PNHP

Des Moines Register: Separate health insurance from jobs

Des Moines Register: Separate health insurance from jobs

By REGISTER EDITORIAL BOARD
September 27, 2005

Your employer does not buy your groceries for you.

Your employer does not make your house payments for you.

Your employer does not pay your utility bills.

So why in the world is your employer expected to provide your health insurance?

Alone among the industrialized countries, the United States drifted into a cockamamie arrangement in which health insurance is job-based. The glaring flaws with such a system include complexity, confusion and gaps that leave 40 million Americans without insurance.

To those drawbacks add another: The soaring cost of job-based health insurance puts American companies at a disadvantage in global competition.

When U.S. companies move jobs to China or India or Mexico, they don’t get just cheaper labor. They escape the steep and rising cost of employee health care. It’s not the only reason U.S. manufacturing is threatened, but it’s a big factor. If America is going to retain a strong manufacturing base, it must level the playing field.

Manufacturers’ tab especially high

A study done for the National Association of Manufacturers looked at the built-in cost disadvantages U.S. companies face in the global marketplace. Employee benefits came in a close second to high corporate tax rates.

The disadvantage is especially felt by manufacturers, which traditionally have offered generous benefits. Health-care costs are one-third higher in manufacturing than in the service sector.

One reason is that venerable U.S. manufacturers pay health-insurance benefits to large numbers of retirees. As they have downsized their work forces, their retiree numbers have increased. Newer, service-sector companies aren’t burdened as much by these so-called legacy costs of retired workers.

General Motors says health-care costs for active and retired employees add $1,500 to the price of every car the company makes. That’s an expense the foreign competition doesn’t have.

Maytag Corp. in Newton is in a similar situation ā€” a mature company that not only provides health benefits to its active work force but also helps retirees with prescription-drug benefits and Medicare supplements. In a message to employees earlier this year, Maytag noted that its worldwide work force decreased about 25 percent (from 24,000 to 18,000) between 2000 and 2004. During the same time, the number of retirees eligible for health benefits increased by 25 percent, to 7,000. Retiree medical benefits cost Maytag $60 million a year and are expected to reach $80 million by 2010. Nationally, it’s estimated that more than 9 million retirees get health benefits from their former employers.

Health insurance was a major issue in a 2004 strike at the Newton plant, as it has been in almost every labor dispute in America in recent years.

Universal system offers pluses

The needed action is obvious, if not easy. The cost of health care should be lifted from the shoulders of employers. It should be the responsibility of individuals and taxpayers.

Studies show that a universal, government-sponsored system ā€” similar to those in every other industrialized nation ā€” could cover everyone in America for about the same amount Americans now pay for a disjointed, job-based system. The bonus: It would improve the competitive position of American manufacturers.

The U.S. Department of Commerce last year published a white paper on competitiveness in manufacturing. It recommended attempting to lower health-care costs through measures such as joint purchasing and malpractice tort reform.

Unfortunately, manufacturers’ groups and the Commerce Department stop short of advocating comprehensive reform. It is not sufficient to tinker with a dysfunctional health-care system. Joint purchasing isn’t enough to get the job done.

The health-care-cost disadvantage borne by American manufacturers will be removed only by abandoning the whole idea of job-based insurance.

And only business has the lobbying clout to make it happen.

Manufacturers and other employers could break the gridlock over health-care reform by weighing in on the side of universal coverage that is not job-based. They need to do so for their own sake, the sake of competitiveness and the sake of the country.

Medicine's Sticker Shock (Kristof)

By Nicholas D. Kristof
The New York Times
October 2, 2005

In the aftermath of Hurricane Katrina, we have an opportunity to construct something far more important than higher levees – a national health care system that looks less like a tightrope and more like a safety net.

A dozen years after Bill Clinton’s health reform efforts were destroyed by the insurance industry’s duplicity, it’s worth trying again. The health care system is steadily becoming more gummed up in ways that are impossible to hide.

One of the bumper stickers attacking the Clinton plan read: “If You Like the Post Office, You’ll Love National Health Insurance.” That wouldn’t work today: the Postal Service runs a system that is manifestly more rational and efficient than our health care system. For starters, imagine a postal system that refused to deliver letters to or from 45 million Americans – except on rare occasions, by ambulance.

“This is one of those fleeting opportunities where a catastrophe creates an opportunity to rebuild something better than before,” says Dr. Irwin Redlener, president of the Children’s Health Fund and associate dean of the Mailman School of Public Health at Columbia University.

In a sign of the growing disenchantment with our health system, 13,000 doctors have joined Physicians for a National Health Program, which lobbies for a single-payer government-financed health program.

There are four main problems with the existing system. First, it leaves out 45 million uninsured Americans, and their number is rising. Second, it is by far the most expensive in the world, costing 15 percent of our national income, yet our outcomes are awful – U.S. life expectancy is worse than Costa Rica’s. Third, our business competitiveness is undermined when, for example, medical expenses add $1,500 to the sticker of each General Motors car. Fourth, our system is catastrophically inefficient: according to a study in The New England Journal of Medicine, health administrative costs are $1,059 per capita in the U.S., and just $307 in Canada.

A single-payer system would be most efficient but probably is not politically feasible at the moment. The smart new book “The Health Care Mess” suggests a variety of more gradual approaches that would face less opposition.

Whatever the mechanism, all children should be covered. It’s a disgrace that we use public funds to save the lives of nonagenarians but not those of 9-year-olds. And kids are a bargain: per capita medical spending is $1,525 for children less than 5, and $9,000 per person aged 65 to 74.

A second principle is that we should put less emphasis on curative medicine and more on public health and prevention – everything from preparing for avian flu to encouraging exercise. Sure, we can buy more “left ventricular assist devices,” which cost $210,000 per patient installed, or buy Erbitux for colon cancer, at $17,000 per month of treatment. But as a wise new book, “Prescription for a Healthy Nation,” argues, you get more bang for the buck when you promote healthier lifestyles – fighting obesity, cigarette smoking and the like.

Raising cigarette taxes saved far more American lives, for example, than an army of neurologists ever could. In the same spirit, I’d like to see a French-fry tax. And imagine the health gains if we banned potato chips and soda from schools.

