PNHP

Grumbach and GAO on primary care crisis

Grumbach and GAO on primary care crisis

Senate Committee on Health, Education, Labor and Pensions
February 12, 2008

Recent Supply Trends, Projections, and Valuation of Services

Testimony of A. Bruce Steinwald, Director, Health Care
United States Government Accountability Office (GAO)
Primary Care Professionals

Health professional workforce projections that are mostly silent on the future supply of and demand for primary care services are symptomatic of an ongoing decline in the nation’s financial support for primary care medicine. Ample research in recent years concludes that the nation’s over reliance on specialty care services at the expense of primary care leads to a health care system that is less efficient. At the same time, research shows that preventive care, care coordination for the chronically ill, and continuity of care – all hallmarks of primary care medicine – can achieve improved outcomes and costs savings. Conventional payment systems tend to undervalue primary care services relative to specialty services. Some physician organizations are proposing payment system refinements that place a new emphasis on primary care services.

http://help.senate.gov/Hearings/2008_02_12/Steinwald.pdf

And…

The Crisis in the Primary Care Physician Workforce

Testimony of Kevin Grumbach, MD, Professor and Chair of the Department of Family and Community Medicine at the University of California, San Francisco

There are three main points I would like to emphasize:

1. Primary care is the essential foundation of a well-performing health system

2. The primary care infrastructure in the United States is crumbling, and patient access to primary care is suffering throughout the nation.

3. The federal government can address the crisis in primary care through:

a. Targeted health professions primary care training programs such as Title VII programs,
b. Reform of Medicare Graduate Medical Education funding,
c. The National Health Services Corps, and
d. Medicare physician payment reform.

Conclusion

Primary care is essential, and it is in crisis. Decisive action is required by the federal government to avert the collapse of primary care and its catastrophic consequences for the public. Many leaders in the private sector, such as large employers, are already taking action on issues such as physician payment reform to support new models of primary care.

Research provides evidence of strategies that are of proven effectiveness in strengthening the primary care workforce and providing incentives for primary care practice. Some of these strategies, such as implementing a split SGR for Medicare physician payment or reforming Medicare GME payments, do not require new funds but rather a reconsideration of how existing funds are allocated. Other strategies, such as a reasonable level of funding for the Section 747 Title VII Primary Care Training Grants Program, require small investments. For example, restoring Title VII Section 747 funding to its 2003 level of $92.4 million would represent an annual investment equivalent to 0.02% of the annual Medicare budget. Such investments in the future of the nation’s primary care physician workforce are a cost-effective investment in the nation’s health care infrastructure and in the health of the public.

http://help.senate.gov/Hearings/2008_02_12/Grumbach.pdf

Comment:

By Don McCanne, MD

The current dialogue on reform is often more narrowly focused on topics such as disease management and electronic medical records. More attention needs to be directed to reform that would put all of this together: reinforcing our primary care infrastructure.

It is difficult to see how this could be accomplished without significant federal support through expanded policies and public financing. As an example, Kevin Grumbach discusses the very important role that Medicare could play in this process. Those changes alone could arrest the downward spiral of the primary care base. Just imagine what we could do if we were all covered by a single, Medicare-like program.

Reforming health care the right way – who is it that keeps saying this isn’t feasible?

10 Myths About Canadian Health Care, Busted

By Sara Robinson
TomPaine.com
February 5, 2008

2008 is shaping up to be the election year that we finally get to have the Great American Healthcare Debate again. Harry and Louise are back with a vengeance. Conservatives are rumbling around the talk show circuit bellowing about the socialist threat to the (literal) American body politic. And, as usual, Canada is once again getting dragged into the fracas, shoved around by both sides as either an exemplar or a warning — and, along the way, getting coated with the obfuscating dust of so many willful misconceptions that the actual facts about How Canada Does It are completely lost in the melee.

I’m both a health-care-card-carrying Canadian resident and an uninsured American citizen who regularly sees doctors on both sides of the border. As such, I’m in a unique position to address the pros and cons of both systems first-hand. If we’re going to have this conversation, it would be great if we could start out (for once) with actual facts, instead of ideological posturing, wishful thinking, hearsay, and random guessing about how things get done up here.

To that end, here’s the first of a two-part series aimed at busting the common myths Americans routinely tell each other about Canadian health care. When the right-wing hysterics drag out these hoary old bogeymen, this time, we need to be armed and ready to blast them into straw. Because, mostly, straw is all they’re made of.

1. Canada’s health care system is “socialized medicine.”
False. In socialized medical systems, the doctors work directly for the state. In Canada (and many other countries with universal care), doctors run their own private practices, just like they do in the US. The only difference is that every doctor deals with one insurer, instead of 150. And that insurer is the provincial government, which is accountable to the legislature and the voters if the quality of coverage is allowed to slide.

The proper term for this is “single-payer insurance.” In talking to Americans about it, the better phrase is “Medicare for all.”

2. Doctors are hurt financially by single-payer health care.
True and False. Doctors in Canada do make less than their US counterparts. But they also have lower overhead, and usually much better working conditions. A few reasons for this:

First, as noted, they don’t have to charge higher fees to cover the salary of a full-time staffer to deal with over a hundred different insurers, all of whom are bent on denying care whenever possible. In fact, most Canadian doctors get by quite nicely with just one assistant, who cheerfully handles the phones, mail, scheduling, patient reception, stocking, filing, and billing all by herself in the course of a standard workday.

Second, they don’t have to spend several hours every day on the phone cajoling insurance company bean counters into doing the right thing by their patients. My doctor in California worked a 70-hour week: 35 hours seeing patients, and another 35 hours on the phone arguing with insurance companies. My Canadian doctor, on the other hand, works a 35-hour week, period. She files her invoices online, and the vast majority are simply paid — quietly, quickly, and without hassle. There is no runaround. There are no fights. Appointments aren’t interrupted by vexing phone calls. Care is seldom denied (because everybody knows the rules). She gets her checks on time, sees her patients on schedule, takes Thursdays off, and gets home in time for dinner.

One unsurprising side effect of all this is that the doctors I see here are, to a person, more focused, more relaxed, more generous with their time, more up-to-date in their specialties, and overall much less distracted from the real work of doctoring. You don’t realize how much stress the American doctor-insurer fights put on the day-to-day quality of care until you see doctors who don’t operate under that stress, because they never have to fight those battles at all. Amazingly: they seem to enjoy their jobs.

Third: The average American medical student graduates $140,000 in hock. The average Canadian doctor’s debt is roughly half that.

