Walter Tsou, MD, MPH
From the October 2007 issue of Clinical Advisor
Commentary

John was 50 years old. He had hypertension, diabetes, and a third and equally insidious condition–no health insurance. Although John had found sporadic medical care in emergency departments and “sliding-scale” clinics over the years, decades of spotty management had irreversibly damaged his kidneys and placed him on the list for hemodialysis. The good news is that dialysis–the only procedure categorically paid for by Medicare–allowed him, finally, to qualify for health insurance.

But isn’t there something perverse about a health-care financing system so dysfunctional that it’s necessary to kill a person’s nephrons before we’re allowed to nurture them?

We spend 40% more per capita on health care than any other country on the planet, yet the World Health Organization ranks the United States 37th in health performance. That’s pretty dismal for the richest country in the world.

Politicians receive millions in campaign contributions and, not surprisingly, continue to pour money into the medical-industrial complex. Wasting tax dollars this way threatens our fiscal integrity. Placing more bandages on a collapsing system seems crazy.

With that in mind, let’s stop and investigate three simple questions:

* When it comes to health care, what goods and services do we want to deliver and to whom?
* What’s the most equitable and economical way to fund what we want to deliver?
* How do we get started down a new path?

Instead of saying, “We have this much money. Figure out what we can deliver for that amount,” ask which services should be delivered and who should deliver them, to whom, and where.

This discussion would force us to confront the simple reality that virtually everyone wants high-quality, affordable health care for all. And that we would rather prevent disease than spend huge sums on treatments and disability payments.

So, if we want good health care for all, what’s the best way to pay for it? I suggest we follow the rule “Everyone contributes, everyone benefits.” To that end, let’s replace medical-insurance premiums with progressive taxes–all citizens pay a percentage of their income into a national health-care fund. For most of us, this would be much less that what we’re currently spending.

In order to ensure quality and freedom of choice, we would keep the delivery system in private hands. However, unlike what happens under our current prescriptive system, we would place a great deal of emphasis on prevention and team approaches to care.

With a national health-insurance system, a person could select any health-care provider or hospital she wants. We would then pay our providers to do everything possible to prevent and, if necessary, manage diabetes and hypertension so we could reduce the number of patients we have to dialyze. We’d do the same, of course, for other conditions.

Sick of the system? Get involved now. The health-care plan of the winning 2008 presidential candidate will shape health-care financing for the next decade. Find out what the candidates are really saying about this important issue. Then be a health-care voter and vote for the candidate with the best plan. Do it for your profession. Do it for your patients.

Below is a link to an on-line tool from the Kaiser Family Foundation that compares the Presidential Candidates’ Health Plans.

The summaries were created by Foundation staff and consultants, and do not include critical information about whether the plans would actually achieve the stated goals, such as expanding access or controlling costs. For critical commentary on the candidates’ health plans, see Dr. Don McCanne’s Health Policy Quote of the Day, archived at https://pnhp.org/news/categories/Quote%20of%20the%20Day/

---

Interactive Online Tool Provides Side-by-Side Comparisons of Presidential Candidate Health Care Proposals

As part of its ongoing effort to inform debate about health care issues in the 2008 presidential election, the Kaiser Family Foundation has released an interactive online tool to compare the health care proposals of presidential candidates. The tool, 2008 Presidential Candidate Health Care Proposals: Side-by-Side Summary, summarizes positions in four overall categories of access to health care coverage, cost containment, improving the quality of care and financing.

The online tool allows users to customize side-by-side comparisons by selecting as many as four candidates for comparison that can then be formatted into a printer-friendly format. Users will also be able to print out documents comparing all the Democratic candidates and all the Republican candidates.

The candidates’ summaries were prepared by Foundation staff with the assistance of Health Policy Alternatives, Inc. They are based on information appearing on the candidates’ websites and supplemented with information from candidate speeches, the campaign debates and news reports. The sources of information are identified for each candidate’s summary (with Internet links). Information will be updated regularly as the campaign unfolds.

The new tool is part of health08.org, a website operated by the Foundation providing analysis of health policy issues, regular public opinion surveys, and news and video coverage from the campaign trail. For further information on the side-by-side comparison or other health08.org efforts contact us at health08web@kff.org.

Looking back at Times editorials on healthcare reform, from World War I to the Clinton era.

