PNHP

J. Kahn on affordability of premiums or of health care?

J. Kahn on affordability of premiums or of health care?

James G. Kahn, MD, MPH, a professor at the Institute for Health Policy Studies at the University of California, San Francisco, responds to the comments on the Kaiser poll on the desire for affordable health care:

Don – you are so right. I would add that the respondents’ focus on affordability means that they are ripe for believing reforms that appear to control costs (premiums, anyway) by (quietly, surreptitiously) restricting benefits and/or excluding the sickest from coverage. – Jim

Comment: Jim’s point is absolutely crucial. Much of the discussion about affordability in health care has centered around the affordability of premiums. That is a very different issue than the affordability of health care.

Employers, individuals and even the government (FEHBP, Medicare + Choice, etc.) have directed attention to keeping premiums affordable. This can be done only by reducing coverage, through a reduction in benefits, an increase in patient cost sharing, or through measures to exclude high risk patients from coverage.

As Jim mentions, the control of premium rates is frequently engineered through quiet, surreptitious manipulations. Defined contribution programs, tiering of services, providing options of streamlined (i.e., bare bones) coverage, and offering low premium, high deductible coverage with some form of health reimbursement arrangement (similar to MSAs) are only a few of the manipulations that are designed to make premiums more affordable. The problem, of course, is that they do nothing to make HEALTH CARE more affordable. They merely shift costs to those with the greatest health care needs.

In our debates over the model of health care reform that should be adopted, we must diligently challenge those that claim affordability when they are referring only to controlling premiums. Those supporting employer mandate or individual mandate models of “universal” coverage will claim that they are controlling costs when, in fact, their current models will only control premiums. These models make health care UNaffordable by shifting costs to individual patients.

A universal, publicly administered program can make global health care costs affordable through mechanisms such as global budgeting, reduction of administrative waste, rate negotiation, and bulk purchasing. And with equitable funding, whether you call it an income-related premium or a tax, health care can be truly affordable for everyone.

Commercial insurers unable to control administrative costs

BlueCross BlueShield Association News Release February 21, 2003 New BCBSA Report Shows Health Insurer Administrative Costs Rising Slower Than Premiums

Health plan administrative costs contribute to rising premium costs, but not as much as you might think. A new report from Milliman USA (Milliman), commissioned by the Blue Cross and Blue Shield Association (BCBSA), shows that administrative costs for America’s health insurers are growing, but at a rate slower than the growth of premiums overall.

Milliman studied national health insurance administrative cost trends from 1998 to 2002 and found that while premiums for commercial business increased by an average of 7.4 percent annually, administrative costs grew at a much slower average rate of 4.6 percent annually. The report shows that in 2001, an average of 85.7 percent of commercial premiums went to pay medical claims with 11.6 percent going to administrative costs and 2.7 percent going to profits. In comparison, an average of 86.5 percent of commercial premiums among Blue Cross and Blue Shield Plans went to medical claims in 2001, with 11 percent going to administrative costs and 2.5 percent going to profits.

“This report clearly demonstrates that the majority of premium dollars are being spent on healthcare services – as they should be,” said Scott P. Serota, BCBSA president and CEO.

“To keep healthcare affordable, we must know more than just how much we are spending. We need to know how well we are investing our healthcare dollars,” Serota said. “This research, like BCBSA’s previous research on healthcare cost-drivers, helps all of us – insurers, hospitals, physicians, employers, drug companies, consumers and government – find ways to eliminate unnecessary costs and improve quality. That’s the only way we as a nation are going to be able to keep healthcare affordable.”

For the press release: http://bcbshealthissues.com/relatives/20445.pdf?PROACTIVE_ID=cecfcbcec8c9c7c

Comment: BCBSA attempts to put a positive spin on these numbers by showing that medical claims grew more than administrative costs, but by the deceptive method of expressing them as a lower percentage increase compared to the higher percentage increase in actual health care costs. At a time when the health plans are under scrutiny for perpetuating excessive administrative waste, they wish to show that they are controlling administrative costs. But they aren’t. Administrative costs grew at a rate of 4.6% annually, in excess of the rate of inflation. In fact, the very nature of the middleman business model of health plans makes it impossible for them to ever control these administrative costs.

The 14.3% of commercial premium dollars that is being burned up in administrative costs and profits is only a small part of the problem. The administrative burden of our fragmented system of multiple private plans, public programs and no programs at all further increases the diversion of funds from patient care to wasted public and especially private administrative excesses. And this does not include the impact of the flawed system of allocating our resources, a system in which some entities and regions receive 30% more funds without any improvement in health care outcomes.

A single, integrated system of funding health care would dramatically reduce these administrative excesses, and would provide a basis for more rational allocation of our resources. Bruce Bodaken, Chairman, President and CEO of Blue Shield of California, recently called for universal coverage, but his model only expands on the current flawed system, perpetuating inequities and waste.

Instead of turning to Milliman for advice on how the egregious administrative waste can be hidden, we should move ahead with change that will minimize the waste, and utilize those resources more effectively, assuring affordable access to comprehensive care for everyone. Unfortunately but understandably, the BlueCross BlueShield Association apparently does not want to lead that charge.

L.A.'s critical condition

Posted on Wed, Feb. 26, 2003

L.A.’s critical condition
The needs of L.A.’s uninsured are overwhelming emergency rooms. Could this be the future for all of California?
By Barbara Feder Ostrov
Mercury News

It’s a routine day at Los Angeles County’s Harbor-UCLA Medical Center’s emergency room: By 3 p.m., every bed is filled. The waiting room is packed with an additional 60 patients. An elderly man on crutches says dejectedly that he’s been waiting 17 hours to see a doctor.

More than 100,000 patients will appear at Harbor-UCLA’s ER this year. Most won’t have health insurance, or doctors of their own. They turn to Los Angeles emergency rooms like this one for basic care — to such an extent that on any given day, 40 percent of the county’s 81 emergency rooms must divert incoming patients and ambulances to less crowded hospitals.

“We are a pitcher of water that can’t be filled any more,” the ER director, Dr. Robert Hockberger, said. “It’s just overflowing.”

Look hard at emergency rooms like this one. As patients around the state see their health care options shrink, the struggle in Los Angeles hospitals could be the future for health care throughout California.

In Los Angeles, the traditional emergency-room patient — the heart attack victim, the person with a broken arm — increasingly collides with California’s newer emergency: millions of people with no health insurance.

