PNHP

AHRQ Disparities Report

AHRQ Disparities Report

2006 National Healthcare Disparities Report

U.S. Department of Health and Human Services
Agency for Healthcare Research and Quality
December 2006

Being uninsured has a large negative impact on almost all aspects of health care quality and access. In fact, among adults, the negative effects of being uninsured are typically larger than the effects of race, ethnicity, income, and education. Multivariate analyses suggest that uninsurance is an important mediator of racial, ethnic, and socioeconomic disparities, although race, ethnicity, and socioeconomic position often have independent effects as well.

http://www.ahrq.gov/qual/nhdr06/nhdr06report.pdf

Comment:

By Don McCanne, MD

Martin Luther King Jr said it:

“Of all the forms of inequality, injustice in health care is the most
shocking and inhumane.”

Realtors face health care crisis

Realtors, Other Small-Business People Face Health Care Crisis

National Association of Realtors
January 10, 2007

Small business employers and the self-employed, including real estate firms and agents, are facing a growing challenge in accessing and providing affordable health insurance, Pat Vredevoogd Combs, president of the National Association of Realtors, told a congressional panel today (U.S. Senate Health, Education, Labor and Pension Committee – Senator Edward Kennedy (D-Mass.), chairman and Senator Michael Enzi (R-Wyo.), ranking member).

“As we sit here, 28 percent of the nation’s 1.3 million Realtors do not have any health insurance. This is nearly double the percentage of uninsured members in 1996. If we add family members to the total, the final estimate for the Realtor family is close to 886,000 individuals,” stated Combs. “We are ready to work with you to fix an insurance delivery system that is not meeting the needs of working Americans,” she pledged.

Making health care insurance available and affordable for Realtors and for all Americans employed by small businesses is a top priority of NAR. “We believe it is important to find a solution to the health insurance crisis that has plagued small businesses. We don’t have all the answers on how to do it, but we do know it must be done,” said Combs.

http://www.realtor.org/press_room/news_releases/2007/realtors_other_small_business_people.html

Comment:

By Don McCanne, MD

How to do it? Sen. Kennedy supports Medicare for all, while Sen. Enzi supports offering lowest-common-denominator, stripped-down coverage through association health plans. One would provide everyone with affordable health care, and the other would provide the right to purchase affordable health insurance that leaves health care unaffordable.

Which do the Realtors really want?

Jacob Hacker's "Health Care for America"

Health Care for America

A proposal for guaranteed, affordable health care for all Americans building on Medicare and employment-based insurance

by Jacob S. Hacker
The Economic Policy Institute
EPI Briefing Paper #180
January 11, 2007

As health care costs have skyrocketed and the proportion of Americans with stable benefits has eroded, health insecurity has become a shared American experience, felt by those who thought they had it made as well as those just struggling to get by.

This growing problem is pushing health care reform back onto the agenda of American politics after more than a decade of neglect. And yet, nothing guarantees that this debate will end differently than previous battles.

To avoid the dismal fate of previous reform campaigns, a successful agenda must take seriously the political constraints and organizational realities that have hamstrung reform efforts in the past. Limits on public budgets, resistance to measures that might be seen as taking away what Americans already have, and the embedded realities of the present system all stand squarely in the path of grand policy redesigns–from single-payer national health insurance, to individual mandates requiring that everyone purchase private coverage, to a universe of individualized Health Savings Accounts. Instead, the most promising route forward is to build on the most popular elements of the present structure–Medicare and employment-based health insurance for well-compensated workers–through a series of large-scale changes that are straightforward, politically doable, self-reinforcing, and guaranteed to produce expanded health security.

Health Care for America embodies this strategy. It would extend insurance to all non-elderly Americans through a new Medicare-like program and workplace health insurance, while creating an effective framework for controlling medical costs and improving health outcomes to guarantee affordable, quality care to all. It is at once comprehensive, realistic, consistent with American values and beliefs, and grounded in the best elements of the present system. It combines employer and personal responsibility with a strong public commitment to ensuring that American workers and their families and American employers can afford coverage. It promises better care, lower costs, more choice, healthier citizens, and immensely stronger guarantees for workers and their families. And it promises real savings for employers and state governments–without unraveling existing sources of health security, without forcing workers to obtain coverage on their own, and without pressuring patients into Health Savings Accounts or tightly managed health maintenance organizations (HMOs).

What Health Care for America would do is simple: every legal resident of the United States who lacks access to Medicare or good workplace coverage would be able to buy into the “Health Care for America Plan,” a new public insurance pool modeled after Medicare. This new program would team up with Medicare to bargain for lower prices and upgrade the quality of care so that every enrollee would have access to either an affordable Medicare-like plan with free choice of providers or to a selection of comprehensive private plans.

At the same time, employers would be asked to either provide coverage as good as this new plan or, failing that, make a relatively modest payroll-based contribution to the Health Care for America Plan to help finance coverage for their workers. At a stroke, then, no one with a direct or family tie to the workforce would remain uninsured. The self-employed could buy into the plan by paying the same payroll-based contribution; those without workplace ties would be able to buy into Health Care for America by paying an income-related premium. The states would be given powerful incentives to enroll any remaining uninsured.

http://www.sharedprosperity.org/bp180.html

For the PDF version of “Health Care for America:”
http://www.sharedprosperity.org/bp180/bp180.pdf

Comment:

By Don McCanne, MD

Jacob Hacker is gifted, really (though some might contend that “gifted political scientist” is an oxymoron). Jacob Hacker cares about people. He knows that we must do something to make health care accessible and affordable for everyone.