Finally, Canadian doctors pay lower malpractice insurance fees. When paying for health care constitutes a one of a family’s major expenses, expectations tend to run very high. A doctor’s mistake not only damages the body; it may very well throw a middle-class family permanently into the ranks of the working poor, and render the victim uninsurable for life. With so much at stake, it’s no wonder people are quick to rush to court for redress.

Canadians are far less likely to sue in the first place, since they’re not having to absorb devastating financial losses in addition to any physical losses when something goes awry. The cost of the damaging treatment will be covered. So will the cost of fixing it. And, no matter what happens, the victim will remain insured for life. When lawsuits do occur, the awards don’t have to include coverage for future medical costs, which reduces the insurance company’s liability.

3. Wait times in Canada are horrendous.
True and False again — it depends on which province you live in, and what’s wrong with you. Canada’s health care system runs on federal guidelines that ensure uniform standards of care, but each territory and province administers its own program. Some provinces don’t plan their facilities well enough; in those, you can have waits. Some do better. As a general rule, the farther north you live, the harder it is to get to care, simply because the doctors and hospitals are concentrated in the south. But that’s just as true in any rural county in the U.S.

You can hear the bitching about it no matter where you live, though. The percentage of Canadians who’d consider giving up their beloved system consistently languishes in the single digits. A few years ago, a TV show asked Canadians to name the Greatest Canadian in history; and in a broad national consensus, they gave the honor to Tommy Douglas, the Saskatchewan premier who is considered the father of the country’s health care system. (And no, it had nothing to do with the fact that he was also Kiefer Sutherland’s grandfather.). In spite of that, though, grousing about health care is still unofficially Canada’s third national sport after curling and hockey.

And for the country’s newspapers, it’s a prime watchdogging opportunity. Any little thing goes sideways at the local hospital, and it’s on the front pages the next day. Those kinds of stories sell papers, because everyone is invested in that system and has a personal stake in how well it functions. The American system might benefit from this kind of constant scrutiny, because it’s certainly one of the things that keeps the quality high. But it also makes people think it’s far worse than it is.

Critics should be reminded that the American system is not exactly instant-on, either. When I lived in California, I had excellent insurance, and got my care through one of the best university-based systems in the nation. Yet I routinely had to wait anywhere from six to twelve weeks to get in to see a specialist. Non-emergency surgical waits could be anywhere from four weeks to four months. After two years in the BC system, I’m finding the experience to be pretty much comparable, and often better. The notable exception is MRIs, which were easy in California, but can take many months to get here. (It’s the number one thing people go over the border for.) Other than that, urban Canadians get care about as fast as urban Americans do.

4. You have to wait forever to get a family doctor.
False for the vast majority of Canadians, but True for a few. Again, it all depends on where you live. I live in suburban Vancouver, and there are any number of first-rate GPs in my neighborhood who are taking new patients. If you don’t have a working relationship with one, but need to see a doctor now, there are 24-hour urgent care clinics in most neighborhoods that will usually get you in and out on the minor stuff in under an hour.

It is, absolutely, harder to get to a doctor if you live out in a small town, or up in the territories. But that’s just as true in the U.S. — and in America, the government won’t cover the airfare for rural folk to come down to the city for needed treatment, which all the provincial plans do.

5. You don’t get to choose your own doctor.
Scurrilously False. Somebody, somewhere, is getting paid a lot of money to make this kind of stuff up. The cons love to scare the kids with stories about the government picking your doctor for you, and you don’t get a choice. Be afraid! Be very afraid!

For the record: Canadians pick their own doctors, just like Americans do. And not only that: since it all pays the same, poor Canadians have exactly the same access to the country’s top specialists that rich ones do.

6. Canada’s care plan only covers the basics. You’re still on your own for any extras, including prescription drugs. And you still have to pay for it.
True — but not as big an issue as you might think. The province does charge a small monthly premium (ours is $108/month for a family of four) for the basic coverage. However, most people never even have to write that check: almost all employers pick up the tab for their employees’ premiums as part of the standard benefits package; and the province covers it for people on public assistance or disability.

“The basics” covered by this plan include 100% of all doctor’s fees, ambulance fares, tests, and everything that happens in a hospital — in other words, the really big-ticket items that routinely drive American families into bankruptcy. In BC, it doesn’t include “extras” like medical equipment, prescriptions, physical therapy or chiropractic care, dental, vision, and so on; and if you want a private or semi-private room with TV and phone, that costs extra (about what you’d pay for a room in a middling hotel). That other stuff does add up; but it’s far easier to afford if you’re not having to cover the big expenses, too. Furthermore: you can deduct any out-of-pocket health expenses you do have to pay off your income taxes. And, as every American knows by now, drugs aren’t nearly as expensive here, either.

Filling the gap between the basics and the extras is the job of the country’s remaining private health insurers. Since they’re off the hook for the ruinously expensive big-ticket items that can put their own profits at risk, the insurance companies make a tidy business out of offering inexpensive policies that cover all those smaller, more predictable expenses. Top-quality add-on policies typically run in the ballpark of $75 per person in a family per month — about $300 for a family of four — if you’re stuck buying an individual plan. Group plans are cheap enough that even small employers can afford to offer them as a routine benefit. An average working Canadian with employer-paid basic care and supplemental insurance gets free coverage equal to the best policies now only offered at a few of America’s largest corporations. And that employer is probably only paying a couple hundred dollars a month to provide that benefit.

7. Canadian drugs are not the same.
More preposterious bogosity. They are exactly the same drugs, made by the same pharmaceutical companies, often in the same factories. The Canadian drug distribution system, however, has much tighter oversight; and pharmacies and pharmacists are more closely regulated. If there is a difference in Canadian drugs at all, they’re actually likely to be safer.

Also: pharmacists here dispense what the doctors tell them to dispense, the first time, without moralizing. I know. It’s amazing.

8. Publicly-funded programs will inevitably lead to rationed health care, particularly for the elderly.
False. And bogglingly so. The papers would have a field day if there was the barest hint that this might be true.

One of the things that constantly amazes me here is how well-cared-for the elderly and disabled you see on the streets here are. No, these people are not being thrown out on the curb. In fact, they live longer, healthier, and more productive lives because they’re getting a constant level of care that ensures small things get treated before they become big problems.

The health care system also makes it easier on their caregiving adult children, who have more time to look in on Mom and take her on outings because they aren’t working 60-hour weeks trying to hold onto a job that gives them insurance.