Both groups need help quickly, often from the same place. There aren’t enough doctors or beds in the public health system to care for them all. Here, the gap between the Beverly Hills executive pulled from a fender-bender and the flu-stricken laborer from East L.A. is erased: Neither can be sure of how quickly they will see an emergency-room doctor.

The shock of that convergence, combined with a severe budget deficit in Los Angeles County, has pushed the health care system here to the edge. The financial collapse has already forced the closing of two of the county’s six public hospitals and 16 of its 40 health clinics. A move to shut down two other hospitals — including Harbor-UCLA — galvanized Los Angeles voters in November to approve a rare property tax increase. For now, the two hospitals are saved.

But the breathing room gained by that tax does nothing to address the underlying problem: that about 20 percent of Los Angeles County’s population has no health insurance, compared with just 8 percent in the Bay Area, and that the needs of the uninsured are overwhelming the entire health system.

“Everybody’s all maxed out,” said Kazue Shibata, executive director of the Asian Pacific Health Care Venture clinic in West Los Angeles, where the wait for appointments has doubled and new patients are being turned away. “It’s a very stressful time.”

Is the rest of California headed the way of Los Angeles? Some experts think so, if other parts of the state begin to mirror Los Angeles’ large numbers of poor, uninsured patients.

Rising health care costs, an increasingly sick population, and more people without insurance certainly aren’t unique to Los Angeles. As the numbers of uninsured grow throughout the state, Los Angeles’ plight — however extreme — looks more and more like California’s fate.

“We’re all on the same highway,” said Bob Sillen, who oversees Santa Clara County’s public health system. “It’s merely a question of timing.”

The following dispatches explore the travails of a health care system shaken to the core, and its implications not only for Angelenos, but the rest of us.

`Lurking danger’

Crowded emergency rooms are the most visible symbol of Los Angeles County’s health care crisis — and the one that most concerns everyone, rich and poor alike.

“I think people know there’s a lurking danger that when they clutch their chests, they’re going to have a hard time getting into an ER and a hospital bed,” said Dr. Michael Karpf, who directs UCLA Medical Center and Santa Monica Community Hospitals, both private hospitals.

“This is not just a problem for the poor,” he said. “The health care crisis in California transcends class. It covers everybody.”

The critical factor is “diversion,” when an emergency room gets so crowded it starts turning away patients. Ambulance drivers must often radio hospital after hospital looking for an ER willing to accept a patient, and then sometimes drive long distances to deliver patients to an open bed. The county’s hospitals are on diversion status 40 percent of the time.

Just after 6 p.m. on a Friday night, the emergency room at UCLA-Harbor Medical Center is already chock-full, and so is its waiting room. In the entire hospital, only two beds are open.

By 8:15 p.m., as paramedics deliver a 20-something drunk driver with a four-inch gash on his scalp, only four of the county’s 81 emergency rooms are accepting new ambulance patients. The others are on diversion.

With a click of a mouse, Harbor-UCLA joins them. “It’s time,” said nurse Russ Wright. “We’re just too full.”

Jennifer Davis, who is 30 and lives in Paramount, was one of the ones who made it in. She had come to the ER to attend to a broken arm that fractured again after a fall. At Arby’s restaurant, where Davis and her husband make sandwiches for $7 an hour, only managers are offered health insurance.

Davis waited only three hours this time. Two days earlier, trying to get her arm cared for, she waited seven hours.

“I was irritated,” she said, “but there are a lot of people that are sicker than I was.”

As Davis leaves at 12:45 a.m., Conan O’Brien, on TV, is failing to entertain dozens of sleepy, frustrated patients. An announcement comes over the ER loudspeaker.

“Will patient number 97 please go to Window 5.”

Preventive care

Los Angeles’ public health system cares for 800,000 people a year, equivalent to nearly the entire population of San Jose.

Most are uninsured. Many are poor, sick and unable or unwilling to change their lives in ways that might make them healthier.

In the 1990s, county health officials tried to save money by paying community clinics to provide preventive care to thousands of uninsured or underinsured patients who previously went to county emergency rooms and clinics.

Doctors tried to do the right thing. At free clinics like the one in South Central operated by the University Muslim Medical Association, primary-care physicians identify problems they are not equipped to treat. They send those patients to specialists at the county’s King-Drew Medical Center.

“The treatment we get at the UMMA clinic is fantastic,” said Kathy Windley, a longtime patient there.

But that “fantastic” care is a key part of the reason the public health system is facing a crippling $710 million deficit over the next four years. The patients’ needs are so great that many are referred to hospitals for expensive specialists — treatment the county can’t afford.

That high level of care has kept Windley, 52, alive. She has survived three heart attacks and five cases of congestive heart failure, the last occurring when her best friend was shot on Windley’s porch.

Unable to exercise because of her weakened heart, she suffers from obesity as well as arthritis, pre-diabetes, hypertension, sinus infections and a persistent depression she doesn’t like to talk about.

Her husband, Sam, also battles pre-diabetes, as well as high cholesterol, sleep apnea and a mysterious infection in his large intestine. Neither can work because of their health. They take 14 medications between them.

“As we emphasized more outpatient care, we picked up more disease that required specialty care or hospitalization,” said Dr. Gail Anderson, medical director of the county-run Harbor UCLA Medical Center, which gets many clinic referrals. “That’s the irony here.”

Rush of patients

The strain on the county’s public health clinics shows in the long lines at the Hubert H. Humphrey Comprehensive Health Center in South Central, a forbidding high-rise that is the most advanced and specialized of the county-run health centers.

When mounting costs forced county supervisors to close 11 public clinics last year, the nearby Imperial Heights clinic was among them. Twenty-thousand patients needed a new medical home, and all were sent to Humphrey.

Clinic officials insist that the quality of care has not changed, that it is merely more inconvenient. But the clinic is bursting at the seams, and experts say quality can’t help but suffer when harried doctors can spend only a few minutes with each patient.

In handling such a huge pool of patients, the clinic is one of the county’s guards against making problems worse at emergency rooms — but crowding is forcing cracks in that wall.

Some patients, who can’t or won’t brave the long waits and leave the clinic before being seen, later wind up in emergency rooms when their illnesses worsen. Some people whose regular clinic closed now have no idea where else to go, and also head for the hospital.

Inside the clinic, interim director Joe Keys sifts through a mountain of 5,000 letters telling such patients where they could now find help. All these letters came back — stamped “Return to sender” because of moves or the false addresses many undocumented patients give their doctors.

