JAMA
May 1, 2002
Book Review by Jerrold P. Schwartz, M.D.

By David Himmelstein and Steffie Woolhandler with Ida Hellander Common Courage Press

“The seven years since the failed attempt of the Clinton administration to enact health care reform have seen the burgeoning of for-profit corporations in all aspects of health care. Giant health insurance and pharmaceutical corporations, for-profit hospital corporations with hundreds of hospitals, hemodialysis and nursing home chains, mental health and home care corporations, and many others less visible, such as quality-of-care and credentialing companies, are now well entrenched in our uniquely American system of health care and are profiting handsomely. But in the free-enterprise free-for-all, how are patients – and doctors – faring? To find out, read this book.”

“Judging by the tone of the book, the authors clearly uphold the US ideals of democracy and egalitarianism.”

“As advocates for our patients and to preserve the ethical underpinnings of our profession, all US physicians should read this compelling argument for medicine as a public service.”

Comment: “Bleeding the Patient” is available from the publisher, Common Courage Press at: http://www.commoncouragepress.com/himmelstein_bleeding.html

An old, dishonorable practice needs to be seen in a new light, namely making people without health insurance pay far more than others for needed health care. This especially affects immigrant groups, and among them, Latinos have the highest rate of uninsurance.

For decades, providers and especially hospitals, have kept raising their charges, far higher than their costs, in order to raise their “profile” for discount payments from government programs and insurers. Each year they raise the charges, and each year the payers respond by lowering the percentage of “charges” they will pay. This game is fine for those in them, and conversations about those not in them usually focus on Sheiks. In a recently conversation, a sub-specialist at a famous hospital was explaining how only millionaires and Sheiks pay full charges – they are so outrageous -and these windfall sums help pay for the uninsured.

But first, the uninsured are billed the “standard charges” (which no insured person pays). Then, when they cannot pay, bill collectors are sent, who attach their credit cards or homes (if they have one), and who threaten to report them to the INS. These charges are typically 3-6 times greater than what is normally collected from HMOs, insurers, and managed care plans. I recently experienced this personally, when a routine blood test was deemed not covered. The lab (a large national company) normally collects $85 for the test from discount contractors, but because they were billing me as an individual, their itemized bill was $401, more than 4 times greater. I got my physician to write a note and the bill was adjusted down to $85. If this had been for a hospitalization, the bill might have been $8500 to a plan or insurer, but $40,100 to an individual.

These practices have been documented by Consejo De Latinos Unidos, and they have a class action suit against Tenet, the huge managed care corporation, for ethnic discrimination. They have even shown in what unsystematic data they have been able to gather, that a hospital recovers more income from uninsured Latinos than from HMOs, i.e., the collection agents get them to pay a third of the bill, or $12,000 before taking them to court and/or getting them deported, when a routine payment would be $8500. Their material include a number of case studies that are an embarrassment to read.

Of course, Tenet replies they are doing what they always do, and that is correct. That’s “how the system works.” The judge on the case happened to speak about it off the record and comments that courts are not set up to change systems. In short, a dishonorable old practice of charge inflation has tragic consequences for the uninsured and especially for immigrants. All discussions about the uninsured, and about individualizing health care by having employees get health insurance for themselves, need to include these issues and practices.

Joanne Landy, Executive Director of the New York Chapter of Physicians for a National Health Program, responds to Rima Cohen on the Health Care Access Resolution – House Concurrent Resolution 99 (HCAR or HCR 99):

I was happy to see on the Q of the D that Rima Cohen, Vice President at the Greater New York Hospital Foundation and Director of the Insurance Options for the Uninsured Project, supports the Health Care Access Resolution – House Concurrent Resolution 99. As a statement committing Congress to enact universal health care by 2004, it is an urgent and necessary resolution.

It’s important to note that HCAR goes beyond calling for universal care; it calls for a guarantee that every person in the United States, regardless of income, age, or employment or health status, has access to decent, humane and affordable care, as detailed in the resolution (see below.)

It is important, however, to urge the public and members of Congress to work simultaneously for a single-payer health care system in the United States that can actually achieve the crucial goals enumerated in HCAR. A single payer system would create a universal risk pool and would finance health care through progressive taxation rather than through an employer-based system that depends on private insurance companies. A single payer system (essentially an improved and expanded Medicare-for-All) would save enormous amounts of precious health care dollars currently spent on marketing, on profits, and on the administrative costs built in to a system that forces providers to comply with hundreds of different insurance plans.

