PNHP

Estimated cost of state’s health plan raises alarm

Estimated cost of state’s health plan raises alarm

Letters to the Editor
Boston Globe
February 10, 2008

JONATHAN GRUBER suggests that a single-payer system “would cost many multiples” of the current effort to expand health insurance coverage in Massachusetts through an individual mandate (letters, Feb 1) (http://www.boston.com/bostonglobe/editorial_opinion/letters/articles/2008/02/01/recognizing_progress_in_massachusetts_health_reform) Yet at least 18 studies conducted since 1991, including two that examined single-payer plans for Massachusetts in 1998, have found that a single-payer plan could provide comprehensive coverage for everyone while costing less than is now being spent. Savings in insurance overhead and hospital and physician office billing costs would more than offset the cost of providing access to care for those who now don’t have it. Massachusetts should reconsider this cost-effective alternative to the increasingly costly approach now being attempted.

LEONARD RODBERG
New York

The writer is a research director with Physicians for a National Health Program

AMA’s Conflicted President

By Adam Doster
In These Times
February 11, 2008

Dr. Nancy Nielsen’s résumé is exhaustive. Currently a clinical professor of medicine and senior associate dean for medical education at the University of Buffalo School of Medicine and Biomedical Sciences, Nielsen has worked for the New York State Department of Health and has held various leadership positions in the American Medical Association (AMA). So it’s not surprising that the AMA voted her president-elect last June, only the second woman to hold the post. Yet other jobs on Nielsen’s résumé have alarmed some progressive healthcare advocates.

From October 2004 to July 2007, Nielsen served as chief medical officer of Independent Health Association, a Buffalo-based HMO. Although AMA spokesperson Brenda Crane notes that Nielsen ended her affiliation with Independent Health upon receiving her promotion at the AMA, her tenure raises flags for Geri Jenkins, president of the California Nurses Association, a healthcare union.

“I think you have a conflict when you have someone in that position who’s worked for an insurance company and is also a physician who’s going to run the AMA,” Jenkins says.

Since 1996, Nielsen has also sat on the board of the Medical Liability Mutual Insurance Company, one of the country’s largest medical liability carriers. While some Republicans have embraced medical malpractice reform as a virtual cure-all for America’s healthcare crisis, critics contend that putting caps on non-economic damages provides unjustified protections for hospitals, HMOs and insurance companies, another potential conflict of interest.

In a vacuum, Nielsen’s professional relationships might be considered inconsequential. But the AMA has a long history of thwarting progressive healthcare reform, which amplifies the importance of her connection to the insurance industry.

As early as the 1930s, then-AMA President Dr. Morris Fishbein wrote that a national healthcare program would cause “a weakening of national caliber,” and signal “a definite step toward either communism or totalitarianism.” When, in 1948, President Harry Truman called for the creation of a government-run national health insurance fund, the AMA characterized the bill as “socialized medicine” and campaigned against it.

Next came the 1961 battle over Medicare that pitted the Kennedy administration against a recently hired General Electric public-relations flak named Ronald Reagan. The future president recorded an LP titled “Ronald Reagan Speaks Out Against Socialized Medicine” that the AMA distributed to housewives across the country. “Operation Coffee Cup” architects suggested that women organize small gatherings, brew some java and listen to the dangers that a national healthcare system would invariably pose.

During the Clinton years, the AMA was active in the coalition that beat back “Hillarycare”–the Democrats’ last attempt at major healthcare reform.

In August, the AMA launched a $15 million advertising campaign that focused on the problems of the uninsured, hoping to persuade voters to cast their ballots in 2008 with the issue in mind. But this project has frustrated reformers, who contend that the organization’s approach to achieving universal care–providing tax breaks and vouchers for those lacking coverage so they can purchase affordable plans–is too timid.

“At best … the AMA is advocating a completely unproven method of achieving their ends and ignoring things that we know will work,” says Dr. Stephanie Woolhandler, co-founder of Physicians for a National Health Program.

Given these realities, many doctors are turning their backs on the AMA. The medical news service MedPage Today estimated that the AMA represented only 15 percent of practicing U.S. physicians in 2005, down from 70 percent during the 1961 Medicare fight.

“A lot of younger doctors,” says Jenkins, “have gone into other groups and organizations because they haven’t always been happy with how the AMA is run and what they do.”

States like Minnesota and Massachusetts show majority support among physicians for a single-payer system, and the American College of Physicians–America’s second-largest physician group–endorsed such a proposal in December.

That’s made no difference to the AMA.

“The AMA has stuck with this position of vehemently opposing national health insurance,” says Woolhandler, “despite a major shift in the physician community in terms of opinion.”

With Nielsen at the helm, the AMA’s intransigence seems likely to continue.

Get ready for a Blue Cross/Blue Shield retailer near you

Blue Cross and Blue Shield opens store in Pembroke Pines

By Jaclyn Giovis
South Florida Sun-Sentinel
February 7, 2008

Blue Cross and Blue Shield of Florida Inc. wants you to buy health insurance the way you might buy a cell phone.

The insurer last month opened “Florida Blue,” its first insurance store in South Florida. Situated in the new Pembroke Lakes Square shopping center in Pembroke Pines, the store allows most consumers to walk in and buy health coverage and dental and life insurance in one visit or have questions about policies answered.

Unlike most insurance offices, Florida Blue features wi-fi access, a flat-screen TV and a PlayStation for kids. The store has computer stations where customers can look up insurance information with help from an agent.

Experts say the health insurance industry is changing, becoming more complex as health-care costs rise, the number of uninsured increases, and employers decide to cut group health insurance plans or provide employees a stipend to find their own provider.

As a result, some health insurers are looking for ways to make shopping for insurance less painful for consumers and attract new business by reaching out to people without coverage, they say.

This weekend, Florida Blue will host a grand opening with free health screenings, chair massages and giveaways.

http://www.sun-sentinel.com/business/sfl-flzinsureretail0207sbfeb07,0,5323731.story

Comment:

By Don McCanne, MD

Placing the consumer in charge of his or her own health care has been touted by the supporters of consumer-directed health care as the answer to our health care cost crisis. This includes providing consumers with a choice of coverage options in the individual private insurance market.

It is not only the advocates of HSAs and high-deductible coverage that support expansion of the individual market, it is also the leading presidential candidates from both political parties. Even the Democratic candidates would expand the individual insurance market and perhaps even mandate the purchase of these products. The clear trend, which is already taking place, is to shift coverage from employer-sponsored plans to the individual market.