Clinic staffers have no time to track these patients down. Last year, doctors treated upward of 130 patients a day in the urgent care center, which stays open until midnight. “Now,” Keys said, “we’re hitting that number before noon.”

Outside, slumped in a plastic chair in a bleak concrete courtyard, Tyrone Jose Ayon had the resigned air of a man whose fate it is to wait.

When he arrived at the clinic’s urgent care center on a weekday morning, Ayon was told it would take 10 hours to see a doctor about the silver-dollar-size abscess on his arm.

Four hours later, he had yet to embark on the first stage of his visit: having a nurse take his vital signs.

“I’m not paying for it,” said Ayon, 43, who is studying to become a medical assistant before his welfare payments run out. “So I guess I can’t really complain. I just sit here. I bring my lunch — and my dinner.”

On the day Ayon visited, the urgent care center had 60 patients waiting when it opened at 7:30 a.m. It had processed 98 patients by 11 a.m.

“We’ll be up to 200 by 5 p.m.,” said Dr. Casper Glenn, who directs urgent care. “There’s just such a big rush of patients now. I just don’t know what’s going to happen.”

Temporary fix

Capri Maddox has health insurance and a good job as a paralegal. She has never set foot in any of Los Angeles County’s public clinics; she’s never needed to.

But she did need emergency-room care for a severe asthma attack in 1999. That experience, she says, gave her new respect for the region’s hospitals and hammered home the need to support them, even if it meant something close to unthinkable in Los Angeles — new taxes.

“We all watch the news and you see every day that someone ordinary all of a sudden has something tragic happen to them,” said Maddox, 31. “You know that everyone is pretty vulnerable.”

For Los Angeles residents who are middle class or richer, the county’s public health crisis isn’t generally a major concern despite intense media coverage. County-run clinics and hospitals typically are in neighborhoods they avoid.

But in November an overwhelming proportion of county voters — 73 percent — approved Measure B, a property tax increase to shore up the county’s public hospitals and trauma centers. They were spurred, many believe, by a last-minute barrage of television ads portraying paramedics desperate to find an open emergency room.

The passage of Measure B, showing public support for the health care system, also proved pivotal in the county’s negotiations with state and federal authorities for a recent $250 million bailout that will help ease some of Los Angeles’ problems. The tax — three cents on each square foot of a building (the annual tax on a 2,000-square-foot house would be $60) is expected to raise $168 million a year.

But even with the passage of Measure B and a temporary bailout, Dr. Jane Spiegel, a West Los Angeles internist, worries that her patients won’t be able to get the care they need, when they need it.

At St. John’s Hospital in Santa Monica, where Spiegel is affiliated, “a lot of the time our ER is completely filled and my patients can’t get a bed in the hospital itself.” Recently, one of her patients had to wait 36 hours for emergency abdominal surgery.

“No one cares if you have insurance if the doors are closed,” said Maddox, the paralegal. “It’s not about insurance; it’s about accessibility.”

L.A.’s critical condition

Posted on Wed, Feb. 26, 2003

L.A.’s critical condition
The needs of L.A.’s uninsured are overwhelming emergency rooms. Could this be the future for all of California?
By Barbara Feder Ostrov
Mercury News

It’s a routine day at Los Angeles County’s Harbor-UCLA Medical Center’s emergency room: By 3 p.m., every bed is filled. The waiting room is packed with an additional 60 patients. An elderly man on crutches says dejectedly that he’s been waiting 17 hours to see a doctor.

More than 100,000 patients will appear at Harbor-UCLA’s ER this year. Most won’t have health insurance, or doctors of their own. They turn to Los Angeles emergency rooms like this one for basic care — to such an extent that on any given day, 40 percent of the county’s 81 emergency rooms must divert incoming patients and ambulances to less crowded hospitals.

“We are a pitcher of water that can’t be filled any more,” the ER director, Dr. Robert Hockberger, said. “It’s just overflowing.”

Look hard at emergency rooms like this one. As patients around the state see their health care options shrink, the struggle in Los Angeles hospitals could be the future for health care throughout California.

In Los Angeles, the traditional emergency-room patient — the heart attack victim, the person with a broken arm — increasingly collides with California’s newer emergency: millions of people with no health insurance.

Both groups need help quickly, often from the same place. There aren’t enough doctors or beds in the public health system to care for them all. Here, the gap between the Beverly Hills executive pulled from a fender-bender and the flu-stricken laborer from East L.A. is erased: Neither can be sure of how quickly they will see an emergency-room doctor.

The shock of that convergence, combined with a severe budget deficit in Los Angeles County, has pushed the health care system here to the edge. The financial collapse has already forced the closing of two of the county’s six public hospitals and 16 of its 40 health clinics. A move to shut down two other hospitals — including Harbor-UCLA — galvanized Los Angeles voters in November to approve a rare property tax increase. For now, the two hospitals are saved.

But the breathing room gained by that tax does nothing to address the underlying problem: that about 20 percent of Los Angeles County’s population has no health insurance, compared with just 8 percent in the Bay Area, and that the needs of the uninsured are overwhelming the entire health system.

“Everybody’s all maxed out,” said Kazue Shibata, executive director of the Asian Pacific Health Care Venture clinic in West Los Angeles, where the wait for appointments has doubled and new patients are being turned away. “It’s a very stressful time.”

Is the rest of California headed the way of Los Angeles? Some experts think so, if other parts of the state begin to mirror Los Angeles’ large numbers of poor, uninsured patients.

Rising health care costs, an increasingly sick population, and more people without insurance certainly aren’t unique to Los Angeles. As the numbers of uninsured grow throughout the state, Los Angeles’ plight — however extreme — looks more and more like California’s fate.

“We’re all on the same highway,” said Bob Sillen, who oversees Santa Clara County’s public health system. “It’s merely a question of timing.”

The following dispatches explore the travails of a health care system shaken to the core, and its implications not only for Angelenos, but the rest of us.

`Lurking danger’

Crowded emergency rooms are the most visible symbol of Los Angeles County’s health care crisis — and the one that most concerns everyone, rich and poor alike.

“I think people know there’s a lurking danger that when they clutch their chests, they’re going to have a hard time getting into an ER and a hospital bed,” said Dr. Michael Karpf, who directs UCLA Medical Center and Santa Monica Community Hospitals, both private hospitals.

