PNHP

The wisdom of a legislated medical loss ratio

The wisdom of a legislated medical loss ratio

Democrats Move To Regulate How Insurers’ Spend Customers’ Money

By Julie Appleby
Kaiser Health News
December 20, 2009
Both the House measure and the newly recast Senate bill would force insurers to spend the vast majority of premium revenue on medical care for their customers, reducing the amount available for profits, executive salaries, sales and administration. The Senate bill would require insurers to spend at least 80 percent on medical care and quality improvements (85 percent minimum for plans sold to large groups), while the House bill specifies 85 percent.
Congressional supporters say those provisions would pressure insurance companies to be more efficient and help restrain price increases. But even some advocates say companies could game the system by broadly defining medical costs, for example. And spending limits alone may not stop insurers from raising rates. When New York State tried to limit non-medical care spending, many insurers companies complied – but still instituted double-digit rate increases.
http://www.kaiserhealthnews.org/Stories/2009/December/20/insurers.aspx

If we are serious about providing everyone with health care while controlling costs, it is imperative that we reduce the profound administrative waste of our current fragmented system of financing health care.
Insurers consume typically about 18 percent of premium dollars (range 8 to 30 percent or sometimes even 50 percent), and they place an administrative burden on physicians and hospitals that consumes another 12 percent or so of the premium dollar. Thus about one-fourth to one-third of premiums paid to private insurers are largely wasted on just the administration of the health care finances. A single, universal, publicly-administered program can provide the same or better financing services for a small fraction of that level of administrative spending.
Congress and the Obama administration understand this waste, so what do they propose? They are going to limit the private insurers take of the premium to 15 to 20 percent, not much different from the typical 18 percent they are already consuming. And they will do very little to reduce the administrative burden placed on physicians and hospitals (suggesting that they use computers for billing, which they already do). Change we can believe in? Not much change here.
At our nearly intolerable level of health care spending, reducing this waste should have been one of the highest priorities during the reform process. It is unthinkable that we would allow the private insurance industry to continue to skim off a major portion of our health care dollars while inflicting this costly burden on the health care delivery system. Unthinkable, but that’s exactly what Congress is doing.
Think a moment about the irony of Congress’s decision to set in stone a medical loss ratio of 80 to 85 percent, meaning that they must spend that amount on patient care. That means that they have an ironclad guarantee, written into law, that they can keep 15 to 20 percent of the premiums they receive – our health care dollars.
Think of what that means. Though a public financing program is designed to use our dollars efficiently through a public service model, private insurer financing is designed on a business model. That business model dictates that they do everything possible to maximize revenues and, of course, profits for the investor-owned companies.
By fixing the insurers’ cut at a percentage of gross premium revenues, they can no longer reach down into the funds allocated for patient care, preventing medical loss ratios in the 50 to 80 percent range. The actual net revenues for the insurers would be the 15 to 20 percent that they keep.
If they can’t glom on to more of the health care dollars actually spend on care, then how do they increase their revenues? Since their revenues are limited to a percentage based on how much is spent on health care, to increase their own net revenues they are highly incentivized to dramatically increase spending on health care! The more dollars they throw at health care, the more their net revenues grow since they receive a fixed percentage of all dollars spent.
Just imagine entrepreneurial innovation at work. They will encourage every imaginable program that they can label as patient care because they will receive a fixed percentage of the spending on those programs. Think of it: more expensive electronic medical records and information technology systems, more home health services with a motorized scooter for each level in the home, more costly high-tech services regardless of demonstrated value, higher-priced brand drugs instead of generics, six-figure biologics and cancer drugs, rewarding increased frequency and intensity of services, and, the clincher, blinders to the massive fraud that would be rewarded under this system!
The hurdle cleared by the Senate reform bill in the early morning hours today has made it quite likely that President Obama will be signing the bill within the next several weeks. This should not be construed as a signal for supporters of health care justice to go into hibernation!
There are many measures in this bill that will benefit the nation, but the fundamental structure of a dysfunctional, fragmented financing system based on private insurance plans is a disaster and cannot possibly achieve the goal of affordable, high quality care for everyone.
The mandate for individuals to purchase private health plans will not begin until 2014. We still have a window of opportunity to educate, intensify grassroots efforts, intensify coalition efforts, and get this thing fixed! But we can’t wait for four more years to recharge our activism. Get off your duffs now!

Sen. Bernie Sanders on his amendment for single payer

By DANIEL BARLOW, Vermont Press Bureau
Times Argus (Barre, Vt.), Dec. 17, 2009

MONTPELIER – U.S. Sen. Bernard Sanders was expecting to make history Wednesday.

Instead, his amendment to create a single-payer health care system was used as a tool by Senate Republicans to create gridlock in the chamber as they sought to derail the health care reform plans of Democrats and President Barack Obama.

“That is an outrage,” said the Vermont independent on the floor of the Senate Wednesday afternoon. “People can have honest disagreements, but in this moment of crisis it is wrong to bring the United States government to a halt.”

Sanders’ proposal wasn’t going to garner many votes on the Senate floor, but it would have been the first time that a single-payer health care system was debated and voted on by Congress. Single-payer supporters saw that as a positive step forward.

But when Sanders introduced his amendment, Sen. Tom Coburn, R-OK, asked that it be read in its entirety before a vote, an unusual move given that the readings of most proposals are waived as a courtesy and for the sake of time.

Sanders’ amendment is 767 pages long. After 20 minutes, a Senate clerk got through reading the table of contents. Three hours later, a reluctant Sanders withdrew his amendment.

