Chapter – Page 841

Starr, Reich and Kuttner on the public option

Debating the Public Option

Paul Starr, Robert B. Reich and Robert Kuttner
The American Prospect
June 29, 2009

In “The Perils of the Public Plan,” Paul Starr warns that a public-insurance option could turn into exactly the opposite of what progressives want. Here he discusses the problems with the Prospect’s two other co-founders, Robert Kuttner and Robert Reich.

Paul Starr:

The public plan will likely end up as a dumping ground for high-cost, mostly low-income people if the exchanges are open only to the individual and small-group market and have inadequate power to risk-adjust premiums or to regulate private insurers’ marketing and benefit design.

In other words, we could get a public plan that instead of “disciplining” private insurers, as the president said last week, actually buttresses their dominance of the system. Watch what you wish for.

Robert Kuttner:

The public option, as it is evolving, is even more dubious than Paul Starr’s apt critique suggests. Under the House leadership bill, people who have coverage through their employers are ineligible. So the proposed, head-to-head competition between the public plan and private competitors is left to employers, not individuals.

Politically, protecting the public option from industry mischief is no less a heavy lift than single-payer. It’s a pity that all the progressive energy that’s gone into defending the public option hasn’t gone to advocate national health insurance.

Robert Reich:

I’d prefer a single-payer, but it’s got no skin in the game. The only practical hope we have for expanding coverage and taming health-care costs lies with the public option. That’s why it’s the epicenter of the current fight. The House is supportive, but the Senate is backing off because Republicans and Blue Dog Democrats have been told it’s a Trojan horse for single-payer. And the medical-industrial lobbies are hard at work convincing the public that the public option will lead to a wholesale government takeover of the health-care system.

Yesterday the president said he might sign a health-care bill that did not include a public option. That’s exactly the wrong message. If progressives fail to work hard for a public option because it’s not a single-payer, or we allow the other side to demagogue a public option, we miss the moment.

Paul Starr:

The public option has gotten all the political attention, but the real “crux” of reform is the system of rules that govern all competing plans. If the Democrats can’t get a strong public plan through the Senate but can get a strong design of the exchanges by trading off a weak public plan, they should take that deal and pass the bill.

Robert Kuttner:

It’s interesting and significant that the three co-founders of the Prospect are reprising the three major strands of progressive views on health reform. Robert Reich is arguing that the Obama plan, with the public option, is the best practical brand of reform available. Paul Starr, holding out for something that looks a lot like the Clinton plan, argues (convincingly in my view) that the most likely form of the public option will backfire. And I continue to be the single-payer guy. We’ve been having different versions of this friendly argument for two decades, as has the progressive community.

Reich says that single-player has “no skin in the game.” Well, let’s put some there, rather than being apologists for a threadbare cloak of a public option.

Where Starr and I disagree is on both his diagnosis of Medicare for All, and on his optimism that “exchanges” could be designed in a way that would meet his hopes (the exchanges sound a lot like the purchasing pools of the Bill Clinton plan that Paul Starr helped devise).

Although Starr and Reich seem to disagree, they have one thing in common. They are both somewhat wishful about what it would take politically to legislate the crucial details of either the Obama public option (Reich) or the exchanges (Starr) necessary to achieve meaningful reforms. In order for the fine print in either approach to do the job, progressives would need first to crush the industry influence in Congress that is very likely to hobble either strategy. And both Reich and Starr are right that a weakened version of the Obama plan could well be worse than nothing.

The political reality is that Medicare for All is no harder politically than a version of the Obama plan that would meet all the tests that Reich and Starr apply. And it would be far simpler and more cost effective.

The regulatory and political nightmare of doing everything that Starr insists is necessary to get a system of insurance exchanges to work efficiently is actually far more of a daunting challenge than having a single system under direct public control. And the odds are that the Obama administration, by the time it is done reassuring Max Baucus, the health insurance industry, the drug companies, and the Blue Dogs, will settle for far less than Starr’s formula.

Reich may say that if we just work hard enough, we can prevent that fate and still get a good program. But Obama began with less than what we need, and he has not painted this as a battle of the people against the interests. The bill gets weaker with each succeeding round. I suspect that by the time there is finally legislation for him to sign, Reich and Starr will both feel that it falls way short. It is high time for progressives to stop settling for badly flawed second bests and to throw their energy into a first best that could rally popular support and produce a system that serves everyone.

