I agree with Dr. LeBow. I was waiting for the other shoe to drop. One of my professors once said, “Don’t let analysis lead to paralysis.” What would it take for the National Coalition on Health Care to address the issue of achieving universal health care in the United States?

Aaron Beckerman

Professor Emeritus Yeshiva University

Adjunct Associate Professor of Medicine New York University Medical Center

Philip Pollner, M.D. and Nancy Wooten, Ph.D. of Unity for NHI (national health insurance) respond to Joel Miller (“A Perfect Storm”) and to Robert LeBow’s comments:

While we are trying, as we have for decades, to make single payer “marketable” to the kinds of organizations and individuals that Joel Miller represents, it would be far better (and probably easier) without “an appearance of some private sector involvement” to market it to those who have the most to gain – the uninsured, underinsured and even the insured who have witnessed the dark side of the present health care system. It would, as a colleague has stated, take only ten minutes to empower such individuals to agree. If only ten million of them were mobilized nationally, our movement would have three times the membership of the powerful NRA (3.5 million members); at those numbers and political clout we would finally achieve our goal. Unity for NHI is struggling to reach out to educate and empower large numbers of the grassroots into a formidable voting bloc. We need the support of all of those activists who wish to make the vision of universal health care a reality.

Philip Pollner, MD
Nancy Wooten, PhD

Robert LeBow, M.D., a former president of Physicians for a National Health Program:

Joel Miller’s essay is great. It gives much useful data and well thought-out projections. Its conclusions supporting universal coverage are succinct and right on. But its shortcoming, like that of the organization he works for, the National Coalition on Health Care, is that he states the obvious (“We need universal coverage for all the right reasons”) but stops there. It’s as if they all know what has to be done, but they’re afraid to come out and say it.

When he says, “We must move towards a health system in which every American has health insurance coverage,” is he endorsing “incremental” change? He must know, and we know, that unless we have universal coverage — and not just tweaking this group or that group to increase the number of insured Americans — none of what he’s advocating for will happen. Risk avoidance will not go away. Profit-seeking and high administrative costs will continue. The most vulnerable will continue to be the most vulnerable. Costs will not be controlled.

So why doesn’t he…and the organization he represents…finally come out and say it? We need one risk pool with everybody in and nobody out. The euphemistic way of saying single payer or its equivalent. Maybe we need to find some way of getting people to accept single payer for what it is by giving it an appearance of some private sector involvement so it’s more marketable to people and groups that make up the kinds of organizations that Joel Miller represents. They’re good people, but I get the feeling their hands are tied. It would be wonderful if the National Coalition on Health Care could come out and say what they know has to happen to solve the dilemma of health care in America.

Bob LeBow

Professor Theodore Marmor responds to Professor James Robinson (Nov. 20 quote – the end of managed care and the introduction of consumerism, which “consumers will hate”):

I agree with your reaction, Don. This commentary is in most ways a comment of nihilism.

TED

Robert LeBow, M.D., a former president of Physicians for a National Health Program:

Joel Miller’s essay is great. It gives much useful data and well thought-out projections. Its conclusions supporting universal coverage are succinct and right on. But its shortcoming, like that of the organization he works for, the National Coalition on Health Care, is that he states the obvious (“We need universal coverage for all the right reasons”) but stops there. It’s as if they all know what has to be done, but they’re afraid to come out and say it.

When he says, “We must move towards a health system in which every American has health insurance coverage,” is he endorsing “incremental” change? He must know, and we know, that unless we have universal coverage — and not just tweaking this group or that group to increase the number of insured Americans — none of what he’s advocating for will happen. Risk avoidance will not go away. Profit-seeking and high administrative costs will continue. The most vulnerable will continue to be the most vulnerable. Costs will not be controlled.