And then he unloaded on his Republican colleagues in the Senate.

“Everybody in this country understands that our nation faces a significant number of major crises, whether it is the disintegration of our health care system, the fact that 17 percent of our people are unemployed or underemployed, one out of four of our children are living on food stamps, we’ve got two wars, we’ve got global warming, we have a $12 trillion national debt,” Sanders said.

“And the best the Republicans can do is try to bring the United States government to a halt by forcing a reading of a 700-page amendment,” he concluded.

Sanders’ amendment to the health care reform bill would have created a single-payer system by allowing all Americans – regardless of age – to be covered by Medicare. [PNHP note: original version erroneously reported everyone could buy into Medicare.] The system would be funded federally through payroll and incomes taxes, but administered on a state level.

“This amendment starts from the premise that health care is a human right and that every citizen, rich or poor, should have access to health care, just as every citizen has access to the fire department, the police or public schools,” Sanders said.

Republicans defended the gridlock created by forcing a reading of the bill.

“I admire Sen. Sanders for his willingness to fight for publicly what many advocate only privately – a single payer health care system funded and controlled by bureaucrats and politicians in Washington,” Coburn said in a statement. “Every American should listen to the reading of this amendment and pay careful attention to its vote tally.”

In a phone interview after the debate, Sanders said he was “very disappointed” in the Republican leadership for effectively blocking a vote on a single-payer system. He said it is part of a pattern for the party to obstruct and delay in order to take down President Obama.

“They don’t want to do anything about health care and they don’t want to do anything about the economy because they want to point to President Obama as a failure,” Sanders said. “This is no secret. This is the goal of the Republican Party right now.”

Sanders said a request from Majority Leader Harry Reid, a Democrat, convinced him to pull the amendment from consideration. Reading the whole bill would have taken 10-15 hours, Sanders said, and a pressing vote on the new defense budget was scheduled for later that evening.

“I’ve been told that if there are more amendments to be considered, mine is at the top of the list,” Sanders said, adding that his single-payer plan still exists as a separate bill introduced earlier this year.

Forcing the reading of the single-payer amendment was just the latest attempt by Republicans “to suppress any debate on health care reform,” said Dr. Quentin Young, the national coordinator for Physicians for a National Health Program, a Chicago-based organization representing 17,000 medical professionals.

“This was a cynical and obvious move,” said Young, who described the country’s health care system as deteriorating.

Young didn’t hold Democrats free of criticism either, however. He said the bill considered by the Senate – which has been stripped of the public health insurance option and the Medicare expansion – is “a giant step backwards.” He said Sanders should vote against the bill.

“The President’s role in this has been shameful,” said Young, who was Obama’s friend and neighbor during the President’s early days as a politician in Chicago. “He’s backed off all of his campaign promises while caving into the insurance industry.”

Sanders said Wednesday that he has not decided yet how to vote on the bill, which now lacks many of the proposals he saw as vital to reform.

“The loss of the public option and the Medicare buy-in were serious blows,” Sanders said. “But, no, I haven’t made up my mind.”

Sanders’ Vermont colleague, U.S. Sen. Patrick Leahy, D-Vt., said in a statement that opponents of health care reform have “thrown around all manner of distortions about Canada’s single-payer system.”

“With his amendment, Sen. Sanders has helped inject some balance into the debate,” Leahy said. “Sen. Coburn may have intended to further obstruct and distort, but his stalling tactics actually have given the Sanders amendment a brighter spotlight.”

While on the Senate floor Wednesday, Sanders struck an optimistic tone, saying it is only a matter of time before the United States joins the rest of the major industrialized nations in the world by creating a single-payer health care system.

“The day will come when the country will do the right thing,” Sanders said.

daniel.barlow@timesargus.com

http://www.timesargus.com/apps/pbcs.dll/article?AID=/20091217/NEWS01/912170342/

CDC/NHIS – uninsured and underinsured

Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey (NHIS), January - June 2009

by Michael E. Martinez, M.P.H., M.H.S.A., and Robin A. Cohen, Ph.D., Division of Health Interview Statistics, National Center for Health Statistics
Centers for Disease Control and Prevention (CDC)
National Center for Health Statistics (NCHS)

From January to June 2009, 45.4 million persons of all ages (15.1%) were uninsured at the time of interview, 58.4 million (19.4%) had been uninsured for at least part of the year prior to interview, and 31.9 million (10.6%) had been uninsured for more than a year at the time of interview.

From January to June 2009, 60.6% of unemployed adults aged 18-64 years and 21.8% of employed adults in this age group had been uninsured for at least part of the past year. Also, 32.9% of unemployed adults aged 18-64 and 13.3% of employed adults in this age group had been uninsured for more than a year.

Estimates of enrollment in HDHPs, CDHPs

Based on data from the January to June 2009 NHIS, 22.7% of persons under age 65 years with private health insurance were enrolled in a HDHP (high-deductible health plan), including 6.4% who were enrolled in a CDHP (consumer-directed health plan) and 16.4 % who were enrolled in a HDHP without a health savings account (HSA). Enrollment in HDHPs increased from 17.5% in 2007 to 22.7% in the first 6 months of 2009. There was a significant increase in enrollment in HDHPs without HSAs and in CDHPs between 2007 (when NHIS started collecting this information) and June 2009.

