Uwe Reinhardt, Ph.D., Professor of Economics and Public Affairs, Princeton University (personal communication):

Don:

Attached is a portrait of what makes America great. Instead of using the coercive power of government to make you and me pay for her dental care, this lady uses a pair of pliers to pull her own tooth. One just has to admire it. It keeps our tax rate (as % of GDP) the lowest in the OECD and our economy strong.

Best,
Uwe

Rather than being included as an attachment to this message, the photograph can be viewed at this link to The New York Times:
http://www.nytimes.com/2004/12/28/business/28dental.html

Comment: It is astounding that, in the world’s wealthiest nation, aversion to taxes is a more important driver of policy than is the health of its people. This is particularly troublesome as we witness the debate over the “stinginess” of our response to the unfathomable tragedy of the Tsunami.

In his Christmas message to the nation, President Bush said, “By volunteering our time and talents where they are needed most, we help heal the sick, comfort those who suffer, and bring hope to those who despair, one heart and one soul at a time.”

And today the president said, “In this case, I think it’s very important for Americans who want to give to provide cash to organizations that will be able to focus resources and assets to meet specific needs,” and, “There are many NGOs now involved that understand what is specifically needed to meet the needs of these countries.”

Volunteers and nongovermental organizations (NGO) do play an important role in society and are to be praised for their very noble efforts. But they can never replace the duty of the government to make every effort to adequately address these very vital issues. The impact of charity and volunteerism remains miniscule when compared to the capability of a wealthy nation and its government resources.

We can bring hope to one heart and one soul at a time by volunteering to lend our pliers when the need is great. Or we can adopt national policies that would bring hope to all hearts and all souls. With tax rates in line with other OECD nations, we would still have the greatest personal wealth, but would also have the capability to do much more to ensure the health of all of our citizens and of the citizens of the world.

Addendum: On a positive note, the article, “U.S. Health Care Spending In An International Context” by Uwe E. Reinhardt, Peter S. Hussey and Gerard F. Anderson, tops the list as the most frequently viewed article on the Health Affairs website. At least the health policy community is interested in learning why we spend so much and receive such mediocrity in health care. The article can be accessed at:
http://content.healthaffairs.org/cgi/content/abstract/23/3/10

There is hope.

Health care – Leave no one out
The Charleston Gazette
Editorial – December 28, 2004

Health-care access in America is a mess. The only sensible way to address these problems is to cover everyone – preferably in a Canada-style, single-payer, universal insurance system. America’s way of rationing health care is expensive, inefficient and, at times, unhealthy.

The United States has been behind other industrialized nations in this category long enough.

http://wvgazette.com/section/Editorials/200412277

Comment: Our drums grow ever louder.

The Charleston Gazette
December 28, 2004
Editorial
Health care Leave no one out

Health-care access in America is a mess. The only sensible way to address these problems is to cover everyone – preferably in a Canada-style, single-payer, universal insurance system. America’s way of rationing health care is expensive, inefficient and, at times, unhealthy.

The United States has been behind other industrialized nations in this category long enough.

http://wvgazette.com/section/Editorials/200412277

Comment: Our drums grow ever louder.

The San Diego Union-Tribune
December 16, 2004
Jack puts health plan on employees’ menu
By Sarah Skidmore

In an effort to reduce employee turnover, fast-food purveyor Jack in the Box
recently began offering all its hourly restaurant employees access to health
insurance.

United HealthCare designed the program and provides the network and administration.

Employees can choose from three medical plans – the better the coverage, the
higher the cost. Premiums range from $10 to $17.50 a week. After one year of
service, the company picks up half of the premium bill.

The program addresses most medical needs but favors preventive care. For
example, doctor’s visits, immunizations and wellness checkups are covered
until, depending on the plan, costs reach $150 to $300. After that, employees pay a discounted rate.

“You can’t get a lot with $520 annually,” said Bob Belko, senior consultant of health care and group benefits practice at consulting firm Watson Wyatt. Belko said employees are largely paying for a discount on health care.

“Competitively speaking we have just put ourselves in with companies that perform very well,” Duarte said (Raul Duarte, division vice president of compensation and benefits for San Diego-based Jack in the Box).

