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Single-payer system controls costs

Single-payer system controls costs

By Phil Lopes
Guest Opinion
Special to the Arizona Daily Star
Published: 07.27.2009

The Congressional Budget Office testified last week that the proposals put forth by the Senate and House committees would not slow the rise of health care costs. Those proposals for health-care reform fail one of the two tests for real reform, namely to moderate and restrain the rate at which costs are rising.

Empirical evidence clearly shows that the one proposal that will restrain the rate is single-payer. Those who fear that single-payer is new and foreign, and therefore untested, need to be reminded that Medicare is, in essence, a single-payer system. For those who are eligible, Medicare is universal and identical, not means-tested and is administered by the government, which acts as a single-payer through contracts with the private sector to provide hospital and outpatient physician services.

Studies by both the Congressional Budget Office and the Government Accountability Office have repeatedly shown that single-payer universal health care would save significant dollars in administrative costs. As early as 1991, the GAO concluded that if the universal coverage and single-payer features of other countries, such as Canada, had been applied in the United States that year, the total savings (then estimated at $66.9 billion) “Would have been more than enough to finance insurance coverage for the millions of American who are currently uninsured.”

More recently, estimates published in the International Journal of Health Services conclude that “streamlining administrative overhead to Canadian levels would save approximately $286 billion in 2002, $6,940 for each of the 41.2 million Americans who were uninsured as of 2001. This is substantially more than would be needed to provide full insurance coverage.” At present, the U.S. spends 50- to 100-percent more on administration than countries with single-payer systems.

Single-payer gives the government greater leverage to control costs. A single-payer system would be able to take advantage of economies of scale and exert greater leverage in bargaining with providers, thereby controlling costs. Recent experiences with both the veterans’ health system and that of Medicare Part D indicate the difference exerting such leverage can make.

The Department of Veterans Affairs uses its power as a major purchaser to negotiate prices with pharmaceutical makers. But when the legislation leading to the drug prescription plan (better known as Medicare Part D) was passed, Congress explicitly barred negotiating prices with drug makers.

The results of this are now becoming evident: at present, the VA is paying 46 percent less for the most popular brand-name drugs than the average prices posted by the Medicare plans for the same drugs. Because Part D increased the demand for drugs without controlling costs, prescription drug prices have risen sharply: during the first quarter of 2006, prices for brand-name drugs “jumped 3.9 percent, four times the general inflation rate . . . and the largest quarterly price increase in six years,” according to The New York Times.

Health-care costs will not decrease but the empirical and practical evidence clearly shows single-payer’s ability to restrain cost increases.

These reasons are in addition to fulfilling the other test of real reform, namely that such a system is the only way we can realistically afford to end the dangerous, embarrassing and worsening situation wherein about 47 million people in this country lack health insurance and tens of millions more are seriously under-insured.

We should all therefore urge Congress and the President to adopt a single-payer system, or make it the public option, without which neither cost moderation nor universal coverage will be achieved.

E-mail Rep. Phil Lopes at plopes@azleg.gov

Media needs to deepen coverage of healthcare reform

By James Rainey
Los Angeles Times
July 29, 2009

A key senator had begun to explain a proposal that might help clear the way to national healthcare reform. Television cameras zoomed in as Max Baucus, Democrat of Montana, began to explain the potential compromise.

But if you were watching CNN on Tuesday about the time that Baucus mentioned instituting a cost-control commission he called a “Med-Pac on steroids,” you quickly found yourself whisked back to the studio. The senator had gotten into messy details, “a little bit in the weeds,” as CNN anchor Tony Harris said.

Rather than try to explain to its viewers how such a commission might control Medicare costs, CNN cut away to an all-important update on . . . Alberto Contador’s ongoing war of words with fellow cyclist Lance Armstrong.

By all means, let’s recap the story of two big-name jocks man-slapping each other, rather than help Americans sort out the central domestic issue (Snore!) of the moment.

America has a healthcare crisis, yes, and so do broad segments of the media, particularly television news. They have transformed the story of how to fix an overpriced and inadequate care system into an overheated political scrum, with endless chatter about deadlines and combatants and very little about the kind of medical care people get and how it might change.

Campaign-style “horse race” coverage seemed to me to have shoved aside more pertinent reporting, and on Tuesday, that view got some confirmation, in the form of research from the Project for Excellence in Journalism.

The Washington-based watchdog group found that more than three-quarters of the coverage (by 55 outlets across television, radio, newspapers and websites) in the week ending last Sunday focused on politics and legislative strategy. That means less than one quarter of the coverage centered on current medical care conditions, the details of reform proposals or the effect of healthcare on the larger economy.

“If the debate over healthcare reform is a potential teaching moment about how we take care of ourselves in America versus other countries, how much healthcare costs and the quality of our medicine, that teaching moment so far is passing us by,” said Tom Rosenstiel, director of the project, which examined 244 stories about healthcare.

The complexity of the debate has not been lost on anyone, but even accepting the difficulties, many outlets have shown a dazzling determination to highlight conflicts and legislative timetables while telling us almost nothing about potential changes in insurance and care.

Many outlets have obsessed, in particular, over the likelihood that the legislation would not be settled by this week’s congressional recess.

“Journalists want to be first to identify a turning point, that critical juncture in history when an initiative is doomed to failure or on its way to ushering in a new era,” said Michelle Levander, who runs a fellowship for healthcare journalists at USC’s Annenberg School for Communication. “In our rush to judgment, we sometimes overlook the fine point of whether we are calling that moment in history or creating it.”

Fox News, not surprisingly, seems most intent on reporting on the potential failure of President Obama to make this week’s deadline, which he set himself.

Exaggerations

Anchor Martha MacCallum seemed almost to be pleading with one Democratic congressman this week to give up the idea of a government-sponsored health insurance option. “Is there any part of you that says, ‘This is not the time?’ ” she prodded.

Jeff Levi, executive director of the non-partisan Trust for America’s Health, said the importance of passing a bill this week has been greatly exaggerated. “What gets lost in the cable TV cacophony is what this is about,” Levi said. “It’s not about meeting a deadline. It’s about a critical public policy issue.”

That’s not to say that the Obama administration doesn’t have itself partly to blame for both setting the goal of early action and pumping up the sense of urgency.

“I believe there was strategy to show that the stars were aligned and this legislation was going to happen. That the time is here,” said Trudy Lieberman, who has followed healthcare and the media’s coverage of the issue for the Columbia Journalism Review.

Lieberman said many reporters accepted with little scrutiny the notion that broad interests — from doctors, to insurers and drug companies — would back reform. Her experience in covering the failed Clinton administration health reform effort taught her that those groups might publicly support change while privately trying to kill crucial details that might move legislation forward.

“Now it looks like that’s happening again,” Lieberman said, “and again, we’ve degenerated to the kind of coverage we had in ’93-’94 — who is up, who is down, who’s winning, who’s losing?”

Both the president and reporters covering the story need to do just what CNN avoided Tuesday and get down in the weeds.

The media, appropriately, reported the Congressional Budget Office’s finding that the Democratic proposal in the House could add as much as $239 billion to the federal deficit over 10 years. But Wendell Potter, a former CIGNA healthcare spokesman-turned-consumer advocate, told Lieberman that reporters routinely fail to assess the huge “costs to society and the economy if reform is not enacted.”

A hole in coverage

That would go a long way toward putting the current debate in Congress in perspective. But it would still leave a gaping hole in much of the media coverage — caused by the failure to investigate practices around the rest of the world, particularly European-style, single-payer programs.

The liberal media watchdog group Fairness & Accuracy in Reporting and a group of progressive activists delivered a petition Tuesday to ABC News in New York (which recently excluded one of the activists from a forum on healthcare) to demand broader reporting, including an assessment of government-managed health systems.

I suspect some in the big media have tiptoed lightly on that turf for the same reason as the politicians. Better to appear ill-informed about the world of healthcare than to appear open to anything, you know, French.

