PNHP

Himmelstein responds to Gawande on single payer

Himmelstein responds to Gawande on single payer

On January 23, a Quote of the Day message discussed an article in The New Yorker by Atul Gawande, Getting There from Here: How Should Obama Reform Health Care? Unfortunately, my response to that article was cluttered with comments about framing, linear polarity and other extraneous concepts that detracted from my primary message.
His theme was that health care reform in any nation is inevitably “path dependent,” building on “its own history, however imperfect, unusual, and untidy.” He applies this concept to the United States stating that we must build on what we have, selecting out features of our current fragmented system of financing health care that he says should be expanded to achieve our goals. It just happens that the features he selects are those in the current leading Democratic proposal for reform.
His article is very well written, and is quite convincing to those who have not been intensively involved in reform activities and have only a limited understanding of health policy. Since it is such a impressive article it now is being circulated widely as a statement that (superficially) seems to make sense as a guideline for reform.
The problem is that Atul Gawande is flat out wrong. He implies that other nations merely made adjustments in their existing systems to expand coverage to everyone. In fact, these were not simple adjustments to systems that weren’t working; they were revolutionary transformations of their health care financing systems. Some residuals incorporated into their new financing systems might be called “path dependent,” but a more appropriate framing would be the antithesis that the thrust of each reform effort was to eliminate the deficiencies and inadequacies of the existing financing system or non-system. This inevitably required new financing systems. The fundamentals of these new financing systems were not based on path dependency, but they were based on path trailblazing.
Gawande dismisses single payer supporters as reformers “on the left” who “reserve special contempt for the pragmatists, who would build around the mess we have.” He explains later that the path dependent, pragmatic approach that we must follow will still be “exasperating, even disappointing,” while still failing to give single payer even short shrift.
In a Common Dreams article, Russell Mokhiber provided a comment by Atul Gawande in which he expanded on his views of single payer, along with a response by David Himmelstein. When you hear people praise Gawande’s New Yorker article, you should provide them with the following comments.

Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis

by Russell Mokhiber
CommonDreams.org
February 10, 2009
As for (Gawande’s) opposition to single payer, he remains steadfast.
In a q/a with New Yorker readers last week, Gawande defended his opposition to single payer now.
“Replacing the entire health-financing system with Medicare would require most working-age people to leave their current insurance plans,” Gawande writes. “It would change the finances of every hospital and doctor in the country overnight. It would require replacing the premiums we pay with a tax, with massive numbers of both losers and winners. It seems simple in theory, but in practice it never is. This would be a whole new path for health care. No country has swept away their health system and simply replaced it like that. As I said in the article, one would have to be prepared for an overnight change in the way people get 3.5 billion prescriptions, 900 million office visits, 60 million operations – because how these are paid for is critical to whether and how they are provided. Doing away with private insurance coverage is no less sweeping than saying we’ll do away with public insurance programs or do away with employer-paid health care. No major country has simply swept away the way so many people’s care is paid for. And the reason is that people have legitimate fears about what will happen to them.”
Dr. David Himmelstein, a founder of Physicians for a National Health Program, calls this argument “bogus.”
“Patients do not care what their insurance plan is – just that it pays for the care they need. A transition from a system where virtually everyone has only partial coverage to one where they have full coverage is not a disruption for patients,” Himmelstein said when we asked him to respond to Gawande. “Several nations have made abrupt changes in the financing of care. The UK instituted the National Health Service – eliminating insurance and private payment for care at a stroke. Each Canadian province went from a private insurance system very like ours to its current system virtually overnight — though not all provinces underwent the change simultaneously. Taiwan changed to a single payer system about 10 years ago at a stroke.”
“Medicare replaced private coverage for the elderly — who account for about 30% of all hospital patients — about nine months after its passage. That occurred in an era before computers. The entire task of enrolling tens of millions of patients, inspecting virtually every hospital in the nation — to certify that they were desegregated, which was mandated by the Medicare law — and set up a new payment apparatus was carried out using paper records. Why is a shift of the other two-thirds of our system more difficult?”
“The new payment system would be far simpler than the current one — hospitals would receive a global budget, which initially would be based largely on their previous year’s revenues. Medicare currently collects all of the financial info needed to do such budgeting at the outset. Per-patient billing for hospital care would be eliminated. For doctors, Medicare already has a fee schedule, which should be modified somewhat, but already serves as the benchmark for most private plans. Expanding this payment system to cover all fee-for-service billings would be trivial. Paying for drugs is similarly pretty simple and straightforward, with most of the needed infrastructure already in place.”
“In sum, his arguments are bogus unless you assume that we are far less competent than people in other nations, and than we used to be,” Himmelstein said.
Mokhiber: Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis
http://www.commondreams.org/view/2009/02/10-1
Gawande: Getting There from Here: How should Obama reform health care?
http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande
qotd: Gawande’s pseudo-pragmatism
https://pnhp.org/news/2009/january/gawandes_pseudopra.php

Himmelstein responds to Gawande on single payer

February 12, 2009

Comment:

By Don McCanne, MD

On January 23, a Quote of the Day message discussed an article in The New Yorker by Atul Gawande, Getting There from Here: How Should Obama Reform Health Care? Unfortunately, my response to that article was cluttered with comments about framing, linear polarity and other extraneous concepts that detracted from my primary message.

His theme was that health care reform in any nation is inevitably “path dependent,” building on “its own history, however imperfect, unusual, and untidy.” He applies this concept to the United States stating that we must build on what we have, selecting out features of our current fragmented system of financing health care that he says should be expanded to achieve our goals. It just happens that the features he selects are those in the current leading Democratic proposal for reform.

His article is very well written, and is quite convincing to those who have not been intensively involved in reform activities and have only a limited understanding of health policy. Since it is such a impressive article it now is being circulated widely as a statement that (superficially) seems to make sense as a guideline for reform.

The problem is that Atul Gawande is flat out wrong. He implies that other nations merely made adjustments in their existing systems to expand coverage to everyone. In fact, these were not simple adjustments to systems that weren’t working; they were revolutionary transformations of their health care financing systems. Some residuals incorporated into their new financing systems might be called “path dependent,” but a more appropriate framing would be the antithesis that the thrust of each reform effort was to eliminate the deficiencies and inadequacies of the existing financing system or non-system. This inevitably required new financing systems. The fundamentals of these new financing systems were not based on path dependency, but they were based on path trailblazing.

Gawande dismisses single payer supporters as reformers “on the left” who “reserve special contempt for the pragmatists, who would build around the mess we have.” He explains later that the path dependent, pragmatic approach that we must follow will still be “exasperating, even disappointing,” while still failing to give single payer even short shrift.

In a Common Dreams article, Russell Mokhiber provided a comment by Atul Gawande in which he expanded on his views of single payer, along with a response by David Himmelstein. When you hear people praise Gawande’s New Yorker article, you should provide them with the following comments.

Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis

by Russell Mokhiber
CommonDreams.org
February 10, 2009

As for (Gawande’s) opposition to single payer, he remains steadfast.

In a q/a with New Yorker readers last week, Gawande defended his opposition to single payer now.

