PNHP

A Sworn Foe of Single-Payer

A Sworn Foe of Single-Payer

Why Sanjay Gupta is the Wrong Man for the Top US Health Job

By VICENTE NAVARRO
CounterPunch
February 9, 2009

President Obama has put forward the name of Dr. Sanjay Gupta, the well-known chief medical correspondent for CNN, for the position of surgeon general of the U.S. Public Health Service — the chief public health officer of the federal government. Dr. Gupta has received wide acclaim as the most important voice on medical matters in the U.S. broadcasting industry. And CNN has played an important role in developing and promulgating the U.S. establishment’s conventional wisdom on what is happening in the country’s medical care. Dr. Gupta has been a major force in the promotion of that wisdom.

It is important that before discussing the appropriateness of President Obama’s choice for surgeon general, I make a few points about the role of the mainstream media, including CNN, in the country’s affairs, in particular, in its major international and domestic conflicts — that is, conflicts not only in, for example, Iraq and Vietnam, but also at home.

As we know, in the buildup to and conduct of the Iraq war, the mainstream media played a crucial role — supporting the invasion and occupation, and uncritically reproducing the Bush administration’s justification for this intervention. The mainstream media considered it their primary role to promote the conventional wisdom on this war, and not to challenge or question it. Not until 4,226 Americans and 654,965 Iraqis had been killed did CNN and the other mainstream media start questioning President Bush’s and the establishment’s justifications for the Iraq War. And it is important to remember that, before reaching this point, CNN and the other mainstream media had consistently ignored, marginalized, or ridiculed those voices that were explaining how the justifications for war had no credibility.

This series of events was nothing new. The same thing had happened with the Vietnam War. This reality on the role of the mainstream media is well known both in the U.S. and abroad. A primary function of the U.S. broadcasting industry is to reproduce the establishment’s position on whatever conflict the country is involved in at the time. But not so well known is the mainstream media’s (including CNN’s) role in the wars at home.

The silent domestic war: invisible casualties

There are types of war other than invasions and occupations abroad occurring right here, in the U.S.A., with deaths, casualties, and enormous suffering — wars taking place without producing a sound. One of them takes place on a daily basis. It is the war carried out by forces in the U.S. that, in defense of their interests, fight to prevent the establishment of one of the basic human rights: access to medical care in time of need — a right, found in all other developed countries but still denied to the citizenry of the U.S. sixty years after President Truman tried to establish it. As a consequence of this, many thousands of people die in the U.S. each year — from 18,000 to more than 100,000, depending on how one defines preventable death — due to lack of medical care. Even if we take the lower figure of 18,000 (given by the conservative Institute of Medicine), this is six times the number of people killed in the World Trade Center on 9/11. That event outraged the entire nation (as, indeed, it should), but the death toll due to lack of medical care seems to go unnoticed. These deaths are not reported on the front pages (or any other pages) of the mainstream newspapers. These deaths are so much a part of everyday reality for millions of ordinary people in the U.S. that they are not even news. Nor are the facts that 102 million people have insufficient health care coverage, that 44 per cent of terminally ill patients worry about how they or their families are going to pay their medical bills, that the inability to pay medical bills is a primary cause of family bankruptcy in the U.S., and that more than 50 per cent of spending on health care by elderly Americans is still not covered by Medicare — the federal program that was supposed to alleviate the health-care-related worries, concerns and anxieties of our elders. None of these facts are news. Again, they are so much a part of everyday life that they are not considered newsworthy.

And there are many other, closely related facts that rarely appear in the news media. One such fact is that the insurance and pharmaceutical industries, among the most profitable industries in the U.S., are largely responsible for the scandalous situation of the medical care non-system. Besides the “military-industrial complex,” responsible for the Iraq and Vietnam wars, there is an “insurance-pharmaceutical industrial complex,” responsible for the war at home — an industrial complex that is frequently behind the news programs that so rarely report on this war. The insurance and pharmaceutical industries are extremely profitable. In 2007, insurance company profits were $12 billion and pharmaceutical industry profits $40 billion, among the highest industry profits in the U.S. and in the world. And this insurance-pharmaceutical complex holds enormous economic, political and media power in our country. For example, the economic power of the pharmaceutical industry is used to create artificially high prices for its products. Just one example: Lanzoprasol, a widely used gastric-secretion-reducing medicine, costs $329 in Baltimore, Maryland, but (for the same product, same dose) $9 in Barcelona, Spain (yes, you read correctly: $9). How can this situation be tolerated? Because, in the U.S., economic power means political power, and political power is facilitated by privatization of the electoral process. These industries buy and influence the political process by donating money to leading politicians whose decisions affect their interests. According to the Center for Responsive Politics, the insurance industry contributed $2,185,727 and the drug industry $1,927,159 to the Obama campaign.

The economic and political power of these industries could not be sustained or reproduced, however, without their media power, through their funding of medical and health news and programs in the broadcasting industry (including CNN) that promote their views.

All of this leads me to the Obama administration’s choice to head the U.S. Public Health Service (USPHS). First, let me clarify what the USPHS is. This body (with 6,000 health professionals) is the federal agency in charge of the U.S. government institutions and programs responsible for taking care of the population’s public health needs. It is also responsible for the federal research institutes, such as the National Institutes of Health. In addition, the Obama administration has decided that the head of the USPHS will play a leading role on the task force in charge of reforming the nation’s health care.

The person chosen by President Obama to fill this position is Dr. Sanjay Gupta, a neurosurgeon at Emory Medical School in Atlanta and chief health correspondent for CNN. Dr. Gupta hosts a health program on CNN, sponsored by the medical and pharmaceutical industries, that popularizes today’s medical “miracles” and medical interventions. The program tends to focus on new technologies in clinical medicine and on preventing disease through changes in individual behavior. You are unlikely to see on this program any reports on the human tragedies caused by the nation’s insurance-based health care non-system, or on the economic abuses of the pharmaceutical industry. The program is presented very smoothly and attractively by Dr. Gupta — described byPeople as one of the sexiest men in the U.S.A. Gupta also hosts other medical-industry-sponsored TV programs and writes a column in Time.He also co-hosts Turner Private Network’s monthly show Accent Health, which airs in doctors’ offices around the country and is a major conduit for targeted ads from the pharmaceutical industry. And, according to Physicians for a National Health Program, in 2003 he downplayed the concerns of the medical community about Vioxx, which was removed from the market a year later by its manufacturer, Merck. Gupta lent support to John McCain’s position that in the U.S., buying private health insurance in the open market is a viable option for most Americans, which is profoundly inaccurate. For the vast majority of people who are without health benefits coverage, it is because they or their employers cannot afford to pay the premiums and costs involved.

