PNHP

Replace for-profit insurance with Medicare for all

Replace for-profit insurance with Medicare for all

Robert Stone
The Journal Gazette (Fort Wayne, IN)
January 5, 2009

The largest gorilla recorded weighed 600 pounds and lived in a zoo. In the wild they don’t get that big. An 800-pound gorilla exists only in our imaginations.

When debating how to fix our ailing health care system, someone always says, “There’s an 800-pound gorilla in the room, and it’s the insurance industry. No matter how we want to reform health care, they are so powerful they are going to call the shots.”

Let’s examine the industry today. The big five health insurers remain huge, but they are beginning to stumble. While the overall stock market fell 40 percent as of last week, heavyweights such as Anthem/WellPoint, United Health and Humana have seen their stock prices plunge 60 percent — $82 billion of value, gone.

We shouldn’t be surprised these companies are in trouble. Insurance, after all, is part of the badly hit financial services sector. And while in 2005 financial firms accounted for 38 percent of total U.S. corporate profits, today many of these former darlings of Wall Street are bankrupt or part of the bailout.

The health insurance industry is deeply enmeshed in finance. Take WellPoint, for example. Last year the company’s executives wanted to incorporate as a bank in Utah so they could directly manage the health savings accounts of wealthy individuals nationwide. They resented the fact that other banks were collecting fees on such accounts. WellPoint also wanted the government to insure its depositors through the FDIC, i.e., it wanted to socialize the risks of its banking venture, but privatize the profits.

Why Utah? Because Utah has some of the loosest banking regulations. State regulators balked at first, arguing that WellPoint looked like an insurance company, not a bank. But WellPoint persevered and succeeded in getting the rules bent to become reclassified as a financial company.

Poor regulation has contributed to the overall financial crisis, no doubt.

In the case of the health insurance industry’s predicament, at least two other forces are undermining its viability: the steadily declining numbers of people in employer-sponsored health plans and skyrocketing costs.

Private health insurance, with its rising premiums, co-pays, deductibles, exclusions and so on, is becoming increasingly unaffordable for individuals, families and businesses. The private model of financing care is no longer sustainable; it is dying. It is more like a dinosaur stumbling toward a tar pit than a mighty gorilla.

We can no longer afford to have these for-profit companies dominate our health care system. They are the problem, and retaining their inefficient, greedy business practices should not be part of the solution.

Instead, we should turn to the “other 800-pound gorilla” in the room — the elegantly simple solution staring us in the face: Medicare for all. Medicare is the universal government financed (“single-payer”) health care system we have already for everyone age 65 and older. We have more than 40 years’ experience with it. Simply replace for-profit insurance with Medicare for everyone.

This makes so much sense that those who want to protect the for-profit insurance industry don’t want to talk about it. When they do, they demonize it and call it “socialized medicine.” Do you think Medicare is socialized medicine?

We can deal with the dying health insurance industry compassionately. People working in the industry will need to be retrained. There is plenty of work to be done. We can retrain them to help care for the 46 million Americans who are currently denied care. And under this plan, displaced workers won’t lose their insurance.

As for the insurance company CEOs with their multimillion-dollar salaries — we may just have to let them fend for themselves.

Robert Stone , M.D., practices emergency medicine in Bloomington. He is director of Hoosiers for a Commonsense Health Plan and a member of Physicians for a National Health Program. He wrote this for Indiana newspapers.

A genuine cure for our health care woes

By Johnathon S. Ross
Toledo Blade
Dec. 20, 2008

With new leadership in place, America can end a national disgrace. Forty-six million of our friends, family and neighbors have no health care coverage at all. The Institute of Medicine estimates that over 18,000 Americans die each year from lack of health insurance alone. Tens of millions more risk bankruptcy because they have bare-bones insurance. Our troubled economy will only worsen this sad situation.

Senate Democrats are poised to prescribe a health reform proposal that will likely be based on a national insurance exchange, similar to the Federal Employees Health Benefit Program. The plan will probably mirror the reform proposals that President-elect Barack Obama made during his campaign.

Under this plan, federal oversight would increase regulation of the insurance plans that participate. The insurance exchange would guarantee coverage to all who purchase coverage, even those with pre-existing health conditions. Low-income individuals and families who do not qualify for the State Children’s Health Insurance Program (SCHIP) or Medicaid would receive subsidies toward the purchase of insurance through the exchange.

Large businesses that do not offer insurance to their employees would be required to contribute a percentage of their payroll to the exchange to help their employees purchase coverage. Small businesses may receive tax credits to help them purchase insurance for their employees. The program will likely include a mandate that requires everyone, or nearly everyone, to have health insurance or pay a fine.

Does this plan sound complicated? It is. It requires regulating hundreds of insurers who consistently strive to avoid sick (and therefore more expensive) patients. It requires regulating thousands of businesses to confirm they cover their employees or pay into the exchange, and it requires finding and fining those who do not buy insurance.The complexity of handling millions of subsidized individual health insurance policies purchased through the new exchange will cost an estimated $100 billion yearly. Yet many people will likely remain uninsured.

Massachusetts is held out as the latest model. Half of the uninsured remain without coverage despite substantial expansions of Medicaid and subsidies for the purchase of private insurance. Massachusetts has yet to confront the issue of fining those who fail to purchase insurance. Costs continue to rise sharply. This is no surprise because this approach keeps the private, for-profit insurers at its center.