Reforming the health system won’t be easy. In the real world, poor kids don’t see doctors not only because they’re uninsured, but also because Mom doesn’t have a car, can’t easily get time off from work, or doesn’t speak English. Those are hard nuts to crack – but one reason to think that we can do better is that much of the world does better.

I’ve been thinking of health care partly because of something that happened when I was on vacation in August. My kids and I were stacking firewood for my parents on the Yamhill, Ore., farm where I grew up, when suddenly the seven-foot stack collapsed – on top of my youngest. She was knocked down and pinned, her face bleeding, under a pile of logs.

I had insurance, and a car to get to the emergency room – and in the end the logs (stained with blood) turned out to be in worse shape than my daughter. She’s just fine. But that instant was heart-stopping in its terror – and the system routinely does fail such children in need. Isn’t it worth fighting one more time for reforms, so that we Americans can get health care every bit as good as Canada’s?

Canadian Physicians called to

Physicians: It’s in Your Court Now
By Steven Lewis

Canadian Journal of Nursing Leadership (CJNL), Vol 18, No. 3, 2005
http://www.longwoods.com/product.php?productid=17616

Abstract:
The Supreme Court decision of June 9, 2005 clarifies the political choice facing organized medicine in Canada.(1) Many of Canada’s doctors are strong and eloquent supporters of single-tier health care. Many are not, and never have been. A mere decade ago, at the CMA’s annual General Council meeting, a motion declaring that citizens “must have the right to choose regulated private insurance for all medical services” fell on a vote of 88 to 68.(2) Focus groups conducted by the CMA in 1996 revealed a wide chasm between the strong public support for public health care and the then 78% of physicians who believed stronger private-sector participation in health care was either very or somewhat acceptable.(3) And, of course, organized medicine was heatedly opposed to the introduction of medicare in Saskatchewan in 1962. More often than not, doctors’ organizations have strongly opposed measures that they have subsequently embraced. In this they are no different from any other privileged group – whatever their virtues, attunement to the will of the demos is not among them.

Article:

The profession’s support for single-tier health care has always been provisional, and it has been largely silent – one must infer approvingly so – on the growth of for-profit clinics. Some physicians have contracted out to the public system, others have plied their trade on both sides of the street and a few have abandoned medicare altogether. Until June 9, the debates among doctors were not central to the future of the system. Proponents of a private and parallel option had to chip away at medicare’s edges, abetted by a federal government that has been castigated by the Auditor General for refusing to enforce the Canada Health Act. Now “private and parallel” has the high court’s blessing, with a new twist: the legal buying and selling of insurance for medically necessary services. The court has tasered medicare; the question is now whether the system is temporarily stunned, or mortally wounded. CMA President Albert Schumacher declared the Supreme Court judgment “a stinging indictment of the failure of governments to respond to the mountains of studies that show we need real action on our health care system.” That we need real action on our health care system is incontestable. That government should be the exclusive or even principal target of indictment is the question on the table. The evidence suggests we should look elsewhere.

Governments fund health care and establish its general legislative and regulatory framework. Beyond that, the system is largely in the hands of physicians, who make the day-to-day decisions, prioritize patients, prescribe drugs, admit patients to and discharge them from hospital, order tests and carry out innumerable interventions with a remarkable degree of autonomy. They are not held accountable in any meaningful way for performance. They are indifferent, apparently, to the clinical practice guidelines produced by their own colleagues. There are huge variations in their practices that go unchecked, despite the obvious implications for quality and access.(4-7)

The “real action” needed on our health care system includes primary health care reform, a more rational division of labour, quality improvement and a remedy for inequities in pay scales that overvalue day-surgery assembly lines and undervalue geriatricians and rheumatologists. The call for these reforms has come largely from governments, and it has been thwarted or delayed not by governments but by doctors.(8) Both Romanow and Kirby noted the glacial advance of primary care reform. It is medical associations, not governments, that allocate incomes among specialties. Nurse practitioners, pharmacists and therapists are anxious to expand their scope of practice and to use their expertise fully. Try to find a government that disagrees. Try to find a medical association fully on board.

According to organized medicine, system failings are always someone else’s fault. Somehow Mr. Zeliotis’ hip surgery delay was caused by the nature and stinginess of the single-payer system. Nothing, apparently, is attributable to physicians retaining control over their individual wait lists and refusing to standardize criteria for assessing and prioritizing patients.(9) The failure to look for doctors with shorter wait times, to share responsibility for fairness and to participate in the kinds of process improvements that by 2003 got 88% of UK citizens into primary care within 48 hours of picking up the phone(10) is – government’s. If it’s government’s fault, it’s because government didn’t follow Whitehall’s lead and just say no to chaos.

Given its anarchic characteristics, it is bordering on miraculous that the system by and large serves most people well most of the time. The median wait time for cardiac surgery in Manitoba is 23 days.(11) Median wait times in British Columbia are well under three months for every surgical category except for corneal transplants (17 weeks), hip replacements (22 weeks) and knee replacements (28 weeks).(12) In Saskatchewan in 2004, 82% of surgeries were completed within six months, but 5% had wait times longer than 18 months.(13) And here is where the problem comes home to roost: if even as few as half of the 5% were waiting involuntarily, great harm was done.

Who is responsible? Governments don’t manage the wait lists. Governments are not responsible for following up, or not, with patients waiting for procedures. Governments do not decide that patient A will get served in two months while patient B, with identical needs, will wait 20 months. Doctors do. The Canadian long waits are not a capacity problem: simple arithmetic demonstrates that no one has to wait 18 months in a system where 4 out of 5 (or more) patients wait well under six months. But until recently the only response of organized medicine to these long waits was to cry poverty and enlist the public in government bashing. One would have thought the Hippocratic oath would have diverted some of this energy toward looking after the long-suffering. It does not take a cynic to observe that the long queues admirably served the purpose of extracting more money for health care – both public and private. And they also provided the pretext for Chaoulli, and here we are.

The history of medicare is a clash between the state’s goals of equity, order and efficiency with medicine’s goals of autonomy, growth and control. Society has made enormous concessions to organized medicine, such as the right of doctors to set up practice anywhere, the right to remain independent contractors rather than full partners in a complex system, freedom from the measurement, scrutiny and accountability of US-style managed care, and pay scales that vastly exceed those extant in the European systems the court and medicare’s critics selectively admire from afar. It has also encouraged governments to increase public spending by an astonishing 60% in the past eight years, an ongoing mea culpa for the four-year period in the last 35 when spending modestly declined. All the public expects in return is a shared commitment to single-tier equity, a willingness to participate in reforms and decent performance. Apparently this has been too much to ask.

