PNHP

Is preventing genetic discrimination enough?

Is preventing genetic discrimination enough?

The Genetic Information Nondiscrimination Act — A Half-Step toward Risk Sharing

By Russell Korobkin, J.D., and Rahul Rajkumar, M.D., J.D.
The New England Journal of Medicine
July 24, 2008
Consider three Americans — one with an increased genetic risk for colon cancer, one with a family history of colon cancer, and one with a colonoscopic finding of several large adenomatous polyps. Under the Genetic Information Nondiscrimination Act (GINA), which was recently signed into law by President George W. Bush, health insurance companies may not refuse to cover and may not raise premiums for the first two people, whose genetic information or family history puts them at higher risk for colon cancer. Insurers could, however, refuse to sell the third person an individual policy or could quadruple his or her premiums. If the third person is enrolled in an employer-sponsored group health plan, insurers could raise the rates for everyone in the group.
In making such distinctions, GINA is emblematic of this country’s piecemeal and inconsistent approach to health care policy, which makes little sense and leaves many Americans without access to care or in danger of financial ruin if they seek care. Our recent history is replete with examples of similar half-measures in health policy.
One response would be to retreat from the egalitarian impulse of GINA and leave health insurance to market forces, as we do with consumer goods. Health insurance risk would be priced as accurately as technology permitted, and patients would pay their own expected medical costs in premiums.
The better solution is to fully embrace the basic ethic of GINA and admit that the law’s distinction between genetic information and other immutable characteristics is arbitrary.
The arbitrary nature of the categories GINA creates suggests that we should fully commit ourselves to the step that the legislation approaches but is too hesitant to take: the prohibition of medical underwriting — the rating and pricing of health insurance on the basis of any health information, not just genetic information. Health insurance premiums should be assessed on the basis of a “community rate” and should be set the same for all people within a given age group — possibly with exceptions somehow made for risk factors that are deemed to be within each person’s reasonable control.
Moreover, to ensure that the costs of bad health are shared equitably, all Americans would have to be in the same risk pool. This would mean enacting a health insurance mandate either for employers or, if health insurance could be made affordable, for individuals — and specifying a minimum set of benefits that everyone would be required to have. Given the growing disparity between the cost of modern medicine and the incomes of many Americans, enforcing such a mandate would be difficult. Even with income-based subsidies, an individual mandate could place an undue financial burden on many families. Nonetheless, bringing everyone into the same risk pool is an important long-term goal.
With such reforms, GINA could become the first step toward a just and sustainable health insurance system. This approach would recognize that, because many of the most important determinants of health are beyond people’s reasonable control, no one should have to bear the costs of health care alone.
http://content.nejm.org/cgi/content/full/359/4/335

The need for the Genetic Information Nondiscrimination Act was obvious. The members of Congress recognized that it would be unfair for private insurers to discriminate against individuals based on their family history or genetic makeup. What is perhaps not so obvious is why Congress chose to ignore all other forms of discrimination by private insurers.
As this article states, medical underwriting should be prohibited in order to permanently eliminate private insurer discrimination. Then a universal risk pool must be established to distribute risk equitably. But for that to work, the authors acknowledge that there must be a mandate that everyone participates.
In recommending community rating and a mandate to participate, the authors further acknowledge that, even with subsidies, reform based on private plans will still place an undue financial burden on many families. That is still a form of discrimination.
What is it that holds back these authors, members of Congress, and others in the health policy community from stating the obvious? Legislating and regulating the private insurance industry may reduce but will never eliminate insurer discrimination; adopting a publicly-funded, single payer national health program would. Why do they choke up when that’s what they need to say?

Is preventing genetic discrimination enough?

The Genetic Information Nondiscrimination Act -- A Half-Step toward Risk Sharing

By Russell Korobkin, J.D., and Rahul Rajkumar, M.D., J.D.
The New England Journal of Medicine
July 24, 2008

Consider three Americans — one with an increased genetic risk for colon cancer, one with a family history of colon cancer, and one with a colonoscopic finding of several large adenomatous polyps. Under the Genetic Information Nondiscrimination Act (GINA), which was recently signed into law by President George W. Bush, health insurance companies may not refuse to cover and may not raise premiums for the first two people, whose genetic information or family history puts them at higher risk for colon cancer. Insurers could, however, refuse to sell the third person an individual policy or could quadruple his or her premiums. If the third person is enrolled in an employer-sponsored group health plan, insurers could raise the rates for everyone in the group.

In making such distinctions, GINA is emblematic of this country’s piecemeal and inconsistent approach to health care policy, which makes little sense and leaves many Americans without access to care or in danger of financial ruin if they seek care. Our recent history is replete with examples of similar half-measures in health policy.

One response would be to retreat from the egalitarian impulse of GINA and leave health insurance to market forces, as we do with consumer goods. Health insurance risk would be priced as accurately as technology permitted, and patients would pay their own expected medical costs in premiums.

The better solution is to fully embrace the basic ethic of GINA and admit that the law’s distinction between genetic information and other immutable characteristics is arbitrary.

The arbitrary nature of the categories GINA creates suggests that we should fully commit ourselves to the step that the legislation approaches but is too hesitant to take: the prohibition of medical underwriting — the rating and pricing of health insurance on the basis of any health information, not just genetic information. Health insurance premiums should be assessed on the basis of a “community rate” and should be set the same for all people within a given age group — possibly with exceptions somehow made for risk factors that are deemed to be within each person’s reasonable control.

Moreover, to ensure that the costs of bad health are shared equitably, all Americans would have to be in the same risk pool. This would mean enacting a health insurance mandate either for employers or, if health insurance could be made affordable, for individuals — and specifying a minimum set of benefits that everyone would be required to have. Given the growing disparity between the cost of modern medicine and the incomes of many Americans, enforcing such a mandate would be difficult. Even with income-based subsidies, an individual mandate could place an undue financial burden on many families. Nonetheless, bringing everyone into the same risk pool is an important long-term goal.

With such reforms, GINA could become the first step toward a just and sustainable health insurance system. This approach would recognize that, because many of the most important determinants of health are beyond people’s reasonable control, no one should have to bear the costs of health care alone.

http://content.nejm.org/cgi/content/full/359/4/335

Comment:

By Don McCanne, MD

The need for the Genetic Information Nondiscrimination Act was obvious. The members of Congress recognized that it would be unfair for private insurers to discriminate against individuals based on their family history or genetic makeup. What is perhaps not so obvious is why Congress chose to ignore all other forms of discrimination by private insurers.

As this article states, medical underwriting should be prohibited in order to permanently eliminate private insurer discrimination. Then a universal risk pool must be established to distribute risk equitably. But for that to work, the authors acknowledge that there must be a mandate that everyone participates.

In recommending community rating and a mandate to participate, the authors further acknowledge that, even with subsidies, reform based on private plans will still place an undue financial burden on many families. That is still a form of discrimination.

What is it that holds back these authors, members of Congress, and others in the health policy community from stating the obvious? Legislating and regulating the private insurance industry may reduce but will never eliminate insurer discrimination; adopting a publicly-funded, single payer national health program would. Why do they choke up when that’s what they need to say?