9. People won’t be responsible for their own health if they’re not being forced to pay for the consequences.
False. The philosophical basis of America’s privatized health care system might best be characterized as medical Calvinism. It’s fascinating to watch well-educated secularists who recoil at the Protestant obsession with personal virtue, prosperity as a cardinal sign of election by God, and total responsibility for one’s own salvation turn into fire-eyed, moralizing True Believers when it comes to the subject of Taking Responsibility For One’s Own Health.

They’ll insist that health, like salvation, is entirely in our own hands. If you just have the character and self-discipline to stick to an abstemious regime of careful diet, clean living, and frequent sweat offerings to the Great Treadmill God, you’ll never get sick. (Like all good theologies, there’s even an unspoken promise of immortality: f you do it really really right, they imply, you might even live forever.) The virtuous Elect can be discerned by their svelte figures and low cholesterol numbers. From here, it’s a short leap to the conviction that those who suffer from chronic conditions are victims of their own weaknesses, and simply getting what they deserve. Part of their punishment is being forced to pay for the expensive, heavily marketed pharmaceuticals needed to alleviate these avoidable illnesses. They can’t complain. It was their own damned fault; and it’s not our responsibility to pay for their sins. In fact, it’s recently been suggested that they be shunned, lest they lead the virtuous into sin.

Of course, this is bad theology whether you’re applying it to the state of one’s soul or one’s arteries. The fact is that bad genes, bad luck, and the ravages of age eventually take their toll on all of us — even the most careful of us. The economics of the Canadian system reflect this very different philosophy: it’s built on the belief that maintaining health is not an individual responsibility, but a collective one. Since none of us controls fate, the least we can do is be there for each other as our numbers come up.

This difference is expressed in a few different ways. First: Canadians tend to think of tending to one’s health as one of your duties as a citizen. You do what’s right because you don’t want to take up space in the system, or put that burden on your fellow taxpayers. Second, “taking care of yourself” has a slightly expanded definition here, which includes a greater emphasis on public health. Canadians are serious about not coming to work if you’re contagious, and seeing a doctor ASAP if you need to. Staying healthy includes not only diet and exercise; but also taking care to keep your germs to yourself, avoiding stress, and getting things treated while they’re still small and cheap to fix.

Third, there’s a somewhat larger awareness that stress leads to big-ticket illnesses — and a somewhat lower cultural tolerance for employers who put people in high-stress situations. Nobody wants to pick up the tab for their greed. And finally, there’s a generally greater acceptance on the part of both the elderly and their families that end-of-life heroics may be drawing resources away from people who might put them to better use. You can have them if you want them; but reasonable and compassionate people should be able to take the larger view.

The bottom line: When it comes to getting people to make healthy choices, appealing to their sense of the common good seems to work at least as well as Calvinist moralizing.

10. This all sounds great — but the taxes to cover it are just unaffordable. And besides, isn’t the system in bad financial shape?
False. On one hand, our annual Canadian tax bite runs about 10% higher than our U.S. taxes did. On the other, we’re not paying out the equivalent of two new car payments every month to keep the family insured here. When you balance out the difference, we’re actually money ahead. When you factor in the greatly increased social stability that follows when everybody’s getting their necessary health care, the impact on our quality of life becomes even more signficant.

And True — but only because this is a universal truth that we need to make our peace with. Yes, the provincial plans are always struggling. So is every single publicly-funded health care system in the world, including the VA and Medicare. There’s always tension between what the users of the system want, and what the taxpayers are willing to pay. The balance of power ebbs and flows between them; but no matter where it lies at any given moment, at least one of the pair is always going to be at least somewhat unhappy.

But, as many of us know all too well, there’s also constant tension between what patients want and what private insurers are willing to pay. At least when it’s in government hands, we can demand some accountability. And my experience in Canada has convinced me that this accountability is what makes all the difference between the two systems.

It is true that Canada’s system is not the same as the U.S. system. It’s designed to deliver a somewhat different product, to a population that has somewhat different expectations. But the end result is that the vast majority of Canadians get the vast majority of what they need the vast majority of the time. It’ll be a good day when when Americans can hold their heads high and proudly make that same declaration.

Next week: More mythbusting on common conservative canards about efficiency, innovation, and competitiveness.

Blue Cross asks doctors to rat on patients

Doctors balk at request for data

By Lisa Girion
Los Angeles Times
February 12, 2008

The state’s largest for-profit health insurer is asking California physicians to look for conditions it can use to cancel their new patients’ medical coverage.

Blue Cross of California is sending physicians copies of health insurance applications filled out by new patients, along with a letter advising them that the company has a right to drop members who fail to disclose “material medical history,” including “pre-existing pregnancies.”

“Any condition not listed on the application that is discovered to be pre-existing should be reported to Blue Cross immediately,” the letters say. The Times obtained a copy of a letter that was aimed at physicians in large medical groups.

(WellPoint spokeswoman Shannon) Troughton said Blue Cross sent the letters to medical groups that operate, in effect, as health maintenance organizations. Blue Cross pays such groups a set amount per patient each month. With a few exceptions, the groups are then responsible for arranging and providing patients’ medical care and take on a substantial piece of the risk.

Troughton said “in the past” physicians in such medical groups had requested information on patients’ pre-existing medical conditions because anything that had not been disclosed could affect the medical group’s finances.

It was important, Troughton added, “to note that participation in this outreach effort is voluntary on the part of the physicians.”

“We’re outraged that they are asking doctors to violate the sacred trust of patients to rat them out for medical information that patients would expect their doctors to handle with the utmost secrecy and confidentiality,” said Dr. Richard Frankenstein, president of the California Medical Assn.

Anthony Wright, executive director of HealthAccess California, a healthcare advocacy organization, said the letter had put physicians in the “disturbing” position of having to weigh their patients’ interests against a directive from the company that, in many cases, pays most of their bills.

“They are playing a game of ‘gotcha’ where they are trying to use their doctors against their patients’ health interests,” Wright said. “That’s about as ugly as it gets.”

http://www.latimes.com/business/la-fi-bluecross12feb12,0,4319662.story

Comment:

By Don McCanne, MD

WellPoint’s Blue Cross of California remains a leader in introducing innovations that reduce expenditures for health care. By limiting spending on health care they have been able to market their insurance products at highly competitive premiums, thereby reaping profits on this large, very healthy sector of our population.

As we have seen before, Blue Cross’s very successful business model is often in conflict with the mission of physicians and other professionals to provide the health care that patients need. This letter to physicians has a particularly nefarious intent.

