PNHP

"Managed consumerism"

"Managed consumerism"

Consumer-Driven Health Care: Promise And Performance

by James C. Robinson and Paul B. Ginsburg
Health Affairs
January 27, 2009

This paper analyzes the evolution of consumer-driven health care in terms of its original vision, its subsequent implementation, and the transformations it has endured as it moves into its second decade. The market is generating product designs that combine elements of consumerism with elements of managed care, but the trend is always toward a stronger role for consumer choice and a weaker role for management of those choices by physicians, insurers, employers, and regulators.

Impact of the PPO

The insurance market has merged the ideas of consumer-driven health care with those of managed care instead of replacing the latter by the former. The dominant form of health insurance today, by far, is the PPO. It combines network principles from managed care with some of the cost-sharing principles from consumer-driven health care; in 2008, PPOs accounted for 58 percent of enrollment in employment-based coverage. The PPO began to displace the HMO in the late 1990s as HMOs’ gatekeeping and utilization review created too much consumer and provider animosity.

Despite the verbiage and vitriol on both sides, it appears that consumer-driven health care and managed care are complements more than they are substitutes for one another. The mainstream health insurance industry is reorienting itself to replace administrative controls with incentives and information but in a manner in which the health plan functions as an important intermediary for structuring choices and informing enrollees about provider price and quality.

A dilution of principles

The heart of the consumer-driven health plan is the philosophical belief that each individual should make his or her own health care decisions. Health care decisions should not be “managed” by third parties, and especially not by physicians and nurses employed by insurance companies. The consumer-driven health care movement has been obliged to dilute its principles in light of the overuse of inappropriate services and underuse of appropriate services in the real world. HDHPs now incorporate elements of disease management for enrollees with chronic conditions; case management for enrollees with complex or comorbid conditions; and utilization management for patients using particularly costly drugs, devices, or procedures. Most of these medical management programs are obtained from the same diversified insurers that offer HMO and PPO products.

Conclusions

As it moves further along the consumer pathway, health insurance is likely to strengthen rather than weaken some vestiges of its managed care heritage, especially the development of programs seeking to improve the care of enrollees along the spectrum from full health to dire illness. These include preventive and wellness programs for healthy enrollees, service coordination for patients needing acute care, disease management for enrollees with chronic conditions, and intensive case management for enrollees with severe conditions. These likely will be presented as options rather than mandates, consistent with the consumer-driven ethos, although perhaps with higher cost sharing for those who are eligible but choose not to participate. What is unclear, over the long term, is the extent to which more choice for consumers will prevent health insurers from being able to continue to offer the steep discounts they currently wrest from their provider networks.

The market continues to pioneer hybrid forms that incorporate elements of both managed care and of health care consumerism. We can name the emerging system “managed consumerism” or “facilitated consumerism,” or we can find some more felicitous phrase. The important point is that for choice to be meaningful, it has to be choice among meaningful options, and meaningful options need to be designed, built, and managed.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w272v1

Comment:

By Don McCanne, MD

Managed care, consumer-driven health care, managed consumerism – these are just labels for a private insurance industry that has evolved from a role of indemnifying individuals and families against loss in the face of medical need, to an industry that has introduced innovative plan designs to enhance the success of its own business model.

Managed care was not designed to benefit patients. Its primary function was to enhance the business success of the insurers through provider contracting, limiting access and choice for the patients.

Consumer-driven health care was not designed to benefit patients. Its primary function was to enhance the business success of the insurers through the erection of financial barriers to health care, primarily through the use of high-deductible health plans.

The hybrid, “managed consumerism,” is not designed to benefit patients. Its primary function will be to continue to limit access and choice through provider contracting, and to continue to reduce access through the use of financial barriers to care.

These measures are designed to reduce spending by the insurers in order to keep their premiums affordable in a competitive market. For the insurers, the importance of consumers is simply that someone with enough money has to be there to purchase their products. Insurance products that take away choice and expose the ill to excessive costs are not the products that people want, but PPO/HDHPs are the predominant product that insurers offer.

Imagine if we had a single payer national health program – an improved Medicare for all. Would “managed care” even be a topic? Not when managed care has come to mean that individuals lose their choice by segregation of physicians and hospitals into plans to create an artificial market. Would “consumer-directed” health care be a topic? Not when consumer-directed care has come to mean that choosing to have the care that you need will cost you money out of your pocket that you may not have.

Tossing around labels and pretending that they represent solutions to our health care problems has got to go. No more con jobs with “managed consumerism.” It’s time to enact our own public system that simply pays our bills when we need health care – health care of our own choosing.

BBC Show on U.S. Health Care Unavailable in USA

John Tepper Marlin
Huffington Post
1/26/09

My sister Brigid Marlin lives in the UK and a few days ago was watching a BBC program on health care in the United States. Brigid is not a public affairs junkie so I was interested when she sent me an email reporting that the program was a shocking portrayal of the high cost and low coverage of U.S. medical care. This itself is not news but there are two things about the show that are worth an alert: (1) The BBC’s effectiveness in describing the problems with U.S. health care, and (2) The fact that Americans can’t watch it. My sister says:

They were discussing the problems that Obama faces in meeting his promise to provide health care for poor Americans. The program showed an English medical team that set out to provide medical services to poor people overseas. They ended up spending 60 percent of their time helping poor Americans, as they are the most needy! We were shown people getting up at 4 am and driving for hundreds of miles to be early in a huge queue for a doctor’s help.

The program was produced by BBC’s Panorama, the world’s oldest television documentary program, begun in 1953.

The Panorama team managed to get inside a briefing that a large US insurance company was giving its staff, awarding them huge bonuses for finding loopholes in the clients’ policies, so they didn’t have to pay up! They boasted that one employee had saved the company $7 million by giving them the basis for refusing to pay out because of a tiny flaw in the way they had filled out the form. This story was contrasted with the company’s television ads, where a kindly fatherly figure assures clients that they will be safe and looked after.

The BBC itself describes the program as follows:

Barack Obama takes over as U.S. President with a promise to dramatically change America and make it a fairer place. He is inheriting the worst economic crisis in almost a century, and a country so unequal that 23,000 people die every year because they cannot afford basic healthcare. To close the gap between rich and poor Obama will have to take on the might of the corporate world, which wields enormous influence in Washington. Can he change the world’s most powerful country, and should he?

My sister’s message to me goes on:

The drug companies are just as bad, Panorama shows. They have bumped up their prices so that Americans pay twice as much for their medicines as the same companies charge to other countries. It seems that the drug companies are uncontrollable because they wine and dine the senators so no votes are cast against their policies. The program showed the drug companies supporting senators with money for electioneering and their favourite charities. They are determined not to allow a comprehensive health care system in America!