Based on data from the first 6 months of 2009, among persons under age 65 with private health insurance, 20.3% with employer-based coverage were enrolled in a HDHP, compared with 48.7% of those with a private plan that was directly purchased or obtained through means other than an employer. The percentage of persons covered by employer-based private plans that are HDHPs increased from 15.6% in 2007 to 20.3% in the first 6 months of 2009. The percentage of persons covered by directly purchased private health plans that are HDHPs increased from 39.2% in 2007 to 48.7% in the first 6 months of 2009. HDHPs constitute a growing share of both employment-based and directly purchased health plans.

http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur200912.htm

Comment: 

By Don McCanne, MD

One-fifth of the nation has been uninsured for at least a part of the past year. What makes that number even more alarming is that, at the beginning of the reform process, President Obama and the Congress decided, in deference to the private insurance industry, that they wouldn’t even begin to try to insure everyone. Instead they decided to include just those who would fit in under under their model that is designed to nurture the private insurance industry.

Still even more alarming is the insurance coverage that they propose. The standard policies for middle-income Americans will have an actuarial value of 60% to 70%, which provides much less financial protection than did more traditional employer-sponsored plans. But look what is already happening. Employers are shifting more workers to high-deductible health plans (HDHPs), and in the individual insurance market, almost half of the plans purchased are HDHPs. Furthermore, almost three-fourths of these do not have the backup of a health savings account (HSA).

Except for relatively wealthy individuals, these HDHPs are underinsurance products. They do not provide adequate financial security for those who do develop health care needs.

So President Obama and the Congress are bailing on not only on the tens of millions who will remain uninsured, but also the ever growing number of us who will be underinsured, whether through individual or employer-sponsored plans.

The status quo is unacceptable, but so is this legislation. Dump it and move on immediately with reform that protects the financial well-being of absolutely everyone who needs medical care.

Health Study for Chicago: Health Gap Widens Between Blacks, Whites

By Deborah L. Shelton
The Chicago Tribune, Dec. 18, 2009

A widening gulf in the health status of blacks and whites in Chicago comes even as disparities between the two races nationally have remained relatively constant, a new study has found.

The disparity is particularly jarring in five areas: death from all causes, heart disease mortality, breast cancer mortality, rates of tuberculosis and the percentage of women who received no prenatal care during the first trimester of pregnancy.

Nationally, the racial gap got worse from 1990 to 2005 for six of the 15 health indicators researchers studied. However, in Chicago, disparities worsened for 11 of the 15 indicators, according to research by the Sinai Urban Health Institute, published online Thursday in the American Journal of Public Health.

Poverty, segregation and access to health care all appear to play a role, researchers said. In Chicago neighborhoods and medical offices, doctors and patients see the same factors.

Dr. Charles Barron, medical director at Access Southwest Family Health Center, said many of his patients struggle to pay for health care.

“Access is definitely an issue, even at federally qualified health centers such as Access Community Health Network, which offers treatment on a sliding-scale basis,” he said.

Tonya Jackson, 39, of North Lawndale, takes seven medications to treat heart failure. She is a patient at Mount Sinai Hospital, which is widely known for its initiatives to treat low-income and poor patients.

“Even with health insurance, a lot of medicines are very expensive,” she said. “When you’re a single parent, you’re trying to pay rent, you have your child, and you’re trying to pay bills and buy food, so it’s difficult. A lot of people don’t get the care they need because they have to decide whether they want to eat that day.”

Dr. Niva Lubin-Johnson, an African-American physician, has witnessed the disparities firsthand in her 20-year solo practice in Chatham.

“Based on what I see,” she said, “we have a greater disease burden, and part of that comes from lifestyle, part of it comes from income, part of it comes from health literacy and people not understanding what they need to do to live a healthy lifestyle.”

An author of the study, institute director Steve Whitman, previously has compared breast cancer disparities in Chicago and New York. He said the health of African-Americans in Chicago fares worse than blacks elsewhere.

“The underlying issue here is racism and poverty,” Whitman said. “In Chicago, it’s exacerbated by segregation. Black people in Chicago are forced to live in neighborhoods where there are no stores to buy fresh fruits and vegetables, where schools are failing, where they don’t have parks to exercise in and where they tend to go to segregated health facilities that are poorly funded and, in different ways, failing.”

Dr. Georges Benjamin, executive director of the American Public Health Association, cautioned about making geographic comparisons.

“While it is important to measure an urban city like Chicago against national numbers,” Benjamin said, “the national statistics include lots of places where some of the challenges of racial disparity don’t exist.

“When you average numbers out — even though researchers try statistically to correct for some of those things — you have to be cautious.”

But he agreed that racial disparities appear to be worsening in Chicago.

“Despite Chicago’s … transit system, it still has pockets of people where people have tremendous problems accessing care, and that’s a huge overlay,” Benjamin said. “Part of it is lack of insurance, and part of it is access to care.”

Ultimately, money might matter most when it comes to good health, Benjamin said.

“If we were serious about doing something about eliminating these disparities, we would pay attention to the social determinants of health that put people in these situations to begin with,” he said. “At the end of the day, there is very strong correlation between health and wealth.”

Sinai researchers analyzed the 15 measures using data from city communicable disease records and Illinois birth and death records.

The study builds on work published in 2004, believed to be the first to examine the health of blacks and whites in a major urban center over time and put findings in the context of national trends.

Researchers reported that the African-American death rate from breast cancer was 99 percent higher in Chicago than for white women, a fivefold increase since 1990.

In 1990, blacks in Chicago were 8 percent more likely than whites to die of heart disease.

In 2005, blacks were 24 percent more likely to die.