Since Blue Cross is paying these physicians a set amount per patient per month (capitation), the physicians themselves are providing an insurance function of assuming risk. Patients with greater health care needs result in a loss since the expenses required to care for them are greater, sometimes much greater, than the capitation payment made by Blue Cross.

So now we see why a physician might consider “ratting” on his or her own patient even though it would result in a rescission of the patient’s insurance policy. Blue Cross does not have to put in print the very strong message of this letter, even though it will jump out between the lines.

“Doctor, your dishonest patient who lied on the insurance application will result in a financial loss for you, not to mention the need to provide additional professional services for which you will not be compensated. Fortunately, you can prevent this loss by notifying us of any medical condition that will allow us to rescind this unfair insurance contract.”

To enhance profits, the private insurance industry is destroying the sacred relationship between the patient and his or her health care professional.

And the politicians are campaigning with the message that we can keep the private insurance we have. Who would want to?

Wyden's "Healthy Americans Act" is Wrong Model for Health Reform

Personal communication, Dr. Walter Tsou
February 12, 2008

The bipartisan authors of the Healthy Americans Act, Senators Ron Wyden (D-OR) and Bob Bennett (R-UT) were in Philadelphia today for a two hour session to explain their bill. Their purpose was to build public support for their bill with the goal of having most of the disagreements worked out by the time a new president takes office in January 2009. The bill depends on the “mandate” model of private insurance. The potential problems with this approach have been extensively written about by PNHP.

Nevertheless, it was a unique meeting to have both Senators explain their bill and to sit with an audience for an hour to answer questions. The first tip off was that the forum was sponsored by AmeriHealth, a large Medicaid HMO. The Mayor of Philadelphia (who will be featured this Wednesday on ABC News with Charles Gibson) came to thank them for coming and stating his gratitude that someone in Washington was working on this problem. He came short of actually endorsing the bill however and conveniently left.

This left the program to Wyden and Bennett.

Wyden and Bennett said there were five major goals in their plan which was a piece in progress. Those goals were choice of plans to fit each family’s needs, portability which is tied to individual insurance supposedly with a lifetime guarantee of coverage as good as members of Congress (a term he used repeatedly), tax reform to support the same tax benefits that large employers get, healthy behavior to promote personal responsibility by giving premium discounts for controlling your blood pressure or diabetes (hard to imagine the kind of gaming that occurs here), and the Republican favorite – market forces, based on transparency in prices and quality and individuals presumably shopping around for cheaper and better care. Bennett says that many Republicans have a hard time even agreeing on universal health coverage.

Wyden mentioned that we spend $2.3 trillion on health care, but were not getting enough value for our money. In order to pay for the premiums to go to private insurers, they would require all employers to give all American workers the actual value of their health care benefits in higher wages but that they then turn around and require you to take those wages and purchase individual insurance. (This idea is something of value to single payer advocates but instead of paying premiums, you would pay taxes to fund a single payer plan. ) There would be three large private insurance risk pools. The first would be all employees who would basically buy into a program like the federal employee health benefit plans. The second would be all individual self employed and uninsured who would be in another big risk pool. In order to avoid adverse risk selection, they would require community rating by insurers and no preexisting condition exclusions. The third risk pool would be all Medicaid patients who could buy their insurance from Medicaid HMOs like AmeriHealth, but if the benefits were not as good as what members of Congress get, the federal government would subsidize these plans to ensure complete benefits. (actually, Medicaid benefits are generally much more comprehensive than private insurance, but because they pay so poorly, few providers accept Medicaid payments).

Several questions were asked, but my question basically challenged why they did not choose single payer since private insurers have much higher administrative costs, that single payer would be a much better negotiator of health prices and quality than Mrs. Jones down the street, and what kind of fines would they envision to enforce their mandate. Wyden stated that whenever he has a public forum, some single payer advocate explains the advantages of single payer and there is cheering in the audience. Then there is someone in the back of the room who denounces government. And finally, someone says “we want what you have”. Wyden pulls out his health card and says that he has private health insurance and explains that his plan would give Americans “what members of Congress have”. This seems to quiet the audience from his perspective. (I have no doubt that members of Congress do not face the denials so nicely outlined in Sicko.) In terms of transparency in prices and quality, Bennett said repeatedly that Utah’s Intermountain Healthcare delivers much better health care for less money and that presumably his state would benefit if there was more transparency in cost since they presumably would choose Intermountain Health. Bennett also seemed to believe that the risk pools were so huge that they could drop the private insurance overhead to “3-4 percent”, (which is sheer fantasy). They dodged the question about “fines” for enforcing the mandate, basically saying that terms like “garnish your wages” were words that opponents use and that basically the plan would deduct premiums from our paychecks in order to fund the plan. (Why deducting premiums from our paychecks to fund private insurance companies is acceptable but deducting a smaller amount using taxes to fund single payer was not acceptable seems an important question, but I wasn’t given a chance to debate them because so many others had questions.)

Others asked about malpractice, about whether states would be allowed to experiment with health care reform (they would), assurance of quality of care, etc.

They believe that since they have a bipartisan bill with six Republicans (Judd, Gregg, Grassley, Coleman, Crapo, Alexander) and six Democrats (Stabenow, Nelson, Lieberman (no surprise here), Carper, and Landrieu) plus the National Federation of Independent Businesses, the CEO of Safeway, and SEIU, they have a good shot at setting the framework for the next president. Add to that that Obama and Clinton are basically using the framework of private insurance in their plans and you have the basis to worry about another 4-8 years of a costly failed experiment in health care reform.

Despite these rumblings, I think it is pretty clear that the American people want single payer. It is the politicians who are out of tune with this. We will need to do a lot more educating about this. The impending recession may cause millions more Americans to lose their health insurance. Simply requiring them to buy insurance is not a solution in the face of a recession and we should demand that Congress create a real safety net, not one based on the fantasy that everyone buy overpriced for profit private insurance with huge deductibles.

Doctors balk at request for data

Physicians object to a letter from Blue Cross seeking information that could lead to policy cancellations.

By Lisa Girion
Los Angeles Times
February 12, 2008

Click here for a pdf of the Blue Cross Letter to health-care providers.

The state’s largest for-profit health insurer is asking California physicians to look for conditions it can use to cancel their new patients’ medical coverage.

Blue Cross of California is sending physicians copies of health insurance applications filled out by new patients, along with a letter advising them that the company has a right to drop members who fail to disclose “material medical history,” including “pre-existing pregnancies.”

