PNHP

Canadian health care better and cheaper than U.S., says research

Canadian health care better and cheaper than U.S., says research

Joanne Laucius
CanWest News Service
Ottawa Citizen
Tuesday, January 08, 2008

OTTAWA – Canada’s health care system offers “excellent value for the money” says a British researcher who has studied preventable deaths in 19 industrialized nations.

The study, to be released today in Health Affairs, looks at “amenable mortality” – deaths that would not have occurred if effective health care had been available.

Conditions that caused these deaths included bacterial infections, treatable cancers, diabetes, some cardiovascular disease and the complications of common surgical procedures. The study, which looked at figures from 2002-03, updated a similar report based on 1997-98 figures. Its goal was to compare amenable deaths in the United States with 14 western European nations, plus Canada, Australia, New Zealand and Japan.

The study also tracked whether gaps in these countries had narrowed or widened. The figures were computed according to amenable deaths per 100,000 population under the age of 75. In the first study, the researchers found that amenable deaths in the U.S. stood at 114.74 per 100,000 population, exceeded only by Ireland, Portugal, Finland and the United Kingdom.

In that time period, Canada’s amenable mortality rate was 88.77 – the seventh-lowest rate after France, Japan, Spain, Australia, Sweden and Italy. In the most recent study, Canada’s amenable death rate had dropped to 76.83, putting Canada sixth after France, Japan, Australia, Spain and Italy.

Meanwhile, amenable mortality rates in the U.S. have barely budged from 114.74 to 109.65 in 2002-03, taking the U.S. from 15th place to last place among the 19 countries.

“This study shows that Canada’s health system has performed very well in its ability to prevent people from dying from treatable conditions,” said Martin McKee, a researcher at the London School of Hygiene and Tropical Medicine, and co-author of the study. “While everyone has to die from something, sometime, in an ideal world, no-one would die from the causes we have looked at, in the age groups we have included.” Of course, we don’t live in an ideal world, said said McKee. “However, the bottom line is that the Canadian health system delivers outcomes that are substantially better than those in its southern neighbour.”

More importantly, outcomes in Canada are improving more quickly than those in the U.S., he said. “Given that the U.S health care system is far more expensive, this suggests that Canadians are getting excellent value for money.”

The researchers expect there will be further improvements in amenable mortality rates in industrialized countries, but the rate will slow down.

The most significant gains were made in the 1970s and 1980s, when drugs to treat common conditions such as hypertension became widely available, said McKee. That raises questions about whether the U.S. will be able to narrow the gap between itself and countries with much lower amenable mortality rates, he said. “Other research shows that many Americans are unable to afford the prescription drugs they need,” said McKee.

“So, if some future administration can tackle this then we could see real improvements there.” In countries like Canada, he expects the main gains will be less in amenable mortality and more the the quality of life, especially for older people.

Health spending growth slower than what?

National Health Spending In 2006: A Year Of Change For Prescription Drugs

By Aaron Catlin, Cathy Cowan, Micah Hartman, Stephen Heffler the National Health Expenditure Accounts Team
Health Affairs
January/February 2008

Health care spending in the United States grew 6.7 percent to $2.1 trillion, or $7,026 per person, in 2006. This rate of growth was slightly faster than the 6.5 percent rate in 2005, which marked the slowest growth since 1999. Health spending accounted for 16.0 percent of gross domestic product (GDP) in 2006. In 2006, health spending growth outpaced nominal GDP growth by 0.6 percentage point.

http://content.healthaffairs.org/cgi/content/full/27/1/14

And…

Don’t Break Out The Champagne: Continued Slowing Of Health Care Spending Growth Unlikely To Last

By Paul B. Ginsburg

Aaron Catlin and colleagues report a fourth year of slowing of the rate of growth of personal health care spending. But many factors indicate that relief for purchasers and consumers will be short-lived. Research on local health care markets suggests that rapid expansion of provider capacity and incentives to increase volume of care are continuing. Increasing incidence of obesity is a major factor behind rising costs. The influence of the economic cycle on health spending, which has lowered the trend in recent years, is likely to reverse its impact shortly.

Hospital activity

Hospitals have been expanding capacity, not predominantly by adding new beds but by expanding specialized facilities (such as operating rooms and imaging facilities) needed to serve patients with the latest technology. When hospitals do increase inpatient beds, the new construction typically occurs in rapidly growing suburbs, where well-insured patients live. Competing hospital systems also have expanded into some communities where hospital systems have already established dominance, raising concerns about overcapacity.

HSC researchers have documented the hospital “specialty-service line” strategy, and such strategies are continuing. Hospitals have identified the types of services that are most profitable–under a mix of diagnosis-related group (DRG), per diem, and discounted charge reimbursement–and are expanding capacity to provide those services. Interviews with hospital executives suggest that the profitability of the services is the key to developing a service line, with cardiac procedures often topping the list. As one hospital chief executive officer (CEO) told me in response to a question about capital spending priorities: “We just list the specialty lines by profitability and go down the list.” We found no hospitals developing a mental health service line; such admissions generally are considered money losers.

Physician activity

More entrepreneurial physicians have recognized the opportunities for particularly high returns from facility, as opposed to professional, payments for procedures such as imaging, endoscopies, and cardiac tests, which are performed in outpatient settings, as well as outpatient surgery. They have formed ventures to open facilities to perform these services, either jointly with hospitals or to compete with hospitals. Physicians also have brought capabilities to perform profitable ancillary services into their offices, sometimes forming larger single-specialty group practices to achieve the scale needed.

