PNHP

Focus on patients, not profits

Focus on patients, not profits

By Rose Ann DeMoro
South Florida Sun-Sentinel
February 5, 2007

Americans expecting relief from the meltdown of our health care system should watch out for the political mugging now unfolding in the current debate on health care reform.

From President Bush’s proposals to proposals in Washington and state capitols, to a recent procession of groups. there is a lot of talk about a new “consensus” on the need for action on what everyone agrees is a crisis careening out of control.

While some have declined to identify specific proposals, there’s been a steady stream of proposals that have a similar theme. They include tax deductions to encourage people to buy insurance, tax penalties to discourage people from using too much of that insurance, mandates that everyone be required to buy insurance, new taxes on employers to pay for more insurance, and expanding existing federal or state programs to buy insurance for the low-income.

No wonder the insurance industry is standing at the front of the line leading the cheers.

For those having trouble following the arcane details, here’s a cheat sheet. All the assorted health care proposals can be boiled down to two fundamental alternatives which go down very different paths.

One is the proposals (and throw in many of the state versions, including the much hyped Massachusetts and California plans) that expand the role of the big insurers and reinforce the role of the private market in health care — those same players that created the present problem by placing increased revenues and profits above patient health.

The other approach, a single-payer system such as Medicare, works. It’s far simpler, more comprehensive and more cost effective — a patient-based, not commercially driven direction.

Under single-payer one public entity collects all revenues and pays for all medically necessary services for everyone, delivered by our present, mostly private, doctors, hospitals, and other providers.

Our failure to enact such a system is the reason the U.S. ranks just 37th in health care quality and performance, according to the World Health Organization. Every other industrialized country has either a single-payer or national health system. We’re No. 1 in one category only: costs. We lag behind in almost all other indicators, including life spans, infant mortality, childhood immunization and per capita access to doctors, nurses, hospital beds and diagnostic equipment.

The primary reason for that disparity is the intrusive role of insurers and other health care corporate giants who siphon off billions of dollars in administrative waste, bureaucracy, profits and executive compensation — sacrificing, as needed, access, quality and affordability along the way.

And they’ve been wildly successful. The 20 largest HMOs in the U.S., for example, made $10.8 billion in profits in 2005, and UnitedHealth Group alone just posted $1.2 billion in profits for the last quarter of 2006. Drug companies make even more; the world’s 13 biggest reported $62 billion in profits in 2004.

Health care corporations have effectively used their economic clout to block real reform both in Washington and in state capitols, becoming the largest spenders on lobbying and setting up a parade of people who rotate back and forth from administration posts and congressional offices to the corporate boardrooms.

But, at a time when even middle class families are holding garage sales and spaghetti suppers to pay for medical bills, more than half the nation’s low income counties lack a health center and even large businesses stagger under the weight of ever rising health care costs, those who have profited off pain and suffering know the game could be up.

A result is the fervent campaign to browbeat a public desperate for genuine reform to lower their expectations, and accept the conventional wisdom that only market-based solutions are feasible.

We’ve heard this before. From abolition of slavery to women’s suffrage to enacting Social Security and Medicare to ending legal segregation, our history is filled with achievements that the pundits and avatars of the status quo said were not realistic.

A single-payer system is not just a dream, it’s legislation — HR 676.

Under HR 676, everyone is guaranteed choice of physician and comprehensive and uniform coverage, businesses are treated fairly, costs are controlled, administrative waste is slashed, and insurers could no longer deny care or continue to price people out of access to medical services.

Let’s stop looking for the worst solutions, and demand the best.

Rose Ann DeMoro is executive director of the 75,000-member California Nurses Association/National Nurses Organizing Committee.

Copyright (c) 2007, South Florida Sun-Sentinel

Edwards Becomes the First To Promise a Big Tax Hike

BY JOSH GERSTEIN
The New York Sun
February 5, 2007

A former North Carolina senator making a second bid for the Democratic presidential nomination, John Edwards, has chosen not to embrace a single-payer health insurance plan, disappointing activists who contend that only a radical overhaul of the health care system can ensure that all Americans are insured.

During an appearance yesterday on NBC’s “Meet the Press,” Mr. Edwards said he plans to announce details today of a plan that would result in universal coverage by building on the current employer-based system.

The Democratic nominee for vice president in 2004 said his plan would cost between $90 billion and $120 billion a year and would require a tax hike. “Yes, we’ll have to raise taxes,” he said. Mr. Edwards said he would roll back President Bush’s income tax cut for Americans making more than $200,000, but he did not indicate if other taxes would also increase as the new plan was implemented.

“We take the 46 million, 47 million people who don’t have health care coverage. We expand Medicaid. We provide subsidies for people who don’t have coverage. We ask employers to play a bigger role, which means they either have to have coverage, or they have to buy into what we’re calling health markets,” Mr. Edwards said. He appeared to be describing what policy experts refer to as “pay or play” or an “employer mandate.” In a bid to mollify liberal Democrats who back a single-payer system, Mr. Edwards highlighted the options for individuals to buy into new government-sponsored plans that would be set up in various regions of the country. “One of the choices, by the way, available in these health markets is the government plan. So people who like the idea of a single-payer insurer health plan, that is actually one of the alternatives that people can choose,” he said.

“That’s not the single payer we’re talking about,” a former director of Physicians for a National Health Program, Don McCanne, told The New York Sun. “That’s way, way short of single payer.”

During a speech in California in December, Mr. Edwards indicated that he and his advisers were mulling the idea of a single-payer system, akin to those used in Canada and Britain. “I think there’s a legitimate debate that should take place on single payer versus building on the existing system. There are honestly good arguments on both sides of that debate,” he said. “Those are the arguments that I’m taking into consideration as I’m trying to make my own decision.”