“Any condition not listed on the application that is discovered to be pre-existing should be reported to Blue Cross immediately,” the letters say. The Times obtained a copy of a letter that was aimed at physicians in large medical groups.

The letter wasn’t going down well with physicians.

“We’re outraged that they are asking doctors to violate the sacred trust of patients to rat them out for medical information that patients would expect their doctors to handle with the utmost secrecy and confidentiality,” said Dr. Richard Frankenstein, president of the California Medical Assn.

Patients “will stop telling their doctors anything they think might be a problem for their insurance and they don’t think matters for their current health situation,” he said. “But they didn’t go to medical school, and there are all kinds of obscure things that could be very helpful to a doctor.”

WellPoint Inc., the Indianapolis-based company that operates Blue Cross of California, said Monday that it was sending out the letters in an effort to hold down costs.

“Enrolling an applicant who did not disclose their true condition (and the condition is chronic or acute), will quickly drive increased utilization of services, which drives up costs for all members,” WellPoint spokeswoman Shannon Troughton said in an e-mail.

“Blue Cross feels it is our responsibility to assure all records are accurate and up to date for HMO providers,” she said. “We send these letters to identify members early on in the process who may not have been honest in their application.”

Blue Cross is one of several California insurers that have come under fire for issuing policies without checking applications and then canceling coverage after individuals incur major medical costs. The practice of canceling coverage, known in the industry as rescission, is under scrutiny by state regulators, lawmakers and the courts.

Patients in a raft of lawsuits accuse the insurers of canceling coverage over honest mistakes and minor inconsistencies on applications that they contend are purposely confusing. Victims of cancer and other serious medical problems often are unable to get new coverage once their insurance has been rescinded and they may go without treatment when they need it most. Suddenly swamped by medical debt, some people have lost homes and businesses.

Insurers say the cancellations are an important weapon against fraud and occur rarely.

Physician groups and doctors who received the letter told The Times they never had seen anything like it. Also unfamiliar with such letters was Don Crane, executive director of the California Assn. of Physician Groups, which represents many of the large HMO-style medical groups.

“I have not heard any dialogue on this business of underwriting or ferreting out existing” conditions, Crane said.

But WellPoint’s Troughton said this was nothing new. “This is something that has been in place for several years and to date we have not received any calls or letters of concern for this service,” she said.

It was important, Troughton added, “to note that participation in this outreach effort is voluntary on the part of the physicians.”

The California Medical Assn. sent a letter to state regulators Friday urging them to order Blue Cross to stop asking doctors for the patient information, saying it was “deeply disturbing, unlawful, and interferes with the physician-patient relationship.”

The letters go out to some physicians who care for Blue Cross’ share of the state’s estimated 3 million people with individual policies.

Troughton said Blue Cross sent the letters to medical groups that operate, in effect, as health maintenance organizations. Blue Cross pays such groups a set amount per patient each month. With a few exceptions, the groups are then responsible for arranging and providing patients’ medical care and take on a substantial piece of the risk.

Troughton said “in the past” physicians in such medical groups had requested information on patients’ pre-existing medical conditions because anything that had not been disclosed could affect the medical group’s finances.

She disputed the notion that the letters could improperly breach patient confidentiality. She said the sharing of medical information with medical groups was within federal law because it fell under “patient, treatment and operations” guidelines.

Blue Cross doesn’t always cancel the policies of patients with discrepancies in their applications, Troughton noted. Sometimes it may offer them another plan, she said.

Lynne Randolph, a spokeswoman for the state Department of Managed Health Care, said the agency would review the letter. Blue Cross is fighting a $1-million fine the department imposed in March over alleged systemic problems the agency identified in the way the company rescinds coverage.

A spokesman for state Insurance Commissioner Steve Poizner said the Insurance Department had not received any complaints about Blue Cross’ letter. But because the medical association had sent a copy of its complaint to the department, the letter is “on our radar now,” spokesman Byron Tucker said.

The letter is “extremely troubling on several fronts,” Tucker said. “It really obliterates the line between underwriting and medical care. It is the insurer’s job to underwrite their policies, not the doctors’. Doctors deliver medical care. Their job is not to underwrite policies for insurers.”

Anthony Wright, executive director of HealthAccess California, a healthcare advocacy organization, said the letter had put physicians in the “disturbing” position of having to weigh their patients’ interests against a directive from the company that, in many cases, pays most of their bills.

“They are playing a game of ‘gotcha’ where they are trying to use their doctors against their patients’ health interests,” Wright said. “That’s about as ugly as it gets.”

lisa.girion@latimes.com

Wyden’s “Healthy Americans Act” is Wrong Model for Health Reform

Personal communication, Dr. Walter Tsou
February 12, 2008

The bipartisan authors of the Healthy Americans Act, Senators Ron Wyden (D-OR) and Bob Bennett (R-UT) were in Philadelphia today for a two hour session to explain their bill. Their purpose was to build public support for their bill with the goal of having most of the disagreements worked out by the time a new president takes office in January 2009. The bill depends on the “mandate” model of private insurance. The potential problems with this approach have been extensively written about by PNHP.

Nevertheless, it was a unique meeting to have both Senators explain their bill and to sit with an audience for an hour to answer questions. The first tip off was that the forum was sponsored by AmeriHealth, a large Medicaid HMO. The Mayor of Philadelphia (who will be featured this Wednesday on ABC News with Charles Gibson) came to thank them for coming and stating his gratitude that someone in Washington was working on this problem. He came short of actually endorsing the bill however and conveniently left.

This left the program to Wyden and Bennett.

Wyden and Bennett said there were five major goals in their plan which was a piece in progress. Those goals were choice of plans to fit each family’s needs, portability which is tied to individual insurance supposedly with a lifetime guarantee of coverage as good as members of Congress (a term he used repeatedly), tax reform to support the same tax benefits that large employers get, healthy behavior to promote personal responsibility by giving premium discounts for controlling your blood pressure or diabetes (hard to imagine the kind of gaming that occurs here), and the Republican favorite – market forces, based on transparency in prices and quality and individuals presumably shopping around for cheaper and better care. Bennett says that many Republicans have a hard time even agreeing on universal health coverage.

