PNHP

The real health care lessons from Europe

The real health care lessons from Europe

By Irfan Dhalla and Chris Mackie
Ottawa Citizen
March 17, 2009

In Belgium, there are four doctors for every 1,000 residents compared to 2.1 per 1,000 in Canada.

In the United Kingdom, the government has established an independent agency to evaluate new technologies before paying for expensive treatments that do not provide significant benefit.

In Denmark, local governments play a role in deciding where family doctors will establish their practices and more than 80 per cent of health care is paid for publicly, compared with about 70 per cent in Canada.

Yet instead of returning from his recent European sojourn trumpeting these facts and all the ways we might innovate within medicare, Canadian Medical Association president Dr. Robert Ouellet has decided that what makes health care work in Europe is that they make better use of the private sector (as favourably reported in the Citizen editorial “Medical improvement,” March 7).

If our goal is merely to convince Canadians that privatization can improve health care, selectively citing some European examples is a pretty good strategy.

But if we truly want to bring the lessons of European health care to Canada, we should realize that privatization has never been the European prescription.

In fact, in almost all European countries, privatization has played only a cameo role.

Some of the lessons of Europe can already be found in Canada.

Across our own country, small-scale solutions are being implemented that are making our system safer, more effective, and more efficient.

Electronic prescribing, integrated home care, centralized waiting lists, better health technology assessment, and increased team-based care are just a few.

But instead of suggesting how we might improve medicare, Dr. Ouellet argues not only for increased private funding, which would mean user fees and a greater role for private insurance companies, but also for increased private delivery within the publicly funded system.

If he examined the evidence, including that produced by the organization he leads, Dr. Ouellet would know that the debates about user fees and private insurance are essentially dead.

Economists have repeatedly demonstrated that user fees reduce health care consumption and short-term costs. But the same research also shows that user fees reduce both necessary and unnecessary health care. Patients often don’t know whether they need to see a doctor or not.

Ignoring a nagging cough that’s been hanging on for a week is unlikely to cause harm. But ignoring a painless lump under the armpit might delay a diagnosis of cancer.

So we should continue to encourage people to seek care early by keeping doctor visits free.

Similarly, private insurance has repeatedly been demonstrated to be both inefficient and unfair. Insurance companies don’t want to insure people who are likely to need health care. Even when they do provide insurance, they use every tool at their disposal to avoid paying out on claims.

Using the private sector to provide publicly funded health care admittedly has some intuitive appeal. At least it used to back in the good old days when we all believed in the supremacy of the market.

But if the economic crisis has taught us anything it should be that we need to be wary of those who answer “privatization” regardless of the question.

Market-based competition in health care might look good on paper, but it doesn’t always work in practice. Many towns need only a single hospital, which makes competition impossible. And even in urban areas, hospitals that are forced to compete rather than co-operate tend to end up fighting over the least complicated and most profitable patients, leaving fewer options for those with complex illnesses who are in greatest need of care.

We should all be wary of selective comparisons to European countries that are devoid of context.

Most European countries are geographically tiny, which makes their health care systems easier to organize. Their social safety nets are more tightly woven, income taxes are higher, and health care professionals are usually paid significantly less — in part because they cannot easily emigrate to the United States.

Is Dr. Ouellet arguing for higher income taxes and lower pay for Canadian doctors?

Although there is much to learn from Europe, and even from the United States, we have a long list of worthwhile innovations right here in Canada that we know will improve our health care system if they are implemented more widely.

What ordinary doctors and Canadians want to see is a movement for change in health care that draws on those aspects of European systems that are based on evidence and consistent with our values.

Dr. Irfan Dhalla is a general internist at St. Michael’s Hospital in Toronto. Dr. Chris Mackie is a public health physician in Hamilton. Both sit on the board of Canadian Doctors for Medicare.

(c) Copyright The Ottawa Citizen

Single-payer health care system touted

150 rally in support of concept at regional forum at UVM

By Nancy Remsen
Burlington Free Press
March 18, 2009

Dr. John Walsh, a neuroscience researcher from Worcester, Mass., stood Tuesday with 150 other sign-carrying supporters of government-financed health care outside the building where 400 invited guests would attend a regional health care reform forum sponsored by the Obama White House. Walsh passed out yellow fliers that denounced President Barack Obama for failing to live up to promises to consider a Canadian-style health insurance system. “Single payer is the choice in the polls,” Walsh declared.

Sandy Eaton of Quincy, Mass., and a member of the Massachusetts Nurses Association, came to the only forum scheduled for the Northeast to add his voice to those demanding that national policymakers weigh the merits of a government-financed system when they discuss reform options. “Let’s make sure there is a fair and legitimate comparison,” Eaton said.

