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Health Care Reform: Learning from the International Experience — A Case for Single Payer

Health Care Reform: Learning from the International Experience — A Case for Single Payer

by Claudia Chaufan
Social Medicine Portal
February 27th, 2009

So President Obama gets it: he has recognized that the time to reform health care is now, and he is right. After touring the country during his campaign, he must be aware that thousands of Americans are going bankrupt, every year, because they cannot afford their medical bills, even when they have insurance, and are employed and middle class. He surely is also aware that thousands die of perfectly preventable illnesses because they lack health insurance. And that all of these things are unheard of, at least in developed economies.

Yet the president has also said that reform will fail unless we can reign on costs. And he is right again, because health care costs are estimated to reach $8,000 a year per person, and are increasing at three times the rate of inflation, even if our extraordinary 2 trillion-dollars per year-expenditure buys us a patchwork system ranked 37th by the World Health Organization in overall performance, below that of every other industrialized nation.

Now, some have argued that the problem is “too much government”. And they are right to say that there is a lot of government: after all, 60% of the two trillion comes already from public funds – in case the reader didn’t know, 10% of anybody’s income, on average, is already financing, through taxes alone, some form of public health care services, whether one qualifies or not for any public program. They are also right to say that this public expenditure is breaking the back of taxpayers, both at the federal and state levels — a case in point is the current individual mandate experiment in Massachusetts, which has turned out to be a fiscal time bomb, draining money as it is from safety net providers, and forcing people who make as little as 31,000 dollars a year to “choose” between adequate yet unaffordable coverage, affordable yet skimpy coverage that hardly qualifies as insurance, or a fine of over 900 dollars.

So recommendations for President Obama for how to reign on costs abound: from the “let’s deregulate the private health insurance market and allow everybody to spend their health care dollars as they choose to” types (one wonders where these folks have been during the meltdown of the global financial system!), to the “consumer driven” types, who suggest shifting (yet more) costs to “consumers” – higher premiums, co-pays, or deductibles — to the “shared responsibility” types (well, who would dare oppose “shared responsibility”, even if it is hardly a meaningful health policy concept? Incidentally, the latest paper by Jacob Hacker, the “father” of the “shared responsibility” model, is the best defense of public financing and indictment of private health insurance I’ve read in a long time!), to the over 100 options-list of the Congressional Budget Office (CBO) – which, incidentally, has (correctly) challenged the enthusiasm for wellness programs, preventive medicine, or electronic medical records, at least as strategies to reign on costs (That’s right! it is not the broccoli that others eat and that we presumably don’t that explain why others spend so much less than what we do! And if you don’t believe me, ask the Brits!).

Remarkably, nobody close enough to the corridors of power, indeed, not even the CBO, seems to mention the “s” word (single payer!). Could it be that “single payer” is too close to “socialism”? (they both begin with an “s”, no?). Or is it that whoever has been organizing the meetings around health care reform under the blessings of Senator Edward Kennedy thought that single payer advocates were unworthy guests to the secret “talks to shape policy”?

Given this notable absence, let me fill this vacuum so that the president hears all the options (don’t you think he’s the type who can appreciate a good challenge?). Let me explain in a simplified way how every other industrialized economy in the world — and even more recently Taiwan — has managed to develop systems that guarantee a basic amount of health care to virtually 100% of their population, based on medical need and not ability to pay, spending no more than 60% of what we do, and yes, using a lot of government! I am quite confident that the president will like my proposal. After all, I remember him saying that the question is not too much or too little government, but government that works for ordinary Americans.

So how do others achieve the remarkable feat that has defied Americans for decades?

First, they’ve created systems that pool health risks widely, because they understand that money spent on dividing people up into different pools or plans — as we do, we spend over 30 cents of each health care dollar pushing paper and underwriting policies — is money not spent on health care, and therefore wasted, if the goal is to provide health care universally (as opposed to, for instance, create a “competitive illness market” just for the heck of it). So at any given moment, the healthy majority subsidizes the unhealthy minority, the young, who on average spend less, subsidize the old, who on average spend more, and so forth.