Similar to our current setup, each insurer, hospital, and doctor must keep track of myriad contracts, discount arrangements, benefit packages, formularies, limited referral networks, and insurance rules designed to reduce utilization and to increase the insurers’ profits. This paperwork, which has nothing to do with delivering care, is a huge waste of resources.

Currently, insurers keep 15-20 percent of the premium dollar for their operating costs and for shareholder profits. Why would they want to reduce spending if they get to keep nearly one-fifth of what ever we spend?

Massachusetts is not alone in finding universal coverage and cost control impossible using this model of reform. Such was the experience in at least seven states where such a model has been tried before. Do we really want to multiply this complex state experiment by 50 before we see if it can actually work?

There is an alternative, however — a proven cure for our health care woes. Physicians for a National Health Program, a membership organization of tens of thousands of physicians from across the county, prescribes a nonprofit, single-payer national health insurance program as outlined in H.R. 676, The U.S. National Health Insurance Act.

This legislation establishes an improved and expanded Medicare for all. Everyone is automatically enrolled. Payroll and individual taxes replace private insurance premiums and out-of-pocket payments. This creates a single insurance pool adequate to cover all with no additional spending.

How can this be? Multiple independent studies confirm that the administrative simplicity of a single universal insurance pool, like Medicare, yields savings that would allow comprehensive coverage for all at current levels of spending. A tax-based public system is simple and efficient. Medicare spends only 3 percent on overhead.

Most other industrial democracies use this type of low overhead, tax-based public insurance system to cover all their citizens. They spend half of what we spend per person and they achieve better health outcomes. America wastes about 30 percent of our $2 trillion health care dollars on administration. Reducing administrative waste could save $300 billion each year, enough to cover all the uninsured and provide better coverage for the rest of us with complete choice of doctor and hospital.

Business owners stand to benefit, as well. A tax-financed, universal national health insurance system will help ensure a healthy workforce at a lower cost. Our current “non-system” is less effective at keeping workers healthy and productive, and its high costs reduce our competitiveness in the global marketplace.

America needs guaranteed, high quality, affordable health insurance for all, with “everybody in and nobody out.” We cannot attain this goal if we rely on schemes designed by Wall Street and the for-profit health insurance industry.

An improved and expanded Medicare for all is the proven cure and the only way to restore America’s health. We can save lives, save money and make the right choice by supporting H.R. 676, the National Health Insurance Act.

Johnathon S. Ross, M.D., M.P.H., is past president of Physicians for a National Health Program (pnhp.org) and a leader of the Single Payer Action Network in Ohio (spanohio.org).

There’s No Place Like Home for The Holidays, Until There is No Home

by Donna Smith
CommonDreams.org
Tuesday, December 23, 2008

A little box arrived from Chicago last week to my temporary digs here in Washington, DC. Inside were some of the trinkets of Christmases long past. Ornaments that used to hang on trees surrounded by mounds of gifts, plush Mickey Mouse stockings I used to fill with fruit and candy and little toys when my sons were younger, and a candle holder – absent the candle, of course, which had long since been burned on a holiday table brimming with food and with good cheer.

The box holds what is left of those middle class holiday memories. The box has become the only link to a home-for-the-holidays Christmas I can never again share with my children or my grandchildren. You see, like millions of other Americans, we lost our home. And with that loss goes not only the physical security of home and hearth but also the generational ties to stability and security and the sense of well-being that come with being home… with having a home to come to and a home in which to frame the happenings of our lives. We are the new economic refugees of this society. And no bail-outs are pending.

Who among us has not spent a time longing for the comforts of home? And that universal longing has little to do with square footage or amenities and much more to do with a place of comfort and clarity and sameness and steadiness that helps soften the twists and turns of life that we all must experience. But for those of us who become unwilling nomads with no permanent place to stash our stuff, home became a more elusive place – and not really a physical place at all, but a feeling, a memory, a fleeting image of happier days gone by.

Americans now losing their homes to the mortgage crisis and the millions more, like us, who have fallen prey to the healthcare crisis in this nation are losing far more than just an address or an extra bedroom or a driveway or a lifestyle. We are losing the boundaries of our lives – those intimate details of everyday living that make home a safe place to land and place to retreat when daily pressures are too great and – most vivid during this season – a place where our children and grandchildren can return for generational sharing and all the ups and downs that brings to a family.

One of the most heart-breaking losses we’ve felt in recent years as we tried in vain to cling to some semblance of middle class reality as health crises crushed us is the loss of holidays, the loss of traditions, the loss of intimacy and the loss of respect from our own children who see no home to come to – and no reason to interrupt more exciting holiday pursuits when we can no longer play host to any sort of Smith family soiree with the same sort of meaning.

Oh, folks will try to say that home is wherever the people you love are gathered, but don’t believe it. Our lack of financial stability and the lack of that home in which to gather have damaged far more than just the edges of our lives. When pushed, the grown kids say they don’t come to visit because we’re not grounded – “There isn’t exactly a place where we all grew up and you kept to come home to, is there?” asked one of our sons. No, son, there isn’t. So, this year, like the past few years, he’ll gather his children (our beautiful grandchildren) and take them to another state and another grandma’s house that sits on land that the family has owned for many years and to a home with a whole basement converted to play space that holds literally thousands of dollars worth of toys. No, son, I cannot offer that.