Los Angeles Times Editorial
October 16, 2007

If you happen to have been a reader of The Times in 1918, you’d probably be terrified to see the German-pedigreed Arnold Schwarzenegger linked to anything having to do with healthcare reform. Of course, times change, and so has the paper’s editorial stance on healthcare reform. In 1918 — the earliest year in which The Times addressed healthcare reform — any semblance of government insurance on the state or national level prompted warnings of creeping toward that hideous German autocracy our boys were fighting in Europe during World War I. At that time, California voters were asked to consider a state constitutional amendment (which ultimately failed) that would have instituted a form of universal healthcare — or “compulsory insurance,” as the paper would unflatteringly call it for decades.

A few decades and a World War later, Times editors were again forced to consider healthcare reform, thanks to Republican Gov. Earl Warren’s proposal for state insurance during the 1940s. The paper, closely linked to the Republican Party at the time, was rhetorically cautious in its opposition to Warren’s healthcare plan — a behavior it didn’t extend to Democratic President Truman when he unveiled a Warren-esque plan for the country in 1945. Both plans ultimately failed, but that didn’t stop The Times from persistently advocating against “socialized medicine,” instead singing the praises of private — or “voluntary” — insurance throughout the 1950s. True to form, The Times opposed President Johnson’s Medicare crusade up to and beyond its passage in 1965.

By the 1970s, however, Times editorials sang a radically different tune on healthcare — a position the paper held through President Clinton’s failed attempt to overhaul insurance in the 1990s.

So how did a newspaper that suffered from Hun fever almost a century ago creep toward the reform-minded stance of the ’90s and today? Let the editorials speak for themselves — all in Original Spelling and Grammar (r), of course.

COMPULSORY SOCIAL INSURANCE — AN OUTRAGEOUS SCHEME FOR GRAFT
January 19, 1918

German paternalism under the form of compulsory health insurance is attempting to fasten itself on the labor and industry of California. A complete scheme of compulsory social insurance, as it is enforced in Prussia under the Hohenzollerns, is embodied in a constitutional amendment which will appear on the ballot for ratification in the November election. Of course it is presented in California first. Whenever an imported device of doubtful value comes to this country it is shoved through the California Legislature …

President Lott of the United States Casualty Company must have had California in mind when he said … “Compulsory social insurance is the latest advertisement of the reformer for revenue only, the latest device of some politicians who shine as philanthropists — while someone else pays for the lustre; both of whom are being aided by certain eminently respectable and altogether praiseworthy citizens.

The Times’ Hun-howling doesn’t ease up a few months later.

REVOLUTIONARY INSURANCE
March 2, 1918

For the past five or six years the subject of compulsory health (or sickness) insurance for wage-earners receiving less than $1200 per annum, has been discussed and agitated by sociologists and welfare workers of the United States …

Germany has been developing this system for nearly thirty years. The Imperial Insurance Commission has become one of the most important autocratic actors in German industrial life, and, indeed, in the political administration of German affairs. The system was inaugurated by Bismarck with the avowed purpose of saving workingmen from the influence of democracy. The cleverness of his politics has been amply proved by events — there can be no question that the working of the state managed indemnity system has become one of the strong holds of autocracy upon the people, in fact, a GIGANTIC POLITICAL MACHINE, operated by the Kaiser’s bose politicians …

At any rate, voters should inform themselves before they decide to venture into the most far-reaching and revolutionary piece of legislation ever proposed in this country. Democracy itself is in the balance — Autocracy and Bismarckian Paternalism are at the door.

Fast-forward to 1944, and Times editors are obviously thrown a curveball by a Republican governor displaying his liberal leanings by sending the Legislature a plan for state-administered health insurance. Note the editorialese tip-toeing statement, “His proposal raises questions that need mature consideration.” (Translation: We’re not sure of our position yet.)

Gov. Warren Revives Health Insurance Proposal
Dec. 31, 1944

In his proposal that the incoming Legislature provide a system of compulsory health insurance in California, Gov. Warren revives a place which, in principle, has been rejected at three recent sessions at Sacramento.