"The Measure of America"

Development: US fails to measure up on ‘human index’

By Ashley Seager
The Guardian
July 17, 2008
Despite spending $230m (£115m) an hour on healthcare, Americans live shorter lives than citizens of almost every other developed country. And while it has the second-highest income per head in the world, the United States ranks 42nd in terms of life expectancy.
These are some of the startling conclusions from a major new report which attempts to explain why the world’s number-one economy has slipped to 12th place – from 2nd in 1990- in terms of human development.
The American Human Development Report, which applies rankings of health, education and income to the US, paints a surprising picture of a country that spends well over $5bn each day on healthcare – more per person than any other country.
The report, Measure of America, was funded by Oxfam America, the Conrad Hilton Foundation and the Rockefeller Foundation. It shows each of the 11 countries that rank higher than the US in human development has a lower per-capita income.
Those countries score better on the health and knowledge indices that make up the overall human development index (HDI), which is calculated each year by the United Nations Development Programme.
One of the main problems faced by the US, says the report, is that one in six Americans, or about 47 million people, are not covered by health insurance and so have limited access to healthcare.
The US has a higher percentage of children living in poverty than any of the world’s richest countries.
It also reveals 14% of the population – some 40 million Americans – lack the literacy skills to perform simple, everyday tasks such as understanding newspaper articles and instruction manuals.
Inequality remains stark. The richest fifth of Americans earn on average $168,170 a year, almost 15 times the average of the lowest fifth, who make do with $11,352.
The US also ranks first among the 30 rich countries of the Organisation of Economic Cooperation and Development in terms of the number of people in prison, both in absolute terms and as a percentage of the total population. It has 5% of the world’s people but 24% of its prisoners.
“Human development is concerned with what I take to be the basic development idea: namely, advancing the richness of human life, rather than the richness of the economy in which human beings live, which is only a part of it,” said the Nobel laureate economist Amartya Sen, who developed the HDI in 1990.
“We get in this report … an evaluation of what the limitations of human development are in the US but also … how the relative place of America has been slipping in comparison with other countries over recent years.”
http://www.guardian.co.uk/society/2008/jul/17/internationalaidanddevelopment.usa

And…

Testimony before the Joint Economic Committee

By Kristen Lewis
American Human Development Project
July 23, 2008
It is important to note that the U.S. has higher income scores than every country but Luxembourg on the global scale – we’re still #2 in income. But the eleven countries ahead of us – particularly fast-moving countries like Australia and Ireland – have been more successful and efficient in transforming income into positive health and education outcomes for their people.
Based on the data in the American Human Development Index and the information and analysis in the American Human Development Report, a steady, broad-based advance of human development in the United States as well as greater security for middle class families will require attention to several priorities.

  • For Americans to live longer, healthier lives as well as remain solvent when serious illness strikes, it is obvious from the report that progress depends in large part on a comprehensive resolution of the problem of health insurance.
  • The days when basic skills were sufficient to ensure a life of reasonable economic security and full participation in society are past; the labor market today is unkind to those who lack high school diplomas, and jobs that afford financial security increasingly require college degrees.
  • For Americans to sustain, or obtain, a decent standard of living, the wages and opportunities of millions of Americans must improve. Growing inequality in income distribution and wealth raises a profound question for Americans: Can the uniquely middle-class nation that emerged in the twentieth century survive into the twenty-first century? Or is it fracturing into a land of great extremes?

http://jec.senate.gov/index.cfm?FuseAction=Hearings.HearingsCalendar&ContentRecord_id=4b4275bc-d7b2-8563-4faf-a21bf4898ba4
American Human Development Project:
http://www.measureofamerica.org/
“The Measure of America,” Executive Summary:
http://measureofamerica.org/wp-content/uploads/2008/07/ahdr-execsumm.pdf

“The American Human Development Project’s mission is to stimulate fact-based public debate about and political attention to human development issues in the United States and to empower people to hold elected officials accountable for progress on issues we all care about: health, education and income.”
From the testimony of Harvard Law School Professor Elizabeth Warren (also available at the jec.senate.gov link above): “Seven years of flat or declining wages, seven years of increasing costs, and seven years of mounting debts have placed unprecedented stress on the ordinary families. By every critical financial measure, these families are losing ground. Without changes in critical economic policies, the strong middle class that has been the backbone of the American economy and the American democracy is in jeopardy.”
When we are addressing the narrower problem of health insurance for everyone, does the broader issue of human development really matter? Well, yes, and here’s why.
The current national debate on reform has concentrated on various models designed to provide insurance coverage to more people. Several policies would fall short of universal coverage, but, to make matters worse, other recommendations accelerate the transition to a market of underinsurance products. Increasing the number of individuals with nominal but inadequate health care coverage defeats one major goal of improving human development within the United States.
In this political season, we need to assess candidates based on whether their policies are merely gimmicks designed to look like they are addressing problems such as the uninsured, or if their policies truly are based on the fundamental goal of improving human development.
Those who are dedicated to human development will make every effort to see that everyone does have health care coverage that actually works. They’ll also support policies that address our serious deficiencies in education and in income levels.
Providing health care alone without improving human development will only serve to be certain that we will remain number one in incarcerating our people. We have more than enough national wealth to be number one in human development.
We should ask our politicians to show us precisely how their policies would improve human development – realizing the dreams of the middle class for a greater number of us. If they don’t provide us with truly concrete proposals, then ask them what plans they have to increase the capacity of our prisons. If they have a well-thought-out answer for that, then maybe we should look elsewhere for candidates with a greater sense of social solidarity.

"The Measure of America"

Development: US fails to measure up on 'human index'

By Ashley Seager
The Guardian
July 17, 2008

Despite spending $230m (£115m) an hour on healthcare, Americans live shorter lives than citizens of almost every other developed country. And while it has the second-highest income per head in the world, the United States ranks 42nd in terms of life expectancy.

These are some of the startling conclusions from a major new report which attempts to explain why the world’s number-one economy has slipped to 12th place – from 2nd in 1990- in terms of human development.

The American Human Development Report, which applies rankings of health, education and income to the US, paints a surprising picture of a country that spends well over $5bn each day on healthcare – more per person than any other country.

The report, Measure of America, was funded by Oxfam America, the Conrad Hilton Foundation and the Rockefeller Foundation. It shows each of the 11 countries that rank higher than the US in human development has a lower per-capita income.

Those countries score better on the health and knowledge indices that make up the overall human development index (HDI), which is calculated each year by the United Nations Development Programme.

One of the main problems faced by the US, says the report, is that one in six Americans, or about 47 million people, are not covered by health insurance and so have limited access to healthcare.

The US has a higher percentage of children living in poverty than any of the world’s richest countries.

It also reveals 14% of the population – some 40 million Americans – lack the literacy skills to perform simple, everyday tasks such as understanding newspaper articles and instruction manuals.

Inequality remains stark. The richest fifth of Americans earn on average $168,170 a year, almost 15 times the average of the lowest fifth, who make do with $11,352.

The US also ranks first among the 30 rich countries of the Organisation of Economic Cooperation and Development in terms of the number of people in prison, both in absolute terms and as a percentage of the total population. It has 5% of the world’s people but 24% of its prisoners.

“Human development is concerned with what I take to be the basic development idea: namely, advancing the richness of human life, rather than the richness of the economy in which human beings live, which is only a part of it,” said the Nobel laureate economist Amartya Sen, who developed the HDI in 1990.

“We get in this report … an evaluation of what the limitations of human development are in the US but also … how the relative place of America has been slipping in comparison with other countries over recent years.”

http://www.guardian.co.uk/society/2008/jul/17/internationalaidanddevelopment.usa

And…

Testimony before the Joint Economic Committee

By Kristen Lewis
American Human Development Project
July 23, 2008

It is important to note that the U.S. has higher income scores than every country but Luxembourg on the global scale — we’re still #2 in income. But the eleven countries ahead of us — particularly fast-moving countries like Australia and Ireland — have been more successful and efficient in transforming income into positive health and education outcomes for their people.

Based on the data in the American Human Development Index and the information and analysis in the American Human Development Report, a steady, broad-based advance of human development in the United States as well as greater security for middle class families will require attention to several priorities.

* For Americans to live longer, healthier lives as well as remain solvent when serious illness strikes, it is obvious from the report that progress depends in large part on a comprehensive resolution of the problem of health insurance.

* The days when basic skills were sufficient to ensure a life of reasonable economic security and full participation in society are past; the labor market today is unkind to those who lack high school diplomas, and jobs that afford financial security increasingly require college degrees.

* For Americans to sustain, or obtain, a decent standard of living, the wages and opportunities of millions of Americans must improve. Growing inequality in income distribution and wealth raises a profound question for Americans: Can the uniquely middle-class nation that emerged in the twentieth century survive into the twenty-first century? Or is it fracturing into a land of great extremes?

http://jec.senate.gov/index.cfm?FuseAction=Hearings.HearingsCalendar&ContentRecord_id=4b4275bc-d7b2-8563-4faf-a21bf4898ba4

American Human Development Project:

Measure of America Home Page

“The Measure of America,” Executive Summary:
http://measureofamerica.org/wp-content/uploads/2008/07/ahdr-execsumm.pdf

Comment:

By Don McCanne, MD

“The American Human Development Project’s mission is to stimulate fact-based public debate about and political attention to human development issues in the United States and to empower people to hold elected officials accountable for progress on issues we all care about: health, education and income.”