Dr. McCanne said Mr. Edwards’s comments on NBC yesterday dashed the hopes of single-payer advocates who were hoping that Mr. Edwards would embrace their goal. “It put us into a funk,” he said.

A professor at Cornell’s Weill Medical College who also supports single-payer insurance, Oliver Fein, said having a government plan compete with privately-run insurers could lead to significant problems. “The private insurance companies are likely to cherry pick in that setting to try to get healthy people to enroll with them and leave the really sick in the single-payer or government program,” he said.

Aides to Mr. Edwards declined to answer questions about his plan until it is formally unveiled today. Mr. Edwards’s decision to reject a single-payer plan leaves Rep. Dennis Kucinich of Ohio as the only notable Democratic candidate supporting the concept. In an interview, he described as unworkable Mr. Edwards’s notion of single-payer insurance within the existing system. “If you have a single-payer option, unless everybody’s participating, you’re not going to have resources to do it,” the congressman said.

Critics of a single-payer system say it would lead to rationing of care, long waiting periods for certain procedures and surgeries, and could fail to deliver the cost savings promised by proponents of such plans.

However, Mr. Kucinich said he suspects that his colleagues are reluctant to back single-payer insurance out of fear that they will lose campaign donations from the insurance and pharmaceutical industries.

“It’s not just Senator Edwards. All these Democratic candidates know full well this is a defining Democratic issue. They want to make it appear they are aligning themselves with the American people, and they want to get help from insurance companies in their campaigns,” Mr. Kucinich said. “You can’t have it both ways.”

Perhaps to inoculate himself against such charges, Mr. Edwards railed against those interests during a speech Friday to the Democratic National Committee. “When it comes to 47 million of our own people who don’t have health care, silence is betrayal,” he said. “We cannot allow America’s health care policy to be set by big insurance companies and big pharmaceutical companies.”

Senator Clinton did not embrace the single-payer plan in her proposed 1993 health care overhaul. Senator Obama of Illinois backed a state-government single-payer plan as a state legislator, but more recently, he has expressed skepticism about the idea.

One person often rumored as a presidential candidate for 2008, Vice President Gore, endorsed the single-payer concept in 2002 but never delivered a promised speech laying out his views in detail. Senator Kennedy of Massachusetts supports the idea. Mr. Kucinich and Rep. John Conyers of Michigan have proposed Medicare-for-All legislation that would bring all Americans into the federal program.

A health-policy analyst who has advised President Clinton and Mrs. Clinton, as well as Messrs. Edwards and Obama, Christopher Jennings, said he would not be surprised to see a similar proposal from one of the second-tier Democratic presidential candidates. “Single-payer is very popular in our Democratic base,” Mr. Jennings said, naming Senators Biden and Dodd as well as a former Iowa governor, Thomas Vilsack, as possible proponents of such a plan. “I don’t necessarily see Obama or Hillary going there.”

Mr. Jennings also said Mr. Edwards might quietly sell his plan as a stepping stone to a government-funded system. “What he’s going to tell single-payer advocates is that this will become a single-payer plan, [that] everyone will eventually go there.”

Hasta la vista, single-payer movement?

By Michael Corcoran
OpEdNews.com

In September, Governor Arnold Schwarzenegger vetoed a bill that would have resulted in a single-payer health care system in California saying that he ” cannot support a government-run health care system.”

While the recently re-elected executive is running from the right on several issues, most notably Climate Change, it appears signing off on something that could be described as a single-payer plan was just too much for this GOP moderate.

But Arnold is tackling the issue again with a new proposal to provide “universal” coverage for California that reflects a growing trend among state governments to reform health care. In many ways similar to health care legislation passed in Massachusetts this spring, the proposal requires consumers to buy insurance while expanding subsidies for low-income families.

Both measures have been praised by many as creative bipartisan ways to provide coverage and in sparking a conversation about the need to reform our countries dismal health care policies, which leave more than 46 million Americans uninsured.

But do these plans offer a real solution? And will they provide “universal coverage” as their architects claim? And should progressives, thinking pragmatically, support such measures as opposed to the single-payer system?

Not according to Dr. Steffie Woolhandler, associate professor of medicine at Harvard University and co-founder of Physicians for a National Health Program who says it is pure “fantasy” to say either of these bills will result in universal coverage.

“Both the MA and CA plans are based on ‘ individual mandates’ … the idea that the uninsured can buy their way out of their predicament,” Woolhandler said in an e-mail. “A good family policy in MA costs $12,000 per year. How many uninsured families have even a fraction of that in hand to purchase coverage? Many families will be forced to buy stripped-down/bare-bones insurance plans, which will have lower (although still unaffordable) premiums, but will leave them unprotected in the event of a major illness.”

These new, highly touted state plans, shift the burden onto patients, while letting business off easy. As Art Pulansky, secretary-treasurer of the California Labor Federation, said in a press release following the announcement of Schwarzenegger’s plan: “the proposed employer contributions is so low that even Wal-Mart, a corporation known for its minimal employee healthcare coverage, already exceeds the requirements.”

Worse, there is reason to be concerned that these state plans could serve to stifle the fight for a national universal health care system. “Finally, the single-payer canard is gone,” boasted then Massachusetts’s Governor Mitt Romney to The New York Times when the Massachusetts plan passed, seemingly pleased the parameters of the debate on this issue have been narrowed considerably.

Unfortunately, many Democrats seem content to help him do it. “I think the Democrats are concerned lest they seem too radical,” said Rep. Pete Stark, (D-CA.) to The Seattle Times. “We’ve [The Democrats] got to win again in 2008, and I don’t think we want to come out and talk about universal coverage or anything that sounds like socialized medicine.”