“Medical arms race”

Before the managed care era, many health policy researchers concluded that increased capacity led to greater use of services. With extensive authorization requirements and use of capitation in the early 1990s, concerns about the “medical arms race” receded. But with the loosening of managed care restrictions, the medical arms race has resurfaced.

Self-referral incentives

Today, as more physicians have an increased financial stake in the provision of services, self-referral incentives apply to a much larger portion of health care spending than in the past.

Two other macro factors

Two macro factors tend to discourage optimism about continued slowing in cost growth. Research by the CMS National Health Expenditures group and by outside economists and actuaries has established the role of the economic cycle in health spending trends. As mentioned in last year’s paper on spending trends, a portion of the slowing in trends over the past few years may in fact be the lagged impact of the 2001 recession, indicating that the impact of recent years of economic recovery and rapid growth on health spending trends is likely to be ahead of us.

The other factor is trends in obesity prevalence.

The reduction in the trend of spending has been a welcome development to those who pay for health care. But it would be a stretch to conclude that the corner has been turned in dealing with the long-term gap between growth in health spending and growth in income and the resulting financial pressures. This diminishing trend has already led to a reduced intensity in efforts to address costs on the part of employers and may be contributing to more-aggressive activities by providers to boost their revenues. With GDP growth starting to slow and most forecasters predicting further slowing, concerns about cost trends are likely to only increase.

http://content.healthaffairs.org/cgi/content/full/27/1/30

Comment:

By Don McCanne, MD

Increases in health care spending continue to outpace increases in wages, and it is only going to get much worse. Paul Ginsburg tells us why. The players in the health care delivery system are busy chasing the buck with ever more excessive high-tech services and facilities, while only cursory attention is being given to actual health care needs (or sometimes no attention, as in mental health).

That we continue to tolerate such a system, we should hang our heads in shame.

Add Insurance Industry to the Iowa Loss Column

Rose Ann DeMoro
The Huffington Post
January 4, 2008

As the scorecard in Iowa is tallied, add insurance companies to the loser camp along with the disgraceful, rhetorical sham that forcing individuals to buy insurance is universal healthcare.

Individual mandate, the policy wonk lingo for requiring the uninsured to purchase private insurance premiums, was the key talking point of Sen. Hillary Clinton’s attack on Sen. Barack Obama in Iowa.

In speech after speech Clinton lambasted Obama for “leaving out” millions because his health plan does not include individual mandate. In the final days leading up to the caucuses, Iowans were barraged with robo calls reinforcing that theme.

While many Iowans, like other Americans yearn for genuine, comprehensive healthcare reform, it’s safe to conclude the tactic did not work. Volunteers on the ground report that healthcare was increasingly the main issue for many Iowans, and numerous voters echoed Obama’s response, as noted in one of his ads opposing the proposal to “force those who can not afford health insurance to buy it, punishing those who don’t fall in line.”

Simply put, the mandate doesn’t solve the problem; it just pads the pockets of insurance corporations who are not exactly scrapping for cash. Indentured servitude to the insurance pirates is hardly a humane or sound healthcare policy.

Clinton made individual mandate a national referendum in Iowa with a stance parroted by several national columnists and supposed healthcare experts who have also embraced it as the deceptive synonym for universal care. And Iowans responded.

It’s not confined to Clinton, of course. Individual mandate is also the centerpiece of Sen. John Edwards’ health plan, Mitt Romney’s law in Massachusetts, and the bill proposed for California by Gov. Arnold Schwarzenegger and state Assembly Speaker Fabian Nunez. Thus the significance of the Iowa vote.

To be clear, Sen. Obama’s health plan shares much in common with Clinton and Edwards in an ongoing reliance on private insurers, and a failure to crack down on insurance denials of care or price gouging.

But Obama deserves credit for not jumping on a bandwagon that plunged off a cliff in Iowa and whose wheels are already coming off in Massachusetts.

In Massachusetts the deadline in that state for buying insurance was December 31. According to national census figures only 44 percent of the state’s uninsured had purchased the mandated policies. And most of those who have enrolled – 79 percent – get full or public subsidies; in other words, the state is using public money to enrich the insurance industry.

But Massachusetts officials are apparently also ignoring the evidence. Their response was to quadruple the tax penalties for those who fail to buy insurance, even while acknowledging that premiums may go up as much as 14 percent next year.

In his election night speech, Edwards described the poignant case of Nataline Sarkisyan, the 17-year old California teenager who died in late December after her insurer, CIGNA, denied a liver transplant until it was too late, even though the transplant had been recommended by her doctors. CIGNA, which like all insurers terms payments for care a “medical loss ratio,” only changed its stance after public humiliation prompted by protests largely organized by the California Nurses Association/National Nurses Organizing Committee.

Los Angeles Times columnist Steve Lopez this week told the story of 10-year-old Preston afflicted with cystic fibrosis whose insurer Blue Cross has just raised his bills for vital medication he needs to keep breathing from $30 a month to $784.

These are the corporations we want to reward by giving them tens of millions of new customers marched into their offices under threat of tax penalties, or as proposed in California, garnishing their wages?

It’s long past time to wrench control of our health out of the hands of CIGNA and Blue Cross and return it to where it belongs, to the medical professionals at the bedside in consultation with patients and their families.