From the testimony of Harvard Law School Professor Elizabeth Warren (also available at the jec.senate.gov link above): “Seven years of flat or declining wages, seven years of increasing costs, and seven years of mounting debts have placed unprecedented stress on the ordinary families. By every critical financial measure, these families are losing ground. Without changes in critical economic policies, the strong middle class that has been the backbone of the American economy and the American democracy is in jeopardy.”

When we are addressing the narrower problem of health insurance for everyone, does the broader issue of human development really matter? Well, yes, and here’s why.

The current national debate on reform has concentrated on various models designed to provide insurance coverage to more people. Several policies would fall short of universal coverage, but, to make matters worse, other recommendations accelerate the transition to a market of underinsurance products. Increasing the number of individuals with nominal but inadequate health care coverage defeats one major goal of improving human development within the United States.

In this political season, we need to assess candidates based on whether their policies are merely gimmicks designed to look like they are addressing problems such as the uninsured, or if their policies truly are based on the fundamental goal of improving human development.

Those who are dedicated to human development will make every effort to see that everyone does have health care coverage that actually works. They’ll also support policies that address our serious deficiencies in education and in income levels.

Providing health care alone without improving human development will only serve to be certain that we will remain number one in incarcerating our people. We have more than enough national wealth to be number one in human development.

We should ask our politicians to show us precisely how their policies would improve human development – realizing the dreams of the middle class for a greater number of us. If they don’t provide us with truly concrete proposals, then ask them what plans they have to increase the capacity of our prisons. If they have a well-thought-out answer for that, then maybe we should look elsewhere for candidates with a greater sense of social solidarity.

Expand successful Medicare program to all

Edith Kenna
Fort Wayne Journal Gazette
July 21, 2008

July 30 is the 43rd anniversary of the passage of Medicare. Medicare began because no one except the government was willing to cover the oldest and sickest of us. Medicare now covers 34 million Americans. Consumer ratings of Medicare remain higher than that of private insurance companies. Medicare itself remains a model of effectiveness and efficiency, publicly funded and privately delivered, operating with administrative cost between 3 percent and 5 percent. If you don’t believe that Medicare is a success, try asking those covered by Medicare, friends, parents or grandparents if they want to give it up and go back to private insurance.

One wonders, then, why some politicians are opposed to building upon Medicare’s success. Rex Nutting of Dow Jones MarketWatch suggested in January that none of the major presidential candidates has endorsed such a simple solution as expanding Medicare. Instead, they generate elaborate Rube Goldberg plans that bring a few more people under insurance coverage but do not fundamentally change our deeply flawed health care system. Medicare has become the proverbial elephant in the room – very few politicians want to notice its successes or its popularity with consumers.

As a result, most health care proposals simply add more layers of complexity to our health care system and do not address the need for basic change. There is one bill, however, that stands out: HR 676, The United States National Health Insurance Act. The goal of HR 676 is to provide true universal coverage by improving and building upon the original Medicare program introduced 43 years ago. HR 676 provides a system of health care that is accessible, affordable, portable, equitable and provides a high standard of quality. This bill has never been granted a public hearing under either a Republican or a Democratic administration, which is not surprising because true social change never takes place from the top. If history proves anything, it is that Washington only enacts major social change when the people get involved and demand it. When it comes to health care, despite what Washington thinks, such a movement is well under way.

Last month the U.S. Conference of Mayors endorsed HR 676.

Religious organizations are also beginning to realize the importance of advocating for health reform as a moral issue. For instance, the Los Angeles Council of Religious Leaders, the Presbyterian National Assembly and the Unitarian Universalists National Assembly also endorse HR 676.

The American College of Physicians, the nation’s largest specialty group of 124,000 internists now supports a national insurance plan like Medicare. In April 2008, the Annals of Medicine reported that 59 percent of all U.S. doctors now support national health insurance as a way to ensure that everyone has access to care.

HR 676 has 91 co-sponsors in the House of Representatives. HR 676 has been endorsed by 438 union organizations in 48 states including 110 Central Labor Councils and Area Labor Federations and 34 state AFL-CIOs.

Thousands and thousands of citizens across the country have signed petitions in favor of HR 676 and have sent e-mail, cards and letters to their representatives urging its passage. Congress could at least have a hearing on the merits of the bill so the concept can be opened to public debate. Such a hearing could look at how Medicare can be improved to cover us all. It could look carefully at how private health insurers cherry pick the healthy and deny coverage to the sick. It could try to explain why we cling to a patchwork quilt of employer-based insurance that is hard to get and easy to lose.

Hoosiers for a Commonsense Health Plan is a grass-roots citizens’ movement that fully supports HR 676. President Bush and Sen. Barack Obama tell us change is hard. We tell them being sick without access to affordable health care is even worse. It is truly mind-boggling to observe Washington politicians swerve and dodge the elephant in the room of HR 676. The United States National Health Insurance Act deserves a hearing on its merits because Americans deserve a chance to have access to the health care they need.

Edith Kenna is licensed clinical social worker in Fort Wayne and a member of Northeast Indiana Hoosiers for a Commonsense Health Plan. She wrote this for The Journal Gazette.

Mayors join those lined up behind national health care

By Steve Porter
Northern Colorado Business Report
July 18, 2008

Another major group recently endorsed a federal bill that would expand the nation’s Medicare system to include everyone in America in a universal health-care plan.

The U.S. Mayors Conference, meeting in Miami in late June, voted for a resolution in support of HR676, also known as the United States National Health Insurance Act.

The resolution noted that 47 million Americans are currently without health insurance and that millions of others have coverage so inadequate that one major illness could lead to financial ruin.

The resolution also noted that:

* Managed care systems like HMOs and other so-called market reforms have failed to contain health-care costs, a situation that now threatens the international competitiveness of U.S. manufacturers;

* Administrative costs of private insurers consume one-third of private health-care spending while Medicare has administrative costs of less than 5 percent;

* U.S. hospitals spend 24.3 percent of their budgets on billing and administration while hospitals in Canada – which has a single-payer system – spend only 12.9 percent;

* Harvard researchers estimate that more than $300 billion could be saved annually by replacing private insurance companies with a single public-payer system;

The United States remains the only advanced nation in the world without universal health coverage while premiums for workers who get their health insurance through their employer – the vast majority – continue to rise by 10 percent, 12 percent or more every year.

And at the same time, private insurance companies continue to reap record profits. In 2006, the nation’s six biggest health insurers earned almost $11 billion in profits, according to ConsumerReports.org.

It’s a situation that can’t continue much longer, universal health-care advocates say. And it’s a system that business can’t carry much longer, according to Nathan Wilkes, a co-founder of the Business Coalition for Single-Payer Healthcare.

“Basically, everybody in the group – we all have different backgrounds in business and political leanings – but we all recognize the current health-care system is crushing business and it’s making us not competitive globally,” said Wilkes, an Englewood resident who helped form the group in 2007.

Wilkes said his group helped formulate the message sent to the mayors that changing to a single-payer system would benefit them through cost savings to their respective cities by no longer dealing with multiple insurance companies, each taking their own profits, and by buying drugs and medical supplies in bulk.

“It doesn’t take a rocket scientist to figure that part out,” Wilkes said.

HR676, sponsored by Rep. John Conyers, D-Mich., and co-sponsored by 70 other representatives, would basically expand the Medicare program – an existing single-payer plan now restricted to those 65 and over – to include every citizen. The bill has been endorsed by numerous medical organizations, including the National Medical Association and the American Nurses Association.

Others lining up behind it include several faith-based organizations, the Kentucky and New Hampshire houses of representatives, 20 cities and counties, the League of Women Voters, AFL-CIO organizations in 33 states and more than 400 labor groups across America, including the Boulder Area Labor Council and the Southern Colorado Labor Council in Pueblo.

Opposed by industry

So with all these groups coming together behind HR676, what’s keeping it from being enacted?

Wilkes says any real change in the current system is strongly opposed by the private insurance industry, big pharmaceutical companies and manufacturers of medical devices. “Anybody that’s making big profits today is against it,” he said.

Last year, Colorado tried to take a step toward insuring all of its residents – about 800,000 aren’t insured – through the 208 Blue Ribbon Commission on Health Care Reform. Five proposals were forwarded to the Legislature in January, including a proposal from Health Care for All Colorado that would have provided coverage for all through a single-payer plan.

Eliza Carney, chair of the Northern Colorado chapter’s steering committee, said she was “disappointed but not surprised” by the legislature’s failure to adopt any of the proposals.

Carney said financial constraints were part of the inaction but also a lack of political will.