Today’s political landscape, however, seems to be begging for progressives to start making the case for drastic reforms. Especially given the folly of President Bush’s latest proposal, which, unlike the state plans, does not even pretend to provide universal coverage. “Bush’s reform plan – fiddling with the tax system and peddling skimpy private health plans – will fail miserably,” said Dr. Oliver Fein, Professor of Medicine at Cornell University in a statement released in response to Bush’s State of The Union speech. He also noted that, like Massachusetts and California proposals that rely on private insurers, “it would leave millions without coverage.”

Consider that in September, an ABC News/Kaiser Family Foundation/USA Today survey found that 56 percent of Americans preferred a government-run universal health system “like Medicare” to our current system-a development that Marcia Angell called the unsung development of 2006 in an op-ed for The Boston Globe. “They want a single-payer system,” she wrote. “We are the only advanced country with market-driven private health care. Other countries spend about half as much per person, cover everyone, and get better health results. Shouldn’t this option be on the table?”

The recent elections have placed some well-known single-payer advocates in positions of prominence, and with enough pressure from constituents they could help to advance the debate. Rep. John Conyers, (D-MI), for example, is has reintroduced key single-payer legislation to Congress.

One of the bill’s cosponsors, Rep. Barney Frank, (D-MA) is now the chair of the House Finance Committee and has been a longtime supporter of the single-payer model. On Jan. 3, in a speech in front of The National Press Club he said, “If we were to have a universal single-payer health care system, which took health care out of the wage system … we would begin to reverse the inequality.”

While the two leading 2008 presidential candidates, Barack Obama and Hillary Clinton, do not advocate a single-payer system, there are some candidates (and potential candidates) who have shown an enthusiasm for it, such as Rep. Dennis Kucinich (D-Ohio) and General Wesley Clark.

“No child in America should grow up without regular medical check-ups and care,” said Clark in a 2006 speech to The New America Foundation. “And inevitably this will mean transitioning over time from a work place centered, private payer system toward greater reliance on some form of single-payer system to ease administrative burdens and reduce costs.”

(John Edwards is touting “universal” coverage but has been noticeably short on details.)

There have also been encouraging signs on the state level. The AFL-CIO of Connecticut recently started lobbying for a single-payer system, and called it “the cornerstone” of their 2007 legislative agenda.

Actually implementing such a system it is indeed a tall order due to staunch opposition from the private health insurance industry and the pharmaceutical manufacturers. “Both Democrats and Republicans get oodles of money from these industries, and are understandably loathe to take them on,” Woolhandler said. “However, a growing number of middle-class, insured Americans are profoundly dissatisfied with the health care finance system.”

With health care reform in the news cycle and at the center of policy debate it is vital that progressives use this opportunity to push for real universal coverage. This is not merely a fight for the health of our citizens, but also for the health of our national debate.

Michael Corcoran is a freelance writer who has been published by The Boston Globe and Common Dreams. He is currently an intern at The Nation Magazine in New York City.

Only a single-payer system will keep all of us healthy

By Dr. Joseph E. Birnbaum
Times Herald-Record
February 05, 2007

I write as a health-care provider and user of the broken system of health-care delivery that has evolved in America, driven not by our medical needs but by the insidious influence of powerful, profit-driven corporate forces that influence our elected representatives on both sides of the aisle.

Consider these facts:

* We lag far behind most other industrialized and some emerging nations in typical health-care indicators such as infant mortality and life expectancy rates, despite spending much more of gross national product for health services.

* Forty-seven million of our citizens are without health insurance and 50 percent of all bankruptcies are a result of health-care debts.

Primary care in the United States ranks far behind England, New Zealand and Australia in almost every measure of care, including access, patient/physician relationships and quality control.

* We are squandering the American health-care dollar in administrative costs levied by for-profit, third-party payers that utilize 30 percent of your health-care dollar to do what a single-payer system like Medicare does for 6-7 percent of that dollar.

* American business can no longer compete easily in the global market because of our unique history (that began during World War II) of asking industry to provide health insurance to their employees. We are the only industrialized nation in the world that does this. American businesses are cutting their health plan coverage in a desperate effort to compete globally.

Health savings accounts are not an equitable reform of the system and will serve primarily as tax shelters for the wealthy. Shopping in the open market (the American way?) for your own health care, as you would for any other commodity (is health care a commodity, like a new car?), assumes that the average American is fully informed and able to manage the complexities of purchasing health care.

The realities are different. Studies have shown that when people must pay a larger out-of-pocket amount for their heath care, they often cut back on necessary care.

Most Americans now agree that the only viable solution to these problems is a universal, single-payer health-care system for all. Every industrialized nation in the world makes this available to their citizens; only our country lags behind.

What to do?

Become knowledgeable about these issues. Use the Internet, your health-care provider and citizens organizations, the library and media resources to fully inform yourselves and then communicate with your elected representatives across the political spectrum to demand that they free themselves from the Big Pharm and Big Insurance industry’s financial largesse and move not incrementally but directly to the only solution that has been proven successful: universal single-payer health care for all.

Dr. Joseph E. Birnbaum lives in Monroe.

Which Side Are You On?

The Nation
Editorial
February 19, 2007 issue

Rarely does the response to a State of the Union address create more buzz than the presidential pontification itself. But that’s what happened with the sharp lesson in populist economics delivered by Senator Jim Webb of Virginia. Webb’s indictment of the Iraq War was direct and powerful, but it was his use of the language of class conflict in discussing domestic policy that really had the country buzzing after January 23. Talk-radio host Laura Ingraham referred to Webb’s response, warning the National Review Institute Conservative Summit, “The party that comes off as the party that represents the American worker best is the party that wins in 2008.”