In 1990, black women were two times more likely to go without prenatal care in the first trimester of pregnancy. By 2005, they were three times more likely to go without prenatal care.

Most of the measures showed improved health for both blacks and whites nationally and locally, but whites’ health status improved much more, widening the gap.

If health indicators were equal, 3,200 fewer African-Americans in Chicago would die every year, or about nine a day, the study estimates.

Joseph M. Harrington, assistant commissioner for chronic disease for the Chicago Department of Public Health, agreed that the problem in Chicago is significant.

“But,” he said, “what do we do about it? You can keep talking about how bad the numbers are, but the real question is, what do you plan to do?”

The city health department has initiated programs to address the problem, including a federally funded project focused on cardiovascular disease among blacks and Hispanics living in North and South Lawndale, Harrington said.

“These findings should provoke us to think about what can be done, that’s the call to action,” Harrington said.

“This should provoke us to do something.”

dshelton@tribune.com

American Journal of Public Health, 10.2105/AJPH.2009.165407
Dec. 17, 2009, First Look online
“Black–White Health Disparities in the United States and Chicago: A 15-Year Progress Analysis”
By Jennifer M. Orsi, Helen Margellos-Anast, Steven Whitman

http://www.chicagotribune.com/health/chi-chicago_health_gapdec18,0,628023.story

CDC/NHIS – uninsured and underinsured

Health Insurance Coverage: Early Release of Estimates from the National Health Interview Survey (NHIS), January – June 2009

by Michael E. Martinez, M.P.H., M.H.S.A., and Robin A. Cohen, Ph.D., Division of Health Interview Statistics, National Center for Health Statistics
Centers for Disease Control and Prevention (CDC)
National Center for Health Statistics (NCHS)
From January to June 2009, 45.4 million persons of all ages (15.1%) were uninsured at the time of interview, 58.4 million (19.4%) had been uninsured for at least part of the year prior to interview, and 31.9 million (10.6%) had been uninsured for more than a year at the time of interview.
From January to June 2009, 60.6% of unemployed adults aged 18-64 years and 21.8% of employed adults in this age group had been uninsured for at least part of the past year. Also, 32.9% of unemployed adults aged 18-64 and 13.3% of employed adults in this age group had been uninsured for more than a year.
Estimates of enrollment in HDHPs, CDHPs
Based on data from the January to June 2009 NHIS, 22.7% of persons under age 65 years with private health insurance were enrolled in a HDHP (high-deductible health plan), including 6.4% who were enrolled in a CDHP (consumer-directed health plan) and 16.4 % who were enrolled in a HDHP without a health savings account (HSA). Enrollment in HDHPs increased from 17.5% in 2007 to 22.7% in the first 6 months of 2009. There was a significant increase in enrollment in HDHPs without HSAs and in CDHPs between 2007 (when NHIS started collecting this information) and June 2009.
Based on data from the first 6 months of 2009, among persons under age 65 with private health insurance, 20.3% with employer-based coverage were enrolled in a HDHP, compared with 48.7% of those with a private plan that was directly purchased or obtained through means other than an employer. The percentage of persons covered by employer-based private plans that are HDHPs increased from 15.6% in 2007 to 20.3% in the first 6 months of 2009. The percentage of persons covered by directly purchased private health plans that are HDHPs increased from 39.2% in 2007 to 48.7% in the first 6 months of 2009. HDHPs constitute a growing share of both employment-based and directly purchased health plans.
http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur200912.htm

One-fifth of the nation has been uninsured for at least a part of the past year. What makes that number even more alarming is that, at the beginning of the reform process, President Obama and the Congress decided, in deference to the private insurance industry, that they wouldn’t even begin to try to insure everyone. Instead they decided to include just those who would fit in under under their model that is designed to nurture the private insurance industry.
Still even more alarming is the insurance coverage that they propose. The standard policies for middle-income Americans will have an actuarial value of 60% to 70%, which provides much less financial protection than did more traditional employer-sponsored plans. But look what is already happening. Employers are shifting more workers to high-deductible health plans (HDHPs), and in the individual insurance market, almost half of the plans purchased are HDHPs. Furthermore, almost three-fourths of these do not have the backup of a health savings account (HSA).
Except for relatively wealthy individuals, these HDHPs are underinsurance products. They do not provide adequate financial security for those who do develop health care needs.
So President Obama and the Congress are bailing on not only on the tens of millions who will remain uninsured, but also the ever growing number of us who will be underinsured, whether through individual or employer-sponsored plans.
The status quo is unacceptable, but so is this legislation. Dump it and move on immediately with reform that protects the financial well-being of absolutely everyone who needs medical care.

Better to Start Over Than to Pass These Bills

By Athena Godet-Calogeras, Peter Mott and Andrew Coates
The Buffalo News, Dec. 17, 2009

You might think that all of us who have worked so long and so hard for comprehensive and affordable health care would be jumping with joy at the recent passage of a House bill and the opening of the Senate debate on health insurance reform. Not so.

In fact, many of us, including some in Congress who are ardent proponents of universal health care — like Rep. Eric Massa, D-Corning— are convinced that the route to comprehensive and affordable health care has taken a dramatically wrong turn.

The main features of the legislation have often seemed obscure, despite unprecedented amounts of attention. For instance, neither a “government takeover” nor a “public option” really have anything much to do with the final bills.