Wyden mentioned that we spend $2.3 trillion on health care, but were not getting enough value for our money. In order to pay for the premiums to go to private insurers, they would require all employers to give all American workers the actual value of their health care benefits in higher wages but that they then turn around and require you to take those wages and purchase individual insurance. (This idea is something of value to single payer advocates but instead of paying premiums, you would pay taxes to fund a single payer plan. ) There would be three large private insurance risk pools. The first would be all employees who would basically buy into a program like the federal employee health benefit plans. The second would be all individual self employed and uninsured who would be in another big risk pool. In order to avoid adverse risk selection, they would require community rating by insurers and no preexisting condition exclusions. The third risk pool would be all Medicaid patients who could buy their insurance from Medicaid HMOs like AmeriHealth, but if the benefits were not as good as what members of Congress get, the federal government would subsidize these plans to ensure complete benefits. (actually, Medicaid benefits are generally much more comprehensive than private insurance, but because they pay so poorly, few providers accept Medicaid payments).

Several questions were asked, but my question basically challenged why they did not choose single payer since private insurers have much higher administrative costs, that single payer would be a much better negotiator of health prices and quality than Mrs. Jones down the street, and what kind of fines would they envision to enforce their mandate. Wyden stated that whenever he has a public forum, some single payer advocate explains the advantages of single payer and there is cheering in the audience. Then there is someone in the back of the room who denounces government. And finally, someone says “we want what you have”. Wyden pulls out his health card and says that he has private health insurance and explains that his plan would give Americans “what members of Congress have”. This seems to quiet the audience from his perspective. (I have no doubt that members of Congress do not face the denials so nicely outlined in Sicko.) In terms of transparency in prices and quality, Bennett said repeatedly that Utah’s Intermountain Healthcare delivers much better health care for less money and that presumably his state would benefit if there was more transparency in cost since they presumably would choose Intermountain Health. Bennett also seemed to believe that the risk pools were so huge that they could drop the private insurance overhead to “3-4 percent”, (which is sheer fantasy). They dodged the question about “fines” for enforcing the mandate, basically saying that terms like “garnish your wages” were words that opponents use and that basically the plan would deduct premiums from our paychecks in order to fund the plan. (Why deducting premiums from our paychecks to fund private insurance companies is acceptable but deducting a smaller amount using taxes to fund single payer was not acceptable seems an important question, but I wasn’t given a chance to debate them because so many others had questions.)

Others asked about malpractice, about whether states would be allowed to experiment with health care reform (they would), assurance of quality of care, etc.

They believe that since they have a bipartisan bill with six Republicans (Judd, Gregg, Grassley, Coleman, Crapo, Alexander) and six Democrats (Stabenow, Nelson, Lieberman (no surprise here), Carper, and Landrieu) plus the National Federation of Independent Businesses, the CEO of Safeway, and SEIU, they have a good shot at setting the framework for the next president. Add to that that Obama and Clinton are basically using the framework of private insurance in their plans and you have the basis to worry about another 4-8 years of a costly failed experiment in health care reform.

Despite these rumblings, I think it is pretty clear that the American people want single payer. It is the politicians who are out of tune with this. We will need to do a lot more educating about this. The impending recession may cause millions more Americans to lose their health insurance. Simply requiring them to buy insurance is not a solution in the face of a recession and we should demand that Congress create a real safety net, not one based on the fantasy that everyone buy overpriced for profit private insurance with huge deductibles.

End fringe debate over mandates – Kuttner

Examining Clinton & Obama's Stances on... Universal Healthcare...

Amy Goodman and Juan Gonzalez interview Robert Kuttner
Democracy Now!
February 8, 2008

Amy Goodman: Let’s talk about the healthcare plans of Hillary Clinton and Barack Obama.

Robert Kuttner: …Clinton has what’s known as a mandate. She requires people to get coverage. Obama doesn’t. Clinton and some liberal commentators, like Paul Krugman, have whacked Obama for not having a mandate. I think a mandate is a very bad idea. I think the difference between universal social insurance and a mandate is that universal social insurance, like Medicare, says that, as an American or a permanent resident of the country, you get health insurance, the same way you get Social Security. A mandate takes a social problem and makes it the individual’s problem. And in the Massachusetts version of this, on the website it says “new penalties for 2008.” You get penalized if you don’t buy health insurance, even if the health insurance that’s available is not high quality and is not affordable.

The other problem with this whole approach is that you don’t get the cost efficiencies that you get from universal health insurance, because you still have all this paperwork, you still have all the profit by private insurance companies, you still have doctors being given incentives to go for the reimbursable procedures. And as a result, the cost-containment pressures hit patients. They come in the form of less care, rather than in the form of less waste.

Juan Gonzalez: …both Krugman, in his various articles, and Clinton have claimed, on the one hand, that Obama does have mandates — he has mandates for coverage of all children — so that the mandates issue is not a principled issue, it’s a tactical issue as to what you think could be approved. Your sense of that?

Robert Kuttner: My point is that a mandate, in a situation where the whole system is sick, makes that sickness the problem of the individual. Instead of putting a gun to people’s heads, typically people who can’t afford good quality insurance, and saying to them, “You must, under penalty of law, or pay a tax or pay a fine, go out and find decent insurance,” it’s so much better policy to just have insurance for everybody. Then there’s no question of a mandate.

I think it’s a very bad position for progressives to back into, because it signals that government is being coercive, rather than government being helpful. Now, we can split hairs and argue whether Obama is being principled or tactical, but I think his discomfort with the idea of a mandate is something that I applaud. I wish that both he and Clinton had gone all the way and said, let’s just to do this right and have national health insurance. I think they could have used this as a teachable moment. They could have bought public opinion around. Medicare is phenomenally popular. Medicare is national health insurance for seniors. Let’s have national health insurance for everybody.

(Clip of Clinton/Obama debate)

Amy Goodman: It’s interesting to note something Hillary Clinton says in that clip. When she mentions a single-payer system, the audience applauds and cheers, even though it’s an option rarely seriously discussed by politicians or the corporate media. And Hillary Clinton acknowledges the applause by saying, “I know a lot of people favor [it], but for many reasons [it’s] difficult to achieve.” She doesn’t explain why she thinks it’s difficult to achieve. And polls repeatedly show a majority of Americans favor it. An A.P. poll in December found nearly two-thirds of voters want universal healthcare, in which everyone’s covered in a Medicare-type program, while more than half of voters explicitly said they support single payer. But it’s the insurance companies that are against it. Robert Kuttner, can you talk about that?