I can offer the little toy box I faithfully move from apartment to apartment and a place at my feet to play. I can offer love beyond what I could explain. But I cannot offer stability of place and the home I so hoped to have until I died – or at least until I could no longer handle the physical constraints of home ownership. But the things I have left to own are not things, and our culture thrives on the ownership of things. So, I am the grandma without enough. And my wonderful husband, the man who gave his body and being to creating a home for us for so many years, is now the grumpy grandpa without enough stuff and without a house.

This is what millions of Americans now losing their homes and their jobs are going to go through all too soon. The unbending cruelty of judgment that comes from having lost one’s home in the United States – or worse yet, having gone bankrupt in America.

You see, say what you will about forgiveness and love and peace on earth, but we Americans judge one another by our stuff and our attainment of things. Those who don’t have a lot must not have wanted it badly enough, we think, or we didn’t work smartly enough. And those who attain homeownership and then lose homes or go bankrupt just managed poorly, lived beyond their means, didn’t tighten the belt enough… on and on and on we go with our judgments. I just heard it again this week on a mainstream media news program… people who go bankrupt, they mused, are gaming the system somehow and need to learn to behave better. Going bankrupt was viewed as sinful and irresponsible. These old and ugly views are part of our middle class DNA. I know, because I was taught the same way.

But then the bottom falls out. Health insurance leaves you bare to huge financial burdens. Job loss strips your ability to have enough cash coming in to covers the basics, savings dries up, all the bartering and begging to stay afloat begins to give way, and the wealth it took years to build is gone overnight.

And with that wealth goes a great deal more in personal costs. Some relationships are damaged beyond repair while others are twisted and tinged with guilt, shame or anger. And the holidays are packed away in little boxes of trinkets where peace on earth and joy to the world still can dwell, if but for an instant.

Home for the holidays? Never again. It takes years to recover from bankruptcy or foreclosure and for some of us, there are not enough working years left to do so; the big banking interests we just helped bail out will view us as too risky for a very long time. And our government will not challenge that reality. The best we economic refugees can hope for is that we can hang on to that little box of ornaments, stockings and candleholders as we move from lease to lease to lease making sure our rent is paid and we are warm. There really is no place like home for the holidays, and for many Americans, that Norman Rockwell sort of holiday setting will never again be possible.

When home is no longer home for so many, the generational and cultural foundations are crumbling in ways that will forever alter our national being. The ground truly is shifting beneath our feet as 2009 dawns. And this year, home is even more elusive for many. For some of us, it’s carried in a little box.

Donna Smith is a community organizer for the California Nurses Association and National Co-Chair for the Progressive Democrats of America Healthcare Not Warfare campaign.

America’s health-care famine is slowly killing us

By Clark Newhall
Editorial columnist
The Salt Lake Tribune
01/03/2009

We don’t have a health-care problem. We don’t have a health-care crisis. What we have is a health-care famine.

I realized this when a friend told me that she was not in favor of universal health insurance. She was opposed to paying for health care for all. She has a little boy with cancer. She was afraid that universal health care would mean her little boy would not be able to get an appointment with the oncologist.

“But all those other children with cancer deserve treatment, too, don’t they?” I asked. “I guess so,” she grudgingly admitted, “but I have to worry about my little boy.”

Too many other people’s children would be trying to get appointments and treatment. Too many other people would be competing for a scarce resource — the time of a doctor.

It is a health-care famine.

Perhaps you know the story of Jacob, who predicted seven years of plenty and seven years of famine. When famine came, he was prepared with full granaries. His brothers, who had sold him into slavery, begged him for grain for their starving families and he gave them grain. We are like Jacob’s brothers in the famine, begging for health care. But for us, there is no Jacob. There is only the for-profit medical-industrial complex, gate-keeping us out of the health-care system.

When too many people are fighting to get the scarce stuff to stay alive, whether the scarce stuff is food or health care, that is a famine.

When those of us who have barely enough are willing to sacrifice those others of us who have too little or none at all, that is a famine.

When our own situation is so desperate that we turn a blind eye to the more desperate situation of others, that is a famine.

When dog-eat-dog surpasses “do unto others” as the Golden Rule, that is a famine.

A famine never strikes everyone equally. In a famine, the have-nots become the have-nothings while the haves become the have-barely-enoughs. And, as always, the wealthy survive, even thrive, even profit, from the shortages that are killing others.

This famine is not new — it has been slowly building for years.

The price of our privately run, profit-driven medical-industrial complex has caused this famine. About one-third of every dollar going to health care pays for administrative costs — for utilization reviewers, for computer programmers, for advertising, for sales managers, for executives of all kinds, for billing clerks, for coding clerks, for CEO bonuses in the millions and hundreds of million — and for profits.

We are not talking about government waste. We are not talking about the cost of actually treating the sick and nurturing the healthy. We are talking only about the cost of running our profit-making health insurance industry.

One third of the health-care dollar — that amount is far more than enough to give excellent medical care to everyone in the nation. It is far more than enough to fund the (privately-owned) surgical centers and imaging centers and Lasik centers that sprout up on every corner. It is even more than the amount we have given to Wall Street to bail out financiers and bankers from their hubristic near-demise.