There’s only one way to accomplish that, with a fundamental overhaul that gets insurance companies out of the way. The day of the Iowa vote, columnist Robert Novak, of all people, reported in the Washington Post that “one longtime Democratic consultant, not involved in any campaign this time, suggested that Clinton propose a genuine universal health-care scheme” which Novak conceded was “a simplified, though far-reaching, health-care plan” – having “everybody covered by Medicare.”

Clinton and her advisers rejected that advice. In the wake of Iowa, she might want to re-consider. There is such a proposal now in Congress, HR 676. All the leading candidates should endorse it. In the meantime, let’s heed the call of Iowa, discard the notion of forced mandates, and tear off the yoke of the insurance industry once and for all.

U.S. Has Most Preventable Deaths Among 19 Nations

Nearly 100,000 excess deaths annually in United States

Measuring the Health of Nations: Updating an Earlier Analysis

Ellen Nolte, Ph.D., and C. Martin McKee, M.D., D.Sc.
Health Affairs
January 8, 2008 | Volume 98

In the Literature

In a Commonwealth Fund-supported study comparing preventable deaths in 19 industrialized countries, researchers found that the United States placed last. While the other nations improved dramatically between the two study periods — 1997-98 and 2002-03 — the U.S. improved only slightly on the measure.

In “Measuring the Health of Nations: Updating an Earlier Analysis” (Health Affairs, Jan./Feb. 2008), Ellen Nolte, Ph.D., and C. Martin McKee, M.D., D.Sc., both of the London School of Hygiene and Tropical Medicine, compared international rates of “amenable mortality”–that is, deaths from certain causes before age 75 that are potentially preventable with timely and effective health care. In addition to the U.S., the study included 14 Western European countries, Canada, Australia, New Zealand, and Japan. According to the authors, if the U.S. had been able reduce amenable mortality to the average rate achieved by the three top-performing countries, there would have been 101,000 fewer deaths annually by the end of the study period.

The concept of amenable mortality was developed in the 1970s to assess the quality and performance of health systems and to track changes over time. For this study, the researchers used data from the World Health Organization on deaths from conditions considered amenable to health care, such as treatable cancers, diabetes, and cardiovascular disease.

U.S. Ranks Last

Between 1997Ć¢ā‚¬ā€œ98 and 2002Ć¢ā‚¬ā€œ03, amenable mortality fell by an average of 16 percent in all countries except the U.S., where the decline was only 4 percent. In 1997Ć¢ā‚¬ā€œ98, the U.S. ranked 15th out of the 19 countries on this measure–ahead of only Finland, Portugal, the United Kingdom, and Ireland–with a rate of 114.7 deaths per 100,000 people. By 2002Ć¢ā‚¬ā€œ03, the U.S. fell to last place, with 109.7 per 100,000. In the leading countries, mortality rates per 100,000 people were 64.8 in France, 71.2 in Japan, and 71.3 in Australia.

The largest reductions in amenable mortality were seen in countries with the highest initial levels, including Portugal, Finland, Ireland, and the U.K, but also in some higher-performing countries, like Australia and Italy. In contrast, the U.S. started from a relatively high level of amenable mortality but experienced smaller reductions.

Many Lives in U.S. Could Be Saved

The researchers estimated the number of lives that could have been saved in 2002 if the U.S. had achieved either the average of all countries analyzed (except the U.S.) or the average of the three top-performing countries. Using this formula, the authors estimated that approximately 75,000 to 101,00 preventable deaths could be averted in the U.S. “[E]ven the more conservative estimate of 75,000 deaths is almost twice the Institute of Medicine’s (lower) estimate of the number of deaths attributable to medical errors in the United States each year,” the authors say.

Future Implications

The rate of amenable mortality is a valuable indicator of health care performance, say the authors–one that can point to potential weaknesses in a nation’s health system that require attention. “[T]he findings presented here are consistent with other cross-national analyses, demonstrating the relative underperformance of the U.S. health care system in several key indicators compared with other industrialized countries,” they say.

Citation: E. Nolte and C. M. McKee, Health Affairs, January/February 2008, 27(1):58-71

US has worst record of death from treatable disease

By Nicholas Timmins
Financial Times
January 8 2008

More US patients die from diseases that could be treated by timely intervention than in any other leading industrialised country, a study by top health academics showed yesterday.

A decade ago, the US had the fourth worst record among a group of 19 industrialised countries in terms of deaths per 100,000 people from diseases that are amenable to treatment. These include infections, treatable cancers, diabetes, and heart and vascular disease, according to Ellen Nolte and Martin McKee of the London School of Hygiene and Tropical Medicine.

Over the succeeding five years, the number of such deaths in the US fell from 115 per 100,000 to 110. But other countries improved faster, leaving the US with the worst record, behind Portugal, Ireland and the UK, where the preventable death rate runs at 103 or 104 per 100,000.

“If the US performed as well as the top three countries in the study” – France, with 65 deaths per 100,000, and Japan and Australia, both with 71 per 100,000 – “there would have been 101,000 fewer deaths per year,” the authors write in the journal Health Affairs.

The study looks at preventable deaths below the age of 75 and found that while most countries had made big strides in reducing them over the past decade, with an average fall of 17 per cent, the US experienced only a 4 per cent decline.

With the rising cost of healthcare and numbers of uninsured becoming issues in the US presidential campaign, the authors say it is “difficult to disregard the observation” that the slow fall in the US preventable death rate “has coincided with an increase in the uninsured population”.