Rebecca Elgie, a retired teacher, traveled six hours from Ithaca, N.Y., because she has made advocacy for a single-payer system her cause. Three years ago she walked 400 miles across her state to raise awareness about the need for a better way to pay for health care. Elgie said, “The employee-based system has outlived its usefulness.”

The rally greeted the invited guests as they strolled toward the Davis Center at the University of Vermont under a bright blue sky. “They need to know there is enough support for people to drop everything and come here to support single payer,” said Dr. Deb Richter, a Montpelier family physician and prime force in the single-payer movement in Vermont.

“Barack Obama is with us,” Richter told the rally participants. “President Obama is in a leaky boat out there in an ocean surrounded by sharks. We can’t expect President Obama to stick his toe in the water. He needs our help. That is why we are here today.”

Many at the rally were sure single-payer advocates would be ignored during the forum, even though some, including Richter, had tickets. But Gov. Deval Patrick of Massachusetts, who co-hosted the forum with Gov. Jim Douglas of Vermont, didn’t duck the topic. He put a spotlight on it.

“Is there one way?” Patrick asked the audience. “Should we have a couple of different ways or should we have a national template? Let’s talk a little about single payer.”

Richard Slusky, chief executive at Mount Ascutney Hospital in Windsor, described himself as a single-payer advocate, but added, “It doesn’t have to be an absolute, government-run system. We can have a system that involves the private sector.”

Susan Baker of the Vermont Public Interest Research Group said, “People want choice.” She said a publicly financed health insurance option should be available to anyone, not just those with low income.

Patrick called on Richter, who sat in a front row in her white coat. Noting the administrative burden that physicians face dealing with dozens of health insurance payers, Richter asked, “Why would we even need private insurance?”

Jim Hughes, a retired physician from West Fairlee, observed the sky didn’t fall when Patrick, a politician, dared to say the words “single payer.”

“We ought to talk about it,” Patrick said.

Nancy-Ann DeParle, director of the White House Office of Health Reform, offered a cautionary note about a single-payer system. She asked how many in the audience had health insurance, and then asked, “How many people would want to change what they have? That is one thing we have to keep in mind.”

Later at a news conference, Douglas replied to a question about the prospects of the single-payer concept with a warning about the politics of the issue. “There are lots of different ideas. We can move in a significant way without moving so dramatically that it is difficult to gain consensus.”

Other speakers posed questions for policymakers to consider as they fashion a new health system.

“What will you do for the next generation?” asked Bronwyn Fleming-Jones, a University of Vermont senior worried about how she will pay for health insurance after she graduates in two months.

Will reform consider the importance of home health care? asked Gary Sheehan, president of Cape Medical Supply.

Ira Byock, director of palliative care at Dartmouth-Hitchcock Medical Center, urged policymakers to “focus on people, not patients and think beyond the silo of the health care budget.”

DeParle and the two governors will report to Obama about the forum. Three more forums are scheduled in other areas of the country. DeParle said she was learning information about programs that work, ideas that should be tried and political strategy to win support for change.

“You have two governors here who figured out how to get that support,” DeParle said.

“It took a very broad coalition to come together to design health care reform in Massachusetts and they have stayed together,” Patrick said. He added, it also took a realization “that there were other choices than the two choices on the table — the perfect solution and no solution at all.”

Contact Nancy Remsen at 578-5685 or nremsen@bfp.burlingtonfreepress.com.

http://www.burlingtonfreepress.com/article/20090318/NEWS03/90318001

Link to many photos:
http://www.burlingtonfreepress.com/apps/pbcs.dll/gallery?Avis=BT&Dato=20090317&Kategori=NEWS&Lopenr=903170803&Ref=PH

SCHIP – a lesson on demographic incrementalism

Beyond Incrementalism? SCHIP And The Politics Of Health Reform

by Jonathan B. Oberlander and Barbara Lyons
Health Affairs
March 17, 2009
Given the enormous political and fiscal barriers to adopting legislation that aims for universal or near-universal coverage, it could be tempting for Congress and the Obama administration to follow the expansion of children’s health insurance with further incremental measures. The political appeal of such a strategy is understandable: maximizing consensus on incremental policies while avoiding harder, more polarizing, and more expensive reforms is a time-tested strategy in U.S. health policy. Indeed, it is the exact political formula that produced SCHIP’s enactment in 1997. Advocates of incrementalism have long recognized that political constraints mean that the alternative to imperfect, limited reforms is, alas, often to do nothing. In that context, incrementalism looks quite appealing–a fallback position seemingly validated by the repeated failure of big-bang reform.
Yet there are real limits to incremental health reform. After all, despite gains in Medicaid and SCHIP, almost nine million children remain uninsured. The insurance system for children, notwithstanding their sympathetic status, is beset by the same problems that plague the rest of the U.S. health care system: fragmentation, inequality, and alarming coverage gaps. It is a sobering reminder of just how far the country has to go in health reform that we have not been able to secure universal coverage even for children.
There are also limits to a health reform strategy premised on demographic incrementalism that insures Americans group by group. Unlike children or the elderly, most uninsured Americans do not fit into sympathetic population subgroups that can be neatly matched to public programs. The SCHIP formula can only take us so far, since “all the ‘good’ (that is, politically attractive) populations are taken.” To make significant progress toward covering all Americans, we will have to adopt insurance expansions that don’t simply target politically attractive populations.
If the past decade has proved anything in American health policy, it is that incrementalism is not enough. A decade of incrementalism and inaction has left us with higher costs and rising numbers of uninsured Americans; absent decisive action, those trends will only worsen in coming years. It is encouraging, then, that both the Obama administration and key players in Congress are now pursuing bolder reforms. Perhaps we are entering a new era where U.S. health policy will finally move beyond incrementalism.
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w399v1