Instead the centerpiece of the House bill will not start until 2013 (2014 in the Senate bill) and at that time health insurance will become mandatory for virtually every person, every family. Being uninsured could become a crime, punishable by an annual fine of up to 2.5 percent of adjusted income under the House bill. The fine in the Senate bill is lower, $95 per person starting in 2014, rising to $750 by 2019.

To make insurance affordable, tax money will be used to subsidize private insurance premiums for those who earn up to 400 percent of the federal poverty level. Even with these subsidies, presently uninsured families with income between 200 percent and 400 percent of poverty will be required to spend 8 percent to 12 percent of their income to purchase insurance. Meanwhile the insurance companies stand to gain tens of millions of new customers and at least $447 billion in taxpayer subsidies.

The bills in Congress offer no meaningful cost controls. Mild promises to “bend the cost curve” fall short when even middle-income people will still end up being saddled with huge, unsustainable health care costs.

Neither will the bills make health coverage universal. By 2019 the House bill still leaves at least 17 million uninsured in the United States. The Senate bill would do less.

Nor will the bills do anything substantial about the high cost of drugs. That is why the pharmaceutical industry has spent hundreds of millions of dollars to help pass the legislation.

We agree with Massa. These “solutions” in Congress will not fix the problems we face. We do not need “insurance reform.” We need health care, comprehensive and affordable for everyone. And we need it now, not over the next four to 10 years.

Congress should reboot the process and start with a proposal for workable reform: a single-payer, national health program, an expanded and improved Medicare for all.

Athena Godet-Calogeras is chairwoman of the Health Care Access Coalition (Allegany/ Olean). Peter Mott, M. D., is associate professor (retired) of community medicine at the University of Rochester. Andrew Coates, M. D., is assistant professor of medicine and psychiatry at Albany Medical College.

http://www.buffalonews.com/149/story/896953.html

U.S. Study: 1 in 5 Lost Health Insurance in Past Year

By Susan Heavey
ABC News (Reuters), Dec. 16, 2009

WASHINGTON (Reuters) – Nearly 20 percent of the U.S. population — or almost 60 million people — went without health insurance at some point since January 2008, according to government estimates released Wednesday.

The analysis by the Centers for Disease Control and Prevention comes as Democratic senators wrestle to pass their version of health reform legislation before the end of the year to help make good on President Barack Obama’s top domestic goal of overhauling the nation’s $2.5 trillion healthcare system.

Much of the focus so far has been on how to expand access to health insurance in a nation where coverage is closely tied to employment but 10 percent of the work force in unemployed. More than 45 million people are uninsured.

While the CDC’s findings largely backed that figure, they also found 58.4 million lacked coverage at some point in the year prior to the survey, while 31.9 million — or nearly 11 percent — did not have insurance for more than a year.

Two-thirds of those who did not have coverage for at least part of the time were unemployed working-age adults. Those most likely to lack health coverage were Hispanics, men and young adults ages 18 to 24, the CDC found.

The CDC’s National Center for Health Statistics analyzed data on 32,694 people who responded from January through June 2009 as part of an ongoing survey.

At a time when much of the debate on the Senate bill has focused on its inclusion of a government-run “public option” insurance plan, the CDC found 20 percent of children and adults age 64 or younger are already covered by government health programs. Democrats plan to strip the public option before the full Senate votes.

The Medicaid program helps cover many of the poor, including children. Youth can also get care under the Children Health Insurance Program, which was extended by lawmakers earlier this year. Younger people with disabilities could also be covered under Medicare, which covers those age 65 or older.

One bright spot in the report: more children received health coverage, largely through the government.

The number of children enrolled in government health insurance programs also rose from 34.2 percent in 2008 to 37.4 percent in the first half of 2009, according to the study.

Overall, 8.2 percent of children still lack health care coverage, it found.

(Reporting by Susan Heavey, editing by Anthony Boadle)

Sen. Sanders' floor speech on his single payer amendment

United States Senate
December 16, 2009

The reading of the Sanders single payer amendment continues in its third hour…

Senate President: The Senator from Vermont.

Sen. Bernie Sanders: I withdraw my amendment.

Voice off camera (believed to be Sen. Tom Coburn): Regular order, Mr. President.

Senate President: The Senator has that right. The amendment is withdrawn.

Sen. Sanders:  Mr. President. Pursuant to the thirty minutes…

Senate President: Under the previous order, the Senator from Vermont is recognized for thirty minutes.

Sen. Sanders: Mr. President, let me begin, not by talking about my amendment, but by talking about Republican action right here on the floor of the Senate. Everybody in this country understands that our nation faces a significant number of major crises, whether it’s the disintegration of our health care system, the fact that seventeen percent of our people are unemployed or underemployed, one out of four of our children are living on food stamps, we’ve got two wars, we’ve got global warming, we have a twelve trillion dollar national debt, and the best the Republicans can do is try to bring the United States government to a halt by forcing a reading of a seven hundred page amendment. That is an outrage! People can have honest disagreements, but in this moment of crisis it is wrong to bring the United States government to a halt.

Now, Mr. President, I am very disturbed that I am unable to bring the amendment that I wanted to bring to the floor of the Senate dealing with a Medicare for all single payer program…

… I was more than aware and very proud that this amendment would have been the first time in American history that a Medicare for all single payer bill was brought before a floor of Congress.

