially…

Marie F. Smith, president of the organization, said, “AARP adamantly opposes replacing any part of Social Security with individual accounts.” But Ms.Smith added that the group supported incentives for people to establish personal retirement accounts in addition to Social Security.

John C. Rother, the organization’s policy director, said, “We favor private accounts when they are in addition to Social Security, but not as a substitute.”

Comment: The single payer model of health care reform is a program of social insurance. Social Security and Medicare are our two existing programs of social insurance. An attack on either of them is an attack on the fundamental concept of social solidarity. Do we care about each other,or are we each on our own? AARP is certainly sensitive to the hit that it took after its highly publicized efforts to assist the Bush administration and the conservatives in Congress in crafting and passing legislation that threatens the Medicare program with privatization schemes. AARP didn’t want to entangle itself in a similar controversy with Social Security.

To ward off any criticism, AARP took the precaution of announcing that they are opposed President Bush’s plan to divert some payroll taxes into private retirement accounts. But does that keep them out of the fray? In the same announcement they state that they support personal retirement accounts in addition to Social Security. That certainly sounds like a wise position. But is it?

As you are well aware, many versions of private accounts already exist.There is a very real risk that another new version that is designed and marketed specifically as an extension of Social Security would be regressively funded. The affluent, the sector with the real political voice, would then advocate for a reduction in the funding of the existing program,or, at a minimum, strongly oppose the increased funding that will be required to support a program that becomes top-heavy in the ratio of retirees to workers.

If AARP truly believed that the interests of all seniors would be served best by delegating more funds to retirement pensions, then they should be supporting the much more equitable method of increasing funding of our existing Social Security program. In sharp contrast, regressive funding of private accounts is highly inequitable.

In supporting private accounts, AARP is stepping up to the negotiating tables having already wasted a major negotiating chip. That is a very fundamental violation of the game-plan rules of negotiation strategy.

We could sound like demagogues by further suggesting that AARP may be contemplating its role in the enterprise of personal retirement accounts for tens of millions of Social Security beneficiaries. We would be consistent since we previously were demagogues when we suggested that AARP’s interests might lie with supplemental Medicare coverage. But if it takes demagoguery to expand understanding, then so be it.

If AARP is to represent the seniors of our nation, it needs to be a strident voice in support of Medicare and Social Security. Sadly, it appears that it is merely using the seniors of our nation as a front to hide their nefarious support of moneyed interests, some of whom don’t want to pay Social Security taxes and others who do want to enrich themselves through the management of private retirement accounts. The seniors deserve much better.

The AARP board needs to be replaced with individuals who will tell CEO Bill Novelli where to go. And maybe he should take with him Erik Olsen, the AARP President-elect, who is former president and CEO of Delta Dental Plan of California.

Urge NIH to provide public access to research

Action Required By November 16, 2004!

Following is a very important communication from Nobel Laureate Harold Varmus and his colleagues. The National Institutes of Health (NIH) has issued a policy recommendation that would ensure that the results of NIH-funded research would be available to all at no cost. This important policy would make sure that taxpayer-funded research would serve the public good. The comment period ends November 16. Please read the following, check the links, and then
Post Your Comments At The Link Provided.

This is a rare opportunity. Your simple act can make a difference. Do it now.

Thanks,
Don McCanne

*************

Dear Open Access Supporter,

On September 3, 2004 the NIH posted for comment an “Enhanced Public Access Policy.” This policy would require the recipients of NIH research grants to provide to the National Library of Medicine a digital copy of the final accepted manuscript (or the published version itself) of every published report resulting from NIH-funded research, so that the research results can be made freely available to scientists and the public through PubMed Central within six months of publication.

We are writing now to urge you to submit a comment in support of this proposal right away. The deadline for comments is just a few days away -November 16th.