Let me point out that cross-subsidization minimizes the need for public subsidies, because there are no longer “special populations” (the old, the poor, the disabled, the “other”) who are shunned by the private insurance sector because, after all, they are not “good customers”. Pooling also exempts health professionals from the time-consuming task of figuring out what is covered, under which conditions, and for whom, and from the expensive paperwork of the multiple payment schemes with the unpredictable rates of reimbursement characteristic of the private sector.

Second, they use the great purchasing power that comes from bulk purchases to get the best bang for their health care dollar. This is the purchasing power that American consumers lack, for which reason we pay the highest prices in the planet for services that cost a fraction elsewhere: for instance, while people in Baltimore, Maryland, spend $329 dollars for Lanzoprasol, a widely used drug to reduce acidity, people in Spain pay $9 for the same dose of the same product.

Third and last, they finance their health care systems collectively with compulsory contributions. One could say that they take shared responsibility seriously, rather than merely advocating for the sum of individual responsibilities, individual-mandate type! But because they understand that it is pointless to demand that people contribute what they cannot afford, in all cases contributions to the system are a predictable proportion of income, which makes contributions affordable to individuals and families, and complies with the principle of financial fairness, as articulated by the World Health Organization.

Now, systems vary from country to country and no system is free of problems. Yet what matters is what they share:

They share a commitment to a goal: to eliminate financial barriers to health care.

They share an understanding of a best strategy: that insuring health care cooperatively is the way to go — cooperative financing is known as “social health insurance”, a type of insurance where everybody plays, where the ability to make a profit from connecting patients with providers is severely restricted if not altogether banned, and where contributions are a predictable proportion of income and entitlements a function of medical need.

And single payer is simply a type of social insurance: it is a hybrid system, a private-public partnership which combines public financing with private delivery of services. And it is the only mechanism that has the capacity to reign on costs while achieving the goal of universal health care. And I say care, not insurance coverage — they are not equivalent and should not be considered so.

Single payer can expand coverage while containing costs by maximizing purchasing power, minimizing administrative waste, and minimizing the need for subsidies, that ultimately have to be picked up by all of us, taxpayers. It embodies the pragmatism that President Obama is often credited with in that it builds upon well-tested, and anything but radical, models of financing, yet clearly in the pursuit of a goal: that of universal health care. And it is fiscally conservative in that it provides relief to states that, like California, among many others, spend enormous amounts of money on public programs and health insurance for employees, including retirees, and their families.

Moreover, under single payer, Americans would be able to choose, and keep, their doctors whatever happened to their financial or work lives. They would have meaningful choices — not choice of “health plans” where people are forced to select from within “preferred provider” lists or to second guess their present or future medical needs, but choice of doctors and whatever services they need, the sort of choice that people care about.

As an aside, the notion of social insurance is over 120 years old. Otto Von Bismarck, first chancellor of the German empire, sponsored the first social health insurance system in 1883, among other reasons to prevent the spread of socialism. And as history shows, he succeeded.

In closing, single payer shares with the health care systems of all developed nations, with the glaring exception of ours, the understanding that social health insurance is both good economics and good morals:

It is good economics because it yields the best bang for the health care dollar. And it is good morals because guaranteeing health care, a basic human need, is the mark of a society that cares about human dignity.

Will President Obama think that we can? I can only hope.

President Obama Must Include Single-Payer Advocates In National Health Care Debate

Statement of Sidney Wolfe, M.D., Director, Public Citizen’s Health Research Group, and James Floyd, M.D., Researcher, Public Citizen’s Health Research Group
Feb. 26, 2009

This morning, President Obama announced he will create a $634 billion reserve fund over the next decade to provide a down payment for expanding health coverage. The announcement comes a week before a White House health care summit that marks the beginning of the first serious effort to reform health care since the Clinton task force in 1993.

The president wants this process to be open and transparent, with the goal of achieving universal coverage. However, groups representing physicians, nurses, and consumers who advocate for a single-payer system of national health insurance have thus far been excluded from the summit.

