PNHP

Health Care That Works

Health Care That Works

By NICHOLAS D. KRISTOF
Op-Ed Columnist
New York Times
September 3, 2009

Here’s a paradox.

Health care reform may be defeated this year in part because so many Americans believe the government can’t do anything right and fear that a doctor will come to resemble an I.R.S. agent with a scalpel. Yet the part of America’s health care system that consumers like best is the government-run part.

Fifty-six to 60 percent of people in government-run Medicare rate it a 9 or 10 on a 10-point scale. In contrast, only 40 percent of those enrolled in private insurance rank their plans that high.

Multiple surveys back that up. For example, 68 percent of those in Medicare feel that their own interests are the priority, compared with only 48 percent of those enrolled in private insurance.

In truth, despite the deeply ingrained American conviction that government is bumbling when it is not evil, government intervention has been a step up in some areas from the private sector.

Until the mid-19th century, firefighting was left mostly to a mishmash of volunteer crews and private fire insurance companies. In New York City, according to accounts in The New York Times in the 1850s and 1860s, firefighting often descended into chaos, with drunkenness and looting.

So almost every country moved to what today’s health insurance lobbyists might label “socialized firefighting.” In effect, we have a single-payer system of public fire departments.

We have the same for policing. If the security guard business were as powerful as the health insurance industry, then it would be denouncing “government takeovers” and “socialized police work.”

Throughout the industrialized world, there are a handful of these areas where governments fill needs better than free markets: fire protection, police work, education, postal service, libraries, health care. The United States goes along with this international trend in every area but one: health care.

The truth is that government, for all its flaws, manages to do some things right, so that today few people doubt the wisdom of public police or firefighters. And the government has a particularly good record in medical care.

Take the hospital system run by the Department of Veterans Affairs, the largest integrated health system in the United States. It is fully government run, much more “socialized medicine” than is Canadian health care with its private doctors and hospitals. And the system for veterans is by all accounts one of the best-performing and most cost-effective elements in the American medical establishment.

A study by the Rand Corporation concluded that compared with a national sample, Americans treated in veterans hospitals “received consistently better care across the board, including screening, diagnosis, treatment and follow-up.” The difference was particularly large in preventive medicine: veterans were nearly 50 percent more likely to receive recommended care than Americans as a whole.

“If other health care providers followed the V.A.’s lead, it would be a major step toward improving the quality of care across the U.S. health care system,” Rand reported.

As for the other big government-run health care system in the United States, Medicare spends perhaps one-sixth as much on administration as private health insurers, although the comparison is imperfect and controversial.

But the biggest weakness of private industry is not inefficiency but unfairness. The business model of private insurance has become, in part, to collect premiums from healthy people and reject those likely to get sick — or, if they start out healthy and then get sick, to find a way to cancel their coverage.

A reader wrote in this week to tell me about a colleague of hers who had health insurance through her company. The woman received a cancer diagnosis a few weeks ago, and she now faces chemotherapy co-payments that she cannot afford. Worse, because she is now unable to work and has to focus on treatment, she has been shifted to short-term disability for 90 days — and after that, she will lose her employer health insurance.

She can keep her insurance if she makes Cobra payments on her own, but she can’t afford this. In her case, her company will voluntarily help her — but I just don’t understand why we may be about to reject health reform and stick with a dysfunctional system that takes away the health coverage of hard-working Americans when they become too sick with cancer to work.

On my blog, foreigners regularly express bewilderment that America may reject reform and stick with a system that drives families into bankruptcy when they get sick. That’s what they expect from the Central African Republic, not the United States.

Let’s hope we won’t miss this chance. A public role in health care shouldn’t be any scarier or more repugnant than a public fire department.

Will safety net hospitals survive health reform?

By Carla K. Johnson
Associated Press
San Jose Mercury News
Sept. 3, 2009

CHICAGO — Janie Johnson has no health insurance, so when she cut her toe while giving herself a pedicure, she limped to the emergency room at one of Chicago’s safety net hospitals and waited her turn.

“I’m 44, but I probably look about 55 right now,” Johnson joked in Stroger Hospital’s emergency department where more than 100 patients sat waiting. Urgent cases, from chest pains to gunshot wounds, are rushed to doctors first. Johnson was glad to have somewhere to go for health care.

“I don’t know what I would do” without the hospital, she said. “My health would probably get worse.”

To all the knotty issues involved in health care overhaul, add one more: The proposals in Congress may threaten the funding and future of the nation’s already-struggling safety net hospitals.

It’s an irony hospital leaders are expressing quietly as Congress reconvenes to take up health care again. Hospital leaders support expanding insurance coverage to more Americans, but they worry financing the expansion will cause some teetering urban hospitals to deteriorate and close.

They point to Massachusetts, the laboratory for health care overhaul, where one safety net hospital, Boston Medical Center, is suing the state claiming it’s covering too much of the cost for expanding coverage. Another safety net standby, Cambridge Health Alliance, has closed health centers and cut services; its Somerville Hospital no longer keeps patients overnight.

“It looks like a national plan will be modeled on Massachusetts and it’s a disaster for poor people,” said Dr. Steffie Woolhandler, Harvard Medical School professor and a doctor at Cambridge Hospital.

“The insurance offered doesn’t cover everyone,” she said. “It’s filled with gaps like copayments and deductibles. Patients can’t afford it, so they turn to the public sector and the public sector isn’t there anymore.”

