PNHP

Canada a mix of U.S., European sensibilities

Canada a mix of U.S., European sensibilities

By Gwendolyn Owens
Special to the Sentinel
March 13, 2005

MONTREAL — There was a joke making the rounds here a few years ago that went like this:
Question: What’s a Canadian?
Answer: An American with a health-care card and no gun. The way Canadians view the United States is a much more complicated matter — roughly analogous to how one might view a rich, overbearing cousin.

Canada sits on the United States’ northern border with a population roughly twice that of Florida, but with a culture and mentality that melds together Europe and the United States.

Having lived in Canada since 1991, I spend a lot of time explaining the differences and similarities to my neighbors here and to friends at home. My professor husband and I moved our family to France for the 2003-04 academic year, and one byproduct was a new perspective on the differences and similarities of the United States, Canada and Europe.

Canada looks more like the United States than it does Europe. Cities in Canada often resemble those to the south that date from the same era: Montreal looks a lot like New York; Toronto looks Midwestern, almost like Chicago. Vancouver, British Columbiais a lot like Seattle, and Calgary, an energy center in the West, has been compared to Dallas with snow.

Everywhere the roads are filled with fast-driving Canadians, largely in trucks and sport utility vehicles, far larger and less energy efficient than those peppy little European cars.

However, in every one of those big cars will be a person with a health-care card entitling him or her to government-paid health care from the doctor of his or her choice. Canada, like European countries, is facing tough choices about how to manage the spiraling costs.

The system itself is a matter of pride. In Quebec, where they are discussing user fees, a friend told me that though she would have no problem financially paying a fee, she resents the idea because that’s not what health care should be about.

The greatest Canadian

Just how dear this system is to Canadian hearts was brought out last fall when the Canadian Broadcasting Corp., the public television of Canada, held a contest for the greatest Canadian. Tommy Douglas (1904-86), the “father” of the Canadian Health Care Act, won.

Though the belief in a public-health system unites Canadians, it is a nation that is often described not as a melting pot of immigrants, but a patchwork. New Canadians are expected to learn French or English — preferably both — but they are encouraged not to forget their roots, their customs and their language; they don’t have to give up their other citizenship.

For business, it is a positive attribute; you can find people who speak the language to help you to do business in just about any part of the world.

A union of many nations

It also makes for wonderful ethnic food as immigrants open businesses, not just to cater to people looking for exotic food, but for people from their own community who want to eat just like they did at home in, for example, India, Morocco or Peru. It is as if the country is a kind of union of many nations, not unlike the new European Union or a small United Nations.

When it comes to sports, Canadians love their homegrown sport, hockey, but they also love the American sports of football, basketball and baseball, even if the Montreal Expos had few real fans left in the end.

The wardrobe malfunction of last year’s Super Bowl, seen by millions of Canadians as well as Americans, was not a big story; the story was the U.S. outrage about the malfunction.

In the subway in downtown Montreal is a billboard advertising a DVD with a photograph showing a dancer in a similar state of undress as Janet Jackson, and no one seems to mind or even notice, although in some more conservative parts of the country, it might raise some eyebrows.

Canadians eat fast food like their southern neighbors do, but the concept of a private college or university for students getting a college degree does not really exist in Canada.

Labor unions are stronger here than across the border — just ask Wal-Mart, which is trying to close a store outside Montreal in which the employees voted to unionize, and is facing unionization, which Wal-Mart regards as a threat, in several other Quebec stores.

Country without a revolution

What’s at the root of Canada’s position as a middle ground? Canada never had a revolution or broke forcibly away from Great Britain as did the United States. It became a confederation in 1867, but it was not until 1982 that Canada got its own constitution with its own powerful version of the Bill of Rights, called the

Charter of Rights and Freedoms.

This is not a country made up of rebels, which is most likely where the jokes come about Canadians being law-abiding. Quebec was allowed by the conquering English in 1759 to stay French-speaking, and while tension has risen and fallen through the years about the place of French in Canadian life, the decision in the first place to let French colonists keep their language now seems very Canadian: It was a decision, while political on the part of Great Britain, that allowed for the beginnings of acceptable differences, the patchwork model.

Geography has had a lot of influence on how Canada works. In a country so vast with relatively few people, delivery of services is a more complex problem. So the government, on the provincial and federal level, has always had a more visible hand in setting up and providing for citizens far afield from one another.

In bed with an elephant

Former Canadian Prime Minister Pierre Trudeau described living next to the United States as being like sleeping in the same bed as an elephant: You cannot avoid knowing that the elephant is there, even if the elephant is being very quiet.
So to give Canadian artists, singers, writers, publishers, et cetera, a chance to be heard and seen, the Canadian government supports the arts in Canada and promotes including Canadian content with rules governing the number of cable channels that must be offered with Canadian content and how many songs an hour on the pop stations should be Canadian.

