PNHP

Bartlett & Steele – "Critical Condition"

Bartlett & Steele – "Critical Condition"

How Health Care in America Became Big Business – And Bad Medicine
By Donald L. Barlett & James B. Steele

Politicians love to say that the United States has the best health care system in the world. In truth, it doesn’t come close. Certainly, no one disputes that the nation has many talented, highly trained professionals who work with the latest equipment, who are knowledgeable and capable of delivering first-rate care. But what kind of system shuts out forty-four million Americans? What kind of system excludes people with illnesses beyond their control? What kind of system insures a husband but denies coverage to his wife? What kind of system forces people to choose between risking financial ruin and risking their lives?

Much of the turmoil is a direct result of a national policy to run health care like a business, a misguided notion promoted by Washington over the last two decades that the free market and for-profit health care would restrain costs and bring high-quality care to all. On both counts, the experiment has failed miserably.

As long as Washington remains wedded to the illusion that market-based medicine will cure health care’s woes, tens of billions of dollars a year will continue to vanish in waste, inefficiency, fraud, and in profits to companies that make money by denying care.

It doesn’t have to be this way. America’s health care crisis can be cured, and, unlike almost every other major challenge facing the nation, it can be solved without spending more money. We already invest enough of our national wealth on medical care. The plan should be to treat this crisis as seriously as if it were an epidemic, and to redirect resources where they belong – into taking care of the health needs of every American.

http://www.randomhouse.com/doubleday/catalog/display.pperl?isbn=0-385-50454-3

Comment: This book is yet another excellent resource on the profound deficiencies in the most expensive health care system on earth. But what is unique about this book is the qualifications of the authors. From the Doubleday website:

“Donald L. Barlett and James B. Steele are America’s most widely acclaimed investigative journalism team. They have worked together for three decades, first at the Philadelphia Inquirer, and, since 1997, as editors at large for Time. They are the only journalists in history to have won two Pulitzer Prizes and two National Magazine Awards, as well as dozens of other national awards. They are the coauthors of six books, including America: What Went Wrong?, which spent eight months on the New York Times bestseller list.”

And what solution do they propose? I’ll give you a hint in the form of a very brief quote that comes from their chapter, THE REMEDY:
“Under a single-payer system…”

Bartlett & Steele – “Critical Condition”

How Health Care in America Became Big Business – And Bad Medicine
By Donald L. Barlett & James B. Steele

Politicians love to say that the United States has the best health care system in the world. In truth, it doesn’t come close. Certainly, no one disputes that the nation has many talented, highly trained professionals who work with the latest equipment, who are knowledgeable and capable of delivering first-rate care. But what kind of system shuts out forty-four million Americans? What kind of system excludes people with illnesses beyond their control? What kind of system insures a husband but denies coverage to his wife? What kind of system forces people to choose between risking financial ruin and risking their lives?

Much of the turmoil is a direct result of a national policy to run health care like a business, a misguided notion promoted by Washington over the last two decades that the free market and for-profit health care would restrain costs and bring high-quality care to all. On both counts, the experiment has failed miserably.

As long as Washington remains wedded to the illusion that market-based medicine will cure health care’s woes, tens of billions of dollars a year will continue to vanish in waste, inefficiency, fraud, and in profits to companies that make money by denying care.

It doesn’t have to be this way. America’s health care crisis can be cured, and, unlike almost every other major challenge facing the nation, it can be solved without spending more money. We already invest enough of our national wealth on medical care. The plan should be to treat this crisis as seriously as if it were an epidemic, and to redirect resources where they belong – into taking care of the health needs of every American.

http://www.randomhouse.com/doubleday/catalog/display.pperl?isbn=0-385-50454-3

Comment: This book is yet another excellent resource on the profound deficiencies in the most expensive health care system on earth. But what is unique about this book is the qualifications of the authors. From the Doubleday website:

“Donald L. Barlett and James B. Steele are America’s most widely acclaimed investigative journalism team. They have worked together for three decades, first at the Philadelphia Inquirer, and, since 1997, as editors at large for Time. They are the only journalists in history to have won two Pulitzer Prizes and two National Magazine Awards, as well as dozens of other national awards. They are the coauthors of six books, including America: What Went Wrong?, which spent eight months on the New York Times bestseller list.”

And what solution do they propose? I’ll give you a hint in the form of a very brief quote that comes from their chapter, THE REMEDY:
“Under a single-payer system…”

Is reinsurance the solution?

The New York Times
October 23, 2004
Momentum Builds for U.S. Role in Paying Highest Health Costs
By Milt Freudenheim and Robert Pear

In seeking to rein in the costs of the runaway insurance premiums paid by employers and their workers – nearly $520 billion this year and rising- politicians of both parties and some business groups are pushing an idea known as reinsurance.

Where the politicians differ is in the details – and the cost to the government.

Senator Kerry says his proposal would reduce health insurance premiums by about 10 percent… Senate Republican leader, Bill Frist… envisions a federally chartered but privately run reinsurance organization, analogous to the Freddie Mac and Fannie Mae mortgage companies… The proposal is in such early form
that cost estimates are not available. But it assumes a large role for the insurance industry, which already offers reinsurance policies without government backing.

The United States Chamber of Commerce, which represents many small businesses and has long called for government action on health care costs,
describes reinsurance as “a worthy concept, an excellent use of federal dollars.”

The health insurance industry is also studying the reinsurance proposals along with various government options like tax credits and other subsidies. “People are starting to think about these concepts,” said Karen M. Ignagni, president of America’s Health Insurance Plans, a trade group in Washington.

Comment: As we assess the various proposed solutions for reform, we should
carefully examine precisely which problem or problems the solution is designed to solve. Does the rhetoric being used to support the proposal match the true intent?

Reinsurance is designed to transfer risk from an insurer to another insurer. Its purpose is to strengthen the primary insurer by reducing its risk. So proposals to provide reinsurance are to address the problem of the weakened status of the insurers. But is that a major problem in health care today? Health insurers are the darlings of Wall Street. Many have converted from non-profit to for-profit, and have merged to gain near monopolistic control of many health insurance markets. Their profits are setting records.

The primary function of insurers is to pool risk, protecting those with greater health care needs from financial ruin. Now we want to relieve the insurers of this crucial function as we provide them with even more security for their profits? It’s the patients, not the insurers, who need to benefit from health care reform!