What worries Woolhandler and others are proposals to finance national reform that would reduce payments gradually to hospitals handling more than their share of uninsured patients. One proposal would reduce these funds — called DSH payments for “disproportionate share hospital” — by $20 billion, in three large annual chunks starting in 2017.

About 2,700 U.S. hospitals receive DSH payments. That’s about half the nation’s hospitals, according to the American Hospital Association.

A small segment of those hospitals provides most of the nation’s charity care to the poor. These institutions, largely supported by reimbursements from Medicaid and other government insurance programs, receive 12 percent of their revenues from DSH payments.

Lawmakers reason that when more Americans have insurance, there will be less need for the payments. Instead, hospitals would get paid by their newly covered patients’ insurance plans. A trigger in the House health care legislation would start the cuts only after the nation achieved a significant increase in insurance coverage.

But critics say illegal immigrants, the mentally ill and drug addicts will keep arriving at safety net hospitals without insurance. Illegal immigrants will be ineligible for the expanded coverage proposed by Congress. The mentally ill and addicted will be unlikely to sign up.

“If they start cutting, I’m scared,” said Dr. Simon Piller, who cares for patients at a county clinic that’s part of the same health system as Stroger Hospital. He describes patients who’ve lost jobs, are living with friends and ran out of medications for chronic conditions months, or years, ago.

Safety net hospitals will continue to have unusual expenses, such as translation services and security, to deal with. Some newly insured patients won’t be able to afford the out-of-pocket copays and deductibles.

“Copays for us are no-pays,” said Dr. Steven Safyer, president and CEO of Montefiore Medical Center in New York City. “Health care reform to me is an issue of humanity. How you can have 47 million uninsured in this country is shocking. But you can’t throw the baby out with the bathwater.”

DSH cuts are part of a deal the White House reached with the American Hospital Association and two other hospital groups. When the hospitals agreed to cuts totaling $155 billion over 10 years, a group of public hospitals wasn’t at the table.

“We were never part of the negotiations and did not sign onto the agreement,” said Larry Gage, president of the National Association of Public Hospitals and Health Systems. The group contends DSH payments also help maintain trauma centers, burn units and other community assets that could be threatened.

Nancy-Ann DeParle, who directs the White House health reform office, said there’s adequate protection for safety net hospitals in the House bill. The payments would be reduced — gradually and starting only after the rate of uninsured Americans declines — in a way that differs greatly from what happened in Massachusetts, DeParle said.

President Barack Obama supports phasing in DSH reductions over 10 years.

“As people get insurance, there will be less of a need for hospitals to get additional funds,” DeParle said. She acknowledged it may be “scary” for hospital administrators to shift from getting these additional payments to a reality where more of their patients have insurance cards.

But hospitals can and must adapt, DeParle said. “We will always need safety net hospitals.”

It’s unclear how much would be cut. The House legislation calls for cuts of $20 billion, representing 8 percent of what the Congressional Budget Office projects in federal outlays to DSH over 10 years. The White House supports larger cuts.

http://www.mercurynews.com/politics/ci_13267257?source=email

California's Real Death Panels: Insurers Deny 21% of Claims

PacifiCare's Denials 40%, Cigna's 33% in First Half of 2009

From California Nurses Association/National Nurses Organizing Committee

For Immediate Release
September 2, 2009

Contact: Charles Idelson, 510-273-2246, Shum Preston, 510-273-2276, or Liz Jacobs, 510-273-2232

More than one of every five requests for medical claims for insured patients, even when recommended by a patient’s physician, are rejected by California’s largest private insurers, amounting to very real death panels in practice daily in the nation’s biggest state, according to data released today by the California Nurses Association/National Nurses Organizing Committee.

CNA/NNOC researchers analyzed data reported by the insurers to the California Department of Managed Care. From 2002 through June 30, 2009, the six largest insurers operating in California rejected 31.2 million claims for care — 21 percent of all claims.

The data will be presented by Don DeMoro, director of CNA/NNOC’s research arm, the Institute for Health and Socio-Economic Policy, at CNA/NNOC’s biennial convention next Tuesday, Sept. 8 in San Francisco. The convention will also feature a panel presentation from nurse leaders in Canada, Great Britain, and Australia exploding the myths about their national healthcare systems.

“With all the dishonest claims made by some politicians about alleged ‘death panels’ in proposed national legislation, the reality for patients today is a daily, cold-hearted rejection of desperately needed medical care by the nation’s biggest and wealthiest insurance companies simply because they don’t want to pay for it,” said Deborah Burger, RN, CNA/NNOC co-president.

For the first half of 2009, as the national debate over healthcare reform was escalating, the rejection rates are even more striking.

PacifiCare denied 40 percent of all California claims in the first six months of 2009. Cigna, which gained notoriety two years ago for denying a liver transplant to 17-year-old Nataline Sarkisyan of Northridge, Calif. and then reversing itself, tragically too late to save her life, was still rejecting one-third of all claims for the first half of 2009.

“Every claim that is denied represents a real patient enduring pain and suffering. Every denial has real, sometimes fatal consequences,” said Burger.

PacifiCare, for example, denied a special procedure for treatment of bone cancer for Nick Colombo, a 17-year-old teen from Placentia, Calif. Again, after protests organized by Nick’s family and friends, CNA/NNOC, and netroots activists, PacifiCare reversed its decision. But like Nataline Sarkisyan, the delay resulted in critical time lost, and Nick ultimately died. “This was his last effort and the procedure had worked before with people in Nick’s situation,” said his older brother Ricky.

