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Can anyone (any viable candidate, that is) say ‘single-payer?’

Can anyone (any viable candidate, that is) say ‘single-payer?’

By BRAD WARTHEN
Editorial Page Editor
The State
Posted on Sun, Dec. 09, 2007

CAN ANYONE among those with a chance of becoming president say “single-payer?” If not, forget about serious reform of the way we pay for health care.

It doesn’t even necessarily have to be “single-payer.” Any other words will do, as long as the plan they describe is equally bold, practical, understandable, and goes as far in uprooting our current impractical, wasteful and insanely complex “system.”

And the operative word is “bold.” Why? Because unless we start the conversation there, all we might hope for is that a few more of the one out of seven Americans who don’t have insurance will be in the “system” with the rest of us — if that, after the inevitable watering-down by Congress. And that’s not “reform.” Actual reform would rescue all of us from a “system” that neither American workers nor American employers can afford to keep propping up.

But the operative word to describe the health care plans put forward by the major, viable candidates is “timid.”

“Single-payer” is definitely not that — at least, not within an American context. Seen from the perspective of most advanced nations — which accept medical care as just another part of a nation’s infrastructure, like roads and post offices — it’s no big deal.

Not here, though — not by a long shot. Here, we have too many people preprogrammed to go ballistic at the mention of “single-payer.” That’s because of the identity of that payer.

It’s… well, it’s the government!

This column will now take a short break while libertarians run around shrieking until they turn blue and fall over… da-da-dum-dum, hmmm… readers might want to go look at the Sunday comics until we resume… da-dee-da-dahhh… Still screaming, so let’s get another cup of coffee… Ah, that’s good stuff…

OK, we’re back, and they’re still screaming, but we’ll just have to accept that they’re going to do that, and proceed.

“Government,” in America, is a word that we use for a free people banding together to do something that we can do far better working together than working separately. Some people don’t accept that fact. They seem to believe that “government” is some scary thing that intrudes on their lives from out there somewhere, like a spaceship full of aliens with ray guns that will turn us all into toads or something.

Those people are one of the two big reasons why you don’t hear any presidential candidates saying “single-payer” except Dennis Kucinich. You may recall recent reports that Mr. Kucinich had a close encounter with a UFO, and it was a positive experience, so I guess he’s just not scared of the aliens any more.

But the major candidates are. Or rather, they’re scared of being labeled as extremists. Also, they don’t want to offend the health insurance companies whose reason for being would disappear under “single-payer.”

Last week, I got a press release from a labor union that complained “that no Republican candidate has a plan to ensure all Americans have access to health care.” That’s true. But the union, which represents blue- and pink-collar workers in health care, was missing the fact that the leading Democrats are little better.

“Sens. Hillary Clinton and Barack Obama have been engaged in a bitter back-and-forth over whose health plan covers more people,” The Wall Street Journal reported last week. “Former Sen. John Edwards has jumped in, saying his plan is the best of all.”

But what they’re fighting over are plans that would pull varying numbers of the uninsured into the same overly expensive, wasteful, maddening system of private health insurance that the rest of us are caught in. Conveniently, they say their plans would be paid for by repealing the “Bush tax cuts for the wealthy.”

Maybe you could pay for a health plan that way — as long as it doesn’t provide real reform.

Make no mistake: A single-payer national health plan would cost a lot of money, and you would pay for it in new taxes. The good news is that most of us would probably still pay less than we currently pay in premiums.

According to the Web site of Physicians for a National Health Program, which promotes single-payer, “This is because private insurance bureaucracy and paperwork consume one-third (31 percent) of every health care dollar. Streamlining payment through a single nonprofit payer would save more than $350 billion per year, enough to provide comprehensive, high-quality coverage for all Americans.”

But when not even touchy-feely liberal Democrats have the guts to say it’s worth paying a new tax to make health care affordable for all, even when that’s the hottest domestic issue among voters (which would not be the case if the insured majority were happy), we’re in trouble.

Little wonder that Dow Jones’ MarketWatch reported last week that “Those who hope the 2008 presidential election will finally bring about drastic health-care reform may well end up finding it’s a case of politics and business as usual, experts say.” The same article noted that Hillary Clinton has received $1.8 million in contributions from accident and health insurers, followed by Barack Obama with $1.45 million, Mitt Romney with $1.09 million and Rudy Giuliani with $1.08 million.

That, by the way, is money that you and I and the guy down the street paid for health care that didn’t go to health care.

Given the odds against substantive reform — between the government haters, the insurance industry and Big Pharma, all of whom have a demonstrated willingness to outlast the rest of us in any protracted political fight — the only way we’re going to see significant change is if a president is elected with a mandate for bold reform. Only a president is elected by the whole nation, so only a president would ever have that kind of juice.

Unfortunately, as previously noted, none of the viable candidates will say “single-payer.”

But I will: Single-payer. Single-payer, single-payer! Now, do you have anything better to say?

Anthem's bare-bones plan for employers

Anthem rolls out bare-bones health plan

By Daniel Lee
The Indianapolis Star
November 29, 2007

Anthem Blue Cross and Blue Shield on Wednesday unveiled a bare-bones health insurance plan designed for employers struggling to offer benefits to their workers because of the rising cost of premiums.

The new plan, called Blue Access Hospital Surgical PPO, provides “catastrophic” coverage for most hospitalizations and surgeries, as well as limited coverage for doctor visits and other services, according to Anthem, a subsidiary of Indianapolis health-insurance giant WellPoint.

“It’s another option for employers who otherwise might be forced to cut back or eliminate health coverage altogether because of budgetary constraints,” said Robert W. Hillman, president of Anthem Blue Cross and Blue Shield in Indiana, in a statement.

Deductibles — or out-of-pocket costs before any coverage starts — range from $1,000 to $5,000 for a single person and $3,000 to $15,000 for a family.

After the deductible is met, a patient would be responsible for a $20 co-pay, plus 50 percent of the total charge for an outpatient doctor visit, according to Anthem. An emergency-room visit requires a $150 co-pay plus 20 percent of the total charge.

http://www.indystar.com/apps/pbcs.dll/article?AID=/20071129/BUSINESS/711290426/-1/LOCAL17

Comment:

By Don McCanne, MD

Although the numbers of uninsured continue to rise, the fastest growing problem in health care financing is underinsurance. In an effort to make health insurance premiums affordable, plans are shifting more of the costs to patients, making health care access unaffordable for many.

Catastrophic underinsurance plans have been much more common in the individual market where most individuals have faced directly the problem of paying in full the insurance premiums. They are faced with a choice of purchasing inadequate plans with premiums they can afford, or having no coverage at all since premiums for comprehensive plans are no longer affordable for average-income individuals.

Employers have been shifting to underinsurace much more gradually by nudging up the cost-sharing requirements for their employees. But that is about to change. Many employers have been struggling with the rising costs of their health benefit programs, and some have discontinued coverage. Now, Wellpoint’s Anthem, by offering Blue Access Hospital Surgical PPO, has provided employers with the opportunity to continue to offer their employees coverage, albeit bare-bones coverage.

As the private insurance industry continues to expand their offering of innovative insurance products, more and more people with health care needs will find that health care access will come with a heavy dose of financial hardship. But isn’t that what the private insurers are supposed to prevent?

New CDC Report: The Nail in the Coffin for Health Care Myths

Niko Karvounis
Health Beat Blog (www.healthbeatblog.org)
December 05, 2007

On Monday the CDC released a landmark, and in many ways devastating, report on health care in the U.S. The report contains a wealth of data that, while not surprising to some, should help silence the dwindling few who insist that America’s health care system is doing just fine. As a public service, I thought it’d be helpful to list some of the myths that the report demolishes (with some help from other sources as needed).

Myth: If people don’t have health insurance or get medical care, it’s because they don’t want it.

Reality: Actually, the big issue with access is cost. According to the CDC report, more than 40 million Americans–almost one in five Americans over the age of 18–have foregone one of the following in the past year because they couldn’t afford it: medical care, prescription medicines, mental health care, dental care, or eyeglasses.

It’s not that uninsured people don’t understand the value of coverage. Last year a study from the Urban Institute found that less than 3 percent of uninsured adults and children have never had insurance or report having no need for insurance. That same report also found that the high cost of coverage alone explained over 50 percent of those cases where people are uninsured

And even when the uninsured cite job-related difficulties as the reason why they can’t access employer sponsored coverage, the problem isn’t just that they can’t get it through work–it’s also that they can’t afford individual policies. (Individual policies are much more expensive than group policies, and in many states private insurers can charge individuals astronomical premiums if individuals have any “pre-existing conditions.) According to the Urban Institute, for 79 percent of adults and 74 percent of children who are uninsured because of job-related problems, the high cost of individual insurance is a major problem.

