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Sen. Baucus wants CBO to be "creative"

Sen. Baucus wants CBO to be "creative"

Hearing: Scoring Health Care Reform: CBO's Budget Options

United States Senate Committee on Finance
February 25, 2009

Closing comments

Sen. Max Baucus, Chairman: Thank you very much, Dr. Elmendorf. We have a huge problem, haven’t we? This is the most difficult public policy undertaking I’ve experienced in my Senate life here. I’ve been here thirty years, and nothing is as difficult as this. Nothing is as important as this, and I cannot think of anything that depends so much on CBO, especially at a time we’re in new territory. We’re not in the old situation where Sen. Grassley once said whatever CBO says is God, you’re God. My judgement, you’re not God.

Douglas Elmendorf, CBO Director: Correct

Sen. Baucus: My judgement is that you got the whole new era – you might be Moses, but not God – but you got the whole new era… where as I said earlier it’s not too much of an overstatement to say CBO can make or break health care reform, and I mean that because we got to go by your numbers…

Dr. Elmendorf: Senator, may I respectfully disagree that…

Sen. Baucus: I do believe that there are several different intellectually honest pathways to get from here to there. It’s not just one automatic, and so it needs – you got to be ever more creative to find intellectually honest pathways to get the savings we have to have – practically and both politically – to get health care reform.

Dr. Elmendorf: Senator, I would like to just respectfully disagree with the make or break role that you have assigned to us. We will do our very best to provide you and all of the members of this committee and the rest of the members of the Congress with the technical information that you need, the best estimates that the knowledge of the world can provide about the effects of alternative policies, but, as you understand, the hard decisions will be yours.

Sen. Baucus: No, that’s incorrect. The hard decisions will be all ours, both of us, you and me. You can’t pass the buck. The hard decisions are here, and the hard decisions are yours and the hard decisions are all of us in this country in trying to make this work. Meeting’s adjourned.

Dr. Elmendorf: Thank you, Senator

http://finance.senate.gov/sitepages/hearing022509.htm

Video of hearing – click link of 2/25/09:
http://finance.senate.gov/sitepages/hearings.htm

Comment:

By Don McCanne, MD

In this closing exchange, Sen. Max Baucus seems to be annoyed with Douglas Elmendorf, Director of the Congressional Budget Office. What is the background here?

Sen. Baucus is determined to lead the way to comprehensive health care reform. His model is basically the Hacker/Obama/Kennedy/Daschle/Massachusetts/Commonwealth model which is based on expanding the use of regulated private health plans, while continuing to expand existing public programs.

To help Congress with its efforts on reform, CBO recently released two volumes on 1) issues on analyzing health insurance proposals, and 2) budget options for health care (both available at the CBO website www.cbo.gov). It is quite clear, based on these two reports and on the innumerable analyses in the health policy literature, that Baucus’s model would be scored by the CBO as outrageously expensive while falling far short on many of the important goals for health care reform.

The CBO is noted for its impartiality in providing Congress with intellectually honest evaluations of various Congressional proposals. From Sen. Baucus’s comments, it’s obvious that this constitutes a major barrier to his ambitions to enact reform along the lines of his model. Rather than an arm’s-length analysis, Sen. Baucus is demanding that Dr. Elmendorf shift from the role of an impartial analyst to the role of a policymaker by becoming “creative,” making the “hard decisions,” to “find intellectually honest pathways to get the savings we have to have.”

We can understand Sen. Baucus’s frustration in his inability to obtain a favorable analysis of his highly flawed, “wish-they-would-work” policies. But we can fault him for demanding that Dr. Elmendorf compromise his professional integrity by participating in the policy decisions over a fundamentally flawed framework of reform, and then applying to the final product his personal stamp of endorsement. That is not and must never be the role of the CBO Director.

This also partially explains why Sen. Baucus is becoming ever more strident in his demand that single payer be totally excluded from the dialogue on reform. Innumerable analyses, including some by the CBO, have shown that the single payer model actually would achieve our goal of affordable health care for everyone. Objective, side-by-side CBO analyses would destroy any chance of convincing Congress to enact Sen. Baucus’s model.

Since reform should be based on the best data available, isn’t such an analysis exactly what we should have right now? If Sen. Baucus is sincere in wanting reform that works for all of us, he should be the first one to request that CBO do that study.

DrSteveB also covers this well in his Daily Kos blog today:
http://www.dailykos.com/story/2009/3/2/7495/94300/238/703544

Single payer only route to Obama's grand vision on healthcare reform

by Chuck Idelson
California Nurses Association blog
February 26, 2009

Hours after President Obama’s speech to Congress in which he laid down a marker for achieving “comprehensive” healthcare reform, and getting it done this year, top administration aides have outlined the goals of what they want to achieve.

What Politico called “the 8 keys to his health plan,” certainly reflect a bold determination for action and a grand vision.

There’s only one problem. Virtually all the proposals being bandied about in various Congressional committees — and the administration made it clear this week they will let Congress figure out the details — fail to meet the test of those “8 keys.”

With one important exception — single payer reform, or expanding and updating Medicare to cover everyone.

So what are those lofty goals set by the administration?

Obama has endorsed eight guiding principles for health reform, the White House officials said on the conference call. They stressed that they intend to work with lawmakers and other stakeholders on how to accomplish the goals, but the principles will lay down a marker for any congressional plan.

Drum roll, please. A healthcare plan, they told reporters, should be:

* Universal, everybody in, nobody out

* Portable, not tied to your job, if you even have one

* Maintaining choice of doctor and insurance

* Ensuring affordable coverage

* Protecting Americans financial health

* Investing in prevention and wellness

* Improving patient safety and quality of care

* Fiscally responsible and sustainable

To the administration’s credit, these should be the benchmarks of any real reform. And to give them further props, the administration is even projecting progressive tax reform as a financing mechanism.