California Blues rejected 28 percent of claims in the first half of 2009. In 2008, six days before RN Kim Kutcher of Dana Point, Calif., was scheduled to have special back surgery, Blue Cross denied authorization for the procedure as “investigational” even though the lumbar artificial disc she was to receive had FDA approval.

At the time of denial, which she calls “insurance hell,” Kutcher notes she had “already gone through pre-op testing, donated a unit of blood, had appointments with four physicians.” Kutcher paid $60,000 out of pocket for the operation and is still fighting Blue Cross.

Kaiser Permanente, which denied 28 percent of all claims in the first half of 2009, was one of two systems to reject options for radiation and chemotherapy for 57-year-old Bob Scott of Sacramento after his diagnosis of a brain tumor in 2005. The reason cited was his age, says wife Cheryl Scott, RN. “He had been in perfect health all of his life. This was his first problem other than a sprained ankle. He died six months later.”

Rejection of care is a very lucrative business for the insurance giants. The top 18 insurance giants racked up $15.9 billion in profits last year.

“The routine denial of care by private insurers is like the elephant in the room no one in the present national healthcare debate seems to want to talk about,” Burger said. “Nothing in any of the major bills advancing in the Senate or House or proposed by the administration would challenge this practice.”

Ć¢ā‚¬Å“The United States remains the only country in the industrialized world where human lives are sacrificed for private profit, a national disgrace that seems on the verge of perpetuation,” she said.

CNA/NNOC supports an alternative approach, expanding Medicare to cover all Americans, which would give the U.S. a national system similar to what exists in other nations. Data released in late August by the Organization for Economic Co-operation and Development, which tracks developed nations, found that among 30 industrial nations, the U.S. ranks last in life expectancy at birth for men, and 24th for women.

CNA/NNOC represents 86,000 registered nurses in all 50 states, and is working toward unification with the Massachusetts Nurses Association and United American Nurses to build a new 150,000 member national nurses organization.

How much will reform cost me?

KHN Exclusive: Congressional Documents Show Health Cost

Kaiser Health News
September 4, 2009

These documents, prepared by the House Committee on Ways and Means and obtained by KHN, show the maximum premiums and out-of-pocket costs low- and moderate-income people might face under the House health overhaul plan, called America’s Affordable Health Choices Act (HR 3200).

One example selected from the tables:

Family of four with an income of 400% of the federal poverty level ($88,200):

Maximum monthly premium: $809 ($9708 per year)

Out-of-pocket cap (in addition to premium): $10,000

http://www.kaiserhealthnews.org/Stories/2009/September/04/House-Bill-Premiums.aspx

Comment:

By Don McCanne, MD

Under the House bill for reform (HR 3200), a family of four with an income of $88,200 that had health care needs could be responsible for $19,708 of their health care costs, which is 22% of their income (23% under the Energy and Commerce amendments). That would leave them with an income of $68,492 for all of their other needs and wants (and some of that could be burnt up in out-of-network costs and non-covered services that do not apply to the cap).

When people want to know what reform is going to cost them, it is usually the numbers in these tables that they want to see. Because of concerns about federal budget deficits, it is likely that the financial responsibility for individuals and families will be even greater than these tentative tables depict.

What is not included here is the amount that we are paying through the tax system for government-financed health care, which is roughly one-half of all health care expenditures (including health plans purchased for government employees, but excluding tax subsidies of employer-sponsored plans which have an uncertain future).

Health care is very expensive, and Congress is selecting the most expensive model that has ever been devised to pay for it.

We’re retired and on Medicare, so the numbers above have little meaning for us. But they mean a lot to our children and will mean even more to our grandchildren. Selecting reform using numbers that don’t work this year and will be even worse in future years is not a legacy that we want to leave to our children and grandchildren nor anyone else’s either.

Let’s improve the least expensive model – Medicare – and then share it with all of our future generations. That’s an American solution of which we would all be proud, and, to the point, one which we could afford.

California’s Real Death Panels: Insurers Deny 21% of Claims

PacifiCare’s Denials 40%, Cigna’s 33% in First Half of 2009

From California Nurses Association/National Nurses Organizing Committee

For Immediate Release
September 2, 2009

Contact: Charles Idelson, 510-273-2246, Shum Preston, 510-273-2276, or Liz Jacobs, 510-273-2232

More than one of every five requests for medical claims for insured patients, even when recommended by a patient’s physician, are rejected by California’s largest private insurers, amounting to very real death panels in practice daily in the nation’s biggest state, according to data released today by the California Nurses Association/National Nurses Organizing Committee.

CNA/NNOC researchers analyzed data reported by the insurers to the California Department of Managed Care. From 2002 through June 30, 2009, the six largest insurers operating in California rejected 31.2 million claims for care — 21 percent of all claims.

The data will be presented by Don DeMoro, director of CNA/NNOC’s research arm, the Institute for Health and Socio-Economic Policy, at CNA/NNOC’s biennial convention next Tuesday, Sept. 8 in San Francisco. The convention will also feature a panel presentation from nurse leaders in Canada, Great Britain, and Australia exploding the myths about their national healthcare systems.

“With all the dishonest claims made by some politicians about alleged ‘death panels’ in proposed national legislation, the reality for patients today is a daily, cold-hearted rejection of desperately needed medical care by the nation’s biggest and wealthiest insurance companies simply because they don’t want to pay for it,” said Deborah Burger, RN, CNA/NNOC co-president.

For the first half of 2009, as the national debate over healthcare reform was escalating, the rejection rates are even more striking.