Myth: The American system relies mostly, if not exclusively, on private enterprise to support health care.

Reality: Yes and no. While the U.S. does have the biggest private sector share of health expenditures in the world, making up 55 percent of our funding, personal health care expenditures (i.e. spending on actual patient care) is mostly public. The CDC reports that in 2005 the federal government and state and local governments combined paid 45 percent of personal health care expenditures; private insurers only paid 36 percent, with 15 percent coming from out-of-pocket payments. So much for the libertarian utopia.

There’s also a bigger public sector coverage presence than many would like to admit. Though two-thirds of insurance policyholders have private coverage, a Census bureau report from earlier this year noted that more than one quarter of Americans (about 27 percent) are covered by government insurance. The American model is much more of a private-public mix than some pundits–and candidates–are willing to admit.

Myth: East coast liberals and the urban poor are the only ones who want a stronger public sector in health care.

Reality: Health care reform is often stigmatized as being something that only socialist, bleeding hearts dream of…But in fact, one particular area that could greatly benefit from a more proactive public sector is Middle America.

The CDC report notes that 4 percent of counties across the nation have no physicians. None. And more than 90 percent of these physician-less counties are non-metropolitan, i.e. do not contain a town of at least 10,000 people. In fact, across the nation only 9 percent of all of the nonfederal patient care physicians in the U.S. are located in these rural counties.

These sparsely populated locales are pretty much where you’d expect them to be: the Plains states and the Southwest (think Texas, the Dakotas, Oklahoma, Alaska)–home to many good old fashioned middle Americans. Initiatives to connect patients in these regions with physicians have come from the government, not the private sector. The FCC, for example, has just selected North Carolina as the first U.S. region to get a grant under the Rural Health Care Pilot Program–a $400 million initiative–to let patients in rural North Carolina connect with the nation’s top doctors over the Internet. The pilot program is meant to provide “underserved communities with a broadband telemedicine network in 42 states and three U.S. territories.”

While this isn’t comprehensive, system-wide health care reform, it is leveraging the public sector to make care more accessible to isolated populations. And as much as critics tend to suggest that rogue liberals are the only ones who want reform, there are plenty of conservative folks across the nation who could benefit from a revitalized public sector making care accessible to regions where the medical market is non-existent. Beefing up the public sector role in our health care system isn’t an insidious big government strategy perpetrated by elites or welfare queens–it’s a way to get health care to the conservative base.

Myth: America has the most and best medical technology of any country in the world, and by God we should use it!

Reality: While the U.S. does rank high in terms of MRI and CT scanners per population relative to most other nations, (27 and 32 units per one million population respectively) our title as most technological heath care system is no sure thing. Japan knocks us out of the park with 40 MRI units and 93 CT scanners per one million people, the most in the world. And, as the CDC report notes, Austria comes close with 29 CT scanners per population and South Korea meets us at 32.

Of course, medical technology is not a game of oneupmanship–and even if it were, this might be one competition we would be better off losing. On November 29, the New England Journal of Medicine published a report from Columbia University’s Center for Radiological Research that raises some big concerns about over-reliance on CT scanners.

“It is estimated that more than 62 million CT scans per year are currently obtained in the United States, including at least 4 million for children,” the report begins, before noting that “CT involves larger radiation doses than the more common, conventional x-ray imaging procedures.” Big doses of radiation are rarely good for the human body, and since the U.S. has become so scan-happy, “it has been estimated that about 0.4 percent of all cancers in the United States [from 1991 to 1996] may be attributable to the radiation from CT studies.” Scale these numbers up for our more frequent CT use today, and “this estimate might now be in the range of 1.5 to 2.0 percent.”

Sure, CT scans do a world of good–so long as we’re giving them to the right people. But “if it is true that about one third of all CT scans are not justified by medical need, and it appears to be likely, perhaps 20 million adults and, crucially, more than 1 million children per year in the United States are being irradiated unnecessarily.” Even if we do someday claim the throne as most technology-rich health care system in the world, the mad rush to use technology just because we have it holds hidden dangers.

So there you have it–a few hard–to-shake myths, some of which are already on their last legs, have been dealt yet another crippling blow by that little thing we call reality.

Anthem’s bare-bones plan for employers

Anthem rolls out bare-bones health plan

By Daniel Lee
The Indianapolis Star
November 29, 2007

Anthem Blue Cross and Blue Shield on Wednesday unveiled a bare-bones health insurance plan designed for employers struggling to offer benefits to their workers because of the rising cost of premiums.

The new plan, called Blue Access Hospital Surgical PPO, provides “catastrophic” coverage for most hospitalizations and surgeries, as well as limited coverage for doctor visits and other services, according to Anthem, a subsidiary of Indianapolis health-insurance giant WellPoint.

“It’s another option for employers who otherwise might be forced to cut back or eliminate health coverage altogether because of budgetary constraints,” said Robert W. Hillman, president of Anthem Blue Cross and Blue Shield in Indiana, in a statement.

Deductibles — or out-of-pocket costs before any coverage starts — range from $1,000 to $5,000 for a single person and $3,000 to $15,000 for a family.

After the deductible is met, a patient would be responsible for a $20 co-pay, plus 50 percent of the total charge for an outpatient doctor visit, according to Anthem. An emergency-room visit requires a $150 co-pay plus 20 percent of the total charge.

http://www.indystar.com/apps/pbcs.dll/article?AID=/20071129/BUSINESS/711290426/-1/LOCAL17

Comment:

By Don McCanne, MD

Although the numbers of uninsured continue to rise, the fastest growing problem in health care financing is underinsurance. In an effort to make health insurance premiums affordable, plans are shifting more of the costs to patients, making health care access unaffordable for many.

Catastrophic underinsurance plans have been much more common in the individual market where most individuals have faced directly the problem of paying in full the insurance premiums. They are faced with a choice of purchasing inadequate plans with premiums they can afford, or having no coverage at all since premiums for comprehensive plans are no longer affordable for average-income individuals.

Employers have been shifting to underinsurace much more gradually by nudging up the cost-sharing requirements for their employees. But that is about to change. Many employers have been struggling with the rising costs of their health benefit programs, and some have discontinued coverage. Now, Wellpoint’s Anthem, by offering Blue Access Hospital Surgical PPO, has provided employers with the opportunity to continue to offer their employees coverage, albeit bare-bones coverage.

As the private insurance industry continues to expand their offering of innovative insurance products, more and more people with health care needs will find that health care access will come with a heavy dose of financial hardship. But isn’t that what the private insurers are supposed to prevent?

Maine's policy lesson to the U.S. – update

Leading the Way? Maine's Initial Experience in Expanding Coverage through Dirigo Health Reforms

By Debra J. Lipson, James M. Verdier, and Lynn Quincy
The Commonwealth Fund
Mathematica Policy Research, Inc.
December, 2007

Since enacting comprehensive health care reform in 2003, Maine’s Dirigo Health program has helped expand coverage for low- and moderate-income individuals. By September 2006, about 16,100 individuals were enrolled in two coverage initiatives: DirigoChoice, a subsidized insurance product, and a Medicaid eligibility expansion for low-income parents of dependent children. While these programs are making health coverage more affordable to low-income individuals, small firms, and sole proprietors, with subsidies targeting those most in need, by late 2006, the initiatives had enrolled less than 10 percent of previously uninsured residents.

http://www.commonwealthfund.org/usr_doc/Lipson_leadingthewayMaineexpDirigo_1079.pdf?section=4039

Quote of the Day, June 14, 2003, predicting failure:
https://pnhp.org/news/2003/june/maine_succeeds_in_ad.php

Comment:

By Don McCanne, MD

Today’s lesson: Most of the nation’s leading politicians who claim that their proposals will achieve health care coverage for everyone are being dishonest with us. Worse, their positions are being supported by highly respected, presumably credible members of the policy community. Politics is displacing policy science in the national discourse on reform.

Effective health policies are not based on measures that we wish would achieve our goals of universality, comprehensiveness, quality, access, equity, efficiency and affordability. Rather they are based on principles well established within the discipline of health policy science.

Let me explain, using the example of Maine.