On his CNN program, Gupta tried to discredit Michael Moore’s documentary film Sicko, which is critical of the insurance-based U.S. health care system, by accusing Moore of presenting incorrect facts and manipulating data — strong accusations aimed at challenging Moore’s credibility. The problem with Gupta’s critique was that, as Paul Krugman noted, it was not Michael Moore but Sanjay Gupta who had his facts wrong and clearly manipulated the data and their presentation. Gupta gave erroneous figures on per capita expenditures and on health indicators in the U.S. and other countries (including Cuba), and he did not correctly identify one of the individuals on his program who was critical of Moore’s documentary: Gupta presented him as an academic, but, in fact, he was a Republican consultant to the insurance industry.

Gupta showed a remarkable ignorance about the health care systems in several European countries. He tried to dismiss France’s universal health care program (defined by WHO as the best in the world) as nonviable economically. He reproduced the widely held erroneous belief that the universal and extensive welfare states in European countries are making their economies very uncompetitive. He stressed that the cost of universal health care in France is creating a public deficit that is a huge handicap to that country’s economic development. In fact, in percentage terms, the U.S. government deficit is larger than the French government deficit and, according to Davos (the Vatican of neoliberal thought), the French economy is as competitive as the U.S. economy, with higher productivity than the U.S. Moreover, the public medical care expenditures per capita are larger in the U.S. than in France. While France provides comprehensive benefits to its population, the U.S. does not. With a smaller amount of public funds, France and the majority of developed countries provide comprehensive coverage that will be a dream for the majority of our people.

I find it highly worrisome that Dr. Sanjay Gupta is likely to be appointed head of the USPHS. He is not an expert on public health and is not sufficiently knowledgeable, or competent, to do the job. Training and experience in neurosurgery do not provide the public health knowledge that the position requires. But, what is far more alarming is that he will most likely be the media spokesperson for the task force on health care reform. And this means that a person hostile to a single-payer system (the type of system that has most support among people in the U.S.); a person clearly unsympathetic to the principle of the government’s guaranteeing universality of health care coverage; a person who is part of the media that have been obfuscating, negating, and avoiding the real problems in health and medical care in this country , will be in control of selling the message of change in U.S. medical care. Is this the change we were promised by candidate Obama?

For the good of the country, I hope President Obama will be a leading force for change in our medical care non-system. The way of funding and organizing medical care in the U.S. is simply wrong. It is not only that 46 million people do not have any form of insurance, but that the majority of health benefits coverage offered by the insurance industry is, besides expensive, insufficient. As it now stands, the system cannot be shifted toward guaranteeing the basic human right of access to health care in time of need without confronting the insurance-pharmaceutical complex. And the extent of commitment to this human right can be measured by the degree to which President Obama is willing to confront this industrial complex.

A final note. I paid special attention to President Obama’s call for a sense of patriotism in his eloquent inaugural address. Love of country is something we can measure. And one measure is the degree to which government guarantees that ordinary people have the right to access to health care. Without that right, the U.S. will not be seen as a credible voice for human rights in the world. It is as simple as that. It is an indicator of how far we have to go that, currently, our major credential for being a country that respects human rights is a guarantee by the Obama administration that the U.S. government will not officially torture. Noble though this purposeis, it is a rather limited and unambitious promotion of a nation’s image. It would have created a much better image, at home and abroad, if, on his first day in office, President Obama had signed an executive order committing our government to establishing the human right of access to health care in time of need for every person living in the U.S. — complying, at last, with the United Nations declaration on human rights that — at least until now — the U.S. government has never respected.

Vicente Navarro, M.D., Ph.D., professor of Health Policy at The Johns Hopkins University and editor-in-chief of the International Journal of Health Services. The opinions expressed here are those of the author and do not necessarily reflect the views of the institutions with which he is affiliated. Dr Navarro can be reached at vnavarro@jhsph.edu

http://www.counterpunch.org/navarro02092009.html

CBO’s Elmendorf on single payer, and a Medicare-like option

Expanding Health Insurance Coverage and Controlling Costs for Health Care

Testimony of Douglas W. Elmendorf, Director, Congressional Budget Office
United States Senate
Committee on the Budget
February 10, 2009

The government could also design an insurance option based on Medicare that would be made more broadly available, on a voluntary basis, to the nonelderly population. The federal costs per enrollee would depend primarily on the benefits that system provided; the rates used to pay doctors, hospitals, and other providers of health care; and the extent of any premium subsidies that were offered to enrollees — all of which could differ from Medicare’s current design. As for whether such a plan would be more or less costly than a private health insurance plan that provided the same benefits to a representative group of enrollees, the answer would vary geographically. Assuming that Medicare’s current rules applied, those costs would be comparable in many urban areas, but in other areas, the cost of the government-run plan would be lower (as is evident in the current program through which Medicare beneficiaries may enroll in a private health plan). At the same time, because Medicare currently provides broad access to doctors and hospitals and employs little benefit management, a Medicare-based option might attract relatively unhealthy enrollees, which could drive up its premiums, federal costs, or both.

Many of the same considerations would arise in designing a single-payer, Medicare-for-all system, but that approach might raise some unique issues as well — and the scale of its impact on federal costs could obviously be much larger if nearly all of the population was covered. Enrollees could be offered a choice of plans under a single-payer system (as happens in Medicare). If, instead, only one design option was offered and all residents were required to enroll in it, then concerns about adverse selection would not arise. That approach could also reduce the administrative costs that doctors and hospitals currently incur when dealing with multiple insurers. The lack of alternatives with which to compare that program, however, could make it more difficult to assess the system’s performance. More generally, that approach would raise important questions about the role of the government in managing the delivery of health care.

Douglas Elmendorf’s written testimony (34 pages):
http://budget.senate.gov/democratic/testimony/2009/02-10-HealthElmendorf_Testimony.pdf

Comment:

By Don McCanne, MD

In his testimony before the Senate Budget Committee, CBO Director Douglas Elmendorf discussed considerations for expanding coverage, and considerations and options for controlling costs and improving efficiency, including a discussion of options under consideration that might not be effective in controlling spending. Most of his comments were confined to various policies that currently are hot topics in the Washington dialogue on reform.

It is no surprise that his discussion of single payer was no more than a tangential paragraph buried in the middle of his written testimony. This seems to reflect their view that single payer has been dismissed as a serious proposal that might have any chance of being enacted.

What might surprise the progressive community is that the proposal to offer the option of purchasing a Medicare-like plan within a market of private health insurance plans has also been relegated to a tangential paragraph, adjacent to the single payer paragraph. It appears that the Congressional Budget Office and the Senate Budget Committee do not consider the controversial Medicare-like option to be a proposal worth serious consideration (likely because of strong Republican opposition, not to mention AHIP’s opposition).

What Elmendorf does say about a Medicare-like option is that design is very important in determining the impact that it would have. He also states, as we have stated before, that a Medicare-like option would be subject to adverse selection, creating much greater challenges in the financing of such an option.

