PNHP

Single-payer health care is smart solution for America

Single-payer health care is smart solution for America

Hedda Haning
The Charleston Gazette
May 16, 2009

CHARLESTON, W.Va. — Everyone agrees that we should all have health care. Most agree the federal government can fund it because we’re desperate. Even the insurance companies agree. The one thing no one discusses is “single payer.”

In case you can’t tell, it’s a swear word; the phrase is always followed by “Socialized medicine. Boo!” You never hear the fact that all other civilized nations have some form of a single-payer system and provide better health care than we do at much lower cost. If that does leak out, the next thing you hear is that it is obviously “Un-American.”

So what is a single-payer health-care system? It is non-profit. It is Un-American like roads and schools and fire and police and Social Security. It is not socialized medicine. Everyone chooses his own private doctor and hospital. The difference is in the payment system. Patients submit a card to doctors and hospitals and payments are made from a single payer, a trust fund established by taxes collected in a fair way at the federal level.

There would be no co-pays, deductibles or balance billing. The tax bill for most people would be much less than they pay for medical insurance and uncovered care because there would be no profits, the administrative costs would be cut by approximately 80 percent, and care would no longer be fragmented and disorganized. Insurance companies would no longer make medical decisions, and no doctor or hospital would be out of network.

There would be negotiated fees and global budgets keeping costs predictable and controllable. The mechanisms would have to be transparent and open to comment and the administrators widely representative. Today, many doctors will not accept Medicare and Medicaid patients because the fees are set lower than their expenses. Everyone suffers. In the single-payer system, the responsible board in charge would have to negotiate regularly with those doctors for changes. Also, without paperwork for each visit by each patient, administrative costs in each office (now huge because of all of the pre-approving, denying and re-submitting) would be greatly reduced – cutting the doctor’s overhead substantially.

A single-payer system would cover everyone, including the CEO of GM, your senator and you. Do you think Congress would pay more attention if they had the same health care we do? The Gazette has recently commented that our Congressional folks want universal coverage. Watch out, because it is a glib trap. Their plan is to mandate that everyone get care through private for-profit insurance firms with public assistance as needed. Unsurprisingly, the insurance industry is strongly supportive. Their huge overhead will be built into the plan. Call it what it is: welfare for insurance corporations.

This approach has been tried in several states, most recently Massachusetts, and has failed everywhere to be affordable and provide necessary care.

In a single-payer national health program, it doesn’t matter if you are rich or poor, just lost your job, have diabetes and heart disease or are healthy. We will no longer have to humiliate people by having them prove they are poor enough to be eligible. The care is comprehensive, covering all medically necessary expenses including primary care, medications, procedures, hospitalizations, mental health, dental, nursing home and home health care.

In case you want to move to Arizona, you will have medical care there, too. Think of single-payer as a better Medicare covering everyone.

A single-payer system can better assess the application of new technology and quality of care outcomes. It can make better long-term decisions and investments, based on patient needs rather than profit. Since we would all be in the same boat, we would all have an incentive to fix the problems that come up. Other countries do this.

Most people don’t know that the federal government already pays for two-thirds of health-care costs through programs including Medicare, Medicaid, the military and tax breaks. The federal government alone already pays – right now – more per capita for health care than any other developed nation pays, but it does not control the system. It is run by insurance companies protecting their profits.

And here’s another little secret: our economy would be much more vibrant if every employer did not have to carry the burden of health care for every employee and if employees were not often stuck in dead-end jobs for fear of losing medical coverage.

Single-payer’s most serious problem is that it puts people before profits: the insurance and pharmaceutical companies hate it. Their lobbyists are already hard at work convincing your legislators that it isn’t feasible. No doubt the ads will be on TV any minute. There was just a conference at West Virginia State University. Single-payer was never mentioned.

It’s apparently not enough that most physicians (an overwhelming majority of primary care physicians) support such a program, as do nurses, many other medical professionals, unions and non-profit organizations.
And doctors in other capitalist countries are quite positive about their own single-payer systems. They are financially comfortable. They do research, develop and use new drugs, and often have access to more advanced technology than we do. They have less interference with their medical decisions than private insurance imposes on our doctors and patients. And study after study shows their health outcomes are better than ours, all while keeping their health-care costs half of ours. Did I mention their patients aren’t bankrupt by medical costs? No other country rations care as we do by ability to pay.

The best kept secret is that polls show two-thirds of Americans supporting such a program, even if they have to pay more in taxes to get it, which would still cost less and be a more predictable expense than paying for private insurance. The fact is if what we’re after is medical care for all Americans at a price we can afford – hugely important to our stressed economy – then single-payer, not-for-profit health care is the ONLY feasible solution.
Haning, a Charleston doctor, is a member of Mountain State Physicians for a National Health Program.

In health care reform, even the supporters are divided

by Bob Braun
Columnist
New Jersey Star-Ledger
May 17, 2009 10:16PM

WASHINGTON — The debate over health care already has turned ugly — and it hasn’t formally begun. Long before Republicans and other opponents of big government involvement in health care even have a chance to denounce it as “socialized medicine,” supporters of bigger involvement are clawing away at each other.

Proponents of a single-payer system feel they were ignored in the congressional debate. That’s hard to refute — activists have been arrested at Senate hearings when they protested the failure of Democrats to take their cause seriously.

Proponents have lashed back, reminding Democrats of inconvenient campaign promises last fall and raising questions about the amount of campaign contributions key Democrats receive from insurance companies and drug firms that oppose single-payer.

“The best solution would be a single-payer system, similar to what all other developed countries have,” says Bill Armbruster of Jersey City, who is active in the group Health Care Now. “Yet single-payer isn’t even on the table in all the discussions about health care reform. That’s because of the power of the insurance lobby.”

Supporters of the bill likely to emerge from the Democrats argue single-payer proponents jeopardize any chance for reform. Says U.S. Rep. Rob Andrews (D-1st Dist.), one of the authors of the impending legislation:

“The country needs a law that will reduce the health care cost explosion for insured people while extending coverage to uninsured people. Single-payer does not have majority support in either house and cannot pass, largely because insured people are understandably reluctant to give up coverage that they have negotiated for and earned.