His proposal does not break new ground in health policy. He has merely combined various concepts that have been under consideration for some time. What is very different about this proposal is that the design features comply with the perceptions of most Americans as to how they want our health care to be financed. It is just possible that he may have crossed the threshold of political feasibility.

There are some very good features in his proposal. It establishes a new and improved Medicare that competes with the existing private plans in the employer-sponsored and individual markets. Employers and individuals who are concerned about replacing their private plans with a government-run program would have the option of continuing with their current standard coverage. It is estimated that about half would switch to the Health Care for America program. It is likely that, with time, the public program would establish its superiority resulting in a massive shift in enrollment. That would bring us very close to a single payer system without having to dump it on the nation all at once. When you read his report, you will recognize that there are many other features that would help to ensure an equitable and affordable system for all.

From the perspective of a single payer advocate, there are some problems. Leaving the private insurers in place perpetuates the administrative waste of those insurers and the administrative burden on the providers. Intense regulatory oversight of the private insurers would be even more imperative since they would increase their efforts to game the system through surreptitious favorable selection and other clandestine market expediencies. The public program would likely concentrate lower-income individuals initially, risking a political transformation into a welfare program. Also his plan includes features of both an employer mandate and an individual mandate, each with its own policy problems, though he does ameliorate the impact to a certain extent with some of the other features of his plan. From a single payer perspective, it would be far better to totally cut the link between financing and coverage. A system of equitable tax funding of the entire risk pool is more efficient than a system of premiums linked to the individual. Other potential problems are evident in the report.

This is a very important contribution to the national dialogue on reform. The report should be downloaded since it will surely become a prominent part of our debate.

Since PNHP’s mission is to inform rather than to negotiate compromise, we will continue to point out specific policies in his model that could be improved. That said, Jacob Hacker’s proposal is a very welcome addition at a time that all options should be on the table. It is such a compelling model that it may shove all others off of the table – except single payer – then we can get down to a serious discussion about reform that really works.

On the Governor's Health-Care Plan

More insurance is not the answer

By Deborah Burger
San Francisco Chronicle
Thursday, January 11, 2007

While Gov. Arnold Schwarzenegger deserves credit for finally responding to the state’s imploding health-care crisis, his plan as designed has major flaws, most notably forcing the uninsured to buy what for many will mostly likely be substandard, unaffordable health plans that primarily serve to further enrich big insurers.

Some provisions in the governor’s package are welcome — notably the intent to end the disgraceful denials of coverage based on age or health status, and his pledge to assure access to health services for the undocumented.

However a plan that begins by criminalizing the uninsured with no controls on skyrocketing premiums and, at this point, no standards on what those health plans will include, is a train wreck waiting to happen. Let us hope that the state would establish uniform and comprehensive benefits for all.

In a state where health insurance typically runs up to $12,000 a year for a family of four, it’s a safe bet that many will gamble with their health and opt for the cheapest plan available. As defined by the governor’s proposal, those plans would require families to spend up to $10,000 a year in out-of-pocket medical costs. In other words, the average consumer will have to pay for presumably all of their health services in addition to the premiums the law will force them to pay.

If it sounds as if someone is making out like a bandit, that bandit has a name – the insurance industry. Insurers will gain millions while consumers will receive little in return. A mandate on individuals to buy insurance is the centerpiece of the Massachusetts health plan as well. The experience there to date does not recommend this approach. Many people are choosing not to sign up, even with the tax penalties, because they cannot afford the plans, and due to funding problems, the state has cut back on public education about the program. That’s in a state with 500,000 uninsured as compared to California’s 6.5 million uninsured.

A second area of concern is the proposal to shift some $2 billion in tax funds that now goes to hospitals to cover indigent care and use it to buy coverage for the uninsured. It takes money used for direct delivery of care, and hands it to insurance companies, which take 25 percent to 30 percent off the top for wasteful administrative expenses.

Moreover, the proposal has an ugly underside: Because 70 percent of those funds go to public hospitals and clinics, the proposal will starve the public sector of desperately needed revenue, hastening the closure or privatization of more public facilities. This could have a particularly deleterious effect on low-income communities where most public hospitals are located.

That demonstrates the biggest fundamental problem with the governor’s entire package: A market-based system always puts increased revenues and profits over the health and well-being of those patients it is supposed to serve. As was the clear intent of a number of the free-market architects of the plan, it reinforces and expands the role of the market in health care, the very source of the present crisis. If the governor’s goal is truly universal health coverage, improved quality and effective cost controls, the state should embark on the same tried-and-true course taken by every other industrialized nation, either a national health system, or a single-payer approach as embodied in the single-payer bill, SB840 authored by state Sen. Sheila Kuehl. Kuehl’s bill was vetoed by the governor last year. It will be reintroduced this year.

Under a single-payer system, such as Medicare, one public entity collects all the financing and pays for all medical services through the existing private-care delivery system, with adequate funding for our doctors, hospitals, clinics, and other care.