Under a single-payer system, doctors, hospitals and other health care providers are paid from a single fund administered by the government. The system would eliminate the wasteful spending and high administrative costs of private insurance, saving almost $400 billion annually. This savings is enough to provide every American with the same high-quality care, including those who currently have insurance but still cannot afford medications and treatment.

If health care is a key to fixing our national deficit and providing the economic stimulus that we need to recover from this recession, it is unacceptable to ignore the only system that will provide true universal coverage. If the only people who have input on health care reform are the lobbyists who represent the interests of insurance and drug companies, the final result will be a system that benefits the insurance and drug companies.

The Clinton task force on health reform made a similar mistake of excluding the voices of those who support a single-payer system, and the result was a complicated, inadequate reform proposal that catered to the interests of insurance companies and failed to garner public support. At a time when public support for single-payer is greater than ever – more than 60 percent in recent polls – we urge President Obama not to make the same mistake. He must include single-payer advocates in the health care summit next week.

Subsidizing COBRA Is Not Enough–We Need Single Payer

Andrew Coates MD

COBRA is a law that allows you to keep your employer-sponsored health insurance for 18 months if you lose or change jobs. To do so, you have to pay 102% of the cost (the full premium plus a 2% surcharge).

The stimulus package just passed provides for laid off workers, who had health insurance on the job, to receive a subsidy of 65% of the health insurance premium for up to nine months.

According to a report by FamiliesUSA, the national average unemployment benefit is $1,278 monthly. Under COBRA, national family coverage averages $1,069 per month. So laid off workers, in order to keep health insurance for their families, will have to pay more than $375 a month but after nine months will have to come up with the full $1,069.

To keep family coverage under COBRA, with the subsidy, it will cost people who are laid off, on average, almost one-third of every unemployment check. This money will go to a health insurance company, instead of food, housing and school expenses for the family.

A recent study by the Commonwealth Fund reported that only 9% of unemployed workers continued health insurance under COBRA. The 65% subsidy should allow some to consider keeping health insurance under COBRA, where before it would have been just unthinkable. This can help those with chronic illnesses, or those with very sick family members, or where a spouse continues working.

But while the subsidy makes private health insurance through COBRA slightly more affordable for the unemployed, purchasing it remains a Faustian bargain. What “stimulus” is there in asking a person who has just lost their job to give almost a third of each unemployment check to the private insurance industry? And what will they do after nine months have come and gone?

Despite the good intentions in Congress and the White House, subsidized COBRA payments are not feasible for the unemployed — and terrible policy for the nation. There is no reason why Congress should shovel our money into an industry that pits its profits against our health, with a program that holds almost one-third of our limited unemployment check hostage and only lasts nine months.

If the leaders of this nation wanted to provide health security for all they would enact a single-payer mechanism to finance health care.

Single payer would mean that no one would ever be without health care. Not first time job seekers, not workers changing jobs, not laid off or striking workers. Everyone would be covered.

A single payer health program would save at least $400 billion in health spending per year, and create millions of new jobs. It would mean enormous savings for employers (including federal, state and local governments as well as schools and not-for-profit agencies) who now pay private health insurance premiums, and allow unions to get back to bargaining for wages and working conditions instead fighting over reduced benefit levels, bigger premiums, more co-pays and deductibles. Everyone would be relieved from the worry about health coverage that now comes with the loss of a job.

Now that would be a stimulus! We really need single payer national health care.

Andrew Coates MD works on the staff of a state hospital near Albany, NY He is a member of the Professional Employees Federation (PEF) a joint statewide affiliate of AFT and SEIU.

Behind Closed Doors, Repeating Mistakes from the Past on Health Care Reform

James Floyd, M.D.
Huffington Post
February 27, 2009

Last week, the New York Times reported that Senator Ted Kennedy has been holding secret meetings with lobbyists to reach “consensus” on a proposal for national health care reform. Included in the list of participants were America’s Health Insurance Plans, the National Federation of Independent Business, and the Pharmaceutical Research and Manufacturers of America — some of the same players who defeated the Clinton health care reform effort 15 years ago. Notably absent was Physicians for a National Health Program, the California Nurses Association, Healthcare-Now, and other advocacy groups that oppose the private insurance industry and support the creation of a national single-payer program.