Cathy Schoen, senior vice- president of the Commonwealth Fund, which supported the research, said: “It is starting to see the US falling even further behind on this crucial indicator.”

Copyright The Financial Times Limited 2008

Sample Letter to Labor Unions to Endorse HR 676

January 2008

Dear Sisters and Brothers:

Capable of great medicine, America’s health care system is in deep trouble. Our system of health insurance has become not only too costly but simply inadequate. Medicaid is in crisis. All of us are at risk — all but the private insurance industry. It doesn’t have to be this way.

The health care crisis facing our country explodes into every collective bargaining session. Employers drive to cut benefits. Health costs shift to individual workers. Health insurance dominates every contract consideration, killing progress in wages and other benefits.

Too many retirees, after a life of hard work, are stripped of health coverage. Health care bills cause over 50% of bankruptcies — and three out of four of those bankrupted by medical bills had health insurance at the outset of their bankrupting illness!

The U. S. spends 16% of gross domestic product (GDP) on health care, twice what any other industrialized nation spends, yet ranks 37th in performance according to the World Health Organization. We lag behind other industrialized countries in life expectancy and infant mortality.

In New York State 2.8 million people, including nearly 500,000 children, had no health coverage whatsoever in 2006. One out of three New Yorkers, roughly 7 million people, went without health insurance at some point during 2006-2007. Nearly 58,000 New Yorkers filed for personal bankruptcy in 2006.

It doesn’t have to be this way. We can do better.

HR 676 is legislation introduced by Congressman John Conyers Jr. (D-MI) and co-sponsored by 86 members of the House of Representatives including New York Representatives Yvette Clark, Eliot Engel, Maurice Hinchey, Carolyn Maloney, Michael McNulty, Gregory Meeks, Jerrold Nadler, Charles Rangel, Jose Serrano, Edolphus Towns, and Anthony
Weiner.

HR 676 would establish a single payer health care system by expanding a greatly improved Medicare system to cover everyone. It would restore our right to choose our physicians and free us from insurance company red tape and interference in medical decisions.

HR 676 would cover everyone 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.

HR 676 will end deductibles and co-payments. HR 676 will save billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.

HR 676 has already been endorsed by 30 state labor federations, 94 Central Labor Councils, and 348 union locals and other labor organizations in 48 states.

We request that your organization join with us in endorsing HR 676.

We can help our fellow union members by taking health care off the bargaining table. By standing up for all working people, and leading the effort to provide healthcare for all, we will affirm labor’s rightful role as a leader in the fight for social justice.

The enclosed resolution is provided as a sample for your convenience. Please send us a copy of any resolution your local approves and send copies to AFL-CIO President John Sweeney (815 16th St. NW, Washington, DC 20006); New York State AFL-CIO President Dennis Hughes (50 Broad St., NYC, NY 10004); the member(s) of Congress who represent your members and Senators Clinton and Schumer. If you would like a representative of our coalition or a medical doctor from Physicians for a National Health Program to speak to your local to learn more, please let us know.

In Solidarity,

RESOLUTION ENDORSING HR 676 — Single Payer Universal Health Care

All of our unions face a healthcare crisis. We must wage an unnecessary and difficult struggle to win or to keep good health care coverage. Almost every union at every contract deadline must battle and sacrifice merely to sustain health care benefits. The rising costs of health insurance block our progress in wages and other areas.

But the crisis extends far beyond union members. More than 47 million people in the U. S. had no health insurance during all of 2006 and more than 75 million went without it for some length of time within the last two years. Millions with health insurance lack adequate coverage or risk losing coverage.

People of color, immigrants and women suffer from inequalities in access and delivery of health care, while the elderly and many others must choose between necessities and life-sustaining drugs and care. Unorganized workers have inadequate coverage or none. The Institute of Medicine reported that each year more than 18,000 in the U. S. die because they had no health insurance.

While we in the United States spend approximately twice as much of our gross domestic product as other developed nations on health care, we remain the only industrialized country without universal coverage. Our problem worsens each year as insurance costs increase and as gradual solutions have failed to make a dent in the problem.

The U. S. health system continues to treat health care as a commodity distributed according to the ability to pay, rather than as a social service to be distributed according to human need. Insurance companies and HMOs compete not by increasing quality or lowering costs, but by avoiding covering those whose needs are greatest.

Economic necessity and moral conscience compel us to seek a better way. Congressman John Conyers, Jr. (D-MI) (joined by 86 co-signers) has introduced HR 676, the United States National Health Insurance Act, also called Expanded and Improved Medicare for All.

This single-payer health care program proposes an effective mechanism for controlling skyrocketing health costs while covering all 47 million uninsured Americans. The bill also restores free choice of physicians to patients and provides comprehensive prescription drug coverage to seniors, as well as to younger people.

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.

HR 676 ends deductibles and co-payments. HR 676 would save billions annually by eliminating high overhead and profits of the private health insurance industry and HMOs. The transition to national health insurance would apply the savings from administration and profits to expanded and improved coverage for all.

A single payer program as provided by HR 676 is the only affordable option for universal, comprehensive coverage.

Resolved:

That __________________________________ wholeheartedly endorses Congressman Conyers’ bill HR 676, “Expanded and Improved Medicare for All,” a single payer health care program.

