PNHP

FRONTLINE's "Sick Around America"

FRONTLINE's "Sick Around America"

Sick Around America

FRONTLINE
March 31, 2009

Investigating the stories of Americans whose lives have become a quest to find and keep health insurance…

Join the Discussion

Dear FRONTLINE,

I am disappointed that this long-awaited special on healthcare did not address the single payer option. There were ample interviews with insurance company lobbyists but no discussion of this obvious choice. Our nation’s people are in crisis and the shameful greed displayed in other industries is replicated in the for profit hospital corporations, insurance companies and pharmceutical industries. We cannot afford profit in healthcare, as we will continue to have a chaotic, threadbare system riddled with donut holes and pitfalls for those who can least navigate: patients and their families. I’d like to see equal time — a Frontline on the single payer option.

Grace Gifford
Conway, SC

FRONTLINE’s editors respond:

Many viewers have written criticizing this report for not looking at solutions, in particular, a single payer system. Certainly, the topic is another important piece of any examination into the health care system and how it can be improved. And it would warrant a separate program of its own. We would like to point out that we did examine how the single payer system works in many European countries in our program last season, Sick Around the World. You can view this online.We believe that our report this week, Sick Around America, was equally of value in focusing on our current private health insurance system and showing how many Americans are only one or two events away from financial disaster or total ruin because they can’t afford this insurance, or because it offers inadequate coverage, or because it suddenly can be rescinded by the insurer for alleged omissions or errors. We also felt it important in this report to look at another major problem with the private insurance system: America’s for-profit medical system means that insurers have a fiscal duty to avoid risk and make profits for investors. Thus, insuring people who already have serious, chronic illnesses works against the interests of stockholders.

FRONTLINE: Sick Around America
http://www.pbs.org/wgbh/pages/frontline/sickaroundamerica/

Join the Discussion
http://www.pbs.org/wgbh/pages/frontline/sickaroundamerica/talk/

PNHP: “‘Sick Around America’ disappoints” – selected responses
https://pnhp.org/blog/2009/04/01/‘sick-around-america’-disappoints/

Columbia Journalism Review: “Sick Around America” by Trudy Lieberman
http://www.cjr.org/campaign_desk/sick_around_america.php?page=all

Comment:

By Don McCanne, MD

T.R. Reid had hosted FRONTLINE’s “Sick Around the World,” an important documentary describing successful health programs in several other nations that provide care for everyone at a fraction of the costs of our fragmented, inefficient health care system that leaves so many out.

We were looking forward to T.R. Reid’s sequel, “Sick Around America,” describing the problems with our private insurance system. Many of us were disappointed with the format of the program, believing that they missed a great opportunity to educate the nation on several health policies that would work well for all of us. Thus it was no surprise to us that T.R. Reid was not mentioned during the program, nor in the credits.

What happened? Reid left the show this February in a dispute with FRONTLINE. Trudy Lieberman of Columbia Journalism Review quotes Reid as saying, “When I saw it, I didn’t agree with it. It took a different view of health policy than I have.”

The program did use anecdotes effectively, demonstrating some of the problems with private insurance. Examples included medical underwriting, rescission, lapses in coverage, financial burdens due to underinsurance, and other deficiencies that most Americans now understand.

Watching this program, it is very clear that change is required. But the message for reform was outrageous. Throughout the program, many executives of the private insurance industry were featured, and they confirmed that these deficiencies were very real and needed to be addressed. That’s good. What was outrageous is that they were in no way contrite, but instead they implied that they would provide the leadership to make sure that private insurance will continue to manage the financing for health care in America, beginning with an individual mandate for every American to buy their lousy products.

We can only speculate on the motives of the producers. My opinion is that they wanted to provide support for the current efforts of the Democrats in Congress and in The White House to build reform based on private health plans. A publicly-administered and publicly-financed program would require a total restart on the reform process, and so it wasn’t offered as a potential solution. In deference to the insurance executives, the producers didn’t even promote a public Medicare-like option.

Remember, these insurance executives are not contrite. They can never provide the moral leadership that we need to create a health care system that serves all of us well.

How many doctors support single payer?

U.S. Physicians' Views on Financing Options to Expand Health Insurance Coverage: A National Survey

By Danny McCormick, Steffie Woolhandler, Anjali Bose-Kolanu, Antonio Germann, David H. Bor and David U. Himmelstein
Journal of General Internal Medicine
April 2009

We asked respondents (physicians engaged in direct patient care) to choose the single option they preferred: 1) “The current health care system, in which most people get their health insurance from private employers, but some people have no insurance”; 2) “A universal insurance program in which everybody is covered under a program like Medicare that is run by government and financed by taxpayers”; or 3) “The current health care system, with the addition of new tax credits for buying, or tax penalties for failing to buy, health insurance”.

9% – The Current Health Care System

42% – Single-Payer National Health Insurance Program

49% – The Current System With Addition of Tax Credits or Penalties

Conclusions: The vast majority of physicians surveyed supported a change in the health care financing system. While a plurality support the use of financial incentives, a substantial proportion support single payer national health insurance. These findings challenge the perception that fundamental restructuring of the U.S. health care financing system receives little acceptance by physicians.

http://www.springerlink.com/content/g6m4153528pq2712/fulltext.html

Comment:

By Don McCanne, MD

This study supports the findings of other surveys that confirm that almost all physicians want reform of our current health care system, but they remain divided over whether or not we should replace the private insurance system with a government-run, taxpayer-financed program.

