PNHP

Dr. Weisbart writes on single payer in the AMA Journal of Ethics

Dr. Weisbart writes on single payer in the AMA Journal of Ethics

A Single-Payer System Would Reduce U.S. Health Care Costs

By Ed Weisbart, MD, CPE
American Medical Association Journal of Ethics, Virtual Mentor, November 2012
Today’s fragmented system is akin to requiring each household in a community to anticipate their needs for the coming year and negotiate their own fees and scope of services with the local police and fire departments. Imagine instead how much of their budgets these life-saving community services would be obliged to devote to marketing to and negotiating with each household and the rampant disparities in service that would result. That is precisely what is happening today in health care, and it is absurdly wasteful. For police and fire departments, we have recognized that it is significantly less wasteful to give all citizens the same “coverage” for set prices and to administer it with regional coordination. Global budgeting is the only sensible strategy for such unpredictable yet universally needed services.
Conclusion
The ACA has begun the process of much needed change. Now we need to go further in reforming health care finance to enable all Americans to achieve their fundamental human right to comprehensive coverage. The rest of the modern world has run the laboratory studies for us; now is the time for us to adopt this well proven solution.
http://virtualmentor.ama-assn.org/2012/11/oped1-1211.html

Health care financing is a fundamental ethical issue, thus it is very appropriate that Ed Weisbart’s article on single payer be published in the AMA’s journal of ethics. Hopefully, the brief excerpt above will entice you to click on the link to read the entire article, and then share it with others to spread the word on the imperative of the single payer model – an improved Medicare for everyone.

What does the election mean for health care reform?

Yes, Obama Won a Mandate

By Jonathan Cohn
The New Republic, November 7, 2012
I’ve waited more than two years to write this sentence: The Affordable Care Act is here to stay. It survived the Supreme Court and now it has survived the threat of a unified Republican government determined to repeal it. Implementation of the law will present huge challenges, but, for the first time in a long while, the administration and its allies can focus on those challenges rather than on rearguard political fights to keep the program alive.
http://www.tnr.com/blog/plank/109818/obama-wins-four-more-years-mandate-…

The reelection of President Obama and the failure of the Republicans to gain more than filibuster control of the Senate means that the Affordable Care Act (Obamacare, or ACA) will be fully implemented by 2014, as scheduled.
Although such complex legislation inevitably calls for legislative refinements, any significant efforts to expand the effectiveness of ACA would surely be blocked in the Republican-controlled House.
In the meantime, efforts on the state level to improve ACA will continue. Although small incremental steps are possible, it is unlikely that any model close to a true single payer system will be enacted within the states, even if the single payer label is used. The reason is that major enabling federal legislation would be required to construct a true stated-based single payer system, and the House still has its primary tool that it has wielded so effectively for the past two years: gridlock.
Although it seems like this might be a time to kick back and wait until the political climate improves, nothing could be further from the truth. The first step in advancing health care justice is to educate – inform the public on the facts.
We have two messages: 1) no matter how many tweaks are applied, ACA will not achieve health care justice – 30 million will remain uninsured, tens of millions underinsured, and health care costs will not be contained, and 2) there is a model that will cover absolutely everyone, provide access to high quality care, reduce financial barriers to care, and slow the increase in health care spending which would benefit us all – a single payer, improved Medicare for everyone.
We need to intensify our efforts to spread the word so that the people of our nation will be ready to support reform enthusiastically when the political climate becomes more favorable.

The Early History of PNHP

By Steffie Woolhandler, M.D., and David Himmelstein, M.D. 

PNHP note: The two articles below describe the founding of Physicians for a National Health Program. The articles span a quarter-century – one was written shortly after the organization’s founding, the other was written in October of this year. We reproduce them here, the most recent one first, as part of the observance of PNHP’s 25th anniversary and as a contribution to understanding its continuing mission. 

We initiated PNHP in the summer of 1986 at a meeting of about 200 clinicians caring for the poor organized by Lucy Candib and Gene Bishop in New Hampshire.

Several factors led us to propose this new organization to colleagues:

1)      Fifteen years after the nationwide implementation of Canada’s Medicare program, research by us and others had recently documented the striking advantages of the single-payer approach in terms of access to care and cost efficiency.

2)      After five years of the Reagan administration assault on safety-net program, we were convinced that efforts focused on defending existing safety-net programs (e.g. Medicare and Medicaid) and institutions (public hospitals and community clinics) could not protect our patients. The public programs were (and are) woefully inadequate.

·         Medicare, despite its positive aspects, covered less than half of the total medical expenses of the elderly; privatization had started with the 1985 Medicare HMO program; and providers siphoned billions, taking advantage of the payment system that had been adopted from private insurers.

·         Medicaid patients were often unwelcome at doctor’s offices and private hospitals; and private HMOs were beginning to make incursions into this program too.

·         Clinics and public hospitals, where we ourselves practiced were chronically starved of resources and hence provided separate and unequal care for minorities, the poor and the poorly insured.


Defense of these woefully inadequate approaches meant defending substandard (if valiant) care.

3)      Advocacy for national health insurance (NHI) or a national health service (NHS), which had been a powerful force in the 1960s and 1970s, had largely died out. The scattered supporters of these different approaches, who had previously been sharply divided, seemed ready to collaborate. Moreover, experience in Canada and the U.K. challenged the traditional view that an NHS necessarily offered a more thoroughgoing reform than NHI. Canada’s single-payer NHI banned competing private insurance, mandating that all Canadians get care from a single, unified medical care system. In contrast, many wealthy Britons opted for private coverage, offering them an escape from the NHS. We chose the name “Physicians for a National Health Program” to avoid the old fights about NHI vs. NHS.

4)      We sensed a growing dissatisfaction among colleagues with the then incipient corporate domination of medicine, which was being stimulated by the emergence of HMOs and managed care. Many doctors seemed ready for an alternative.

5)      A ballot initiative in Massachusetts instructing congresspeople to support single-payer reform was the immediate trigger for our initiative. A group of Massachusetts Gray Panthers – Dave Danielson, Art Mazer and Gerry Bergman, among others – had succeeded in getting the question on the ballot. They were concerned that the Massachusetts Medical Society might openly oppose the measure and encouraged a public display of physician support for single payer.

At the New Hampshire conference, colleagues reacted enthusiastically to our proposal. Discussion centered on whether the new group should be a physicians’ organization or seek to organize a broader constituency.

Influenced by the Massachusetts Gray Panthers’ request for support from a group specifically identified as physicians, and the belief that many physicians supportive of single payer would hesitate to join a broader group, we chose the PNHP path. But we agreed that PNHP should be part of a broader “Network of Health Professionals for a National Health Program” (NHP2), and eventually “People for a National Health Program.”

Several colleagues who remain active in PNHP participated in those discussions, including Oli Fein, Howard Waitzkin, Gordy Schiff, Mardge Cohen, Henry Kahn, Jeff Scavron and Len Rodberg. (We are surely forgetting many others). Len offered to create a database program to maintain the membership list (an esoteric feat in 1986). Milton Terris volunteered to have stationary printed (including NHP2 stationery).

Following the conference, we set about enlisting colleagues willing to be listed as “Founding Members” on a membership solicitation letter that we had drafted, which outlined the essential elements of a single-payer reform. Many responded positively.

Aided by Steffie’s sister (who spent some months with us in Cambridge) we mailed membership invitations to several thousand colleagues, using lists obtained from other physician organizations. By late 1987, about 200 dues-paying members had signed up.

From the outset, there was general agreement that the group should draw up a single-payer physicians’ manifesto, with the hope that it could be published in a major journal, allowing us to increase our legitimacy and recruitment. In early 1988 we met with Arnold Relman, the editor of the New England Journal of Medicine, to explore whether he was open to publishing such an article. He made no commitment, but expressed interest.

We set about drafting an article, with extensive feedback from 28 colleagues who formed the writing group. Relman eventually accepted and published the article, which appeared on January 12, 1989.

The New England Journal’s publication of PNHP’s proposal was greeted as a “man bites dog” story by the press. Colleagues in several cities organized press conferences to reach out to the lay media. We and many other PNHP colleagues were interviewed by major media outlets, and PNHPers made appearances on national television programs including “The Today Show,” “Good Morning America” and the “Mac
Neil/Lehrer NewHour.” PNHP had arrived as an organization, and memberships flowed in by the dozens.

The surge in membership allowed us to hire a staffer to take over maintenance of the membership database and other essential tasks, and necessitated moving the organization’s office out of our home. Bob Lawrence (our department chair at the time) agreed to allow us to utilize our hospital offices to house PNHP.

From the outset, PNHP was envisaged as a membership-driven organization, focused on providing opportunities for progressive physicians to express their views in an effective manner. We were convinced that a large number of physicians each spending a modest amount of time on PNHP work could accomplish far more than a few paid staffers. Moreover, leadership that was intimately aware of the daily realities encountered in medical practice was essential to assure that PNHP remained relevant to physicians. Hence, the staff role was not to lead, but to facilitate communication among the members, and to assume many of the burdensome tasks of maintaining the organization’s infrastructure.

Another feature of PNHP that was established early on was a monthly conference call for active members to share information and ideas for effective action.  Many of the early members of PNHP went on to start local chapters, and the monthly phone call provided them with regular support and inspiration.

Our first experience with an executive director was an unfortunate one. Several months after starting work, she became convinced that adhering strictly to the single-payer message compromised our possibilities for funding. (We later learned that a foundation had let her know that watering down PNHP’s advocacy agenda would result in a substantial donation.) She asked PNHP’s newly formed board – led by Jeff Scavron, the first PNHP president – to make this change in focus, and eject us from the organization. Instead, the board unanimously endorsed our approach and dismissed the staffer.