“We are trying to build a coalition broad and strong enough to deliver the change in health care that Americans voted for.”

U.S. Rep. Frank Pallone (D-6th Dist.), another author of the administration-backed bill, warns that division among reform supporters will endanger a key provision — a government insurance plan competing with private insurers in a so-called “marketplace.”

“It represents a clear compromise between those on the right who want competition only among private plans and those on the left who might prefer a sole public option or even a single-payer system,” says Pallone.

So that’s the stark choice, as painted by congressional Democrats — get on board the compromise train or health care reform will never leave the station.

Only one New Jersey congressmen, Donald Payne (D-10th Dist.), is supporting a single-payer bill. He is one of 75 co-sponsors of legislation — HR 676 — creating a system that would provide every American with government-backed health insurance.

One of the state’s chief supporters of single-payer is Winthrop Dilliway, a faculty member at the University of Medicine and Dentistry of New Jersey and a member of the Physicians for a National Health Program.

He called such a system “the most humane, most efficient, and most democratic” way of providing health care. It would not be “socialized medicine,” he says, because, unlike the British system, there would be no national health service that actually provides the doctors. The payment would come from the government — not the service.

All doctors would be paid by the same system so issues of choice would not come up. It would, in effect, extend the Medicare system for retirees to all Americans.

“It is the most efficient provider in the nation right now,” he says.

The Canadian single-payer system, he says, has reduced health care costs so that they are now one-half of those in the United States.

“There are complaints, sure, but Canadians would never give up their system for the non-system we have — who would? They do not have inferior quality of care.”

Dilliway argues that costs for private insurance companies are twice those of Medicare “because they have dividends to pay and all those clerks to hire.”

The issue at the heart of the debate is the risk pool. Medicare covers the elderly, the people most likely to need health care. If Medicare were extended to everyone, the pool would be expanded to include young as well as old, sick as well as healthy. Insurance can be efficient to the extent it can spread the risk.

Keeping private insurers — even in a “marketplace” approach with a public option — would not allow for a large risk pool with low-risk insured, Dilliway says.

“The government is already paying for costly programs — it needs the rest of the population on board to keep per-capita costs down,” he says.

Dilliway cites polls suggesting majorities of both the general population and of physicians themselves favor a national insurance system.

He knows, however, that, without Obama’s support, single-payer doesn’t have much of a chance — at least this time around.

“The president doesn’t want to have that fight now.”

Questioned, Obama Says Single Payer Would Be Best

Institute for Public Accuracy
News Release
May 14, 2009

AP is reporting: “President Barack Obama says if he were building the health care system from scratch, a single-payer system would be the best approach. But he says his goal is to improve the current system.” The comments were made in response to the first question at the “town hall” type event in Rio Rancho, N.M. by Linda Allison, a local resident. Video of her question and Obama’s reply is here.

Reached by the Institute for Public Accuracy, Allison said: “I asked why they were excluding single payer from healthcare reform. We have this convoluted system where veterans get one system, Indians get another, there’s Medicare, Medicaid and of course many employees get coverage from their companies. Why not just cover everyone under one plan?

“I see people without healthcare, like my son. He served in Iraq and Afghanistan as a reservist. He’s in college now and he’s doesn’t have health insurance. There are people who work who don’t have coverage, or their children don’t have coverage. Why should having healthcare be tied to your employment?

“It’s pretty unclear to me, but Obama seems to be for a plan that would leave the insurance companies in a dominant position and we really need to get them out.

“Obama said that single payer would be good if we were starting from scratch. Well, I think things are pretty bad, so we should start from scratch. But actually, a single-payer system is basically like expanding Medicare to include everyone, so we have a model just waiting for us to use. I recently learned that in Taiwan, they looked around the world for a system and they decided they would copy our Medicare and use it to cover all the people there. Why don’t we do that?

“The other part of my question, which Obama didn’t respond to, was about Max Baucus [chairman of the Senate Finance Committee] and about how he’s chairing the hearings while he’s taken all this money from the insurance companies. I asked if that wasn’t a conflict of interest.” According to the Center for Responsive Politics, Baucus’s top funders include PACs associated with American International Group, Goldman Sachs, New York Life Insurance and Blue Cross/Blue Shield.

For more information, contact at the Institute for Public Accuracy:
Sam Husseini, (202) 347-0020; or David Zupan, (541) 484-9167

What Is 'Socialized Medicine'?: A Taxonomy of Health Care Systems

By Uwe E. Reinhardt
New York Times
Economix Blog
May 8, 2009, 6:48 am

With another “national conversation” about health reform upon us — as it is every decade or so — we will hear a lot of derisive talk about the evils of “socialized medicine.”

The term is regularly confused with “social health insurance,” which is not at all the same concept. The chart below may be helpful in appreciating the distinction.

Socialized medicine refers to health system in which the government owns and operates both the financing of health care and its delivery. Cell A in the chart represents socialized medicine.

Social health insurance, on the other hand, refers to systems in which individuals transfer their financial risk of medical bills to a risk pool to which, as individuals, they contribute taxes or premiums based primarily on ability to pay, rather than on how healthy or sick they are.

Socialized medicine is one form of social insurance. More typically, however, social insurance is coupled on the health-care delivery side with a mixture of government-owned facilities (e.g., municipal hospitals), private nonprofit hospitals (roughly 90 percent of all American hospital beds) or private for-profit facilities (investor-owned hospitals, private medical practices, pharmacies and so on). It follows that one cannot simply treat social insurance as socialized medicine. In principle, one could have social insurance with 100 percent private for-profit delivery facilities.

Under private commercial insurance, individuals also transfer the financial risk of bills for health care to a risk pool, but the premium the individual contributes to the risk pool reflects that individual’s health status. These premiums are, as actuaries put it, “medically underwritten” and “actuarially fair.” The risk pools under private insurance can be operated by not-for-profit or for-profit insurers. And like social insurance, private insurance typically is coupled with a mixed private and public delivery system.