HCAR was introduced by U.S. Representative John Conyers, who is to be congratulated for his vision in doing so. He will shortly be introducing a single-payer health care bill, which will address the question of how to contain health care costs while assuring universal access to quality health care. I hope that Rima Cohen and other supporters of House Concurrent Resolution 99 support the Conyers single-payer bill as well.

HCAR calls for healthcare that: (1) is affordable to individuals and families, businesses and taxpayers and that removes financial barriers to needed care ; (2) is as cost efficient as possible, spending the maximum amount of dollars on direct patient care; (3) provides comprehensive benefits, including benefits for mental health and long term care services; (4) promotes prevention and early intervention; (5) includes parity for mental health and other services; (6) eliminates disparities in access to quality health care; (7) addresses the needs of people with special health care needs and underserved populations in rural and urban areas; (8) promotes quality and better health outcomes; (9) addresses the need to have adequate numbers of qualified health care caregivers, practitioners, and providers to guarantee timely access to quality care; (10) provides adequate and timely payments in order to guarantee access to providers; (11) fosters a strong network of health care facilities, including safety net providers; (12) ensures continuity of coverage and continuity of care; (13) maximizes consumer choice of health care providers and practitioners; and (14) is easy for patients, providers and practitioners to use and reduces paperwork.

Does anyone seriously believe that our private, employer based heath care system can deliver this package? To ask the question is to answer it.

–Joanne Landy Executive Director Physicians for a National Health Program New York Chapter

Comment: It is very easy to ask your member of Congress to support House Concurrent Resolution 99 by sending a message through the following link: http://www.house.gov/writerep/

America’s Health Together (www.healthtogether.org)
April 30, 2002
Washington, DC

Rima Cohen,Vice President at the Greater New York Hospital Foundation and Director of the Insurance Options for the Uninsured Project, whose mission is to devise and implement strategies for expanding health insurance coverage in New York:

… we know for sure that the market has not taken care of the problem. Indeed, about a million people every single year since the census began collecting these statistics, have been added to the ranks of the uninsured. So, that’s a difficult thing for me to grapple with looking back on so many years working on health insurance coverage.

So, I jumped at the chance to move into the state health policy arena, thinking that this is where the action is going to be in the coming years, and to a certain extent, I was right. And I was very fortunate when I moved to New York to be involved with an effort that started off with a coalition of organizations where we developed a health insurance plan that was meant to build on our Child Health Plus Program. It was for parents and childless adults, and within a couple of years of my arrival in New York, that legislation passed into law. And, it was the single biggest expansion in New York’s history since–or I should say, since the creation of Medicare and Medicaid in 1965.

So, having been through that experience, you would think that I might be a big advocate of states as the laboratories of democracy, states experimenting with health insurance coverage initiatives, maximum state flexibility to develop locally tailored solutions to the health insurance crisis, but actually, I came away with exactly the opposite sense.

… health insurance coverage is really something that should not be thrown onto the states. And indeed, New York, with all the fanfare of this huge health insurance expansion, we really have not seen a drop in the uninsured. I think all we’ve done is managed to keep people–more people from losing their coverage.

So, let me just tie this all together with a couple of pearls of wisdom that I think can be used to think about strategies going forward. And the most important one is the one that I call, “Bigger is better when it comes to health insurance coverage.” And what I mean by that is, the lens through which I look at every health reform solution is always, “Does it pool the greatest number of people in the largest pool and the greatest number and the most diverse in terms of their ages and illnesses and so forth?” Because that’s the only way that health insurance works.

Health insurance does not work when people can segment themselves into tiny groups and divide themselves based on their illnesses or even geography or their age. And the system now really divides people, and what we really should be doing is pooling people. That’s the principle of health insurance and that’s why–one of the reasons why I think a resolution like this is so important. It’s saying, “Everybody needs health insurance coverage. Let’s pool the largest number of people together,” and a corollary of that is, “Don’t be fooled by calls for more choice.” I think all Americans want choice of their health care providers. I don’t see individuals clamoring as much for their choice of health plans, their–lots of other kinds of choices that you hear set up. Choices of benefit packages. That only allows people to segment themselves again. We need to be thinking about large solutions, comprehensive solutions. That’s the only way we’re really going to–to see a real program for all Americans.

And that’s why I think a Resolution like this is so important (H Con Res 99). Because it doesn’t say that this is exactly the way the health–the health care solution has to be built, but it says, regardless of the method, it has to be done. And the appropriate place to start is in the U.S. Congress passing this resolution, saying that by a date certain, the feds will come up, hopefully in partnership with the states and with lots of organizations that care about this issue, will come up with a solution but it cannot be done by states alone.