Subsequently Judy Kaplan took over as the staffer in Cambridge, followed by Donna Pound. Both performed yeoman service, helping us to initiate the PNHP Newsletter.

Communicating with Colleagues 

 Shortly before PNHP was initiated, Malcolm Peterson (chief-of-staff at the Seattle VA) had invited us to present the case for single-payer reform at a session he chaired at the American College of Physicians annual meeting. Responding to Malcolm’s invitation, we assembled a raft of slides for the presentation, adopting a traditional, data-intensive grand rounds style. The positive response to the presentation bolstered our view that many physicians would more readily embrace the single-payer message if it were communicated in such a traditional format.

Ike Taylor, who had moved to Boston after retiring as dean of the University of North Carolina School of Medicine, helped to shape these presentations. He had sought us out after reading the New England Journal article. Ike dived into PNHP activism on many fronts, and agreed to assume the PNHP presidency.

As invitations for presentations grew, many PNHP colleagues became skilled speakers on single payer, often using the PNHP slide set, which was updated annually and widely distributed.

Further publications in the JAMA outlining PNHP’s views on quality improvement (led by Gordy Schiff); financing (in collaboration with Kevin Grumbach and Tom Bodenheimer) and long-term care (led by Charlene Harrington) fleshed out key aspects of PNHP’s program, and gained visibility for the organization.

Moving to Chicago

In 1991 a decision was made to move PNHP’s headquarters to Chicago. This decision was motivated by several factors.

  • We were planning a sabbatical year in Washington and hence would not be present at the Cambridge office.
  • We and others felt it important to broaden leadership of the organization.
  • Ron Sable, a dynamic and much loved physician who had founded the AIDS program at Cook County Hospital was stepping back from clinical work because of illness, and was available to assume the role of coordinator, supported by the very strong Chicago PNHP cohort that included Quentin Young, Gordy Schiff, and Claudia Fegan
  • Chicago made sense as the home base of a national physician organization.

Ron and Quentin skillfully built PNHP in Chicago.  Taking advantage of an opportunity to share office space with another group Quentin chaired, the Health and Medicine Policy Research Group (focused on Illinois health policy issues), the new office of PNHP opened on January 1, 1992. Ida Hellander, who was working at Sid Wolfe’s Public Citizen Health Research Group where David spent his sabbatical, was recruited to join them in leading the Chicago office.

After Ron’s death in 1993, Quentin Young stepped in to the role of national coordinator.

Quentin and Ida vastly increased PNHP’s recruiting efforts and public visibility, turned our periodic meetings from small, informal affairs into well-organized, dynamic gatherings, and greatly facilitated membership communications.  With help from Mike McCally, they secured grants from three foundations and tripled the budget.

Claudia – at that time a partner in Quentin’s practice – and Gordy both assumed an increasingly critical role in the organization, serving as PNHP Presidents, traveling speakers, and unofficially helping to oversee the Chicago office.

With Bill Clinton’s election and the 1993-1994 health reform debate, single-payer advocates swung into action. Vicente Navarro, included in the White House task force at Jesse Jackson’s insistence, remained firm in advocating single payer from the inside, and Several PNHP representatives were invited to present their case to Hillary Clinton. Once the Clinton plan was unveiled, a lively debate within PNHP resulted in a clear stance to continue single-payer advocacy, and point out the flaws in the Clinton plan – prefiguring PNHP’s position on President Obama’s reform plan.

The subsequent years brought new energy and leadership from colleagues across the nation. We are certainly omitting the names of many who played foundational roles in PNHP’s earlier years, both nationally and in building chapters around the country.

*********

Physicians for a National Health Program: 

Report from the United States 

By Steffie Woolhandler and David U. Himmelstein

International Journal of Health Services, 1987

A new organization called Physicians for a National Health Program (PNHP) is mobilizing physician support for a universal, comprehensive public system of health care for the United States. Recent changes in power relations within medicine (the so-called proletarianization of physicians) are prodding many physicians to abandon their traditional reactionary role in health policy. PNHP is working with elderly, labor, community, and health care activist groups to put a national health program (NHP) back on the U.S. health policy agenda. In this article, five key features of an NHP needed to simultaneously assure access, control costs, and minimize bureaucracy are noted.

Physicians have long been a bulwark of conservatism in U.S. health policy. Organized medicine has opposed virtually every initiative to extend access
to services and democratize health care decision-making. As corporate control increasingly threatens the preeminent position of physicians (1), a significant portion of the medical profession appears ready to break with this tradition of reaction. Physicians for a National Health Program (PNHP) is a new organization attempting to crystallize and direct the growing discontent of physicians into support for a national health program (NHP).

An NHP is the only stable solution to the widely perceived crisis in U.S. health care. There is overwhelming evidence that an NHP could provide universal access to high quality care and control costs. In contrast, current health policies have failed to contain costs and have exacerbated problems in both access to and quality of care. Health care costs (corrected for overall inflation) have risen more rapidly over the past six years than during the last half of the 1970s. This escalation occurred despite, or perhaps because of, the growing preoccupation of policy makers with cost control through competitive strategies, health maintenance organizations (HMOs), prospective reimbursement, and the like. Meanwhile the number of people without health insurance increased 43 percent between 1978 and 1985, and both physicians and hospital social workers report feeling pressured to discharge patients from hospitals prematurely.

While cost control initiatives have failed to control costs, they are rapidly changing power relations within health care. These recent initiatives have shared a common thread – they offer financial incentives for hospitals, HMOs, and insurers to control physicians and patients. Much of the recent cost increase is attributable to the growing administrative structure required to operate health care as a profit-making capitalist industry and enforce inequality in access to medical services. Administration consumes at least 22 percent of U.S. health spending, in contrast to 6 percent in the United Kingdom and 8 percent in Canada (2). U.S. physicians increasingly confront hospital, insurance company, and other corporate bureaucracies that dictate the parameters of medical care. Marx’s classic description of the evolution of an industry appears germane. The power of physicians as independent petit bourgeois medical producers is rapidly giving way before the onslaught of corporate control (3).

The U.S. public has long supported an NHP (4), a support that was reaffirmed by the 67 percent majority of the Massachusetts electorate who voted for the National Health Program Referendum in November of 1986. Surprisingly, 56 percent of physicians also favor some form of NHP, though three-quarters of doctors are convinced that most of their colleagues oppose such reform (5). Unfortunately, politicians, wary of threatening insurance companies and other elements of the medical-industrial complex, persist in dismissing an NHP as utopian and unpopular. In this context, we are convinced that physicians can help place an NHP on the political agenda. There will undoubtedly be considerable struggle over the precise form of an NHP in the United States, and aspects of many proposals will threaten the self­interest of physicians. However, we believe that the following features are both crucial to progress in health care and attractive to many physicians.

1. Coverage must be universal and comprehensive, including coverage of preventive, curative, mental health, occupational, and rehabilitative care. This could assure access to care, avoid a two-class system, and minimize administrative expense. Allowing balance billing, competing private insurance, or out-of-pocket payments negates these advantages.

2. Hospitals should be paid on an annual lump sum basis for operating expenses. This would minimize incentives for both undercare (since hospitals could not retain a surplus) and overcare (since excess services would not generate additional income). Lump sum budgeting also streamlines administration since billing is eliminated.

3. Payment for capital costs must be separated from hospital operating costs and physician fees. If hospitals can buy new buildings and equipment with surplus funds from their yearly budgets, they have a strong incentive to skimp on care. Real health planning becomes impossible since rich hospitals can continue to expand, while areas without sufficient resources will remain underserved. Similarly, paying physicians for capital such as office-based computed tomography (CT) scanners encourages unnecessary purchase and use of such expensive equipment.

4. Private insurance companies should be excluded from any NHP. Public administration is cheaper, and allows much more democratic control of key policy decisions. Private insurance firms have incentives to increase costs and bureaucracy since these result in higher income. Reimbursement decisions are important public policy and must be recognized as such.

5. Public accountability should be encouraged, but should not be confused with bureaucratic dominance a la diagnosis related groups (DRGs). Detailed administrative oversight of clinical practice (e.g., how many EKGs should be allowed for a patient with a myocardial infarction) should be discouraged. Such oversight costs as much as it saves, and is unnecessary if financial incentives for or against the use of technology and services are minimal.

The Canadian NHP meets many of these criteria, and offers a concrete, though flawed, point of reference in mobilizing support for an NHP in the United States. We recognize that Canadian health care remains largely a sickness care system, dominated by a bourgeois medical model, antagonistic to “alternative” providers, basically insufficient in its approach to social and environmental problems, and riven by class inequalities among
health workers. Nonetheless, Canada has achieved a surprising degree of equality in access to health services, without excessive costs. The Canadian working class is no longer threatened with the termination of coverage in case of unemployment, strikes, or disability. We have found the real-life experience of the Canadian NHP vital in countering the powerful disinformation campaign against public medicine, and in answering the hundreds of what-if questions that arise in discussion of an NHP. The early, enthusiastic response to PNHP confirms that many physicians are prepared to embrace the concept of an NHP.