In the chart, cells A, B, C jointly represent single-payer social insurance — e.g., traditional Medicare. Cells D, E, F jointly represent multiple-payer social insurance — e.g., Medicaid Managed Care. Cells G to L jointly represent individually purchased private insurance with actuarially fair premiums. Finally, cells M, N and O represent the uninsured or the cost-sharing portion of insured persons.

In between these distinct systems falls employment-based health insurance.

Large employers typically self-insure and use private insurers only to procure health care on behalf of employees (e.g., negotiate fees with the providers of health care) and administer claims. Other employers do not self-insure and instead purchase so-called group health insurance policies for all their employees jointly, as if they were one large family. The premium for a group policy is “experience rated” over the covered group of employees, which means that they reflect the average actuarial cost of all of one company’s employees.

The individual employee’s own contribution toward his or her employment-based insurance, however, is divorced from the individual’s (or the attached family’s) health status. In this sense, then, employment-based insurance could be described as “private social insurance,” as distinct from “government-run social insurance.”

Former Mayor Rudolph Giuliani of New York has exemplified the perennial confusion in this country over socialized medicine. In his ill-fated presidential bid, and subsequently as a supporter of Senator John McCain’s bid for the presidency, Mr. Giuliani routinely decried as socialized medicine (or “socialist”) any proposal presented by Democratic candidates, because typically the latter advocated tax-financed subsidies toward the purchase of health private insurance or expansions of public insurance programs. But technically none of them advocated socialized medicine.

Perhaps Mr. Giuliani was unaware that Americans all along the ideological spectrum reserve the purest form of socialized medicine — the V.A. health system — for the nation’s veterans. I find this cognitive dissonance amusing. Indeed, if socialized medicine is so evil, why didn’t Republicans privatize the V.A. health system when they controlled both the White House and the Congress during 2001-06?

Mr. Giuliani also seems to forget that, in 1996, he found social health insurance a perfect solution to the financial problems faced by former Mayor John V. Lindsay, who fell on financially hard times during the 1990s as a result of chronic illness.

In a fit of compassion, then Mayor Giuliani rushed to his friend’s assistance with — you guessed it — taxpayers’ money, rather than with a private sector solution. He did so by appointing Mr. Lindsay to two no-show city jobs that came with tax-financed municipal health insurance and a tax-financed pension.

It seems fair, then, to ask Mr. Giuliani why it was perfectly fine to bail out a financially distressed man who had been wealthy enough in his younger years to provide adequately for his old age, when proposals to extend the same kind of assistance to hard-working, uninsured members of lower-income families are decried by him as “socialism.”

One can only hope that our members of Congress and the typical American voter can make the right distinctions.

Uwe E. Reinhardt is an economics professor at Princeton.

Insurance companies want to hide truth

Judith Dasovich
Springfield (Mo.) News-Leader
May 16, 2009

Government-financed health care is not government-run health care. Private for-profit insurance companies do not want you to understand this. Right now, your health care is run by people who value profits, not patients. Private insurance companies set the fees you can’t afford, for care they will deny you when you need it. They decide which doctor you can see and which hospital you can use. You think you’re “covered” until you get sick and find out that you are not. This is what happened to President Obama’s mother when she was dying.

In contrast, improved Medicare for all (also called single payer financing or national health insurance) uses the same system that builds interstate highways — general tax revenues pay private businesses to produce a common good. Medicare for all is not government run. It pays the same private doctors and hospitals that deliver your care now, just like our current Medicare system. Traditional Medicare has an overhead of less than 3 percent. Private insurance companies average 16-20 percent. Doctors and hospitals pay additional money to deal with their complex systems. Duke University Hospital has 900 billing clerks for 900 beds. Do you think they have one nurse for every patient? William McGuire, former CEO of United Health Care insurance company, received $37.7 million per year in salary and $1.776 billion in stock options. That “b” is not a typo. In retirement, he is guaranteed $5 million per year. $350 billion dollars per year goes to administrative waste and profits. We could provide everyone in the U.S. with health care if we used this money for actual care. The money is already there. You could have your choice of doctors and hospitals, not the ones dictated to you by the insurance companies.

The private insurance companies do not want you to understand this. That is why they will not allow Sen. Max Baucus of the Senate Finance Committee to have even one single-payer advocate at the “reform” table. Private insurance companies do not want real reform. They want you to be forced by law to buy insurance you can’t afford for care you won’t get when you need it. In 2008, Sen. Max Baucus took $1,826,652 from health care special interests in his virtually uncontested re-election bid. Patients, not profits, are the special interests of the single-payer advocates. Our speech is truly “free.” We haven’t paid Max Baucus a single dime. Is that why we can’t get a seat at his table? Is that why his response to this question was “Call the police?”

Editor’s note: Dr. Dasovich was among a group of protesters Capitol Police removed from a health care hearing after interrupting U.S. senators.

Judith Dasovich, MD, FACP is the volunteer Medical Director at the Kitchen Clinic.

Health care’s enigma in chief

David Sirota
San Francisco Chronicle
Friday, May 15, 2009

The most stunning and least reported news about President Obama’s press conference with health industry executives this week wasn’t those executives’ willingness to negotiate with a Democrat. It was that Democrat’s eagerness to involve those executives in a discussion about health care reform even as they revealed their previous plans to pilfer $2 trillion from Americans.

That was the little-noticed message from the made-for-TV spectacle administration officials called a health care “game changer”: In saying they can voluntarily slash $200 billion a year from the country’s medical bills over the next decade and still preserve their profits, health care companies implicitly acknowledged they were plotting to fleece consumers, and have been fleecing them for years. With that acknowledgment came the tacit admission that the industry’s business is based not on respectable returns but on grotesque profiteering and waste – the kind that can give up $2 trillion and still guarantee huge margins.

Chief among the profiteers at the White House event were insurance companies, which have raised premiums by 119 percent since 1999, and one obvious question is why – why would Obama engage those particular thieves?