But look at what he says about single payer with “only one design option” (an improved Medicare program). It would cover everyone, eliminate adverse selection, shift funding to the federal government (through equitable tax policies), and reduce administrative costs. Sounds pretty good.

Though he states that single payer would “raise important questions about the role of the government,” aren’t those the questions that are already being raised today. When the financial systems don’t work, the government needs to step in.

Consumer-driven fire department (lesson for Canada and U.S.)

Fire fighters rescue the highest bidder

YouTube
video (40 seconds):
http://www.youtube.com/watch?v=bnjQ3cV4x1I

Though not quite so graphic, free market private health insurance is not unlike the rescue purchased by this unfortunate lady. Just as she purchased a contract to avoid hitting the ground when she jumped from this burning building, private health insurance is purchased to prevent financial hardship or bankruptcy in the face of medical need. It doesn’t always work.
Private enterprises, whether for fire protection or for the financing of health care, work by the rules of the market wherein money sets priorities. Access is subject to the vagaries the market. Public services, whether fire protection or a public national health program, work by the rules of social solidarity wherein human decency sets priorities. Public services are always there when you need them.
There is a difference.
In all fairness, this fictional bit of sick humor could be used by the opponents of a public national health program to point out that queues are a problem in public systems. Even there, many public health systems do not have excessive queues since they monitor and adjust capacity as needed, and apply queue management techniques when appropriate, all in the interests of better public service. Private health systems attempt to reduce queues for well funded patients, but they also oppose adequate funding of the public systems in order to create a greater market demand from those who can buy their way to the front of the inevitably longer queues.
We are seeing a renewal of legal challenges by Brian Day and his colleagues in Canada to create an artificial private market for health care. Just as limiting capacity in the public fire department theoretically would open up the opportunity for private entrepreneurial protection, Day is attempting to convince the courts that wealthier Canadians should have the right to pay extra to the private sector in order to bypass public queues. He contends that relieving the pressure in the public system reduces public queues, but all evidence is that two-tiered systems result in greater impairment of access in the public welfare system (think of Medicaid and the lack of willing providers, especially in the lucrative procedure-oriented specialties, who who seek the security of the better-funded private sector).
There really is a difference.

Consumer-driven fire department (lesson for Canada and U.S.)

Fire fighters rescue the highest bidder

YouTube

video (40 seconds):
http://www.youtube.com/watch?v=bnjQ3cV4x1I

Comment:

By Don McCanne, MD

Though not quite so graphic, free market private health insurance is not unlike the rescue purchased by this unfortunate lady. Just as she purchased a contract to avoid hitting the ground when she jumped from this burning building, private health insurance is purchased to prevent financial hardship or bankruptcy in the face of medical need. It doesn’t always work.

Private enterprises, whether for fire protection or for the financing of health care, work by the rules of the market wherein money sets priorities. Access is subject to the vagaries the market. Public services, whether fire protection or a public national health program, work by the rules of social solidarity wherein human decency sets priorities. Public services are always there when you need them.

There is a difference.

In all fairness, this fictional bit of sick humor could be used by the opponents of a public national health program to point out that queues are a problem in public systems. Even there, many public health systems do not have excessive queues since they monitor and adjust capacity as needed, and apply queue management techniques when appropriate, all in the interests of better public service. Private health systems attempt to reduce queues for well funded patients, but they also oppose adequate funding of the public systems in order to create a greater market demand from those who can buy their way to the front of the inevitably longer queues.

We are seeing a renewal of legal challenges by Brian Day and his colleagues in Canada to create an artificial private market for health care. Just as limiting capacity in the public fire department theoretically would open up the opportunity for private entrepreneurial protection, Day is attempting to convince the courts that wealthier Canadians should have the right to pay extra to the private sector in order to bypass public queues. He contends that relieving the pressure in the public system reduces public queues, but all evidence is that two-tiered systems result in greater impairment of access in the public welfare system (think of Medicaid and the lack of willing providers, especially in the lucrative procedure-oriented specialties, who who seek the security of the better-funded private sector).

There really is a difference.

'Medicare-for-all' cure for health woes

Single-payer system is best reform approach

By DANIEL P. WIRT, M.D.
Houston Chronicle
Feb. 8, 2009

The data and evidence are clear: To a scientific certainty, only a single-payer “Medicare-for-All” system of health care financing will solve the serious cost and access problems and achieve good, affordable health care for all in the United States. As a scientist and physician, this is my conclusion after studying the data for years. The data are voluminous, stretching back to World War II, and come not only from the United States, but from all other industrialized countries. Except for the United States, all industrialized countries have some form of universal health care.

Americans are increasingly afraid that they can’t afford to get sick, and with good reason. About half of all personal bankruptcies are caused by medical expenses, and 76 percent of these individuals had health insurance when they got sick or injured. Those of us with insurance are paying a greater share of the premium and more deductibles and co-pays as well. Thus, not only do we have 46 million Americans without health insurance, but at least an equal number who are seriously underinsured. With the recent economic downturn, the ranks of those who are uninsured and underinsured are growing. Many are faced with choosing between paying for medicine and needed health care and paying for food and housing. A typical story is: get sick or injured, lose your job, lose your health insurance, go bankrupt.

A majority of physicians (59 percent) and an even higher proportion of Americans (at least 62 percent) support single payer national health insurance or “Medicare-for-All”. In spite of this, virtually all we are hearing about today are mandate plans that would require everyone to buy the same private for-profit insurance that is already failing us. The for-profit insurance companies and their plethora of plans make for a terribly complex, fragmented, costly and inefficient system. Administrative overhead consumes about 31 percent of health care dollars in the United States, and the for-profit insurance companies are responsible for half of this, or 15 percent of $2.4 trillion. This money, more than $350 billion per year, provides no health care: it is consumed by enormous administrative costs, profits for investors and shareholders, and large salaries for managers of these for-profit insurance companies.

All of the incremental reform programs proposed – tax subsidies, health savings accounts, individual or employer mandates, increased regulation of for-profit insurance companies – keep these proverbial foxes in the henhouse and are doomed to fail to control costs and provide universal access. Competition among the foxes does not benefit the chickens, the patients, the doctors or the hospitals. The for-profit insurance companies fundamentally reduce choice – your preferred doctor or hospital is “out-of-network”? Too bad, we won’t pay, says your insurance company.

The data are in. Incremental reforms, mostly mandate schemes which retain the for-profit insurance companies, have been tried in seven states over the past two decades: Massachusetts, Tennessee, Washington, Oregon, Minnesota, Vermont, Maine. In all of these states the reforms have failed to contain costs. In all but Massachusetts, they have failed to reduce the number of uninsured. In Massachusetts, there has been a modest decrease in the number of uninsured, falling from 13 percent of adults in 2006 to 7.1 percent of adults in 2007, but at the cost of a substantial increase in public spending (spending for “Commonwealth Care” was $629.8 million in fiscal year 2007, $1089.2 million in fiscal year 2008 and $1317.7 million in fiscal year 2009). Most of the gain in Massachusetts has come from expanding Medicaid and subsidizing the purchase of private insurance; very few people have signed up for the unsubsidized private insurance. Not to mention that 7.1 percent uninsured is unacceptably high. Far from controlling costs, these mandate plans will add hundreds of billions of dollars to the nation’s health care costs.