Now, thanks to the Supreme Court, the legal underpinnings of the system have been dealt a blow, and the choices are starker for doctors. They can now openly abandon the public system and get in on the ground level of an emerging private insurance system catering to people with money. They can market the virtues of commodified medicine and concentrate on the sexy diagnostics and high-volume procedures under the guise of enhancing Canadians’ Charter rights. No more unlucrative sessions with the complex geriatric case. No more dealing with intractable chronic diseases. No more unrewarding encounters with the underclass. It’s an easy and pleasant $275,000 a year for family doctors at a clinic that bundles core services with the extras, charging $1,700 up front and $2,300 annually.(14) No doubt surgeons in the orthopedic and cataract centres can easily double and triple that income.

The Supreme Court has raised the stakes, and the public needs to know where official medicine stands. Will it accelerate public-system reforms, improve its performance and effectively preempt the market for private insurance? Or will it decant more care to the private sector, which, according to recent evidence from Australia’s hybrid system, increases public sector wait times?(15) Will it promote a fair income distribution so that graduating doctors no longer leave family medicine and geriatrics residencies unfilled while they flock to dermatology and orthopedics? Will it propose and participate in comprehensive wait-list management systems, like Saskatchewan’s, to ensure that no patient’s health is endangered by unmonitored waits and that those with greater needs get served first? Will it leap to the fore of the quality revolution, or continue to provide an endless source of material for the small-area-variation research industry?(16)

Perhaps, in its testily divided decision, the court has done the country a favour. We have not had a national, focused debate on where to draw the line on two-tier health care for decades, resorting to fictions about medically unnecessary services and ignoring the evidence under our very noses – most recently that for-profit long-term care facilities provide significantly less direct and support care to residents than their nonprofit counterparts.(17) Nor have we carefully and conclusively debated Tommy Douglas’s unrealized vision of a genuinely balanced continuum of care. Physicians have fought long and successfully to remain at arm’s length from the system. You wouldn’t get on a plane built by engineers who decided independently what parts to make and whether and how to fit them together. Why would anyone expect excellence from a health care system that is largely ungoverned and where mistakes and overuse trigger an avalanche of funding and income while prudent, efficient practice has the bracing effect of lowering one’s income?

This is not a time for hysteria or fear-mongering, but for self-examination, reflection and choice. How governments respond to the challenge is of course vitally important, and the political exchanges promise to be lively. But citizens and governments delude themselves if they imagine that a public system can succeed without a medical profession that is widely and officially committed to its values and more often than not promotes rather than resists constructive change.

For too long the rule of the game has been to spend more or lose physician support. We’ve spent more – a lot more – and the return on investment has been low. Canada is a country governed by elites. Will the medical profession rise to the challenge of creating a new and improved medicare, or will it, like so many elites, talk about the public interest but act in the interests of the few?

Steven Lewis is with Access Consulting Ltd., in Saskatoon, SK., and the Centre for Health and Policy Studies, University of Calgary, Calgary, AB.
——————————————————————————–
Footnotes
1. Chaoulli v. Quebec (Attorney General). 2005 SCC 35.

2. Sullivan P. Private health care dominates meeting as General Council calls for national debate. CMAJ 1995;153(6):801-3.

3. Sullivan P. Focus groups confirm that MDs, public differ on role of private health care. CMAJ 1996;154(8):1247-9.

4. Kennedy J, Quan H, Ghali WA, Feasby TE. Variations in rates of appropriate and inappropriate carotid endarterectomy for stroke prevention in 4 Canadian provinces. CMAJ 2004;171(5):455-9.

5. Jaglal SB, Carroll J, Hawker G, McIsaac WJ, Jaakkimainen L, Cadarette SM, et al. How are family physicians managing osteoporosis? Qualitative study of their experiences and educational needs. Can Fam Physician 2003;49:462-8.

6. Brownell M. Tonsillectomy rates for Manitoba children: temporal and spatial variations. Healthc Manage Forum 2002;Suppl:21-6.

7. Katz A, DeCoster C, Bogdanovic B, Soodeen RA, Chateau D. Using administrative data to develop indicators of quality in family practice. Winnipeg: Manitoba Centre for Health Policy; 2004. Available: www.umanitoba.ca/centres/mchp/reports/pdfs/quality_wo.pdf (accessed 2005 Jun 20).

8. Medical Reform Group. Nearsighted physicians reject deal with government [media release]. Toronto: The Group; 2004 Nov 21. Available: www.hwcn.org/link/mrg/press.release.html#Nearsighted_Physicians_Reject_Deal_With (accessed 2005 Jun 20).

9. Sanmartin C, Shortt SED, Barer ML, Sheps S, Lewis S, McDonald PW. Waiting for medical services in Canada: lots of heat, but little light. CMAJ 2000;162(9):1305-10.

10. Department of Health. Achieving shorter waits: the PPF promises shorter waiting times across the service. London (UK): The Department; 2005. Available: www.dh.gov.uk/PolicyAndGuidance/PatientChoice/WaitingBookingChoice/WaitingBookingChoiceArticle/fs/en?CONTENT_ID=4066038&chk=ZurIX5 (accessed 2005 Jun 20).

11. Winnipeg Regional Health Authority. Health services wait time information: cardiac surgery. Winnipeg: Manitoba Health. Available: www.gov.mb.ca/health/waitlist/cardiac.html (accessed 2005 Jun 20).

12. Median wait times and wait lists. Victoria: Government of British Columbia; 2005 Mar 31. Available: www.healthservices.gov.bc.ca/cpa/mediasite/waittime/median.html (revised 2005 May 17, accessed 2005 Jun 20).

13. Wait time information. Regina: Saskatchewan Surgical Care Network. Available: www.sasksurgery.ca/wait-list-info.html (accessed 2005 Jun 20).

14. Copeman D. Interview with Don Copeman, Copeman Health Centre, Vancouver. Interviewed by Barbara Budd and Mary Lou Finlay, As It Happens [radio program]; 2005 Jun 1. Produced by the Canadian Broadcasting Corporation, Toronto. Available: www.cbc.ca/insite/AS_IT_HAPPENS_TORONTO/2005/6/1.html (accessed 2005 Jun 20).

