PNHP

Letter to American College of Surgeons on single payer: enact Medicare for all

Letter to American College of Surgeons on single payer: enact Medicare for all

Sherif Emil, MD, CM, FACS
Irvine, CA
Bulletin of the American College of Surgeons
Volume 93, Number 12

In August 2003, an article endorsed by 7,784 physicians and medical students, “Proposal of the Physicians Working Group for Single-Payer National Health Insurance,” was published in the Journal of the American Medical Association.1 In his commentary on the article, Thomas Russell, MD, FACS, Executive Director of the American College of Surgeons, reminded us that “tremendous administrative costs and competition between plans that have a for-profit mentality have resulted in an arcane and costly system, which diverts money from patient care and breeds the corporate mindset that has become pervasive in the medical profession,”2 a position espoused by me and thousands of my colleagues in Physicians for a National Health Program. However, Dr. Russell did not believe that “the crisis in health care has reached a threshold that would command such a startling transformation.”2 To this, I responded, “The crisis in our health care system may be below the threshold only because we keep elevating the threshold.”3 Five years later, it appears that we may have finally reached the threshold, as evidenced by the resurfacing of health care as a major issue on the national agenda and in the presidential election.

Our present system of health care delivery is not sustainable. It may putter along for a decade or two, but it will finally collapse. And as it self-destructs, tens of thousands more will be hurt. Presently, the Institute of Medicine estimates that 1,500 Americans die every month due to lack of health care coverage. I would argue that it is not universal health care that is un-American–it is our present system.

Few in the surgical and medical profession would disagree that change is needed. Respected surgical leaders are speaking out. Donald Trunkey, MD, FACS, called the U.S. health care system the “best mediocre health care in the world.”4 In a lecture at Rice University, the late Michael DeBakey, MD, FACS, stated, “Our health care system is in disarray and cannot be rectified by the incrementalism approach.”5

The disagreement has to do with the type of change. You cannot build a second floor on a house with a rotten foundation. Although we have all the components to indeed have the best health care in the world, our health care delivery system is terminal. The problem of the uninsured is the most visible and perhaps the most profound. I travel frequently on surgical missions to east Africa. I am ashamed to say that I am starting to see here in California the type of late presentations and catastrophes I typically see in Kenya, Tanzania, and Zambia. But multiple other problems abound. Private insurers thrive by denying care and injecting tremendous inefficiency into the system. The burden of insuring the riskiest patients-the elderly, the poor, end-stage renal failure patients, Native Americans-is shifted to the government. Physicians practice with their hands tied behind their backs. I cannot get a simple X ray or blood test on most of my patients until the test is authorized. Often, the patient has to be sent to another facility.

Patients are trapped in health care plans that treat them as widgets that can be manipulated for financial gain. Choice of physician has become a luxury most patients cannot afford. This, in turn, has created stagnation among some physicians who, consciously or unconsciously, know that they have a trapped audience. Continuity of care is easily disrupted if insurance shifts to a different plan or is lost altogether, the treating physician changes practice, or job changes occur. Resources are poorly utilized due to competition driven by market forces, not quality. While 46 million are uninsured and millions more are not getting the care they need, hospitals are closing under financial stress. Why would we want to take this system, which is already at the breaking point, and expand it to cover everyone?

Medicare for all! Despite all the criticisms directed at Medicare, it has survived for more than 40 years, given our elderly the peace of mind we all deserve, improved the health of its beneficiaries, avoided micromanagement of clinical interventions, preserved patient freedom to choose their physician, and sustained efficiency in claim reimbursement. It has done all that with virtually no shared risk, providing services for almost all its beneficiaries. Despite its difficulties, the program’s popularity was recently evidenced by the congressional overturn of a presidential veto, an effort the College valiantly led. When we advocate for a single-payor model, our opponents immediately bring up waiting lists in Canada and other industrialized countries. Joint replacement is typically the sentinel operation used to demonstrate inadequate wait times in Canada. Ironically, most joint replacements in the U.S. are also paid for by a single-payor system: Medicare! Under Medicare, waiting lists are not an issue because spending and system capacity are significantly higher than those in Canada. We should also remember that Canadians spend approximately half of what we spend per capita on health care, cover everyone, and have public health and some tertiary care outcomes superior to ours. Shrinking the waiting list is a national priority in Canada, as evidenced by last year’s attendance of Prime Minister Stephen Harper at the annual “Taming of the Queue” conference. The Canadians have problems with their system, but they have a system.

The conventional wisdom is that a single-payor system is not popular with the public or physicians and cannot be realized in the U.S. But in a recent survey by the American Academy of Pediatrics, one-third of pediatricians favored a single-payor system, a substantial finding given that it is very difficult to get this many physicians to agree on another specific alternative. In a survey of 904 Massachusetts physicians randomly chosen from the American Medical Association master file, almost two-thirds of respondents identified single payor as “the structure that would provide the best care for the most people for a fixed amount of money.”6 In poll after poll, a majority of Americans favor a universal health care system, even if financed through increased taxation.

Americans, the public, and their physicians have a major decision ahead. Will health care continue to be treated as a commodity bought and sold according to means or as a service sought and delivered according to need? American surgeons should continue to lead the world in innovation and creativity, but they should also apply the results of their resourcefulness to any patient in need, in an atmosphere of evidence-based care, patient freedom to choose their doctor, and resource optimization, free from micromanagement and bureaucratic hassles. I don’t believe this can be achieved through expanding or amending our current nonsystem.

As called for by an idealistic, young surgeon in the August Bulletin, “When physicians place the health of our patients as our first consideration, we reclaim our autonomy, our morale, and ultimately our dignity as a profession.”7 A radical shift in our approach and our priorities–a shift that would produce a startling transformation–is necessary! References

1. Proposal of the physicians’ working group for single-payer national health insurance. JAMA. 2003;290:798-805.
2. Russell TR. From my perspective. Bull Am Coll Surg. 2003;88(10):3-4.
3. Emil S. Crisis in health care [Letters]. Bull Am Coll Surg. 2004;89(1):53.
4. Trunkey DD. A growing crisis in patient access to emergency care: A different interpretation and alternative solutions. Bull Am Coll Surg. 2006;91(11):1322.
5. DeBakey ME. The role of the government in health care: A societal issue. Am J Surg. 2006;191:145-157.
6. McCormick D, Himmelstein DU, Woolhandler S. Single-payer national health insurance. Physicians’ views. Arch Intern Med. 2004;164:300-304.
7. Kuy’S. Stand..d up for patients. Bull Am Coll Surg. 2008;93:(8):23-24.

The Politics of Healthcare Reforms in US Presidential Elections

Vicente Navarro, MD, PhD
Harvard Health Policy Review
Vol. 9, No. 1, Spring 2008 35

I appreciate the invitation from the Harvard Health Policy Review to discuss the relationship between national health care systems and the policy process. One cannot analyze this relationship without analyzing the political context in which it occurs, and since the U.S. is now in the midst of a very important political process — the presidential primaries of 2008 — it may be of special interest to readers of the Review to focus on the impact of the political process on the health care reform proposals put forward by the presidential candidates in this and past elections.

The invitation from the senior editor of the Review left open the possibility of presenting a comparison of the political context of health policy formation in the U.S. with that in other countries. Rather than making such comparisons, however, I am going to focus on the U.S., but with a few notes on how this country compares with other developed democratic countries at levels of economic development similar to that of the U.S. — specifically, the countries of the European Union (E.U.).

I use the E.U. countries for reference because I know them well. I was born in Spain, and received a degree in medicine there. I then had to leave Spain because of my participation in the anti-fascist underground in the 1950s. I went first to Sweden and studied economics, and was much influenced by my intellectual mentor, Gunnar Myrdal, from whom I learned everything I know about economics. I have always been a great admirer of the Swedish welfare state, although I am not oblivious to some of its weaknesses. (I described this in my book The National Health Planning in Sweden, published by the Fogarty Center of the National Institutes of Health in 1974.) I then studied social policy at the London School of Economics, under another great influence in my intellectual life, Richard Titmus, and later studied health policy and management at Edinburgh University, Scotland. I admired Britain’s National Health Service, the jewel of the British welfare state (as Churchill once called it), but again was aware of some of its faults (as expressed in my book Class Struggle, The State of Medicine: An Historical and Contemporary Analysis of the Medical Sector in Great Britain, published in 1978). In 1965 I arrived in the U.S. and joined the Johns Hopkins University, where I have worked ever since. My early analysis of the U.S. health care system was published as Medicine under Capitalism (1976), which described the greatness but also the miseries of the U.S. house of medicine. Much has changed since then, yet much has remained the same.

Before focusing on the U.S., with some comparative notes on the European situation, let me make several observations that are necessary to a better understanding of health policy on both sides of the Atlantic. The U.S. and E.U. political cultures are very different. Just one example: red is the color of the conservative forces (the Republican Party) in the U.S., and blue is the color of the progressive forces (the Democratic Party). The reverse is true in the E.U.: red is the color of the left and center-left parties, and blue the color of the right and center-right parties. In Europe, a “red region” is a region such as Barcelona, which has always been governed by leftwing parties during Spain’s democratic period. In the U.S., a “red state” is one governed by the Republican Party. This difference may seem a minor point, but it isn’t. It shows how even the symbols of the political cultures differ. Such differences also appear in the political discourse. A “liberal” in the U.S. is a politician, such as Jesse Jackson Sr., who is in favor of a larger role for the state (or, in popular language, the “government”) in society, supporting higher public expenditures for social ends and encouraging redistributive policies backed up by more progressive taxation. A liberal in the E.U. is precisely the opposite — someone who favors reducing the role of government in society, advocates lower taxation, is against redistributive policies, and supports a reduction of public expenditures. These opposite meanings of “liberal” explain the enormous confusion created in Europe when the media there translate the term “liberal” literally. In Europe, the parties that advocate the types of policies called “liberal” in the U.S. are referred to as social democratic. Liberals in the E.U. are small parties that usually have limited influence in the political representative institutions.

The nature of the medical problem in the U.S.

