My reply to DuPont is: What about Medicare? Is he willing to criticize Medicare (and commit political suicide) since it is a government program. Of course it does include choice. And is EMTALA un-American? It mandates (a classic unfunded mandate) that all emergency departments treat all comers without regard to ability to pay? As good Americans we already believe that many or most of us DO deserve coverage: the elderly, the emergencies, the poorest of the poor, the pregnant and babies, and as the patches in the quilt get smaller and smaller, the wonderfully inclusive programs covering dialysis and HIV care and the blind and many others. The people whom we discriminate against the most are young taxpayers who don’t have coverage from their work. That doesn’t sound very American to me. I believe universal coverage is true to the American Dream, even the conservative Republican dreams of Pete DuPont.
Rob Stone, M.D., an ER physician from Indiana, responds to Pete du Pont’s rhetoric on single payer reform
My reply to DuPont is: What about Medicare? Is he willing to criticize Medicare (and commit political suicide) since it is a government program. Of course it does include choice. And is EMTALA un-American? It mandates (a classic unfunded mandate) that all emergency departments treat all comers without regard to ability to pay? As good Americans we already believe that many or most of us DO deserve coverage: the elderly, the emergencies, the poorest of the poor, the pregnant and babies, and as the patches in the quilt get smaller and smaller, the wonderfully inclusive programs covering dialysis and HIV care and the blind and many others. The people whom we discriminate against the most are young taxpayers who don’t have coverage from their work. That doesn’t sound very American to me. I believe universal coverage is true to the American Dream, even the conservative Republican dreams of Pete DuPont.
The Unraveling of Health Insurance
Consumer Reports
July, 2002
“New health-insurance policies that increase employees’ responsibility for costs could ultimately result in shrinking coverage for insured people. Instead of bringing people into one gigantic pool where the risk is spread evenly, market-driven policies further fragment the system. Just as the young, in effect, subsidize Social Security for the old, the healthy have traditionally subsidized health-insurance costs for the sick or injured so that no one is clobbered by huge bills. Consumers Union does not support replacing Social Security with self-directed savings accounts, nor does it support undermining health insurance with personal health accounts.”
“With no viable solutions in sight… ”
Comment: Personal health accounts are the insurance industry’s response to medical savings accounts. They will have appeal for the young and healthy who can watch their accounts grow, and they will be a disaster for those with significant medical needs who will rapidly spend down their accounts and be left with inadequate PPO or EPO catastrophic coverage.
Consumers Union recommends budgeting for health care expenses even if you think you have good insurance. Because insurance companies are shifting risk to the beneficiaries, any significant medical problem can leave you financially strapped.
Formerly, health insurance provided security that would allow you to build financial reserves for other needs such as supplementing Social Security at retirement. Now, the insurance industry is using your financial reserves to provide them with security against losses in the event that you would require health care. And for that non-service, we pay them close to a couple hundred billion dollars. Why do the incrementalists insist that we protect this industry, especially at the cost of perpetuating profoundly inhumane health care injustice?
A Question of Access
Medical Economics
May 24, 2002
Memo from the Editor
By Marianne Dekker Mattera
At its Annual Session in Philadelphia last month, the American College of Physicians-American Society of Internal Medicine announced a plan that is supposed to ensure that all Americans have health insurance coverage within seven years.
According to ACP-ASIM incoming president, Sara Walker, the plan is meant to build on the health care system already in place in this country, not replace it with the sort of single-payer systems found elsewhere around the world.
I find it difficult to believe that the ACP-ASIM plan stands much of a chance.
Why? Because the organization hasn’t answered the hard questions. When asked who’s lined up in Congress to sponsor the plan, they had no answer. (In fact, at press time the plan hadn’t even been mentioned on the Hill yet.) When asked how much their plan is likely to cost, they had no answer.
Well, actually that’s not quite true. We were told that they deliberately didn’t do the calculations because they wanted to focus not so much on what insuring everyone would cost, but on what not insuring everyone would cost. Trouble, is, they didn’t have numbers for that either.