According to the Times, lobbyists have discussed increasing health care coverage by subsidizing the purchase of private insurance and expanding public programs. This was the approach taken in Massachusetts following the passage of the Massachusetts Health Reform Law in 2006. Touted as providing universal health care, it expanded and modified Medicaid, subsidized skimpy coverage for those not poor enough to qualify for Medicaid, and imposed financial penalties against those who didn’t purchase insurance. This reform has been hailed as a bipartisan success and appears to be favored by both President Obama and Senator Kennedy.

But what has been the result of the Massachusetts reform? A report released last week by Physicians for a National Health Program and Public Citizen documents that as much as 5 percent of the state remains uninsured — a decrease of only half from the baseline rate of 10 percent and a far cry from universality. New financial barriers, such as co-payments for medications and office visits, have led some of the poorest patients to interrupt care for life-threatening illnesses. The additional cost of the reform has topped $1 billion annually, forcing the state to cut funding to the public hospitals and community clinics that provide a crucial safety net for those who cannot afford health care.

Over the past 20 years, similar reform efforts have been attempted in other states — Oregon, Minnesota, Tennessee, Vermont, Washington, and Maine. Because these incremental reforms did not address the problems and waste created by private insurers, they all failed to significantly reduce the number of uninsured while costs continued to outpace inflation.

The Times reported that a key feature of the Massachusetts reform that has been embraced in the Kennedy meetings is the requirement that every American have insurance, with financial penalties for those who don’t. This mandate is a backwards formula for universality, one that can be arrived at only by starting with the premise that the financial interests of the insurance and pharmaceutical corporations are to be protected. According to James Gelfand of the United States Chamber of Commerce, “Forcing individuals to purchase insurance in the current market would be a disaster. Before we even have that discussion, we need to make health care more affordable and improve its quality.”

In other words, we shouldn’t force people to buy a flawed and unaffordable product. The only fair way to mandate universal coverage is to automatically enroll everyone in a program that provides a single, high standard of care and allows them to pay based on what they can afford, through progressive taxation. Even Nobel laureate and former Clinton economic advisor Joseph Stiglitz “has reluctantly come to the view that it’s the only alternative.”

There are troubling parallels between Kennedy’s secret meetings and the meetings of the Task Force on National Health Care Reform chaired by Hillary Clinton in 1993. Although special interests were officially excluded from the Clinton task force, documents obtained through a lawsuit filed by the National Legal and Policy Center revealed that more than 300 individuals who participated in task force working groups came from the private sector, and included representatives of the insurance industry and small business groups. In addition, a report from the Center for Public Integrity revealed that around the time of the task force, 80 former government officials — including 12 former members of Congress — had gone through the “revolving door” to work for health care interests, many of whom actively lobbied on health care reform.

Fast-forward to 2009 and former-Senator Tom Daschle’s failed appointment as Secretary of Health and Human Services. The official story focused on his failure to pay his taxes, but what angered most health care reform activists most was his previously undisclosed work as a health insurance lobbyist.

In post-mortems on the Clinton health care reform effort, pundits concluded that it was overly ambitious and too complicated to garner the necessary public support. They also recognized the impact of the highly successful lobbying effort by the health insurance industry — the “Harry and Louise” television ads — and the anemic response from the White House. Perhaps what doomed the Clinton effort to failure at an early stage was the inclusion of the very interests that must be fought to guarantee comprehensive and universal coverage to every American.

Yesterday, President Obama released a budget proposal that includes $634 billion to fund health care reform, days before a White House summit on health care reform begins. Like the Kennedy meetings, this summit currently does not include advocates for single-payer but is well-represented by lobbyists for the insurance industry and other groups who oppose fundamental reform.

President Obama, we urge you not to make the same mistake that the Clintons made. Please don’t exclude from the discussion the people who are your grassroots support for real change. Although people in your meetings may be telling you otherwise, there is tremendous support throughout the country for a single-payer system. Give us a seat at the table if you truly want to build consensus around health care reform.