In 2003, Maine rejected single payer reform, but passed Dirigo Health claiming that it would achieve, within five years, the same goal as single payer, but without being disruptive to the current system. Well, it certainly has not been disruptive in that 90 percent of the uninsured are still without coverage.

For political reasons, Maine substituted for single payer a series of wish-they-would-work policies. The impact of those policies were completely predictable. In fact, if you read the Quote of the Day for June 14, 2003 (link above), the failure was fully predicted – not on guesswork or hunches, but on fundamental principles of health policy science.

Current efforts in other states to achieve universal coverage will not be mentioned here other than to state that all proposals that are not single payer are doomed to fall far short on our goals of reform because they are based on wish-they-would-work policies which have already been demonstrated to fail the tests of health policy science.

Because we are in another window wherein reform is possible, we need to look at the leading proposal which is most likely to be adopted, possibly as early as 2009. This is the proposal of the leading Democratic candidates. They contend that their model of a market of private health plans, with a competing public, Medicare-like program, would achieve all of the goals listed above. Again, the politicians and their policy advisors are using wish-they-would-work policies rather than the fundamentals of health policy science.

Let’s suppose their proposal passed in 2009. What would our health care system look like five years later, in 2014? Those with greater health care needs being left out by our current system would flood to the public program. Adverse selection would cause premiums to skyrocket resulting in a death spiral as everyone would bail out since they couldn’t possibly afford the premiums. Health care costs would continue to escalate due to a lack of effective cost containment measures. That would cause a further decline in private coverage, even with an individual mandate since individuals cannot pay premiums for which they simply lack the funds necessary. To try to make coverage more affordable, underinsurance would become the standard, but then financial barriers to actual health care would increase, further impairing access.

With this proposal, the politicians promise us universality, yet many more would be without coverage. They promise us comprehensive coverage, yet the majority of the plans would be stripped of benefits to slow the rise in the cost of insurance premiums. They promise us quality, yet an underfunded delivery system weighted down with charity care, would lack the resources to identify and correct quality deficiencies. They promise us access, yet they would fail to provide the most important first step to ensure access – comprehensive insurance coverage for everyone. They promise us equity, yet they would destroy what little equity we already have by ensuring that only the wealthy could access all of the care they need. They promise us efficiency, yet they reject the single payer model that would bring us that efficiency. And they promise us affordability, yet combined insurance and health care costs would be much worse for individuals, but, ironically, health care cost increases might well begin to slow for society as a whole. How? Health care would become so unaffordable for individuals that they would begin to relinquish care that merely maintains or improves quality of life, and access only life saving services.

Supporting a private insurance industry that thrives by keeping us away from care, and backing that industry up with a bankrupt public program creates an absolute guarantee for failure.

We know that many politicians distort and lie to get elected. But shame on their policy advisors. Reinforcing distortions and lies for political purposes compromises the ethics of their profession.

Instead of supporting wish-they-would-work policies, let’s support effective, proven policies based on the foundations of health policy science. If we really want to achieve these stated goals of reform, let’s enact a single payer national health program. A truly rational system of financing health care would move us a long way toward these goals.

Silencing nurses endangers patients' care

Louisville Courier-Journal
Readers’ forum
Monday, December 3, 2007

The results of the studies have been released and they prove what every hospital nurse knows from experience. Understaffing endangers patients.

For each additional patient assigned to an RN, the likelihood of death within 30 days increases by 7 percent. Four additional patients increase the risk by 31 percent (JAMA, 10/22/02).

In 1989 Louisville nurses formed the Nurses Professional Organization with the goal of organizing their union so that they could win better staffing and conditions for their patients and themselves.

The nurses took on the giants of corporate health care. Staff nurses stood their ground before high salaried CEOs, anti-union consultants, and supervisors who, under threat themselves, threatened the jobs and licenses of nurses who continued to speak up. Nurses threw themselves into the struggle with hope. The hospitals hired consultants to spread fear.

By committing mountains of unlawful actions, Norton Healthcare as well as Columbia/HCA blocked the nurses’ efforts. But these powerful corporations did not violate the law unchallenged. In almost every case in which the NPO filed charges against the hospitals, the nurses won. NPO nurses have exposed the understaffing, testified on patient care issues in Frankfort, won back the jobs of nurses unjustly dismissed, called in the state inspectors, testified before the JCAHO, spoken to the press, and kept alive the hope that staff nurses can organize and make things better. Bruised but never broken, the NPO has now won another victory. The turtle’s pace of labor law enforcement in our nation allows employers to delay interminably. First Columbia/HCA, and then Norton Healthcare, stalled the progress for the 13 years since the 1994 election at Audubon. In August, the NLRB turned down Norton Audubon’s appeal of one of NPO’s cases.

In November, Norton Audubon paid over $171,000 to three nurses who were unlawfully denied positions. Nurses at Audubon and in Louisville now have a new opportunity to organize and to win the right to practice under truly professional conditions.

The Nurses Professional Organization has affiliated with the California Nurses Association/National Nurses Organizing Committee. This 75,000 strong organization has empowered nurses to win the best contracts and the best patient protections in the nation. CNA staff nurses used their power to advocate for patients. Now they have minimum staffing ratios in hospitals that are enforceable — written into both California law and into union contracts. No more than five patients per nurse on a medical/surgical floor. No more than two patients per nurse in Intensive or Critical Care. No more than four patients on a step down unit — advancing to no more than three in 2008. No more than four patients per nurse in ER; no more than 2 ICU patients per nurse in the ER — no more than one ER Trauma patient. No more than five patients per nurse in telemetry moving to no more than four in 2008. In addition, nurses must be increased above these ratios whenever acuity levels require. Plus the ratios apply on all shifts at all times including during lunch and breaks. (www.calnurses.org) Nurse power makes a difference.

Bringing good conditions to patients and nurses ends the nursing shortage. Actively licensed RNs in California increased by more than 60,000 following enactment of the staffing ratio law. Since the ratio law was signed, actively licensed RNs have grown by nearly 10,000 a year, compared to just 3,200 a year prior to the law. (Board of Registered Nursing data).

We cannot solve the nursing “shortage” in Louisville without solving the conditions that force good nurses from the bedside and from their chosen profession. Many can’t sleep after their 12-hour shifts for thinking about what almost happened and what could happen. The lack of organized nurse power to change these conditions and win truly professional standards of care and benefits has stifled health care progress in Louisville.

When Norton Healthcare, called Alliant at the time, purchased Audubon Hospital, there was an NLRB bargaining order in place. Norton Audubon didn’t sit down and bargain with the nurses. Instead Norton Healthcare spent our community’s health care dollars on a nine year oppositional path of challenges to NLRB orders and to nurses’ rights.

Among Norton Healthcare’s numerous unfair labor practices are: unlawful discipline for protected activity, unlawful termination, unlawful denial of a position, unlawful restriction of the right to distribute literature in the cafeteria and non-work areas, unlawful restriction of the right of a nurse to speak about the union in the break room, unlawful institution of a more restrictive distribution policy in response to a union campaign, unlawful attack on a nurse’s license, and unlawful interrogation.

The NLRB overturned the unfair election at Audubon Hospital and has ordered a new election. Audubon nurses are talking and organizing and will move forward to advocate for their patients and to build their union. Nurses across Louisville are once again hopeful. When nurses organize, the patients and the community are the beneficiaries. Silencing nurses endangers patients.  

KAY TILLOW

Director of Organization

Nurses Professional Organization/CNA/NNOC

Louisville 40202

Insurance access must improve

By Mary Ann Garnar
OP-ED
Special to The Courier-Journal
Monday, December 3, 2007

Most thoughtful people in the United States recognize that the difficulties of obtaining health insurance — with the resulting lack of access to quality medical care — must be remedied.

Advances in the field of medicine, dazzling new diagnostic tools, the ever-increasing range of procedures and the proliferation of new and better drugs have driven the cost of medical care beyond the reach of far too many people of even average means, if they lack health insurance.

At the same time, health insurance premiums continue to rise to unconscionable levels, in large part to satisfy stockholders’ demands for higher and higher profits, to the point that purchase of health insurance is an impossibility for millions.

Those of us with insurance take for granted our routine medical examinations, blood work, X-rays, inoculations, etc. If we have the flu, we don’t hesitate to see the doctor, who prescribes the needed medicine and off we go to the pharmacy, hardly giving a thought to the actual cost of it all. We spend a few days recovering and then return to work.
If the gall bladder goes bad, we are not troubled beyond anxiety about the actual surgery. We yield to the surgeon’s knife, spend a day or two in the hospital being looked after by doctors, nurses and attendants, and don’t worry too much about the co-pay.