The current rhetoric is that reinsurance would insulate employers against higher costs of employer-sponsored health care coverage. But the most ambitious proposal would provide only a 10% reduction in premiums. Premiums have been increasing at double digit rates for the past few years. A 10% reduction would give us only a one year relief from premium escalation. And it would provide absolutely no relief from true increases in health care costs since the reinsurance would be funded by federal tax increases or premiums paid to the federally chartered reinsurers.

Its no wonder that America’s Health Insurance Plans (AHIP) and the United States Chamber of Commerce (USCOC) are in support of reinsurance. The insurers receive an infusion of tax dollars, and the employers are relieved
of the need to fund a portion of their health benefit programs. Its a win-win for AHIP and USCOC, but, alas, once again, the patient-employee-taxpayers are the losers.

Tommy Douglas A Remarkable Canadian

Tommy Douglas A Remarkable Canadian
Kevin Wong
Winner of the Norm Quan Bursary

When considering the giants of Canadian politics, T.C. Douglas surely stands at the forefront. Tommy Douglas was a remarkable Canadian whose contributions have helped to shape our great nation. Although he is most famous as the founding father of Medicare, the most advanced health-care system in the world, Douglas’ contributions to Saskatchewan and Canada were tremendous. Douglas established democratic socialism as a mainstream in Canadian politics and his CCF government became the first socialist government in North America. A visionary who achieved his dreams, Douglas changed the face of Canadian politics. More importantly, Tommy Douglas was a politician who put the good of the people he represented first and foremost.

Tommy Clement Douglas was born on October 20, 1904 in Falkirk, Scotland. In 1911, Tommy, his mother and his sister moved to Winnipeg to join his father who had moved there the previous year. Shortly after settling in Winnipeg, Tommy was diagnosed with osteomyelitis in his right leg. Tommy’s family was not healthy and subsequently his family could not pay for the best or most immediate treatment. The delay nearly cost Tommy his leg. This experience marked the beginning of Tommy’s quest for universal, public health care. By the time he was 18, Tommy set his sights on a career as a preacher.

In 1924, when Tommy reached 20 years of age, he enrolled at Brandon College in Manitoba. Brandon College, which was founded by the missionary Baptists of Ontario, provided young ministers with the opportunity to receive an educational background. In college, Tommy was active in elocution classes, drama, and debating. His peers accepted Douglas as a natural leader and scholar. During weekends and summer months, Tommy would speak at rural churches. At one such trip Tommy met Irma Dempsey, his future wife. By the time he had left Brandon College, Tommy had earned his Bachelor’s degree in the Faculty of Arts.

In the fall of 1929, Tommy became a minister at Calvary Baptist church in Weyburn, Saskatchewan. The town immediately opened its arms to the young preacher who possessed boundless energy and eloquence. His time in Weyburn allowed Douglas a first hand perspective of the harshness of the Depression in the prairies. Douglas knew that something had to be done for the common man. His experience with the vast unemployment and poverty transformed T.C. Douglas, the clergyman, into a social activist.

By 1932, Douglas helped organize an Independent Labour Party in Weyburn of which he became president. Saskatchewan’s Independent Labour movement was not large in numbers but they began raising awareness for socialist politics. The movement soon evolved into the Farmer Labour Party. The Farmer Labour Party offered hospital care for everyone on an equal basis, including unemployment insurance and universal pension. By July of 1932, the labour parties of the four western provinces formed an alliance under the name Cooperative Commonwealth Federation. The CCF became Canada’s first national socialist party. The Farmer Labour Party now had something it desperately lacked, the backing of a national movement. In 1934, Douglas made his first foray in the Saskatchewan provincial election. Although he lost, this sparked an internal flame which could not be extinguished.

In 1935, Douglas was elected into parliament under the CCF. This was a time of great turmoil for Canadian politics. Nearly all the provincial governments had been tossed out of office as Canadians turned to anyone who promised to lead them out of the troubled times. Along with Douglas, there were only four other members of the CCF caucus. At the tender age of 31, the young Douglas impressed the House of Commons with his fiery, yet relevant, speeches. The CCF, with only five seats, did not have much political clout, but that did not stop Douglas from fighting for legislation to support the western provinces. By the end of the 193 Os, the Depression and World War II had created an opening for popular support towards the CCF and its socialist ideas.

By the end of World War II, Douglas found a new way to support his socialist solution to Canada’s economic problems. Canada had successfully financed a war against a foreign aggression but could not do the same against poverty. “Surely,” said Douglas in a radio broadcast, “if we can produce in such abundance in order to destroy our enemies, we can produce in equal abundance in order to provide food, clothing, and shelter for our children.”

In his two terms in cabinet, Douglas often argued that Ottawa had no effective western farm policy. The CCF, a socialist party, had begun to build momentum at this time. By the early 1940s Douglas began to move away from Federal politics after being frustrated with the slow legislation and lack of progress. By 1942 Tommy Douglas became the leader of the Saskatchewan provincial CCF party although he remained a MP for the Weyburn constituency.

In 1944, the CCF, under Douglas, won the provincial election to become the first socialist government in North America. The CCF election slogan was “Humanity First” and his government’s budget was to have 70% of expenditure to social services. Douglas’s emphasized that his brand of socialism depended on political and economic democracy. Saskatchewan listened. In 1944, the old age pension plan included medical, hospital and dental services. Douglas’ government radically changed the education system and established larger school units and provided the University of Saskatchewan with a medical school. In his first four years in government, Douglas paid off the provincial debt, created a province wide hospitalization plan, paved the roads, and provided electricity and sewage pipes to the common man.

In 1948, when time for a re-election had come, opponents took advantage of the cold war and the widespread fear of communism. This was dirty politics at it’s worst and it swayed the public. Douglas fought back with radio telecasts, a medium which he could reach the public with his oratory skill. In one such telecast Douglas said “Don’t let them deceive you again. If you let them fool you once, shame on them. If you let them fool you twice, shame on you.”Although he defended his government’s outstanding record, it was Douglas’ sincerety and his committment to the people of Saskatchewan which prevailed. Douglas’ first re-election proved to be the most difficult. He would be re-elected for three more terms to serve Saskatchewan as Premier for 17 years. In his latter terms as Premier, Douglas saw the province through prosperous times. Douglas would not see great changes in legislation like his first term until the inception of Medicare.