Republicans are right to fear Webb’s words. Blunt talk of America “drifting apart along class lines” and the observation that “it takes the average worker more than a year to make the money that his or her boss makes in one day” connect with voters soured on the GOP, as even George W. Bush implicitly acknowledged when he told a Wall Street crowd a week later that corporate boards “need to pay attention”to executive compensation. As proven by Webb’s upset victory in November, and the victories of Ohio’s Sherrod Brown, Vermont’s Bernie Sanders and Montana’s Jon Tester, candidates willing to break with the bosses can draw working-class voters out of the clutches of moralizing right-wingers and back into the Democratic fold.

Now Democrats need to prove with deeds that match Webb’s rhetoric just which side they’re on. With moves to raise the minimum wage and tax Big Oil, House Democrats have taken some significant steps. Senate Democrats have done the same with efforts to raise taxes on executive pay. But much more is possible.

Take the question of what to do about healthcare, our most critical domestic issue. George W. Bush’s answer in his speech was to tax workers whose employers offer high-quality plans (“gold-plated” in Bush’s snide reference) in order to cover a small number of the currently uninsured, while offering the wealthy yet another new tax deduction if they buy their own plans.

The Democrats should counter Bush with a plan that’s already backed by seventy-eight House members, HR 676, the National Health Insurance Act, introduced by Representatives John Conyers and Dennis Kucinich. Some 225 labor unions back the bill, which would expand Medicare to every US resident. A tax on the top 5 percent of income earners, among other measures, would pay for the program.

Too radical? Consider that in September, an ABC News/Kaiser Family Foundation/USA Today survey found that 56 percent of Americans would prefer a government-run universal healthcare system “like Medicare” to our current system.

Or take the matter of education. The median income of workers with a BA or higher is about double that of those with only a high school diploma. But as Jeff Madrick noted here recently, thanks to rising costs and inadequate aid, the march to higher graduation rates has stalled in America as other countries have surpassed us. How should Congress respond? It could start with the plan, proposed by Edward Kennedy, chair of the Senate Committee on Health, Education, Labor and Pensions, to forgive all college loans if graduates work in public service for ten years.

There’s more. How about dusting off legislation to deny corporations tax deductions when executive compensation exceeds twenty-five times the pay of the lowest-paid full-time worker? How about responding to Bush’s request for fast-track authority on free-trade agreements by requiring the inclusion of labor, environmental and human rights standards in any new deals?

Senator Webb invoked the example of Teddy Roosevelt’s progressive reforms in the early twentieth century. That’s a good place for Democrats to look for inspiration in turning Webb’s message into enthusiasm for their party in 2008. More important, they can begin work now on an economic program that, to borrow Webb’s phrase, will insure that the benefits of our immense wealth are “properly shared among all Americans.”

Will Health Care Reform Lead to a Single-Payer System?

by George Lauer
California HealthCare Foundation
January 29, 2007

What a difference a year makes.

Not too long ago, California had one big-picture proposal on the table to fix the state’s ailing health care system. There was a noticeable lack of discussion until Gov. Arnold Schwarzenegger [R] vetoed that plan, decreed 2007 “The Year of Health Care” and promised a plan of his own. Assembly and Senate leaders scurried to work up alternative plans and announced them a couple of months ago. The governor unveiled his much-anticipated proposals earlier this month. And now, President Bush has a plan.

We’ve gone from not much to look at or say to lots of both.

“No matter which proposals you might like or what you think will or won’t work, you have to be really glad that people are at last finally talking about health reform,” says Randolph Boyle, staff attorney with the National Health Law Program in Los Angeles.

“We’re way overdue.”

Gov. Schwarzenegger proposes a $12 billion health care reform package fueled by “contributions,” not taxes. Under his plan, all California residents would be required to have some kind of health insurance, similar to the stipulation now that all drivers must carry auto insurance. Medi-Cal and Healthy Families would be expanded to help provide coverage to low- and moderate-income residents. Individuals without insurance would face a reduction in state income tax refunds or have wages withheld.

In many ways, the governor’s plan mirrors those of Assembly leader Fabian Nunez (D-Los Angeles) and Senate President Pro Tem Don Perata (D-Oakland).

How President Bush’s national proposals might affect California’s plans is far less clear and will depend on which parts of whose proposals are adopted.

Long- vs. Short-term Strategies
One way to make sense of these competing proposals is to classify the components in each plan as long-term or short-term solutions. In one crucial context, four of the five measures now on the table can be construed as short-term solutions because they’re predicated on a system whose days might be numbered.

There is growing agreement that the current employer-provided health insurance system can’t last forever.

“I don’t think this system was meant to go on and on indefinitely, and it’s becoming pretty clear that it can’t,” Boyle says. “It’s already a couple decades past its prime.”

After World War II, hoping to stimulate the economy while guarding against profiteering, the government encouraged employers to offer fringe benefits to attract labor. Heath insurance was one of them. Over the past half century, however, health care has become so expensive that providing for it is no longer a fringe — it’s an expectation.

And it soon could become a mandate, although there is potential for legal challenges on that front. A federal appeals court ruled this month against a Maryland law requiring minimum employer health care contributions. That could create a significant roadblock for Schwarzenegger, Perata and Nuñez.

Is a Single-Payer System the Answer?
As costs continue to rise — and there’s no reason to expect they won’t — employers, as well as individuals, are being priced out of the health insurance market, mandate or no mandate. The main alternative to such a scenario is a single-payer system, a notion already adopted in almost every other nation in the industrialized world.