Frankly, without numbers no one in Congress is going to back this plan-or any plan. Especially not in an election year.
You can’t leave the really hard work-gathering the financing numbers that will make or break any health care reform measure-to someone else. I know I’m never anxious to champion a new proposal that means I have to do a lot of the legwork before I can take it any further. I can’t imagine even one member of Congress will be thrilled about doing that either.
I’d urge the ACP-ASIM to go back and do some of that legwork. They might also think about how they’re going to twist enough arms to get the measures through Congress once they convince someone to introduce it.
For the full editorial:
Comment: The legwork on financing has been done. Numerous studies, the latest being the landmark California Health Care Options Project, have demonstrated that proposals such as that of ACP-ASIM which build on the current inequitable system will significantly increase costs. For California, that increase is about $3 billion per year. On the other hand, single payer models that would provide comprehensive services for everyone would save Californians about $7 billion per year. Merely multiplying those numbers by a factor of ten would provide a very reasonable estimate of the national financial implications of reform. Reform is not being stalled for the lack of numbers. We have those.
But what about the political legwork? A large minority in Congress personally support national health insurance. But since Americans are not clamoring for comprehensive reform, and many remain sensitive to the Clinton debacle on reform, most politicians are not willing to take a public stance that might risk a negative response from their constituency. The politicians may listen to the PACs, but they will not act on such a sensitive issue until they believe that they have the overwhelming support of the public.
Unfortunately, our citizens are still willing to reject affordable, comprehensive, high quality health care services for everyone, through a program of national health insurance, merely because of their infatuation with anti-government rhetoric. Like many other foolish infatuations, the consequence is a terrible price to pay.
Canadian Medical Association Journal
May 28, 2002
A systematic review and meta-analysis of studies comparing mortality rates of private for-profit and private not-for-profit hospitals
By P.J. Devereaux, et al
Interpretation: Our meta-analysis suggests that private for-profit ownership of hospitals, in comparison with private not-for-profit ownership, results in a higher risk of death for patients.
Why is there an increase in mortality in for-profit institutions? Typically, investors expect a 10%-15% return on their investment. Administrative officers of private for-profit institutions receive rewards for achieving or exceeding the anticipated profit margin. In addition to generating profits, private for-profit institutions must pay taxes and may contend with cost pressures associated with large reimbursement packages for senior administrators that private not-for-profit institutions do not face. As a result, when dealing with populations in which reimbursement is similar (such as Medicare patients), private for-profit institutions face a daunting task. They must achieve the same outcomes as private not-for-profit institutions while devoting fewer resources to patient care.
Considering these issues one might feel concern that the profit motive of private for-profit hospitals may result in limitations of care that adversely affect patient outcomes. Our results suggest that this concern is justified. Studies included in our review that conducted an initial analysis adjusting for disease severity, and another analysis with further adjustment for staffing levels, support this explanation for our results. The private for-profit hospitals employed fewer highly skilled personnel per risk-adjusted bed. The number of highly skilled personnel per hospital bed is strongly associated with hospital mortality rates, and differences in mortality between private for-profit and private not-for-profit institutions predictably decreased when investigators adjusted for staffing levels. Therefore, lower staffing levels of highly skilled personnel are probably one factor responsible for the higher risk-adjusted mortality rates in private for-profit hospitals.
Given the differences in the organization of the Canadian and US health care systems, one might question whether our results can be applied to Canada. The structure of US health care has, however, shifted dramatically over time. With the exception of a single study, the results are remarkably consistent over time, suggesting that the adverse effect of private for-profit hospitals is manifest within a variety of health care contexts. Furthermore, whatever the context within which they function, for-profit care providers face the problem of holding down costs while delivering a profit. One would, therefore, expect the resulting problems in health care delivery to emerge whatever the setting. Finally, should Canada open its doors to private for-profit hospitals, it is the very same large US hospital chains that have generated the data included in this study that will soon be purchasing Canadian private for-profit hospitals. In summary, we think it plausible, indeed likely, that our results are generalizable to the Canadian context.