That __________________________________ will work with other unions and community groups to build a groundswell of popular support and action for single payer universal health care and HR 676 until we make what is morally right for our nation into what is also politically possible.

That __________________________________ will take other actions to mobilize our members and our community at the grassroots to encourage other members of the House to sign on as co-sponsors of HR 676 and to encourage Senators to introduce a companion bill in the Senate.

Our local union/district council/labor council has endorsed HR 676:

Union______________________________________International__________________

Address_________________________________________________________________

City__________________________ State _______________________ Zip__________

Phone:__________________ Fax:_____________________ email:_____________________

Signed by__________________________________Title______________________________

Date____________________

Missing the Boat on Health Care?

Missing the Boat on Health Care?

By John P. Geyman
Tikkun
Jan/Feb 2008

… instead of taking a progressive view of the responsibility of government to help solve our increasing problems of access, cost, quality, and equity of health care, we have the leading Democratic candidates perpetuating market approaches, with the already discredited notion that the insurance industry will respond to competition. Despite conservative public policies favoring health care markets, as illustrated by continued over-payments and lack of oversight of private Medicare plans, these leaders remain unwilling to confront the insurance industry in the public interest.

The public health policy choice facing us is whether or not to replace a failing private financing system with public single-payer financing. Making the right choice is the only way to gain affordable universal coverage of necessary care for everyone. It is that simple. This is not an issue to be compromised away by politicians. We need a new structure to heal many of the problems of U.S. health care. We have an opportunity now to galvanize a grassroots movement for real health care reform that may not come again for a long time. The Democrats are poised to regain the Presidency in 2008, together with both houses of Congress. We need activist government and leaders, as we have had earlier in our history, to confront our health care crisis. It is a matter of moral, economic, and social urgency.

http://www.tikkun.org/magazine/tik0801/frontpage/missing/

And…

The Democratic Debate in New Hampshire (transcript)

The New York Times
January 5, 2008

Sen. Barack Obama: I have been entirely consistent in my position on health care. What I said, and I have said on the campaign trail this time, is if I were designing a system from scratch, I would set up a single-payer system because we could gain enormous efficiencies from it. Our medical care costs twice as much per capita as any other advanced nation. But what I’ve also said is that given that half of the people are getting already employer-based health care, that it would be impractical for us to do so…

http://www.nytimes.com/2008/01/05/us/politics/05text-ddebate.html?ref=politics&pagewanted=all

And…

The Republican Debate in New Hampshire (transcript)

Rudolph Giuliani: To go in the direction that the Democrats want to go – much more government care, much more government medicine, socialized medicine – is going to mean a deteriorated state of medicine in this country. I mean, I said jokingly in one debate, if we go in the direction of socialized medicine, where will Canadians come for health care? (Laughter.)

http://www.nytimes.com/2008/01/05/us/politics/05text-rdebate.html?_r=1&oref=slogin&pagewanted=all

Comment:

By Don McCanne, MD

John Geyman’s Tikkun article on whether we are about to miss the boat on health care reform is an important piece that you may want to share with others. The policies that we need to enact are clear, but they are taking a back seat to politics, being an election year.

Barack Obama’s comment demonstrates that he does understand health policy principles and specifically which policies would best serve our nation. But he also understands politics. The other leading Democratic candidates do as well. In a political year, politics prevails, but that does not mean that we should let up on our efforts to make sound policy drive the politics.

It is not clear to me that the Republicans understand the physical suffering and financial hardships that their health policies would cause. Though it is no surprise that Rudolph Giuliani would treat health care reform as a joke, it did cause me considerable anguish to watch his Republican audience laugh at it. I am going to assume the best by viewing this as an awkward response to a staged pratfall since I cannot believe that most Republicans would truly believe that reform is a joke.

At any rate, read and distribute John Geyman’s article. The health care reform boat is ready to pull up its anchors, and we need to be on board. As John Geyman says, “It is a matter of moral, economic, and social urgency.”

Advocates push new hospital care funding

By DANIEL BARLOW
Vermont Press Bureau
Article published Jan 4, 2008

MONTPELIER — While legislative leaders talk about a slow expansion of Catamount Health and Gov. James Douglas eyes reforms to stem jumps in insurance premiums, a wide-reaching proposal for the health care crisis is gaining steam among advocates.

The Vermont Hospital Security Plan would create a new statewide hospital budget to pay for all visits to the 14 nonprofit facilities, essentially creating a single-payer health insurance system for hospital care.

“As a state we need to deal with the rising cost of health care and a big part of that is the cost of hospital care,” said Rep. Francis “Topper” McFaun, R-Barre Town, one of the three lead supporters of the bill. “With this proposal, no one would have to worry if they can afford an important trip to the hospital.”

The bill was proposed during the 2007 legislative session, but seems to be gaining traction among single-payer advocates as lawmakers return to Montpelier for the 2008 session.

Take Back Vermont Healthcare, a new statewide lobbying network of single-payer advocates, intends to apply some pressure on lawmakers to support the Hospital Security Plan. The group will kick off its efforts with a rally on the Statehouse lawn on Jan. 9 at 11 a.m.

“This is a bill that would do something for all Vermonters,” said Dr. Deb Richter, a Cambridge physician who founded the Take Back Vermont Healthcare network. “No other bill out there would reduce premiums by 40 percent.”

Advocates point to potential cost-savings of such as system: While Vermonters would still need insurance for doctor visits and prescriptions, cutting hospital care out of the equation should reduce premiums by 40 percent.