But there are millions of people whose asthma, aching joints, chest pains and even more serious ailments go untreated because they lack health insurance. Critical diagnostic procedures are missed because they cannot afford to pay the doctor. Drugs are not bought. The consequences can, and often do, escalate into something more difficult and more costly to treat.

Allowing this crisis to continue is morally and economically indefensible. Because of damage to the health, finances and dignity of people affected, and to the larger economy, we must find a solution — and find it soon.

People of conscience are earnestly trying to sort through the many plans being proposed to correct the inequities in order to determine which plan will provide a remedy that is both affordable and covers the cost of needed medical care. And they are beginning to understand that the solution must not be piecemeal; it must be one which guarantees insurance for everyone. No one can be left out.

Most people now agree that government must be a part of any solution.

A realistic and honest assessment of the proposals leads to the inevitable conclusion that the best solution for the greatest number is what is called universal, single-payer health insurance. That is, health insurance for all residents of the United States, largely funded with a tax based on income, and benefits paid out by the federal government. (A bill now in Congress, HR 676, the United States National Health Insurance Act, if passed, would establish just such a plan.)

Single-payer insurance is the most efficient use of available health care resources because there is no profit motive and administrative waste is eliminated. Medicare, the model for a universal, single payer system, spends only 3 cents of every dollar paid into the system on administrative expenses. Fully 97 cents on the dollar is spent on patients’ medical bills. Private insurance companies and health maintenance organizations (HMOs), on the other hand, spend 20-30 cents on the dollar for administrative costs and only 70-80 cents for patient care.

Single-payer insurance is not “socialized medicine.” Those who now have private insurance would receive the same medical care from the same doctors, dentists, psychiatrists, hospitals, etc., as they do now. Those currently without insurance would have their medical needs met. And the joy of it is that, for most people, their costs would be less than the costs of their private insurance, because the unnecessary costs of the private health insurance industry would be removed.

Opponents’ claims to the contrary, we can afford to do this.

No new government program will be free of problems. But people of goodwill will be prepared to give such a program a chance to work.

We cannot continue to allow people to go without medical care because they cannot afford to pay the doctor or buy insurance. And we must not treat inability to pay as a moral failure.

The moral failure would be to allow the crisis to continue.

Mary Ann Garnar lives in Louisville and is a retired attorney. She is a 2007 Forum Fellow.

Socialized Medicine Belittled on Campaign Trail

by Julie Rovner
NPR Morning Edition
December 6, 2007

Click here to listen to the story.

In the debate over health care on the campaign trail, the term “socialized medicine” is getting thrown around more and more often.

It is almost never a compliment. But the politically loaded phrase means different things to different people.

For example, when Democratic Sen. Hillary Clinton unveiled her health plan in September, it included a requirement that all individuals have health insurance.

Republican rival Mitt Romney labeled the plan “socialized medicine” in his critique. “It’s a European-style socialized medicine plan,” he said. “That’s where it leads, and that’s the wrong direction for America.”

Romney’s fellow Republican candidate Rudolph Giuliani extends that label to all of the Democratic front-runners’ plans, even though Sen. Barack Obama’s wouldn’t require everyone to be insured.

“Whether it’s HillaryCare or ObamaCare or EdwardsCare, the idea that it’s not socialized medicine is a trick,” Giuliani said. “It’s a massive growth of government control of medicine.”

History of Term

But what is socialized medicine?

“The term socialized medicine, technically, to most health policy analysts, actually doesn’t mean anything at all,” says Jonathan Oberlander, a professor of health policy at the University of North Carolina.

Oberlander says the phrase actually dates back to the American Medical Association’s fights against national health insurance in the early decades of the 1900s.

“The AMA used it to mean any kind of proposal that involved an increased role for the government in the health care system,” he says. “They also used it to mean things in the private system that they didn’t like. So, at one point, HMOs were a form of socialized medicine.”

In terms of government programs, Oberlander says it was used against Medicare in the 1960s, and prenatal care in the 1920s and 1930s. “It really is a term that is very flexible, and because it means nothing precisely, you can define everything by it.”

These days, there is one potentially accurate use of the phrase, Oberlander says. It can be used to make the distinction between a so-called single-payer health care system — where the government pays all the health care bills — and a truly government-operated health system, he says.

Term’s Definition

“When you talk about Europe, and you talk about a British system where the hospitals are owned by the government and the doctors are directly employed by the government, then you might say that’s socialized medicine,” Oberlander says.

But that is different from what most single-payer proposals would do. “There, you would essentially have government financing, just like you do with Medicare, but you would continue to have private practicing physicians and private hospitals,” Oberlander says.

None of the leading Democratic candidates, however, has proposed anything like a single-payer system, much less a fully government-run program like Britain’s National Health Service.

One candidate, Rep. Dennis Kucinich, does support the leading single-payer proposal in Congress. But that bill would also give the federal government authority to determine the number and location of health facilities. So, it would go quite a bit further than other single-payer systems like Medicare in the U.S., or even like Canada’s system.

In a forum with health reporters earlier this fall, Kucinich was asked directly if that meant what he supports wasn’t more like England’s government-operated system than Canada’s single-payer plan.

“Is it like the U.K.’s? Somewhat similar. And it’s similar in form to many of the industrial democracies of the world where they provide health care to their people,” Kucinich responded.

Curbing Medicare Advantage Overpayments Would Strengthen Medicare

Center on Budget and Public Policies
December 5, 2007

This week, the Senate Finance Committee is planning to consider Medicare legislation averting a scheduled cut in Medicare physician payments. The legislation is also expected to modestly reduce the sizable overpayments now being made to private insurance plans that participate in the Medicare Advantage program. (In July, the House voted to fully eliminate these overpayments as part of legislation to strengthen Medicare and children’s health coverage.) “Leveling the playing field” in payments between Medicare Advantage and traditional Medicare would be a sound move for Congress to take before its year-end recess, for several reasons:

* The government pays Medicare Advantage plans roughly $1,000 more per beneficiary per year than it would cost to cover the same person through traditional Medicare. Even though private plans were brought into Medicare to lower costs, the Medicare Payment Advisory Commission (“MedPAC,” Congress’ expert advisory body on Medicare payment policy) and the Congressional Budget Office (CBO) have found that they are paid 12 percent more, on average, than it would cost traditional Medicare to cover the same beneficiaries. These overpayments currently average about $1,000 per beneficiary, according to The Commonwealth Fund. Moreover, CBO says the average overpayment will likely rise in the future because Medicare Advantage enrollment is growing fastest in the areas with the highest overpayments.

* These overpayments significantly weaken Medicare’s finances. The overpayments will total $54 billion over the next five years and $149 billion over ten years, according to CBO. That puts an added strain on Medicare, moving up by two years (from 2021 to 2019) the date when its trust fund will become insolvent, according to the chief actuary at the Centers for Medicare and Medicaid Services (CMS). It also means restoring solvency will require much larger benefit cuts and/or tax increases than would otherwise be needed; as MedPAC chairman Glenn Hackbarth warned Congress, Medicare faces “a very clear and imminent risk from this overpayment that will put this country in an untenable position.” Similarly, CBO director Peter Orszag has testified that if current trends in Medicare Advantage continue, “the result would be a fundamental change in the nature of the Medicare system that may then be hard to reverse.”

* The overpayments also force beneficiaries in traditional Medicare to pay higher premiums. According to both MedPAC and CMS’s chief actuary, the overpayments raised the premiums for Part B of traditional Medicare (which includes physician visits and other types of outpatient care) by $2 per month per person, or $48 a year for a couple, in 2007. This means that the 35 million seniors and people with disabilities enrolled in traditional Medicare are charged higher premiums every month in order to help subsidize overpayments for private plans that serve approximately 8 million beneficiaries. (For about 7 million of these 35 million beneficiaries — low-income people whose premiums are paid by Medicaid — the added costs are borne by the federal government and the states, which jointly fund Medicaid.)

* Medicare Advantage plans do not have to provide all the benefits available through traditional Medicare — and many do not. While the plans use part of their overpayments to offer services that Medicare otherwise does not cover or to reduce premiums and costsharing (the rest goes to administrative costs, marketing, and profits), some of the private plans have scaled back benefits available through traditional Medicare that are used primarily by sicker individuals, evidently to deter sicker people from enrolling. As a result, some beneficiaries in poorer health can wind up significantly worse off if they enroll in Medicare Advantage. Analyses by the Medicare Rights Center, The Commonwealth Fund, the Kaiser Family Foundation, and MedPAC all have found that Medicare Advantage beneficiaries who need hospital care, home health care, or another specialty service may have to pay more for it — or may receive less of it — under the private plans. Even CMS has acknowledged this problem. CMS recently stated it will scrutinize cost-sharing levels among the private plans for services such as physician-administered chemotherapy drugs and dialysis services.