The Canadian experience demonstrates that monopsony government payment for health care can assure considerable public control of health resources and personnel despite private ownership and practice. In contrast, the British National Health Service owns most health facilities and employs most personnel, but coexists with a private sector. This allows for two-class care, as well as the underfunding of the public sector since the well-to-do can seek care elsewhere. The Canadian experience also suggests a possible strategy for overcoming political obstacles to an NHP. The Canadian NHP originated in Saskatchewan, where a socialist provincial government introduced a province-wide health insurance plan. The spark from Saskatchewan spread rapidly across the prairie resulting in a universal, comprehensive health care program throughout Canada within five years. Statewide demonstration projects in states with relatively progressive regimes might provide a similar springboard for winning a nationwide program in the United States.

PNHP is actively pursuing outreach to the physician community through presentations at conferences, grand rounds, and public forums. The decision to organize a physicians’ group followed several months of discussion. PNHP’s founders felt that a broader group could not attract many sympathetic physicians who are not already activists. PNHP is seen as a part of a Network of Health Professionals for a National Health Program, which can amplify the voices of existing organizations like the Coalition for a National Health Service, and the National Association for Public Health Policy. We are already working jointly with elderly and community organizations to formulate proposals for statewide demonstration programs in Massachusetts and a few other states.

To join PNHP or obtain information on our activities, write: Physicians for a National Health Program, Center for National Health Program Studies, Department of Medicine, The Cambridge Hospital, 1493 Cambridge Street, Cambridge, MA 02139. [PNHP note: PNHP’s current address is Physicians for a National Health Program, 29 E. Madison St., Suite 1412, Chicago IL 60602.]

References

1. McKinlay, J. B., and Arches, J. Towards the proletarianization of physicians. Int. J. Health Serv. 15(2): 161-196, 1985.

2. Himmelstein, D.U., and Woolhandler, S. Socialized medicine: A solution to the cost crisis in health care in the United States. Int. J. Health Serv. 16(3): 339-354, 1986.

3. Himmelstein, D.U., and Woolhandler, S. Medicine as industry: The health sector in the U.S. Monthly Rev. 35(11): 13-25, 1984.

4. Navarro, V. Where is the popular mandate? N. Engl. f. Med. 307: 1516-1518, 1982.

5. Colombotos, J., and Kirchner, C. Physicians and Social Change. Oxford University Press, New York, 1986.

International Journal of Health Services, Volume 17, Number 4, 1987.

© 1987, Baywood Publishing Co., Inc. http://baywood.com

doi: 10.2190/C343-W933-786Q1R3T

What does the election mean for health care reform?

Yes, Obama Won a Mandate

By Jonathan Cohn
The New Republic, November 7, 2012

I’ve waited more than two years to write this sentence: The Affordable Care Act is here to stay. It survived the Supreme Court and now it has survived the threat of a unified Republican government determined to repeal it. Implementation of the law will present huge challenges, but, for the first time in a long while, the administration and its allies can focus on those challenges rather than on rearguard political fights to keep the program alive.

http://www.tnr.com/blog/plank/109818/obama-wins-four-more-years-mandate-agenda-validation-obamacare

Comment:

By Don McCanne, MD

The reelection of President Obama and the failure of the Republicans to gain more than filibuster control of the Senate means that the Affordable Care Act (Obamacare, or ACA) will be fully implemented by 2014, as scheduled.

Although such complex legislation inevitably calls for legislative refinements, any significant efforts to expand the effectiveness of ACA would surely be blocked in the Republican-controlled House.

In the meantime, efforts on the state level to improve ACA will continue. Although small incremental steps are possible, it is unlikely that any model close to a true single payer system will be enacted within the states, even if the single payer label is used. The reason is that major enabling federal legislation would be required to construct a true stated-based single payer system, and the House still has its primary tool that it has wielded so effectively for the past two years: gridlock.

Although it seems like this might be a time to kick back and wait until the political climate improves, nothing could be further from the truth. The first step in advancing health care justice is to educate – inform the public on the facts.

We have two messages: 1) no matter how many tweaks are applied, ACA will not achieve health care justice – 30 million will remain uninsured, tens of millions underinsured, and health care costs will not be contained, and 2) there is a model that will cover absolutely everyone, provide access to high quality care, reduce financial barriers to care, and slow the increase in health care spending which would benefit us all – a single payer, improved Medicare for everyone.

We need to intensify our efforts to spread the word so that the people of our nation will be ready to support reform enthusiastically when the political climate becomes more favorable.

Employers gradually bailing out on employee coverage

Health-Care Law Spurs a Shift to Part-Time Workers

By Julie Jargon, Louise Radnofsky and Alexandra Berzon
The Wall Street Journal, November 4, 2012

Some low-wage employers are moving toward hiring part-time workers instead of full-time ones to mitigate the health-care overhaul’s requirement that large companies provide health insurance for full-time workers or pay a fee.

Several restaurants, hotels and retailers have started or are preparing to limit schedules of hourly workers to below 30 hours a week. That is the threshold at which large employers in 2014 would have to offer workers a minimum level of insurance or pay a penalty starting at $2,000 for each worker.

If a company offers health insurance but the coverage is deemed sparse or unaffordable, the company must pay $3,000 for every worker who gets a federal tax subsidy to purchase coverage as an individual.

Pillar Hotels & Resorts this summer began to focus more on hiring part-time workers among its 5,500 employees. The company has 210 franchise hotels, under the Sheraton, Fairfield Inns, Hampton Inns and Holiday Inns brands.

CKE Restaurants Inc., parent of the Carl’s Jr. and Hardee’s burger chains, began two months ago to hire part-time workers to replace full-time employees who left.

Home retailer Anna’s Linens Inc. is considering cutting hours for some full-time employees to avoid the insurance mandate if the health-care law isn’t repealed.

Darden Restaurants Inc. was among the first companies to say it was changing hiring in response to the health-care law. The Orlando, Fla., parent of Red Lobster and Olive Garden in February began testing hiring part-time workers in four markets to replace some full-time employees who had left, a spokesman said.

http://online.wsj.com/article/SB10001424052970204707104578094941709047834.html

And…

Jobs Without Benefits: The Health Insurance Crisis Faced by Small Businesses and Their Workers

By Ruth Robertson, Kristof Stremikis, Sara R. Collins, Michelle M. Doty, and Karen Davis
The Commonwealth Fund, November 2012

The share of U.S. workers in small firms who were offered, eligible for, and covered by health insurance through their jobs has declined over the past decade. Less than half of workers in companies with fewer than 50 employees were both offered and eligible for health insurance through their jobs in 2010, down from 58 percent in 2003.

http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2012/Oct/1640_Robertson_jobs_without_benefits_small_businesses.pdf

And…

Employers Expected To Keep Some Of Health Law’s Popular Provisions, Even If Obama Loses

By Julie Appleby
Kaiser Health News, November 5, 2012

No matter who wins the presidential election…

Employers will continue looking for ways to cap expenses, moving toward higher deductible policies, or placing limits on how much they pay toward their workers’ premiums — both trends that predate the federal health law, analysts say.

http://www.kaiserhealthnews.org/Stories/2012/November/06/employer-insurance-coverage-election.aspx

Comment:

By Don McCanne, MD

As we have stated several times before, the Affordable Care Act (ACA) was designed to encourage the perpetuation of employer-sponsored health plans which currently provide the majority of the population with coverage. Current trends do not look favorable. More than half of workers in small companies do not even receive health care coverage, and some larger employers are beginning to shift to part-time employment in order to escape the insurance requirements of ACA. Those that continue coverage are shifting more costs to employees through higher deductibles and through a shift to defined contribution programs.

A health care financing system should provide full coverage for everyone automatically. Obviously, ACA does not do that. The CBO predicts that 30 million will remain without coverage, but based on the fact that employers are beginning to bail out, it is likely that the numbers of uninsured will be even greater. We have to do something different.

How could we achieve automatic enrollment for everyone? Simple. Just as with Medicare Part A, enroll every qualified individual automatically. In a properly designed single payer system, absolutely everyone would be qualified, and therefore everyone would be enrolled.

Wealth & Health: Public Taxes, Private Dollars

By Carl Finamore
BeyondChron (San Francisco), Nov. 5, 2012

Let’s not kid ourselves, despite all the talk about healthcare reform the last few years, getting sick in America is still very risky.

There are 25 million people with insurance in 2010 still struggling to pay medical bills according to a conservative estimate by the Commonwealth Fund. In fact, nearly two-thirds of all personal bankruptcies are still linked to those debts. Meanwhile, those without any health insurance were estimated at 48 million in 2011 with the Congressional Budget Office estimating that even after the Affordable Care Act is fully implemented seven years from now, at least 29 million people will remain completely uninsured. Overall, not such a good social contract for most Americans. However, it appears to be a very good deal for wealthy investors. What better source to consult than Bain & Company. Yes, that Bain & Company.

According to Bain, private equity global investments in healthcare doubled in one year – from $15 billion in 2010 to $30 billion in 2011.

That remarkably concentrated investment represents a whopping 15 percent of all private equity deals in the world last year and netted an astounding profit of $500 billion. The question is raised – what impact, aside from the aforementioned huge profits for the few, does that investment in private healthcare have on the rest of us?

I wanted to ask this and other questions of someone equally expert at providing care to patients as Bain is at making money off patients. So, I paid a visit to a working doctor attending the October 27 national conference of Physicians for a National Health Program (PNHP) held in San Francisco.

Andy Coates, MD, is president-elect of PNHP, an acute care physician at a community hospital in upstate Troy, New York, a medical director at a county public nursing home and a faculty member at Albany Medical College. A busy guy.

Asked to identify the number one problem with healthcare in the United States, Dr. Coates replied: “I am very tempted to say ‘profit is the problem,’ end of story.”