Nobel Laureate Joseph Stiglitz on single payer

Nobel Prize-Winning Economist Joseph Stiglitz

Democracy Now!
February 25, 2009
We get reaction to President Obama’s speech from Nobel economics laureate and former World Bank chief economist, Joseph Stiglitz.
Amy Goodman: And healthcare? He’s called for universal healthcare, but he does not call for single-payer healthcare.
Joseph Stiglitz: I think that there are some fundamental problems in the efficiency of our healthcare system. And what we’ve seen is that the private healthcare insurers do not know how to deliver an efficient way.
Amy Goodman: Do you support single-payer healthcare?
Joseph Stiglitz: I think I’ve reluctantly come to the view that it’s the only alternative. You know, we’ve tried a lot of other things. And we’ve been — you know, I was in the Clinton administration, and we debated a lot of alternatives, and I’ve watched things as they’ve emerged and, you know, evolved over the last twelve, sixteen years, and I think there’s a growing consensus that the private market exclusion is not going to work.
Amy Goodman: Joe Stiglitz, I want to thank you for being with us, the Nobel Prize-winning economist, professor at Columbia University, co-author of The Three Trillion Dollar War: The True Cost of the Iraq Conflict.
These are the closing comments in this 28 minute video, audio and transcript:
http://www.democracynow.org/2009/2/25/stieglitz

Comment:

By Don McCanne, MD
What does Joseph Stiglitz have to say?
That’s a question we ask when we are faced with difficult issues such as the current financial crisis, and what we should do about the troubled banks. To our benefit, Amy Goodman did ask him, and we learn what he has to say.
At the end of the interview, Amy Goodman tacked on this crucial question regarding our health care crisis. Single payer?
Joseph Stiglitz’s response must be shared with the nation, and especially with those in Washington who say that single payer is not feasible. We should inundate Washington with his statement that single payer is “the only alternative.”

Nobel Laureate Joseph Stiglitz on single payer

Nobel Prize-Winning Economist Joseph Stiglitz

Democracy Now!
February 25, 2009

We get reaction to President Obama’s speech from Nobel economics laureate and former World Bank chief economist, Joseph Stiglitz.

Amy Goodman: And healthcare? He’s called for universal healthcare, but he does not call for single-payer healthcare.

Joseph Stiglitz: I think that there are some fundamental problems in the efficiency of our healthcare system. And what we’ve seen is that the private healthcare insurers do not know how to deliver an efficient way.

Amy Goodman: Do you support single-payer healthcare?

Joseph Stiglitz: I think I’ve reluctantly come to the view that it’s the only alternative. You know, we’ve tried a lot of other things. And we’ve been — you know, I was in the Clinton administration, and we debated a lot of alternatives, and I’ve watched things as they’ve emerged and, you know, evolved over the last twelve, sixteen years, and I think there’s a growing consensus that the private market exclusion is not going to work.

Amy Goodman: Joe Stiglitz, I want to thank you for being with us, the Nobel Prize-winning economist, professor at Columbia University, co-author of The Three Trillion Dollar War: The True Cost of the Iraq Conflict.

These are the closing comments in this 28 minute video, audio and transcript:
http://www.democracynow.org/2009/2/25/stieglitz

Comment:

By Don McCanne, MD

What does Joseph Stiglitz have to say?

That’s a question we ask when we are faced with difficult issues such as the current financial crisis, and what we should do about the troubled banks. To our benefit, Amy Goodman did ask him, and we learn what he has to say.

At the end of the interview, Amy Goodman tacked on this crucial question regarding our health care crisis. Single payer?

Joseph Stiglitz’s response must be shared with the nation, and especially with those in Washington who say that single payer is not feasible. We should inundate Washington with his statement that single payer is “the only alternative.”

Insurers, drug makers poised to profit from Obama health plan

By Timothy P. Carney
DC Examiner
Beltway Confidential blog
2/25/09

Although President Barack Obama promised that he would freeze out the lobbyists in order to finally reform our broken health-care system, his nascent push to overhaul the industry already shows signs of becoming a lobbying feeding frenzy, with health insurers, drug makers and employers all poised to benefit from government’s expanded role.