In announcing that he will sponsor a measure calling for prepaid medical care through a system of pay-roll taxation, the Governor emphasizes that he is not for State medicine, stressing the difference between his proposal and any scheme to put the doctors on a State pay roll or “pay for the medical and hospital expenses of the people out of public funds.” …

His proposal raises questions that need mature consideration. One is whether action is presently desirable in the face of the many uncertainties facinf the State economy in the coming transition to peace. Pay roll and other taxes already are nearing the point where they may handicap the efforts to provide a high level of wages and employment in the postwar years. Any tax-supported system of compulsory benefits tends toward political controlled paternalism and, in this case, is likely to meet with opposition from the younger groups of workers who, less in need of medical care, believe that health insurance should be on a voluntary basis.

The question needs more study that it has had and the Governor does well to provide extra time for it.

Later, the paper inches closer to opposing Warren.

Gov. Warren’s Message to the Legislature
Jan. 9, 1945

Health insurance is a complicated problem on which much has been said and much remains to be said, pro and con. There are at least two serious practical objections to the Governor’s program: first, that it is proposed to finance it by pay-roll taxes, which would increase the cost of production in California and put the manufacturing plants of this State at a competitive disadvantage with those of other States; and second, that California does not have enough physicians at present to carry it out, nor any possibility of increasing its medical roster under war-time conditions.

A few months later, The Times displays more skepticism of Warren’s tax-funded plan, and introduces a tactk it will employ for more than a decade: calling on private doctors and other medical professionals to dissuade the public from government insurance and make their case for a better plan.

Report on Health Insurance Bills
April 5, 1945

… If the Legislature can evolve some plan to further the voluntary movement it might prove constructive. Every effort should be made to accomplish the desired objectives on a voluntary basis before resort to compulsory methods …

Even with provision that a compulsory health insurance pay roll tax measure would not be placed in effect during the war, the uncertainties surrounding the coming reconversion period in California do not make this a good time to launch such an experiment. Such a measure with its far-reaching social and economic implications should be subjected to thorough study before the Legislature attempts to pass on it.

Meantime the medical profession has an opportunity to exert more leadership and progressiveness than has marked it in the past in helping to solve this complex problem. Particularly in the field of health education, the doctors can an should exert a greater community influence in formulating community health programs designed to instruct people how to preserve health and to acquaint them with facilities available to them in case of illness.

Enter Democrat Truman and his national plan, and The Times lays out its position with more punch.

The Doctors’ Voluntary Health Plan for Nation
July 20, 1945

Now the physicians of the nation have advanced their own voluntary health insurance plan.

It is frankly an effort to forestall government action for socialization of medicine …

The public must be convinced that voluntary health insurance is better than regimentation.

And it must not be forgotten that socialized medicine is being advocated most vigorously by certain political elements who continually are conducting an all-out campaign for regimentation of this entire nation. These elements will not rest a minute. They have some sincere converts to their belief, but many of them are motivated by selfish aims …

Now the lines have been drawn.

The Family Physician vs. the Government Doctor.

In the final analysis the public must make its choice.

Four years later, with Truman still pressing his case, The Times forcefully articulates its anti-tax reasons for opposing the president.

The Complete Social Security
May 1, 1949

President Truman’s colossal social security program is not in the Congressional worlds. “Social Security” is used here in the broad sense — in the cradle-to-grave sense of government assistance to almost everybody. The President outlined his program last January, and the with introduction of the health insurance legislation last Monday, all of the proposals are pending in bills which would provide the following things:

1 — More old-age and survivor insurance for more people, with higher benefits.
2 — Temporary disability insurance for workers sick or injured for more than seven days but not more than 26 weeks.
3 — Permanent disability insurance for workers found incapable in any “substantially gainful work.”
4 — Health insurance for 120,000,000 Americans.

Almost everybody would draw some benefit from this program at one time or another in his life — and everybody would pay for it …

Overtaxation does not kill suddenly; the symptoms are not clear. It is an insidious disease, like cancer, and when its damage is discovered, it is usually too late to accomplish a cure. Meanwhile the patient suffers no pain, but rather an exhilaration; he usually has the delusion that he is getting something for nothing — or very little.

That same year, the paper finally admits its opposition to Republican Warren’s plan in plain English.

Gov. Warren’s Health Plan
March 20, 1949

Upon careful study of Gov. Earl Warren’s program for a prepaid health service in California, and following discussions both with proponents and opponents of the plan, The Times, recognizing the sincerity of the Governor’s position and the worth-while objectives he seeks, nevertheless finds itself unalterably opposed to the basic principle involved — compulsory insurance.