Incrementalism: the crossroads of policy and politics.
When each attempt at comprehensive reform fails, the usual response is for everyone to walk away. A few come back to try to retrieve whatever little bit that seems to be politically feasible.
The path of incrementalism has failed to slow the increase in costs and has resulted in increases in the numbers of uninsured and now greater increases in the underinsured. Lauding the mini-successes rings hollow when the health care system continues to have “fragmentation, inequality, and alarming coverage gaps.” By any reasonable standard, incrementalism has been a miserable policy failure.
The incrementalists tell us that the Children’s Health Insurance Program (CHIP) shows us that incrementalism can be a very successful approach to reform. There is no question that this program has been beneficial at least for those children covered. The primary detriment is that it reduced the political pressure for more comprehensive reform.
As the authors point out, children are perhaps the most attractive group for demographic incrementalism. It passes the test of politics, but fails on policy. The CHIP program that “covers all children” has left 9 million children without coverage, perpetuating “fragmentation, inequality, and alarming coverage gaps” for children! The very best incremental program that we have enacted in the past four decades has fallen far short of our goals for reform because beneficial policies were traded away in the politics of reform.
We are now at a rare moment in time when the politics seem aligned so that we can set aside incremental approaches for the time being and seriously consider comprehensive reform. The difficulty is that those leading the reform process are already abandoning important beneficial policies in what they believe will be a successful strategy to keep the politics aligned.
Let’s look at one important example. In their article, Oberlander and Lyons describe the fight over “crowd out,” the concept that, as you raise the qualifying income level for a government children’s insurance program, you increase the number of children that will move from private health plans to the public program that provides a better value. The qualifying income level is very problematic because it is middle-income families that have incomes too high to qualify for the program yet too low to readily afford private insurance. Although the opposition to crowd out could be perceived as an attempt to protect the private insurance industry, the policy principle is much more fundamental.
As the authors explain, “The SCHIP debate revolved around the same boundary issues that will determine the fate of comprehensive reform in 2009 and beyond: the balance between public and private insurance, who should be eligible for government subsidies and at what income level, whether health care is an individual responsibility or social good. Those issues are far from resolved.”
So… the intersection of policy and politics. Those who are leading the reform process and who should believe that health care is a social good are supporting policies that will leave the private insurers in charge, invoking the politics of appeasement to satisfy those who believe that health care is an individual responsibility.
If we are going to achieve our goals of affordable, high quality health care for everyone, it is absolutely imperative that we adopt policies that advance health care as a social good. Policies that shift the responsibility to the individual will further increase our problems with fragmentation, inequality, and alarming coverage gaps.
Whether following a path of incrementalism or the enactment of comprehensive reform, this political divide will never go away. Appeasement politics will always be ruinous for the social good of health care.
The bottom line: The politics must support the policies of health care as a social good, with no compromise. The battle must continue until it is successfully executed. Perceptions of defeat are only perceptions. That is not the time to walk away and eventually crawl back on the ragged path of incrementalism. We must continue the charge, no matter the battle scars, until we achieve health care justice for all. Our finances, our health, and our lives depend on it.

SCHIP – a lesson on demographic incrementalism

Beyond Incrementalism? SCHIP And The Politics Of Health Reform

by Jonathan B. Oberlander and Barbara Lyons
Health Affairs
March 17, 2009

Given the enormous political and fiscal barriers to adopting legislation that aims for universal or near-universal coverage, it could be tempting for Congress and the Obama administration to follow the expansion of children’s health insurance with further incremental measures. The political appeal of such a strategy is understandable: maximizing consensus on incremental policies while avoiding harder, more polarizing, and more expensive reforms is a time-tested strategy in U.S. health policy. Indeed, it is the exact political formula that produced SCHIP’s enactment in 1997. Advocates of incrementalism have long recognized that political constraints mean that the alternative to imperfect, limited reforms is, alas, often to do nothing. In that context, incrementalism looks quite appealing–a fallback position seemingly validated by the repeated failure of big-bang reform.