“This is not just a problem for the poor,” he said. “The health care crisis in California transcends class. It covers everybody.”

The critical factor is “diversion,” when an emergency room gets so crowded it starts turning away patients. Ambulance drivers must often radio hospital after hospital looking for an ER willing to accept a patient, and then sometimes drive long distances to deliver patients to an open bed. The county’s hospitals are on diversion status 40 percent of the time.

Just after 6 p.m. on a Friday night, the emergency room at UCLA-Harbor Medical Center is already chock-full, and so is its waiting room. In the entire hospital, only two beds are open.

By 8:15 p.m., as paramedics deliver a 20-something drunk driver with a four-inch gash on his scalp, only four of the county’s 81 emergency rooms are accepting new ambulance patients. The others are on diversion.

With a click of a mouse, Harbor-UCLA joins them. “It’s time,” said nurse Russ Wright. “We’re just too full.”

Jennifer Davis, who is 30 and lives in Paramount, was one of the ones who made it in. She had come to the ER to attend to a broken arm that fractured again after a fall. At Arby’s restaurant, where Davis and her husband make sandwiches for $7 an hour, only managers are offered health insurance.

Davis waited only three hours this time. Two days earlier, trying to get her arm cared for, she waited seven hours.

“I was irritated,” she said, “but there are a lot of people that are sicker than I was.”

As Davis leaves at 12:45 a.m., Conan O’Brien, on TV, is failing to entertain dozens of sleepy, frustrated patients. An announcement comes over the ER loudspeaker.

“Will patient number 97 please go to Window 5.”

Preventive care

Los Angeles’ public health system cares for 800,000 people a year, equivalent to nearly the entire population of San Jose.

Most are uninsured. Many are poor, sick and unable or unwilling to change their lives in ways that might make them healthier.

In the 1990s, county health officials tried to save money by paying community clinics to provide preventive care to thousands of uninsured or underinsured patients who previously went to county emergency rooms and clinics.

Doctors tried to do the right thing. At free clinics like the one in South Central operated by the University Muslim Medical Association, primary-care physicians identify problems they are not equipped to treat. They send those patients to specialists at the county’s King-Drew Medical Center.

“The treatment we get at the UMMA clinic is fantastic,” said Kathy Windley, a longtime patient there.

But that “fantastic” care is a key part of the reason the public health system is facing a crippling $710 million deficit over the next four years. The patients’ needs are so great that many are referred to hospitals for expensive specialists — treatment the county can’t afford.

That high level of care has kept Windley, 52, alive. She has survived three heart attacks and five cases of congestive heart failure, the last occurring when her best friend was shot on Windley’s porch.

Unable to exercise because of her weakened heart, she suffers from obesity as well as arthritis, pre-diabetes, hypertension, sinus infections and a persistent depression she doesn’t like to talk about.

Her husband, Sam, also battles pre-diabetes, as well as high cholesterol, sleep apnea and a mysterious infection in his large intestine. Neither can work because of their health. They take 14 medications between them.

“As we emphasized more outpatient care, we picked up more disease that required specialty care or hospitalization,” said Dr. Gail Anderson, medical director of the county-run Harbor UCLA Medical Center, which gets many clinic referrals. “That’s the irony here.”

Rush of patients

The strain on the county’s public health clinics shows in the long lines at the Hubert H. Humphrey Comprehensive Health Center in South Central, a forbidding high-rise that is the most advanced and specialized of the county-run health centers.

When mounting costs forced county supervisors to close 11 public clinics last year, the nearby Imperial Heights clinic was among them. Twenty-thousand patients needed a new medical home, and all were sent to Humphrey.

Clinic officials insist that the quality of care has not changed, that it is merely more inconvenient. But the clinic is bursting at the seams, and experts say quality can’t help but suffer when harried doctors can spend only a few minutes with each patient.

In handling such a huge pool of patients, the clinic is one of the county’s guards against making problems worse at emergency rooms — but crowding is forcing cracks in that wall.

Some patients, who can’t or won’t brave the long waits and leave the clinic before being seen, later wind up in emergency rooms when their illnesses worsen. Some people whose regular clinic closed now have no idea where else to go, and also head for the hospital.

Inside the clinic, interim director Joe Keys sifts through a mountain of 5,000 letters telling such patients where they could now find help. All these letters came back — stamped “Return to sender” because of moves or the false addresses many undocumented patients give their doctors.

Clinic staffers have no time to track these patients down. Last year, doctors treated upward of 130 patients a day in the urgent care center, which stays open until midnight. “Now,” Keys said, “we’re hitting that number before noon.”

Outside, slumped in a plastic chair in a bleak concrete courtyard, Tyrone Jose Ayon had the resigned air of a man whose fate it is to wait.

When he arrived at the clinic’s urgent care center on a weekday morning, Ayon was told it would take 10 hours to see a doctor about the silver-dollar-size abscess on his arm.

Four hours later, he had yet to embark on the first stage of his visit: having a nurse take his vital signs.

“I’m not paying for it,” said Ayon, 43, who is studying to become a medical assistant before his welfare payments run out. “So I guess I can’t really complain. I just sit here. I bring my lunch — and my dinner.”

On the day Ayon visited, the urgent care center had 60 patients waiting when it opened at 7:30 a.m. It had processed 98 patients by 11 a.m.

“We’ll be up to 200 by 5 p.m.,” said Dr. Casper Glenn, who directs urgent care. “There’s just such a big rush of patients now. I just don’t know what’s going to happen.”

Temporary fix

Capri Maddox has health insurance and a good job as a paralegal. She has never set foot in any of Los Angeles County’s public clinics; she’s never needed to.

But she did need emergency-room care for a severe asthma attack in 1999. That experience, she says, gave her new respect for the region’s hospitals and hammered home the need to support them, even if it meant something close to unthinkable in Los Angeles — new taxes.

“We all watch the news and you see every day that someone ordinary all of a sudden has something tragic happen to them,” said Maddox, 31. “You know that everyone is pretty vulnerable.”

For Los Angeles residents who are middle class or richer, the county’s public health crisis isn’t generally a major concern despite intense media coverage. County-run clinics and hospitals typically are in neighborhoods they avoid.

But in November an overwhelming proportion of county voters — 73 percent — approved Measure B, a property tax increase to shore up the county’s public hospitals and trauma centers. They were spurred, many believe, by a last-minute barrage of television ads portraying paramedics desperate to find an open emergency room.