To read the full article:
http://prospect.org/cs/articles?article=debating_the_public_option

Comment:

By Don McCanne, MD

To rephrase the very important point that Paul Starr brings to this debate, it is not the design of the public option that is crucial to successful reform under the model being advanced in Congress, but rather it is that the design of the insurance exchanges must be absolutely compliant with the rules of social insurance. If the exchanges are poorly designed, the public option would become a Medicaid-like dumping ground for low-income people with high-cost problems, and would suffer from a lack of willing providers because of chronic underfunding. And poorly designed exchanges could never meet the test of social insurance.

Robert Reich would have us design an empowered public option that could shape up the private insurers by exerting full competitive pressure within the exchanges. That’s a nice wish, but all Republicans and an insurmountable number of Democrats in Congress have already made an irrevocable decision that an empowered public option will never survive the legislative process. It is possible that the “public option” label might survive, but only if applied to a private market-type plan, public in name only.

So can the insurance exchanges function as a bona fide social insurance program? Look at some of the decisions that have already been made.

Social insurance programs based on private plans require an individual mandate for everyone to purchase the plans, except those whose incomes are too low and therefore qualify for public programs. Congress and the state governors are very concerned about the costs of the Medicaid program and want it to be limited to the poor, especially since Medicaid is crippling many state budgets. Medicaid will not be expanded to include average-income individuals.

Adequate health insurance plans are no longer affordable for average-income individuals and families. Some form of tax subsidies will be required to assist with the mandated purchase of these plans. The amount of tax funds that would be required for everyone to be able to purchase coverage has proven to be far more than members of Congress are willing to budget. Consequently, it has been decided that hardship waivers must be a part of any reform legislation, effectively providing tens of millions of individuals with a government permission slip to remain uninsured.

Just to try to pull a few more in, the government will require insurers to provide multiple tiers of coverage. The lowest tier will be designed to be affordable, even though affordable plans, by design, are underinsurance products that fail to protect those who need health care.

Then the government would regulate the insurance exchanges, but look at the results in the most highly regulated states. No state has escaped the problems that are driving our current efforts at reform. No matter how many regulations are passed, the private insurers have always introduced innovations that relieved them of any real responsibility to address the severe deficiencies in our dysfunctional health care system.

Paul Starr may want well designed insurance exchanges, but this Congress has already rejected them. Robert Reich may want an empowered public plan, but this Congress has already rejected that.

As Robert Kuttner states, “progressives would need first to crush the industry influence in Congress that is very likely to hobble either strategy.”

But then, “It is high time for progressives to stop settling for badly flawed second bests and to throw their energy into a first best that could rally popular support and produce a system that serves everyone.”

And, “The political reality is that Medicare for All is no harder politically than a version of the Obama plan that would meet all the tests that Reich and Starr apply. And it would be far simpler and more cost effective.”

Puerto Rican doctors rally at White House, urge Obama to create pilot single-payer system on island

Public Citizen
News release
June 30, 2009

WASHINGTON — The Puerto Rico College of Physicians and Surgeons urged President Obama today to create a single-payer pilot program on the island, saying it is the best way to provide universal coverage to all of Puerto Rico’s 4 million residents.

Members of the organization, which represents all 11,000 physicians on the island, joined other health professionals and representatives from community groups this morning to demonstrate their support for single-payer health reform. The advocates rallied in Lafayette Park in front of the White House and are also meeting with congressional representatives during their visit to Washington.

“This is a matter of both health and social justice,” said Dr. Eduardo Ibarra, president of the College of Physicians and Surgeons. “We can create a system in which access to health care is recognized as a basic right for all, and does not depend on ability to pay, age, race, gender or health status. Puerto Rico stands ready to take the lead in health reform.”

The physicians’ group has petitioned Obama to support a pilot program that would create a single-payer system administered by the government that would provide universal health coverage to all Puerto Rico residents.

The proposed program would end the island’s multi-tiered system, under which those who need the most coverage receive the least health care. Puerto Rico has enough hospitals, clinics and private physicians to adequately care for its population if there a single-payer health program, Ibarra said.

The proposed pilot project would:

* Address the current inequities, and bring social justice to its citizens,
* Remedy the current erosion of employer-based health insurance, the result of growing unemployment, and
* Centralize all billing, leading to administrative efficiencies.