The famine has grown while insurance companies charge higher premiums and reduce coverage, while employers cut their contributions and increase deductibles, while legislators reduce Medicaid and Children’s Health Insurance Program budgets, and on and on.

We are in a health-care famine. Millions of us are suffering and millions more will suffer soon. More than 20,000 people die each year in this famine because they cannot afford the price of for-profit health insurance.

The famine will not end until, like Jacob, we open the granaries and give aid to the starving. The health-care famine will not end until we end the money-hoarding that health insurance companies call “reserves” and “administrative costs” and “profits.”

It will not end until we open our blind eye and see the plight of our neighbor. It will not end until we learn that tolerating a profit-making middleman in the health-care system builds a wall between patient and doctor. It will not end until we learn that good things for everyone can only be accomplished by the will of everyone.

It will not end until we pay for health care in the same way that we pay for everything else that we value highly — our security, our freedom, our laws. It will not end until we have a national health-care system that covers everyone equally and is paid for by everyone equitably.

It is time for national single-payer health insurance. It is time to remove the profit-making middleman from medical care. It is time to see health care for the public good that it is and not for the profitable business it has become. Support Medicare for all.

Clark Newhall is a physician and attorney in Salt Lake City.

http://www.sltrib.com/opinion/ci_11357007

Student Debt, Resident Hours, and Primary Care

Student Debt, Resident Hours, and Primary Care Redux

By Josh Freeman
Medicine and Social Justice (A Blog)
January 2, 2009
The December 18, 2008 issue of the New England Journal of Medicine includes Perspectives on 3 topics that have been previously addressed on this blog: Medical student debt (Dec 14), resident duty-hours (Dec 3, 9), and the future of primary care (Dec 11).
The piece on “Medical Student Debt — Is there a Limit?” by Robert Steinbrook presents data on the extraordinary rise in tuition, and debt, among medical students, most surprisingly in the public medical schools. “For the current academic year, tuition, fees, and health insurance at private medical schools range from $15,278 (for Texas residents) or $28,378 (for non-residents) at Baylor University to $51,969 at Tufts University in Massachusetts and $52,236 at Temple University (for nonresidents of Pennsylvania — state residents are charged at $43,232.” While tuition rates at private medical schools are generally higher than at public, the non-resident tuition at public schools is about the same as that of the privates, and the rate of rise (percent change) in the last 10 years at public schools has far exceeded that at private schools (100% vs 50% increase). Indebtedness ranged from an average (high is different) of $80,000 to $163,000 at public schools, and $70,000 to $182,000 at private schools. Some schools give significant tuition scholarships, but others are more challenged: Stanford’s endowment allows it to give a far larger number of scholarships relative to loans than does, say Drexel. More important, the article points out that the high debt burden may discourage lower-income students from applying to medical school, and to enter specialties with higher income potentials. “It is not surprising that a recent analysis showed a ‘strong direct correlation’ between higher mean salary in a specialty, such as orthopedic surgery or radiology, and the percentage of residency positions filled by US graduates.” The piece says that there is no easy solution, and probably there is not. But most countries have very low medical school tuitions, but require national service of their graduates.
“Revisiting Duty Hour Limits — IOM Recommendations for patient safety and resident education” by John Iglehart, discusses that topic in a balanced way. It points out the acknowledgment in the IOM report that “Although some might propose further reductions in total duty hours, the report notes, ‘evidence suggests it is an indirect and inefficient approach given the moderate correlation that exists between resident duty hours and sleep time.'” Igelhart also notes that “the 2003 limits on duty hours have resulted in an increase in handoffs of patient care between physicians — transitions associated with increased risks to patient safety.” I have discussed this at length, but I did note that this article includes a table with a recommendation I had missed — that internal and external moonlight be counted against the 80-hour per week limits. I have no difficulty with that conceptually, as it makes perfect sense — what is the point of limiting work hours in the residency if residents can moonlight for extra money in an unrestricted fashion? — but I wonder about the legal ability of program directors to restrict the moonlighting activities of their residents in their off hours.
“The Future of Primary Care — the Community Responds” involves a followup to a series of opinion pieces and a roundtable discussion with Drs. Thomas Bodenheimer, Barbara Starfield, Katharine Treadway, Allan Goroll, and Thomas H. Lee that appeared in the November 13, 2008 issue. The comments, and responses from the roundtable participants, are salient and generally useful. Several writers noted the role of physician assistants, and one (Paul Lombardo) states that “Patients, and the U.S. health care system as a whole, would be better served if the content of and level of primary care education were better matched to the needs of patients. The physician assistant (PA) model of medical education, with its emphasis on physician-physician assistant teams, needs to be expanded.”
These are all thorny, and not unrelated, issues. What is the relationship between resident work hours and physician’s assistants? Well, someone has to do the work. Since residents, even with the 80-hour restriction, work twice as many hours as do physician’s assistants, for about half the salary, and have a greater scope of practice, it would be incredibly expensive for hospitals to replace resident labor with that of physician’s assistants, not to mention physicians. As hospitals complain about the “cost” of resident education, this needs to be kept in mind; they are much better at accounting the cost than the benefit. Even if a hospital closes its residencies because it assesses the costs are greater than the benefit, this usually includes the fact that the residents care for many medically indigent patients, and you can be sure that the hospitals are planning to no longer care for them at all, not to pay someone else to do it. This, of course, again decreases access for the most needy.
I have repeatedly said that the nucleus of a solution is a comprehensive national health program, which includes a single-payer and a system that is tasked with ensuring the health and access to quality health care of all Americans. With such a system, addressing issues such as resident work hours, medical student debt, and the composition of the physician (and NP and physician assistant) workforce could be feasible; without it, they all remain insoluble because they all depend upon each other.
(Joshua Freeman, M.D. is Professor and Chair of the Department of Family Medicine at the University of Kansas School of Medicine, though the comments in this blog are his own. He does understand his topic: http://www2.kumc.edu/fammed/Chairman.htm)
http://medicinesocialjustice.blogspot.com/2009/01/student-debt-resident-hours-and-primary.html