Let’s now turn to the U.S. One of the major problems faced by large sectors of the population is their limited access to medical services in time of need, their insufficient health benefits coverage if they do have health insurance, and their difficulties in paying premiums to the health insurance companies and paying the medical bills they receive. None of these problems, experienced in the U.S., are found in the publicly funded health services of the E.U. (or in Canada for that matter).

In 2006, 47 million Americans did not have any form of health benefits coverage, and 108 million had insufficient coverage. And people die because of this. Estimates of the number of preventable deaths vary, from 18,000 per year (estimated by the conservative Institute of Medicine) to a more realistic level of more than 100,000 (calculated by Professor David Himmelstein of Harvard University). The number depends on how one defines “preventable deaths.” But even the conservative figure of 18,000 deaths per year is six times the number of people killed in the World Trade Center on 9/11. That event outraged people (as it should), but the deaths resulting from lack of health care seem to go unnoticed; these deaths are not reported on the front pages, or even on the back pages, of the New York Times, Washington Post, Los Angeles Times, or any other U.S. newspaper. These deaths are so much a part of our everyday reality that they are not news.

But besides the problem of the uninsured, the U.S. has another major problem: the underinsured. Most people believe that because they have health insurance, they will never face the problem of being unable to pay their medical bills. They eventually find out the truth, however — that their insurance is dramatically insufficient. Even for families with the best health benefits coverage available, the benefits are much less comprehensive than those provided as entitlements in Canada and in most E.U. countries. Paying medical bills in the U.S. is a serious difficulty for many people. In fact, inability to pay medical bills is the primary cause of family bankruptcy, and most of these families have health insurance. Furthermore, 20% of families spend more than 10% of their disposable income on insurance premiums and medical bills (the percentage is even higher for those with individual insurance: 53%). In 2006, one of every four Americans lived in families that had problems with paying medical bills. And most of them had health insurance. None of the E.U. countries face this dramatic situation.

Can the U.S. afford a comprehensive universal health care program?

The roots of this human and economic problem cannot be lack of resources. The U.S. spends 16% of its GNP on medical care, almost double the percentage spent by Canada and most E.U. countries on providing their populations with universal, comprehensive health care coverage. We in the U.S. spend $2.1 trillion annually on medical care, making the medical care sector one of the largest economies in the world (if the medical care sector were a country, rather than a massive sector within a country). And it has been estimated that this spending will reach 20% of GNP in a few years (7 years according to some, 12 years according to others). Lack of money is not the root of the medical care problem in the U.S. We spend far, far more than any other developed country, and far more than we would need to spend to provide comprehensive health care coverage for everyone. The frequently heard argument that the U.S. cannot afford universal, comprehensive care has no credibility. It is a poor rationale for keeping the situation as it is.

If lack of resources is not the problem, then what is? The answer is fairly easy to see. The root of the problem is the channels through which the money is managed and spent. The U.S. is the only country where medical care is predominantly private (although if we include the tax exemptions for private insurers, most of the funding in the U.S. is public). And the health insurers play a critical role in the funding and management of medical care in the U.S. The current system of funding and managing medical care is based on an employers-insurers alliance that was established in 1948 in the Taft-Hartley Act. Immediately after World War II, a pact was established between the major employers associations and the insurance companies and was crystallized in the Act (initially vetoed by President Truman). The health benefits coverage of the working population was to be provided, not through the state (as in the majority of European countries), but through people’s place of employment by a process of negotiation between trade unions and employers that takes place in a highly decentralized collective-bargaining process. Employers and employees pay the insurance premiums for health benefits coverage, coverage that varies enormously depending on the strength of the labor unions. Wherever trade unions are strong (as in manufacturing) the health benefits coverage has been good, although never as good as in the publicly funded medical care systems in the E.U. Wherever trade unions are weak or absent, the health benefits coverage has been very limited or nonexistent. This is the reason for the enormous variability in health benefits coverage in the U.S. One reason why employers supported this arrangement was that this system of funding is one of the most powerful ways of controlling employees. The U.S. is the only country where, when workers are fired, they lose not only their salary but also their health benefits coverage for their family. This is one reason for the U.S. being the country with the fewest working days lost due to strikes: workers think twice before striking. Today, the high costs of health insurance premiums are weakening employers’ support for this employer-based insurance. But the majority of large employers (major components of the “corporate class”) still favor this system. Individuals who don’t receive health insurance through their place of employment must buy their own, or they have no insurance. If a person has a chronic illness or disability, the price of the premium may be prohibitive, or the person is not accepted by an insurer because of a “preexisting condition.”

The other side of this employer’s insurer’s alliance is that the health insurance industry is one of the most profitable in the U.S. The insurance industry and other sectors of the medical-industrial complex enjoy the highest rates of profit in the country. Just last year, insurance industry profits reached $12 billion, and pharmaceutical industry profits $49 billion, the highest in the U.S. and in the world. According to Fortune magazine, health-related industries are among the most profitable industries in the U.S. A lot of money is being made from people’s suffering. This scandalous situation is easy to document. For example, Lanzoprasol, a gastric-secretion-reducing medicine widely used in the U.S., costs $329 in Baltimore, Maryland; the same medicine (same number of doses) costs $9 in Barcelona, Spain! And the current Bush administration signed legislation for a program that, in theory, covers drug costs for elderly people, but in practice this is an enormous rip-off. It forbids the government to negotiate with drug companies on the cost of drugs — that is, the price of their products. What this means is that the federal government pays the prices dictated by the pharmaceutical industry.

Why have U.S. governments consistently failed to resolve this situation?

Why does this continue? Why hasn’t the U.S. government done something about it? Is it that the government could not provide comprehensive health benefits coverage? It certainly could. All E.U. governments do so. All provide publicly funded, comprehensive health care coverage to their entire population. And on this side of the Atlantic, Canada (which once had a system identical to ours, health insurers included) also provides this entitlement to all its citizens. In Canada in the 1960s, a social democratic government in Saskatchewan did a very logical thing. My good friend Dr. Samuel Wolfe, who was then Chief Health Officer of Saskatchewan, proposed to the province’s social democratic government that rather than paying premiums to insurance companies, people would pay earmarked taxes to a public trust fund, controlled by their representatives. This trust fund would negotiate with doctors and hospitals for the payments they receive for the care they provide. This saved a lot of money by bypassing the insurance companies. The Saskatchewan Health Plan provided comprehensive care to everyone in the province at a much lower cost than before. Soon, the other provinces adopted similar plans, eventually establishing Canada’s nationwide health plan that now covers everyone. The overhead for the public system in Canada is only 4%, compared with 30% in the U.S. insurance industry — 30% that goes to marketing, administration (a lot of paper shuffling goes on in U.S. health care), and the salaries of extremely well paid executives and insurance lobbyists. One of the best-paid individuals in the U.S. is William McGuire, CEO of an insurance company — UnitedHealth. He makes $37 million a year, plus $1.7 billion in stock options. And all of this money comes from premiums paid by people, many of whom have insufficient coverage.

The political context: it’s not just the medical sector that is privatized — the electoral process is also privatized

The U.S. is also the only country where the electoral process is privatized. This means that most of the money for candidates’ political campaigns is private money. And we are speaking of big money. The idealized version of the U.S. electoral process, in which candidates are funded by a conglomeration of small contributions from ordinary citizens, is plain wrong. According to Common Cause, the most credible center for the study of elections in the U.S., most of the funding for candidates comes from large economic interests (insurance companies, drug companies, professional associations, banking, construction industries, and a long list of others) and from the 30% of the population with highest incomes. Candidates need this money for, among other things, buying media space in the private broadcasting industry that sells airtime to the highest bidder. The more money your campaign takes in, the greater is your chance of winning the election. According to Common Cause, 94% of the best-funded candidates won in the last Congressional election, in 2006.

Money is indeed the major motor behind politics. This is what gives the insurance companies their enormous power, both in Washington, DC, and in most state legislatures. In Maryland, for example, a former governor arranged for candidates for Insurance Commissioner to be interviewed by the insurance associations before he made his final selection. But insurance industry influence is strongest in Washington. The insurance companies pay a lot of money to candidates. According to the Center for Responsive Politics, as of February 12, 2008, the insurance industry had contributed $525,188 to Hillary Clinton, $414,863 to Barack Obama, and $274,724 to John McCain. As a consequence, not one of the candidates is asking for a publicly funded health care system. The major players in medical care in the U.S. — insurance companies, drug companies, professional associations, and so on, as noted above — have given a lot of money to the candidates. The splendid document called the U.S. Constitution, which begins “We the people,” should have a footnote: “and the insurance companies, the drug companies . . .” The U.S. Congress is indeed the best Congress money can buy (for a further discussion of how money corrupts the electoral system, see my article “How to Read the U.S. Primaries: Guide for Europeans,” CounterPunch, February 13, 2008). Privatization of the electoral process corrupts the democratic process. I am not implying that politicians are corrupt (although some are). I am willing to admit that most are honorable persons. But the need to constantly raise funds for their campaigns (for election and reelection) corrupts the democratic process. And the unwillingness of most members of Congress to change this situation makes them accomplices in that corruption. Such practices are illegal in most democratic countries. Many ministers of European governments have had to resign when it came to light that they had received private funds for the electoral process.

And people know all about this. In surveys, 68% of people believe the U.S. Congress does not represent their interests, but represents the interests of the financial and economic groups that fund political campaigns. But the establishments, including the political, media, and academic establishments, want everyone to believe that the reason we don’t have a universal health program is that people don’t want it. They would like people to believe that Congress legislates what people actually want. Meanwhile, the long list of public policies that people want but do not get from their government is growing: 65% of people want a publicly funded health care system similar to that in Canada, a single-payer system. In a single-payer system, the government, rather than the insurance companies, negotiates with providers — doctors, hospitals, nurses, and so on — for the provision of medical care. We already have a system of this type in Medicare (with an administrative overhead of only 4%, compared with the 30% overhead in the insurance system). By eliminating the huge administrative expenses, we could provide comprehensive health care coverage for everyone without spending an extra penny. Let me add that according to Annals of Internal Medicine, 59% of physicians across the U.S. “support government legislation to establish a national health insurance.”