In addition, the single-payer system would be able to collect up-to-date data on health care consumption patterns, unmet needs, and costs. This information database would also allow for more effective allocation of resources, and would identify potential overutilization of services.

Uninsured by choice

Wealth, Income, And The Affordability Of Health Insurance

By Didem M. Bernard, Jessica S. Banthin and William E. Encinosa
Health Affairs
May/June 2009
There have been debates over how many uninsured people can afford insurance but refuse to purchase it.
The difference in purchasing power between the insured and the uninsured is not fully revealed by income comparisons. Median income of the privately insured was 2.9 times the median income of the uninsured in 2002-03 ($53,130 versus $18,404). However, median net wealth among those with private insurance was 23.2 times that of the uninsured ($78,472 versus $3,384). This discrepancy is even larger when we focus on families in the individual market. Median net wealth among those with nongroup insurance was 34.6 times that of the uninsured without access to employer coverage ($105,819 versus $3,057). Our results suggest that assets are an important determinant of effective affordability, undermining the notion that many people are uninsured by choice.
http://content.healthaffairs.org/cgi/content/abstract/28/3/887

By now you must be annoyed by those on the right who repeatedly claim that we do not have a problem with uninsured individuals. They say that the actual problem is that we are not counting them properly. Most of the uninsured would be insured, if only they showed a little more personal responsibility.
Many of the uninsured have incomes that are low enough to establish their eligibility for public programs. But those denying the problem would exclude these individuals from the count because they are “technically insured,” but merely too lazy to enroll. This ignores the multiple logistical barriers that make it impossible to enroll everyone who is eligible.
Many others without insurance are “illegals” who do not have their immigration papers in order. As long as we continue with national policies that include these individuals in our workforce, regardless of immigration status, then we have to accept the fact that they are part of our intrinsic economy and will access our health care system. Excluding them from the count would understate the issues we face when trying to figure out how to finance the care of uninsured individuals.
Although these undercounters dismiss most of the uninsured as failures of personal responsibility, they do remain conflicted on higher-income individuals who elect not to purchase insurance. Some consider these to be individuals who are exercising their right to freedom of choice – the freedom to self-insure instead of purchasing an insurance plan. Others consider these to be free riders who transfer the risk of catastrophic costs to the rest of us who are already paying our share.
But are these really individuals who are simply declining to purchase coverage they can afford? With health care costs now averaging $16,700 for an employed worker with a family of four, that takes quite a bit out of a typical income of $60,000. Many of theses families have little in the way of assets, living paycheck to paycheck, and really don’t have enough money to purchase a reasonable health plan.
This Health Affairs study demonstrates that not only income but also net wealth are important determinants of whether or not health insurance is affordable. Expanding net wealth requires both a higher level of discretionary income and a longer interval to accumulate assets. Thus both income margins and time are variables that influence the affordability of health insurance.
Since current proposals for reform would use tax subsidies to help individuals and families purchase private health plans, does this mean that we need to establish an eligibility grid that includes both income and net assets as variables? If we did, we might see an epidemic of personal failure based on the inability of so many to master the logistical requirements of the eligibility grid. (Have you tired calculating your precise net wealth recently?)
Why do we keep playing these games with all of the variables that go into determining our insurance status? Why don’t we simply make it automatic for everyone? If you exist, you’re covered.

Uninsured by choice

Wealth, Income, And The Affordability Of Health Insurance

By Didem M. Bernard, Jessica S. Banthin and William E. Encinosa
Health Affairs
May/June 2009

There have been debates over how many uninsured people can afford insurance but refuse to purchase it.

The difference in purchasing power between the insured and the uninsured is not fully revealed by income comparisons. Median income of the privately insured was 2.9 times the median income of the uninsured in 2002-03 ($53,130 versus $18,404). However, median net wealth among those with private insurance was 23.2 times that of the uninsured ($78,472 versus $3,384). This discrepancy is even larger when we focus on families in the individual market. Median net wealth among those with nongroup insurance was 34.6 times that of the uninsured without access to employer coverage ($105,819 versus $3,057). Our results suggest that assets are an important determinant of effective affordability, undermining the notion that many people are uninsured by choice.

http://content.healthaffairs.org/cgi/content/abstract/28/3/887

Comment:

By Don McCanne, MD

Many of the uninsured have incomes that are low enough to establish their eligibility for public programs. But those denying the problem would exclude these individuals from the count because they are “technically insured,” but merely too lazy to enroll. This ignores the multiple logistical barriers that make it impossible to enroll everyone who is eligible.