The United States spends about twice as much per capita on health care as other industrialized countries. Yet it is a myth that the United States has the best health care in the world. The United States ranks near the bottom of industrialized countries in terms of important morbidity and mortality outcomes (for example, life expectancy and infant and maternal mortality).

About 18,000 American adults die unnecessarily every year due to lack of insurance (Institute of Medicine, 2002). As reported in the Archives of Internal Medicine in 2003, repair of an aortic aneurysm cost $8,647 in Canada and $13,432 in the U.S.

What accounted for the substantial difference? Most of the difference was due to much greater overhead costs in the U.S. The surgeons and surgical facilities are top-notch in Canada. The surgeons are very well paid. The difference is that Canada has adopted a true insurance system for financing health care, one that spreads risk across a broad population: a publicly funded single-payer national health insurance plan that eliminates the parasitic, investor-owned “insurance” companies that make profits by enrolling the healthy, screening out the sick and denying claims.

Single-payer national health insurance for financing health care is NOT “socialized medicine.”

Under a single-payer, “Medicare-for-All” system, delivery of health care remains private. The providers of health care remain private. Patients choose any doctor and any hospital.

Parenthetically, replacing the wasteful for-profit insurance companies with a single-payer national health insurance program for financing health care in the United States would save enough money (more than $350 billion) to not only achieve universal coverage, but allow the coverage to expand and be more comprehensive.

We have an American system that works. It’s Medicare. It’s not perfect, but Americans with Medicare are far happier than those with for-profit insurance. Doctors face fewer hassles in getting paid, and Medicare has been a leader in keeping costs down. And keep in mind that Medicare insures people with the greatest health care needs: people over 65 and the disabled. We should improve and expand Medicare to cover everyone. In contrast to the for-profit insurance companies, Medicare has a very low overhead – about 3 percent.

Unfortunately, the for-profit insurance companies have been infiltrating Medicare in the form of “Medicare Advantage” plans, substantially raising costs when compared to traditional Medicare.

A single-payer “Medicare-for-All” system is embodied in a bill currently in the U.S. House of Representatives, H.R. 676, sponsored by U.S. Rep. John Conyers, D-Mich., and cosponsored by 93 other members of Congress.

Its features are: automatic enrollment for everyone; comprehensive services covering all medically necessary care and drugs; free choice of doctor and hospital, who remain independent and negotiate their fees and budgets with a public or nonprofit agency; processing and payment of bills by a public or nonprofit agency; promotion of job growth and the entire U.S. economy by removing the excessive burden of health care costs from businesses; coverage for everyone without spending any more than we are now.

The growth in health care costs must be addressed if any proposal is to succeed. Single-payer offers real tools to contain costs: budgeting, especially for hospitals, planning of capital investments (to avoid wasteful duplication and concentration of expensive technology), and an emphasis on primary care and coordination of care. Mandate plans offer only false hopes: competition among for-profit insurance companies, computerization and chronic disease management. Competition among the shrinking number of for-profit insurance companies has already failed to contain costs and, in the absence of single-payer and reformed primary care (so that everyone has a primary care home), computerization and chronic disease management will raise costs, not lower them.

Business leaders are well on their way to understanding how the current system makes their businesses uncompetitive with businesses in industrialized countries that have cost-effective health care systems not based on profit.

Finally, the most important group is patients. We are all sometimes patients. All patients must rise up and remove the foxes from the henhouse.

Foxes are not evil, but their nature is such that they must not be allowed in the henhouse.

Wirt is a pathologist at Memorial Hermann Northeast Hospital in Humble.

http://www.chron.com/disp/story.mpl/editorial/outlook/6251537.html

What now for health reform?

By Mike Dennison
Helena Independent Record
02/08/09

With last week’s political demise of Tom Daschle, the man expected to shepherd serious health care reform through the minefield of Congress, has reform been dealt a deadly blow?

Not according to Montana’s senior U.S. senator, Max Baucus, who said in no uncertain terms last week that he remains committed to enacting “comprehensive health care reform” this year.

Baucus, the chairman of the Senate Finance Committee, and U.S. Sen. Ted Kennedy, D-Mass., who chairs the Senate Health Committee, sent a strongly worded letter to President Barack Obama in the wake of Daschle’s withdrawal of his nomination to be Obama’s secretary of health and human services.

In the letter, Baucus and Kennedy said we have a “moral duty” to ensure that every American gets quality health care, and that “we must act now” to confront rising health-care costs, growing numbers of people without health insurance, and the fact that America spends far more on health care than any other developed nation.

“Incremental efforts will no longer suffice and we cannot afford to wait any longer,” they wrote. “We remain certain that our goal of enacting comprehensive health care reform can be accomplished this year.”

You can’t state things much more directly than that. Of course, the question then becomes, what sort of health care reform might we get? What is the “comprehensive” reform that Baucus and Kennedy have in mind, and how will it work for all of us?

We’ll get to those questions, but first, let’s just say that devotees of health care reform shouldn’t be shedding too many tears at the demise of Daschle.

Daschle, the former Democratic U.S. senator from South Dakota, withdrew as nominee for health and human services secretary after it was revealed he hadn’t paid $128,000 in taxes on a car and driver provided him by an investment firm.

While it was the tax problems that probably sunk Daschle, it wasn’t the only thing that should have given people pause. As reported by the New York Times last week, the former senator had been receiving lots of money from lots of high-powered interests for “advice” on things political.

Those interests included UnitedHealth, the nation’s largest health insurer that had more than $25 billion in revenue last year from selling Medicare-related private insurance plans, and the Mayo Clinic, for whom Daschle helped beat back a government loan to a company that wanted to build a freight rail line near the clinic’s Rochester, Minn., campus.

So, this is the guy who was supposed to be the Flying V wedge on health care reform, plowing through the entrenched lobbies that want to muck up any attempts to dislodge their profits?

Which brings us back to Sen. Baucus, who told us last week that health care reform in America will include “both public and private coverage,” and that he’ll be carrying legislation that will have “a very strong incentive for private (insurance) coverage.”

Baucus hasn’t rolled out any bills yet, but in December he said he wants to require everyone to buy health insurance and take steps to ensure that the insurance will be affordable. The actual details of his multi-pronged approach are much more complex, but that’s the general idea, along with expansion of some public-insurance programs like Medicare and the Children’s Health Insurance Program.