We don’t yet have the specifics of Obama’s plan, but we do know its centerpiece: an individual mandate on health insurance. Obama has said — and corporate-labor lobbying coalitions have agreed — that Washington should require Americans to buy health insurance. When healthy people opt out of the insurance pool, the theory goes, risk is not adequately spread.

You can guess who’s most enthusiastic about the individual mandate: the insurance companies. Sure enough, The New York Times reported last week that America’s Health Insurance Plans, the trade association representing health maintenance organizations, has been working with Sen. Edward Kennedy, D-Mass., to help draft a plan that includes a mandate.

Another player in Kennedy’s backroom meetings is the Pharmaceutical Research and Manufacturers of America, usually a bete noire for liberals because it represents the drug companies. PhRMA’s primary stake in this fight is also obvious. It wants mandates and subsidies, and it wants to limit cost-control measures that would favor cheaper generic drugs.

La Merie, a “business intelligence” publisher, wrote in a recent pharmaceutical industry report: “Obama’s new universal health-care program will increase demand for drugs, both branded and generic, reduce the need for free drug programs due to universal health-care coverage, and boost pediatric drug and vaccine programs.” Sounds like a good deal for drug makers.

Groups lobbying on health-care policy include the Coalition to Advance Healthcare Reform, led by Safeway Chief Executive Officer Steve Burd, who actively backed Arnold Schwarzenegger’s plan to require all California businesses to cover their workers or face a new 4 percent tax. The coalition’s lobbyists include Judith Lemons, the former chief of staff for House Speaker Nancy Pelosi.

Lobbying powerhouse General Electric is a champion of Obama’s proposals to create a national health database — a database GE plans to build, manage or both.

What about the small-business coalitions that were crucial to killing HillaryCare in 1993? “They’re going to have to buy off small business,” says Cato Institute health-care expert Michael Tanner. Subsidies for small employers to afford health insurance are likely to do the trick.

To be sure, drug makers and insurers will have to bear the brunt of new regulations that come with increased government involvement. A priority for Kennedy and Obama is the pair of policies called “guaranteed issue” and “community rating.” The latter means insurers may not charge customers different premiums based on their health or age. Because this would encourage insurers to simply refuse to insure older customers or those with pre-existing conditions, government would require “guaranteed issue,” meaning that insurers could not turn down applicants.

Requiring insurers to charge one price and accept all comers would boost prices and drive away younger customers, who would find it cheaper to pay medical expenses out of pocket. Then only sick people, old people and families with kids would buy insurance — a high-risk pool, requiring even higher premiums. That’s why government will force younger and healthier people to join the pool with the individual mandate. Even so, the addition of high-risk and newly insured people will drive up the cost of health insurance — and taxpayers will get stuck with the bill.

Regulations spur mandates, which spur regulations, which spur subsidies. Insurers love the subsidies and the mandates, and the regulations don’t bother them too much — huge regulatory burdens, after all, keep out competition.

The great irony is that Kennedy and Obama, when calling for universal health care, have portrayed themselves as battling big business and freezing out the lobbyists. But it’s not as if Obama’s victory has cowed big business to the point of surrender. Many big businesses have long called for a greater government role in health care.

Insurers, drug makers, General Electric, regulators and employers will all benefit, and Obama will declare it a great group effort and a win-win solution. In truth, not everyone wins. “In the end, the taxpayers are going to lose,” says Tanner, “because the taxpayers are going to pay to buy everyone off.”

Tell Baucus single-payer is best

by Bob Balhiser
Queen City News, Montana
Wednesday, February 11, 2009

To the Editor:

Now that Tom Daschle is out of contention for HHS secretary, Sen. Baucus seems to think he has an inside track and is teaming up with Sen. Kennedy to push through his plan for health care reform. I cannot imagine a worse outcome.