One interesting subset of this study suggests an answer to the question as to whether or not the AMA supports single payer reform. Although official positions of the AMA are decided by their House of Delegates, this survey helps us determine if the views of AMA members are different from a cross-section of practicing physicians. AMA members support the current system with the addition of tax credits or penalties over single payer by a ratio of 55 to 36. Physicians who are not AMA members are evenly divided with a ratio of 46 to 45.

When the physicians were asked if they agreed that people without health insurance have access to the medical care they need, single payer supporters disagreed at a ratio of 5 to 1. Supporters of the current system with added tax credits/penalties were more evenly divided. There is a fundamental difference, even if with fuzzy divisions.

Please forgive me for a moment of introspection, which seems apropos here. When I retired from practice and set up my home office to work on health care reform, I put all of my framed certificates, awards and other documents in a box in the garage, except for one that I received on graduation from medical school: The Oath of Hippocrates. My desk faces it. Frankly, much of the rhetoric doesn’t particularly resonate with me. I mean… pessary for abortion? … mischief and corruption? … seduction of females, males and slaves?

But there are two lines in the Oath that I hold sacred:

“I will follow that system of regimen which, according to my ability and judgement, I consider for the benefit of my patients, and abstain from whatever is deleterious and mischievous.”

“With purity and holiness I will pass my life and practice my art.”

I have been very thankful for having had the opportunity to have known and worked with physicians who share these values – roughly one-half of the physicians whom I’ve met through the years. And the single payer supporters in PNHP with whom I continue to work? All of them, 100 percent, understand the sanctity of the healing arts. That’s what we’re all about.

Single payer pushed

By DANIEL BARLOW
Times Argus
April 2, 2009

MONTPELIER — When Ariel Zevon opened up her Barre business two years, she wanted to offer good health care to her employees. They signed up for a plan under the state’s largest health insurance company.

That lasted about a month.

“As a business, we couldn’t float it,” said Zevon, the owner of the Local Agricultural Community Exchange, know as LACE. “It was completely unattainable for our family and our employees.”

Nearly 100 Vermonters attended a Statehouse rally Wednesday morning to draw attention to an issue that has seen little discussion this year: Reforming health care. Major reforms to the industry have been pushed aside this year as lawmakers grapple with holes in the state budget.

Dr. Deb Richter of Montpelier said the session was held to draw attention to two bills — S.88 and H.100, both of which would establish a single-payer health care system in Vermont — that have not been debated in this legislative session.

“There have been no formal hearings on these bills, so we decided to hold one,” Richter said.

Russ Bennett, the owner of a design and construction company in Waitsfield, told the crowd that health insurance costs make up about 10 percent of his payroll. He wants to offer insurance to all his employees, but doing so puts him at a competitive disadvantage in bidding for work.

He said health care should not be coupled with employment.

“If you crash your car into a tree, the insurance company pays for it,” Bennett said. “But I have different policies for my eyes and teeth … as if they all weren’t connected to the same body.”

Rep. Mary Hooper, D-Montpelier, who also serves as the city’s mayor, said officials in City Hall have been grappling with health insurance cost increases. Over the last seven years, the city’s health insurance costs have increased 94 percent, she said.

The city’s payroll includes $1.2 million annually for employee health insurance, she said. And as costs went up again this year, the city cut five jobs to continue paying for the health insurance plans.

“Don’t talk to me about the potholes,” Hooper said. “We’re fixing them, but not the way we should be. The cost of health insurance is wiping everything else out. We shouldn’t have to make the choice between city services and providing health care.”

Senate President Pro Tem Peter Shumlin, D-Windham, a supporter of a single-payer health care system, told the crowd Wednesday morning that he is hopeful that the new administration of President Obama will make dramatic reforms to the health care system.

If that effort falls short — which Shumlin said would be because of the strong influence of money from reform opponents in Washington, D.C. — states such as Vermont can step in and experiment with new models, which if proven effective, could be implemented across the country.

“It’s clear that we need to move away from an employer-based health care system to one that mirrors what every other developed country in the world has,” Shumlin said.

Shumlin praised a federal bill introduced earlier this week by U.S. Sen. Bernard Sanders, I-Vt., that would establish a universal, single-payer health care system.

“This bill provides every citizen with health care coverage and services through a state-administered, single payer program,” explained Sanders’ spokesperson Will Wiquist.

Ben Graham, the owner of Plainfield’s Natural Design and Build, said he also has been unable to find affordable insurance. He worries that if the state waits for the Obama administration, it may be waiting too long.

“Sen. Shumlin says maybe in the next decade,” Graham said. “That makes me nervous. We need change now.”

Rep. Francis “Topper” McFaun, R-Barre Town, received a standing ovation from the crowd Wednesday. He teamed up with Richter last year to push a bill that would make hospital care in Vermont free. He said he was kicked off the House Health Care Committee this year for sponsoring that bill.

He said the only way to create the political atmosphere to pass a single-payer health care bill is for supporters to lobby their legislators.

“That’s the only way you’ll get this done,” McFaun said. “You’ve got to get, not in my face, but in my heart. That’s how you will change things.”

Contact Daniel Barlow at Daniel.Barlow@timesargus.com.

Health forum hears from uninsured

By Mark Binker
Greensboro News & Record
Wednesday, April 1, 2009

GREENSBORO — When she lost her job a decade ago, Kirby Heard joined the N.C. Farm Bureau so she could get health insurance. But when one of her payments arrived late, her coverage was terminated.

That, the High Point graphic designer told the Regional White House Forum on Health Care Reform on Tuesday, was when she joined the growing ranks of uninsured. Between 750 and 1,000 people attended the forum at the N.C. A&T Alumni Foundation Event Center on Benbow Road.