Obviously Blue Cross and Blue Shield of Florida recognizes this trend and is positioning itself to be a leader in the market. Retail centers seem to be a promising untapped market outlet for their products. Although this may start a new trend that may be very beneficial for the insurance industry, it does have a downside for “health care consumers.”

Health plans in the individual market provide about 30 percent lower value than do plans in the employer-sponsored group market. The administrative costs are much higher because of marketing (advertising) costs, underwriting expenses, brokers fees, plan maintenance (individual billing), high attrition rates, and other expenses related to the fact that they are selling one individual policy at a time rather than marketing a single large package to an employer.

Another problem is that reasonably comprehensive plans have become very expensive. The average employer-sponsored plan is now over $4,500 for an individual and over $12,000 for a family. Many middle-income families can no longer afford these premiums, much less premiums adjusted upward by 30 percent because of the additional costs in the individual market.

When you shop at a retail outlet, you are looking for a good deal. In insurance, that means an affordable or even a bargain-rate premium. What kind of an insurance product will you be able to buy that has premiums well below the employer-sponsored plans, plus has protection reduced by another 30 percent to make up for the higher administrative costs? Whatever it is, if you develop significant medical problems, you’ll be at high risk of joining those insured individuals who filed for bankruptcy because of medical debt. (Medical debt is a major contributor to one-half of all personal bankruptcies, and three-fourths of those with medical debt were insured at the onset of their financial problems.)

Oh wait. What about the high overhead costs of operating a retail center? Subtract those costs as well from the benefits that your plan would cover. Whatever coverage you have left, don’t expect it to pay your medical bills.

Thankfully, there's an alternative to the AMA

By John Warner
Op-Ed
West Virginia Gazette
February 8, 2008

I HAVE written very critically of the American Medical Association, nor am I finished with my criticism. But I will report to you that there is light at the end of the tunnel. Not all physicians are enamored with the senior medical association. Today there is a younger organization, the Physicians for a National Health Program, comprising 14,000 physicians who support a plan for universal health care in America. It’s about time.

I HAVE written very critically of the American Medical Association, nor am I finished with my criticism. But I will report to you that there is light at the end of the tunnel. Not all physicians are enamored with the senior medical association. Today there is a younger organization, the Physicians for a National Health Program, comprising 14,000 physicians who support a plan for universal health care in America. It’s about time.

Let’s start with this. It is estimated that about 47 million Americans lack health insurance. That means they cannot cover trips to the doctor, prescriptions, dental or eye appointments. That means when they get sick, they just suck it up. Forty-seven million. Friends, that number is equal to 26 states the size of West Virginia. There is no explanation other than the severe opposition to universal health insurance provided by the American Medical Association and its Republican friends in Congress. That is a national shame.

The AMA has never campaigned for good health, although it has pretended to do so. Its stated interest throughout most of the 20th century has been such political ideals as “free enterprise” and “voluntary medicine.” The result has been a national disgrace.

The AMA has never attempted to look at medicine from the point of view of the consumer, those of us who need a doctor’s care. It has always seen medicine as a business and has argued only for good business, never good health care. What it did in the past is precisely what it is doing again in the current campaign for a new health system. The leopard does not change his spots. The result has been that we rank at the very bottom of the industrialized world in life expectancy and infant mortality.

The association has labeled all attempts at universal health care as “socialistic” and “compulsory.” Early in the Clinton administration, the president assigned his wife to redesign America’s health care. So opposed was the AMA to the plans Hillary was making that it plastered her work with bold-faced lies, telling us that under the Clinton plan we could no longer choose our own physicians, that those decisions would be made by bureaucrats in Washington, and that the AMA supported “voluntary” health care, not the “compulsory” system recommended by Bill and Hillary. That was a lie. Remember those television ads sponsored by the AMA, an attractive couple worried that they could no longer choose their own doctor? That was a lie.

In order to block health-care plans in the 1960s (Medicare and Medicaid) – and the work begun by Harry Truman before that – the AMA set up local committees of physicians to meet with their members of Congress and advise them against government-aided health care. They worked to defeat members of Congress who disagreed with them. They provided literature to be distributed in physicians’ offices warning patients against socialized medicine. They joined efforts with Readers’ Digest to flood physicians’ offices with propaganda. They provided leaflets to doctors’ wives, leaflets they could slip into every letter they mailed. Physicians put pressure on nurses in their offices to support AMA claims, while several nurses’ organizations actually supported government-supported insurance.

Here is one leaflet: “An important message from your doctor.” It claims that the Kennedy-Johnson plan would be “socialized medicine,” placing the government at your bedside, providing bureaucrats with confidential information about your health. It claims that “socialized medicine,” as practiced in European countries, was “a system which has resulted in the deterioration of medical care wherever it has been tried.”

“Working together,” the AMA argued in this doctors’ office literature, “we can preserve the high quality of health care now available in this country. Let’s keep politics out of medicine.”

What a frightful lie. American medical care is not better than our European friends’ care. Ask those 47 million Americans who live on the edge of disaster, who lack health coverage, for whom a health crisis means economic ruin.

Today, realizing that the health-care die is being cast and recognizing that the next Congress, a Democratic Congress, will pass new health-care legislation, the AMA has proposed what it calls the “Voice of the Uninsured.”

In August 2007, just last summer, AMA president-elect Nancy Nielson announced the new AMA health-care plan. “Under the AMA plan, the vast majority of Americans would have the means to purchase health-care coverage,” she said. “It would give individuals choices, so they can select the appropriate coverage for them and their families, and would promote market reform in the insurance industry.” Friends, that is a lie.

I said above that there is light at the end of the tunnel. The younger organization, Physicians for a National Health Program, denounced the claims made by Ms. Nielson, saying: “What the AMA isn’t saying is that its plan would steer about 47 million people into the health insurance industry’s most expensive form of coverage. And it would probably leave taxpayers holding the bag.”

“It’s a flawed plan because it’s the most expensive way that we could extend health coverage to everyone,” reports a representative for the Physicians for a National Health Program. Thank heavens for the PNHP. They are on our side.

Warner, professor emeritus at West Virginia Wesleyan College, is a Gazette contributing columnist. This is the last of three essays on medical care.

The New Bailout: Individual Health Insurance Mandates and Greater Personal Debt

Rose Ann DeMoro
The Huffington Post
Posted February 8, 2008 | 11:43 AM (EST)

Behind the escalating debate on the health care between Senators Hillary Clinton and Barack Obama on individual mandate — she’s for it, he’s against it — is a critical policy battle that not only cuts across health care reform but also the neo-liberal privatization dreams, the home mortgage crisis, and the recession that is no longer looming, it’s here.

