PNHP

Our health care system is inefficient, wasteful

Our health care system is inefficient, wasteful

Maine

Who among us cannot be ashamed that more than 45 million Americans lack health insurance and millions more have inadequate coverage? How do we spend twice as much as anyone else while being the only developed nation not to provide universal health coverage for its people?

The high cost of private insurance billing is one part of the problem. A recent study published in Health Affairs (www.pnhp.org/Kahn/kahn_galley.pdf) shows that 1 in 5 health care dollars goes to billing and paperwork. A 2003 Harvard study pegged these costs at 31 percent of U.S. health spending — about $400 billion — vs. 17 percent in Canada.

It is no surprise that our fragmented health care financing system is very inefficient and wasteful. Dozens of insurance companies have their own departments for enrollment, exclusions, referrals, billing, sales and marketing. Add to this massive duplication of effort the cost of huge salaries to CEOs, and shareholder profits generated by minimizing payments for patient care services.

The money squandered is more than enough to cover the uninsured and to eliminate exclusions, co-payments and deductibles that often bankrupt even insured families in the face of serious illness.

Only single payer national health insurance can squeeze the bureaucratic waste out of health care and use the savings to give patients affordable, high-quality and comprehensive care without waits.

As a member of Physicians for a National Health Program, I urge everyone to learn more about how to deal with our health care crisis by visiting www.healthcare-now.org.

John Benziger
South China

thebenzigers@hotmail.com

AHPs for the Blues

Sen. Enzi To Introduce Compromise Legislation on Association Health Plans
Kaiser Daily Health Policy Report
March 3, 2006

Senate Health, Education, Labor and Pensions Committee Chair Michael Enzi (R-Wyo.) early next week plans to introduce a bill (S 1955) that would allow association health plans to form under certain conditions, and he has scheduled a March 8 markup for the proposal, CongressDaily reports (CongressDaily, 3/3). Like two other pending bills, Enzi’s proposal would allow small businesses and trade associations to join together to offer group health coverage on a statewide or nationwide basis. However, Enzi’s bill differs from pending House (HR 525) and Senate (S 406) legislation in that it would require AHPs to cover any benefits mandated by at least 45 states. To address further the concerns of opponents who say the plans would impair state-mandated consumer protections, Enzi’s bill would leave supervision of the plans with state officials rather than the Department of Labor. In addition, while the bill “would permit business and trade associations to pool their members independently, they would not be allowed to establish self-insured plans, but would rather have to provide benefits through a fully-funded plan,” CQ HealthBeat reports. Enzi said, “Working with a diverse group of senators and business groups representing small business, we’ve bridged the gap between small business proponents of traditional AHPs and state-based interests worried about the prospects of dramatic regulatory changes in health insurance markets.” Mary Nell Lehnhard, senior vice president of the Blue Cross Blue Shield Association, a group that has opposed other AHP proposals, said, “I feel all of our concerns have been listened to. The process has been amazing.”

http://www.kaisernetwork.org/daily_reports/print_report.cfm?DR_ID=35779&dr_cat=3

S. 1955:
http://thomas.loc.gov/cgi-bin/bdquery/z?d109:s.01955:

And…

January 21, 2006
President’s Radio Address
The White House

Congress also needs to pass Association Health Plans, which allow small businesses across the country to join together and pool risk so they can buy insurance at the same discounts big companies get.

http://www.whitehouse.gov/news/releases/2006/01/
20060121.html

Comment: By Don McCanne, M.D.

Proposals for Association Health Plans (AHPs) have been criticized partly because they allow circumvention of state mandated benefits. The savings for small businesses would not come from group discounts, but rather from being able to purchase stripped down plans with very low premiums. Such plans would fall far short of the protection that their employees need. Also they would allow employers who currently provide coverage to drop their plans in favor of these cheap alternatives.

Sen. Enzi’s proposal pretends to address this issue by requiring that benefits mandated by at least 45 states be covered. If only 6 states fail to mandate any given benefit, then it would not be a requirement of the AHPs. Although I haven’t seen any survey, it is improbable that there is any state mandate that would end up being a required benefit for AHPs.

Insurers have not been supportive since they could be left out if the AHPs established their own self-insured pools. Small businesses are potentially a very large market for insurers. Sen. Enzi’s new version pleases the insurers since it would require that benefits be provided through fully-funded plans.

The BlueCross BlueShield Association management finds it amazing that their concerns were listened to. S 1995 will protect and enhance their market for their highly profitable, stripped down plans.

So the President and his colleagues in Congress are addressing the concerns of his friends in the insurance industry.

But, Mr. Bush… What about the patients?

Recourse Grows Slim for Immigrants Who Fall Ill

By Nina Bernstein
The New York Times
March 3, 2006

When Ming Qiang Zhao felt ill last summer, he lay awake nights in the room he shared with other Chinese restaurant workers in Brooklyn. Though he had worked in New York for years, he had no doctor to call, no English to describe his growing uneasiness.

Mr. Zhao, 50, had been successfully treated for nasal cancer in 2000 at Bellevue Hospital in Manhattan, which has served the immigrant poor since its founding in 1736. But the rules there had changed, and knowing that he would be asked for payment and that security guards would demand an ID, he had concluded that he could not go back.

So Mr. Zhao went to an unlicensed healer in Manhattan’s Chinatown and came away with three bags of unlabeled white pills.

A week later, his roommates, fellow illegal immigrants from Fujian Province in China, heard him running to and from the toilet all night. In the street the next day, July 6, he collapsed.

Immigrants have long been on the fringes of medical care. But in the last decade, and especially since the terrorist attacks of Sept. 11, 2001, steps to include them have faltered in a political climate increasingly hostile to those who face barriers of language, cost and fear of penalties like deportation, say immigrant health experts, providers and patients. More and more immigrants are delaying care or retreating into a parallel universe of bootleg remedies and unlicensed practitioners.

Last year, about 80 bills in 20 states sought to cut noncitizens’ access to health care or other services, or to require benefit agencies to tell the authorities about applicants with immigration violations. Arizona voters approved such a requirement in 2004 with Proposition 200. Virginia has barred adults without proof of citizenship or lawful presence from state and local benefits. Maryland’s governor excluded lawful immigrant children and pregnant women from a state medical program for which they had been eligible.