The event was one of five regional health reform forums that the White House says will build on a national gathering in Washington earlier this year.

Since losing her insurance, Heard, 52, said she has gotten treatment from a community care network, a group of local health providers that tries to coordinate medical care for people without insurance. Gov. Bev Perdue, who moderated the event, praised those networks as something the federal government should help expand.

“If you need a specialist, they can’t cover that,” Heard said, adding she was grateful for the care she could get. “I have a lot of achy-painy kind of things that are specialist oriented and I have learned to live with them. … I’ve been on a waiting list to see a dentist after losing a filling for eight months now.”

Also on hand Tuesday was Nancy-Ann DeParle, director of the White House Office for Health Reform. She told the audience that President Barack Obama has set two main health care goals: lowering the cost of services and making sure that everyone has some sort of health insurance coverage.

DeParle and Perdue called on people who had been pre-selected to tell their stories as well as people in the audience such as Heard who raised their hands.

Obama addressed the gathering by video.

“Through your own experience, you know what works, what doesn’t,” Obama said in the message. “I look forward to hearing your ideas.”

After the forum, DeParle said the federal government was in the “sausage-making process” of trying to craft a new national health care strategy, a task that has befuddled presidents going back more than a century.

When asked how forums such as Tuesday’s would play into that crafting, DeParle said it was important for the administration to see different ways states are helping to provide health coverage to those without.

“The personal stories are really something you take back,” she said, recalling Heard’s story as something that would stick with her. “You don’t lose that story, so it makes you understand the problem better. … On the good side, I heard more first-hand and saw more first-hand about the community care network and how that is working.”

As participants made their way to the forum, about a dozen protesters waved signs and chanted slogans in favor of a single-payer health care system, one that would be run by the federal government.

“Because the people say so, insurance companies got to go,” protester Marcia Everett, 46, yelled into a bullhorn.

“We are trying to encourage them to take a serious look at single payer,” Everett said. Advocates for that viewpoint felt they were initially excluded from the first White House forum and still say it’s an option the Obama administration should consider more closely.

“Single payer is the only way we can provide health care for everyone and save money,” said Jonathan Kotch, who heads Health Care for All N.C.

That viewpoint had sympathy inside the forum, and at least one presenter explicitly made the point. In the audience, Albertina McGirt said she wasn’t sure single-payer was the way to go but said something needed to be done.

A breast cancer survivor who describes herself as fiftyish, McGirt said she had health insurance when she got ill. But she still had to pay 20 percent of what it cost to beat back her disease.

“That 20 percent was monumental. After treatment, I was teetering,” she said. “Instead of being poor I was just ‘po.’ ”

McGirt said she hoped changes could be made to help people avoid those kind of financial trials.

“Whatever we do, we need to approach it carefully,” she said. “You must talk to those people who are in it, who have been affected by it.”

Contact Mark Binker at (919) 832-5549 or mark.binker@news-record.com

Media Advisory: Single-payer supporters to rally at April 6 health forum in Los Angeles

Physicians, nurses and health reform advocates to urge enactment of an improved ‘Medicare for All,’ decry outsized influence of corporate medicine in health reform debate

FOR IMMEDIATE RELEASE
April 2, 2009

Contacts:
John Shearer, M.D.
Roberto Ramos, California Physicians’ Alliance, (510) 665-8523
Mark Almberg, Physicians for a National Health Program, (312) 782-6006, cell: (312) 622-0996, mark@pnhp.org

What

Press conference and rally to express support for single-payer national health insurance and to protest the “marginalization of majority opinion” at Monday’s White House Forum on Health Care Reform at the California Endowment, 1000 North Alameda St., Los Angeles, at 9 a.m. PDT.

The health forum will be hosted by California Gov. Arnold Schwarzenegger and Washington Gov. Christine Gregoire. Senior White House policy officials will also participate and help moderate a discussion involving diverse stakeholders in health care reform, according to the Obama administration. People in San Diego, Clovis and Oakland will also participate in the Los Angeles event via satellite.

Advocates of single-payer national health insurance, sometimes called an improved “Medicare for All,” will be inside and outside, urging that single payer be “on the table” as a full-fledged option for reform. They will also decry the outsized role of the private health insurance industry, Big Pharma and other representatives of corporate medicine at the forum.

Physicians wearing their white coats, nurses in their scrubs, and other health reform advocates will assert that national health insurance is being accorded a minor, marginalized role at the forum, even though surveys show two-thirds of Americans and 59 percent of U.S. physicians support it.

They will demand that the single-payer model be given pride of place in the health care debate in view of that model’s effectiveness in providing universal, comprehensive care; its ability to contain costs; and the fact that the annual savings in administrative costs — $400 billion — would mean that a U.S. single-payer system would require no increase in overall health spending.

The pro-single-payer rally is co-sponsored by the California Physicians’ Alliance, the state chapter of Physicians for a National Health Program (PNHP); the California Nurses Association/NNOC; the California School Employee Association; Health Care for All — California; California Student Health Professional Alliance for Universal Health Care; the Labor Task Force for Universal Healthcare; Singlepayer Now; Progressive Democrats of America; and Healthcare-Now; among others.

Who

Stephen Tarzynski, M.D., pediatrician, Los Angeles
Parker Duncan, California Student Health Professional Alliance for Universal Health Care (CaSHPA)
Speakers from other sponsoring organizations.

When

9 a.m. PDT, Monday, April 6

Where

California Endowment, 1000 North Alameda St., Los Angeles

Why

Dr. Stephen Tarzynski: “Physicians are sick and tired of jumping over barriers to caring for our patients created by for-profit insurance companies. They really have no meaningful role in medical care. All we need to take care of people is the doctors, the hospitals, and one publicly funded, fair and speedy payment system where doctors have a powerful voice.”