Duarte said that until this design, the company could not find a plan that was affordable to the company and employees.

If Jack in the Box reduces turnover by 1 percent with this program, the company thinks it will recoup the $300,000 it anticipates in initial costs.

“This wasn’t all social do-good,” Duarte said. “There’s definitely a business case for it.”

http://www.signonsandiego.com/uniontrib/20041216/news_1b16jbx.html

It is of interest to note that Jack in the Box is paying $300,000 for this program ($9 for each of their 33,000 employees) shortly after paying $313,610 to oppose Proposition 72, California’s employer mandate which lost by a 49.1% to 50.9% vote.

http://www.health-access.org/2004_12_01_Sac_archives.htm#110304184728297352

Comment: Jack in the Box’s program is primarily a discount card for health
care services. Employees do have the option of selecting plans with greater
benefits, but these plans provide only extremely Spartan benefits with very
low caps on maximum coverage. It is obvious that, for low wage employees,
this program provides virtually no financial security when faced with significant health care expenses.

There may be more “social do-good” than the Jack in the Box management
realizes. The outrage over the insensitivity of the management toward the
health care needs of their employees may drive the rest of us to finally demand a comprehensive system for everyone. I hope that we don’t have to wait for the tragic stories of what happens when the Jack in the Box employees attempt to access the health care system.

—————————————————————————————-

Message: 2
Date: Fri, 24 Dec 2004

PublicAffairs
The Bubble of American Supremacy
By George Soros

Markets are designed to facilitate the free exchange of goods and services among willing participants, but are not capable, on their own, of taking care of collective needs. Nor are they competent to ensure social justice.
These “public goods” can only be provided by a political process.

http://www.publicaffairsbooks.com/publicaffairsbooks-cgi-bin/display?book=1586482173

The Washington Post
December 24, 2004
Truth in Medicine
By Paul H. O’Neill

… the president should appoint a commission with a tight deadline to redesign the health care reimbursement system with the goal of making it pro-patient.

The 30 to 50 percent of national medical care spending that is currently paying for waste and errors can be captured only through deliberate action at the local level. With the health care industry and the government playing their parts, hundreds of billions of dollars can be freed up. This would make it easy to solve the so-called “access” problem of uninsured Americans and still leave large amounts for other important needs.

http://www.washingtonpost.com/wp-dyn/articles/A23570-2004Dec23.html

Comment: While George Soros and Paul O’Neil do not occupy the same point on the political spectrum, they both recognize that the government must play a
role in ensuring social justice, or, more specifically, affordable access to high quality care for everyone.

What could better represent the spirit of Christmas than to set aside partisanship and begin to seriously discuss the role of government in ensuring quality, access and affordability of health care for everyone? Even Ebenezer Scrooge eventually became enlightened.

The San Diego Union-Tribune
December 16, 2004
Jack puts health plan on employees’ menu
By Sarah Skidmore

In an effort to reduce employee turnover, fast-food purveyor Jack in the Box
recently began offering all its hourly restaurant employees access to health
insurance.

United HealthCare designed the program and provides the network and administration.

Employees can choose from three medical plans – the better the coverage, the
higher the cost. Premiums range from $10 to $17.50 a week. After one year of
service, the company picks up half of the premium bill.

The program addresses most medical needs but favors preventive care. For
example, doctor’s visits, immunizations and wellness checkups are covered
until, depending on the plan, costs reach $150 to $300. After that, employees pay a discounted rate.

“You can’t get a lot with $520 annually,” said Bob Belko, senior consultant of health care and group benefits practice at consulting firm Watson Wyatt. Belko said employees are largely paying for a discount on health care.

“Competitively speaking we have just put ourselves in with companies that perform very well,” Duarte said (Raul Duarte, division vice president of compensation and benefits for San Diego-based Jack in the Box).

Duarte said that until this design, the company could not find a plan that was affordable to the company and employees.

If Jack in the Box reduces turnover by 1 percent with this program, the company thinks it will recoup the $300,000 it anticipates in initial costs.

