By David Lazarus
Los Angeles Times
May 27, 2009

San Marcos resident Maggie Yount wasn’t surprised when the letter from insurance giant Anthem Blue Cross arrived the other day. Yet she couldn’t help but be frustrated.

“Some medical conditions, either alone or in combination with the cost of medication, present uncertain medical underwriting risks,” Anthem informed her. “In view of these risks, we find we are unable to offer you enrollment at this time.”

In other words, no health coverage for you.

Yount, 24, finds herself in that cloudy area in which a “preexisting condition” makes her too great a risk in the eyes of money-minded insurance companies. And so she’s being excluded from the system.

“It looks like I’ll just have to be very, very careful about everything,” Yount told me. “But what kind of way is that to live your life?”

If that were all there was to it, her story would still be worth telling as the Obama administration embarks on an ambitious effort to reform the woefully dysfunctional U.S. healthcare system.

But Yount’s tale runs even deeper.

In November 2007, she was rushed to the emergency room after a drunk driver crashed into her car on a Nova Scotia highway.

Yount awoke from a coma four days later. She had suffered a brain injury in the head-on collision. Thirteen bones were broken, from her leg to her cheek. The other driver was killed.

Yount, a Canadian citizen, spent three months in a Halifax hospital, receiving treatment and rehab that must have cost a small fortune.

“I have no idea how much it cost,” she said. “It’s not something I’ve ever needed to know.”

So who paid the bill?

“The government of Canada.”

The United States is the only industrialized democracy that doesn’t have a government-run insurance system. Under such systems, universal coverage is provided through tax revenue. There are no premiums, co-pays or deductibles.

It’s not a perfect system — people often end up waiting for nonessential treatment. But it won’t leave you destitute if things go bad. Basically, you’re covered. For everything.

In Yount’s case, that ended when she moved to San Marcos in northern San Diego County a year ago to be with her fiance. They were married last July.

She then tried to obtain health coverage under the U.S. system. Her American husband works as a software engineer on a contract basis and doesn’t have employer-provided coverage.

Before applying to Anthem, Yount applied for an individual policy offered by Aetna Inc. She received a letter a couple of months ago informing her that her application had been rejected.

The letter noted that Yount’s medical record includes “a history of traumatic brain injury with multiple fractures treated with hospitalization.” It concluded that “this condition exceeds the allowable limits provided by our underwriting guidelines.”

That’s a fancy way of saying there’s a pretty good chance Yount will require medical care of one sort or another in the future. This would be bad for Aetna’s business.

“If anybody from Aetna had actually spoken to me, they’d see I’m not mentally challenged because of the brain injury,” Yount said. “I still have some issues related to it, such as short-term memory loss, but I no longer have the need for acute medical care.”

As for all those broken bones: “They’ve healed,” Yount said. “That’s over. What, are they going to deny people coverage because they once had a broken arm?”

Anjanette Coplin, an Aetna spokeswoman, was unable to discuss Yount’s case. But she said the company considers a variety of factors before rejecting an applicant for coverage. These can include a person’s overall condition, medical history and prospects for ongoing treatment.

“We feel that our underwriting guidelines give the greatest number of consumers the opportunity to purchase affordable, quality health insurance products,” Coplin said.

Yount’s response: Companies like Aetna and Anthem are denying coverage based solely on history rather than a reasonable expectation of what could happen down the road.

“I want insurance for what could happen in the future — just in case,” she said. “That’s what insurance is for. But I can’t get it.”

I don’t blame Aetna or Anthem. If you offer health insurance as a for-profit business, it goes without saying that you’ll do everything you can to avoid making payouts. That means you’ll shun anyone with even a whiff of medical trouble.

But this is no way to run an insurance system, let alone to protect people from financial ruin due to catastrophic events such as being sent to the hospital by a drunk driver.

The Obama administration has already rejected the idea of a single-payer system similar to Canada’s — a mistake, in my opinion. Instead, it wants a smaller public program that would compete with private insurers and keep costs down.

Private insurers, not surprisingly, are lobbying aggressively to kill off that idea. They’d rather have a national mandate that would require all Americans to buy their product.

In return, they say, they’d stop sending rejection letters to people like Yount with preexisting conditions. But policyholders would still be subject to the companies’ various terms and conditions.

Maybe one compromise would be to let private insurers handle the small stuff and to have a public program that could tackle the catastrophic stuff.

I asked Yount what would have happened if she’d gotten into her accident in Southern California instead of Nova Scotia.

“I can’t say whether my care would have been better or worse,” she replied. “But I know this: I’d be bankrupt now.”

“I’m not a religious person,” Yount added. “But I thank God my accident happened where it did.”