About 35 percent of the music on the radio and 60 percent of the programs on television are required to be Canadian, but there are no such rules for movies in theaters. However, the Canadian government provides generous tax credits to Canadian film producers to encourage the homegrown film industry.

Americans still welcome

In discussions since 2001, the question of whether Americans are being singled out for bad treatment abroad usually comes up. Our experience, in Canada and Europe, has been positive; outside the United States, American foreign policy is often seen as misguided or downright wrong, but individual Americans still welcome visitors to Canada, France and the other places we have visited in the past year.

Are Americans ready to be as welcoming to people from abroad? Many people we met in Europe were planning to visit North America — not the United States, only Canada — just because they were not sure how they would be treated. They felt comfortable about coming to Canada; it was not as different, not as far a trip metaphorically as the United States.

Originally from Baltimore, Gwendolyn Owens is a writer and historian of American art who lives in Montreal.

Stanford Dean Pizzo supports single payer

Stanford School of Medicine
Stanford Medicine Magazine
Winter 2005
Letter from the Dean

It’s hard to fathom why our nation, with its great financial and intellectual capital, has a health-care system that’s so far from world class. Much of the trouble comes from the belief that health care must be run like a business – as if personal health were a commodity. This notion, promoted over the past two decades by our leaders in Washington, posits that the free market will restrain costs and bring high-quality care to all. Obviously, this strategy has failed miserably.

I do not believe that modifications around the edges of our health-care quagmire are going to do it. We need sweeping change. I personally favor a single-payer model incorporating support for medical training, innovation and discovery. But I’m not convinced that our political leaders can muster the will to overcome the obstacles from special interests with stakes in supporting the status quo.

Philip A. Pizzo, MD
Dean, Stanford University School of Medicine

http://mednews.stanford.edu/stanmed/2005winter/letter.html

Universal Health Care System Has Local Support

Store Owner Pleads For It
By Gary E. Lindsley, Staff Writer

ST. JOHNSBURY — His voice quivering, businessman Tom Hurst pleaded Monday for the creation of a universal health care system.

Hurst, who is his family’s fifth generation to run Willey’s Store in Greensboro, asked state Rep. Steve Larrabee, R-Danville, to push for such a system for all Vermonters.

He made his plea during a special meeting called by the National Federation of Independent Business Monday afternoon at the Comfort Inn & Suites in St. Johnsbury.

NFIB representatives were in town to urge business owners to get engaged in debates regarding health care, energy and minimum wage.

The purpose of the “Act Now or Pay Later” meeting was to highlight the “anti-small-business legislation” making its way through the Legislature, according to NFIB information.

Hurst focused on health care.

“I’ve got two four-hour periods a day I can function,” he said, his left hand shaking. “The rest of the time my arms don’t work. The rest of the time I am unable to help.”

Sitting with a number of prescription bottles and two piles of money in front of him, he spoke about how he is suffering with a serious illness. He declined to reveal what the illness is.

“I am unable to hug my daughter,” Hurst said, “but she hugs me.”

He offered $1 and $5 bills to Larrabee and others who might be able to muster a universal health care system through the state Legislature.

“Take $1 because tonight I will not be able to use my hand,” Hurst said. “Please take a $5 bill so you can say I bribed you to really consider universal health care.”

He said his store provides his 17 employees 100 percent health insurance coverage. The employees’ family members are also covered. This year, the store’s health insurance premium went up $20,000, he said.

“Now we are in financial trouble,” he said. “So Steve, I want you to become a person behind universal health care.”

He spoke about how his grandfather Robert Willey had first been a Greensboro state representative and later a state senator.

“He had a passion for education,” he said. “Steve, I would like you to work on health care.”

George Pratt of Bradford Oil said he also would like to see NFIB officials back a universal health care system.

“I don’t understand why they are not,” Pratt said.

Hurst bemoaned the fact that having health insurance coverage is dependent on being employed.

“It favors the wealthy,” he said. “Health care should be like education. It should not be just for full-time [employees].”

Mary Grant, executive director of Rural Community Transportation Inc., agreed.

Grant said she believes everyone should have access to health care. And she believes there should be a universal health care system. She said her son cannot afford to buy health insurance for himself and his family because it would cost about $1,200 a month.

“Our state has to look at the true costs,” Grant said. “Vermont is small enough. We are always doing new stuff. Why not?”