It’s a difficult query to answer, because Obama is a health care mystery, struggling to muster consistent positions on the issue.

Listening to a 2003 Obama speech, it’s hard to believe he has become such an enigma. Back then, he declared himself “a proponent of a single-payer universal health care program” – i.e., one eliminating private insurers and their overhead costs by having government finance health care. Obama’s position was as controversial then as today – which is to say, controversial among political elites, but not among the public. ABC’s 2003 poll showed almost two-thirds of Americans desiring a single-payer system “run by the government and financed by taxpayers,” just as CBS’ 2009 poll shows roughly the same percentage today.

In that speech six years ago, Obama said the only reason single-payer proponents should tolerate delay is “because first we have to take back the White House, we have to take back the Senate, and we have to take back the House.”

This might explain why when Illinois contemplated a 2004 health care proposal raising insurance lobbyists’ “fears that it would result in a single-payer system,” those lobbyists “found a sympathetic ear in Obama, who amended (read: gutted) the bill more to their liking,” according to the Boston Globe. Maybe Obama didn’t think single payer was achievable without a Democratic Washington. And when, in a 2006 interview, he told me he was “not convinced that (single payer) is the best way to achieve universal health care,” perhaps he was following the same rationale, considering his insistence that he must “take into account what is possible.”

Of course, even as a senator aiming for the “possible” in a Republican Congress, Obama promised to never “shy away from a debate about single payer.” And after the 2008 election fulfilled his single-payer precondition of Democratic dominance, it was only logical to expect him to initiate that debate.

That’s why the White House’s current posture is so puzzling. As the Associated Press reports, Obama aides are trying to squelch any single-payer discussion, deploying their health care point-person, Sen. Max Baucus, D-Mont., to announce that “everything is on the table with the single exception of single-payer.”

So it’s back to why – why Obama’s insurance industry-coddling inconsistency? Is it a pol’s payback for campaign cash? Is it an overly cautious lawmaker’s paralysis? Is it a conciliator’s desire to appease powerful interests? Or is it something else?

For a president who spends so much time on camera answering questions, these have become the biggest unanswered questions.

David Sirota is a fellow at the Campaign for America’s Future. Find his blog at OpenLeft.com or e-mail him at ds@davidsirota.com.

This article appeared on page A – 13 of the San Francisco Chronicle
http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/05/14/EDMF17KIVP.DTL

Health-care status quo pushing out single-payer advocates in nation’s capital

By Amy Goodman
Syndicated columnist
The Seattle Times
Thursday, May 14, 2009

Barack Obama appeared this week with health-industry bigwigs, proclaiming light at the end of the health-care tunnel. Among those gathered were executives from HMO giants Kaiser Foundation Health Plan and Health Net Inc., and the health-insurance lobbying group America’s Health Insurance Plans; from the American Hospital Association and the American Medical Association; from medical-device companies; and from the pharmaceutical industry, including the president and CEO of Merck and former Rep. Billy Tauzin, now president and CEO of PhRMA, the massive industry lobbying group. They have pledged to voluntarily shave some $2 trillion off U.S. health-care costs over 10 years. But these groups, which are heavily invested in the U.S. health-care status quo, have little incentive to actually make good on their promises.

This is beginning to look like a replay of the failed 1993 health-care reform efforts led by then-first lady Hillary Rodham Clinton. Back then, the business interests took a hard line and waged a PR campaign, headlined by a fictitious middle-class couple, Harry and Louise, who feared a government-run health-care bureaucracy.

Still absent from the debate are advocates for single-payer, often referred to as “Canadian-style” health care. Single-payer health care is not “socialized medicine.” According to Physicians for a National Health Program, single-payer means “the government pays for care that is delivered in the private (mostly not-for-profit) sector.”

A February CBS News poll found that 59 percent in the U.S. say the government should provide national health insurance.

Single-payer advocates have been protesting in Senate Finance Committee hearings, chaired by Democratic Montana Sen. Max Baucus. Last week, at a committee hearing with 15 industry speakers, not one represented the single-payer perspective. A group of single-payer advocates, including doctors and lawyers, filled the hearing room and, one by one, interrupted the proceedings.

Protester Adam Schneider yelled: “We need to have single-payer at the table. I have friends who have died, who don’t have health care, whose health care did not withstand their personal health emergencies. … Single-payer now!”

Baucus gaveled for order, guffawing, “We need more police.” The single-payer movement has taken his words as a rallying cry. At a hearing Tuesday, five more were arrested. They call themselves the “Baucus 13.”

One of the Baucus 13, Kevin Zeese, recently summarized Baucus’ career campaign contributions:

“… from the insurance industry, $1,170,313; from health professionals, $1,016,276; pharmaceuticals/health-products industry, $734,605; hospitals/nursing homes, $541,891; health services/HMOs, $439,700.”

That’s almost $4 million from the very industries that have the most to gain or lose from health-care reform.

Another of the Baucus 13, Russell Mokhiber, co-founder of SinglePayerAction.org, has been charged with “disruption of Congress.”

He was quick to respond: “I charge Baucus with disrupting Congress. It once was a democratic institution; now it’s corrupt, because of people like him. He takes money from the industry and does their bidding. He won’t even diffuse the situation by seating a single-payer advocate at the table.”

As I traveled through Montana recently, from Missoula to Helena to Bozeman, health-care activists kept referring to Baucus as the “money man.” Montana state Sen. Christine Kaufmann sponsored an amendment to the Montana Constitution, granting everyone in Montana “the right to quality health care regardless of ability to pay,” or health care as a human right. It died in committee.

Wisconsin Sen. Russ Feingold, a single-payer advocate, said his position will not likely prevail in Washington: “I don’t think there’s any possibility that that will come out of this Congress.” That’s if things remain business as usual.

Mario Savio led the Free Speech Movement on the UC Berkeley campus. In 1964, he said: “There comes a time when the operation of the machine becomes so odious, makes you so sick at heart, that you can’t take part, you can’t even passively take part, and you’ve got to put your bodies upon the gears and upon the wheels, upon all the apparatus, and you’ve got to make it stop. And you’ve got to indicate to the people who run it, the people who own it, that unless you’re free, the machine will be prevented from working at all.”