Somewhere a line must be drawn between responsibility of the individual and of government. Eventually America must choose between a free society and a regimented society …

In 1965, The Times laments the coming passage of Johnson’s Medicare program by warning of vast welfare programs to come.

Vote for Medicare Opens a New Era
April 12, 1965

The overwhelming House vote for a vast federal plan of medical insurance for the aged marks the ends of one era on the American domestic scene, and the beginning of another.

Always before Congress has rejected health insurance legislation for fear of embarking down a one-way street to socialized medicine.

Now the House has taken the plunge, and Senate approval appears only a matter of time …

President Johnson, as the prime mover behind this legislation, has the responsibility now for resisting any pressures to extend the medicare provisions to the other age groups …

The experience of European countries indicates that we are letting ourselves in for back-breaking tax burdens unless restrain is used on this new program.

In a way, The Times’ prediction of a paradigm shift in how expansive government programs will take hold comes true in 1971 — especially in how dramatically the paper’s own position on universal healthcare changes. It took The Times just six years to pull an about-face on a position it had held for almost five decades. The paper does, however, resign itself to its new stance more than taking up the mantle of national insurance.

Improve Health Care — but How?
February 22, 1971

This year or next, Congress will almost certainly enact a comprehensive medical insurance plan to provide coverage for almost everyone in the country, along with supporting programs for improving the nation’s health care system

President Nixon has submitted his proposals for reorganization, Sen. Edward M. Kennedy and others have offered theirs. There is not argument about the need for reforms; everyone agrees our present system is unsatisfactory. Rather the debate will be on the scope and methods of change …

We all know what we want: better and more readily available health care at a reasonable cost. What remains to be decided is, as Henry James said, “the dear, deadly little question of how to do it.”

Less than three years later, The Times is more comfortable with its position, this time encouraging action instead of merely acknowledging the inevitability of reform.

The Sad State of Health Insurance
Oct. 8, 1973

The national health insurance plan introduced the other day by Sen. Russell B. Long (D-La.) and 13 other influential senators may or may not be the best answer to this country’s creeping health care crisis. If its introduction does nothing more than stir the Nixon Administration and House leaders out of lethargy, however, it will be a real public service.

Two years ago national health insurance — covering not just poor people and old people but all of us — looked like an idea whose time had come. The question had become not whether such a program was needed but what kind.

With The Times firmly ensconced in the reform-minded camp, the paper welcomes Bill and Hillary Clinton’s push for universal care.

Health Care Sent to Surgery
Jan 27, 1993

Health care costs are eating up a record 14% of the gross domestic product. That means the United States spends more on health care than any other industrialized nation–yet in one key health indicator, preventing infant death, it has slipped to a dismal 19th in the world. Thirty-seven million Americans have no health insurance. Thus Clinton must get a grip on runaway health costs if there is to be any hope of managing the nation’s budget.

There are big political risks for Clinton in putting the First Lady in charge of the team seeking to devise a health care proposal within three months. Yes, it shows he’s serious, but if the plan falls short, both of the Clintons will have to be prepared, to put it mildly, to take the heat. And if it falls short, questions will be raised about the wisdom of putting the President’s wife, an attorney not known as a health care expert, in charge of so crucial a project.

But those possibilities pale in comparison to the certain disaster that awaits if Clinton does not stick to his campaign promise to tend to the economy and overhaul the health care system. It’s a job almost as tough as curing the common cold. Here’s hoping the Clintons can offer the nation’s ailing health care system something at least as good as chicken soup.

by Ellen R. Shaffer and Joe Brenner
Common Dreams

Elected officials are trailing voters on the critical issues of trade and health. Voters, including Republicans, increasingly oppose the current crop of trade agreements and also support raising taxes to pay for health care, according to recent polls.

It looks as if the public is prioritizing jobs and health benefits over buying cheap imports at Walmart. Trade agreements that dismantle the middle class sap all nations’ political will, and ability to protect public health. Voters are catching on that all these issues are linked.

We understand that countries don’t win or lose from deals like NAFTA. Rather, some large corporations win market share, while the majority of households lose income and services.