Jim Harrison, president of the Vermont Grocers’ Association, said it is very important for business owners to get involved as well as to learn about the issues. He said there are a lot of business owners interested in the universal health care issue because they cannot afford 20 percent increases in their health insurance costs each year.

He also said individuals are interested as well because they cannot afford co-pays and deductibles.

“We encourage you to get engaged,” Harrison said. “It’s a huge, huge issue.”

Shawn Banfield, state director of NFIB, said the health care issue has been “percolating” since the beginning of the current Legislative session.

Banfield believes there is a lot of momentum behind establishing a single-payer system.

“The business community for the most part has not taken the bull by the horns,” she said. “There’s a lot of dollars at stake.”

Should reducing the uninsured rate by half be our goal?

The Commonwealth Fund
March 8, 2005
News Release
New Health Care Opinion Leaders Survey: Uninsured Rate Could Be Reduced
by Half in Ten Years

The proportion of Americans without health insurance can and should be reduced to 8 percent in ten years, less than half the current rate, according to the Commonwealth Fund Health Care Opinion Leaders survey, an online survey of widely-recognized experts in health care practice and policy.

Three-quarters (75%) of respondents say that employer-sponsored insurance should not be permitted to decline. There was also wide support from respondents for a range of policy efforts to improve coverage. About four-fifths (82%) favor incentives for employers to provide insurance that meets minimum standards, and tax credits or other subsidies for low-wage workers (79%). Other popular policy options included requiring employers who do not provide health benefits to pay into a fund to insure workers and their families (70%), allowing employers to buy into Medicaid or CHIP for their employees (60%), and employer mandates to help finance benefits (52%).

Respondents expressed lower rates of support for replacing employer coverage with a single-payer plan, with about two-fifths supporting (42%) or opposing (40%) this policy.

In contrast, three-fifths (62%) of respondents oppose making HSAs the centerpiece of efforts to cut health care costs (combined with making high- deductible plan coverage more widely available).

http://www.cmwf.org/usr_doc/HCOL_survey2_release.pdf

The survey questions and results:
http://www.cmwf.org/usr_doc/HCOL_survey2_topline.pdf

Comment: The good news about this survey is that health care opinion leaders support protecting the coverage that we do have, and they support improving coverage. The bad news is that this survey was designed to support the current path of incrementalism, an approach that has been ineffective in expanding coverage.

As an example, the very first question: “Health care costs, market pressures, and public and private policies are changing insurance coverage in the U.S. For each of the following, please indicate what you would see as both an achievable and a desirable target or goal for policy action for the next ten years: (1) The proportion of under-65 population that has no health insurance (now about 18%).”

The median answer given was a goal of 8% without insurance. Thus the survey begins with a concession on the part of the respondents that 100% coverage is not an achievable goal. Obviously that makes it very easy to reject 100% solutions as lacking political feasibility.

The third question: “About 160 million Americans get health insurance coverage through their employers who spend more than $400 billion on such benefits. Would you favor or oppose each of the following options for such coverage in the future? Please consider each option in isolation.” (Seven options are offered, in randomized order.) One option: “Employer coverage should be replaced with a single-payer plan, with current employer premium contributions redirected to help pay for coverage.”

Results: 42% in favor, 40% opposed, and 17% not sure. But this was not a question about abolishing the current fragmented system of funding care, including employer-sponsored coverage, and replacing it with a single,
publicly-administered program. Instead, this was a question about preference for a universal insurance program in which employers must bear much of the burden of the funding of health care for everyone. It makes the assumption that employer sponsorship would continue to be the mainstay of health care funding, thereby losing the support that much of the business community would have for a single payer system.

The political consequences of rejecting a 100% solution before beginning negotiations are exemplified by the comments of Charles Kahn in an accompanying commentary. He is the president of the Federation of American Hospitals, an advocacy organization for investor-owned hospitals. He is also the “strange bedfellow” of Ron Pollack, the executive director of Families USA. Although of different ideological persuasions, they had joined together to drive consensus on the development of public policy to address the problem of the uninsured.

Kahn’s comments:

“Up to this point, it has been my belief that the best way to proceed on this front is to bring together people with varying ideas about health policy and to work within the current context.”

“I still have great hope for this approach… But after many years of coalition building and consensus development, the number of uninsured Americans continues to grow, dramatically. Rather than risk inactivity and allow this number to escalate, perhaps we should adapt this approach to better reflect current political reality.”

“Republicans, who control the White House and both Houses of Congress, dominate the current political landscape. Therefore, if health policy advocates want to see progress on the uninsured, we have to look to President Bush and the GOP majority to take the lead.”