Most proposed measures were not adopted, but new versions are expected. Ballot initiatives modeled on Arizona’s Proposition 200 are circulating in California and Colorado. And in December, the United States House of Representatives passed a sweeping bill that would make “unlawful presence” in this country a felony and redefine “criminal alien smuggling” to include helping any immigrant without legal status.

“We’ve seen a real rise in anti-immigration measures across the country,” said Tanya Broder, a public benefits lawyer in Oakland, Calif., for the National Immigration Law Center, “and it’s engendered confusion and fear that prevent immigrant families from getting the care they need.”

Some who had been drawn into medical treatment by outreach efforts have retreated, like Mr. Zhao, fearing the harder line toward immigrants, especially those without money or proper papers. Even legal immigrants and parents of children with legal status are more skittish about their health care, scared that medical bills and public medical insurance can hurt their chances for citizenship, bar relatives from coming to the United States or break up their families.

“I heard that if you go to the emergency room or go to the doctor, they were going to deport you,” said Alejandra, a mother from Colombia living in Queens, referring to a rule proposed in 2004 by the Centers for Medicare and Medicaid Services that would have made hospitals report the immigration status of emergency-room patients in exchange for more federal money. “So then my four children are going to be without me because I don’t have documents here.”

The proposal did not pass, but like many of the proposed rules immigrants hear about on television or from neighbors, its chilling effects lasted.

Restrictive bills are part of what supporters describe as a movement to end tolerance for the country’s estimated 11 million illegal residents.

“It’s certainly an effort to make them go back,” said Dan Stein, president of the Federation for American Immigration Reform, a group calling for fewer immigrants and stricter enforcement of immigration laws. “It will never be acceptable for people to break our laws and then expect taxpayers to provide health care.”

Almost by definition, the most fearful immigrants are the least likely to talk. The Colombian mother in Queens, however, was among 75 immigrant parents, both legal and illegal, who were interviewed in depth by researchers from the New York Academy of Medicine for a study to be released later this year, with the guarantee that their real names would be withheld.

What emerges from the transcripts, and from dozens of other interviews conducted by The New York Times with patients, health-care providers and experts on immigration, is a picture not only of heightened anxiety but also of immigrants who are primed to flee rather than fight for help from a system that even the native-born often find baffling and rude.

For Nadege, pregnant and in pain when she sought treatment at Queens Hospital Center, a public hospital, the defining moment was a snub by a fellow Haitian who had been summoned to interpret. “She said to me, ‘Don’t come here saying that you have a bellyache: no one is going to stay with you the entire day,’ ” Nadege recalled.

“I cried,” she said. “I picked up my belongings and left. Even if I was dying that day, I wouldn’t go back.”

Lard and Vodka, Not Doctors

No one is suggesting that hospitals and clinics are seeing a decline in immigrant patients. On the contrary, as a decade of record immigration continues at an estimated annual clip of 1.2 million newcomers, the number of patients who speak little or no English is growing everywhere. And some hospitals and clinics are trying harder than ever to at least meet language needs.

But even in New York, a gateway of immigration, a national climate that makes immigrant patients more timid also emboldens some front-line workers to bar the way.

“If you have one renegade public-benefits worker who thinks they should be discouraging access because they believe it’s a drain on taxes, the word on the street is it’s too much of a hassle to apply,” said Adam Gurvitch, director of health advocacy for the New York Immigration Coalition, an umbrella group for more than 150 immigrant organizations.

Problems getting insurance sometimes lead to risky decisions about children’s health care. A legal immigrant from Russia, Oksana, confessed to academy researchers that she had delayed her daughter’s vaccinations for months, keeping her out of school until she could borrow $300 to pay for them. Melosa, of Mexico, had so many problems with state-subsidized insurance that when her severely asthmatic son ran a high fever she resorted to rubs of pig lard and carbonate, instead of taking him to a doctor.

Vera, a Brooklyn mother from Belarus, used vodka rubs and borrowed medications when her daughter was delirious with fever from the flu. “We couldn’t go to the doctor without medical insurance,” she said.

In the end, immigrants often return to mainstream care in dire need, only to have their chaotic medical histories compounded by a beleaguered system whose costliest medical technology is no substitute for timely treatment. In Mr. Zhao’s case, an ambulance took him, unconscious, to a bankrupt hospital system where his life hung in the balance for weeks, and where one of his roommates, a 19-year-old waiter with uneven English, served as the interpreter.

“No money, no ID, no good English,” said the waiter, Hong Chung. “What you going to do? Nobody pay attention to us.”

Mr. Zhao was in a coma when his brother, Ming Tong, 49, and Fujianese friends came to the hospital, clutching the unlabeled pills, which had been described as herb-based remedies for high blood sugar, high blood pressure and insomnia.

Mr. Chung remembers pleading, “If you find out the name of the ingredients, maybe he won’t have to die.” But he said doctors told him that the hospital was unable to do such an analysis. The hospital, St. Mary’s in Brooklyn, was scheduled to close after more than a century serving the immigrant poor. St. John’s in Queens, where Mr. Zhao was transferred for more tests 12 days later, was up for sale. Their parent organization, St. Vincent’s Catholic Medical Centers, the largest Roman Catholic hospital system in New York State, had just filed for bankruptcy protection.

At struggling hospitals, interpretation can seem like a luxury, despite longstanding federal and state laws requiring equal language access and studies showing that it cuts cost by improving quality. Few hospitals have laboratories capable of analyzing underground remedies.

“With regular drugs, we know what the side effects and interactions are,” said Dr. Sarvesh Parikh, a resident at St. John’s, who wrote a note in Mr. Zhao’s chart about his roommates’ account of the pills. “About these kinds of pills, we don’t know anything.”

The larger mystery was why Mr. Zhao, a thin, quiet, frugal man, had gone without medical care instead of returning to Bellevue. In 2000, seven years after he and his brother arrived on American shores, jammed into the fetid hold of a smuggling ship, Bellevue doctors had diagnosed and eradicated his nasal cancer.

But even when treatment is a medical triumph, without sick pay or a safety net it can be personally devastating. In Mr. Zhao’s case, the effects of surgery, radiation and chemotherapy left him unable to work. His wife and son in China had counted on his income, and without it, she divorced him to marry another man. Then staggering medical bills arrived at the apartment that he and his brother shared with six roommates.

Medicaid reimburses hospitals for emergency care of the poor, regardless of immigration status. Outside of emergency care, however, illegal immigrants like Mr. Zhao are ineligible for Medicaid; in two-thirds of states, so are most legal noncitizens, no matter how indigent.