He also reiterated last week that he won’t support or even consider a Medicare-for-all system that would extend government coverage to everyone, financed by taxes.

“I just have to make a judgment, and I think at this time in this country that single-payer is not going to get even to first base in Congress,” he said at a Washington, D.C., conference on health policy conference.

Sara Kuban, spokeswoman for Baucus in Washington, D.C., said Friday that Baucus doesn’t want to waste time pursuing policies “all but certain to fail,” because he thinks reform is urgently needed.

As reported by Congressional Quarterly, Baucus also said at the D.C. conference that single-payer or Medicare-for-all would be too drastic of a change and too much of a government takeover of the private (insurance) sector.

“We’re a big country,” he said. “We’re a battleship, an ocean liner. It takes time to turn big ships. You can’t just turn them overnight.”

He’s certainly correct on that account. However, Medicare-for-all advocates have an answer, and that’s to phase in Medicare coverage for everyone over several years, adding groups of the population at a time.

Of course, Medicare-for-all isn’t the only way to skin the health care reform cat. Other models of national systems exist around the world, including those that have private health insurance. But the common denominator in these latter types is that for-profit insurance is all but eliminated, having highly regulated, non-profit insurance instead.

Sure, turning a big ship isn’t easy. But you have to have the political will to do it and you need to turn it in the right direction. It’s up to average citizens to keep the pressure on those making the political decisions on the critical issue of health care reform, because the policy-makers will be hearing plenty from the UnitedHealths and Mayo Clinics of the world.

Next week, we’ll take a look at how health care reform happened in other countries — and what it might mean for the path of reform here in America.

http://www.helenair.com/articles/2009/02/08/state/75st_090208_dennison.txt?rating=true

‘Medicare-for-all’ cure for health woes

Single-payer system is best reform approach

By DANIEL P. WIRT, M.D.
Houston Chronicle
Feb. 8, 2009

The data and evidence are clear: To a scientific certainty, only a single-payer “Medicare-for-All” system of health care financing will solve the serious cost and access problems and achieve good, affordable health care for all in the United States. As a scientist and physician, this is my conclusion after studying the data for years. The data are voluminous, stretching back to World War II, and come not only from the United States, but from all other industrialized countries. Except for the United States, all industrialized countries have some form of universal health care.

Americans are increasingly afraid that they can’t afford to get sick, and with good reason. About half of all personal bankruptcies are caused by medical expenses, and 76 percent of these individuals had health insurance when they got sick or injured. Those of us with insurance are paying a greater share of the premium and more deductibles and co-pays as well. Thus, not only do we have 46 million Americans without health insurance, but at least an equal number who are seriously underinsured. With the recent economic downturn, the ranks of those who are uninsured and underinsured are growing. Many are faced with choosing between paying for medicine and needed health care and paying for food and housing. A typical story is: get sick or injured, lose your job, lose your health insurance, go bankrupt.

A majority of physicians (59 percent) and an even higher proportion of Americans (at least 62 percent) support single payer national health insurance or “Medicare-for-All”. In spite of this, virtually all we are hearing about today are mandate plans that would require everyone to buy the same private for-profit insurance that is already failing us. The for-profit insurance companies and their plethora of plans make for a terribly complex, fragmented, costly and inefficient system. Administrative overhead consumes about 31 percent of health care dollars in the United States, and the for-profit insurance companies are responsible for half of this, or 15 percent of $2.4 trillion. This money, more than $350 billion per year, provides no health care: it is consumed by enormous administrative costs, profits for investors and shareholders, and large salaries for managers of these for-profit insurance companies.

All of the incremental reform programs proposed – tax subsidies, health savings accounts, individual or employer mandates, increased regulation of for-profit insurance companies – keep these proverbial foxes in the henhouse and are doomed to fail to control costs and provide universal access. Competition among the foxes does not benefit the chickens, the patients, the doctors or the hospitals. The for-profit insurance companies fundamentally reduce choice – your preferred doctor or hospital is “out-of-network”? Too bad, we won’t pay, says your insurance company.

The data are in. Incremental reforms, mostly mandate schemes which retain the for-profit insurance companies, have been tried in seven states over the past two decades: Massachusetts, Tennessee, Washington, Oregon, Minnesota, Vermont, Maine. In all of these states the reforms have failed to contain costs. In all but Massachusetts, they have failed to reduce the number of uninsured. In Massachusetts, there has been a modest decrease in the number of uninsured, falling from 13 percent of adults in 2006 to 7.1 percent of adults in 2007, but at the cost of a substantial increase in public spending (spending for “Commonwealth Care” was $629.8 million in fiscal year 2007, $1089.2 million in fiscal year 2008 and $1317.7 million in fiscal year 2009). Most of the gain in Massachusetts has come from expanding Medicaid and subsidizing the purchase of private insurance; very few people have signed up for the unsubsidized private insurance. Not to mention that 7.1 percent uninsured is unacceptably high. Far from controlling costs, these mandate plans will add hundreds of billions of dollars to the nation’s health care costs.

The United States spends about twice as much per capita on health care as other industrialized countries. Yet it is a myth that the United States has the best health care in the world. The United States ranks near the bottom of industrialized countries in terms of important morbidity and mortality outcomes (for example, life expectancy and infant and maternal mortality).

About 18,000 American adults die unnecessarily every year due to lack of insurance (Institute of Medicine, 2002). As reported in the Archives of Internal Medicine in 2003, repair of an aortic aneurysm cost $8,647 in Canada and $13,432 in the U.S.

What accounted for the substantial difference? Most of the difference was due to much greater overhead costs in the U.S. The surgeons and surgical facilities are top-notch in Canada. The surgeons are very well paid. The difference is that Canada has adopted a true insurance system for financing health care, one that spreads risk across a broad population: a publicly funded single-payer national health insurance plan that eliminates the parasitic, investor-owned “insurance” companies that make profits by enrolling the healthy, screening out the sick and denying claims.

Single-payer national health insurance for financing health care is NOT “socialized medicine.”

Under a single-payer, “Medicare-for-All” system, delivery of health care remains private. The providers of health care remain private. Patients choose any doctor and any hospital.

Parenthetically, replacing the wasteful for-profit insurance companies with a single-payer national health insurance program for financing health care in the United States would save enough money (more than $350 billion) to not only achieve universal coverage, but allow the coverage to expand and be more comprehensive.

We have an American system that works. It’s Medicare. It’s not perfect, but Americans with Medicare are far happier than those with for-profit insurance. Doctors face fewer hassles in getting paid, and Medicare has been a leader in keeping costs down. And keep in mind that Medicare insures people with the greatest health care needs: people over 65 and the disabled. We should improve and expand Medicare to cover everyone. In contrast to the for-profit insurance companies, Medicare has a very low overhead – about 3 percent.