The California Physicians’ Alliance (http://www.capa.pnhp.org/) is the California chapter of Physicians for a National Health Program (www.pnhp.org), a membership organization of over 16,000 physicians, supports a single-payer national health insurance program. PNHP is headquartered in Chicago and has chapters across the United States. To contact a physician-spokesperson in your area, contact info@pnhp.org or call (312) 782-6006.

FRONTLINE’s “Sick Around America”

Sick Around America

FRONTLINE
March 31, 2009

Investigating the stories of Americans whose lives have become a quest to find and keep health insurance…

Join the Discussion

Dear FRONTLINE,

I am disappointed that this long-awaited special on healthcare did not address the single payer option. There were ample interviews with insurance company lobbyists but no discussion of this obvious choice. Our nation’s people are in crisis and the shameful greed displayed in other industries is replicated in the for profit hospital corporations, insurance companies and pharmceutical industries. We cannot afford profit in healthcare, as we will continue to have a chaotic, threadbare system riddled with donut holes and pitfalls for those who can least navigate: patients and their families. I’d like to see equal time — a Frontline on the single payer option.

Grace Gifford
Conway, SC

FRONTLINE’s editors respond:

Many viewers have written criticizing this report for not looking at solutions, in particular, a single payer system. Certainly, the topic is another important piece of any examination into the health care system and how it can be improved. And it would warrant a separate program of its own. We would like to point out that we did examine how the single payer system works in many European countries in our program last season, Sick Around the World. You can view this online.We believe that our report this week, Sick Around America, was equally of value in focusing on our current private health insurance system and showing how many Americans are only one or two events away from financial disaster or total ruin because they can’t afford this insurance, or because it offers inadequate coverage, or because it suddenly can be rescinded by the insurer for alleged omissions or errors. We also felt it important in this report to look at another major problem with the private insurance system: America’s for-profit medical system means that insurers have a fiscal duty to avoid risk and make profits for investors. Thus, insuring people who already have serious, chronic illnesses works against the interests of stockholders.

FRONTLINE: Sick Around America
http://www.pbs.org/wgbh/pages/frontline/sickaroundamerica/

Join the Discussion
http://www.pbs.org/wgbh/pages/frontline/sickaroundamerica/talk/

PNHP: “‘Sick Around America’ disappoints” – selected responses
https://www.pnhp.org/blog/2009/04/01/‘sick-around-america’-disappoints/

Columbia Journalism Review: “Sick Around America” by Trudy Lieberman
http://www.cjr.org/campaign_desk/sick_around_america.php?page=all

Comment:

By Don McCanne, MD

T.R. Reid had hosted FRONTLINE’s “Sick Around the World,” an important documentary describing successful health programs in several other nations that provide care for everyone at a fraction of the costs of our fragmented, inefficient health care system that leaves so many out.

We were looking forward to T.R. Reid’s sequel, “Sick Around America,” describing the problems with our private insurance system. Many of us were disappointed with the format of the program, believing that they missed a great opportunity to educate the nation on several health policies that would work well for all of us. Thus it was no surprise to us that T.R. Reid was not mentioned during the program, nor in the credits.

What happened? Reid left the show this February in a dispute with FRONTLINE. Trudy Lieberman of Columbia Journalism Review quotes Reid as saying, “When I saw it, I didn’t agree with it. It took a different view of health policy than I have.”

The program did use anecdotes effectively, demonstrating some of the problems with private insurance. Examples included medical underwriting, rescission, lapses in coverage, financial burdens due to underinsurance, and other deficiencies that most Americans now understand.

Watching this program, it is very clear that change is required. But the message for reform was outrageous. Throughout the program, many executives of the private insurance industry were featured, and they confirmed that these deficiencies were very real and needed to be addressed. That’s good. What was outrageous is that they were in no way contrite, but instead they implied that they would provide the leadership to make sure that private insurance will continue to manage the financing for health care in America, beginning with an individual mandate for every American to buy their lousy products.

We can only speculate on the motives of the producers. My opinion is that they wanted to provide support for the current efforts of the Democrats in Congress and in The White House to build reform based on private health plans. A publicly-administered and publicly-financed program would require a total restart on the reform process, and so it wasn’t offered as a potential solution. In deference to the insurance executives, the producers didn’t even promote a public Medicare-like option.

Remember, these insurance executives are not contrite. They can never provide the moral leadership that we need to create a health care system that serves all of us well.

What’s Race Got to Do with It?

A startling new analysis of the difference between Canadian and U.S. healthcare funding

By Gregory P. Marchildon
Literary Review of Canada, April 2009

BOOK REVIEW

“National Health Insurance in the United States and Canada: Race, Territory and the Roots of Difference”

By Gerard W. Boychuk
Georgetown University Press, 234 pages, softcover

The word “race” divides us ­– primarily according to skin colour and secondarily according to ethnicity. While the concept of race lacks a biological basis, categorization by race continues to shape relations within societies, particularly in those countries where slavery was a central institution for centuries or where settlement involved the displacement of large numbers of indigenous peoples. For example, because of the legacy of slavery, the racial division between African Americans and white Americans is the single most important theme in the national narrative of the United States. In his famous speech on race in March 2008 in Philadelphia, Barack Obama said it was time for America to confront the accumulated anger, resentments, stereotypes and distortions in order to get beyond the race divide. Only then, he said, would it be possible to fix the most broken parts of American public policy, including health care.