The political response: the proposals for health care reform

These enormous problems in obtaining medical care in the U.S. explain why medical care reform has become — along with the economy and Iraq — a top issue in this year’s presidential election. For this reason, candidates in the presidential primaries (the Democrats more often than the Republicans) have been recounting stories about the health-related tragedies they have encountered in meetings with ordinary people around the country (an exercise conducted in the U.S. every four years, at presidential election time). These stories tell of the enormous difficulties and suffering faced by many people in their attempts to get the medical care they need. I have been around long enough — I was senior health advisor to Jesse Jackson in the Democratic primaries of 1984 and 1988 — to know how frequently Democratic candidates, over the years, have referred to such cases. The only things that change are the names and faces in these human tragedies. Otherwise, the stories, year after year, are almost the same.

In the Democratic Party primaries of 1988, for example, candidate Michael Dukakis talked about a young single mother who had two jobs and still could not afford medical insurance for herself and her children. In 1992, Bill Clinton did the same, changing the story only slightly. This time it was the case of a woman with diabetes who could not get health insurance because of her chronic condition. And now, in the 2008 primaries, Hillary Clinton (whom I worked with on the White House Health Care Reform Task Force in 1993) describes a similar case. This time it’s a single woman, with two daughters, who cannot pay her medical bills because her congenital heart defect makes it impossible for her to get insurance coverage. And Barack Obama describes similar cases, with the eloquence that characterizes all of his speeches. He frequently refers to his own mother, who had cancer and had to worry not only about her illness but about paying her medical bills. Republican candidates rarely make references to such situations.

All these cases are tragic and are representative of a situation faced by millions of people in the U.S. every year. But, I am afraid that unless the winning Democratic candidate, once elected president (and I hope he or she will be), develops a more comprehensive health care proposal than any of those put forward in the primaries so far, we will see the same situation continue. Democratic candidates in the 2012 primaries, and in the 2016 primaries, will still be referring to single mothers with chronic health conditions who cannot pay their medical bills. The proposals put forward by Obama and Clinton (not to speak of McCain) underestimates the gravity of the problem in the U.S. medical care sector. The situation is bad and is getting worse: the number of people who are uninsured and underinsured has been growing since 1978. There were 21 million uninsured people in the U.S. in 1972. By 2006, that number had more than doubled to 47 million. And this increase has occurred independent of economic cycles. The number of uninsured grew by 3.4 million from 2004 to 2006, even as a resurgent economy raised incomes and lowered poverty rates. Meanwhile, during those years, the Republican establishment ignored the situation altogether and the Democratic establishment distanced itself from any commitment to resolving these problems. Even though the 1976, 1980, 1984, 1988, and 1992 Democratic platforms included calls for health care benefits coverage for everyone (or “universal health care”), that call was usually made without much conviction. In the primaries of 1988, when I was involved in preparing the Democratic platform, Dukakis (the winner of the primaries) resisted including universal health care in the party platform. He was afraid of being perceived as “too radical.” He had to accept it, however, because Jesse Jackson agreed to support Dukakis (Jackson had 40% of the Democratic delegates at the Atlanta convention) only if the platform included this call for universal care.

Then, in 1992, Bill Clinton (who borrowed extensively from Jackson’s 1988 proposals) put the call for universal health care at the center of his program. But, once president, his closeness to Wall Street, and his intellectual dependence on Robert Rubin of Wall Street (who became his Secretary of the Treasury), made him leery of antagonizing the insurance industry. It was President Clinton’s unwillingness to confront the insurance companies that led to his failure to honor his commitment to work toward a universal health care program (see my article “Why Hillary-Care Failed,” CounterPunch, November 12, 2007). The type of reform President Clinton called for was a health-insurance- based model called “managed care,” in which insurance companies remain at the center of health care. An alternative approach could have been to establish a publicly funded health care program (which was favored by the majority of the population) that would cover everyone, providing medical care as an entitlement for all citizens and residents. This could have been achieved, such as by expanding the federal Medicare program to cover everyone. To do so, however, would have required neutralizing the enormous power of the insurance companies with a massive mobilization of the population against them and in favor of a comprehensive and universal health care program.

But President Clinton’s loyalty to Wall Street prevailed. His administration’s top priorities were reduction of the federal deficit (at the cost of reduced public social expenditures) and approval of NAFTA (without amending President George H. W. Bush’s proposal, which Clinton had inherited, and refusing to address the concerns of the labor and environmental movements). These actions antagonized and demoralized the grassroots of the Democratic Party. Clinton lost any power to mobilize people for the establishment of a universal health care program. This frustration of the grassroots, and especially the working class, also led to the huge abstention by the Democratic Party base in the 1994 congressional elections and the consequent loss of the Democratic majority in the House, the Senate, and many state legislatures. At the root of this disenchantment with the Clinton administration was its unwillingness to confront the insurance companies and Wall Street. Could that happen again? The answer is yes. Regardless of who wins the coming presidential election, we are likely to face a similar situation. I doubt that the Republican candidate would dare carry out proposals that might antagonize the powerful forces that shape the funding and organizations of medicine in the U.S. But, the same could occur with the Democratic candidate. Unless there is a profound change in the way the U.S. funds the electoral process, we are not going to see major reforms in the health sector. It is as plain as that.

Speak up at Sen. Daschle’s house parties

Participant Guide for Health Care Community Discussions

Obama-Biden Transition Project

Policy Background and Key Questions

II. The President-elect’s Health Care Plan

Expand Coverage to all Americans:

* Build upon and strengthen employer coverage;

* Allow people to keep the coverage that they have and maintain patients’ choice of doctor;

* Establish a National Health Insurance Exchange that offers a range of private insurance options as well as a new public plan option;

* Require insurance companies to cover pre-existing conditions so all Americans regardless of their health status or history can get comprehensive benefits at fair and stable premiums;

* Expand Medicaid and SCHIP and provide sliding-scale premium assistance for low-income people.

III. QUESTIONS

1. Briefly, from your own experience, what do you perceive is the biggest problem in the health system?

2. How do you choose a doctor or hospital? What are your sources of information? How should public policy promote quality health care providers?

3. Have you or your family members ever experienced difficulty paying medical bills? What do you think policy makers can do to address this problem?

4. In addition to employer-based coverage, would you like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare?

5. Do you know how much you or your employer pays for health insurance? What should an employer’s role be in a reformed health care system?

6. Below are examples of the types of preventive services Americans should receive. Have you gotten the prevention you should have? If not, how can public policy help?

7. How can public policy promote healthier lifestyles?

http://change.gov/page/-/Health%20Care%20Community%20Discussion%20Participant%20Guide.pdf

Health Care Community Discussion: Host and Moderator Guide

II. Your Role

If you are serving as the moderator, you should not strongly advocate for specific health policy positions. Instead, your role is to listen, facilitate discussion that elicits the views of all attendees, and help the participants draft a submission to the Transition Health Policy Team. In addition, please identify the most compelling personal stories that illustrate the need for health care reform in our country.

http://change.gov/page/-/Health_Care_Community_Discussion_Moderator_Guide.pdf

To sign up as a host:
http://change.gov/page/s/hcdiscussion

Comment:

By Don McCanne, MD

Throughout the nation during the next two weeks HHS Secretary-designate Tom Daschle is encouraging grassroots, community level discussions of health care reform. The purpose is to give the public a sense that they are actively involved in the reform process, avoiding a repetition of the Clinton political error of crafting reform behind closed doors.

If you look at both the moderator guide and the participant guide, it’s quite clear that this is not an effort to collect information to guide the policy makers in their decisions. The fundamental policy decisions have already been made, and they are listed above. This is strictly a process to build on the momentum for reform.

We have seen this process before. In 2006, a series of community hearings for the Citizens’ Health Care Working Group (CHCWG) were held throughout the United States:

“When given a choice of ten reform options at public hearings held by the CHCWG, participants clearly favored a national health program by a margin of at least 3 to 1. At meetings where participants were asked to rank the 10 options, national health insurance was ranked first 16 of 19 times (Billings, MT; Denver; Des Moines; Detroit; Eugene, OR; Jackson, MS; Kansas City, MO; Memphis; Miami; New York, NY; Philadelphia; Phoenix; Providence, RI; Sacramento; and Seattle). At two meetings participants were neither polled nor options ranked. Despite the clear public mandate, the CHCWG’s report makes no mention of the vast support for a national health program. Instead, the group’s official recommendations include only generic suggestions such as promoting ‘efforts to improve quality of care and efficiency,’ and finding a way to protect ‘against very high health costs.'” (https://www.pnhp.org/news/2006/october/citizens_health_ca.php)

The organizers of the CHCWG process were caught off guard by the intense support for a national health program. During the sessions the computer programs had to be modified to include serious consideration of the public insurance option. Yet the final report did not reflect the intensity of this support.

The scripted discussions for Sen. Daschle’s community meetings exclude any consideration of a single payer national health program. The closest they come is to discuss a “public plan like Medicare” that can be purchased as another option to a private plan through an insurance exchange. Yet a legislative staff member for a Democratic Senator recently stated that the “public option” proposal looked at present to be completely blocked by the Republicans – they will only discuss changes based upon the existing private insurance industry. One of the reform negotiators, Republican Senator Mike Enzi, last week wrote, “… we must focus on promoting new options and choices for patients. This means expanding competitive, free market plans – not moving toward a single payer health care system.”

Even though the process is a sham, that doesn’t mean that we shouldn’t speak up. We should do so, though in a civil but firm manner. The very first question asking what is the biggest problem in the health system can be answered by stating that our fragmented financing system based on private plans and public programs is wasting a huge amount of funds that should be used for health care for the uninsured and underinsured, and we can actually do that by replacing our dysfunctional financing system with a single payer national health program. We need to be certain that Sen. Daschle is shocked yet pleasantly surprised to see overwhelming support for single payer about which he has written is “brilliantly simple, ensures equity by providing all people with the same benefits, and saves billions of dollars by creating economies of scale and streamlining administration.”

Be sure to stay at the meetings long enough to be certain that the single payer message is included in the submission to the Transition Health Policy Team. We need to send that message. It remains to be seen whether or not the bureaucrats are going to try to bury it again. If they do, then maybe it’s time for a march on Washington.