So why doesn’t he…and the organization he represents…finally come out and say it? We need one risk pool with everybody in and nobody out. The euphemistic way of saying single payer or its equivalent. Maybe we need to find some way of getting people to accept single payer for what it is by giving it an appearance of some private sector involvement so it’s more marketable to people and groups that make up the kinds of organizations that Joel Miller represents. They’re good people, but I get the feeling their hands are tied. It would be wonderful if the National Coalition on Health Care could come out and say what they know has to happen to solve the dilemma of health care in America.

Bob LeBow

Professor Theodore Marmor responds to Professor James Robinson (Nov. 20 quote – the end of managed care and the introduction of consumerism, which “consumers will hate”):

I agree with your reaction, Don. This commentary is in most ways a comment of nihilism.

TED

National Coalition on Health Care
November 15, 2001
by Joel E. Miller, Director of Policy

“What we are about to witness is a fundamental sea change with the storm’s aftermath leaving a significant number of middle-class people uninsured in the foreseeable future. In 2000, health insurance coverage rates decreased for those with household incomes between $50,000 and $75,000. This drop occurred during good economic times. With the economy in a recession, this drop for middle-income people will become even more pronounced.”

“A sustained recession over the next few years would very likely exacerbate the decline in employer-based coverage. In the absence of government or private sector intervention, the erosion of employer-based health insurance coverage will be significant. The situation will not self-correct. We need to protect all Americans who are in the storm’s path. Steps must be taken to ensure that the number of uninsured Americans does not increase, and instead is reduced over time. We must move towards a health system in which EVERY American has health insurance coverage, health care costs are contained, and quality of care is assured.”

“The three major problems plaguing our health system today – mounting costs, the growing number of uninsured, uneven quality of care – are interrelated. Without universal coverage, you cannot assure equity or quality, and in the absence of quality, you cannot contain costs. In addition, without universal coverage you can neither make the system less complex administratively, control costs, stop risk selection and cost-shifting, achieve a level playing field of equitable financing, or create a truly competitive market-based system. It is thus a vicious cycle.”

http://www.nchc.org/APerfectStorm.pdf

Comment: We have seen the numerous analyses of health care coverage and costs, and we have seen the gloomy predictions. Joel Miller has assembled these current studies and forecasts and has weaved them into a rousing treatise using the appropriate analogy of “A Perfect Storm,” with the antecedent calm, the storm, the tidal wave, the sea change, and finally the need for a safe harbor of health insurance. It is a tragic story up to this point, but it has not ended. He shows us that we still can find the safe harbor of universal coverage.

California Medical Association Fifth Annual Leadership Academy
La Quinta, CA
November 16-18, 2001

James C. Robinson, PhD, MPH, Professor of Health Economics, UC Berkeley:

“I think that we are heading into a more consumer driven system… Why? Because the other four candidates – government, employer, insurer, and physician organization – have all bailed… In the end, it is going to be the consumer who is going to have to make the decisions of who gets what and how much am I going to pay? Insurance is going to have a role in that, but clearly we’re going to be placing a lot of this on the consumer, and that’s going to be problematic. Some consumers are great decision makers. Some consumers have disposable income. Others are lousy decision makers. Others are in a coma. You know, they don’t fit the profile of a shopper that well. This is no one’s idea of a perfect system. There is no happy ending to this story.”

Question from audience: “… I’m interested to find out what your theory is on medical savings accounts where the individual takes responsibility for their own health care.”

Prof. Robinson: “What about MSAs? More broadly, the notion of the consumer paying more out of pocket. I do believe that it is going to be a major part of our system going forward. Deductibles are rising like crazy. The big new Aetna product – the high deductible MSA-type product… This is happening very, very fast. This is considered part of consumerism. I think that consumers are going to hate consumerism… I think that deductibles can be really good. All of us should be more cost conscious. But the problem is that they discriminate against the poor, against the sick. Aside from that, they’re great.”