C-SPAN video of Sen. Sanders remarks (36 minutes):
http://www.c-span.org/Watch/Media/2009/12/16/Health/A/27367/Sen+Bernard+Sanders+IVT+Senate+Floor+Remarks+on+Single+Payer+Amendment.aspx

Comment: 

By Don McCanne, MD

Yesterday’s Quote of the Day message left off as the reading of the the Sanders amendment to the Senate health reform bill continued. It was suggested that this abuse of process and lack of civility on the part of Sen. Coburn and the Republican leadership be used as a teaching moment. That moment is here. The video of this Senate floor speech by Sen. Sanders should be shared with others who believe that everyone in our nation should have the health care that they need without having to face financial hardship.

Sen. Sanders’ floor speech on his single payer amendment

United States Senate
December 16, 2009

The reading of the Sanders single payer amendment continues in its third hour…

Senate President: The Senator from Vermont.

Sen. Bernie Sanders: I withdraw my amendment.

Voice off camera (believed to be Sen. Tom Coburn): Regular order, Mr. President.

Senate President: The Senator has that right. The amendment is withdrawn.

Sen. Sanders:  Mr. President. Pursuant to the thirty minutes…

Senate President: Under the previous order, the Senator from Vermont is recognized for thirty minutes.

Sen. Sanders: Mr. President, let me begin, not by talking about my amendment, but by talking about Republican action right here on the floor of the Senate. Everybody in this country understands that our nation faces a significant number of major crises, whether it’s the disintegration of our health care system, the fact that seventeen percent of our people are unemployed or underemployed, one out of four of our children are living on food stamps, we’ve got two wars, we’ve got global warming, we have a twelve trillion dollar national debt, and the best the Republicans can do is try to bring the United States government to a halt by forcing a reading of a seven hundred page amendment. That is an outrage! People can have honest disagreements, but in this moment of crisis it is wrong to bring the United States government to a halt.

Now, Mr. President, I am very disturbed that I am unable to bring the amendment that I wanted to bring to the floor of the Senate dealing with a Medicare for all single payer program…

… I was more than aware and very proud that this amendment would have been the first time in American history that a Medicare for all single payer bill was brought before a floor of Congress.

C-SPAN video of Sen. Sanders remarks (36 minutes):
http://www.c-span.org/Watch/Media/2009/12/16/Health/A/27367/Sen+Bernard+Sanders+IVT+Senate+Floor+Remarks+on+Single+Payer+Amendment.aspx

Comment: 

By Don McCanne, MD

Yesterday’s Quote of the Day message left off as the reading of the the Sanders amendment to the Senate health reform bill continued. It was suggested that this abuse of process and lack of civility on the part of Sen. Coburn and the Republican leadership be used as a teaching moment. That moment is here. The video of this Senate floor speech by Sen. Sanders should be shared with others who believe that everyone in our nation should have the health care that they need without having to face financial hardship.

White House as helpless victim on healthcare

By Glenn Greenwald
Salon.com, Wednesday, Dec 16, 2009 05:17 EST

Of all the posts I wrote this year, the one that produced the most vociferous email backlash — easily — was this one from August, which examined substantial evidence showing that, contrary to Obama’s occasional public statements in support of a public option, the White House clearly intended from the start that the final health care reform bill would contain no such provision and was actively and privately participating in efforts to shape a final bill without it.  From the start, assuaging the health insurance and pharmaceutical industries was a central preoccupation of the White House — hence the deal negotiated in strict secrecy with Pharma to ban bulk price negotiations and drug reimportation, a blatant violation of both Obama’s campaign positions on those issues and his promise to conduct all negotiations out in the open (on C-SPAN).  Indeed, Democrats led the way yesterday in killing drug re-importation, which they endlessly claimed to support back when they couldn’t pass it.  The administration wants not only to prevent industry money from funding an anti-health-care-reform campaign, but also wants to ensure that the Democratic Party — rather than the GOP — will continue to be the prime recipient of industry largesse.

As was painfully predictable all along, the final bill will not have any form of public option, nor will it include the wildly popular expansion of Medicare coverage.  Obama supporters are eager to depict the White House as nothing more than a helpless victim in all of this — the President so deeply wanted a more progressive bill but was sadly thwarted in his noble efforts by those inhumane, corrupt Congressional “centrists.”  Right.  The evidence was overwhelming from the start that the White House was not only indifferent, but opposed, to the provisions most important to progressives.  The administration is getting the bill which they, more or less, wanted from the start — the one that is a huge boon to the health insurance and pharmaceutical industry.   And kudos to Russ Feingold for saying so:

Sen. Russ Feingold (D-Wis.), among the most vocal supporters of the public option, said it would be unfair to blame Lieberman for its apparent demise. Feingold said that responsibility ultimately rests with President Barack Obama and he could have insisted on a higher standard for the legislation.

“This bill appears to be legislation that the president wanted in the first place, so I don’t think focusing it on Lieberman really hits the truth,” said Feingold. “I think they could have been higher. I certainly think a stronger bill would have been better in every respect.”

Let’s repeat that:  “This bill appears to be legislation that the president wanted in the first place.”  Indeed it does.  There are rational, practical reasons why that might be so.  If you’re interested in preserving and expanding political power, then, all other things being equal, it’s better to have the pharmaceutical and health insurance industry on your side than opposed to you.  Or perhaps they calculated from the start that this was the best bill they could get.  The wisdom of that rationale can be debated, but depicting Obama as the impotent progressive victim here of recalcitrant, corrupt centrists is really too much to bear.  