Well, I attempted to watch the program myself and give you a link to it. It was broadcast on BBC One, 8:30 pm, January 19. It’s a half-hour show produced by Jeremy Vine. My sister is not the only fan of the show. It is posted as a “pick” by blogger “Up Your Ego: Love Your Inner Geek”. The blogger is trying to emulate the “brilliant” Watchification, Telegraph iPlayer Pick of the Day and the Radio Times Downloads index, and says:

My pick is the Panorama special on the USA health care system. I really enjoyed Michael Moore’s Sicko but it was a little (ok a lot) one sided. A great piece of entertainment and a good piece of journalism when preaching to the choir BUT lacking slightly in balance. The BBC tries to look at both sides of the story. Watch it HERE.

Unfortunately, when I tried the link in several places, I got a message each time that the link won’t work in the United States. So the best anyone can do, so far as I know, is to get a U.S.-formatted DVD sent over or persuade a PBS station to air the program in the United States. The program’s e-mail address is: panorama@bbc.co.uk. I have written to them asking to be advised if the health care show has been or will be aired here. No answer to my question yet.

John Tepper Marlin teaches corporate responsibility and finance to MBA and MPA students as Adjunct Professor at NYU’s Stern School of Business, the University of Geneva, and Pace University.

BBC documentary takes on Obama’s plans for American health care system

Nick Cargo
Raw Story
Sunday, January 25, 2009

A January 19 episode of BBC One’s Panorama, the world’s longest running television documentary show, tackles the dismal state of health care in the United States, the lengths to which its estimated 45 million uninsured citizens will go to in pursuit of care, the pharmaceutical industry’s rigged pricing against the American patient, and the insurance industry’s efforts to deny care whenever possible.

The documentary opens in rural Kentucky, where people have driven within a 200-mile radius to wait in line in the early morning for a spot in line to see a volunteer doctor thanks to the efforts of Remote Access Medical, who originally set out to help people in the Amazon jungle, but now focus 60% of their time on Americans.

“The need is enormous,” said the organization’s founder Stan Brock. “We discovered…there are people here that need help just as much as they do in Guatemala or in the Amazon and all these other places we go to.”

President Obama faces a difficult task to deliver on his promises of change, the segment explains, the country divided between the “super rich” and the “new poor,” and lobbyists putting their power to work to prevent reforms from taking place. Also, 533 members of Congress, out of 535, have received campaign contributions from within the health sector.

“We plan on mounting a national campaign,” warned health insurance industry lobbyist Angela Hunter, “and what we hope to do is to, number one, get some articles in the newspaper explaining what the problems are that we see with the plan. Two: Educate lawmakers, people who are members of our organizations, their clients–to go and lobby members of Congress–call them on the phone, visit them in their offices, and to just do everything that we can possibly do to preserve the freedom of choice for individuals in health care in America.”

“It’s really a system of legalized bribery,” said Richard Kirsch of Healthcare for America Now. “As one congressman says, we’re the only people in the world who are expected to take money from strangers and provide nothing in return.”

Due to licensing restrictions, the episode, “What Now, Mr. President?,” is only officially available to view online from connections within the United Kingdom. However, it has also been uploaded to YouTube, where it appears in three parts below.

Single-payer health bill has healthier prospects than ever

With dozens of coauthors, the Minnesota Health Act has its best chance in 15 years of making it out of committee

By Andy Birkey
The Minnesota Independent
1/23/09

Sen. Linda Berglin chairs the powerful Health and Human Services Budget Division in the Minnesota Senate and has long advocated a managed-care approach to rising health care costs. Although a staunch progressive on health care policy (she helped create and protect MinnesotaCare, the state’s health insurance program for low-income residents), she has typically demonstrated lukewarm interest in a single-payer system.

But this year, Berglin has signed on as a coauthor of the Minnesota Health Act, the bill that would create the Minnesota Health Plan. The Act (HF 135, SF 118) would take health insurance out of the private sector and put it under the control of a state board to cover all Minnesotans.

Citizens would be free to choose their own physicians or practitioners and would not be subject to any preexisting conditions clauses. The premiums that employees and employers currently pay would go into the state-run system, and each user would pay premiums according to his or her ability to pay. Advocates say those premiums will shrink for everyone under the plan.

When asked why Berglin seemed to have changed her mind on the single-payer plan, her office said her position is not quite a break from the past: “She has supported this bill in the past, so her support is not new.”

But this year, as the bill’s co-sponsor, she has brought that advocacy to a new level.

Berglin is not alone, as the bill is seeing more profound backing this year than in the previous 15 years or so that it’s been up for consideration.

While conservatives decry the plan as costly, advocates point to a number of ways a state-run health care plan could stimulate the economy.

“It makes the entire health care system less costly by making it more efficient,” said health policy expert Kip Sullivan, who has been active in Minnesota’s push for a single-payer system.

“The largest single improvement in efficiency under the plan will be the elimination of the excessive administrative costs created by health insurance companies,” he said.

Supporters expect the system to generate a 20 percent savings in health care costs. Those lowered costs would attract businesses to the state, they argue.

“[The plan] is especially beneficial to smaller employers because they are the least likely to be able to afford health insurance under the current system,” said Sullivan.

Indeed, small businesses are struggling to cover their employees and themselves, according to a study of 1,200 small businesses released this month (pdf) by the Main Street Alliance. Only 34 percent of small employers offer health coverage for their employees, and 43 percent of those only offered coverage for the business owner. Almost half, 49 percent, said that “any insurance, even bare bones coverage, is too expensive.”

Among small business owners, 59 percent said they would support a public solution to rising health care costs, compared to just 26 percent who said they’d rather let the private market sort the problem out.

Sullivan says that in addition to helping struggling small businesses, the Minnesota Health Plan could have a positive impact on the foreclosure crisis.

“Another benefit that will materialize in both good and bad economic times is fewer personal bankruptcies and home mortgage foreclosures, both of which are caused to a large extent by medical bills people can’t afford to pay.”

And as the foreclosure crisis continues to unfold in the United States, several studies have shown that just under half of all foreclosures were precipitated by medical crises, and one-quarter were due directly to insurmountable medical costs.

Under the Minnesota Health Plan, advocates say, those medical crises would be muted.

The bill co-sponsored by Berglin has two dozen coauthors in the Senate and three dozen in the House, but even with that support it’s unclear whether the measure will make it out of committee, as more conservative DFLers tend to support a free-market approach. In the past, single-payer bills have not reached the Minnesota House or Senate floors for votes.

And even if it does, passing the Legislature and making it to Gov. Tim Pawlenty’s desk most certainly means a veto.