15. Duckett SJ. Private care and public waiting. Aust Health Rev 2005;29:87-93.

16. Tu JV, Pinfold SP, McColgan P, Laupacis A. April 2005. Access to health services in Ontario: ICES Atlas. Toronto: Institute for Clinical Evaluative Sciences; 2005. Available: www.ices.on.ca/webpage.cfm?site_id=1&org_id=67&morg_id=0&gsec_id=0&item_id=2862&type=atlas (accessed 2005 Jun 20).

17. McGregor MJ, Cohen M, McGrail K, Broemeling AM, Adler RN, Schulzer M, et al. Staffing levels in not-for-profit and for-profit long-term care facilities: Does type of ownership matter? CMAJ 2005;172(5):645-9.

——————————————————————————–
Acknowledgements
Reprinted from the Canadian Medical Association Journal 173(3): 275-77 by permission of the publisher. Ā© 2005 CMA Media Inc.
Correspondence to: Steven Lewis, Access Consulting Ltd., 211-4th Ave. S., Saskatoon SK S7K 1N1; fax 306- 343-1071; steven.lewis@shaw.ca.

A Radical Healthcare Solution

Michael Hiltzik
LA Times
October 6, 2005

Business leaders, acting in what they regard as their economic self-interest, have torpedoed every attempt to improve the nation’s ridiculously ineffective healthcare system for decades. There hasn’t been a significant reform since Lyndon B. Johnson expanded Medicare and Medicaid in the 1960s.

The chickens are finally coming home to roost.Private industry assumed financial responsibility for employee healthcare after World War II. It no longer wants the burden. The crippling cost has been cited as a factor in the bankruptcies of United, Northwest and Delta airlines. Unscrupulous employers leave their workers medically stranded, thus undercutting competitors who try to do the right thing. (Think of the Wal-Mart effect in retail.)

The number of uninsured citizens is growing ā€” more than a fifth of all non-elderly Californians, or 6.6 million persons, lack coverage ā€” and the number of those insured whose benefits are being cut back by their employers is growing even faster.

So it shouldn’t be surprising that solutions once dismissed out of hand are suddenly getting a closer look. The most appealing is a single-payer system, which would replace today’s jigsaw puzzle of private insurance, public programs and nothing with a government-run healthcare program. In California, that option is being pushed by state Sen. Sheila Kuehl (D-Santa Monica), who says she senses growing, albeit still insufficient, support around the state after three years of proselytizing.

Kuehl’s plan is a work in progress. (She hopes to draft a full-fledged version next year.) Her basic proposal is for the state to finance comprehensive health coverage for all residents through a tax surcharge. Private insurers would be barred from selling equivalent coverage, but could market supplemental policies for services not on the state menu. An elected commissioner would establish benefits, set payments for providers, negotiate prescription drug deals, and so on.

Kuehl says her program would achieve universal coverage while cutting more than $8 billion from the medical costs of state government, employers and families, which are projected to reach $184 billion next year. (Her figures come from an analysis by the Lewin Group, a Virginia consulting firm, paid for by single-payer advocates.)

Hers is a radical solution. But many of the proposed alternatives in Sacramento merely involve letting insurance companies sell “affordable” strippeddown medical plans to workers. These remind me of my home earthquake policy, which won’t pay for most of the damage I might incur, but at least it’s cheap.

Critics of single-payer plans say they’re inefficient ā€” the wait time for CAT scans in Canada averages a few months, to repeat a common rap on that country’s program. But such criticism assumes that the alternative is a system in which all patients have instant access to all the treatment they need. That system doesn’t exist in the United States, where even the insured can suffer long delays for diagnostic procedures and treatments, and the uninsured are lucky to get emergency room care.

Among single-payer’s virtues is that it cuts private insurers out of the loop. These companies exist largely to convert premium dollars into profits, sometimes at a rate of 10% or more. They win praise from Wall Street when they reduce the share of the premium dollar spent on medical treatment.

It’s true that the very notion of a government system gives some people the willies. “Considering our experience with having Congress run Medicare and Medicaid, I don’t think any physician or knowledgeable patient would say, let’s have them run it all,” says Jack Lewin, chief executive of the California Medical Assn. (He’s not connected to the Lewin Group.)

But the main objection doctors and hospitals have to those programs is that their reimbursements are too low. On the plus side, Medicare’s administrative costs are less than 2% of its benefit payments; for some private insurance plans, the ratio is 25%.

Still, even if one were to accept that a single-payer program would improve on the crumbling system we have today, there’s reason to doubt that it can work in a single state, even one with California’s immense bargaining power. As long as the rest of the country is operating by different rules, California will struggle with federal bureaucrats doing business the old way. (The state will need government waivers to absorb federally funded programs into its system.)
By replacing healthcare premiums with an employer-employee tax, Kuehl’s plan might reduce overall costs for employers who already offer comprehensive coverage, but it will raise costs for those that offer skimpy plans or none at all. This will anger small businesses and lobbyists for big skinflint companies. (Surprise: The California Chamber of Commerce has already labeled Kuehl’s proposal a “job killer.”) Such competitiveness issues can’t be solved except by nationwide healthcare reform.

Another concern is how the system will handle political pressure. Think it’s tough to close an urban firehouse? Wait until the state healthcare czar tries to close a neighborhood hospital. Of course, such decisions tend to be made now by insurance executives thousands of miles away; empowering a publicly accountable state official to weigh the pros and cons might be a step forward.

Kuehl’s plan isn’t perfect, but perfection is elusive in medicine, inside the hospital and out. It is an attempt to fix a failing system in one fell swoop, rather than with stopgap measures that will merely delay the reckoning. At the very least, it should focus the debate. As Kuehl told me this week, “We need to do more than nibble around the edges.”

U.S. cancer expert: Canadians aren’t aware of value of medicare system

Provided by: Canadian Press
Written by: JOHN COTTER
Sep. 27, 2005

EDMONTON (CP) – World-renowned cancer specialist Eduardo Bruera is homesick for Canada’s health-care system.

Dr. Bruera left Edmonton’s Cross Cancer Institute after 15 years in 1999 to become chairman of the department of palliative care at the University of Texas M.D. Anderson Cancer Center in Houston. After working in both countries, Bruera, an oncologist, has a message for people who complain about medicare or who want to expand the use of private health insurance in Canada.