Robert Kuttner: Well, one of the reasons that it’s difficult to achieve is the lack of leadership on the part of leaders like Hillary Clinton and, for that matter, Barack Obama. I mean, if you had Hillary Clinton and Barack Obama say, “You know, this is an intramural debate that we should not be having, this debate about mandates; we should do this right: we should have national health insurance,” public opinion would turn around on a dime. And instead of it being this fringe idea, all of a sudden, just because the two of them had blessed it, it would become a mainstream idea, and we would be having a debate that we should have been having all along.

http://www.democracynow.org/2008/2/8/examining_clinton_obamas_stances_on_the

Comment:

By Don McCanne, MD

Talk about incompetent framing of the health care reform debate. Clinton and Obama are engaged in a cat fight over coercing the purchase of unaffordable and inadequate private plans, versus allowing individuals to go without coverage because it is unaffordable. Neither is acceptable.

Robert Kuttner is right. We need leadership on this issue. Affordable, comprehensive health care for everyone is fundamental to the Democratic position on reform, whereas this fundamental principle is nowhere to be found in the Republican proposals.

Either party could pull it together and support a universal, comprehensive national health program. For Democrats, it would require only minor policy adjustments and a revision of the framing. Republicans would have to build an entirely new policy infrastructure.

Barack Obama has said that, if starting anew, he would support a single payer system. Hillary Clinton understands that there is considerable public support for single payer and has said that she would sign a single payer bill if it came to her desk as president. So, how about showing a little leadership? Both of you.

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

Prescription for change

Hoosier doctor leads drive to fix ailing health system

By Daniel Lee
The Indianapolis Star
February 9, 2008

Dr. Rob Stone was a teenager in Southern Indiana when he felt the call to become a physician.

It began during a stint as a counselor at a camp in Tell City for children with disabilities. An Ivy League education and career as a doctor followed.

Then, decades later, came a second calling: He became an agitator for changing the nation’s health-care system.


Danese Kenon / The Star

Passion for public service: Bloomington doctor Rob Stone
consults with Lori Wilbur, Bloomington, at the Volunteers in
Medicine of Monroe County clinic. Stone, co-founder of
Hoosiers for a Commonsense Health Plan, donates time to
the clinic that serves the uninsured.

Stone, an emergency room physician at Bloomington Hospital, has emerged as one of Indiana’s most outspoken advocates for making insurance accessible to all. He is co-founder and director of Hoosiers for a Commonsense Health Plan, which contends that the current system is too profit-driven, too inefficient, and leaves too many people without affordable access to health care.

HCHP — made up of doctors, nurses, social workers, patients and others — is an affiliate of the national Physicians for a National Health Program.

From its founding in September 2005, HCHP has grown from a small band of advocates to a statewide citizens group with dozens of active volunteers and an e-mail list of more than 1,500.

Stone, 55, said his motivation stems from his many years of seeing the struggles of patients needing care.

“It started dawning on me just how crazy our current system is, and the cost shifting and the crazy patchwork quilt of payer sources, just how insane the system seems to be,” Stone said. “That, coupled with watching as the ER became more and more of the safety net for the uninsured.”

Stone brings that message to Indianapolis today during a public forum titled “Understanding the Health Care Crisis: Problems and Solutions,” which runs from 9 a.m. to noon at Indianapolis First Friends, 3030 Kessler Blvd., East Drive.

One of Stone’s favorite targets is Indiana’s largest health-care insurance provider, Indianapolis-based WellPoint, a $61 billion health insurance giant that provides coverage to 35 million people in America.
“WellPoint epitomizes our system,” he said. “They’re it.”

Stone’s PowerPoint presentation lays out his case. A Medicare-type program for all is better than the current system, he says. Medicare is currently for the elderly.

One slide — with information attributed to the International Journal of Health Services in 2005 — shows Medicare overhead spending was 3.1 percent of its budget, compared with 26.5 percent for investor-owned Blue Cross and Blue Shield plans.

Another slide — with information from the Employer Health Benefits Annual Survey and Bureau of Labor Statistics — showed that from 2000 to 2006 health insurance premiums rose 87 percent while workers’ earnings rose 18 percent.

About 47 million Americans, including 750,000 Hoosiers, are without health insurance.
It’s a complex and uphill battle.

” ‘Single payer’ is not a phrase that is rolling off anyone’s lips in the presidential race, with the exception of Dennis Kucinich,” said Alwyn Cassil, director of public affairs for the Center for Studying Health System Change, a Washington, D.C.-based research group.

Many Americans, she said, tend not to be interested in what they consider a government solution to the health-care crisis. Cassil said hospitals, insurers, device makers and many doctors benefit from the current system.

But Stone does have some allies. Physicians for a National Health Program was founded by two Harvard professors of medicine, David Himmelstein and Steffie Woolhandler, and has grown to more than 14,000 members.
“They’re a very dedicated, committed group,” Cassil said.

Groups like Stone’s, while small in the number of physicians who take part, are credible advocates because they’re out on the front lines of medicine and often stand to lose income if the reforms they seek ever become reality, Cassil said.

For its part, WellPoint sees having a competitive, free-market system as key to improving the quality of care and controlling costs.

“We believe a single-payer health-care system would hinder progress in these areas by eliminating competition and restricting patient choice and could require patients to endure long wait times for care while possibly reducing the quality of health care,” WellPoint spokesman Jim Kappel said in an e-mail.

In its recent earnings report, WellPoint touted that it lowered its administrative expenses to 14.5 percent of premium revenue in 2007 from 15.7 percent in 2006 even as it added 708,000 members.

The company also pointed to flaws in other nations’ health-care systems.

“In Canada, which has a single-payer system, the average wait between a general practitioner referral and a specialty consultation at times has been longer than 17 weeks.”

Stone stands by his position. He recalls a patient who refused to seek treatment for chest pains that turned out to be a heart attack. He finally sought treatment for a second attack, only because the first attack left him disabled — but now eligible for government coverage.

The physician has scaled back his work at Bloomington Hospital to two shifts a week to devote more time to HCHP. He volunteers at a clinic for the uninsured and serves on the hospital’s board and as chief of its medical staff. He also is a partner of his physician practice, Unity Physician Group.

Stone and his wife, Karen Green Stone, who heads HCHP’s education committee, live in a home that Stone built outside Bloomington. Their home is unofficial headquarters for the state organization.

He is finding many people who are willing to listen.

“Dr. Stone put together an incredible amount of information. It was very eye-opening,” said Beth Henricks, a tax consultant and Geist-area resident who saw Stone’s presentation to a group of executives several months ago in Indianapolis. “When I see somebody who’s that passionate, that’s really appealing to me.”

Stone’s point that the United States already has a “single-payer” program in Medicare that covers millions seemed to make sense, said Henricks, whose company First Advantage has faced annual health insurance premium increases of 20 percent to 25 percent in recent years.