“Rather than trying to achieve a sufficiently broad consensus, there is a compelling argument to be made that, to begin reducing the number of uninsured Americans, we instead ought to reach for what is already within our grasp.”

“I recognize that tax credits and expanded health savings accounts are not the preferred policy approaches for some members of our ‘strange bedfellows’ coalition. However, these are the approaches most likely to be approved by Congress. Given the rising number of uninsured Americans, we owe it to them, and to ourselves, to work to pass what can be passed, and then allow these approaches sufficient time to work.”

http://www.cmwf.org/publications/publications_show.htm?doc_id=262376

Further comment: When you wake up in the morning and find your bedfellow gone, you suddenly realize that your self-esteem left with him. But all is not lost. There is no better way to recover your self-respect than to pick yourself up, reject the siren song of incrementalism, and move forward with great certitude toward a fully achievable 100% solution in health care.

Fortunately, we can find more inspirational guidance in another commentary by Michael Rodgers, interim president of the Catholic Health Association:

“Most important, those working to amplify the voice of the uninsured and the marginalized are well served to remember that the cause for which they fight is nothing short of a moral imperative.

“We are a fortunate nation with plentiful resources and a community spirit rooted in equality and fairness. Now it is our monumental but unavoidable task to express the need for change, to mobilize the nation behind it, and to once and for all meet our obligation not just to the sick specifically, but to one another generally.”

http://www.cmwf.org/publications/publications_show.htm?doc_id=260394

Frist and Kennedy on health disparities

Health Affairs
March/April 2005
Overcoming Disparities In U.S. Health Care
By William H. Frist

…the best way to eliminate health disparities is through improvements in the care we deliver to each patient, emphasizing patient dignity and empowerment.

Patients must be central to our efforts to improve health care. For instance, a person with a chronic illness such as diabetes must essentially “own” that illness if he or she is to have any hope of effectively managing it. Providers can help with high-quality treatment and the best recommendations, but patients must act on those recommendations. They must stop smoking, eat right, exercise, take their medication, and monitor their blood sugar, based on their own volition and usually outside of the clinical setting. Public policies must encourage patients to embrace personal responsibility.

Policies that promote dignity and personal responsibility will help decrease individuals’ risky behavior. The major causes of death among African Americans, for instance, are heart disease, cancer, stroke, accidents, and diabetes. Most of these are chronic diseases rather than acute illnesses, and all of these causes of death are at least arguably preventable.

Further, the top three can be reduced by decreasing tobacco use alone. We must
promote policies that help people address individual behavior, such as smoking.
Some have voiced concerns that health care is somehow different: that the
therapeutic relationship between doctor and patient should not be subject to
competitive forces. Further, many argue that quality chasms and health disparities cannot be fixed by fostering competition. Certainly, competition does not provide all of the answers. We will need a strong safety net and vigorous attention to vulnerable populations. But all of our immediate health care system problems-rising costs, questionable quality, patient safety, rising numbers of uninsured people, and, yes, health disparities-are interrelated and can be improved by empowering patients and providers.

We simply cannot afford to forgo the lower costs and increased quality and value that the right kind of competition will drive.
http://content.healthaffairs.org/cgi/content/abstract/24/2/445

Health Affairs
March/April 2005
The Role Of The Federal Government In Eliminating Health Disparities
By Edward M. Kennedy

The state of U.S. minority health is an embarrassment to the nation. Minority communities are struggling with rising numbers of uninsured citizens, festering epidemics, and lower health care quality, all of which mean increased rates of diseases and preventable deaths. To end the minority health crisis, Congress and the Bush administration need to step up to the plate by increasing health insurance coverage and investing in cultural competence, workforce diversity, minority data collection and reporting, and overall public health. Greater resources should be given to the HHS Office for Civil Rights and Office of Minority Health, both of which lead the fight to reduce disparities. All of these efforts must be integrated into the larger effort to increase access and improve quality of care, since we face not only a minority problem, but a national problem. In addition, the country must be mindful that health is inextricably tied to educational opportunities for children, job security and living wages for families,
safe and affordable community housing, and pension stability and social security
for seniors. Elimination of disparities in health depends in part on progress in each of these critical areas.