“The portability and the universality of health care in Canada are unbelievably good. I think Canadians are not aware of that,” said Bruera, who was to compare care in the two countries in a speech Wednesday at the annual conference of the Canadian Hospice Palliative Care Association.

“Don’t look at the United States. The public health-care system makes it possible for patients to access palliative care in Canada earlier and more effectively.”

Since moving to Texas, Bruera said he can’t get over the spectre of crushing debt that even upper-middle-class Americans face when a family member is dying from an advanced illness.

Even premium private health insurance in the United States rarely covers all the costs, which can lead to bereaved survivors facing an almost never ending list of medical bills, he said.

Of every $100 spent by families on medical care at the M.D Anderson Centre, only $32 is paid for by private insurance, he said.

More than 41 million Americans don’t have health insurance, he said. Of those who are insured, one in three will lose all their financial assets during illness.

“To me it is an enormous impact on quality of life. The burden of dying in the U.S. of cancer is much heavier than the burden . . . in Canada.”

Bruera’s remarks come as the federal and provincial governments work to come to grips with a Supreme Court of Canada decision in a Quebec case earlier this year which approved some uses of private health insurance.

Since the ruling, provinces such as Alberta have been actively considering expanding the use of private health insurance.

The province is expected to announce by the end of October which private insurance firm will be chosen to conduct an actuarial study of the pros and cons of such a scheme.

Premier Ralph Klein has said allowing private insurance firms to sell policies would benefit Albertans who want to shorten their waiting times for non-emergency medical procedures.

However, the province has yet to define exactly what it means by “non-emergency.”

Bruera said he is “100 per cent sure” that private insurance would not improve palliative care.

“In general, services such as palliative care, that is not highly profitable or high tech, are generally not insured very well in the U.S.,” he said.

“If you privatize parts of the system, the juicy parts, the ones that are more profitable, will be taken by the private insurers. The most costly and less rewarding will be left for the government services.”

Medicine’s Sticker Shock (Kristof)

By Nicholas D. Kristof
The New York Times
October 2, 2005

In the aftermath of Hurricane Katrina, we have an opportunity to construct something far more important than higher levees – a national health care system that looks less like a tightrope and more like a safety net.

A dozen years after Bill Clinton’s health reform efforts were destroyed by the insurance industry’s duplicity, it’s worth trying again. The health care system is steadily becoming more gummed up in ways that are impossible to hide.

One of the bumper stickers attacking the Clinton plan read: “If You Like the Post Office, You’ll Love National Health Insurance.” That wouldn’t work today: the Postal Service runs a system that is manifestly more rational and efficient than our health care system. For starters, imagine a postal system that refused to deliver letters to or from 45 million Americans – except on rare occasions, by ambulance.

“This is one of those fleeting opportunities where a catastrophe creates an opportunity to rebuild something better than before,” says Dr. Irwin Redlener, president of the Children’s Health Fund and associate dean of the Mailman School of Public Health at Columbia University.

In a sign of the growing disenchantment with our health system, 13,000 doctors have joined Physicians for a National Health Program, which lobbies for a single-payer government-financed health program.

There are four main problems with the existing system. First, it leaves out 45 million uninsured Americans, and their number is rising. Second, it is by far the most expensive in the world, costing 15 percent of our national income, yet our outcomes are awful – U.S. life expectancy is worse than Costa Rica’s. Third, our business competitiveness is undermined when, for example, medical expenses add $1,500 to the sticker of each General Motors car. Fourth, our system is catastrophically inefficient: according to a study in The New England Journal of Medicine, health administrative costs are $1,059 per capita in the U.S., and just $307 in Canada.

A single-payer system would be most efficient but probably is not politically feasible at the moment. The smart new book “The Health Care Mess” suggests a variety of more gradual approaches that would face less opposition.

Whatever the mechanism, all children should be covered. It’s a disgrace that we use public funds to save the lives of nonagenarians but not those of 9-year-olds. And kids are a bargain: per capita medical spending is $1,525 for children less than 5, and $9,000 per person aged 65 to 74.

A second principle is that we should put less emphasis on curative medicine and more on public health and prevention – everything from preparing for avian flu to encouraging exercise. Sure, we can buy more “left ventricular assist devices,” which cost $210,000 per patient installed, or buy Erbitux for colon cancer, at $17,000 per month of treatment. But as a wise new book, “Prescription for a Healthy Nation,” argues, you get more bang for the buck when you promote healthier lifestyles – fighting obesity, cigarette smoking and the like.

Raising cigarette taxes saved far more American lives, for example, than an army of neurologists ever could. In the same spirit, I’d like to see a French-fry tax. And imagine the health gains if we banned potato chips and soda from schools.

Reforming the health system won’t be easy. In the real world, poor kids don’t see doctors not only because they’re uninsured, but also because Mom doesn’t have a car, can’t easily get time off from work, or doesn’t speak English. Those are hard nuts to crack – but one reason to think that we can do better is that much of the world does better.

I’ve been thinking of health care partly because of something that happened when I was on vacation in August. My kids and I were stacking firewood for my parents on the Yamhill, Ore., farm where I grew up, when suddenly the seven-foot stack collapsed – on top of my youngest. She was knocked down and pinned, her face bleeding, under a pile of logs.

I had insurance, and a car to get to the emergency room – and in the end the logs (stained with blood) turned out to be in worse shape than my daughter. She’s just fine. But that instant was heart-stopping in its terror – and the system routinely does fail such children in need. Isn’t it worth fighting one more time for reforms, so that we Americans can get health care every bit as good as Canada’s?

Lack of insurance is lethal for injured children

Injured kids: no insurance, no chance?
Florida children who are hospitalized without insurance are more that twice as likely to die there, a study shows.
By Lisa Greene
St. Petersburg Times
October 4, 2005

Children stream into Florida hospitals every day after falling off bicycles or into swimming pools, being hurt in car wrecks or at the hands of a violent adult.

Whether they have insurance could in part foreshadow how well they will fare.

Children in Florida who enter the hospital without health insurance are more than twice as likely to die there as children with private health insurance or public insurance such as Medicaid, according to a new study by local researchers.

Of the nearly 11,000 children hospitalized in Florida with injuries in 2002, 131 died. About 18 percent of those deaths were uninsured patients, even though those patients made up only 8.5 percent of hospitalizations. Researchers released the findings Monday in a report produced by All Children’s Hospital, the Florida Suncoast SAFE KIDS Coalition and USF Health.