The corporate winners who now drive the global economy have unmoored themselves from the social contract, no longer relying on secure employment and rising standards of living to bolster consumer spending. The safety net to tide us over in troubled times has been abandoned. Weakened public institutions have also damaged health and the availability of health care.

Domestically, the shift in public opinion has not deterred unconditional cheerleading for the bottom line. The Bush administration’s best idea for fiscal austerity at the moment is to slash publicly subsidized health care coverage for kids so that for-profit insurance companies can take a swipe at them.

The private sector has declined to enroll these uninsured young malingerers, to date, and probably won’t start now. But this misguided stonewalling gives an ideological lift to the fable that market-driven health care is still a viable policy option.

Specific trade policies damage health and undermine health protections. Until this year, fast-track rules prevented Congress from amending trade agreements. Unhealthy trade policies written by corporations were virtually assured to be enacted.

* Drug companies have imposed trade rules that protect their rights to exorbitant profits while excluding many from needed life-saving drugs, by driving out competition from generics.

* The tobacco industry has stealthily used trade agreements to pry open export opportunities and to increase consumption of their lethal products.

* State, local and national measures to ban a carcinogenic gasoline additive, and to regulate internet gambling, have been delayed or overturned by powerful international trade tribunals with no expertise in health, or accountability to the U.S. court system.

* Licensing establishes both quality standards and fair treatment for health care professionals. But under the pending trade agreement with Korea, hospital chains could employ U.S. health care personnel in Korea, with no respect for local licensing rules. Other trade agreements would impose discriminatory treatment of immigrant Filipino nurses working in Japan.

What do all these policies have in common? Selected corporations benefit from policies they write, while the public is shut out. Through these agreements, corporate lobbyists are dictating public policy. Bringing public health voices to the table can provide balance to our trade policy and is long overdue. It’s also time for elected officials to catch up with the public in supporting trade deals that boost our economic security, while expanding health care to all Americans.

Below is a link to an on-line tool from the Kaiser Family Foundation that compares the Presidential Candidates’ Health Plans.

The summaries were created by Foundation staff and consultants, and do not include critical information about whether the plans would actually achieve the stated goals, such as expanding access or controlling costs. For critical commentary on the candidates’ health plans, see Dr. Don McCanne’s Health Policy Quote of the Day, archived at https://www.pnhp.org/news/categories/Quote%20of%20the%20Day/

---

Interactive Online Tool Provides Side-by-Side Comparisons of Presidential Candidate Health Care Proposals

As part of its ongoing effort to inform debate about health care issues in the 2008 presidential election, the Kaiser Family Foundation has released an interactive online tool to compare the health care proposals of presidential candidates. The tool, 2008 Presidential Candidate Health Care Proposals: Side-by-Side Summary, summarizes positions in four overall categories of access to health care coverage, cost containment, improving the quality of care and financing.

The online tool allows users to customize side-by-side comparisons by selecting as many as four candidates for comparison that can then be formatted into a printer-friendly format. Users will also be able to print out documents comparing all the Democratic candidates and all the Republican candidates.

The candidates’ summaries were prepared by Foundation staff with the assistance of Health Policy Alternatives, Inc. They are based on information appearing on the candidates’ websites and supplemented with information from candidate speeches, the campaign debates and news reports. The sources of information are identified for each candidate’s summary (with Internet links). Information will be updated regularly as the campaign unfolds.

The new tool is part of health08.org, a website operated by the Foundation providing analysis of health policy issues, regular public opinion surveys, and news and video coverage from the campaign trail. For further information on the side-by-side comparison or other health08.org efforts contact us at health08web@kff.org.

Note: Diane Francis is a well-known conservative analyst in Canada. Even the right-wing acknowledges the value of the Canadian health system.

Note: Canadian physicians working in the U.S. are just 1.1 percent of the U.S. physician workforce, which is similar to the percentage of U.S.-trained physicians working in Canada (0.8 percent) (“The Metrics of the Physician Brain Drain”, Fitzhugh Mullan, MD NEJM 10/27/05).

Corporate control of Congress prevents reform

Diane Francis
Financial Post
October 9, 2007

American health care is an oxymoron and the system represents our major trading partner’s biggest competitive disadvantage going forward.

And yet it is the 800-pound gorilla in the room that’s ignored during these presidential-election primaries and runoffs. Nobody touches the fact that this is a huge business and economic issue, besides a socio-political one.