Health insurance for all is still my overarching goal, so that the basic right to health care can become a reality for all citizens.
http://content.healthaffairs.org/cgi/content/abstract/24/2/452

Comment: Perhaps the most appropriate comment comes from an article in this
same issue of Health Affairs: The Role Of Health Insurance Coverage In Reducing Racial/Ethnic Disparities In Health Care, by Marsha Lillie-Blanton and Catherine Hoffman:

“To assess whether insurance expansions could be expected to reduce racial/ethnic disparities in access to care, this paper reviews evidence from studies specifically designed to quantify the contribution of health insurance to racial/ethnic disparities in access. The studies provide evidence that a sizable share of the differences in whether a person has a regular source of care could be reduced if Hispanics and African Americans were insured at levels comparable to those of whites.”

http://content.healthaffairs.org/cgi/content/abstract/24/2/398

Philip Morris helps us frame the debate on reform

Pediatrics
March 2005
Changing Conclusions on Secondhand Smoke in a Sudden Infant Death
Syndrome
Review Funded by the Tobacco Industry
By Elisa K. Tong, MD; Lucinda England, MD; and Stanton A. Glantz, PhD

Prenatal and postnatal exposure to tobacco smoke adversely affects maternal and child health. Secondhand smoke (SHS) has been linked causally with sudden infant death syndrome (SIDS) in major health reports.

In 1997, PM (Philip Morris) commissioned a consultant, Frank Sullivan, to write a review, with coauthor Susan Barlow, of all possible risk factors for SIDS. The first draft concluded that prenatal and postnatal smoking exposures are both independent risk factors for SIDS. After receiving comments and meeting with PM scientific executives, Sullivan changed his original conclusions on smoking and SIDS. The final draft was changed to emphasize the effects of prenatal maternal smoking and to conclude that postnatal SHS effects were “less well established.”

Clinicians, parents, and public health officials are most vulnerable to the changed conclusions of the SIDS review. The national SIDS “Back to Sleep” campaign has been very successful in reducing SIDS rates. However, estimates of SIDS risk from SHS (odds ratios range from 1.4 to 5.1) have considerable overlap with estimates of risk from prone sleep positioning (odds ratios range from 1.7 to 12.9). With the Back to Sleep campaign well underway, efforts to address parental smoking behavior in both the prenatal and postnatal periods should be intensified.

http://pediatrics.aappublications.org/cgi/content/abstract/115/3/e356

Comment: What does the malfeasance of toxicologist consultant Frank Sullivan have to do with national health insurance? My response may be a stretch, but the issues are fundamental.

The opponents of national health insurance have framed the debate as the efficiency of the private marketplace in providing higher quality and greater value versus the inefficiency and poor value wrought by government bureaucracies. But the overwhelming preponderance of health policy literature indicates that this framing of the ideological divide is incorrect. In the financing of health care, the private bureaucracy has been profoundly inefficient, and the failure to provide adequate coverage has negatively impacted quality by leaving in place financial barriers to care.

In contrast, government bureaucracies have been much more effective in ensuring affordable access to care with greater efficiency through streamlined administration.

If the framing of the ideological divide as efficient markets versus inefficient government bureaucracies is incorrect, then how should this ideological divide be framed? One does not need to be an astute observer to recognize that the divide is between those who support freedom in the marketplace as a means to achieve maximum personal wealth versus those who support solidarity through government action to be certain that all of us have our most basic needs met first before we enjoy our hedonistic pursuits in the marketplace. This reframing of the debate over the ideological divide is not merely rhetorical, but it is fundamental because it places the issue of solidarity ahead of money in our society.

And today’s quote? The medical literature has been used in an attempt to preserve profits of the tobacco industry at a cost of loss of lives due to SIDS. What could be more fundamental than that? We have enough solidarity to be outraged by these individuals who would sacrifice infants’ lives for personal greed.

But do we have enough solidarity to act to save the lives of the 18,000 young adults who die prematurely each year due to lack of health insurance? Or is it more important to maximize the wealth of those who have learned the ways of success in the health care marketplace? This is really the way that we need to frame the debate.

Efficient free markets versus oppressive government bureaucracies? Balderdash! Let’s quit debating their ideology and start debating polices that save lives!

The Right to Health Care

Congressman Pete Stark
March 3, 2005
Stark Introduces Constitutional Amendment to Establish Right to Health Care

Today, Rep. Pete Stark (D-CA) announced his introduction of a proposed amendment to the US Constitution to guarantee health care as a right for every American. The amendment, H.J. Res. 30, is cosponsored by Rep. Jesse Jackson, Jr. (D-CA) and 27 other House members.

“The health of every American is vital to their unalienable rights of ‘life, liberty, and the pursuit of happiness,'” said Rep. Pete Stark. “To ensure these rights are fully enjoyed, we must be certain that every American can access quality health care – regardless of their income, race, education or job status. This Constitutional amendment is aimed at achieving this fundamental goal.”