Sound far-fetched? Take a closer look, starting with the millions of Americans staring at the loss of their homes due to the sub-prime loan debacle. It’s not a loan or a mortgage crisis for those families; it’s a debt crisis being forced upon them by the banks, hedge funds, and insurers who are desperate to shift their own mammoth debt onto someone else.

Banking, other financial institutions, insurance and real estate which make up the finance sector, now account for about half of U.S. corporate profits. And, they are in trouble with more than $2.5 trillion in outstanding consumer credit, $800 billion of that in credit card debt, and another $10.1 trillion in domestic mortgage debt.

Being thrifty won’t solve that problem. The financial planners have identified two lucrative pots of money. Trading carbon credits for industries and employers that want to brand themselves as green while continuing to pollute. And, making a killing in health care, currently 16 percent of our national economic pie and rapidly growing.

The banks are already into health care in a big way, serving as a repository for health savings accounts and other tax credit schemes so beloved by the Bush administration and the Republican presidential candidates. But the financiers would like more.

Enter the neo-liberal think tanks and policy wonks and plans they hawk to expand the reach of the market, especially the financial market, in health care. Central to that approach is shotgun insurance, forcing everyone not currently covered to buy health insurance policies.

Compelling people to buy insurance, however, is not the easiest sell. Big insurers and HMOs have a well deserved bad reputation for heartless denials of care – that’s how they make money. And, it’s pricey. Premiums the past decade have gone up 87 percent, not to mention the ever climbing bills for deductibles, co-pays, and a host of other transaction fees.

The finance industry is over the moon with this scheme.

For insurers, it means millions of new customers marched into their offices with the force of law. With no controls on costs, many consumers will just add on more debt. That’s a boon for the credit card companies and other financial institutions, but a heavy new burden on many of the same people now losing their homes or struggling with other financial hardship.

Moreover, it doesn’t work. The carrot is public subsidies for those least able to pay, but that approach has noticeable flaws, best evidenced in Massachusetts, the individual mandate pioneer and model.

As a result of the state’s failure to control premium hikes, costs of the subsidized program are projected to double over the next three years to $1.35 billion, the Boston Globe reported February 6, and Massachusetts is debating whether to slash the health services offered through the subsidized plans or cut payments to doctors and hospitals.

To shroud the colossal problems and the real story of who actually makes out like bandits under this scheme, the proponents, including some liberal policy experts, have dressed it up with poll-tested rhetoric that mandatory insurance is “universal health care.”

But “having” insurance is not the same as being able to use it. You’re only being mandated to purchase the premiums; they’re not mandating the insurance companies to make sure you get the care you need. Nor does “having” insurance protect you from financial ruin.

It accelerates the dismantling of group insurance plans with individuals forced to go it alone in the individual market, and institutionalizes risk and cost shifting on to the backs of individuals and families.

It distorts the role of government, which should be to protect people, not act as an insurance agent.

Finally, by expanding and entrenching the iron grip of the private insurance industry, it promotes the further privatization of health care, yet another crucial linchpin of the neo-liberal agenda.

Our health should not be a commodity, traded on the market like pork bellies or sold off to some hedge fund overseas to collect on medical bills we can not pay.

There’s only one way to achieve genuine universal health care, the approach taken by every other industrialized country with a national health care or single payer system.

In the U.S. that would look a lot like an expanded and improved Medicare for all. With guaranteed health care, not mandated insurance profits, and insurance companies out of the way. Surely, Americans deserve no less.

Clinton vs. Obama on Health Care — Interviews Available

STEFFIE WOOLHANDLER, M.D.,

QUENTIN YOUNG, M.D., via Todd Main, (312) 782-6006, (708) 738-7365, todd@pnhp.org, https://pnhp.org

Woolhandler is professor of medicine at Harvard University and a co-founder of Physicians for a National Health Program. She said today: “Hillary and Obama are both right. Hillary’s individual mandates would, as Obama charges, financially punish uninsured families. Obama’s plan contains no individual mandate, but would, as Hillary charges, fail to cover 15 million or more Americans. In Massachusetts, where the individual mandates’ high fines on the uninsured will not kick in until the end of the year, few of the state’s quarter million middle-income uninsured have yet purchased coverage.

“Hillary’s, Obama’s and Massachusetts’ mandate model health plans leave the private insurance industry in charge. Hence, the plans will continue to waste nearly one of every three health dollars on the overhead and paperwork that private insurers generate.

“Covering everyone in a non-profit single-payer national health insurance plan could cut health administrative costs in half, freeing up enough money to cover all of the uninsured with no increase in costs. Until politicians embrace the single payer model, they will have to choose between unaffordable costs (on one hand) or leaving millions of Americans uninsured (on the other) — a choice that is all the more bitter because it is completely unnecessary.”

Young, national coordinator of Physicians for a National Health Program, said today: “Any reform based on the private health industry will fail. Experience has proven that private insurers can neither control costs nor assure universal coverage; they are simply too bureaucratic and expensive. The administrative overhead in the current private-based system is 31 percent. Single-payer systems have overheads that are only about half that.”

ROSE ANN DeMORO, via Charles Idelson, (510) 273-2246, cell: (415) 559-8991, cidelson@calnurses.org, http://www.calnurses.org

DeMoro is executive director of the California Nurses Association. She said today: “Candidates need to hear that you cannot reform health care by selling insurance. Expanding the reach of the insurance industry — which is at the center of all the candidates’ plans — is not universal health care and it will not control costs.

“Sparks between Senators Clinton and Obama on individual mandate — she’s for it, he’s against it — reflect an important component of that problem. Forcing people to buy insurance, especially while insurers can continue to charge as much as they want and still deny needed medical care, further entrenches a broken system, and it’s not humane.

“Only one solution will solve our health care crisis, a genuine universal, single-payer system, such as expanding and improving Medicare to cover everyone.”

The California Nurses Association has produced a number of video segments focusing on several presidential candidates, available at: http://www.guaranteedhealthcare.org.

For more information, contact at the Institute for Public Accuracy: Sam Husseini, (202) 347-0020, (202) 421-6858; or David Zupan, (541) 484-9167

Thankfully, there’s an alternative to the AMA

By John Warner
Op-Ed
West Virginia Gazette
February 8, 2008

I HAVE written very critically of the American Medical Association, nor am I finished with my criticism. But I will report to you that there is light at the end of the tunnel. Not all physicians are enamored with the senior medical association. Today there is a younger organization, the Physicians for a National Health Program, comprising 14,000 physicians who support a plan for universal health care in America. It’s about time.