The text of the proposal is available at:
http://grants.nih.gov/grants/guide/notice-files/NOT-OD-04-064.html
You can post comments here:
http://grants.nih.gov/grants/guide/public_access/add.htm

A powerful lobby of publishers and scientific societies is trying to block this plan. They claim that this is an unwarranted government intrusion on their business practices. In fact, the NIH policy has no authority over publishers – its rules apply only to the scientists who voluntarily accept grants from the NIH. The publishers remain free to operate their businesses as they always have and to compete in the free market to provide the best service and value to their authors and readers. But the publishers are wrong in arguing that they are entitled to monopoly control over access to the results of research that American taxpayers have paid for. On the contrary, the taxpayers who fund the research, and the scientists who carry it out, have every right to ask the grant recipients to provide open access to the published results. And they have every right to expect that the benefits of the research will be amplified by making it freely and widely available for others to use and to build on.

Let the NIH know that you support this policy proposal. Even better would be to tell the NIH that you would prefer an even stronger policy that requires full and immediate open access to all papers resulting from NIH-funded research. It is important that the NIH and other policymakers understand that this is not (as some publishers would have them believe) a radical proposal destined to destroy scientific publishing, but a thoughtful compromise that balances the desire for better access with the commercial interests of scientific publishers.

More information about the policy is available at:
http://www.nih.gov/about/publicaccess/index.htm

Home Page

Notable statements of support for the plan include:
An open letter to the US Congress signed by 25 Nobel Laureates:
http://www.taxpayeraccess.org/bof.html
The Council of the National Academy of Sciences:
http://www4.nationalacademies.org/news.nsf/isbn/s09162004?OpenDocument

Please let us know if you have any questions.
Harold Varmus
Patrick Brown
Michael Eisen

Care for veterans

Lexington Herald-Leader Lexington, KY
Editorial, November 11, 2004

Care for veterans
Honor them by providing health services

When a group of Harvard Medical School researchers reported last month that almost 1.7 million military veterans have no health coverage, a spokeswoman for the Bush administration disputed the study.

She said fewer than 900,000 veterans lack health coverage or care. Either way, there’s no way to feel good about so many veterans going without health care, especially on this Veterans Day when war casualties are mounting in Iraq.

The physicians who produced the study are proponents of a single-payer national health care system and were accused by a Department of Veterans Affairs spokeswoman of using veterans to advance their agenda. Whatever their motives, they drew their findings from two government studies– the Current Population Survey and the National Health Interview Survey — that interview large random samples of the U.S. population.

For analysis purposes, they counted a veteran who had no health insurance but had been seen at a VA hospital or clinic as insured. Among the study’s
findings:
Uninsured veterans have increased by 235,259 since 2000 to 1,694,312. The typical uninsured veteran was an employed man in his late 40s with one or two family members.More than two-thirds were employed, and 7 percent worked more than one job.

Many uninsured vets had major health problems, and a disturbingly high number reported problems in obtaining health care. Two-thirds reported receiving no preventive care the previous year.

Almost all World War II and Korean War vets are old enough to have medicare coverage. But 1 in 11 of the 7.85 million Vietnam-era vets have no health coverage. Among the 8.7 million veterans who served in other eras, including the Persian Gulf War, 1 in 8 are uninsured.

3.9 million members of veterans households lack health coverage. About half of uninsured veterans have incomes that disqualify them from VA health care under means-tests issued by the Bush administration last year for veterans with no service-related injuries.

The authors say the VA lacks resources to care for an influx of 1.7 million uninsured vets. They also said that in terms of access to care, uninsured vets are indistinguishable from the 45 million Americans with no insurance. Five million Americans lost health insurance over the last four years.

Nov. 11 is the day we set aside each year to honor those who gave part of their lives to defending our nation in the armed services. A good many of them, it seems, are on their own the other 364 days.

A primer on health care

A primer on health care
In the first of a two-part series on the Japanese health insurance system, Tomoko Furukawa goes back to basics
By TOMOKO FURUKAWA
There are two main types of Japanese Health Insurance: National Health Insurance and Employees’ Health Insurance

Once you have joined the health insurance system, you will be issued with an insurance card (“hokensho”), which you must bring with you every time you pay a visit to a clinic or hospital or other medical facility. If you forget your card, you may have to pay the full amount for treatment, though this is refunded later.