PacifiCare denied 40 percent of all California claims in the first six months of 2009. Cigna, which gained notoriety two years ago for denying a liver transplant to 17-year-old Nataline Sarkisyan of Northridge, Calif. and then reversing itself, tragically too late to save her life, was still rejecting one-third of all claims for the first half of 2009.

“Every claim that is denied represents a real patient enduring pain and suffering. Every denial has real, sometimes fatal consequences,” said Burger.

PacifiCare, for example, denied a special procedure for treatment of bone cancer for Nick Colombo, a 17-year-old teen from Placentia, Calif. Again, after protests organized by Nick’s family and friends, CNA/NNOC, and netroots activists, PacifiCare reversed its decision. But like Nataline Sarkisyan, the delay resulted in critical time lost, and Nick ultimately died. “This was his last effort and the procedure had worked before with people in Nick’s situation,” said his older brother Ricky.

California Blues rejected 28 percent of claims in the first half of 2009. In 2008, six days before RN Kim Kutcher of Dana Point, Calif., was scheduled to have special back surgery, Blue Cross denied authorization for the procedure as “investigational” even though the lumbar artificial disc she was to receive had FDA approval.

At the time of denial, which she calls “insurance hell,” Kutcher notes she had “already gone through pre-op testing, donated a unit of blood, had appointments with four physicians.” Kutcher paid $60,000 out of pocket for the operation and is still fighting Blue Cross.

Kaiser Permanente, which denied 28 percent of all claims in the first half of 2009, was one of two systems to reject options for radiation and chemotherapy for 57-year-old Bob Scott of Sacramento after his diagnosis of a brain tumor in 2005. The reason cited was his age, says wife Cheryl Scott, RN. “He had been in perfect health all of his life. This was his first problem other than a sprained ankle. He died six months later.”

Rejection of care is a very lucrative business for the insurance giants. The top 18 insurance giants racked up $15.9 billion in profits last year.

“The routine denial of care by private insurers is like the elephant in the room no one in the present national healthcare debate seems to want to talk about,” Burger said. “Nothing in any of the major bills advancing in the Senate or House or proposed by the administration would challenge this practice.”

Ć¢ā‚¬Å“The United States remains the only country in the industrialized world where human lives are sacrificed for private profit, a national disgrace that seems on the verge of perpetuation,” she said.

CNA/NNOC supports an alternative approach, expanding Medicare to cover all Americans, which would give the U.S. a national system similar to what exists in other nations. Data released in late August by the Organization for Economic Co-operation and Development, which tracks developed nations, found that among 30 industrial nations, the U.S. ranks last in life expectancy at birth for men, and 24th for women.

CNA/NNOC represents 86,000 registered nurses in all 50 states, and is working toward unification with the Massachusetts Nurses Association and United American Nurses to build a new 150,000 member national nurses organization.

More lessons from Massachusetts

Consumers’ Experience in Massachusetts: Lessons for National Health Reform

By Carol Pryor and Andrew Cohen
Kaiser Family Foundation
The Access Project
September 2009
In developing its health reform initiative, designers of the Massachusetts system tried to ensure that programs were available to help almost everyone get either insurance coverage or assistance in paying for health care. MassHealth continues to serve traditional populations, such as low-income families with children. Commonwealth Care plans are designed for low-income adults without access to other sources of coverage. People with employer-sponsored coverage are expected to keep that coverage. For higher income people without access to employer-sponsored coverage, non-subsidized Commonwealth Choice plans were created to provide what was considered affordable non-group coverage. And for people who still “fell through the cracks,” the Health Safety Net subsidizes certain costs for uninsured people or people with inadequate insurance.
One issue for consumers is that the protections provided to Commonwealth Care and MassHealth enrollees regarding limits on premium and out-of-pocket health care costs were not extended to all lower and moderate income people. As a result, workers in employer-sponsored coverage, especially those with lower incomes, may end up with insurance premiums and out-of-pocket costs that are unmanageable given their incomes. For moderate income workers without access to employer-sponsored coverage, especially those just over the limits for Commonwealth Care eligibility, the options available to them may be an improvement on what was available prior to health reform but still unaffordable. Although the HSN (Health Safety Net) provides some back up coverage, it does not cover everything and the support it provides may not be adequate for everyone.
These problems in part reflect affordability decisions that set coverage limits based on the state resources available. They may also reflect misconceptions about the costs that people at various income levels are able to absorb. People generally think of financial problems resulting from health care costs as the result of catastrophic bills people incur because of major illness. However, a recent study found that most people who reported problems paying medical bills had relatively modest levels of out-of-pocket spending.
The second issue is that the reformed system is complicated for consumers to navigate, which may lead to gaps in coverage as people move among different types of insurance, both public and private.
The Massachusetts experience shows that to make affordable health care accessible to consumers, it is not sufficient to ensure that programs are available to cover everyone. The quality of the coverage provided and the interrelationships between the programs are also important.
http://www.kff.org/healthreform/upload/7976.pdf

Although there are many reports on the deficiencies of the Massachusetts reforms, this report stresses two serious design flaws that impair affordability and access for low and middle income patients: 1) both public and private plans often fail to provide adequate financial protection even for those with only modest health care needs, and 2) the complex maze of programs and plans are very difficult to navigate with ever changing eligibility for the various programs, leading to frequent unavoidable lapses in coverage or no coverage at all.
Many have recommended that we use the Massachusetts model as the basis for national health reform. Basically, that is what Congress is doing. If you read this full report to see what the authors believe are the lessons for national reform, you will see that they recommend yet another half dozen or so patches to be applied to this system with a failing financing infrastructure – failing because it began as a patched together system in the first place.
Perhaps the most telling of their recommendations: “Even in a reformed health system, a health care safety net will be needed.” They assume that we will always have significant numbers of uninsured and underinsured individuals. Providing everyone adequate health care is not possible, that is unless we adopt an improved Medicare program for everyone. But that isn’t feasible.
That last line reminds me of a comment Andy Rooney once made after noting that so many people were told by a doctor that they had only six months to live and yet they lived on for years or decades longer. He said that we should conduct a national manhunt to find that doctor and arrest him.
Likewise, we need to find the person who is telling everyone that the one health care reform program that would actually work isn’t feasible, and then arrest him. At least the people who went to the doctor Andy Rooney mentioned survived his bad advice. This guy who is blocking reform because of some “feasibility” nonsense is killing people wholesale. We have to stop him.