In 1961, the CCF joined with big labour unions to create the New Democratic Party in which Douglas was elected leader. The NDP platform remained consistent with that of the CCF with minor changes. The forming of a new party provided the CCF with a self-renewal. The NDP attracted new supporters and triggered a new movement of democratic socialism. Douglas’ New Democratic Party was gaining momentum on a national level but there were troubles at home.

The North American Medical Establishment tried to defy Medicare, Douglas’s top priority project, and Saskatchewan became an intense battleground. This turbulent time was marked by the Doctor’s Strike as the physicians of the province protested socialized healthcare. However, the striking doctors were no match for Douglas. When the dust settled with the resolution of the strike, Medicare in Saskatchewan was born. Douglas showed Canada two things: that it was possible to develope and finance a universal Medicare system and that the medical profession could be confronted. Had Douglas not have made these first ground breaking steps, national Medicare would never have happened.

In 1962, Douglas was struck with a devastating blow. Running in the Regina contituency, Douglas, the leader of the NDP party, was defeated. Fortunately, a New Democrat MP in British Columbia resigned his seat in favour of Douglas. Immediately Douglas began his by-election campaign on the west coast. By mid October, he was back in the House of Commons representing the Burnaby- Coquitlam riding. As leader of the NDP, Douglas fought hard for socialist legislature on federal level but never achieved the success he found as Premier of Saskatchewan under the CCF. By 1971, Douglas resigned as Leader of the NDP, although he remained the party’s energy critic which he took on in 1969.

In 1976, Douglas announced that he would not seek re-election and bowed out of Canadian politics. Douglas spent much of his retirement in the national NDP headquarters as an independent missionary for the cause of socialism. Weeks before his death, weakened by cancer, Douglas made one final trip to Parliment Hill. Tommy Douglas passed away on February 24, 1986. At his memorial service, the Liberal leader, John Turner, and the Conservative prime minister, Brian Mulroney, led a standing ovation for this courageous man.

During his 42 years in politics, Tommy Douglas proved himself as an outstanding Canadian leader. He is largely responsible for our central banking, old age pensions, unemployment insurance, and our universal Medicare. When asked why he stayed with NDP when he could have done better with a more powefful party, Douglas simply replied, ” I have watched politicians for the last forty years drop their principles in order to get power only to find that those who paid and controlled the party which they joined prevented them from all the things they really believed in.” To the end of his days Tommy Douglas was true to himself, to what he stood for, and to the people he represented.

Endnotes

1. McLeod, Thomas. & McLeod, Ian. (1987) Tommy Douglas: The Road to Jerusalem Hurtig Publishers. Pg. 42

2. Elsie Swerhone (1980) Tommy Douglas: Keeper Of The Flame National Film Board of Canada

3. Elsie Swerhone (1980) Tommy Douglas: Keeper Of The Flame National Film Board of Canada

Bibliography

1. McLeod, Thomas. & McLeod, Ian. (1987) Tommy Douglas: The Road to Jerusalem Hurtig Publishers.

2. Whelan, Ed. & Whelan, Pemrose. (1990) Touched by Tommy Whelan Publications.

3. Lovick, L.D. (1975) Tommy Douglas Speaks Oolichan Books.

4. Thomas, Lewis H. (1982) The Making of a Socialist: The Recollections of T.C. Douglas The University of Alberta Press.

5. Elsie Swerhone (1980) Tommy Douglas: Keeper Of The Flame National Film Board of Canada

The Health of Nations

The New York Times

The Health of Nations
By Donald L. Barlett and James B. Steele

For years the people in Washington have offered one plan after another that they said would provide health care for all Americans and rein in costs. Each plan has failed. Today more people than ever have inadequate coverage or no insurance at all. And still costs continue to spin out of control.

Notably absent from the rhetoric has been any mention of the existing system’s inherent flaw – the inability of market-based, for-profit medicine to deliver on the political promises.

Two decades ago, when Washington embraced the for-profit model to curb escalating charges, health care spending represented 10.5 percent of gross domestic product. Now it is approaching 16 percent. We spend more per capita on health care than any other developed country. Yet on the important yardsticks, like life expectancy measured in healthy years, we don’t even rank among the top 20 nations. In fact, according to the World Health Organization, we come in an embarrassing 29th, sandwiched between Slovenia and Portugal.

The explanation for this abysmal record is one that politicians decline to discuss. The market functions wonderfully when we want to sell more cereals, cosmetics, cars, computers or any other consumer product. Unfortunately, it doesn’t work in health care, where the goal should hardly be selling more heart bypass operations. Instead, the goal should be to prevent disease and illness. But the money is in the treatment – not prevention – so the market and good health care are at odds. Just how much at odds is seen in the current shortage of flu vaccine, as men and women in their 80’s and 90’s line up for hours at a time, hoping to get the shot they have been told they need, but may not receive because not nearly enough has been manufactured.

The reason for the shortage is this: Preventing a flu epidemic that could kill thousands is not nearly as profitable as making pills for something like erectile dysfunction, a decidedly non-fatal condition. Viagra, for example, brings in more than $1 billion a year for its maker, Pfizer. The profits to be made from selling flu vaccine are measly in comparison. If selling flu vaccine were as lucrative as marketing Viagra, sports broadcasts and the nightly news would be flooded with commercials warning that “winter is almost here; ask your doctor about flu vaccine” – and it would be available to anyone who wanted it. Instead, while many of those at risk of the flu go without the vaccine, primetime programs are sponsored by the makers of Viagra (“Get back to mischief”), Cialis (“Will you be ready?”) and Levitra (“Stay in the game”).

To understand what has gone wrong in health care, one need only look at the booming market for prescription drugs. Once upon a time, drugs were a needs-based product. You received a prescription when you were truly ill. Now many drugs are demand-driven, just like Froot Loops and Lucky Charms. Instead of using the cartoon characters that sell cereals, the drug companies employ celebrities.

One of the earliest was Lauren Hutton, the supermodel whose enthusiastic endorsement of Wyeth’s hormone replacement therapy helped propel prescriptions for all such drugs from 58 million in 1995 to 90 million in 1999. Ms. Hutton made the rounds of the talk shows, telling her “personal” story. She said her doctor warned her that if she didn’t take estrogen, “I was up for colon cancer, eye loss, osteoporosis, shrinkage, lots of things.”