National Health Insurance
All residents of Japan who are planning to stay in the country for at least one year and haven’t joined another health insurance program are entitled, and expected, to join the National Health Insurance Program.

This includes part-time workers, the self-employed, and those without full-time status at a company they work for (this often includes teachers at English schools).

Under this system, both the policy holder and dependents enjoy equal coverage.

The amount you must pay into the National Health Insurance System is based on local resident tax (which, in turn, is based on income), your assets, the number of people benefiting from coverage and, often, the number of people living in your area that have joined the system (eg. ward, city, town etc.).

At present, regardless of income and assets, the highest amount payable annually is 530,000 yen, though this can rise to 610,000 yen depending on the number of people over age 40 in your household. Payments are not automatically deducted from wages, but must be paid in installments at a post office or health insurance office.

Foreign residents are often shocked when they see a massive jump in their premium from the first year of joining the system to the next.

The reason for this jump is that, for the first year, the premium is set at a minimum of around 2,500 yen.

For the second year, however, it is calculated based on income.

Under National Health Insurance, the policy holder and his/her dependents must pay 30 percent of inpatient and outpatient fees, with 70 percent covered by insurance.

Those enrolled in all health insurance schemes can avail of some free or very low-costs general check-ups (chest X-ray, urinalysis, blood test etc.). Also available are dental checks (for cavities, gum disease etc.), TB tests and treatment if sick.

Health exams and check-ups are generally not covered by insurance. Local authorities and companies arrange yearly or twice-yearly check-ups at designated times for local residents and employees.

However, while a preventative check-up may not be covered, there’s nothing stopping the insured person from going to their doctor with a complaint (fictitious or otherwise) and having a check-up performed as part of diagnostic treatment.

The NHI reimburses amounts paid over 63,000 yen (35,400 yen for low-income families) for medical treatment in one month; amounts over 37,200 yen, starting from the fourth time, if a household receives high-cost medical care four or more times a year; amounts over 10,000 yen for treating long-term, government designated ailments such as diabetes. A list of these designated diseases and conditions is available from your local city/town office.

However, reimbursement details under national health insurance are decided by local governments, so specific details of benefits should be checked with your local insurance office.

You may also be reimbursed if you receive treatment at a facility that does not accept your insurance and consequently hits you with a hefty bill.

In order to qualify for the above, you must be able to show that you were forced, through an emergency or unavoidable situation, to go to that facility. However, applicants will not necessarily be reimbursed the full amount, but rather will receive repayment based on a government-fixed fee.

If you get prior permission from your local EHI office, you can be reimbursed for transportation costs to hospital.

The Japanese health insurance system does not cover costs incurred as a result of accident caused by a third-party, since in Japanese custom the third-party is expected to pay. However, if that person cannot pay, then the insurance system may reimburse your costs and bill the person involved themselves.

If you cause the accident you have no coverage under the health insurance system.

Employees Health Insurance

This plan is for company employees and their dependents. It covers those who work full-time or at least 3/4 of the hours that a full-time worker puts in for a company that has joined an EHI plan.

In order for your dependents (basically your extended family stretching back three generations) to benefit from your policy, they must rely on you for more than half of their livelihoods and have an annual income of less than half of yours — or up to 1,200,000 yen per annum.

Under the national pension plan, employer and employee each pay half the premium, which is based on a percentage of income.

Unlike the national health insurance system, the EHI policyholder pays 10 percent of costs, while dependents pay 20 percent of inpatient care costs, and 30 percent of outpatient costs.

For high-cost medical care, the EHI will reimburse any high-cost medical expenses or extraordinary medical expenses along the same lines as National Health Insurance.

Reimbursement usually occurs within two months of payment, though interest-free loans are available for those in need of funds to tide them over until the cash arrives.

Benefits are the same as those under NHI with the exception of coverage amount.