“Replacing the entire health-financing system with Medicare would require most working-age people to leave their current insurance plans,” Gawande writes. “It would change the finances of every hospital and doctor in the country overnight. It would require replacing the premiums we pay with a tax, with massive numbers of both losers and winners. It seems simple in theory, but in practice it never is. This would be a whole new path for health care. No country has swept away their health system and simply replaced it like that. As I said in the article, one would have to be prepared for an overnight change in the way people get 3.5 billion prescriptions, 900 million office visits, 60 million operations – because how these are paid for is critical to whether and how they are provided. Doing away with private insurance coverage is no less sweeping than saying we’ll do away with public insurance programs or do away with employer-paid health care. No major country has simply swept away the way so many people’s care is paid for. And the reason is that people have legitimate fears about what will happen to them.”

Dr. David Himmelstein, a founder of Physicians for a National Health Program, calls this argument “bogus.”

“Patients do not care what their insurance plan is – just that it pays for the care they need. A transition from a system where virtually everyone has only partial coverage to one where they have full coverage is not a disruption for patients,” Himmelstein said when we asked him to respond to Gawande. “Several nations have made abrupt changes in the financing of care. The UK instituted the National Health Service – eliminating insurance and private payment for care at a stroke. Each Canadian province went from a private insurance system very like ours to its current system virtually overnight — though not all provinces underwent the change simultaneously. Taiwan changed to a single payer system about 10 years ago at a stroke.”

“Medicare replaced private coverage for the elderly — who account for about 30% of all hospital patients — about nine months after its passage. That occurred in an era before computers. The entire task of enrolling tens of millions of patients, inspecting virtually every hospital in the nation — to certify that they were desegregated, which was mandated by the Medicare law — and set up a new payment apparatus was carried out using paper records. Why is a shift of the other two-thirds of our system more difficult?”

“The new payment system would be far simpler than the current one — hospitals would receive a global budget, which initially would be based largely on their previous year’s revenues. Medicare currently collects all of the financial info needed to do such budgeting at the outset. Per-patient billing for hospital care would be eliminated. For doctors, Medicare already has a fee schedule, which should be modified somewhat, but already serves as the benchmark for most private plans. Expanding this payment system to cover all fee-for-service billings would be trivial. Paying for drugs is similarly pretty simple and straightforward, with most of the needed infrastructure already in place.”

“In sum, his arguments are bogus unless you assume that we are far less competent than people in other nations, and than we used to be,” Himmelstein said.

Mokhiber: Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis
http://www.commondreams.org/view/2009/02/10-1

Gawande: Getting There from Here: How should Obama reform health care?
http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande

qotd: Gawande’s pseudo-pragmatism
https://pnhp.org/news/2009/january/gawandes_pseudopra.php

National Health Care Reform – Dr. Ana Malinow

by David Lemberg
Science and Society
February 6, 2009

Click here to listen to the interview

Dr. Ana Malinow discusses health care reform, a single-payer health system, and making health care available and affordable for all Americans.

Dr. Malinow is Associate Professor of Pediatrics at Baylor College of Medicine and full-time faculty at the Ben Taub General Hospital Pediatric Emergency and Ambulatory Center, located in Houston, TX. Dr. Malinowā€™s experiences with the underserved in Cleveland and Houston motivated her in 2002 to co-found Health Care for All Texas, and to promote single-payer universal health care through education and policy setting.

Dr. Malinow has been a guest speaker on health care reform in local and national lectures, and has been featured on multiple television and radio programs. She is the author of numerous Op-Ed articles and is past president of Physicians for a National Health Program. Physicians for a National Health Program has more than 15,000 members and chapters across the United States.

Care coordination – a wrong way and a right way

Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries

By Deborah Peikes, PhD; Arnold Chen, MD, MSc; Jennifer Schore, MS, MSW; Randall Brown, PhD
JAMA
February 11, 2009
Objective: To determine whether care coordination programs reduced hospitalizations and Medicare expenditures and improved quality of care for chronically ill Medicare beneficiaries.
Interventions: Nurses provided patient education and monitoring (mostly via telephone) to improve adherence and ability to communicate with physicians. Patients were contacted twice per month on average; frequency varied widely.
Main Outcome Measures: Hospitalizations, monthly Medicare expenditures, patient-reported and care process indicators.
Results: Thirteen of the 15 programs showed no significant (P<.05) differences in hospitalizations; however, (one program had fewer hospitalizations and another had more). None of the 15 programs generated net savings. These programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined. Conclusions: Viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings. Programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care. http://jama.ama-assn.org/cgi/content/full/301/6/603

And…

The Elusive Quest for Quality and Cost Savings in the Medicare Program

John Z. Ayanian, MD, MPP
JAMA
Editorial (on the Peikes, et al study)
With voluntary enrollment of more than 18,000 participants from all US regions, these 15 programs implemented a varied set of approaches to improve care coordination. Common features of the programs included the use of nurses trained as care coordinators to interact on a regular basis with patients who had serious chronic health conditions. These nurses provided patients with health education and sent written reports to their physicians. Participants were substantially sicker than Medicare beneficiaries in general, with much higher rates of cardiovascular disease, diabetes, and chronic lung disease, and correspondingly greater monthly Medicare expenditures before enrollment ($1535 vs $551, respectively). The CMS paid each program a negotiated monthly fee that averaged $235 per participant to provide outreach, health education, and support to these chronically ill patients–and in some cases to their physicians. An independent evaluation of these programs was funded by CMS to assess their effects on quality of care, hospitalizations, and Medicare expenditures in a consistent and rigorous manner.
The financial and clinical results of this careful evaluation were sobering. Only 2 of the 12 largest programs had a statistically significant effect on the annual number of hospital admissions. A hospital-sponsored program in Iowa (Mercy Medical Center) significantly reduced hospitalizations by 17%, with a nonsignificant 9% reduction in Medicare expenditures. In contrast, a retirement center program in Maryland (Charlestown) significantly increased both hospitalizations and expenditures by 19%. When program fees were incorporated in the analysis, total expenditures were 8% to 41% higher (P < .10) in the intervention groups than the control groups for 9 of the 12 largest programs, and no programs reduced expenditures. In the clinical domain, the interventions had only sporadic effects on process measures of quality of care, such as vaccinations, cancer screening, or diabetes services, and had minimal or no effects on patients' functional status and health-related quality of life. Another ongoing Medicare project, the Care Management for High-Cost Beneficiaries Demonstration, is assessing the effectiveness of clinician-directed chronic care management programs. A variety of approaches focused on improving care coordination and home support through patients' own health care practitioners are being tested in 6 sites across the country. Many of these approaches are consistent with new models for patient-centered medical homes that have been endorsed by leading professional organizations in primary care. In addition, CMS is now developing plans to launch the Medicare Medical Homes Demonstration that will pay monthly fees of $40 to $100 per patient to 2000 physicians to coordinate the care of their chronically ill beneficiaries. By involving patients' own physicians in coordinating their care, these programs hold greater promise for achieving better quality of care and possibly cost savings. http://jama.ama-assn.org/cgi/content/full/301/6/668

Most of the leading proposals for health financing reform include magical (sleight-of-hand) concepts that purportedly would reduce health care costs. One of these is disease management, or chronic care coordination, or whatever label you want to give it.
This study adds to many others that confirm that these programs, as currently structured, do not work. A fee (average $235 per patient per month) paid to an entity that hires a nurse to coordinate care (most frequently through two telephone calls per month) does not reduce the rate of hospitalization, does not generate a net savings, and has only a negligible impact on quality.
This does not mean that there is no place for chronic disease management. Many studies have shown that systems with strong primary care infrastructures do provide higher quality care at lower costs. The concept of the patient-centered, clinician-directed medical home is the logical environment for management of chronic diseases. The important difference is that it is the patient’s medical condition that is being managed, rather than management of the funds in a third-party contract designed on a business model that enhances profits. This is not to say that there should be no profits, but the profits should be directed to the portion of the health care delivery system actually providing the care. Pay the medical home to provide the care, not third-party private administrators.
There is still a need to look beyond the sleight-of-hand magical proposals to find solutions to our escalating health care costs. That solution is on the table right in front of the D.C. policy makers, if they’ll only look up long enough to see that a monopsonistic, administratively-efficient, single payer national health program is precisely what would work – for all of us.