The Canadian health care system is at a crucial juncture with many individuals suggesting that we would be better served by private for-profit health care delivery. Our systematic review raises concerns about the potential negative health outcomes associated with private for-profit hospital care. Canadian policy-makers, the stakeholders who seek to influence them and the public whose health will be affected by their decisions should take this research evidence into account.
Comment: Since it was “the very same large US hospital chains that have generated the data included in this study,” shouldn’t policy makers in the United States also take this research evidence into account?
Health-Care Funding for All of Us
Los Angeles Times
May 28, 2002
Letters to the Editor
Re “County Health System Faces Dire Options,” May 23:
Most Americans remain reluctant to support tax increases to assure access to health care for the uninsured or to replace their current coverage with a comprehensive program of public insurance.
The lack of funding for the uninsured has resulted in the drafting of plans that, at a minimum, would close the King/Drew trauma center. Even affluent auto accident victims are threatened by a system that causes them to bypass a locked-up trauma center as they are transported to an overcrowded facility through heavily congested city traffic. People will die no matter how much money they have.
The recent California Health and Human Services landmark study of health-care reform demonstrated that we already are spending enough to provide truly comprehensive care for absolutely everyone. But what we lack is a rational system to properly direct those funds.
Our current system of private health plans, government plans and no plans at all is egregiously wasteful of our resources. The study revealed that merely replacing this sick system with a single, more efficient program of universal health insurance would solve most of the problems in funding and access in health care without significantly increasing costs. Why aren’t we taking a serious look at this proposal?
Don McCanne MD
San Juan Capistrano
Deaths Rates are Higher at Investor-Owned Hospitals, According to Analysis of 35 million U.S. Hospitalizations
Contacts:
P.J. Devereaux, MD (905) 525-9140
Steffie Woolhandler, MD (617) 497-1268
Holger Schunemann, MD, PhD (716) 898-5792
Deaths Rates are Higher at Investor-Owned Hospitals, According to Analysis of 35 million U.S. Hospitalizations
Investor-owned hospitals have 2% higher death rates than non-profit hospitals, according to a major study appearing in today�s Canadian Medical Association Journal. The journal article reports the first comprehensive analysis based on all studies that have compared mortality at investor-owned and non-profit hospitals. The study was carried out by researchers from McMaster University who are considered the world�s leading experts on research methodology.
The 17 researchers reviewed 8665 medical articles on hospital care, eventually honing in on the 15 highest quality and most relevant studies � which included 35 million patients – examining the performance of investor-owned facilities. To prevent bias, they blacked out study results before deciding which studies to include. They then contacted the original authors of all the research papers to verify the findings and ascertain additional details. Finally, they combined the 15 studies using advanced statistical techniques to compare death rates at investor-owned and non-profit hospitals,
�Our findings are consistent and unequivocal: death rates are higher in investor-owned hospitals,� commented lead author Dr. P.J. Devereaux . �We think that investor-owned hospitals provide poorer care because stockholders expect a 10-15% profit. This money must be extracted from patient care. This means less skilled personnel, inlcuding nurses and pharmacists. Care suffers, and death rates increase. For Canada, our study is a warning not to allow investor-owned hospitals into our country; switching from our current non-profit hospitals to an investor-owned hospital system would result in over 2,000 additional deaths each year, as many as the number of Canadians who die each from colon cancer.�
According to Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard and a Founder of Physicians for a National Health Program: “Investor-owned hospitals care for about one eighth of all hospital patients in the U.S. The study suggests that converting all U.S. hospitals to investor-ownership would result in 14,312 additional deaths each year. Conversely, converting current investor-owned hospitals to non-profit status would prevent 2047 deaths annually.”
Physicians for a National Health Program is an organization of 10,000 US physicians advocating non-profit national health insurance.