Discard this health plan

Congress is bowing to special interests

Ray Bellamy
Tallahassee Democrat
July 29, 2009

I supported Barack Obama when he ran for president. Still do. But he made a fatal mistake allowing Congress to generate his health care reform bill. Congress invited affected industry groups to the table and excluded us regular taxpayers from the sausage-making.

Proposals were generated in the House and Senate that protect industry profits and expand their markets but soak us and future generations. The result is awful. Unsustainable, unaffordable, doomed to fail. Little or no cost-control measures and little reform. Most of the current health system’s flaws remain. Perhaps one or two minor features of the proposal are worth saving, but in general both the House and Senate proposals must be completely discarded. Let me elaborate.

I confess to not having read the more-than-1,000-page House bill or studied emerging details of what the Senate has ginned up. But I have followed the process for months with increasing alarm. Now a very worthwhile executive summary of the impact of the House bill is available (https://pnhp.org/news/2009/july/more_of_the_same_is_.php), “More of the Same is not Health Care Reform, It’s a Placebo” by Leonard Rodberg, a professor of urban studies in New York. If you were inclined to support this attempt to cover the health care needs of all Americans, you need to read this short explanation of why you should not.

* The massive wasted administrative expense in the present system, estimated at 31 percent, remains intact. The journal Health Affairs published a May article estimating each physician wastes two hours a week just wrestling with the many insurers. That waste remains, perhaps increases, with Congress’ proposal.

* No serious cost-control measures. The Med Pac feature and some effort to deal with disparity between reimbursement in Medicare between rural and urban areas are minor exceptions.

* Employers must either provide insurance, likely to be more expensive, or pay a fee. Everyone is required to have insurance, and if your employer offers insurance you must take the plan offered unless you cannot afford it. The only access to the insurance exchange is to people who are not covered by their employer; they cannot choose the public option.

* The public option, originally envisioned by Jacob Hatcher of Berkeley, was to cover 130 million of us at affordable rates and lead to single payer, eventually. To assuage critics’ concerns, it would now be available only to the uninsured on a limited basis, expected to cover about 10 million of us, and we are assured by Obama Health Secretary Kathleen Sibelius that the public option will not be allowed to eventuate in single payer.

* Medicaid is to be expanded to those who earn less than 133 percent of the federal poverty level. States should take note, as Florida currently pays $17 billion as its share of Medicaid, the largest item in our state budget.

* Subsidies to help the poor pay insurance premiums are inadequate and, although there is a mandate to purchase insurance, there are no limits on the cost of premiums or the amount of deductibles or copays or on drug prices.

The House bill is patterned after the Massachusetts Plan, which was apparently authored in large part by Blue Cross. Like all other state plans with goals to cover all their citizens, it seems to be failing in its third year because of cost overruns. Some 45,000 taxpaying Massachusetts citizens were cut from the insured rolls in the last 10 days to save $117 million in the stressed state budget. Since much of the safety net infrastructure of neighborhood health clinics has been dismantled in that state, those unfortunately dropped from coverage will have to go to the ER for care.

The proposal out of Congress does not meet Obama’s goals, which I share, of universality (at least 10 million would not be covered), does not meet the affordability goal, and does not meet the guaranteed choice goal, since employees must take the plan offered to them at work.

The scrambling about in Congress to “find some more savings” should ring alarm bells. Already, in order to gain the endorsement of the American Medical Association, a $245 billion fix of the Sustainable Growth Rate for Medicare has been promised, with the entire $245 billion not to be counted in calculations of cost for the “deficit-neutral” aspect of this plan.

(The Medicare Sustainable Growth Rate formula is an annual sticking point and has been for years, and sometimes nearly shuts down government and stops payment to MDs for a few weeks causing cash flow problems.)

It appears the pharmaceutical industry also has garnered promises that it will not be subjected to demands for volume discounts in return for nonbinding promises by Big Pharma of $80 billion in savings.

Perhaps we are faced with something akin to the situation when a massive sports stadium is being sold to taxpayers. The cost of the project is low-balled, then, when the stadium is half-built and the money has run out, the taxpayers find they must finish the project by coming up with more money or leave the unfinished stadium as an eyesore.

I agree with the Congressional Budget Office analysis that there are few cost controls and no savings in the proposal. My fellow physicians would predict massive cost increases just as in Massachusetts, and eventual failure of the plan.

I agree with Obama’s goals and with his observation that doing nothing is not an option, as we have reached a crisis in this country with unsustainable costs in health care. Let’s be honest with the American people; rationing will be necessary.

Major restructuring of our delivery system is urgently needed. However, the proposals churned out by Congress, with only affected industries providing input, are indeed only placebo. A very expensive placebo. Taxpayers deserve much better.

In my dreams, I imagine an America where politicians are immune to the need to constantly raise funds for re-election. That is not likely to happen in my lifetime. But just maybe, when legislators have tried everything else and realized that all of their proposals to “build on the present system” are unaffordable, they will reluctantly come to the realization that the only affordable and sustainable pathway to universal health coverage is a single-payer system, a variation of what almost all industrialized countries have adopted.

Cost controls, reasonable decisions about rationing, most of the money spent on health care going to help people rather than to wrestle with insurance companies, universal coverage from the day of birth, no medical bankruptcies — then we will have arrived. This would actually be the most fiscally responsible position.

Sorry, Rush and Sean Hannity, I had to say it.

ABOUT THE AUTHOR: Ray Bellamy is a physician practicing in Tallahassee. Contact him at ray.bellamy@med.fsu.edu.

House Members Debate Medical Bankruptcy Numbers

By Jane Norman, CQ HealthBeat Associate Editor
CQ HEALTHBEAT NEWS
July 28, 2009

A House Judiciary subcommittee hearing on medical debt turned at times into a battle Tuesday between Democrats and Republicans over single-payer health insurance and the health care overhaul — though, as one Republican member observed, the panel has no jurisdiction over health care.

The hearing in the Commercial and Administrative Law Subcommittee tackled a subject that often comes up in discussions of the need for health care system changes, and that’s how often Americans declare bankruptcy because of heavy medical bills. A recent study published in the American Journal of Medicine — and written by an advocate of single-payer insurance — found 62 percent of bankruptcies in 2007 tracked back to medical debt in some form.

That study came under fire at the hearing from an American Enterprise Institute scholar who said it overstated the problem.

Subcommittee Chairman Steve Cohen, D-Tenn., said the problem with medical bankruptcies “lies with the runaway cost of health care in America” so that when financial20disaster hits, it hits hard. Cohen said he’d like to hear ideas for amending the Bankruptcy Code to aid people burdened with medical debt, including revisiting a 2005 revision of bankruptcy law.

Judiciary Committee Chairman John Conyers Jr., D-Mich., agreed that changes should be made in credit counseling requirements under the 2005 law because for people with medical debt “it would not make one iota of difference in their financial lives.” Conyers, who plugged a single-payer plan, also said that the House health overhaul bill (HR 3200) should be amended to include a rule that no family should have to pay more than 2.5 percent of gross adjusted annual income in out-of-pocket expenses for health care. Conyers said it should include a cap on premiums so that “no family should pay an unreasonable amount on health insurance.”

Elizabeth Edwards, a senior fellow at the Center for American Progress Action Fund and the wife of ex-Democratic presidential candidate John Edwards, testified that “medical expenses are a major factor in the majority of bankruptcy filings.” Edwards said that a recent analysis by the Commonwealth Fund found 25 million adults who were underinsured, with out-of-pocket medical spending that took up 10 percent of family income. Another study by the Center for Studying Health System Change found one out of five Americans reported problems paying medical bills in 2007, she said.

“Congress can fix these problems” by approving the health overhaul, she said.

But Rep. Trent Franks, R-Ariz., said he objected that “somehow the answer to medical ba nkruptcy is nationalized health care.” Franks said he doubted the federal government could save money by “doing anything of this complexity” such as health care. “The highway of history is littered with the wreckage of governments who thought socialistic perspectives or tendencies would somehow create more products or services that would be better or cheaper,” he said.