But there’s more. “The American system has an enormous amount of unnecessary bureaucratic waste,” he elaborated. “A great burden of time-consuming administrative efforts, aimed at extracting profit from caregiving, weighs upon us. So much of the cost of healthcare has nothing to do with what is happening at the bedside. The quest for corporate profits undermines the effort to provide medical care to human beings.”

Healthcare is Big Business Funded by Our Taxes

Some might be surprised that the for-profit healthcare system Dr. Coates criticizes so sharply is mostly paid for with our tax dollars. Through tax subsidies for private health insurance and for public employee health benefits, through direct government Medicare and Medicaid subsidies and through numerous other ways, our taxes pay around 60 percent of our current health spending, or as PNHP leaders Drs. Steffie Woolhandler and David U. Himmelstein say, we are “paying for national health insurance and not getting it.”

Woolhandler, MD, is professor of public health at City University of New York, visiting professor of medicine at Harvard Medical School and spokesperson for PNHP. She told me that “the majority of healthcare funding in other developed countries is also paid through taxes but in each case the costs are much lower and you get more.”

Incredibly, health spending amounts to around $9000 per capita in this country whereas other developed countries spend about half as much because they have some version of a not-for-profit national public healthcare system.

It’s another sad commentary that the data also clearly establishes that “our system does not perform any better,” says Woolhandler, such as, for example, in life expectancy where we are two or three years behind other developed countries.

Actually, we do not have to go too far to find more comparisons between private and public forms of healthcare delivery. We can look right here in this country.

For example, the completely government paid and operated Veterans Health Administration (VA), widely acclaimed for its superior medical services, makes bulk purchases of prescription drugs at substantially reduced costs.

By contrast, the government is prohibited by law from making these same bulk purchases on the open market on behalf of Medicare and Medicaid patients because it would undercut monopoly profits of pharmaceutical giants.

Another comparison is the cost advantages of the two systems. Fortune magazine called the not-for profit VA “the most wired and cost-effective health system in the land” whereas the private sector squanders around 31 percent of their budget on non-treatment related administrative costs. These statistics are not secret. In fact, they are generally known.

As Walter Tsou, MD ,PNHP member and past president of the American Public Health Association told a San Francisco public forum on October 29, “We know what works, all we have to do is pay attention to the social science data.”

But even when these savings are clearly documented, the for-profit system is so entrenched that government Medicare and Medicaid tax funds continue flowing to private providers and insurers such as the expanding Medicare Advantage programs. And here is where, according to PNHP, the private sector grievously repeats its pattern of extravagance and greed.

Facts are Facts but Money is Power

According to research soon to appear in the International Journal of Health Services by a group of policy experts, including Dr. Woolhandler, it was determined that the amount of tax dollars that Medicare has “overpaid private insurance companies under the Medicare Advantage program and its predecessors over the past 27 years is a startling figure of $282.6 billion in excess payments, most of them over the past eight years.”

That’s wasted money that should have been spent on improving patient care, shoring up Medicare’s trust fund or reducing the federal deficit, researchers said.

So, here we have the rather noteworthy variance of huge amounts of public dollars going to private suppliers of healthcare, often insatiable Wall Street investors operating without any of the control or regulation taxpayers should expect. Is there any wonder costs are going up?

We as a society will pay the price as millions of uninsured avoid treatment, millions suffer economic hardship because of rising co-pay and deductible costs and millions discover too late their skimpy insurance coverage will not cover their medically recommended recovery plan.

“We need to be active on these issues,” San Francisco single-payer activist Don Bechler told me at the PNHP conference.

“When we have access to the microphone, we win these debates. So, to organize the campaign for universal healthcare minus the insurance companies, it is important that people go to singlepayernow.net or healthcare-now.org and support the national ‘Improved and Expanded Medicare for All Act’ in Congress (HR 676).”

Certainly both research and activism are necessary components of the renewed and reinvigorated national healthcare debate that we so desperately need. But, for this debate to be productive, it cannot, unlike the Congressional discussions we’ve seen, tap dance around the greed and inefficiency of the profiteers who are engulfing and undermining our medical system.

Sources available upon request.

Carl Finamore is Machinist Lodge 1781 delegate to the San Francisco Labor Council. He can be reached at local1781@yahoo.com

http://www.beyondchron.org/articles/Wealth_Health_Public_Taxes_Private_Dollars_10671.html

Wealth & Health: Public Taxes, Private Dollars

By Carl Finamore
BeyondChron (San Francisco), Nov. 5, 2012

Let’s not kid ourselves, despite all the talk about healthcare reform the last few years, getting sick in America is still very risky.

There are 25 million people with insurance in 2010 still struggling to pay medical bills according to a conservative estimate by the Commonwealth Fund. In fact, nearly two-thirds of all personal bankruptcies are still linked to those debts. Meanwhile, those without any health insurance were estimated at 48 million in 2011 with the Congressional Budget Office estimating that even after the Affordable Care Act is fully implemented seven years from now, at least 29 million people will remain completely uninsured. Overall, not such a good social contract for most Americans. However, it appears to be a very good deal for wealthy investors. What better source to consult than Bain & Company. Yes, that Bain & Company.

According to Bain, private equity global investments in healthcare doubled in one year – from $15 billion in 2010 to $30 billion in 2011.

That remarkably concentrated investment represents a whopping 15 percent of all private equity deals in the world last year and netted an astounding profit of $500 billion. The question is raised – what impact, aside from the aforementioned huge profits for the few, does that investment in private healthcare have on the rest of us?

I wanted to ask this and other questions of someone equally expert at providing care to patients as Bain is at making money off patients. So, I paid a visit to a working doctor attending the October 27 national conference of Physicians for a National Health Program (PNHP) held in San Francisco.

Andy Coates, MD, is president-elect of PNHP, an acute care physician at a community hospital in upstate Troy, New York, a medical director at a county public nursing home and a faculty member at Albany Medical College. A busy guy.

Asked to identify the number one problem with healthcare in the United States, Dr. Coates replied: “I am very tempted to say ‘profit is the problem,’ end of story.”

But there’s more. “The American system has an enormous amount of unnecessary bureaucratic waste,” he elaborated. “A great burden of time-consuming administrative efforts, aimed at extracting profit from caregiving, weighs upon us. So much of the cost of healthcare has nothing to do with what is happening at the bedside. The quest for corporate profits undermines the effort to provide medical care to human beings.”

Healthcare is Big Business Funded by Our Taxes

Some might be surprised that the for-profit healthcare system Dr. Coates criticizes so sharply is mostly paid for with our tax dollars. Through tax subsidies for private health insurance and for public employee health benefits, through direct government Medicare and Medicaid subsidies and through numerous other ways, our taxes pay around 60 percent of our current health spending, or as PNHP leaders Drs. Steffie Woolhandler and David U. Himmelstein say, we are “paying for national health insurance and not getting it.”

Woolhandler, MD, is professor of public health at City University of New York, visiting professor of medicine at Harvard Medical School and spokesperson for PNHP. She told me that “the majority of healthcare funding in other developed countries is also paid through taxes but in each case the costs are much lower and you get more.”

Incredibly, health spending amounts to around $9000 per capita in this country whereas other developed countries spend about half as much because they have some version of a not-for-profit national public healthcare system.

It’s another sad commentary that the data also clearly establishes that “our system does not perform any better,” says Woolhandler, such as, for example, in life expectancy where we are two or three years behind other developed countries.

Actually, we do not have to go too far to find more comparisons between private and public forms of healthcare delivery. We can look right here in this country.

For example, the completely government paid and operated Veterans Health Administration (VA), widely acclaimed for its superior medical services, makes bulk purchases of prescription drugs at substantially reduced costs.

By contrast, the government is prohibited by law from making these same bulk purchases on the open market on behalf of Medicare and Medicaid patients because it would undercut monopoly profits of pharmaceutical giants.

Another comparison is the cost advantages of the two systems. Fortune magazine called the not-for profit VA “the most wired and cost-effective health system in the land” whereas the private sector squanders around 31 percent of their budget on non-treatment related administrative costs. These statistics are not secret. In fact, they are generally known.

As Walter Tsou, MD ,PNHP member and past president of the American Public Health Association told a San Francisco public forum on October 29, “We know what works, all we have to do is pay attention to the social science data.”

But even when these savings are clearly documented, the for-profit system is so entrenched that government Medicare and Medicaid tax funds continue flowing to private providers and insurers such as the expanding Medicare Advantage programs. And here is where, according to PNHP, the private sector grievously repeats its pattern of extravagance and greed.

Facts are Facts but Money is Power

According to research soon to appear in the International Journal of Health Services by a group of policy experts, including Dr. Woolhandler, it was determined that the amount of tax dollars that Medicare has “overpaid private insurance companies under the Medicare Advantage program and its predecessors over the past 27 years is a startling figure of $282.6 billion in excess payments, most of them over the past eight years.”

That’s wasted money that should have been spent on improving patient care, shoring up Medicare’s trust fund or reducing the federal deficit, researchers said.

So, here we have the rather noteworthy variance of huge amounts of public dollars going to private suppliers of healthcare, often insatiable Wall Street investors operating without any of the control or regulation taxpayers should expect. Is there any wonder costs are going up?

We as a society will pay the price as millions of uninsured avoid treatment, millions suffer economic hardship because of rising co-pay and deductible costs and millions discover too late their skimpy insurance coverage will not cover their medically recommended recovery plan.

“We need to be active on these issues,” San Francisco single-payer activist Don Bechler told me at the PNHP conference.

“When we have access to the microphone, we win these debates. So, to organize the campaign for universal healthcare minus the insurance companies, it is important that people go to singlepayernow.net or healthcare-now.org and support the national ‘Improved and Expanded Medicare for All Act’ in Congress (HR 676).”