The combined effect of the two revenue-raising proposals, on top of Mr. ObamaĆ¢ā‚¬ā„¢s existing plan to roll back the Bush-era income tax reductions on households with income exceeding $250,000 a year, would be a pronounced move to redistribute wealth by reimposing a larger share of the tax burden on corporations and the most affluent taxpayers.

But on the construct of the plan itself, a huge barrier stands in the way. The present private insurance-based system is an implacable impediment to every one of these goals.

The insurance giants, of course, are not care providers. They are big corporations. They exist to make money, primarily to return profits for their shareholders. Every aspect of their operations are geared to that end.

Private insurance plans:

* Aren’t universal because they exclude people based on pre-existing conditions or age or anyone else they think will be expensive to cover.

* Don’t guarantee choice of physician or hospital, but limit you to their network of providers.

* Won’t assure affordability because they are constantly raising premiums, deductibles, co-pays, and other fees to generate high revenues and profits.

* Can’t guarantee safety and quality because they actively discourage the delivery of care or deny treatments, diagnoses, or referrals because they don’t want to pay for it.

* Will never be fiscally responsible because there is no independent oversight, decisions are made in secret in closed board rooms or CEO offices, and, again, their priority is profits.

Thus any plan which sustains, protects, or expands the role of the insurance industry in healthcare cannot, by definition, achieve any of these worthy aims.

One bill, however, does succeed in all eight areas. That is HR 676, the U.S. National Health Care Act by Rep. John Conyers, which also happens to be the one reform that has a broad, national grassroots constituency led by nurses, doctors, patients, and health care activists.

With the administration having laid our a vision, but deferred implementation to Congress, that should be a signal to all of us to put their feet to the fire and push for real reform, like HR 676.

Millions losing jobs will mean many without health care

By James E. Dalen
Arizona Republic
Feb. 28, 2009

Due to the recession, more than 2 million Americans lost their jobs in 2008 and millions more are expected to lose their jobs in 2009.

The consequences of increasing unemployment will be much more serious in the United States than in other western countries. Our country is unique in that most of its citizens, at least 175 million, have employment-based health insurance. In most cases, loss of job means loss of health insurance.

The situation is most serious for the employee who is the only breadwinner for his or her family. Private health insurance for family coverage may be available, but is very expensive, especially for someone who is out of work.

If the employee is older or, if anyone in the family has a “prior condition,” insurance may be unavailable or have an extraordinary price tag. COBRA, a federal program that allows one to continue their employment insurance is available but also is very expensive.

Some estimate that less than 25 percent of those losing their jobs will be covered by COBRA. Many unemployed families will turn to Medicaid to provide health care. Arizona and many other states are facing budget deficits because of the recession. It is very unlikely that they will be able to increase the number of their citizens covered by Medicaid (AHCCCS in Arizona).

What happens to those who are unable obtain alternative health insurance and remain uninsured?

Not much will happen to the young invincibles, those healthy Americans age 19 to 29. Many of them only seek health care in case of accidents. Few seek primary care, and very few require medications on a regular basis.

The outlook for the family without health insurance is very different. Multiple studies have shown the uninsured are much less likely to have regular medical care or to seek care for illness.

Ongoing preventive care becomes a luxury that the uninsured cannot afford. If they do seek care, they use emergency rooms. Our already overcrowded emergency rooms will become even more over burdened as the number of uninsured Americans increases.

The health consequences of being uninsured are most severe for the nearly half of our citizens who have a chronic condition such as hypertension, diabetes, asthma, cancer and heart disease. These conditions require ongoing medical care and usually require daily medications to prevent complications that may lead to hospitalization, disability or even death.

In a study of patients with chronic conditions, one third of the uninsured with chronic conditions had an unmet need for prescription drugs, compared with 10 percent of insured.

When Americans lose their jobs and their health insurance, their health will suffer. The Institute of Medicine has reported that the annual mortality of the uninsured is 25 percent higher than for the insured.

In addition to jeopardizing the health of our citizens the loss of health insurance by the millions losing their jobs will further escalate U.S. health-care costs. Emergency-room visits will increase, and hospitalizations that could have been prevented with ongoing preventive care will increase. The increase in uninsured patients will further challenge the financial viability of many of our hospitals.

In the many countries that ensure access to health care to all its citizens, whether employed or not, increasing unemployment will not jeopardize the health of their citizens and will not escalate health-care costs.

Maybe the U.S. should consider national health insurance that is not dependent on employment!

James E. Dalen, M.D., MPH, is dean emeritus at University of Arizona College of Medicine.

Letter to Obama: Health care access a national scandal

By ANA M. MALINOW, MD
Houston Chronicle
Feb. 28, 2009

Dear Mr. President:

Last week, in the public clinic where I work, I treated a 6-year-old girl who had visited the emergency room for cellulitis, an infection of the skin, over her hand. Usually a relatively minor condition that is easily treated with a 10-day course of antibiotics, cellulitis can sometimes cause severe consequences, including life-threatening sepsis, if not treated promptly.

The reason this patient was notable was because she was uninsured and had been sent home with a prescription that her mother tried to fill but was unable to afford. How much did the antibiotic suspension cost? $500.

When I saw her three days after her ER visit, her hand was swollen twice the normal size, purple, tender and warm to the touch, with a red streak (signifying an extension of the infection from the skin to the bloodstream) up to her elbow. I took one look at her and quickly made the decision to admit her for IV antibiotics, including a consultation with pediatric surgery to ensure that the infection had not spread between the deep layers of her skin.

What struck me most about this visit, other than the child’s deformed hand, was the mother’s shame at not being able to afford her child’s medication. I assured her that I did not blame her, that our health care system was unconscionable, and that we needed a health care system where everyone was included and everyone paid according to his or her ability to pay. She agreed.