“I think some of the (Democratic) legislative leaders were swayed by pundits who said it was a controversial issue and they would be hammered by the Republicans at election time,” she said.

Both Carney and Wilkes strongly support HR676 but say getting momentum behind a national health-care plan probably won’t happen without successful state-level programs. Both said they would like to see Colorado develop a pilot program that could serve as a possible prototype for a national health care program.

“It’s not going to happen without a lot of grassroots action,” Carney said.

Asked whether a change in the White House this year might increase HR676’s chances of passing in Congress, Wilkes said he holds out hope under a Barack Obama presidency.

“I’m always hopeful,” he said. “It’s definitely getting better for something like that to happen. I would love to see a situation where Barack Obama is president with a filibuster-proof Congress to finally pass a universal health-care plan.

“That would be phenomenal.”

Steve Porter covers health care issues for the Northern Colorado Business Report. He can be reached at 970-221-5400, Ext. 225 or at sporter@ncbr.com.

Testimony of Joe Bak, Ph.D. before the House Judiciary Committee

Presented before the Chairman of the House Judiciary Committee John Conyers, Jr. (MI-14) and Senior Member of the House Judiciary Committee Sheila Jackson Lee (TX-18) In Houston, Texas on July 18, 2008

My name is Dr. Joseph Bak. I am a clinical psychologist in private practice for 25 years and therefore, also the owner of a small business. In addition, I have been actively involved in advocating for universal healthcare since the early 1990s. Most importantly, I am a consumer of healthcare services. It is from five different perspectives, that of psychologist, small business owner, taxpayer, healthcare reform advocate and patient that I strongly support the enactment of H.R. 676. I believe it is the only solution that can comprehensively and cost-effectively address what is wrong with our fatally flawed healthcare system; a system that long ago became too sick to cure.

In my role as clinical psychologist I provide mental healthcare services within a system that routinely discriminates against my patients. Health insurance policy benefits for mental healthcare are seldom comparable to physical healthcare benefits. They are typically severely and differentially capped by placing limits on the number of outpatient sessions, inpatient treatment days, annual and lifetime dollar amount, etc. H.R. 676 explicitly eliminates such discriminatory practices by providing coverage for all medically necessary mental healthcare on the same basis as coverage for other conditions.

In my role as healthcare reform advocate and collector of healthcare horror stories, it is imperative that H.R. 676 be enacted for Melissa, and for unnamed tens of thousands of Americans with equally tragic stories that are unfolding as we speak. Melissa, a vibrant young woman working at a city library in Austin, decided two years ago to sign a one year contract to work in the Japanese school system to teach English. While there she was diagnosed with Stage 2 Hodgkin’s lymphoma, the same cancer her brother has contracted, for which she is now being treated with chemotherapy in Japan. She was able to extend her work contract for another year but has no idea how or when she might be able to return to the U.S. She would have no health insurance, be uninsurable in the individual health insurance market, and likely be treated as a leper by most small and midsize employers because of the impact she would have on their company’s health insurance premiums. So she stays in Japan with a potentially life threatening medical condition, visited only occasionally by family and friends. Universal healthcare afforded by H.R. 676 would allow Melissa to return to the U.S. to be reunited with her family and friends, and to be treated for her lymphoma without question.

As a small business owner, I want to know that I will be able to obtain health insurance and drug benefit coverage at affordable rates even though I am not a member of a large employer’s risk pool. As a taxpayer, I want to know that my tax dollars are paying for the most cost-efficient system of healthcare delivery possible. As a patient, I do not want to be subjected to double jeopardy. I do not want to discover after the fact of sustaining a catastrophic illness, that I was unknowingly one of the underinsured and now have to file for bankruptcy. I do not want to find out that I am responsible for overwhelming medical bills once my insurance company determines that they are not required to pay for services that I thought my policy was supposed to cover.

For decades now it has proven to be a dismal failure to blindly insist that merely allowing health insurance companies to compete without restrictions in the marketplace will fix the problems in our healthcare system. It has become obvious that private market forces are severely limited in their ability to achieve valued social objectives. However we continue to try to rely upon free market strategies in the healthcare sector to no avail, when measured either by their ability to control costs or to expand services to everyone.

Few people understand that what markets do best is to distribute goods and services according to price. They do a masterfully efficient job of creating winners and losers according to one’s ability to pay. This seems fair and just regarding the distribution of televisions, refrigerators and computers. However, when market forces are relied upon to determine the distribution of healthcare services, the losers stand to lose their wellbeing, or possibly even their lives if they are uninsured or underinsured.

If you believe as I do that healthcare is a right that is central to human dignity, and necessary to preserve equal opportunity in our country, not a privilege or a commodity to be distributed according to one’s ability to pay, then it is essential that H.R. 676 be passed into law as it is designed to embody these beliefs. It eliminates wasteful, cost-inefficient competition between health insurance companies and replaces them with a system based upon single source payment. As has been demonstrated repeatedly in other countries, single source payment represents the “gold standard” in administrative efficiency. Single source payment is the proven method to achieve effective cost containment and rational healthcare resource distribution, which then makes it possible to provide comprehensive and affordable healthcare services for everyone.

Health-care matchup finds Ohio falls short

Buckeye State doesn't measure up when compared to Ontario, which has Canada's universal coverage

By David Knox
Beacon Journal staff writer
Published on Sunday, Jul 20, 2008

The United States pays far more for health care — more than $7,000 a year for every American, from infant to codger — than any other advanced nation in the world.

That’s an undisputed fact.

The only argument is whether Americans are getting their money’s worth.

There’s plenty of evidence they’re not.

A study released last fall by the research arm of Congress found Americans have shorter life spans and die at faster rates because of major diseases than the averages for 30 democracies that make up the Organization for Economic Cooperation and Development.

The death rate for infants is especially chilling: The United States came in third worst, ahead of only Mexico and Turkey.

But that dismal showing by the nation doesn’t necessarily say anything about the cost and quality of health care in Ohio.

To explore how Ohio compares to the nation and the world, the Beacon Journal looked 60 miles across Lake Erie to the Canadian province of Ontario.

How does Ohio measure up to its neighbor?

Not very well:

* A 65-year-old Ontario resident can look forward to living about 20 more years — three years more than an Ohioan the same age can expect. At birth, the difference in life expectancy is greater — 76.4 years for Ohioans, compared to 80.7 years in Ontario.

* In Ohio, nearly eight of 1,000 newborns die each year — significantly higher than the U.S. rate of 6.8 deaths. In Ontario, the infant mortality rate is 5.5

* Ontario also has lower death rates for each of the top six causes: heart disease, cancer, stroke, emphysema and other chronic lower respiratory diseases, diabetes and accidents.

Overall, the gap in these key health-care yardsticks was wider between Ohio and Ontario than between the two nations as a whole in all but two categories: strokes and accidents.

That difference was striking because the state and the province are so similar demographically.

While the 300 million people in the United States are nine times more than Canada’s head count, Ohio and Ontario are close in population, overall economic size and demographic measures such as median age, average household and family size, and education.

Ohio and Ontario also have similar economies, with almost the same percentage of both work forces employed in manufacturing and retail and wholesale trade — the two largest industry categories. Wages and salaries also are comparable.

There are differences.

Ontario has a larger minority population — nearly 23 percent, compared to 17 percent for Ohio. But the largest group in Ontario is Asian. About three of four of Ohio’s minority residents are black, compared to about 4 percent in Ontario.

Canada adopted a national system more than 40 years ago calling for universal insurance coverage for all basic hospital and doctor care, with a “single-payer” — the government — picking up the bill. Private spending pays for care beyond the basics, including drugs, dental and eye care in most areas.

In the United States, public dollars pay for only 46 percent of health care, mainly for Medicare for the elderly and Medicaid for the poor. The rest comes from private insurance, often through employers, and out of pocket.

The United States is one of only three OECD countries — the others are Mexico and Turkey — without some form of universal coverage.

Millions uninsured

According to last year’s Census Bureau figures, about 16 percent of Americans — about 47 million — are uninsured at any one time.

Ohio’s figure is about 12 percent.

Canada’s system covers everyone, but struggles with long waiting lists for nonlife-threatening surgery and high-tech tests, such as magnetic resonance imaging (MRI) scans.

Earlier this year, the average wait was 121 days for cataract surgery, 216 days for a hip replacement and 110 days for an MRI.

