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

Journal of the American Geriatrics Society
February, 2003
Differences in Mortality of Black and White Patients Enrolled in the Program of All-Inclusive Care for the Elderly
By Erwin J. Tan, Li-Yung Lui, Catherine Eng, Ashish K. Jha & Kenneth E. Covinsky

Abstract

OBJECTIVES: To examine the relationship between race and mortality in frail community-dwelling older people with access to a program providing comprehensive access and coordination of services.

DESIGN: A longitudinal cohort study.

SETTING: Twelve nationwide demonstration sites of the Program of All-Inclusive Care for the Elderly (PACE) from 1990 to 1996. PACE provides comprehensive medical and long-term care services for nursing home-eligible older people who live in the community.

PARTICIPANTS: Two thousand two white patients and 859 black patients.

MEASUREMENTS: Patients were followed after enrollment until death or the end of the follow-up period. Time from enrollment to death was measured with adjustment of the Cox proportional hazards model for comorbid conditions, functional status, site, and other demographic characteristics.

RESULTS: Black patients were younger than white patients (mean age 77 vs 80, P < .001) but had worse functional status (mean activity of daily living (ADL) score 6.5 vs 7.2, P < .001) on enrollment. Survival for black and white patients was 88% and 86% at 1 year, 67% and 61% at 3 years, and 51% and 42% at 5 years, respectively (unadjusted hazard ratio (HR) for black patients = 0.77; 95% confidence interval (CI) = 0.67-0.89). After adjustment for baseline comorbid conditions, functional status, site, and demographic characteristics, black patients still had a lower mortality rate (HR = 0.77; 95% CI = .65-0.93). The survival advantage for black patients did not emerge until about 1 year after PACE enrollment (HR for first year after enrollment = 0.97; 95% CI = 0.72-1.31; HR after first year = 0.67; 95% CI = 0.54-0.85, P-value for time interaction < .001). During the first year of enrollment, black patients were more likely to improve and less likely to decline in ADL function than white patients (P < .001). CONCLUSION: In PACE, a system providing access to and coordination of comprehensive medical and long-term care services for frail older people, black patients have a lower mortality rate than white patients. This survival advantage, which emerges approximately 1 year after PACE enrollment, may be related to the comprehensive access and coordination of services provided by the PACE program. J Am Geriatr Soc 51:246-251, 2003. http://www.blackwellpublishing.com/abstract.asp?ref=0002-8614&vid=51&iid=2&aid=16&s=

Comment: Impaired access is clearly a major contributor to heath care disparities. The significance of this study is that it demonstrates that providing access to comprehensive services was followed by an elimination of these disparities.

The first step in assuring access is to eliminate financial barriers to care by establishing a universal, comprehensive health insurance program. The PACE program is unique, and undoubtedly many other measures will be required to reduce disparities in other situations. But eliminating disparities is virtually impossible without an equitable system of funding health care.

Uwe Reinhardt, Ph.D. sends us a message in response to news reports on the elimination of retiree health benefits by Bethlehem Steel and by Aetna. Our response follows his.

Click on this link to learn about another American chicken coming home to roost. (Not ever having raised chickens, I don’t actually understand this metaphor, but I hope its use here is appropriate). Bethlehem’s workers should have expected this, as should all other workers with retiree benefits promised them by a corporation. After all, they were presumably adults when these deals with their company were done.

For some reason, millions of American workers in their prime were convinced that their particular company was stronger, smarter and had longer longevity than does the United States government. Where people learn such civics and economics has always been a mystery to me. But that is the “truth” they knew, perhaps because they had been taught it in high school or on TV or by their local Chamber of Commerce.

Did it ever occur to anyone that when the executive of the ABC Corporation in, say, 1975, promised a worker then that “the company” would purchase him or her $10,000 or more worth of health care 30 years hence (when that promising executive might be dead already), that such a promise was highly dubious on its face? How could that executive possibly have known that the ABC Corporation would even exist in 2005? After all, it might have been wiped out in 1995 by a competitor in Shanghai or Singapore or Japan. If not that, it might have been wiped out by a future American genius, such as Jerry Levin of Time Warner, who virtually gave away that company to the shareholders of AOL, a fluffy virtual company whose stock would be called “funny money” if it were not so tragically worthless (not even to speak of the geniuses who ran WorldCom, Enron and so on). If not that, the ABC Corporation might in the future be headed by a ruthless, greedy executive who might look to breaking such earlier promises as a nifty way to shore up the company’s bottom line and, thereby, the value of his gazillion stock options–all to the loud cheers of an adulating financial press?

Where did Americans ever gain the impression that, over the long haul, a string of unknown future ABC Corporation executives of a corporation constantly being buffeted by global competition would be a more reliable source of retirement security than the government of these United States? Who teaches them these fairy tales? Can anyone enlighten me on this one?

In 2001, General Motors acknowledged in its annual report to have completely unfunded liabilities for retiree benefits other than pensions (mainly health care) of $34.5 billion. The company’s net worth (shareholders’ equity) that year was $19.7 billion. It gives you some idea of the financial pressures besetting the company for having taken on this social security system on behalf of GM workers, current and former. Although Rock Wagoner, the current CEO, is widely acclaimed for his operating skill, GM’s stock tanked when earnings were up recently, reportedly over the huge unfunded retiree benefit overhang (health care plus unfunded pension obligations that should, ideally, have been funded). Can’t you see some future GM manager simply throwing in the towel, union be damned? Sitting out a strike over that issue might be worth it to the GM shareholders and the executive’s stock options.