Many others without insurance are “illegals” who do not have their immigration papers in order. As long as we continue with national policies that include these individuals in our workforce, regardless of immigration status, then we have to accept the fact that they are part of our intrinsic economy and will access our health care system. Excluding them from the count would understate the issues we face when trying to figure out how to finance the care of uninsured individuals.

Although these undercounters dismiss most of the uninsured as failures of personal responsibility, they do remain conflicted on higher-income individuals who elect not to purchase insurance. Some consider these to be individuals who are exercising their right to freedom of choice – the freedom to self-insure instead of purchasing an insurance plan. Others consider these to be free riders who transfer the risk of catastrophic costs to the rest of us who are already paying our share.

But are these really individuals who are simply declining to purchase coverage they can afford? With health care costs now averaging $16,700 for an employed worker with a family of four, that takes quite a bit out of a typical income of $60,000. Many of theses families have little in the way of assets, living paycheck to paycheck, and really don’t have enough money to purchase a reasonable health plan.

This Health Affairs study demonstrates that not only income but also net wealth are important determinants of whether or not health insurance is affordable. Expanding net wealth requires both a higher level of discretionary income and a longer interval to accumulate assets. Thus both income margins and time are variables that influence the affordability of health insurance.

Since current proposals for reform would use tax subsidies to help individuals and families purchase private health plans, does this mean that we need to establish an eligibility grid that includes both income and net assets as variables? If we did, we might see an epidemic of personal failure based on the inability of so many to master the logistical requirements of the eligibility grid. (Have you tired calculating your precise net wealth recently?)

Why do we keep playing these games with all of the variables that go into determining our insurance status? Why don’t we simply make it automatic for everyone? If you exist, you’re covered.

Health care vs. sick care

A significant difference

By Dr. M. Joycelyn Elders
United Methodist News Service
6/25/09

LITTLE ROCK, Ark. (UMNS) — The United States has the best “sick-care” system in the world, but our “health-care” delivery system is lacking. We have the best doctors, the best hospitals, best academic health centers, best nurses, the best drugs, and we are leaders in research.

Our problem is that the system is not available to all of our citizens. In addition, our health care is not equitable, coherent, comprehensive and cost-effective, nor do we have choice. The United States has 5% of the people of the world and 25% of the world’s wealth. We are the richest country in the world and the only industrialized country that does not provide health care for its entire people.

Health care now consumes 17% of the U.S. Gross Domestic Product, or $2.4 trillion in 2007. Health care continues to grow in its appetite for our economic resources. At the same time, the United States continues to fall in overall health care for its citizens in comparison with the remainder of the industrialized world.

We do not have the best health, ranking 46th in life expectancy, 42nd in infant mortality and 57th in overall goodness and fairness as compared to 192 other members of the Organization for Economic Development & Cooperation.

If the rest of the industrialized world can manage to serve all its citizens on less, why can we not?
Lives at risk

The lack of access to health care for so many is literally bankrupting our people and endangering all our lives.

Lack of access to health care for so many is literally bankrupting our people and endangering all our lives.

We have depended upon employers to carry much of the burden of health insurance over the years. Now we find in this global economy, however, that they are at a disadvantage trying to compete with countries that have a public health-care system.

Health insurance expenses are the fastest-growing cost component for employers. Unless something changes dramatically, health insurance costs will overtake profits.

President Obama desires a health-care plan that improves coverage for the 45 million to 50 million uninsured citizens, contains costs, and offers high-quality, cost-effective, equitable, portable and affordable care for everyone.

We must simultaneously address, integrate and solve the three major components of health-care reform: financing, organizing the delivery system, and educating patients and community, in order to facilitate behavioral and lifestyle changes.

Quality of care would improve if every patient had access to a medical home and an accountable care organization with electronic medical records where care was patient-centered, coordinated and cost-effective.

Monitoring of many of our procedures, techniques, new technologies and drugs needs to be evaluated. We need to replace our inefficient, inequitable financing system with one that works. It needs to include everybody with subsidies for the young, poor and sick. It must require all to pay their fair share.

Physicians must have the information (electronic medical records), infrastructure and incentives they need to improve quality and control cost.
Physicians, heal this system

Physicians must become involved in population health, which is influenced by factors in five domains: genetic, social circumstances, environmental exposures, behavioral patterns and health care. The single greatest opportunity to improve health and reduce premature death lies in personal behavior.