Josh Freeman’s comments were selected to start off this year of reform (hopefully) because they set the theme that reform should not be simply about tweaking private and public insurance options; reform needs to be about fundamental restructuring of our health care financing and delivery systems.
Single payer is frequently conceived of as simply an administrative system of collecting funds for health care through an equitable system that is designed to include everyone. Well, it is that, and that would be a great improvement over the dysfunctional, fragmented, inequitable, and inadequate system that we have.
But there is the other side to single payer: spending. Imagine having two and a half trillion dollars under the control of our own single, public purchaser of health care – a monopsony. Scary? Well, yes, but not when you compare it to the horrendously frightening system that we now have – a system which the policy makers in Washington unbelievably wish to expand.
Our current system bankrupts and even kills people. With our own public single payer system the funds would be used to save lives, preserve health, and prevent financial hardship in the face of medical need. Professor Freeman is right on target when he says, “the nucleus of a solution is a comprehensive national health program, which includes a single-payer and a system that is tasked with ensuring the health and access to quality health care of all Americans.” Otherwise our problems “all remain insoluble because they all depend upon each other.”
If we expect someday to have an efficient, high-performance health care system for all of us, repairing and expanding our primary care infrastructure is not an option; it’s an absolute necessity.

Student Debt, Resident Hours, and Primary Care

Student Debt, Resident Hours, and Primary Care Redux

By Josh Freeman
Medicine and Social Justice (A Blog)
January 2, 2009

The December 18, 2008 issue of the New England Journal of Medicine includes Perspectives on 3 topics that have been previously addressed on this blog: Medical student debt (Dec 14), resident duty-hours (Dec 3, 9), and the future of primary care (Dec 11).

The piece on “Medical Student Debt — Is there a Limit?” by Robert Steinbrook presents data on the extraordinary rise in tuition, and debt, among medical students, most surprisingly in the public medical schools. “For the current academic year, tuition, fees, and health insurance at private medical schools range from $15,278 (for Texas residents) or $28,378 (for non-residents) at Baylor University to $51,969 at Tufts University in Massachusetts and $52,236 at Temple University (for nonresidents of Pennsylvania — state residents are charged at $43,232.” While tuition rates at private medical schools are generally higher than at public, the non-resident tuition at public schools is about the same as that of the privates, and the rate of rise (percent change) in the last 10 years at public schools has far exceeded that at private schools (100% vs 50% increase). Indebtedness ranged from an average (high is different) of $80,000 to $163,000 at public schools, and $70,000 to $182,000 at private schools. Some schools give significant tuition scholarships, but others are more challenged: Stanford’s endowment allows it to give a far larger number of scholarships relative to loans than does, say Drexel. More important, the article points out that the high debt burden may discourage lower-income students from applying to medical school, and to enter specialties with higher income potentials. “It is not surprising that a recent analysis showed a ‘strong direct correlation’ between higher mean salary in a specialty, such as orthopedic surgery or radiology, and the percentage of residency positions filled by US graduates.” The piece says that there is no easy solution, and probably there is not. But most countries have very low medical school tuitions, but require national service of their graduates.

“Revisiting Duty Hour Limits — IOM Recommendations for patient safety and resident education” by John Iglehart, discusses that topic in a balanced way. It points out the acknowledgment in the IOM report that “Although some might propose further reductions in total duty hours, the report notes, ‘evidence suggests it is an indirect and inefficient approach given the moderate correlation that exists between resident duty hours and sleep time.'” Igelhart also notes that “the 2003 limits on duty hours have resulted in an increase in handoffs of patient care between physicians — transitions associated with increased risks to patient safety.” I have discussed this at length, but I did note that this article includes a table with a recommendation I had missed — that internal and external moonlight be counted against the 80-hour per week limits. I have no difficulty with that conceptually, as it makes perfect sense — what is the point of limiting work hours in the residency if residents can moonlight for extra money in an unrestricted fashion? — but I wonder about the legal ability of program directors to restrict the moonlighting activities of their residents in their off hours.

“The Future of Primary Care — the Community Responds” involves a followup to a series of opinion pieces and a roundtable discussion with Drs. Thomas Bodenheimer, Barbara Starfield, Katharine Treadway, Allan Goroll, and Thomas H. Lee that appeared in the November 13, 2008 issue. The comments, and responses from the roundtable participants, are salient and generally useful. Several writers noted the role of physician assistants, and one (Paul Lombardo) states that “Patients, and the U.S. health care system as a whole, would be better served if the content of and level of primary care education were better matched to the needs of patients. The physician assistant (PA) model of medical education, with its emphasis on physician-physician assistant teams, needs to be expanded.”