More recently, Merck recruited Dorothy Hamill, the Olympic gold medalist, to pitch Vioxx. “This is my favorite time to skate,” Ms. Hamill said in a commercial. “I guess it’s from all those years of 5 a.m. practices. But it’s also the time when the pain and stiffness of osteoarthritis can be at their worst.”

As has been the case with so many other drugs, estrogen therapy and Vioxx proved to be a triumph of marketing over science. Not only did the hormone replacement drugs fail to provide the promised protection, studies found they increased the risk for developing cancer and heart disease. Vioxx was withdrawn last month after evidence from clinical trials showed that it increased the risk of heart attacks and strokes.

Since 1997, when the Food and Drug Administration loosened restrictions on television commercials for prescription drugs, the marketing departments of pharmaceutical companies have exercised ever-greater influence on which drugs will be brought to market. That’s why we have three drugs to treat erectile dysfunction, a condition that once was called “impotence.” The name change was essential for the products to be sold by the likes of Bob Dole or Mike Ditka, the former Chicago Bears coach.

Aggressive marketing and pricing have made pharmaceutical companies America’s most profitable industry. On the whole, Americans pay higher prices for prescription drugs than anyone else in the world because the United States is the only industrialized nation that does not exert influence over prices.

What’s needed to control the costs and to provide basic health and hospitalization coverage for all Americans is an independent agency that would set national health care policy, collect medical fees, pay claims, reimburse doctors fairly and restrain runaway drug prices – a single-payer system that would eliminate the costly, inefficient bureaucracy generated by thousands of different plans. It’s not such a radical idea; a single-payer system already exists for Medicare.

Such an agency would need to be free of politics and could be modeled on the Federal Reserve System, whose members are appointed to terms that do not coincide with the terms of either the president or the Senate. It could be financed through two taxes, a gross-receipts business tax and a flat tax, similar to Medicare, but on all individual income.

Under a single-payer system, never again would you be asked, when calling to make a medical appointment, “What type of insurance do you have?” Never again would doctors need bloated office staffs to track what is and is not covered under thousands of insurance plans. Never again would you have to worry about being bankrupted by a medical emergency. Never again would American business be saddled with the responsibility for providing health insurance.

A unified, single-payer system could do more than pay the bills. It could gather information to more accurately identify the surgical procedures and drugs that work, and those that don’t. It could funnel research money to where it will do the most good rather than to those areas with the largest and most vocal constituency, thereby treating the victims of various diseases and conditions more equitably.

It could make possible a centralized computer network to reduce the 100,000 deaths each year from adverse drug reactions – a number of fatalities five times greater than those caused by street drugs like cocaine and heroin. Similarly, a nationwide network could track medical errors across the country to increase accountability and to identify hospitals or surgeons who make repeated mistakes. And it could guarantee supplies of needed medications. In short, over time such a system could transform the practice of medicine and give all Americans the first-class health care they deserve – without breaking the bank.

Donald L. Barlett and James B. Steele are editors at large at Time and the authors, most recently, of “Critical Condition: How Health Care in America Became Big Business-And Bad Medicine.”

New report shows nearly half of Americans in medicare at risk of losing coverage

FOR IMMEDIATE RELEASE
OCTOBER 22, 2004
1:16 PM
CONTACT:  Families USA
Geraldine Henrich (202) 628-3030
 
New Report Shows Nearly Half of Americans in Medicare at Risk of Losing Coverage
Millions of Seniors and People with Disabilities will Experience Temporary or Long-Term Reductions in Care Under New Medicare Law

WASHINGTON- A careful analysis of the new Medicare law and the Administration’s proposed regulations shows that approximately half of the program’s beneficiaries are at risk of being worse off than they are today, according to a special report released by Families USA, the voice for health care consumers.

Seniors and people with disabilities may lose drug coverage altogether, lose access to needed drugs, have higher out-of-pocket costs for their medicines, find their retiree coverage scaled back, or enjoy fewer consumer protections. As a result, they will experience temporary or long-term reductions in care that is vital to their health.

Those at risk of being worse off include:

* The 6.4 million so-called “dual eligibles,” those who qualify for both Medicare and Medicaid. America’s poorest seniors and people with disabilities will lose their current drug coverage provided by Medicaid on December 31, 2005.

* The 13 million retirees with drug coverage from their previous employers, who are at risk of losing at least portions of that coverage.

* The 4.7 million seniors currently enrolled in Medicare Managed Care Plans, who will receive fewer protections than they have today.

Families USA is the national organization for health care consumers. It is nonprofit and nonpartisan and advocates for high-quality health care for all Americans. www.familiesusa.org Families USA Foundation

###

Who Uses Emergency Departments?

Poor Health, Not Lack of Primary Care or Medical Insurance Found to Drive Emergency Visits
American College of Emergency Physicians
News Release – October 18, 2004

The first large-scale study of its kind finds the majority of individuals who use emergency departments have a usual source of care, medical insurance and are not poor. The biggest factor driving people to seek emergency care is poor physical and mental health…

In this study, based on a sample of nearly 50,000 adults interviewed between 2000 and 2001, 83 percent of emergency department visits were made by people who reported having a usual source of health care other than an emergency department, 85 percent reported having medical insurance, and 79 percent reported having incomes exceeding the poverty threshold. Individuals without health insurance were no more likely to have had an emergency visit than those with private health insurance, and individuals without a usual source of care were 25 percent less likely to have had an emergency visit than those with a private physician.

“Contrary to popular perception, individuals who do not have a usual source of care are actually less likely to have visited an emergency department than those who have such care,” said the study’s lead author Ellen J. Weber, MD, Professor of Clinical Medicine in the division of emergency medicine at the University of California, San Francisco. “Many insurance programs, and particularly public and private HMOs, require beneficiaries to have a primary care physician, which may be expected to improve overall health and health care, but the continued rise in emergency visits implies that such programs have not had a substantial impact on overall emergency department use.”

“The mistaken belief that emergency departments are overcrowded by a small disenfranchised portion of the U.S. population can lead to misguided policy decisions and a perception by hospital administrators that emergency patients are not as valuable to the institution as patients having elective surgeries,” said Dr. Weber. “But our findings indicate that emergency departments serve as a safety net, not just for the poor and uninsured, but for mainstream Americans, and in particular those with serious and chronic illness.”

http://www.acep.org/1,34130,0.html

Comment: Clearly, the primary role of emergency departments is to serve as a safety net for mainstream Americans. Although much concern is expressed over the use of emergency departments by the disenfranchised poor and uninsured, this study confirms that emergency facilities are not being used as convenience clinics by this group. These people are simply not receiving the care that they need.