As bad as things are now, it would be better to do nothing than to hurriedly implement the complex Baucus plan. How can Max reasonably expect to have a worthwhile outcome by simply tweaking our existing system which, by his own admission, costs twice as much as other industrialized nations and delivers worse outcomes?
We need to ask Max why he is so deathly afraid to see a single-payer plan given a fair hearing. I suspect it is because he knows a well-designed system of Medicare for all U.S. citizens will “pencil out” far better, be more user-friendly, and be less complex than his plan.

Most people recognize that private health insurers add no value to our health care system and just complicate the process of delivering health care and paying health-care bills. Single-payer systems are far simpler, more user-friendly, and have a track record for reliably paying health care bills with far fewer hassles for far less cost.
If you want real health care reform, I suggest you write or call Max. Tell him, before we do anything with health care, it is important that we know what we are doing is right. That means first showing how his plan stacks up in all respects against a well-designed single-payer system before doing anything.

Joseph Stiglitz on Single Payer

Excerpt from Democracy Now
2/25/09

AMY GOODMAN: And healthcare? He’s called for universal healthcare, but he does not call for single-payer healthcare.

JOSEPH STIGLITZ: I think that there are some fundamental problems in the efficiency of our healthcare system. And what we’ve seen is that the private healthcare insurers do not know how to deliver an efficient way.

AMY GOODMAN: Do you support single-payer healthcare?

JOSEPH STIGLITZ: I think I’ve reluctantly come to the view that it’s the only alternative. You know, we’ve tried a lot of other things. And we’ve been–you know, I was in the Clinton administration, and we debated a lot of alternatives, and I’ve watched things as they’ve emerged and, you know, evolved over the last twelve, sixteen years, and I think there’s a growing consensus that the private market exclusion is not going to work.

AMY GOODMAN: Joe Stiglitz, I want to thank you for being with us, the Nobel Prize-winning economist, professor at Columbia University, co-author of The Three Trillion Dollar War: The True Cost of the Iraq Conflict.

Health care spending for 2009

Health Spending Projections Through 2018: Recession Effects Add Uncertainty To The Outlook

By Andrea Sisko and colleagues at Office of the Actuary, Centers for Medicare and Medicaid Services
Health Affairs
February 24, 2009
Projected spending for 2009:
$2,509.5 billion – National Health Expenditures (NHE)
$8,160.3 – NHE per capita
17.6% – NHE as percent of GDP
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w346v1

These are the most reliable numbers to use that represent our health care spending for this year. Rounding off these numbers makes them easier to remember and eases communication of the amounts:
Total health spending is two and one-half trillion dollars
Health spending per person is over 8100 dollars
That amounts to about seventeen and one-half percent of our GDP

Health care spending for 2009

Health Spending Projections Through 2018: Recession Effects Add Uncertainty To The Outlook

By Andrea Sisko and colleagues at Office of the Actuary, Centers for Medicare and Medicaid Services
Health Affairs
February 24, 2009

Projected spending for 2009:

$2,509.5 billion – National Health Expenditures (NHE)

$8,160.3 – NHE per capita

17.6% – NHE as percent of GDP

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w346v1

Comment:

By Don McCanne, MD

These are the most reliable numbers to use that represent our health care spending for this year. Rounding off these numbers makes them easier to remember and eases communication of the amounts:

Total health spending is two and one-half trillion dollars

Health spending per person is over 8100 dollars

That amounts to about seventeen and one-half percent of our GDP

Doctors urge greater caution, skepticism in prescribing drugs

EMBARGOED UNTIL:
Feb. 25, 2009

CONTACTS:
Gordon D. Schiff, M.D.
Mark Almberg, (312) 782-6006, mark@pnhp.org

Physicians should be more conservative in their drug prescribing practices and more skeptical about the benefits of drugs that don’t have a proven track record, says an article in today’s Journal of the American Medical Association, or JAMA.

Citing the “well-documented prevalence of medication-related harm and inappropriate prescribing,” and pointing to “disasters” like the Vioxx episode, in which a popular painkiller was later found to increase the risk of heart disease, the authors welcome recent proposals for the reform of pharmacology education by the Association of American Medical Colleges. But such reforms are not enough, they say.