Getting out

It is essentially impossible to leave the Japanese health insurance system once you have joined, unless you are leaving the country, moving somewhere else, or starting a new job.

If you move jobs and go from full-time to part-time status you may decide to opt out of the health insurance system altogether and get private health insurance.

If you shift from EHI to NHI, you will be charged from the date you left the EHI.

You can receive an exemption from paying premiums if you have trouble paying due to unemployment, bankruptcy issues etc.

Health resources

There are several good resources for information on health insurance and health care in general in Japan.

One of the best is the Japan Health Handbook, published by Kodansha.

The book contains sections ranging from alternative medicine and mental health to old-age care, with lots more in between. Though Kodansha no longer prints the book, it may be still possible to find copies in English-language bookstores in major Japanese cities, and the book can certainly be found on Amazon and other online book retailers.

On the Web, many embassy homepages provide information on English-speaking hospitals and clinics around Japan. One particularly comprehensive list can be found on the homepage of the U.S. Embassy in Japan at japan.usembassy.gov/e/acs/tacs-7119.htm

Another good resource is the AMDA International Mediscal Information Center homepage ( homepage3.nifty.com/amdack)

This provides telephone services to foreign residents in eight languages, explaining the health care system in Japan to foreign residents and pointing them in the direction of medical facilities with staff who speak their language.

What’s not covered

Not covered under the two systems are normal childbirth; abortion for economic reasons; vaccinations; cosmetic surgery; orthodontics; alternative medicine. Also not covered are accidents that occur in or on the way to work.

Health resources

There are several good resources for information on health insurance and health care in general in Japan.

One of the best is the Japan Health Handbook, published by Kodansha.

The book contains sections ranging from alternative medicine and mental health to old-age care, with lots more in between. Though Kodansha no longer prints the book, it may be still possible to find copies in English-language bookstores in major Japanese cities, and the book can certainly be found on Amazon and other online book retailers.

On the Web, many embassy homepages provide information on English-speaking hospitals and clinics around Japan. One particularly comprehensive list can be found on the homepage of the U.S. Embassy in Japan at japan.usembassy.gov/e/acs/tacs-7119.htm

Another good resource is the AMDA International Mediscal Information Center homepage ( homepage3.nifty.com/amdack)

This provides telephone services to foreign residents in eight languages, explaining the health care system in Japan to foreign residents and pointing them in the direction of medical facilities with staff who speak their language.

Next week’s column will cover the above issues, aswell as those of tax deductions, coverage, high medical expenses, specialist treatment, back payments and more.

Send your questions and views, good and bad, on the Japanese health care system to community@japantimes.co.jp

The Japan Times: Nov. 9, 2004

Vets return, but not always with healthcare

Vets return, but not always with healthcare
Alexandra Marks Staff writer of The Christian Science Monitor
11/10/2004

After serving 410 days in Iraq with the 1st Armored Division, Spc.Stuart Wilf came home to Colorado on Oct. 2. He changed his clothes, borrowed his mother’s car, and went out with friends to celebrate. On the way home, he fell asleep at the wheel and had a head-on collision with a tree. He survived, but since he was newly discharged, he had no health insurance.

“That was a mind-boggling thing to find out the first day he’s out of the service,” says his mother, Becky Wilf. “His bill was $54,000 just for the hospital. That doesn’t include the surgeon.”

Specialist Wilf is just one of thousands of veterans returning home from Iraq and Afghanistan who advocates contend are falling through the cracks of a federal system unprepared to deal with so many soldiers. After spending months in a war zone, many of the 170,000 soldiers who’ve returned home are struggling with their transition to back to civilian life – from coping with a maze of red tape and contradictory messages on healthcare to finding affordable housing and jobs with adequate incomes to accessing disability payments.

One of the biggest problems, according to advocates and a report by the Government Accountability Office, is a lack of resources to deal with battle fatigue, or posttraumatic stress disorder, as it’s now called. Another is providing support for Reserve and National Guard troops, who make up 45 percent of the troops in Iraq.