“Unless you’re free,” the Baucus 13 might add, “to speak.” The current official debate has locked single-payer options out of the discussion, but also escalated the movement — from Healthcare-NOW! to Single Payer Action — to shut down the orderly functioning of the debate, until single-payer gets a seat at the table.

Amy Goodman is the host of “Democracy Now!,” a daily international TV/radio news hour airing on more than 750 stations in North America. Denis Moynihan contributed research to this column.

Universal health care: Private enterprise can’t fix our ailing system

By PAUL DeMARCO
Spartanburg (S.C.) Herald-Journal
Sunday, May 17, 2009

I live in a town with a population of 7,000. I own a pair of shotguns, and I know how to use them — a wood duck and a turkey are mounted on my office wall. I drive a 2001 Dodge Dakota pickup with 150,000 miles on it.

I wear a coat and tie every day to work. I’m in church each Sunday and am not embarrassed to tell you that Jesus is my Savior. I believe in chivalry; I open doors for women and expect my teenage daughter’s dates to come into the house when they visit.

My usual TV-watching dilemma is “The Andy Griffith Show” or “M*A*S*H.” I’m about as old-fashioned, square and conservative as they come.

So where do I get off backing a single-payer national health plan, a plan where everybody’s covered in one big risk pool and health care is publicly financed (but privately delivered)? Shouldn’t I be a rugged individualist, telling people that if they want good health insurance they can pay attention in class, go to college and get a good job with full benefits just like I did?

Well, part of me could do that. No country can survive unless individual responsibility is at the core of its ethos.

But to the other part of me, the go-it-alone attitude just sounds downright mean.

That puts me in about the same mind-set as a Midwestern farmer in the mid-19th century. Farmers then and now are often independent, self-sufficient

and hesitant to incur a debt. But when a neighboring family needed a barn raised, that was a different story. No matter how hearty the farmer, he couldn’t raise a barn alone. And there was a healthy dose of self-interest in the proposition. If I help raise your barn, then when mine needs repairs, I’ll have your help.

So I look at single-payer health care in that conservative light. I recognize that a significant portion of America’s chronic disease burden is self-induced (e.g., some people eat, drink or smoke too much and make themselves sick). But I also know that much of your health is beyond your control — it’s either in your genes or not significantly altered by lifestyle. Think breast cancer and many other malignancies, flu and many other infectious diseases, Alzheimer’s dementia or rheumatoid arthritis.

I don’t suspect that farmers of yore did any research on the family who they helped. Whether the family was industrious or lazy, a barn was built because everyone needed a barn. Without a place to store hay and protect animals in the upcoming winter, livestock would die and the family would soon follow. No farmer, no matter how stoic, would consign his neighbor to that fate.

I support single-payer health care in this tradition. A single-payer program, which would expand Medicare to all Americans (rather than just those 65 and over), would create one large barn-raising community, 300-million strong. We would all chip in our share so that all families could have health care. Almost all of us would end up paying less than we do now (there would be no co-pays or deductibles), and we could choose any doctor or hospital we wanted.

Under our present setup, it’s hit and miss. Money typically dictates who gets care and who doesn’t.

A carpenter who works for a big company with insurance may get care; another who works for a small one can only dream about it.

A woman with lupus loses her job and her insurance and then becomes uninsurable because of her pre-existing condition.

A 60-year-old man with a bad knee is laid off when a plant closes in his rural hometown. Lame and unskilled in a region with rising unemployment, he will limp for five years until he qualifies for Medicare and can have his knee replaced.

Barn-raising worked because it is was a nonprofit enterprise. A farming community bound itself in a social contract. Many countries have single-payer social contracts, including our neighbor Canada, to ensure the health of all their citizens. There are many ways to inject a profit motive into the process, but they all taint it. Until the 1960s, medicine was also primarily a nonprofit endeavor. In recent decades, the huge profits available to for-profit insurance companies and hospitals have often elevated shareholders above patients, resulting in higher costs and inferior care.

All my instincts call for problems to be solved by individuals operating in a free-market economy. But private enterprise cannot solve this one. We have 40 years of evidence of the free market’s failure to control costs or cover everyone.

The plain truth is that the public single-payer systems we already have (Medicare, Medicaid and the VA) provide better coverage with less overhead than private companies. I know that statement is hard for many, including me, to swallow, but it’s true.

Medicare for all will not be a perfect system, but it will be far better than the fragmented, profit-warped system we have.

When America was younger, we knew not to turn our backs on new neighbors in need of a barn. In this older — and I hope wiser — America, we should not turn our backs on those who need health care. Tell your representative and senators to put single payer on the table in Washington.

Paul DeMarco, MD is a general internist who lives in Marion. He is a member of Physicians for a National Health Program (www.pnhp.org).

What Is ‘Socialized Medicine’?: A Taxonomy of Health Care Systems

By Uwe E. Reinhardt
New York Times
Economix Blog
May 8, 2009, 6:48 am

With another “national conversation” about health reform upon us — as it is every decade or so — we will hear a lot of derisive talk about the evils of “socialized medicine.”

The term is regularly confused with “social health insurance,” which is not at all the same concept. The chart below may be helpful in appreciating the distinction.

Socialized medicine refers to health system in which the government owns and operates both the financing of health care and its delivery. Cell A in the chart represents socialized medicine.

Social health insurance, on the other hand, refers to systems in which individuals transfer their financial risk of medical bills to a risk pool to which, as individuals, they contribute taxes or premiums based primarily on ability to pay, rather than on how healthy or sick they are.

Socialized medicine is one form of social insurance. More typically, however, social insurance is coupled on the health-care delivery side with a mixture of government-owned facilities (e.g., municipal hospitals), private nonprofit hospitals (roughly 90 percent of all American hospital beds) or private for-profit facilities (investor-owned hospitals, private medical practices, pharmacies and so on). It follows that one cannot simply treat social insurance as socialized medicine. In principle, one could have social insurance with 100 percent private for-profit delivery facilities.