Observed Rep. Darrell Issa, R-Calif.: “The chairman has cleverly found a way to get into the health care debate, which we have virtually no jurisdiction over.”

Steffie Woolhandler, a physician and professor of medicine at Harvard Medical School who was the senior author of the study that found 62 percent of bankruptcies linked to medical debt, said that between 2001 and 2007 the proportion of all bankruptcies attributable to medical problems rose by 49 percent.

“The striking conclusion from our study is that private health insurance is a defective product that leaves millions of middle-class families vulnerable to financial ruin,” said Woolhandler. A single-payer system — which was not considered by the committees of jurisdiction for the health overhaul but continues to be pushed by advocates, some of whom applauded in the audience — “is not socialized medicine — it’s socialized insurance, like Medicare for all,” said Woolhandler.

But Aparna Mathur, a research fellow at the American Enterprise Institute, said her studies have found that “the extent of the problem is being overstated and therefore misdiagnosed.” Mathur said data from the Survey of Consumer Finance, which samples 4,500 households every three years, found medical indebtedness has not changed significantly during the past decade. Data from several surveys suggests medical debt is responsible for 16 to 29 percent of bankruptcies, said Mathur. While rising health care costs are an area of concern, families are being pushed to the brink of bankruptcy for a multitude of reasons, she said.

John Pottow, a University of Michigan law school professor, said any study, however, that doesn’t take into account that some credit card debt is actually medical debt is “missing the point.” Many people pay co-pays or other bills with credit cards, said Pottow. He said his own research has found that elderly Americans are increasingly filing for bankruptcy, rising from 2 percent of all filers in 1991 to about 7 percent in 2007. Of those filers, Pottow said he has found 39 percent specifically identified medical problems of the debtor or spouse as a reason, even though the elderly are covered by Medicare and thus should not have high medical bills.

Steve Burd’s magic elixir

How Safeway Is Cutting Health-Care Costs: Market-based solutions can reduce the national health-care bill by 40%

By Steven A. Burd, CEO of Safeway Inc.
The Wall Street Journal
June 12, 2009

As with most employers, Safeway’s employees pay a portion of their own health care through premiums, co-pays and deductibles. The big difference between Safeway and most employers is that we have pronounced differences in premiums that reflect each covered member’s behaviors. Our plan utilizes a provision in the 1996 Health Insurance Portability and Accountability Act that permits employers to differentiate premiums based on behaviors. Currently we are focused on tobacco usage, healthy weight, blood pressure and cholesterol levels.

Safeway’s Healthy Measures program is completely voluntary and currently covers 74% of the insured nonunion work force. Employees are tested for the four measures cited above and receive premium discounts off a “base level” premium for each test they pass. Data is collected by outside parties and not shared with company management. If they pass all four tests, annual premiums are reduced $780 for individuals and $1,560 for families.

During this four-year period, we have kept our per capita health-care costs flat (that includes both the employee and the employer portion), while most American companies’ costs have increased 38% over the same four years.

While comprehensive health-care reform needs to address a number of other key issues, we believe that personal responsibility and financial incentives are the path to a healthier America. By our calculation, if the nation had adopted our approach in 2005, the nation’s direct health-care bill would be $550 billion less than it is today.

http://online.wsj.com/article/SB124476804026308603.html

And…

Preventive health plan may prevent cost increases

By Victoria Colliver
San Francisco Chronicle
February 11, 2007

Safeway chief executive Steve Burd has turned into an evangelist of sorts, spreading the lower-cost, better-health gospel to other business executives around the country.

Starting in January 2006, Safeway began offering a new plan to its 30,000 nonunion employees.

The plan, administered by Cigna Corp., is the lowest-premium option for nonunion employees, but it comes with a high deductible. To encourage enrollment, Safeway offered the plan last year for 22 to 30 percent less than what employees were paying for Cigna’s preferred provider organization option.

The company said its program focuses more on rewards for good behavior than penalties for bad. For example, smokers who agreed to fill out the questionnaire and try to quit smoking saw no increase in their 2007 premiums.

Virtually all the savings generated in the program’s first year came from changing the plan design, Burd said. But even if the company manages to keep spending flat, Burd noted, Safeway will remain ahead of the trend.

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/02/11/BUG02O20R81.DTL

And…

Mr. Burd Goes to Washington

By Kimberley A. Strassel
The Wall Street Journal
June 19, 2009

Mr. Burd explains that the “cure for today’s ills is simply removing the obstacles to a free health-care market.”

The Safeway plan has two main parts that work in tandem. The first involves giving employees a financial stake in the system. Safeway demolished the traditional PPOs and HMOs that encourage consumers to be cavalier about costs. The company deposits $1,000 each year into a “health reimbursement account,” which workers can use to pay for care. The next $1,000 in expenses is the employee’s responsibility. After that, employees pay 20% of costs up to a $4,000 maximum.

The second part of Safeway’s plan… Safeway’s “Healthy Measures” program, which is voluntary. Employees are tested for smoking, weight, blood pressure and cholesterol. Every area they “pass” results in a reduction in their premium, of as much as $1,560 for a family, a year.

When I ask Mr. Burd what he hopes to accomplish here, he is blunt that one goal is to prevent a “public option” that would only “piggyback on the experience of Medicare.” It’s a “Trojan Horse” that will steer people to government and ultimately squeeze out innovative programs like his.

He’s also working to ensure that any health-care bill contains provisions that would replicate or encourage Safeway’s success. That includes changing current law so that he can offer even steeper premium discounts for good behavior.

http://online.wsj.com/article/SB124536722522229323.html

And…

Just Rewards? Healthy Workers Might Get Bigger Insurance Breaks

By Mary Agnes Carey
Kaiser Health News
July 28, 2009

The discounts are being pushed by Steve Burd, the chief executive officer of Safeway Inc., who has met with several lawmakers on Capitol Hill and says that rewarding healthy behavior has helped keep his firm’s health care costs flat while other companies’ have skyrocketed.

Health care overhaul legislation passed by the Senate Health, Education, Labor and Pensions Committee would allow employers to increase those discounts to 30 percent and up to 50 percent if the secretaries of Labor, Health and Human Services and Treasury agree. A House proposal would allow employers to charge workers who participate in wellness programs 50 percent less than workers who don’t.

“If you give one person a discount, someone else is going to end up paying more,” said Paul Cotton, senior legislative representative, federal affairs, at AARP, one of more than 60 groups that’s fighting the provision. “So the people who aren’t able to change their behavior or participate in the program will end up paying more. Our fear is that premiums will become unaffordable for people who can’t change their behavior.”

By Safeway’s calculations, “if the nation had adopted our approach in 2005, the nation’s direct health-care bill would be $550 billion less than it is today,” Burd wrote in a June 12 op-ed in the Wall Street Journal. Critics of Burd’s data have said (that) has not been independently verified. A Safeway spokeswoman acknowledged that there has been no independent analysis, but “we were able to see savings clearly and immediately the first year we implemented the program.”

http://www.kaiserhealthnews.org/Stories/2009/July/28/Prevention.aspx

Comment:

By Don McCanne, MD

Safeway’s Steve Burd has been making the rounds in Washington and elsewhere claiming that his program would reduce our national health care bill by $550 billion, even though there is absolutely no verification of that.

So what is his program? It has two parts: 1) changing from traditional coverage to a high deductible plan with 20 percent coinsurance, and 2) premium reductions for better health.

Changing to consumer-directed high-deductible plans, with coinsurance replacing copays, reduces the amount that Safeway pays for its health benefit programs, but it does so by shifting more costs to the employees in out-of-pocket expenses, and by reducing the amount of health care received, no matter how beneficial. Since most health care spending is not subject to the negative impact of deductibles, the impact on our total national health spending would be negligible. So where is the $550 billion savings?

Reducing premiums for healthier employees automatically results in higher premiums for employees with health problems who are in the same risk pool. Hypertension, hypercholesterolemia, and a higher body mass index are problems that are much more complex than simple lifestyle choices. Health insurance is already unaffordable for the majority of us, and pushing premiums higher for those who have have greater health care needs is unsound policy, assuming that our goal is affordable health care for everyone.