The passage of Measure B, showing public support for the health care system, also proved pivotal in the county’s negotiations with state and federal authorities for a recent $250 million bailout that will help ease some of Los Angeles’ problems. The tax — three cents on each square foot of a building (the annual tax on a 2,000-square-foot house would be $60) is expected to raise $168 million a year.

But even with the passage of Measure B and a temporary bailout, Dr. Jane Spiegel, a West Los Angeles internist, worries that her patients won’t be able to get the care they need, when they need it.

At St. John’s Hospital in Santa Monica, where Spiegel is affiliated, “a lot of the time our ER is completely filled and my patients can’t get a bed in the hospital itself.” Recently, one of her patients had to wait 36 hours for emergency abdominal surgery.

“No one cares if you have insurance if the doors are closed,” said Maddox, the paralegal. “It’s not about insurance; it’s about accessibility.”

Personal savings must supplement Medicare

Employee Benefit Research Institute
Issue Brief
February 2003
Retiree Health Benefits: Savings Needed to Fund Health Care in Retirement
by Paul Fronstin and Dallas Salisbury

An individual with access to employment-based health benefits in retirement to supplement Medicare will have needed to save a present value of between $37,000-$750,000 to retire at age 65 in 2003. The range is determined by various assumptions regarding age at time of death, premium levels, annual changes to premiums, and out-of-pocket expenses. An individual without access to employment-based health benefits who instead purchases Medigap coverage will have needed to save between $47,000-$1,458,000, to retire at age 65 in 2003. Estimates also are provided for early retirees. The illustrations presented from the model used in this report may underestimate health care expenses in retirement. Expenses for long-term care are not included in this discussion.

This Issue Brief has illustrated the amounts of money a person may need to save by his or her date of retirement in order to pay for insurance premiums and out-of-pocket costs in retirement. The estimates vary with assumptions on insurance premium levels, growth of insurance premiums over time, estimated age at time of death, rates of return on investments, out-of-pocket expenses, and retirement age. These are important factors in determining savings needs, and, just as important, they are uncertain factors.

http://www.ebri.org/pdfs/0203ib.pdf

Comment: Because there are so many variables, this study shows that the amount of supplemental savings needed to fund health care in retirement can be as high as $5,343,000. Although that amount is improbable for most of us, our potential exposure is nonetheless significant. Medicare pays only about one-half of health care costs. Medigap coverage is overpriced and provides only meager benefits. And now employment-based health benefit programs are diminishing in numbers and in the amount of coverage provided. All of this means that the exposure to financial risk of health care costs in retirement is increasing dramatically and is highly unpredictable for most of us.

Exposure to unpredictable major financial risk is reduced by pooling that risk. That is what insurance is all about. At our level of current spending, $1.66 trillion, we have enough to fund a universal pool that would cover comprehensive services for everyone. Distributing that risk to individuals makes no sense since it exposes those with the greatest health care needs to financial ruin.

Shall we adopt a rational approach and establish a comprehensive, universal health care risk pool, or shall we each set aside an extra $5 million in retirement savings to cover our worst case scenario?

Medicaid's future is bleak

California HealthCare Foundation
Health Currents
February 22, 2003

In Time of Need, Many to Lose Medicaid Coverage
by Robert Rosenblatt

If misery loves company, then Governor Gray Davis has a front-row seat in a packed house. Each of the nation’s 50 governors is singing the blues about fiscal woes. And all of them are trying to balance their books by taking a bite out of Medicaid, the massive health program for the poor.

At least a million people in just 11 states, including California, are going to lose their benefits, according to a recent study by the Center for Budget and Policy Priorities, a liberal Washington research group. That figure could grow by several million more when all of the states have completed cuts needed to balance their budgets.

The conventional view is that recessions come and go and people go on and off the Medicaid rolls. But there is something much more ominous at work here: a combination of factors that could menace the future of Medicaid, which has become the workhorse of the national health care system, delivering services to 47 million low-income people.

It is even bigger than Medicare, which serves 40 million people (35 million over age 65 and 5 million disabled Americans). Rich or poor, they qualify for benefits because of their age or because they have been certified by the Social Security Administration as being disabled. But Medicaid eligibility is strictly determined by income and assets-it is only for those deemed poor enough to meet the rules.

Medicaid is the largest single insurer for children under 18, pays for a third of all births in the United States, and pays for more than 40 percent of the cost of nursing home care. It offers a comprehensive package of benefits: hospital care, doctor services, laboratory tests, and x-rays. States have the option of offering additional services and California provides dental care and eyeglasses under the Medi-Cal program.

Medicaid is a joint effort, with the federal government paying from 50 percent to 77 percent of the total tab, depending on how poor the state is. Last year’s bill was $130 billion from Washington and $94 billion from the states. With prescription drugs leading the way, Medicaid has become the fastest growing social program, with spending up 10.8 percent in 2001, the fastest rate of growth since 1993. At the same time, enrollment rose 8.5 percent, reflecting the fact that more people were drawn into poverty during the recession.

There is no relief in sight because of the worsening fiscal situation for state governments. The federal government can simply print money and run unlimited deficits, but states are mandated by law to balance their budgets.

Last year, total revenues of the 50 states declined for the first time since anyone began keeping accurate records. But this did not just happen because of the plunge in revenue from capital gains taxes on the sale of stock in the aftermath of the dot-com bubble.

On a more basic level, the states’ tax systems, with their heavy dependence on sales tax revenues, are outmoded. They were designed for the manufacturing economy of the 1950s. But the volume of goods on which sales taxes can be levied is growing at a comparatively slow pace. Instead, “Services are growing and we don’t tax them,” Raymond Sheppach, executive director of the National Governors Association, said at a recent briefing on the Medicaid crisis. And then there is the Internet, where growing volumes of commerce escape taxes entirely. Nobody knows for sure about the revenue loss, but Sheppach offers a guess that $10 billion to $20 billion a year in potential revenue is escaping untouched through the Internet.

State pension obligations, meanwhile, are taking up a bigger share of the budget, further squeezing Medicaid, which, even in the best of times, has little support among middle class voters. During the fat years of the stock market boom, state governments didn’t have to send much money to the pension funds because the market was taking care of things. Between 1993 and 2000, pension payments by the 50 states rose from $52 billion to $100 billion. However, state earnings on stock and bond investments, which soared from $74 billion to $232 billion, dwarfed these obligations.