I’m not surprised she agreed. From 1943 to today, opinion polls consistently show that a stable majority of Americans favor a government role in the financing of health care. In the lead-up to President Truman’s national health care proposal, 82 percent of Americans agreed that something needed to be done to make health bills easier to afford.

Today, 65 percent of Americans, including 59 percent of U.S. physicians, support a tax-financed national health insurance plan. Why wouldn’t my patient’s mother support national health care?

What she probably doesn’t know is how much she already pays for the health care her child does not get, or gets late. Her uninsured family pays an extra 10 percent out of its paycheck in taxes to pay for our health care system. Her daughter’s hospitalization will be covered by emergency Medicaid, for which she pays through her sales taxes, income taxes, property taxes and other hidden taxes. She will still have many out-of-pocket costs, of course.

I was struck this week by remarks by David Axelrod, your adviser. Referring to the difference between Washington insiders and most polls over the stimulus package, Axelrod said, “This town talks to itself and whips itself into a frenzy with its own theories that are completely at odds with what the rest of America is thinking.” The moral, he said, is “not just that Washington is too insular but that the American people are a lot smarter than people in Washington think.”

I agree. As I talk about a single-payer national health program across Texas (yes, Texas!) and other states, I am repeatedly amazed by the ability of Americans to understand the complex issues of health reform if it is adequately explained to them. People quickly understand that a sustainable solution will come only when we contain costs and eliminate fragmentation.

The more I listen, the more I hear that all Americans want a health care system that is affordable, accountable, accessible, comprehensive, universal and just — not another Band-Aid that will condemn thousands of us to unnecessary pain, suffering, bankruptcy and death. Listen for yourself, and you will hear Americans clamoring for true health care reform.

By Washington standards, single payer is politically unfeasible. But step outside the beltway and you will be surprised by the genuine support that exists for a publicly funded, privately delivered, expanded and improved Medicare for all.

This mother should not be made to feel ashamed. Nor should her child be relegated to suffer like a Third World beggar. Your compromise plan that keeps the private, for-profit insurance industry in the game will perpetuate the shame and the begging. Already, there is a grass-roots movement building against private health insurance and for single payer. It will reach Washington, whether Washington is ready or not.

Sincerely yours,

Ana M. Malinow, MD

Malinow is a Houston pediatrician and co-founder of Health Care for All Texas.

Massachusetts healthcare reform is failing us

By Susanne L. King
Boston Globe
March 2, 2009

Massachusetts has been lauded for its healthcare reform, but the program is a failure. Created solely to achieve universal insurance coverage, the plan does not even begin to address the other essential components of a successful healthcare system.

What would such a system provide? The prestigious Institute of Medicine, part of the National Academy of Sciences, has defined five criteria for healthcare reform. Coverage should be: universal, not tied to a job, affordable for individuals and families, affordable for society, and it should provide access to high-quality care for everyone.

The state’s plan flunks on all counts.

First, it has not achieved universal healthcare, although the reform has been a boon to the private insurance industry. The state has more than 200,000 without coverage, and the count can only go up with rising unemployment.

Second, the reform does not address the problem of insurance being connected to jobs. For individuals, this means their insurance is not continuous if they change or lose jobs. For employers, especially small businesses, health insurance is an expense they can ill afford.

Third, the program is not affordable for many individuals and families. For middle-income people not qualifying for state-subsidized health insurance, costs are too high for even skimpy coverage. For an individual earning $31,213, the cheapest plan can cost $9,872 in premiums and out-of-pocket payments. Low-income residents, previously eligible for free care, have insurance policies requiring unaffordable copayments for office visits and medications.

Fourth, the costs of the reform for the state have been formidable. Spending for the Commonwealth Care subsidized program has doubled, from $630 million in 2007 to an estimated $1.3 billion for 2009, which is not sustainable.

Fifth, reform does not assure access to care. High-deductible plans that have additional out-of-pocket expenses can result in many people not using their insurance when they are sick. In my practice of child and adolescent psychiatry, a parent told me last week that she had a decrease in her job hours, could not afford the $30 copayment for treatment sessions for her adolescent, and decided to meet much less frequently.

In another case, a divorced mother stopped treatment for her son because the father had changed insurance, leaving them with an unaffordable deductible. And at Cambridge Health Alliance, doctors and nurses have cared for patients who, unable to afford the new copayments, were forced to interrupt care for HIV and even cancers that could be treated with chemotherapy.

Access to care is also affected by the uneven distribution of healthcare dollars between primary and specialty care, and between community hospitals and tertiary care hospitals. Partners HealthCare, which includes two major tertiary care hospitals in Boston, was able to negotiate a secret agreement with Blue Cross Blue Shield of Massachusetts to be paid 30 percent more for their services than other providers in the state, contributing to an increase in healthcare costs for Massachusetts, which are already the highest per person in the world. Agreements that tilt spending toward tertiary care threaten the viability of community hospitals and health centers that provide a safety net for the uninsured and underinsured.

There is, though, one US model of healthcare that meets the Institute of Medicine criteria: Medicare. Insuring everyone over 65, Medicare achieves universal coverage and access to care, is not tied to a job, and is affordable for individuals and the country. Medicare simplifies the administration of healthcare dollars, thereby saving money. We need to improve Medicare, and expand this program to include everyone.

A bill before Congress, the United States National Health Insurance Act, would provide more comprehensive coverage for all. The bill includes doctor, hospital, long-term, mental health, dental, and vision care, prescription drugs, and medical supplies, with no premiums, copayments, or deductibles.

People would be free to choose doctors and hospitals, and insurance would not be tied to a job. Costs would be controlled because health planning in a national health program can reestablish needed balance between primary/preventive care and high-tech tertiary care. A modest, progressive tax would replace what people currently pay out of pocket. This program would pay for itself by eliminating the wasteful administrative costs and profits of private insurance companies, and save $8 billion to $10 billion in Massachusetts alone.