Under private commercial insurance, individuals also transfer the financial risk of bills for health care to a risk pool, but the premium the individual contributes to the risk pool reflects that individual’s health status. These premiums are, as actuaries put it, “medically underwritten” and “actuarially fair.” The risk pools under private insurance can be operated by not-for-profit or for-profit insurers. And like social insurance, private insurance typically is coupled with a mixed private and public delivery system.

In the chart, cells A, B, C jointly represent single-payer social insurance — e.g., traditional Medicare. Cells D, E, F jointly represent multiple-payer social insurance — e.g., Medicaid Managed Care. Cells G to L jointly represent individually purchased private insurance with actuarially fair premiums. Finally, cells M, N and O represent the uninsured or the cost-sharing portion of insured persons.

In between these distinct systems falls employment-based health insurance.

Large employers typically self-insure and use private insurers only to procure health care on behalf of employees (e.g., negotiate fees with the providers of health care) and administer claims. Other employers do not self-insure and instead purchase so-called group health insurance policies for all their employees jointly, as if they were one large family. The premium for a group policy is “experience rated” over the covered group of employees, which means that they reflect the average actuarial cost of all of one company’s employees.

The individual employee’s own contribution toward his or her employment-based insurance, however, is divorced from the individual’s (or the attached family’s) health status. In this sense, then, employment-based insurance could be described as “private social insurance,” as distinct from “government-run social insurance.”

Former Mayor Rudolph Giuliani of New York has exemplified the perennial confusion in this country over socialized medicine. In his ill-fated presidential bid, and subsequently as a supporter of Senator John McCain’s bid for the presidency, Mr. Giuliani routinely decried as socialized medicine (or “socialist”) any proposal presented by Democratic candidates, because typically the latter advocated tax-financed subsidies toward the purchase of health private insurance or expansions of public insurance programs. But technically none of them advocated socialized medicine.

Perhaps Mr. Giuliani was unaware that Americans all along the ideological spectrum reserve the purest form of socialized medicine — the V.A. health system — for the nation’s veterans. I find this cognitive dissonance amusing. Indeed, if socialized medicine is so evil, why didn’t Republicans privatize the V.A. health system when they controlled both the White House and the Congress during 2001-06?

Mr. Giuliani also seems to forget that, in 1996, he found social health insurance a perfect solution to the financial problems faced by former Mayor John V. Lindsay, who fell on financially hard times during the 1990s as a result of chronic illness.

In a fit of compassion, then Mayor Giuliani rushed to his friend’s assistance with — you guessed it — taxpayers’ money, rather than with a private sector solution. He did so by appointing Mr. Lindsay to two no-show city jobs that came with tax-financed municipal health insurance and a tax-financed pension.

It seems fair, then, to ask Mr. Giuliani why it was perfectly fine to bail out a financially distressed man who had been wealthy enough in his younger years to provide adequately for his old age, when proposals to extend the same kind of assistance to hard-working, uninsured members of lower-income families are decried by him as “socialism.”

One can only hope that our members of Congress and the typical American voter can make the right distinctions.

Uwe E. Reinhardt is an economics professor at Princeton.

Senate Finance report on financing health care reform

Baucus, Grassley Release Policy Options for Financing Comprehensive Health Care Reform

United States Senate
Committee on Finance
News Release
May 18, 2009
The options released today are the third and final round of policy options for discussion before the Finance Committee marks up legislation in June. The options for financing health reform follow the release of policy options for reducing costs in the health care delivery system and for expanding quality, affordable health care coverage to all Americans. Three areas of potential funding sources explored in the financing options are: savings achieved from within the health care system from reductions in current levels of spending; reevaluating current health tax subsidies; and changing non-health tax provisions.
Reducing Geographic Variation
Researchers at Dartmouth and elsewhere have found that health care spending varies widely across the United States. Moreover, higher health care spending does not correspond to better quality care of care. The portion of total spending on health care items and services that do not produce better health outcomes is estimated to be as high as 30 percent of Medicare spending. The policy options explore ways to reduce geographic spending variation by reducing Medicare payments in areas where spending is above the national average. Adjustments would be made to reflect differences in input prices and beneficiary health status.
Exclusion for Employer-Provided Health Insurance
Under current law, employer-provided health insurance is not counted as income for tax purposes and the amount of health care benefits that are counted as tax free is unlimited. This tax-free status encourages employers to offer ā€œCadillac plans,ā€ or overly generous health care plans that promote the overuse of health care services and drive up health care costs. Moreover, the plans are subsidized by taxpayers as a result of being tax free. The policy options explore five changes to make the exclusion more equitable and efficient. These options include capping the exclusion based on the value of health insurance policy or the income level of the employee eligible for the exclusion. A third option would be to cap the exclusion based on both the value of the health insurance policy and income level. Another option would be to convert the employer-provided health insurance exclusion to an individual tax deduction or credit. The options also consider whether to grandfather in existing plans so that benefits provided under existing collective bargaining agreements are not limited.
http://finance.senate.gov/press/Bpress/2009press/prb051809.pdf
Financing Comprehensive Health Care Reform: Proposed Health System Savings
and Revenue Options (41 pages):
http://finance.senate.gov/sitepages/leg/LEG%202009/051809%20Health%20Care%20Description%20of%20Policy%20Options.pdf
The two previous reports:
Transforming the Health Care Delivery System: Proposals to Improve Patient
Care and Reduce Health Care Costs (52 pages):
http://finance.senate.gov/sitepages/leg/LEG%202009/042809%20Health%20Care%20Description%20of%20Policy%20Option.pdf
Expanding Health Care Coverage: Proposals to Provide Affordable Coverage to
All Americans (63 pages):
http://finance.senate.gov/sitepages/leg/LEG%202009/051109%20Health%20Care%20Description%20of%20Policy%20Options.pdf