“This wasn’t all social do-good,” Duarte said. “There’s definitely a business case for it.”

http://www.signonsandiego.com/uniontrib/20041216/news_1b16jbx.html

It is of interest to note that Jack in the Box is paying $300,000 for this program ($9 for each of their 33,000 employees) shortly after paying $313,610 to oppose Proposition 72, California’s employer mandate which lost by a 49.1% to 50.9% vote.

http://www.health-access.org/2004_12_01_Sac_archives.htm#110304184728297352

Comment: Jack in the Box’s program is primarily a discount card for health
care services. Employees do have the option of selecting plans with greater
benefits, but these plans provide only extremely Spartan benefits with very
low caps on maximum coverage. It is obvious that, for low wage employees,
this program provides virtually no financial security when faced with significant health care expenses.

There may be more “social do-good” than the Jack in the Box management
realizes. The outrage over the insensitivity of the management toward the
health care needs of their employees may drive the rest of us to finally demand a comprehensive system for everyone. I hope that we don’t have to wait for the tragic stories of what happens when the Jack in the Box employees attempt to access the health care system.

—————————————————————————————-

Message: 2
Date: Fri, 24 Dec 2004

PublicAffairs
The Bubble of American Supremacy
By George Soros

Markets are designed to facilitate the free exchange of goods and services among willing participants, but are not capable, on their own, of taking care of collective needs. Nor are they competent to ensure social justice.
These “public goods” can only be provided by a political process.

http://www.publicaffairsbooks.com/publicaffairsbooks-cgi-bin/display?book=1586482173

The Washington Post
December 24, 2004
Truth in Medicine
By Paul H. O’Neill

… the president should appoint a commission with a tight deadline to redesign the health care reimbursement system with the goal of making it pro-patient.

The 30 to 50 percent of national medical care spending that is currently paying for waste and errors can be captured only through deliberate action at the local level. With the health care industry and the government playing their parts, hundreds of billions of dollars can be freed up. This would make it easy to solve the so-called “access” problem of uninsured Americans and still leave large amounts for other important needs.

http://www.washingtonpost.com/wp-dyn/articles/A23570-2004Dec23.html

Comment: While George Soros and Paul O’Neil do not occupy the same point on the political spectrum, they both recognize that the government must play a
role in ensuring social justice, or, more specifically, affordable access to high quality care for everyone.

What could better represent the spirit of Christmas than to set aside partisanship and begin to seriously discuss the role of government in ensuring quality, access and affordability of health care for everyone? Even Ebenezer Scrooge eventually became enlightened.

The claim is often made by HSA supporters that the premiums of the HDHPs are much lower because of the high deductible. But, in fact, they are usually much lower only because the plans are priced in the individual market which excludes from coverage individuals with preexisting disorders. When the plans include guaranteed issue (everyone is allowed in the plan) and community rating (the premiums reflect the average costs of all individuals in the plan) then the premiums reported above are typical ($11,772 per year for a family in California).

Either we support the insurance principle of spreading risk by including everyone, or we don’t. But let’s end the lie that we can lower premiums for everyone by a modest increase in the deductible, when in reality we are lowering premiums by leaving out those who have the greatest need to be included.

Alan Sager, Ph.D., Professor of Health Services, Boston University School of Public Health, responds:

Agreed!

But one thing: insurance is about sharing risks among similar people. That’s experience rating and why actuaries exist. Leaky boats pay higher premiums. That’s the essence of insurance.

It’s also why insurance does not work in health care. We use the word, but we mean social insurance, community rating. Community rating is not real insurance. To claim otherwise, I think, inadvertently plays into the hands of the privatizers because the game is then played on their (insurance) court.

I think it’s helpful to be clear on this because it shows that only government action can win durably affordable coverage for all. That’s because community rating never survives in any market.

Alan Sager, Ph.D.
Professor of Health Services
Director, M.P.H. Program in Health Services
Director, Health Reform Program
Boston University School of Public Health
www.healthreformprogram.org

Comment: Professor Sager is absolutely right. Many current proposals for reform of the insurance market are specifically directed against community rating. To keep premiums low and therefore competitive, private insurers and the policymakers who support them will inevitably tailor insurance pools to exclude high cost beneficiaries with greater health care needs.

We do need to conduct the debate in our court of social insurance (government) with everyone included, and not in the court of the private insurers (market) who would leave out those who have the greatest needs.