Even if financial incentives were capable of reversing hypertension, hypercholesterolemia, and obesity, it would take many years – decades – to see a benefit in the form of lower national health care spending. Steve Burd’s claim that he has dramatically reduced costs in just a couple of years by shifting more out-of-pocket expenses to the less healthy employees is a crock!

Let’s say it like it is. When Steve Burd says that his program would save the nation $550 billion, he is lying. And he needs to be called on it.

His primary goal is to convince Congress that it needs to block the public option. The Senate Finance Committee decided this week that the reform bill will exclude the public option. Score one for Burd.

His other goal is to take care of his lower-cost healthy employees while punishing those with health care problems. Both the Senate HELP bill and the House Tri-Committee bill would shift even more of the premiums from the healthy to those with health problems than has Burd with his Safeway program. Score two for Burd!

It’s seems like a waste of time to even talk about Burd’s dishonest bull. But we have to, because Congress is converting his bull into our policy. At the same time, Congress is pushing aside the policies that would enable all of us to have affordable access to health care.

I only wish my anger were more contagious. The nation needs a massive epidemic of anger right now.

Diagnosing Proposals for Healthcare Reform

Click here to watch the interview.

Bill Moyers sits down with Trudy Lieberman, director of the health and medical reporting program at the CUNY Graduate School of Journalism, and Marcia Angell, senior lecturer in social medicine at Harvard Medical School and former editor in chief of the New England Journal of Medicine

Transcript

BILL MOYERS: Welcome to the Journal.

Push finally came to shove in Washington this week as the battle over health care reform escalated from scattered sniper fire into all-out combat.

REP. STEVE KING: Socialized medicine produces rationing of care

PRESIDENT BARACK OBAMA: One of the plans that we’ve talked about is a public option

MALE REPORTER: You’ve been pushing Congress to pass health care reform by August. Why the rush?

MICHAEL STEELE: $239 billion to the deficit by 2019.

REP. LOUISE GOHMERT: We’re talking about a nightmare for the American people.

KATIE COURIC: It’s not going to add to the deficit?

PRESIDENT BARACK OBAMA: It will not add to the deficit

REP. LOUISE GOHMERT: It is insane

BILL MOYERS: If this all seems to be getting more and more confusing, well join the club. It’s hard to see what’s happening through all the gunsmoke.

The Republicans have more than health care reform in their bomb sights — they want a loss for Obama so crushing it will bring the administration to its knees and restore Republican control of Congress after next year’s elections. In the words of Republican Senator Jim DeMint, “If we’re able to stop Obama on this, it will be his Waterloo. It will break him.”

The Waterloo of DeMint’s metaphor, of course, was the battle in 1815 that ended Napoleon Bonaparte’s rule as Emperor of France — a humiliating defeat and a turning point in European history. Right-wingers like Glenn Beck see Obama as Napoleon, an emperor who must be stopped.

GLENN BECK: I mean, this guy is practically an imperial president now. When he starts to lose and people start to question him and push him back against the wall, he’s not going to know how to react.”

BILL MOYERS: The Republican strategy is almost identical to the way they turned health care into Waterloo for Bill and Hillary Clinton in 1993.

HARRY: Find more you like in the President’s plan?

LOUISE: Yeah.

HARRY: And?

LOUISE: It just doesn’t have the choice we want. Look at this.

BILL MOYERS:Back then, one of their chief propagandists, William Kristol, urged his party to block any health care plan for fear Democrats would be seen as, quote “…the generous protector of middle-class interests.” Now he’s telling the G.O.P. to “Go for the kill…throw the kitchen sink [at it]…drive a stake through its heart… we need to start over.”

So in lockstep are the Republicans that when strategist Alex Castellanos issued a memo on the battle plan, party chairman Michael Steele echoed it word for word in a speech at Washington’s National Press Club.

Castellanos: “Slow down, Mr. President. We can’t afford to get health care wrong.”

MICHAEL STEELE: “Slow down, Mr. President. We can’t afford to get health care wrong.”

BILL MOYERS: Castellanos: “The old, top-down Washington-centered system the Democrats propose will empower Washington to restrict the cures and treatments your doctor can prescribe for you.”

MICHAEL STEELE: “The old top-down Washington-centered system the Democrats propose is designed to grow Washington’s power to restrict the cures and treatments your doctor can prescribe for you.”

BILL MOYERS: Castellanos: “President Obama is experimenting with America, too much, too soon, and too fast.”

MICHAEL STEELE: Your experiment promotes — proposes too much, too soon, too fast.

BILL MOYERS: As the Republicans fired away, big business stepped up the attack, too, their lobbying and advertising guns blazing. In certain key states where members of Congress remain on the fence, the airwaves are vibrating with television commercials aimed at shifting hearts and minds away from any change that might threaten profits.

[ADVERTISEMENT SOT]: What will happen to your family’s health care if Washington runs it?

[ADVERTISEMENT SOT]: Now Washington wants to bring Canadian-style health care to the US.

BILL MOYERS: President Obama rejected the Republicans’ Waterloo metaphor, but mounted a massive media counteroffensive of his own.

PRESIDENT BARACK OBAMA: Another Republican senator, that defeating health care reform is about breaking me. So let me be clear. This isn’t about me.

I have great health insurance, and so does every member of Congress. This debate is about the letters I read when I sit in the Oval Office every day, and the stories I hear at town hall meetings… I’m the President. And I think this has to get done.

BILL MOYERS: But the President’s already stepped on booby traps of his own making, and minefields laid by his own party, especially when the Congressional Budget Office reported that his reforms, instead of controlling costs, would send the national debt further into the stratosphere.

Meanwhile, supporters who want to scrap the present system for fundamental change are staring glumly through the fog of war at a battlefield in total disarray. They fear that in the White House’s desire to get a bill — any bill — passed by Congress, it will have been so compromised, so bent to favor the big interests, that it will be less Waterloo than water down, a steady diluting of what they’d hoped for, or America needs.

The big drug companies are already so pleased with what they’ve been promised that they’ve brought back Harry and Louise — the make-believe TV couple who helped take down the Clinton health care plan.

LOUISE: Because everyday more and more people are finding out that they can’t afford healthcare.

BILL MOYERS: But this time they’re in favor of reform…

LOUISE: Coverage people can afford. Coverage they can get…

BILL MOYERS: Could it be that Harry and Louise are happier because this time, they’re in on the deal?

What to make of all this? I’ve asked two expert analysts of health care to help me out.

Trudy Lieberman covers health care reform for the Columbia Journalism Review and directs the health and medicine reporting program at the City University of New York’s Graduate School of
Journalism.

Marcia Angell, a physician herself, is Senior Lecturer in the Department of Social Medicine at Harvard University Medical School and was the first woman Editor-in-Chief of the New England Journal of Medicine. She, too, has written widely and often about health care reform.

Welcome to both of you.

MARCIA ANGELL: Thank you.

TRUDY LIEBERMAN: Thank you.

BILL MOYERS: So, Trudy Lieberman, is it Waterloo or no Waterloo, is that the question?

TRUDY LIEBERMAN: Waterloo for who? Whether it’s a Waterloo for the American people, who aren’t going to or may not get a resolution of this, and they certainly do need some help along the way with health care. Or is it, say, a political question for the President?

BILL MOYERS: Well, the Republicans have made it this week, clearly and sharply, a political challenge to him.

TRUDY LIEBERMAN: I think it’s going to be interesting to see what happens. A lot of people have said this is a do or die issue for the President. That’s certainly— that rhetoric certainly hadn’t been coming up really before the last several weeks.

MARCIA ANGELL: And I would say, on the politics first, that it is something of a Waterloo. In the sense that if he doesn’t get it right he’s going to be President for three more years. And the chickens will come home to roost.

BILL MOYERS: How so?

MARCIA ANGELL: So— well, it can— the failure can show up before he’s out the door. And then he’s got a real problem. He was right in his press conference, when he talked about cost as the central issue. And he said, if we don’t control cost, not only will the health system continue to disintegrate, but it’ll drag the whole economy down with it.