Confronting Health Care 'Demons' Anthony Welters Took an Unlikely Route to Head AmeriChoice, an HMO for the Poor
The Washington Post
May 27, 2002
By Bill Brubaker
Anthony Welters grew up in a one-room tenement in Harlem, sleeping behind a curtain with his three brothers, he says.
Today, he lives in a five-bedroom, seven-bathroom house on five acres in McLean. He has a 75-acre farm in the Blue Ridge Mountains. For a change of pace, there is a 5,000-square-foot house in Aspen, Colo., recently assessed at $3 million.
Welters, 47, made his fortune in health insurance, serving a specialized market.
The market is the poor.
Federal and state audits concluded in the early and mid-1990s that ineffective oversight by Pennsylvania officials had enabled Welters and his partners to make too much money from their taxpayer-supported business.
The audits said the Welters group had paid itself millions of dollars in management fees — paid to other companies they controlled — and millions more in bonuses.
Welters’s health-insurance business expanded to New York in 1994 and New Jersey in 1996. In both states, the HMO was known as Managed Healthcare Systems (MHS).
In New York, state investigators discovered something was not right about two clinics that MHS retained to serve patients in the borough of Brooklyn.
They determined that from 1995 to 1997 the clinics were being staffed largely by “unsupervised physician assistants or nurse practitioners,” New York state Attorney General Eliot Spitzer announced in May 2000.
The investigation also found that patients were “consistently complaining that they were having difficulty getting services or being seen by a doctor.”
MHS “failed to take any corrective action or properly oversee” the clinics.
Spitzer announced a settlement in which MHS repaid more than $2 million to the Medicaid program for services the clinics never provided.
In October 2000 MHS changed its name to AmeriChoice of New York.
Anthony Welters, Chairman of AmeriChoice Corp.:
“What [should] a person who takes a $200,000 investment and turns it into a billion-dollar company . . . receive? I don’t know. But I know this: I’m not going to apologize for it.”
Comment: Medicaid’s chronic under-funding threatens access to care for the low-income individuals covered by this program primarily because many providers will not participate at rates that frequently do not even pay overhead expenses. Several state governments have turned over their Medicaid funds to private corporations to administer these programs. Mr. Welters exemplifies how well these plans fulfill their corporate responsibility to their shareholders and executives.
In 2002 we are already spending over $5500 per capita for health care in the United States. Pool that into a single fund, eliminate the middleman thieves, establish a program of public administration, and we would have affordable, comprehensive care for everyone.
Until we do that, those of us that sit back and do nothing must concede the wisdom of the words that William Shakespeare assigned to Puck: “Lord, what fools these mortals be!”
Felix Schwarz, MA, MPH, Executive Director of the Health Care Council of Orange County, comments on Dr. Munoz’s article on mental health carve outs:
For years we have been fighting for “parity” for mental health coverage. I am now telling my mental health advocate friends, as forcefully as I can, that we should no longer seek parity in a broken health care system. We should try to fix the system as a whole — to include mental health coverage in a universal, single payer, fair and rational system that does not try to “carve out” mental health, or carve up the patient population to leave out those whose needs for health care are greatest!
Confronting Health Care ‘Demons’ Anthony Welters Took an Unlikely Route to Head AmeriChoice, an HMO for the Poor
The Washington Post
May 27, 2002
By Bill Brubaker
Anthony Welters grew up in a one-room tenement in Harlem, sleeping behind a curtain with his three brothers, he says.
Today, he lives in a five-bedroom, seven-bathroom house on five acres in McLean. He has a 75-acre farm in the Blue Ridge Mountains. For a change of pace, there is a 5,000-square-foot house in Aspen, Colo., recently assessed at $3 million.
Welters, 47, made his fortune in health insurance, serving a specialized market.
The market is the poor.
Federal and state audits concluded in the early and mid-1990s that ineffective oversight by Pennsylvania officials had enabled Welters and his partners to make too much money from their taxpayer-supported business.