Don McCanne

The claim is often made by HSA supporters that the premiums of the HDHPs are much lower because of the high deductible. But, in fact, they are usually much lower only because the plans are priced in the individual market which excludes from coverage individuals with preexisting disorders. When the plans include guaranteed issue (everyone is allowed in the plan) and community rating (the premiums reflect the average costs of all individuals in the plan) then the premiums reported above are typical ($11,772 per year for a family in California).

Either we support the insurance principle of spreading risk by including everyone, or we don’t. But let’s end the lie that we can lower premiums for everyone by a modest increase in the deductible, when in reality we are lowering premiums by leaving out those who have the greatest need to be included.

Alan Sager, Ph.D., Professor of Health Services, Boston University School of Public Health, responds:

Agreed!

But one thing: insurance is about sharing risks among similar people. That’s experience rating and why actuaries exist. Leaky boats pay higher premiums. That’s the essence of insurance.

It’s also why insurance does not work in health care. We use the word, but we mean social insurance, community rating. Community rating is not real insurance. To claim otherwise, I think, inadvertently plays into the hands of the privatizers because the game is then played on their (insurance) court.

I think it’s helpful to be clear on this because it shows that only government action can win durably affordable coverage for all. That’s because community rating never survives in any market.

Alan Sager, Ph.D.
Professor of Health Services
Director, M.P.H. Program in Health Services
Director, Health Reform Program
Boston University School of Public Health
www.healthreformprogram.org

Comment: Professor Sager is absolutely right. Many current proposals for reform of the insurance market are specifically directed against community rating. To keep premiums low and therefore competitive, private insurers and the policymakers who support them will inevitably tailor insurance pools to exclude high cost beneficiaries with greater health care needs.

We do need to conduct the debate in our court of social insurance (government) with everyone included, and not in the court of the private insurers (market) who would leave out those who have the greatest needs.

Don McCanne

Daily Express
(Independent National Newspaper of East Malaysia)
December 16, 2004
National Health Insurance scheme gets green light

After two years of study, the Government has agreed to implement the proposed National Health Insurance Scheme (NHIS) soon to reduce the healthcare burden on the Government and help ease the long waiting time in public healthcare facilities.

Health Minister Datuk Dr Chua Soi Lek said it would be based on a community-rated model.

“This means it would be based on cost and risk-sharing across the population, with the rich subsidising the poor, the young for the elderly, the healthy for the sick and the employed for the unemployed,” he said.

“The mechanism will be affordable, viable and sustainable, provide Universal and comprehensive coverage and achieve greater equity and accessibility to quality health are for all Malaysians,” he added.

Chua said the present system would be retained and be improved with greater integration between the public and private sectors while the mechanism would help to ensure better access to healthcare, either in the public or private sector.

“To govern and run the national health financing mechanism, there is also a need to set up a National Health Financing Authority under the Ministry of Health and to be wholly owned by the Government,” he said.

The National Health Financing Authority would function as a single payer for the healthcare of all citizens and eligible non-citizens.

http://www.dailyexpress.com.my/news.cfm?NewsID=31399

Comment: So they’re proposing “a single payer for the healthcare of all citizens” through a National Health Financing Authority to be wholly owned by the government. Sounds like a good idea. Do you think that might work here?

The Commonwealth Fund
Newsletter
December 2004
Issue of the Month: The British National Institute for Clinical Excellence
By Vida Foubister

The mission of U.K.’s five-year-old National Institute for Clinical Excellence is to create, disseminate, and foster implementation of standards of health care. There is no such model for national standards in the U.S. What can we learn from NICE?

Last February, the National Institute for Clinical Excellence (NICE)-a relatively new part of the British National Health Service (NHS) created to improve the quality of health care-released a clinical guideline on in vitro fertilization (IVF).

Surprisingly, there was little reaction among those affected even though the clinical guideline, like much of the guidance issued by NICE in the past five years, limited the care available through the NHS based on clinical as well as cost effectiveness. Specifically, the infertility guideline recommends that the NHS provide no more than three cycles of IVF to women between ages 23 and 39 as the clinical evidence shows a low success rate beyond those parameters.