“Those of us supporting the Minnesota Health Plan expect it will take multiple sessions of the Legislature to get it passed,” said Sullivan.

“What’s different now is that a single-payer bill like the Minnesota Health Act is actually being heard in the Legislature. That is the first step to educating the Legislature, the media and the public about the need for a single-payer solution to the crisis.”

“Managed consumerism”

Consumer-Driven Health Care: Promise And Performance

by James C. Robinson and Paul B. Ginsburg
Health Affairs
January 27, 2009

This paper analyzes the evolution of consumer-driven health care in terms of its original vision, its subsequent implementation, and the transformations it has endured as it moves into its second decade. The market is generating product designs that combine elements of consumerism with elements of managed care, but the trend is always toward a stronger role for consumer choice and a weaker role for management of those choices by physicians, insurers, employers, and regulators.

Impact of the PPO

The insurance market has merged the ideas of consumer-driven health care with those of managed care instead of replacing the latter by the former. The dominant form of health insurance today, by far, is the PPO. It combines network principles from managed care with some of the cost-sharing principles from consumer-driven health care; in 2008, PPOs accounted for 58 percent of enrollment in employment-based coverage. The PPO began to displace the HMO in the late 1990s as HMOs’ gatekeeping and utilization review created too much consumer and provider animosity.

Despite the verbiage and vitriol on both sides, it appears that consumer-driven health care and managed care are complements more than they are substitutes for one another. The mainstream health insurance industry is reorienting itself to replace administrative controls with incentives and information but in a manner in which the health plan functions as an important intermediary for structuring choices and informing enrollees about provider price and quality.

A dilution of principles

The heart of the consumer-driven health plan is the philosophical belief that each individual should make his or her own health care decisions. Health care decisions should not be “managed” by third parties, and especially not by physicians and nurses employed by insurance companies. The consumer-driven health care movement has been obliged to dilute its principles in light of the overuse of inappropriate services and underuse of appropriate services in the real world. HDHPs now incorporate elements of disease management for enrollees with chronic conditions; case management for enrollees with complex or comorbid conditions; and utilization management for patients using particularly costly drugs, devices, or procedures. Most of these medical management programs are obtained from the same diversified insurers that offer HMO and PPO products.

Conclusions

As it moves further along the consumer pathway, health insurance is likely to strengthen rather than weaken some vestiges of its managed care heritage, especially the development of programs seeking to improve the care of enrollees along the spectrum from full health to dire illness. These include preventive and wellness programs for healthy enrollees, service coordination for patients needing acute care, disease management for enrollees with chronic conditions, and intensive case management for enrollees with severe conditions. These likely will be presented as options rather than mandates, consistent with the consumer-driven ethos, although perhaps with higher cost sharing for those who are eligible but choose not to participate. What is unclear, over the long term, is the extent to which more choice for consumers will prevent health insurers from being able to continue to offer the steep discounts they currently wrest from their provider networks.

The market continues to pioneer hybrid forms that incorporate elements of both managed care and of health care consumerism. We can name the emerging system “managed consumerism” or “facilitated consumerism,” or we can find some more felicitous phrase. The important point is that for choice to be meaningful, it has to be choice among meaningful options, and meaningful options need to be designed, built, and managed.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.2.w272v1

Comment:

By Don McCanne, MD

Managed care, consumer-driven health care, managed consumerism – these are just labels for a private insurance industry that has evolved from a role of indemnifying individuals and families against loss in the face of medical need, to an industry that has introduced innovative plan designs to enhance the success of its own business model.

Managed care was not designed to benefit patients. Its primary function was to enhance the business success of the insurers through provider contracting, limiting access and choice for the patients.

Consumer-driven health care was not designed to benefit patients. Its primary function was to enhance the business success of the insurers through the erection of financial barriers to health care, primarily through the use of high-deductible health plans.

The hybrid, “managed consumerism,” is not designed to benefit patients. Its primary function will be to continue to limit access and choice through provider contracting, and to continue to reduce access through the use of financial barriers to care.

These measures are designed to reduce spending by the insurers in order to keep their premiums affordable in a competitive market. For the insurers, the importance of consumers is simply that someone with enough money has to be there to purchase their products. Insurance products that take away choice and expose the ill to excessive costs are not the products that people want, but PPO/HDHPs are the predominant product that insurers offer.

Imagine if we had a single payer national health program – an improved Medicare for all. Would “managed care” even be a topic? Not when managed care has come to mean that individuals lose their choice by segregation of physicians and hospitals into plans to create an artificial market. Would “consumer-directed” health care be a topic? Not when consumer-directed care has come to mean that choosing to have the care that you need will cost you money out of your pocket that you may not have.

Tossing around labels and pretending that they represent solutions to our health care problems has got to go. No more con jobs with “managed consumerism.” It’s time to enact our own public system that simply pays our bills when we need health care – health care of our own choosing.

Journalism professor on reporting about Canadian health system

Universal Health Care For Elephant, Mouse

By Gene Costain
Tampa Bay Online
January 26, 2009
Ben Jonson was a cantankerous, 17th century British dramatist who despised the early days of journalism because he thought it was overrun with propagandists and charlatans.
I’m no modern-day cynic, but the record of news coverage on universal health care has been rife with ideological cant and tall tales. In my view, journalists have formed a kind of parasitic osmosis with powerful interests that impairs robust debate.
My meager standing for wading in is that in the past 25 years I’ve lived half of that time in Canada and the other half here in the last Western refuge of commoditized medicine.
I have been making mental notes on the accumulated fallacies and misnomers about the Canadian universal system. Your neighbor to the north has always been a great case study, because the country is a near mirror image of America on many levels.
My first memory of family struggle over medical bills was in 1962, when my mother was about to give birth to the last of seven kids. The single-payer system – in which all health care providers bill a single entity – was still a few years away. Just before she went into the hospital to deliver, I overheard an anxious conversation she had with my father about how they were going to pay the anticipated $300 hospital bill. My working-class father supported us on a salary of $55 a week. Within a few years, that financial anxiety vanished, and all they had to deal with was a small plastic card, with the added bonus of virtually no paper trail.
My move to America in 1996 meant facing a small pile of bureaucratic paper before starting my doctorate in Tennessee. During my adult life in Canada, a little card was my official point of contact with the health care bureaucracy. Forget about annoying co-pays, a new concept for me. The relative wonder of it all captured my imagination, and for years I’ve been monitoring debates about the issue in a vain search for balance, especially as it relates to some of the good things you don’t hear about the Canadian system.
Let me frame this in a larger context. The late Canadian Prime Minister Pierre Trudeau said that living next door to America was like a mouse sleeping with an elephant. Canada has one-tenth of the U.S. population, and its citizens are largely resigned to (but secretly admire) the large American pachyderm. Despite the similarities, Americans have missed out on an honest depiction of what Canadians think about their system.
There is one key element in the Canadian story that Americans rarely hear about in their media. Polls show that Canadians would not trade their single-payer system for all the tea in Indonesia. Most Canadians say their health care is their most valued citizenship asset. That is not hyperbole: For years, Gallup polls have chronicled this high regard for the system. It makes you wonder why we don’t often get this view here – after all, there are plenty of Canadians sunning themselves in these parts.
One of the most persistent challenges is that there are long waiting lines for some services in Canada; my experience is that both systems are virtually indistinguishable. An informal consensus of family and friends in Canada, including my aging mother, is that the medial service is good to great. I have honestly not heard of one major medical service horror story.
But who is to blame for Americans not receiving these political, cultural and news representations? One reason is that journalists here are like reporters in other nations, they root around in their backyards for sources and social insight.
As the debate returns this year, we may get a more expansive rendering of the story because everyone agrees the system is broken. But it won’t happen unless more journalists, filmmakers and bloggers chip in with a more balanced rendering of this Byzantine story. It might make the cynical ghost of Ben Jonson happy.
(Gene Costain is a University of Tampa journalism professor.)
http://www2.tbo.com/content/2009/jan/24/co-universal-health-care-for-elephant-mouse/