Certainly both research and activism are necessary components of the renewed and reinvigorated national healthcare debate that we so desperately need. But, for this debate to be productive, it cannot, unlike the Congressional discussions we’ve seen, tap dance around the greed and inefficiency of the profiteers who are engulfing and undermining our medical system.

Sources available upon request.

Carl Finamore is Machinist Lodge 1781 delegate to the San Francisco Labor Council. He can be reached at local1781@yahoo.com

http://www.beyondchron.org/articles/Wealth_Health_Public_Taxes_Private_Dollars_10671.html

Employers gradually bailing out on employee coverage

Health-Care Law Spurs a Shift to Part-Time Workers

By Julie Jargon, Louise Radnofsky and Alexandra Berzon
The Wall Street Journal, November 4, 2012
Some low-wage employers are moving toward hiring part-time workers instead of full-time ones to mitigate the health-care overhaul’s requirement that large companies provide health insurance for full-time workers or pay a fee.
Several restaurants, hotels and retailers have started or are preparing to limit schedules of hourly workers to below 30 hours a week. That is the threshold at which large employers in 2014 would have to offer workers a minimum level of insurance or pay a penalty starting at $2,000 for each worker.
If a company offers health insurance but the coverage is deemed sparse or unaffordable, the company must pay $3,000 for every worker who gets a federal tax subsidy to purchase coverage as an individual.
Pillar Hotels & Resorts this summer began to focus more on hiring part-time workers among its 5,500 employees. The company has 210 franchise hotels, under the Sheraton, Fairfield Inns, Hampton Inns and Holiday Inns brands.
CKE Restaurants Inc., parent of the Carl’s Jr. and Hardee’s burger chains, began two months ago to hire part-time workers to replace full-time employees who left.
Home retailer Anna’s Linens Inc. is considering cutting hours for some full-time employees to avoid the insurance mandate if the health-care law isn’t repealed.
Darden Restaurants Inc. was among the first companies to say it was changing hiring in response to the health-care law. The Orlando, Fla., parent of Red Lobster and Olive Garden in February began testing hiring part-time workers in four markets to replace some full-time employees who had left, a spokesman said.
http://online.wsj.com/article/SB1000142405297020470710457809494170904783…
And…

Jobs Without Benefits: The Health Insurance Crisis Faced by Small Businesses and Their Workers

By Ruth Robertson, Kristof Stremikis, Sara R. Collins, Michelle M. Doty, and Karen Davis
The Commonwealth Fund, November 2012
The share of U.S. workers in small firms who were offered, eligible for, and covered by health insurance through their jobs has declined over the past decade. Less than half of workers in companies with fewer than 50 employees were both offered and eligible for health insurance through their jobs in 2010, down from 58 percent in 2003.
http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief…
And…

Employers Expected To Keep Some Of Health Law’s Popular Provisions, Even If Obama Loses

By Julie Appleby
Kaiser Health News, November 5, 2012
No matter who wins the presidential election…
Employers will continue looking for ways to cap expenses, moving toward higher deductible policies, or placing limits on how much they pay toward their workers’ premiums — both trends that predate the federal health law, analysts say.
http://www.kaiserhealthnews.org/Stories/2012/November/06/employer-insura…

As we have stated several times before, the Affordable Care Act (ACA) was designed to encourage the perpetuation of employer-sponsored health plans which currently provide the majority of the population with coverage. Current trends do not look favorable. More than half of workers in small companies do not even receive health care coverage, and some larger employers are beginning to shift to part-time employment in order to escape the insurance requirements of ACA. Those that continue coverage are shifting more costs to employees through higher deductibles and through a shift to defined contribution programs.
A health care financing system should provide full coverage for everyone automatically. Obviously, ACA does not do that. The CBO predicts that 30 million will remain without coverage, but based on the fact that employers are beginning to bail out, it is likely that the numbers of uninsured will be even greater. We have to do something different.
How could we achieve automatic enrollment for everyone? Simple. Just as with Medicare Part A, enroll every qualified individual automatically. In a properly designed single payer system, absolutely everyone would be qualified, and therefore everyone would be enrolled.

UnitedHealth takes over risk adjustment function from government

Conflict-of-interest concerns raised as Obama races to implement health reform

By Alexander Bolton
The Hill, November 3, 2012
The Obama administration is relying heavily on outside contractors to implement a core component of healthcare reform as it races to set up a federal health insurance marketplace before 2014.
The fast-approaching deadline gives the administration little time to scrutinize private-sector partners for conflicts of interest.
The purchase of one of these contractors, Quality Software Services, Inc. (QSSI), by UnitedHealth Group, a major healthcare conglomerate, has sparked concerns about a potentially uneven playing field.
QSSI, a Maryland-based contractor, in January won a large contract to build a federal data services hub to help run the complex federal health insurance exchange.
It will be working with several other contractors, including CGI Federal, Inc., to create the technological architecture for the exchange.
The quiet nature of the transaction, which was not disclosed to the Securities and Exchange Commission (SEC), has fueled suspicion among industry insiders that UnitedHealth Group may be gaining an advantage for its subsidiary, UnitedHealthcare.
It is difficult to know QSSI’s precise role because its contract is not publicly available and the department of health and human services did not provide a copy. A draft statement of work issued by HHS and used for the bidding process offers a glimpse of what the contract requires.
It reveals QSSI will finalize technical and systems requirements to develop and deliver plan management services, which includes the certifying and decertifying of health plans offered on the exchange. Plan management services also entails monitoring agreements with health plans to ensure compliance.
The technology will wield massive flows of socio-economic and health information for populations around the country that an insurance company, if privy to, could use as valuable business intelligence to determine what markets to play in.
If an insurance company had influence over the information technology architecture used to run the exchange, it could interpret federal standards in a way to exclude competitors or make it more difficult for them to win approval, say some insurance experts. Or it could have an inside track on knowing how to design plans that meet the standards.
The contractors working on the exchange will also have responsibility over payment calculation for risk adjustment.
This program is intended to redistribute funding from plans that attract younger and healthier participants, and thus have lower costs, to plans that attract people with more chronic diseases.
The draft statement of work for the contract shows QSSI will also work on technical requirements to deliver financial management services, such as payment calculation for risk adjustment.
The prospect that a subsidiary of UnitedHealth Group could have a role in calculating the reallocation of federal funds among rival health plans has unnerved some industry insiders.
“Financial management services include the services necessary to spread risk among issuers and to accomplish financial interactions with issuers,” the document states. “The risk spreading services include but are not limited to: payment calculation for reinsurance, risk adjustment and risk corridors, along with required data collection to support these services.”
The contract, which underwent a full and open competition, was initially awarded to QSSI in September of 2011 and finalized in January.
A senior executive with Optum, the subsidiary of UnitedHealth Group which bought QSSI at the end of September, said his firm and UnitedHealthcare are entirely separate businesses despite belonging to the same parent company.
“UnitedHealthcare is a client of Optum, an arms-length client, separately reported financially and separately managed,” said Andy Slavitt, group executive vice president at Optum.
“Optum has a very simple mission and that is to engage in activities to make sure the healthcare system works better for all participants,” he said, citing services such as helping an employer or union manage pharmacy benefits or helping a health company implement technologies.”
http://thehill.com/blogs/healthwatch/health-reform-implementation/265659…

One of the many reasons that we don’t want private health insurers to manage our health care funds is that they have mastered gaming health care risks.
In the Medicare program, private insurers have selectively marketed their Medicare Advantage products to healthier individuals, yet have been paid at higher rates based on the average health care needs of this older and sicker population. The Medicare administration attempted to correct for this by risk adjustment. That is, they increased payments for patients diagnosed with more significant disorders, while reducing payments for patients with minimal disorders. The insurers responded by coding not very sick patients as if they had more serious disorders – not frank fraud, but taking liberties with diagnoses. Instead of correcting the overpayment problem this actually further increased the amount of overpayments to the private insurers.
With the Affordable Care Act, do you believe that the private insurers have had an epiphany and now want to give patients and taxpayers the best health care value possible? If you think so, you don’t understand this industry.
Follow this timetable:
* The Obama administration decided to use outside contractors to build a federal data services hub to help run the federal health insurance exchange.
* One of the more important functions of that hub is to have responsibility over payment calculation for risk adjustment. “This program is intended to redistribute funding from plans that attract younger and healthier participants, and thus have lower costs, to plans that attract people with more chronic diseases.”
* Under a competitive process, the contract was awarded to Quality Software Services, Inc. (QSSI) in September 2011, and finalized in January 2012.
* Steve Larsen, a senior official at HHS “left the Center for Consumer Information and Insurance Oversight, the office tasked with crafting rules for the national exchange, in July to take a job with Optum.”
* In September 2012, QSSI was purchased by Optum, a subsidiary of UnitedHealth Group, the parent company of UnitedHealthcare, the largest insurer in the nation.
Lest anyone might suggest that Steve Larsen may have been involved in a nefarious plot to benefit UnitedHealth, former Rep. Earl Pomeroy, a registered lobbyist with Alston & Bird, which represents Aetna, “dismissed the notion that Larsen may have given Optum an unfair advantage.”
UnitedHeathcare’s stealth takeover of the administrative entity that will allow their subsidiary to supervise risk adjustment for the plans in the federal health insurance exchange should have us all concerned. Considering their prior bad behavior, should we trust them now that they have even greater control over risk adjustment? Think not.
Okay, it’s clear that the problem is that we have turned control of health care financing over to an industry that must place its own interests over those of patients. So what is the solution? Do we further increase regulatory oversight? History has shown that they will always meet their fundamental business obligations by finding other ways to skirt regulatory interventions, just as they found a way improve their return when risk adjustment was applied as a solution to their practice of favorable selection (selectively marketing the healthy).
No, it is not that they need more government oversight, because that clearly is an inadequate solution. Rather, the solution is that this industry needs to be replaced with a public program owned by the people of this nation. We need a public service model instead of a private business model of health care financing. We need a single payer national health program – an improved Medicare that covers everyone.