Researchers weren’t sure why but were concerned about the disparity and were applying for grant money to do another study.

These children are most likely in families of the working poor – those whose parents make too little to afford private insurance but too much for the children to be covered by Medicaid. For now, researchers can only guess at disturbing possibilities:

–There might be something different about the way these children are hurt. Maybe they’re in older cars that don’t protect them as well in accidents. Maybe their places to play aren’t as safe. Maybe they’re more likely to be abused.

–Parents of children with insurance may be more willing to rush their child to the emergency room after an injury just in case, while parents without might wait longer to see if the child is seriously hurt or not have a car to drive to the hospital.

–The children might be treated differently after they arrive at the hospital. Emergency rooms are required to treat patients regardless of whether they can pay, but studies have shown differences in outcomes for some medical conditions based on who has insurance.

http://www.sptimes.com/2005/10/04/State/Injured_kids__no_insu.shtml

And…

Care without Coverage: Too Little, Too Late
Institute of Medicine

The uninsured more often… receive fewer diagnostic and treatment services after a traumatic injury or a heart attack, resulting in an increased risk of death even when in the hospital.

http://www.iom.edu/Object.File/Master/4/160/0.pdf

Comment: The authors of this report are careful to point out that, although the lack of insurance is correlated with twice the risk of death in children with trauma, the cause of this higher mortality was not established.

Opponents of insurance reform will undoubtedly dismiss this study with their usual rhetoric. “Everyone gets the care they need whether they’re insured or not, and that is certainly always true for emergencies.” They will also resort to blaming the victim. “These people don’t take care of their kids. They don’t fasten their seatbelts. They don’t watch their kids around pools or on the playground.”

Everyone would agree that injury prevention efforts must be expanded, both in design and education. No matter how effective these measures are, some injuries are inevitable since people and systems are never perfect. The “blame the victim” mentality needs to be shifted to a “let’s do all we can to prevent injuries” mentality.

As far as everyone getting the care they need, innumerable studies have confirmed that the uninsured do not. The Institute of Medicine report confirms that uninsured trauma victims taken to hospitals do not receive as much care as the insured, and death rates are higher.

Lack of insurance kills children. How much longer are we going to tolerate this entirely preventable cause of death? They may be the victims, but we have only ourselves to blame.

Medicare Part E

Medicare Extra: A Comprehensive Benefit Option For Medicare Beneficiaries
By Karen Davis, Marilyn Moon, Barbara Cooper, Cathy Schoen
Health Affairs
October 4, 2005

Abstract

The proposed Part E, Medicare Extra, outlined in this paper adds a comprehensive benefit option to Medicare, eliminating the need for beneficiaries to purchase a private drug plan and Medigap supplemental coverage. Financed by a budget-neutral beneficiary premium, it has the advantages of greater simplicity, efficiency, and value without adding to federal costs. Beneficiaries now enrolled in Medigap plans would save money, as could employers by choosing a lower-cost alternative to current retiree health plans. Eliminating some of the excess payments to Medicare Advantage plans would yield savings that could be used to help finance premium subsidies for low-income beneficiaries.

Concluding Comments

Medicare beneficiaries have consistently expressed higher satisfaction with their coverage than nonelderly enrollees in employer health plans have. They are much more confident that they will be able to obtain care when needed, and they report fewer problems obtaining access to care. They are less likely than people with employer coverage to report negative insurance experiences and problems paying medical bills. Improving Medicare’s benefits should build on this record and permit those beneficiaries who are genuinely pleased with the traditional FFS program to consolidate their benefits there.

A comprehensive Part E benefit offered by traditional Medicare would have strong advantages for beneficiaries. Beneficiaries would get the benefits they want at lower cost and with much less confusion and complexity. It would create choices for beneficiaries and a genuine choice between Medicare Extra and MA plans. A strong role would remain for private insurers, both offering MA plans and serving as fiscal intermediaries in paying claims for basic Medicare and Medicare Extra. But savings also would be achieved, by having the government assume fiscal risk and negotiating rates with providers. In addition, employers could save money on retiree health benefits. Such an alternative should be a part of the debate over the future of Medicare and any midcourse corrections to the new drug benefit.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.442v1

For a brief description of this proposal from The Commonwealth Fund:
http://www.cmwf.org/publications/publications_show.htm?doc_id=302930&#doc302930

Comment: Although Medicare is the most popular insurance program in the United States, it does have some deficiencies.

Part A covers hospitalization and Part B covers physicians and other services, but with cost sharing. In order to reduce the financial vulnerability caused by Medicare cost sharing, Medigap plans were introduced into the private market. Unfortunately, these plans represent one of the worst values in health insurance. Not only are they overpriced considering the minimal benefits offered, they also compound the administrative burden of our fragmented system of funding health care. The Medicare Part E proposal would expand Medicare Parts A and B by rolling in the function of the Medigap plans, thereby eliminating the tremendous waste inherent in this supplemental coverage.

Medicare Part D establishes the principle that drugs are an essential part of health care and must be included as a Medicare benefit, but it is one the worst designed public insurance programs ever devised. Without listing the major flaws, we’ll simply state that, for Medicare Part E, many of the Part D defects are corrected and then this drug benefit is folded in as well.

The Medicare Advantage plans are private plans that can be selected by opting out of the traditional Medicare program. At present, the private plans are able to offer more generous coverage for two reasons. Plans have successfully marketed healthier sectors of the population, but Congress has continued to ignore adverse selection and has continued to compensate the plans as if they were covering their share of high-cost patients. Even worse, to encourage a greater shift to the private insurance market, Congress has authorized huge bonuses for the private plans to provide them with a perverse competitive advantage over the traditional providers. What an abusive use of our tax dollars! If Congress were a private corporate board, the SEC would have all of them in prison. If required to compete on an equal dollar basis, with full Medicare benefits and appropriate risk adjustment, the Medicare Advantage plans would walk away. And they should, once we allow the traditional Medicare program to include a bona fide prescription benefit.

Medicare Part E then is a combination of Medicare Parts A, B and an improved D, and the expansion would be funded mostly by eliminating the waste of Medigap and Medicare Advantage plans.