It’s the only plan that assures everyone is covered with one high standard of benefits and care, as opposed to good care for the wealthy only. It assures choice of physician, reduces administrative waste, provides commonsense budgeting, and ends insurance industry interference in the form of high premiums, high deductibles and denials of care.

Americans spend twice as much per person on health care as the other 21 wealthiest countries, yet World Health Organization data shows Americans live the shortest time in good health and have poorer patient outcomes in category after category from infant mortality to life expectancy to doctor visits.

Being number 21 is hardly good enough. By enacting the single-payer Kuehl bill this year, we could finally have the plan Californians need and deserve.

Deborah Burger, R.N., is the president of the California Nurses Association.

A second, third and fourth opinion on healthcare

By Sheila James Kuehl
LA Times
January 9, 2007

Sen. Kuehl (D-Santa Monica) chairs the state Senate Health Committee.

IF ATTENTION IS the precursor to action, something might finally be done in Sacramento about the dismal state of healthcare insurance in California.

Four healthcare proposals are now before the Legislature, including one crafted by Gov. Arnold Schwarzenegger, which will be spotlighted in his State of the State address tonight.

Unfortunately, that plan and two others — state Senate President Pro Tem Don Perata’s SB 48 and Assembly Speaker Fabian Nuñez’s AB 13 — are short-term solutions that have the potential to expand coverage but at the end of the day can’t be relied on to achieve what 80% of Californians say they want: a government guarantee of access to affordable healthcare coverage in the state.

In SB 48, all employers could either spend a percentage of their payroll toward employee health insurance or pay an equivalent amount into a healthcare trust fund, which would offer plans from private insurers. Insurance companies that wanted to participate in the fund would be required to restrain administrative expenses and provide a basic level of benefits. Working individuals would be required to purchase coverage for themselves and their dependants via their employers or the fund; out-of-pocket costs would be limited. For the unemployed, the plan would also expand children’s eligibility for the existing Healthy Families program.

AB 13 covers otherwise uninsured employees and their dependents through a purchasing pool paid for by employers that have two or more employees and do not offer healthcare coverage. As with the trust fund in Perata’s bill, this pool would offer healthcare coverage from private insurance companies. Workers offered coverage from their employers would be required to accept it unless premiums and out-of-pocket costs exceeded a certain level, in which case they could buy insurance from the pool. Individuals and the self-employed could buy into the pool, which would offer several plans, each of which would provide a minimum set of benefits. As with the Perata bill, the Healthy Families plan would be expanded to offer more public healthcare for the poorest children.

In their present forms, these bills are limited because they emphasize covering the employed and because they mandate that insurance will be funded by a percentage of wages, which may not be enough for all workers in the state, much less all Californians. Nor do these bills specify what is meant by basic coverage, which may mean that the insurance that is offered isn’t adequate.

Schwarzenegger’s plan, which was unveiled Monday, doesn’t do anything to solve these problems and creates some new ones. His plan mandates that every individual have insurance (not just every worker), yet it doesn’t ensure that coverage will be comprehensive and affordable.

Schwarzenegger also calls for increasing reimbursements paid to providers under public programs by billions of dollars. Like Perata and Nuñez, the governor would expand the Healthy Families program to help pay for insurance for the poorest children in the state.

How does he pay for it? Individuals and employers will contribute, but employers are required to spend only 4% of payroll to insure their employees, or contribute the same amount to a state fund. This is not sufficient to purchase insurance for the working uninsured, who will be required to have it. This means that the governor’s plan can at best provide high-cost, low-benefit plans for many Californians; it limits what employers pay but not what individuals must pay or what insurance companies can charge.

A portion of the funding for the plan would also come from federal money that is at this point only “hoped for.” There also would be a tax on providers, such as doctors and hospitals, and the governor would redirect public money now spent on poor people in hospitals to insurance companies. This would create an immediate problem for hospitals, which are already closing because of inadequate reimbursement from private insurance companies.

Finally, the governor would adopt President Bush’s plan for individual health savings accounts by requiring employers to “allow” employees to put away money, pretax, to pay for unreimbursed medical expenses. These accounts effectively shift the costs and liability of healthcare away from insurance companies and onto consumers. Such a plan would not benefit people who are already too strapped to meet current expenses, and it does nothing to expand coverage or affordability.

The fourth proposal before the Legislature is SB 840, which I wrote last year. It is the only proposal that establishes universal, affordable, comprehensive health insurance for all Californians and guarantees the right of each patient to choose his or her doctor.

SB 840 would replace insurance companies with a statewide trust fund that collects premiums paid by employers and individuals, who together would share the responsibility for funding the program. The creation of a single state fund reduces the administrative portion of California’s healthcare costs from nearly 30% to under 10%. With everyone in one pool, which spreads the risk as widely as possible, no one would be denied coverage for a preexisting condition. Individuals would be free to change jobs, start a business, go to school or start a family without losing coverage or doctors they trust.

SB 840 mandates truly comprehensive coverage; it keeps down the overall cost of healthcare; and it specifically limits the out-of-pocket costs to individuals.

The governor says he will not sign a universal insurance bill. Nevertheless, the Legislature will continue to develop the plan as the only long-term, universal solution to the health crisis.