James Saunders, a spokesman for Bellevue, like Debby Cohen, a spokeswoman for St. John’s, said confidentiality laws barred discussion of Mr. Zhao’s case. But Mr. Saunders emphasized that Bellevue has a mandate not to turn anyone away because of immigration status or lack of money, “and an obligation to the federal government to collect what we can.”

After the Sept. 11 attacks, about the same time Bellevue security guards began demanding ID cards, clerks started collecting sliding-scale fees from the uninsured. Mr. Zhao was charged $20 per visit, then $150 for a CAT scan. Destitute, intimidated, unable to keep borrowing such sums, and unaware that the fees could be waived, his brother said, Mr. Zhao gave up on Bellevue in 2002.

“The doctor said that he was supposed to come back every two months, every three months, every six months, until the end of his life,” Ming Tong Zhao recalled through an interpreter. “But he couldn’t go back, because he couldn’t pay.”

By the time Mr. Zhao again ended up in a hospital, he was in a coma; just his intensive care bed, at St. Mary’s and then at St. John’s, cost Medicaid $5,400 a day. For more than a month, a parade of doctors did spinal taps, EKG’s, CAT scans and an M.R.I.; infused him with antibiotics, anticonvulsants and blood thinners; and placed him on a ventilator. Tests showed diabetes and high blood pressure, though their role in his collapse was uncertain.

Ming Tong, visiting between his work renovating kitchens in Manhattan, could not get a clear answer about what was wrong with his brother and was afraid to press. “You understand,” he said, “people in the United States without legal status don’t want to cause too much trouble.”

Afraid to Seek Help

Whether legal or illegal ・and many immigrant families include members in both categories ・noncitizens are fearful of asking for too much. Many echo Catalina, a Queens woman from Colombia who hesitated to sign her toddler up for the free speech therapy urged by his pediatrician because she and her husband had a pending application for a green card. “It scared us,” the woman said, “because if you are asking for residency, you have to show you are capable of living here without any help.”

Noncitizens are two to three times more likely to lack health insurance than citizens, studies show, and the gap has widened, even for children. Even legal immigrants qualified for government medical coverage often think twice about accepting it.

Special concerns arise among different ethnic groups. Korean parents in Staten Island mistakenly fear that their children will forfeit future chances for a college loan, said Jinny J. Park, a health specialist at Korean Community Services. And mothers at the Latin American Integration Center in Queens worry unnecessarily that free medical care will later mean their children’s military conscription. As one, Melosa, put it, “Everything we receive from the government is like giving my children away little by little” to the Army.

The changing political climate makes it hard to separate myth from reality. Laws codify disapproval of government aid for noncitizens. An immigrant deemed “likely to become a public charge,” for example, is to be denied a green card as undesirable. The 1996 welfare overhaul barred most legal immigrants who arrived after August of that year from receiving federal Medicaid until they become citizens, and the state-by-state patchwork of exceptions is confusing.

Even New York, which extends Medicaid to lawful immigrants and to low-income children regardless of status, reserves the right to sue their sponsoring relatives for reimbursement, though it is not doing so.

Those who do apply for public insurance discover a stark gap between the enthusiastic multilingual marketing of H.M.O.’s and the Kafkaesque task of getting and keeping an insurance card that works. They tell of learning only in the doctor’s office that a sick child’s card is not valid and then being turned away for lack of money.

The public health implications alarm James R. Tallon, president of the United Hospital Fund, a nonprofit policy group in New York. “Anything that keeps anyone away from the health system makes no sense at all,” Mr. Tallon said, noting that early detection is crucial in case of Avian flu or bioterrorism. “It takes one epidemic to change everyone’s attitudes about this.”

In some cases, the change in attitude comes instead from immigrants who arrived with high expectations of American medicine and now yearn for the kind they left back home. Yelena Deykin, a legal refugee who came from Ukraine in 2000, said that if she had the money, she would take her son back there for treatment of his thyroid ailment. “Our doctor not like your doctor,” she said. “Altruism ・not business.”

In Mr. Zhao’s hospital room, visitors began to hope for his recovery. After three weeks, he seemed responsive when they called his name. So it came as a shock when Mr. Chung, the waiter acting as a translator, relayed a new request from a doctor: Would they agree to let Mr. Zhao die?

Mr. Chung, who would soon return to work at an Asian restaurant in South Charleston, W.Va., translated the request for a “do not resuscitate” order as best he could, and drew his own conclusions. “Maybe some people don’t like Chinese,” he said.

Ming Tong refused to sign the order, then telephoned his brother’s son, in China, and asked him to decide. The son wept. Now 23, he had been a child of 9 when he last saw his father. As they discussed it again on Aug. 9, Mr. Zhao grew agitated. He tried to pull free of his tubes and his oxygen mask, as though he wanted to speak. Instead, despite resuscitation efforts, he died without a word.

In the End, No Answers

“The one thing that he wanted the most in his life was to see his son again, and he didn’t even get that chance,” Ming Tong said. “Why did he die? I asked the doctors. They didn’t know. They didn’t answer me.”

For immigrants, the divide of language and culture often deepens after death. In this case, doctors requested an autopsy. Ming Tong refused, in keeping with Chinese tradition. Doctors certified the death as natural, not mentioning the pills. The official cause of death was lobar pneumonia and sepsis, secondary to diabetes and hypertension ・acute lung and blood infections, that can attack patients on ventilators, but whose origins in this case are unknown, and chronic conditions that weaken the system.

On Aug. 13, The World Journal, a Chinese-language newspaper circulating to 300,000 in North America, described Mr. Zhao’s death as part of a pattern of fatal misdiagnoses and wrong medications given by unlicensed practitioners on East Broadway, the thoroughfare of Fujianese Chinatown.

But at the Medical Examiner’s Office, where an inquiry could have been ordered, no one reads Chinese and no one was aware of questions about the case. Permission for cremation was granted the next day.

Most of Mr. Zhao’s possessions fit into his coffin. The rest, including the pills, were discarded. But a woman going to his funeral called The New York Times and accused an unlicensed practitioner on East Broadway of mishandling Mr. Zhao’s case.

A decade ago, the Chinese American Medical Society helped spur a short-lived state crackdown on a Chinatown subculture of fake doctors. But “there are more illegal doctors than ever now,” said Dr. Peter Fong, an ophthalmologist and a former vice president of the society. They are not just offering herbal supplements, for which no license is required, he said, but practicing medicine without a license ・a crime.