Comment: Our next great experiment in health care funding is consumerism, and consumers are going to hate it. And yet we will continue to discriminate against the poor and sick. Do we really have to complete this experiment which we already know is doomed to fail? Instead, can’t we just go ahead now and introduce equity into health care by adopting a publicly administered program of universal health insurance? If, in advance, we agree to maintain our current generous level of funding, patients would emphatically support our system. And, after all, isn’t health care really about patients?

California Medical Association Fifth Annual Leadership Academy
Creating the Future of Health Care
La Quinta, CA
November 16-18, 2001

Dee Hock, Founder and CEO Emeritus, VISA International, and Founder, The Chaordic Commons:

“Only with the evolution of a self-organizing, Chaordic, transcendent organization in which all parties have an appropriate voice in governance –in which the whole does not control the parts and the parts do not control the whole — in which competition and cooperation are harmoniously blended — in which public and private entities are seamlessly related –can order emerge and a universal, effective, low-cost system of health evolve. Such a governance structure could be put in place within two years, could extend nationwide within five and expand globally within a few more.”

“It is far too late and things are far too bad for pessimism.”

http://www.chaordic.org/

USA Today
November 16, 2001

USA TODAY commentary writers Ted Halstead and Michael Lind make the claim that the war on terrorism calls for shifting the responsibility for health insurance to the individual and that a single universal plan should be avoided (”Lack of health care for all creates U.S. security risk,” The Forum, Monday).

Their organization, the New America Foundation, supports the crafting of new public-policy solutions for our social ills. Shifting health-insurance purchasing from the employer to the employee might be new, but relying on the fragmented, inefficient and ineffective health-plan marketplace is a stale solution that should be discarded.

Private market approaches have failed to control costs and have fallen short of improving coverage. Even worse, current trends are to shift more of the costs on to patients, exposing them to even greater financial risk.

We already have excess capacity in our health-care system. But access to health care is impaired due to financial barriers and will only grow worse.

If we were to eliminate the egregious waste of the private plans, the financial resources currently directed to health care would be enough to pay for comprehensive care for everyone.

Publicly funded universal health insurance would solve the problems that have been compounded by perverse incentives in the market. Everyone would have health-care coverage, and costs would be contained by a public system that would require value for our health care investment.

Don R. McCanne, M.D. President-elect, Physicians for a National Health Program

AMNews
November 19, 2001
by Markian Hawryluk

The Centers for Medicare & Medicaid Services announced Nov. 1 that the conversion factor used to calculate payments to physicians would decline by 5.4%.

Unlike payments for hospitals or other providers for which Medicare’s annual updates allow some government discretion, physician payment is updated based on a set formula. In essence, CMS must simply input the numbers and arrive at an answer.

Unlike payments for hospitals or other providers for which Medicare’s annual updates allow some government discretion, physician payment is updated based on a set formula. In essence, CMS must simply input the numbers and arrive at an answer.

The self-correcting nature of the formula is primarily responsible for the impending reduction. The formula updates payments on the basis of estimated changes in physician costs. But the update only equals the estimated change if actual spending is equal to a target — the sustainable growth rate.

The target is based on four things: gross domestic product, enrollment in the traditional Medicare program, input prices, and spending due to new laws or regulations. If actual spending misses the target, the next year’s update must be raised or lowered to bring spending in line. This year, revisions to previous year estimates of GDP, increases in physician spending and the economic slowdown have all added up to a large negative update.

http://www.ama-assn.org/sci-pubs/amnews/pick_01/gvl11119.htm

Comment: Medicare has led the way in slowing the rate of inflation in health care, using fee controls designed to reflect the real costs of delivering care. Private managed care health plans followed with measures that excessively squeezed profits and drove many physician groups into bankruptcy. Medicare’s formula was designed to assure adequate compensation for physicians while still providing value for the taxpayer. Private health plans were strictly bottom line oriented, ignoring the threat to the fiscal stability of the medical profession.