Today, there are 45 million uninsured Americans, including 8 million children. Millions more are underinsured, excluded from certain types of health coverage or being quickly priced out of the health insurance market altogether. Additional disparities in access, treatment, and outcomes exist for people of color.

Facing skyrocketing costs, many employers are cutting benefits or dropping coverage for their employees, chipping away at the very foundation of health care insurance in the United States. Proposed cuts in Medicaid now endanger coverage for the over 50 million Americans that currently rely on the program for medical care.

“We face a health care crisis where equal opportunity and basic fairness in our nation are at stake,” said Rep. Stark. “I’m frustrated, as many Americans are, that the President and Congress continue to ignore the problems we face. A Constitutional guarantee of health care for all will force Congress to take action to ensure that health coverage is there for all Americans.”

H.J. Res. 30 would amend the Constitution to say “all persons shall enjoy the right to health care of equal high quality.” It would require ratification by three-fourths of the States and so-called implementing legislation must be passed by Congress to ensure compliance with the amendment.

“I firmly believe that until we can guarantee that all people have the right to equal, high-quality health care through the Constitution, the interests of the people will continue to play second fiddle to the corporate bottom-line,” said Rep. Stark. “It’s time we put the health care of the people first. Our Constitution should be amended to promote that common interest.”

http://www.house.gov/stark/news/109th/pressreleases/03-02_healthamendment.htm

Comment: We are already spending more than enough to provide high quality health care for everyone. But only the government can mandate that those funds be used to ensure that everyone has the right of access to affordable care.

We have long given lip service to the right to health care. But now it’s finally time to have a serious, definitive national debate on the constitutional right to quality health care for all. Let’s rally around H.J. Res. 30.

Does President Bush support community health centers?

National Association of Community Health Centers and The George Washington University
March 2005
Growing Uninsured, Budget Cutbacks Challenge President’s Initiative to Put a Health Center in Every Poor County
By Michelle Proser, Peter Shin and Dan Hawkins

Given the Bush Administration’s new goal of expanding health centers into every poor county in the country, the National Association of Community Health Centers (NACHC) and the George Washington University identified poor counties that are “unserved” in that they lack at least one health center. A total of 929 counties around the country fit these criteria. These poor, unserved counties represent almost a third of all US counties and more than half of all poor counties.

The number of communities needing a health center far exceeds available resources. For instance, available funding for FY 2002 and 2003 allowed only one out of three qualified applications for new health center sites to be approved for funding. In FY 2004, less than one in ten of qualified applications were approved. Moreover, while inflation-adjusted federal funding between 2002 and 2003 increased by 7%, the number of uninsured patients at federally-funded health centers rose by 11%. Many health centers around the country are reporting significantly higher growth in the proportion of uninsured patients. For every one uninsured, low income patient that a health center treats, there are four others needing their services, not to mention countless others lacking access to regular primary care regardless of insurance status. Compounding the need is rising poverty.

Given these multiple factors, there are not enough health centers for the people and communities who need them. Of course, in order to improve health on the greatest scale, the preservation of insurance is equally important. Expanding both insurance coverage and the health center program are needed to improve access to care,and both approaches are in fact complementary. Health centers provide services that many other providers do not, such as enabling services, making them preferred providers for many patients.

President George W. Bush (January 27, 2005, Cleveland, OH):

“.here are some practical ways for us to deal with the rising costs in health care. One is to make sure that people who can’t afford health care have got health care available to them in a common-sense way. And that’s why I’m such a big backer of expanding community health centers to every poor county in America. We really want people who cannot afford health care- the poor and the indigent – to be able to get good primary care at one of these community health centers, and not in the emergency rooms of the hospitals across the United States of America.”

http://www.nachc.com/research/Files/poorcountiesSTIB9.pdf

Comment: In 2004, over 90% of qualified applications for community health centers were rejected because of lack of available funding. Is it fair to ask the president what he means when he says that he’s “such a big backer of expanding community health centers”?

The voters lead (Vermont)

Rutland Herald
The voters lead
March 3, 2005

Vermont voters sent a clear message on Town Meeting Day that they are ready for the Legislature to take a serious look at the establishment of a system of universal health care coverage.

Twenty-one of 23 towns voting on the measure approved a nonbinding resolution calling for action leading toward universal care. The margins were often overwhelming. In Springfield the vote was 1,318 to 395. In Montpelier it was 1,433 to 792. Only Stockbridge and Bennington rejected the measure.

These results do not represent a scientific sampling of public opinion. Rather they are an expression of an emerging political consensus that the present health care system is caught in a hopeless cycle of higher costs and declining care. Something has to be done.

This consensus is shaped by a new awareness: that it is a mistake to view health care as a business.