We must let Congress know we want improved access to affordable healthcare for all, not more expensive private health insurance we can’t afford to use when we are sick. Massachusetts healthcare reform fails on all five Institute of Medicine criteria. Congress should not make it a model for the nation.

Susanne L. King, M.D., practices in Berkshire County.

http://www.boston.com/bostonglobe/editorial_opinion/oped/articles/2009/03/02/mass_healthcare_reform_is_failing_us/

National Health Care Act worthy of public support

By BETH SIRR
Helena Independent Record
03/01/2009

Sick of health insurance costs? Then pay attention. Some in Congress want to perpetuate the power of insurance corporations over our health care and what we pay to get it. There is an alternative. The U.S. National Health Care Act: Expanded and Improved Medicare for All, HR 676 could be implemented within 13 months (like Medicare was) and unlike the Wall Street bailout, would be funded by eliminating waste while providing a real hand up for every American family and business — except the insurance industry.

HR 676 would save billions annually by eliminating the high overhead costs and profits of the private health insurance industry and HMOs. According to the Government Accountability Office, the Economic Policy Institute, and others a single-payer system saves enough to offset the costs of providing the health care, about $1.1 trillion. That is how other countries are under-spending, yet out-performing us in health care.

HR 676 would expand an improved Medicare as the publicly accountable “insurance” payer for all of us. Doctors would remain in private practice providing our care. Patients would be free to seek care with the doctor or hospital of their choice.

HR 676 would cover every person in the U. S. for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care, chiropractic and long term care.

In the 110th Congress, HR 676 had 93 co-sponsors in addition to its sponsor Rep. Conyers.

HR 676 has been endorsed by the U.S. Conference of Mayors, Physicians for a National Health Program, 480 union organizations in 49 states including 118 Central Labor Councils and Area Labor Federations and 39 AFL-CIO’s (including Montana).

HR 676, as part of its funding, calls for a modest increase in payroll taxes to replace insurance premiums, and economists estimate that both businesses and individuals would pay less than they do now.

Is there support for such reforms? Oh yes! In 2008, the National Federation of Independent Business survey found a majority of businesses polled preferred a payroll tax to fund employee health care rather than our current insurance system. Large independent polls also find a majority (64-65 percent) of Americans support a federally funded single payer approach to health care (AP/Yahoo, CBS News/New York Times, Harvard School of Public Health, and CNN, 2007-2008). People are ready for reform — now for the politicians!

Senator Baucus needs to hear that we don’t need or want a health care plan like the expensive and complicated Medicare drug plan. Ask Senator Baucus to put the greatest public good ahead of corporate profits — ask him to set aside his white paper and sponsor HR 676 in the Senate. Call him at: (800) 828-0498 or (800) 332-6106, or come March 1 at 6 p.m. to the YWCA on Park Avenue to hear Bob Putsch, M.D. “Making Sense of Health Care Reform,” to learn more.

Beth Sirr is a family nurse practitioner in Helena.

http://www.helenair.com/articles/2009/03/01/opinions/sirr_090301.txt

Sen. Baucus wants CBO to be “creative”

Hearing: Scoring Health Care Reform: CBO’s Budget Options

United States Senate Committee on Finance
February 25, 2009

Closing comments

Sen. Max Baucus, Chairman: Thank you very much, Dr. Elmendorf. We have a huge problem, haven’t we? This is the most difficult public policy undertaking I’ve experienced in my Senate life here. I’ve been here thirty years, and nothing is as difficult as this. Nothing is as important as this, and I cannot think of anything that depends so much on CBO, especially at a time we’re in new territory. We’re not in the old situation where Sen. Grassley once said whatever CBO says is God, you’re God. My judgement, you’re not God.

Douglas Elmendorf, CBO Director: Correct

Sen. Baucus: My judgement is that you got the whole new era – you might be Moses, but not God – but you got the whole new era… where as I said earlier it’s not too much of an overstatement to say CBO can make or break health care reform, and I mean that because we got to go by your numbers…

Dr. Elmendorf: Senator, may I respectfully disagree that…

Sen. Baucus: I do believe that there are several different intellectually honest pathways to get from here to there. It’s not just one automatic, and so it needs – you got to be ever more creative to find intellectually honest pathways to get the savings we have to have – practically and both politically – to get health care reform.

Dr. Elmendorf: Senator, I would like to just respectfully disagree with the make or break role that you have assigned to us. We will do our very best to provide you and all of the members of this committee and the rest of the members of the Congress with the technical information that you need, the best estimates that the knowledge of the world can provide about the effects of alternative policies, but, as you understand, the hard decisions will be yours.

Sen. Baucus: No, that’s incorrect. The hard decisions will be all ours, both of us, you and me. You can’t pass the buck. The hard decisions are here, and the hard decisions are yours and the hard decisions are all of us in this country in trying to make this work. Meeting’s adjourned.

Dr. Elmendorf: Thank you, Senator

http://finance.senate.gov/sitepages/hearing022509.htm

Video of hearing – click link of 2/25/09:
http://finance.senate.gov/sitepages/hearings.htm

Comment:

By Don McCanne, MD

In this closing exchange, Sen. Max Baucus seems to be annoyed with Douglas Elmendorf, Director of the Congressional Budget Office. What is the background here?

Sen. Baucus is determined to lead the way to comprehensive health care reform. His model is basically the Hacker/Obama/Kennedy/Daschle/Massachusetts/Commonwealth model which is based on expanding the use of regulated private health plans, while continuing to expand existing public programs.

To help Congress with its efforts on reform, CBO recently released two volumes on 1) issues on analyzing health insurance proposals, and 2) budget options for health care (both available at the CBO website www.cbo.gov). It is quite clear, based on these two reports and on the innumerable analyses in the health policy literature, that Baucus’s model would be scored by the CBO as outrageously expensive while falling far short on many of the important goals for health care reform.