For the transcript: http://www.kaisernetwork.org/health_cast/uploaded_files/Transcript_HealthTogether.pdf (cut and paste to rest of link)

For House Concurrent Resolution 99: http://www.house.gov/conyers/hr99.PDF

The resolution calls for legislation by October 2004 that would guarantee that every person has access to health care that meets fourteen specific criteria that we all support. Read it, and then contact your Congressional representative to enlist his or her endorsement.

The New York Times
May 3, 2002

As a private psychiatrist with about 45 percent of my patients on Medicaid or Medicare, I agree with Marc Siegel (Op-Ed, May 1) that Medicare should be expanded. But let’s not stop with prescription drugs. The program should cover all Americans. We could change its name to National Health Insurance. Were this to happen, I’d gladly accept a pay cut.

J. WESLEY BOYD, M.D. Northampton, Mass. The writer is a lecturer in religion at Smith College and in psychiatry at Harvard Medical School.

http://www.nytimes.com/2002/05/03/opinion/L03DOCS.html

The original Op-Ed by Marc Siegel (“… choosing not to take Medicare patients should not be seen as simply a neutral business decision.”): http://www.nytimes.com/2002/05/01/opinion/01SIEG.html

Comment: “National Health Insurance” or “NHI” is a neutral term that can be used for broad audiences. Now that health reform is back in the news and on many agendas, it is helpful to have a term that represents comprehensive reform but without invoking concepts for which organized opposition already exists. “Medicare for All” provokes negative responses from those that are unhappy with the affects of neglect and political damage done to our Medicare program. “Single payer” provokes responses from those that have been saturated with misinformation about the Canadian system. These terms are certainly acceptable for selected, targeted audiences, but might not be the best terms for large, broad audiences.

“National Health Insurance” suggests the option of comprehensive reform, a concept that is now being accepted as an alternative to our current incremental approaches, now that the public is showing concern about the failures of incrementalism (skyrocketing premiums, excessive cost-sharing, and more uninsured). Once the forum is opened up to National Health Insurance, we can use this opportunity to explain to the public the beneficial features such as equity in funding, comprehensiveness, improved access, and elimination of financial barriers while containing costs.

Although no single terminology would be appropriate for all circumstances, National Health Insurance, or NHI, should be in our tool box as we communicate to the nation the advantages of reform that would provide affordable, comprehensive care for everyone.

May 2, 2002

Academics, analysts, lawmakers and the public: from all sides there are complaints that the country’s health care system isn’t working. More than 40 million are uninsured. Costs are soaring and so are premiums, nowhere more than in California, where many will see their rates rise 25% in the next year.

James Kahn, M.D., an epidemiologist and health services researcher at the Institute for Health Policy Studies at the University of California, San Francisco:

“We spend ($15 billion in California) every year to administer the health care system, and what do we get for that? Are people pleased that they have to change health plans? Are they pleased that they have to change doctors, that they have to fight with insurance plans about what’s covered and what isn’t?”

… single payer advocates claim that they can give more people more services for less money, a claim substantiated by an independent review of California’s single payer proposals from the Lewin Group.

In order to overhaul the system there needs to be broad political backing and extensive public education and support, but California advocates of a single payer system point to the increasing premiums, dwindling benefits, and the growing number of uninsured. The time is right for change, they say, and California, with its history of political independence, stands the best chance of making it happen.

This audio report is available through a link at KFF’s Daily Health Policy Report at: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=10945 Those with RealPlayer can hear PRI’s three minute report by clicking “online” at the end of the KFF written report.

James Kahn’s co-authors of the UCSF single payer proposal for the California Health Care Options Project include Thomas Bodenheimer, Kevin Grumbach, Vishu Lingappa, Krista Farey and Don McCanne. All proposals and the analyses of them are now available at: http://www.healthcareoptions.ca.gov/doclib.asp

May 2, 2002

Academics, analysts, lawmakers and the public: from all sides there are complaints that the country’s health care system isn’t working. More than 40 million are uninsured. Costs are soaring and so are premiums, nowhere more than in California, where many will see their rates rise 25% in the next year.

James Kahn, M.D., an epidemiologist and health services researcher at the Institute for Health Policy Studies at the University of California, San Francisco:

“We spend ($15 billion in California) every year to administer the health care system, and what do we get for that? Are people pleased that they have to change health plans? Are they pleased that they have to change doctors, that they have to fight with insurance plans about what’s covered and what isn’t?”

… single payer advocates claim that they can give more people more services for less money, a claim substantiated by an independent review of California’s single payer proposals from the Lewin Group.