I’m committed to working with all stakeholders — the governor, the Legislature, medical professionals, labor, business and consumers — to craft real healthcare reform this session. I believe that SB 840 provides the best way to meet the goal of universal healthcare for Californians.

Any other incremental reform must move us toward that goal.

Working to extend health care

Column by Kevin Eigelbach
Cincinnati Post
January 01, 2007

Dr. Donald L. Rucknagel has a very unscientific theory about why people – other than those with a vested interest in the present system – oppose government-funded health insurance:

In addition to the 12 already discovered, there are two cranial nerves in the human brain. Mention the words government or taxes, and the two nerves shut the brain down.

It’s the only explanation. The arguments for single-payer, universal health care are just too compelling.

In his 78th year, the former director of the Sickle Cell Center at Children’s Hospital has found the most important work of his life: lobbying for the Health Care For All Ohioans Act.

The act would set up a system of free medical care for all residents, with a patient’s choice of doctors, paid for by a combination of taxes and savings:

A 3.5 percent payroll tax paid by employers.

A 3 percent gross receipts tax on businesses.

A 6.2 percent addition to the state income tax for those making more than $90,000 a year, plus a 5 percent surtax on gross income for those making more than $200,000 a year.

$11.6 billion in cost savings from having all claims paid by a single payer, plus the savings from making preventative care more accessible.

From the office inside his home in downtown Cincinnati, Rucknagel’s helping the Single-Payer Action Network of Ohio collect 143,000 signatures supporting the Act, plus raising money to lobby for its passage.

If the General Assembly doesn’t pass the act, the group plans to collect 143,000 more signatures and put the issue on the November ballot. It’s a moral issue, Rucknagel says, quoting Martin Luther King Jr.: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”

He can tell you story after story about how people without health insurance use the hospital emergency room as their primary care physician. This drives up costs because emergency room care costs more, and because the patients have often put off care until their condition is harder to treat.

Rising costs drive companies to stop paying for their employees’ health insurance. This creates more uninsured people, further driving up costs, and so on.

“What good is it to have all this medical care if people can’t afford it?” Rucknagel asked.

Selling the Act to the 60 percent of Ohio employers who still provide health insurance shouldn’t be hard, he said, because they would pay less than they now do. The harder sell will be to the wealthy and to the health-insurance companies, which see this as a step toward national health insurance.

That’s exactly what it is, Rucknagel says.

All progressive movements begin in the states. “The states are the laboratories of democracy,” he said. California and Ohio have the best shot at creating a system that other states can emulate, he said.

Imagine living in an Ohio with this health-care system: You wouldn’t have to check if you’re covered for a procedure before you have it. You wouldn’t have to worry that your doctor didn’t prescribe you something your insurance wouldn’t pay for.

You wouldn’t fear changing jobs because you’d lose your health insurance. You wouldn’t have health care co-pays and deductibles that threatened to bankrupt you.

Sound good? You can find out more at www.spanohio.org. Or call Rucknagel at (513) 931-3459.

Staff reporter Kevin Eigelbach writes on religion for The Post. Write him at keigelbach@cincypost.com.

Top 10 for a More Perfect Union

Editor’s Cut

By Katrina Vanden Heuvel
The Nation

The “thumping” taken by the Republican Congress on election day was not just a rejection of K Street corruption and the catastrophe in Iraq. It was a call to action on issues that are more immediately relevant to people’s lives. House Speaker Nancy Pelosi will begin to answer that call by pushing a “100 Hours” agenda–including common-sense legislation to increase the minimum wage, cut interest on student loans and open the way for Medicare to negotiate prescription drug prices.

That’s a good beginning, but it’s only a down payment on a broader agenda. As Bill Moyers writes in this issue, progressives now have the opportunity to develop a new vision that returns power to the American people for the first time in generations. Moyers is right that to-do lists don’t add up to a vision. But Democrats must show they are serious by passing bold measures that define a new “people’s agenda.” With that in mind, here are ten existing pieces of legislation that deserve to be passed by our new Congress. Some of these bills are eminently passable, a few are related to the “100 Hours” agenda and others can be seen as long-term goals. But all would help return our nation to the path to a more perfect union (note: Bill numbers may change in the new Congress).

1. Healthcare for All

More than 47 million Americans are now living without health coverage. Representative John Conyers’s United States National Health Insurance Act (HR 676) would create a single-payer healthcare system by expanding Medicare to every resident. All necessary medical care would be covered–from prescription drugs to hospital services to long-term care. There would be no deductibles or co-payments. Funding would come from sources including savings from negotiated bulk procurement of medications; a tax on the top 5 percent of income earners; and a phased-in payroll tax that is lower than what employers currently pay for less comprehensive employee health coverage. With seventy-eight Congressional co-sponsors, and the endorsement of more than 200 labor organizations as well as healthcare groups, there is muscle and momentum behind this bill. To get involved, check out www.Healthcare-Now.org.

excerpted from longer article

Jacob Hacker’s “Health Care for America”

Health Care for America

A proposal for guaranteed, affordable health care for all Americans building on Medicare and employment-based insurance

by Jacob S. Hacker
The Economic Policy Institute
EPI Briefing Paper #180
January 11, 2007

As health care costs have skyrocketed and the proportion of Americans with stable benefits has eroded, health insecurity has become a shared American experience, felt by those who thought they had it made as well as those just struggling to get by.