Yet numerous Obama defenders — such as Matt Yglesias, Ezra Klein and Steve Benen — have been insisting that there is just nothing the White House could have done and all of this shows that our political system is tragically “ungovernable.”  After all, Congress is a separate branch of government, Obama doesn’t have a vote, and 60 votes are needed to do anything.  How is it his fault if centrist Senators won’t support what he wants to do?  Apparently, this is the type of conversation we’re to believe takes place in the Oval Office:

The President:  I really want a public option and Medicare buy-in.  What can we do to get it?

Rahm Emanuel:  Unfortunately, nothing.  We can just sit by and hope, but you’re not in Congress any more and you don’t have a vote.  They’re a separate branch of government and we have to respect that.

The President:  So we have no role to play in what the Democratic Congress does?

Emanuel:  No.  Members of Congress make up their own minds and there’s just nothing we can do to influence or pressure them.

The President:  Gosh, that’s too bad.  Let’s just keep our fingers crossed and see what happens then.

In an ideal world, Congress would be — and should be — an autonomous branch of government, exercising judgment independent of the White House’s influence, but that’s not the world we live in.  Does anyone actually believe that Rahm Emanuel (who built his career on industry support for the Party and jamming “centrist” bills through Congress with the support of Blue Dogs) and Barack Obama (who attached himself to Joe Lieberman when arriving in the Senate, repeatedly proved himself receptive to “centrist” compromises, had a campaign funded by corporate interests, and is now the leader of a vast funding and political infrastructure) were the helpless victims of those same forces?  Engineering these sorts of “centrist,” industry-serving compromises has been the modus operandi of both Obama and, especially, Emanuel.

Indeed, we’ve seen before what the White House can do — and does do — when they actually care about pressuring members of Congress to support something they genuinely want passed.  When FDL and other liberal blogs led an effort to defeat Obama’s war funding bill back in June, the White House became desperate for votes, and here is what they apparently did (though they deny it):

The White House is playing hardball with Democrats who intend to vote against the supplemental war spending bill, threatening freshmen who oppose it that they won’t get help with reelection and will be cut off from the
White House, Rep. Lynn Woolsey (D-Calif.) said Friday.  “We’re not going to help you. You’ll never hear from us again,” Woolsey said the White House is telling freshmen.

That’s what the White House can do when they actually care about pressuring someone to vote the way they want.  Why didn’t they do any of that to the “centrists” who were supposedly obstructing what they wanted on health care?  Why didn’t they tell Blanche Lincoln — in a desperate fight for her political life — that she would “never hear from them again,” and would lose DNC and other Democratic institutional support, if she filibustered the public option?  Why haven’t they threatened to remove Joe Lieberman’s cherished Homeland Security Chairmanship if he’s been sabotaging the President’s agenda?  Why hasn’t the President been rhetorically pressuring Senators to support the public option and Medicare buy-in, or taking any of the other steps outlined here by Adam Green?  There’s no guarantee that it would have worked — Obama is not omnipotent and he can’t always control Congressional outcomes — but the lack of any such efforts is extremely telling about what the White House really wanted here.

Independent of the reasonable debate over whether this bill is a marginal improvement over the status quo, there are truly horrible elements to it.  Two of the most popular provisions (both of which, not coincidentally, were highly adverse to industry interests) — the public option and Medicare expansion — are stripped out (a new Washington Post/ABC poll out today shows that the public favors expansion of Medicare to age 55 by a 30-point margin).  What remains is a politically disastrous and highly coercive “mandate” gift to the health insurance industry, described perfectly by Digby:

Obama can say that you’re getting a lot, but also saying that it “covers everyone,” as if there’s a big new benefit is a big stretch. Nothing will have changed on that count except changing the law to force people to buy private insurance if they don’t get it from their employer. I guess you can call that progressive, but that doesn’t make it so. In fact, mandating that all people pay money to a private interest isn’t even conservative, free market or otherwise. It’s some kind of weird corporatism that’s very hard to square with the common good philosophy that Democrats supposedly espouse.

Nobody’s “getting covered” here. After all, people are already “free” to buy private insurance and one must assume they have reasons for not doing it already. Whether those reasons are good or bad won’t make a difference when they are suddenly forced to write big checks to Aetna or Blue Cross that they previously had decided they couldn’t or didn’t want to write. Indeed, it actually looks like the worst caricature of liberals: taking people’s money against their will, saying it’s for their own good — and doing it without even the cover that FDR wisely insisted upon with social security, by having it withdrawn from paychecks. People don’t miss the money as much when they never see it.

In essence, this reinforces all of the worst dynamics of Washington.  The insurance industry gets the biggest bonanza imaginable in the form of tens of millions of coerced new customers without any competition or other price controls.  Progressive opinion-makers, as always, signaled that they can and should be ignored (don’t worry about us — we’re announcing in advance that we’ll support whatever you feed us no matter how little it contains of what we want and will never exercise raw political power to get what we want; make sure those other people are happy but ignore us).  Most of this was negotiated and effectuated in complete secrecy, in the sleazy sewers populated by lobbyists, industry insiders, and their wholly-owned pawns in the Congress.  And highly unpopular, industry-serving legislation is passed off as “centrist,” the noblest Beltway value. 

Looked at from the narrow lens of health care policy, there is a reasonable debate to be had among reform advocates over whether this bill is a net benefit or a net harm.  But the idea that the White House did what it could to ensure the inclusion of progressive provisions — or that they were powerless to do anything about it — is absurd on its face.  Whatever else is true, the overwhelming evidence points to exactly what Sen. Feingold said yesterday:  “This bill appears to be legislation that the president wanted in the first place.”