What he has essentially advocated is throwing more money into the current system. He’s treating the symptom and he’s not treating the underlying cause of our problem. Our problem is that we spend two and a half times as much per person on health care as other advanced countries, the average of other advanced countries. And we don’t get our money’s worth. So, now he says, okay, this is a terribly inefficient, wasteful system. Let’s throw some money into it.

BILL MOYERS: Into the same system?

MARCIA ANGELL: Into the same system. That’s his problem. The other problem, in the press conference, was that he was trying to mobilize public support for a bill, and we don’t know what that bill is.

TRUDY LIEBERMAN: I want to get to that point, because he’s been vague right from the very beginning on this point. We have not known exactly what the Obama health plan has been. Even though the headline writers, and the press has been talking about his health care overhaul for months. And so, I like to step back and say, “Well, what exactly is he talking about? What exactly does he mean?” And he has not been clear on that.

BILL MOYERS: You said he’s been AWOL, AW-O-L-

TRUDY LIEBERMAN: Yes.

BILL MOYERS: —on details.

TRUDY LIEBERMAN: He has been out to lunch on this. And I think that’s a deliberate strategy on the part of the White House.

MARCIA ANGELL: Yes.

TRUDY LIEBERMAN: What they had done is learn from what they call the Clinton mistakes in ‘93-’94. And what happened then is that Hillary came out with this big 1 thousand-page bill, although we have now another 1 thousand-page bill. And let the special interest groups sort of pick it apart. This time, they decided not to do that. That they would be deliberately vague about this. And stay as vague as they could be until push came to shove.

And so basically, it’s my belief that this whole discussion about health care reform is flying over the heads of the American people. They know about reform, but they don’t know— they know the words reform, but they don’t know what they mean at all.

BILL MOYERS: I had the same reaction you did to that press conference. And I woke up Thursday morning after the press conference, to the headline of “The New York Times” that read, “President Seeks Public Support On Health Care.” And in the margin of the Times I said, “Does the public know what is in this health care—”

MARCIA ANGELL: He doesn’t know. Nobody knows. One thing we—

BILL MOYERS: Well, somebody has to know. They keep talking about it.

MARCIA ANGELL: Well, he says, let Congress do it. In their wisdom, they’ll come out with something, and I will give you a few feel-good principles. And then we’ll wait and see what happens. Because he doesn’t want his fingerprints on it if it fails.

TRUDY LIEBERMAN: I feel the American people need to know what is in that bill. And what’s in the bill is an individual mandate that is going to require all Americans with a few exceptions, to carry health insurance. And that means if you do not get insurance from Medicare or Medicaid or your employer. You’re going to have to go out and buy health insurance.

And that is a lot of money for most people because most of them would buy it now if they could afford it. About 85 percent of the uninsured require subsidies, because they can’t afford it. And I think this is going to come up as a big surprise to people to realize they’re going to have to buy insurance from private insurance companies or face a tax penalty.

MARCIA ANGELL: Well, that goes to the cause of the problem. We are the only advanced country in the world that has chosen to leave health care to the tender mercies of a panoply of for-profit businesses, whose purpose is to maximize income and not to provide health. And that’s exactly what they do.

BILL MOYERS: The President, as you were saying a moment ago, is saying to everybody who’s not covered, we’re going to mandate that you exercise that right. We’re going to mandate that you buy some form—

MARCIA ANGELL: We’re going to deliver the private insurance companies a captive market. That’s right. And they love that.

BILL MOYERS: Say that again.

MARCIA ANGELL: They love that.

BILL MOYERS: The— his policy does what? His program?

MARCIA ANGELL: Delivers to the private insurance industry a captive market.

BILL MOYERS: By the mandate.

MARCIA ANGELL: By the mandate.

BILL MOYERS: It says “Marcia Angell, you’ve got to—”

MARCIA ANGELL: For whatever price they want to charge. Right. And so, this will increase costs. And let me tell you what he’s running into, and he’d like to be able to pull a rabbit out
of the hat, but he won’t be able to. If you leave this profit-oriented system in place, you can’t both control costs and increase coverage. You inevitably, if you try to increase coverage, increase costs. The only answer, the only answer, and he said it at the beginning of his press conference, is a single payer system. In his first sentence, he said, that is the only way to cover everyone.

BILL MOYERS: But he’s also said, if we were starting the system from scratch, we could have single payer. But we’re not starting this system from scratch.

MARCIA ANGELL: You know, you don’t pour more money into a failing system. You convert.

BILL MOYERS: I saw back in the spring— the chief lobbyist for the Big Pharma industry, Billy Tauzin, used to be a member of Congress. He was on CNBC. And he was in support of this bill, whatever this bill is. Because it would broaden the industry’s customer base by providing subsidies for people to buy—

MARCIA ANGELL: Exactly.

BILL MOYERS: More coverage from the private insurers.

TRUDY LIEBERMAN: At whatever price they want to charge. It will be a bonanza for the health insurance industry. And a bonanza for the pharmaceutical industry. And for the doctors, too. Because the doctors are going to get more paying patients, because people will now have this ticket, this insurance card, that they can whip out when they need medical services.

BILL MOYERS: So, does this explain why Harry and Louise, who were around 15 years ago to help defeat Bill Clinton’s health plan, Bill and Hillary Clinton’s health plan, are back now in support? Seemingly to be in support?

MARCIA ANGELL: You bet it does. You bet it does.

BILL MOYERS: Let me show you the commercials that’s been running now, watch closely.

HARRY: Well, it looks like we may finally get health care reform.

LOUISE: It’s about time. Because everyday more and more people are finding they can’t afford health care.

HARRY: Or they’re losing coverage?

LOUISE: We need good coverage people can afford. Coverage they can get—

HARRY: Even if they have a pre-existing condition.

LOUISE: And coverage they can keep if they change jobs.

HARRY: Or lose their jobs. Sounds simple enough.

LOUISE: A little more cooperation, a little less politics. We can get the job done this time.

BILL MOYERS: Wouldn’t that make you think that Big Pharma is supporting health care reform?

TRUDY LIEBERMAN: That’s exactly—

MARCIA ANGELL: Yes, yes.

TRUDY LIEBERMAN: That’s what they’re supposed to be—

BILL MOYERS: But on their terms, right?

MARCIA ANGELL: On their terms. Exactly. Exactly.

TRUDY LIEBERMAN: This is what those ads are supposed to do. They’re supposed to make the ordinary person believe that they’re good guys this time around.

BILL MOYERS: And on their terms means what for them?

MARCIA ANGELL: Well, they can charge whatever they want. That there will be no bargaining. That—

TRUDY LIEBERMAN: Medicare.

MARCIA ANGELL: That Medicare Part D will not bargain for lower prices. There’ll be no formularies. You know, even this thing about the pharmaceutical industry is going to kick in $80 billion over ten—

BILL MOYERS: Have we heard—

MARCIA ANGELL: —years. That the President mentioned in the press conference.

TRUDY LIEBERMAN: Only if health care passes. So.

MARCIA ANGELL: First this is $8 billion a year for the pharmaceutical industry. This is chump change. And second, it’s only for brand-name drugs. So, in a sense, it’s a subsidy for the most expensive drugs.

BILL MOYERS: Do you believe the health care industry when it tells President Obama that “we will voluntarily cut costs”?

MARCIA ANGELL: No. I mean, these are investor owned businesses. If they behave like charities, heads would roll in the executive suites. They are there to maximize profits. And that’s exactly what they do.

TRUDY LIEBERMAN: What’s happened now is that the industries have gotten pretty much what they want out of the bills that are going forward.

And so, they need to build public support. They need to make everybody in the public realize that they actually are wearing white hats in this one. But behind the scenes, they are lobbying ferociously against the public plan, against cuts in doctors fees, against all kinds of things that they don’t want. And for that they’re using a different sort of lobbying tactic. All of these are communications or lobbying strategies that they know how to do and they are very excellent at doing them.