I HAVE written very critically of the American Medical Association, nor am I finished with my criticism. But I will report to you that there is light at the end of the tunnel. Not all physicians are enamored with the senior medical association. Today there is a younger organization, the Physicians for a National Health Program, comprising 14,000 physicians who support a plan for universal health care in America. It’s about time.

Let’s start with this. It is estimated that about 47 million Americans lack health insurance. That means they cannot cover trips to the doctor, prescriptions, dental or eye appointments. That means when they get sick, they just suck it up. Forty-seven million. Friends, that number is equal to 26 states the size of West Virginia. There is no explanation other than the severe opposition to universal health insurance provided by the American Medical Association and its Republican friends in Congress. That is a national shame.

The AMA has never campaigned for good health, although it has pretended to do so. Its stated interest throughout most of the 20th century has been such political ideals as “free enterprise” and “voluntary medicine.” The result has been a national disgrace.

The AMA has never attempted to look at medicine from the point of view of the consumer, those of us who need a doctor’s care. It has always seen medicine as a business and has argued only for good business, never good health care. What it did in the past is precisely what it is doing again in the current campaign for a new health system. The leopard does not change his spots. The result has been that we rank at the very bottom of the industrialized world in life expectancy and infant mortality.

The association has labeled all attempts at universal health care as “socialistic” and “compulsory.” Early in the Clinton administration, the president assigned his wife to redesign America’s health care. So opposed was the AMA to the plans Hillary was making that it plastered her work with bold-faced lies, telling us that under the Clinton plan we could no longer choose our own physicians, that those decisions would be made by bureaucrats in Washington, and that the AMA supported “voluntary” health care, not the “compulsory” system recommended by Bill and Hillary. That was a lie. Remember those television ads sponsored by the AMA, an attractive couple worried that they could no longer choose their own doctor? That was a lie.

In order to block health-care plans in the 1960s (Medicare and Medicaid) – and the work begun by Harry Truman before that – the AMA set up local committees of physicians to meet with their members of Congress and advise them against government-aided health care. They worked to defeat members of Congress who disagreed with them. They provided literature to be distributed in physicians’ offices warning patients against socialized medicine. They joined efforts with Readers’ Digest to flood physicians’ offices with propaganda. They provided leaflets to doctors’ wives, leaflets they could slip into every letter they mailed. Physicians put pressure on nurses in their offices to support AMA claims, while several nurses’ organizations actually supported government-supported insurance.

Here is one leaflet: “An important message from your doctor.” It claims that the Kennedy-Johnson plan would be “socialized medicine,” placing the government at your bedside, providing bureaucrats with confidential information about your health. It claims that “socialized medicine,” as practiced in European countries, was “a system which has resulted in the deterioration of medical care wherever it has been tried.”

“Working together,” the AMA argued in this doctors’ office literature, “we can preserve the high quality of health care now available in this country. Let’s keep politics out of medicine.”

What a frightful lie. American medical care is not better than our European friends’ care. Ask those 47 million Americans who live on the edge of disaster, who lack health coverage, for whom a health crisis means economic ruin.

Today, realizing that the health-care die is being cast and recognizing that the next Congress, a Democratic Congress, will pass new health-care legislation, the AMA has proposed what it calls the “Voice of the Uninsured.”

In August 2007, just last summer, AMA president-elect Nancy Nielson announced the new AMA health-care plan. “Under the AMA plan, the vast majority of Americans would have the means to purchase health-care coverage,” she said. “It would give individuals choices, so they can select the appropriate coverage for them and their families, and would promote market reform in the insurance industry.” Friends, that is a lie.

I said above that there is light at the end of the tunnel. The younger organization, Physicians for a National Health Program, denounced the claims made by Ms. Nielson, saying: “What the AMA isn’t saying is that its plan would steer about 47 million people into the health insurance industry’s most expensive form of coverage. And it would probably leave taxpayers holding the bag.”

“It’s a flawed plan because it’s the most expensive way that we could extend health coverage to everyone,” reports a representative for the Physicians for a National Health Program. Thank heavens for the PNHP. They are on our side.

Warner, professor emeritus at West Virginia Wesleyan College, is a Gazette contributing columnist. This is the last of three essays on medical care.

Kuttner on market-based failure

Market-Based Failure -- A Second Opinion on U.S. Health Care Costs

By Robert Kuttner
The New England Journal of Medicine
February 7, 2008

Relentless medical inflation has been attributed to many factors — the aging population, the proliferation of new technologies, poor diet and lack of exercise, the tendency of supply (physicians, hospitals, tests, pharmaceuticals, medical devices, and novel treatments) to generate its own demand, excessive litigation and defensive medicine, and tax-favored insurance coverage.

Here is a second opinion. Changing demographics and medical technology pose a cost challenge for every nation’s system, but ours is the outlier. The extreme failure of the United States to contain medical costs results primarily from our unique, pervasive commercialization. The dominance of for-profit insurance and pharmaceutical companies, a new wave of investor-owned specialty hospitals, and profit-maximizing behavior even by nonprofit players raise costs and distort resource allocation. Profits, billing, marketing, and the gratuitous costs of private bureaucracies siphon off $400 billion to $500 billion of the $2.1 trillion spent, but the more serious and less appreciated syndrome is the set of perverse incentives produced by commercial dominance of the system.

Markets are said to optimize efficiencies. But despite widespread belief that competition is the key to cost containment, medicine — with its third-party payers and its partly social mission — does not lend itself to market discipline. Why not?

The private insurance system’s main techniques for holding down costs are practicing risk selection, limiting the services covered, constraining payments to providers, and shifting costs to patients. But given the system’s fragmentation and perverse incentives, much cost-effective care is squeezed out, resources are increasingly allocated in response to profit opportunities rather than medical need, many attainable efficiencies are not achieved, unnecessary medical care is provided for profit, administrative expenses are high, and enormous sums are squandered in efforts to game the system. The result is a blend of overtreatment and undertreatment — and escalating costs. Researchers calculate that between one fifth and one third of medical outlays do nothing to improve health.