“I still believe single-payer is the correct answer for the long term,” says Sen. Sheila Kuehl (D-Los Angeles), chair of the Senate Health Committee and author of SB 840, a single-payer proposal for California that essentially would shift responsibility for providing health care coverage off employers’ shoulders and onto the government’s. Her plan would leave the insurance industry out of the loop and give the government considerable clout in negotiating prices with all kinds of medical providers from pharmaceutical companies to hospitals.

Passed by the Legislature last year and summarily vetoed by Schwarzenegger, her bill has been reintroduced in the Senate this year. Not surprisingly, it once again faces fierce opposition from the insurance industry, drug makers and others who profit from market-driven health care.

“What I see happening on the short term is 840 continues independently on its track, hopefully passes both houses and is again put on the governor’s desk,” Kuehl says. “And at the same time, we see what we can do in this two-year session to alleviate some of the immediate problems and expand coverage where we can,” Kuehl says.

“I don’t think there will be support for individual mandates,” Kuehl predicts. “The governor’s proposal closely mirrors what they’re trying to do in Massachusetts and they’re having trouble there. Private industry health insurance is just too expensive to force everybody to buy it.”

Recent estimates in Massachusetts show family premiums may be twice what originally was envisioned when the plan was approved.

Several single-payer plans are in the works nationally – Sen. Ted Kennedy’s push to expand Medicare, the AmeriCare plan from Rep. Pete Stark, D-California, Physicians for a National Health Program. They face the same opposition – and occasional support – as Kuehl sees in California.

“We would support an extension of Medicare,” says David Lipschutz, attorney for California Health Advocates, a consumer group based in Los Angeles. “It’s the flagship social insurance program for the federal government and generally beloved by most of its enrollees. There have been suggestions of gradually expanding the system to eventually include everyone, and that makes sense to us.”

Although President Bush in his State of the Union speech broached the issue of rising health costs for the first time, there is general consensus that the country is years away from entertaining – let alone embracing — any kind of single-payer plan.

Many health care experts, politicians and pundits predict it will be states such as California that lead the way.

“I think, ultimately, we will come to an agreement as a nation that free-market health care is not a good idea,” says Boyle from the National Health Law Program, “but we’re still pretty far away from that day, unfortunately.

“Most of the rest of the world went to single-payer plans at the beginning of the 20th century,” Boyle says. “We’ll be about 100 years behind, but I’m confident we’ll get there.”

Harry and Louise on John Edwards’ plan

Universal Health Care Through Shared Responsibility

John Edwards 08
February 5, 2007

“We have to stop using words like ‘access to health care’ when we know with certainty those words mean something less than universal care. Who are you willing to leave behind without the care he needs? Which family? Which child? We need a truly universal solution, and we need it now.”
— John Edwards

John Edwards’ vision for health care reform is built on four steps:

First: Business Responsibility.

Businesses… will be required to either provide a comprehensive health plan to their employees or to contribute to the cost of covering them through Health Markets.

Second: Government Responsibility.

* Offer New Health Insurance Tax Credits: …to subsidize insurance purchased through Health Markets… …sliding scale to middle class families and refundable…

* Expand Medicaid and SCHIP: …to serve all adults under the poverty line and all children and parents under 250 percent of the poverty line…

* Require Fair Terms for Health Insurance: …community rating and guaranteed issue…

* Secure the Health Care Safety Net: …a health care safety net including public hospitals, clinics, and community health centers remains necessary.

Third: New Health Markets.

The U.S. government will help states and groups of states create regional Health Markets, non-profit purchasing pools that offer a choice of competing insurance plans. At least one plan would be a public program based upon Medicare. All plans will include comprehensive benefits, including full mental health benefits. Families and businesses could choose to supplement their coverage with additional benefits. The markets will be available to everyone who does not get comparable insurance from their jobs or a public program and to employers that choose to join rather than offer their own insurance plans.

* Freedom and Security: (Health Market plans are portable)

* Choice between Public and Private Insurers: Health Markets will offer a choice between private insurers and a public insurance plan modeled after Medicare, but separate and apart from it. Families and individuals will choose the plan that works best for them. This American solution will reward the sector that offers the best care at the best price. Over time, the system may evolve toward a single-
payer approach if individuals and businesses prefer the public plan.

* Promoting Affordable Care: Health Markets will negotiate low premiums through their economies of scale… …reducing the need for underwriting and marketing activities…

* Finally: Individual Responsibility. Once insurance is affordable, everyone will be expected to take responsibility for themselves and their families by obtaining health coverage. Some Americans will obtain coverage from public programs like Medicare, Medicaid, and SCHIP and others will get coverage through their jobs. Other families can buy insurance through the regional Health Markets. Special exemptions will be available in cases of extreme financial hardship or religious beliefs.

http://johnedwards.com/about/issues/health-care-overview.pdf

Comment:

By Don McCanne, MD

One of the more important reasons that John Edwards wants to be president is that he really wants to reform health care. He understands the great advantages of the single payer model. But he also understands that he cannot be elected when Harry and Louise point out to the nation that John Edwards is going to “raise our taxes in order to force socialized medicine on us.”

The health policy experts in the progressive community understand this. They understand that the polls demonstrate strong support for Medicare, but also strong support for employer-sponsored plans. Employers currently cover 59 percent of the nation. The workforce and their families are comparatively healthy and most are content with their current coverage. In spite of polls indicating strong support for single payer or Medicare for All, there is a very real reluctance to give up private plans perceived as largely funded by the employers in exchange for a government-run program, especially since many equate that with queues and rationing.

For this reason, the progressive policy community has proposed reform which would allow individuals the option of keeping their current coverage, while establishing a competing public program that would prove to be so compelling that eventually most individuals would want to trade in their private plans for Medicare for All coverage. Although an abrupt shift to a single payer system is not considered to be politically feasible at this time, this gradual shift would be, or would it?