To John C. Liu, the first Asian-American elected to the New York City Council, the reason is obvious: “What empowers the quacks is lack of access to health care.”

Chinese workers scattered in jobs throughout New York and across the country periodically return to East Broadway, the hub of Fujianese life in the United States, to find health care ・of a sort.

No. 52, where Mr. Chung says he accompanied Mr. Zhao last summer and saw the dispensing of the pills, is stacked with self-styled clinics. One thrives at the back of a basement computer store; another features $30 pregnancy sonograms and a crookedly lettered sign for “precise dental art.”

The establishment of Yu Yuan Zhang, 50, where Mr. Chung said he and Mr. Zhao went, has operated for 11 years. Near drawers of Chinese herbs hangs a New York State medical license ・in someone else’s name. Visibly nervous, Mr. Zhang denied that any pills he dispensed could cause harm. “They’re made in China,” he said, “available all over, in the street.”

By then, the only evidence left of Mr. Zhao’s 12 years in the United States were bills, ashes and a death certificate that his brother could not read. Pressed about the case, the practitioner did not hesitate.

“There is no such person,” he said. “There is no Ming Qiang Zhao.”

More community health centers, but fewer clinicians

Shortages of Medical Personnel at Community Health Centers Implications for Planned Expansion
By Roger A. Rosenblatt, MD, MPH; C. Holly A. Andrilla, MS; Thomas Curtin, MD; L. Gary Hart, PhD
JAMA
March 1, 2006

Residents of the United States lack universal access to health care, and millions of people have difficulty obtaining medical care. The year 2005 marked the 40th anniversary of one of the nation’s most enduring attempts to remedy this problem: the creation of community health centers (CHCs) as part of the “war on poverty.”

The role and responsibility of CHCs have increased as more people in the United States have difficulty gaining access to medical care. CHCs now provide care to more than 14 million US residents in more than 3500 communities. Governed by nonprofit boards with majority representation from the patient population served, CHCs are different from the private practices and for-profit entities that deliver most ambulatory care in the United States.

A national decision to invest further in CHCs has occurred during a period when access to health care in the United States is limited for more people than ever before in the country’s history.

Our results show that in 2004, CHCs were understaffed and were having difficulty recruiting essential health care personnel. This inability to fill budgeted vacancies could become a rate-limiting factor as they seek to expand their clinical activities to care for needy populations, particularly in rural areas.

The clinical role of CHCs is dependent on primary care clinicians, both physicians and nonphysician clinicians. This is occurring in a national environment in which primary care in general has lost popularity as a practice discipline. For example, the US production of family physicians has decreased rapidly in the last 7 years, with the number of US medical graduates matching in family medicine declining 51.6% from 1997 to 2005. Filling the existing CHC vacancies would absorb 20% of the 2005 output from the family medicine residencies.

Conclusions: CHCs face substantial challenges in recruitment of clinical staff, particularly in rural areas. The largest numbers of unfilled positions were for family physicians at a time of declining interest in family medicine among graduating US medical students. The success of the current US national policy to expand CHCs may be challenged by these workforce issues.

http://jama.ama-assn.org/cgi/content/full/295/9/1042#REF-JOC60013-9

Comment: By Don McCanne, M.D.

Expanding community health centers seems to be an almost futile exercise when the primary care workforce is contracting.

What can be done, under our current system of funding health care, to address this problem? On the other hand, what might the public administrator of a single payer monopsony do if presented with this same problem? More importantly, would this degree of deterioration of the primary care workforce have been allowed to happen under a single payer system?

Why pick on Wal-Mart?

Editorial
LA Times
March, 2 2006

WAL-MART’S RECENT DECISION to offer health coverage to more of its 1.4 million U.S. employees is a little like getting a date with a favorite crush because she feels sorry for you. Sure, you’re happy to have it, but you wish it had happened for a different reason.

The retailing behemoth is only expanding employee benefits because so many state legislatures are bullying it to do so. Two months ago, Maryland passed the Fair Share Health Care Act, which requires companies with more than 10,000 workers to spend at least 8% of their payroll on healthcare or pay the difference to the state; only Wal-Mart is affected.

More than two dozen states have threatened similar legislation. In response, Wal-Mart has said it will try to increase the number of its insured workers — currently about half are covered — by significantly reducing the waiting period for new employees to qualify for coverage and by offering bare-bones health plans for as little as $11 a month.

This kind of legislative intimidation is bad for a couple of reasons. First, it’s arbitrary and unfair. Why not go after companies with 5,000 employees? Or 50? Or ones with employees who wear funny hats and ask, “You want fries with that?” Second, employer mandates don’t work. To make up for higher healthcare costs, Wal-Mart is likely to reduce salaries or other benefits. That’s partly why Californians two years ago rejected Proposition 72, which would have forced businesses with 50 or more employees either to insure their workers or pay a fee to the state.

It’s true that Wal-Mart is the nation’s largest private employer and that its approach to healthcare can have a disproportionate effect, much like its approach to retailing does. But it’s foolish to think that Wal-Mart alone can fix the deep problems afflicting the nation’s healthcare system. Although healthcare spending is expected to jump to $4 trillion in the next decade — to 20% of the nation’s gross domestic product — the number of uninsured is increasing by more than a million people a year, and Americans are no healthier than citizens of countries that spend half what we do. That’s the definition of bad medicine.

Fortunately, the public appears to be growing so tired of the problem that national healthcare reform is all but inevitable. Proposals range from a comprehensive overhaul to minor tweaks. More moderate reforms could simply increase the number of low-income adults eligible for existing public programs. And even after President Clinton’s disastrous healthcare reform proposals a decade ago, momentum is growing again for a “single payer” government agency that would insure everyone in the country.

Whatever Americans decide, they should understand that any serious reforms will require shared sacrifice. Meanwhile, shaming Wal-Mart or any other company into covering more of its workers isn’t necessarily productive. Employers alone didn’t create the American healthcare crisis, and they alone can’t solve it.

Managed care is alive and sick

Doctors object to ultimatum on health care
By Cheryl Clark
The San Diego Union-Tribune
February 26, 2006

Dozens of doctors are protesting a Sharp physician network’s demand that their senior patients enroll in one health plan, Secure Horizons, if they want to use Sharp’s services in San Diego County.

Some 22,000 patients could be caught in the cross hairs, the doctors said.