Despite those problems, Canada typically scores higher than the United States in overall quality of health care.

An especially damning study released this year ranked Canada fifth and the United States last among 19 industrialized nations in deaths that could have been prevented “by timely and effective” medical treatment.

“They looked at things like people who died of diabetes before the age of 50, kids 15 and under who die of infectious diseases and people who die of treatable cancers,” said Robin Osborn, vice president of the Commonwealth Fund, a nonpartisan foundation that sponsors research on health issues.

“These are things we know we’ve got the medical artillery to attack — things you shouldn’t be dying of.”

Osborn cited the growing number of Americans without health insurance as one reason for the poor U.S. showing.

“If you don’t have health-care insurance, you’re not going to get the preventive care you need,” she said. “You’re basically going to get stuck in the emergency room.”

The study concluded that the United States wasn’t keeping pace with medical advances in other countries, noting that five years earlier, the United States ranked 15th in preventable deaths.

In contrast, Canada moved up a notch, over the same time. France, Japan and Australia were best.

Within the United States, Ohio fares slightly worse than the U.S. average of 110 preventable deaths per 100,000 population, according to another Commonwealth study.

A comparable score for Ontario isn’t available. But the Beacon Journal’s comparison found Ontario’s death rates are better than the Canadian average for three of the six leading causes of death.

Ohio’s rates are worse than the nation’s in every category but accidents.

Unhealthy lifestyles

Some experts argue such international comparisons are unfair because the United States is so much larger, wealthier and more culturally diverse than other countries.

Rather than lack of care, they blame the poor U.S. rankings on higher rates of illness, triggered by unhealthy lifestyles led by many Americans. In fact, studies do show Americans eat the most sugar, are fatter and have the highest rates of cancer and AIDS among developed nations.

While the factors behind the health results can be debated, there’s no question the Canadian system is less costly.

According to the latest OECD data, U.S. health-care spending in 2006 was 15.3 percent of its gross domestic product, with per-person spending more than double the average of all 30 member nations.

Latest figures from the Department of Health and Human Services put U.S. spending even higher: 16 percent of GDP and $7,026 per person.

Canada spends $3,768 per person, or about 10 percent of GDP. Ontario does even better, with health spending at 6.2 percent of GDP in 2004, according to the province’s Ministry of Finance. That works out to be less than $2,000 per person — about a third of what the United States spent that year.

Why is Ontario’s cost so much lower?

Canada’s universal health insurance system is better able to take advantage of the province’s large urban population, health ministry spokesman Mark Nesbitt said.

About 40 percent of Ontario’s 12.8 million people live in the Greater Toronto area, along the northwest shore of Lake Ontario.

“It’s less expensive to deliver health care where the infrastructure is already set up, where the transit is there, where the equipment and manpower is there,” Nesbitt said.

There are no comparable total health-care expenditure figures for states. But available data indicate that Ohio spends about 6 percent more than the U.S. per-person average.

On its Web site aimed at attracting new businesses, Ontario crows about how little the province spends for health care compared to the United States and other nations.

The pitch is aimed directly at companies in Ohio and other states saddled with providing health coverage for their employees: “This provides a valuable advantage for Ontario in competing for jobs against U.S. jurisdictions, especially in manufacturing sectors, where the cost of health benefits is cited as harming U.S. competitiveness.”

Costs add up

Indeed, in 2006, the Detroit News reported that health care added more than $1,500 to the cost of each General Motors vehicle assembled in the United States.

The same vehicles made in Canada cost GM $197 in health care. The company pays only for supplemental insurance covering dental bills and prescription drugs.

Workers also benefit from not having to fight for health insurance, said Gordon Lilley, an official with United Auto Workers Local 251, in southwestern Ontario.

“It makes negotiations easier because health care is a big-ticket item that isn’t on the table,” said Lilley, whose local represents about 2,700 workers in the auto-parts industry and other manufacturers.

Lilley acknowledged the Canadian system has flaws, such as the waiting lists, but he would never switch to a U.S.-style system that relied on private insurance.

“Absolutely not,” he said. “I have peace of mind, knowing that if anything happens to a member of my family or myself, that we’re taken care of and it’s not going to cost us our house or thousands and thousands of dollars.

“I just think it would be disastrous to have it go private. I think it would do away with our middle class.”

Most Canadians agree with Lilley, according to a 2007 survey sponsored by the Commonwealth Fund.

While 60 percent of the Canadians agreed that “fundamental changes were needed” in their health-care plan, only 12 percent favored “completely rebuilding the system.”

But more than a third of the Americans surveyed agreed with the statement, “Our health-care system has so much wrong with it that we need to completely rebuild it.”

That isn’t likely to happen soon, according to Dr. C. William Keck, who served 27 years as Akron’s health director, retiring in 2003.

Keck, a longtime critic of the American health-care system, blamed the insurance lobby for blocking change.

“There are a lot of well-monied, powerful, smart people who benefit from the system the way it currently is,” Keck said. “They have spread money in ways that make it difficult for anyone to take them on.”

Keck noted that all of the major presidential candidates “seem to have automatically ruled out a single-payer system.”

“It’s almost like they’ve conceded they can’t beat the insurance companies.”

David Knox can be reached at 330-996-3532 or dknox@thebeaconjournal.com

A Response to HCAN: Flawed Data, Failed Strategy

A collection of five responses to “Health Care for American Now” (HCAN) is below by authors Kip Sullivan, Ph.D., Dr. Quentin Young, Dr. Oliver Fein, PNHP co-founders Drs. David Himmelstein and Steffie Woolhandler, and Nicholas Skala.

We call them H-CAN’T (since you can’t talk about single payer if you join their group) for short!

To read Richard Kisch’s original blog posting, please click here.

by Nicholas Skala
07/16/08

The core of Richard Kirsch’s argument is that reformers should forego advocacy of a proven and effective reform — single-payer — in favor of policies which have already been demonstrated to be failures, because the latter are politically expedient. In other words, because failure is politically achievable, failure should be advocated.

The great wealth of literature and experience — both foreign and domestic — should leave us with no doubt that Kirsch and HCAN’s proffered reforms will not only fail to achieve anything approaching universal coverage, they will almost certainly make things worse. As Dr. David Himmelstein of Harvard Medical School points out, we’ve already heard promises that strict regulation of private insurers, placed in competition with a public plan, will demonstrate the public plan’s superiority. But the experience in Medicare has been quite the opposite — private insurers still managed to game the system and attract the healthy and profitable, to the detriment of the public system. This storyline is not confined to the United States: the private health insurer BUPA recent left the Irish market after a judge determined the company had unfairly skimmed healthier patients from the public system, and ordered the company to make adjustment payments.

The definition of insanity is to continue to repeat the same actions, expecting a different result. Yet this is exactly what Kirsch and HCAN advocate, and the results with be predictable. Their response to evidence that the medicine they peddle is nothing more than a placebo is simply to commission more pollsters to produce charts and graphs emphasizing its political feasibility.

In contrast, single-payer national health insurance works both on paper and in practice. Kirsch purports to dispel the “myth” that all European nations have single-payer by replacing it with a new one: that these systems preserve — as he and HCAN would — a substantial role for U.S.-style private insurance. Nothing could be further from the truth. In reality, all of these systems work only because they have regulated U.S.-style insurance companies out of existence. Even in the most privatized system, insurers are required to be non-profit, have their benefits and premiums dictated by the government, and must make “risk equalization” payments if one profits at the expense of another. We need not commission a poll in order to discern whether U.S. insurance companies are going to find such an arrangement more politically acceptable than single-payer.

After many years in the darkness, there is a groundswell of popular support for single-payer. “The U.S. National Health Insurance Act” (HR 676) has 92 co-sponsors in the U.S. House of Representatives. The U.S. Conference of Mayors has just voted unanimously to endorse it. Twenty-five state labor federations and hundreds of union locals have backed single-payer through a grassroots campaign. The majority of physicians and two-thirds of the American public say they support single-payer when polled. To raise the white flag of surrender and retreat to a position more favorable to insurance industry interests at precisely the time when popular support and grassroots energy are on the side of true reform is the real political miscalculation.

Statement of Dr. Quentin Young on “Health Care for America Now”

Press Release

For Immediate Release:
July 8, 2008

Contact:
Quentin Young, M.D., (312) 782-6006, info@pnhp.org

In a statement coinciding with today’s announcement of a new coalition called Health Care for America Now, Dr. Quentin Young, national coordinator of Physicians for a National Health Program, made the following remarks:

“Physicians for a National Health Program welcomes the call for quality, affordable health care for all by the new Health Care for America Now coalition.