Why was there no professional or public outcry? “We go through a very iterative process where we involve the main stakeholders,” explains Sir Michael D. Rawlins, M.D., a professor of clinical pharmacology at the University of Newcastle upon Tyne who has served as chairman of NICE since its inception.

NICE issues three types of guidance: technology appraisals of new and existing medicines, medical devices, diagnostic techniques, surgical procedures, and health promotion activities; clinical guidelines for the appropriate treatment and care of people with specific diseases and conditions; and recommendations on the safety and efficacy of interventional procedures, that is, predominantly new diagnosis or treatment processes that involve gaining access to the inside of a patient’s body, with or without cutting, and the use of electromagnetic energy or ultrasound.

Although the primary goal is to improve the standard of care received by NHS patients, cost effectiveness is a factor in the technology appraisals and clinical guidelines. Cost is not considered in the interventional procedure reviews.

Since January 2002, the NHS has been legally obliged to provide funding and resources for medicines and treatments NICE recommends as a part of the technology appraisals program. This means that, in some cases, the cost of medicines and devices NICE chooses not to approve are shifted to patients.

In addition, clinicians are wary of using interventional procedures that NICE deems unsafe.

Across the pond in the United States, there is no similarly focused federal agency and NICE’s approach appears to have attracted considerable interest-as indicated by the 10,000 daily hits on its Web site from U.S. visitors.

“We have something that looks somewhat analogous in many of the domains
in which NICE is working,” says Joseph Newhouse, Ph.D., professor of health care policy at Harvard Medical School… It’s just not “pulled together in one agency with a crisp mandate.”

(In the public and private sectors) there are a number of technology assessment groups that analyze drugs, devices, and procedures… There is another major difference between these groups and NICE-none of them explicitly considers cost effectiveness. “Right now, we’re not facing it. We’re making coverage decisions based on safety and efficacy; the costs are not supposed to enter into the decision,” says Victor R. Fuchs, Ph.D., Henry J. Kaiser, Jr., Professor Emeritus at Stanford University.

“You don’t hear a huge hue and cry in Britain through the media or the legal system [about] the fact that they’re doing this,” Fuchs continues. “England, apparently, is much more willing to come to terms with the fact that every health care system has to make some kind of rationed decisions.”

In the final analysis, it appears that both the United States and the United Kingdom are moving toward evidence-based medicine. The British model doesn’t have the duplication of effort seen in the United States and, as a result, is likely to be less costly. However, with the rapid evolution of medical technology, one concern with this approach, Neumann says (Peter Neumann, Sc.D., an associate professor at the Harvard School of Public Health), is “What if the government gets it wrong?”

http://www.cmwf.org/publications/publications_show.htm?doc_id=252181#issue

Comment: The health care system in the United States is unique in its continued acceleration in health care costs, primary related to ever greater utilization of high tech and specialized services, but without a demand from us for a commensurate increase in health care value.

In fact, the studies of John Wennberg and his colleagues have confirmed that regions with greater capacity and utilization of high tech, specialized services have not demonstrated significant improvement in health care outcomes. In fact, in some studies, greater spending has been correlated with lower quality care. And Barbara Starfield and colleagues have demonstrated that placing a greater priority on primary care services ensures higher quality at a lower cost.

Unfortunately, the issue is frequently framed as a need to ration services because of the limitations of our finite resources. The implication is that we should deny individuals of some highly beneficial services because we can’t afford to pay for all of them.

Rather than frame the debate as an issue over rationing, it would be much more instructive to frame the debate as to whether we should continue to allow unlimited funding of the large amount of care that is not beneficial and maybe even detrimental. Although the precise amount of funds that could be recovered has not been quantified, it is clearly in the hundreds of billions of dollars. If we were to decide that we would pay only for beneficial services, we could provide comprehensive care for everyone and actually reduce health care spending.

But I remain very dubious that fragmented, private and public sector efforts could accomplish this. There are too many vested interests that would continue to support the profound waste on which they thrive.

It’s time to get over the fear of the government bogeyman, and establish a single, public National Institute for Clinical Excellence. After all, Uncle Sam is our very own bogeyman, and we do have some control over him!