These 45 doctors have until Tuesday to accept or reject Sharp’s ultimatum. If the physicians decide to work exclusively with Sharp, their non-Secure Horizons patients must switch to Secure Horizons or find primary-care doctors who accept their current health plan by June 1.

If the independent doctors contract exclusively with Sharp, community hospitals such as the 301-bed Paradise Valley Hospital also would suffer.

Dr. Alan Schoengold, Sharp Community Medical Group’s president, said his network “is very well aware of the ramifications” for patients, hospitals and physicians.

For doctors who face financial difficulties because they gave up non-Secure Horizons patients, Sharp will advance payment and provide loans to them.

No matter what the dissenting doctors choose, they will lose some patients. If they select Sharp, they will lose patients who want to stay with Health Net or other providers. If they opt to remain independent, they will lose their Secure Horizons patients to Sharp.

Lincoln Acres resident Ruth Wells, 87, said she recently switched from Blue Cross to Health Net, whose network includes her specialists and whose pharmacy plan covers the drugs she needs.

But when Wells was told that her physician may require her to switch to Secure Horizons, she became very upset.

“It’s not fair,” she said. “I want to see doctors in my neighborhood.”

http://www.signonsandiego.com/uniontrib/20060226/
news_1m26sharp.html

And…

Blue Cross Coverage Extended in Dispute
By Lisa Girion
Los Angeles Times
February 25, 2006

State regulators stepped in Friday to delay a showdown that threatens access for more than 175,000 Blue Cross members to three hospitals in Los Angeles County.

The state Department of Managed Health Care intervened in a long-running fee dispute that pits struggling hospital operator Centinela Freeman HealthSystem against the nation’s largest insurer, WellPoint Inc.

Centinela Freeman Chief Executive Mike Rembis said the company had hoped to go into the black this year. But, he said, that hinged on getting an adequate increase in reimbursements from Blue Cross.

Almost a quarter of Centinela Freeman patients are Blue Cross members but they provide only 9% of revenue, administrators said.

Blue Cross has asked the Department of Managed Health Care for permission to send its members to other hospitals in the event that they fail to reach a new agreement. Blue Cross members also could use Centinela Freeman hospitals but would be reimbursed at a lower, out-of-network rate.

http://www.latimes.com/business/la-fi-centinela25feb25,1,3558558.story

Comment: By Don McCanne, M.D.

Those who claim that the age of managed care is ending simply haven’t been paying attention.

Health care intermediaries continue to leverage their positions by taking choice away from patients, physicians and hospitals. Periodic contract changes create instability, negatively impacting patients’ choice of physicians and hospitals, while threatening the solvency of the providers.

The consumer-directed (CDHC) advocates claim that their model would replace managed care. But the high-deductible health plans (HDHPs) that they are touting are still managed-care preferred provider organizations (PPOs). Though these plans may allow out-of-network health care, the patients’ out-of-pocket expenses are so great that it is almost equivalent to having no coverage at all.

Adopting a single payer national health insurance system would return to patients free choice of health care providers, including the option of choosing integrated health systems such as Kaiser Permanente. The CDHC advocates want patients to participate in their health care decisions. They should start by giving them choice of their physicians and hospitals. That will never happen with PPO HDHPs which, by design, deliberately restrict choices.

Seducing the medical profession

The New York Times
Editorial
Originally published February 6, 2006

New evidence keeps emerging that the medical profession has sold its soul in exchange for what can only be described as bribes from the manufacturers of drugs and medical devices. It is long past time for leading medical institutions and professional societies to adopt stronger ground rules to control the noxious influence of industry money.

Recently, two new cases came to light that reveal the lengths to which companies will go to buy influence with doctors, pharmacists, and other medical professionals. Reed Abelson reported in The New York Times on Jan. 24 about a whistle-blowers lawsuit alleging that Medtronic had paid tens of millions of dollars to surgeons in a position to use and recommend its medical devices. In one particularly egregious example, a prominent Wisconsin surgeon received $400,000 for just eight days of consulting.

In the Times last month, Gardiner Harris and Robert Pear revealed that a Danish company paid a pharmacist, doctors assistants, and a drug store chain to switch diabetic patients to the company’s high-priced insulin products.

In the wake of past reports of industry’s influence over prescribing practices, medical and industry groups have issued guidelines defining appropriate behavior. But as an article in The Journal of the American Medical Association made clear, these guidelines are far too weak.

The influential authors called for a complete ban on all gifts, free meals, and payments for attending meetings. They urged doctors to reject free drug samples because they are a powerful incentive to use medicines that are expensive but not more effective.

These proposals are hardly onerous. Kaiser Permanente has adopted nearly all of the recommendations. Its doctors prescribe heavily marketed medicines far less frequently.

The critical issue is that doctors must have the best interests of their patients at heart in prescribing drugs or recommending medical devices. Their judgment must not be clouded by financial self-interest or the desire to please industrial benefactors.

Goodbye, Europe. Hello, USA.

Alberta headed for USA-style health care system
By Diana Gibson
Parkland Institute
Originally published February 21, 2006

Ralph Klein has wasted no time challenging the election promises of Stephen Harper’s Conservative minority government.

In early February, Alberta Health Minister Iris Evans presented the first phase of Alberta’s health care reform plans to the provincial cabinet. Evans, who plans to announce additional reforms this month, acknowledged that the reforms will potentially violate the Canada Health Act.

Harper solemnly pledged to uphold the Canada Health Act, which requires, among other things, universality, comprehensiveness and public administration.

Yet Klein has announced that he is rolling out an agenda to dramatically expand private health insurance and delivery. Carefully crafted rhetoric like “third way,” “increasing access,” “medicare plus,” “increasing choice”
and “European model” is used to shroud the fact that he is talking about privatization, and taking Alberta toward a US- style, corporate health system.

There is no “third way” or “European model.” As the Supreme Court’s Justice Marie Deschamps pointed out in the Chaoulli decision, “There is no single model; the approach in Europe is no more uniform than in Canada.” There is, rather, a spectrum of health care models ranging from purely public to purely private.

Canada already has significant private-sector involvement on both the funding side (insurance) and the delivery side (private surgeries, labs and diagnostics). In fact, Canada is already farther down the path to private insurance than most European countries.

In most European countries, private insurance covers less than 10 percent of health care costs, whereas Canada is already at approximately 14 percent.

In fact, Canada is already fourth among OECD countries for private health insurance spending.