UPDATE:  It’s also worth noting how completely antithetical claims are advanced to defend and excuse Obama.  We’ve long heard — from the most blindly loyal cheerleaders and from Emanuel himself — that progressives should place their trust in the Obama White House to get this done the right way, that he’s playing 11-dimensional chess when everyone else is playing checkers, that Obama is the Long Game Master who will always win.  Then, when a bad bill is produced, the exact opposite claim is hauled out:  it’s not his fault because he’s totally powerless, has nothing to do with this, and couldn’t possibly have altered the outcome.  From his defenders, he’s instantaneously transformed from 11-dimensional chess Master to impotent, victimized bystander.

The supreme goal is to shield him from all blame.  What gets said to accomplish that goal can — and does — radically change from day to day.
UPDATE II:  I’ll be on MSNBC this afternoon at 3:00 p.m. EST with David Shuster/Tamron Hall discussing this post.

UPDATE III:  Over at Politico, Jane Hamsher documents how Joe Lieberman’s conduct on the health care bill provides the perfect vehicle to advance the agenda of the White House and Harry Reid.  Consistent with that, she independently notes media reports that White House officials are privately expressing extreme irritation with Howard Dean for opposing the Senate bill as insufficient, but have nothing bad to say about Lieberman, who supposedly single-handedly sabotaged what the White House was hoping for in this bill.

UPDATE IV:  Immediately prior to the MSNBC segment I just did — video for which I will post when it’s available — an NBC reporter explained how Robert Gibbs used his Press Briefing today to harshly criticize Howard Dean for opposing the health care bill.  Why did Gibbs never publicly cri
ticize people like Blanche Lincoln, Ben Nelson, Joe Lieberman and the like if they were supposedly obstructing and impeding the White House’s agenda on health care reform (this is a point Yglesias acknowledges as a “fair” one)?  Having a Democratic White House publicly criticize a Democratic Senator can be a much more effective pressure tactic than doing so against a former Governor who no longer holds office.

Meanwhile, as one would expect, health insurance stocks are soaring today in response to the industry-serving “health care reform” bill backed by the Democratic Senate and White House — the same people who began advocating for “health care reform” based on the need to restrain on an out-of-control and profit-inflated health insurance industry (h/t Markos).

UPDATE V:  Here’s the roughly 4-minute segment I did with David Shuster today:

http://www.salon.com/news/opinion/glenn_greenwald/2009/12/16/white_house/index.html

Single-Payer Amendment Withdrawn after GOP Delay Tactics

By Emily P. Walker
MedPage Today, December 16, 2009

WASHINGTON — In an earnest but doomed attempt to create a single-payer healthcare system, Sen. Bernie Sanders (I-Vt.) brought up a Medicare-for-all amendment to the healthcare reform bill on Wednesday, but was forced to withdraw it in the face of Republican stalling tactics.

Sanders, the chamber’s only vocal proponent of a national health insurance program, introduced an amendment to create just that — and expand coverage to every U.S. citizen.

“Every American — 100%, not 94% — would have health insurance,” he said in an impassioned speech on the Senate floor.

He referred to the current Senate bill, which would expand coverage to 94% of legal U.S. citizens, according to the Congressional Budget Office.

Sanders said his amendment would save $350 billion in administrative expenses by eliminating private insurance companies from the picture.

Sen. Tom Coburn (R-Okla.), an ob/gyn, demanded that the 776-page amendment be read by Senate clerks — a move that is always an option, but very rarely invoked. Coburn complained that he hadn’t seen Sanders’ amendment before it was brought to the floor.

The reading began at noon and continued on for several hours until Sanders withdrew the measure, ending a monotone afternoon read-a-thon that further delayed work on the healthcare measure. Sen. Dick Durbin (D-Ill.) estimated that reading the whole amendment would have taken 10 hours.

After withdrawing the amendment, Sanders delivered a few more pointed words in favor of loosening the insurance industry’s grasp on medical care and the need for universal coverage.

“A Medicare-for-all program is the way to go,” he said. “And I know it’s not going to pass today. I know we don’t have the votes. I know the insurance company and the drug lobbyists will fight us.

“But mark my words . . . the day will come when this country will do the right thing. And on that day, we will pass a Medicare-for-all single-payer system.”

David Himmelstein, MD, the national spokesperson for Physicians for a National Heath Program, told MedPage Today he wasn’t surprised by the maneuvering that blocked the amendment from coming up for a vote.

“It’s another in a long line of bizarre dancing that Congress has been engaged in that distract from debating the issues,” said Himmelstein, an associate professor of medicine at Harvard. “The whole debate has been a circus and sounds like another side show in the circus.”

Himmelstein said he agrees with Sanders that meaningful reform can only be achieved with a single-payer system because there is too much waste in the private insurance industry.

He criticized the current reform effort for “dumping hundreds of billions of dollars into the private insurance industry for a short term gain.”

He said the current debate “is akin to debating whether you ought to use aspirin or Tylenol for someone with cancer.”

After Sanders’ amendment, the Senate took up a defense spending measure.

It is appearing less and less likely that the Senate will vote on healthcare reform before Christmas, which Senate Majority Leader Harry Reid (D-Nev.) has said is his goal.

Reid has yet to introduce his manager’s amendment, which will include a series of changes to the older version of the healthcare bill.

Republicans can again request that the amendment be read aloud. Hoping to avoid that, Democrat leaders have told the GOP that the amendment will be available publicly for at least 72 hours before it’s brought up on the floor.

http://www.medpagetoday.com/PublicHealthPolicy/Washington-Watch/17585