For incrementalists, Medicare Part E would be a dramatic step forward. For single payer supporters, Part E would fall far short. We must not let up on our message of affordable, high quality, comprehensive health care coverage for everyone. Until we are there, and we will be, we can support the efforts of those who would improve our system through beneficial, incremental steps. Under incrementalism, all parameters of our health care system are worse, but the fact that we are pushed two steps back doesn’t mean that we shouldn’t take one step forward when we can.

Single payer supporters may want to become actively involved in the Part E process. We could advocate for additional improvements that characterize the single payer model. Once an ideal Part E Medicare were established, we could advocate for expanding it to cover everyone. That would provide smug complacency to those in our movement who believe that we should be using the label, “Medicare for All.” I’m quite willing to give them that, as long as we end up with a single payer system.

Pandemic of under-insurance

Medical Debt and Access to Health Care
Prepared by Catherine Hoffman, Diane Rowland and Elizabeth C. Hamel
The Kaiser Commission on Medicaid and the Uninsured
September 2005

Health insurance alone is no longer a guarantee of financial protection from the costs of health care for many. Today’s higher premiums, deductibles, and copayments can create a substantial financial burden for families and many learn only through an unexpected serious injury or illness that they are not well protected financially.

In this study… we found that one in six adults who are privately insured – 17.6 million adults – report having substantial problems paying their medical bills.

Privately insured adults with medical debt are largely from middle-class families, not as poor as the uninsured, but not as well-off as the privately insured who have no medical debt. The large majority hold full-time jobs. An important difference between the privately insured with vs. without medical debt is their health status. Those with medical debt are more than twice as likely to report being in only fair or poor health and they are almost twice as likely to have an ongoing or serious health problem compared to others with private coverage.

Perhaps not surprising, the majority of those with medical debt reported underestimating what their health plan would pay towards their medical bills (vs. a third of those without sizable medical debt) and nearly half said their plan had not paid anything for care they thought had been covered.

If current trends in greater cost-sharing continue, more low- and middle-income families with private insurance, particularly those who are in less than good health, will not have the same access to care as others with private coverage who have higher incomes. In fact, as this study shows, they will limit their care in many of the same ways and as often as those who have no health insurance at all.

http://www.kff.org/uninsured/upload/Medicaid-Debt-and-Access-to-Health-Care-Report.pdf

Comment: Monotonous, isn’t it – study after study demonstrating that private health insurance is no longer serving its purpose – to ensure financial security for those who have health care needs.

Current insurance innovations are designed to make premiums affordable, and they do this by making access to care unaffordable. The insurers are not going to fix this broken system for us. Isn’t it time that we gave up on them?

Tax cuts, health spending, and reviving the economy

Medicaid Responsiveness, Health Coverage, and Economic Resilience:
A Preliminary Analysis
By Stan Dorn (The Economic and Social Research Institute), Barbara Markham Smith (Health Policy Innovation, Inc.) and Bowen Garrett (The Urban
Institute)
The Health Policy Institute of the Joint Center for Political and Economic Studies
September 27, 2005

With $10 billion in Medicaid spending reductions under consideration by Congress, the issue of Medicaid has returned to the forefront of the nation’s public policy debate. One recurring proposal to limit federal Medicaid spending would place firm caps on either Medicaid enrollment or federal Medicaid spending.

Such caps could dramatically restructure the program. Currently, individuals who meet their state program’s eligibility requirements are guaranteed coverage. Accordingly, when changed economic conditions increase the number of people who qualify for Medicaid, enrollment automatically rises. This capacity to expand in response to need has prevented millions of Americans from losing coverage in recent years. From 2000 to 2004, enrollment in employer-sponsored insurance (ESI) fell from 63.6 percent to 59.8 percent of all U.S. residents. Many workers who lost ESI became uninsured, but others instead qualified for Medicaid. If Medicaid had not been allowed to grow, and enrollment was instead capped at 1999 levels, the number of uninsured in 2004 would have been 6 million higher – roughly 52 million, rather than the 46 million estimated by the Census Bureau several weeks ago.

If health insurance premiums continue to grow much faster than total earnings, the next few years are likely to see further declines in employer-sponsored coverage and an ongoing rise in the number of uninsured. That rise could be much steeper if national policymakers undercut Medicaid’s capacity to expand.

Medicaid’s responsiveness to changing conditions may also have important implications for the economy as a whole, not just for individuals in need. When recession hits, more households have incomes low enough to qualify for Medicaid. Because Medicaid guarantees coverage to eligible individuals, enrollment automatically rises, which increases state and federal spending. Such spending stimulates the economy, limiting further job loss and contributing to economic recovery.

http://www.jointcenter.org/publications1/publication-PDFs/MediCaidFullReport.pdf

And…

Sailing into the Perfect Storm
Uwe Reinhardt, Ph.D., Princeton University
National Conference of State Legislatures Annual Meeting
August 19, 2005

Tax Cuts versus Added Health Spending

The tax cuts of 2001 and 2003 were passed on the (Keynesian) argument that it would put added money into the pockets of taxpayers who would then spend more and, thus, revive the economy.

An economist would find it hard to argue with this theory. It is standard fare in macro-economic policy and it works.

That same theory, however, also predicts that added government spending – be it on health care, education, roads, or mass transit – revives the economy as well.

For example, without the rapid growth of health spending during the 1980s and the jobs it added, the Reagan recovery of that decade would not have been nearly as robust.

Every added dollar of health spending diffuses quickly throughout the entire US and, most importantly, stays at home. Hardly any of it leaks abroad.

By contrast, good parts of a major tax cut may leak abroad in the form of offshore investments or spending on consumer goods made abroad.

The construction of new hospital facilities or of new golf resorts both are scored as “investments” in the national GDP accounts.

We always pretend that building golf courses boosts the economy, while building hospitals is a drag on the economy.

Does that make sense to you?

http://www.ncsl.org/print/press/UReinhardtslides_AMSeattle05.pdf

And…

The White House
August 8, 2005

To ensure the economy remains strong, President Bush has called on Congress to act on other aspects of his agenda. His plans include making his tax cuts permanent, restraining spending by the Federal government…

http://www.whitehouse.gov/infocus/economy/index.html

Comment: How many times have you heard it? The only way that we can keep the economy going is to cut taxes and cut federal spending. The establishment of a commission to find $10 billion in cuts for the Medicaid program is an extension of the administration’s principle that any cut in federal spending is good for the economy.