Care coordination – a wrong way and a right way

Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries

By Deborah Peikes, PhD; Arnold Chen, MD, MSc; Jennifer Schore, MS, MSW; Randall Brown, PhD
JAMA
February 11, 2009

Objective: To determine whether care coordination programs reduced hospitalizations and Medicare expenditures and improved quality of care for chronically ill Medicare beneficiaries.

Interventions: Nurses provided patient education and monitoring (mostly via telephone) to improve adherence and ability to communicate with physicians. Patients were contacted twice per month on average; frequency varied widely.

Main Outcome Measures: Hospitalizations, monthly Medicare expenditures, patient-reported and care process indicators.

Results: Thirteen of the 15 programs showed no significant (P<.05) differences in hospitalizations; however, (one program had fewer hospitalizations and another had more). None of the 15 programs generated net savings. These programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined. Conclusions: Viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings. Programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care. http://jama.ama-assn.org/cgi/content/full/301/6/603

And…

The Elusive Quest for Quality and Cost Savings in the Medicare Program

John Z. Ayanian, MD, MPP
JAMA
Editorial (on the Peikes, et al study)

With voluntary enrollment of more than 18,000 participants from all US regions, these 15 programs implemented a varied set of approaches to improve care coordination. Common features of the programs included the use of nurses trained as care coordinators to interact on a regular basis with patients who had serious chronic health conditions. These nurses provided patients with health education and sent written reports to their physicians. Participants were substantially sicker than Medicare beneficiaries in general, with much higher rates of cardiovascular disease, diabetes, and chronic lung disease, and correspondingly greater monthly Medicare expenditures before enrollment ($1535 vs $551, respectively). The CMS paid each program a negotiated monthly fee that averaged $235 per participant to provide outreach, health education, and support to these chronically ill patients–and in some cases to their physicians. An independent evaluation of these programs was funded by CMS to assess their effects on quality of care, hospitalizations, and Medicare expenditures in a consistent and rigorous manner.

The financial and clinical results of this careful evaluation were sobering. Only 2 of the 12 largest programs had a statistically significant effect on the annual number of hospital admissions. A hospital-sponsored program in Iowa (Mercy Medical Center) significantly reduced hospitalizations by 17%, with a nonsignificant 9% reduction in Medicare expenditures. In contrast, a retirement center program in Maryland (Charlestown) significantly increased both hospitalizations and expenditures by 19%. When program fees were incorporated in the analysis, total expenditures were 8% to 41% higher (P < .10) in the intervention groups than the control groups for 9 of the 12 largest programs, and no programs reduced expenditures. In the clinical domain, the interventions had only sporadic effects on process measures of quality of care, such as vaccinations, cancer screening, or diabetes services, and had minimal or no effects on patients' functional status and health-related quality of life. Another ongoing Medicare project, the Care Management for High-Cost Beneficiaries Demonstration, is assessing the effectiveness of clinician-directed chronic care management programs. A variety of approaches focused on improving care coordination and home support through patients' own health care practitioners are being tested in 6 sites across the country. Many of these approaches are consistent with new models for patient-centered medical homes that have been endorsed by leading professional organizations in primary care. In addition, CMS is now developing plans to launch the Medicare Medical Homes Demonstration that will pay monthly fees of $40 to $100 per patient to 2000 physicians to coordinate the care of their chronically ill beneficiaries. By involving patients' own physicians in coordinating their care, these programs hold greater promise for achieving better quality of care and possibly cost savings. http://jama.ama-assn.org/cgi/content/full/301/6/668

Comment:

By Don McCanne, MD

Most of the leading proposals for health financing reform include magical (sleight-of-hand) concepts that purportedly would reduce health care costs. One of these is disease management, or chronic care coordination, or whatever label you want to give it.

This study adds to many others that confirm that these programs, as currently structured, do not work. A fee (average $235 per patient per month) paid to an entity that hires a nurse to coordinate care (most frequently through two telephone calls per month) does not reduce the rate of hospitalization, does not generate a net savings, and has only a negligible impact on quality.

This does not mean that there is no place for chronic disease management. Many studies have shown that systems with strong primary care infrastructures do provide higher quality care at lower costs. The concept of the patient-centered, clinician-directed medical home is the logical environment for management of chronic diseases. The important difference is that it is the patient’s medical condition that is being managed, rather than management of the funds in a third-party contract designed on a business model that enhances profits. This is not to say that there should be no profits, but the profits should be directed to the portion of the health care delivery system actually providing the care. Pay the medical home to provide the care, not third-party private administrators.

There is still a need to look beyond the sleight-of-hand magical proposals to find solutions to our escalating health care costs. That solution is on the table right in front of the D.C. policy makers, if they’ll only look up long enough to see that a monopsonistic, administratively-efficient, single payer national health program is precisely what would work – for all of us.

No Day is an Ordinary Day

by doctoraaron
DailyKos
Sun Feb 08, 2009

Saturday was a short day in the office. I came in to handle some paperwork and to see a few patients whom I couldn’t manage to work in over the course of a busy week. It was an ordinary day with a typical, ordinary selection of patients….which is to say, that almost every one came with a story which cried out about how we desperately need change in our health care system.

The first item on my plate was a patient who called to say that the asthma medication he had been on for years and which had allowed him to control his symptoms and stay out of the hospital was no longer covered by his insurance.

I explained to him that there were likely alternatives that would probably work as well and proceeded to compose an email to his pharmacist, outlining the possibilities I wanted him to explore.

From my perspective, the pressure from health care financing sources, be they public or private, to encourage doctors and patients to find equally effective treatment modalities at a lower cost is not wrong. I often appreciate this push. Particularly in an environment where drug companies and medical technology companies are pushing their expensive new treatments or diagnostics as the only way to go, a little pushback can help a busy provider make more appropriate decisions.

What is wrong is when the pushback comes because insurance company “alpha” had made a deal with drug company “beta” that makes drug “A” suddenly “preferred” and drug “B” suddenly “non-formulary” while another insurance company has struck a deal with another drug company to do just the opposite! This wastes my time and leads to patient confusion and non-compliance while serving little or no social benefit. Multiply these arbitrary rules by the three pages of different insurance companies with which I must be involved and you can imagine the daily waste this produces.


My patients are gathered in the waiting room of my office
on December 31, 2008 to discuss health care. A less than ten
minute edited video of this discussion can be seen here.

My first patient, M.R., walked in, largely recovered after his recent hernia surgery, but concerned about the findings of his pre-operative exam when he was noted to have aortic stenosis, a type of heart condition which makes control of his elevated blood pressure even more important. His major concern, however, was to see if I could provide him with free samples of the blood pressure medication, the dose of which had been increased by his cardiologist. His insurance company, like most, only allows him refills once monthly, and with the increased dose he was going to run out earlier than expected.