A Single-Payer System Would Reduce U.S. Health Care Costs

By Ed Weisbart, M.D.
Virtual Mentor: the AMA Journal of Ethics, November 2012

We Have Not Yet Solved the Health Care Crisis

The Affordable Care Act (ACA) is introducing insurance reforms that will improve the lives of millions of Americans, but we need to go much further to solve the crisis in health care.

Without correcting the fundamental structural flaws in health care financing, overall health care costs will remain poorly controlled. Though our clinical outcomes are mediocre by comparison [1], the average per capita cost of health care in the United States is twice that of other modern nations [2]. Increasingly, these costs are being borne by patients and government, driving personal bankruptcies and ever more austere public policies [3, 4]. Under the ACA, 30 million people will still have no coverage [5], and countless more will have inadequate coverage [1].

For most Americans, the glory days of “Cadillac health plans” are over, if they ever existed. The declining actuarial value of plans offered by employers means that the ACA will still leave those who need health care with financial hardships and high rates of bankruptcy, in spite of the subsidies for premiums and out-of-pocket expenses. (The actuarial value of a plan is the percentage of a patient’s predictable costs within the covered list of services that would generally be paid by the insurance company.) In order to participate in one of the ACA’s new health insurance exchanges, insurance companies are required to offer at least one “silver” and one “gold” plan, with 70 percent or 80 percent actuarial value, respectively. An insurance policy with a 70 percent actuarial value would, by definition, leave patients responsible for 30 percent of the overall cost of the care on the list of covered services. Many other medically necessary services, such as home and long-term care, dental treatment, hearing aids, and basic vision care, will not be covered and are therefore not captured in out-of-pocket maximums.

Health insurance exchanges are envisioned to function like many familiar online marketplaces, such as Travelocity or Amazon. The fate of the ACA’s health insurance exchanges may not be determined entirely until after the upcoming elections. At the moment, only a handful of states have fully committed to implementing exchanges [6]. States that do not implement an exchange will have an exchange implemented for them by the federal government, assuming Congress allocates the appropriate resources. They will be available on January 1, 2014, for uninsured individuals and small groups to compare insurance plans.

Comparison shopping makes sense when buying a product like an automobile, about which individual preferences vary widely. With health insurance, however, we all need the same thing: affordable access to high-quality health care. We need to be able to select our own physicians, but the complexities of selecting an insurance company distract us from genuinely beneficial health care activities. Given the currently dominant role of insurers in our health care, the exchanges are a step forward. But what we need is a leap forward, changing the insurance companies’ role and allowing us to focus on our health, not our insurance.

In the 6 years since Massachusetts adopted legislation very similar to the ACA, the cost of health care has continued to drive patients into financial ruin [7]. The state has achieved nearly universal coverage, but, like the ACA, its legislation has yet to effectively address cost and sustainability. Its newly enacted cost-containment law relies heavily on unproven measures such as capitated payments and wellness programs, offering little promise of success [8].

We will not solve our health care crisis as long as private insurance plays a dominant role. We should correct the flaws of the current Medicare program and extend this coverage to all age groups. This approach was well described in 2003 in the Physicians for a National Health Program’s “Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance” [9].

Major Deficiencies Remain

The Dartmouth Atlas of Health Care has repeatedly documented “glaring variations in how medical resources are distributed and used in the United States” [10]. They attribute much of this variation to supply-sensitive care, that is, care determined by resources and capacity rather than by medical need, and conclude that supply-sensitive care “accounts for more than half of all Medicare spending” [11], some of which is of no medical value and a waste of resources.

A second problem is that the uniquely American plethora of private insurance companies drives a squandering of resources. Legions of staff manage independent computer systems. Each insurance company devotes an enormous number of personnel to responding to emerging regulations from a variety of disparate governmental programs. The expense of this redundancy is considered “overhead” and passed along to the consumer. The intent behind those regulations could instead be implemented once, in a single system servicing the entire country.

Each insurance company develops its own programs for utilization management, prior authorizations, and evidence-based drug formularies to compel the use of that plan’s preferred vendors and pharmaceuticals, consuming resources but adding little proven value to health outcomes. No two “evidence-based” formularies have the same drugs on their lists. It’s virtually impossible for a physician to remember which low-molecular-weight heparin is preferred by which insurer. Medical groups and hospitals all dedicate staff to managing within this environment, eroding their profits and contributing to a demand for higher reimbursement.

Cost-containment efforts today are focused on the back end of delivery, placing economic pressures on individual physicians and patients who cannot realistically be expected to pursue systemwide solutions [12]. This is the illogic behind “pay for performance” and “consumer engagement.”

In a cynical denial of the responsibility for national planning, patients and physicians are expected to be able to control costs today. Information about the prices of treatment regimens is seldom available at the point of health care delivery, especially not for the complex needs of the desperately ill who consume the lion’s share of resources. It is inhumane to ask someone dealing with the most dangerous phase of a major illness to attempt a cost-benefit comparison of a variety of therapies and health care providers.

Furthermore, pretending that health care is a commodity does not make it easier to reduce it to something simplistic like a spreadsheet comparing airline tickets. Neither the full cost nor the relevant quality is readily available for comparison-shopping.

The ACA began an important discussion of cost containment through the modernization of broad systems such as electronic health records, prevention, and accountable care organizations. While these may hold promise, there is little reason to anticipate their leading to the savings necessary to reverse the crisis [13, 14].

A Single-Payer System Would Improve Resource Allocation

A single-payer system offers several strategies that have succeeded in other countries. As Marmor and Oberlander have written, “they may not be modern, exciting, or ‘transformational.’ But they do have the advantage of working” [15].

Consolidate fragmented finances. It’s been said that when you are trapped in a hole, the first rule is to stop digging. Certainly don’t dig faster.

Profound administrative excesses divert resources into activities that do not improve health outcomes. They often represent the entire careers of countless highly skilled and compassionate peop
le who could be spending their time delivering health care rather than impeding it.

Insurance companies have balked at the ACA’s requiring them to spend at least 80-85 percent of their revenue on delivery of health care. (In contrast, more than 98 percent of Medicare’s expenditures are clinical [16].) Estimates vary, but one-quarter to one-third of our current costs are driven by insurance company overhead, profits, and the administrative costs embedded in clinical settings. Roughly half of these costs would be recovered under single-payer and could be reallocated to the delivery of meaningful health care services [17, 18].

A single-payer model would eliminate the inefficiencies of fragmentation by converting public programs such as Medicare, Medicaid, and CHIP into a single administratively efficient financing system. Streamlined billing under single payer would save physicians vast amounts in overhead [19].

In addition to reduced billing expenses, physicians would also enjoy a meaningful drop in their malpractice premiums. Roughly half of all malpractice awards are for present and future medical costs [20], so if malpractice settlements no longer need to include them, premiums would fall dramatically.

Use bulk purchasing to negotiate lower costs. We spend more but use less of most services [21] than other member nations of the Organization for Economic Cooperation and Development. In other words, our prices are much higher [22]. As health care economist Uwe Reinhardt noted, “prices for identical products or services in the U.S. tend to be, on average, twice or more than the prices of the same products and services paid in other countries…. Prices are high here because the payment side of the health system is so fragmented that few payers have sufficient market power to bargain for lower prices from an increasingly consolidated supply side.” [23]

Drug formularies vary widely among health plans. The medical evidence behind the formulary selections is the same in Florida and Alaska, yet the drug lists are sometimes as different as the geography. Although pharmacy benefit managers work within the boundaries of medical evidence, they also consider the prices they have negotiated and the local drug market shares on their formulary selections. Any industry’s power to negotiate prices depends upon its purchasing volume.

Only a single-payer system enables the kind of bulk purchasing of drugs and medical devices that would give the buyer power. A model for this structure exists today in the United States: the Department of Veterans Affairs. Due to governmental authority to negotiate drug prices for the VA, it pays roughly half of the retail price of drugs [24].

Negotiations with clinicians should ensure adequate reimbursement of expenses plus fair profits, while ensuring value for taxpayers. A recent careful analysis found that this model is effective and does not lead to a loss in physician income [25].

Adopt responsible, rather than profit-driven, strategies. The United States has little national planning of health care resource allocation. Uncontrolled costs consuming an ever-increasing percentage of the GDP create the appearance of inadequate resources, but the experience of other nations [20] belies this. Under a single-payer system, regional planning of resource allocation would be aligned with public health needs rather than duplicating services and driving up medically questionable utilization. Investing in health care buildings and equipment for reasons other than anticipated need duplicates services and drives up utilization. Intelligently planning capital investments to match community health care needs is the key to aligning utilization of services with public health priorities.

According to the Physicians’ Working Group for Single-Payer National Health Insurance, “Capital spending drives operating costs and determines the geographic distribution of resources. When operating and capital payments are combined, as they currently are, prosperous hospitals can expand and modernize while impoverished ones cannot” [9], threatening the viability of safety-net institutions that serve vulnerable populations. This self-stimulating relationship is dependent upon market opportunities, often not the same as public health priorities. Regions with excess capacity inevitably have excess utilization [10]; better planning could also ensure adequate capacity in underserved areas. Divorcing capital from operating budgets eliminates the ongoing pressure to reap future capital growth by limiting reimbursement to clinicians. Capital, operating, and educational budgets would be nationally funded, regionally administered, and nonfungible. Applying national planning to regional budgeting would right-size capacity.