Special Message to the Congress Recommending a Comprehensive Health Program

By HARRY S. TRUMAN
November 19, 1945

To the Congress of the United States:

In my message to the Congress of September 6, 1945, there were enumerated in a proposed Economic Bill of Rights certain rights which ought to be assured to every American citizen.

One of them was: “The right to adequate medical care and the opportunity to achieve and enjoy good health.” Another was the “right to adequate protection from the economic fears of . .. sickness .…”

Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.

The people of the United States received a shock when the medical examinations conducted by the Selective Service System revealed the widespread physical and mental incapacity among the young people of our nation. We had had prior warnings from eminent medical authorities and from investigating committees. The statistics of the last war had shown the same condition. But the Selective Service System has brought it forcibly to our attention recently—in terms which all of us can understand.

As of April 1, 1945, nearly 5,000,000 male registrants between the ages of 18 and 37 had been examined and classified as unfit for military service. The number of those rejected for military service was about 30 percent of all those examined. The percentage of rejection was lower in the younger age groups, and higher in the higher age groups, reaching as high as 49 percent for registrants between the ages of 34 and 37-

In addition, after actual induction, about a million and a half men had to be discharged from the Army and Navy for physical or mental disability, exclusive of wounds; and an equal number had to be treated in the Armed Forces for diseases or defects which existed before induction.

Among the young women who applied for admission to the Women’s Army Corps there was similar disability. Over one-third of those examined were rejected for physical or mental reasons.

These men and women who were rejected for military service are not necessarily incapable of civilian work. It is plain, however, that they have illnesses and defects that handicap them, reduce their working capacity, or shorten their lives.

It is not so important to search the past in order to fix the blame for these conditions. It is more important to resolve now that no American child shall come to adult life with diseases or defects which can be prevented or corrected at an early age.

Medicine has made great strides in this generation—especially during the last four years. We owe much to the skill and devotion of the medical profession. In spite of great scientific progress, however, each year we lose many more persons from preventable and premature deaths than we lost in battle or from war injuries during the entire war.

We are proud of past reductions in our death rates. But these reductions have come principally from public health and other community services. We have been less effective in making available to all of our people the benefits of medical progress in the care and treatment of individuals.

In the past, the benefits of modern medical science have not been enjoyed by our citizens with any degree of equality. Nor are they today. Nor will they be in the future—unless government is bold enough to do something about it.

People with low or moderate incomes do not get the same medical attention as those with high incomes. The poor have more sickness, but they get less medical care. People who live in rural areas do not get the same amount or quality of medical attention as those who live in our cities.

Our new Economic Bill of Rights should mean health security for all, regardless of residence, station, or race—everywhere in the United States.

We should resolve now that the health of this Nation is a national concern; that financial barriers in the way of attaining health shall be removed; that the health of all its citizens deserves the help of all the Nation.

There are five basic problems which we must attack vigorously if we would reach the health objectives of our Economic Bill of Rights.

n The first has to do with the number and distribution of doctors and hospitals. One of the most important requirements for adequate health service is professional personnel—doctors, dentists, public health and hospital administrators, nurses and other experts.

The United States has been fortunate with respect to physicians. In proportion to population it has more than any large country in the world, and they are well trained for their calling. It is not enough, however, that we have them in sufficient numbers. They should be located where their services are needed. In this respect we are not so fortunate.

The distribution of physicians in the United States has been grossly uneven and unsatisfactory. Some communities have had enough or even too many; others have had too few. Year by year the number in our rural areas has been diminishing. Indeed, in 1940, there were 31 counties in the United States, each with more than a thousand inhabitants, in which there was not a single practicing physician. The situation with respect to dentists was even worse.

One important reason for this disparity is that in some communities there are no adequate facilities for the practice of medicine. Another reason—closely allied with the first—is that the earning capacity of the people in some communities makes it difficult if not impossible for doctors who practice there to make a living.

The demobilization of 60,000 doctors, and of the tens of thousands of other professional personnel in the Armed Forces is now proceeding on a large scale. Unfortunately, unless we act rapidly, we may expect to see them concentrate in the places with greater financial resources and avoid other places, making the inequalities even greater than before the war.

Demobilized doctors cannot be assigned. They must be attracted. In order to be attracted, they must be able to see ahead of them professional opportunities and economic assurances.

Inequalities in the distribution of medical personnel are matched by inequalities in hospitals and other health facilities. Moreover, there are just too few hospitals, clinics and health centers to take proper care of the people of the United States.

About 1,200 counties, 40 percent of the total in the country, with some 15,000,000 people, have either no local hospital, or none that meets even the minimum standards of national professional associations.

The deficiencies are especially severe in rural and semirural areas and in those cities where changes in population have placed great strains on community facilities.

I want to emphasize, however, that the basic problem in this field cannot be solved merely by building facilities. They have to be staffed; and the communities have to be able to pay for the services. Otherwise the new facilities will be little used.

2. The second basic problem is the need for development of public health services and maternal and child care. The Congress can be justifiably proud of its share in making recent accomplishments possible. Public health and maternal and child health programs already have made important contributions to national health. But large needs remain. Great areas of our country are still without these services. This is especially true among our rural areas; but it is true also in far too many urban communities.

Although local public health departments are now maintained by some 18,000 counties and other local units, many of these have only skeleton organizations, and approximately 40,000,000 citizens of the United States still live in communities lacking full-time local public health service. At the rece
nt rate of progress in developing such service, it would take more than a hundred years to cover the whole Nation.

If we agree that the national health must be improved, our cities, towns and farming communities must be made healthful places in which to live through provision of safe water systems, sewage disposal plants and sanitary facilities. Our streams and rivers must be safeguarded against pollution. In addition to building a sanitary environment for ourselves and for our children, we must provide those services which prevent disease and promote health.

Services for expectant mothers and for infants, care of crippled or otherwise physically handicapped children and inoculation for the prevention of communicable diseases are accepted public health functions. So too are many kinds of personal services such as the diagnosis and treatment of widespread infections like tuberculosis and venereal disease. A large part of the population today lacks many or all of these services.

Our success in the traditional public health sphere is made plain by the conquest over many communicable diseases. Typhoid fever, smallpox, and diphtheria—diseases for which there are effective controls-have become comparatively rare. We must make the same gains in reducing our maternal and infant mortality, in controlling tuberculosis, venereal disease, malaria, and other major threats to life and health. We are only beginning to realize our potentialities in achieving physical well-being for all our people.

3. The third basic problem concerns medical research and professional education.

We have long recognized that we cannot be content with what is already known about health or disease. We must learn and understand more about health and how to prevent and cure disease.

Research—well directed and continuously supported—can do much to develop ways to reduce those diseases of body and mind which now cause most sickness, disability, and premature death—diseases of the heart, kidneys and arteries, rheumatism, cancer, diseases of childbirth, infancy and childhood, respiratory diseases and tuberculosis. And research can do much toward teaching us how to keep well and how to prolong healthy human life.

Cancer is among the leading causes of death. It is responsible for over 160,000 recorded deaths a year, and should receive special attention. Though we already have the National Cancer Institute of the Public Health Service, we need still more coordinated research on the cause, prevention and cure of this disease. We need more financial support for research and to establish special clinics and hospitals for diagnosis and treatment of the disease especially in its early stages. We need to train more physicians for the highly specialized services so essential for effective control of cancer.

There is also special need for research on mental diseases and abnormalities. We have done pitifully little about mental illnesses. Accurate statistics are lacking, but there is no doubt that there are at least two million persons in the United States who are mentally ill, and that as many as ten million will probably need hospitalization for mental illness for some period in the course of their lifetime. A great many of these persons would be helped by proper care. Mental cases occupy more than one-half of the hospital beds, at a cost of about 500 million dollars per year—practically all of it coming out of taxpayers’ money. Each year there are 125,000 new mental cases admitted to institutions. We need more mental-disease hospitals, more out-patient clinics. We need more services for early diagnosis, and especially we need much more research to learn how to prevent mental breakdown. Also, we must have many more trained and qualified doctors in this field.

It is clear that we have not done enough in peace-time for medical research and education in view of our enormous resources and our national interest in health progress. The money invested in research pays enormous dividends. If any one doubts this, let him think of penicillin, plasma, DDT powder, and new rehabilitation techniques.

4. The fourth problem has to do with the high cost of individual medical care. The principal reason why people do not receive the care they need is that they cannot afford to pay for it on an individual basis at the time they need it. This is true not only for needy persons. It is also true for a large proportion of normally self-supporting persons.

In the aggregate, all health services—from public health agencies, physicians, hospitals, dentists, nurses and laboratories—absorb only about 4 percent of the national income. We can afford to spend more for health.

But four percent is only an average. It is cold comfort in individual cases. Individual families pay their individual costs, and not average costs. They may be hit by sickness that calls for many times the average cost—in extreme cases for more than their annual income. When this happens they may come face to face with economic disaster. Many families, fearful of expense, delay calling the doctor long beyond the time when medical care would do the most good.

For some persons with very low income or no income at all we now use taxpayers’ money in the form of free services, free clinics, and public hospitals. Tax-supported, free medical care for needy persons, however, is insufficient in most of our cities and in nearly all of our rural areas. This deficiency cannot be met by private charity or the kindness of individual physicians.

Each of us knows doctors who work through endless days and nights, never expecting to be paid for their services because many of their patients are unable to pay. Often the physician spends not only his time and effort, but even part of the fees he has collected from patients able to pay, in order to buy medical supplies for those who cannot afford them. I am sure that there are thousands of such physicians throughout our country. They cannot, and should not, be expected to carry so heavy a load.

5. The fifth problem has to do with loss of earnings when sickness strikes. Sickness not only brings doctor bills; it also cuts off income.

On an average day, there are about 7 million persons so disabled by sickness or injury that they cannot go about their usual tasks. Of these, about 3 1/4 millions are persons who, if they were not disabled, would be working or seeking employment. More than one-half of these disabled workers have already been disabled for six months; many of them will continue to be disabled for years, and some for the remainder of their lives.