I suspect that this connection between race and healthcare policy must seem a little peculiar to most Canadians. In his new book, National Health Insurance in the United States and Canada: Race, Territory and the Roots of Difference, Gerard Boychuk, a political science professor at the University of Waterloo, explains why the politics of race prevented the introduction of universal health care in the United States. He also introduces a bold new hypothesis as to why Canada did the opposite. Boychuk’s surprising explanation for the introduction of universal health care in Canada, while not rooted in race, is nonetheless based on the politics of identity and the competition between the federal government and the provinces (particularly Quebec) for the hearts and minds of its citizens.

The different paths taken by the two countries have fascinated and perplexed commentators and social scientists on both sides of the 49th parallel for decades, particularly given the fact that the two countries once had congruent health systems. However, after universal hospitalization was implemented in Canada in the late 1950s and universal medical care insurance in the 1960s, two things changed.[1] First, access to health care (or at least that portion deemed medically necessary) would now be based on need rather than ability to pay. Second, payment for such services would now be administered through provincial and territorial single-payer systems, thereby avoiding the overhead associated with private health insurance carriers and their need to assess risk, calculate premiums and administer claims.

As a consequence of this change, Canadians increasingly perceived health care as a collective right rather than an individual benefit, a social service rather than a commodity to be bought and sold on the marketplace. This policy divergence produced a different way of viewing the world, a difference reflected in everyday language—health care is generally described as an industry by Americans and as social policy by Canadians. However, the consequences of this policy divergence go beyond the philosophic. Before medicare, Canadians spent almost as much as Americans on health care. After medicare, Canadians began to spend less than Americans on both private and public health care thanks in part to the cost control exerted by single-payer administration in Canada and the escalating cost of public and private health care insured by private insurance carriers in the United States. Today, we spend less than one half of what Americans spend on private and public health care combined. Even when it comes to public health care alone, we spend less per capita, prompting some to ask why American taxpayers pay for European-style universality but get only partial coverage in return.

In the United States, opposition to universality went well beyond an ideological preference for the market and hostility to the state. As Boychuk shows, the more deep-rooted issue was the threat posed by health reform proposals to segregated health services. Southern congressional representatives, the majority of whom were Democrats, were viscerally opposed to reforms that might have required white people to be treated in hospitals, nursing homes and medical clinics alongside black patients. Segregationist sentiment was also a pronounced feature of organized labour, and the unions worked with conservative Democrats as well as the most vocal opponent of universal health care, organized medicine. The American Medical Association was itself a segregated organization and opposed universal public health care for racial as well as political and economic reasons in the 1940s and ’50s.

It was only after the Civil Rights Act of 1964 forced the desegregation of all public programs funded by the American government that the racial objections to universality receded and the political and economic objections to universality and government intervention took priority. One year later, a three-layer policy cake had been baked by Lyndon B. Johnson, assisted by Democrats and Republicans in Congress. The first layer, part A of Medicare, was designed to please Democrats. It involved extending federal social security (first introduced by Franklin D. Roosevelt in the 1940s) as health insurance for contributing seniors. Republicans endorsed the second layer, part B, which introduced government-subsidized private insurance for physician care. The final layer was Medicaid, covering the poor as well as seniors who had not made sufficient social security contributions to qualify for Medicare. It was understood by all that these three layers were to supplement, not replace, employment-based private health coverage, which Democrats and Republicans, industry and labour, still viewed as the core of American health care.

Of course, this bipartisan policy did not, and could not, deliver universality. Instead, it further entrenched a system of entitlements based on employment, age and income—an old-fashioned passenger ship with clearly demarcated classes, to introduce a different metaphor. In first class, you have Medicare and comprehensive private health insurance. In second class, you have Medicaid and private health insurance plans with less than comprehensive coverage. In steerage, you have the chronically underinsured, while those without any coverage—the working poor without private insurance and seniors without Medicare benefits—are always under threat of being thrown overboard. In eschewing universality, the U.S. displayed its exceptionalism, at least relative to the majority of wealthy nations in Europe, Australasia and Canada that have adopted some form of universal health care.

Aside from the lack of universality, the downside of the three-layer policy is the inability of federal and state governments to control the cost of Medicare and Medicaid, a constant thorn in the side of the American body politic. This generates a perpetual crisis. As private health insurance costs rise, companies cut or eliminate their employee health insurance benefits. As Americans lose benefits, they depend more heavily on the public safety net, but the more they rely on public benefits, the higher public costs grow. Not surprisingly, Americans regularly call upon their elected officials to address this recurring crisis in health care. In 1993, in response to public outcry, Bill Clinton told Congress that “this health care system of ours is badly broken, and it is time to fix it” only to see his administration’s efforts go down to spectacular defeat.

As Barack Obama begins his presidency, expectations are high that health care will finally be repaired if not reformed. This is so despite an eco
nomic crisis that is beginning to bear a striking resemblance to the Great Depression. If 50 percent of all personal bankruptcies in more prosperous times were a consequence of the inability to pay medical bills, just imagine the situation that faces the working poor, many of whom are African American, in the next two years. Obama is also aware that 95 percent of African Americans voted for him hoping for some improvement in their lives, including the constant worry whether the next hospital visit will push them into welfare and poverty.