This year, health care represents 15.6% of our Gross Domestic Product (GDP). That’s a huge hunk of our economy.

Policies that increase the flow of funds to the health care delivery system benefit the economy, whether those are private funds funneled through private insurers or public funds funneled through public insurance programs. The primary difference is that more of the funds passing through the hands of the private insurers are diverted to administrative services. Although the funds that insurers consume also enter the economy, most of us would rather see those funds spent on health care instead of superfluous paperwork.

The lesson: Do not ever let the opponents of reform get away with stating that the taxes that would be required to pay for a national health insurance program would destroy the economy. The exact opposite is true. It’s difficult to think of a better way to nurture a healthy economy than to nuture our health care system.

Priced out of health insurance, or health care?

‘Skeletal’ benefits in doubt
Critics say cut-rate policies offer little coverage in need
By Victoria Colliver
San Francisco Chronicle
September 21, 2005

As health care costs soar, insurers are offering a growing array of low-cost policies with high deductibles and limited benefits.

Now, some public officials are questioning the value of those plans, and specifically whether they give consumers access to health care at a price they can afford.

In a hearing Tuesday in San Francisco, state Insurance Commissioner John Garamendi explored the issue, gathering testimony from insurers, physician groups and hospital groups in an effort to determine whether tougher standards should be set for policies with so-called skeletal benefits.

Such plans include those with strict caps on costs for hospitalization and medical events, as well as those that offer no coverage for maternity and other conditions. Some high-deductible policies generally come with tax-deferred savings accounts that can belong either to the employer or to the employee.

“As a regulator, I am troubled to see the floor of standard benefits eroding,” said Garamendi.

Inexpensive bare-bones plans might be attractive to consumers, but “it’s all well and good until you happen to need that coverage,” Garamendi said. Such policies could lead to bankruptcies and draw younger and healthier people out of insurance risk pools, causing more comprehensive policies to become more expensive, he said.

Representatives from the insurance industry said health plans are simply responding to the marketplace by creating more-affordable policies that give consumers more control in making health care decisions.

“The concern we have is people seem to be priced out of health insurance,” said Anne Eowan, of the Association of California Life and Health Insurance Companies.

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2005/09/21/BUGVHEQULR1.DTL&hw=garamendi&sn=001&sc=1000

Comment: Tragically, the insurers, in preventing premium increases that would price their insurance products out of the market, are pricing patients out of health care.

Why do we leave them in charge? What saving grace is there that should cause us to continue to support market competition of private insurance plans over a universal program of public social insurance?

There is a saving grace for the latter: our health.

Correlating societal health with religiosity and secularism

Note: The following Quote of the Day is highly controversial. If you are not in the mood to contemplate difficult societal issues, you may want to delete this message at this point.

Cross-National Correlations of Quantifiable Societal Health with Popular Religiosity and Secularism in the Prosperous Democracies A First Look
Gregory S. Paul
Journal of Religion & Society
Volume 7 (2005)

Abstract:

Large-scale surveys show dramatic declines in religiosity in favor of secularization in the developed democracies. Popular acceptance of evolutionary science correlates negatively with levels of religiosity, and the United States is the only prosperous nation where the majority absolutely believes in a creator and evolutionary science is unpopular.

Abundant data is available on rates of societal dysfunction and health in the first world. Cross-national comparisons of highly differing rates of religiosity and societal conditions form a mass epidemiological experiment that can be used to test whether high rates of belief in and worship of a creator are necessary for high levels of social health. Data correlations show that in almost all regards the highly secular democracies consistently enjoy low rates of societal dysfunction, while pro-religious and antievolution America performs poorly.

From the Introduction:

This study is a first, brief look at an important subject that has been almost entirely neglected by social scientists. The primary intent is to present basic correlations of the elemental data. Some conclusions that can be gleaned from the plots are outlined. This is not an attempt to present a definitive study that establishes cause versus effect between religiosity, secularism and societal health.

Conclusion:

The United States’ deep social problems are all the more disturbing because the nation enjoys exceptional per capita wealth among the major western nations (Barro and McCleary; Kasman; PEW; UN Development Programme, 2000, 2004). Spending on health care is much higher as a portion of the GDP and per capita, by a factor of a third to two or more, than in any other developing democracy (UN Development Programme, 2000, 2004). The U.S. is therefore the least efficient western nation in terms of converting wealth into cultural and physical health. Understanding the reasons for this failure is urgent, and doing so requires considering the degree to which cause versus effect is responsible for the observed correlations between social conditions and religiosity versus secularism. It is therefore hoped that this initial look at a subject of pressing importance will inspire more extensive research on the subject. Pressing questions include the reasons, whether theistic or non-theistic, that the exceptionally wealthy U.S. is so inefficient that it is experiencing a much higher degree of societal distress than are less religious, less wealthy prosperous democracies.

Conversely, how do the latter achieve superior societal health while having little in the way of the religious values or institutions? There is evidence that within the U.S. strong disparities in religious belief versus acceptance of evolution are correlated with similarly varying rates of societal dysfunction, the strongly theistic, anti-evolution south and mid-west having markedly worse homicide, mortality, STD, youth pregnancy, marital and related problems than the northeast where societal conditions, secularization, and acceptance of evolution approach European norms (Aral and Holmes; Beeghley, Doyle, 2002). It is the responsibility of the research community to address controversial issues and provide the information that the citizens of democracies need to chart their future courses.

http://moses.creighton.edu/JRS/pdf/2005-11.pdf

The Journal of Religion & Society is a cross-disciplinary, electronic journal published by the Rabbi Myer and Dorothy Kripke Center for the Study of Religion and Society at Creighton University.
http://moses.creighton.edu/JRS/index.html

Comment: Many will dispute that there is a cause and effect relationship in this correlation, and some will dispute the conclusions regarding the comparisons of societal health between prosperous developed democracies. It is not the intent of this message to address these debates.

There is an important health policy lesson here. Policies that accept the status quo in health care, and depend on societal faith-based, charitable impulses to address the deficiencies, have not and never will ensure adequate access and coverage for the tens of millions of Americans currently left out. All other prosperous democracies have depended on secular government interventions and resources to ensure health security for all. The United States has no other choice than to do the same if we ever expect to realize our Samaritan values extolled by our religious leaders.