The CBO is noted for its impartiality in providing Congress with intellectually honest evaluations of various Congressional proposals. From Sen. Baucus’s comments, it’s obvious that this constitutes a major barrier to his ambitions to enact reform along the lines of his model. Rather than an arm’s-length analysis, Sen. Baucus is demanding that Dr. Elmendorf shift from the role of an impartial analyst to the role of a policymaker by becoming “creative,” making the “hard decisions,” to “find intellectually honest pathways to get the savings we have to have.”

We can understand Sen. Baucus’s frustration in his inability to obtain a favorable analysis of his highly flawed, “wish-they-would-work” policies. But we can fault him for demanding that Dr. Elmendorf compromise his professional integrity by participating in the policy decisions over a fundamentally flawed framework of reform, and then applying to the final product his personal stamp of endorsement. That is not and must never be the role of the CBO Director.

This also partially explains why Sen. Baucus is becoming ever more strident in his demand that single payer be totally excluded from the dialogue on reform. Innumerable analyses, including some by the CBO, have shown that the single payer model actually would achieve our goal of affordable health care for everyone. Objective, side-by-side CBO analyses would destroy any chance of convincing Congress to enact Sen. Baucus’s model.

Since reform should be based on the best data available, isn’t such an analysis exactly what we should have right now? If Sen. Baucus is sincere in wanting reform that works for all of us, he should be the first one to request that CBO do that study.

DrSteveB also covers this well in his Daily Kos blog today:
http://www.dailykos.com/story/2009/3/2/7495/94300/238/703544

Single payer only route to Obama’s grand vision on healthcare reform

by Chuck Idelson
California Nurses Association blog
February 26, 2009

Hours after President Obama’s speech to Congress in which he laid down a marker for achieving “comprehensive” healthcare reform, and getting it done this year, top administration aides have outlined the goals of what they want to achieve.

What Politico called “the 8 keys to his health plan,” certainly reflect a bold determination for action and a grand vision.

There’s only one problem. Virtually all the proposals being bandied about in various Congressional committees — and the administration made it clear this week they will let Congress figure out the details — fail to meet the test of those “8 keys.”

With one important exception — single payer reform, or expanding and updating Medicare to cover everyone.

So what are those lofty goals set by the administration?

Obama has endorsed eight guiding principles for health reform, the White House officials said on the conference call. They stressed that they intend to work with lawmakers and other stakeholders on how to accomplish the goals, but the principles will lay down a marker for any congressional plan.

Drum roll, please. A healthcare plan, they told reporters, should be:

* Universal, everybody in, nobody out

* Portable, not tied to your job, if you even have one

* Maintaining choice of doctor and insurance

* Ensuring affordable coverage

* Protecting Americans financial health

* Investing in prevention and wellness

* Improving patient safety and quality of care

* Fiscally responsible and sustainable

To the administration’s credit, these should be the benchmarks of any real reform. And to give them further props, the administration is even projecting progressive tax reform as a financing mechanism.

The combined effect of the two revenue-raising proposals, on top of Mr. ObamaĆ¢ā‚¬™s existing plan to roll back the Bush-era income tax reductions on households with income exceeding $250,000 a year, would be a pronounced move to redistribute wealth by reimposing a larger share of the tax burden on corporations and the most affluent taxpayers.

But on the construct of the plan itself, a huge barrier stands in the way. The present private insurance-based system is an implacable impediment to every one of these goals.

The insurance giants, of course, are not care providers. They are big corporations. They exist to make money, primarily to return profits for their shareholders. Every aspect of their operations are geared to that end.

Private insurance plans:

* Aren’t universal because they exclude people based on pre-existing conditions or age or anyone else they think will be expensive to cover.

* Don’t guarantee choice of physician or hospital, but limit you to their network of providers.

* Won’t assure affordability because they are constantly raising premiums, deductibles, co-pays, and other fees to generate high revenues and profits.

* Can’t guarantee safety and quality because they actively discourage the delivery of care or deny treatments, diagnoses, or referrals because they don’t want to pay for it.

* Will never be fiscally responsible because there is no independent oversight, decisions are made in secret in closed board rooms or CEO offices, and, again, their priority is profits.

Thus any plan which sustains, protects, or expands the role of the insurance industry in healthcare cannot, by definition, achieve any of these worthy aims.

One bill, however, does succeed in all eight areas. That is HR 676, the U.S. National Health Care Act by Rep. John Conyers, which also happens to be the one reform that has a broad, national grassroots constituency led by nurses, doctors, patients, and health care activists.

With the administration having laid our a vision, but deferred implementation to Congress, that should be a signal to all of us to put their feet to the fire and push for real reform, like HR 676.

David Himmelstein and Len Nichols debate

Can US Achieve Meaningful Healthcare Reform Within For-Profit System?