“The bottom line is that the VA [Department of Veterans Affairs] wasn’t prepared for the 33,000 troops that have come back and gone to the VA needing care,” says Paul Rieckhoff of Operation Truth, a nonprofit advocacy group for veterans of Iraq and Afghanistan. “They’re definitely not ready for the flood that’s going to come back next year.”

View from the other side
The VA disputes that and says it has ordered its services so that returning veterans will receive top-priority care. Last year, it announced that it would no longer be able to provide health services to veterans who make more than $26,000 a year (on average) and have no service-connected health problems. As a result, VA spokeswoman Cynthia Church says that what were once “unbelievable wait times” have been reduced. That allows the VA to treat returning combat veterans who were wounded or have service-related problems for free for two years.

“No veteran now waits longer than 30 days for their first appointment,” she says. “In terms of access to facilities, we’ve got more than 158 hospitals and more than 800 clinics, and we contract with service providers in communities where there may be a need.”

The VA’s policy are less clear when it comes to vets like Wilf, who sustained injuries after he was discharged. He and his family spoke with four different VA representatives and were told that because his injuries were not combat related, he was ineligible for VA care.

After inquiries from reporters, the VA in Washington said that if Wilf had been enrolled in the VA system, he would have been eligible for treatment for noncombat problems because he had just returned from combat duty. But he would have to pay for a percentage of the cost if he were able, and he would not be a priority case. “Part of the problem is the way the law reads. It says it’s mandatory to provide care for a condition possibly related to service, but doesn’t really address treatment of an unrelated condition,” says Gary Baker, head of the Eligibility Center at the VA.

Wilf has since filled out the application to enroll but is still waiting for it to be processed. In the meantime, the hospital where he was treated has forgiven most of the $54,000 bill because he was technically indigent. But he still has another $24,000 in related bills to pay.

Wilf was active duty, but some returning troops in the National Guard and Reserves have also found themselves without healthcare. When they were activated, they were eligible for Tricare, the Defense Department’s health-insurance program, but they lost coverage when they returned home.

Last summer, however, Congress voted to extend Tricare coverage for 180 days after deactivation. And last month, it voted to extend the coverage again, this time allowing Guard and Reserve troops to receive a year of Tricare coverage for every 90 consecutive days they serve.

Mr. Rieckhoff of Operation Truth lauds Congress for the move, but he contends it’s still not enough. He points to his own situation. He was on active duty and served as an infantry platoon leader in central Baghdad for 11 months. But now he finds himself in a job with no insurance. He was also told that the VA would treat only service-related injuries.

“The ironic part is that I’m drilling in the National Guard. It’s not like I’m completely out of the military,” he says.

Harvard’s numbers

A study done at Harvard University has found that almost 1.7 million veterans of all wars lack health insurance, an increase of 13 percent since 2000. More than one in three vets under the age of 25, like Wilf, have no health insurance. “It’s particularly offensive to send people off to war and not take care of them when they come home,” says Dr. Steffie Woolhandler, a professor at Harvard Medical School and coauthor of the study.

The VA contends the number of veterans without healthcare coverage is far smaller. Ms. Church says 60 percent of those uninsured veterans would be eligible for care if they enrolled in the VA. The study’s authors dispute that, noting that many have incomes higher than $26,000, live in areas where there are no VA services, or were unable to receive care due to long waiting lists. Church charges that the study’s authors are using the issue of uninsured vets to further a political agenda of creating a national health-insurance system. Veteran activists discount that. “This is not a political issue; it’s a soldier issue,” says Steve Robinson of the National Gulf War Resource Center.

A Gulf War veteran, he retired from active duty in October 2001, applied for benefits in 2002, and has yet to be enrolled in the VA healthcare system. “What happens in Washington is that these important things get turned into political footballs to get kicked around,” he says. “Then the issue doesn’t get the attention it deserves.”
(c) Copyright 2004 The Christian Science Monitor.  All rights reserved.