Harry (sitting at the breakfast table, reading the newspaper): I see this guy Edwards wants to tax us to fund some nutty government “Health Markets,” whatever the heck that is.

Louise: Why can’t those politicians leave our health care alone? Why do they keep wanting to get the government involved?

Harry: Like I’ve been telling you for years, Louise, those liberals just want to “raise our taxes in order to force socialized medicine on us.”

In aiming for this highly dubious goal of political feasibility, what beneficial policies has Edwards sacrificed?

* Employer mandate: Smaller employers and those in many of the service industries will struggle with the affordability of plans that provide reasonable coverage, or with the affordability of their contributions to the Health Markets.

* Individual mandates: The requirement for individuals to buy health plans is dependent on the fiction that affordable plans that provide reasonable coverage will be available. With community rating and guaranteed issue, they can never be. Health care costs too much. Premiums can be made affordable only by making access to health care unaffordable through high out-of-pocket expenses.

* Tax credits: To work, refundable tax credits must be very generous for not only lower-income individuals, but average-income individuals as well. The amount would have to be close to what employers are already contributing. Tax credits would introduce the administrative complexity and the unnecessary demeaning intrusion of means testing. It is much more efficient to establish progressive funding of a health care system through tax revenues rather than through tailoring premiums and tax credits to each of the 300 million people in our nation.

* Medicaid and SCHIP: As welfare programs, without an adequate political voice, chronic underfunding will remain a problem. Access will remain a problem because of a lack of willing providers, perpetuating a two-tiered system.

* Health care safety net: Policies do need to be established to be certain that adequate facilities are available in underserved areas. But rather than being near the bottom of government budget priorities, the presence of safety net facilities can best be assured by by funding them through the same high-quality coverage that everyone else would have.

* Health Markets: The model of competing private plans has been thoroughly discredited. No matter what regulations are established, private plans will continue to select the healthy – especially the healthy workforce and their healthy families. The private plans cover the majority of us who are healthy and cost very little, while we taxpayers pay most of the costs for health care for those with medical needs. Even Harry and Louise should understand how absurd this is.

* Administrative inefficiencies: The program suggests that the Health Markets will provide oversight that would reduce administrative costs. Maintaining a fragmented system of public and private programs with thousands of plans and provider lists would perpetuate the excesses of the plans and the administrative burden on the providers. Keeping the plans in place and adding a new administrative intermediary, the Health Markets, is not exactly the ket to achieving administrative efficiency.

* A new public Medicare program: The current Medicare program includes higher-cost seniors and individuals with long-term disabilities, including chronic renal disease. If we were to open the existing Medicare program to everyone else, the pro rata share of the premiums would be so high that Medicare could never compete with the private plans that insure the healthy. In recognition of this, a separate new Medicare has been proposed. Early enrollees would likely include individuals with greater needs, including the currently uninsurable and those from plans terminated by employers with unfavorable claims experiences. It is likely that this separate Medicare risk pool would have much higher premiums than would the private plans insuring the healthy, resulting in the death spiral of Medicare premiums (premiums spiraling upward causing the healthy to leave and concentrating even more of the high-cost individuals in the plan, until no one can pay the premiums).

The way to avoid a Medicare death spiral would be to eliminate the current fragmentation of risk pools: low-cost pools for the healthy and high-cost pools for the sick. All pools need to be combined into one universal risk pool that really does redistribute the risk. Since average-income individuals can no longer afford a pro rata premium, the risk pool must be funded equitably through a progressive tax. Once you solve the problem of pooling risk, why keep in place superfluous private plans that serve no real function but which burn up funds in useless administrative services.

Louise (sitting at her computer, while Harry reads the newspaper): Harry, I’ve really been concerned about how much we’re spending on my health care and how little I’m getting for it. You don’t have to worry because of your Medicare, but I do. When I googled some of the problems, the computer kept taking me to Physicians for a National Health Program. So I looked over their website.

Harry: Yeah? What do they have to say?

Louise: Well, a whole lot.

Harry: Like what?

Louise: Well, it’s too much to say in one sentence. There are a lot of issues I’ve never given much thought to.

Harry: National health. Sounds like socialized medicine to me. I can’t imagine that they’re on to something.

Louise: Well, I don’t know, Harry. I think that we’ve been missing the big picture when we stopped listening because the government would be involved. But these folks have shown that we’re already paying enough taxes to pay for insurance for all of us, but we’re not getting it merely because we keep protecting the private insurance companies.

Harry: You mean WellPoint, UnitedHealth, Cigna, and them others?

Louise: Yeah.

Harry: Those crooks! They’d better not mess with my Medicare!

Louise: That’s the point, Harry. If we’d throw them out we could all have Medicare and save money while we’re doing it.

Harry: Like I was telling you, Louise. You can’t listen to those liberals like Edwards. He wants to leave the private plans in control. Those liberals will never get it right.

How would single payer control costs?

Crossroads/Health Care

Sacramento Bee
sacbee.com
January 29, 2007

How would single payer control costs?

From Daniel Weintraub:

In this commentary in the Boston Globe (link below), Marcia Angell says that “Medicare for all” is the only idea that could control the cost of health care. But other than a one-time drop in administrative costs, she doesn’t offer any examples of how a government-run system would control costs. She complains that private insurers are good for nothing but denying care to people who need it. But denying care would seem to be the single best way to control costs. It might even be the only way.