The cost of creating a state-run hospital system is pegged at $710 million a year, which would require implementing new taxes. But Richter said this is really a cost shift from people paying their premiums for insurance to paying the state, a move which is estimated to reduce the costs by 9 percent (Vermont now spends about $776 million annually on hospital care).

How to create a state-funding mechanism for the single-payer hospital system is something lawmakers need to decide, Richter said, but she added that one option would be a 5.5 percent payroll tax, split between employers and employees, and an annual $225 fee for each Vermonter.

“We are already paying more than this,” she said. “And this is one way to get our arms around the hospital budgets.”

But the state’s hospitals have some serious concerns about the plan, according to Beatrice Grause, the president and CEO of the Vermont Association of Hospitals and Health Systems.

She praised McFaun for raising the issue of payment reform in the medical field, but added that “this seems to be the wrong approach.”

She added she doesn’t think this will reduce costs on hospitals; in fact it may increase costs if Vermonters put off day-to-day health maintenance in favor of going to the hospital when a crisis occurs because the trip will be free.

“The devil is in the details, but I don’t think this will offer a peace of mind for the hospitals,” Grause said. “This could really result in some cash flow problems for the hospitals.”

Meanwhile, top elected officials in Montpelier also are not embracing the single-payer hospital proposal.

The Democratic leaders of the Vermont House and Senate are proposing an expansion of Catamount Health, the state’s new insurance program for uninsured residents, to also include small businesses, which are in a pinch with employee health insurance cost increases that for many are hitting the double digits.

Senate President Pro Tem Peter Shumlin, D-Windham, said Wednesday at a Statehouse press conference that he is a supporter of a single-payer system — but that smaller reforms, such as the proposed Catamount expansion, are needed to get there.

“If you are asking me if we will be passing a $1.2 billion health care bill in this session, the answer is no,” Shumlin said.

House Speaker Gaye Symington, D-Jericho, said during her press conference Thursday that a single-payer hospital system was discussed in the legislature in 2006. But, that option was dropped in favor of tackling the problem with the uninsured — a move that led to the creation of Catamount Health, she explained.

And Gov. James Douglas said in his meeting with reporters Thursday that stemming the tide of health insurance premium increases is one of his top issues this year, but added that he could not support proposals that relied on new taxes.

Still, Rep. Steven Maier, D-Middlebury, the chair of the House Health Care Committee, said McFaun’s proposal is one of the options that he will hold hearings on this year — even though he himself has some reservations as well.

“Once we start, there will probably be lots of debate over this one,” he said. “And I have some of my own questions. We all agree on the goals, but the disagreement seems to be how to get there.”

Maier added that the name of Richter’s new network left him feeling cold. The phrase, “Take Back Vermont,” was a slogan used by those who opposed gay rights during the civil union debate seven years ago and has become a symbol of the divisiveness and animosity of those times.

“The name unfortunately invokes that time in Vermont,” Maier said.

Richter acknowledged the name is intended to provoke. She explained it reflects the movement to take the health care system in Vermont away from the insurance companies.

Richter added that she and other supporters are facing an uphill battle on the single-payer hospital plan. But she is hopeful that hearings under the Golden Dome will result in a stronger groundswell of support.

“We at least want this proposal to see the light of day,” she said. “Let’s explore this idea and see what Vermonters think about it.”

During the months between the end of the 2007 legislative session and the start of the new one, McFaun traveled across the state to hold town hall-style meetings on his proposal — and said he received many welcoming and supportive comments.

“I’m grateful that this has gone from being a piece of paper stuck on the committee room wall to the promise that there will actually be hearings,” he said.

Contact Daniel Barlow at daniel.barlow@rutlandherald.com.

To Our Health, in the New Year

New York Times
LETTERS
December 21, 2007

To the Editor:

Re ”I Am Not a Health Reform,” by David U. Himmelstein and Steffie Woolhandler (Op-Ed, Dec. 15):

While the authors make a compelling economic argument for a single-payer health care system, they do not address a fundamental underlying question: why should a government provide health care for its citizens?

I believe that the answer to that question rests on two notions.

First, we need to accept the idea that a right to good health is essential in a democratic society. Pursuing democracy’s noble goals of life, liberty and happiness is problematic for people dealing with serious health care problems.

Second, we must put aside the idea that our health care system responds to ”market forces.” Patients needing critical care cannot bargain for the best deal.

When I had a heart attack several years ago, I was in no position to ask my cardiologist if he was inserting the least expensive stent into my blocked artery.

Rivers Singleton Jr.
Newark, Del., Dec. 15, 2007
The writer is an associate professor of biological sciences and English at the University of Delaware.

To the Editor:

As a physician in a state in which all of its citizens are now supposed to have health insurance, I am continually dismayed at the number of individuals I see who do not have health insurance or whose ”insurance” plans barely cover anything.

And among those lucky enough to have reasonably good health insurance, I am constantly confused by the various insurance plan rules about how often I can see patients or what drugs I can prescribe.

The single-payer plan that David U. Himmelstein and Steffie Woolhandler put forward would not only cost less than our current expenditures on health care and simultaneously cover everyone, but it would also be far simpler for both patients and physicians to navigate.

Why can’t the leading Democratic candidates muster the courage to propose real health reform that will save lives, time and money — and in addition that would be the most equitable of all options — instead of rehashing proposals that have never resulted in universal coverage and haven’t done anything to rein in the costs of health care?

