PNHP

World’s Best Medical Care? (New York Times)

World’s Best Medical Care? (New York Times)

World’s Best Medical Care?

Editorial
The New York Times
August 12, 2007

Many Americans are under the delusion that we have “the best health care system in the world,” as President Bush sees it, or provide the “best medical care in the world,” as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.

Michael Moore struck a nerve in his new documentary, “Sicko,” when he extolled the virtues of the government-run health care systems in France, England, Canada and even Cuba while deploring the failures of the largely private insurance system in this country. There is no question that Mr. Moore overstated his case by making foreign systems look almost flawless. But there is a growing body of evidence that, by an array of pertinent yardsticks, the United States is a laggard not a leader in providing good medical care.

Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. More recently, the highly regarded Commonwealth Fund has pioneered in comparing the United States with other advanced nations through surveys of patients and doctors and analysis of other data. Its latest report, issued in May, ranked the United States last or next-to-last compared with five other nations — Australia, Canada, Germany, New Zealand and the United Kingdom — on most measures of performance, including quality of care and access to it. Other comparative studies also put the United States in a relatively bad light.

Insurance coverage. All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients. The United States, to its shame, has some 45 million people without health insurance and many more millions who have poor coverage. Although the president has blithely said that these people can always get treatment in an emergency room, many studies have shown that people without insurance postpone treatment until a minor illness becomes worse, harming their own health and imposing greater costs.

Access. Citizens abroad often face long waits before they can get to see a specialist or undergo elective surgery. Americans typically get prompter attention, although Germany does better. The real barriers here are the costs facing low-income people without insurance or with skimpy coverage. But even Americans with above-average incomes find it more difficult than their counterparts abroad to get care on nights or weekends without going to an emergency room, and many report having to wait six days or more for an appointment with their own doctors.

Fairness. The United States ranks dead last on almost all measures of equity because we have the greatest disparity in the quality of care given to richer and poorer citizens. Americans with below-average incomes are much less likely than their counterparts in other industrialized nations to see a doctor when sick, to fill prescriptions or to get needed tests and follow-up care.

Healthy lives. We have known for years that America has a high infant mortality rate, so it is no surprise that we rank last among 23 nations by that yardstick. But the problem is much broader. We rank near the bottom in healthy life expectancy at age 60, and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care. The good news is that we have done a better job than other industrialized nations in reducing smoking. The bad news is that our obesity epidemic is the worst in the world.

Quality. In a comparison with five other countries, the Commonwealth Fund ranked the United States first in providing the “right care” for a given condition as defined by standard clinical guidelines and gave it especially high marks for preventive care, like Pap smears and mammograms to detect early-stage cancers, and blood tests and cholesterol checks for hypertensive patients. But we scored poorly in coordinating the care of chronically ill patients, in protecting the safety of patients, and in meeting their needs and preferences, which drove our overall quality rating down to last place. American doctors and hospitals kill patients through surgical and medical mistakes more often than their counterparts in other industrialized nations.

Life and death. In a comparison of five countries, the United States had the best survival rate for breast cancer, second best for cervical cancer and childhood leukemia, worst for kidney transplants, and almost-worst for liver transplants and colorectal cancer. In an eight-country comparison, the United States ranked last in years of potential life lost to circulatory diseases, respiratory diseases and diabetes and had the second highest death rate from bronchitis, asthma and emphysema. Although several factors can affect these results, it seems likely that the quality of care delivered was a significant contributor.

Patient satisfaction. Despite the declarations of their political leaders, many Americans hold surprisingly negative views of their health care system. Polls in Europe and North America seven to nine years ago found that only 40 percent of Americans were satisfied with the nation’s health care system, placing us 14th out of 17 countries. In recent Commonwealth Fund surveys of five countries, American attitudes stand out as the most negative, with a third of the adults surveyed calling for rebuilding the entire system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada.

That may be because Americans face higher out-of-pocket costs than citizens elsewhere, are less apt to have a long-term doctor, less able to see a doctor on the same day when sick, and less apt to get their questions answered or receive clear instructions from a doctor. On the other hand, Gallup polls in recent years have shown that three-quarters of the respondents in the United States, in Canada and in Britain rate their personal care as excellent or good, so it could be hard to motivate these people for the wholesale change sought by the disaffected.

Use of information technology. Shockingly, despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines.

Top-of-the-line care. Despite our poor showing in many international comparisons, it is doubtful that many Americans, faced with a life-threatening illness, would rather be treated elsewhere. We tend to think that our very best medical centers are the best in the world. But whether this is a realistic assessment or merely a cultural preference for the home team is difficult to say. Only when better measures of clinical excellence are developed will discerning medical shoppers know for sure who is the best of the best.