And…

Health Care in Canada

Canadian Institute for Health Information
2008
Physician migration
Information on health care workers’ migrations into and out of Canada, and into and out of individual professions, is difficult to capture. However, data on physicians show that the number of physicians leaving and returning from abroad declined over the five years to the end of 2006, with those emigrating declining by more than half (56.9%) and those returning dropping by 18.2%. In the three years to the end of 2006, physicians returning to Canada outnumbered those who left.
Wait time
While it is difficult to compare jurisdictions’ progress in reducing wait times, it is possible to compare jurisdictions’ surgery rates in the priority areas. Overall, rates in these areas rose by 8% more than the expected increase from population growth and aging between 2004-2005 and 2006-2007.
Diagnostic imaging
Over the three years ended in 2006-2007, the number of MRI and CT exams in Canada rose by 42.9% (to 31.2 per 1,000 population) and 27.9% (to 103.3 per 1,000 population), respectively. During the same period, the increase in the number of exams was greater than in the number of scanners, for both MRI and CT. In the case of MRI, a 27% growth in the number of scanners led to a 47% growth in the number of exams. In the case of CT, a 12% growth in the number of scanners led to a 32% growth in the number of exams.
http://secure.cihi.ca/cihiweb/products/HCIC_2008_e.pdf

The data base that most of us use for our routine thoughts is that which is stored in our memories. When we have need for other information, we know that there are other resources to which we can turn, but for most of our rote activities, memory is presumed to be adequate and reliable.
Almost every resident of the United States can tell you several things about the Canadian health care system. The problem is that much of it is wrong.
How did it happen that our memories/knowledge of the Canadian system are so distorted? One of the more important reasons is that we have little exposure to the routine functioning of the Canadian health care system. It’s not that the information isn’t available. The Canadian Institute for Health Information is a highly credible resource for such information. You can learn quite a bit just by reading their 2008 report, Health Care in Canada.
So why hasn’t our media reported any of this information? Quite simply, it is boring. There is no mention of problems such as the number of uninsured, bankruptcy due to medical debt, or care denied because of the inability to pay for it, because those problems don’t even exist in Canada. The reports are of a system that is functioning well, but is not perfect, so measures that are being taken to improve their system are also reported. What U.S. journalist would waste their time with that, and which editor would approve it in the first place?
Another reason that our views are so distorted is that, for decades, several conservative and libertarian organizations opposed to public insurance have spoon fed the U.S. media with reports of problems in the Canadian system that happen to make good copy. Although those reports are often embellished, most do have a factual basis even if they don’t represent the mainstream functioning of their system. They are great fodder for our journalists who themselves have misperceptions about Canadian health care because they also are exposed to these highly selected, exceptional stories that do not include the boring stories of the routine.
A couple of examples of distortions were pulled out of the CIHI report. Everyone knows that physicians are fleeing Canada based on innumerable stories here, yet the reality is that more physicians are returning to Canada. Wait times for elective (not emergency) surgery have been an issue, but this report shows that the problem is being addressed with some success. The availability of diagnostic imaging also is improving significantly.
We hear stories of journalistic misbehavior, which are all too frequent, but they are not balanced with stories of the day in and day out routine of journalism. Responsible journalism is the norm in this nation, but we don’t hear much about it, thus our view of journalists may be inappropriately jaded. What journalists here often don’t realize is that, like most of the rest of us, their views of the Canadian health system are highly distorted by the selective reporting of others who are also driven by these same distortions that dwell in our cumulative memories.
Our thinking is based on what we know, but not on what we don’t know, and we won’t even know what it is that we don’t know unless our journalists start doing some more intensive research, even if it is very boring.

Journalism professor on reporting about Canadian health system

Universal Health Care For Elephant, Mouse

By Gene Costain
Tampa Bay Online
January 26, 2009

Ben Jonson was a cantankerous, 17th century British dramatist who despised the early days of journalism because he thought it was overrun with propagandists and charlatans.

I’m no modern-day cynic, but the record of news coverage on universal health care has been rife with ideological cant and tall tales. In my view, journalists have formed a kind of parasitic osmosis with powerful interests that impairs robust debate.

My meager standing for wading in is that in the past 25 years I’ve lived half of that time in Canada and the other half here in the last Western refuge of commoditized medicine.

I have been making mental notes on the accumulated fallacies and misnomers about the Canadian universal system. Your neighbor to the north has always been a great case study, because the country is a near mirror image of America on many levels.

My first memory of family struggle over medical bills was in 1962, when my mother was about to give birth to the last of seven kids. The single-payer system – in which all health care providers bill a single entity – was still a few years away. Just before she went into the hospital to deliver, I overheard an anxious conversation she had with my father about how they were going to pay the anticipated $300 hospital bill. My working-class father supported us on a salary of $55 a week. Within a few years, that financial anxiety vanished, and all they had to deal with was a small plastic card, with the added bonus of virtually no paper trail.

My move to America in 1996 meant facing a small pile of bureaucratic paper before starting my doctorate in Tennessee. During my adult life in Canada, a little card was my official point of contact with the health care bureaucracy. Forget about annoying co-pays, a new concept for me. The relative wonder of it all captured my imagination, and for years I’ve been monitoring debates about the issue in a vain search for balance, especially as it relates to some of the good things you don’t hear about the Canadian system.