The stream of cash has dried up and may never return. In 2001, investment earnings plunged to $53.6 billion. State receipts, including contributions by workers and governments, along with earnings from stocks and bonds, totaled $118 billion, barely enough to cover the pension payments of $111 billion. The states will be hard pressed to meet their pension obligation to retired public workers and Medicaid will certainly be a prime target.

In the first two years of recent budget cuts, the states began trimming payments to providers, the doctors and hospitals and nursing homes that deal with Medicaid patients. But they can’t do that anymore. If they cut too deeply, there will be no doctors left who accept Medicaid patients.

So California and other states now plan to trim the Medicaid rolls by tightening income eligibility standards and making it harder for people to qualify for benefits. Lots of health care that is now routine will become exceptional.

But there are limits to what the states can do. Women without health insurance will still give birth. The nursing homes will still be filled with hundreds of thousands of Alzheimer’s patients who have exhausted all their savings and now rely on Medicaid to pay the bills. And millions of poor children will still need their immunization shots and their bones mended when they get hurt in schoolyard accidents.

Without help from Washington, and with a budget crunch that will persist for years, the states are likely to keep looking for additional ways to trim Medicaid benefits. It will be painful.

The process is called “going back to the trash can,” according to Velvet Miller, a former deputy commissioner of the New Jersey Department of Human Services. Miller added, “These are ideas that you absolutely threw out [because] they were too harmful-now you have to revisit [them] again and again.”

http://www.chcf.org/healthcurrents/

Comment: The clear message is that underfunding of Medicaid is here to stay. Health care for low-income individuals will be doled out from the “trash can.”

The solution is obvious. Fund health care for low-income individuals at the same level as care is funded for the rest of us. Eliminate the profound inequities inherent in a “poverty program,” inequities that are now also pervading our system of benefit-rich health plans for the wealthy, and deficient, Spartan plans for those with moderate income. Even the generous plans negotiated by unions are being paid for by dramatic reductions in the disposable income component of the paychecks of union members, or even by failure to provide inflationary increases required to fund the most basic needs. A disproportionate share of global health care funding is now being shifted to union members.

Health care spending for 2003 is $5775 per capita (CMS). Pooled together, we are spending $1.66 trillion. By eliminating the roughly $200 billion in excess administrative waste, we would have more than enough funds to pay for truly comprehensive health care services for absolutely everyone. And we could free up another $250 billion by reducing in half the current inappropriate utilization of our resources, a not unrealistic prospect if we had a single, integrated method of funding care. That would provide a nice buffer for new technological advances (worth funding as long as they provide value in health care).

Or shall we, instead, follow our current course and send the poor to the “trash can,” and start sending moderate-income individuals to the “thrift store” of health care?

Medicaid’s future is bleak

California HealthCare Foundation
Health Currents
February 22, 2003

In Time of Need, Many to Lose Medicaid Coverage
by Robert Rosenblatt

If misery loves company, then Governor Gray Davis has a front-row seat in a packed house. Each of the nation’s 50 governors is singing the blues about fiscal woes. And all of them are trying to balance their books by taking a bite out of Medicaid, the massive health program for the poor.

At least a million people in just 11 states, including California, are going to lose their benefits, according to a recent study by the Center for Budget and Policy Priorities, a liberal Washington research group. That figure could grow by several million more when all of the states have completed cuts needed to balance their budgets.

The conventional view is that recessions come and go and people go on and off the Medicaid rolls. But there is something much more ominous at work here: a combination of factors that could menace the future of Medicaid, which has become the workhorse of the national health care system, delivering services to 47 million low-income people.

It is even bigger than Medicare, which serves 40 million people (35 million over age 65 and 5 million disabled Americans). Rich or poor, they qualify for benefits because of their age or because they have been certified by the Social Security Administration as being disabled. But Medicaid eligibility is strictly determined by income and assets-it is only for those deemed poor enough to meet the rules.

Medicaid is the largest single insurer for children under 18, pays for a third of all births in the United States, and pays for more than 40 percent of the cost of nursing home care. It offers a comprehensive package of benefits: hospital care, doctor services, laboratory tests, and x-rays. States have the option of offering additional services and California provides dental care and eyeglasses under the Medi-Cal program.

Medicaid is a joint effort, with the federal government paying from 50 percent to 77 percent of the total tab, depending on how poor the state is. Last year’s bill was $130 billion from Washington and $94 billion from the states. With prescription drugs leading the way, Medicaid has become the fastest growing social program, with spending up 10.8 percent in 2001, the fastest rate of growth since 1993. At the same time, enrollment rose 8.5 percent, reflecting the fact that more people were drawn into poverty during the recession.

There is no relief in sight because of the worsening fiscal situation for state governments. The federal government can simply print money and run unlimited deficits, but states are mandated by law to balance their budgets.

Last year, total revenues of the 50 states declined for the first time since anyone began keeping accurate records. But this did not just happen because of the plunge in revenue from capital gains taxes on the sale of stock in the aftermath of the dot-com bubble.

On a more basic level, the states’ tax systems, with their heavy dependence on sales tax revenues, are outmoded. They were designed for the manufacturing economy of the 1950s. But the volume of goods on which sales taxes can be levied is growing at a comparatively slow pace. Instead, “Services are growing and we don’t tax them,” Raymond Sheppach, executive director of the National Governors Association, said at a recent briefing on the Medicaid crisis. And then there is the Internet, where growing volumes of commerce escape taxes entirely. Nobody knows for sure about the revenue loss, but Sheppach offers a guess that $10 billion to $20 billion a year in potential revenue is escaping untouched through the Internet.

State pension obligations, meanwhile, are taking up a bigger share of the budget, further squeezing Medicaid, which, even in the best of times, has little support among middle class voters. During the fat years of the stock market boom, state governments didn’t have to send much money to the pension funds because the market was taking care of things. Between 1993 and 2000, pension payments by the 50 states rose from $52 billion to $100 billion. However, state earnings on stock and bond investments, which soared from $74 billion to $232 billion, dwarfed these obligations.

The stream of cash has dried up and may never return. In 2001, investment earnings plunged to $53.6 billion. State receipts, including contributions by workers and governments, along with earnings from stocks and bonds, totaled $118 billion, barely enough to cover the pension payments of $111 billion. The states will be hard pressed to meet their pension obligation to retired public workers and Medicaid will certainly be a prime target.