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David Lazarus’ column runs Wednesdays and Sundays. Send your tips or feedback to david.lazarus@latimes.com.

http://www.latimes.com/business/la-fi-lazarus27-2009may27,0,2252325.column

By David Lazarus
Los Angeles Times
May 27, 2009

San Marcos resident Maggie Yount wasn’t surprised when the letter from insurance giant Anthem Blue Cross arrived the other day. Yet she couldn’t help but be frustrated.

“Some medical conditions, either alone or in combination with the cost of medication, present uncertain medical underwriting risks,” Anthem informed her. “In view of these risks, we find we are unable to offer you enrollment at this time.”

In other words, no health coverage for you.

Yount, 24, finds herself in that cloudy area in which a “preexisting condition” makes her too great a risk in the eyes of money-minded insurance companies. And so she’s being excluded from the system.

“It looks like I’ll just have to be very, very careful about everything,” Yount told me. “But what kind of way is that to live your life?”

If that were all there was to it, her story would still be worth telling as the Obama administration embarks on an ambitious effort to reform the woefully dysfunctional U.S. healthcare system.

But Yount’s tale runs even deeper.

In November 2007, she was rushed to the emergency room after a drunk driver crashed into her car on a Nova Scotia highway.

Yount awoke from a coma four days later. She had suffered a brain injury in the head-on collision. Thirteen bones were broken, from her leg to her cheek. The other driver was killed.

Yount, a Canadian citizen, spent three months in a Halifax hospital, receiving treatment and rehab that must have cost a small fortune.

“I have no idea how much it cost,” she said. “It’s not something I’ve ever needed to know.”

So who paid the bill?

“The government of Canada.”

The United States is the only industrialized democracy that doesn’t have a government-run insurance system. Under such systems, universal coverage is provided through tax revenue. There are no premiums, co-pays or deductibles.

It’s not a perfect system — people often end up waiting for nonessential treatment. But it won’t leave you destitute if things go bad. Basically, you’re covered. For everything.

In Yount’s case, that ended when she moved to San Marcos in northern San Diego County a year ago to be with her fiance. They were married last July.

She then tried to obtain health coverage under the U.S. system. Her American husband works as a software engineer on a contract basis and doesn’t have employer-provided coverage.

Before applying to Anthem, Yount applied for an individual policy offered by Aetna Inc. She received a letter a couple of months ago informing her that her application had been rejected.

The letter noted that Yount’s medical record includes “a history of traumatic brain injury with multiple fractures treated with hospitalization.” It concluded that “this condition exceeds the allowable limits provided by our underwriting guidelines.”

That’s a fancy way of saying there’s a pretty good chance Yount will require medical care of one sort or another in the future. This would be bad for Aetna’s business.

“If anybody from Aetna had actually spoken to me, they’d see I’m not mentally challenged because of the brain injury,” Yount said. “I still have some issues related to it, such as short-term memory loss, but I no longer have the need for acute medical care.”

As for all those broken bones: “They’ve healed,” Yount said. “That’s over. What, are they going to deny people coverage because they once had a broken arm?”

Anjanette Coplin, an Aetna spokeswoman, was unable to discuss Yount’s case. But she said the company considers a variety of factors before rejecting an applicant for coverage. These can include a person’s overall condition, medical history and prospects for ongoing treatment.

“We feel that our underwriting guidelines give the greatest number of consumers the opportunity to purchase affordable, quality health insurance products,” Coplin said.

Yount’s response: Companies like Aetna and Anthem are denying coverage based solely on history rather than a reasonable expectation of what could happen down the road.

“I want insurance for what could happen in the future — just in case,” she said. “That’s what insurance is for. But I can’t get it.”

I don’t blame Aetna or Anthem. If you offer health insurance as a for-profit business, it goes without saying that you’ll do everything you can to avoid making payouts. That means you’ll shun anyone with even a whiff of medical trouble.

But this is no way to run an insurance system, let alone to protect people from financial ruin due to catastrophic events such as being sent to the hospital by a drunk driver.

The Obama administration has already rejected the idea of a single-payer system similar to Canada’s — a mistake, in my opinion. Instead, it wants a smaller public program that would compete with private insurers and keep costs down.

Private insurers, not surprisingly, are lobbying aggressively to kill off that idea. They’d rather have a national mandate that would require all Americans to buy their product.

In return, they say, they’d stop sending rejection letters to people like Yount with preexisting conditions. But policyholders would still be subject to the companies’ various terms and conditions.

Maybe one compromise would be to let private insurers handle the small stuff and to have a public program that could tackle the catastrophic stuff.

I asked Yount what would have happened if she’d gotten into her accident in Southern California instead of Nova Scotia.

“I can’t say whether my care would have been better or worse,” she replied. “But I know this: I’d be bankrupt now.”