MARCIA ANGELL: It’s clear that they can turn it to their advantage.

TRUDY LIEBERMAN: Right.

MARCIA ANGELL: That nobody is really trying to break their— except the single payer people — their death grip on the system. And here you have hundreds of for profit insurance companies that maximize their income by denying care to the people who need it most. And that’s the insurance system. That’s how we pay for health care.

But you also have to look at how we deliver health care. And we deliver that, primarily or largely, in for-profit facilities — businesses, hospitals — whose interest is in delivering only profitable care. So, we have a system that’s through and through, in both the payment system and the delivery system, is oriented toward profits. Neither the Senate nor the House is doing anything to change that.

BILL MOYERS: The President says there will be a public option in my bill that will compete with the private insurance. To bring the cost down.

TRUDY LIEBERMAN: That’s—

BILL MOYERS: That’s what he said.

TRUDY LIEBERMAN: That’s what he says. Again, we get back to the detail question and the particulars, which are so absent in this whole discussion. We don’t know what a public plan will look like. And even if there’s going to be a public plan. The insurers don’t want it. It’s not clear that the doctors want it. And the pharmaceutical companies don’t want it.

So my question is, are they working behind the scenes to make sure this doesn’t happen? My guess is— my answer is, they proba
bly are.

MARCIA ANGELL: A lot is said about how the public wants to cling to what it has. What I’m finding is something that confirms the polls that have been done. Showing that something like two-thirds of the public would favor a Canadian style or a Medicare for all style single payer system.

The same is true of physicians, now. About 60 percent of physicians favor Medicare for all, or a single payer system. So, what is against it? The pharmaceutical and the insurance industries are the biggest lobbies in Washington. They spend millions and millions on influential members of Congress. And the amount that they are spending now to the Chairman of the relevant health committees has increased enormously in the past few months.

BILL MOYERS: Just the other day the Chamber of Commerce began running an advertising campaign. And the Chamber says a new government run plan will undermine employer sponsored coverage and eventually lead to a government takeover of the health care system.

MARCIA ANGELL: Like Medicare.

BILL MOYERS: Alright. That will limit—

MARCIA ANGELL: That’s scary.

BILL MOYERS: That will limit patients’ choices. I mean, isn’t that proving to be a convincing argument with the public? That seems to be—

MARCIA ANGELL: Well, it’s phony, of course.

BILL MOYERS: Phony?

MARCIA ANGELL: It’s phony, in the sense that Medicare is a single payer system, embedded within our larger market-based system. You have totally free choice of a physician in Medicare. You don’t in most employer-sponsored private plans. Canada, totally free choice of doctors. So, this is simply not true.

BILL MOYERS: Let me show you both a couple of clips from the House floor recently. And get your comments on them. These are two Congressmen who are opposed to any kind of national insurance or general coverage. Look at this.

REP. STEVE KING: They’re going to save money by rationing care, getting you in a long line, places like Canada and the United Kingdom and Europe. People die when they’re in line.

REP LOUIE GOHMERT: One in five people have to die because they went to socialized medicine! Now I’ve got three daughters and a wife. I would hate to think that among five women, one of them is going to die because we go to socialized care and we have to have these long lists to get a mammogram. Once you find it to get treatment. It’s insane.

TRUDY LIEBERMAN: We’ve heard these arguments since 1948. And what amazes me — they opposed a national health system under President Truman. So, that notion, that conventional wisdom in America is pretty ingrained and pretty deep. What they fail to say here is that people are waiting in line in

John Geyman's "The Cancer Generation"

The Cancer Generation: Baby Boomers Facing a Perfect Storm

by John Geyman
Common Courage Press
You can be sure that cancer will be a part of your life. You’ll either get it – nearly half of all men and more than a third of women will. Or you’ll have a close friend who gets it, or be the child of someone who gets it, or the spouse of someone who has it, or in the worst case scenario, be the parent of a child struggling with cancer. You cannot help but stand on the battlefield of the war against cancer. How America wages this war is leaving an indelible mark on your life.
Cancer is now on track to replace heart disease as America’s leading cause of death within the next few years. This is a fight we have to win. Are we winning? And if we are off target, what changes are imperative for victory? Everything we discuss here focuses on these two questions.
So What Will Happen?
Lives hang in the balance on the answer to this question. The future down our current path is crystal clear – and devastating. Deregulated markets and the corrosive effects of profits over service over many years have brought U.S. health care to a crisis point. Because of soaring costs, patients with cancer are finding effective care increasingly unaffordable. Health care has entered a perfect storm, and it is certain to get much worse without real reform. Our primary care infrastructure is collapsing. ERs are overwhelmed, the ranks of the unemployed are rising quickly, adding to the numbers of uninsured. The economy has tanked, the federal deficit is massive, many states are forced to cut Medicaid to the bone, and our presumed safety net is falling apart.
Meanwhile, market stakeholders increase their efforts to maintain the status quo. The private insurance industry calls for the government to change tax policy and keep the subsidies flowing so that insurers can continue to rake off their profits from the system while offloading sicker and lower-income patients onto public programs.
http://www.commoncouragepress.com/index.cfm?action=book&bookid=398

No topic could serve as a better proxy for the deficiencies in the financing and delivery of health care in the United States than the ever increasing prevalence and expense of cancer. In The Cancer Generation, John Geyman describes the tragic and costly impact of the cancer burden, but then provides us with hope by describing a plan that would reduce these burdens of cancer.
His eight-point plan for one-tier cancer care stresses not only the importance of single payer national health insurance, Medicare for all, but also describes the great power that our own public national health program would have to strengthen our health care system, enabling everyone to have affordable access to high-quality cancer care if and when needed.

John Geyman's "The Cancer Generation"

The Cancer Generation: Baby Boomers Facing a Perfect Storm

by John Geyman
Common Courage Press

You can be sure that cancer will be a part of your life. You’ll either get it – nearly half of all men and more than a third of women will. Or you’ll have a close friend who gets it, or be the child of someone who gets it, or the spouse of someone who has it, or in the worst case scenario, be the parent of a child struggling with cancer. You cannot help but stand on the battlefield of the war against cancer. How America wages this war is leaving an indelible mark on your life.

Cancer is now on track to replace heart disease as America’s leading cause of death within the next few years. This is a fight we have to win. Are we winning? And if we are off target, what changes are imperative for victory? Everything we discuss here focuses on these two questions.

So What Will Happen?

Lives hang in the balance on the answer to this question. The future down our current path is crystal clear – and devastating. Deregulated markets and the corrosive effects of profits over service over many years have brought U.S. health care to a crisis point. Because of soaring costs, patients with cancer are finding effective care increasingly unaffordable. Health care has entered a perfect storm, and it is certain to get much worse without real reform. Our primary care infrastructure is collapsing. ERs are overwhelmed, the ranks of the unemployed are rising quickly, adding to the numbers of uninsured. The economy has tanked, the federal deficit is massive, many states are forced to cut Medicaid to the bone, and our presumed safety net is falling apart.

Meanwhile, market stakeholders increase their efforts to maintain the status quo. The private insurance industry calls for the government to change tax policy and keep the subsidies flowing so that insurers can continue to rake off their profits from the system while offloading sicker and lower-income patients onto public programs.

http://www.commoncouragepress.com/index.cfm?action=book&bookid=398

Comment:

By Don McCanne, MD

No topic could serve as a better proxy for the deficiencies in the financing and delivery of health care in the United States than the ever increasing prevalence and expense of cancer. In The Cancer Generation, John Geyman describes the tragic and costly impact of the cancer burden, but then provides us with hope by describing a plan that would reduce these burdens of cancer.

His eight-point plan for one-tier cancer care stresses not only the importance of single payer national health insurance, Medicare for all, but also describes the great power that our own public national health program would have to strengthen our health care system, enabling everyone to have affordable access to high-quality cancer care if and when needed.

Many inconvenient truths on health care

By Dr. Stephen Sokol
Sun Journal (Lewiston, Maine)
Jul 26, 2009

Health care in America is a shambles and will, like a critically ill patient, likely collapse if not properly and promptly attended to.