Although Medicare’s efforts were more noble, they didn’t quite get it right. Although a 5.4 % decrease doesn’t look like much, it can be disastrous. Keep in mind that overhead expenses are relatively fixed for solo and small group medical practices. The percentage change affects primarily the net income of the physicians. Thus a 5.4 % decrease in fees may translate into a 10 % or 15 % decrease in take-home pay. If similar adjustments were to occur in consecutive years (unlikely but not impossible), the implications are obvious. Using physicians’ net income as the ultimate adjustment for the “sustainable growth rate” places on physicians too much of the burden of health care inflation control.

Private health plans have wreaked financial havoc without containing costs. They have to go. Universal insurance holds the promise of containing costs through global budgets and negotiation of provider rates. Although the formulas used by Medicare are rational, they create excessive instability of physician income. Negotiation must be added to the process. But allowing physician negotiation in our fragmented system could threaten further disruption of delivery of health care services (beyond that of contract terminations and bankruptcies). On the other hand, a universal program of public insurance should strive for equity in rate setting by adding negotiation to the process. Physicians would be protected from excessive decreases during unfavorable years, and the taxpayers would be protected from excessive physician compensation in more favorable years.

Does anyone in America oppose equity, or fairness, in the funding and delivery of health care? Then why aren’t we moving ahead with reform that would establish equity?

eHealth Institute
November 14-16, 2001 Aptos, CA

Convened by the nonprofit eHealth Institute, the Developers’ Summit is the only national meeting that is solely focused on issues of importance to eHealth application developers.

Objectives: The eHealth Developers’ Summit seeks to catalyze the sustainable development, adoption, and dissemination of effective eHealth tools by leveraging the collective expertise and vision of the most respected eHealth developers in the world. The Summit will:

1. Identify solutions for sustainable development and implementation of effective eHealth applications; 2. Enhance communication and collaboration among developers and other stakeholders; and 3. Provide a unique networking opportunity that fosters business relationships and collaborations among developers from commercial entities, academia, government and the nonprofit sector.

Invitation Only Attendance is by invitation only and limited to about 100 people. Invitees are chosen on the basis of their direct involvement in eHealth development and their potential impact on the field. Institutions that will be represented at the Summit include technology and health-related corporations, small businesses, academic institutions, health care organizations, investors, foundations, non-profit organizations, government agencies, and health care purchasers and payers.

Access a Detailed agenda for the meeting: Log in to the eHealth Summit 2001 Participants Only Site Provide your Email Address & Password

Participant directory: Log in to the eHealth Summit 2001 Participants Only Site Provide your Email Address & Password

http://www.ehealthinstitute.org/summit/index.cfm

Comment: eHealth Institute is a private, charitable organization with a mission of seeking to “explore ways to use emerging information and communication technologies to improve the health and well being of all people, including the underserved.”

Inevitably, information technology will play a very major role in the future of our health care system. The industry is rapidly developing innovations that will bring us significant improvements in efficiency, error reduction, communication, quality enhancement, and other benefits of health care applications. The problem is that the private sector is designing systems that will maximize their access to the $1.4 trillion dedicated to health care today. If you believe that private health plans have been draining funds that should go to patient care, just wait until you see what this industry has in mind.

A very important summit on this topic is now being held, as the excerpts from the announcement above indicate. The secrecy of both the agenda and the list of invited-only attendees brings back unpleasant memories of the secret sessions during the planning of the failed Clinton health care reform proposal.

It is essential that such summits be held. But it is also essential that eHealth be developed in an environment that encourages value while enhancing our health care system, rather than an environment that is designed to develop methods of diverting funds away from patient care. It is essential that public policies in health care information technology be developed immediately, and that the NIH be enlisted to supervise the development of the technology in the public domain. Only with that approach can we be assured that we will be receiving value for our investment.

Those who believe that a public process will stifle technological development must also accept the belief that this industry will walk away from their rightful share of a $1.4 trillion health care budget. They will see to it that they get their share, and the public will see to it that we receive value.

eHealth Institute
November 14-16, 2001 Aptos, CA

Convened by the nonprofit eHealth Institute, the Developers’ Summit is the only national meeting that is solely focused on issues of importance to eHealth application developers.