“I’m not a religious person,” Yount added. “But I thank God my accident happened where it did.”

---

David Lazarus’ column runs Wednesdays and Sundays. Send your tips or feedback to david.lazarus@latimes.com.

http://www.latimes.com/business/la-fi-lazarus27-2009may27,0,2252325.column

By Dr. Marcia Angell
Boston Globe
May 23, 2009

The Senate Finance Committee’s hearings on health reform earlier this month did not include testimony from any advocate for single-payer insurance. Physicians for a National Health Program, which represents 16,000 doctors, asked the committee to invite me to testify, but it chose not to. If I had been invited, this is what I would have said:

The reason our health system is in such trouble is that it is set up to generate profits, not to provide care. We rely on hundreds of investor-owned insurance companies that profit by refusing coverage to high-risk patients and limiting services to others. They also cream off about 20 percent of the premiums for profits and overhead.

In addition, we provide much of our medical care in investor-owned health facilities that profit by providing too many services for the well-insured and too few for those who cannot pay. Most physicians are paid fee-for-service, which gives them a similar incentive, particularly specialists who receive very high fees for performing expensive tests and procedures. Nonprofits behave much like for-profits, because they must compete with them. In sum, healthcare is directed toward maximizing income, not maximizing health. In economic terms, it’s a highly successful industry, but it’s a massive drain on the rest of the economy.

The reform proposals advocated by President Obama are meant to increase coverage for the uninsured. That is certainly a worthwhile goal, but the problem is that they leave the present profit-driven and highly inflationary system essentially unchanged, and simply pour more money into it – an unsustainable situation. That is what is happening in Massachusetts, where we have nearly universal health insurance, but costs are growing so rapidly that its long-term prospects are poor without cutting benefits and greatly increasing co-payments. Initiatives such as electronic records, case management, preventive care, and comparative effectiveness studies may improve care, but the Congressional Budget Office and most health economists agree that they are unlikely to save much money. Promises by for-profit insurers and providers to mend their ways voluntarily are not credible.

Nearly every other advanced country has a largely nonprofit national health system that provides universal and comprehensive care. Expenditures are on average about half as much per person, and health outcomes are generally much better. Moreover, these countries offer more basic services, not fewer. They have on average more doctors and nurses, more hospital beds, longer hospital stays, and there are more doctor visits. But they don’t do nearly as many tests and procedures, because there is little financial incentive to do so.

It is often argued that the first order of business should be to expand coverage, and then worry about costs later. But it is essential to deal with both together to stop the drain on the rest of the economy and the further fraying of healthcare. The only way to provide universal and comprehensive coverage and control costs is to adopt a nonprofit single-payer system. Medicare is a single-payer system, with low overhead costs, but it uses the same profit-oriented providers as the private system and also preferentially rewards specialists for tests and procedures. Consequently, its costs are rising almost as rapidly as those in the private sector. Representative John Conyers introduced an excellent bill that calls for extending Medicare to everyone in a nonprofit delivery system. That could be done gradually, by lowering the Medicare age a decade at a time.

A single-payer system is ignored by lawmakers because of the influence of the health industry lobbies. They raise the specter of rationing and long waits for care. There are indeed waits for some elective procedures in some countries with national health systems, such as the United Kingdom. But that’s because they spend far less on healthcare than we do. For them, the problem is not the system; it’s inadequate funding. For us, it’s not the funding; it’s the system. We spend more than enough.

I urge you to consider a nonprofit single-payer system. The economic interests of the health industry should not be permitted to hold the rest of the economy hostage and threaten the health and well-being of the public.

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Dr. Marcia Angell is a senior lecturer in social medicine at Harvard Medical School and former editor-in-chief of the New England Journal of Medicine.

By BRIAN ETTKIN
Times Union (Albany, NY)
Saturday, May 23, 2009

In Andrew Coates’ first week as a doctoral intern in Cooperstown, he learned a harsh reality that disturbs him to this day: His ability to care for patients is inhibited by their ability to pay for health care.

“As a brand new intern, I went to my teachers and I said: ‘How can I have only learned the state-of-the-art practice of medicine when the ability to pay trumps our ability to provide that? I can’t prescribe the drug that I want to because the patient can’t afford it. I have to question whether or not I can order the test I want to because the patient can’t afford it. What are we going to do about this?’

“And so then began for me a very serious process about how I could make a difference on behalf of all of the patients.”

Coates, an Albany internist and professor at Albany Medical College, sits on the board of directors of Physicians for a National Health Program and is secretary of PNHP’s Capital District Chapter. He has advocated for single-payer health care for more than a decade (he recently started blogging on the subject at http://blog.timesunion.com/coates/) and is scheduled to speak at the single-payer lobby day and rally Wednesday at the state Capitol.