Unfortunately, the for-profit insurance companies have been infiltrating Medicare in the form of “Medicare Advantage” plans, substantially raising costs when compared to traditional Medicare.

A single-payer “Medicare-for-All” system is embodied in a bill currently in the U.S. House of Representatives, H.R. 676, sponsored by U.S. Rep. John Conyers, D-Mich., and cosponsored by 93 other members of Congress.

Its features are: automatic enrollment for everyone; comprehensive services covering all medically necessary care and drugs; free choice of doctor and hospital, who remain independent and negotiate their fees and budgets with a public or nonprofit agency; processing and payment of bills by a public or nonprofit agency; promotion of job growth and the entire U.S. economy by removing the excessive burden of health care costs from businesses; coverage for everyone without spending any more than we are now.

The growth in health care costs must be addressed if any proposal is to succeed. Single-payer offers real tools to contain costs: budgeting, especially for hospitals, planning of capital investments (to avoid wasteful duplication and concentration of expensive technology), and an emphasis on primary care and coordination of care. Mandate plans offer only false hopes: competition among for-profit insurance companies, computerization and chronic disease management. Competition among the shrinking number of for-profit insurance companies has already failed to contain costs and, in the absence of single-payer and reformed primary care (so that everyone has a primary care home), computerization and chronic disease management will raise costs, not lower them.

Business leaders are well on their way to understanding how the current system makes their businesses uncompetitive with businesses in industrialized countries that have cost-effective health care systems not based on profit.

Finally, the most important group is patients. We are all sometimes patients. All patients must rise up and remove the foxes from the henhouse.

Foxes are not evil, but their nature is such that they must not be allowed in the henhouse.

Wirt is a pathologist at Memorial Hermann Northeast Hospital in Humble.

http://www.chron.com/disp/story.mpl/editorial/outlook/6251537.html

Insurance failing cancer patients

Spending to Survive: Cancer Patients Confront Holes in the Health Insurance System

By Karyn Schwartz, Gary Claxton, Kristi Martin, and Christy Schmidt
Kaiser Family Foundation
American Cancer Society
February 2009
1) High cost-sharing, caps on benefits and lifetime maximums leave cancer patients vulnerable to high out-of-pocket health care costs.
2) People who depend on their employer for health insurance may not be protected from catastrophically high health care costs if they become too sick to work.
3) Cancer patients and survivors are often unable to find adequate and affordable coverage in the individual market.
4) While high-risk pools are designed to help cancer patients and others who are uninsurable, they are not available to all cancer patients and some find the premiums difficult to afford.
5) Waiting periods, strict restrictions on eligibility, or delayed application for public programs can leave cancer patients who are too ill to work without an affordable insurance option.
It is impossible to determine exactly how many privately insured individuals in the United States are at risk for high out-of-pocket health costs. However, research indicates that a growing percentage of the population is already facing high out-of-pocket costs. Gaps in the current private health insurance system leave cancer patients and others with serious illnesses vulnerable even when they have coverage.
Addressing the holes in the current health insurance system will be key to providing the privately insured with economic security and access to health care in the face of illness.
Spending to Survive (55 pages):
http://www.kff.org/insurance/upload/7851.pdf

An excellent test of how well our insurance system is working is to determine how well it serves those individuals who have the tragic misfortune of developing cancer. This report shows that all too often the insurance system fails to protect cancer patients from the additional burden of financial hardship, defeating one of the most important reasons for having health insurance in the first place.
KFF and ACS are to be commended for producing this important report exposing these injustices in our health insurance system, but, at the same time, they can be condemned for their timidity in their suggested solution for this tragic problem. “Addressing the holes in the current insurance system” might be the politically safe recommendation, but we’ve been doing that for half of a century. Patching holes doesn’t fix a rotten system.
People need the support of a financing system that provides them access to the health care that they need, when they need it. They do not need a financing system that exposes them to financial hardship merely because fate has handed them the misfortune of illness or injury.
We could add hundreds of billions of dollars to our current health care financing system and still leave people vulnerable, or we could dump our dysfunctional system and replace it with one that works – a single payer national health program. It seems like the decision should be ours, but we have turned it over to the Washington clique that supports our rotten system. How smart is that?

Insurance failing cancer patients

Spending to Survive: Cancer Patients Confront Holes in the Health Insurance System

By Karyn Schwartz, Gary Claxton, Kristi Martin, and Christy Schmidt
Kaiser Family Foundation
American Cancer Society
February 2009

1) High cost-sharing, caps on benefits and lifetime maximums leave cancer patients vulnerable to high out-of-pocket health care costs.

2) People who depend on their employer for health insurance may not be protected from catastrophically high health care costs if they become too sick to work.

3) Cancer patients and survivors are often unable to find adequate and affordable coverage in the individual market.

4) While high-risk pools are designed to help cancer patients and others who are uninsurable, they are not available to all cancer patients and some find the premiums difficult to afford.

5) Waiting periods, strict restrictions on eligibility, or delayed application for public programs can leave cancer patients who are too ill to work without an affordable insurance option.

It is impossible to determine exactly how many privately insured individuals in the United States are at risk for high out-of-pocket health costs. However, research indicates that a growing percentage of the population is already facing high out-of-pocket costs. Gaps in the current private health insurance system leave cancer patients and others with serious illnesses vulnerable even when they have coverage.

Addressing the holes in the current health insurance system will be key to providing the privately insured with economic security and access to health care in the face of illness.

Spending to Survive (55 pages):
http://www.kff.org/insurance/upload/7851.pdf

Comment:

By Don McCanne, MD

An excellent test of how well our insurance system is working is to determine how well it serves those individuals who have the tragic misfortune of developing cancer. This report shows that all too often the insurance system fails to protect cancer patients from the additional burden of financial hardship, defeating one of the most important reasons for having health insurance in the first place.

KFF and ACS are to be commended for producing this important report exposing these injustices in our health insurance system, but, at the same time, they can be condemned for their timidity in their suggested solution for this tragic problem. “Addressing the holes in the current insurance system” might be the politically safe recommendation, but we’ve been doing that for half of a century. Patching holes doesn’t fix a rotten system.

People need the support of a financing system that provides them access to the health care that they need, when they need it. They do not need a financing system that exposes them to financial hardship merely because fate has handed them the misfortune of illness or injury.

We could add hundreds of billions of dollars to our current health care financing system and still leave people vulnerable, or we could dump our dysfunctional system and replace it with one that works – a single payer national health program. It seems like the decision should be ours, but we have turned it over to the Washington clique that supports our rotten system. How smart is that?