Hosted by Amy Goodman and Juan Gonzalez
Democracy Now!
February 27, 2009
(Excerpts)
We host a debate between Dr. David Himmelstein of Physicians for a National Health Program and Len Nichols of the New America Foundation.
Juan Gonzalez: …if these private insurance companies will remain involved in the healthcare — in healthcare insurance in the future, how can those costs be controlled?
Len Nichols: …a lot of the administrative costs that David talked about, which is borne by the providers, I agree completely, they’re wasting a lot of energy now satisfying a lot of different kinds of claims forms. You could have a common claims form required by the government. You would get the industry to agree on what it is or tell them you’re going to impose one. They would agree in about an hour. And then you could have very much more efficient ways of billing and collecting, so that the extra costs that we’re spending now could be taken out of the system by rules and regulations that would make their self-interest pursue our social interest.
Dr. David Himmelstein: …Len Nichols claims all we need is a common billing form for hospitals. We already have that. It’s called UB82. And we have computerized virtually all hospital billing. It hasn’t saved a nickel. It’s because the insurance companies aren’t actually interested in saving money on administration. That’s where they make their dime. And no amount of government regulation is going to change their behavior, as long as they’re still in the game.
Amy Goodman: Len Nichols, we’re talking nationalizing banks. Why not nationalize health insurance? Why not nationalize healthcare in this country?
Len Nichols: You know, it certainly is tempting, and at a certain level, you’re right. The atmosphere is one where it seems like all things are possible. But I would just say the American people, by and large, are not ready for government-run healthcare. Look at the way people can be scared by one-size-fits-all kinds of rhetoric. …but I think the American people are nowhere near ready to have the government take over their healthcare, because that set of decisions about how you treat your illness, etc., is so private and so emotional. They do want choice. They want to believe in their doctor, and they do, in large part, believe in their individual doctor.
Amy Goodman: So, Dr. Himmelstein, respond to that. It’s not practical right now. It’s not achievable.
Dr. David Himmelstein: Well, yeah. I mean, people want choice. They want to be able to choose their doctor, and they want to be able to choose their hospital. They want to choose their care. And that’s what they can’t do at this point. We’re saying every American should be able to go to any doctor, any hospital in the country, and have a completely free choice. And under the private insurance system, they don’t have that.
Juan Gonzalez: …I’d also like to throw in a little personal experience that I’ve had recently. I just had a minor shoulder surgery a few weeks ago. And I have to tell you, because I am insured through my company, and I have to tell you the amount of time that I have had to spend on the phone with my employer, with the health insurer, with the hospital, the various bills from both the hospital, the surgeon, the laboratories, the amount of time that I’ve had to spend to try to maneuver through this incredibly complex system — and is it in network or out of network? And I have to imagine that millions and millions of Americans every day are going through the same procedure, even those who have insurance, enormous amounts of time and energy and frustration spent trying to maneuver through the system.
Len Nichols: Sir, I agree. I’ve shared some of that same frustration in my own life, as have we all. And I would agree, our system is a mess. …Today, insurers make money by excluding the sick and by making it hard for people to get the carrier talking about it. I agree that’s what they’re doing. It’s about that. But if you change the rules and you say, “Look, we’re going to publish patient satisfaction. We’re going to publish what things cost. We’re going to publish what it would cost to be covered by you,” and make all that very clear, and you make — essentially you give people choices among them, they will compete on the right dimensions, because that’s the way they’ll make money.
Amy Goodman: Len Nichols, we started with you. Fifteen seconds, Dr. Himmelstein, we’ll end with you.
Dr. David Himmelstein: Well, we need single-payer national health insurance. If private insurance could solve this problem, I’d be all for it. Unfortunately, it can’t. My patients desperately need it. Our nation desperately needs it. There are things we say are not appropriate for the market, like the fire department and the police department. Medical care ought to be one of those.
Amy Goodman: We’ll leave it there. Dr. David Himmelstein, associate professor of medicine at Harvard University, co-founder of Physicians for a National Health Program. And Len Nichols, director of the Health Policy Program at the New America Foundation.
For the full 18 minute video, audio, and transcript:
http://i4.democracynow.org/2009/2/27/can_us_achieve_meaningful_health_care

Primarily because of political perceptions, Len Nichols continues to support what he believes to be the pragmatic approach of covering everyone with regulated private plans. However, when experts like David Himmelstein continue to confront him with the facts about our flawed financing system, Nichols’ support for private insurance seems to be shifting from knowing that it would work, to wishing that it could, even though “our system is a mess.” He needs to take the next step of acknowledging that private insurance can’t work so that we can move forward and fix the “mess” by enacting a single payer national health program.

David Himmelstein and Len Nichols debate

Can US Achieve Meaningful Healthcare Reform Within For-Profit System?

Hosted by Amy Goodman and Juan Gonzalez
Democracy Now!
February 27, 2009

(Excerpts)

We host a debate between Dr. David Himmelstein of Physicians for a National Health Program and Len Nichols of the New America Foundation.

Juan Gonzalez: …if these private insurance companies will remain involved in the healthcare — in healthcare insurance in the future, how can those costs be controlled?

Len Nichols: …a lot of the administrative costs that David talked about, which is borne by the providers, I agree completely, they’re wasting a lot of energy now satisfying a lot of different kinds of claims forms. You could have a common claims form required by the government. You would get the industry to agree on what it is or tell them you’re going to impose one. They would agree in about an hour. And then you could have very much more efficient ways of billing and collecting, so that the extra costs that we’re spending now could be taken out of the system by rules and regulations that would make their self-interest pursue our social interest.

Dr. David Himmelstein: …Len Nichols claims all we need is a common billing form for hospitals. We already have that. It’s called UB82. And we have computerized virtually all hospital billing. It hasn’t saved a nickel. It’s because the insurance companies aren’t actually interested in saving money on administration. That’s where they make their dime. And no amount of government regulation is going to change their behavior, as long as they’re still in the game.

Amy Goodman: Len Nichols, we’re talking nationalizing banks. Why not nationalize health insurance? Why not nationalize healthcare in this country?

Len Nichols: You know, it certainly is tempting, and at a certain level, you’re right. The atmosphere is one where it seems like all things are possible. But I would just say the American people, by and large, are not ready for government-run healthcare. Look at the way people can be scared by one-size-fits-all kinds of rhetoric. …but I think the American people are nowhere near ready to have the government take over their healthcare, because that set of decisions about how you treat your illness, etc., is so private and so emotional. They do want choice. They want to believe in their doctor, and they do, in large part, believe in their individual doctor.

Amy Goodman: So, Dr. Himmelstein, respond to that. It’s not practical right now. It’s not achievable.