We have single-payer armed services, fire prevention and road maintenance. Aren’t we long overdue for single-payer universal health care?

J. Wesley Boyd
Needham, Mass., Dec. 15, 2007

To the Editor:

David U. Himmelstein and Steffie Woolhandler present several important cases in which states that have tried to put into effect health insurance plans based on an employer or individual mandate have failed both to restrain costs and to cover the uninsured.

We agree that the crux of this failure lies in the fact that ”reliance on private insurers makes universal coverage unaffordable.”

Private insurance companies waste billions of dollars a year on marketing and administrative costs that do nothing to improve the quality of our health care. Physicians and hospitals are forced to waste money on staff hired solely for the purpose of filling out endless forms required by multiple insurers used by their patients.

That is why we are convinced, and numerous studies have shown, that a single-payer national health system is the most efficient, cost-effective way to provide universal coverage. It is time our elected officials stopped treating health care as a commercial commodity and recognized it as a public good. We all suffer if we all do not have access to quality, affordable health care.

Peter Pepper
New York, Dec. 15, 2007
The writer is president of The Workmen’s Circle/Arbeter Ring, an organization dedicated to community, Yiddish culture and social justice.

To the Editor:

Your compelling Op-Ed article cites the overwhelming evidence that the Democratic front-runners’ ”mandate model” for health care won’t work.

In 1999, we wrote a single-payer bill in Connecticut. We argued that despite being the insurance mecca, Connecticut — small and wealthy — was a good place to experiment with this, following the example of Social Security, which began in one state. Alas, despite popular support here for a publicly financed insurance plan, such an experiment was apparently too dangerous for the insurance industry.

What is truly dangerous is the vise grip corporations have on our candidates, hence our policies. Consequently, third parties like the Green Party, which advocates publicly financed elections and single-payer health insurance, are, like Dennis J. Kucinich, not given a hearing.

It appears that until our political system is transformed, neither will our health care system.

Justine McCabe & John Battista
New Milford, Conn., Dec. 15, 2007
The writers are, respectively, a clinical psychologist and a psychiatrist.

Market justice and moral compass

Market Justice and US Health Care

By Peter P. Budetti, MD, JD
JAMA
January 2, 2008

In the United States, health care competes for consumers with other items in the marketplace. Individual resources and choices determine the distribution of health care, with little sense of collective obligation or a role for government. Known as market justice, this approach derives from principles of individualism, self-interest, personal effort, and voluntary behavior. The contrasting approach, social justice, allocates goods and services according to the individual’s needs. It stems from principles of shared responsibility and concern for the communal well-being, with government as the vehicle for ensuring equity. Social justice in health care requires universal coverage and ensured access to care, whether through social insurance, private insurance, or some combination.

The End of Market Justice

The dominance of market justice as the vehicle for allocating health resources in the United States has been associated with numerous troubling characteristics of its health system. The US population has clearly rejected using pure market justice to apportion health care goods and services, yet has expressed no collective demand that society achieve equity through social justice. The general public has insisted on the buffer of insurance, but has focused on coverage for individuals and their respective families, not the population as a whole. Consequently, health care coverage, although desired by the vast majority of Americans, is incomplete. Now, the key element, employment-based insurance, is disintegrating in both the population that is covered and the benefits provided.

Simultaneously, health care has become a valuable commodity that created enormously influential vested commercial interests with little motive to abandon market justice. Medicine, which might have played a role in promoting social justice, has not done so, and has been transformed by the imperatives of market justice. Fragmented and struggling to come to terms with externally imposed pressures, medicine is losing both its political force and moral compass. The medicalization of health has simultaneously enhanced the investment in health care goods and services while distracting clinicians and policy makers from attention to the needs for health promotion and disease prevention and constraining the capacity to meet the expanding challenges to public health. Market justice may have outlived its role in US health care.

http://jama.ama-assn.org/cgi/content/full/299/1/92

Comment:

By Don McCanne, MD

The quasi-electromagnetic fields of market justice have screwed up our moral compass. Let’s take it over to the terrain of social justice and see if we can get it to work again.

Denying care or denying payment?

Take a deep breath, and read

By Steve Lopez
Los Angeles Times
January 2, 2008

Preston doesn’t have cancer, but he was born with cystic fibrosis. And the cost of the medicine that keeps him breathing just shot up like a rocket, thanks to an insurance company decision I’m still trying to decipher.

… the cost of Pulmozyme… had been running them $30 a month. Suddenly it was $784.

If a cheaper generic were available, they’d gladly switch. But they said there is no substitute for Pulmozyme, an enzyme-based medication that controls mucus secretions.

Hoping for an explanation, and reconsideration, Preston’s parents filed a grievance. Blue Cross quickly rejected it.

“Pulmozyme is no longer a Formulary medication,” said the virtually incomprehensible letter, which gallingly suggested the increase was part of Blue Cross’ commitment to providing its customers “the best possible care and access to medications.”