A comprehensive national system is far better positioned to match resources with needs — and not through the so-called rationing of care. (It is the U.S. system that has the most de facto rationing — high rates of uninsurance, exclusions for preexisting conditions, excessive deductibles and copayments, and shorter hospital stays and physician visits.) A universal system suffers far less of the feast-or-famine misallocation of resources driven by profit maximization. It also saves huge sums that our system wastes on administration, billing, marketing, profit, executive compensation, and risk selection. When the British National Health Service faced a shortage of primary care doctors, it adjusted pay schedules and added incentives for high-quality care, and the shortage diminished. Our commercialized system seems incapable of producing that result.

http://content.nejm.org/cgi/content/full/358/6/549

Comment:

By Don McCanne, MD

How many articles have you seen or speeches that you’ve heard begin with the premise that we must first eliminate the waste in our health care system before we can provide health care coverage for everyone?

In this article, Robert Kuttner has provided a concise summary of why those steps must be in reverse order. We will never be able to control the overtreatment , undertreatment, and escalating costs due to the pervasive commercialization of our health care system until we put in place a comprehensive, national, health care financing system.

What Government Does Better: Health Care

Howard A. Green, MD, FACP, FAAD, FACMS
Palm Beach County Medical Society

You’ll listen to me because I’m your doctor. I only have your health interests in mind.. I have written this article without ‘prior authorization’ from any insurance companies.

There are some intuitively obvious services that the government runs more productively and efficiently than private for-profit enterprises. For example, our armed forces and GI’s conquer and hold and protect territory more effectively and at a fraction of cost of private militias such as Blackwater USA and the Crescent Security Corporations. In addition, the government rules and regulations which our governments’ military adhere to insure an ethical cohesive fighting force compared to the unregulated for-profit corporate armies. Our GI soldiers assigned to kitchen duty prepare and cook meals at a fraction of the cost of identically prepared meals from the private for-profit logistics divisions of the Halliburton or Kellog Brown and Root Corporations. Government regulated public education in America such as the undergraduate and college systems of the City of New York and other large metropolises have for over a century produced more CEO’s, doctors, lawyers, accountants, engineers, chemists, poets, philosophers and military officers than any private school system, and at a fraction of the cost compared to all the private schools in the country combined. Take away the government grants, government tax breaks, and government sponsored free overseas labor from Americas top private Colleges and their classrooms and graduate programs would most likely shut down, no matter how large their private endowments. The government run and regulated public school systems of Israel, India and China are churning out competent engineers, scientists and entrepreneurs at a quality and rate much greater than that of any collection of private schools in any country in the world. These non-American people, highly educated by their government run school systems, have formed a new collective worldwide labor arbitrage system which is fueling the productivity of intercontinental private business. The Marshall Plan, Interstate Highways, Space Program, Peace Corps, and the GI Bill all demonstrate successful government run bureaucracies of their time.

In a similar fashion, our mammoth government-run health insurance company (Medicare) operates at a fraction of the cost of private insurance corporations such as Aetna, Cigna, United, Blue Shield Blue Cross, Kaiser Permanente and Humana. Medicare, the government health insurance for the elderly uses only 1-2% of your dollar to achieve rates of morbidity (sickness) and mortality (death) among their patients which are identical to those of the private health insurance corporations. However, private insurance corporate bureaucracies inefficiently siphon $350 billion per year, or 20-25% of your hard earned dollars away from doctors, hospitals and patient care into the pockets of their executives, administrative employees, shareholders and politicians. The recent stock option fraud perpetrated by the CEO of United Health Care demonstrates the negligent disdain the private insurance corporations have for physicians, hospitals, health care workers and patients. Since their founding 40 years ago, private health maintenance insurance corporations have failed to deliver what their business plans always promise; lower rates of morbidity and mortality associated with low costs to the patients. These insurance companies are financially profitable for their shareholders and executives, but medically bankrupt for their patients. Without their own massive government subsidies, government protection from malpractice lawsuits, and a government ban on collective bargaining by physicians the private health insurance corporate bureaucracies of Aetna, Cigna, United and Humana, and hundreds of other smaller health insurance companies of the health insurance industry would undoubted fail to exist. Most elderly people who call themselves Republicans, and conservative physicians in this Country have recognized the efficacy of our government regulated Medicare health insurance corporation and have enrolled themselves and utilized this Government run health insurance company for their own medical needs (despite the shrill cries of socialized medicine from their leaders). 40 years ago we heard these same shrill cries from organized medicine and Republicans concerning the establishment of Medicare. After accepting hundreds of billions of dollars in Medicare Insurance payments over the ensuing 4 decades, one can only wonder why conservative physicians still rally like Quixote against this government run insurance product.

The following 9 steps will simply suggest how, without the inefficiencies and burden to productivity of private insurance corporations, we can deliver efficient and effective comprehensive health care with great savings and no sacrifice of jobs. In fact, we may be able to decrease morbidity and mortality in this Country with one coordinated system which cares for all Americans, and concurrently analyzes optimal diagnoses and treatment modalities through its integrated computerized billing system. The savings incurred insuring all Americans through the more efficient Medicare system will benefit all citizens of our Country.

9 Steps to Comprehensive Quality Health Care in America

1) Shut down the private health insurance corporations.

2) Enroll all Americans (including Veterans) and the 40 million uninsured citizens into the Medicare Health Insurance Corporation. Since the current functioning Medicare Insurance Company is already accepted by almost all physicians, Hospitals and clinics in the Country, hardly any infrastructure investments on the health care delivery end will be necessary. Have all private businesses pay a Medicare premium for their employees instead of private health insurance premiums. Let employees as well as businesses contribute a fixed premium amount based on their age up until 65 for their Medicare services and drugs. Freeze current premiums for all Americans over 65 and adjust in the future according to the cost of living index. These premiums paid by businesses to Medicare for their employees should be less than that paid to current private insurance companies because of the lower overhead costs of the Medicare Corporation.

3) Hire the now unemployed former private health insurance corporate bureaucrats to actually deliver and not inhibit health care by working in hospitals, doctors’ offices, clinics and nursing homes around our Country. Demographically, the percentage of elderly Americans is rapidly increasing. With every American now insured through Universal Medicare Insurance, real health care workers will be in desperate need. For the first time in the brief but bloody history of managed care, these former private insurance corporation employees will actually touch and improve care for patients by working in physical therapy, nursing, home health care and other ancillary patient care capacities.