Tomorrow the members of the Senate Finance Committee will retreat to a closed-door session, taking this report with them to walk through their options for financing comprehensive health care reform. Sen. Baucus and others have said that the success of the reform effort is dependent on their ability to find ways to pay for it. What are their prospects for success?
Most of the options discussed in this report are merely tweaks to our current system of financing health care and can have very little impact in overall health care spending. Some of the changes would be beneficial and some are problematic, but most would fall far short of the financing needs of the multi-payer model that the committee has selected.
There are two potential sources that involve real money, though one is quite explicit and the other is not much more than an abstraction.
Reducing the 30 percent of spending in Medicare that does not improve outcomes (Dartmouth Atlas) would seem like a logical source of funds to pay for reform, but recapturing those funds would be very difficult. Merely reducing payments in regions where spending is above average is a very blunt instrument that can have serious negative impacts even if there were some reduction in waste. Also, no mention is made in this report of the Medicare underpayment in other regions.
A much more appropriate use of any wasted funds that could be recovered would be to increase payments in regions that are underfunded, and to shift funds to services that would improve the quality and efficiency of the system, especially by expanding primary care. If these changes were made not only in Medicare, but in our entire health care system, that would entail a large shift in spending, but only as a redistribution of funds. It is merely an abstraction to think of this as a new source of additional funds to finance the other components of the reform proposal.
The real money is in the tax subsidy we provide by making employer-sponsored insurance a tax deductible benefit. That amounts to about $137 billion. A table in the report lists many other tax subsidies for a total of $194 billion, plus another $93 billion for reduced payroll taxes to make a grand total of $287 billion. It is really the $137 billion that is important since the other numbers are primarily accounting issues. For instance, the $93 billion in reduced payroll taxes must be offset by payroll taxes on the balance of income and/or by other taxes if the Medicare and Social Security programs are to remain solvent.
Can we simply eliminate the tax deductibility of employer-sponsored plans and shift that $137 billion to the reform proposals? No. Since premiums for employer-sponsored plans are paid by employees in the form of forgone wage increases, workers could not collectively afford to pay the additional 137 billion in premium costs. If the deductibility is eliminated, that $137 billion would have to be returned to the workers in the form of tax credits,vouchers, or personal tax deductions. Poof! There goes the real money that the committee is counting on finding somewhere.
The report suggests that since the tax deductibility of employer-sponsored coverage represents a regressive tax policy (the wealthy have more of their premium subsidized with taxes than do lower-income individuals) some of the $137 billion could be recovered from higher-income individuals, even if it would result in more administrative complexities. But then how much are you recovering to pay for reform? Maybe $20 billion? That doesn’t help much with our $2.5 trillion health care budget.
The tragedy is that the report that they are taking into closed session gives them very little to work with. At the hearing leading up to this report, they had arrested the individuals who would explain that we very easily could free up maybe $400 billion in pure waste merely by replacing our dysfunctional multi-payer system with a single payer national health program. Even for those who contend that the amount would not be that great, it would still be far, far more than any other proposal on the table.
To keep single payer off the table, to exclude it from their report, and to slam the door on it as they retreat to their secret sessions constitutes legislative malpractice. We should sue them for triple damages. $1,200 billion would certainly pay for a lot of health care. We can pretend that they can come up with $1,200 billion just as they are pretending that they can come up with the funds to pay for the most expensive model of health care reform ever devised, and, at that, one that falls far short on equity, efficiency and universality.

Senate Finance report on financing health care reform

Baucus, Grassley Release Policy Options for Financing Comprehensive Health Care Reform

United States Senate
Committee on Finance
News Release
May 18, 2009

The options released today are the third and final round of policy options for discussion before the Finance Committee marks up legislation in June. The options for financing health reform follow the release of policy options for reducing costs in the health care delivery system and for expanding quality, affordable health care coverage to all Americans. Three areas of potential funding sources explored in the financing options are: savings achieved from within the health care system from reductions in current levels of spending; reevaluating current health tax subsidies; and changing non-health tax provisions.

Reducing Geographic Variation

Researchers at Dartmouth and elsewhere have found that health care spending varies widely across the United States. Moreover, higher health care spending does not correspond to better quality care of care. The portion of total spending on health care items and services that do not produce better health outcomes is estimated to be as high as 30 percent of Medicare spending. The policy options explore ways to reduce geographic spending variation by reducing Medicare payments in areas where spending is above the national average. Adjustments would be made to reflect differences in input prices and beneficiary health status.

Exclusion for Employer-Provided Health Insurance

Under current law, employer-provided health insurance is not counted as income for tax purposes and the amount of health care benefits that are counted as tax free is unlimited. This tax-free status encourages employers to offer “Cadillac plans,” or overly generous health care plans that promote the overuse of health care services and drive up health care costs. Moreover, the plans are subsidized by taxpayers as a result of being tax free. The policy options explore five changes to make the exclusion more equitable and efficient. These options include capping the exclusion based on the value of health insurance policy or the income level of the employee eligible for the exclusion. A third option would be to cap the exclusion based on both the value of the health insurance policy and income level. Another option would be to convert the employer-provided health insurance exclusion to an individual tax deduction or credit. The options also consider whether to grandfather in existing plans so that benefits provided under existing collective bargaining agreements are not limited.

http://finance.senate.gov/press/Bpress/2009press/prb051809.pdf

Financing Comprehensive Health Care Reform: Proposed Health System Savings
and Revenue Options (41 pages):
http://finance.senate.gov/sitepages/leg/LEG%202009/051809%20Health%20Care%20Description%20of%20Policy%20Options.pdf

The two previous reports:

Transforming the Health Care Delivery System: Proposals to Improve Patient
Care and Reduce Health Care Costs (52 pages):
http://finance.senate.gov/sitepages/leg/LEG%202009/042809%20Health%20Care%20Description%20of%20Policy%20Option.pdf

Expanding Health Care Coverage: Proposals to Provide Affordable Coverage to
All Americans (63 pages):
http://finance.senate.gov/sitepages/leg/LEG%202009/051109%20Health%20Care%20Description%20of%20Policy%20Options.pdf

Comment:

By Don McCanne, MD

Tomorrow the members of the Senate Finance Committee will retreat to a closed-door session, taking this report with them to walk through their options for financing comprehensive health care reform. Sen. Baucus and others have said that the success of the reform effort is dependent on their ability to find ways to pay for it. What are their prospects for success?