In contrast, health care in Canada seems less of an issue in these hard economic times in large part because medicare has eradicated the spectre of medical bankruptcy. I would go even further than Boychuk in arguing that national medicare was an inspired act of nation building, and in this sense was much more than a reaction to province building—but I am almost sure that this is a view of history not shared by Stephen Harper and most members of his government today in Ottawa. Nation building is what Boychuk calls territorial integration, a term he borrows from Canadian social policy scholar Keith Banting, from whom he quotes:

Social programs controlled by the central government can become instruments of nation-building, helping to mediate regional tensions and strengthen the state against centrifugal forces rooted in territorial politics. Alternatively, social programs designed and controlled at the regional level can become instruments for strengthening regional cultures and enhancing the significance of local communities in the lives of citizens, thereby reinforcing differentiation and centrifugal tendencies at the centre.

In other words, in response to the secessionist forces within Quebec as well as the expansionist tendencies of nationalist Quebec governments, the federal government inserted itself into healthcare policy in order to “create a direct connection” with Quebec residents and “foster a sense of attachment between them and the national polity.” Boychuk argues that the federal government’s desire to exert a degree of territorial integrity is a better explanation for why Canada differs in its healthcare policy from the United States than the more commonly offered alternatives. One of these alternatives is the different ideology and values of the two countries, what Boychuk calls political culture. We can see this in terms of the social democratic ideology that led Tommy Douglas’s government in Saskatchewan to pioneer medicare, as well as the Red Tory influences in the old Progressive Conservative Party that allowed its members eventually to go along with medicare, however grudgingly. Another explanation is that Canada’s political institutions facilitated the adoption of universal health care while America’s diffused checks-and-balances structure prevented (and may continue to prevent) a similar reform. The fusion of the legislative and executive in Canada allows for majority governments to make major policy changes without compromise while a decentralized federation permits major experiments in areas of provincial jurisdiction, thus Saskatchewan’s innovations in hospitalization and medical care insurance could easily be adopted in other provinces with the encouragement of cost-share financing by the federal government.

A third common explanation is “path dependency” and its accompanying notion that timing is everything in public policy. Policy pathways are notoriously difficult to break from, in large part because of the financial, intellectual and ideological capital invested by individuals, organizations and institutions in the status quo. As difficult as it is, however, there are moments—critical junctures—when dissatisfaction with the status quo is powerful enough, or when the investments have not yet triggered a “lock-in” of the policy status quo, when change becomes possible. These windows of opportunity are rare. If not taken advantage of, policy change may be permanently blocked. Saskatchewan, for example, introduced universal hospital and medical care before private health insurance covered the majority of the population, although the same argument seems to fall flat for most urbanized provinces, such as Ontario, that had quite high rates of public coverage before medicare was introduced.

In the United States, the window of opportunity was 1965, but legislators chose incremental improvements over universality, making major change in the future even more difficult. As Jacob Hacker explained about American health care in the New England Journal of Medicine, the sad truth is that “most Americans—even the underinsured and soon-to-be-insured, the potentially uninsurable and the one-illness-from-bankrupt—can be frightened into believing that changing this entrenched and inadequate system means paying more for less.” While race may not seem relevant to this explanation, the fact is that a disproportionate number of the underinsured and uninsured are African Americans. They have the most to lose in this economic downturn and therefore are the most at risk from medical bankruptcy. They have the most to lose if President Obama and Congress do not finally fix the healthcare mess, but some, as Hacker identified in 2007, may object to any major change to the status quo for fear of losing what little they have under the current system.

Returning to Canada, I must admit that I still find aspects of the path dependency explanation more compelling than Boychuk’s argument concerning territorial integrity. In the second half of the 1950s, the Duplessis government in Quebec was opposed to government involvement in health care, so it hardly seems logical that the St. Laurent and Diefenbaker governments would have been attempting to steal a march by establishing a connection with Quebec residents through universal hospitalization. The argument holds a little more water in the 1960s during the Quiet Revolution in Quebec, but even here it seems to me that Boychuk has not made the case. In fact, it seems that successive nationalist governments in Quebec were only too willing to accept federal principles in return for tax room and cash for universal medical care.

It is possible to reject Boychuk’s argument yet accept his conclusion that the policy has become linked with national identity because health care has become one of the key differences between the two countries. This may be for a variety of reasons, including the very simple fact that in terms of ideology, Canada continues to be influenced by a set of social democratic values that are very much in the minority south of the border, although it remains to be seen whether Obama’s election marks a move toward more liberal communitarian values. Still, a more collectivist approach to health care in the U.S. seems to fly in the face of the more highly individualistic ethos that underpins both major political parties as well as civil society. On the other hand, the American emphasis on individual rights combined with the legacy of the civil rights movement may lead to health care being declared a fundamental right by the courts. This would strengthen the hand of those political leaders who feel that it is time, finally, for all Americans to have universal access to essential health care. Race once prevented this from occurring, and now, the intersection of race and rights may allow it to happen. As Roosevelt demonstrated during the Great Depression, a crisis can actually provide the opportunity for a new policy direction, if not a new social contract.

ENDNOTE

1. Although the word “medicare” in Canada was originally a contraction of “medical care insurance,” it soon became shorthand for both universal hospital and medical (physican) care coverage. It should not be confused with American “Medicare,” which is not universal.

Gregory P. Marchildon is the former executive director of the Romanow Commission, the Canada Research Chair at the Johnson-Shoyama Graduate School of Public Policy at University of Regina and a member of the Health Evi
dence Network of Canada.

What’s Race Got to Do with It?