Every year, four or five hundred million working days are lost from productive employment because of illness and accident among those working or looking for work—about forty times the number of days lost because of strikes on the average during the ten years before the war. About nine-tenths of this enormous loss is due to illness and accident that is not directly connected with employment, and is therefore not covered by workmen’s compensation laws.

These then are the five important problems which must be solved, if we hope to attain our objective of adequate medical care, good health, and protection from the economic fears of sickness and disability.

To meet these problems, I recommend that the Congress adopt a comprehensive and modern health program for the Nation, consisting of five major parts—each of which contributes to all the others.

FIRST: CONSTRUCTION OF HOSPITALS AND RELATED FACILITIES

The Federal Government should provide financial and other assistance for the construction of needed hospitals, health centers and other medical, health, and rehabilitation facilities. With the help of Federal funds, it should be possible to meet deficiencies in hospital and health facilities so that modern services—for both prevention and cure—can be accessible to all the people. Federal financial aid should be
available not only to build new facilities where needed, but also to enlarge or modernize those we now have.

In carrying out this program, there should be a clear division of responsibilities between the States and the Federal Government. The States, localities and the Federal Government should share in the financial responsibilities. The Federal Government should not construct or operate these hospitals. It should, however, lay down minimum national standards for construction and operation, and should make sure that Federal funds are allocated to those areas and projects where Federal aid is needed most. In approving state plans and individual projects, and in fixing the national standards, the Federal agency should have the help of a strictly advisory body that includes both public and professional members.

Adequate emphasis should be given to facilities that are particularly useful for prevention of diseases—mental as well as physical—and to the coordination of various kinds of facilities. It should be possible to go a long way toward knitting together facilities for prevention with facilities for cure, the large hospitals of medical centers with the smaller institutions of surrounding areas, the facilities for the civilian population with the facilities for veterans.

The general policy of Federal-State partnership which has done so much to provide the magnificent highways of the United States can be adapted to the construction of hospitals in the communities which need them.

SECOND: EXPANSION OF PUBLIC HEALTH, MATERNAL AND CHILD HEALTH
SERVICES

Our programs for public health and related services should be enlarged and strengthened. The present Federal-State cooperative health programs deal with general public health work, tuberculosis and venereal disease control, maternal and child health services, and services for crippled children.

These programs were especially developed in the ten years before the war, and have been extended in some areas during the war. They have already made important contributions to national health, but they have not yet reached a large proportion of our rural areas, and, in many cities, they are only partially developed.

No area in the Nation should continue to be without the services of a full-time health officer and other essential personnel. No area should be without essential public health services or sanitation facilities. No area should be without community health services such as maternal and child health care.

Hospitals, clinics and health centers must be built to meet the needs of the total population, and must make adequate provision for the safe birth of every baby, and for the health protection of infants and children.

Present laws relating to general public health, and to maternal and child health, have built a solid foundation of Federal cooperation with the States in administering community health services. The emergency maternity and infant care program for the wives and infants of servicemen—a great wartime service authorized by the Congress—has materially increased the experience of every State health agency, and has provided much-needed care. So too have other wartime programs such as venereal disease control, industrial hygiene, malaria control, tuberculosis control and other services offered in war essential communities.

The Federal Government should cooperate by more generous grants to the States than are provided under present laws for public health services and for maternal and child health care. The program should continue to be partly financed by the States themselves, and should be administered by the States. Federal grants should be in proportion to State and local expenditures, and should also vary in accordance with the financial ability of the respective States.

The health of American children, like their education, should be recognized as a definite public responsibility.

In the conquest of many diseases prevention is even more important than cure. A well-rounded national health program should, therefore, include systematic and wide-spread health and physical education and examinations, beginning with the youngest children and extending into community organizations. Medical and dental examinations of school children are now inadequate. A preventive health program, to be successful, must discover defects as early as possible. We should, therefore, see to it that our health programs are pushed most vigorously with the youngest section of the population.

Of course, Federal aid for community health services—for general public health and for mothers and children—should complement and not duplicate prepaid medical services for individuals, proposed by the fourth recommendation of this message.

THIRD; MEDICAL EDUCATION AND RESEARCH

The Federal Government should undertake a broad program to strengthen professional education in medical and related fields, and to encourage and support medical research.

Professional education should be strengthened where necessary through Federal grants-in-aid to public and to non-profit private institutions. Medical research, also, should be encouraged and supported in the Federal agencies and by grants-in-aid to public and non-profit private agencies.

In my message to the Congress of September 6, 1945, I made various recommendations for a general Federal research program. Medical research—dealing with the broad fields of physical and mental illnesses-should be made effective in part through that general program and in part through specific provisions within the scope of a national health program.

Federal aid to promote and support research in medicine, public health and allied fields is an essential part of a general research program to be administered by a central Federal research agency. Federal aid for medical research and education is also an essential part of any national health program, if it is to meet its responsibilities for high grade medical services and for continuing progress. Coordination of the two programs is obviously necessary to assure efficient use of Federal funds. Legislation covering medical research in a national health program should provide for such coordination.

FOURTH: PREPAYMENT OF MEDICAL COSTS

Everyone should have ready access to all necessary medical, hospital and related services.

I recommend solving the basic problem by distributing the costs through expansion of our existing compulsory social insurance system. This is not socialized medicine.

Everyone who carries fire insurance knows how the law of averages is made to work so as to spread the risk, and to benefit the insured who actually suffers the loss. If instead of the costs of sickness being paid only by those who get sick, all the people—sick and well—were required to pay premiums into an insurance fund, the pool of funds thus created would enable all who do fall sick to be adequately served without overburdening anyone. That is the principle upon which all forms of insurance are based.

During the past fifteen years, hospital insurance plans have taught many Americans this magic of averages. Voluntary health insurance plans have been expanding during recent years; but their rate of growth does not justify the belief that they will meet more than a fraction of our people’s needs. Only about 3% or 4% of our population now have insurance providing comprehensive medical care.

A system of required prepayment would not only spread the costs of medical care, it would also prevent much serious disease. Since medical bills would be paid by the insurance fund, doctors would more often be consulted when the first signs of disease occur instead of when the disease has become serious. Modern hospital, specialist and laboratory services, as needed, would also become available to
all, and would improve the quality and adequacy of care. Prepayment of medical care would go a long way toward furnishing insurance against disease itself, as well as against medical bills.

Such a system of prepayment should cover medical, hospital, nursing and laboratory services. It should also cover dental care—as fully and for as many of the population as the available professional personnel and the financial resources of the system permit.

The ability of our people to pay for adequate medical care will be increased if, while they are well, they pay regularly into a common health fund, instead of paying sporadically and unevenly when they are sick. This health fund should be built up nationally, in order to establish the broadest and most stable basis for spreading the costs of illness, and to assure adequate financial support for doctors and hospitals everywhere. If we were to rely on state-by-state action only, many years would elapse before we had any general coverage. Meanwhile health service would continue to be grossly uneven, and disease would continue to cross state boundary lines.

Medical services are personal. Therefore the nation-wide system must be highly decentralized in administration. The local administrative unit must be the keystone of the system so as to provide for local services and adaptation to local needs and conditions. Locally as well as nationally, policy and administration should be guided by advisory committees in which the public and the medical professions are represented.

Subject to national standards, methods and rates of paying doctors and hospitals should be adjusted locally. All such rates for doctors should be adequate, and should be appropriately adjusted upward for those who are qualified specialists.

People should remain free to choose their own physicians and hospitals. The removal of financial barriers between patient and doctor would enlarge the present freedom of choice. The legal requirement on the population to contribute involves no compulsion over the doctor’s freedom to decide what services his patient needs. People will remain free to obtain and pay for medical service outside of the health insurance system if they desire, even though they are members of the system; just as they are free to send their children to private instead of to public schools, although they must pay taxes for public schools.

Likewise physicians should remain free to accept or reject patients. They must be allowed to decide for themselves whether they wish to participate in the health insurance system full time, part time, or not at all. A physician may have some patients who are in the system and some who are not. Physicians must be permitted to be represented through organizations of their own choosing, and to decide whether to carry on in individual practice or to join with other doctors in group practice in hospitals or in clinics.

Our voluntary hospitals and our city, county and state general hospitals, in the same way, must be free to participate in the system to whatever extent they wish. In any case they must continue to retain their administrative independence.

Voluntary organizations which provide health services that meet reasonable standards of quality should be entitled to furnish services under the insurance system and to be reimbursed for them. Voluntary cooperative organizations concerned with paying doctors, hospitals or others for health services, but not providing services directly, should be entitled to participate if they can contribute to the efficiency and economy of the system.

None of this is really new. The American people are the most insurance-minded people in the world. They will not be frightened off from health insurance because some people have misnamed it “socialized medicine”.

I repeat—what I am recommending is not socialized medicine.

Socialized medicine means that all doctors work as employees of government. The American people want no such system. No such system is here proposed.

Under the plan I suggest, our people would continue to get medical and hospital services just as they do now—on the basis of their own voluntary decisions and choices. Our doctors and hospitals would continue to deal with disease with the same professional freedom as now. There would, however, be this all-important difference: whether or not patients get the services they need would not depend on how much they can afford to pay at the time.

I am in favor of the broadest possible coverage for this insurance system. I believe that all persons who work for a living and their dependents should be covered under such an insurance plan. This would include wage and salary earners, those in business for themselves, professional persons, farmers, agricultural labor, domestic employees, government employees and employees of non-profit institutions and their families.

In addition, needy persons and other groups should be covered through appropriate premiums paid for them by public agencies. Increased Federal funds should also be made available by the Congress under the public assistance programs to reimburse the States for part of such premiums, as well as for direct expenditures made by the States in paying for medical services provided by doctors, hospitals and other agencies to needy persons.

Premiums for present social insurance benefits are calculated on the first $3,000 of earnings in a year. It might be well to have all such premiums, including those for health, calculated on a somewhat higher amount such as $3,600.

A broad program of prepayment for medical care would need total amounts approximately equal to 4% of such earnings. The people of the United States have been spending, on the average, nearly this percentage of their incomes for sickness care. How much of the total fund should come from the insurance premiums and how much from general revenues is a matter for the Congress to decide.