Let me frame this in a larger context. The late Canadian Prime Minister Pierre Trudeau said that living next door to America was like a mouse sleeping with an elephant. Canada has one-tenth of the U.S. population, and its citizens are largely resigned to (but secretly admire) the large American pachyderm. Despite the similarities, Americans have missed out on an honest depiction of what Canadians think about their system.

There is one key element in the Canadian story that Americans rarely hear about in their media. Polls show that Canadians would not trade their single-payer system for all the tea in Indonesia. Most Canadians say their health care is their most valued citizenship asset. That is not hyperbole: For years, Gallup polls have chronicled this high regard for the system. It makes you wonder why we don’t often get this view here – after all, there are plenty of Canadians sunning themselves in these parts.

One of the most persistent challenges is that there are long waiting lines for some services in Canada; my experience is that both systems are virtually indistinguishable. An informal consensus of family and friends in Canada, including my aging mother, is that the medial service is good to great. I have honestly not heard of one major medical service horror story.

But who is to blame for Americans not receiving these political, cultural and news representations? One reason is that journalists here are like reporters in other nations, they root around in their backyards for sources and social insight.

As the debate returns this year, we may get a more expansive rendering of the story because everyone agrees the system is broken. But it won’t happen unless more journalists, filmmakers and bloggers chip in with a more balanced rendering of this Byzantine story. It might make the cynical ghost of Ben Jonson happy.

(Gene Costain is a University of Tampa journalism professor.)

http://www2.tbo.com/content/2009/jan/24/co-universal-health-care-for-elephant-mouse/

And…

Health Care in Canada

Canadian Institute for Health Information
2008

Physician migration

Information on health care workers’ migrations into and out of Canada, and into and out of individual professions, is difficult to capture. However, data on physicians show that the number of physicians leaving and returning from abroad declined over the five years to the end of 2006, with those emigrating declining by more than half (56.9%) and those returning dropping by 18.2%. In the three years to the end of 2006, physicians returning to Canada outnumbered those who left.

Wait time

While it is difficult to compare jurisdictions’ progress in reducing wait times, it is possible to compare jurisdictions’ surgery rates in the priority areas. Overall, rates in these areas rose by 8% more than the expected increase from population growth and aging between 2004-2005 and 2006-2007.

Diagnostic imaging

Over the three years ended in 2006-2007, the number of MRI and CT exams in Canada rose by 42.9% (to 31.2 per 1,000 population) and 27.9% (to 103.3 per 1,000 population), respectively. During the same period, the increase in the number of exams was greater than in the number of scanners, for both MRI and CT. In the case of MRI, a 27% growth in the number of scanners led to a 47% growth in the number of exams. In the case of CT, a 12% growth in the number of scanners led to a 32% growth in the number of exams.

http://secure.cihi.ca/cihiweb/products/HCIC_2008_e.pdf

Comment:

By Don McCanne, MD

The data base that most of us use for our routine thoughts is that which is stored in our memories. When we have need for other information, we know that there are other resources to which we can turn, but for most of our rote activities, memory is presumed to be adequate and reliable.

Almost every resident of the United States can tell you several things about the Canadian health care system. The problem is that much of it is wrong.

How did it happen that our memories/knowledge of the Canadian system are so distorted? One of the more important reasons is that we have little exposure to the routine functioning of the Canadian health care system. It’s not that the information isn’t available. The Canadian Institute for Health Information is a highly credible resource for such information. You can learn quite a bit just by reading their 2008 report, Health Care in Canada.

So why hasn’t our media reported any of this information? Quite simply, it is boring. There is no mention of problems such as the number of uninsured, bankruptcy due to medical debt, or care denied because of the inability to pay for it, because those problems don’t even exist in Canada. The reports are of a system that is functioning well, but is not perfect, so measures that are being taken to improve their system are also reported. What U.S. journalist would waste their time with that, and which editor would approve it in the first place?

Another reason that our views are so distorted is that, for decades, several conservative and libertarian organizations opposed to public insurance have spoon fed the U.S. media with reports of problems in the Canadian system that happen to make good copy. Although those reports are often embellished, most do have a factual basis even if they don’t represent the mainstream functioning of their system. They are great fodder for our journalists who themselves have misperceptions about Canadian health care because they also are exposed to these highly selected, exceptional stories that do not include the boring stories of the routine.

A couple of examples of distortions were pulled out of the CIHI report. Everyone knows that physicians are fleeing Canada based on innumerable stories here, yet the reality is that more physicians are returning to Canada. Wait times for elective (not emergency) surgery have been an issue, but this report shows that the problem is being addressed with some success. The availability of diagnostic imaging also is improving significantly.

We hear stories of journalistic misbehavior, which are all too frequent, but they are not balanced with stories of the day in and day out routine of journalism. Responsible journalism is the norm in this nation, but we don’t hear much about it, thus our view of journalists may be inappropriately jaded. What journalists here often don’t realize is that, like most of the rest of us, their views of the Canadian health system are highly distorted by the selective reporting of others who are also driven by these same distortions that dwell in our cumulative memories.

Our thinking is based on what we know, but not on what we don’t know, and we won’t even know what it is that we don’t know unless our journalists start doing some more intensive research, even if it is very boring.

Health care forum looks at single-pay insurance

By Robert Wolfington III
Marshall (Minn.) Independent
January 24, 2009

MARSHALL – Dr. Michael DeBrule said he has seen a lot of his patients have to pass on important procedures because their insurance wouldn’t cover it.

“There are a lot of un-insured people that I can’t help even if I wanted to; even if I waved my surgical fees, they would still have $4,000 at the hospital (and other fees).”

DeBrule, along with supporters of a national single-pay insurance plan, discussed its feasibility and explained how it would work during a town hall forum Thursday night at the Marshall Area YMCA.

Dr. Ann Settgast, co-chairwoman of the Minnesota chapter of Physicians for A National Health Program, said a single-pay insurance program would provide care for all U.S. citizens, while at the same time save money compared to the current multi-payer system.

“The cost savings in single-payer comes from getting rid of the administrative waste in a multi-payer system,” said Settgast. “You have providers filling hundreds of insurers, that is a lot more inefficient then if we are billing one payer.”

Settgast said a single-payer system would provide more flexibility in choices for health care.

“If you were a patient in a single-payer system nothing would change very much for you assuming you currently have health insurance,” said Settgast. “About 46 million people in America right now don’t have any health insurance, and for them we would bring them into the system.

“For someone who already has health insurance, the only thing that would change is you would have a different insurer, except your insurance card would be the national insurance,” she said.

Settgast said there is criticism of moving to a single-payer system because of the loss of jobs from insurance providers.