This growing problem is pushing health care reform back onto the agenda of American politics after more than a decade of neglect. And yet, nothing guarantees that this debate will end differently than previous battles.

To avoid the dismal fate of previous reform campaigns, a successful agenda must take seriously the political constraints and organizational realities that have hamstrung reform efforts in the past. Limits on public budgets, resistance to measures that might be seen as taking away what Americans already have, and the embedded realities of the present system all stand squarely in the path of grand policy redesigns–from single-payer national health insurance, to individual mandates requiring that everyone purchase private coverage, to a universe of individualized Health Savings Accounts. Instead, the most promising route forward is to build on the most popular elements of the present structure–Medicare and employment-based health insurance for well-compensated workers–through a series of large-scale changes that are straightforward, politically doable, self-reinforcing, and guaranteed to produce expanded health security.

Health Care for America embodies this strategy. It would extend insurance to all non-elderly Americans through a new Medicare-like program and workplace health insurance, while creating an effective framework for controlling medical costs and improving health outcomes to guarantee affordable, quality care to all. It is at once comprehensive, realistic, consistent with American values and beliefs, and grounded in the best elements of the present system. It combines employer and personal responsibility with a strong public commitment to ensuring that American workers and their families and American employers can afford coverage. It promises better care, lower costs, more choice, healthier citizens, and immensely stronger guarantees for workers and their families. And it promises real savings for employers and state governments–without unraveling existing sources of health security, without forcing workers to obtain coverage on their own, and without pressuring patients into Health Savings Accounts or tightly managed health maintenance organizations (HMOs).

What Health Care for America would do is simple: every legal resident of the United States who lacks access to Medicare or good workplace coverage would be able to buy into the “Health Care for America Plan,” a new public insurance pool modeled after Medicare. This new program would team up with Medicare to bargain for lower prices and upgrade the quality of care so that every enrollee would have access to either an affordable Medicare-like plan with free choice of providers or to a selection of comprehensive private plans.

At the same time, employers would be asked to either provide coverage as good as this new plan or, failing that, make a relatively modest payroll-based contribution to the Health Care for America Plan to help finance coverage for their workers. At a stroke, then, no one with a direct or family tie to the workforce would remain uninsured. The self-employed could buy into the plan by paying the same payroll-based contribution; those without workplace ties would be able to buy into Health Care for America by paying an income-related premium. The states would be given powerful incentives to enroll any remaining uninsured.

http://www.sharedprosperity.org/bp180.html

For the PDF version of “Health Care for America:”
http://www.sharedprosperity.org/bp180/bp180.pdf

Comment:

By Don McCanne, MD

Jacob Hacker is gifted, really (though some might contend that “gifted political scientist” is an oxymoron). Jacob Hacker cares about people. He knows that we must do something to make health care accessible and affordable for everyone.

His proposal does not break new ground in health policy. He has merely combined various concepts that have been under consideration for some time. What is very different about this proposal is that the design features comply with the perceptions of most Americans as to how they want our health care to be financed. It is just possible that he may have crossed the threshold of political feasibility.

There are some very good features in his proposal. It establishes a new and improved Medicare that competes with the existing private plans in the employer-sponsored and individual markets. Employers and individuals who are concerned about replacing their private plans with a government-run program would have the option of continuing with their current standard coverage. It is estimated that about half would switch to the Health Care for America program. It is likely that, with time, the public program would establish its superiority resulting in a massive shift in enrollment. That would bring us very close to a single payer system without having to dump it on the nation all at once. When you read his report, you will recognize that there are many other features that would help to ensure an equitable and affordable system for all.

From the perspective of a single payer advocate, there are some problems. Leaving the private insurers in place perpetuates the administrative waste of those insurers and the administrative burden on the providers. Intense regulatory oversight of the private insurers would be even more imperative since they would increase their efforts to game the system through surreptitious favorable selection and other clandestine market expediencies. The public program would likely concentrate lower-income individuals initially, risking a political transformation into a welfare program. Also his plan includes features of both an employer mandate and an individual mandate, each with its own policy problems, though he does ameliorate the impact to a certain extent with some of the other features of his plan. From a single payer perspective, it would be far better to totally cut the link between financing and coverage. A system of equitable tax funding of the entire risk pool is more efficient than a system of premiums linked to the individual. Other potential problems are evident in the report.

This is a very important contribution to the national dialogue on reform. The report should be downloaded since it will surely become a prominent part of our debate.

Since PNHP’s mission is to inform rather than to negotiate compromise, we will continue to point out specific policies in his model that could be improved. That said, Jacob Hacker’s proposal is a very welcome addition at a time that all options should be on the table. It is such a compelling model that it may shove all others off of the table – except single payer – then we can get down to a serious discussion about reform that really works.

On the Governor’s Health-Care Plan

More insurance is not the answer

By Deborah Burger
San Francisco Chronicle
Thursday, January 11, 2007

While Gov. Arnold Schwarzenegger deserves credit for finally responding to the state’s imploding health-care crisis, his plan as designed has major flaws, most notably forcing the uninsured to buy what for many will mostly likely be substandard, unaffordable health plans that primarily serve to further enrich big insurers.