Objectives: The eHealth Developers’ Summit seeks to catalyze the sustainable development, adoption, and dissemination of effective eHealth tools by leveraging the collective expertise and vision of the most respected eHealth developers in the world. The Summit will:

1. Identify solutions for sustainable development and implementation of effective eHealth applications; 2. Enhance communication and collaboration among developers and other stakeholders; and 3. Provide a unique networking opportunity that fosters business relationships and collaborations among developers from commercial entities, academia, government and the nonprofit sector.

Invitation Only Attendance is by invitation only and limited to about 100 people. Invitees are chosen on the basis of their direct involvement in eHealth development and their potential impact on the field. Institutions that will be represented at the Summit include technology and health-related corporations, small businesses, academic institutions, health care organizations, investors, foundations, non-profit organizations, government agencies, and health care purchasers and payers.

Access a Detailed agenda for the meeting: Log in to the eHealth Summit 2001 Participants Only Site Provide your Email Address & Password

Participant directory: Log in to the eHealth Summit 2001 Participants Only Site Provide your Email Address & Password

http://www.ehealthinstitute.org/summit/index.cfm

Comment: eHealth Institute is a private, charitable organization with a mission of seeking to “explore ways to use emerging information and communication technologies to improve the health and well being of all people, including the underserved.”

Inevitably, information technology will play a very major role in the future of our health care system. The industry is rapidly developing innovations that will bring us significant improvements in efficiency, error reduction, communication, quality enhancement, and other benefits of health care applications. The problem is that the private sector is designing systems that will maximize their access to the $1.4 trillion dedicated to health care today. If you believe that private health plans have been draining funds that should go to patient care, just wait until you see what this industry has in mind.

A very important summit on this topic is now being held, as the excerpts from the announcement above indicate. The secrecy of both the agenda and the list of invited-only attendees brings back unpleasant memories of the secret sessions during the planning of the failed Clinton health care reform proposal.

It is essential that such summits be held. But it is also essential that eHealth be developed in an environment that encourages value while enhancing our health care system, rather than an environment that is designed to develop methods of diverting funds away from patient care. It is essential that public policies in health care information technology be developed immediately, and that the NIH be enlisted to supervise the development of the technology in the public domain. Only with that approach can we be assured that we will be receiving value for our investment.

Those who believe that a public process will stifle technological development must also accept the belief that this industry will walk away from their rightful share of a $1.4 trillion health care budget. They will see to it that they get their share, and the public will see to it that we receive value.

HEALTH AFFAIRS
Web Exclusive
November 13, 2001
by Robert J. Blendon, et al

“In contrast to health problems, health care issues have become less salient to the public. This is likely to lead to decreased support for government action on health care issues that were being debated by the Congress before September 11. These include Medicare reform, a Medicare prescription drug benefit, patients’ rights legislation, and coverage for the uninsured.

“How long these opinion changes last and what direction they take in the future depend upon three critical yet unknown factors: the occurrence and severity of new domestic terrorist attacks; the duration and success of the war in Afghanistan; and the duration and depth of the economic recession.”

http://www.healthaffairs.org/

HEALTH AFFAIRS
Web Exclusive
November 13, 2001
by Robert J. Blendon, et al

“In contrast to health problems, health care issues have become less salient to the public. This is likely to lead to decreased support for government action on health care issues that were being debated by the Congress before September 11. These include Medicare reform, a Medicare prescription drug benefit, patients’ rights legislation, and coverage for the uninsured.

“How long these opinion changes last and what direction they take in the future depend upon three critical yet unknown factors: the occurrence and severity of new domestic terrorist attacks; the duration and success of the war in Afghanistan; and the duration and depth of the economic recession.”

http://www.healthaffairs.org/