Don't Be Fooled by the Public Option

By Bill Boyarsky
Truthdig
Sept. 3, 2009

While the media are transfixed by all the screaming in town halls and on television, the real work of health care reform is being done in secret by congressional staff technocrats, government bureaucrats, health industry lobbyists and sometimes even a member of the Senate or House.

The controversy over the so-called public option is a prime example of what is happening. Under this arrangement, government health insurance plans are supposed to compete with those offered by private insurance companies, with the hope of forcing the private companies to lower prices and expand benefits. Advocates of this scheme offer it as an alternative to what’s known as universal medical care, Medicare for all or “single payer,” which would eliminate the role of insurance companies altogether in favor of a government-only plan. Many liberals say such far-reaching reform is unattainable. As a compromise, they support the public option.

The fight over the public option has occupied much of the media coverage, but left unsaid is the fact that weeks of behind-the-scenes negotiations have weakened the public option proposal to the point that it is hardly an option at all.

I discussed the matter with Rep. Dennis Kucinich, D-Ohio. Kucinich favors universal health insurance coverage, not the public option. So do I.

A health care reform bill was approved by the House Energy and Commerce Committee in July. Kucinich said that a final version–the real bill–is now being rewritten and will be presented to committee chairs and other leaders, who will bring the revised version to the House floor. “It’s happening now,” he said. “It’s being done by the leadership, and we [members of Congress] don’t know what’s going on.”

Kucinich is the author of an amendment to the House bill that would ease federal barriers to states wanting to enact universal care plans of their own. Legislators are engaged in such efforts in California, Colorado, Illinois, Minnesota, Montana, New Mexico, New York, Ohio, Pennsylvania and Washington. He told me it “was one of the few provisions in a badly flawed bill that could provide benefits.”

Kucinich suggested I read articles written by health insurance expert Kip Sullivan on the Web site of Physicians for a National Health Program, which advocates government-run universal health care. Sullivan, he said, has figured out the real story.

Sullivan writes that public option advocates once promised a program as far-reaching as Medicare but “now promote something entirely different. To make matters worse, they have not told the public they have backpedaled. The campaign for the Ć¢ā‚¬Ėœpublic option’ resembles the classic bait-and-switch scam: Tell your customers you’ve got one thing for sale, when in fact you are selling something very different.”

Sullivan documents how the public option has been watered down since Jacob Hacker, now a political science professor at the University of California at Berkeley, proposed it several years ago. Hacker first estimated that 129 million would be covered, drawn by its generous terms. But the public option plans now before Congress would cover no more than 10 million, Sullivan said. Reducing subsidies to low-income people has cut the number covered, while limits on private insurance benefits have been eased.

In addition, the public option would actually be run by insurance companies such as Blue Cross, acting as contractors for the federal government. What is everyone arguing over? Heads they win, tails they win.

Referring to a bill approved by the Senate Health, Education, Labor and Pension Committee, Sullivan writes that the language of these provisions is so complex “it requires at least two readings to understand it.” The language of this and the other bills is no doubt designed to be purposely incomprehensible to most lawmakers, who will receive the final bill only at the last moment. The bills certainly are not being written to be understood by the general public.

Another important issue being decided in private is what precisely will Americans get from the new plan. “What level of subsidies [will] be available to make coverage more affordable for people?” asked Drew Altman, president of the Henry J. Kaiser Family Foundation. “What kind of coverage will people receive, and will it meet the public’s expectations?”

Kucinich doesn’t like the secret process. Neither does a newspaper that seldom, if ever, agrees with him on anything: The Wall Street Journal. Noting that President Barack Obama has complained that critics have misrepresented him, the paper said, “Who’s to know what’s reality and what’s a myth when the public and Members of Congress aren’t able to read a bill that would restructure one-seventh of our economy.”

So far, the loser in this game of backroom politics is the consumer or, in this case, the patient. The winner is the medical care industry.

President Obama is scheduled to speak to Congress on Wednesday on the issue. He’ll have to assure the rest of us that we’ll be winners, too.

http://www.truthdig.com/report/item/20090903_dont_be_fooled_by_the_public_option/?ln

More lessons from Massachusetts

Consumers' Experience in Massachusetts: Lessons for National Health Reform

By Carol Pryor and Andrew Cohen
Kaiser Family Foundation
The Access Project
September 2009

In developing its health reform initiative, designers of the Massachusetts system tried to ensure that programs were available to help almost everyone get either insurance coverage or assistance in paying for health care. MassHealth continues to serve traditional populations, such as low-income families with children. Commonwealth Care plans are designed for low-income adults without access to other sources of coverage. People with employer-sponsored coverage are expected to keep that coverage. For higher income people without access to employer-sponsored coverage, non-subsidized Commonwealth Choice plans were created to provide what was considered affordable non-group coverage. And for people who still “fell through the cracks,” the Health Safety Net subsidizes certain costs for uninsured people or people with inadequate insurance.