Some provisions in the governor’s package are welcome — notably the intent to end the disgraceful denials of coverage based on age or health status, and his pledge to assure access to health services for the undocumented.

However a plan that begins by criminalizing the uninsured with no controls on skyrocketing premiums and, at this point, no standards on what those health plans will include, is a train wreck waiting to happen. Let us hope that the state would establish uniform and comprehensive benefits for all.

In a state where health insurance typically runs up to $12,000 a year for a family of four, it’s a safe bet that many will gamble with their health and opt for the cheapest plan available. As defined by the governor’s proposal, those plans would require families to spend up to $10,000 a year in out-of-pocket medical costs. In other words, the average consumer will have to pay for presumably all of their health services in addition to the premiums the law will force them to pay.

If it sounds as if someone is making out like a bandit, that bandit has a name – the insurance industry. Insurers will gain millions while consumers will receive little in return. A mandate on individuals to buy insurance is the centerpiece of the Massachusetts health plan as well. The experience there to date does not recommend this approach. Many people are choosing not to sign up, even with the tax penalties, because they cannot afford the plans, and due to funding problems, the state has cut back on public education about the program. That’s in a state with 500,000 uninsured as compared to California’s 6.5 million uninsured.

A second area of concern is the proposal to shift some $2 billion in tax funds that now goes to hospitals to cover indigent care and use it to buy coverage for the uninsured. It takes money used for direct delivery of care, and hands it to insurance companies, which take 25 percent to 30 percent off the top for wasteful administrative expenses.

Moreover, the proposal has an ugly underside: Because 70 percent of those funds go to public hospitals and clinics, the proposal will starve the public sector of desperately needed revenue, hastening the closure or privatization of more public facilities. This could have a particularly deleterious effect on low-income communities where most public hospitals are located.

That demonstrates the biggest fundamental problem with the governor’s entire package: A market-based system always puts increased revenues and profits over the health and well-being of those patients it is supposed to serve. As was the clear intent of a number of the free-market architects of the plan, it reinforces and expands the role of the market in health care, the very source of the present crisis. If the governor’s goal is truly universal health coverage, improved quality and effective cost controls, the state should embark on the same tried-and-true course taken by every other industrialized nation, either a national health system, or a single-payer approach as embodied in the single-payer bill, SB840 authored by state Sen. Sheila Kuehl. Kuehl’s bill was vetoed by the governor last year. It will be reintroduced this year.

Under a single-payer system, such as Medicare, one public entity collects all the financing and pays for all medical services through the existing private-care delivery system, with adequate funding for our doctors, hospitals, clinics, and other care.

It’s the only plan that assures everyone is covered with one high standard of benefits and care, as opposed to good care for the wealthy only. It assures choice of physician, reduces administrative waste, provides commonsense budgeting, and ends insurance industry interference in the form of high premiums, high deductibles and denials of care.

Americans spend twice as much per person on health care as the other 21 wealthiest countries, yet World Health Organization data shows Americans live the shortest time in good health and have poorer patient outcomes in category after category from infant mortality to life expectancy to doctor visits.

Being number 21 is hardly good enough. By enacting the single-payer Kuehl bill this year, we could finally have the plan Californians need and deserve.

Deborah Burger, R.N., is the president of the California Nurses Association.

PNHP Research: The Case for a National Health Program

Over the past two decades, PNHP research has influenced health policy and focused debate on the need for fundamental health care reform.

1. Administrative costs consume 31 percent of US health spending, most of it unnecessary.

  1. Woolhandler, et al “Costs of Health Administration in the U.S. and Canada,” NEJM 349(8) Sept. 21, 2003.

2. Medical bills contribute to half of all personal bankruptcies. Three-fourths of those bankrupted had health insurance at the time they got sick or injured.

  1. “Illness and Injury as Contributors to Bankruptcy,” Himmelstein et al, Health Affairs Web Exclusive, February 2, 2005.
  2. “Medical Bankruptcy in the United States, 2007: Results of a National Study,” Himmelstein, D.U., Thorne, D., Warren, E., Woolhandler, S. (2009), Am J Med, 122, 741-746.
  3. “Medical Bankruptcy Fact Sheet,” Himmelstein, D.U., Thorne, D., Warren, E., Woolhandler, S. (2009).
  4. “Medical Bankruptcy Q&A,” Himmelstein, D.U., Thorne, D., Warren, E., Woolhandler, S. (2009).

3. Taxes already pay for more than 60 percent of US health spending. Americans pay the highest health care taxes in the world. We pay for national health insurance, but don’t get it.

  1. Woolhandler, et al. “Paying for National Health Insurance — And Not Getting It,” Health Affairs 21(4); July/Aug. 2002.

4. Despite spending far less per capita for health care, Canadians are healthier and have better measures of access to health care than Americans.

  1. Lasser et al. “Access to Care, Health Status, and Health Disparities in the United States and Canada: Results of a Cross-National Population-Based Survey,” American Journal of Public Health; July 2006, Vol 96, No. 7.

5. Business pays less than 20 percent of our nation’s health bill. It is a misnomer that our health system is “privately financed” (60 percent is paid by taxes and the remaining 20 percent is out-of-pocket payments).