In the first two years of recent budget cuts, the states began trimming payments to providers, the doctors and hospitals and nursing homes that deal with Medicaid patients. But they can’t do that anymore. If they cut too deeply, there will be no doctors left who accept Medicaid patients.

So California and other states now plan to trim the Medicaid rolls by tightening income eligibility standards and making it harder for people to qualify for benefits. Lots of health care that is now routine will become exceptional.

But there are limits to what the states can do. Women without health insurance will still give birth. The nursing homes will still be filled with hundreds of thousands of Alzheimer’s patients who have exhausted all their savings and now rely on Medicaid to pay the bills. And millions of poor children will still need their immunization shots and their bones mended when they get hurt in schoolyard accidents.

Without help from Washington, and with a budget crunch that will persist for years, the states are likely to keep looking for additional ways to trim Medicaid benefits. It will be painful.

The process is called “going back to the trash can,” according to Velvet Miller, a former deputy commissioner of the New Jersey Department of Human Services. Miller added, “These are ideas that you absolutely threw out [because] they were too harmful-now you have to revisit [them] again and again.”

http://www.chcf.org/healthcurrents/

Comment: The clear message is that underfunding of Medicaid is here to stay. Health care for low-income individuals will be doled out from the “trash can.”

The solution is obvious. Fund health care for low-income individuals at the same level as care is funded for the rest of us. Eliminate the profound inequities inherent in a “poverty program,” inequities that are now also pervading our system of benefit-rich health plans for the wealthy, and deficient, Spartan plans for those with moderate income. Even the generous plans negotiated by unions are being paid for by dramatic reductions in the disposable income component of the paychecks of union members, or even by failure to provide inflationary increases required to fund the most basic needs. A disproportionate share of global health care funding is now being shifted to union members.

Health care spending for 2003 is $5775 per capita (CMS). Pooled together, we are spending $1.66 trillion. By eliminating the roughly $200 billion in excess administrative waste, we would have more than enough funds to pay for truly comprehensive health care services for absolutely everyone. And we could free up another $250 billion by reducing in half the current inappropriate utilization of our resources, a not unrealistic prospect if we had a single, integrated method of funding care. That would provide a nice buffer for new technological advances (worth funding as long as they provide value in health care).

Or shall we, instead, follow our current course and send the poor to the “trash can,” and start sending moderate-income individuals to the “thrift store” of health care?

Single payer bill introduced in California

California State Senate
Bill Number: SB 921
February 21, 2003

SB 921, as introduced, Kuehl (Sen. Sheila Kuehl). Single payer health care coverage.

This bill would establish the California Health Care System to be administered by the newly created Health Care Agency under the control of an elected Health Care Commissioner. The bill would make all California residents eligible for specified health care benefits under the California Health Care System, which would, on a single-payer basis, negotiate for or set fees for health care services provided through the system and pay claims for those services.

http://info.sen.ca.gov/pub/bill/sen/sb_0901-0950/sb_921_bill_20030221_introduced.html

Comment: Sen. Kuehl’s bill is based on the findings of the California Health Care Options Project which demonstrated that all residents of Californian could have affordable, comprehensive health care coverage merely by eliminating the administrative excesses of the current system and establishing a single, publicly administered payer for health care services.

Sen. John Burton is also introducing a pay-or-play employer mandate which apparently is receiving the support of AFL-CIO and the California Medical Association.

Another measure (AB 30, Richman) would “reduce state funding for county hospitals and safety net providers” and transfer those funds to the Medicaid and SCHIP programs. Another proposal (AB 293, Daucher) would allow small businesses to provide insurance to employees working a minimum of 40 hours per week, using an hour of overtime to help pay for health care coverage.

Obviously, the debate in California will be between single payer and an employer mandate. Although the leadership of AFL-CIO and CMA may be attracted to the “politically feasible” employer mandate model, union members and physicians need to take a careful look at both proposals. They will see that the single payer program will not only provide greater benefit for all patients in California, but it will also provide greater benefit for union members and physicians. Union members will have greater health and financial security, and physicians will have freedom and the resources to provide the care that their patients need.

Bipartisan or nonpartisan solutions?

sun-herald.com
02/20/03
Dr. Klein invited to speak in Washington

Dr. David Klein, who volunteers to help destitute AIDS patients and migrant workers in his spare time, will also be volunteering to tell the nation’s leaders how to improve the medical system next week.

Klein was invited to speak to congressional leaders Tuesday and Wednesday in Washington, D.C., at the annual meeting of the Physicians Advisory Board.

To be held at the J.W. Marriott Hotel, the meeting features a series of “round table” discussions with such leaders as U.S. Sen. Majority Leader Bill Frist, R-Tenn., a medical doctor, and other Republican members of Congress.

“Somehow, I got invited,” Klein said Wednesday. “I’ve been a pretty good member of the (Republican) party.”

… Klein said he will also emphasize the need to address the plight of America’s uninsured during his remarks.

“There’re 45 million uninsured Americans,” he pointed out, adding that all Americans should have access to at least a minimum level of basic health care.

He said he will advocate that the nation move toward a “single-payer” medical system, in which a government insurance program would replace the current system.

Under the current system, Medicaid, Medicare, private insurance and patients themselves pay for their health care.

“We’re moving toward a single-payer system — and that’s my wish,” he said.

http://www.sun-herald.com/NewsArchive2/022003/tp10ew9.htm?date=022003&story=tp10ew9.htm

Comment: In this day and age, when the term “bipartisan” has come to mean that a token Democrat has joined with the Republican majority, some may say that Dr. Klein is supporting a “bipartisan,” single payer solution to our health care crisis (but with the parties reversed). Maybe it is time to set aside political polarization, and look at our reform options from a unified, nonpartisan perspective.

WTO/Bush prevent poor countries from obtaining generic drugs

by Charlotte Denny in Geneva
Published on Wednesday, February 19, 2003 by the Guardian/UK
 
George Bush’s close links with the drugs industry were last night blamed for the failure of talks in Geneva aimed at securing access to cheap medicines for developing countries.

Delegates at the World Trade Organization expressed frustration after the US again rejected a deal that would have loosened global patent rules to enable poor countries to import cheap copies of desperately needed drugs.

“We believe that governments should maintain their distance and should not be directed by pressure groups,” one EU trade official said.

Negotiators said a solution to the deadlock lay in America’s hands. “The pharmaceuticals lobby is running the show in Washington,” one development activist said.