These are all thorny, and not unrelated, issues. What is the relationship between resident work hours and physician’s assistants? Well, someone has to do the work. Since residents, even with the 80-hour restriction, work twice as many hours as do physician’s assistants, for about half the salary, and have a greater scope of practice, it would be incredibly expensive for hospitals to replace resident labor with that of physician’s assistants, not to mention physicians. As hospitals complain about the “cost” of resident education, this needs to be kept in mind; they are much better at accounting the cost than the benefit. Even if a hospital closes its residencies because it assesses the costs are greater than the benefit, this usually includes the fact that the residents care for many medically indigent patients, and you can be sure that the hospitals are planning to no longer care for them at all, not to pay someone else to do it. This, of course, again decreases access for the most needy.

I have repeatedly said that the nucleus of a solution is a comprehensive national health program, which includes a single-payer and a system that is tasked with ensuring the health and access to quality health care of all Americans. With such a system, addressing issues such as resident work hours, medical student debt, and the composition of the physician (and NP and physician assistant) workforce could be feasible; without it, they all remain insoluble because they all depend upon each other.

(Joshua Freeman, M.D. is Professor and Chair of the Department of Family Medicine at the University of Kansas School of Medicine, though the comments in this blog are his own. He does understand his topic: http://www2.kumc.edu/fammed/Chairman.htm)

http://medicinesocialjustice.blogspot.com/2009/01/student-debt-resident-hours-and-primary.html

Comment:

By Don McCanne, MD

Josh Freeman’s comments were selected to start off this year of reform (hopefully) because they set the theme that reform should not be simply about tweaking private and public insurance options; reform needs to be about fundamental restructuring of our health care financing and delivery systems.

Single payer is frequently conceived of as simply an administrative system of collecting funds for health care through an equitable system that is designed to include everyone. Well, it is that, and that would be a great improvement over the dysfunctional, fragmented, inequitable, and inadequate system that we have.

But there is the other side to single payer: spending. Imagine having two and a half trillion dollars under the control of our own single, public purchaser of health care – a monopsony. Scary? Well, yes, but not when you compare it to the horrendously frightening system that we now have – a system which the policy makers in Washington unbelievably wish to expand.

Our current system bankrupts and even kills people. With our own public single payer system the funds would be used to save lives, preserve health, and prevent financial hardship in the face of medical need. Professor Freeman is right on target when he says, “the nucleus of a solution is a comprehensive national health program, which includes a single-payer and a system that is tasked with ensuring the health and access to quality health care of all Americans.” Otherwise our problems “all remain insoluble because they all depend upon each other.”

If we expect someday to have an efficient, high-performance health care system for all of us, repairing and expanding our primary care infrastructure is not an option; it’s an absolute necessity.

Health economists: Their facts, but our values

Health Economists’ Views of Health Policy

By Michael A. Morrisey and John Cawley
Journal of Health Politics, Policy and Law
August 2008
This article reports the views of a national survey of U.S. health economists on a series of questions ranging from mergers among health care providers to the profits of pharmaceutical manufacturers to fundamental health care reform. We find a high degree of agreement on issues of fact but considerable disagreement on issues that depend on values.
Issues of Fundamental Disagreement
Arguably the most divisive statement in our entire survey was, “The United States should adopt a Canadian-style system of universal and compulsory health insurance.” Of U.S. health economists, 47 percent agreed that the United States should adopt such a system. What makes the responses to this question so divided is the fact that the entire range of answers is used; 22 percent strongly agreed, 25 percent agreed, 21 percent disagreed, and 22 percent strongly disagreed. The nearly uniform spread of answers is unique; for all other issues reported, answers tend to be concentrated around the middle (agree or disagree) with few responses in the extreme tails (strongly agree, strongly disagree). Moreover, only 10 percent responded that they didn’t know, which is among the smallest response in that category to any question.
http://jhppl.dukejournals.org/cgi/content/abstract/33/4/707