The plan which I have suggested would be sufficient to pay most doctors more than the best they have received in peacetime years. The payments of the doctors’ bills would be guaranteed, and the doctors would be spared the annoyance and uncertainty of collecting fees from individual patients. The same assurance would apply to hospitals, dentists and nurses for the services they render.

Federal aid in the construction of hospitals will be futile unless there is current purchasing power so that people can use these hospitals. Doctors cannot be drawn to sections which need them without some assurance that they can make a living. Only a nation-wide spreading of sickness costs can supply such sections with sure and sufficient purchasing power to maintain enough physicians and hospitals.

We are a rich nation and can afford many things. But ill-health which can be prevented or cured is one thing we cannot afford.

FIFTH: PROTECTION AGAINST LOSS OF WAGES FROM SICKNESS AND DISABILITY

What I have discussed heretofore has been a program for improving and spreading the health services and facilities of the Nation, and providing an efficient and less burdensome system of paying for them.

But no matter what we do, sickness will of course come to many. Sickness brings with it loss of wages.

Therefore, as a fifth element of a comprehensive health program, the workers of the Nation and their families should be protected against loss of earnings because of illness. A comprehensive health program must include the payment of benefits to replace at least part of the earnings that are lost during the period of sickness and long-term disability. This protection can be readily and conveniently provided through expansion of our present social insurance system, with appropriate adjustment of premiums.

Insurance against loss of wages from sickness and disability deals with cash benefits, rather than with services. It has to be coordinated with the other cash benefits under existing social insuran
ce systems. Such coordination should be effected when other social security measures are reexamined. I shall bring this subject again to the attention of the Congress in a separate message on social security.

I strongly urge that the Congress give careful consideration to this program of health legislation now.

Many millions of our veterans, accustomed in the armed forces to the best of medical and hospital care, will no longer be eligible for such care as a matter of right except for their service-connected disabilities. They deserve continued adequate and comprehensive health service. And their dependents deserve it too.

By preventing illness, by assuring access to needed community and personal health services, by promoting medical research, and by protecting our people against the loss caused by sickness, we shall strengthen our national health, our national defense, and our economic productivity. We shall increase the professional and economic opportunities of our physicians, dentists and nurses. We shall increase the effectiveness of our hospitals and public health agencies. We shall bring new security to our people.

We need to do this especially at this time because of the return to civilian life of many doctors, dentists and nurses, particularly young men and women.

Appreciation of modern achievements in medicine and public health has created widespread demand that they be fully applied and universally available. By meeting that demand we shall strengthen the Nation to meet future economic and social problems; and we shall make a most important contribution toward freedom from want in our land.

Provided courtesy of The American Presidency Project. John Woolley and Gerhard Peters. University of California, Santa Barbara.

OECD Economic Survey of the United States

Economic Survey of the United States, 2008

OECD (Organization for Economic Cooperation and Development)
Policy Brief
December 2008
The US economy is going through an exceptionally difficult period after having been hit by converging adverse developments, some in reaction to previous excesses during the upswing, others more exogenous. A sharp downturn in the housing market, a financial crisis and temporarily high commodity prices have caused activity to slow sharply during 2008. This happened at a time when the external position was persistently weak and the fiscal stance had become unsustainable in the long term — making for a difficult challenge to steer policy between competing objectives. Policymakers have taken actions to support growth and stabilise the financial system, while keeping a careful eye on inflation expectations. It is nonetheless likely that activity will get worse before it gets better. In addition to these short-term severe difficulties, adverse social trends need to be addressed, including incomplete access to health care, the topic of a special chapter in this Survey.
Health-care reform is needed. Despite health spending being much higher in the United States than in any other OECD country, the US population’s health status does not compare favourably on key indicators, in part because many people do not have adequate financial access to medical care. Starting from the present situation, a plan likely to be successful would replace the health insurance tax exclusion with subsidies for individual purchase of insurance and reform the insurance market as needed. There appears to be wide interest for such reform and numerous packages along these lines have been proposed.
(Omitted here are discussions of the financial crisis and the economic outlook, monetary and fiscal policies, markets for housing finance, and financial sector regulation and supervision.)
* How well does the health system perform?
Notwithstanding very high health spending (about 15% of GDP) and the use of cutting-edge technology, the health status of the US population does not appear to fare well by international comparison.
A particular source of concern is the large number of people who lack adequate health insurance.
Making progress towards health insurance coverage for all Americans should be given a high priority on the policy agenda.
* What could be done to encourage more efficient healthcare purchasing decisions?
The existing health tax exclusion should be terminated.
The tax revenues resulting from the elimination of the tax exclusion would be available to subsidise the purchase of insurance by individuals in a way that is independent of the choice of health plan.
Policy makers should consider means testing these subsidies.
* What could be done to promote health insurance coverage?
At present, the individual health insurance market is not attractive, in part because adverse selection risks have led to high premiums compared to their actuarial value, and because administrative costs are high. These problems could be addressed by increasing the size of risk pools and reforming individual and small-group insurance markets by requiring community-rated and guaranteed-issue policies, thus disconnecting the payments from individual health risks.
This approach would have a greater impact on coverage if accompanied by a requirement to be insured, as otherwise healthy people may choose to be uninsured rather than to pay community-rated premiums, which are higher than experience-rated premiums for healthy people.
Some hospitals seem prone to high-cost procedures without additional benefit to patients, while others seem able to provide lower-cost care that proves to be effective. The authorities should consider ways to enhance the dissemination of information on the effectiveness and cost of treatments and procedures. Savings could also be made by reducing payments to Medicare Advantage (MA) plans.
Currently, Medicare administrators are prohibited from harnessing competition or negotiating prices of medical equipment and supplies; instead, they must use fee schedules based on historical charges. On the basis of pilot programmes, it has been estimated that using a competitive bidding process instead of the fee schedules could reduce costs by 26% on average, based on strict criteria for product quality and security of suppliers, without significantly reducing access of beneficiaries to supplies. Generalisation of competitive bidding for medical equipment and supplies should not be delayed beyond the 18-month period stipulated in recent legislation.
Policy Brief:
http://www.oecd.org/dataoecd/60/54/41812368.pdf
Economic Survey of the United States 2008:
http://www.oecd.org/document/32/0,3343,en_2649_33733_41803296_1_1_1_1,00.html

The OECD is an important and highly credible resource for economic studies for the 30 member nations. An Economic Survey is published every 1 1/2 to 2 years for each OECD country. The newly released economic survey of the United States will be widely distributed amongst U.S. economists and policy makers.
For supporters of a single payer national health program, this report is not worth downloading. It is presented here only so that you can be aware of it in the event that someone cites it as an important contribution to our national dialogue on health care reform. It isn’t. The recommendations are the opinion of the OECD economists who have a bias toward regulated insurance markets, as opposed to government-administered public health care financing. That’s really all that you need to understand about the health care reform section of this report.

OECD Economic Survey of the United States

Economic Survey of the United States, 2008

OECD (Organization for Economic Cooperation and Development)
Policy Brief
December 2008

The US economy is going through an exceptionally difficult period after having been hit by converging adverse developments, some in reaction to previous excesses during the upswing, others more exogenous. A sharp downturn in the housing market, a financial crisis and temporarily high commodity prices have caused activity to slow sharply during 2008. This happened at a time when the external position was persistently weak and the fiscal stance had become unsustainable in the long term — making for a difficult challenge to steer policy between competing objectives. Policymakers have taken actions to support growth and stabilise the financial system, while keeping a careful eye on inflation expectations. It is nonetheless likely that activity will get worse before it gets better. In addition to these short-term severe difficulties, adverse social trends need to be addressed, including incomplete access to health care, the topic of a special chapter in this Survey.

Health-care reform is needed. Despite health spending being much higher in the United States than in any other OECD country, the US population’s health status does not compare favourably on key indicators, in part because many people do not have adequate financial access to medical care. Starting from the present situation, a plan likely to be successful would replace the health insurance tax exclusion with subsidies for individual purchase of insurance and reform the insurance market as needed. There appears to be wide interest for such reform and numerous packages along these lines have been proposed.

(Omitted here are discussions of the financial crisis and the economic outlook, monetary and fiscal policies, markets for housing finance, and financial sector regulation and supervision.)

* How well does the health system perform?

Notwithstanding very high health spending (about 15% of GDP) and the use of cutting-edge technology, the health status of the US population does not appear to fare well by international comparison.

A particular source of concern is the large number of people who lack adequate health insurance.

Making progress towards health insurance coverage for all Americans should be given a high priority on the policy agenda.

* What could be done to encourage more efficient healthcare purchasing decisions?

The existing health tax exclusion should be terminated.

The tax revenues resulting from the elimination of the tax exclusion would be available to subsidise the purchase of insurance by individuals in a way that is independent of the choice of health plan.

Policy makers should consider means testing these subsidies.

* What could be done to promote health insurance coverage?

At present, the individual health insurance market is not attractive, in part because adverse selection risks have led to high premiums compared to their actuarial value, and because administrative costs are high. These problems could be addressed by increasing the size of risk pools and reforming individual and small-group insurance markets by requiring community-rated and guaranteed-issue policies, thus disconnecting the payments from individual health risks.

This approach would have a greater impact on coverage if accompanied by a requirement to be insured, as otherwise healthy people may choose to be uninsured rather than to pay community-rated premiums, which are higher than experience-rated premiums for healthy people.

Some hospitals seem prone to high-cost procedures without additional benefit to patients, while others seem able to provide lower-cost care that proves to be effective. The authorities should consider ways to enhance the dissemination of information on the effectiveness and cost of treatments and procedures. Savings could also be made by reducing payments to Medicare Advantage (MA) plans.

Currently, Medicare administrators are prohibited from harnessing competition or negotiating prices of medical equipment and supplies; instead, they must use fee schedules based on historical charges. On the basis of pilot programmes, it has been estimated that using a competitive bidding process instead of the fee schedules could reduce costs by 26% on average, based on strict criteria for product quality and security of suppliers, without significantly reducing access of beneficiaries to supplies. Generalisation of competitive bidding for medical equipment and supplies should not be delayed beyond the 18-month period stipulated in recent legislation.