At a pair of U.S. Senate Finance Committee meetings on health care access and coverage earlier this month, 13 medical practitioners and single-payer advocates were arrested when they protested that a single-payer advocate was not included in the discussion.

Coates, 47, speaks thoughtfully and argues persuasively for single-payer health care. A married father of three children who lives in Delmar, he speaks from personal experience too.

After Coates’ father-in-law, Tom Williams, retired from his managerial job at Chrysler in Detroit with “gold-plated” health insurance, he was diagnosed with a rare sarcoma in his knee.

“The history of this tumor was that it would spread, and very few of the patients would survive a year … very, very few patients would survive five years,” Coates said.

Coates said his father-in-law’s insurance covered health care provided by the surgical oncologist with the most experience treating that type of sarcoma. Through treatment, Coates said, his father-in-law was cured and his leg saved.

But about five years after the start of his father-in-law’s treatment at the Mayo Clinic in Rochester, Minn., Coates said, he received a letter from his health insurer that stated, in effect: “Congratulations, you have lived five years. We will no longer pay for any follow-up for the care of your cancer. We have paid enough money for the care of your cancer.”

“And that’s the gold-plated health insurance,” said Coates, who paused to compose himself several times as he recounted his father-in-law’s story. “That’s the Cadillac coverage that the conservatives decry.”

His father-in-law’s cancer has not recurred.

Wearing a bow tie and a sweater vest over a button-down white shirt, his long sleeves rolled up on a workday, Coates sat down for an interview this week with the Times Union, excerpts of which follow:

Q: What’s at stake in the single-payer debate?

A: As I’ve gotten deeper into this cause, I begin to understand that it’s a question of the American democracy. Of course I believe that health is a human right, I passionately believe that. I recognize that’s not a universally shared viewpoint. But health is a necessity of modern life, an unbelievably expensive necessity of modern life, and the only way to provide the necessary care for the sick is for us to share the costs somehow as a society. So I really believe that this becomes a test of the democracy and whether we will have the will to do what’s best for the people and best for the health of the nation, or will we choose profitability of a particular industry as the nation’s priority.

Q: Some government agencies, it’s been noted, don’t operate efficiently. Why should we believe a single-payer health care agency would behave differently?

A: We have how many health insurance companies in the United States, how many different plans, how many different processes on each level? I think it’s over 1,500. We have a massive tangle of bureaucracy now. How many different fee schedules, how many different plan options are there? How many formulary and prior authorization systems? There’s a massive bureaucracy. We have the model of Medicare, which works with as little as one-tenth of the overhead costs of the private insurance industry. We have a positive model, and then we have a massive bureaucracy right now.

As far as the question of you can’t trust the government: I realize that many of us all our adult lives have heard that everything private is good and everything public is bad, and even though I scratch my head and wonder what kind of a people that want to live in a democracy would say such a thing, I realize that that’s kind of a political reality that we live with. I don’t believe that a single-payer system would be perfect. I just believe that would be vastly superior to privatization and profiteering at the expense of the sick.

The health of individuals and the health of people are too important to leave to people who are trying to make a buck. It is the proper role of the public to say so.

Q: How do you respond to critics who decry this is socialism?

A: There are some services that the public has to share. I was being interviewed on the radio once and the caller said, “Isn’t this socialism?” It was (WAMC’s) Alan Chartock who said, “Oh, right, socialism, like the fire department, socialism like the public schools, socialism like the interstate highway system — next caller.” And even with that said, single payer is not a proposal that the government should own the public health care system. It’s a proposal that the government should manage the money that pays for the care privately delivered.

Q: Has the absence of a single-payer system directly affected you as a patient?

A: My own physician dropped my insurance. I have the Empire plan, and over many years, the Empire Plan, which went from not-for-profit to for-profit status, has become increasingly impossible for many physician practices to deal with. So I myself am in the process of finding a new physician who will take my health insurance. These things intervene in all our lives.

Brian Ettkin can be reached at 454-5457 or by e-mail at bettkin@timesunion.com.

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Critical condition

More than 45.7 million Americans lacked health insurance in 2007.

More than 18,000 adults die every year from lack of health insurance coverage.

Every other developed nation has some form of national health insurance, and yet U.S. health spending is far higher — 56% higher than in Switzerland, which has the world’s second-most-expensive health care system, and 83% higher than in Canada.

A survey published in 2008 found that 59% of U.S. physicians support national health insurance.

A survey published in 2003 found that administrative expenses consume 31% of U.S. health costs, nearly twice the proportion of Canada’s administrative expenses (16.7 percent).

Sources: U.S. Census Bureau, Institute of Medicine of the National Academy of Sciences, Organization for Economic Cooperation and Development Health Database, Annals of Internal Medicine, New England Journal of Medicine.