  1. Carrasquillo et al. “A Reappraisal of Private Employers’ Role in Providing Health Insurance,” NEJM 340:109-114; January 14, 1999.

6. For-profit, investor-owned hospitals1-4, HMOs,5 nursing homes6,7 and home health care agencies8 have higher costs and score lower on most measures of quality than their non-profit counterparts.

  1. Himmelstein, D and Woolhandler, S “The high costs of for-profit care,” Commentary, Can. Med. Assoc. J., June 8, 2004
  2. Devereaux, PJ “Payments at For-Profit and Non-Profit Hospitals,” Can. Med. Assoc. J., Jun 2004; 170
  3. Devereaux, PJ “Mortality Rates of For-Profit and Non-Profit Hospitals,” Can. Med. Assoc. J, May 2002; 166
  4. Himmelstein, et al “Costs of Care and Admin. At For-Profit and Other Hospitals in the U.S.” NEJM 336, 1997
  5. Himmelstein, et al “Quality of Care at Investor-Owned vs. Not-for-Profit HMOs” JAMA 282(2); July 14, 1999
  6. Harrington et al “Does Investor Ownership of Nursing Homes Compromise the Quality of Care?” American Journal of Public Health; Vol 91, No. 9, September 2001
  7. Comondore, et al “Quality of care in for-profit and not-for-profit nursing homes: systematic review and meta-analysis,” BMJ 2009;339:b2732-b2732
  8. Cabin W et al “For-Profit Medicare Home Health Agencies’ Costs Appear Higher And Quality Lower When Compared To Nonprofit Agencies,”Health Affairs, August 2014

7. Immigrants1 and emergency department visits2 by the uninsured are not the cause of high and rising health care costs. Immigrants also subsidize Medicare’s trust fund.3

  1. Mohanty et al. “Health Care Expenditures of Immigrants in the United States: A Nationally Representative Analysis,” American Journal of Public Health; Vol 95, No. 8, August 2005
  2. Tyrance et al. “US Emergency Department Costs: No Emergency,” American Journal of Public Health; Vol 86, No. 11, November 1996
  3. Zallman et al,   “Immigrants contributed an estimated $115.2 billion more to the Medicare Trust Fund than they took out in 2002-09,” Health Affairs, June 2013

8. 45,000 annual deaths are associated with lack of health insurance1. That figure is about two and a half times higher than an estimate from the Institute of Medicine (IOM) in 2002. The uninsured do not receive all the medical care they need — one-third of uninsured adults have chronic illness and don’t receive needed care2. Those most in need of preventive services are least likely to receive them.

  1. Wilper, et al “Health Insurance and Mortality in U.S. Adults,” American Journal of Public Health; Vol. 99, Issue 12, Dec 2009 
  2. Wilper, et al “A National Study of Chronic Disease Prevalence and Access to Care in Uninsured U.S. Adults” Ann Intern Med, Aug 2008; 149: 170 – 176.

9. The US could save enough on administrative costs1 (more than $350 billion annually) with a single-payer system2 to cover all of the uninsured.

  1. Woolhandler, et al “Costs of Health Administration in the U.S. and Canada,” NEJM 349(8) Sept 21, 2003
  2. “Proposal of the Physicians’ Working Group for Single-Payer National Health Insurance,” JAMA 290(6): Aug 30, 2003

10. Competition among investor-owned, for-profit entities has raised costs, reduced quality in the US

  1. Himmelstein DU, Woolhandler S. “Competition in a publicly funded healthcare system.” BMJ 2007;335:1126-1129 (1 December), doi:10.1136/bmj.39400.549502.94
  2. Hellander I, Himmelstein DU, Woolhandler S. “Medicare overpayments to private plans, 1985-2012: Shifting seniors to private plans has already cost Medicare US$282.6 billion.” International Journal of Health Services 2013;43(2):305–319. doi: http://dx.doi.org/10.2190/HS.43.2.g

11. The Canadian single payer healthcare system produces better health outcomes1,2 with substantially lower administrative costs3,4 than the United States.

  1. Guyatt GH, et al. “A systematic review of studies comparing health outcomes in Canada and the United States.” Open Medicine (2007); 1(1): E27-35.
  2. Lasser KE, Himmelstein DU, Woolhandler S. “Access to Care, Health Status, and Health Disparities in the United States and Canada: Results of a Cross-National Population-Based Survey.” American Journal of Public Health (July 2006); 96(7): 1300-1307.
  3. Himmelstein DU, Lewontin JP, Woolhandler S. “Who administers? Who cares? Medical administrative and clinical employment in the United States and Canada.” American Journal of Public Health. (1 Feb. 2006); 86(2):172-178.
  4. Woolhandler S, Campbell T, Himmelstein DU. “Cost of Health Care Administration in the United States and Canada.” New England Journal of Medicine. (21 August 2003); 349(8).

12. Computerized medical records1-3 and chronic disease management4 do not save money. The only way to slash administrative overhead5 and improve quality6,7 is with a single payer system.