I guess I am supposed to feel sorry for the Bethlehem Steel workers who might lose the promised health benefits, or for other workers who surely will in the years ahead. I don’t. “Should have respected your government more,” is what I would tell them. “Shouldn’t call everyone who proposes to have government do what a private corporation cannot possibly do a ‘socialist.’ Now sit back and enjoy your American dream, my friends. And a dream it was, if only you had thought about it.” That’s where I am on this one.

Best

Uwe R.

Here’s another story on retiree health benefits. Like the previous one, it comes to me courtesy of Naomi Shaiken.

http://www.ctnow.com/business/hc-aetna0208.artfeb08,0,5399206.story?coll=hc%2Dheadlines%2Dbusiness

Similar story–same response by me.

Uwe

Don’s comment: What is your response to Professor Reinhardt’s message? Are you angry with him for slamming the hapless working stiff who is the victim of corporate abuse? Are you angry with the corporate leaders who are depriving their hard-working employees of their promised benefits? Are you angry with the union leaders who failed to assure that trusts that they fought for were fully and permanently funded? Are you angry with the superfluous vested interests that are thriving as they continue to dispense the “government can’t do it” rhetoric? Or are you angry with yourself for your continued inertia when the need is so great?

Regardless, do NOT walk away from this message simply fuming. Do NOT simply leave it to others to take up the task of reforming health care. The average American really does not understand the policy implications of various reform proposals. It will take a massive grassroots effort to educate the public. Each one of us MUST be a part of that effort.

The Coalition for a National Health Program (CNHP) is being launched to conduct education and advocacy on the only truly workable, cost-efficient solution: a publicly funded, publicly-administered national health insurance program for the United States. Participation in the coalition will require “only” that you agree to support health care reform by mobilizing friends, associates, organizations and the community in activities that advance the understanding of this option that is clearly the imperative. The strength of this movement will not be in funds, but in people: you, me, and everyone else that cares about the future of health care in America.

The CNHP website:
http://www.cnhp.us

Bookmark it now, and be prepared to visit it soon to sign on, and to use its resources in your grassroots efforts.

Our concern is health, and everyone agrees that war is unhealthy.

The concepts in the following article make it clear that there are options other than war.

Washington Post
February 9, 2003
Is There a Better Way to Go?
By Jessica Tuchman Mathews

http://www.washingtonpost.com/wp-dyn/articles/A42716-2003Feb7.html

Jessica Tuchman Mathews is president of the Carnegie Endowment for
International Peace:
http://www.ceip.org

All of America must understand that war is not our only option, only our worst one.

Please make this message yours, and share it with others.

GhanaHomePage
Ghana
05 February 2003
Health Insurance scheme to be fully operational

The National Health Insurance Bill would soon be placed before Parliament and become fully operational by the end of the year, Vice President Aliu Mahama, said on Tuesday.

The Vice President, who said this when he launched the Ghana Health Service (GHS), the service delivery arm of the Health Ministry, urged Ghanaians to support the scheme when it is implemented.

He said: “It is better to have an arrangement that enables you to prepare and plan for inevitable but unpredictable day of ill-health by paying for a health insurance policy, rather than the “Cash and Carry” system, which makes you pay when you are ill and at your most vulnerable.

“I am convinced that in the long run, health insurance is a more humane way of paying for health services and I urge you all to support the system when it comes into being later in the year.”

The insurance scheme is being tested in 42 districts by mutual health organisations, owned by the communities. Vice President Mahama stressed the government’s commitment to ensure that Ghanaians stay healthy and work for the growth of the economy…

http://www.ghanaweb.com/GhanaHomePage/NewsArchive/artikel.php?ID=32446

Comment: As the United States moves further toward a consumer-directed health care system “which makes you pay when you are ill and at your most vulnerable,” Ghana is creating National Health Insurance which “enables you to prepare and plan for inevitable but unpredictable day of ill-health.”

American Heritage Dictionary: “civilized” – adjective: … 2. Showing evidence of moral and intellectual advancement; humane, ethical, and reasonable…

Hmmm…

Health Affairs
Web Exclusive
February 7, 2003
Health Spending Projections For 2002-2012
By Stephen Heffler, Sheila Smith, Sean Keehan, M. Kent Clemens, Greg Won, and Mark Zezza (from the Office of the Actuary, Centers for Medicare and Medicaid Services)

Projection for 2003:

National Health Expenditures (NHE) (billions):
$1660.5

NHE, per capita:
$5775

NHE, as percent of GDP:
15.2%

Both the recently released historical health spending estimates and this set of projections have highlighted the enormous pressures mounting on our health care system. Private health insurance premiums are rising at rapid rates, federal and state budget shortfalls exist, a softer labor market has reduced the number of people with private insurance and has increased Medicaid enrollment, and provider costs are continuing to rise. These trends have the unique, although not unparalleled, impact of affecting all of the relevant parties-from payers to providers to employers to consumers-at the same time.

Experience indicates that changes in the mechanisms of payment and delivery of care, as well as consumers’ preferences and public sentiment, will result in a slowdown in growth, temporarily alleviating some of these pressures. However, experience also indicates that society is likely to be willing to allocate more of each dollar of income to health care. We project both of these outcomes over the next decade: national health spending growth slowing from 8.7 percent in 2001 to 6.7 percent in 2012, and the share of GDP accounted for by health care increasing from 14.1 percent in 2001 to 17.7 percent in 2012. The intriguing part of the next decade may be where it leaves us, since the baby-boom generation will begin to become eligible for Medicare at the end of the projection period, and an unparalleled set of pressures on the system is likely to develop.

http://www.healthaffairs.org/WebExclusives/Heffler_Web_Excl_020703.htm