In order to overhaul the system there needs to be broad political backing and extensive public education and support, but California advocates of a single payer system point to the increasing premiums, dwindling benefits, and the growing number of uninsured. The time is right for change, they say, and California, with its history of political independence, stands the best chance of making it happen.

This audio report is available through a link at KFF’s Daily Health Policy Report at: http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=10945 Those with RealPlayer can hear PRI’s three minute report by clicking “online” at the end of the KFF written report.

James Kahn’s co-authors of the UCSF single payer proposal for the California Health Care Options Project include Thomas Bodenheimer, Kevin Grumbach, Vishu Lingappa, Krista Farey and Don McCanne. All proposals and the analyses of them are now available at: http://www.healthcareoptions.ca.gov/doclib.asp

The New York Times
April 26, 2002
By Milt Freudenheim

Aetna reported a turnaround in its troubled health insurance business yesterday, reflecting sharply higher premiums and the loss of millions of members that it said had been money losers.

Aetna said its premiums would rise 18 percent this year, ahead of medical costs, which are expected to grow 15 to 16 percent.

Dr. John W. Rowe, chief executive of Aetna, said that as premiums rose many employers were passing some costs to employees. Workers, who are paying more in premiums, deductible amounts and copayments, may hesitate before going to a hospital emergency room for, say, a sprained ankle, he said.

http://www.nytimes.com/2002/04/26/business/26CARE.html

Comment: It is reassuring to learn that everyone now knows how to determine whether an ankle injury is a tear of the anterior talo-fibular ligament or a fracture of the distal fibula. If it is a tear, they also know the degree of the tear and the management of each level of severity. Not only that, they also know how to prevent the prolonged disability that results from an enlarging hematoma typical of these injuries. They also understand the rehabilitation measures that will optimize their return to normal function. Or do they? Have we come to the point that any medical problem that is not a life-threatening event is to be considered an abusive use of our health care system by a woose and therefore not worthy of being funded by health insurance?

Dr. Rowe’s insensitive comments confirm that he and others like him should no longer control our health care funds. Let’s throw out this egregiously wasteful middleman industry that is now abandoning its essential role of funding health care.

We know that we can replace this abusive system with a program of national health insurance which would provide truly comprehensive coverage for everyone at a lower cost. What are we waiting for?

“Harry, did you see this article on the California study on single payer?”

“Is that like that terrible Clinton plan?”

“No, honey. This one’s really different. This study was done by reputable health policy researchers, including many from the University of California. It shows that absolutely everyone could have truly comprehensive health care while saving Californians billions in health care costs.”

“Now Louise, that’s impossible.”

“No. Really. By replacing the hodgepodge of health plans with a single insurance program, enough administrative waste would be eliminated to pay for comprehensive health care for everyone. And we wouldn’t be limited to that list of doctors that our current plan requires. We’d have free choice again.”

“Wow. It sounds like the voters should be checking this out.”

“And our legislators too.”

April 19, 2002
By David DeWitte

American Medical Association President Dr. Richard Corlin drop-kicked the notion that national health insurance will ever solve the health insurance crisis during a visit to Cedar Rapids on Thursday.

Finding a system that will cover all Americans is both costly and politically hamstrung, Corlin said.

Richard Corlin, M.D., AMA president:

“We need a pragmatic, not an ideological solution. Reduce the number from 39 million to its irreducible minimum, probably about 15 million, and consider that a victory and not a terrible tragedy.”

http://www.gazetteonline.com

Comment: Dr. Corlin leaves virtually no doubt as to why Physicians for a National Health Program should supersede the American Medical Association as the legitimate physician organization representing the cause of health care justice.

From Karen Palmer, who is currently on a sabbatical at the World Health Organization in Switzerland, commenting on the findings of The Lewin Group in the California Health Care Options Project:

I was skimming through a textbook written by two of my colleagues here at WHO, and I came across this quote, which so supports the findings of the Lewin group. Maybe folks are starting to get the picture, which is so well-known in the rest of the world that it is part of a standard college level text book on public health:

“The United States of America epitomises the problems wealthy countries experience when public health is neglected. The major dilemma facing public health in the United States continues to be its relationship with the organisation and delivery of medical care services. Until a national and equitable system of medical care is achieved, public health will be neglected and receive an inadequate share of the vast resources devoted to “health” in the United States. The tremendous amount spent on medical care limits the availability of funds for a whole range of public services, not just public health.”

Citation: “Public Health at the Crossroads: achievements and prospects” by Robert Beaglehole and Ruth Bonita, Cambridge University Press 1997.