“With all the strengths of our nation’s medical curricula, including in pharmacology, there is surprisingly little time devoted to teaching trainees how to become lifelong effective prescribers,” said Dr. Gordon Schiff, associate professor of medicine at Harvard Medical School and co-author of the JAMA commentary. “More training in pharmacokinetics and drug dosing is all to the good. But trainees also need to acquire a set of guiding principles to help them become more careful, cautious, evidence-based, and frankly skeptical prescribers throughout their careers.”

To that end, Schiff and co-author Dr. William Galanter, assistant professor of clinical medicine at the University of Illinois at Chicago and head of the UIC Medical Center’s pharmacy and therapeutics committee, offer 25 “principles for more conservative prescribing” grouped under six subheadings:

* Think beyond drugs. Prescribe non-drug alternatives first, including physical therapy, exercise and diet changes, rather than reflexively reaching for the prescription pad to treat every symptom a patient might experience.

* Practice more strategic prescribing. Take a smarter approach to initiating or changing a drug regimen. Use only a few drugs; learn to use them well. Start only one drug at a time, so if there is a side effect it will be less confusing which drug is responsible.

* Heightened vigilance regarding adverse effects. Maintain a high index of suspicion for adverse drug effects. Rather than failing to warn patients about potential side effects, educate patients to recognize them earlier so the drug can be discontinued before more serious harm occurs.

* Caution and skepticism regarding new drugs. Limit use of new drugs. New drugs always appear safer, but as pointed out in earlier research conducted by physicians associated with Physicians for a National Health Program (“Timing of new black box warnings and withdrawals for prescription medications,” JAMA, 2002), serious adverse effects can take five or more years to emerge. Instead, rely on proven drugs with long-term safety records and do not stretch indications away those supported by trial-based evidence.

* Shared agenda with patients. Become more skillful at handling patients’ requests for drugs that they have seen advertised. Obtain accurate medical histories. Patients themselves often favor more conservative use of drugs, so physicians should build trust based on realistic expectations and a shared desire to use the minimum drugs necessary.

* Weigh longer-term, broader impacts. Think beyond short-term effects. For example, weight-loss drugs are often promising in the short-term, but longer-term results are often disappointing.

While the authors say these principles are not novel and should not be terribly controversial, “taken together they represent a significant shift in current prescribing patterns.”

Beyond countering the massive advertising and miseducation of physicians and the public to use more and more drugs, there are other barriers to physicians adopting more conservative prescribing practices, they say. These include the time pressures doctors are under, their desire to enhance their reputations by embracing the latest medical advances, and their fear of disappointing patients who request a drug they have seen advertised. The medical literature is also biased against conservative prescribing, because studies with negative results are less likely to be published or publicized.

Given existing practices and recent experience, the authors say, it is time to swing the pendulum back from “newer and more is better” back in favor of a prescribing philosophy that states that “fewer and more time-tested is best.”

Dr. Quentin Young, national coordinator of PNHP, said, “This is yet another example of why and how we have to put patients’ needs for safe and effective treatment ahead of the profitability of the insurance and drug companies. While drug companies promote using the newest, often most expensive and aggressive treatments, we favor a more cautious patient-centered approach – one that stresses the more ‘tried and true drugs’ over the ‘latest and greatest’ drugs pushed by the industry.”

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The JAMA commentary was an outgrowth of a Chicago-based project funded by the Attorney General Consumer and Prescriber Education Grant Program (the Neurontin settlement) and also supported by grant U18HS016973 from the Agency for Health Care Quality and Research.

“Promoting more conservative prescribing,” Gordon D. Schiff, M.D., and William L. Galanter, M.D., Ph.D., Journal of the American Medical Association (JAMA), Feb. 25, 2009, Vol. 301, No. 8.

A copy of the study is available at www.pnhp.org/prescribing

Physicians for a National Health Program (www.pnhp.org), a membership organization of over 15,000 physicians, supports a single-payer national health insurance program. PNHP is headquartered in Chicago and has chapters across the United States.