We can do more to improve our own health than all the medical discoveries in the past 100 years.

On an individual level, we can do more to improve our own health than all the medical discoveries in the past 100 years.

We must dream big: Our vision is for healthy people in healthy communities with a health-care system that is right for all of our citizens. It needs to be available, affordable, accessible, patient-centered, prevention-focused, purpose-driven and solution-oriented. It must empower individuals to take care of themselves, foster responsibility and human dignity, improve health and enhance quality of life.

Any new health-care system must contain a provision for a public health-care policy: This is a single-payer system. People who prefer private insurance can always purchase it instead of purchasing a public health-care policy. In this public health-care policy, we must provide every person with access to basic health care, including physical and cultural access through transportation and language sensitivity.

We also must provide education to promote health maintenance, preventive measures in order to thwart disease, basic dental health care, mental health care, emergency services and necessary medicines.
A public option

Ask Medicare patients if they would like to give up their insurance. I think few would answer in the affirmative. Public health care is well liked in the United States.

A public health-care policy would likely be similar to purchasing Medicare.

People who do not receive Medicare may not know that each person pays almost $100 per month for the insurance, which is deducted from Social Security checks automatically. After a yearly deductible, Medicare pays 80% of most medical care but not dental care. There is a prescription Medicare (Part D) that is separate from other Medicare and has a variety of plans.

A public health-care policy would likely be similar to purchasing Medicare. With Medicare, about 98 cents of every dollar paid in payroll taxes are spent on actually providing health care. When you look at the private insurance companies, it is more like 80 cents. The rest goes to administrative expenses and profits.

There are many additional costs imposed on the doctors and health-care providers themselves. They must deal with a fragmented, complex system in which they have to negotiate, amend, or cajole payment from many different insurers.

Both business and individuals are breaking under the strain of our very expensive health-care system. We must overhaul our system now; its condition is beyond tweaking to make it function for our people.

We have tried to tweak the way we perform health care for many decades with disastrous results. We have tried HMOs, PPOs, indemnity with an assortment of public health systems to catch some of our people who fall between the cracks. It has failed while costing us precious lives, health and money of our people along the way.

We need an overhaul of the health-care system to save lives, money and U.S. business.

Let Medicare cover all Americans

Letter to the Editor
St. Petersburg Times
Friday, June 26, 2009

Re: What health reform must do | June 21, editorial

The three guiding principles espoused in your editorial are certainly laudable, but our current direction toward health care “reform” will not, unfortunately for the American people, make any of them come to pass.

Universal coverage is essential to any true reform, but the current plans being debated in Congress fall woefully short of that goal. As you note, the Congressional Budget Office estimates that current plans in the Senate come with a price tag of $1 trillion over the next 10 years, while still leaving 36 million without any coverage.

We already spend enough to insure everyone right now and it’s 2 1/2 times what the average industrialized country spends. To pump additional monies into a system that over the last 50 years has proven itself wasteful, expensive, complicated and which produces poorer health outcomes than other countries is as absurd as it is reckless.

Medical cost increases dramatically outpace inflation and wages year after year. The only way we will ever control these costs is to utilize the purchasing power of the federal government to negotiate with suppliers, pharmaceutical companies, doctors and hospitals on behalf of all taxpayers and demand quality, efficiency and effectiveness for our health care dollars.

We currently lose more than 30 percent of each dollar spent for private insurance companies’ overhead, profits and bonuses. That’s $600 billion annually that should be spent on providing health care. The current plans look to cutting Medicare and Medicaid funding and taxing the health benefits of workers to pay for more private plans. Those “solutions” can only exacerbate the current problems and inequities in our system.

I agree that we need to build on what works in our current system, but that is not private insurance. It’s Medicare, a program that already provides care to more than 44 million seniors with higher satisfaction ratings than employer-sponsored private insurance plans. Medicare enrollees have more choice of doctors and hospitals than those in “network” limited private plans. And with only a 3 percent overhead, the savings of a “Medicare for All” program would be more than enough to cover all of the uninsured without any additional benefit cuts or spending.