Yet there are real limits to incremental health reform. After all, despite gains in Medicaid and SCHIP, almost nine million children remain uninsured. The insurance system for children, notwithstanding their sympathetic status, is beset by the same problems that plague the rest of the U.S. health care system: fragmentation, inequality, and alarming coverage gaps. It is a sobering reminder of just how far the country has to go in health reform that we have not been able to secure universal coverage even for children.

There are also limits to a health reform strategy premised on demographic incrementalism that insures Americans group by group. Unlike children or the elderly, most uninsured Americans do not fit into sympathetic population subgroups that can be neatly matched to public programs. The SCHIP formula can only take us so far, since “all the ‘good’ (that is, politically attractive) populations are taken.” To make significant progress toward covering all Americans, we will have to adopt insurance expansions that don’t simply target politically attractive populations.

If the past decade has proved anything in American health policy, it is that incrementalism is not enough. A decade of incrementalism and inaction has left us with higher costs and rising numbers of uninsured Americans; absent decisive action, those trends will only worsen in coming years. It is encouraging, then, that both the Obama administration and key players in Congress are now pursuing bolder reforms. Perhaps we are entering a new era where U.S. health policy will finally move beyond incrementalism.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w399v1

Comment:

By Don McCanne, MD

Incrementalism: the crossroads of policy and politics.

When each attempt at comprehensive reform fails, the usual response is for everyone to walk away. A few come back to try to retrieve whatever little bit that seems to be politically feasible.

The path of incrementalism has failed to slow the increase in costs and has resulted in increases in the numbers of uninsured and now greater increases in the underinsured. Lauding the mini-successes rings hollow when the health care system continues to have “fragmentation, inequality, and alarming coverage gaps.” By any reasonable standard, incrementalism has been a miserable policy failure.

The incrementalists tell us that the Children’s Health Insurance Program (CHIP) shows us that incrementalism can be a very successful approach to reform. There is no question that this program has been beneficial at least for those children covered. The primary detriment is that it reduced the political pressure for more comprehensive reform.

As the authors point out, children are perhaps the most attractive group for demographic incrementalism. It passes the test of politics, but fails on policy. The CHIP program that “covers all children” has left 9 million children without coverage, perpetuating “fragmentation, inequality, and alarming coverage gaps” for children! The very best incremental program that we have enacted in the past four decades has fallen far short of our goals for reform because beneficial policies were traded away in the politics of reform.

We are now at a rare moment in time when the politics seem aligned so that we can set aside incremental approaches for the time being and seriously consider comprehensive reform. The difficulty is that those leading the reform process are already abandoning important beneficial policies in what they believe will be a successful strategy to keep the politics aligned.

Let’s look at one important example. In their article, Oberlander and Lyons describe the fight over “crowd out,” the concept that, as you raise the qualifying income level for a government children’s insurance program, you increase the number of children that will move from private health plans to the public program that provides a better value. The qualifying income level is very problematic because it is middle-income families that have incomes too high to qualify for the program yet too low to readily afford private insurance. Although the opposition to crowd out could be perceived as an attempt to protect the private insurance industry, the policy principle is much more fundamental.

As the authors explain, “The SCHIP debate revolved around the same boundary issues that will determine the fate of comprehensive reform in 2009 and beyond: the balance between public and private insurance, who should be eligible for government subsidies and at what income level, whether health care is an individual responsibility or social good. Those issues are far from resolved.”

So… the intersection of policy and politics. Those who are leading the reform process and who should believe that health care is a social good are supporting policies that will leave the private insurers in charge, invoking the politics of appeasement to satisfy those who believe that health care is an individual responsibility.

If we are going to achieve our goals of affordable, high quality health care for everyone, it is absolutely imperative that we adopt policies that advance health care as a social good. Policies that shift the responsibility to the individual will further increase our problems with fragmentation, inequality, and alarming coverage gaps.

Whether following a path of incrementalism or the enactment of comprehensive reform, this political divide will never go away. Appeasement politics will always be ruinous for the social good of health care.

The bottom line: The politics must support the policies of health care as a social good, with no compromise. The battle must continue until it is successfully executed. Perceptions of defeat are only perceptions. That is not the time to walk away and eventually crawl back on the ragged path of incrementalism. We must continue the charge, no matter the battle scars, until we achieve health care justice for all. Our finances, our health, and our lives depend on it.