4) Obtain by eminent domain (for the public good) the best of the intellectual property protected computer codes which the closed private insurance businesses previously used to monitor patient care and doctors utilization and performance. Private health insurance companies have used these computer programs exclusively for the purpose of strong-arming their contracted health care providers into doing less for their patients and increasing the premium costs for sicker patients in order to achieve higher corporate profits. Medicare on the other hand can use these same computer programs for the common good; to monitor, collect data and eventually improve the efficacy of diagnoses and the treatment of diseases and medical outcomes every time a doctor submits a bill. For example, wouldn’t it be nice to know as a medical consumer (patient) which oncology groups in Boston, New York or Houston have the highest cure rates for stage III breast cancer or Stage II prostate cancer? All those numbers currently exist in cancer registries nation wide and just need to be collected and honestly disseminated. Currently, instead of solid medical data which delineates morbidity and mortality and performance, the medical consumer when choosing an oncologist must rely on word of mouth, physician referrals or advertisements in the local papers which show photographs of smiling doctors in white coats who claim to be the ‘best’ doctors in town. In addition to garnering invaluable instantaneous epidemiologic data on diagnoses and treatment of diseases based on severity and other variables, a strong Medicare based utilization review computer code would also allow Medicare to monitor doctors and hospitals who abuse a fee-for-service billing system. Any physician, institution or service found to abuse the Medicare fee for service billing system after proper review and appeal should be dealt with severely through stiff penalties and loss of their Universal Medicare provider contract.

5) Freeze Medicare physician, hospital and ancillary services reimbursements at current 2007-2008 levels. Adjust reimbursements for future services yearly by Cost of Living increases, or in the event of a deflationary economy a decreases in doctor and hospital payments. Ask any physician and they’ll tell you they would accept current reimbursement rates with COLA over the current mysterious illogical fee adjustment system of Medicare, or the physician population density reimbursement formula used by most private insurance corporations. Two tiered medical systems separating the “haves and have not’s” of society have and will always exist. Therefore, we must allow physicians to practice medicine without enrolling in or accepting the Universal Medicare reimbursement. With private medical insurance no longer available, and no performance based evidence for improved morbidity and mortality among their private for-pay patients, these extraordinarily expensive private ‘VIP’ practices will be limited.

6) Allow Medicare, much like the current Veterans Administration System and every private health insurance company and government health care system around the world, to bid on medications from pharmaceutical corporations for its Medicare drug formulary. Every physician recognizes that we don’t need a choice of a dozen redundant drugs in each pharmaceutical category. For example, we need only 2-3 statins for cholesterol, a handful of antibiotics for infections, 2 beta blockers for hypertension, and a few pain killers. Once the Government bids on pharmaceuticals for the Medicare Corporation formulary, macro economics will force prices to massively decrease to levels identical to that which all the other people of the world outside of America are paying for the same medicines. Since it has not effectively decreased morbidity or mortality in this Country, and only wastes money, we should also prohibit pharmaceutical companies and their workers from contributing to political campaigns or buying commercials on the public airways. We need to also prohibit the current practice whereby your local pharmacy and pharmacist sells your private medical diagnoses and your doctors private prescribing drug information to pharmaceutical companies so the pharmaceutical companies in-turn can directly pressure-market physicians. Prohibit pharmaceutical companies from contributing to organized medicine societies, colleges or associations because the doctors can’t rely on soft bribes or free lunches to prescribe what’s best for their patients. Prevent pharmaceutical representatives from visiting doctors’ offices or hospital pharmacies directly. Allow delivery of Medicare formulary approved sample medications for patients to physicians’ offices via post office mail only. Allow pharmaceutical companies to market products to physicians only via peer reviewed publications delivered by email or snail mail.

7) With the savings incurred from closing the private insurance corporations and paying less for drugs, have the American government fully fund the National Institutes of Health (NIH) and the National Cancer Institute (NCI) and Small Business Innovative Research (SBIR) programs. Emphasis should be placed on basic bench research carried out at not-for-profit American Institutions which employ or utilize a majority of American Citizens in their laboratories and clinics. Too often American Universities rely on free overseas labor to conduct bench research. Clinical trials should emphasize new drugs and devices which have promise to significantly decrease morbidity and mortality for any disease, including orphan diseases. Since a large percentage of private funding for drug and device studies will originate in the expanding financial liquidity and innovations and patients of the emerging developing world, we should allow the FDA to utilize research data obtained by reproduced laboratory and clinical studies performed overseas as well as in this Country.

Corruption of honest academics should be curtailed. Force all investigators to release reproduced publicly funded scientific data for all scientists to review on the internet via the Freedom of Information act (The Senator Shelby Amendment). Prohibit rights of first refusal on scientific data for private companies performing research in non-for profit institutions which receive public funding. Any rights to profits obtained from intellectual property and patents invented with combined funding from government and private sources should be split fairly among the contributing government institutions and any other private corporations funding the research, as well as with the individual inventor. Prevent organized medicine societies, associations or colleges from contributing to political campaigns since campaign donations have no relevance for physician performance or patient morbidity or mortality.

8) Offer physicians the same legal protection from malpractice lawsuits which have been established for commercial health insurance corporations during the last 3 decades.

9) The quality of current medical records software lags two decades behind business software. Therefore, we need to fund and challenge America’s best software corporations to finally develop standardized electronic medical records software for use in doctors’ offices and hospitals in order to increase the efficiency and productivity of physician charting, billing and prescribing. We should use the integrated medical records system to instantaneously and confidentially gather important epidemiologic data on physicians’ performance, patient diseases, and treatments. With new potent viruses and unsophisticated biomedical and nuclear warfare on the horizon, this system will be absolutely necessary for rapid National Security responses. Protect patient confidentiality at all costs to prevent the commercialization and abuse of patient data like that which the pharmacies trade today.

Lastly, some argue that Universal Government run health care in America will result in delays in diagnosis and treatment similar to those experienced in Britain and Canada. One can not simply compare the massive extremely functional Medicare insurance corporation based infrastructure which seamlessly delivers health care to tens of millions of people yearly in the USA to the government run westernized health care systems of Canada and Britain, France, Switzerland, Netherlands, Scandinavia, and Israel. America, for the last 40 years, thanks to the government run health insurance corporation-Medicare, has built an incredibly dense and fluid public insurance system involving almost all doctors’ offices, hospitals, clinics and ancillary services. The Medicare system dwarfs in breadth and actual practitioners and efficacy the lesser insurance systems established in all other countries. The billing and reimbursement bureaucracy for health care providers contracted with Medicare Insurance is already relatively streamlined and efficiently centralized in America thanks to 40 years of physician, hospitals and government cooperation.