Almost all of us want 2009 to be the Year of Health Care Reform. Almost all of us agree on the facts. We agree not only on what the deficiencies are in our health care financing and delivery systems, but we also largely agree on what the impact would be of various public policies that might be enacted during the reform process.
But the debate isn’t about facts; it’s about values! Just think about the strongly held values on the two sides of the debate over whether or not “the United States should adopt a Canadian-style system of universal and compulsory health insurance.”
Many of us can speak to one side of that debate. We want a health care system that can provide high-quality care for everyone at a cost that we can afford, both individually and collectively. An improved Canadian-style single payer system would do that. Those strongly opposed to single payer have not provided us with any model that would come close to all of those goals.
If the other side doesn’t share our specific goals, then what values do they support? Perhaps it’s unfair to try to describe their values since there is such an intense disagreement, but we can parrot some of their published statements on their values.
Many support the concept of individual responsibility. Each individual should be responsible for acquiring the means to obtain whatever products or services they desire, including health care. For those who are truly incapable, minimal basic services can be provided by private charity or by public safety-net welfare programs. For average-income individuals who can no longer afford health care, it is their responsibility to make choices – either a choice to advance themselves so they can afford care, or a choice to reduce other spending such as on rent, transportation, education or other less essential products or services, or simply to do without health care.
Many oppose wealth transfer, especially in the form of progressive taxes. They believe that those who have achieved great wealth should be allowed to keep it, and those who haven’t should simply make do. Wealth should not be confiscated by the government simply because tens of millions of individuals are not capable of paying for health care that they might need. In their view it is morally just that society be stratified, richly rewarding the producers.
Many passionately support the concept of freedom, meaning “free exercise of the natural right of sole dominion over their own lives, liberty and property,” relegating government to a minimal, custodial role. They specifically reject the United Nations Universal Declaration of Human Rights, which states, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.”
They value greatly the entrepreneurial spirit of the private marketplace that brings us wealth-creating insurance company middlemen, and an abundance of expensive technologies that shift the profit/benefit ratios ever upward. To them, private business success has a priority over public social policies.
Freedom, entrepreneurialism, and individual responsibility are values that are not the exclusive domain of the opponents of single payer, for we all share them. The disagreement is in how we value public policies that make these concepts work for all of us. We need freedom – freedom to chose our health care professionals – a freedom that the insurers have taken away from us. We need entrepreneurialism to provide us with better technology – but technology that meets the test of value. We need to exercise our individual responsibility to take care of ourselves – but along with our responsibility to support public policies that will enhance the health of all of us.
Princeton health economist Uwe Reinhardt has said that we can do this. The facts are easy. You tell us your values and then we can design a health care system that matches them. The question is, whose values will Congress and the Obama administration honor?

Health economists: Their facts, but our values

Health Economists' Views of Health Policy

By Michael A. Morrisey and John Cawley
Journal of Health Politics, Policy and Law
August 2008

This article reports the views of a national survey of U.S. health economists on a series of questions ranging from mergers among health care providers to the profits of pharmaceutical manufacturers to fundamental health care reform. We find a high degree of agreement on issues of fact but considerable disagreement on issues that depend on values.

Issues of Fundamental Disagreement

Arguably the most divisive statement in our entire survey was, “The United States should adopt a Canadian-style system of universal and compulsory health insurance.” Of U.S. health economists, 47 percent agreed that the United States should adopt such a system. What makes the responses to this question so divided is the fact that the entire range of answers is used; 22 percent strongly agreed, 25 percent agreed, 21 percent disagreed, and 22 percent strongly disagreed. The nearly uniform spread of answers is unique; for all other issues reported, answers tend to be concentrated around the middle (agree or disagree) with few responses in the extreme tails (strongly agree, strongly disagree). Moreover, only 10 percent responded that they didn’t know, which is among the smallest response in that category to any question.

http://jhppl.dukejournals.org/cgi/content/abstract/33/4/707

Comment:

By Don McCanne, MD

Almost all of us want 2009 to be the Year of Health Care Reform. Almost all of us agree on the facts. We agree not only on what the deficiencies are in our health care financing and delivery systems, but we also largely agree on what the impact would be of various public policies that might be enacted during the reform process.

But the debate isn’t about facts; it’s about values! Just think about the strongly held values on the two sides of the debate over whether or not “the United States should adopt a Canadian-style system of universal and compulsory health insurance.”

Many of us can speak to one side of that debate. We want a health care system that can provide high-quality care for everyone at a cost that we can afford, both individually and collectively. An improved Canadian-style single payer system would do that. Those strongly opposed to single payer have not provided us with any model that would come close to all of those goals.

If the other side doesn’t share our specific goals, then what values do they support? Perhaps it’s unfair to try to describe their values since there is such an intense disagreement, but we can parrot some of their published statements on their values.

Many support the concept of individual responsibility. Each individual should be responsible for acquiring the means to obtain whatever products or services they desire, including health care. For those who are truly incapable, minimal basic services can be provided by private charity or by public safety-net welfare programs. For average-income individuals who can no longer afford health care, it is their responsibility to make choices – either a choice to advance themselves so they can afford care, or a choice to reduce other spending such as on rent, transportation, education or other less essential products or services, or simply to do without health care.

Many oppose wealth transfer, especially in the form of progressive taxes. They believe that those who have achieved great wealth should be allowed to keep it, and those who haven’t should simply make do. Wealth should not be confiscated by the government simply because tens of millions of individuals are not capable of paying for health care that they might need. In their view it is morally just that society be stratified, richly rewarding the producers.

Many passionately support the concept of freedom, meaning “free exercise of the natural right of sole dominion over their own lives, liberty and property,” relegating government to a minimal, custodial role. They specifically reject the United Nations Universal Declaration of Human Rights, which states, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.”

They value greatly the entrepreneurial spirit of the private marketplace that brings us wealth-creating insurance company middlemen, and an abundance of expensive technologies that shift the profit/benefit ratios ever upward. To them, private business success has a priority over public social policies.

Freedom, entrepreneurialism, and individual responsibility are values that are not the exclusive domain of the opponents of single payer, for we all share them. The disagreement is in how we value public policies that make these concepts work for all of us. We need freedom – freedom to chose our health care professionals – a freedom that the insurers have taken away from us. We need entrepreneurialism to provide us with better technology – but technology that meets the test of value. We need to exercise our individual responsibility to take care of ourselves – but along with our responsibility to support public policies that will enhance the health of all of us.