Health insurance and eye care

Reported Eye Care Utilization and Health Insurance Status Among US Adults

By David J. Lee, PhD; Byron L. Lam, MD; Sahel Arora, BS; Kristopher L. Arheart, EdD; Kathryn E. McCollister, PhD; D. Diane Zheng, MS; Sharon L. Christ, MS; Evelyn P. Davila, MPH
Archives of Ophthalmology
March 2009
The association between low eye care utilization rates and lack of, or inconsistent, health insurance coverage, even after adjustment for income and educational attainment, suggests that overall ocular health care access would be enhanced if progress is made toward securing coverage for the 46.6 million Americans who do not currently have health insurance. Our findings have also identified troubling gaps in eye care utilization among adults with health insurance coverage. Adults who reported an interruption in health insurance coverage in the 12 months prior to the interview were less likely to report a visit to an ocular health care provider than were those who were consistently insured. In our analyses, 3.8% or an estimated 7.8 million US community-residing adults annually reported such a coverage gap in the past 12 months.
We also found that adults who reported concurrent private and public health care coverage were generally more likely to report an ocular health care visit in the preceding 12 months than were adults who had private insurance only, even after adjustment for level of visual impairment, sex, and educational attainment. The NHIS (National Health Interview Survey) did not assess whether ocular care was included as part of the participants’ insurance coverage. It is nevertheless possible that public coverage filled in some of the well-known gaps in ocular health care coverage of many of the private health care plans offered in the United States. For example, Medicare and Medicaid typically include basic eye care services, such as annual eye examinations. Our findings point to the need for addressing the coverage limitations for ocular care in private insurance plans as well as addressing the broader need for health insurance for all Americans.
http://archopht.ama-assn.org/cgi/content/full/127/3/303

And…

Is Universal Vision Care Coverage the Best Way to Get People to See Their Eye Care Providers?

By Steven M. Kymes, PhD, MHA; Kevin D. Frick, PhD
Archives of Ophthalmology
March, 2009
In this issue of Archives, Lee et al present a report on the relationship between insurance coverage and recommended visits to ophthalmologists or optometrists. They find several important predictors of such visits, one of which is health insurance coverage. In their conclusion, they call upon vision care professionals to assume a role as advocates for universal health insurance coverage, in particular vision care insurance, for all Americans. They assert that providing universal vision care coverage would insure that financial resources are no longer a barrier for those seeking access to a vision care provider. However, we must also consider whether this would indeed be the most effective method to achieve the social goal of increased use of vision care services.
It is important to recognize that if we as a society provide universal health insurance coverage, it would not come without a cost.
(The authors then provide a highly dubious analysis that purports to show that “our health care system would pay $435 in annual insurance coverage for each new person who is motivated to seek vision care.”)
There is no doubt that providing preventive vision care services is important, as is providing care for those with chronic eye conditions. But before taking this step, we should ask if the benefit of spending $435 to motivate someone to seek an annual visit to their eye care provider outweighs the cost. Answering the question would involve a rigorous evaluation of the benefits of the ocular examination. What is the probability that an undiagnosed ocular condition will be found? What is the benefit of identifying that condition in reducing future health care costs? What is the benefit of regular examinations of people with chronic eye conditions in adjusting treatment strategies, insuring compliance, and making referrals for specialized care? By asking such questions, we can determine the balance between costs and benefits. The results would help policymakers and physicians to determine if providing insurance coverage would indeed be the best approach to promoting vision care or if other methods of improving access should be considered.
Lee and colleagues have made an important contribution to this growing literature by examining barriers to vision care. However, the principles of scientific inquiry should not be shortchanged simply because we are debating a policy question rather than a biochemical one. The vision care community has an obligation to fully consider alternative solutions and their consequences in seeking ways to remove barriers to vision care.
http://archopht.ama-assn.org/cgi/content/full/127/3/335

One single word, whether it’s “and” or “or,” can make such a difference in health policy.
This study confirms that what we already know about the importance of insurance in improving access and utilization of health care also applies specifically to eye care. Individuals with insurance have higher rates of access and utilization of eye care than those who are uninsured and those have have interruptions of their insurance coverage.
This study also indicates that those who have public coverage in addition to private coverage have significantly higher utilization rates than those who have private coverage alone. Public coverage seems to help fill in the gaps in private coverage.
The obvious policy conclusion is that everyone should be covered with health insurance that has adequate benefits, including eye care. Quite simple.
Apparently that is not the conclusion of the authors of the commentary on this study that appears in the same issue of Archives of Ophthalmology, a publication of the American Medical Association. To improve access to vision care, they do not suggest removing one of the more important barriers to care by providing everyone with health insurance. Without stating it explicitly, they imply that their estimate of a $435 premium (a straw man estimate) is too high of a price to pay for eye coverage. Instead they recommend the consideration of insurance coverage “or” the consideration of other methods of improving access. There is that all important “or” word, when most members of the policy community would have used “and.”
Just to indicate that this wasn’t simply a slip of words, they reinforce their view by stating that “the vision care community has an obligation to fully consider alternative solutions,” where “alternative” is another “or” word.
This study is a valuable contribution to the health policy literature, indicating, once again, that we must repair our health care financing system so that everyone has affordable access to all necessary health care. It is sad that there are those who continue to use garbage policy pseudo-science to battle the champions of health care justice. And it is especially tragic that they have continued to win.