Most of the options discussed in this report are merely tweaks to our current system of financing health care and can have very little impact in overall health care spending. Some of the changes would be beneficial and some are problematic, but most would fall far short of the financing needs of the multi-payer model that the committee has selected.

There are two potential sources that involve real money, though one is quite explicit and the other is not much more than an abstraction.

Reducing the 30 percent of spending in Medicare that does not improve outcomes (Dartmouth Atlas) would seem like a logical source of funds to pay for reform, but recapturing those funds would be very difficult. Merely reducing payments in regions where spending is above average is a very blunt instrument that can have serious negative impacts even if there were some reduction in waste. Also, no mention is made in this report of the Medicare underpayment in other regions.

A much more appropriate use of any wasted funds that could be recovered would be to increase payments in regions that are underfunded, and to shift funds to services that would improve the quality and efficiency of the system, especially by expanding primary care. If these changes were made not only in Medicare, but in our entire health care system, that would entail a large shift in spending, but only as a redistribution of funds. It is merely an abstraction to think of this as a new source of additional funds to finance the other components of the reform proposal.

The real money is in the tax subsidy we provide by making employer-sponsored insurance a tax deductible benefit. That amounts to about $137 billion. A table in the report lists many other tax subsidies for a total of $194 billion, plus another $93 billion for reduced payroll taxes to make a grand total of $287 billion. It is really the $137 billion that is important since the other numbers are primarily accounting issues. For instance, the $93 billion in reduced payroll taxes must be offset by payroll taxes on the balance of income and/or by other taxes if the Medicare and Social Security programs are to remain solvent.

Can we simply eliminate the tax deductibility of employer-sponsored plans and shift that $137 billion to the reform proposals? No. Since premiums for employer-sponsored plans are paid by employees in the form of forgone wage increases, workers could not collectively afford to pay the additional 137 billion in premium costs. If the deductibility is eliminated, that $137 billion would have to be returned to the workers in the form of tax credits,vouchers, or personal tax deductions. Poof! There goes the real money that the committee is counting on finding somewhere.

The report suggests that since the tax deductibility of employer-sponsored coverage represents a regressive tax policy (the wealthy have more of their premium subsidized with taxes than do lower-income individuals) some of the $137 billion could be recovered from higher-income individuals, even if it would result in more administrative complexities. But then how much are you recovering to pay for reform? Maybe $20 billion? That doesn’t help much with our $2.5 trillion health care budget.

The tragedy is that the report that they are taking into closed session gives them very little to work with. At the hearing leading up to this report, they had arrested the individuals who would explain that we very easily could free up maybe $400 billion in pure waste merely by replacing our dysfunctional multi-payer system with a single payer national health program. Even for those who contend that the amount would not be that great, it would still be far, far more than any other proposal on the table.

To keep single payer off the table, to exclude it from their report, and to slam the door on it as they retreat to their secret sessions constitutes legislative malpractice. We should sue them for triple damages. $1,200 billion would certainly pay for a lot of health care. We can pretend that they can come up with $1,200 billion just as they are pretending that they can come up with the funds to pay for the most expensive model of health care reform ever devised, and, at that, one that falls far short on equity, efficiency and universality.

Put single-payer on the table

Editorial
Times Union (Albany, NY)
Tuesday, May 19, 2009

Earlier this month, eight courageous doctors, lawyers and other activists interrupted a Senate Finance Committee meeting on health care reform to ask why there wasn’t one advocate of a single-payer health care system at the table. Chairman Max Baucus, a Montana Democrat, had them arrested. Shame on Senator Baucus, and shame on Congress if it continues to stifle debate on one of the biggest issues facing this country.

To claim, as they have, that “everything is on the table” except a nationalized health insurance system, similar to what many other modern, industrial Western nations have, is much like saying the Thanksgiving meal is complete, except for the turkey.

We are not saying single-payer is necessarily the answer. We are saying that a full discussion of the future of health care in America can’t take place if all credible potential solutions aren’t examined.

We are mindful that there are powerful pressures on President Obama and Congress against discussing a government-run health care program — whether it is one that coexists with a private insurance market or one, like single-payer, that replaces it entirely. There are the inevitable charges from critics on the right of the S-word — socialism — at any hint of the government suggesting it could do a better job than the private sector.

And then there’s the vast and entrenched health care industry, looking to scuttle mere talk of a plan that might help the nation gain control of spiraling health care costs and provide decent, affordable coverage to the 50 million people without it. Hence its vague offer last week to trim an astounding $2 trillion in costs over 10 years. That the industry could shave $2 trillion, just like that, would seem to only hint at the excess there is in the current health care system.

And what exactly was this offer?

To trim future growth from a crushing 7 percent a year to a still-unsustainable 5.5 percent. And if costs grow faster anyway? Will we be told, well, it’s still less than it might have been?

We recognize that Democrats would want to avoid the more uncomfortable discussion. There are many — including New York’s own Sen. Charles Schumer — who agree a single-payer system is the solution America needs, but that it isn’t practical right now.

Well, if we can’t even discuss it now — when the country is in a recession and the ranks of the uninsured are growing; when major industries like automakers are buckling, in no small measure because of health care costs; when Americans are poised for change and the party that promised it is in power — then when?

Perhaps those who prefer to shy away from the uncomfortable yet absolutely necessary discussion could take courage from 75 members of Congress, including 10 from New York — among them freshman Democrat Paul Tonko of Amsterdam — who signed on to Rep. John Conyers Jr.’s single-payer bill. Or from the people who earlier this month, at the risk of arrest, went to Washington to say what they thought was best for the nation.

We’d like to imagine we sent our representatives there for the same reason.

The issue:

Congress shut down debate on a single-payer health care system before it even started.

The Stakes:

A solution that many believe is the best for the nation needs to at least be discussed.