European health care is more comprehensive. Among members of the EU, health insurance tends to be more universal and more comprehensive than Canada’s, covering a wider range of benefits such as pharmaceuticals, dental care and long-term care.

If there is a trend in OECD countries, it is towards less, and not more, private funding. Between 1994 and 2004, the private share of health spending was either constant or decreased in more than half of OECD countries.

European countries protect the publicly funded system. Health care practitioners can’t be in two places at the same time. So creating a parallel, for-profit system will simply take doctors, nurses and radiologists away from the public sector, where there is already a shortage.

For this reason, many European countries have instituted regulations that protect the public sector from such erosion. Examples include requirements that doctors and even patients must opt in or out of the public system; and limits on what practitioners can charge and insurance companies can pay in the private system. For example, in Austria, private insurance can only pay 80 percent of the cost billed by professionals practising in the public
sector.

Alberta currently has a provision that doctors must opt out of the publicly funded system if they want to offer services covered by the public system on a for- profit basis. As the bulk of the work is in the publicly funded system, this presents a disincentive to doctors practising outside of the publicly funded system; they can’t do both.

Such protections are precisely what Ralph Klein is proposing be eliminated. He has already clearly said that the requirement for doctors to opt in or out will be eliminated.

There have also been hints that the protections for the public system introduced in Bill 11 will be reversed – for example, the provision that private, for-profit surgical clinics could operate but not private, for-profit hospitals.

These changes take us down an American path, not a European one.

There are other reasons to believe that Klein is taking the US path and not the European path.

First, Canada is integrating our economy with the US, not with Germany, Sweden or France – and Canada has clearly become part of a North American health care market.

Second, it is US health care corporations, not European ones, who are pushing for access to the Canadian health care system.

Not surprisingly, the US has the world’s largest health insurance industry.

The influence wielded by US health insurance corporations is reason enough to carefully scrutinize Klein’s choices.

Witness the Alberta government’s decision to hire US-owned AON Corporation to design health care options for Alberta.

This choice speaks volumes; AON will be intimately familiar with the US model.

And yes, this is the same AON whose American parent recently paid out $190 million following a probe into allegations of fraud and anti-competitive practices.

Once the door is opened to further privatization in Canada’s health care system, it will be difficult to turn back to the principle of universality – equal access to health care regardless of ability to pay.

Private interests will be heavily invested, and NAFTA’s infamous Chapter 11 may open us to lawsuits if we try to make our system public again.

We are embarking on a critical debate about the future of our health care system, a system that represents the fundamental values of equity and justice at the core of Canadian society.

Will Harper stand up for Canada? Will he stand up to Klein?

Diana Gibson is the Research Director for the Parkland Institute. She has an extensive background in public policy research and as an educator. Prior to joining Parkland, Diana worked as staff and a consultant to various community organizations, colleges, government agencies and trade unions on topics ranging from health care policy and water security to international trade.

AHIP pays for Dranove and Millenson's swift boat tickets

Medical Bankruptcy: Myth Versus Fact
This response to a widely cited paper by David Himmelstein and colleagues challenges the basis of its conclusions.
By David Dranove and Michael L. Millenson
Health Affairs
28 February 2006

The great enemy of the truth is very often not the lie-deliberate, contrived and dishonest-but the myth: persistent, persuasive and unrealistic.
-President John F. Kennedy, Commencement Address at Yale University, 11 June 1962.

It is no secret that bad health and bad debt often coincide. Unexpectedly large medical bills can impose a sizable burden on those who are already physically and economically fragile. In some cases, medical debt can contribute to a collapse of creditworthiness that forces some people to declare personal bankruptcy.

David Himmelstein and colleagues contend that this scenario is pervasive. “Medical problems contribute to about half of all bankruptcies,” they write. They warn that “solidly middle-class Americans.face impoverishment following a serious illness,” and they propose a solution: comprehensive national health insurance such as that offered in Canada and Western Europe.

Unfortunately, a closer examination of their paper suggests three reasons why their conclusions are also unrealistic.

First, they fail to provide a causal relationship to support the claim that medical spending contributes to “half of all bankruptcies” (54.5 percent).

Second, the authors’ methodology does not provide a definitive answer to the policy question they implicitly pose: how national health insurance would affect the rate of personal bankruptcy.

Lastly, their suggestion that national health insurance would greatly reduce the number of bankruptcies linked to medical spending is misleading.

According to Himmelstein and colleagues, 28.3 percent of respondents stated that illness or injury was a cause of bankruptcy. They also reported that medical bills contributed to the bankruptcy of 60 percent of this group.
Multiplying the two figures together, we conclude that 17 percent of their sample had medical expenditure bankruptcies.

Congressional Budget Office: The CBO review cites many factors that contribute to bankruptcy, including large medical bills, divorce, loss of income as a result of unemployment, and poor debt management. Even so, the CBO reports that “researchers have made little progress in judging the relative importance of the factors that lead people to file.”

Fay, Hurst, and White: They conclude that bankruptcy is the response to an accumulation of debt, not to one particular factor such as a health problem.

2005 Commonwealth Fund: The survey found that 41 percent of adults ages 19-64 had a high rate of medical bill problems or incurred medical debt. Sixty-two percent of these nonelderly adults had insurance when the problem occurred.

Domowitz and Sartain: They first reported that “high medical debt (in excess of two percent of income) has the greatest single impact of any household condition variables in raising the conditional probability of bankruptcy.” Accounting for prevalence of various sources of debt, Domowitz and Sartain found that “the largest single contribution to bankruptcy at the margin is credit card debt.” Other data on credit card payments support our previous contention that those with trouble paying all of their bills, not just medical expenses, are most vulnerable to bankruptcy.

Gross and Souleles: Gross and Souleles used multivariate regression to predict personal bankruptcies, with one of their predictors being health insurance coverage. Overall, it is difficult to draw firm conclusions from Gross and Souleles’ analysis.

There is one methodological problem that occurs in all the papers cited above, including that of Himmelstein and colleagues. They all fail to address the problem of reverse causality-that is, whether medical spending causes bankruptcy or whether financial turmoil causes medical problems (for example, because of stress). The resulting endogeneity bias will therefore overstate the extent to which medical bills cause bankruptcy.

Himmelstein and colleagues omit any reference to personal choices, such as taking on debt, even in their household interviews. In this they act more like good doctors than good economists or policymakers. For although it is good medical practice to work as hard to save the life of a careless drunk driver as a sober careful one, it is equally good economics and public policy to penalize the careless driver with higher insurance rates and possible criminal prosecution.