Views on IRAs and HSAs contrast sharply

Not the Next IRA: How Health Savings Accounts Shape Public Opinion

By Jason Barabas
Journal of Health Politics, Policy and Law
April 2009
This study has documented policy feedback effects of a personal nature. The central finding is that policy feedback effects occur, but they can be domain specific. That is, participation in investment accounts for retirement or health do not lead to uniformly conservative or liberal policy opinions. As expected, IRA owners tend to favor Social Security privatization, but that does not mean that investing always or unequivocally engenders support for investment account-based policy solutions. Participation in HSAs reduces public support for health care privatization. In particular, HSA owners, owing to their wildly different programmatic experiences, are much less likely to endorse individualized health care coverage. Thus, HSAs and related forms of consumer-driven health plans are not automatically designed to become “the next IRA.” The irony is that dissatisfaction with HSAs is greatest among those who have them.
http://jhppl.dukejournals.org/cgi/content/abstract/34/2/181

Much has already been written about the wisdom, or lack thereof, of health savings accounts (HSAs) and the high-deductible health plans that are linked with them. By design, they benefit higher-income individuals who are able to take advantage of the regressive tax policies, and who remain healthy, allowing the savings to accumulate for use in their retirement years. But they don’t work for individuals with modest incomes who have significant health care needs.
You would think that HSAs would be dismissed from the current dialogue on reform, but no. Our politicians are struggling with how to pay for comprehensive reform. One goal is to reduce spending on insurance premiums, and that makes lower-cost, high-deductible plans more attractive to those attempting to make reform cost-neutral, for the government, that is.
As Congress plays games with the budgeting of health care reform, it is imperative that they understand that the “dissatisfaction with HSAs is greatest among those who have them,” whether conservative or liberal.
It is hoped that soon Congress will give up looking for magical solutions to pay for health care for everyone, and get serious about a solution that actually would work – a single payer national health program.

Views on IRAs and HSAs contrast sharply

Not the Next IRA: How Health Savings Accounts Shape Public Opinion

By Jason Barabas
Journal of Health Politics, Policy and Law
April 2009

This study has documented policy feedback effects of a personal nature. The central finding is that policy feedback effects occur, but they can be domain specific. That is, participation in investment accounts for retirement or health do not lead to uniformly conservative or liberal policy opinions. As expected, IRA owners tend to favor Social Security privatization, but that does not mean that investing always or unequivocally engenders support for investment account-based policy solutions. Participation in HSAs reduces public support for health care privatization. In particular, HSA owners, owing to their wildly different programmatic experiences, are much less likely to endorse individualized health care coverage. Thus, HSAs and related forms of consumer-driven health plans are not automatically designed to become “the next IRA.” The irony is that dissatisfaction with HSAs is greatest among those who have them.

http://jhppl.dukejournals.org/cgi/content/abstract/34/2/181

Comment:

By Don McCanne, MD

Much has already been written about the wisdom, or lack thereof, of health savings accounts (HSAs) and the high-deductible health plans that are linked with them. By design, they benefit higher-income individuals who are able to take advantage of the regressive tax policies, and who remain healthy, allowing the savings to accumulate for use in their retirement years. But they don’t work for individuals with modest incomes who have significant health care needs.

You would think that HSAs would be dismissed from the current dialogue on reform, but no. Our politicians are struggling with how to pay for comprehensive reform. One goal is to reduce spending on insurance premiums, and that makes lower-cost, high-deductible plans more attractive to those attempting to make reform cost-neutral, for the government, that is.

As Congress plays games with the budgeting of health care reform, it is imperative that they understand that the “dissatisfaction with HSAs is greatest among those who have them,” whether conservative or liberal.

It is hoped that soon Congress will give up looking for magical solutions to pay for health care for everyone, and get serious about a solution that actually would work – a single payer national health program.

Insurers waste your dollars to invade your privacy and cheat you

Insurers shun those taking certain meds

How health insurers secretly blacklist those with certain ailments.

By John Dorschner
The Miami Herald
March 28, 2009
Some insurers will automatically reject applicants who are using certain prescription drugs.
The medications, of course, are indications of specific health problems. To make sure that applicants are not lying, insurers hire a data-gathering service — Medical Information Bureau, Milliman’s Intelliscript or Ingenix Medpoint.
Intelliscript and Medpoint do computerized searches of a person’s drug use, gleaned from pharmacy benefits managers and other databases. The two companies say they comply with privacy laws. “Ingenix requires each Medpoint client to obtain the authorization of the individual applicant or insured person,” said Ingenix spokeswoman Karin Olson.
http://www.miamiherald.com/living/health/costs/story/973158.html

The health care financing systems in other nations are designed to assist patients in paying for their health care. Computerized searches of personal drug use as described in this article is yet one more example of how our private insurance industry adopts policies that are designed to avoid paying for the patients’ health care.
It is no surprise that UnitedHealth’s Ingenix is a player in this scheme to protect the insurers’ finances to the detriment of patients. They recently reached a settlement for cheating patients and physicians through another scheme to underpay for legitimate services, again protecting the insurers finances.
There are two issues here, about which we should all be concerned. First is that this is still another example of health care costs that are wasted on excessive administrative services. It is particularly egregious that these services, for which we are the payers, are detrimental rather than beneficial for the patients. That’s the opposite of what we should expect from our health care financing system.
The second concern is perhaps more ominous. Right now Congress and the administration are pushing the expansion of information technology (IT) systems when it is not at all clear that privacy and confidentiality issues are being adequately addressed. Pharmacy benefit managers (PBMs) are already using IT systems, and look at what is happening. Private insurers are doing computerized searches of your personal drug use gleaned from the PBM databases. Not only are they invading your privacy, but the intent is to defeat the purpose of insurance by denying you coverage.
Intelliscript (Milliman) and Medpoint (Ingenix/UnitedHealth) say that they comply with privacy laws, yet how many people in this gigantic private administrative bureaucracy have access to your personal information? The Fair Credit Reporting Act requires the companies to let you see your personal information if you so request, and how many more administrators are there to peek at your private records as the information is transmitted back to you? Merely passing laws against invasion of medical privacy is not enough. If invading your privacy in an IT system can be done, it will be done.
Isn’t there a theme here? We pay a whole lot of extra money to a private health care financing industry that uses our funds to cheat us out of the health care that we should have. And Congress and the administration are calling for an expansion of this very sick system of financing health care?
Congress should have the common sense, integrity, and decency to jettison the private insurance industry and provide us with our own public health care financing system that would save us money so it could be used where we want it to be used – on our health care. What is so difficult about this concept?