The audits said the Welters group had paid itself millions of dollars in management fees — paid to other companies they controlled — and millions more in bonuses.
Welters’s health-insurance business expanded to New York in 1994 and New Jersey in 1996. In both states, the HMO was known as Managed Healthcare Systems (MHS).
In New York, state investigators discovered something was not right about two clinics that MHS retained to serve patients in the borough of Brooklyn.
They determined that from 1995 to 1997 the clinics were being staffed largely by “unsupervised physician assistants or nurse practitioners,” New York state Attorney General Eliot Spitzer announced in May 2000.
The investigation also found that patients were “consistently complaining that they were having difficulty getting services or being seen by a doctor.”
MHS “failed to take any corrective action or properly oversee” the clinics.
Spitzer announced a settlement in which MHS repaid more than $2 million to the Medicaid program for services the clinics never provided.
In October 2000 MHS changed its name to AmeriChoice of New York.
Anthony Welters, Chairman of AmeriChoice Corp.:
“What [should] a person who takes a $200,000 investment and turns it into a billion-dollar company . . . receive? I don’t know. But I know this: I’m not going to apologize for it.”
Comment: Medicaid’s chronic under-funding threatens access to care for the low-income individuals covered by this program primarily because many providers will not participate at rates that frequently do not even pay overhead expenses. Several state governments have turned over their Medicaid funds to private corporations to administer these programs. Mr. Welters exemplifies how well these plans fulfill their corporate responsibility to their shareholders and executives.
In 2002 we are already spending over $5500 per capita for health care in the United States. Pool that into a single fund, eliminate the middleman thieves, establish a program of public administration, and we would have affordable, comprehensive care for everyone.
Until we do that, those of us that sit back and do nothing must concede the wisdom of the words that William Shakespeare assigned to Puck: “Lord, what fools these mortals be!”
Felix Schwarz, MA, MPH, Executive Director of the Health Care Council of Orange County, comments on Dr. Munoz’s article on mental health carve outs:
For years we have been fighting for “parity” for mental health coverage. I am now telling my mental health advocate friends, as forcefully as I can, that we should no longer seek parity in a broken health care system. We should try to fix the system as a whole — to include mental health coverage in a universal, single payer, fair and rational system that does not try to “carve out” mental health, or carve up the patient population to leave out those whose needs for health care are greatest!
National Health Insurance Liberal Benefits, Conservative Spending
Archives of Internal Medicine
May, 2002
by Steffie Woolhandler, MD, MPH and David U. Himmelstein, MD
In the 35 years since the implementation of Medicare and Medicaid, a welter of patchwork reforms has been tried. Health maintenance organizations and diagnosis related groups promised to contain costs and free up funds to expand coverage. Billions of dollars have been allocated to expanding Medicaid and similar programs for children. Both Medicare and Medicaid have tried managed care. Oregon essayed rationing in its Medicaid program, Massachusetts and Hawaii passed laws requiring all employers to cover their workers, Tennessee promised nearly universal coverage, and several states have implemented high-risk pools to insure high-cost individuals. For-profit firms pledged to bring business-like efficiency to running HMOs, hospitals, dialysis clinics, and nursing homes. And market competition has roiled health care’s waters.
None of these initiatives has made a dent in the number of uninsured, durably controlled costs, or lessened the inexorable bureaucratization of medicine.
National health insurance could solve the cost-vs-access conflict by slashing bureaucratic waste. It would reorient the way we pay for care, and eliminate financial barriers to access. National health insurance could restore the physician-patient relationship, offer patients a free choice of physicians and hospitals, and free physicians from the bonds of managed care.
How many more failed patchwork reforms, how many more patients turned away from care they cannot afford, how many trillions of dollars squandered on malignant bureaucracy, before we adopt the only viable solution: NHI?