Policy Brief:
http://www.oecd.org/dataoecd/60/54/41812368.pdf

Economic Survey of the United States 2008:
http://www.oecd.org/document/32/0,3343,en_2649_33733_41803296_1_1_1_1,00.html

Comment:

By Don McCanne, MD

The OECD is an important and highly credible resource for economic studies for the 30 member nations. An Economic Survey is published every 1 1/2 to 2 years for each OECD country. The newly released economic survey of the United States will be widely distributed amongst U.S. economists and policy makers.

For supporters of a single payer national health program, this report is not worth downloading. It is presented here only so that you can be aware of it in the event that someone cites it as an important contribution to our national dialogue on health care reform. It isn’t. The recommendations are the opinion of the OECD economists who have a bias toward regulated insurance markets, as opposed to government-administered public health care financing. That’s really all that you need to understand about the health care reform section of this report.

There is a cure available for our health care woes

By DR. OLIVER FEIN
Atlanta Journal-Constitution
Sunday, December 14, 2008

The report last week that the U.S. economy lost nearly 2 million jobs this year, and 533,000 jobs in November alone, sent shudders through our nation’s households. That’s the biggest one-month plunge in jobs in 34 years. “Horrendous” was how one economist put it, while others said the number of unemployed, and underemployed, could easily double over the next year.

These job losses spell disaster for our health. Millions of people are losing their employer-sponsored health insurance, joining the 46 million who already lack coverage. Millions more are finding it harder to pay their co-pays and deductibles and are scrimping on their medications and doctor visits. Many go without care, risking their health and often their very lives.

In short, affordable health care has never been more urgently needed. Yet most of the health reform proposals coming out of Washington these days won’t get us there.

Sen. Max Baucus (D-Mont.) recently unveiled his proposals for incremental health reform, which largely mirror the ideas of President-elect Barack Obama and Sen. Edward Kennedy (D-Mass.).

However well-intentioned, the Obama/Baucus/Kennedy approaches share a fatal flaw: they preserve a central role for the private health insurance industry.

To varying degrees, they would mandate that everyone buy private health insurance — the private insurance that is failing us today. Some of these plans offer a Medicare-like, public option that people could buy into, but experience with Medicare shows that the private plans refuse to compete on a level playing field. They cherry-pick healthier patients and insist on more than their share of payment.

Experience with mandate-based plans in Washington state (1993), Oregon (1992) and Massachusetts (1988 and today) shows that they simply don’t work, achieving neither universal health care nor cost containment.

As long as we rely on private health insurers, universal coverage will be unaffordable. These companies generate immense overhead costs and force doctors and hospitals to spend heavily on billing and paperwork.

Administration consumes about one-third of every health care dollar in the U.S. By contrast, in countries with nonprofit national health insurance, administrative costs consume only half that amount.

There is a cure, however. Eliminating the private insurance industry would save $400 billion annually in administrative costs, enough to ensure that everyone is covered and to eliminate all co-pays and deductibles.

At this critical juncture, a single-payer plan is the only medically, morally and fiscally responsible path to take.

We already have an example of an American single-payer system that works — traditional Medicare. It’s not perfect, but people with Medicare are far happier than those with private insurance. Doctors face fewer hassles in getting paid, and Medicare has been a leader in keeping costs down, at least until Washington politicians decided to pay private insurance plans to enroll seniors at a cost 12- to 19-percent higher than traditional Medicare.

Single-payer systems give patients complete freedom to choose their doctor and hospital. They also enhance cost containment through global budgeting, the bargaining power of being the sole buyer, and an emphasis on primary care and prevention.

With a universal plan of this type, doctors and other health professionals could return to their main task: caring for their patients.

Single payer, or an improved Medicare for All, is embodied in the U.S. National Health Insurance Act, H.R. 676, sponsored by Rep. John Conyers (D-Mich.) and 92 other members of Congress.

Opponents of single payer often admit it’s the best, most efficient and equitable way to provide quality care, but say it’s not politically feasible and is therefore off the table in this round of the debate. How so? A solid majority of physicians, 59 percent, and an even higher percentage of the public, 62 percent or more, support national health insurance, recent surveys show. Single payer should be front and center.

Medicare for All is within reach, but only if we are prepared to take on the private health insurance industry. The time is now. It requires only the political will.

Dr. Oliver Fein is associate dean and professor of clinical medicine and public health, Weill Cornell Medical College in New York and president of Physicians for a National Health Program.

Note: This article was originally published under the title of “There is a cure available for current plan.”

Health insurance proposal: Medicare for all

By Saul Friedman
Newsday
Gray Matters
December 13, 2008

Here’s a question for Medicare beneficiaries and those who will soon become eligible: Why should you care about the estimated 47 million American men, women and children who have too little or no health coverage?

The answer: Because there is some danger that Medicare and the 45 million older and disabled people it serves could become caught in a generational conflict in the coming campaign to extend health coverage to the uninsured – a conflict between those who have and those who have not. What part, if any, will Medicare play in the health care reforms? Medicare’s needs may simply get lost in the smoke of battle. But there is another way, which we’ll get to presently.

Medicare’s costs are $450 billion a year and growing rapidly. Its Part D drug benefit is confusing and more expensive than expected. Critics say Medicare’s growth may overwhelm the federal budget, and its friends acknowledge its shaky finances need to be fixed. As a result of these fears, a new coalition of Medicare defenders has formed the Alliance to Restore Medicare, to roll back the weakening of the public portions of the program during Republican rule.

In addition, Medicaid, the federal-state program for the poor and the elderly, costs around $200 billion a year and places an increasingly heavy budget burden on states, which are cutting benefits and restricting help for the elderly who need Medicaid for long-term care. And congressional Democrats intend next year to add millions to the State Children’s Health Insurance Program (SCHIP), which President George W. Bush opposed as a “step toward socialism.”

With such problems looming among many others facing the new administration, my experience covering Congress tells me that it will be difficult for members to focus on fixing Medicare while they are occupied with the popular cause of providing health insurance for younger workers and their families who have little or no protection.

Another conflict: Medicare is a mostly government-run program, while most of the proposals to cover the uninsured would depend largely on private insurance. That likely will rekindle the ideological struggle in Congress between Democrats who favor a wider government role and Republicans who favor reliance on the market.

In the coming battles, industry lobbyists will crowd the congressional corridors to follow up on contributions they have poured into Capitol Hill, and pay for advertising campaigns like those that killed the 1993 attempt by then-President Bill Clinton to provide universal health care. On the other side, health care and union lobbyists will fight for their views, but they won’t have the financial clout of industry.

In the 2008 elections, according to Opensecrets.org, the insurance industry contributed $38.2 million to presidential and congressional candidates, split between Republicans (54 percent) and Democrats (46 percent).

Senate Finance Committee chairman Max Baucus, (D-Mont.) who had an easy race (he won with 72 percent of the vote) will be a key player in the effort to extend coverage to all Americans. Baucus got $269,000 from the insurance industry. He was eighth among senators, behind John McCain ($2 million). Barack Obama ($1.5 million) and Hillary Clinton ($1.2 million), all of whom supported similar proposals.

Last month, Baucus introduced legislation to provide health care protection for the uninsured. It was widely praised, but Baucus based his proposal on the use of private insurance to be paid for by employers, individuals and/or the government.

At least a dozen other lawmakers, including Sen. Edward Kennedy (D-Mass.), have their own ideas. But all of them would use private insurance companies to provide the coverage, with all the problems consumers face with insurance coverage restrictions. Their administrative costs are nearly 20 percent, including stockholder dividends and executive salaries. Liberal economist Dean Baker said of the insurance industry: “The health care system’s waste is their profit.”

There is another possibility. Some call it single-payer, but more easily understood, is a proposal backed by the 5,000 Physicians for a National Plan (including mine) that would gradually provide Medicare for everyone who wants it and would pay a premium.

Medicare, all polls show, is the nation’s most popular health insurance plan – even among the young. But for me, the most compelling argument for “Medicare for All” is this: Unless the risk pool for Medicare grows and is strengthened to include millions of younger, healthier workers, their families and their kids, Medicare as we know it could die of old age. And with out-of-pocket costs soaring and people leaving Medicare for private, Medicare Advantage plans, the Congressional Budget Office has warned that original Medicare is in danger of becoming another private insurance plan.

Congress has before it a proposal for “Medicare for All,” which I have written about, introduced in February 2007 by Rep. John Conyers Jr., (D-Mich.). He’s been in Congress since 1965, the second- longest-serving House member. I mention this because Conyers, chairman of the House Judiciary Committee, is a liberal of substance and influence.

His proposal, which you may read at johnconyers.com/healthcare or thomas.loc.gov/cgi-bin/bdquery/z?d109:h.r. 00676: has 94 co-sponsors, including some House veterans. Called the U.S. National Health Insurance Act or The Expanded and Improved Medicare for All Act, it also has the endorsement of most labor unions, thousands of doctors, nurses and health care professionals.

The bill does not call for socialized medicine, but rather an extension of the Medicare model to include all Americans. It would absorb such programs as Medicaid, SCHIP and be paid for by taxes and premiums. It could relieve auto manufacturers and other businesses of paying for health insurance for employees and retirees. Its sponsors say it would save $300 billion a year in administrative costs, for it would deny insurance companies a role.

Getting over that hurdle may be why HR 676 has gotten so little publicity, even from alleged friends of older people. There is no mention of it on the Web site of AARP, which earns $700 million a year in royalties on the sale of private health insurance it sponsors. Even the Kaiser Family Foundation, which has the most complete Web site for health care information, has virtually ignored HR 676. It may not pass, but it should have a place in the coming discussion.

WRITE TO Saul Friedman, Newsday, 235 Pinelawn Rd., Melville, NY 11747-4250, or by e-mail at saulfriedman@comcast.net.

http://www.newsday.com/news/columnists/ny-bzsaul5962994dec13,0,6902079.column

Single-payer insurance puts more money into health care

By Robert W. Putsch
Helena Independent Record
Your Turn
12/14/08

Great work by Mike Dennison writing on health care reform: “Baucus health plan preserves much of the status quo” and “Why is single payer health reform not viable?” And thanks to the IR for publishing these two articles.