One issue for consumers is that the protections provided to Commonwealth Care and MassHealth enrollees regarding limits on premium and out-of-pocket health care costs were not extended to all lower and moderate income people. As a result, workers in employer-sponsored coverage, especially those with lower incomes, may end up with insurance premiums and out-of-pocket costs that are unmanageable given their incomes. For moderate income workers without access to employer-sponsored coverage, especially those just over the limits for Commonwealth Care eligibility, the options available to them may be an improvement on what was available prior to health reform but still unaffordable. Although the HSN (Health Safety Net) provides some back up coverage, it does not cover everything and the support it provides may not be adequate for everyone.

These problems in part reflect affordability decisions that set coverage limits based on the state resources available. They may also reflect misconceptions about the costs that people at various income levels are able to absorb. People generally think of financial problems resulting from health care costs as the result of catastrophic bills people incur because of major illness. However, a recent study found that most people who reported problems paying medical bills had relatively modest levels of out-of-pocket spending.

The second issue is that the reformed system is complicated for consumers to navigate, which may lead to gaps in coverage as people move among different types of insurance, both public and private.

The Massachusetts experience shows that to make affordable health care accessible to consumers, it is not sufficient to ensure that programs are available to cover everyone. The quality of the coverage provided and the interrelationships between the programs are also important.

http://www.kff.org/healthreform/upload/7976.pdf

Comment:

By Don McCanne, MD

Although there are many reports on the deficiencies of the Massachusetts reforms, this report stresses two serious design flaws that impair affordability and access for low and middle income patients: 1) both public and private plans often fail to provide adequate financial protection even for those with only modest health care needs, and 2) the complex maze of programs and plans are very difficult to navigate with ever changing eligibility for the various programs, leading to frequent unavoidable lapses in coverage or no coverage at all.

Many have recommended that we use the Massachusetts model as the basis for national health reform. Basically, that is what Congress is doing. If you read this full report to see what the authors believe are the lessons for national reform, you will see that they recommend yet another half dozen or so patches to be applied to this system with a failing financing infrastructure – failing because it began as a patched together system in the first place.

Perhaps the most telling of their recommendations: “Even in a reformed health system, a health care safety net will be needed.” They assume that we will always have significant numbers of uninsured and underinsured individuals. Providing everyone adequate health care is not possible, that is unless we adopt an improved Medicare program for everyone. But that isn’t feasible.

That last line reminds me of a comment Andy Rooney once made after noting that so many people were told by a doctor that they had only six months to live and yet they lived on for years or decades longer. He said that we should conduct a national manhunt to find that doctor and arrest him.

Likewise, we need to find the person who is telling everyone that the one health care reform program that would actually work isn’t feasible, and then arrest him. At least the people who went to the doctor Andy Rooney mentioned survived his bad advice. This guy who is blocking reform because of some “feasibility” nonsense is killing people wholesale. We have to stop him.

Don’t Be Fooled by the Public Option

By Bill Boyarsky
Truthdig
Sept. 3, 2009

While the media are transfixed by all the screaming in town halls and on television, the real work of health care reform is being done in secret by congressional staff technocrats, government bureaucrats, health industry lobbyists and sometimes even a member of the Senate or House.

The controversy over the so-called public option is a prime example of what is happening. Under this arrangement, government health insurance plans are supposed to compete with those offered by private insurance companies, with the hope of forcing the private companies to lower prices and expand benefits. Advocates of this scheme offer it as an alternative to what’s known as universal medical care, Medicare for all or “single payer,” which would eliminate the role of insurance companies altogether in favor of a government-only plan. Many liberals say such far-reaching reform is unattainable. As a compromise, they support the public option.

The fight over the public option has occupied much of the media coverage, but left unsaid is the fact that weeks of behind-the-scenes negotiations have weakened the public option proposal to the point that it is hardly an option at all.

I discussed the matter with Rep. Dennis Kucinich, D-Ohio. Kucinich favors universal health insurance coverage, not the public option. So do I.

A health care reform bill was approved by the House Energy and Commerce Committee in July. Kucinich said that a final version–the real bill–is now being rewritten and will be presented to committee chairs and other leaders, who will bring the revised version to the House floor. “It’s happening now,” he said. “It’s being done by the leadership, and we [members of Congress] don’t know what’s going on.”

Kucinich is the author of an amendment to the House bill that would ease federal barriers to states wanting to enact universal care plans of their own. Legislators are engaged in such efforts in California, Colorado, Illinois, Minnesota, Montana, New Mexico, New York, Ohio, Pennsylvania and Washington. He told me it “was one of the few provisions in a badly flawed bill that could provide benefits.”

Kucinich suggested I read articles written by health insurance expert Kip Sullivan on the Web site of Physicians for a National Health Program, which advocates government-run universal health care. Sullivan, he said, has figured out the real story.

Sullivan writes that public option advocates once promised a program as far-reaching as Medicare but “now promote something entirely different. To make matters worse, they have not told the public they have backpedaled. The campaign for the Ć¢ā‚¬Ėœpublic option’ resembles the classic bait-and-switch scam: Tell your customers you’ve got one thing for sale, when in fact you are selling something very different.”