* The private plans have not been shown to provide better care. Some plans have sought to justify their overpayments as promoting better quality of care. The lack of suitable measures makes it hard to compare the quality of care in Medicare Advantage and traditional Medicare, but MedPAC reports that their levels of beneficiary satisfaction are similar, and people in traditional Medicare are less likely to report problems seeing specialists. MedPAC has also found that more Medicare Advantage plans are reporting poor health outcomes and that the plans are failing to keep pace with commercial and Medicaid plans in improving quality of care. In addition, CBO has stated that “though Medicare Advantage plans cost more than care under [traditional Medicare] does, on average, they would be more cost-effective if they delivered a sufficiently higher quality of care. The limited [quality] measures available suggest that Medicare Advantage plans are not more cost-effective” than traditional Medicare.

* The overpayments have contributed to the marketing abuses committed by some Medicare Advantage plans. Over the past year, numerous media reports and several congressional hearings have documented a pattern of misleading and abusive marketing practices by some insurance agents, who seek to lure Medicare beneficiaries into Medicare Advantage plans without explaining how they differ from traditional Medicare. In one recent survey, 37 of the 43 states responding reported complaints about inappropriate or confusing marketing practices. The overpayments encourage such abuses by giving private plans a significant incentive to maximize their enrollment; many private plans have established lucrative financial inducements for agents who sign up new enrollees. In sum, by reducing wasteful private plan overpayments, Congress can strengthen Medicare and better serve the millions of seniors and people with disabilities who rely on it for health coverage.

http://www.cbpp.org/12-5-07health.pdf

Maine’s policy lesson to the U.S. – update

Leading the Way? Maine’s Initial Experience in Expanding Coverage through Dirigo Health Reforms

By Debra J. Lipson, James M. Verdier, and Lynn Quincy
The Commonwealth Fund
Mathematica Policy Research, Inc.
December, 2007

Since enacting comprehensive health care reform in 2003, Maine’s Dirigo Health program has helped expand coverage for low- and moderate-income individuals. By September 2006, about 16,100 individuals were enrolled in two coverage initiatives: DirigoChoice, a subsidized insurance product, and a Medicaid eligibility expansion for low-income parents of dependent children. While these programs are making health coverage more affordable to low-income individuals, small firms, and sole proprietors, with subsidies targeting those most in need, by late 2006, the initiatives had enrolled less than 10 percent of previously uninsured residents.

http://www.commonwealthfund.org/usr_doc/Lipson_leadingthewayMaineexpDirigo_1079.pdf?section=4039

Quote of the Day, June 14, 2003, predicting failure:
https://www.pnhp.org/news/2003/june/maine_succeeds_in_ad.php

Comment:

By Don McCanne, MD

Today’s lesson: Most of the nation’s leading politicians who claim that their proposals will achieve health care coverage for everyone are being dishonest with us. Worse, their positions are being supported by highly respected, presumably credible members of the policy community. Politics is displacing policy science in the national discourse on reform.

Effective health policies are not based on measures that we wish would achieve our goals of universality, comprehensiveness, quality, access, equity, efficiency and affordability. Rather they are based on principles well established within the discipline of health policy science.

Let me explain, using the example of Maine.

In 2003, Maine rejected single payer reform, but passed Dirigo Health claiming that it would achieve, within five years, the same goal as single payer, but without being disruptive to the current system. Well, it certainly has not been disruptive in that 90 percent of the uninsured are still without coverage.

For political reasons, Maine substituted for single payer a series of wish-they-would-work policies. The impact of those policies were completely predictable. In fact, if you read the Quote of the Day for June 14, 2003 (link above), the failure was fully predicted – not on guesswork or hunches, but on fundamental principles of health policy science.

Current efforts in other states to achieve universal coverage will not be mentioned here other than to state that all proposals that are not single payer are doomed to fall far short on our goals of reform because they are based on wish-they-would-work policies which have already been demonstrated to fail the tests of health policy science.

Because we are in another window wherein reform is possible, we need to look at the leading proposal which is most likely to be adopted, possibly as early as 2009. This is the proposal of the leading Democratic candidates. They contend that their model of a market of private health plans, with a competing public, Medicare-like program, would achieve all of the goals listed above. Again, the politicians and their policy advisors are using wish-they-would-work policies rather than the fundamentals of health policy science.

Let’s suppose their proposal passed in 2009. What would our health care system look like five years later, in 2014? Those with greater health care needs being left out by our current system would flood to the public program. Adverse selection would cause premiums to skyrocket resulting in a death spiral as everyone would bail out since they couldn’t possibly afford the premiums. Health care costs would continue to escalate due to a lack of effective cost containment measures. That would cause a further decline in private coverage, even with an individual mandate since individuals cannot pay premiums for which they simply lack the funds necessary. To try to make coverage more affordable, underinsurance would become the standard, but then financial barriers to actual health care would increase, further impairing access.

With this proposal, the politicians promise us universality, yet many more would be without coverage. They promise us comprehensive coverage, yet the majority of the plans would be stripped of benefits to slow the rise in the cost of insurance premiums. They promise us quality, yet an underfunded delivery system weighted down with charity care, would lack the resources to identify and correct quality deficiencies. They promise us access, yet they would fail to provide the most important first step to ensure access – comprehensive insurance coverage for everyone. They promise us equity, yet they would destroy what little equity we already have by ensuring that only the wealthy could access all of the care they need. They promise us efficiency, yet they reject the single payer model that would bring us that efficiency. And they promise us affordability, yet combined insurance and health care costs would be much worse for individuals, but, ironically, health care cost increases might well begin to slow for society as a whole. How? Health care would become so unaffordable for individuals that they would begin to relinquish care that merely maintains or improves quality of life, and access only life saving services.

Supporting a private insurance industry that thrives by keeping us away from care, and backing that industry up with a bankrupt public program creates an absolute guarantee for failure.

We know that many politicians distort and lie to get elected. But shame on their policy advisors. Reinforcing distortions and lies for political purposes compromises the ethics of their profession.

Instead of supporting wish-they-would-work policies, let’s support effective, proven policies based on the foundations of health policy science. If we really want to achieve these stated goals of reform, let’s enact a single payer national health program. A truly rational system of financing health care would move us a long way toward these goals.

Silencing nurses endangers patients’ care

Louisville Courier-Journal
Readers’ forum
Monday, December 3, 2007

The results of the studies have been released and they prove what every hospital nurse knows from experience. Understaffing endangers patients.

For each additional patient assigned to an RN, the likelihood of death within 30 days increases by 7 percent. Four additional patients increase the risk by 31 percent (JAMA, 10/22/02).

In 1989 Louisville nurses formed the Nurses Professional Organization with the goal of organizing their union so that they could win better staffing and conditions for their patients and themselves.

The nurses took on the giants of corporate health care. Staff nurses stood their ground before high salaried CEOs, anti-union consultants, and supervisors who, under threat themselves, threatened the jobs and licenses of nurses who continued to speak up. Nurses threw themselves into the struggle with hope. The hospitals hired consultants to spread fear.

By committing mountains of unlawful actions, Norton Healthcare as well as Columbia/HCA blocked the nurses’ efforts. But these powerful corporations did not violate the law unchallenged. In almost every case in which the NPO filed charges against the hospitals, the nurses won. NPO nurses have exposed the understaffing, testified on patient care issues in Frankfort, won back the jobs of nurses unjustly dismissed, called in the state inspectors, testified before the JCAHO, spoken to the press, and kept alive the hope that staff nurses can organize and make things better. Bruised but never broken, the NPO has now won another victory. The turtle’s pace of labor law enforcement in our nation allows employers to delay interminably. First Columbia/HCA, and then Norton Healthcare, stalled the progress for the 13 years since the 1994 election at Audubon. In August, the NLRB turned down Norton Audubon’s appeal of one of NPO’s cases.

In November, Norton Audubon paid over $171,000 to three nurses who were unlawfully denied positions. Nurses at Audubon and in Louisville now have a new opportunity to organize and to win the right to practice under truly professional conditions.