So to those who support the Medicare for all approach, or any other form of single payer, please help us understand: after cutting out the “administrative fat,” marketing and profits that are part of a private system, how would it control the cost of health care? Anyone?

http://www.sacbee.com/static/weblogs/crossroads/healthcare/

Marcia Angell, “Fix the system with Medicare for all,” Boston Globe, January 29, 2007:
http://www.boston.com/news/globe/editorial_opinion/oped/articles/2007/01/29/fix_the_system_with_medicare_for_all/

Comment:

By Don McCanne, MD

A single payer system, such as the proposed Medicare for all, would have the very powerful economic advantage of being a public monopsony: the single purchaser of health care. Although private monopsonies raise havoc in marketplaces, monopsonies owned by the citizens play a much more beneficial role. The mission of a publicly-owned, single payer monopsony would be to obtain the best health care value for all of us. That means not only reducing waste and inefficiency, but it also means providing adequate resources to develop and maintain the necessary health delivery infrastructure and to attract dedicated professionals that provide our care. It means obtaining truly beneficial care at the fairest prices.

This is much more than mere theory. All other industrialized nations have universal programs that function as monopsonies, whether through government ownership, single payer insurance programs, or very tightly regulated non-profit, quasi-public insurance systems. All have been more successful at slowing the rate of health care inflation, spending much less than we do, while providing care for everyone. They all receive greater value for their health care investment.

To control costs we need to understand why our costs are so high. A few reasons will be listed along with potential policy solutions.

The six largest private insurers in the United States spend an average of 80 percent of insurance premiums on health care; that means they keep 20 percent for administration and profit. Physicians and hospitals consume another 12 percent of private insurance premiums on billing and insurance related functions alone. No other nation would tolerate a system that consumes one-third of insurance premiums on insurance functions. A single payer system dramatically reduces this waste and some of the waste on other administrative inefficiencies as well. Although that is a one-time adjustment, it is a benefit that is perpetuated on into the future.

Health care prices are much higher in the United States than in other nations. Using prescription drugs as an example, a single payer system would negotiate prices to cover legitimate costs and provide fair profits. Allowances would no longer be made for the 80 percent of research that is designed simply to restart the patent clock. Rather, generous allowances would be made for innovations that provide hope of new, beneficial products. Marketing which results in misuse of drugs would not be supported. Since the marginal costs of increased production are quite small, the expansion of appropriate prescribing under a universal system would be quite affordable. A single payer monopsony would be more effective in getting prices right, whether with pharmaceuticals or with any other health care products or services.

A strong primary care infrastructure provides higher quality care at lower costs. Our primary care system is rapidly deteriorating. A single payer monopsony would realign incentives to strengthen our primary care base. Our costs would be lower, and everyone would have access to the quality provided by a medical home of their choice.

Because of the maldistribution of our health care resources and because of variations in medical practice patterns, overuse of high-tech, specialized services that provide no health care benefit have characterized much of our system. A single payer monopsony would have much better information resources to help realign incentives to promote more optimal use of the technologically-advanced products and services. Incentives should be provided to be sure that new and better technology does its best to live up to its promise to lower costs by replacing out-dated but more expensive technology.

With a single payer system, budgeting decisions become more rational. Budgets could be adjusted based on demographics, legitimate delivery costs, inflation, beneficial new technology, changing health care needs, fair profits, and any other appropriate factor. Global budgets, such as for hospitals, would be negotiated to be sure that adequate funds would be available to carry out the hospitals’ mission, while the temptation to drive up revenues by over-utilization would be eliminated.

In a new book, “Medicare Prospective Payment and the Shaping of U.S. Health Care,” Rick Mayes and Robert Berenson demonstrate how Medicare has been able to provide health care value-purchasing through oversight and continual refinement of payment systems. They demonstrate that private plans have not been innovators in cost management but have merely followed the government’s lead through measures such as private, managed care price fixing. Medicare’s prospective payment certainly is not perfect and will continue to be a work in progress, as it should be. Since Medicare controls the spending on less than 15 percent of our population, there are limits to its impact on shaping U.S. health care. But imagine the rich information of a universal Medicare program, and how that information could be used to improve health care value for all of us through a Medicare-type single payer monopsony.

What about rationing? The United States has the worst and most cruel form of rationing because we ration care based on ability to pay. Essential acute care is not rationed in any other nation. Some nations have excessive backlogs (queues) for non-urgent or elective services. But, according to the OECD, many other nations do not have excessive queues because they control them by appropriate monitoring of their systems and applying queue management techniques, or minor adjustments in capacity, if necessary. With the funds that we are already devoting to health care, rationing of beneficial services would not be necessary.

One more very important point: health care does not burden our economy; it is a part of our economy. In fact, health care is the fastest growing sector within our economy. It adds to our economic health. And it does so within our domestic economy, keeping dollars and jobs at home. Although we want far better value for our current health care spending, if health advances can provide greater value, we should encourage them. Economic analyses have demonstrated that we could double our health care enterprise without any negative impact on the other sectors of our economy.

So, Daniel, that is how single payer could control costs, if we want it to. But it is also how single payer could provide us with more health care with even greater value, if we want it to.

Maine provides another lesson – for failure

Report of the Blue Ribbon Commission On Dirigo Health (Maine)

January 2007

From the Final Recommendations:

The Commission expresses its unanimous support for the Dirigo Health Program and its goals…

* Regarding making health care coverage more affordable overall, the Commission endorsed the following initiatives:

– increase transparency of insurance rates by building publicly available data sets that allow consumers and employers to review health plan offerings against broad set of comparative metrics.

– allow sole proprietors to purchase coverage in the small group market

– create options to allow non-subsidized individuals and employees to purchase health care coverage using pre-tax dollars

* Regarding individual market reform, the Commission recommends that the Governor appoint a work group representing the Bureau of Insurance, GOHPF, consumers, insurers, providers and employers to begin immediately to conduct an analysis of three options — (1) high risk pools, (2) merger of the individual and small group markets, and (3) reinsurance options applied to the individual market or merged market option — as well as combinations of and different versions of these options, and that the results of that study guide policy makers in proposing specific solutions to the individual health insurance market in 2007.