Sullivan documents how the public option has been watered down since Jacob Hacker, now a political science professor at the University of California at Berkeley, proposed it several years ago. Hacker first estimated that 129 million would be covered, drawn by its generous terms. But the public option plans now before Congress would cover no more than 10 million, Sullivan said. Reducing subsidies to low-income people has cut the number covered, while limits on private insurance benefits have been eased.

In addition, the public option would actually be run by insurance companies such as Blue Cross, acting as contractors for the federal government. What is everyone arguing over? Heads they win, tails they win.

Referring to a bill approved by the Senate Health, Education, Labor and Pension Committee, Sullivan writes that the language of these provisions is so complex “it requires at least two readings to understand it.” The language of this and the other bills is no doubt designed to be purposely incomprehensible to most lawmakers, who will receive the final bill only at the last moment. The bills certainly are not being written to be understood by the general public.

Another important issue being decided in private is what precisely will Americans get from the new plan. “What level of subsidies [will] be available to make coverage more affordable for people?” asked Drew Altman, president of the Henry J. Kaiser Family Foundation. “What kind of coverage will people receive, and will it meet the public’s expectations?”

Kucinich doesn’t like the secret process. Neither does a newspaper that seldom, if ever, agrees with him on anything: The Wall Street Journal. Noting that President Barack Obama has complained that critics have misrepresented him, the paper said, “Who’s to know what’s reality and what’s a myth when the public and Members of Congress aren’t able to read a bill that would restructure one-seventh of our economy.”

So far, the loser in this game of backroom politics is the consumer or, in this case, the patient. The winner is the medical care industry.

President Obama is scheduled to speak to Congress on Wednesday on the issue. He’ll have to assure the rest of us that we’ll be winners, too.

http://www.truthdig.com/report/item/20090903_dont_be_fooled_by_the_public_option/?ln

Paying for community health centers

Using Primary Care to Bend the Curve: Estimating the Impact of a Health Center Expansion on Health Care Costs

By Leighton Ku, PhD, MPH, Patrick Richard, PhD, Avi Dor, PhD, Ellen Tan, MSc, Peter Shin, PhD, MPH, Sara Rosenbaum, JD
The George Washington University
School of Public Health and Health Services
Geiger Gibson / RCHN Community Health Foundation Research Collaborative
September 1, 2009
This research brief, the third in a series examining the link between national health reform proposals and community health centers, estimates the cost savings that would be realized by making important investments in non-profit health centers as an element of national health reform.
These projected savings to the nationā€™s health care costs become possible because of the insurance reforms on which they build, supplemented by a direct health center investment. Health insurance coverage expansions, coupled with investments in the nationā€™s primary health care infrastructure, can spur high quality and sustainable primary health care in medically underserved rural, urban, and suburban communities, and help bend the curve of health care cost growth.
Under the health reform proposals, a large number of people will gain insurance coverage from the health insurance exchanges, which will primarily offer private plans (although the House bill also offers a public plan option). As reported earlier, private insurance plans tend to pay health centers considerably less than the actual costs of providing care at health centers; data from the 2007 Uniform Data System indicate that private insurance underpays by about 43 percent. One option under health reform would be to require plans offering care under the exchange to pay health centers according to the prospective payment system (PPS) used in both Medicaid and Medicare, which comes much closer to paying full costs. In 2007, Medicaid payments were about 15 percent below health centersā€™ estimated costs.
As has been demonstrated by a number of studies, in addition to this one, health centers are a cost-effective means to furnish primary health care, which can lead to better health and lower health care expenditures. Investments in health centers can serve as a complement to health reform efforts to expand the number of people with health insurance, by ensuring that there is an increased availability of primary health care providers to serve the newly insured, as well as those who remain uninsured. This will be particularly important in medically underserved areas where there is already an insufficient supply of primary care providers. Thus, this is a case in which the national economic value of the investment is further enhanced by its ability to bring better health to the nationā€™s most underserved communities.
http://www.gwumc.edu/sphhs/departments/healthpolicy/dhp_publications/pub_uploads/dhpPublication_61D685D5-5056-9D20-3DDB6CDE10382393.pdf

Regardless of what proposals for health care reform are adopted, it is essential that financing be included for non-profit community health centers in underserved rural, urban and suburban communities. Would these centers be better served by health insurance exchanges and their private plans, or by a public financing program?
Although the insurance industry whines that public plans would provide unfair competition because they pay less than private plans, what is the record with community health centers? Unfortunately, Medicaid does underpay – by about 14 percent below the health centers’ estimated costs. But the private plans, which the members of Congress are so diligently protecting, are underpaying by about 43 percent!
There are two financing considerations for community health centers: 1) capital investments to build and expand the facilities, and 2) operating expenses, including payment for health care services.
Capital investments can be authorized through various legislative efforts, including as a component of the current health care reform legislation. But such efforts tend to be sporadic and not always well aligned with need. In contrast, the single payer model separately budgets capital improvements, providing more coordinated capital allocations based on community need. It ensures a perpetual resource that is responsive to fluctuating needs.
For operating expenses, the thousands of private health plans each do whatever they can to avoid paying health care costs. Community health centers serving vulnerable populations do not have the clout to demand that their expenses be met by the private insurers. Medicaid, a chronically underfunded welfare program, comes much closer, but still falls short. In contrast, a single payer system is designed to pay for the legitimate costs of appropriate health care. The community health centers would be served much better by an improved Medicare-like plan that covers everyone.
Community health centers have strong bipartisan support. Now if only we could could get our legislators to agree on adopting an efficient and equitable system of financing the centers…

Mad as hell across the country

Andrea Hektor reports on the plans of Oregon doctors and single-payer advocates to take their cause on the road.