Health insurance and eye care

Reported Eye Care Utilization and Health Insurance Status Among US Adults

By David J. Lee, PhD; Byron L. Lam, MD; Sahel Arora, BS; Kristopher L. Arheart, EdD; Kathryn E. McCollister, PhD; D. Diane Zheng, MS; Sharon L. Christ, MS; Evelyn P. Davila, MPH
Archives of Ophthalmology
March 2009

The association between low eye care utilization rates and lack of, or inconsistent, health insurance coverage, even after adjustment for income and educational attainment, suggests that overall ocular health care access would be enhanced if progress is made toward securing coverage for the 46.6 million Americans who do not currently have health insurance. Our findings have also identified troubling gaps in eye care utilization among adults with health insurance coverage. Adults who reported an interruption in health insurance coverage in the 12 months prior to the interview were less likely to report a visit to an ocular health care provider than were those who were consistently insured. In our analyses, 3.8% or an estimated 7.8 million US community-residing adults annually reported such a coverage gap in the past 12 months.

We also found that adults who reported concurrent private and public health care coverage were generally more likely to report an ocular health care visit in the preceding 12 months than were adults who had private insurance only, even after adjustment for level of visual impairment, sex, and educational attainment. The NHIS (National Health Interview Survey) did not assess whether ocular care was included as part of the participants’ insurance coverage. It is nevertheless possible that public coverage filled in some of the well-known gaps in ocular health care coverage of many of the private health care plans offered in the United States. For example, Medicare and Medicaid typically include basic eye care services, such as annual eye examinations. Our findings point to the need for addressing the coverage limitations for ocular care in private insurance plans as well as addressing the broader need for health insurance for all Americans.

http://archopht.ama-assn.org/cgi/content/full/127/3/303

And…

Is Universal Vision Care Coverage the Best Way to Get People to See Their Eye Care Providers?

By Steven M. Kymes, PhD, MHA; Kevin D. Frick, PhD
Archives of Ophthalmology
March, 2009

In this issue of Archives, Lee et al present a report on the relationship between insurance coverage and recommended visits to ophthalmologists or optometrists. They find several important predictors of such visits, one of which is health insurance coverage. In their conclusion, they call upon vision care professionals to assume a role as advocates for universal health insurance coverage, in particular vision care insurance, for all Americans. They assert that providing universal vision care coverage would insure that financial resources are no longer a barrier for those seeking access to a vision care provider. However, we must also consider whether this would indeed be the most effective method to achieve the social goal of increased use of vision care services.

It is important to recognize that if we as a society provide universal health insurance coverage, it would not come without a cost.

(The authors then provide a highly dubious analysis that purports to show that “our health care system would pay $435 in annual insurance coverage for each new person who is motivated to seek vision care.”)

There is no doubt that providing preventive vision care services is important, as is providing care for those with chronic eye conditions. But before taking this step, we should ask if the benefit of spending $435 to motivate someone to seek an annual visit to their eye care provider outweighs the cost. Answering the question would involve a rigorous evaluation of the benefits of the ocular examination. What is the probability that an undiagnosed ocular condition will be found? What is the benefit of identifying that condition in reducing future health care costs? What is the benefit of regular examinations of people with chronic eye conditions in adjusting treatment strategies, insuring compliance, and making referrals for specialized care? By asking such questions, we can determine the balance between costs and benefits. The results would help policymakers and physicians to determine if providing insurance coverage would indeed be the best approach to promoting vision care or if other methods of improving access should be considered.

Lee and colleagues have made an important contribution to this growing literature by examining barriers to vision care. However, the principles of scientific inquiry should not be shortchanged simply because we are debating a policy question rather than a biochemical one. The vision care community has an obligation to fully consider alternative solutions and their consequences in seeking ways to remove barriers to vision care.

http://archopht.ama-assn.org/cgi/content/full/127/3/335

Comment:

By Don McCanne, MD

One single word, whether it’s “and” or “or,” can make such a difference in health policy.

This study confirms that what we already know about the importance of insurance in improving access and utilization of health care also applies specifically to eye care. Individuals with insurance have higher rates of access and utilization of eye care than those who are uninsured and those have have interruptions of their insurance coverage.

This study also indicates that those who have public coverage in addition to private coverage have significantly higher utilization rates than those who have private coverage alone. Public coverage seems to help fill in the gaps in private coverage.

The obvious policy conclusion is that everyone should be covered with health insurance that has adequate benefits, including eye care. Quite simple.

Apparently that is not the conclusion of the authors of the commentary on this study that appears in the same issue of Archives of Ophthalmology, a publication of the American Medical Association. To improve access to vision care, they do not suggest removing one of the more important barriers to care by providing everyone with health insurance. Without stating it explicitly, they imply that their estimate of a $435 premium (a straw man estimate) is too high of a price to pay for eye coverage. Instead they recommend the consideration of insurance coverage “or” the consideration of other methods of improving access. There is that all important “or” word, when most members of the policy community would have used “and.”