…weaving a medical-cost safety net that could protect virtually every person from bad behavior or bad luck might actually poke holes in the safety net for other vulnerable citizens. Good intentions are not enough. The Book of Job, far older than the Roman laws cited by Himmelstein and colleagues, teaches the hard lesson that no amount of good fortune is irreversible. Some combination of illness, job loss, and personal problems can assuredly dislodge even the most firmly rooted member of the middle class.

Unfortunately, expansive proposals to protect all of us distract from the pressing need to protect some of us, such as the forty-five million Americans with no health insurance and millions of others who are underinsured and vulnerable. “First, do no harm” is not just good advice for physicians; it should apply to those who would make health policy as well.

The authors are grateful to America’s Health Insurance Plans for supporting this research.

http://content.healthaffairs.org/cgi/content/full/hlthaff.25.w74/DC1

And…

America’s Health Insurance Plans

Welcome to America’s Health Insurance Plans (AHIP), the voice of America’s health insurers. AHIP is the national association representing nearly 1,300 member companies providing health insurance coverage to more than 200 million Americans.

Our goal is to provide a unified voice for the health care financing industry, to expand access to high quality, cost effective health care to all Americans, and to ensure Americans’ financial security through robust insurance markets, product flexibility and innovation, and an abundance of consumer choice.

http://www.ahip.org/content/default.aspx?bc=31

And…

Discounting The Debtors Will Not Make Medical Bankruptcy Disappear
By David U. Himmelstein, Elizabeth Warren, Deborah Thorne, and Steffie Woolhandler
Health Affairs
28 February 2006

David Dranove and Michael Millenson seem determined to deny that financial fallout from illness pushes middle-class families into bankruptcy. Anxious to erase the headline that three-quarters of U.S. medical bankrupts had health insurance at the onset of their illnesses and the resulting spotlight on inadequate coverage and insurance cancellation practices, they ignore most of our data and misrepresent the rest. They dismiss families’ explanations of their difficulties and blame those ruined by illness for their own problems. However, the data from the bankruptcy courts are undeniable. Bankruptcies affect mainly middle-class, privately insured families, and about half are triggered, at least in part, by illnesses.

Let’s be clear: Every number, percentage, and variation in how to interpret the data that Dranove and Millenson seize upon in attempting to dismiss our work came from our manuscript. We offered detailed breakdowns of our numbers so that different readers could weigh the data. Unfortunately, these commentators manipulate the data far beyond legitimate reinterpretation.

Their central claim is that no more than 17 percent of bankruptcies are medical-far lower than the 54.5 percent figure they attribute to us (in fact, we gave a range of estimates, from 46.2 percent to 54.5 percent, in anticipation of different possible interpretations of the data). In their effort to whittle down the number of medical bankruptcies, they ignore huge chunks of the data we reported. First, they assert that only the 28.3 percent of debtors who gave “illness or injury” as the specific reason for filing for bankruptcy could possibly be classified as “medically bankrupt.” Next, they narrow this group to include only the 59.9 percent who also cited bills from medical providers as a major contributor to bankruptcy. (These latter data came from our interviews with a subset of 331 debtors, not, as Dranove and Millenson state, from our questionnaire survey of 1,771 filers.)

Thus, their calculation rests on responses to two items from our data, disregarding the hundreds of other pieces of data we collected that give a fuller and more accurate picture of the reasons for filing for bankruptcy. Moreover, they misrepresent both items.

Dranove and Millenson portray medical debtors as irresponsible deadbeats, their plight a result of bad choices analogous to those made by drunk drivers. But medical catastrophe is not a choice. And, unlike other expenses, most medical debt is not voluntary, any more than breathing is voluntary. Most medical debtors had taken the prescribed steps to protect themselves: Three-quarters had health insurance when they got sick. But for many, private coverage lapsed when they lost work because of illness. In other cases, the insurance they bought in good faith had so many holes that it left them unprotected. To families financially hard-pressed by illness, Dranove and Millenson preach acceptance of the hard message of the prophet Job. Instead of blaming ruined families, or the wrath of Jehovah, they should take a hard look at the defective products sold by their funders in the insurance industry.

To Dranove and Millenson, a safety net strong enough to cushion the impact of illness is inconceivable. Yet many other countries have implemented comprehensive health and disability coverage that does the job quite well.

http://content.healthaffairs.org/cgi/content/full/hlthaff.25.w84/DC1

And…

Medical Bankruptcy: Dranove And Millenson Respond
By David Dranove and Michael L. Millenson
Health Affairs
28 February 2006

In responding to our study, David Himmelstein and colleagues state that we “seem determined to deny that financial fallout from illness pushes middle-class families into bankruptcy.” This is simply untrue. Our paper denies neither the presence of medical bankruptcies nor their serious impact on families. Rather, we carefully critique the methods they used to analyze those bankruptcies. Nothing in Himmelstein and colleagues’ response suggests that our criticism of their methodology was incorrect. They continue to offer only one direct causal measure: namely, that medical bills “contribute” to 17 percent of personal bankruptcies. The remaining anecdotes and correlations they offer do not constitute systematic empirical research, and they do not establish causation or the magnitude of the problem. Thus, it is impossible to determine from their study whether and by how much the expansion of health insurance coverage would reduce the personal bankruptcy rate.

We admit to being unprepared for the political attack-dog tone that dominates their response. One might have thought that our paper, rather than appearing after rigorous peer review, had been issued as a press release by insurance industry magnates. In fact, although our time was paid for by America’s Health Insurance Plans, our work was completely independent, and we, along with the journal’s editors, insisted on the peer-reviewed publication process. Perhaps Himmelstein and colleagues are simply taking out on us their frustration that middle-class American voters have ignored their decades-old advocacy of a Canadian-style health system.

We agree with Himmelstein and colleagues that too many vulnerable Americans are financially devastated by the cost of illness. They seem to regard with a sense of outrage our objective examination of the methods they use to establish just how many such individuals there are. We, in contrast, continue to believe that passion to right a wrong does not justify abandoning dispassionate analysis of the best way to do so.

http://content.healthaffairs.org/cgi/content/full/hlthaff.25.w93/DC1

And…

Bankruptcy Is The Tip Of A Medical-Debt Iceberg
By Robert W. Seifert and Mark Rukavina
Health Affairs
28 February 2006

Medical bankruptcy, whatever its actual frequency, is an extreme example of a much broader phenomenon. Medical debt is surprisingly common, affecting about twenty-nine million nonelderly adult Americans, with and without health insurance. The presence of medical debt, even for the insured, appears to create health care access barriers akin to those faced by the uninsured. Policymakers, researchers, and medical providers should consider medical debt a risk factor for reduced health access and poorer health status. Simply reducing the number of uninsured Americans would be a hollow policy victory if the problems arising from medical debt persist.