We all know that the medically bankrupt private health insurance corporations and medical malpractice lawsuit threats have caused many disheartened physicians to quit practicing or downsize their practices in America. A continuation and technological upgrading of our most fair Universal Medicare based health insurance Corporation based on the concepts outlined above would undoubtedly motivate those disenfranchised physicians to return to the profession and bright younger physicians to invigorate the field. If patients, physicians and the Medicare Corporation continue to work together, without the deleterious interference of private for-profit health insurance corporations, malpractice threats and overt pharmaceutical marketing, the future for American health care will be healthy indeed.. A continuation of the status-quo mixture of a government subsidized private health maintenance insurance industry operating parallel to and within Medicare is wasteful, and will continue to provide no potential future health improvements for America.

Would Clinton sign a single-payer bill?

Posted by Marcella Bombardieri
Political Reporter
Boston Globe.com
February 6, 2008

NEW YORK — On a day that’s all about the horserace, we bring you an interesting tidbit about policy, specifically, health care, which has been one of the biggest issues in the Democratic race.

Both Democrats offer relatively moderate health care proposals that would give Americans choices about where to get their insurance. Hillary Clinton learned the hard way in the early 1990s that many Americans are squeamish about the idea of giving up choice to the government.

A “single-payer” plan, basically where the government runs health insurance, is usually considered politically untenable. In fact, at the South Carolina debate a couple weeks ago, Clinton charged Barack Obama with being inconsistent on, among other things, health care – by having flipflopped on single-payer. Obama denied having supported it, but in a 2003 speech, he said, “I happen to be a proponent of a single-payer health care program.”

But perhaps, in a different world, would Clinton agree?

In New Haven on Monday, a fourth-year Yale medical student named Liza Goldman approached us excitedly to report on a conversation she had with the New York Senator on the rope line.

According to Goldman, she told Clinton, “I’m sure you know that single-payer would save billions of dollars and thousands of lives.”

Clinton, Goldman says, responded in agreement but said, “It’s not politically feasible.”

So Goldman offered her a hypothetical: “Would you sign it if it came across your desk?”

“She said yes, and shook my hand,” Goldman said.

A Clinton spokesman did not get back to us about whether Clinton remembers the conversation the same way.

Note from PNHP – Liza Goldman is the daughter of Dr. Sarah Huertas-Goldman, chair of PNHP’s Puerto Rico chapter.

Market-Based Failure — A Second Opinion on U.S. Health Care Costs

By Robert Kuttner
The New England Journal of Medicine
Volume 358:549-551 / February 7, 2008 / Number 6
Perspective

U.S. health care expenditures rose 6.7% in 2006, the government recently reported. According to the Centers for Medicare and Medicaid Services, total health care expenditures exceeded $2.1 trillion, or more than $7,000 for every American man, woman, and child.1 Medicare costs jumped a record 18.7%, driven by the new privatized drug benefit. Total health care spending, now amounting to 16% of the gross domestic product, is projected to reach 20% in just 7 years.

Relentless medical inflation has been attributed to many factors — the aging population, the proliferation of new technologies, poor diet and lack of exercise, the tendency of supply (physicians, hospitals, tests, pharmaceuticals, medical devices, and novel treatments) to generate its own demand, excessive litigation and defensive medicine, and tax-favored insurance coverage.

Here is a second opinion. Changing demographics and medical technology pose a cost challenge for every nation’s system, but ours is the outlier. The extreme failure of the United States to contain medical costs results primarily from our unique, pervasive commercialization. The dominance of for-profit insurance and pharmaceutical companies, a new wave of investor-owned specialty hospitals, and profit-maximizing behavior even by nonprofit players raise costs and distort resource allocation. Profits, billing, marketing, and the gratuitous costs of private bureaucracies siphon off $400 billion to $500 billion of the $2.1 trillion spent, but the more serious and less appreciated syndrome is the set of perverse incentives produced by commercial dominance of the system.

Markets are said to optimize efficiencies. But despite widespread belief that competition is the key to cost containment, medicine — with its third-party payers and its partly social mission — does not lend itself to market discipline. Why not?

The private insurance system’s main techniques for holding down costs are practicing risk selection, limiting the services covered, constraining payments to providers, and shifting costs to patients. But given the system’s fragmentation and perverse incentives, much cost-effective care is squeezed out, resources are increasingly allocated in response to profit opportunities rather than medical need, many attainable efficiencies are not achieved, unnecessary medical care is provided for profit, administrative expenses are high, and enormous sums are squandered in efforts to game the system. The result is a blend of overtreatment and undertreatment — and escalating costs. Researchers calculate that between one fifth and one third of medical outlays do nothing to improve health.

Great health improvements can be achieved through basic public health measures and a population-based approach to wellness and medical care. But entrepreneurs do not prosper by providing these services, and those who need them most are the least likely to have insurance. Innumerable studies have shown that consistent application of standard protocols for conditions such as diabetes, asthma, and elevated cholesterol levels, use of clinically proven screenings such as annual mammograms, provision of childhood immunizations, and changes to diet and exercise can improve health and prevent larger outlays later on. Comprehensive, government-organized, universal health insurance systems are far better equipped to realize these efficiencies because everyone is covered and there are no incentives to pursue the most profitable treatments rather than those dictated by medical need. Although the populations of most countries that belong to the Organization for Economic Cooperation and Development are older than the U.S. population, these countries have been far more successful at containing costs without compromising care (see graph).


Health Care Expenditures in Selected Countries.
The growth rate of medical expenditures has been slowest in
nations with universal health insurance systems. Data are from
the Organization for Economic Cooperation and Development.
GDP denotes gross domestic product.

Many U.S. insurers do reward physicians for following standard clinical practices, but these incentives do not aggregate to an efficient national system of care. After more than three decades of managed care — and the same three decades of studies by Wennberg and colleagues identifying wide variations in practice patterns — consistent practices are still far from the norm.2 Commercial incentives are not fixing what’s broken.

Instead, cost-containment efforts have fallen heavily on primary care physicians, who have seen caseloads increase and net earnings stagnate or decline. A popular strategy among cost-containment consultants relies on the psychology of income targeting. The idea is that physicians have a mental picture of expected earnings — an income target. If the insurance plan squeezes their income by reducing payments per visit, doctors compensate by increasing their caseload and spending less time with each patient.