Bipartisanship breaks down over "public option"

The Public Plan Option: Bipartisanship, Or Fear And Loathing?

by Rob Cunningham
Health Affairs Blog
February 5, 2009
The tea leaves say President Barack Obama will do more than pay lip service to bipartisanship, but they don’t say whether others will follow his example.
“I sense a genuine interest in working together on the part of key Republicans in the Congress,” Senate Finance Committee chairman Max Baucus (D-MT) said this week. “They all want to be in on this. There’s a lot of excitement.” To be sure, differences over how to promote effectiveness research or IT will test the commitment of the pragmatic center. But, arguably, where there’s a will there’s a way.
That may not be the case, however, with another critical feature of the Democrats’ reform vision. Jeanne Lambrew, of the White House office of Health Reform, said this week that the administration eventually wants… to create a structured market, or “exchange,” as it is called in the Massachusetts version of universal coverage… and also a “public option.”
The subject of the public option came up frequently in the course of the Feb. 2-3 National Health Policy Conference, sponsored by Health Affairs and AcademyHealth. Whenever it did, old wounds seemed ready to reopen. A Business Roundtable representative asked if administrative costs of the public plan would be subsidized with taxpayer funds, giving it an unfair advantage over private plans. If the market power of the public plan enabled it to force lean reimbursement on providers, as the Medicare and Medicaid programs do, would providers shift costs onto private payers? The public plan idea makes the private sector nervous, said a participant in a workshop on employers’ perspectives on reform. “There’s a lot of concern.”
Republican Hill staffers at the AcademyHealth conference also expressed deep reservations about the public plan option and the related idea of creating a National Health Board to oversee the national exchange and other health-system functions. Ryan Long, minority staffer on the House Energy and Commerce Committee, asked if the public option would mean that everyone in the exchange would end up on Medicaid. Dan Elling, from the House Ways and Means Committee, wondered if the Health Board would constitute “one big HMO.” But Democratic staffers insisted that the public plan option is a must for them.
Lambrew said that details of the administration’s plans aren’t likely to be available for weeks, because work on the stimulus package takes precedence. So the exact shape of this new animal is still somewhat obscure. But fear and loathing of public-sector solutions in health care remains powerful, as it has been for most of the past century. It may be the ultimate test of the new president’s dream of post-partisanship.
http://healthaffairs.org/blog/2009/02/05/the-public-plan-option-bipartisanship-or-fear-and-loathing/

Well, we are there now. The progressive community had decided that the political barriers that have prevented reform over the past century must be brought down. A solution that would appease the conservative community must leave in place a private market of financing options. The progressives have agreed, and have asked only for one more option – a plan administered by the government.
In this Health Affairs Blog, Rob Cunningham reports on the pulse of the cross section of attendees at the National Health Policy Conference this week. What is clear is that every single detail of The Great Compromise – the public Medicare-like option – will be challenged during the legislative process. It is a fantasy to think that a bipartisan or post-partisan process will ever lead to the enactment of public option that would have any resemblance to the progressive concept of a comprehensive, better-than-Medicare plan with a financing system that would make it affordable for anyone.
Rob Cunningham reports that the mere discussion of such an option created an atmosphere in which “old wounds seemed ready to reopen.” But those wounds have never healed! And they never will.
Removing politics from policy is an impossibility. So are we going to establish battle lines over an emasculated public option that will send us back to our corners to sulk because we failed again? Or are we going to establish those same battle lines over a bona fide single payer national health program? The alignment would be the same, but with the first option, we surrender before the battle has even begun.

Bipartisanship breaks down over "public option"

The Public Plan Option: Bipartisanship, Or Fear And Loathing?

by Rob Cunningham
Health Affairs Blog
February 5, 2009

The tea leaves say President Barack Obama will do more than pay lip service to bipartisanship, but they don’t say whether others will follow his example.

“I sense a genuine interest in working together on the part of key Republicans in the Congress,” Senate Finance Committee chairman Max Baucus (D-MT) said this week. “They all want to be in on this. There’s a lot of excitement.” To be sure, differences over how to promote effectiveness research or IT will test the commitment of the pragmatic center. But, arguably, where there’s a will there’s a way.

That may not be the case, however, with another critical feature of the Democrats’ reform vision. Jeanne Lambrew, of the White House office of Health Reform, said this week that the administration eventually wants… to create a structured market, or “exchange,” as it is called in the Massachusetts version of universal coverage… and also a “public option.”

The subject of the public option came up frequently in the course of the Feb. 2-3 National Health Policy Conference, sponsored by Health Affairs and AcademyHealth. Whenever it did, old wounds seemed ready to reopen. A Business Roundtable representative asked if administrative costs of the public plan would be subsidized with taxpayer funds, giving it an unfair advantage over private plans. If the market power of the public plan enabled it to force lean reimbursement on providers, as the Medicare and Medicaid programs do, would providers shift costs onto private payers? The public plan idea makes the private sector nervous, said a participant in a workshop on employers’ perspectives on reform. “There’s a lot of concern.”

Republican Hill staffers at the AcademyHealth conference also expressed deep reservations about the public plan option and the related idea of creating a National Health Board to oversee the national exchange and other health-system functions. Ryan Long, minority staffer on the House Energy and Commerce Committee, asked if the public option would mean that everyone in the exchange would end up on Medicaid. Dan Elling, from the House Ways and Means Committee, wondered if the Health Board would constitute “one big HMO.” But Democratic staffers insisted that the public plan option is a must for them.

Lambrew said that details of the administration’s plans aren’t likely to be available for weeks, because work on the stimulus package takes precedence. So the exact shape of this new animal is still somewhat obscure. But fear and loathing of public-sector solutions in health care remains powerful, as it has been for most of the past century. It may be the ultimate test of the new president’s dream of post-partisanship.

http://healthaffairs.org/blog/2009/02/05/the-public-plan-option-bipartisanship-or-fear-and-loathing/

Comment:

By Don McCanne, MD

Well, we are there now. The progressive community had decided that the political barriers that have prevented reform over the past century must be brought down. A solution that would appease the conservative community must leave in place a private market of financing options. The progressives have agreed, and have asked only for one more option – a plan administered by the government.

In this Health Affairs Blog, Rob Cunningham reports on the pulse of the cross section of attendees at the National Health Policy Conference this week. What is clear is that every single detail of The Great Compromise – the public Medicare-like option – will be challenged during the legislative process. It is a fantasy to think that a bipartisan or post-partisan process will ever lead to the enactment of public option that would have any resemblance to the progressive concept of a comprehensive, better-than-Medicare plan with a financing system that would make it affordable for anyone.

Rob Cunningham reports that the mere discussion of such an option created an atmosphere in which “old wounds seemed ready to reopen.” But those wounds have never healed! And they never will.

Removing politics from policy is an impossibility. So are we going to establish battle lines over an emasculated public option that will send us back to our corners to sulk because we failed again? Or are we going to establish those same battle lines over a bona fide single payer national health program? The alignment would be the same, but with the first option, we surrender before the battle has even begun.