The rule that patients can only get a month’s worth of medication at their local pharmacy (a three month supply is generally allowed if patients use a mail order service) has its origin in the fact that in our mobile society patients may switch employers, and hence health insurers, fairly often and is tied also to the fact that there are so many uninsured in our country. It is a logical business decision. If an “insured” this month may be an “uninsured” or an insured of a different company the next month, then why allow him to have two months of therapy? Similarly, why take the chance that an insured might pass on medication to an uninsured friend or relative? Of course this would not be a meaningful issue if all health care were covered under a single payer financing system, but that is not the system I deal with.

B.R. slipped in briefly afterwords so I could remove sutures that had been placed a week earlier in the emergency room. While I snipped and pulled them out of the well-healed wound we discussed his gouty arthritis and I reviewed the proper use of his medications. It is good, indeed essential, that there are emergency rooms when we need them, but as he left I considered how much more efficient and cost effective it would be if we had a health care system which would have made it easier for B.S. to have had his stitches placed by his primary care doctor who could manage his gout at the same time.

Next came, G.C., a longstanding patient whom I hadn’t seen for three or more years. Her blood pressure was way up. Why? “I haven’t had insurance, and times are hard.” She had been separated from her husband, an alcoholic and methamphetamine addict, but now they were back together, he was clean and sober and employed with insurance. We joked in a bitter way about how unfair it seemed that she and her husband should not have had health coverage at a time when they needed it most. Understanding the nature of one aspect of the waste generated by the private health insurance industry she sardonically remarked, “My husband works for The cable company. They’ve got a pile of different cable ‘plans’ to choose from. I guess it works the same way with health insurance. The companies spend a lot of our money figuring out “plans” that can extract the most money from each one of us.”

D.E., my next patient, came to update much-delayed health care maintenance evaluations. A lovely, gentle man, this 59 year old handyman carries so-called consumer-directed health insurance because this type of high deductible high co-payment insurance is all he felt he could afford. Unfortunately, the up front costs to him had delayed him from coming to see me. As he confided that he was at a loss, not sure what he was going for health coverage in the future after having this month received a notice that his family’s insurance cost was set to rise by $400 a month, I realized that today’s visit was a way of getting as much done as possible before he would take a chance without insurance.

His predicament reveals the fallacy in the notion that making insurance “available” will somehow lead to people being insured. Instead, it results in patients not buying the medications they need, delaying or avoiding preventive health care, and ultimately, as I suspect D.D. will decide, risking going without insurance at all. A need for even a minor surgery or an illness requiring a few days hospitalization could be all that is needed push D.D. into bankruptcy, joining the 50% of all American bankruptcies caused by health care expenses.

In the interest of completeness, I’ll note that the next two patients, K.N., a 62 year old man with severe heart and kidney failure as a result of a viral infection, whose health coverage comes from the county’s Medicaid HMO, and B.E., who has a private employer-based H.M.O. insurance had no current problems with respect to their health coverage.

I then taught L.Q., a twenty one year old student here for the third time this week for treatment of an abscess, how to care for her wound herself. It probably would have been better to have scheduled one more visit, but as she has no health coverage, even with the deep discounts I had provided for my services, the costs of treating this infection have been adding up.

In considering her care, and the way in which I’ve offered her a discount, I think about the health insurance crisis in this country from my perspective. I serve a wide variety of patients, from all ethnic and economic circumstances, and with many different sources of payment for their care, in my practice. From some I feel well-paid, from some I feel less well paid. Although I try not to let this happen, there are times where this disparity has felt oppressive to me and where I’ve felt it could affect my judgment or my enthusiasm in providing the care a patient needs. Many of my colleagues wrestle with the same issue, some resolving the problem by going outside the usual health care system or restricting their practices to patients or insurers which pay the best; others accepting the reality that even a “poor-payer” pays more than the marginal cost of adding on an extra patient. I have found it difficult to place any limits on my practice based upon ability to pay but find myself longing for a unified system where such disparities would disappear.

E.R. came next, thinking he needed a physical, a result of having paid on his own for a “comprehensive health screening” which had identified a number of problems for which he was advised to follow up with his physician. His insurance plan is actually quite adequate, and the health screening he had paid for included tests which were not only unnecessary, but which are considered by The United States Preventive Health Services Taskforce to be counterproductive, because of their documented uselessness or tendency to lead to bad medical care. As I discussed with him the results of his screening tests and reviewed appropriate health care maintenance guidelines, I mused to myself about how good it would be to have a health care system guided by research into what really works best at lowest cost rather than a system which is pushed primarily by a focus on how to make the most money….

Finally, came M.N., a new patient, a 31 year old research biologist with acne. I enjoyed the visit. We talked about the pathophysiology of acne, the pluses and minuses of the different drugs, and about her work. I decided not to address the fact that her insurance might not allow a dermatology referral because her condition, at her age, was considered cosmetic. I wanted to enjoy just practicing medicine for a moment.

Note: In the interest of developing diverse dialogue on this topic, this essay was first posted in slightly modified form at RedState.com where it was surprisingly well-received…. before it was removed and I was “banned”… for expressing a politically incorrect view?

More Than a Band-Aid for Health Care Reform, Single-Payer is the Solution

By James Floyd, M.D.
Huffington Post
Feb. 11, 2009

As the global economic crisis deepens, our broken health care system continues to neglect an increasing number of uninsured Americans, which will top 50 million this year. Tens of millions more who have health insurance still cannot afford the care they need. The resulting illness from inadequate health coverage will lead to missed days of work and lost jobs, making it harder for us to recover from the recession.

Two weeks ago, the House passed President Obama’s economic stimulus plan, which includes $127 billion in federal funding to expand Medicaid and subsidize health insurance for the unemployed. Most of this has been retained in the Senate version of the bill as well.

These measures are a prelude to Obama’s proposal for comprehensive health care reform, which will likely boil down to increased regulation of the private insurance industry and subsidies for the poor and middle-class to purchase coverage. Some Democrats will fight to include a competing public plan. However, a weak public plan in our current system could easily become a dumping ground for patients with costly and unprofitable illness who are already shunned by private insurers.

There is a better solution that will expand health care access to all Americans and also help our struggling economy: eliminate private health insurance and create a single-payer system that automatically covers everyone under one national health insurance plan. A single-payer system would be funded by progressive income taxation, rather than unaffordable premiums or employer contributions that distort labor markets and leave workers tied to undesirable jobs. It would also address the fundamental problem of costs.

Private health insurers drive up health care spending with unnecessary overhead – high executive salaries, decreased cost-efficiency from smaller insured groups, and profit. They also increase administrative costs for hospitals and physicians who must deal with hundreds of different insurance plans. As a result, Americans spend 31 cents of every health care dollar on administrative costs, by far the highest rate in the world and much higher than the 17 cents spent in Canada.

Further driving up costs is the unrestricted use of expensive and unproven technology and medications. Such waste is best controlled with a centralized system of payment, as has been done successfully by the Veterans Health Administration. A single-payer system would eliminate enough excess spending to provide every American with the same high-quality coverage, without spending more money than we already do.

China recently announced plans to spend $123 billion to provide universal health care for its 1.3 billion citizens. Two decades after free-market reforms dismantled their system of non-profit rural-based care, drugs and visits with physicians are now unaffordable for most of the poor, who often incur crippling debts to pay for care. Chinese economists argue that providing government funding for universal coverage is important for productivity. Also, not having to worry about catastrophic health care costs encourages people to consume rather than save, providing a direct boost to the economy. These same arguments apply to the United States, where half of all personal bankruptcies and home foreclosures are caused by medical bills.