Just to indicate that this wasn’t simply a slip of words, they reinforce their view by stating that “the vision care community has an obligation to fully consider alternative solutions,” where “alternative” is another “or” word.

This study is a valuable contribution to the health policy literature, indicating, once again, that we must repair our health care financing system so that everyone has affordable access to all necessary health care. It is sad that there are those who continue to use garbage policy pseudo-science to battle the champions of health care justice. And it is especially tragic that they have continued to win.

Forum to highlight Vt. health successes

Single-payer advocates fight preference for incremental changes

By Nancy Remsen
Burlington Free Press
March 15, 2009

For 90 minutes Tuesday afternoon, 400 people will vie for time to share an idea or concern they have about health care during the second of five regional health reform forums sponsored by the Obama White House.

Critics say that’s hardly sufficient time to take the public’s pulse on health reform. Some will rally outside the Davis Center at the University of Vermont, where the forum takes place, to demonstrate support for publicly financed health care. It’s an idea they say is getting short shrift from President Barack Obama as he assembles a health reform plan.

Others say this forum signals the president’s new approach to developing health reform policy and a recognition that Vermont is home to some good reform ideas.
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“He is reaching out to states and regions that have something to offer,” said Republican Gov. Jim Douglas, who will co-host the forum with Gov. Deval Patrick, a Democrat from Massachusetts. The first forum was held last week in Michigan. Others are planned in Iowa, California and North Carolina.

Greg Marchildon, state director of AARP in Vermont, is among the 400 people invited to attend.

“Of all of the five, this one matters most,” he said, “because Vermont, Massachusetts and Maine are where things have been done over the past 10 years.”

Marchildon lists Vermont’s accomplishments in chronic-care management, progress toward development of an electronic network for medical information and creation of Catamount Health, which showed how to subsidize private health insurance and expand coverage to more uninsured people.

“Vermont is an unquestioned national leader,” Marchildon said. “Some very important components of what Vermont has done are getting close attention from the Obama administration and in Congress.”

Dr. Deb Richter of Montpelier, a family practice physician and advocate for a publicly financed health care system, has also been invited. She’ll go in, but first will join the rally outside.

“I’ll bring the message from the people outside,” she said. “Our intent is to show the amount of support for publicly financed health care.”

While single-payer advocates such as Richter have been invited to this and other forums, she said White House officials have indicated a total overhaul of the health care financing system they advocate isn’t under consideration.

“We want this discussed as a serious option,” Richter said. “This problem is too big for small fixes.”

Another forum participant, Dr. Paul Jarris, warns, “If we try to go for the perfect, we will end up with nothing.” Jarris is a former commissioner of health in Vermont who now serves as executive director of the Association of State and Territorial Health Officials in Washington, D.C. “Let’s just do something.”

“Obama is bringing people around the table and saying there are many good ideas. Let’s see what is achievable,” Jarris explained. He contrasted this with the Clinton administration’s decision to roll out a completed plan. “It is a fundamentally different approach and far more likely to succeed,” Jarris said.

Before leaving Vermont in 2006, Jarris helped launch the Blueprint for Health, one of the programs attracting national attention. The Blueprint focuses on promoting public health through means as diverse as advocating for walking paths, teaching patients how to stay well and manage illnesses, and transforming medical practices so doctors focus more on prevention rather than after-the-fact treatment.

Jarris said he met Friday with Nancy-Ann DeParle, director of the White House Office of Health Reform, who will attend Tuesday’s forum in Burlington. “She is very interested in the Blueprint and how to make it a national model.”

The Douglas administration sees the forum as the start of a national health reform conversation. Douglas said he would have a chance to share more details about Vermont’s successes in April when he and other forum hosts meet to report on the proceedings.

Douglas noted he has already had conversations with Obama about the president’s health reform concerns and areas of interest. “I really think what we have in place here is quite consistent with his goals,” Douglas said.

Contact Nancy Remsen at 578-5685 or nremsen@bfp.burlingtonfreepress.com. To get Free Press headlines delivered free to your e-mail, sign up at www.burlingtonfreepress.com/newsletters

How to Pay Less for More Health Care

New York Times
Letters
Published: March 14, 2009

To the Editor:

Re “A Start on Health Care Reform” (editorial, March 8):

Yes, the administration has “ducked some of the most contentious issues.” President Obama has said he wants “ideas that work.” But any plan that retains the private, multipayer insurance system that is the source of our out-of-control costs cannot possibly work. And a plan in which people keep the insurance they have will not help the growing number of Americans who find they are underinsured.