When the need for comprehensive reform is so obvious, we should not be distracted by efforts to enact misguided policies based on fundamental misperceptions.

Let’s first provide comprehensive coverage for everyone. Once health care funding is no longer the overriding issue, we can concentrate on policies that would ensure timely access to a usual source of care. Because of work conflicts and transportation issues, that might include enabling access to integrated convenience clinics. Whatever. But, at a current spending level of $1.8 trillion, we don’t need to increase funding; we need to start spending our funds more effectively.

Health care in America/Canada'S way

Thursday, October 14, 2004 (SF Chronicle)
In Critical Condition: Health Care In America/Canada’s Way/What a universal health care system delivers, good and bad
Barry Brown, Chronicle Foreign Service

Toronto — Discovering he had colon cancer came as a shock to John Kioussis, but after 10 days in the hospital, attended by a battery of medical specialists, technicians, nurses and other staff, his bill came to less than $85 in American dollars — and that was only for his phone and cable TV.

Under Canada’s government-funded health insurance system, Kioussis’ care, from the first visit to a family doctor, through visits to two specialists of his choice and his hospital stay, was free, paid for by Ontario’s publicly funded universal health coverage.

“When you’re sick like that and off work, the last thing you want to worry about is how to pay the bill,” said Kioussis, 55. “I had excellent care and one of the top specialists in the country, the same doctor who would treat the prime minister.”

That’s the side of Canadian health care familiar to many Americans — a system that provides free cradle-to-grave treatment to all, regardless of income or employment status.

The fact is, though, that Canada’s system is riddled with problems, many stemming from inadequate funding. As a result, delays of several months are common before seeing a specialist or getting nonemergency surgery.

For his part, Kioussis said the month he waited between seeing his family doctor and his surgery did not seem unreasonable. He admitted, though, that because of a personal connection between his brother and the surgeon, the doctor operated on him just before he left for vacation.

Although delays and other problems have caused support to dip slightly, Canadians still overwhelmingly back their universal health program. They think of their health care system as a mark of their national identity, something that separates them from Americans.

Meanwhile, a recent ABC News poll showed that while Americans value the quality of U.S. health care, 62 percent think the nation should shift to a universal health insurance program like Canada’s.

As a result of the sharply differing approaches Canada and the United States have taken toward financing health care, their medical systems have developed in contrasting ways.

The United States has more hospital beds per person than Canada because most American hospitals are private, while almost all Canadian hospitals are publicly funded. As a result, American hospitals compete for patients, while Canadian hospitals “don’t fund excess capacity,” said Sharon Sholzberg-Gray, chief executive of the Canadian Healthcare Association.

By many measures, Canadians are healthier than Americans, with a longer lifespan and lower infant mortality, even though they spend much less on medical care. Canadians devote about 10 percent of their gross domestic product, the total of a nation’s goods and services, to provide full health coverage for all citizens. American health costs account for about 14 percent of GDP, yet 45 million Americans have no health insurance and many more have limited coverage.

One of the main culprits pushing up the cost of care in the United States is the expense of administering a plethora of complicated health plans. It has been estimated that any large health insurer in a midsize U.S. state spends more on administration than is spent on health administration in all Canada.

Dr. Catherine Kurosu is a gynecologist at two San Diego hospitals. A Canadian, she said the biggest differences between the two systems are that poorer Americans won’t seek medical care until their problems have become serious. In addition, she said, American insurers often play games to avoid paying bills.

In San Diego, a lot of pregnant women — especially illegal immigrants — show up with problems that could have been avoided with prenatal care, she said. The idea that they can’t get this kind of care “still seems foreign to me,” she said.

My patients are always interested in finding out about the health care system when they find out I’m Canadian,” she continued.When it comes to billing, the Canadian system is a simple matter of sending an invoice to the Ministry of Health, which pays on a fee-for-service basis, she explained. In the United States, there are so many insurance companies, each with its own rules covering not only the patient but also the doctor — as Kurosu learned when she had to wait months for an insurance company to approve her.

U.S. health insurers nickel and dime doctors by always sending bills back and questioning everything, she said. “It’s like a game to see how long they can forestall payment.”

Eleven years ago, Colleen Burns started a medical imaging business in Buffalo, N.Y., right across the border from Ontario. She expected 20 percent of her business would come from Canadians willing to pay $300 to $600 in U.S. for quicker access to high-tech diagnostics. Instead, the proportion is only about 8 to 10 percent, she said. Canadians need to feel a sense of urgency and have the money before coming to the United States, “because they can get an MRI for free in Canada,” she said.

The health system is now itself in need of emergency care in order to continue offering the benefits Canadians have come to think of as their birthright, according to many experts. Dr.Albert Schumacher, president of the Canadian Medical Association, warns that shortfalls of cash and medical staff have left the system unsustainable without major reform.

Twenty years ago, Canada’s federal government unified the various health insurance programs run by the provinces.Ottawa offered to pay 50 percent of the programs’ operating budgets, provided the provincial plans accepted five basic principles, including nationwide acceptance of each provincial plan, comprehensive coverage and no out-of-pocket costs (co-payments or deductibles) for insured services.

“But since then, the federal share has dropped to as low as 14 percent,” said Schumacher, a family physician from the border city of Windsor, Ontario.

In the 1990s, Canadian governments at all levels began attacking their budget deficits with single-minded intensity. With health care accounting for about 40 percent of public sector spending, hospitals were closed, physician fees were frozen or cut, nurses were laid off, and spaces for medical students and medical technicians at government-funded universities and colleges were cut back.

Along with a money crunch, Canada “has a terrible shortage of physicians, “particularly specialists and surgeons, a high proportion of whom are over 55 and ready to retire, Schumacher said. Fixing the health care system has become a high priority for Canada’s political leaders.

Last month, Prime Minister Paul Martin made good on his main election promise to inject more cash into provincial health programs and move to shorten waiting lists.