The Nurses Professional Organization has affiliated with the California Nurses Association/National Nurses Organizing Committee. This 75,000 strong organization has empowered nurses to win the best contracts and the best patient protections in the nation. CNA staff nurses used their power to advocate for patients. Now they have minimum staffing ratios in hospitals that are enforceable — written into both California law and into union contracts. No more than five patients per nurse on a medical/surgical floor. No more than two patients per nurse in Intensive or Critical Care. No more than four patients on a step down unit — advancing to no more than three in 2008. No more than four patients per nurse in ER; no more than 2 ICU patients per nurse in the ER — no more than one ER Trauma patient. No more than five patients per nurse in telemetry moving to no more than four in 2008. In addition, nurses must be increased above these ratios whenever acuity levels require. Plus the ratios apply on all shifts at all times including during lunch and breaks. (www.calnurses.org) Nurse power makes a difference.

Bringing good conditions to patients and nurses ends the nursing shortage. Actively licensed RNs in California increased by more than 60,000 following enactment of the staffing ratio law. Since the ratio law was signed, actively licensed RNs have grown by nearly 10,000 a year, compared to just 3,200 a year prior to the law. (Board of Registered Nursing data).

We cannot solve the nursing “shortage” in Louisville without solving the conditions that force good nurses from the bedside and from their chosen profession. Many can’t sleep after their 12-hour shifts for thinking about what almost happened and what could happen. The lack of organized nurse power to change these conditions and win truly professional standards of care and benefits has stifled health care progress in Louisville.

When Norton Healthcare, called Alliant at the time, purchased Audubon Hospital, there was an NLRB bargaining order in place. Norton Audubon didn’t sit down and bargain with the nurses. Instead Norton Healthcare spent our community’s health care dollars on a nine year oppositional path of challenges to NLRB orders and to nurses’ rights.

Among Norton Healthcare’s numerous unfair labor practices are: unlawful discipline for protected activity, unlawful termination, unlawful denial of a position, unlawful restriction of the right to distribute literature in the cafeteria and non-work areas, unlawful restriction of the right of a nurse to speak about the union in the break room, unlawful institution of a more restrictive distribution policy in response to a union campaign, unlawful attack on a nurse’s license, and unlawful interrogation.

The NLRB overturned the unfair election at Audubon Hospital and has ordered a new election. Audubon nurses are talking and organizing and will move forward to advocate for their patients and to build their union. Nurses across Louisville are once again hopeful. When nurses organize, the patients and the community are the beneficiaries. Silencing nurses endangers patients.  

KAY TILLOW

Director of Organization

Nurses Professional Organization/CNA/NNOC

Louisville 40202

The Presidential Candidates on Health Care

Farhana Hossain
The New York Times

Presidential candidates in both parties are promising to overhaul the nation’s health care system and cover more – if not all – of the nation’s uninsured. In 2005, 44.8 million people – 15.3 percent of the population – were without health insurance, according to estimates released by the Census Bureau in March. The leading Democrats are competing among themselves over who has the better plan to control costs and approach universal coverage. The Republicans, for the most part, are promising to expand coverage without increasing the role of the federal government, and reduce cost through tax incentives. Most of the candidates have not presented a detailed outline of their health care plans, but here is what they have said so far.

Read Len Rodberg’s Critique of the mainstream Democratic candidates’ proposals for universal health care.

Read Dr. Don McCanne’s Quote of the Day Comment on Sen. Hillary Clinton’s Health reform proposal.

Joseph R. Biden Jr.
Democrat

PROPOSAL TO EXPAND COVERAGE

IMMEDIATELY INSURE EVERYONE UNDER 18
“I would move immediately to insure all children under age 18, modernize medical records and provide catastrophic health insurance to lift the burden on the 46 million people who can’t afford coverage.”
— Las Vegas Sun, March 23, 2007

WORK WITH STATES TO MOVE TOWARDS UNIVERSAL COVERAGE
“I think the thing that will get us to total health coverage – health insurance for everybody the quickest – is to do what we did on welfare reform. What we did was we allowed the states considerable flexibility and leeway in reorganizing the system and we underwrote the cost of the poor states in doing it to get work programs going. Do the same exact thing with health care. You have a dozen states, including big ones, that are now passing legislation requiring universal insurance, just like liability insurance. Once you get to a critical mass of 30 to 35 states, you’ve established a national consensus. Cherry-pick those elements of the plans. Maybe even give them localized flavor rather than one simple standard that exists that require that there be total complete coverage across the board.”
— In New Hampshire, April 14, 2007

PAYING FOR ADDITIONAL COSTS

END WAR IN IRAQ; ROLL BACK PRESIDENT BUSH‘S TAX CUTS FOR THE HIGHEST EARNERS
“The first two things we could do and we could do it without having to fundamentally change anything other than the president’s unneeded tax cut for people making an average of $1.43 million dollars a year in the top one percent.”
— In Nevada, April 2007

“Eliminate the break for investment on dividends, which is $195 billion. For $26 billion a year, I can insure every single solitary child under the age of 18 in the United States. You need start-up dollars. The place I’d start off with is somewhere over $220 billion a year by the tax cuts and ending the war.”
— On NBC’s “Meet the Press,” April 2007

Hillary Rodham Clinton
Democrat

PROPOSAL TO EXPAND COVERAGE

REQUIRE EVERYONE TO GET INSURANCE, SUBSIDIZED BY EMPLOYERS AND THE GOVERNMENT
“I call my plan, the American Health Choices plan. … If you have private insurance you like, nothing changes … you can keep that insurance. … If, however, you don’t have health insurance or you don’t like the insurance you have, you can choose from the same wide variety of private plans that members of Congress choose from. … You will have access to a public plan that will provide a stable, competitive alternative to private insurance if that is your choice.”

“While I will be requiring all Americans to have health care, I will be calling on employers to do their part as well. … Under my plan, large companies will be required to help pay for their employees’ health care. Those that do so can simply maintain their current policy that they choose. Those that don’t, will need to contribute towards the cost of covering their employees on a sliding scale based on their size and average wages. … We won’t require small businesses to cover employees. Instead we will provide tax credits to ensure that many of them do. … The government will provide tax-credits to insure that every single American can afford health insurance.”
— In Des Moines, Sept. 17, 2007

PAYING FOR ADDITIONAL COSTS

ROLL BACK PRESIDENT BUSH‘S TAX CUTS FOR PEOPLE EARNING OVER $250,000 AND BY SAVINGS IN THE EXISTING HEALTH CARE SYSTEM
“I won’t pay for it by pouring money into a broken system. I won’t pay for it by raising taxes on middle class families who are already struggling with rising costs and stagnant wages. Instead, I’ll pay for part of it by implementing the cost saving measures I outlined in May. And I will pay for some of it by rolling back part of President Bush’s fiscally irresponsible tax breaks for the highest income Americans. And I’ll pay for some of it by limiting the tax breaks for people making over $250,000 a year to the same level that ordinary, middle class Americans get.”
— In Des Moines, Sept. 17, 2007

HAS OUTLINED A SEVEN-POINT PLAN TO CONTROL COST
– Ensure better preventative care
– Modernize record-keeping
– Streamline care for the chronically ill
– Create large insurance pools
– Start a “Best Practices Institute” to finance research
– Control prescription drug costs
– Revise medical malpractice system
— At George Washington University, May 24, 2007

Chris Dodd
Democrat

PROPOSAL TO EXPAND COVERAGE

HAS PLEDGED
UNIVERSAL HEALTH CARE, SUBSIDIZED BY EMPLOYERS AND THE GOVERNMENT
“Everyone participates, everyone benefits. All the stakeholders — individuals, employers, the government — are involved in coming up with a system here that would make it possible to reduce those numbers of 47 million of our fellow citizens who have no health care to make sure they’ll be included.
– Second is prevention alone. Minimum we try to do is see to it to reduce the cost by stopping people from getting ill in the first place.
– Thirdly is building upon the good things we’ve done already: Forty years of Medicaid and Medicare. I would extend Medicaid to poorer families, 100 percent of poverty; the ones with children, 300 percent of poverty.
– Last is the fourth principle, dealing with technology. Some $80 or $90 billion could be saved, not to mention the morbidity rates by doing a far better job and utilizing the technology that exists today.”
— Presidential Forum on Health Care, March 27, 2007