The Congressional Budget Office has shown that a mandate to purchase insurance will not lead to universal coverage. It has shown, as well, that neither information technology nor chronic disease management nor comparative effectiveness analysis — all of which the administrationis counting on — will significantly curb costs. Only a unified public plan, based on our successful experience with Medicare, can truly address the problems of the health care system.

Leonard Rodberg
Flushing, Queens, March 8, 2009

The writer is research director of the New York metro chapter of Physicians for a National Health Program and a professor of urban studies at Queens College, CUNY.

Fair-Weather Reformers

Washington Post
Letter to the Editor
Thursday, March 12, 2009; Page A18

The pharmaceutical and insurance lobbies have offered early support for President Obama’s effort to reform health care [“In Health Plan, Industry Sees Good Business,” front page, March 5]. Judging by the measures discussed, they have little reason to oppose it.

Mr. Obama and many legislators favor incremental changes such as increasing Medicaid drug rebates and expanding the use of health information technology, measures that do nothing to trim the massively wasteful administrative spending associated with private insurance. Subsidizing expensive and inadequate health insurance or requiring that Americans purchase it would be a windfall to the private insurance industry, as Medicare Part D is to the pharmaceutical industry.

However, the moment the bottom line of these special interests is threatened, the reception will not be so rosy. Karen Ignagni, president and chief executive of the lobby group America’s Health Insurance Plans, has fired warning shots over proposed cuts to Medicare Advantage. With this program, private insurers receive a government subsidy of 14 percent over the costs of regular Medicare while selectively enrolling seniors with less costly illnesses and pocketing the difference.

If we truly want to reduce costs and expand health-care access to all Americans, we must eliminate private insurance and move to a single-payer system of financing. But we must be prepared to fight the special interests that won’t see this as “good business.”

James Floyd
Research Fellow
Public Citizen
Washington

Health care now rationed by ability to pay

By Bill Roy
Topeka Capital-Journal
March 13, 2009

Some claim universal medical care would open the floodgates of use and cost of medical care, and the government would soon be in the business of overtly rationing care. That’s pretty frightening unless we look objectively at how we are now rationing medical care, and how badly our results compare with nations with universal coverage.

Today, only America among advanced nations rations medical care by ability to pay. And the results are horrendous except for rich Americans, many of whom are trying to scare you out of universal medical care provided on the basis of need, not price. They like what they have.

No one disputes that this nation spends at least 1 1/2 times per capita more for medical care than any other nation. Some studies indicate we do not get more medical care, we just pay more for what we get.

It’s hard to have missed the numbers: $8,000 per capita this year; $15,000 a year for a family policy that may include deductibles and co-pays; annual increases usually twice the rate of increase of the gross domestic product; and government expenditures similar to nations with universal medical care.

Today, one of $6 goes for medical care and salaries of for-profit health insurance executives.

Our system of rationing medical care by ability to pay costs us money and lives. No other civilized nation requires a ransom to access medical care.

A 2002 study by the Institute of Medicine of the National Academy of Science estimates conservatively that 18,000 people died in 2000 because they did not have health insurance. The IOM further concluded “137,000 people died from 2000 through 2006 because they lacked health insurance, including 22,000 people in 2006.”

Rationing medical care by price is deadly for the poor, but not for the rich. Health and Human Services studies indicate the rich live on average 4½ years longer than the poor in America. This difference is widening as incomes have widened more rapidly since Reagan and the rich won America’s class war.

Our nation, which is the only industrial nation in the world that rations medical care by price, ranks 41st in the world in life expectancy. We lose more young lives too.

America lags in newborn mortality and children who die before age 5. Forty-four nations have lower death rates before age 5 than we do.

One can only conclude our medical care rationing system is both very costly and very deadly, especially for poorer Americans. It would be difficult not to do better with any universal care system that does not ration care by ability to pay.

Nations where individual states plan and administer medical care systems can work well, and could approach utopia if they had as much money as we spend. Federal Medicare worked very well until Republicans and their fellow treasury-raiders legislated Medicare D and Medicare Advantage, programs set up to favor for-profit providers, not patients or taxpayers.

How well and at what price states could deliver medical care will depend on how well-structured their delivery systems are and the availability of proper personnel. With resources now available in America, waiting lines or delayed services would be the exception.

No medical care system can do everything for everyone everywhere.

Services are and will be available in Topeka that are not available in Hays, and services will be available in Hays that are not available in Goodland. But movement through the system, whether physical or administrative, can be planned, facilitated, and markedly superior to our present non-system.

In sum, we can have a rational system and use it to its optimum as needed. Any covert rationing would come about because of limitations of personnel or physical facilities, which at current expenditure rates would be highly unlikely.

Beware of those who feign fear of medical care rationing in any universal system, but seem unaware of the death-dealing results we have in our present system of rationing by ability to pay.

Dr. Bill Roy is a retired physician and former member of Congress. He has a law degree and lives in Topeka. He may be reached at wirroy@aol.com.