At a national health care summit, Martin told provincial leaders Ottawa would ante up the equivalent of an additional $34 billion in U.S. funds over 10 years to provincial and territorial health programs, as well as an additional $3 billion to ease wait times for hip replacement surgeries, cardiac and cancer treatments. He also agreed to a plan for monitoring waiting lists to determine the best method of reducing them.

As in the United States, the main problems bedeviling Canada are the soaring cost of prescription drugs and an aging population. Canada’s provinces had called on Ottawa to use its hefty budgetary surplus to launch a national drug plan and leave to them the remaining health care costs, including home care and services like psychiatry and chiropractics.But during the summit, provincial leaders abandoned that effort in exchange for more overall funding from Ottawa.

Sholzberg-Gray of the Canadian Healthcare Association said another challenge plaguing the Canadian system is the drain of doctors and nurses lured by higher pay and lower taxes in the United States.

“There is also a circular effect, because some doctors come back so they don’t have to collect bills,” she added. On the issue of waiting lists for nonemergency surgery, Sholzberg-Gray believes the federal government should establish time limits for treatment.

One feature of Canada’s health care system is that if someone wants to bypass the public program and, for example, pay a doctor to perform hip replacement surgery after hours, he cannot. Because of fears that slipping the doctor a little something extra could lead to the breakdown of the equal- access-for-all principle, paying for insured services is illegal.Those who believe that more private care clinics would solve the problem of funding and shortages have taken their case to Canada’s Supreme Court in an effort to open the system.

ODD MAN OUT
The United States is the only developed nation without universal health care. Although health insurance systems worldwide are straining as populations age, safety nets have largely remained in place. Here are brief descriptions of insurance systems of several nations..

France
Health care as percentage of GDP: 9.6
Health expenditure per person: $2,567
Universal care funded through mandatory health insurance provided by
Social Security, with private supplemental coverage filling gaps..
Germany
Health care as percentage of GDP: 10.8
Health expenditure per person: $2,820
All individuals are enrolled in government-approved health insurance plans partly financed by employer and employee contributions, although high-income workers may buy private insurance instead..
Japan
Health care as percentage of GDP: 8
Health expenditure per person: $2,131
A dual system in which workers enroll in insurance programs through their jobs, while all others join Japan’s national health insurance plan..
United Kingdom
Health care as percentage of GDP: 7.6
Health expenditure per person: $1,989
A publicly funded National Health Service provides free care, with the option of private insurance for those wanting treatment outside the state system..
United States
Health care as percentage of GDP: 13.9
Health expenditure per person: $4,887
Federal and state governments pay most of the cost of care for seniors and
the poor, with employer or individually financed insurance available for others. About 45 million people lack coverage.
*2001 figures
Source: World Health Organization, Chronicle research

Five-Part Series
This week The Chronicle is examining in depth the causes, effects and responses to rising health care costs in America.
Monday
Why health care costs are rising fast. Plus the Bush and Kerry health care plans.
Tuesday
Retirees hit hard as health benefits are lost.
Wednesday
Health care tops the labor-management agenda.
Today
How Canada provides health care for all.
Friday
Employees are digging deeper to pay for health insurance.

Health care in America/Canada’S way

Thursday, October 14, 2004 (SF Chronicle)
In Critical Condition: Health Care In America/Canada’s Way/What a universal health care system delivers, good and bad
Barry Brown, Chronicle Foreign Service

Toronto — Discovering he had colon cancer came as a shock to John Kioussis, but after 10 days in the hospital, attended by a battery of medical specialists, technicians, nurses and other staff, his bill came to less than $85 in American dollars — and that was only for his phone and cable TV.

Under Canada’s government-funded health insurance system, Kioussis’ care, from the first visit to a family doctor, through visits to two specialists of his choice and his hospital stay, was free, paid for by Ontario’s publicly funded universal health coverage.

“When you’re sick like that and off work, the last thing you want to worry about is how to pay the bill,” said Kioussis, 55. “I had excellent care and one of the top specialists in the country, the same doctor who would treat the prime minister.”

That’s the side of Canadian health care familiar to many Americans — a system that provides free cradle-to-grave treatment to all, regardless of income or employment status.

The fact is, though, that Canada’s system is riddled with problems, many stemming from inadequate funding. As a result, delays of several months are common before seeing a specialist or getting nonemergency surgery.

For his part, Kioussis said the month he waited between seeing his family doctor and his surgery did not seem unreasonable. He admitted, though, that because of a personal connection between his brother and the surgeon, the doctor operated on him just before he left for vacation.

Although delays and other problems have caused support to dip slightly, Canadians still overwhelmingly back their universal health program. They think of their health care system as a mark of their national identity, something that separates them from Americans.

Meanwhile, a recent ABC News poll showed that while Americans value the quality of U.S. health care, 62 percent think the nation should shift to a universal health insurance program like Canada’s.

As a result of the sharply differing approaches Canada and the United States have taken toward financing health care, their medical systems have developed in contrasting ways.

The United States has more hospital beds per person than Canada because most American hospitals are private, while almost all Canadian hospitals are publicly funded. As a result, American hospitals compete for patients, while Canadian hospitals “don’t fund excess capacity,” said Sharon Sholzberg-Gray, chief executive of the Canadian Healthcare Association.

By many measures, Canadians are healthier than Americans, with a longer lifespan and lower infant mortality, even though they spend much less on medical care. Canadians devote about 10 percent of their gross domestic product, the total of a nation’s goods and services, to provide full health coverage for all citizens. American health costs account for about 14 percent of GDP, yet 45 million Americans have no health insurance and many more have limited coverage.

One of the main culprits pushing up the cost of care in the United States is the expense of administering a plethora of complicated health plans. It has been estimated that any large health insurer in a midsize U.S. state spends more on administration than is spent on health administration in all Canada.

Dr. Catherine Kurosu is a gynecologist at two San Diego hospitals. A Canadian, she said the biggest differences between the two systems are that poorer Americans won’t seek medical care until their problems have become serious. In addition, she said, American insurers often play games to avoid paying bills.

In San Diego, a lot of pregnant women — especially illegal immigrants — show up with problems that could have been avoided with prenatal care, she said. The idea that they can’t get this kind of care “still seems foreign to me,” she said.

My patients are always interested in finding out about the health care system when they find out I’m Canadian,” she continued.When it comes to billing, the Canadian system is a simple matter of sending an invoice to the Ministry of Health, which pays on a fee-for-service basis, she explained. In the United States, there are so many insurance companies, each with its own rules covering not only the patient but also the doctor — as Kurosu learned when she had to wait months for an insurance company to approve her.