With health care emerging as a major issue in the presidential campaign and in Congress, it will be important to get beyond empty boasts that this country has “the best health care system in the world” and turn instead to fixing its very real defects. The main goal should be to reduce the huge number of uninsured, who are a major reason for our poor standing globally. But there is also plenty of room to improve our coordination of care, our use of computerized records, communications between doctors and patients, and dozens of other factors that impair the quality of care. The world’s most powerful economy should be able to provide a health care system that really is the best.

http://www.nytimes.com/2007/08/12/opinion/12sun1.html?pagewanted=all

Comment:

By Don McCanne, MD

We have the money. We should have “the best health care system in the world.” But building on mediocrity will only bring us more mediocrity at ever greater levels of spending.

We are already using the tax system to pay for two-thirds of our health care (Reinhardt). But now we need to do what every other nation has done: establish public policies that improve the allocation of our health care resources. That means that we must remove the private stewards of our health care funds as they have proven themselves to be utterly incompetent.

If we are going to raise our health care system above the level of mediocrity, we simply have to place our public funds under the control of our own public stewards – through a program of national health insurance.

Uwe Reinhardt quote on two-thirds of health care spending through the government:
https://www.pnhp.org/news/2006/december/private_plans_pay_so.php

Health-care system: Single payer is the way to go

By Hedda Haning
The Charleston Gazette
August 12, 2007

Three commentaries in the Aug. 5 Sunday Gazette-Mail related to the costs of medical care in the United States — one on children’s coverage, one on the negative effects on business and one reporting the negative effects of privatization on Medicare. But the most stunning demonstration that the system is broken was the article describing a Florida couple receiving nursing home care in India.

In the 1930s FDR’s original Social Security legislation included medical coverage, modeled on European programs of the time. The AMA fought the medical part vigorously. Not wanting to risk his entire program, FDR removed medical insurance from the plan.

During World War II, wages were controlled, and employers, trying to attract workers in a tight labor market, added medical insurance to wages as an inducement. The strategy worked. Thus was medical insurance linked to employment. It was really a pragmatic accident of the times, rather than the result of studious deliberation.

Which brings us to where we are now. Because of major advances in science and technology, medicine has much more to offer us, and it is now an expensive necessity rather than an optional nicety. Many jobs have been outsourced. Few jobs last a lifetime. The labor market is not tight, so employers don’t need benefits to attract workers. The result is that far fewer people have coverage through their work. And the self-employed have always had to finance their own care, all while costs are climbing far faster than inflation.

Co-payments and deductibles raise consumers’ out-of-pocket costs substantially higher. Claims are denied. Many insured do not get the care they need, and the uninsured are totally out in the cold, but often invisible to the community.

Furthermore, as Dr. Dan Foster mentioned, the high cost of privately insured health care is becoming an unsustainable burden for business. Plainly the system that worked in World War II and through the 1980s is not working now.

Contrary to President Bush’s assertion, desperately getting emergency help is not equivalent to having dependable, readily available health care. Everyone agrees we have a problem. The solution is in contention. The favorite approach now is to help Americans buy into private insurance plans.

It is time for a reality check.

Private insurers are in business to make a profit for their stockholders. For most companies, 30 percent of premiums go to administration, marketing and profits. Private insurers have an incentive to hold down their own costs and increase their profits. They have no incentive to hold down subscriber costs or improve subscriber care, both of which would cut into profits.

Perhaps we should use our experience with safety services, schools, libraries and roads to suggest a solution. First, concentrate on care, not insurance. Insurance is only one route toward paying for health care. All health care should be:

* Universal and equitable — the same care available to everyone, including Congress.

* Unaffected by employment status, pre-existing conditions or ability to pay.

* Comprehensive, covering all medically necessary expenses including primary care, medications, procedures, hospitalizations, mental health, dental, nursing home and home health care.

* Non-profit, a regulated public service.

* Totally paid for from tax-supported public funds with no co-payments and no deductibles.

* Portable throughout the United States.

You would continue to choose your own doctor and hospital. The difference is in the payment system. Payments to providers and hospitals would come from a single payer, an agency local enough to be workable, such as representing a single state or a group of states. Without paperwork for each visit, administrative costs would be greatly reduced.

A single system can better assess the application of new technology and quality of care outcomes, and regulate medication quality and cost. Since we would all be in the same boat, we would all have an incentive to fix the problems that will surely arise.

Furthermore, preventive and primary care could become the priority they should be. That would include paying for all children to have routine exams and immunizations.

Most people don’t know that the federal government already pays for two-thirds of health-care costs through programs including Medicare, Medicaid, the military and tax breaks. The federal government already pays — right now — more per capita for health care than other developed nations pay.

Some think that the most important goal is to protect private insurance company profits. That is why the attempt is being made to privatize Medicare in spite of demonstrable increased cost and poorer performance.