Dr. David Himmelstein: Well, yeah. I mean, people want choice. They want to be able to choose their doctor, and they want to be able to choose their hospital. They want to choose their care. And that’s what they can’t do at this point. We’re saying every American should be able to go to any doctor, any hospital in the country, and have a completely free choice. And under the private insurance system, they don’t have that.

Juan Gonzalez: …I’d also like to throw in a little personal experience that I’ve had recently. I just had a minor shoulder surgery a few weeks ago. And I have to tell you, because I am insured through my company, and I have to tell you the amount of time that I have had to spend on the phone with my employer, with the health insurer, with the hospital, the various bills from both the hospital, the surgeon, the laboratories, the amount of time that I’ve had to spend to try to maneuver through this incredibly complex system — and is it in network or out of network? And I have to imagine that millions and millions of Americans every day are going through the same procedure, even those who have insurance, enormous amounts of time and energy and frustration spent trying to maneuver through the system.

Len Nichols: Sir, I agree. I’ve shared some of that same frustration in my own life, as have we all. And I would agree, our system is a mess. …Today, insurers make money by excluding the sick and by making it hard for people to get the carrier talking about it. I agree that’s what they’re doing. It’s about that. But if you change the rules and you say, “Look, we’re going to publish patient satisfaction. We’re going to publish what things cost. We’re going to publish what it would cost to be covered by you,” and make all that very clear, and you make — essentially you give people choices among them, they will compete on the right dimensions, because that’s the way they’ll make money.

Amy Goodman: Len Nichols, we started with you. Fifteen seconds, Dr. Himmelstein, we’ll end with you.

Dr. David Himmelstein: Well, we need single-payer national health insurance. If private insurance could solve this problem, I’d be all for it. Unfortunately, it can’t. My patients desperately need it. Our nation desperately needs it. There are things we say are not appropriate for the market, like the fire department and the police department. Medical care ought to be one of those.

Amy Goodman: We’ll leave it there. Dr. David Himmelstein, associate professor of medicine at Harvard University, co-founder of Physicians for a National Health Program. And Len Nichols, director of the Health Policy Program at the New America Foundation.

For the full 18 minute video, audio, and transcript:
http://i4.democracynow.org/2009/2/27/can_us_achieve_meaningful_health_care

Comment:

By Don McCanne, MD

Primarily because of political perceptions, Len Nichols continues to support what he believes to be the pragmatic approach of covering everyone with regulated private plans. However, when experts like David Himmelstein continue to confront him with the facts about our flawed financing system, Nichols’ support for private insurance seems to be shifting from knowing that it would work, to wishing that it could, even though “our system is a mess.” He needs to take the next step of acknowledging that private insurance can’t work so that we can move forward and fix the “mess” by enacting a single payer national health program.

Health Care Reform: Learning from the International Experience — A Case for Single Payer

by Claudia Chaufan
Social Medicine Portal
February 27th, 2009

So President Obama gets it: he has recognized that the time to reform health care is now, and he is right. After touring the country during his campaign, he must be aware that thousands of Americans are going bankrupt, every year, because they cannot afford their medical bills, even when they have insurance, and are employed and middle class. He surely is also aware that thousands die of perfectly preventable illnesses because they lack health insurance. And that all of these things are unheard of, at least in developed economies.

Yet the president has also said that reform will fail unless we can reign on costs. And he is right again, because health care costs are estimated to reach $8,000 a year per person, and are increasing at three times the rate of inflation, even if our extraordinary 2 trillion-dollars per year-expenditure buys us a patchwork system ranked 37th by the World Health Organization in overall performance, below that of every other industrialized nation.

Now, some have argued that the problem is “too much government”. And they are right to say that there is a lot of government: after all, 60% of the two trillion comes already from public funds – in case the reader didn’t know, 10% of anybody’s income, on average, is already financing, through taxes alone, some form of public health care services, whether one qualifies or not for any public program. They are also right to say that this public expenditure is breaking the back of taxpayers, both at the federal and state levels — a case in point is the current individual mandate experiment in Massachusetts, which has turned out to be a fiscal time bomb, draining money as it is from safety net providers, and forcing people who make as little as 31,000 dollars a year to “choose” between adequate yet unaffordable coverage, affordable yet skimpy coverage that hardly qualifies as insurance, or a fine of over 900 dollars.

So recommendations for President Obama for how to reign on costs abound: from the “let’s deregulate the private health insurance market and allow everybody to spend their health care dollars as they choose to” types (one wonders where these folks have been during the meltdown of the global financial system!), to the “consumer driven” types, who suggest shifting (yet more) costs to “consumers” – higher premiums, co-pays, or deductibles — to the “shared responsibility” types (well, who would dare oppose “shared responsibility”, even if it is hardly a meaningful health policy concept? Incidentally, the latest paper by Jacob Hacker, the “father” of the “shared responsibility” model, is the best defense of public financing and indictment of private health insurance I’ve read in a long time!), to the over 100 options-list of the Congressional Budget Office (CBO) – which, incidentally, has (correctly) challenged the enthusiasm for wellness programs, preventive medicine, or electronic medical records, at least as strategies to reign on costs (That’s right! it is not the broccoli that others eat and that we presumably don’t that explain why others spend so much less than what we do! And if you don’t believe me, ask the Brits!).

Remarkably, nobody close enough to the corridors of power, indeed, not even the CBO, seems to mention the “s” word (single payer!). Could it be that “single payer” is too close to “socialism”? (they both begin with an “s”, no?). Or is it that whoever has been organizing the meetings around health care reform under the blessings of Senator Edward Kennedy thought that single payer advocates were unworthy guests to the secret “talks to shape policy”?