U.S. health insurers nickel and dime doctors by always sending bills back and questioning everything, she said. “It’s like a game to see how long they can forestall payment.”

Eleven years ago, Colleen Burns started a medical imaging business in Buffalo, N.Y., right across the border from Ontario. She expected 20 percent of her business would come from Canadians willing to pay $300 to $600 in U.S. for quicker access to high-tech diagnostics. Instead, the proportion is only about 8 to 10 percent, she said. Canadians need to feel a sense of urgency and have the money before coming to the United States, “because they can get an MRI for free in Canada,” she said.

The health system is now itself in need of emergency care in order to continue offering the benefits Canadians have come to think of as their birthright, according to many experts. Dr.Albert Schumacher, president of the Canadian Medical Association, warns that shortfalls of cash and medical staff have left the system unsustainable without major reform.

Twenty years ago, Canada’s federal government unified the various health insurance programs run by the provinces.Ottawa offered to pay 50 percent of the programs’ operating budgets, provided the provincial plans accepted five basic principles, including nationwide acceptance of each provincial plan, comprehensive coverage and no out-of-pocket costs (co-payments or deductibles) for insured services.

“But since then, the federal share has dropped to as low as 14 percent,” said Schumacher, a family physician from the border city of Windsor, Ontario.

In the 1990s, Canadian governments at all levels began attacking their budget deficits with single-minded intensity. With health care accounting for about 40 percent of public sector spending, hospitals were closed, physician fees were frozen or cut, nurses were laid off, and spaces for medical students and medical technicians at government-funded universities and colleges were cut back.

Along with a money crunch, Canada “has a terrible shortage of physicians, “particularly specialists and surgeons, a high proportion of whom are over 55 and ready to retire, Schumacher said. Fixing the health care system has become a high priority for Canada’s political leaders.

Last month, Prime Minister Paul Martin made good on his main election promise to inject more cash into provincial health programs and move to shorten waiting lists.

At a national health care summit, Martin told provincial leaders Ottawa would ante up the equivalent of an additional $34 billion in U.S. funds over 10 years to provincial and territorial health programs, as well as an additional $3 billion to ease wait times for hip replacement surgeries, cardiac and cancer treatments. He also agreed to a plan for monitoring waiting lists to determine the best method of reducing them.

As in the United States, the main problems bedeviling Canada are the soaring cost of prescription drugs and an aging population. Canada’s provinces had called on Ottawa to use its hefty budgetary surplus to launch a national drug plan and leave to them the remaining health care costs, including home care and services like psychiatry and chiropractics.But during the summit, provincial leaders abandoned that effort in exchange for more overall funding from Ottawa.

Sholzberg-Gray of the Canadian Healthcare Association said another challenge plaguing the Canadian system is the drain of doctors and nurses lured by higher pay and lower taxes in the United States.

“There is also a circular effect, because some doctors come back so they don’t have to collect bills,” she added. On the issue of waiting lists for nonemergency surgery, Sholzberg-Gray believes the federal government should establish time limits for treatment.

One feature of Canada’s health care system is that if someone wants to bypass the public program and, for example, pay a doctor to perform hip replacement surgery after hours, he cannot. Because of fears that slipping the doctor a little something extra could lead to the breakdown of the equal- access-for-all principle, paying for insured services is illegal.Those who believe that more private care clinics would solve the problem of funding and shortages have taken their case to Canada’s Supreme Court in an effort to open the system.

ODD MAN OUT
The United States is the only developed nation without universal health care. Although health insurance systems worldwide are straining as populations age, safety nets have largely remained in place. Here are brief descriptions of insurance systems of several nations..

France
Health care as percentage of GDP: 9.6
Health expenditure per person: $2,567
Universal care funded through mandatory health insurance provided by
Social Security, with private supplemental coverage filling gaps..
Germany
Health care as percentage of GDP: 10.8
Health expenditure per person: $2,820
All individuals are enrolled in government-approved health insurance plans partly financed by employer and employee contributions, although high-income workers may buy private insurance instead..
Japan
Health care as percentage of GDP: 8
Health expenditure per person: $2,131
A dual system in which workers enroll in insurance programs through their jobs, while all others join Japan’s national health insurance plan..
United Kingdom
Health care as percentage of GDP: 7.6
Health expenditure per person: $1,989
A publicly funded National Health Service provides free care, with the option of private insurance for those wanting treatment outside the state system..
United States
Health care as percentage of GDP: 13.9
Health expenditure per person: $4,887
Federal and state governments pay most of the cost of care for seniors and
the poor, with employer or individually financed insurance available for others. About 45 million people lack coverage.
*2001 figures
Source: World Health Organization, Chronicle research

Five-Part Series
This week The Chronicle is examining in depth the causes, effects and responses to rising health care costs in America.
Monday
Why health care costs are rising fast. Plus the Bush and Kerry health care plans.
Tuesday
Retirees hit hard as health benefits are lost.
Wednesday
Health care tops the labor-management agenda.
Today
How Canada provides health care for all.
Friday
Employees are digging deeper to pay for health insurance.

AMSA's Casey Kirkhart on Liability Reform

Yesterday’s message on physicians’ ranking of liability reform as their number one issue provoked numerous responses. The predominant theme of the replies was that the dramatic increases in liability insurance premiums cannot be absorbed by fee increases since most fees are now controlled by public and private third party payers. It is clear that the current debate limited to MICRA-type reforms is missing the point. We need dramatic new approaches to the problem of medical injury.

Following is a much more inspiring message from a voice representing the future of health care in America.

Casey KirkHart, DO, Jack Rutledge Fellow of the American Medical Student Association (AMSA):

Thank you for this post and for your insightful comments.

I too have experienced a mix of reactions to the swelling of physician (and medical student) involvement in the political process vis a vis medical liability. As an organizer of future physicians, I relish the idea of students and physicians standing up together in the public eye to call for change to our dire health care system. Health professionals, in particular young doctors and students, must lead the call to reform as AMSA and others have done for decades.

On the other hand, I can’t think of a more fruitless and uninspiring political battle than the one surrounding tort reform. I spent the last few weeks touring medical schools in various swing states discussing the candidates’ health plans. The debate would invariably turn to medical liability, despite potential real ground to be made this November 2nd on health care access and affordability. While an important issue to address, I feel that it is more political “smoke and mirrors” in comparison to the bevy of ailments facing medical practice and the health care system.