Many politicians agree that a single-payer system is the best way to eliminate wasteful spending and provide health care to every American, but argue that we cannot win a battle with the narrow interests that defend our broken system. To quote President Obama during his inauguration speech: “Stale political arguments that have consumed us for so long no longer apply.” The economic recession and hundreds of billions of dollars in corporate bailouts and stimulus spending have changed everything. It is finally time for us to move to a single-payer system.

James Floyd, M.D., is an internist and health researcher with Public Citizen.

http://www.huffingtonpost.com/james-floyd-md/more-than-a-band-aid-for_b_165112.html

Et Tu, Atul?: Test-Case for a Single-Payer Hypothesis

by Russell Mokhiber
CommonDreams.org
February 10, 2009

A politician says — I support health care for all.

That is a politician you should support, right?

Wrong.

A politician says — I support universal health care.

That is a politician you should support, right?

Wrong.

Universal health care.

Health care for all.

More often than not, these are code words for — keep the private insurance companies in the game.

The only way we are going to dramatically improve the health care system is to get the private insurance companies out of the game.

That means replacing the hundreds of private insurance companies with one payer.

One nation.

One payer.

Single payer.

Single payer already exists for Americans over 65.

It’s called Medicare.

Why not single payer for everyone else?

Because the insurance companies don’t want it.

And they have a lot of money and political influence.

Last week, Tom Daschle was forced to pull out as Obama’s nominee for Secretary of Health and Human Resources because he failed to pay taxes on a limousine and chauffeur.

Or as one DC insider summed up Daschle’s problem — “he’s a limousine liberal who didn’t pay taxes on his limousine.”

But what was widely overlooked in the flood of news last week?

Daschle’s close ties to the health insurance industry.

The fact that he gave speeches to the industry’s key lobbying group — America’s Health Insurance Plans (AHIP) — at $20,000 a pop.

AHIP has one litmus test — you must oppose single payer at all cost.

If you oppose single payer, you are with the insurance industry.

If you favor single payer, you are against the insurance industry.

Daschle opposed single payer.

He was with the insurance industry.

And against the interests of the American people.

Just go down the list of health advocates and advocacy groups — and apply
this test.

Ron Pollack and Families USA — opposed to single payer now.

Physicians for a National Health Program — for single payer now.

SEIU — opposed to single payer now.

California Nurses — for single payer now.

Health Care for American Now — opposed to single payer now.

Public Citizen — for single payer now.

AARP — opposed to single payer now.

And if you dig deep enough, you will find that that most people and groups who are opposed to single payer have ties to the health insurance industry.

I decided to test out my thesis with the case of Atul Gawande.

Gawande is the Boston surgeon and New Yorker writer.

And he’s being pushed by Pollack and others as a replacement for Daschle at HHS.

In his most recent article in the January 26 New Yorker titled Getting There From Here: How Should Obama Reform Health Care? Gawande argues against single payer now.

I started looking to find out whether Gawande had ties to the insurance industry.

And sure enough, there it was.

Gawande is scheduled to give the keynote speech to AHIP’s annual public policy conference on March 11 in Washington, D.C.

So, I shoot off an e-mail to the New Yorker and to Gawande and ask – is Gawande being paid by the health insurance industry for this speech?

And how much has he been paid by the insurance industry for speeches in the past?

And why weren’t New Yorker readers informed of his ties to the industry?

Alexa Cassanos from the New Yorker writes back first.

“Atul Gawande does not accept speaking fees from pharmaceutical or medical-device companies, and speaking payments from insurers or insurance lobbyists are relayed directly to charity,” Cassanos says.
Okay, a follow-up.

Why does he take money from the insurance industry but not from the pharmaceutical or medical device companies?

And how much has he taken from the insurance industry?

On the phone, Cassanos says “there’s no story here,” but that she will try and track down the information.

I next hear from Dr. Gawande, via e-mail, who points me to a just updated (February 6, 2009) conflicts of interest disclosure statement on his web page.

In it, Gawande says: “I don’t benefit financially from speaking to for-profit medical businesses (whether they are drug companies, device
companies, or insurance companies) — either I’m not paid or I arrange for the fee to be donated to charity (including my family’s church, our WHO work in patient safety, and a rural college my father started in India).”

I write back to Dr. Gawande.

I again ask him why he says he will not take money from medical device and pharma companies, but will take money (for his charities) from health insurance companies.

This time, he clarifies what Cassanos from the New Yorker said.

“The reason I haven’t received money from for-profit drug or device manufacturers is that neither have asked me to lecture,” Gawande says. “If either did and I accepted, I would donate the fee to charity or not accept the fee.”

As for his insurance industry ties, Gawande writes:

“Since I decided in April, 2007, to write on health reform policy – I spoke to AHIP once (and the fee I received was donated to charity), I’ve scheduled to speak to AHIP again in March (that fee will be donated to charity), and I’ve not lectured to any for-profit insurers.”

AHIP is of course the lobbying group (technically a non-profit) of the for-profit insurance industry.

“I would have received $31,500 in 2008 after the speaking agency’s 30% fee was taken, and $28,000 in 2009,” Gawande writes.

“I chose the charities independently and AHIP is not informed whom they are,” Gawande says. “The charities are the Trinity Church, Boston, the Student Education Support Association which provides for students attending a nonprofit college my father started in rural India, and the Brigham and Women’s Hospital Foundation for our work with the WHO to reduce unsafe care globally — I am not permitted to benefit financially from these funds.”

Gawande does not reveal what he was paid by the insurance industry prior to April 2007.

He has been speaking to AHIP groups around the country since at least 2004, according to the AHIP web site.

But more importantly, don’t his New Yorker readers deserve to be told that his favorite charities — including his church, a non-profit set up by his father, and a foundation affiliated with the hospital where he works — are benefiting financially – and by how much — when he speaks to the private health insurance industry ?

As for his opposition to single payer, he remains steadfast.

In a q/a with New Yorker readers last week, Gawande defended his opposition to single payer now.

“Replacing the entire health-financing system with Medicare would require most working-age people to leave their current insurance plans,” Gawande writes. “It would change the finances of every hospital and doctor in the country overnight. It would require replacing the premiums we pay with a tax, with massive numbers of both losers and winners. It seems simple in theory, but in practice it never is. This would be a whole new path for health care. No country has swept away their health system and simply replaced it like that. As I said in the article, one would have to be prepared for an overnight change in the way people get 3.5 billion prescriptions, 900 million office visits, 60 million operations – because how these are paid for is critical to whether and how they are provided. Doing away with private insurance coverage is no less sweeping than saying we’ll do away with public insurance programs or do away with employer-paid health care. No major country has simply swept away the way so many people’s care is paid for. And the reason is that people have legitimate fears about what will happen to them.”

Dr. David Himmelstein, a founder of Physicians for a National Health Program, calls this argument “bogus.”

“Patients do not care what their insurance plan is – just that it pays for the care they need. A transition from a system where virtually everyone has only partial coverage to one where they have full coverage is not a disruption for patients,” Himmelstein said when we asked him to respond to Gawande. “Several nations have made abrupt changes in the financing of care. The UK instituted the National Health Service – eliminating insurance and private payment for care at a stroke. Each Canadian province went from a private insurance system very like ours to its current system virtually overnight — though not all provinces underwent the change simultaneously. Taiwan changed to a single payer system about 10 years ago at a stroke.”