“One complaint you hear commonly is people would lose their job,” said Settgast. “That’s true, there is some superfluous work going on in the administrative sector. There are provisions in the state and national bills to allow for job retraining and also employment benefits for people who lose their jobs through this.”

Settgast said a single-payer system would simplify a system that is complicated.

“There would be no role for private insurance, so the main transition would not be as expensive as it would be disruptive,” said Settgast. “There would be some administration needed within a single-payer system, but you certainly wouldn’t need the vast bureaucracy that we have right now to run this multi-payer system.”

Settgast said PNHP is a national organization with 15,000 physician members advocating for a single-payer system.

Settgast said Minnesota has 2,000 physician members who support a single-payer system.

Settgast said the forum Thursday was an opportunity to address concerns from people including quality of care.

“A lot of our role is re-assuring people about maintaining high quality under a single-payer system, talking about where the cost savings would come from and how we can cover everyone,” said Settgast.

http://www.marshallindependent.com/page/content.detail/id/507329.html

Tell Sen. Baucus single-payer should be on the table

By GENE FENDERSON
Great Falls Tribune
January 5, 2009

In presenting his national health-care plan, “A Call to Action — Health Reform 2009,” Sen. Max Baucus said, “My door is open and I seek partners with ‘can-do’ spirits and open minds.'”

Earlier though, in the health-care forums he held around Montana, Sen. Baucus stated very strongly that a single-payer health-care plan “is off the table”.

Believing that the senator’s “door is open,” I maintain that a single-payer system must be on the table because it can help save our present and future economic well being as a state and nation.

The estimated cost of our present health-care system is $2.3 trillion dollars per year, more than 16 percent of our gross national product, compared to less than 9 percent of GNP in other industrialized countries.

I estimate the total amount spent on health care in Montana at $5.5 billion a year, including both private and public sectors. Well over $1 billion of that is spent on exorbitant administrative fees and cost shifting (people with insurance being billed higher charges to offset some of the losses from providing care to people who are underinsured or uninsured because they cannot personally afford it, their employer cannot afford it, or they don’t think they need it and do not want to pay for it).

We don’t really have a “system.” What we have is a confused maze of coverage types and providers — Medicare, Medicare Advantage, Medicaid, SCHIP, military, veterans administration, Indian Health Service, federal employee coverage, health savings accounts, community health centers, private insurance, dental insurance, vision insurance, medical coverage in auto insurance and more.

Unfortunately, the Baucus plan simply adds even more layers of confusion to this hodgepodge, which is already driving costs up and up for all Americans. We can do better. We must do better. That is why a single-payer system must be on the table.

What do we need? A basic, simple plan that charges all individuals who can afford it and all employers their fair share. One that covers all Americans, rich and poor, healthy and ill, young and old. A plan with no one refused coverage, no exclusions for pre-existing conditions, absolute choice of providers, total portability, no bankruptcies due to health-care bills, and an overall cost comparable to other industrialized nations.

A plan that will also provide our primary caregivers a standard of living that will attract and retain them.

What would work? A plan modeled on Medicare.

Medicare works well. It has overhead of 2.2 percent compared to 15 percent to 20 percent or higher for private insurers, even some nonprofit insurers.

Medicare has kept millions of Americans out of poverty, protected their hard earned savings and their homes, and allowed them to live with dignity.

Medicare includes supplemental insurance plans which help hold down over-utilization. A comprehensive American Medicare Plan could cover all Americans with a simple enrollment process based on proof of citizenship.

Existing systems serving specific populations (the military, veterans, and American Indians residing on their reservations) could continue to cover these populations. At their option, Indian tribes could choose to be covered by the American Medicare Plan.

A comprehensive American Medicare Plan could be implemented over a 10-year period allowing the system to expand in stages.

An incremental approach also allows insurance companies to change their product lines and services in a systematic, orderly fashion. Coverage would start the first two years by enrolling children and young people through age 25, by far the cheapest group to insure.

The second two-year group to enroll would be adults age 26 through 36, then the next two-years, those 37 through 47, the final two-year group would be those 48 through 64, the most expensive group.

As each adult group (those ages 26 through 64) enrolled in the comprehensive American Medicare Plan, they would also select a supplemental plan.

A person whose employer provided a supplemental plan as a benefit would automatically be covered under that plan, in addition to the American Medicare Plan.

Union members whose health and welfare trust offered a supplemental plan would be enrolled in that plan. Others could choose a supplemental plan from those offered by the government or by private insurers.

The American Medicare Plan would be paid for through an employer payroll tax calculated on a sliding scale of wages and number of employees, helping to level the playing field among all employers. Payroll tax credits would apply, as they do now. Full coverage for children from age 0 to young adults age 25 and people earning less than two hundred percent of the poverty level would be paid for from these revenues.

Adults making more than 200 percent of poverty would pay the normal Medicare fee and their own supplemental plan premium, based on a sliding scale. These costs would also be tax deductible for the individual.

This is just the outline of a uniquely American single-payer plan that could work, but only if Sen. Baucus puts a single-payer approach to health reform back on the table and opens the door to discuss all the options.

We need real change in health-care and we need it now. Please join me in urging Sen. Baucus, all of our congressional delegation and President-elect Obama to keep single-payer on the table and a part of the discussion.

Gene Fenderson was a board member for a Montana Taft-Hartley Health-care Trust Fund for 25 years and continues to participate in the health plan. Write to him at gfenderson@imt.net.

http://www.greatfallstribune.com/apps/pbcs.dll/article?AID=/200901050500/OPINION/901050304

Who Does Senator Baucus Listen To

Unions for Single Payer Health Care
January 25, 2009

Montana Senator Max Baucus, Chairman of the Senate Finance Committee, has said that in writing his new healthcare legislation “everything is on the table” except single payer. One wonders if Senator Baucus has been reading his home state newspapers or just listening to the lobbyists for the private insurance industry. (www.Opensecrets.org).

After Baucus ruled single payer “off the table” in his search for an “American” solution to the healthcare crisis, Montana’s newspapers have carried several articles calling for Senator Baucus to put single payer back on the table.

Writing in “The Great Falls Tribune” under the headline “Tell Sen. Baucus Single-payer Should Be On the Table,” Gene Fenderson, who served for twenty-five years as a union trustee of a Taft-Hartley joint healthcare fund, wrote: “I maintain that a single-payer system must be on the table because it can help save our present and future economic well being as a state and nation.” Fenderson criticized the Baucus plan directly saying: “Unfortunately, the Baucus plan simply adds even more layers of confusion to this hodgepodge, which is already driving costs up and up for all Americans. We can do better. We must do better. That is why a single-payer system must be on the table.”