Greg M. Silver, M.D., Clearwater

State cuts its health coverage by $115m

Board to slow enrollment in Commonwealth Care

By Kay Lazar
Boston Globe
June 24, 2009

Overseers of Massachusettsâ€™ trailblazing healthcare program made their first cuts yesterday, trimming $115 million, or 12 percent, from Commonwealth Care, which subsidizes premiums for needy residents and is the centerpiece of the 2006 law.

The board of the Connector Authority made the cuts as officials confronted two side effects of the recession: the state budget crisis and a surge in enrollment by the recently unemployed.

The largest share of the savings will come from slowing enrollment. An estimated 18,000 poor residents who qualify for full subsidies, but who forget to designate a health plan, will no longer be automatically assigned a plan and enrolled and thus could face delays in getting care.

Savings will also come from eliminating dental coverage for the poorest residents enrolled in Commonwealth Care, roughly 92,000 people who currently are the only ones in the program who receive that care. This $10 million cut was included in Governor Deval Patrick’s revised budget proposal, but then was restored in the budget lawmakers approved last week. It now falls to the governor to decide the program’s fate.

Also hanging in the balance is the health insurance status of 28,000 legal immigrants whose Commonwealth Care coverage was dropped in the budget lawmakers approved for the fiscal year that begins July 1. Patrick has until Monday to decide whether to veto any of that budget, which set aside $116 million less for Commonwealth Care than he proposed.

â€œNo decision has been madeâ€™â€™ on restoring immigrant coverage, said Leslie Kirwan, chairwoman of the Connector Authority board and Patrickâ€™s secretary of administration and finance. â€œItâ€™s certainly going to be at the top of our listâ€™â€™ of items the governor is considering adding back to the budget, she said.

But Kirwan said the $115 million in cuts the Connector Authority board approved yesterday were merely to deal with shrinking state revenues and the rapid growth in enrollment in Commonwealth Care, which has 177,000 members and was projected to grow to 212,000 in the next year.

These cuts do not provide any wiggle room for adding back the 28,000 immigrants who are facing elimination. If the governor decides to restore coverage for the immigrants, Kirwan said, he would have to find other areas to cut in the already razor-thin budget.

Patrick Holland, the Connector Authorityâ€™s chief financial officer, said enrollment spiked during the last three months, from 165,000 to nearly 177,000 members, because so many workers are losing their jobs and, with that, employer-provided health insurance.

The progress of the Massachusetts healthcare initiative is being closely watched in Washington, where Congress is crafting national legislation to extend coverage to more Americans. The Massachusetts law, cited as one model in the national debate, requires nearly everyone to have health insurance or pay a tax penalty.

The residents affected by yesterdayâ€™s cuts earn too little to be subject to the penalty. They also would be eligible for free emergency care for three months under the stateâ€™s Health Safety Net.

Leaders of Health Care for All, one of the stateâ€™s largest consumer groups, said the changes will be especially hard on residents whose first language is not English and who have difficulty understanding the complex enrollment paperwork.

But the group said state officials appear to have made the best of a bad situation. â€œThereâ€™s no other place to go for money,â€™â€™ said Lindsey Tucker, the organizationâ€™s healthcare reform manager. â€œ. . . My concern is people will not get the care that they need.â€™â€™

While the groupâ€™s leaders are resigned to that cut, they said they will continue to lobby the governor to restore coverage for legal immigrants. Lawmakers said they cut this class of legal immigrants because they do not qualify for matching federal subsidies. Thus, they are more expensive for the state to insure. The move has enraged advocates for the immigrant community.

Much of the rest of the $115 million in savings, $32 million, comes from slowing payments to the managed-care health insurance companies that won bids to offer insurance through the Commonwealth Care program. Regulators said that by slowing enrollment growth, the companies would receive less money than they had banked on when they submitted their bids earlier this year.

Kirwan stressed that when the economy improves, the changes made by the authority can be revisited. She also said the changes still protect the basic eligibility rules for the program and benefits that members receive, but put the brakes only on enrollment growth during an â€œunprecedented time.â€™â€™

While the emergency changes approved by the Connector Authority go into effect July 1, Kirwan said the board will schedule a hearing, probably in late July, to seek public comments on the issues.

Kay Lazar can be reached at klazar@globe.com.

Correction: Because of a reporting error, a Page One story yesterday incorrectly described the decision to cut dental coverage for the poorest residents enrolled in the Commonwealth Care subsidized health insurance program. Dental care for this population was eliminated in Governor Deval Patrickâ€™s revised state budget proposal but was restored in the budget lawmakers approved last week. The Connector Authority board did not vote to cut this coverage.