“Medicare replaced private coverage for the elderly — who account for about 30% of all hospital patients — about nine months after its passage. That occurred in an era before computers. The entire task of enrolling tens of millions of patients, inspecting virtually every hospital in the nation — to certify that they were desegregated, which was mandated by the Medicare law — and set up a new payment apparatus was carried out using paper records. Why is a shift of the other two-thirds of our system more difficult?”

“The new payment system would be far simpler than the current one — hospitals would receive a global budget, which initially would be based largely on their previous year’s revenues. Medicare currently collects all of the financial info needed to do such budgeting at the outset. Per-patient billing for hospital care would be eliminated. For doctors, Medicare already has a fee schedule, which should be modified somewhat, but already serves as the benchmark for most private plans. Expanding this payment system to cover all fee-for-service billings would be trivial. Paying for drugs is similarly pretty simple and straightforward, with most of the needed infrastructure already in place.”

“In sum, his arguments are bogus unless you assume that we are far less competent than people in other nations, and than we used to be,” Himmelstein said.

Gawande will travel to Washington on March 11 to speak to AHIP.

The title of his speech — Fixing Health Care from the Inside Out: The Physician’s Role in Health Care Reform.

The majority of physicians in the United States now support a single payer system.

Dr. Gawande does not and is coddling the private health insurance industry.

When Daschle was driven out of office last week, a DC insider made the following observation:

When people first come to Washington, they see it as a putrid swamp that breeds corruption.

But after they stay awhile, they begin to see it as a hot tub.

Et tu, Atul?

Russell Mokhiber is editor of the Washington, D.C.-based Corporate Crime Reporter.

CBO's Elmendorf on single payer, and a Medicare-like option

Expanding Health Insurance Coverage and Controlling Costs for Health Care

Testimony of Douglas W. Elmendorf, Director, Congressional Budget Office
United States Senate
Committee on the Budget
February 10, 2009
The government could also design an insurance option based on Medicare that would be made more broadly available, on a voluntary basis, to the nonelderly population. The federal costs per enrollee would depend primarily on the benefits that system provided; the rates used to pay doctors, hospitals, and other providers of health care; and the extent of any premium subsidies that were offered to enrollees — all of which could differ from Medicare’s current design. As for whether such a plan would be more or less costly than a private health insurance plan that provided the same benefits to a representative group of enrollees, the answer would vary geographically. Assuming that Medicare’s current rules applied, those costs would be comparable in many urban areas, but in other areas, the cost of the government-run plan would be lower (as is evident in the current program through which Medicare beneficiaries may enroll in a private health plan). At the same time, because Medicare currently provides broad access to doctors and hospitals and employs little benefit management, a Medicare-based option might attract relatively unhealthy enrollees, which could drive up its premiums, federal costs, or both.
Many of the same considerations would arise in designing a single-payer, Medicare-for-all system, but that approach might raise some unique issues as well — and the scale of its impact on federal costs could obviously be much larger if nearly all of the population was covered. Enrollees could be offered a choice of plans under a single-payer system (as happens in Medicare). If, instead, only one design option was offered and all residents were required to enroll in it, then concerns about adverse selection would not arise. That approach could also reduce the administrative costs that doctors and hospitals currently incur when dealing with multiple insurers. The lack of alternatives with which to compare that program, however, could make it more difficult to assess the system’s performance. More generally, that approach would raise important questions about the role of the government in managing the delivery of health care.
Douglas Elmendorf’s written testimony (34 pages):
http://budget.senate.gov/democratic/testimony/2009/02-10-HealthElmendorf_Testimony.pdf

In his testimony before the Senate Budget Committee, CBO Director Douglas Elmendorf discussed considerations for expanding coverage, and considerations and options for controlling costs and improving efficiency, including a discussion of options under consideration that might not be effective in controlling spending. Most of his comments were confined to various policies that currently are hot topics in the Washington dialogue on reform.
It is no surprise that his discussion of single payer was no more than a tangential paragraph buried in the middle of his written testimony. This seems to reflect their view that single payer has been dismissed as a serious proposal that might have any chance of being enacted.
What might surprise the progressive community is that the proposal to offer the option of purchasing a Medicare-like plan within a market of private health insurance plans has also been relegated to a tangential paragraph, adjacent to the single payer paragraph. It appears that the Congressional Budget Office and the Senate Budget Committee do not consider the controversial Medicare-like option to be a proposal worth serious consideration (likely because of strong Republican opposition, not to mention AHIP’s opposition).
What Elmendorf does say about a Medicare-like option is that design is very important in determining the impact that it would have. He also states, as we have stated before, that a Medicare-like option would be subject to adverse selection, creating much greater challenges in the financing of such an option.
But look at what he says about single payer with “only one design option” (an improved Medicare program). It would cover everyone, eliminate adverse selection, shift funding to the federal government (through equitable tax policies), and reduce administrative costs. Sounds pretty good.
Though he states that single payer would “raise important questions about the role of the government,” aren’t those the questions that are already being raised today. When the financial systems don’t work, the government needs to step in.

CBO's Elmendorf on single payer, and a Medicare-like option

Expanding Health Insurance Coverage and Controlling Costs for Health Care

Testimony of Douglas W. Elmendorf, Director, Congressional Budget Office
United States Senate
Committee on the Budget
February 10, 2009

The government could also design an insurance option based on Medicare that would be made more broadly available, on a voluntary basis, to the nonelderly population. The federal costs per enrollee would depend primarily on the benefits that system provided; the rates used to pay doctors, hospitals, and other providers of health care; and the extent of any premium subsidies that were offered to enrollees — all of which could differ from Medicare’s current design. As for whether such a plan would be more or less costly than a private health insurance plan that provided the same benefits to a representative group of enrollees, the answer would vary geographically. Assuming that Medicare’s current rules applied, those costs would be comparable in many urban areas, but in other areas, the cost of the government-run plan would be lower (as is evident in the current program through which Medicare beneficiaries may enroll in a private health plan). At the same time, because Medicare currently provides broad access to doctors and hospitals and employs little benefit management, a Medicare-based option might attract relatively unhealthy enrollees, which could drive up its premiums, federal costs, or both.

Many of the same considerations would arise in designing a single-payer, Medicare-for-all system, but that approach might raise some unique issues as well — and the scale of its impact on federal costs could obviously be much larger if nearly all of the population was covered. Enrollees could be offered a choice of plans under a single-payer system (as happens in Medicare). If, instead, only one design option was offered and all residents were required to enroll in it, then concerns about adverse selection would not arise. That approach could also reduce the administrative costs that doctors and hospitals currently incur when dealing with multiple insurers. The lack of alternatives with which to compare that program, however, could make it more difficult to assess the system’s performance. More generally, that approach would raise important questions about the role of the government in managing the delivery of health care.

Douglas Elmendorf’s written testimony (34 pages):
http://budget.senate.gov/democratic/testimony/2009/02-10-HealthElmendorf_Testimony.pdf

Comment:

By Don McCanne, MD

In his testimony before the Senate Budget Committee, CBO Director Douglas Elmendorf discussed considerations for expanding coverage, and considerations and options for controlling costs and improving efficiency, including a discussion of options under consideration that might not be effective in controlling spending. Most of his comments were confined to various policies that currently are hot topics in the Washington dialogue on reform.

It is no surprise that his discussion of single payer was no more than a tangential paragraph buried in the middle of his written testimony. This seems to reflect their view that single payer has been dismissed as a serious proposal that might have any chance of being enacted.