The problem of how to think about health care is examined in an insightful article in the latest New Republic magazine. Arnold S.Relman, a professor emeritus of medicine at Harvard, examines the ways that market economics make the health care system worse, rather than better and shows that new proposals applying market principles to health care are doomed to failure.

Relman cites an earlier analysis of the health care system to show several ways that the ordinary rules of market economics do not apply to health care. First, the demand for health care is seldom a matter of consumer choice; it is driven by illness or injury. Second, the supply of services comes not in response to buyers, the way the supply of automobiles does. It comes from the judgments of physicians about the needs of patients. Doctors differ from car salesmen in that they are supposed to put the interest of the customer above the need for profit.
Third, the supply of health care providers is limited by the costly process of entering the field. Fourth, prices are usually insensitive to market forces. Fifth, there is a virtual absence of price competition.

During the past decade there have been efforts to subject the health care system to market forces, but they have only made things worse. For one thing, competitive pressures put doctors in a contradictory position. They are supposed to be looking out for the patient, not trying to cut a good deal for themselves. Hospitals are supposed to be serving populations, not trying to market ever more expensive services. Insurance companies that are free to shun some patients create large populations of uninsurable people, usually the ones who need services the most.

Vermonters have seen these things happen. In the past four years the number of uninsured Vermonters has jumped by about 50 percent. A system that provides coverage in helter-skelter fashion to some people but not others puts an insupportable burden on those who do have coverage and worsens the health prospects of those who don’t.

The Vermont Legislature ought to hear the message from Vermont’s voters about universal care and consider the lessons ontained in Relman’s article. Health care is a service, not a product. It is delivered by a system that ought to be supported fairly by the broad base of Vermont’s citizens, who in turn ought to receive dependable, affordable health care. That is the direction the Legislature appears to be heading, and the voters are beginning to show that they approve.

KY Rural Health Asso. President Endorses Single Payer Health Care

So, how many uninsured is too many?
By Greg Bausch, President, Kentucky Rural Health Association
From Rural Health Update, Fall 2004

“Ranks of the Uninsured Grow in 2003,” exclaims the headline.

“Rural Uninsured Continues to Rise,” notes another. And yet a third despairs that a “Report Examines Decline in Employment-based Health Coverage.”

According to these reports, a staggering 45 million Americans, 15.6 percent of our population, lacked health insurance during 2003, representing an increase of 1.5 million of our friends and neighbors since 2002. It is also alarming to note that rural Americans have an uninsured rate about 6 percent higher than our urban counterparts. So I ask you, “How many uninsured is too many?”

This decline is largely due to reductions in employer-sponsored coverage, which fell from 61.3 percent to 60.4 percent from 2002 to 2003. Unfortunately, the rates for employer-sponsored healthcare are 11.5 percent lower for the rural areas of our country as compared to urban areas, making this vulnerable population disproportionately affected.

We can point to countless businesses like lumber mills, agricultural operations, and Mom & Pop stores that offer no health benefits to even their fulltime employees. Why even at Wal-Mart, the largest employer in the country, only around 50 percent of employees have company-sponsored health insurance. So please tell me, how many people are too many without employer-sponsored health care coverage?

At my institution, we have seen our bad debt rate soar in the past couple of years, as have many other providers And while much of this problem is due to the growing number of uninsured, a whopping 40 percent of this increase at our system was from folks who have health insurance but were unable to pay the new higher co-pays and deductibles of their health plans.

That illustrates for me a significant rise in the underinsured and the financial stress that is being placed on our providers in caring for them. So I ask you again, “How many underinsured is too many?”

We cannot allow ourselves to get caught up in a numbers game about these
issues. They are just too important for that. Access to quality health care for all Americans regardless of their location, ethnicity, or ability to pay should be a right, not a privilege for a select few.

Unfortunately, it appears that only a select few will be able to afford these services in the very near future without some drastic change to the health care system.

In my view, only a system of government-sponsored universal health coverage, funded largely with the premiums we’re already paying, can hope to correct the looming crisis. The efficiencies of a single-payer, non-profit system could make the difference.

So, how many is too many? My answer is this: “One is too many.”

Oh, and while we’re at it, since William W. McGuire, chief executive officer for UnitedHealth Group Inc., personally earned $94,177,531 (including exercised stock options) in 2003, we may also want to ask how much is too much?

Greg Bausch, Pharm.D., is president of the Kentucky Rural Health Association, a member organization that educates providers and consumers on rural health issues and advocates actions by private and public leaders to assure equitable access to health care for rural Kentuckians. He also is vice president for regional services at St. Claire Regional Medical Center in Morehead.