Recent research findings cry out for new measures to assess how well our country is addressing the health care access issue. It is now documented that medical debt resulting from being uninsured or having inadequate insurance reduces access to care and undermines the financial security of American families. Thus, this debt is, in itself, a risk factor for reduced access and poorer health status.

Policymakers, researchers, and medical providers should all be encouraged to focus attention on this risk factor. Financial protection must be a tenet of health insurance. Requiring additional costs to be borne by the patient will likely have a detrimental effect on access, particularly for those with chronic illnesses, although low-wage workers and even middle-income families may be at risk as well.

To truly improve health care access for Americans, it is time to expand our policy vocabulary beyond insurance coverage and begin to examine the adequacy of that coverage in ensuring health access and improving health status and financial security.

http://content.healthaffairs.org/cgi/content/full/hlthaff.25.w89/DC1

Comment: By Don McCanne, M.D.

There is no disagreement on the fundamental issue here: Medical debt is pervasive, and, directly or indirectly, contributes to a significant portion of personal bankruptcies.

So what is the point of the article by Dranove and Millenson? It is clearly a blatant “swift boat” effort to discredit the messengers, and by implicit but invalid extension, to evade the message that there is a pressing need to effectively address the issue of medical debt through comprehensive reform. The opinion of the authors was purchased by an industry that is compounding the problem of medical debt, and is threatened by the single payer model which would be the most effective in insuring against financial loss in the face of medical need.

Dranove and Millenson state that “expansive proposals to protect all of us distract from the pressing need to protect some of us, such as the forty-five million Americans with no health insurance and millions of others who are underinsured and vulnerable.” They have it wrong. The private insurance industry, which leaves forty-five million Americans with no health insurance and millions of others who are underinsured and vulnerable, should not distract us from an expansive proposal that would protect all of us with an equitable, efficient, comprehensive, affordable system that would do far more to prevent medical debt than would the flawed policies of the private insurers.

Sadly, the damage is done. Whenever the issue of medical debt is raised, the opponents of national health insurance will dismiss it with the statement that the bankruptcy issue is a myth (while remaining silent on the consequences of medical debt). Those in the policy community who really do care will understand, but the public at large won’t. All that they’ll understand is the myth that private insurance provides the best protection.

Dr. Martin Luther King, Jr.'s Favorite Union Endorses HR 676

The Executive Board of 1199SEIU United Healthcare Workers East has unanimously endorsed HR 676, a bill to legislate a single payer health care system in the U.S. The union represents 275,000 members in Maryland, Washington DC, New York and Massachusetts.

Dr. Martin Luther King Jr. was an early supporter of 1199’s effort to organize low wage, largely African American and Hispanic hospital workers. He often referred to Local 1199 as his “favorite” union. In later years, both he and his wife, Coretta Scott King, supported 1199’s efforts in Baltimore, MD and Charleston, SC.

HR 676 now has 68 congressional co-sponsors in addition to John Conyers Jr. (D-MI). It would institute a single payer health care system in the U.S. by expanding a greatly improved Medicare system to every resident.

HR 676 would cover every person in the U. S. for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care, chiropractic and long term care. HR 676 ends deductibles and co-payments. HR 676 would save billions annually by eliminating high overhead and profits of the private health insurance industry and HMOs.

Californians respond to Sacramento Bee editorial on health care reform

Letters to the editor
Our social contract

Published 2:15 am PST Sunday, February 19, 2006
Story appeared in Forum section, Page E6

Re “The new shades of gray,” Forum, Feb. 12: For a multitude of unavoidable reasons, our population is aging, becoming more treatable and costing much more to treat.

The private health-care industry is preparing for this by expanding and adding facilities and services, not out of any real concern for our health but mainly to stay financially ahead of the game. While this is good for well-funded patients, none of it will help the growing numbers (in all age groups) who are unable to finance their access to essential care.

There remains only one “big idea” worth considering: a system of government-sponsored access to essential universal health care. Further, access to essential care must remain untarnished by private industry. For this we need to bite the bullet and pay a tax, but it will be less in taxes than we pay in premiums.

Government is the only institution with a valid social contract to protect our health and welfare.

– Lawrence A. Danto, M.D. , Truckee

A single-payer solution

Re “Health care needs big ideas but gets small ones,” editorial, Feb. 12: Health care already has the big idea – the California Health Insurance Reliability Act. SB 840 by Sen. Sheila Kuehl would establish a single-payer health insurance system for all Californians.

The health care system is in critical condition. Costs are escalating higher than the rate of inflation. Prescription drug costs have grown exponentially, as advertising consumes 31 percent of costs and profits exceed 20 percent. Employers are reducing coverage and demanding that employees pay higher costs. More people, including children, are uninsured or underinsured. Public funding has been cut. Competition among health plans has failed to demonstrate effectiveness in assuring access or contain costs.

The evidence is overwhelming that “profit and greed” are driving the system.

SB 840, which has already passed the Senate, enunciates a fundamental moral principle, that health care is a basic human right. It provides for universal access, comprehensive benefits, a wellness model, and significant cost savings.

The Lewin Group has done extensive economic analysis of SB 840, and documents that everyone in California would have coverage with less money spent.

– Emanuel Gale, Sacramento

Big ideas in health care

Apparently the editorial board has not heard of SB 840, the universal health care bill by state Sens. Shiela Kuehl and Deborah Ortiz, with several coauthors in the Senate and Assembly.
This bill would provide fiscally sound, affordable health insurance to all Californians, provide every Californian the right to choose his or her own physician and control health cost inflation.

The system would be paid for by federal, state and county monies already being spent on health care and by affordable insurance premiums that would replace those now paid by employers and consumers.

This plan would eliminate waste by consolidating the functions of many insurance companies into one comprehensive insurance plan, saving California about $20 billion and reducing total health spending by $8 billion in the first year alone.

For more information about this bill, visit www.healthcareforall.org.

– Lindy Tillement, Rio Linda