What might surprise the progressive community is that the proposal to offer the option of purchasing a Medicare-like plan within a market of private health insurance plans has also been relegated to a tangential paragraph, adjacent to the single payer paragraph. It appears that the Congressional Budget Office and the Senate Budget Committee do not consider the controversial Medicare-like option to be a proposal worth serious consideration (likely because of strong Republican opposition, not to mention AHIP’s opposition).

What Elmendorf does say about a Medicare-like option is that design is very important in determining the impact that it would have. He also states, as we have stated before, that a Medicare-like option would be subject to adverse selection, creating much greater challenges in the financing of such an option.

But look at what he says about single payer with “only one design option” (an improved Medicare program). It would cover everyone, eliminate adverse selection, shift funding to the federal government (through equitable tax policies), and reduce administrative costs. Sounds pretty good.

Though he states that single payer would “raise important questions about the role of the government,” aren’t those the questions that are already being raised today. When the financial systems don’t work, the government needs to step in.

A Sworn Foe of Single-Payer

Why Sanjay Gupta is the Wrong Man for the Top US Health Job

By VICENTE NAVARRO
CounterPunch
February 9, 2009

President Obama has put forward the name of Dr. Sanjay Gupta, the well-known chief medical correspondent for CNN, for the position of surgeon general of the U.S. Public Health Service — the chief public health officer of the federal government. Dr. Gupta has received wide acclaim as the most important voice on medical matters in the U.S. broadcasting industry. And CNN has played an important role in developing and promulgating the U.S. establishment’s conventional wisdom on what is happening in the country’s medical care. Dr. Gupta has been a major force in the promotion of that wisdom.

It is important that before discussing the appropriateness of President Obama’s choice for surgeon general, I make a few points about the role of the mainstream media, including CNN, in the country’s affairs, in particular, in its major international and domestic conflicts — that is, conflicts not only in, for example, Iraq and Vietnam, but also at home.

As we know, in the buildup to and conduct of the Iraq war, the mainstream media played a crucial role — supporting the invasion and occupation, and uncritically reproducing the Bush administration’s justification for this intervention. The mainstream media considered it their primary role to promote the conventional wisdom on this war, and not to challenge or question it. Not until 4,226 Americans and 654,965 Iraqis had been killed did CNN and the other mainstream media start questioning President Bush’s and the establishment’s justifications for the Iraq War. And it is important to remember that, before reaching this point, CNN and the other mainstream media had consistently ignored, marginalized, or ridiculed those voices that were explaining how the justifications for war had no credibility.

This series of events was nothing new. The same thing had happened with the Vietnam War. This reality on the role of the mainstream media is well known both in the U.S. and abroad. A primary function of the U.S. broadcasting industry is to reproduce the establishment’s position on whatever conflict the country is involved in at the time. But not so well known is the mainstream media’s (including CNN’s) role in the wars at home.

The silent domestic war: invisible casualties

There are types of war other than invasions and occupations abroad occurring right here, in the U.S.A., with deaths, casualties, and enormous suffering — wars taking place without producing a sound. One of them takes place on a daily basis. It is the war carried out by forces in the U.S. that, in defense of their interests, fight to prevent the establishment of one of the basic human rights: access to medical care in time of need — a right, found in all other developed countries but still denied to the citizenry of the U.S. sixty years after President Truman tried to establish it. As a consequence of this, many thousands of people die in the U.S. each year — from 18,000 to more than 100,000, depending on how one defines preventable death — due to lack of medical care. Even if we take the lower figure of 18,000 (given by the conservative Institute of Medicine), this is six times the number of people killed in the World Trade Center on 9/11. That event outraged the entire nation (as, indeed, it should), but the death toll due to lack of medical care seems to go unnoticed. These deaths are not reported on the front pages (or any other pages) of the mainstream newspapers. These deaths are so much a part of everyday reality for millions of ordinary people in the U.S. that they are not even news. Nor are the facts that 102 million people have insufficient health care coverage, that 44 per cent of terminally ill patients worry about how they or their families are going to pay their medical bills, that the inability to pay medical bills is a primary cause of family bankruptcy in the U.S., and that more than 50 per cent of spending on health care by elderly Americans is still not covered by Medicare — the federal program that was supposed to alleviate the health-care-related worries, concerns and anxieties of our elders. None of these facts are news. Again, they are so much a part of everyday life that they are not considered newsworthy.

And there are many other, closely related facts that rarely appear in the news media. One such fact is that the insurance and pharmaceutical industries, among the most profitable industries in the U.S., are largely responsible for the scandalous situation of the medical care non-system. Besides the “military-industrial complex,” responsible for the Iraq and Vietnam wars, there is an “insurance-pharmaceutical industrial complex,” responsible for the war at home — an industrial complex that is frequently behind the news programs that so rarely report on this war. The insurance and pharmaceutical industries are extremely profitable. In 2007, insurance company profits were $12 billion and pharmaceutical industry profits $40 billion, among the highest industry profits in the U.S. and in the world. And this insurance-pharmaceutical complex holds enormous economic, political and media power in our country. For example, the economic power of the pharmaceutical industry is used to create artificially high prices for its products. Just one example: Lanzoprasol, a widely used gastric-secretion-reducing medicine, costs $329 in Baltimore, Maryland, but (for the same product, same dose) $9 in Barcelona, Spain (yes, you read correctly: $9). How can this situation be tolerated? Because, in the U.S., economic power means political power, and political power is facilitated by privatization of the electoral process. These industries buy and influence the political process by donating money to leading politicians whose decisions affect their interests. According to the Center for Responsive Politics, the insurance industry contributed $2,185,727 and the drug industry $1,927,159 to the Obama campaign.

The economic and political power of these industries could not be sustained or reproduced, however, without their media power, through their funding of medical and health news and programs in the broadcasting industry (including CNN) that promote their views.

All of this leads me to the Obama administration’s choice to head the U.S. Public Health Service (USPHS). First, let me clarify what the USPHS is. This body (with 6,000 health professionals) is the federal agency in charge of the U.S. government institutions and programs responsible for taking care of the population’s public health needs. It is also responsible for the federal research institutes, such as the National Institutes of Health. In addition, the Obama administration has decided that the head of the USPHS will play a leading role on the task force in charge of reforming the nation’s health care.

The person chosen by President Obama to fill this position is Dr. Sanjay Gupta, a neurosurgeon at Emory Medical School in Atlanta and chief health correspondent for CNN. Dr. Gupta hosts a health program on CNN, sponsored by the medical and pharmaceutical industries, that popularizes today’s medical “miracles” and medical interventions. The program tends to focus on new technologies in clinical medicine and on preventing disease through changes in individual behavior. You are unlikely to see on this program any reports on the human tragedies caused by the nation’s insurance-based health care non-system, or on the economic abuses of the pharmaceutical industry. The program is presented very smoothly and attractively by Dr. Gupta — described byPeople as one of the sexiest men in the U.S.A. Gupta also hosts other medical-industry-sponsored TV programs and writes a column in Time.He also co-hosts Turner Private Network’s monthly show Accent Health, which airs in doctors’ offices around the country and is a major conduit for targeted ads from the pharmaceutical industry. And, according to Physicians for a National Health Program, in 2003 he downplayed the concerns of the medical community about Vioxx, which was removed from the market a year later by its manufacturer, Merck. Gupta lent support to John McCain’s position that in the U.S., buying private health insurance in the open market is a viable option for most Americans, which is profoundly inaccurate. For the vast majority of people who are without health benefits coverage, it is because they or their employers cannot afford to pay the premiums and costs involved.