Medicare 'Rip-Off' Hits Elderly as Obama Maps Changes

By Avram Goldstein
Bloomberg News
February 4, 2009

Just as President Barack Obama prepares to overhaul the U.S. medical system, providers of U.S.- backed health plans for the elderly are raising prices.

Humana Inc., Health Net Inc. and other providers increased 2009 premiums by 13 percent on average, or more than five times as much as last year, for people who use the Advantage version of Medicare, according to Avalere Health, a consulting company in Washington. The elderly say higher costs for the Advantage plans, which add features such as drug coverage to Medicare, are reducing money for groceries and utilities.

Obama has vowed to control spending in the $2.6 trillion U.S. health-care system while extending coverage to more people, and, during his campaign, criticized the costs of Advantage plans to taxpayers. The premium increases, charged directly to the elderly rather than the government, are further evidence that insurers’ need for profits is ballooning patients’ expenses and reducing the efficiency of care, said Arnold Relman, former editor of the New England Journal of Medicine.

“Medicare Advantage is a rip-off,” said Relman, 85, who is also a professor emeritus at Harvard Medical School in Boston, in a telephone interview on Jan. 23. “I cannot see that they do anything better than public insurance does, and they do a lot of things worse.”

Medicare will spend 14 percent more this year, on average, for Advantage enrollees than for beneficiaries with basic coverage, according to a staff report in December by the Medicare Payment Advisory Commission, an independent agency that advises Congress.

Obama’s Stance

Obama considers the government payments “excessive,” said Jen Psaki, a spokeswoman now on the White House staff, in a Jan. 5 e-mail. During his campaign Obama promised to cut subsidies to Advantage by as much as $15 billion a year, or about 15 percent from last year’s total of $100 billion.

In addition, insurers collected about $5 billion in Advantage premiums from consumers last year, said Thomas Scully, the former top administrator of the U.S. Centers for Medicare & Medicaid Services, with headquarters in Baltimore.

Scully, who helped design the Advantage program, said that he doesn’t consider the premiums excessive and that Advantage is less expensive than alternatives. Scully is a lawyer for the New York private equity firm Welsh, Carson, Anderson & Stowe, and for the Atlanta law firm Alston & Bird.

“I don’t think you’re going to see a mass exodus from Medicare Advantage,” Scully said in a Jan. 9 interview.

Bundling Options

Medicare is the U.S. health plan for the disabled and those over 65. Basic Medicare, with a monthly fee of $96, lets patients use any U.S. doctor or hospital. Beneficiaries can also buy separate private policies to cover prescription drugs and expenses exempted from standard benefits. Advantage, which covers 10.5 million people, bundles those options.

“There are almost 11 million people who have chosen to participate in Medicare Advantage because they feel they’re good plans,” said Richard Barasch, chief executive officer of Universal American Corp., an insurer in Rye Brook, New York, in a telephone interview. “Medicare Advantage is a great value to them.”

The Advantage premiums paid by Blair Law and his wife, Mary, soared to $50 a month this year, up from zero under the policy’s initial terms.

“These guys have you by the short hairs,” said Blair Law, 77, a retired construction-company executive now living in Fort Myers, Florida, in a telephone interview. “They know you’re disinclined to shift to another plan, so they keep ratcheting the cost up.”

Rebates End

In 2007, the Laws joined an Advantage plan provided by Universal Health Care Corp. of St. Petersburg, Florida. Initially, the plan charged no monthly premium, and the insurer rebated the couple’s basic-Medicare premiums, according to the Laws. The rebate ended last year, and this year the company began charging the couple an additional $50 a month.

Pinched for funds, Law said he doesn’t eat as much beef as before, uses less air conditioning, and will cut back travels to see relatives across the country.

“That’s a real hardship,” Law said.

Universal Health Care Chief Executive Officer Akshay Desai didn’t respond to a request for comment. Many Advantage policies had no monthly payments first, according to analysts.

The absence of premiums was a “come-on” to spur enrollment for many insurers and was “unsustainable,” said Uwe Reinhardt, a professor of political economy at Princeton University in New Jersey. Advantage plans serve about 23 percent of Medicare enrollees, up from about 12 percent in 2003, according to Medicare officials.

Insurers’ ‘Dream’

“The insurers’ dream was that maybe 80 percent of the elderly would enroll in Medicare Advantage and then traditional Medicare would just die, and these private health plans could do what they want,” Reinhardt, whose specialty is health-care issues, said in a telephone interview on Jan. 23.

Investors, favorable toward price increases yet wary of the threat of cuts in U.S. subsidies, aren’t sure if there is money to be made in stocks of Advantage providers, said Carl McDonald, an analyst with Oppenheimer & Co. in New York. Most of the companies, in any case, also have other profit centers, and their fate isn’t tied wholly to Advantage.

On average, the almost 200 companies selling Advantage policies raised prices 13 percent this year for enrollees, to $41.40 a month, according to Avalere Health. In 2008, premiums rose 2.5 percent, Avalere found.

Doubling Premiums

Humana, based in Louisville, Kentucky, more than doubled average premiums for its Advantage clients, to $30 from $14, the largest percentage jump identified in the Avalere analysis conducted for Bloomberg News. Universal American had the second- largest rise among publicly traded companies, moving up average monthly premiums 44 percent to $39. Health Net, of Woodland Hills, California, increased the monthly fee 24 percent to $51.

In calculating the averages, Avalere compared premiums for plans offered in both 2008 and 2009 and weighted each company’s average increase by membership.

Health Net, Humana and other insurers also are requiring elderly plan members to pay more for ambulance rides and hospital stays or raise the amount people must spend before 100 percent coverage kicks in, according to Medicare data.

Humana, with 1.44 million Advantage members on Dec. 31, said yesterday it expects to add no more than 75,000 people to the plans this year, after gaining 293,000 last year. Health Net said yesterday its Advantage enrollment may fall as much as 2 percent this year, from 295,000 at the end of last year.

UnitedHealth

Not all companies are raising premiums. UnitedHealth Group Inc. dropped what it said were unprofitable Advantage plans for the chronically ill and increased out-of-pocket costs in other Advantage plans. The company, based in Minnetonka, Minnesota, is the largest Advantage provider, with 1.6 million members.

UnitedHealth is counting on competitors’ premium increases to drive the elderly to its policies, said Simon Stevens, former head of the insurer’s Medicare plans, in an e-mail. The company added at least 97,000 customers for policies that began on Jan. 1, according to U.S. government figures.

Meanwhile, Martha Baker, 74, said her Health Net plan increased her share of costs for ambulance care and other services this year. Her premium also went up, to $38 a month from zero.

“What’s disheartening is, I’m a person who has never taken from the system,” said Baker, who retired after directing the women’s ministry at a Tucson, Arizona, church. “I’ve always paid into it, and now it seems to be failing me.”

To contact the reporter on this story: Avram Goldstein in Washington at agoldstein1@bloomberg.net.