September 1, 2009

A SMALL group of Oregon-based doctors and their supporters is getting ready for a cross-country tour to demand health care reform that will actually work to end the crisis–a government-run single-payer system that would cover everyone and cut out the private insurance industry.

The doctors’ “Care-A-Van” will start out September 8 on a journey from Portland, Ore., to Washington, D.C.

The trip will include town hall meetings on health care along the way. But these forums won’t be like the ones sponsored by Washington politicians, where right-wingers denounced all reform and Democratic legislators attempted to defend their proposals. Even before those town halls occurred, the Democrats conceded on a series of crucial questions, leaving their legislation “toothless” and giving the insurance industry everything it could have hoped for.

In contrast, the town halls organized for the six physicians, who call themselves the “Mad As Hell Doctors,” will seek to educate people about single-payer and get people involved in the movement fighting for a rational health care system.

As Dr. Paul Hochfield, the lead Mad As Hell Doctor and producer of the documentary Health, Money, and Fear, said in a statement, “We’re mad as hell because our health care system is run by people who profit from illness. The rest of the civilized world has test-driven single-payer, and it works. But elected officials in America won’t even allow a discussion.”

With millions in the U.S. uninsured and millions more with coverage that would likely stick them with enough bills to land them in bankruptcy court were they ever to have a serious medical emergency, the vast majority of the U.S. public supports some type of global government-run system for all citizens.

Yet the term “universal health care” has been expropriated by Democrats to mean “mandated coverage”–something like the health care scheme imposed in Massachusetts in 2004 that requires all residents to purchase some form of coverage, likely from a private company, or face tax penalties.

So while many people see the need for reform, the debate about health care among elected officials and in the corporate-controlled–and insurance-industry friendly–mainstream media has skewed people’s idea of what single-payer, “everybody in, nobody out” health care coverage.

Getting real information about single-payer out there is half the reason for the Mad As Hell Care-A-Van, according to Dr. Mike Huntington, a radiologist from Corvallis, Ore., who will be on the trip. As Huntington put it:

People need to understand what single-payer is–and isn’t. It isn’t socialism, any more than police and fire are socialism. And it doesn’t require any more money.

Simply put, single-payer is a way to take the current premium payments that go to a thousand different private insurance companies, and redirect them into a single, public fund that insures everyone. That’s all it is. But when we do this, lots of wonderful things happen, not the least of which is to save Americans $500 billion a year, starting day one. That’s billion–with a “b.” America needs this information. That’s why we’re taking the tour.

The other motive behind the tour is to get people involved in activism. “We’re doing this because we care,” said Dr. Gene Uphoff, a retired family physician from Portland. “The time to demand single-payer in America is now. We may not get another opportunity for real change like this in our lifetime. Washington needs to hear all of us right now.”

Every move the Mad as Hell Doctors make will be videotaped, and then edited and uploaded to the Internet that same day. The uploaded segments will be promoted on social networking web sites such as Facebook, Twitter, YouTube, MySpace and elsewhere–giving Mad As Hell Doctors Tour followers the opportunity to follow their stories in real time.

The tour will end on September 30 in Washington, D.C. with a plan for thousands of cars to pull up for a protest in front of the White House, where the Mad As Hell Doctors hope to meet with President Barack Obama to discuss real healthcare reform.

“This is not a campaign,” the Mad As Hell Doctors said in a press release. “In campaigns, there are spectators. This is a movement. Everybody plays.”

These doctors are right–right to be mad, right that we need a real debate about health care, and right that it’s going to take a movement to win single-payer.

The Public Option: Doomed to Fail

The Nation
Letters
July 29, 2009

Regarding your editorial “Public Option Now!” (July 20/27): a public option won’t fix the mainstream Democrats’ flawed healthcare reform proposals. Only a single-payer reform would make universal, first dollar coverage affordable. It would save about $400 billion annually on bureaucracy and rein in costs over the long term through global budgeting and rational health planning.

Even a public plan option far more robust than anything on the table in Washington would forgo most of these savings, making comprehensive coverage unaffordable. While a public plan might cut into private insurers’ roughly $10 billion in yearly profits (which is why they hate it), that’s only 10 percent of their overhead. They spend much more tracking eligibility, collecting premiums, marketing to healthy (profitable) patients, demarketing to avoid the sick, and shifting costs to patients and providers. A competitive public plan couldn’t match the efficiency of Medicare, whose integration with Social Security allows automatic enrollment, disenrollment and premium collection.

Moreover, a hybrid plan would forgo hundreds of billions in administrative savings because hospitals and doctors would still have to maintain armies of administrators and billing clerks to joust with hundreds of insurers.

A kinder, gentler public plan would quickly fail in the healthcare marketplace. Insurers compete by not paying for care. Competition in health insurance is a race to the bottom, not the top. A public plan that did no marketing would soon be saddled with the sickest patients, whose high costs would overwhelm any administrative efficiencies and drive premiums to uncompetitive levels. Similarly, eschewing private insurers’ schemes that shift costs to patients and other payers would be a crippling competitive disadvantage. To survive, a public plan would have to imitate private plans’ bad behaviors.

A healthcare system dominated by private insurers cannot provide families with the affordable coverage they need. A public clone of private insurers won’t help.

David U. Himmelstein, MD
Steffie Woolhandler, MD, MPH
Sidney M. Wolfe, MD
Quentin Young, MD
Marcia Angell, MD

Cambridge, Mass.; Washington; Chicago

http://www.thenation.com/doc/20090817/letter