The WTO’s 144 members agreed more than a year ago that countries could override patent rules in the interests of public health and license local producers to copy essential drugs. But they failed to spell out how countries with no manufacturing capacity would gain access to life-saving medicines.

A draft accord on imports was rejected by the US last December after lobbying from drugs firms, which fear that relaxing the rules to allow poor countries to import copycat drugs will help generics manufacturers in India and Brazil to steal their markets.

America’s counter proposal, limiting imports to drugs for a shortlist of diseases including HIV/Aids, malaria and tuberculosis, was rejected by developing countries as too restrictive.

Eduardo Perez Motta, the Mexican ambassador to the WTO, who chairs the drugs talks, admitted the Organization’s reputation had been damaged by the deadlock.

A Brazilian proposal, to let the World Health Organization decide which countries were allowed to import copycat drugs, was not even discussed yesterday.

Last week a South African plan that would have required countries to declare a national emergency also failed to win over the US drug industry.

© Guardian Newspapers Limited 2003

###

Balanced coverage of reform that isn't

The Hartford Courant
February 12, 2003
Who’s Shaping The Debate On Health Care Reform?
By Theodore Marmor and Kip Sullivan

The 2003 debate about health care reform, unfortunately, is likely to be as muddled as it was a decade ago, when President Clinton promoted universal health insurance under the banner of managed care and the inflation rate in health insurance premiums was also in double digits.

Now, as then, those with interests in rising health expenditures will try to make sure the American public does not understand the real causes of the recent surge in medical inflation. Their loudest argument is that Americans overuse medical care and that such overuse would only worsen if all Americans were insured.

Overuse does exist, the evidence indicates. But so does worrisome underuse. And overuse cannot explain the latest burst in health insurance prices or the sharp rises in what drugstores and doctors charge. There is no credible evidence that Americans received a lot more medical care in the past few years. But the price of health care has skyrocketed nonetheless. That inflation is because of the market power of insurers, drug manufacturers, hospitals and other suppliers of medical services.

Advocates of medical savings accounts and other high-deductible plans talk of overuse because they think they have an answer to it. With a few exceptions, these advocates avoid discussion of underuse. They know they have no solution for underuse and that their practices will almost surely aggravate it. But that does not dissuade them from disseminating the overuse thesis at the meetings of health insurers and the gatherings of groups like the National Association of Manufacturers.

In that context, a sensible discussion of medical inflation, let alone universal health insurance, is very difficult. It is almost impossible when the news media act like an echo chamber, amplifying the voices of the already heard. Well-financed interest groups have lobbyists who are paid and prodded to comment and who show up regularly in debates that journalists try to “balance.” The trouble is that there are 50 industry spokespeople for every underfinanced representative of ordinary citizens. The news all too often then turns out to be what prominent figures in the medical-commercial complex claim.

No wonder that Americans support the reform principles of universal coverage but express fear at most efforts to act on them.

http://www.ctnow.com/news/opinion/op_ed/hc-marmor0212.artfeb12,0,2104280.sto ry?coll=hc%2Dheadlines%2Doped

Comment: Forums on reform today are amazing. As Marmor and Sullivan note, much of the discussion is on shifting to “consumer-directed” health care, based on the theory that the primary problem that needs to be addressed is the waste resulting from patients’ incessant demand for unnecessary health care services.

The irony is that the problem of overutilization is not due to patients’ quests to get more. It is due to practice patterns that fail to acknowledge that sometimes no medical intervention is a preferred course to an intervention that, in reality, is not beneficial or may even potentially be detrimental. Unnecessary hysterectomies, arthroscopies, antibiotic usage, body imaging and similar excesses are selected and controlled by the physician to whom the patient has turned for the best advice on health care decisions. These are problems that call for systemic reform that would improve physician behavior (another topic). Placing financial penalties between the patient and health care (consumer-directed care) results in decreased use of all services, including, especially, beneficial services. The most serious impact of this is in the care of patients with major medical needs. Erecting financial barriers will often prevent those with the greatest need to have precisely the services they require. This is perhaps the worst health care “reform” ever devised, the epitome of non-solutions.

The forums on health care still acknowledge that the numbers of uninsured continue to increase, that health care inflation continues to exceed the general rate of inflation, that the level of disparities are unacceptable, and, ironically, that the rate of under-insurance (consumer-directed!) is dramatically increasing to the point of causing a surge of personal bankruptcies for medical costs of both insured and uninsured patients. But then the forums go on to address the shift from the age of managed care to the age of consumerism. Where is the discussion of real solutions to these real problems?

Well, there is some discussion. But much of it is directed to finding compromises with this “consumerist” element that has gained control of the debate. Thus the discussion has shifted to tax credits, health reimbursement arrangements or MSAs, association health plans, and other reforms which may tweak the number of uninsured, but will leave those with the greatest health care needs highly vulnerable to financial risk. It is mind-boggling that those supporting universal access to comprehensive services are considering compromise as if there were something of substance with which to compromise. There isn’t. Consumer-directed proposals have nothing to offer in the way of solutions to the real problems in health care.

Those covering the health care debate must insist on receiving answers to the questions they should be asking about these real problems in health care. I emphatically recommend reading the article, “Soaring health premiums creating more uninsured,” by Nancy McVicar of the Sun-Sentinel in Florida. She addresses the real problems and discusses realistic solutions. Admittedly, she does discuss our approach, but then, is there any other that is better?

http://www.sun-sentinel.com/features/health/sfl-rxinsure09feb09,0,4782118.st ory?coll=sfla%2Dnews%2Dhealth

New York Times Magazine Slideshow

When Sheila Wessenberg’s breast cancer was diagnosed and she needed a lumpectomy and then a mastectomy, her husband Bob’s insurance covered her care. Then Bob lost his job in December 2001, and they and their two children went from living comfortably on his $102,000-a-year salary to facing bankruptcy. They managed to pay for health insurance out of pocket for six months, until the premiums jumped to $832 a month. After being rejected for Medicaid because they had too many assets, the Wessenbergs joined the ranks of the 41 million uninsured Americans. Sheila, who was forced to quit chemotherapy midtreatment, is tempting the odds.

”We used to have a little left over for nicer things and enough to start saving for a rainy day,” says Bob, a 51-year-old former Lotus programmer who recently found an $11-an-hour job. ”Then we got a rainy month and now we got a rainy year.” Things remain dire, so his wife has turned to panhandling. Read the full story.