“Medicare works pretty well, and it’s been around for a long time, so why not pattern something after Medicare?”

Veterans are growing segment of the uninsured in America

By Dr. Rob Stone
Bloomington Herald Times
Guest Column
February 9, 2008

Recently I heard someone refer to those without health insurance as “losers.” It made my blood boil. The implication was that they had made poor choices and didn’t “deserve” health care.

Of the 47 million without health insurance in this country, about 18 percent are children. The majority of the uninsured work, many at more than one job, but either they work a job that doesn’t offer insurance, or if it is offered, they can’t afford it.

Many of them made the mistake of getting sick, and now that they have diabetes or cancer, they have a “pre-existing condition,” and cannot get coverage for any affordable price. Is it an American value to dismiss children, sick adults, and working people as “losers”?

A newly published study from Harvard in the American Journal of Public Health (Himmelstein, Woolhandler, et al, December issue) adds a new sad story to the picture — another bunch of losers — American veterans. Almost 2 million of the uninsured are veterans, along with almost 4 million of their family members, so that one in every eight uninsured is a veteran or member of a veteran’s household.

The number of uninsured vets is up 290,000 since 2000, and many are barred from VA care because of a 2003 Bush administration order that halted enrollment for most middle-income veterans.

Uninsured veterans have as much trouble getting medical care as other uninsured people; 26 percent of uninsured veterans reported that they had failed to get needed care due to costs; 31 percent had delayed care due to costs; 49 percent had not seen a doctor within the past year; and two-thirds failed to receive preventive care. And like the uninsured in general, nearly two-thirds of uninsured veterans are working.

“Since President Bush took office, the number of uninsured vets has skyrocketed, and he’s cut eligibility, barring hundreds of thousands of veterans from care. This administration has put troops in harm’s way overseas and abandoned them and their families once they got home,” said Dr. David Himmelstein, coauthor of the study and co-founder of Physicians for a National Health Program. “We need a solution that works for veterans, their families, and all Americans — single payer national health insurance.”

I went into medicine to care for the sick. Everyone who is sick has lost something, and the health care system is supposed to help. Yes, we have winners and losers in America. Anthem and the other insurance companies are making record profits, so they look like winners. Wall Street loves them. But there are too many losers, like the millions of veterans and their family members who cannot get health care. Let’s not write off the uninsured as losers — let’s figure out how to make us all winners.

I work in the emergency room, and every day I take care of people who are afraid to come to a doctor because they know they can’t pay the bill, who fear the cost as much as they fear the diagnosis I may give them. They have lost something. Most have lost piece of mind. Many have lost dignity. Some have lost hope. It’s disgraceful that some would rather write them off as losers, and turn away.

It’s a matter of values. As Americans, we take care of each other. We take care of the young, the elderly, and the sick. We should take care of veterans. We should take care of everyone. Let’s work together to get health care for all.

This guest column was written by Rob Stone, a Bloomington physician.

Hey, candidates: selling insurance no health plan

By Rose DeMoro
Guest Column
Waco Tribune
Sunday, February 10, 2008

With the presidential contest closing in on Texas, voters may well wonder how to distinguish among the various candidates on health care, which — at least on the Democratic side — has been one of the hottest issues of debate.

The central difference is on the role of insurance. Why does this matter?

Listen to Lyle Schiele of Dallas.

“As an owner/operator in the trucking industry, I was contracted to a major trucking company. I purchased my health insurance at what was to me an enormous monthly cost of $760 through that company.

“In February ’06 I had some minor chest pains. Doctors found clogged coronary arteries and treated them with stents in two locations. As a result of this diagnosis and treatment, I was medically disqualified from trucking for 90 days. As a contractor, I wasn’t covered by COBRA and therefore lost my health insurance.

“After returning to trucking as an owner/operator and applying with several different insurance companies, I found none would sell me any. Recently, as a matter of necessity, I sold my truck and went to work as a driver with a company, primarily for the health insurance benefit.

“I was not looking for a handout. I don’t mind paying my own way. But I am no longer given that opportunity. The ‘American Dream’ of owning and operating one’s own business and success based on one’s ability and performance has been taken away. Because of the health insurance issue I can no longer operate as an independent again.”

Lyle is one of hundreds who responded to a California Nurses Association/National Nurses Organizing Committee ad describing the disparity of care available to Vice President Cheney and members of Congress and the rest of us (www.cheneycare.org).

His story is not unique. One in six insured adults has substantial problems paying medical bills, one report noted last year, and 42 percent told Zogby-UPI pollsters that their insurer had refused to pay a medical bill.

Yet, selling us more insurance — without ending insurance industry price gouging or the callous, all too routine denials of care — is at the heart of the leading candidates’ proposals in both parties.

Republicans mainly emphasize tax incentives and further unleashing a market that has already ushered in an 87 percent increase in insurance premiums alone the past decade, not counting the co-pays, deductibles and other staggering costs.

Top Democrats favor a more comprehensive approach with expanded public programs for children and the poor. But only Sen. Hillary Clinton is pushing an “individual mandate,” the requirement for everyone to buy insurance with no meaningful controls on its cost or assurances that you won’t be denied care when you need it.

Sen. Barack Obama says people don’t have insurance not because they don’t want it, “but because they can’t afford it.” He has a point.

A Kaiser Family Foundation 2007 survey found that family premiums now average $12,106 — not including all the add-ons.

Clinton’s argument that Obama is “leaving out” people by objecting to the mandate, and that requiring everyone to buy insurance constitutes “universal health care” is disingenuous.

“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.

Clinton has also criticized Obama for his past comments about a real alternative to an insurance-based system. In 2003 Obama called himself “a proponent of single-payer, universal healthcare coverage . . . everybody in, nobody out” — essentially an expanded and improved Medicare for all.

It’s a system, with some nuances, in place in every other Western country, and it works. A January, study by the London School of Hygiene and Tropical Medicine, for example, found the U.S. ranked worst among 19 industrial nations in preventable deaths.

Those results should make such a system a model for the U.S., not a campaign attack point.

What Obama says now, as he did again in a recent debate in South Carolina, is “if I were designing a system from scratch, I would set up a single-payer system.”

We are starting from scratch. Our present system has hit rock bottom, as Lyle and so many others can attest. Our families deserve no less.

Rose Ann DeMoro is executive director of the 80,000-member California Nurses Association/National Nurses Organizing Committee and a national vice president of the AFL-CIO.

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.