PAYING FOR ADDITIONAL COSTS

END WAR IN IRAQ; ROLL BACK PRESIDENT BUSH‘S TAX CUTS FOR THE HIGHEST EARNERS
“If you get rid of these permanent tax cuts to the top one percent of income earners, get the war ended in Iraq that we’re spending $2 million a week, $8 million a month, we can provide the resources to really move in this direction. So I would make it a top priority in my administration. I wouldn’t want to put a time frame on it because I think it’s too important, but for us to get there as soon as possible.”
— Presidential Forum on Health Care, March 27, 2007

John Edwards
Democrat

PROPOSAL TO EXPAND COVERAGE

REQUIRE EVERYONE TO GET INSURANCE, SUBSIDIZED BY EMPLOYERS AND THE GOVERNMENT
“What we’re going to do is cover every single American, including the 47 million who don’t have coverage. We’re going to bring down costs for everybody. And for most Americans, we’re going to help them pay the cost. It’s based on a concept of shared responsibility. In the case of employers, we’re going to ask them to do more to either insure all their employees or to contribute to their being insured. The government will help subsidize the health care and create health care markets so we have more competition and deal with issues like preventative care, mental health care, to make sure those kind of things — chronic care — are, in fact, being done. And then, finally, for individuals, we’re going to make sure they have insurance. They have to have insurance so that everybody has health insurance.”
— On NBC’s “Meet the Press,” Feb. 4, 2007

PAYING FOR ADDITIONAL COSTS

ROLL BACK PRESIDENT BUSH‘S TAX CUTS FOR THE HIGHEST EARNERS
“The tax cuts that George Bush gave to people who make over $200,000 a year will have to go away to pay for my health care plan. My universal health care plan costs 90- to $120 billion a year. I do not believe, having spent a lot of time on this, that you can achieve universal health care without—without finding a revenue source, and that’s my revenue source.”
— Face the Nation, Feb.25, 2007

Mike Gravel
Democrat

PROPOSAL TO EXPAND COVERAGE

ISSUE VOUCHERS TO EVERYONE BASED ON THEIR PROJECTED NEEDS
“Under the plan we would issue vouchers to every single American. And the vouchers, you don’t pay for them, they’re issued to you. You sign up every year for them. And the vouchers will have a very modest co-pay, a very modest deductible, but that’s it. Everybody gets the same product universally in the United States of America. And then if you want more than the product you got, you pay for it.
The vouchers are set up for risk on an individual basis, not on a collective this fits all, because if you’re young, you probably don’t have a cost of more than $3,000. When you’re my age, it could be $150,000-$180,000 in one year. One of the facets of the plan would be to keep in place Medicare and Medicaid and phase them out over time. Because plans to put everybody on Medicare aren’t going to fly financially and just can’t be met.”
— Presidential Forum on Health Care, March 24, 2007

PAYING FOR ADDITIONAL COSTS

FEDERAL GOVERNMENT WITH TAXPAYER‘S MONEY; CONTROL COST BY MODERNIZING RECORDS
“All Americans pay for it regardless of the system you have now but the system you’re going to get, single-payer Health Care Voucher plan. There’s no magic in this whole process. Somebody is going to pay. You know who pays, it’s the average American, one way or the other, particularly under our present system. And so to want to trash the business community and trash our tax system, which is already corrupt, with greater corruption as a way to solve the problem is a nonstarter. The way the plan is designed, it won’t raise costs, because the 30 percent that they’re talking about is paper cost. If you took that and put it into some real costs in health care, we’d cover everybody without raising any costs.”
— Presidential Forum on Health Care, March 24, 2007

Dennis Kucinich
Democrat

PROPOSAL TO EXPAND COVERAGE

ESTABLISH MEDICARE FOR ALL
“A not-for-profit health care system is not only possible, but H.R. 676, a bill that I introduced, and a number of Congressmen, the Conyers-Kucinich bill, actually establishes Medicare for all, a single-payer system and it’s a not-for-profit system. It’s time we ended this thought that health care is a privilege. It is a basic right, and it’s time to end this control that insurance companies have not only over health care but over our political system. I’m talking about a real deal for the American people, a universal single-payer not-for-profit Medicare for all.”
— Presidential Forum on Health Care, March 24, 2007

PAYING FOR ADDITIONAL COSTS

REMOVE COSTS RELATED TO PRIVATE INSURERS
“At least 30% of the $3.2 trillion spent annually for health care in the United States goes to the for-profit system, while 50 million Americans, many of them working, are without health insurance. About $660 billion goes for corporate profits, executive salaries, stock options, advertising, marketing, and the cost of paperwork. If we took all that money and we put it into a public health system, a national health care plan, we would have enough money to cover everything for everyone.”
— House floor, July 12, 2006

IMPLEMENT TAXES FOR THE HIGHEST EARNERS AND A PAYROLL TAX
“B). Increasing personal income taxes on the top 5 percent income earners.
C). Instituting a modest and progressive excise tax on payroll and self-employment income.
D). Instituting a small tax on stock and bond transactions.”
— H.R. 676

Barack Obama
Democrat

PROPOSAL TO EXPAND COVERAGE

REQUIRE CHILDREN TO GET INSURANCE; AIMS FOR UNIVERSAL COVERAGE
“The main disagreement with John [Edwards] and I is John believes that we have to have mandatory insurance for everyone in order to have universal health care. My belief is that most families want health care but they can’t afford it. And so my emphasis is on driving down the costs, taking on the insurance companies, making sure that they are limited in the ability to extract profits and deny coverage — that we make sure the drug companies have to do what’s right by their patients instead of simply hoarding their profits. If we do those things then I believe that we can drive down the costs for families. In fact, we’ve got very conservative, credible estimates that say we can save families that do have health insurance about a thousand dollars a year, and we can also make sure that we provide coverage for everybody else. And we do provide mandatory health care for children.”
— CNN debate for Democratic candidates, June 3, 2007

PAYING FOR ADDITIONAL COSTS

ROLL BACK PRESIDENT BUSH‘S TAX CUTS FOR PEOPLE EARNING OVER $250,000
To help pay for all this, we will ask all but the smallest businesses who don’t make a meaningful contribution today to the health care coverage of their employees to do so by supporting this new plan. And we’ll also allow the temporary Bush tax cuts for the wealthiest Americans to expire.
— University of Iowa, May 29, 2007

Bill Richardson
Democrat

PROPOSAL TO EXPAND COVERAGE

REQUIRE EVERYONE TO GET INSURANCE, SUBSIDIZED BY EMPLOYERS AND THE GOVERNMENT
“No. 1, my plan is mandatory. You do have everybody sharing — the employer, the employee, you have the state and the federal government. Secondly, I believe that we can have a plan where if you were satisfied with your health care plan, you can keep it. No new bureaucracy. But in addition to that, you focus on prevention. You allow everybody to get the Congressional plan that every member here has.You bring Medicare 55 and over.”
— CNN debate for Democratic candidates, June 3, 2007

“Our main responsibility should be to insure all children under five. We’ve done that in New Mexico and we should do that nationally. Secondly, we should insure all working adults, all working families. The third phase would be the chronically unemployed. The way you do that is by improving efficiencies and costs. The way you do that is not have Medicare and Medicaid covering seniors and disabled, it should be one. We should expand the S-Chip [State Children’s Health Insurance Program] to cover children.”
— A.F.S.C.M.E. forum, Feb. 21, 2007

PAYING FOR ADDITIONAL COSTS

FORM PARTNERSHIP WITH HEALTH CARE COMMUNITY
“I would not increase taxes. I believe that, if anything, Democrats have been viewed – our solution is always to increase taxes, and we shouldn’t. I don’t think the solution of the Democratic Party should always be to either spend more or tax more. I believe if we have partnerships between hospitals, between communities, between the state, the federal government, and you give flexibility to the states, we can have universal health care.”
— A.F.S.C.M.E. forum, Feb. 21, 2007

Rudy Giuliani
Republican

DETAILS OF THEIR PLANS

ADVOCATES MARKET-BASED HEALTH CARE; MAKE PRIVATE INSURANCE AFFORDABLE THROUGH TAX DEDUCTIONS
“I believe we can reduce costs and improve the quality of care by increasing competition. We can do it through tax cuts, not tax hikes. We can do it by empowering patients and their doctors, not government bureaucrats.”
— Boston Globe op-ed, Aug. 3, 2007

No estimate of cost. He proposes an income tax credit of up to $7,500 for individuals and $15,000 for families, allowing that money to be directed toward the purchase of health insurance and other medical spending. He also said he opposed any government mandates that would require people or businesses to buy insurance. He criticized Democrats’ plans, saying they should leave the important decision of choosing insurance to individuals, not the government. He did not promise that all the uninsured would be covered under his proposal. He would expand health savings accounts by simplifying the rules and regulations to participate in them. He wants to increase the efficiency of the evaluation process for new drugs. He said the current process is too heavily regulated.