But is Dennison right? Is there enough money in the system to provide health care for all?

There’s been a long-standing dispute over how much a single-payer system can contribute to lowering health care costs.

In August 2003, Drs. Woolhandler, Campbell and Himmelstein published a study of health-care administrative costs in the U.S. and Canada. They stated that administrative expenditures in the U.S. stood at 31 percent of overall health-care costs. A year later they wrote “only single-payer national health insurance could… allow universal coverage without any increase in total health spending.”

Montanans spent $4.9 billion on health care in 2003. If these authors are right, then Montanans paid over $1,600 in administrative costs for every man, woman and child in the state, including the uninsured. That means that only 69 cents of every dollar spent went to health care needs. Remember, administrative costs are passed on to patients, bill by bill, paycheck deduction by paycheck deduction, and even at the pharmacy!

We argued about these numbers while discussing health reform here in Helena a few years back. A physician at the meeting (employed by an insurance company) blew off the 31 percent figure. His argument went something like this: “There’s a lot of controversy about Woolhandler and Himmelstein’s work … you know, basic questions about that number and about their methodology.”

Mike Dennison quoted figures of 15 to 25 percent for administrative costs in private health insurance premiums. Uwe Reinhardt, a Princeton economist who testified this November to the Baucus committee quoted a figure of 25 percent. Are administrative costs really this high? And if so, how high?

In 2005, James Kahn and coworkers undertook to see if the 31 percent overhead figure was correct. They said, “these estimates, the most comprehensive for the United States, have been taken to task for a variety of reasons.” So they studied hospitals, doctors’ offices and insurance companies in California.

Their report in Health Affairs showed that billing and insurance-related functions added up to 21 percent of spending. They added in 13 percent for the rest of the overhead and administrative costs and came to a total of 34 percent! That’s in the ballpark, but even higher than the 2003 New England Journal of Medicine report by Woolhandler!

The Senate Finance Committee has heard about the problem of overhead. On Nov. 19, Professor Uwe Reinhardt, who is also on the board of trustees of the 900-bed Duke University Hospital, used Duke to illustrate the problem: “We have 900 billing clerks at Duke. I’m not sure we have a nurse per (each) bed, but we have a billing clerk per bed…it’s obscene.” Two days later, the New York Times published his article: “Why does U.S. Health Care Cost So Much? (Part II): Indefensible Administrative Costs.”

Hopefully, Senator Baucus’ Finance Committee will examine the only known means to cut these excessive expenditures — a single-payer health plan. As Mike Dennison pointed out, there is an excellent single-payer proposal before Congress; it’s HR 676, sponsored by Rep. John Conyers of Michigan.

Senator Max Baucus has called for reform of the system in 2009, and he is to be congratulated for his efforts. The plan has led to an incredible response.

However, the Baucus proposal has ruled out a government program because, it says, “such a system may not be viable in a country that values individuality, choice and a preference for market-based solutions.” In a June 17 radio interview on Philadelphia’s WHYY, Reinhardt agreed, but only after first pointing out that single-payer is the way to go. “It’s political,” he said, “it’s as difficult to do that (pass single payer) as it would be to grow oranges at the North Pole.” So who needs economics? It’s political.

Thinking about these issues, I e-mailed Professor Kahn at the University of California this week to see if the 34 percent figure was correct. It was, he said, but he added a proviso: A new study of these costs shows that the percentage of administrative overhead is even higher. “We’re in the process of writing this up,” he said, “It looks like only 62 cents out of every dollar spent goes to actual care!”

The e-mail exchange left me shaking my head. Even if the number is closer to Woolhandler’s 31 percent, cut that in half via single-payer and you have well more than enough to cover every resident in the state of Montana!

So thanks again for Mike Dennison’s articles on the single-payer and the Baucus plans. For those of you who missed them, they can still be accessed on the IR Internet Web site. Hopefully we’ll take the advice of the writer of another letter to the IR. On Dec. 7, Bill Balhiser said: “Write or call Max Baucus. Tell him to include a Medicare-for-all plan in his deliberations.” It’s a great idea!

Robert W. Putsch III is a medical doctor who lives in Canyon Creek.

Who's A Health Care "Moderate"?

by Paul Bass
New Haven Independent
December 10, 2008

Who’s a health care moderate? And what would “Give ‘Em Hell” Harry Truman say today?

Those questions — from health care debates past and present — emerged Wednesday from a presentation at the Greater New Haven Chamber of Commerce’s 2009 Regional Economic Outlook Breakfast at the Lawn Club.

The presentation was made by Martha Wofford, Northeast manager for Aetna’s Consumer Segment.

She filled in hundreds of local businessfolk on where the current political battle over health care reform stands. She made the presentation at a time when activists and politicians from President-Elect Barack Obama on down are promising to overhaul a broken system at both the state and federal levels.

The main new reform plan being advanced in Connecticut was unveiled this week by the Universal Health Care Foundation. It calls for an end to insurers denying coverage based on pre-existing conditions, and limits the size of deductibles and co-pays, among other changes. A centerpiece of the plan is expanding the state employees’ health plan to include people who work for themselves, for not-for-profits, for local governments, or for small businesses. (Click here and here for details.)

By Wofford’s account, “extreme left”ists are pushing government-paid health coverage for all. “Conservatives” consider any government involvement in health care “bad.” Meanwhile “most Americans” — and her insurance company — are the sensible “moderates” working toward a solution to cover at least some of the nation’s 45.7 million uninsured people, with some government help.

Wofford’s presentation began with a mystery quote. Who, she asked the Chamber members in the crowd, said the following?

“Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.”

Wofford revealed the answer at the end of her talk: President Harry S. Truman.

Afterward, she said used the quotation for inspiration, to set the tone for her remarks. She said she wanted “to show that health care has been a challenging issue since 1945.”

The quotation came from a Nov. 19, 1945 speech in which Truman advocated a national government-sponsored universal health care system. Here’s the speech.

She said she didn’t know a lot about the health care plan Harry S. Truman pushed at the time. It was a universal health care plan. Government-run. Business interests like General Motors killed it by arguing that Americans don’t trust government to run health care. They argued that private interests do it better — private insurers, and private companies that offer the insurance plans to employees. Six decades later, companies like GM are struggling to stave off bankruptcy in part because of out-of-control health care costs.

Road Map

Harry Truman would have shown up at one extreme of the ideological road map Wofford presented Wednesday morning. (It’s pictured at the top of this story.)

She divided three main approaches to health care into three camps. On the left was a column headlined “liberal.” In her remarks, she referred to people espousing the positions there as the “far left.”

These people see health care “coverage as a right.” In their view, the “private sector creates market failures.” So they support expanded “government-based solutions” like a “single payer system.” Their mantra: “Regulation is Good.”

At the other end of Wofford’s spectrum are “Conservatives” like the McCain presidential campaign. They see health care “coverage as a commodity.” They trust in “free market,” “private sector solutions,” with a “lean” role for government. Their mantra: “Regulation is Bad.”

In the center? The “moderates.” That’s most of us. And Wofford’s employer. “The American people are right in the middle,” she said. “Aetna is also in the middle.”

This group advocates a “reasonable” public role in health care. It sees universal coverage as a “goal” to work toward. It supports solutions based on “public-private partnerships,” government working in tandem with insurers and employers.

Wofford pointed out that 85 percent of Americans do have health insurance. Most of them get insurance through employers. She argued that the employer-based system works best and should stay in place. She advocated a “pay of play” system for employers, encouraging them to offer employees insurance, fining them if they don’t.

The 15 percent of the country without insurance needs attention, in a variety of ways, she argued.

Of the 45.7 million uninsured, she reported, 11 million are eligible for Medicaid, but are not enrolled. So part of the solution is to figure out how to enroll them. She favors a Massachusetts-style mandate on individuals to have health insurance, the way the law requires that drivers have car insurance.

Another 9.7 million of the uninsured aren’t U.S. citizens, she said. Many of them are here legally, but could use help being plugged into the system.

More than 9 million uninsured adults have annual incomes above $75,000, according to Wofford. That means any health care solution needs to look at controlling spiraling health costs so those people can afford to buy in, she said.

The remaining 13 to 16 million people “need a government plan,” she said.

A Peer Review

Reviewing Wofford’s PowerPoint later on Wednesday, a Yale health care policy historian called the presentation “a desperate attempt to protect and preserve a failed for-profit market for health insurance.” One that benefits private insurers like Aetna.

Harry Truman would be aghast, in the view of the historian, history professor Jennifer Klein. Klein (pictured) wrote the 2003 prize-winning book For All These Rights, which detailed the development of the American system of employer-based health insurance and pension benefits.

Klein said that the presentation left out a key reason so many people can’t afford or find health care: “the for-profit imperatives in the whole system.”

“We’ve had over five decades to see how the commercial insurance market works as
the key means of providing health care access,” Klein said. “The bottom line is that in all that time health care has gotten neither more affordable nor more accessible. Numerous policy fixes have been applied to goad the private health insurance system toward universality or to rein in costs. As we can see, these goals are no more within reach than they were 20 or 30 years ago.”

She added that Wofford’s statistic about the prevalence of employer-offered health insurance is outdated. Employers are raising premiums or eliminating coverage by the day — and in the recession laying off employees en masse.

“The employer providing coverage is a system that’s on the decline. It peaked in the late 1970s,” Klein said.

Harry Truman did in fact propose a “government-run” single-payer plan, Klein said. People often confuse such “government-run” proposals with nationalized medical systems, she said.

“Truman believed in expanding social security to include a universal health plan. He wanted to amend the Social Security Act to include national health insurance. Government would replace private insurance companies,” Klein said.

“You have to be careful about ‘government run.’ People think that means hospitals are government hospitals, and doctors are government doctors. [Rather] it was about the insurance mechanism. It was about the financing.”

Truman would have landed in the blue left-hand column of Wofford’s chart, Klein said. “As he saw it, offering national health insurance was a way of delivering on the New Deal.”