“We note that a number of the organizations in Health Care for America Now are supporters of single-payer national health insurance, and we sincerely hope they will convince the entire coalition to adopt single payer as its platform and hasten the enactment of HR 676.”

“Based on more than two decades of research, including the study of domestic programs like Medicare and the failed “universal” reform efforts of several states, as well as the health care systems of other nations, we remain convinced that the only way to achieve the goal of truly universal, equitable and affordable health care in the United States is to remove the for-profit private insurance industry from the health care picture and to establish a single-payer national health insurance system, an improved and expanded version of Medicare for all.”

“The U.S. private insurance system is not the solution, but the source of the present problem.”

“We share the coalition’s abhorrence of health care policies that have been associated with the Bush administration and the presidential campaign platform of Sen. John McCain. These policies, if fully implemented, would substantially worsen an already untenable situation in which 47 million Americans are uninsured and a comparable number are underinsured, thanks to the profiteering and administrative waste of the for-profit private insurance industry.”

“At a time when the U.S. Conference of Mayors unanimously endorsed HR 676 and a recent poll indicated that 59 percent of U.S. physicians now support government-sponsored national health insurance, this is hardly the time to fall back to failed private insurance programs.”

####

Physicians for a National Health Program (www.pnhp.org), a membership organization of over 15,000 physicians, supports a single-payer national health insurance program. PNHP is headquartered in Chicago and has chapters across the United States. To contact a physician-spokesperson in your area, contact info@pnhp.org or call (312) 782-6006.

PNHP Response to Health Care for America Now (HCAN) Campaign

Oliver Fein, M.D.
President-elect, PNHP

The American health care system is in deep trouble. Everyone recognizes that it needs substantial reform. For too many Americans, health care is simply unaffordable. As each year passes, millions more are added to the rolls of the uninsured and underinsured. Physicians for a National Health Program believes that only a real structural change, to a publicly-financed single payer program, can effectively address its many problems.

Now a number of progressive public interest organizations and labor unions have announced a health care reform campaign called Health Care for America Now ( www.healthcareforamericanow.org). We welcome the attention they are bringing to the critical problems of the health care system. We applaud their recognition that the reliance on private insurance companies lies at the heart of the problems we face, and that it is the responsibility of government to assure access to affordable health care for everyone. The more that Americans understand that government must play a key role in the necessary reform, and that the private insurance industry is incapable of providing us with the health care we need, the sooner we will get the reforms that must take place.

Unfortunately, although the founders of HCAN correctly identify the problem, the remedy they offer — a choice of private plans and a new public plan with government playing a “watchdog” role — takes us away from actually achieving decent health care for everyone in this country. Past attempts by many states to increase access and improve coverage by regulating the insurance companies have all failed miserably. As long as they are “players” in our health care, these insurers will use their power and influence to see to it that there is no meaningful regulation of their behavior. Time and again in this country’s history, we have seen such regulation founder as the regulators become captives of those they are supposed to regulate.

Under the HCAN plan, private health insurance would remain a nightmare for consumers and physicians with continuing co-pays, deductibles, delays, and denials of coverage. The cost of what is already the world’s most expensive system would continue to climb, with no effective cost control mechanisms in place. Those who think they are insured will still find, when they are sick, that their insurance has failed them and that they can’t afford the care they need.

In short, what the Campaign is proposing would add hundreds of billions of dollars to the cost of the system and yet would fail to solve the many problems Americans face in trying to get care. We will only solve these problems when we get the private insurance companies out of our health care. Only a publicly-funded system modeled on the very popular Medicare program can cover everyone while making it possible to contain the continually rising cost of care.

We believe that the leaders of many of the organizations involved in HCAN, as well as many of their members, know that creating a single payer system is the only truly workable remedy for what ails our health care system. Instead of adopting an approach that appears to be politically expedient, we urge them to support the only program that can truly accomplish their goal of quality affordable health care for everyone: a single payer national health program.

A Policy Response to Health Care for America Now

by David Himmelstein, MD
PNHP Blog
Wednesday, Jul 9, 2008

Health Care for America Now (HCAN) is pushing a superficially attractive health reform model that has a long record of failure — akin to prescribing a placebo for a serious illness when effective treatment is available. They would offer Americans a new public insurance plan and a menu of private ones, with subsidies for coverage for low income families.

This approach reprises the format of Medicare’s ongoing privatization. Despite promises of strict regulation and a level playing field that would allow the public plan to flourish, private insurers would (as they have done in Medicare) predictably overwhelm regulatory efforts through crafty schemes to selectively recruit profitable, lower-cost patients, and avoid the expensively ill. Like the Medicare Advantage program, originally touted as a market-based strategy to improve Medicare’s efficiency, the HCAN plan would evolve into a multibillion dollar subsidy for private insurers whose massive financial power (amassed largely at government expense) would prove a political roadblock to terminating the failed experiment.

Unfortunately, proposals like HCAN’s that cede a central role to private insurers can only add coverage by adding costs. They promise savings from computerization and chronic disease care management. Yet the Congressional Budget Office has warned that there is little or no evidence for such savings.

The HCAN proposal forgoes most of the $350 billion annually in administrative savings possible under single payer national health insurance (NHI). Administrative waste is a natural byproduct of the private insurance firms that would retain a central role under HCAN’s plan. Private plans’ overhead is 12-fold higher than under NHI; the excess is squandered on marketing, underwriting, utilization reviewers and profits, and for the billions paid to executives. And the multiplicity of insurers envisioned in the plan precludes paying hospitals a global, lump sum budget; such budgets would save additional billions by obviating the need for most hospital billing and much of the internal accounting needed to attribute hospital costs to individual patients and payers.

HCAN’s proposal duplicates key elements of health reforms that have passed (and then failed) in multiple states: Massachusetts in 1988; Oregon in 1989; Tennessee, Minnesota and Vermont in 1992; Washington State in 1993; and Maine in 2003. In each case, rising costs scuttled the reform effort; none had a durable impact on the number of uninsured. The 2006 Massachusetts law, which incorporates many of the features of HCAN’s plan, is already threatened by rising costs, despite offering skimpy coverage and leaving many uninsured. And Massachusetts, with its low rate of uninsurance to begin with, and a large fund devoted to care of the uninsured, offered the optimal conditions for trying such a plan.

HCAN’s proposal tries to avoid a head-on collision with private insurers, but the result is a plan that cannot achieve universal coverage or make care affordable. For physicians, offering a placebo in place of effective treatment is a serious ethical violation. Hence, while we salute the good intentions of the members of the HCAN coalition, we must warn against their proposal.

Response to Richard Kirsch’s “Why Not Single Payer?”

by Kip Sullivan, JD

My work history very closely resembles Richard Kirsch’s. Like Richard, I began organizing for universal coverage in the mid-1980s with a state chapter of what used to be called Citizen Action. Like Richard, I co-wrote a state-level single-payer bill (I was one of a half-dozen Minnesotans who, in 1990, wrote the single-payer bill that has been introduced in Minnesota’s legislature every year since 1991). But unlike Richard, I never abandoned single-payer.

I need to be blunt: Richard has abandoned single-payer. When you urge Americans not to work for single-payer and to support instead a plan which feeds tax dollars to the insurance industry (a diehard opponent of single-payer), you have abandoned single-payer. It is not a stretch to say you have become an opponent of single-payer. I appreciate the fact that Richard has stayed in community organizing all these years. I can testify to how financially and emotionally difficult that can be. But I strongly disagree with the path Richard has taken on health care reform.

To stress how similar our career paths have been, let me add an anecdote to one Richard tells in Will It Be Déjà vu All Over Again, his 2003 account of the history of the fight for universal coverage. (I thoroughly enjoyed reading the historical portions of this account, as opposed to Richard’s explanations of why history turned out the way it did.) Richard describes a national event involving several caravans of ambulances that traveled cross-country (west to east) in 1991 to dramatize the need for universal coverage. An ambulance in one of those caravans, a three-ambulance caravan that started in Minnesota, broke down just south of Duluth. When word of the breakdown arrived at the Minneapolis headquarters of Minnesota COACT (Citizens Organized Acting Together) where I worked, I dropped everything, took a bus from Minneapolis to Duluth, got the ambulance repaired, and drove it back down to Minneapolis at unlawful speeds in time for the ambulance to catch up with the rest of the “caravan” the next day.