We are told we have the best health care in the world, yet when we are ranked by the World Health Organization, we are 37 of 137 countries, just above Cuba and well below the United Kingdom and Canada, both of whom have single-payer systems. In the same ranking, we are 32nd in the world in infant mortality, 24th in life expectancy and 54th in fairness, which measures equality of access and quality of health care across religion, race or ability to pay.

Almost 50 million Americans are uninsured and a similar number are underinsured, 75 percent of whom are employed. Thirteen percent of Mainers live below the poverty level and over 9 percent lack health insurance. A similar number are underinsured. The Institute of Medicine of the National Academy of Sciences has shown that 50 Americans die daily because of lack of health insurance. Imagine if that figure were the fatalities of our troops in Iraq and Afghanistan. Yet we expended 17 percent of our gross national product, $2.4 trillion, on health care in 2007, twice as much as most other industrialized nations and still achieved significantly lower quality. We are now in the throes of a severe recession and more Americans, as they lose their jobs, lose their health insurance. Medical bills cause 60 percent of bankruptcies and 75 percent of these folks are insured.

Why? Private insurance companies are driven by profit and expend 16 percent of their income on overhead and therefore are stringent about what they will and will not cover. Most people with underlying common chronic problems such as hypertension and diabetes are excluded. In contrast, Medicare spends 2.1 percent and Canada 1.2 percent on overhead and there are no exclusions. We spend over $7,000 per-person, per-year, while Canada spends $2,500 and achieves better results.

We have been told that free market forces and competition will correct these problems, yet since the inception of the private health insurance sector during World War II, costs have only accelerated. When you have a heart attack or appendicitis, it is hard to shop around for price. These companies are not market-driven. They are for-profit. Keeping the present system of myriad private insurers only guarantees the status quo.

Remember the health care sector spent $450.7 million on lobbying alone in 2007 — and that was not to ensure equal access for all. Pharmaceutical companies spent over $14 billion on advertising, not only to doctors but to everyone. Remember the slogan on those TV ads, “Ask your doctor if … is right for you.” Some of those very drugs are quite hazardous. Hospitals, purporting to exist only to guarantee us excellent care, spend enormous amounts in competition for their “market share.” Just check the ads on TV and in the newspapers. Sadly, doctors have also joined in.

A single-payer system would eliminate many of these inequities by significantly reducing overhead, regulating costs and eliminating much of this frivolous waste. Good examples of excess here in Lewiston are the presence of three CT scanners, two MRI scanners and a part-time PET scanner, more hardware than available in any developing nation. Excess equipment ensures excess procedures.

We also now have a cardiac surgical unit, which cost millions, while there is one of the best in the country 40 miles down the road. A criticism of a single-payer system has been long waiting times. Having had personal experience in Canada and Germany, I can state no critically ill or urgent patient has been refused immediate, excellent care. Unlike here, where over 300,000 yearly are denied access, no one is turned away because of inability to pay as there is true universal coverage.

In 1995, Taiwan changed from a U.S. type system in which only 60 percent of the people were covered to a single payer system. By 2001, 97 percent were covered with only a minimal increase in cost.

I agree with the Founding Fathers, who believed that “all men were created equal” and that we all had “certain unalienable Rights, that among these are Life, Liberty and the Pursuit of Happiness.” Now I wonder how preserving these rights are possible for those of us who are sick and cannot get proper care. A single-payer system similar to Medicare, which has made a huge impact on the health of the elderly, can achieve these ends and keeps with the values that America and Americans espouse.

Health care is a right for all, not a commodity for the privileged.

Dr. Stephen Sokol is an assistant professor of geriatric medicine at the University of New England and a volunteer with Doctors Without Borders and the International Rescue Committee. He lives in Lewiston.

http://www.sunjournal.com/node/35624/

Single-payer system required for real reform

Tucson Citizen
Arizona Voices
Published: 07.27.2009

President Obama’s push to make minor changes to U.S. health-care policy has the demagogues out in full force.

Conservative talk radio is all aquiver about Obama’s and the Democrats’ efforts to cram “socialized medicine” down the throats of the U.S. public.

Republican senators and representatives are making speeches about how passing Obama’s health-care plan will be the end of the world as we know it, which is the same thing Obama and the Democrats say will happen if the plan isn’t passed now.

It’s all horse puckey.

It’s much ado about nothing because Obama’s plan doesn’t do much.

Though Obama is touting his plan as major reform, it’s not. It’s tinkering on the margins.

The stated goal is to provide health insurance to about 46 million Americans who don’t have any. Except most analyses of Obama’s plan show that it comes up about 16 million people short.

It also does little to fix many of the things that are wrong with the system, such as runaway costs, monopolistic drug pricing, exorbitant malpractice insurance premiums and Byzantine rules and laws that vary from state to state, to name a few.

If Obama was really serious about reforming the entire system he could simply say that he wants to make Medicare available to everyone.

It would take a tax increase to pay for it but that increase would be equal to or less than the hundreds of billions of dollars Americans already spend each year on insurance premiums, deductibles and copays.

And some of the tax increase would be offset by businesses being freed from the burden of paying insurance premiums for their workers and the need for large human resources staff to handle employee benefits claims.

Imagine the economic stimulus if businesses suddenly had hundreds of billions of dollars a year to spend on salaries, new employees, plant expansions and the like instead of paying all that money to health insurance companies.

Extending Medicare to everyone also would help reduce costs because doctors’ offices and hospitals would no longer need enormous billing departments to process the claims for dozens of different health plans.

As for socialized medicine, about 120 million Americans, or about 1 in 3, already get their health care or insurance paid for or subsidized by taxpayers:

* 59 million Medicaid recipients
* 44 million Medicare recipients
* 10 million state and local government employees
* 6 million U.S. military veterans
* 2.5 million active U.S. military personnel
* And 2.3 million federal and state prisoners

Adding the rest of the country to the list is only fair.

True reform must start with a single-payer system. From there, other problems and cost elevators can be tackled one at a time.

But that kind of reform will never happen. The health-care industrial complex makes sure it crushes any government action that puts its billions of dollars in annual profits at risk.

Which is why Obama crafted this goofy plan that appears to do much but does very little in terms of reform.

So as the blowhards try to froth the masses into a lather about the destruction of the American way of life, pay no attention.

Our health-care system will still suck no matter the outcome.

More’s the pity.

Testimony of Steffie Woolhandler, M.D., M.P.H., on medical bankruptcy

Before the Subcommittee on Administrative and Commercial Law
House Judiciary Committee
July 28, 2009

Mr. Chairman, members of the Committee. I’m Steffie Woolhandler. I am a primary care doctor in Cambridge, Massachusetts, and professor of medicine at Harvard. I am also senior author of two studies on medical causes of bankruptcy, one published in Health Affairs in 2005, and the latest in the August 2009 issue of the American Journal of Medicine. Both studies were done in collaboration with colleagues at Harvard Law School and Ohio University.

In our most recent study, medical bills and illness contributed to 62.1 percent of all personal bankruptcies. Between 2001 and 2007, the proportion of all bankruptcies attributable to medical problems rose by 49.6 percent. The striking conclusion from our study is that private health insurance is a defective product that leaves millions of middle-class families vulnerable to financial ruin. Unfortunately, the health reform plan now under consideration in the House would do little to address this grave problem.

We found that most of the medical bankruptcy were middle class — before their financial crisis hit. Two-thirds were homeowners and three-fifths had gone to college. In many cases, high medical bills were part of a cascade of problems that resulted from illness, along with lost income as illness forced a breadwinner to lose time from work. Often illness led to job loss, and with it the loss of health insurance.

The overwhelming majority of those bankrupted by illness in our study had health insurance. Seventy-eight percent were insured at the start of the bankrupting illness; 60.3 percent who had private coverage. These families had done everything right. They worked hard, paid their premiums and thought they were covered. Yet when illness hit they found themselves unprotected, ruined by co-payments, deductibles and bills for uncovered services like home care and physical therapy. Medically bankrupt families with private insurance ran up uncovered medical bills that averaged $17,749.