In my leadership capacity, I have been asked to speak to and support efforts around tort reform, and when I do, I do so with caution. I suggest to medical students to examine every side of the medical malpractice issue, from the patient, lawyer, physician, and systemic perspectives, before investing oneself in the tort battle. Until we create a more comprehensive solution to malpractice, including those proposed by Kerry and Edwards, I fear little relief from the so-called medical malpractice crisis.

Some physicians’ organizations have made this their #1 legislative issue, but medical students have, quite possibly, the only comprehensive answers. In the last few years, AMSA has passed policy that describes our priorities in medical malpractice and I am proud to say that they are founded first and foremost in patient safety, physician security and excellence, and honoring the clinical relationship.

I invite you to read AMSA’s stance on medical malpractice at http://www.amsa.org/about/ppp/prof.pdf#zoom=120,40,50

We have produced a number of sophisticated educational pieces on medical malpractice and the forces that shape it. Please feel free to share this resource with your colleagues and students. I would appreciate feedback on this useful tool.

http://www.amsa.org/hp/issues.cfm

I hope you found these comments, well, hopeful. I can attest that in the hearts and minds of future physicians, our priorities differ greatly from those of the survey. The future of medicine is in good, strong hands.

In solidarity,
Casey KirkHart, DO
AMSA Jack Rutledge Fellow

Don’s comment: For those interested in this topic, I emphatically recommend the links noted in Casey’s message.

AMSA’s Casey Kirkhart on Liability Reform

Yesterday’s message on physicians’ ranking of liability reform as their number one issue provoked numerous responses. The predominant theme of the replies was that the dramatic increases in liability insurance premiums cannot be absorbed by fee increases since most fees are now controlled by public and private third party payers. It is clear that the current debate limited to MICRA-type reforms is missing the point. We need dramatic new approaches to the problem of medical injury.

Following is a much more inspiring message from a voice representing the future of health care in America.

Casey KirkHart, DO, Jack Rutledge Fellow of the American Medical Student Association (AMSA):

Thank you for this post and for your insightful comments.

I too have experienced a mix of reactions to the swelling of physician (and medical student) involvement in the political process vis a vis medical liability. As an organizer of future physicians, I relish the idea of students and physicians standing up together in the public eye to call for change to our dire health care system. Health professionals, in particular young doctors and students, must lead the call to reform as AMSA and others have done for decades.

On the other hand, I can’t think of a more fruitless and uninspiring political battle than the one surrounding tort reform. I spent the last few weeks touring medical schools in various swing states discussing the candidates’ health plans. The debate would invariably turn to medical liability, despite potential real ground to be made this November 2nd on health care access and affordability. While an important issue to address, I feel that it is more political “smoke and mirrors” in comparison to the bevy of ailments facing medical practice and the health care system.

In my leadership capacity, I have been asked to speak to and support efforts around tort reform, and when I do, I do so with caution. I suggest to medical students to examine every side of the medical malpractice issue, from the patient, lawyer, physician, and systemic perspectives, before investing oneself in the tort battle. Until we create a more comprehensive solution to malpractice, including those proposed by Kerry and Edwards, I fear little relief from the so-called medical malpractice crisis.

Some physicians’ organizations have made this their #1 legislative issue, but medical students have, quite possibly, the only comprehensive answers. In the last few years, AMSA has passed policy that describes our priorities in medical malpractice and I am proud to say that they are founded first and foremost in patient safety, physician security and excellence, and honoring the clinical relationship.

I invite you to read AMSA’s stance on medical malpractice at http://www.amsa.org/about/ppp/prof.pdf#zoom=120,40,50

We have produced a number of sophisticated educational pieces on medical malpractice and the forces that shape it. Please feel free to share this resource with your colleagues and students. I would appreciate feedback on this useful tool.

http://www.amsa.org/hp/issues.cfm

I hope you found these comments, well, hopeful. I can attest that in the hearts and minds of future physicians, our priorities differ greatly from those of the survey. The future of medicine is in good, strong hands.

In solidarity,
Casey KirkHart, DO
AMSA Jack Rutledge Fellow

Don’s comment: For those interested in this topic, I emphatically recommend the links noted in Casey’s message.

#1 Issue for Physicians

Political passions drive doctors to campaign
By Joel B. Finkelstein
American Medical News – Oct. 25, 2004

Issues important to physicians
In a survey of 1,050 physicians…
Ranked as No. 1 issue:

42% – Liability reform
20% – Cost of coverage
18% – Uninsured Americans
10% – Abortion
04% – Medicare
03% – Patients’ rights
02% – Cost of Rx drugs
01% – Benefits for seniors

Source: Muhlenberg College

http://www.ama-assn.org/amednews/2004/10/25/gvl21025.htm

Comment: My first reaction was the profound sense of sorrow felt on my realization that physicians do not place the plight of the uninsured and lack of affordability of health care above all else. The actual impact of liability issues on the health care system is almost negligible when contrasted with the major impact of financial hardship, suffering and even loss of life that insurance and cost issues have. How could physicians ever come to the conclusion that the nuisance of facing lawsuits is a more important issue than the suffering and financial hardship of many of their patients?

But giving this more thought, instead of going into a funk over how physicians could be so callous, I decided that we need to ask ourselves why so many physicians do place this as the number one priority. It is unlikely that individuals who have dedicated their lives to the healing arts are really insensitive to their patients’ needs. It is more likely that physicians are exposed to unrelenting anxiety and stress that has made their lives relatively miserable. Although, objectively, that level of misery cannot compare to the suffering of their patients who cannot afford access to care, it must be foremost in their minds, probably because it is a psychological pain that never seems to go away.

There is a lesson here. We want our health care professionals to be contented as they dedicate themselves to improving the health of their patients. Malcontented professionals will always underperform.

Medical injury is certainly an issue that we must address. But it is very clear that the process must be revolutionized so that the physicians’ motivations will be to assist their patients in attaining access to care in an environment that is as error-free as possible, but also to assist them in obtaining appropriate compensation when the system has failed to prevent harmful errors.

The patient must always be placed first. And the patients’ interests will be served best in an environment that is a rewarding experience for the patients’ health care professionals.