Fenderson concluded: “We need real change in health-care and we need it now. Please join me in urging Sen. Baucus, all of our congressional delegation and President-elect Obama to keep single-payer on the table and a part of the discussion.”

http://www.greatfallstribune.com/apps/pbcs.dll/article?AID=/200901050500/OPINION/901050304

As if to add emphasis to Fenderson’s argument, a second article, this time in the Helena Independent Record, reported on results of meetings held throughout Montana at the urging of President Obama’s healthcare transition team. The meetings were to report to the transition team what ordinary citizens think about healthcare reform.

“The consensus of (our group) was that we did not see a lot of change coming unless we went to a single-payer, universal health system,” said Deborah Hanson of Miles City, who organized a meeting of local citizens at the behest of Obama’s transition team. “That was sort of a general consensus – knowing, of course, that may not happen.”

“The Miles City meeting, held Dec. 21 at Hanson’s home, was one of several in Montana and thousands held across the nation during the last two weeks of December.”

http://www.helenair.com/articles/2009/01/07/top/53lo_09017_healthcare.txt

Meanwhile, back in Washington, Senator Baucus was attending a lavish pre-inaugural ball at a posh nightclub where he told Brian Ross of ABC News that “lobbyists just want what’s best for America.” Baucus also had praise for the drug, insurance and other lobbyists who paid for the party, saying: “They really care about our country.”

http://abcnews.go.com/Video/playerIndex?id=6694754

So the question remains. Who does Senator Baucus listen to?

Call, write or Fax Senator Baucus and tell him single payer should be on the table and should be given a full and fair hearing by the Senate Finance Committee.

Senator Max Baucus
511 Hart Senate Office Bldg.
Washington, D.C. 20510
(202) 224-2651(Office)
(202) 224-9412 (Fax)

Conyers To Introduce Universal Healthcare Bill Today

Ryan Grim
The Huffington Post
January 26, 2009

John Conyers plans to introduce his universal healthcare legislation today, a Conyers aide tells the Huffington Post. The bill – known last session as H.R. 676 – is a favorite of healthcare reformers who back a single-payer system.

The bill, which will again be H.R. 676, is one of the more elegant to be introduced in the House, clocking in at just a few pages.

The plan is simple: everyone is eligible for a version of Medicare under a new U.S. National Health Insurance Program.

The program would effectively put private insurers out of business. What to do with all those employees? Hire them, says Conyers’ bill.

“The Program shall provide that clerical, administrative, and billing personnel in insurance companies, doctors offices, hospitals, nursing facilities, and other facilities whose jobs are eliminated due to reduced administration (1) should have first priority in retraining and job placement in the new system; and (2) shall be eligible to receive 2 years of unemployment benefits.”

Conyers, a Michigan Democrat and chairman of the Judiciary Committee, last introduced his bill, which garnered 93 cosponsors, in February 2007. It was referred to committee but never given a hearing.

If the 647-page House stimulus bill was too much to get through, try Conyers’ out.

Gawande's pseudo-pragmatism

Getting There from Here: How should Obama reform health care?

by Atul Gawande
The New Yorker
January 26, 2009
People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse — especially for those who already have dependable coverage and access to good doctors and hospitals.
Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.
Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have.
Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.
Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area — even if prices, taxes, and competition are stiffer.
Some people regard the path-dependence of our policies as evidence of weak leadership; we have, they charge, allowed our choices to be constrained by history and by vested interests. But that’s too simple. …consider a health-care example: the 2003 prescription-drug program for America’s elderly.
On January 1, 2006, the program went into effect nationwide. The result was chaos. There had been little realistic consideration of how millions of elderly people with cognitive difficulties, chronic illness, or limited English would manage to select the right plan for themselves. Even the savviest struggled to figure out how to navigate the choices: insurance companies offered 1,429 prescription-drug plans across the country. People arrived at their pharmacy only to discover that they needed an insurance card that hadn’t come, or that they hadn’t received pre-authorization for their drugs, or had switched to a plan that didn’t cover the drugs they took. Tens of thousands were unable to get their prescriptions filled, many for essential drugs like insulin, inhalers, and blood-pressure medications. The result was a public-health crisis in thirty-seven states, which had to provide emergency pharmacy payments for the frail. We will never know how many were harmed, but it is likely that the program killed people.
This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.
Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.
Massachusetts, where I live and work, recently became the first state to adopt a system of universal health coverage for its residents.
The results have been remarkable. After a year, 97.4 per cent of Massachusetts residents had coverage, and the remaining gap continues to close.
The Massachusetts plan didn’t do anything about medical costs, however, and, with layoffs accelerating, more people require subsidized care than the state predicted. Insurance premiums continue to rise here, just as they do elsewhere in the country. Many residents also complain that eight per cent of their income is too much to pay for health insurance, even though, on average, premiums amount to twice that much.
For years, about one in ten of my patients — I specialize in cancer surgery — had no insurance. Even though I’d waive my fee, they struggled to pay for their tests, medications, and hospital stay.
For the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage.
It will be no utopia. People will still face co-payments and premiums. There may still be agonizing disputes over coverage for non-standard treatments. Whatever the system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation — which is to say, a health-care system that works. And there are ways to get there that start from where we are.
http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande

Atul Gawande is a highly respected physician who has a well deserved reputation as a gifted writer. This commentary should not be construed as an attack on him; rather, it is an attack on his message. On his writing skills I give him an A, but on his content, a D-.
This article represents what I believe to be a misuse of framing. Gawande uses overly simplistic framing, but then bends, breaks or even replaces his frames as he develops his theme.
Gawande uses the linear polarity that I condemned in a recent qotd comment. In the four dimensional model that I described, he places single payer at one end of a linear polarity, free marketeers at the other end, and pragmatists in the middle.
His stated goal is a health care system that works, a goal that most of us share. Single payer is not only a financing system, but it is an administrative system that is specifically designed to make our health care system work for all of us. It is a system designed to address our problems not only in breadth, not only in depth, but throughout the three dimensions of all parameters, and over the fourth dimension of time. It is a system that is not “on the left” as he states, but, by design, it constitutes the health care universe in its four dimensions.
The free marketeers do not provide us with a universal system, but rather would disassemble much of what we have. They would have us each attend to our own needs, paying for whatever health care we need, or purchasing private health plans, even if the premiums alone are 16 percent of our income. No serious student of health policy would ever consider that to be a system that would work for all of us. At least Gawande is correct when he places the free marketeers out “on the right.”
What about the pragmatists? Of course, pragmatism is the theme of Gawande’s article. He cites path dependency as the natural model to achieve reform. Use what we have, and build on it to bring us closer to our goals.
But what is it that we do have? We have an expensive, dysfunctional health care delivery system that needs extensive repair along with adoption of efficiencies so that we can pay for it. Within the health care delivery system, we need to build on what is working, and replace that which isn’t.
But what else is it that we have? We have a health care financing system that is wasting tremendous resources, while impairing access to much needed health care, and exposing individuals to financial hardship or even financial ruin. Gawande’s major error in framing is that he conflates our health care delivery system with our health care financing, as if they were one and the same. Since we need to build on our existing delivery system, he includes as a given that building on our current fragmented financing system is an integral part of the process.
Look at the example that he gave us: the Medicare drug benefit. By the model of path dependency that he supports, drug coverage should have been added to Medicare as yet another benefit in the program, and it would have served us very well. Instead, it followed another path dependent road – our dependency on private health plans to cover prescription drugs. As Gawande states, this decision has likely killed people. Yet he insists that building on a financing system dependent on private insurers is essential because it’s path dependent.
He leaves us with an example of a successful application of path dependent reform – the Massachusetts “system of universal health coverage.” He glosses over the point that their system is not universal, although he does concede that the plan has done nothing to control costs, even though humane cost containment is an absolute imperative of any reform program.
But then it is hard to dispute Gawande’s perception that the Massachusetts plan is a success. After all, his surgical fees are being paid.
The pragmatic approach to financing reform is to follow a path dependent program that works, and discard those that don’t. With improvements, Medicare would work well for all of us; private health plans would work for those of us who are relatively healthy and have good incomes, like Dr. Gawande.