The Prescription From Obama's Own Doctor

By NICHOLAS D. KRISTOF
Op-Ed Columnist
New York Times
Published: June 24, 2009

As a society, we trust doctors to be more concerned with the pulse of their patients than the pulse of commerce. Yet the American Medical Association is using that trust to try to block a robust public insurance option as part of health reform.

In fact the A.M.A. now represents only 19 percent of practicing physicians (that’s my calculation, which the A.M.A. neither confirms nor contests). Its membership has declined in part because of its embarrassing historical record: the A.M.A. supported segregation, opposed President Harry Truman’s plans for national health insurance, backed tobacco, denounced Medicare and opposed President Bill Clinton’s health reform plan.

So I hope President Obama tunes out the A.M.A. and reaches out instead to somebody to whom he’s turned often for medical advice. That’s Dr. David Scheiner, a Chicago internist who was Mr. Obama’s doctor for more than two decades, until he moved into the White House this year.

“They’ve always been on the wrong side of things,” Dr. Scheiner told me, speaking of the A.M.A. “They may be protecting their interests, but they’re not protecting the interests of the American public.

“In the past, physicians have risked their lives to take care of patients. The patient’s health was the bottom line, not the checkbook. Today, it’s just immoral what’s going on. It’s abominable, all these people without health care.”

Dr. Scheiner, 70, favors the public insurance option and would love to go further and see Medicare for all. He greatly admires Mr. Obama but worries that his health reforms won’t go far enough.

Dr. J. James Rohack, the president of the A.M.A., insisted to me that his group is committed to making health insurance accessible for all Americans, and that its paramount concern is patient health.

“When you don’t have health insurance, you live sicker and you die younger,” he said. “And that’s not something we’re proud of as Americans.”

He added that the A.M.A. is not necessarily opposed to a public option, and I have the impression that it might accept a pallid one built on co-ops. Dr. Rohack wouldn’t repudiate his association’s letter to the Senate Finance Committee warning against a new public plan. That letter declared: “The introduction of a new public plan threatens to restrict patient choice by driving out private insurers.”

I don’t mind the A.M.A. lobbying on behalf of doctors in the many areas where physicians and patients have common interests. The association is dead right, for example, in calling for curbs on lawsuits, which raise medical costs for everyone.

An excellent study published in 2006 in The New England Journal of Medicine found that for every dollar paid in compensation as a result of lawsuits against doctors, 54 cents goes to legal and administrative costs.

That’s an absurd waste of money. Moreover, aggressive law leads to defensive medicine, in the form of extra medical tests that waste everybody’s money. Tort reform should be a part of health reform.

Yet when the A.M.A. uses its lobbying muscle to oppose major health reform — yet again! — that feels like a betrayal. Doctors work hard to keep us healthy when we’re in their offices, and that’s why they win our trust and admiration — yet the A.M.A.’s lobbying has sometimes undermined the health of the very patients whom the doctors have sworn to uphold.

I might expect the American Association of Used Car Dealers to focus exclusively on wallet-fattening, but we expect better of physicians.

In fairness, most physicians expect better as well, which is why the A.M.A. is on the decline.

“It’s what has led to the decline of the A.M.A. over the last half century,” said Dr. David Himmelstein, a Massachusetts physician who also teaches at Harvard Medical School. “At this point only one in five practicing doctors are in the A.M.A., and even among its members about half disagree with its policies.” To back that last point, Dr. Himmelstein pointed to surveys showing a surprising number of A.M.A. members who support a single-payer system.

For his part, Dr. Himmelstein co-founded Physicians for a National Health Program, which now has more than 16,000 members. The far larger American College of Physicians, which is composed of internists and is the second-largest organization of doctors, is also open to a single-payer system and a public insurance option. It also quite rightly calls for emphasizing primary care.

The American Medical Student Association has issued a sharp statement disagreeing with the A.M.A.

The student association declared that it “not only supports but insists upon a public health insurance option.”

Look, a public option is no panacea, and it won’t automatically set right the many shortcomings in our health system. But if that option is killed in gestation, then we’re back to Square 1 and there’s little hope of progress in solving the vast challenges confronting us.

So, President Obama, don’t listen to the A.M.A. on this issue. Instead, for starters, call your doctor!

The Prescription From Obama’s Own Doctor