Our study raises a warning flag that leaving most Americans to rely on private insurance plans means leaving them unprotected. And a public plan option that mimics the rules and coverage of private plans won’t help.

In Massachusetts, we have three years of experience with the kind of plan the House is now debating, and it’s a sad experience. Reform hasn’t made care affordable for the middle class, and it has decimated the safety net that the poor continue to rely on. In 2007, only 5.4 percent of Massachusetts were uninsured — the lowest in the nation. Yet, medical problems underlay 3 out of 5 bankruptcies — the same proportion as in the rest of the country.

In our state, failure to buy insurance is illegal, punishable by a $1,000 fine — as big a fine as for beating your wife or making a terrorist threat. For a middle-income 56-year-old, the cheapest coverage available through the Connector — the state’s insurance exchange — costs $4,900 for a policy with a $2,000 deductible before it pays for any care, and a 20 percent co-payment after that. A diabetic with such coverage is almost certain to lay out $10,000 each year for medical care. In two years he’d accumulate $20,000 in medical bills — more than the amount that bankrupted the average family in our study. This kind of insurance — sold with the stamp of approval of the Connector — is a cruel joke which Congress should not repeat.

And for everyone financially ruined by illness, many more suffer physically because they don’t get the care they need. Access to an insurance policy is not the same thing as access to health care. By 2008, only 3 percent remained uninsured in Massachusetts, yet among those WITH health insurance, 18 percent skipped care because they couldn’t afford it. Moreover, those unable to afford care find safety net hospitals and clinics shuttered. Our governor and Legislature — desperate to keep the reform afloat as costs escalate more rapidly than predicted — have drained funds from the safety net.

Reform needs to replace the defective private insurance that most families have with insurance that is always there, and that covers all medically necessary care without co-payments or deductibles. That’s the kind of coverage people in other wealthy nations get through single-payer national health insurance. Only single-payer national health insurance can make universal, comprehensive coverage affordable by saving the hundreds of billions we now waste on insurance overhead and bureaucracy . In nations like Canada that have single payer health plans, medical bankruptcy is rare. You have a historic opportunity to make real reform happen this year. But overwhelming evidence indicates that the reform you seem poised to pass will fail to protect American families.

Public Option Advocates: Time to Come Home to Single Payer

By Mark Dunlea
Executive Director, Hunger Action Network of NYS
Co-chair, Single Payer New York

As the various public option proposals in Congress for national health care reform become weaker every day, there is still time for its proponents to support what they really believe in: a single payer, Medicare for all type program.

The architects of creating a “public option” as part of the push for national universal health care have always admitted that a single payer Medicare for All type programs was the best solution for America. It does the best job in controlling costs by eliminating the waste and bureaucracy of private health insurance while guaranteeing that every American would receive quality health care and have freedom of choice in selecting whom to receive health care services from.

The public option advocates — well-funded public interest groups and unions used to insider political wheeling and dealing — argued that the lesson from the 1993 defeat of the Clinton plan was that insurance companies were too powerful to defeat. Thus they had to abandon the best solution, single payer, to instead craft a proposal that would have a chance of passage by ensuring a continued large role for the present for-profit health insurance industry.

Their solution was to create an “800 pound gorilla” in the form of a public health insurance system that would provide quality and affordable health care coverage to more than one hundred million Americans. It would be large enough to operate efficiently and achieve cost savings. They argued that by setting up a fair fight between a public option and the private for-profit health insurance companies, over time the advantages of the public option — no profit margins, reduced paperwork and administrative costs, less marketing costs — would become clear. The public option would grow stronger, and under the best case scenario, either we would move to a single payer system or private for-profit health insurance would become a boutique industry serving the rich.

Before either House of Congress has adopted a specific plan, the public option 800 pound gorilla has turned into a five pound Chihuahua. And with four months or more of intense negotiations to take place among the nation’s power players before a final deal is reached, the public option will only get weaker.

The only clear winner in the process will be insurance companies. Americans will be mandated to purchase health insurance — or pay a fine. Insurance companies’ revenues — and profits — will increase under the Congressional plans. The mandate that everyone purchase insurance is one of the few consensus positions; the fight instead is over how taxpayers, employees and employers will have to pay for it.

Single payer advocates have always contended that public option proponents, despite their commitment to Machiavellian politics, were naive politically.

First, public option advocates violated the basic rule of negotiation by significantly weakening their opening position (i.e., dropping single payer for a public option) without getting any concessions in exchange. In addition, by calling for a major continued role for private for-profit health insurance, public option proponents also removed what should have been a key focus on the health care debate, namely that it was in the public interest to eliminate our present insurance system

Second, there was the real question of whether a public option would actually accomplish what its proponents claimed. The history of similar approaches at the state level in recent decades was quite bad. Doctors and hospitals would still have to keep in place their expensive billing and cost-tracking systems to deal with the various insurance programs.

Third, it was quite clear to everyone but its proponents that a “robust” public option was going to generate significant political opposition from the insurance industry. Like most industries, it would oppose anything that sought major cuts in its market share. Unlike single payer, which had the evidence of both Medicare and most of the other industrial nations to prove that it would work, the insurance industry would have a much easier time challenging the claims of benefits of a public option. State plans which had tried similar approaches had all crashed and burned, largely due to its failure to control costs. In addition, evidence from prior Congressional fights – say with Medicare – showed that rather than setting up a “fair fight” between the public option and insurance companies, Congress would likely seek to tilt the “competition” to favor the insurance companies.

So how has the public option fared so far in Congress?

When the “public option” campaign began, its proponents sought a huge “Medicare-like” program. Studies by the Lewin think tank group of the Hacker proposal estimated that it would enroll as many as 130 million people. Thus it would enjoy the advantages that make Medicare so efficient — large size, low provider payment rates (about 20% less than what private insurance pays) and low overhead (2 to 3%).

Today, the “public options” outlined in the Democrats’ legislation, according to the Congressional Budget Office, might enroll 10 million people and will have virtually no effect on health care costs. The program is so small it would have no impact by itself on reducing the number of the uninsured. The main House bill would delay establishing a public option until 2013 — conveniently after the next Presidential election — and would require it to follow the same rules (drawbacks) of private insurance. The ability of workers and others who presently have insurance to move into a public option program is significantly restricted.

Hacker had proposed jump-starting the public option plan by moving all or most of uninsured people as well as Medicaid and SCHIP enrollees into it. Starting with a huge population would reduce its startup, administrative and marketing costs and give it the ability to negotiate lower premiums. Under the present Congressional proposals, it starts with no one, which will greatly increase its initial overhead and marketing costs while largely eliminating its ability to cut costs through lower premium.

The power and political campaign activities of the public option proponents means that many liberal Congresspeople feel obligated to insist that a public option be included in the final bill. It will a public option primarily in name only, especially since so few people ever understood the details of the initial proposal. Meanwhile, the Republicans and right wingers are using the “public option” as a focal point of their criticism of Congressional efforts for universal health care, claiming it is socialism and a first step to single payer, an effort to drive insurance companies out of business. Rather than saying “yes, we want to eliminate private health insurance”, Congress instead seeks to deflate these attacks by doing more to subsidize and strengthen insurance companies.

An additional problem is that Congress is largely equating access to quality health care with having insurance. Yet neither private health insurance nor even public programs like Medicaid guarantee that you will actually obtain health services. We see this in the fact that 77% of Americans who go bankrupt due to high health care bills had health insurance. The co-pays, deductibles, exclusions, prior approval and restrictions on out of network services that come with insurance all impede access to health care. Many Medicaid patients, due to lower physician reimbursement rates, have a difficult time accessing health services outside of a clinic setting. It is quite possible that the public option will experience some if not all of these problems.

Public option proponents started with good intentions. It is time for them to admit that their vision for a public option has been rejected by Congress. Hopefully they will rejoin the movement for single payer health care and fight to establish health care as a human right in America.