In this post, Richard tells us that “people” (which presumably means a sizable majority of Americans) are fearful of a single-payer system. He claims he discovered this unpleasant fact (to his “surprise”) in 2003 in the course of writing Will It Be Déjà vu…, and this discovery forced him to “reframe [his] view” and abandon single-payer. But if you read Will It Be Déjà vu…., you will see that Richard abandoned single-payer in 1993 or shortly thereafter, not in 2003.

In 1993, Citizen Action’s national staff and many of the state Citizen Action affiliates, including New York Citizen Action (the organization Richard has directed for two decades), shifted their resources away from the single-payer legislation pending in Congress to lobby for Bill Clinton’s awful Health Security Act, a bill that would have pushed all but wealthy Americans into HMOs. My organization, Minnesota COACT, was among the Citizen Action affiliates that refused to lift a finger to promote the Clinton bill despite considerable lobbying from the national Citizen Action office and AFSCME (another organization that abandoned single-payer to lobby for the Health Security Act). So Richard’s answer to his question, “What happened to me?” doesn’t ring true to me.

Richard’s answer — his current explanation for why he must continue to turn his back on single-payer in favor of the plan promoted by Health Care For America Now (HCAN) — suffers from three big defects: (1) He ignores numerous polls and other evidence indicating two-thirds of the public support a single-payer (or Medicare-for-all) system; (2) he ignores the fact that his “guaranteed affordable choice” proposal has at least as many unsightly warts (from the point of view of the insurance industry and the right wing) as single-payer does; and (3) even assuming his jaundiced view of public opinion about single-payer is correct, he totally ignores the role that courageous and passionate advocacy of single-payer can play in altering public opinion and inoculating the public against false accusations by the right. I’ll describe each defect briefly.

Defect 1 (turning a blind eye to evidence he disagrees with): Numerous polls and at least two “citizen jury” experiments (one involving Senator Paul Wellstone) indicate approximately two-thirds of Americans support universal coverage with a single-payer. I’ll give you just four examples:

* A 1991 Wall Street Journal-NBC poll found 69 percent support single-payer.

* A 2003 ABC News Poll found 62 percent said yes to the following question (note the bogeyman words “taxpayers” and “government” are in this question): “[Do you support] a universal health insurance program, in which everyone is covered under a program like Medicare that’s run by the government and financed by taxpayers?”

* An AP-Yahoo poll taken at the end of 2007 asked the same question ABC News asked and reported that 65 percent said yes.

* At the end of five eight-hour days of interviewing expert advocates for single-payer, the Clinton plan, and the Republicans’ high-deductible proposal, a 24-person “citizen jury” convened by the Jefferson Center in 1993 voted 17 for single-payer, 5 for the Clinton plan, and zero for the Republican proposal.

Note the high level of support for single-payer exists despite the absence of a well-endowed, highly visible single-payer movement. Of course, the absence of such a movement is due in part to the refusal of the AFL-CIO, SEIU, Health Care for America Now, USAction (the successor to Citizen Action) and other groups Richard works with to put resources into the single-payer movement. Note also that these high levels of public support for single-payer exist despite constant trashing of single-payer systems (like Medicare and Canada’s system) by the insurance industry and other powerful right-wing forces.

Richard offers no evidence in his post nor in Will It Be Déjà vu… that contradicts the evidence that two-thirds of Americans support single-payer. Nor does he offer any evidence to support his claim that a majority of the “people” oppose single-payer and that support for single-payer among citizens is more vulnerable to degradation under right-wing attacks than support for his “guaranteed affordable choice” plan would be. (It is possible to find polls, some with biased phrasing, that indicate that when Americans are given choices between a variety of proposals and asked which they prefer, fewer than half indicate they prefer single-payer. But even these polls do not contradict the statement that two-thirds of Americans will support a single-payer system if asked. They merely indicate “preferences,” not opposition to any particular proposal. In any case, Richard does not cite these.)

(In 2006, a group that Richard helped form called the Herndon Alliance began cranking out junk science that allegedly supports Richard’s claims. Obviously, given the timing of Richard’s decision to abandon single-payer–either 2003 or 1993–the Alliance’s junk science could not have played a role in that decision.)

Defect 2 (seeing the mote but not the log): Richard has an eagle eye for the controversial features of single-payer and a blind eye (or at least a very forgiving eye) for the controversial features of his proposal. Richard is eager to tell readers how “scary” single-payer is, but he is unwilling to help readers understand the enormous obstacles his “guaranteed affordable choice” plan faces. He is unwilling, in other words, to help his readers think about whether the obstacles to his proposal are less daunting than those he sees for single-payer. The most serious of the obstacles to his proposal will be the high cost of universal coverage under his plan and the need for costly and stringent regulations on the insurance industry that will infuriate the insurance industry and the right wing.

There is no cost containment in the proposal promoted by Richard and HCAN. In fact, as Richard and his allies flesh out their proposal (which at this date it is little more than ten bullet points on the HCAN Web site), I expect we will see provisions that will actually raise costs (such as the cost of the bureaucracy that will decide which health insurance companies get more money for insuring sicker people, the cost of detecting and investigating abuses of patients by insurance companies, the cost of switching from paper medical records to electronic medical records, and the cost of hiring more nurses to do “disease management”). By contrast, numerous studies, including those done by the US GAO and the Congressional Budget Office, demonstrate that a single-payer plan will achieve universal coverage for a lot less than Richard’s proposal or any other proposal that leaves the insurance industry in the mix.

Another huge impediment to Richard’s proposal is the need to impose regulations on the insurance industry to make his proposal work.(The most essential regulations will never be sufficiently effective, but I don’t need to get into that here.) The insurance industry and the right wing will fight these regulations with as much ferocity as they will fight single-payer.

A fair and useful discussion of the political feasibility of Richard’s proposal versus single-payer, then, would ask (among other questions) whether Richard’s proposal really is more feasible than single-payer when you take into account the high cost of his plan versus the lower cost of single-payer, and the intense resistance the insurance industry will put up against both plans. Richard doesn’t do that.

Defect 3 (leadership doesn’t matter): In his post and in his article, Richard has nothing to say about the role that enthusiastic support for single-payer from a large coalition of politicians and citizen, labor, and religious organizations could play in antidoting the corrosive effect of anti-single-payer propaganda. He is not only cynical about where public opinion is today, but he treats public opinion as if it were movable only in the anti-single-payer direction, never in the pro-single-payer direction.

That is, obviously, nonsense. If HCAN were to devote the $40 million they plan to spend on “guaranteed affordable choice” to a Medicare-for-all system (either implemented overnight or in stages), and if politicians like Senators Obama and Clinton would start talking about extending Medicare to everyone, the combined effect might well be to offset, and possibly even more than offset, insurance industry propaganda, which is to say, to maintain public support for single-payer at two-thirds or even increase it.

Richard’s “guaranteed affordable choice” plan is so poorly described in HCAN’s and Richard’s publications that it is a bit risky to predict what will happen to it. But here I go anyway. Odds are very high it will suffer a fate similar either to Clinton’s bill (it will never be enacted) or to the current Massachusetts “individual mandate” law (it will be enacted but it won’t achieve universal coverage because it will be too expensive and the insurance industry won’t be prevented from rationing). My fervent hope is that it will never be enacted.

My worst fear is that if it is enacted the Medicare-like public program that HCAN wants to create to “compete” with the insurance industry will be destroyed by the antisocial behavior of the insurance industry that simply can’t be regulated away. The public program will behave honestly while the insurance industry will keep doing what it does best — it will deny services and frustrate its enrollees and thereby drive the sickest of them into the public program — thereby pushing the public program’s costs up and its own costs down, and eventually driving the public program from the market. If that happens, the right wing will chortle, “See, we told you single-payers aren’t efficient, and now we’ve got proof.” It will be difficult for single-payer advocates, or HCAN for that matter, to explain that what actually happened was that the bad destroyed the good. The result could be prolonged damage to the public’s opinion of single-payer and further delay in establishing universal coverage.