Today’s fragmented system is akin to requiring each household in a community to anticipate their needs for the coming year and negotiate their own fees and scope of services with the local police and fire departments. Imagine instead how much of their budgets these life-saving community services would be obliged to devote to marketing to and negotiating with each household and the rampant disparities in service that would result. That is precisely what is happening today in health care, and it is absurdly wasteful. For police and fire departments, we have recognized that it is significantly less wasteful to give all citizens the same “coverage” for set prices and to administer it with regional coordination. Global budgeting is the only sensible strategy for such unpredictable yet universally needed services.

Conclusion

The ACA has begun the process of much needed change. Now we need to go further in reforming health care finance to enable all Americans to achieve their fundamental human right to comprehensive coverage. The rest of the modern world has run the laboratory studies for us; now is the time for us to adopt this well proven solution.

References

1. Organisation for Economic Co-operation. OECD Health Data 2012: frequently requested data. http://www.oecd.org/els/healthpoliciesanddata/ oecdhealthdata2012-frequentlyrequesteddata.htm. Accessed August 8, 2012
2. Organisation for Economic Co-operation. Data: health expenditure and financing. http://stats.oecd.org/Index.aspx?DataSetCode=SHA. Accessed August 6, 2012.
3. Himmelstein DU, Warren E, Thorne D, Woolhandler S. Illness and injury as contributors to bankruptcy. Health Aff (Millwood). 2005;Suppl Web Exclusive:W5-W73.
4. Himmelstein D, Thorne D, Warren E, Woolhandler S. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med. 2009;122(8):741-746.
5. Congressional Budget Office. Estimates for the insurance coverage provisions of the Affordable Care Act updated for the recent supreme Court decision. http://www.cbo.gov/publication/43472. Accessed August 8, 2012.
6. So, where do states stand on the Medicaid expansion? MSNBC.com. http://leanforward.msnbc.com/_news/2012/07/24/ 12707197-so-where-do-states-stand-on-the- medicaid-expansion?lite. Accessed October 2, 2012.
7. Himmelstein DU, Thorne D, Woolhandler S. Medical bankruptcy in Massachusetts: has health reform made a difference? Am J Med. 2011;124(3):224-228.
8. Howe P. Mass. Gov. Patrick signs health care bill. New England Cable News. http://www.necn.com/08/06/12/ Mass-Gov-Patrick-signs-health-care-bill/ landing_newengland.html?blockID=752369&feedID=7512. Accessed August 8, 2012.
9. Woolhandler S, Himmelstein DU, Angell M, Young QD; Physicians’ Working Group for Single-Payer National Health Insurance. Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance. JAMA. 2003;290(6):798-805.
10. Dartmouth Atlas of Health Care web site. http://www.dartmouthatlas.org. Accessed August 7, 2012.
11. Dartmouth Atlas of Health Care. Supply-sensitive care. http://www.dartmouthatlas.org/ keyiss
ues/issue.aspx?con=2937. Accessed October 10, 2012.
12. Marmor T, Oberlander J. From HMOs to ACOs: the quest for the holy grail in U.S. health policy. J Gen Intern Med. March 13, 2012. Epub. http://www.springerlink.com/content/ m86245k22018507n/fulltext.pdf. Accessed October 3, 2012.
13. DesRoches CM, Campbell EG, Vogeli C, et al. Electronic health records’ limited successes suggest more targeted uses. Health Aff (Millwood). 2010;29(4):639-646.
14. Congressional Budget Office. Budget options volume 1: health care [2008]. http://www.cbo.gov/system/assets/drupal/cbofiles/ ftpdocs/99xx/doc9925/12-18-healthoptions.pdf. Accessed August 6, 2012.
15. Marmor, Oberlander, 1217.
16. Kaiser Family Foundation. Medicare Spending and Financing. http://www.kff.org/medicare/upload/7731-03.pdf. Accessed August 7, 2012.
17. Woolhandler S, Campbell T, Himmelstein DU. Costs of health administration in the U.S. and Canada. N Engl J Med. 2003;349(8):768-775.
18. Kahn JG, Kronick R, Kreger M, Gans DN. The cost of health insurance administration in California: estimates for insurers, physicians, and hospitals. Health Aff (Millwood). 2005;24,(6):1629-1639.
19. Morra D, Nicholson S, Levinson W, Gans DN, Hammons T, Casalino LP. US physician practices versus Canadians: spending nearly four times as much money interacting with payers. Health Aff (Millwood). 2011;30(8):1443-1450.
20. Felice C, Lambrakos L. Medical liability in three single-payer countries. Physicians for a National Health Program. https://pnhp.org/facts/medical_liability _in_three_singlepayer_countries.php. Accessed August 8, 2012.
21. Organisation for Economic Co-operation. Health care utilisation. http://stats.oecd.org/Index.aspx?DataSetCode=HEALTH_PROC. Accessed August 8, 2012.
22. Anderson GF, Reinhardt UE, Hussey PS, Petrosyan V. It’s the prices, stupid. Health Aff (Millwood)., 2008;22(3):89-105.
23. Reinhardt UE. Where ‘socialized medicine’ has a U.S. foothold. New York Times: Economix. August 3, 2012. http://economix.blogs.nytimes.com/2012/08/03/ where-socialized-medicine-has-a-u-s-foothold/. Accessed October 3, 2012.
24. Zaneski CT. VA buys drugs cheaply, many veterans benefit. Baltimore Sun. May 5, 2004. http://articles.baltimoresun.com/2004-05-05/ business/0405050160_1_medicare-drug-buying-power. Accessed October 3, 2012.
25. Duffin J. The impact of single-payer health care on physician income in Canada, 1850-2005. Am J Public Health. 2011;101(7):1198-1208.

Ed Weisbart, MD, CPE, is a founding member of the Saint Louis chapter of Physicians for a National Health Program, a single-issue organization advocating a universal, comprehensive single-payer national health program; a faculty member at Washington University of Saint Louis; chief medical officer at Rx Outreach, a nonprofit mail-order pharmacy providing affordable medications for people in need; and a volunteer in a variety of safety-net clinics across the country. Formerly, he was a family medicine practitioner and then the chief medical officer of Express Scripts.

Virtual Mentor is the American Medical Association’s online ethics journal.  The viewpoints expressed on this site are those of the authors and do not necessarily reflect the views and policies of the AMA.

Virtual Mentor. November 2012, Volume 14, Number 11: 897-903.
© 2012 American Medical Association. All Rights Reserved.

http://virtualmentor.ama-assn.org/2012/11/oped1-1211.html

UnitedHealth takes over risk adjustment function from government

Conflict-of-interest concerns raised as Obama races to implement health reform

By Alexander Bolton
The Hill, November 3, 2012

The Obama administration is relying heavily on outside contractors to implement a core component of healthcare reform as it races to set up a federal health insurance marketplace before 2014.

The fast-approaching deadline gives the administration little time to scrutinize private-sector partners for conflicts of interest.

The purchase of one of these contractors, Quality Software Services, Inc. (QSSI), by UnitedHealth Group, a major healthcare conglomerate, has sparked concerns about a potentially uneven playing field.

QSSI, a Maryland-based contractor, in January won a large contract to build a federal data services hub to help run the complex federal health insurance exchange.

It will be working with several other contractors, including CGI Federal, Inc., to create the technological architecture for the exchange.

The quiet nature of the transaction, which was not disclosed to the Securities and Exchange Commission (SEC), has fueled suspicion among industry insiders that UnitedHealth Group may be gaining an advantage for its subsidiary, UnitedHealthcare.

It is difficult to know QSSI’s precise role because its contract is not publicly available and the department of health and human services did not provide a copy. A draft statement of work issued by HHS and used for the bidding process offers a glimpse of what the contract requires.

It reveals QSSI will finalize technical and systems requirements to develop and deliver plan management services, which includes the certifying and decertifying of health plans offered on the exchange. Plan management services also entails monitoring agreements with health plans to ensure compliance.

The technology will wield massive flows of socio-economic and health information for populations around the country that an insurance company, if privy to, could use as valuable business intelligence to determine what markets to play in.

If an insurance company had influence over the information technology architecture used to run the exchange, it could interpret federal standards in a way to exclude competitors or make it more difficult for them to win approval, say some insurance experts. Or it could have an inside track on knowing how to design plans that meet the standards.

The contractors working on the exchange will also have responsibility over payment calculation for risk adjustment.

This program is intended to redistribute funding from plans that attract younger and healthier participants, and thus have lower costs, to plans that attract people with more chronic diseases.

The draft statement of work for the contract shows QSSI will also work on technical requirements to deliver financial management services, such as payment calculation for risk adjustment.

The prospect that a subsidiary of UnitedHealth Group could have a role in calculating the reallocation of federal funds among rival health plans has unnerved some industry insiders.

“Financial management services include the services necessary to spread risk among issuers and to accomplish financial interactions with issuers,” the document states. “The risk spreading services include but are not limited to: payment calculation for reinsurance, risk adjustment and risk corridors, along with required data collection to support these services.”

The contract, which underwent a full and open competition, was initially awarded to QSSI in September of 2011 and finalized in January.

A senior executive with Optum, the subsidiary of UnitedHealth Group which bought QSSI at the end of September, said his firm and UnitedHealthcare are entirely separate businesses despite belonging to the same parent company.