  1. Woolhandler, et al. “Hope And Hype: Predicting The Impact Of Electronic Medical Records,” Health Affairs, September/October 2005; 24(5): 1121-1123.
  2. Himmelstein, et al “Hospital computing and the costs and quality of care: a national study,” Am J Med, Vol 123, Issue 1, Pages 40-46, Jan 2010
  3. McCormick, D, Bor, DH, Woolhandler, S, Himmelstein, DU, “Giving Office-Based Physicians Electronic Access To Patients’ Prior Imaging And Lab Results Did Not Deter Ordering Of Tests,” Health Affairs, March 2012, 31(3): 488-496.
  4. Geyman, J “Disease Management: Panacea, Another False Hope, or Something in Between?,” Ann Fam Med 2007;5:257-260. DOI: 10.1370/afm.649.
  5. Woolhandler, et al “Costs of Health Administration in the U.S. and Canada,” NEJM 349(8) Sept. 21, 2003
  6. Schiff, et al “A Better Quality Alternative” JAMA, 272(10); Sept. 12 1994
  7. Schiff, et al “You Can’t Leap a Chasm in Two Jumps,” Public Health Reports 116, Sept / Oct 2001

13. Alternative proposals for “universal coverage” do not work. State health reforms over the past two decades have failed to reduce the number of uninsured1.

  1. Woolhandler, et al “State Health Reform Flatlines,” International Journal of Health Services, Volume 38, Number 3, Pages 585-592, 2008

The truth about health savings accounts (HSAs)

HSA Funding: Are Health Care Consumers Leaving Money on the Table?

By Thomas Cochrane, CFA
A Vimo Research Group Report
January 4, 2007

This Vimo ReportTM will discuss funding trends that have emerged within the HSA market over the past several years. From Vimo’s perspective, HSA funding levels are a key indicator of the health of the consumer directed movement. By focusing on recent enrollment statistics, it is clear that there is a significant gap between high deductible health plan enrollment and HSA adoption. Not surprisingly, it is also evident that HSA asset levels are deficient.

Both indicators point to a troubling trend within the budding CDH industry. Inadequate HSA funding levels will be especially detrimental to the healthcare consumer if the trend continues over time.

Many employers and individual policyholders seem to view CDH as some sort of cost containment panacea.

Vimo’s view is that treating consumer directed plans solely as cost containment tools misses the point almost entirely. Americans should be focused on the fact that the triple tax advantages of HSAs make them the most powerful qualified savings vehicles available. In addition, the point of CDH is not to avoid spending money on health care, but rather to replace insurance with highly tax advantaged savings accounts that are owned and controlled by individuals.

http://www.vimo.com/reports/hsafunding.pdf

Comment:

By Don McCanne, MD

This report from the consumer-directed health industry provides us with a rare instance of when bad health is good news.

Also the report exposes HSAs for what they really are: powerful tax-advantaged savings vehicles for the wealthy.

U.S. health care puts profit over people

By JOANNA GARRITANO
GUEST COLUMNIST
Seattle Post-Intelligencer

Though elected officials and experts alike are perplexed about how to solve the current health care crisis, it isn’t difficult to recognize the health care problems facing Americans. The 47 million Americans without health care coverage are not the only ones who confront tremendous barriers to health in this country. Businesses, families, workers and people of all ages are finding U.S. health care too expensive and unresponsive to their needs.

Why is this happening?

Modern medicine has morphed from a healing profession into a business where the primacy of profit takes precedence over greater human needs. Trusting relationships with medical professionals have taken a back seat to efficiency standards as patients are rushed through doctors’ offices.

With just enough time to peer into a few orifices and change a prescription or two, doctors race to keep up with market demands. Market-driven medicine tears at our moral fabric as people are seen as commodities — mere bodies to insure rather than complex individuals with diverse human needs. Sharp market strategies, though suitable when shopping for goods, will always fall short in defining the value of health, or the value of life, for that matter.

With the resources and ingenuity of the American people, we certainly can do better. Yet, we are fooled into believing that more expensive means better care. The truth is that we spend twice the cost per capita compared with other developed nations, yet are ranked 37th in overall quality, according to the World Health Organization. Americans face higher infant and maternal mortality rates and a shorter life span than our counterparts in other industrialized nations that offer comprehensive health coverage for all their residents.

Why do we tolerate this unstable and unjust situation?

The answer: There is still profit to be made maintaining the status quo. However dismal the health care situation has become for individuals and families, the for-profit health care industry still churns out billions in profits. In a democratic nation founded on principles of “liberty and justice for all,” the health and well-being of the many should not come second to the financial benefit for the few.

Close to home, Gov. Chris Gregoire has recognized the disastrous effects that the current health care system is having on Washington residents. In 2006 she charged a team of state officials, the Blue Ribbon Commission on Health Care Costs and Access, to seek solutions at the state level. The recommendations from the BRC will influence legislation in 2007 and direct health care changes in the years to come.

Though the commission should be acknowledged for attempting to address cost and monitor quality, its recommendations fall far short of offering any tangible solutions to the most pressing issue — how to provide affordable high-quality health care for everyone.

It is incumbent upon us all to demonstrate the political will to fundamentally challenge the system in which administrative waste and profiteering are allowed to stand in the way of human health and well-being. Single-payer publicly funded health insurance with privately delivered health care may just be the solution we are looking for.

Joanna Garritano, M.D., is an emergency department physician at Virginia Mason Medical Center, Seattle, and chairwoman of Physicians for a National Health Program, Western Washington.