On his CNN program, Gupta tried to discredit Michael Moore’s documentary film Sicko, which is critical of the insurance-based U.S. health care system, by accusing Moore of presenting incorrect facts and manipulating data — strong accusations aimed at challenging Moore’s credibility. The problem with Gupta’s critique was that, as Paul Krugman noted, it was not Michael Moore but Sanjay Gupta who had his facts wrong and clearly manipulated the data and their presentation. Gupta gave erroneous figures on per capita expenditures and on health indicators in the U.S. and other countries (including Cuba), and he did not correctly identify one of the individuals on his program who was critical of Moore’s documentary: Gupta presented him as an academic, but, in fact, he was a Republican consultant to the insurance industry.

Gupta showed a remarkable ignorance about the health care systems in several European countries. He tried to dismiss France’s universal health care program (defined by WHO as the best in the world) as nonviable economically. He reproduced the widely held erroneous belief that the universal and extensive welfare states in European countries are making their economies very uncompetitive. He stressed that the cost of universal health care in France is creating a public deficit that is a huge handicap to that country’s economic development. In fact, in percentage terms, the U.S. government deficit is larger than the French government deficit and, according to Davos (the Vatican of neoliberal thought), the French economy is as competitive as the U.S. economy, with higher productivity than the U.S. Moreover, the public medical care expenditures per capita are larger in the U.S. than in France. While France provides comprehensive benefits to its population, the U.S. does not. With a smaller amount of public funds, France and the majority of developed countries provide comprehensive coverage that will be a dream for the majority of our people.

I find it highly worrisome that Dr. Sanjay Gupta is likely to be appointed head of the USPHS. He is not an expert on public health and is not sufficiently knowledgeable, or competent, to do the job. Training and experience in neurosurgery do not provide the public health knowledge that the position requires. But, what is far more alarming is that he will most likely be the media spokesperson for the task force on health care reform. And this means that a person hostile to a single-payer system (the type of system that has most support among people in the U.S.); a person clearly unsympathetic to the principle of the government’s guaranteeing universality of health care coverage; a person who is part of the media that have been obfuscating, negating, and avoiding the real problems in health and medical care in this country , will be in control of selling the message of change in U.S. medical care. Is this the change we were promised by candidate Obama?

For the good of the country, I hope President Obama will be a leading force for change in our medical care non-system. The way of funding and organizing medical care in the U.S. is simply wrong. It is not only that 46 million people do not have any form of insurance, but that the majority of health benefits coverage offered by the insurance industry is, besides expensive, insufficient. As it now stands, the system cannot be shifted toward guaranteeing the basic human right of access to health care in time of need without confronting the insurance-pharmaceutical complex. And the extent of commitment to this human right can be measured by the degree to which President Obama is willing to confront this industrial complex.

A final note. I paid special attention to President Obama’s call for a sense of patriotism in his eloquent inaugural address. Love of country is something we can measure. And one measure is the degree to which government guarantees that ordinary people have the right to access to health care. Without that right, the U.S. will not be seen as a credible voice for human rights in the world. It is as simple as that. It is an indicator of how far we have to go that, currently, our major credential for being a country that respects human rights is a guarantee by the Obama administration that the U.S. government will not officially torture. Noble though this purposeis, it is a rather limited and unambitious promotion of a nation’s image. It would have created a much better image, at home and abroad, if, on his first day in office, President Obama had signed an executive order committing our government to establishing the human right of access to health care in time of need for every person living in the U.S. — complying, at last, with the United Nations declaration on human rights that — at least until now — the U.S. government has never respected.

Vicente Navarro, M.D., Ph.D., professor of Health Policy at The Johns Hopkins University and editor-in-chief of the International Journal of Health Services. The opinions expressed here are those of the author and do not necessarily reflect the views of the institutions with which he is affiliated. Dr Navarro can be reached at vnavarro@jhsph.edu

http://www.counterpunch.org/navarro02092009.html

CBO’s Elmendorf on single payer, and a Medicare-like option

Expanding Health Insurance Coverage and Controlling Costs for Health Care

Testimony of Douglas W. Elmendorf, Director, Congressional Budget Office
United States Senate
Committee on the Budget
February 10, 2009

The government could also design an insurance option based on Medicare that would be made more broadly available, on a voluntary basis, to the nonelderly population. The federal costs per enrollee would depend primarily on the benefits that system provided; the rates used to pay doctors, hospitals, and other providers of health care; and the extent of any premium subsidies that were offered to enrollees — all of which could differ from Medicare’s current design. As for whether such a plan would be more or less costly than a private health insurance plan that provided the same benefits to a representative group of enrollees, the answer would vary geographically. Assuming that Medicare’s current rules applied, those costs would be comparable in many urban areas, but in other areas, the cost of the government-run plan would be lower (as is evident in the current program through which Medicare beneficiaries may enroll in a private health plan). At the same time, because Medicare currently provides broad access to doctors and hospitals and employs little benefit management, a Medicare-based option might attract relatively unhealthy enrollees, which could drive up its premiums, federal costs, or both.

Many of the same considerations would arise in designing a single-payer, Medicare-for-all system, but that approach might raise some unique issues as well — and the scale of its impact on federal costs could obviously be much larger if nearly all of the population was covered. Enrollees could be offered a choice of plans under a single-payer system (as happens in Medicare). If, instead, only one design option was offered and all residents were required to enroll in it, then concerns about adverse selection would not arise. That approach could also reduce the administrative costs that doctors and hospitals currently incur when dealing with multiple insurers. The lack of alternatives with which to compare that program, however, could make it more difficult to assess the system’s performance. More generally, that approach would raise important questions about the role of the government in managing the delivery of health care.

Douglas Elmendorf’s written testimony (34 pages):
http://budget.senate.gov/democratic/testimony/2009/02-10-HealthElmendorf_Testimony.pdf

Comment:

By Don McCanne, MD

In his testimony before the Senate Budget Committee, CBO Director Douglas Elmendorf discussed considerations for expanding coverage, and considerations and options for controlling costs and improving efficiency, including a discussion of options under consideration that might not be effective in controlling spending. Most of his comments were confined to various policies that currently are hot topics in the Washington dialogue on reform.

It is no surprise that his discussion of single payer was no more than a tangential paragraph buried in the middle of his written testimony. This seems to reflect their view that single payer has been dismissed as a serious proposal that might have any chance of being enacted.

What might surprise the progressive community is that the proposal to offer the option of purchasing a Medicare-like plan within a market of private health insurance plans has also been relegated to a tangential paragraph, adjacent to the single payer paragraph. It appears that the Congressional Budget Office and the Senate Budget Committee do not consider the controversial Medicare-like option to be a proposal worth serious consideration (likely because of strong Republican opposition, not to mention AHIP’s opposition).

What Elmendorf does say about a Medicare-like option is that design is very important in determining the impact that it would have. He also states, as we have stated before, that a Medicare-like option would be subject to adverse selection, creating much greater challenges in the financing of such an option.

But look at what he says about single payer with “only one design option” (an improved Medicare program). It would cover everyone, eliminate adverse selection, shift funding to the federal government (through equitable tax policies), and reduce administrative costs. Sounds pretty good.

Though he states that single payer would “raise important questions about the role of the government,” aren’t those the questions that are already being raised today. When the financial systems don’t work, the government needs to step in.