“UnitedHealthcare is a client of Optum, an arms-length client, separately reported financially and separately managed,” said Andy Slavitt, group executive vice president at Optum.

“Optum has a very simple mission and that is to engage in activities to make sure the healthcare system works better for all participants,” he said, citing services such as helping an employer or union manage pharmacy benefits or helping a health company implement technologies.”

http://thehill.com/blogs/healthwatch/health-reform-implementation/265659-conflict-of-interests-concerns-raised-as-obama-races-to-implement-health-reform

Comment:

By Don McCanne, MD

One of the many reasons that we don’t want private health insurers to manage our health care funds is that they have mastered gaming health care risks.

In the Medicare program, private insurers have selectively marketed their Medicare Advantage products to healthier individuals, yet have been paid at higher rates based on the average health care needs of this older and sicker population. The Medicare administration attempted to correct for this by risk adjustment. That is, they increased payments for patients diagnosed with more significant disorders, while reducing payments for patients with minimal disorders. The insurers responded by coding not very sick patients as if they had more serious disorders – not frank fraud, but taking liberties with diagnoses. Instead of correcting the overpayment problem this actually further increased the amount of overpayments to the private insurers.

With the Affordable Care Act, do you believe that the private insurers have had an epiphany and now want to give patients and taxpayers the best health care value possible? If you think so, you don’t understand this industry.

Follow this timetable:

* The Obama administration decided to use outside contractors to build a federal data services hub to help run the federal health insurance exchange.

* One of the more important functions of that hub is to have responsibility over payment calculation for risk adjustment. “This program is intended to redistribute funding from plans that attract younger and healthier participants, and thus have lower costs, to plans that attract people with more chronic diseases.”

* Under a competitive process, the contract was awarded to Quality Software Services, Inc. (QSSI) in September 2011, and finalized in January 2012.

* Steve Larsen, a senior official at HHS “left the Center for Consumer Information and Insurance Oversight, the office tasked with crafting rules for the national exchange, in July to take a job with Optum.”

* In September 2012, QSSI was purchased by Optum, a subsidiary of UnitedHealth Group, the parent company of UnitedHealthcare, the largest insurer in the nation.

Lest anyone might suggest that Steve Larsen may have been involved in a nefarious plot to benefit UnitedHealth, former Rep. Earl Pomeroy, a registered lobbyist with Alston & Bird, which represents Aetna, “dismissed the notion that Larsen may have given Optum an unfair advantage.”

UnitedHeathcare’s stealth takeover of the administrative entity that will allow their subsidiary to supervise risk adjustment for the plans in the federal health insurance exchange should have us all concerned. Considering their prior bad behavior, should we trust them now that they have even greater control over risk adjustment? Think not.

Okay, it’s clear that the problem is that we have turned control of health care financing over to an industry that must place its own interests over those of patients. So what is the solution? Do we further increase regulatory oversight? History has shown that they will always meet their fundamental business obligations by finding other ways to skirt regulatory interventions, just as they found a way improve their return when risk adjustment was applied as a solution to their practice of favorable selection (selectively mark
eting the healthy).

No, it is not that they need more government oversight, because that clearly is an inadequate solution. Rather, the solution is that this industry needs to be replaced with a public program owned by the people of this nation. We need a public service model instead of a private business model of health care financing. We need a single payer national health program – an improved Medicare that covers everyone.

Health is not a commodity: Let us get the language right

By Josh Freeman, M.D.
Medicine and Social Justice, Nov. 2, 2012

Sometimes the starkest realities are hidden by the language that we choose to speak about them. This week I attended two important conferences, the annual American Public Health Association (APHA) meeting of about 8,000 or more public health workers from across the country, and, on the day preceding it, the annual Physicians for a National Health Program (PNHP) meeting, with about 400 doctors and medical students.

While the PNHP program was more targeted, examining the impact of lack of access to health care in the U.S. on the health of our people, it also included international participants. One, Dr. Alex Benos of Greece, talked articulately about the impact of European Union and IMF imposed “austerity” measures on the health of the Greek people — so bad that the child poverty rate there has risen to 16 percent. The impact of the penalties for “bad” (albeit sanctioned and even encouraged by governments) behavior by bankers is being borne by the people, and especially the poorest, in Greece, in Spain, in Portugal – and in the U.S., where the child poverty rate, 23 percent, still significantly exceeds that of Greece. While they have been dramatically underplayed by the U.S. media, there have been massive, massive, and regular demonstrations against these attacks on the people, and in Greece (as elsewhere) physicians such as Dr. Benos are there on the lines with their patients, providing medical care and demanding the core basic social services that their patients need.

“Health and health care,” Dr. Benos says, “are not commodities that exist to drive the economy. They are among the social goals which we have an economy to achieve.”Source: Dr. David Himmelstein and Dr. Steffie Woolhandler

Think about that. We have been so inundated with news articles, pundits, politicians, and others talking about The Market, about the need for austerity, that we have forgotten to ask the key question of “Why is there an economy? What is the goal of production?” It is the national and international version of the phrase we hear so often in businesses, including hospitals: “No margin, no mission.” Perhaps, but much more important is to have a mission; otherwise it is “No mission, no mission.” When a hospital makes money on its profitable “product lines,” what is the mission? To help provide for the basic health care needs of the poor and uninsured? Or to invest in expanding those already-profitable product lines? If our national and international economies generate wealth, is the goal to provide the basic health needs of those whose labor created that wealth? It is clear what we have, de facto, chosen in the U.S.: since 1992 the top 400 taxpayers have had a 500 percent increase in income, and the rest of the top 5 percent a 150 percent increase. Fifty percent of the total increase in income over that period has gone to the top 400 people, and 93 percent to the top 5 percent!

”Solidarity,” Dr. Benos adds, “means no one should be left alone in this crisis.”

His work and that of other Greek physicians is to be sure that this definition of solidarity is the one they live by. For us, in the U.S., a stronger sense of social solidarity would be important; indeed, any sense of social solidarity would be an improvement. The evil myth propagated by many in the U.S. is that when we support the core needs of the most vulnerable, we weaken the economy; in fact, the reverse is true. Providing a core set of social service, including health care, education, housing, food, and opportunity, increases our ability to be a strong society. It is the opposite, the concentration of all wealth in a few, that jeopardizes our future. Trickle down, it should be clear now, doesn’t happen.

“The ideology,” said Dr. Andrew Coates, another speaker and PNHP president-elect, “is that whatever is private is good and whatever is public is bad. It is not true, and it is certainly not cheaper.” Let us compare the U.S. to our closest neighbor, Canada, where most health care services are privately delivered, but are paid for by a single payer, the government. The U.S. spends $8,230 per capita on health care, of which $5,290 are public dollars (counting not only direct expenditures for Medicare, Medicaid, VA, military, and federal, state and local employees and retirees, but also the foregone tax revenue resulting from employer contributions to health insurance being tax exempt). In Canada, total expenditures are $4,440 per capita. Thus our public fund expenditures per capita exceed Canada’s total expenditure. Hospital billing administrative costs in the U.S. are $570 per capita and total administrative costs are $2,685; in Canada, the numbers are $182 and $809 respectively. The gap in life expectancy between the highest and lowest quintiles of income was 1.5 years in 1972. In 2011 it was nearly 6 years. Life expectancy is lower in the U.S., as are life years adjusted for disability, infant mortality, and virtually every other health indicator. Our money is not buying value; it is accruing wealth to a few.

That language is important was emphasized by presenters at several of the APHA sessions I attended (there are literally hundreds of them over the course of the conference). Sonja Bettez, from the University of New Mexico, observed that talking about health “disparities” tends to minimize the structural violence done to the populations of people who suffer those disparities, and that in Latin America this term is never used; rather the discussion is of inequities, or inequalities. Broad-based differences in health status between populations based on class, race, and other characteristics are not just disparities, they result from deeply seated societal and social problems. Using the language of disparities serves a political purpose, she notes, as it tends to pre-empt social change by emphasizing individual behavior change. She also notes the absence of the term “social justice” from any of the decennial iterations of Healthy People, not to mention the absence of “racism.” How we label things has a great deal to do with how we think about what is necessary to correct them.

In another vein, Donald Light spoke about pharmaceutical companies and marketing, noting the language of “the risk-benefit” ratio (which I have used in this blog) does not make sense because it doesn’t identify risk of what? Accurately, it is a risk-risk ratio, the risk of harm vs the risk of benefit, or “harm-benefit” ratio. This is more stark, and more correct. Dr. Light also discussed what he calls the “inverse benefit law”: that the more widely marketed and used a drug is, the less benefit and more harm results. This makes sense; the lowest harm-benefit ratio accrues from the limited use of a drug for those specific conditions, and in those specific people, in whom it has been shown to have the most benefit; as the use of the drug expands to conditions for which it has been less clearly shown to be beneficial, the risk of harm does not decrease and the harm-benefit ratio increases.

It was a very instructive week, and one in which a lot of information was shared. Sadly, it was not all good, and the future, from the economic crisis in Greece to the health care system in the U.S., is pretty cloudy. But using language carefully and accurately to correctly label problems helps us to identify potential solutions. I think a good touchstone is for us to reject the idea that our health, and that of our families and friends and the entire society, should be a vehicle for profit. Dr. Benos has it right when he says the health is a social good for which we must strive, not a commodity.

Now our task is to make that a reali
ty in the U.S.

http://medicinesocialjustice.blogspot.com/2012/11/let-us-get-language-right-health-is-not.html