Canadians are lucky on this one. We may have lineups and our newspapers may occasionally publish horror stories about someone left on a gurney for hours outside an emergency room.

But the U.S. system is the worst-executed in the world and its private-sector interests have convinced the government to insure the riskiest people — namely veterans, indigents and seniors — while leaving the gravy to private-sector insurers to profit from.

Government in the United States provides medical care for more than half of the population, in these high-risk subgroups. But if government covered all the population, younger and healthier, the cost per capita would decline because these would be spread over a less-expensive population of clients.

So the private sector gets to do what it wishes, which is to cover those who maximize its profits, and the governments are drubbed for the costs of Medicare, Medicaid and other programs for the needy or risky.

So the United States has two medical systems: One private-sector for the well-off, where insurance companies simply pass along costs, rather than wrestle with them, as do privately owned hospitals, clinics, labs and physician practices. And another that takes care of the old, disabled, impoverished or militarily wounded.

It’s hard to imagine the human suffering that has resulted from this situation. Canadians don’t have the anxiety about health care that underlies American existence. People there don’t leave jobs, don’t start new ones or businesses because they fear losing insurance benefits.

Insurance companies, according to congressional testimony by one physician, pay doctors bonuses based on how many claims for medical care they refuse.

And yet, most of the presidential candidates duck the issue whenever possible, although it’s becoming harder now that Michael Moore’s documentary Sicko has done a good job exposing the system.

But the economic problem is overlooked by everybody. The United States is spending 15.3% of its GDP on medicine and that doesn’t include the cost of litigation over medical bills. Forecasts are costs will hit 20% of GDP by 2012. More disadvantages: – 49 million people without any insurance. The same number inadequately insured. – Despite that shortfall, the United States spends far more per capita than other OECD countries, and has worse results by measures such as lifespan or infant mortality. Estimates are medical costs will hit 20% of GDP by 2016. – Costs are high, even though the system is so poorly executed, because the rich are over-serviced and pampered and the poor under-serviced or ignored. – One estimate is that half of U.S. personal bankruptcies are because of high medical bills due to a catastrophic illness. – Congress is co-opted by pharmaceutical giants, the American Medical Association (the country’s most powerful trade union), insurance companies and ambulance-chasing lawyers.
Meanwhile, medical professionals are paid much higher salaries and fees than elsewhere in the world, which has resulted in a serious brain drain of personnel from Canada and Europe. Some 9,000 Canadian doctors now practice south of the border and thousands more nurses.

For that and many other reasons, Canadians should urge Americans to do major surgery.

More info on my blog at financialpost.com/dianefrancis

Click here to read “letter from a Canadian friend” at scopes.com

By Dr. Robert McMurtry

The fake letter is so patently ridiculous and written from an right wing American view that it should be exposed.

My response in brief is that single payer works. A few points about health care in Canada.

* There is no anxiety about physician and hospital bills.

* For the first time in many years I sat at a department of surgery meeting and heard that we are not filling the OR time! Why? Because the government of Ontario has been so effective at attacking wait times.

* There are no wait times for cardiac and cancer care in Ontario.

* No one has ever been denied care for smoking and the outcomes for health care are better in Canada
than in the U.S.

* We are competing very successfully with the U.S. because of single payer health care.

* Our dollar is now worth more than the American dollar.

The only question is why profit and greed in the U.S.continue to trump compassion, efficiency and quality.

http://www.snopes.com/politics/medical/canada.asp

Click here to read “letter from a Canadian friend” at scopes.com

By Dr. Robert McMurtry

The fake letter is so patently ridiculous and written from an right wing American view that it should be exposed.

My response in brief is that single payer works. A few points about health care in Canada.

* There is no anxiety about physician and hospital bills.

* For the first time in many years I sat at a department of surgery meeting and heard that we are not filling the OR time! Why? Because the government of Ontario has been so effective at attacking wait times.

* There are no wait times for cardiac and cancer care in Ontario.

* No one has ever been denied care for smoking and the outcomes for health care are better in Canada
than in the U.S.

* We are competing very successfully with the U.S. because of single payer health care.

* Our dollar is now worth more than the American dollar.

The only question is why profit and greed in the U.S.continue to trump compassion, efficiency and quality.

http://www.snopes.com/politics/medical/canada.asp