Princeton health economist Uwe Reinhardt has said that we can do this. The facts are easy. You tell us your values and then we can design a health care system that matches them. The question is, whose values will Congress and the Obama administration honor?

House party attendees in agreement

At House Party on Health Care, the Diagnosis Is It’s Broken

By Robert Pear
The New York Times
December 22, 2008
When a dozen consumers gathered over the weekend to discuss health care at the behest of President-elect Barack Obama, they quickly agreed on one point: they despise health insurance companies.
http://www.nytimes.com/2008/12/23/health/23health.html?_r=1&hp

And for reform, our nation’s political leaders are going to bring us… even more of the same?

House party attendees in agreement

At House Party on Health Care, the Diagnosis Is It's Broken

By Robert Pear
The New York Times
December 22, 2008

When a dozen consumers gathered over the weekend to discuss health care at the behest of President-elect Barack Obama, they quickly agreed on one point: they despise health insurance companies.

http://www.nytimes.com/2008/12/23/health/23health.html?_r=1&hp

Comment:

By Don McCanne, MD

And for reform, our nation’s political leaders are going to bring us… even more of the same?

Ovation extorts innocent premature babies

FTC accuses firm of drug monopoly

By James Rowley
The Seattle Times
December 17, 2008

Antitrust enforcers accused Ovation Pharmaceuticals of cornering the U.S. market on a drug for a congenital heart defect in premature infants and asked a court to break up the company’s monopoly on the medication.

Ovation, based in Deerfield, Ill., purchased the rights to Indocin from Merck in August 2005. The FTC said Ovation then bought the rights to NeoProfen from Abbott Laboratories in January 2006.

As soon as it acquired NeoProfen, Ovation raised the $36 price it had been charging hospitals for each vial of Indocin to about $500, the FTC alleged in its complaint. Ovation set a price of $483 a vial for NeoProfen when it started selling the drug in July 2006, the FTC said.

The two drugs are the only alternative to risky surgery to treat a condition known as patent ductus arteriosus in which a blood vessel connecting two heart arteries fails to close.

http://seattletimes.nwsource.com/html/nationworld/2008528981_ftc17.html

Comment:

By Don McCanne, MD

Imagine if we had a publicly-financed and publicly-administered national health program covering everyone that included a comprehensive drug benefit. Would we be reading this story? Of course not. This does not mean that pharmaceutical firms will not engage in other criminal activities, but this one would have been prevented if we had a rational system of financing health care.

This one isn’t only about money; it’s about the soul of our health care system. It is about a pharmaceutical company that merely bought rights to products developed by others and then used those rights to egregiously extort innocent premature infants who had the misfortune of being born with a patent ductus arteriosus.

Depending on antitrust enforcers to establish health policy doesn’t seem like a smart way to run a health care system. With a single payer national health program we’d be able to eliminate many of the causes of excessive spending that often brings us only mediocrity in health care. Leaving the middlemen money managers in place will never allow us to achieve a high-performance system at a reasonable cost. Yet our national policy makers are determined to protect these middlemen no matter how much it costs us both in dollars and in tradeoffs in beneficial health policies.

Atlanta physicians on curing faulty system

Letters to the Editor
Atlanta Journal-Constitution
Dec. 21, 2008

Responses to “Health care reform: We can’t afford to wait to fix this broken system” and “There is a cure available,” by Dr. Oliver Fein,” Dec. 14.

Stabilize primary care

I agree with the AJC editorial that pooling all our children in one consolidated system of health financing could solve many problems.

Even among families with insurance, children must often defer needed care when their health plan changes rules, raises costs, drops a physician or terminates the employer’s contract.

Effective primary care needs stability and continuity in the patient-doctor relationship, and it functions best when the families have freedom to choose their doctor or clinic.

A universal, single-payer system would — for less money — bring us closer to these goals for children.

Why not extend a universal single-payer system to all Americans?

Dr. Oliver Fein’s commentary provided good reasons why the National Health Insurance Act offers a sensible way forward.

Dr. HENRY S. KAHN
Kahn is a professor emeritus at Emory University School of Medicine.

Single-payer system works

As a board-certified internist, I concur with Dr. Oliver Fein’s idea of a single-payer system.

I have seen many Georgia patients with strokes and myocardial infarctions that could have been prevented if they had access to good primary care. Helping these victims fit into a broken health care system has been frustrating to say the least.

Although born and raised in the United States, my medical education at McGill University in Montreal gave me a chance to observe the Canadian single-payer health care system.

While it is not perfect, it is far better overall (and less expensive) than what we have here.

Let’s put the dollars that would otherwise be spent paying administrators back into the health care system and enact a single-payer system.

Dr. SUSAN HENDERSON
Henderson is a physician at Grady Health System.

And the downside is …

Dr. Oliver Fein, in arguing for a single-payer health care system, states that eliminating the $400 billion private health insurance industry would enable us to cover the uninsured and do away with co-pays and deductibles for most Americans. But think of what we would lose if that industry vanished!

Hmmmm … can’t seem to think of anything.

Dr. ANNETTE BERNARD
Bernard is an Atlanta physician.