Richard opens his article, Will It Be Déjà vu All Over Again, with this question: “Is this time really the time for universal health care? … . Or will the political process invent other half-measures rather than provide a government guarantee of affordable, quality health care for all?” Richard has answered his own question. He and others who abandoned single-payer in 1993 to support Clinton’s awful plan are repeating the mistakes they made 15 years ago. In 2008, as in 1993, they are urging Americans to abandon single-payer to support yet another “half measure” — a plan that can’t work but which, on the basis of superficial and biased analysis, seems to be more “politically feasible” than single-payer. Talk about Déjà vu!

“The Measure of America”

Development: US fails to measure up on ‘human index’

By Ashley Seager
The Guardian
July 17, 2008

Despite spending $230m (£115m) an hour on healthcare, Americans live shorter lives than citizens of almost every other developed country. And while it has the second-highest income per head in the world, the United States ranks 42nd in terms of life expectancy.

These are some of the startling conclusions from a major new report which attempts to explain why the world’s number-one economy has slipped to 12th place – from 2nd in 1990- in terms of human development.

The American Human Development Report, which applies rankings of health, education and income to the US, paints a surprising picture of a country that spends well over $5bn each day on healthcare – more per person than any other country.

The report, Measure of America, was funded by Oxfam America, the Conrad Hilton Foundation and the Rockefeller Foundation. It shows each of the 11 countries that rank higher than the US in human development has a lower per-capita income.

Those countries score better on the health and knowledge indices that make up the overall human development index (HDI), which is calculated each year by the United Nations Development Programme.

One of the main problems faced by the US, says the report, is that one in six Americans, or about 47 million people, are not covered by health insurance and so have limited access to healthcare.

The US has a higher percentage of children living in poverty than any of the world’s richest countries.

It also reveals 14% of the population – some 40 million Americans – lack the literacy skills to perform simple, everyday tasks such as understanding newspaper articles and instruction manuals.

Inequality remains stark. The richest fifth of Americans earn on average $168,170 a year, almost 15 times the average of the lowest fifth, who make do with $11,352.

The US also ranks first among the 30 rich countries of the Organisation of Economic Cooperation and Development in terms of the number of people in prison, both in absolute terms and as a percentage of the total population. It has 5% of the world’s people but 24% of its prisoners.

“Human development is concerned with what I take to be the basic development idea: namely, advancing the richness of human life, rather than the richness of the economy in which human beings live, which is only a part of it,” said the Nobel laureate economist Amartya Sen, who developed the HDI in 1990.

“We get in this report … an evaluation of what the limitations of human development are in the US but also … how the relative place of America has been slipping in comparison with other countries over recent years.”

http://www.guardian.co.uk/society/2008/jul/17/internationalaidanddevelopment.usa

And…

Testimony before the Joint Economic Committee

By Kristen Lewis
American Human Development Project
July 23, 2008

It is important to note that the U.S. has higher income scores than every country but Luxembourg on the global scale — we’re still #2 in income. But the eleven countries ahead of us — particularly fast-moving countries like Australia and Ireland — have been more successful and efficient in transforming income into positive health and education outcomes for their people.

Based on the data in the American Human Development Index and the information and analysis in the American Human Development Report, a steady, broad-based advance of human development in the United States as well as greater security for middle class families will require attention to several priorities.

* For Americans to live longer, healthier lives as well as remain solvent when serious illness strikes, it is obvious from the report that progress depends in large part on a comprehensive resolution of the problem of health insurance.

* The days when basic skills were sufficient to ensure a life of reasonable economic security and full participation in society are past; the labor market today is unkind to those who lack high school diplomas, and jobs that afford financial security increasingly require college degrees.

* For Americans to sustain, or obtain, a decent standard of living, the wages and opportunities of millions of Americans must improve. Growing inequality in income distribution and wealth raises a profound question for Americans: Can the uniquely middle-class nation that emerged in the twentieth century survive into the twenty-first century? Or is it fracturing into a land of great extremes?

http://jec.senate.gov/index.cfm?FuseAction=Hearings.HearingsCalendar&ContentRecord_id=4b4275bc-d7b2-8563-4faf-a21bf4898ba4

American Human Development Project:

Measure of America Home Page

“The Measure of America,” Executive Summary:
http://measureofamerica.org/wp-content/uploads/2008/07/ahdr-execsumm.pdf

Comment:

By Don McCanne, MD

“The American Human Development Project’s mission is to stimulate fact-based public debate about and political attention to human development issues in the United States and to empower people to hold elected officials accountable for progress on issues we all care about: health, education and income.”

From the testimony of Harvard Law School Professor Elizabeth Warren (also available at the jec.senate.gov link above): “Seven years of flat or declining wages, seven years of increasing costs, and seven years of mounting debts have placed unprecedented stress on the ordinary families. By every critical financial measure, these families are losing ground. Without changes in critical economic policies, the strong middle class that has been the backbone of the American economy and the American democracy is in jeopardy.”

When we are addressing the narrower problem of health insurance for everyone, does the broader issue of human development really matter? Well, yes, and here’s why.

The current national debate on reform has concentrated on various models designed to provide insurance coverage to more people. Several policies would fall short of universal coverage, but, to make matters worse, other recommendations accelerate the transition to a market of underinsurance products. Increasing the number of individuals with nominal but inadequate health care coverage defeats one major goal of improving human development within the United States.

In this political season, we need to assess candidates based on whether their policies are merely gimmicks designed to look like they are addressing problems such as the uninsured, or if their policies truly are based on the fundamental goal of improving human development.

Those who are dedicated to human development will make every effort to see that everyone does have health care coverage that actually works. They’ll also support policies that address our serious deficiencies in education and in income levels.

Providing health care alone without improving human development will only serve to be certain that we will remain number one in incarcerating our people. We have more than enough national wealth to be number one in human development.

We should ask our politicians to show us precisely how their policies would improve human development – realizing the dreams of the middle class for a greater number of us. If they don’t provide us with truly concrete proposals, then ask them what plans they have to increase the capacity of our prisons. If they have a well-thought-out answer for that, then maybe we should look elsewhere for candidates with a greater sense of social solidarity.

A decade of change for those with chronic conditions

Eroding Access Among Nonelderly U.S. Adults With Chronic Conditions: Ten Years Of Change

By Catherine Hoffman and Karyn Schwartz
Health Affairs
July 22, 2008
More than 40 percent of the U.S. population lives with one or more chronic conditions. However, because people with chronic conditions have greater health needs than others, they account for three-quarters of all personal medical care spending in this country. We focused on nonelderly adults with chronic conditions.
Both the connection to health care and its affordability worsened for many nonelderly U.S. adults living with chronic conditions between 1997 and 2006. This erosion varied by health insurance coverage. Access to care among uninsured adults with chronic conditions deteriorated on all of our basic measures between 1997 and 2006. In addition, more of both the privately and publicly insured with chronic conditions went without health care because of its cost over this ten-year span.
http://content.healthaffairs.org/cgi/content/full/hlthaff.27.5.w340/DC1

It would have been sad if this report had demonstrated that there had been no improvement in access and affordability in the past decade for this expensive, non-elderly population with chronic conditions. What it did show is that access and affordability deteriorated further, even amongst the insured. That’s not sad; that’s tragic.
Obviously our national health policies are not working. Dare anyone suggest that we change them?

A decade of change for those with chronic conditions

Eroding Access Among Nonelderly U.S. Adults With Chronic Conditions: Ten Years Of Change

By Catherine Hoffman and Karyn Schwartz
Health Affairs
July 22, 2008

More than 40 percent of the U.S. population lives with one or more chronic conditions. However, because people with chronic conditions have greater health needs than others, they account for three-quarters of all personal medical care spending in this country. We focused on nonelderly adults with chronic conditions.

Both the connection to health care and its affordability worsened for many nonelderly U.S. adults living with chronic conditions between 1997 and 2006. This erosion varied by health insurance coverage. Access to care among uninsured adults with chronic conditions deteriorated on all of our basic measures between 1997 and 2006. In addition, more of both the privately and publicly insured with chronic conditions went without health care because of its cost over this ten-year span.

http://content.healthaffairs.org/cgi/content/full/hlthaff.27.5.w340/DC1

Comment:

By Don McCanne, MD

It would have been sad if this report had demonstrated that there had been no improvement in access and affordability in the past decade for this expensive, non-elderly population with chronic conditions. What it did show is that access and affordability deteriorated further, even amongst the insured. That’s not sad; that’s tragic.

Obviously our national health policies are not working. Dare anyone suggest that we change them?