Insurers waste your dollars to invade your privacy and cheat you

Insurers shun those taking certain meds

How health insurers secretly blacklist those with certain ailments.

By John Dorschner
The Miami Herald
March 28, 2009

Some insurers will automatically reject applicants who are using certain prescription drugs.

The medications, of course, are indications of specific health problems. To make sure that applicants are not lying, insurers hire a data-gathering service — Medical Information Bureau, Milliman’s Intelliscript or Ingenix Medpoint.

Intelliscript and Medpoint do computerized searches of a person’s drug use, gleaned from pharmacy benefits managers and other databases. The two companies say they comply with privacy laws. “Ingenix requires each Medpoint client to obtain the authorization of the individual applicant or insured person,” said Ingenix spokeswoman Karin Olson.

http://www.miamiherald.com/living/health/costs/story/973158.html

Comment:

By Don McCanne, MD

The health care financing systems in other nations are designed to assist patients in paying for their health care. Computerized searches of personal drug use as described in this article is yet one more example of how our private insurance industry adopts policies that are designed to avoid paying for the patients’ health care.

It is no surprise that UnitedHealth’s Ingenix is a player in this scheme to protect the insurers’ finances to the detriment of patients. They recently reached a settlement for cheating patients and physicians through another scheme to underpay for legitimate services, again protecting the insurers finances.

There are two issues here, about which we should all be concerned. First is that this is still another example of health care costs that are wasted on excessive administrative services. It is particularly egregious that these services, for which we are the payers, are detrimental rather than beneficial for the patients. That’s the opposite of what we should expect from our health care financing system.

The second concern is perhaps more ominous. Right now Congress and the administration are pushing the expansion of information technology (IT) systems when it is not at all clear that privacy and confidentiality issues are being adequately addressed. Pharmacy benefit managers (PBMs) are already using IT systems, and look at what is happening. Private insurers are doing computerized searches of your personal drug use gleaned from the PBM databases. Not only are they invading your privacy, but the intent is to defeat the purpose of insurance by denying you coverage.

Intelliscript (Milliman) and Medpoint (Ingenix/UnitedHealth) say that they comply with privacy laws, yet how many people in this gigantic private administrative bureaucracy have access to your personal information? The Fair Credit Reporting Act requires the companies to let you see your personal information if you so request, and how many more administrators are there to peek at your private records as the information is transmitted back to you? Merely passing laws against invasion of medical privacy is not enough. If invading your privacy in an IT system can be done, it will be done.

Isn’t there a theme here? We pay a whole lot of extra money to a private health care financing industry that uses our funds to cheat us out of the health care that we should have. And Congress and the administration are calling for an expansion of this very sick system of financing health care?

Congress should have the common sense, integrity, and decency to jettison the private insurance industry and provide us with our own public health care financing system that would save us money so it could be used where we want it to be used – on our health care. What is so difficult about this concept?

The way forward on health care reform

By CORNELIUS HOGAN
Rutland Herald
Published: March 25, 2009

President Obama and Budget Director Peter Orzag are “on the money” in their views about controlling the cost of health care as the key to future health care access and quality, plus the role that controlling health care costs plays in our economic recovery. Without controlling cost, all changes and initiatives currently in motion and contemplated will not work and will quickly make things worse.

For example, in the two states of Massachusetts and Vermont, which were highlighted at the president’s health care forum at the University of Vermont on March 17, well-meaning programs and actions taken to date, are doomed to failure because they do not begin to address the cost issue.

In Vermont subsidizing health care has perhaps helped a very few people, but it is fiscally unsustainable in an environment where the cost of health care is rising at two to three times inflation. Nor will “disease management,” although good public policy, have an impact on controlling health care cost within our lifetime.

In Massachusetts, if it were not for the temporary and major largesse of the federal government, the mandate program would be dead in its tracks.

Both of these experiments, even though positioned as paradigms of progress, don’t come close to being remotely sustainable.

If we are to have even a chance at controlling the overall cost of health care, we need to put in place several basic practices, which at this point are not in evidence, or even being contemplated. They are: an integrated, enforceable budget (what other human enterprise doesn’t have one?); fair financing where we all contribute and all are in; health care planning based on the need of the population; and elimination of unnecessary and costly utilization review, benefit review, eligibility review, advertising, and the gross transaction costs of billing, collecting, generally chasing the money, much of it from people who cannot afford it.

Actions short of these will continue to promote uncontrolled cost rises (health care costs have doubled over the last eight years) which will result, at some point in the near future, in a collapse of our hospitals, physician practices, and other vital health care services. It will also result in pricing tens of thousands more Vermonters out of care. Federal bailouts won’t last forever.

Let us help our president control these costs. Put some bigger options, such as Medicare for all, hospital benefit for all, or even single-payer on the table. These broad-based approaches are our only chance at up-righting health care, which is now ever ripe for a collapse.

Cornelius Hogan was secretary of human services under Govs. Richard Snelling and Howard Dean. He was coauthor of “At the Crossroads: The Future of Health Care in Vermont.”