This false economy is a telling example of the myopia of commercialized managed care. It may save the plan money in the short run, but as any practicing physician can testify, the strategy has multiple self-defeating effects. A doctor’s most precious commodity is time — adequate time to review a chart, take a history, truly listen to a patient. You can’t do all that in 10 minutes. Harried primary care doctors are more likely to miss cues, make mistakes, and — ironically enough — order more tests to compensate for lack of hands-on assessment. They are also more likely to make more referrals to specialists for procedures they could perform more cost-effectively themselves, given adequate time and compensation. And the gap between generalist and specialist pay is widening.3

A second cost-containment tactic is to hike deductibles and copayments, whose frank purpose is to dissuade people from going to the doctor. But sometimes seeing the doctor is medically indicated, and waiting until conditions are dire costs the system far more money than it saves. Moreover, at some point during each year, more than 80 million Americans go without coverage, which makes them even less likely to seek preventive care.4

The system also has inflationary effects on hospitals’ revenue-maximization strategies. Large hospitals, which still have substantial bargaining power with insurers, necessarily cross-subsidize services. The emergency department may lose money, but cardiology makes a bundle. So hospitals fiercely defend their profit centers, investing heavily in facilities for lucrative procedures that will attract physicians and patients. For the system as a whole, it would be far more cost-effective to shift resources from subspecialists to primary care. But in an uncoordinated, commercialized system, specialists might take their business elsewhere, so they have the leverage to maintain their incomes and privileges — and thereby distort cost-effective resource allocation.

Defenders of commercialized health care contend that economic incentives work. And indeed they do — but often in perverse ways. The privately regulated medical market is signaling pressured physicians to behave more like entrepreneurs, inspiring some to defect to “boutique medicine,” in which well-to-do patients pay a premium, physicians maintain good incomes, and both get leisurely consultation time. It’s a convenient solution, but only for the very affluent and their doctors, and it increases overall medical outlays.

Other doctors opt out by becoming proprietors of specialty hospitals, usually day surgeries. In principle, it is cost-effective to shift many procedures to outpatient settings that are less expensive but still offer high-quality care. In a government-organized universal system, the cost savings can be usefully redirected elsewhere. But in our system, the savings go into the surgeons’ pockets, and their day hospitals often have a parasitic relationship with community hospitals, which retain the hardest cases and give up the remunerative procedures needed to subsidize those which lose money.

A comprehensive national system is far better positioned to match resources with needs — and not through the so-called rationing of care. (It is the U.S. system that has the most de facto rationing — high rates of uninsurance, exclusions for preexisting conditions, excessive deductibles and copayments, and shorter hospital stays and physician visits.) A universal system suffers far less of the feast-or-famine misallocation of resources driven by profit maximization. It also saves huge sums that our system wastes on administration, billing, marketing, profit, executive compensation, and risk selection. When the British National Health Service faced a shortage of primary care doctors, it adjusted pay schedules and added incentives for high-quality care, and the shortage diminished. Our commercialized system seems incapable of producing that result.

Despite our crisis of escalating costs, dwindling insurance coverage, and deteriorating conditions of medical practice, true national health insurance that would not rely on private insurers remains at the fringes of the national debate. This reality reflects the immense power of the insurance and pharmaceutical industries, the political fragmentation and ambivalence of the medical profession, the intimidation of politicians, and the erroneous media images of dissatisfied patients in universal systems.5

Sometimes, we Americans do the right thing only after having exhausted all other alternatives. It remains to be seen how much exhaustion the health care system will suffer before we turn to national health insurance.

No potential conflict of interest relevant to this article was reported.

Source Information

Mr. Kuttner is co-editor of the American Prospect and a senior fellow at Demos, a New York-based public policy research and advocacy organization.

References

1. Catlin A, Cowan C, Hartman M, Heffler S. National health spending in 2006: a year of change for prescription drugs. Health Aff (Millwood) 2008;27:14-29. [Free Full Text]

2. Wennberg JE, Gittlesohn A. Small area variations in health care delivery. Science 1973;182:1102-1108. [Free Full Text]

3. 2007 Medical Group Compensation and Financial Survey. Alexandria, VA: American Medical Group Association, 2007.

4. Going without health insurance: nearly one in three non-elderly Americans. Princeton, NJ: Robert Wood Johnson Foundation, March 2003.

5. Schoen C, Osborn R, Doty MM, Bishop M, Peugh J, Murukutla N. Toward higher-performance health systems: adults’ health care experiences in seven countries, 2007. Health Aff (Millwood) 2007;26:w717-w734. [Free Full Text]

More Fiscal Trouble Lies Ahead

by David Himmelstein, MD
WBUR.org
Thursday, February 7th, 2008

Last week the news leaked out from the Patrick administration that public spending for the health reform plan in the coming fiscal year will be about $400 million over the original projections. This follows a $146 million cost overrun in the current year.

Why are such miscalculations the norm? Are the costs of health reform unknowable? Or did politicians (and the media) listen only to the “experts” who told them what they wanted to hear?

As I wrote here several months ago, the Census Bureau has been saying for years that there were far more uninsured in Massachusetts than state leaders cared to admit. But politicians and the economists who advised them stuck to their guns. It turns out the Census Bureau was right. The result is that many more people are eligible for the subsidized coverage than the legislature or governor planned for. And, by the way, the demand for free care from safety-net hospitals and clinics is not dropping as fast as projected, again a result of undercounting the uninsured and ignoring the large number of immigrants who are mostly ineligible for insurance under the reform.

Of course, the economic advisors also underestimated the impact of rising medical costs, taken in by claims that that the “Quality and Cost Control Council” would rein in costs, and that the computerized health records and improved prevention touted in the bill would save money. I laughed those off last May in this space.

(By the way, the same health economist who advised the legislature as it was drawing up the original budget, recently told a real whopper in the letters section of the Boston Globe — claiming that a single payer reform “would cost many multiples of the current Massachusetts reform effort.” He chose to ignore the reams of evidence that single payer would save vast sums on bureaucracy and profits. Indeed, the CBO, the GAO, and even the Lewin Group, a consulting firm which is owned by a health insurer, have all projected that single payer would cover everyone without any increase in total costs).

Unfortunately, any reasonable forecast sees more fiscal trouble ahead for Massachusetts’ health reform. The $400 million overrun estimated for the coming year doesn’t account for the recession that looks to be headed our way. If we’re lucky, it’ll be no worse than the fairly mild downturn in 2001-2003. Back then, the number of working age people who didn’t have jobs climbed by 167,000, and the number of uninsured rose by 168,000 — presumably including many of those who lost jobs, as well as some of their dependents. So a modest downturn is likely to swell the ranks of the low-income uninsured by about 165,000 — adding perhaps $400 to $600 million to the bill for public subsidies.

So as we plan for the next year or two, let’s factor in the real costs that lie ahead, not the fantasy projections politicians would like to believe. If those realistic cost estimates look unsustainable, then lets get ready to talk about a reform that we can afford — like a single payer program.

David Himmelstein is an associate professor of medicine at Harvard Medical School and Co-founder of Physicians for a National Health Program