(www.kyrha.org)

Why Americans settle for a broken health-care system

Stanford School of Medicine
Stanford Medicine Magazine
Winter 2005

OK, you say you want a revolution Why Americans settle for a broken health-care system
By Michelle Brandt

“The whole thing is broken,” says David Magnus, PhD, director of the Stanford Center for Biomedical Ethics. “The core problem is that we have a completely irrational way of paying for and delivering health care.”

Our national leaders haven’t adequately addressed the issues, and- despite survey after survey showing that Americans believe our health-care system needs reform – the public hasn’t taken them to task for it. Health care hasn’t
reached critical mass as a political issue, experts say, because Americans are worried about the future but not concerned enough with their current situation to clamor for change.

Yet many continue to push for reform, including medical student (Graham) Walker, who is hoping to soon begin a documentary on the health-care system.
He’s among those who feel confident that change is coming. Says another believer in change, advocate (Don) McCanne: “I personally suspect it will happen in years, rather than decades.

“We want our technology, we want great advances in health care. When we see
only the wealthy can get them, that’s not going to be acceptable.” Sociology professor (Donald) Barr agrees and predicts that increasing numbers of “horror stories” will eventually cause people to vote only for those politicians who address the health-care issue. And that’s exactly what we need to have happen: only when the public puts the pressure on legislators – and becomes entrenched in the fight like Walker and others – will the nation get real reform.

http://mednews.stanford.edu/stanmed/2005winter/healthcare-main.html

Comment: Michelle Brandt is the Media Relations Manager of the Office of Communication and Public Affairs at Stanford University Medical Center. In this article she has captured the essence of our broken system of funding care and the oxymoronic unstable inertia of reform. Although the article is somewhat long, it makes for a great Sunday read.

Idaho State Journal, (lead editorial)

Our View: It’s time to revisit national health care

Idaho, like virtually every other state, can’t figure out how to cope with the black hole of Medicaid. The state’s Medicaid spending has grown 935 percent since 1990 with no end in sight for escalating costs. Lawmakers recently refused to pump an added $15 million into the program for health care of the poor and disabled until reforms are enacted.

 But what reforms? Stop paying health care providers is one option; another is to tell them they cannot accept any new patients. Too drastic, by far. It is not just the poor who are running up bills for health care.

Some 4,500 personal bankruptcies resulted from unpaid medical bills in Idaho last year. And many of those were people who thought they were protected by having health care insurance, only to find that high deductibles and co-pays cost them several thousand dollars out of pocket. “The people out there who are middle class and have health insurance believe that it will keep them from financial ruin if they should get sick,” says Dr. Bill Woodhouse, a physician for Pocatello Family Medicine. “The reality is that ain’t so.”

And when people can’t pay medical bills, they may wind up in the Bannock County indigent office -some 400 to 450 cases a year. That’s a hardship not only for local government, but for individuals, who can find a lien placed on their property to repay the county.

Furthermore, about one in five adults in Idaho does not have health insurance because of its cost. Typically, the young and healthy members of the population drop out. As a result, the rest of us -who are more likely to be sick or laid up-pay ever higher premiums for insurance. Some small employers find they cannot afford insurance for employees, or they skimp on benefits.

Not surprisingly, the federal government is not immune from the problem. Within a decade, the government will be footing the bill for nearly half the nation’s medical costs, its share propelled higher by the hugely expensive Medicare drug legislation enacted in 2003. To win its passage, the Bush administration told wavering lawmakers that the program would cost $400 billion; the latest estimate of costs when the program goes into effect next year is more than $720 billion.
The president has touted health savings accounts, which in theory would work in conjunction with a health insurance policy to help pay off the deductible, co-pay or services above a coverage limit. But that would not help the growing number of people who cannot afford medical insurance.

The administration of President Bill Clinton pushed hard for a national health insurance system a decade go. Vested interests torpedoed that effort, making Hillary Clinton the scapegoat for its demise. But that was then, and this is now.

Here’s what Dr. Woodhouse says in a well-written, thorough Journal story by reporter Elizabeth Ziegler:
“While many claim that we have the best health care system in the world, I know of nobody who believes we have the best way of paying for health care, as evidenced by the high number of the uninsured and medical bankruptcies,” Woodhouse says. “I feel our health care financing system has failed everyone, including the providers. It’s an extractive industry right now. I’ve reluctantly come to believe in the single payer, national health program. I am a pretty conservative person, but this is one thing in which the free market has failed.”

The mounting evidence, in doctor’s offices, in legislative halls, in the bankruptcy courts, and in households shattered by medical debt, is that this doctor knows best.