PAYING FOR ADDITIONAL COSTS

HAS NOT ADDRESSED HOW HE WOULD PAY FOR THE TAX DEDUCTIONS; HAS SAID THAT A FREE-MARKET WOULD BRING DOWN COSTS
“He said competition among insurers for customers would lead them to reduce the costs of their policies, estimating that only 20 million to 30 million
of the 120 million who currently get their insurance through an employer would need to sign up for individual insurance plans for that to happen. “You have to start bringing the price down before you can figure out how many people can you include. It can’t be done with a magic wand all at once.”
— Rochester, N.H., July 30, 2007

Mike Huckabee
Republican

DETAILS OF THEIR PLANS

ADVOCATES MARKET-BASED HEALTH CARE; MAKE PRIVATE INSURANCE AFFORDABLE THROUGH TAX DEDUCTIONS AND COST CONTROL MEASURES
“We don’t need universal health care mandated by federal edict or funded through ever-higher taxes. We do need to get serious about preventive health care instead of chasing more and more dollars to treat chronic disease, which currently gobbles up 80% of our health care costs, and yet is often avoidable. The result is that we’ll be able to deliver better care where and when it’s needed.
I advocate policies that will encourage the private sector to seek innovative ways to bring down costs and improve the free market for health care services. I also value the states’ role as laboratories for new market-based approaches, and I will encourage those efforts. “

PAYING FOR ADDITIONAL COSTS

IMPLEMENT COST CONTROL MEASURES
“We can make health care more affordable by reforming medical liability; adopting electronic record keeping; making health insurance more portable from one job to another; expanding health savings accounts to everyone, not just those with high deductibles; and making health insurance tax deductible for individuals and families as it now is for businesses. Low-income families would get tax credits instead of deductions.”
— Campaign Web site

Duncan Hunter
Republican

DETAILS OF THEIR PLANS

ADVOCATES MARKET-BASED HEALTH CARE; OPPOSED TO GOVERNMENT-SUBSIDIZED UNIVERSAL HEALTH CARE
“I am not for universal health care. If everything is paid for by the government, you’ll have companies trying to get in and trying to overcharge. And you’ll lose what I call a consumer interest, in keeping the cost of health care down.”
— WMUR-TV, April 13, 2007

LET AMERICANS SHOP FOR INSURANCE ACROSS STATE LINES
“We need to be able to buy our health care insurance across state lines. Right now the same single policy that can be purchased in Long Beach for $73 costs $334 in New Jersey. The states lock up the insurance industry. They won’t let Americans buy across state lines just like they do everything else. If we’re able to do that, we’re going to bring down the cost of health insurance.”
— CNN debate for Republican candidates, June 5, 2007

PAYING FOR ADDITIONAL COSTS

NOT AVAILABLE

John McCain
Republican

DETAILS OF THEIR PLANS

HAS PLEDGED AFFORDABLE HEALTH CARE FOR EVERY AMERICAN WITHOUT A FEDERAL MANDATE
“The biggest problem with the American health care system is that it costs too much. … Businesses and families pay more and more every year to get what they often consider to be inadequate attention or poor care.”
— Des Moines, Oct. 11, 2007

No estimate of cost. He would provide $2,500 refundable tax credits for individuals, and $5,000 tax credits to families, if they have health insurance. He opposes universal health care mandates. He said he believed in limited government intervention, and wanted to give individuals freedom to choose their own health care. He would allow people to have portable insurance that could be purchased across state lines. He wants to bring greater competition to drug markets by safe reimportation of drugs and streamlining the process for introducing generic drugs.

PAYING FOR ADDITIONAL COSTS

SAYS UNIVERSAL HEALTH CARE IS POSSIBLE WITHOUT A TAX INCREASE
“I’m certainly not interested in raising people’s taxes, as many of the Democrats are interested in doing. I’m absolutely opposed to that.”
— On ABC’s “This Week,” June 10, 2007

Employers would no longer be allowed to deduct health care costs from their taxes under his plan.

Ron Paul
Republican

DETAILS OF THEIR PLANS

ADVOCATES MARKET-BASED HEALTH CARE; OPPOSED TO FEDERAL MANDATE
“It’s time to rethink the whole system. The rise of HMOs has created a harmful collusion between politicians, drug companies, and organized medicine that raises the price of health care by stifling competition between providers. And all this in favor of moving us towards universal health care! I believe strongly that patients are better served by having an element of choice in the matter, which is why I support letting the free-market determine health care costs. This won’t happen, however, until we unravel the HMO web and change the tax code to allow individuals to fully deduct health care costs from their taxes, as employers can.”
— Muckraker Report, June 28, 2007

PAYING FOR ADDITIONAL COSTS

WANTS TO MAKE HEALTH CARE MORE AFFORDABLE WITHOUT TAX INCREASE
“Congress needs to craft innovative legislation that makes health care more a
ffordable without raising taxes or increasing the deficit. It also needs to repeal bad laws that keep health care costs higher than necessary.”
— LewRockwell.com, August 23, 2006

Mitt Romney
Republican

DETAILS OF THEIR PLANS

ENCOURAGE STATES TO DEVELOP MARKET-BASED HEALTH CARE PROGRAMS; OPPOSED TO A NATIONAL VERSION OF THE PLAN HE SUPPORTED FOR MASSACHUSSETS AS GOVERNOR OF THE STATE, REQUIRING EVERYONE TO GET INSURANCE
“The way we improve something is not by putting more government into it. … Instead, the right way for us to go is to bring in place the kind of market dynamics that make the rest of the economy so successful.”
— Republican Debate, Dearborn, Mich., Oct. 9, 2007

The cost would depend on what kinds of plans states propose. He wants to allow people who buy their own health insurance to be able to deduct premiums, deductibles and co-payments from their income. He is against individual or employer health care mandates, but said he wanted to get everybody “in the system” by driving down costs with market reforms. His plan would assist low-income Americans in buying private health insurance plans of their choice. He has not specified a way to change the current process of regulating drugs.

PAYING FOR ADDITIONAL COSTS

USE FEDERAL MONEY NOW BEING USED TO HELP STATES COVER THE COST OF MEDICAL CARE FOR THE UNINSURED
“It’s a conservative idea insisting that individuals have responsibility for their own health care. I think it appeals to people on both sides of the aisle: insurance for everyone without a tax increase.”
— USA Today, July 5, 2005

Tom Tancredo
Republican

DETAILS OF THEIR PLANS

ADVOCATES MARKET-BASED HEALTH CARE; WOULD NOT RULE OUT FEDERAL SUBSIDIES FOR THE NEEDY
“As for the uninsured: as many as 25 percent of them are illegal aliens and should be deported or encouraged to leave. For citizens and legal residents who are employed by businesses which cannot afford coverage, I favor association health plans which band small businesses together to access lower-cost insurance. For those out of work, state governments should be the primary source of relief, although I would not rule out federal incentives or limited subsidies to make sure families who have fallen on hard times are not without coverage.”

PAYING FOR ADDITIONAL COSTS

PROPOSES IMMIGRATION REFORM TO CURB COST
“The two major problems are the high cost of care and the number of uninsured. Tort reform and immigration enforcement would save the system billions and drive down costs. In California alone, illegal immigrants cost the system $800 million annually and have forced 84 hospitals to close.
As for the uninsured: as many as 25 percent of them are illegal aliens and should be deported or encouraged to leave.”
— Campaign Web site

Fred D. Thompson
Republican

DETAILS OF THEIR PLANS

ADVOCATES MARKET-BASED HEALTH CARE, OPPOSES FEDERAL MANDATE
“The best way to improve the best health care in the world, which is what we get right here in the United States, is to expand choice—not punishment.”
— Orlando, September 2007

“Those who propose a one-size-fits-all Washington-controlled program ignore the cost, inefficiency, and inadequate care that such a system offers.”
— Campaign Web site

PAYING FOR ADDITIONAL COSTS

IMPLEMENT MEASURES TO CONTROL COSTS AND SAVE MONEY
Access to affordable, portable health care can be made available for all Americans without imposing new mandates or raising taxes. Current government programs must also be streamlined and improved so that those who truly need help can get the health care they need.
— Campaign Web site