Single-Payer Health Care By Any Other Name Is Still A Monopoly
National Center for Policy Analysis
April 2, 2002
Opinion Editorial
by The Honorable Pete du Pont, Policy Chairman of NCPA
“Under our current system, if a health insurance company raised prices and reduced benefits, consumers would switch in droves. But, when there is only one game in town, consumers would have to accept whatever costs and benefits were offered. Without the incentives created by competition, a single-payer system would likely exemplify the innovation, compassion and efficiency of the Internal Revenue Service in no time.”
Comment: Some would consider using false innuendoes and false analogies to be the equivalent of lying. At best, they reflect the desperation of an ideologue who is unable to find logical arguments to oppose a rational concept.
National health insurance or single payer reform has been demonstrated to be the most credible option that would assure affordable, comprehensive health care for everyone. The single payer message is very powerful. It has resumed its rightful position back in the national debate on reform. Opponents are now coming out in force with their false rhetoric to attempt to beat back the anticipated groundswell of support. Be prepared.
Beth Capell, Ph.D. on Pete du Pont’s rhetoric:
Du Pont’s arguments are real ones that need to be effectively rebutted–they reflect beliefs deeply held by many Americans that a government-run operation for any purpose is not as good as a private-run operation. This is perhaps the toughest hurdle faced by those of us who support single payer.
His argument also speaks of the importance of the market, of competition, of choice, of consumer power.
The error here is the notion that the most important social value for health care is giving individuals choice and preserving the private market rather than assuring a basic level of service for everyone.
Choice, competition and the market work against people who need health care but have only modest incomes. But these are deeply held values in this country and the force of the belief in them must be respected.
It is entirely possible for people to hold beliefs and values that have conflicting implications–all of us do it: I want to save money, I want to go on vacation; I want to lose weight, boy, that dessert looks great; I want consumer choice in health care, I want to be sure that I can get the care I need when I need it.
The problem in this country is that policy does not yet include the principle that every one of us should be able to get health care when we need it. It exists for people with insurance (that’s what the Patient Bill of Rights was about.) This principle exists for seniors, for pregnant women and for children. Here in California we are in the midst of a debate over whether it includes parents.
Fighting for the principle that every one of us should be able to get health care when we need it is fundamental.
Parity or Parody How health care insurers avoid treating mental illness
The San Diego Union-Tribune
May 22, 2002
By Rodrigo Munoz, a psychiatrist and president of the San Diego County Medical Society
… San Diegans will continue to be on the short end of the stick when it comes to accessing critical mental health services. That is because of the little-known but powerfully disruptive practice called a “carve-out,” which allows insurers to skirt around the laws on mental health parity and deliver the least amount of care for the greatest financial return.
On paper, carve-outs are simple to understand. Insurance industry giant XYZ Health is given the contract to insure the employees of a large corporation, probably by tendering the lowest premium bid. XYZ Health promptly subcontracts with a for-profit company to handle the mental health claims under the insurance policy, severing the mental health benefit from the rest of the policy, usually for as little as 25 cents per member, per month.
If you ask how any company could turn a profit when it is being reimbursed a quarter a month for each member of the insurance plan that might seek treatment, you’re onto something. The only way that these firms (called “behavioral health companies” in industry jargon) can make money is by making it virtually impossible for those in need to get treatment.
These companies make it hard for people to see a psychiatrist in the first place, limit the number of times a patient can see a psychiatrist, limit the amount of time they will pay for the psychiatrist to see the patient to 20 minutes and force people out of the hospital before they can safely go home, with no adequate follow-up provided. This is a clear violation of the mental health parity law, but they get away with it, because the benefit has been “carved out.”
The saddest thing is that many patients and even the employers who pay the bill don’t realize that the HMO they have entrusted with their business and their health has washed its hands of a piece of it. They only find out that XZY Health is out of the picture when they go to access treatment, unsuccessfully.
Treatment for disorders of the brain should not be carved out and away from the insurance benefit any more than diseases of the kidneys, eyes or heart. “Separate but equal” is no more tolerable in health care than it was in public education. Unless we end the practice, we will have to substitute the word “parody” for “parity” when discussing mental health treatment in San Diego.