Given this notable absence, let me fill this vacuum so that the president hears all the options (don’t you think he’s the type who can appreciate a good challenge?). Let me explain in a simplified way how every other industrialized economy in the world — and even more recently Taiwan — has managed to develop systems that guarantee a basic amount of health care to virtually 100% of their population, based on medical need and not ability to pay, spending no more than 60% of what we do, and yes, using a lot of government! I am quite confident that the president will like my proposal. After all, I remember him saying that the question is not too much or too little government, but government that works for ordinary Americans.

So how do others achieve the remarkable feat that has defied Americans for decades?

First, they’ve created systems that pool health risks widely, because they understand that money spent on dividing people up into different pools or plans — as we do, we spend over 30 cents of each health care dollar pushing paper and underwriting policies — is money not spent on health care, and therefore wasted, if the goal is to provide health care universally (as opposed to, for instance, create a “competitive illness market” just for the heck of it). So at any given moment, the healthy majority subsidizes the unhealthy minority, the young, who on average spend less, subsidize the old, who on average spend more, and so forth.

Let me point out that cross-subsidization minimizes the need for public subsidies, because there are no longer “special populations” (the old, the poor, the disabled, the “other”) who are shunned by the private insurance sector because, after all, they are not “good customers”. Pooling also exempts health professionals from the time-consuming task of figuring out what is covered, under which conditions, and for whom, and from the expensive paperwork of the multiple payment schemes with the unpredictable rates of reimbursement characteristic of the private sector.

Second, they use the great purchasing power that comes from bulk purchases to get the best bang for their health care dollar. This is the purchasing power that American consumers lack, for which reason we pay the highest prices in the planet for services that cost a fraction elsewhere: for instance, while people in Baltimore, Maryland, spend $329 dollars for Lanzoprasol, a widely used drug to reduce acidity, people in Spain pay $9 for the same dose of the same product.

Third and last, they finance their health care systems collectively with compulsory contributions. One could say that they take shared responsibility seriously, rather than merely advocating for the sum of individual responsibilities, individual-mandate type! But because they understand that it is pointless to demand that people contribute what they cannot afford, in all cases contributions to the system are a predictable proportion of income, which makes contributions affordable to individuals and families, and complies with the principle of financial fairness, as articulated by the World Health Organization.

Now, systems vary from country to country and no system is free of problems. Yet what matters is what they share:

They share a commitment to a goal: to eliminate financial barriers to health care.

They share an understanding of a best strategy: that insuring health care cooperatively is the way to go — cooperative financing is known as “social health insurance”, a type of insurance where everybody plays, where the ability to make a profit from connecting patients with providers is severely restricted if not altogether banned, and where contributions are a predictable proportion of income and entitlements a function of medical need.

And single payer is simply a type of social insurance: it is a hybrid system, a private-public partnership which combines public financing with private delivery of services. And it is the only mechanism that has the capacity to reign on costs while achieving the goal of universal health care. And I say care, not insurance coverage — they are not equivalent and should not be considered so.

Single payer can expand coverage while containing costs by maximizing purchasing power, minimizing administrative waste, and minimizing the need for subsidies, that ultimately have to be picked up by all of us, taxpayers. It embodies the pragmatism that President Obama is often credited with in that it builds upon well-tested, and anything but radical, models of financing, yet clearly in the pursuit of a goal: that of universal health care. And it is fiscally conservative in that it provides relief to states that, like California, among many others, spend enormous amounts of money on public programs and health insurance for employees, including retirees, and their families.

Moreover, under single payer, Americans would be able to choose, and keep, their doctors whatever happened to their financial or work lives. They would have meaningful choices — not choice of “health plans” where people are forced to select from within “preferred provider” lists or to second guess their present or future medical needs, but choice of doctors and whatever services they need, the sort of choice that people care about.

As an aside, the notion of social insurance is over 120 years old. Otto Von Bismarck, first chancellor of the German empire, sponsored the first social health insurance system in 1883, among other reasons to prevent the spread of socialism. And as history shows, he succeeded.

In closing, single payer shares with the health care systems of all developed nations, with the glaring exception of ours, the understanding that social health insurance is both good economics and good morals:

It is good economics because it yields the best bang for the health care dollar. And it is good morals because guaranteeing health care, a basic human need, is the mark of a society that cares about human dignity.

Will President Obama think that we can? I can only hope.

President Obama Must Include Single-Payer Advocates In National Health Care Debate

Statement of Sidney Wolfe, M.D., Director, Public Citizen’s Health Research Group, and James Floyd, M.D., Researcher, Public Citizen’s Health Research Group
Feb. 26, 2009

This morning, President Obama announced he will create a $634 billion reserve fund over the next decade to provide a down payment for expanding health coverage. The announcement comes a week before a White House health care summit that marks the beginning of the first serious effort to reform health care since the Clinton task force in 1993.

The president wants this process to be open and transparent, with the goal of achieving universal coverage. However, groups representing physicians, nurses, and consumers who advocate for a single-payer system of national health insurance have thus far been excluded from the summit.

Under a single-payer system, doctors, hospitals and other health care providers are paid from a single fund administered by the government. The system would eliminate the wasteful spending and high administrative costs of private insurance, saving almost $400 billion annually. This savings is enough to provide every American with the same high-quality care, including those who currently have insurance but still cannot afford medications and treatment.

If health care is a key to fixing our national deficit and providing the economic stimulus that we need to recover from this recession, it is unacceptable to ignore the only system that will provide true universal coverage. If the only people who have input on health care reform are the lobbyists who represent the interests of insurance and drug companies, the final result will be a system that benefits the insurance and drug companies.

The Clinton task force on health reform made a similar mistake of excluding the voices of those who support a single-payer system, and the result was a complicated, inadequate reform proposal that catered to the interests of insurance companies and failed to garner public support. At a time when public support for single-payer is greater than ever – more than 60 percent in recent polls – we urge President Obama not to make the same mistake. He must include single-payer advocates in the health care summit next week.