Gawande's pseudo-pragmatism

Getting There from Here: How should Obama reform health care?

by Atul Gawande
The New Yorker
January 26, 2009

People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse — especially for those who already have dependable coverage and access to good doctors and hospitals.

Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.

Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have.

Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.

Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area — even if prices, taxes, and competition are stiffer.

Some people regard the path-dependence of our policies as evidence of weak leadership; we have, they charge, allowed our choices to be constrained by history and by vested interests. But that’s too simple. …consider a health-care example: the 2003 prescription-drug program for America’s elderly.

On January 1, 2006, the program went into effect nationwide. The result was chaos. There had been little realistic consideration of how millions of elderly people with cognitive difficulties, chronic illness, or limited English would manage to select the right plan for themselves. Even the savviest struggled to figure out how to navigate the choices: insurance companies offered 1,429 prescription-drug plans across the country. People arrived at their pharmacy only to discover that they needed an insurance card that hadn’t come, or that they hadn’t received pre-authorization for their drugs, or had switched to a plan that didn’t cover the drugs they took. Tens of thousands were unable to get their prescriptions filled, many for essential drugs like insulin, inhalers, and blood-pressure medications. The result was a public-health crisis in thirty-seven states, which had to provide emergency pharmacy payments for the frail. We will never know how many were harmed, but it is likely that the program killed people.

This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.

Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.

Massachusetts, where I live and work, recently became the first state to adopt a system of universal health coverage for its residents.

The results have been remarkable. After a year, 97.4 per cent of Massachusetts residents had coverage, and the remaining gap continues to close.

The Massachusetts plan didn’t do anything about medical costs, however, and, with layoffs accelerating, more people require subsidized care than the state predicted. Insurance premiums continue to rise here, just as they do elsewhere in the country. Many residents also complain that eight per cent of their income is too much to pay for health insurance, even though, on average, premiums amount to twice that much.

For years, about one in ten of my patients — I specialize in cancer surgery — had no insurance. Even though I’d waive my fee, they struggled to pay for their tests, medications, and hospital stay.

For the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage.

It will be no utopia. People will still face co-payments and premiums. There may still be agonizing disputes over coverage for non-standard treatments. Whatever the system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation — which is to say, a health-care system that works. And there are ways to get there that start from where we are.

http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande

Comment:

By Don McCanne, MD

Atul Gawande is a highly respected physician who has a well deserved reputation as a gifted writer. This commentary should not be construed as an attack on him; rather, it is an attack on his message. On his writing skills I give him an A, but on his content, a D-.

This article represents what I believe to be a misuse of framing. Gawande uses overly simplistic framing, but then bends, breaks or even replaces his frames as he develops his theme.

Gawande uses the linear polarity that I condemned in a recent qotd comment. In the four dimensional model that I described, he places single payer at one end of a linear polarity, free marketeers at the other end, and pragmatists in the middle.

His stated goal is a health care system that works, a goal that most of us share. Single payer is not only a financing system, but it is an administrative system that is specifically designed to make our health care system work for all of us. It is a system designed to address our problems not only in breadth, not only in depth, but throughout the three dimensions of all parameters, and over the fourth dimension of time. It is a system that is not “on the left” as he states, but, by design, it constitutes the health care universe in its four dimensions.

The free marketeers do not provide us with a universal system, but rather would disassemble much of what we have. They would have us each attend to our own needs, paying for whatever health care we need, or purchasing private health plans, even if the premiums alone are 16 percent of our income. No serious student of health policy would ever consider that to be a system that would work for all of us. At least Gawande is correct when he places the free marketeers out “on the right.”

What about the pragmatists? Of course, pragmatism is the theme of Gawande’s article. He cites path dependency as the natural model to achieve reform. Use what we have, and build on it to bring us closer to our goals.

But what is it that we do have? We have an expensive, dysfunctional health care delivery system that needs extensive repair along with adoption of efficiencies so that we can pay for it. Within the health care delivery system, we need to build on what is working, and replace that which isn’t.

But what else is it that we have? We have a health care financing system that is wasting tremendous resources, while impairing access to much needed health care, and exposing individuals to financial hardship or even financial ruin. Gawande’s major error in framing is that he conflates our health care delivery system with our health care financing, as if they were one and the same. Since we need to build on our existing delivery system, he includes as a given that building on our current fragmented financing system is an integral part of the process.

Look at the example that he gave us: the Medicare drug benefit. By the model of path dependency that he supports, drug coverage should have been added to Medicare as yet another benefit in the program, and it would have served us very well. Instead, it followed another path dependent road – our dependency on private health plans to cover prescription drugs. As Gawande states, this decision has likely killed people. Yet he insists that building on a financing system dependent on private insurers is essential because it’s path dependent.

He leaves us with an example of a successful application of path dependent reform – the Massachusetts “system of universal health coverage.” He glosses over the point that their system is not universal, although he does concede that the plan has done nothing to control costs, even though humane cost containment is an absolute imperative of any reform program.

But then it is hard to dispute Gawande’s perception that the Massachusetts plan is a success. After all, his surgical fees are being paid.

The pragmatic approach to financing reform is to follow a path dependent program that works, and discard those that don’t. With improvements, Medicare would work well for all of us; private health plans would work for those of us who are relatively healthy and have good incomes, like Dr. Gawande.