When I asked Blue Cross for an explanation, I got this by e-mail:

“As with other health plans, the decision to add or remove a drug from the formulary is done through a review committee made up of medical experts. At Blue Cross, this group is the Pharmacy and Therapeutic committee. Pulmozyme is currently considered a specialty medication and is covered for our members, but at a higher member share of the cost than other medications. The goal of these ongoing reviews is to assure access to all necessary drugs while also keeping costs as affordable as possible for all of our members.”

http://www.latimes.com/news/local/la-me-lopez2jan02,1,3588546,full.column?coll=la-headlines-california

And…

Individual and Family Health Care Plans for California

Blue Cross of California

We believe that the cost of our plans should be consistent with a member’s expected health care needs and risk factors. That’s why Blue Cross offers various levels of coverage.

http://www.bluecrossca.com/member/noapplication/plansbenefits/individualsfamilies/medicalplansummaries/pw_a082352.pdf

And…

Moves from the Cigna playbook

By Giuseppe Del Priore
Los Angeles Times
January 3, 2008

Insurers always qualify their denial letters with a sentence to the effect that the doctors must provide whatever care is necessary and that the payment is a separate issue. Insurers never deny care — only the authorization for payment. To stall the actual delivery of care, insurers hold out an insincere promise to authorize payment if the doctor provides more information. This leads the doctor on indefinitely, while insurers never say absolutely “no” until the patient gives up or dies.

http://www.latimes.com/news/opinion/web/la-oew-delpriore3jan03,1,7350723.story

Comment:

By Don McCanne, MD

Preston’s family pays $1,200 per month for their high-deductible health plan. You would think that this premium would provide a level of coverage that Blue Cross states is “consistent with a member’s expected health care needs and risk factors.”

Blue Cross has been a leader in insurance plan innovations that slow the rate of premium increases (to a smaller multiple of the rate of inflation) in order to remain competitive in the health insurance market. Blue Cross suggests that they are balancing “assuring access” with “keeping costs as affordable as possible for all of our members.” But their scales are locked in at (barely) affordable premiums, which requires that they increase financial barriers to access. Changing the copayment for Pulmozyme from $30 to $784 is a good example. They continue to have “access” since Pulmozyme is still covered in another drug tier, and they continue to have “affordable” insurance premiums.

Giuseppe Del Priore’s op-ed makes a very important point. Insurers never deny health care. They only deny payment. They have a private contract with the patient, and they have another private contract with the health care provider. They do not use those contracts to prevent health care from being accessed; they use them to escape their obligation to pay for that care.

Or do they actually have that obligation? Not really. Their obligation is to succeed as a business entity by enforcing those contracts in a manner that accrues to their own financial benefit. That’s the way the marketplace works.

What if we had a universal public insurance program, owned and financed by the taxpayers? Would we have individual contracts with patients and providers that would be used to manipulate health care payments to accrue to the benefit of the administrators of the public program? Of course not.

Would we use our public program to deny access to health care? We might if that care were demonstrated to result in impaired health outcomes and impaired quality compared to care complying with more appropriate standards. But we would do that through a process that identifies beneficial practices and then realigns incentives.

Instead of a private system that uses innovations to deny payment for appropriate care, wouldn’t it be better to have a public system that is specifically designed to finance all reasonable health care services and products? Blue Cross doesn’t think so.

Editorial: Honesty in health care

By Bangor Daily News Staff
Monday, December 31, 2007

Polls show that health care is a major issue — rivaled only by the Iraq war — in the current presidential campaign. Complaints about the present system include the mounting cost, the many left out, poor service and too much paperwork. Yet all the major candidates of both parties advocate only makeshift modifications of a system widely viewed as broken.

Republican candidates insist on keeping health care “market based,” which sounds great but has left some 47 million Americans uninsured and produces exorbitant salaries, huge advertising campaigns and enormous political contributions from the insurance and drug industries. They stoke the widespread fear of “socialized medicine” fostered by generations of propaganda.

Most Democratic candidates do the same, though without saying so, and stick to the accidental and failing linkage of health care and employment. That connection began in World War II, when employers dodged wage caps by offering health benefits instead of pay raises, and has hung on ever since. Now large as well as small businesses are finding health benefits an unsupportable burden. Only Dennis Kucinich, Mike Gravel and Bill Richardson dare to favor an active role by the federal government, and they probably have no chance of getting the nomination.

So whoever the nominees are, the presidential race looks certain to avoid any consideration of a fundamental change in the present American health care system, which costs twice per capita what is paid by virtually all other developed nations, while the United States rates 37th in overall performance according to the World Health Organization and has the highest infant mortality rate and highest prescription drug costs in the industrialized world.

Two Harvard professors, co-founders of Physicians for a National Health Program, advocated a “single payer” health plan for the United States, in the Dec. 15 New York Times. David U. Himmelstein and Steffi Woolhandler wrote that the various efforts to reduce the number of uninsured were all little different from a 1971 plan by President Nixon and did little or nothing to reduce the number of uninsured. They write that only a single payer plan could cut costs substantially and estimated the savings at $350 billion.

But the major candidates seem put off by faulty arguments such as that the Canadian plan is disliked by some doctors and involves long wait times for elective surgery. Yet polls show that most Canadians prefer their plan to ours. And wait times, which don’t interfere with emergency medicine, could be rectified by better financing.

Much of American health care is already run quite satisfactorily on a single payer basis: Medicare, Medicaid and the veterans’ health system.

Government run health plans, usually single payer plans, are good enough for Canada, Britain, France, Denmark, Sweden, Germany, Australia, New Zealand and most other developed countries. Why can’t they even be considered and debated by candidates for the U.S. presidency?

If both parties continue to avoid even mentioning a single payer plan, election day could see ballots marked “none of the above.”