* Regarding employer and individual mandates, the Commission endorses the concept of an employer mandate along with a mandate for individuals with income over 400% FPL, and recommends that the Governor move forward to explore the parameters of how such mandates would work, including, but not limited to such issues as: what is considered credible coverage; what would be a reasonable payment for businesses who elect not to purchase coverage; and how the individual mandate would be enforced.

http://dirigohealth.maine.gov/BRC%20Final%20Report.pdf

Comment:

Don McCanne, MD

When the Maine legislature passed the Dirigo Health bill in June, 2003, it was hailed as a bill that promised “affordable coverage to all Mainers.” A Quote of the Day message at that time stated that the policies developed sacrificed “the goal of an affordable, comprehensive and truly universal system.”

https://pnhp.org/news/2003/june/maine_succeeds_in_ad.php

Since the Dirigo Health program was not working, Governor Baldacci issued an Executive Order establishing The Blue Ribbon Commission on Dirigo Health. They have now released their final report.

We have covered many times the reasons why state efforts to achieve universal coverage through individual and employer mandates to purchase private health plans cannot ever achieve the goal of reasonably comprehensive coverage for everyone. I do not need to restate those reasons to come to the conclusion that the recommendations of the Blue Ribbon Commission “cannot ever achieve the goal of reasonably comprehensive coverage for everyone.” (Is there an echo in here?)

My message on June 14, 2003 to health care reform activists in Maine remains the same today:

“Those of you in Maine who are continuing to craft the single payer model, please do not leave your tables. Maine desperately needs your program, as will soon be evident.” (as if it weren’t already)

A Connecticut lesson for state reformers

Although a prior Quote of the Day discussed a Policy Brief on which this report is based, some specifics in this final report are very pertinent to the current debate over various state efforts to provide universal coverage.

Health Coverage in Connecticut: Three Routes to Reform

By Stan Dorn, Jack Meyer and Elliott Wicks
Prepared for Universal Health Care Foundation of Connecticut

Three models for reform:

* One Health Plan Serving All Residents (Single plan)
* Health Insurance Purchasing Pool with Competing Private Plans (Private plans)
* Expanding the Health Coverage Safety Net While Requiring All Parents To Cover Their Children (Safety net)

Benefits:

* Single plan – All state residents get comprehensive coverage; no high deductibles
* Private plans – 61% of residents in pool, with diverse private options
* Safety net – Some adults get tax credits to access purchasing pools

Population covered:

* Single plan – No uninsured
* Private plans – No uninsured
* Safety net – 3.6% uninsured

Integration of low-income households:

* Single plan – Integrated into state health plan
* Private plans – Partial and voluntary integration into pool
* Safety net – Very little integration

Employer health costs:

* Single plan – Major savings
* Private plans – Significant savings
* Safety net – Minimal savings

Household health costs:

* Single plan – Major savings
* Private plans – Significant savings
* Safety net – Minimal savings

Total spending on health care and insurance:

* Single plan – $10.03 B
* Private plans – $10.56 B
* Safety net – $10.66 B

http://www.universalhealthct.org/admin/uploads/1057745758a8a7e7ef7.89093563.pdf

Comment:

By Don McCanne, MD

The “single plan” above technically is not a single payer proposal since it leaves Medicare in place, and it defines benefits as those typical of employer-sponsored plans. But it does include important features of the single payer model in that everyone is automatically enrolled, and the plan is administered by a state commission. Thus the impact demonstrated by the modeling of the “single plan” approaches that of the the beneficial effects previously demonstrated by other studies modeling bona fide single payer plans.

There are no surprises here. As with single payer, the “single plan” covers everyone, with the most comprehensive benefits of the proposals, and with the greatest cost savings – globally, and individually for businesses and households as well.

The current surge of interest in achieving universal coverage at the state level is certainly understandable considering the continued negligence of the federal government in failing to address this gross injustice. What is particularly valuable about this report is that it provides insight into the potential impact of the current proposals under consideration.

The “safety net” model has the greatest likelihood of being enacted since it merely entails expanding coverage for children and perhaps for a few low-income adults. But it is the most expensive and has almost a negligible impact on the problems we are facing. Those supporting this model (e.g., Families USA) contend that the perfect should not be the enemy of the good. But when a much more effective and less expensive option is available, then the “good” is actually bad as it is the enemy of the perfect.

Recognizing the gross inadequacies of the “safety net” model, many states are turning to the “private plans” model in the form of mandates for either employers or individuals to purchase private plans. This report indicates that the “private plans” model is significantly more costly than the “single plan,” and other studies have indicated that expanding coverage through private plans is the most expensive form of attempting to achieve universal coverage.

Also this report indicates that the “private plans” model would be universal, when, in fact, a mandate to purchase insurance can never be universal because many individuals or businesses simply do not have the funds required. This model fails because premiums for plans that are effective in preventing medical debt are too expensive for far too many people. We usually include Switzerland, the second most expensive system, in the list of countries with universal coverage, though actually many there are left without coverage because they also use an individual mandate. In fact, they will have a single payer measure on their ballot this year as a reaction to the inequities of their individual insurance market.

The most important lesson for states appears above under “Benefits.” The states are struggling to find affordable options, which really means affordable insurance premiums, but not affordable health care. The “private plans” model calls for “diverse private options,” which means plans with affordable premiums that expose individuals with significant health care needs to major medical debt. The “single plan” calls for “comprehensive coverage with no high deductibles.”

The policy lesson? The least expensive proposal, “single plan,” is the only one that really does cover everyone, and does it with coverage that really works. A bona fide national single payer program would be even better.