You’ve heard the argument against this proposal: “not politically feasible,” which means the insurance and pharmaceutical companies don’t like it.

Yet most primary-care physicians support such a program, as do numerous medically affiliated professionals, unions and non-profit organizations. Doctors in other capitalist countries are quite positive about their own single-payer systems, as are the patients they serve. They do research, develop and use new drugs, and have access to more advanced technology than we do. They have less interference with their medical decisions than our doctors. And their health outcomes are better than ours, all while keeping health care reasonably affordable.

Perhaps it’s un-American? Still polls show that two-thirds of Americans support such a program, even if they have to pay more in taxes to get it, which would still cost less than paying for private insurance. Single payer is the only feasible plan.

Of course there are details to be worked out, but we are in serious trouble here. Other developed countries have succeeded in providing better health care than we do for half the cost. Aren’t we as smart as they are?

Haning is an anesthesiologist and a member of the Mountain State Physicians for a National Health Program.

CMA testimony on Blue Cross

CMA Calls Blue Cross a Leader in Profits, Not Patient Care

California Medical Association
California Physician
August 9, 2007

CMA on Tuesday asked the Department of Managed Health Care to take action against Blue Cross of California for jeopardizing the physician-patient relationship and engaging in unlawful business practices that have reduced patient access to care.

CMA testified at a public hearing in Los Angeles that Blue Cross has violated the promises it made to California patients when it merged with Anthem Health Care in 2004. Since that merger, Blue Cross has consistently increased premiums, while reducing the amount of money spent on patient care. The insurer is now dangerously close to not having enough physicians available to serve the 8.3 million Blue Cross patients in California.

With the consolidation of the health plan industry, both nationally and in this state, competition among the insurance companies has been severely diminished, if not eliminated, much to the detriment of the very individuals these plans promise to serve patients and their treating physicians, CMA said in its written testimony. The turmoil created by Blue Cross has taken its toll on everyone. It must be remembered that it is physicians who provide medical care to patients, not health plans.

DMHC called the hearing to review commitments made by Blue Cross when it merged with Anthem three years ago. DMHC this year alone has initiated 18 enforcement actions against Blue Cross, including multiple fines a significant increase from previous years.

CMA contends that among a vast collection of misdeeds, Blue Cross has:

* reimbursed physicians at unconscionably low levels, at times below the actual cost of care;

* increased consumer premiums at a much higher rate than any other major health insurer, raising rates as much as 10 percent in a single year;

* rescinded authorization and refused to pay for care provided in good faith;

* reduced reimbursement levels without appropriate notice;

* retroactively canceled individual health insurance coverage after policyholders got sick.

For at least a decade, Blue Cross has consistently spent less on medical care than the 85 percent required by law, at the same time raising premiums and increasing profits.

While Blue Cross seems averse to paying physicians fairly and spending adequately on health care, the insurer plans to spend $2 million this year trying to defeat health reform proposals designed to increase access to care in California.

Blue Cross’s misbehavior shows significant signs of diminishing the supply of physicians, already a growing problem in California. CMA and its county component medical societies have received a number of calls from physicians who have determined that they can no longer financially and ethically provide medical care under the dictates of Blue Cross and are being forced to terminate their contracts altogether.

http://www.calphys.org/html/cc482.asp

CMA testimony:
http://www.cmanet.org/upload/bc_testimony_080707.pdf

Comment:

By Don McCanne, MD

Wall Street analysts have continued to praise Blue Cross of California and its parent company (WellPoint) as being leaders in private insurance innovations that have led to stellar performances in the equities markets. Blue Cross/WellPoint has led, and in order to remain competitive, the others (including the non-profits) have followed.

As we reform our system of health care financing, do we really want more of this type of leadership? If not, we’re going to have to let our politicians know, because they’re headed that way.

WHO report on private insurance and cost sharing

What are the equity, efficiency, cost containment and choice implications of private health-care funding in western Europe?

By Sarah Thomson and Elias Mossialos (London School of Economics and Political Science)
World Health Organization
Health Evidence Network
July 2004

The issue

Over the last 20 years the level of private spending on health care has risen in many western European countries, leading to concern about its impact. The main channels of private spending are private health insurance policies and cost-sharing schemes in public health systems.

Findings

Evidence shows that private sources of health care funding are often regressive and present financial barriers to access. They contribute little to efforts to contain costs and may actually encourage cost inflation.

Private health insurance

The role of private insurance in western European health systems is largely determined by the extent of statutory health insurance. The evidence shows that:

* Allowing people to opt out of statutory health insurance threatens its long-term financial stability.

* Relying on complementary private health insurance to protect people against high levels of statutory user charges can increase inequities in access to care between those who can and cannot obtain such coverage.

* Supplementary private insurance increases inequalities of access, particularly where there are no clear boundaries between public and private health care provision.

* Tax subsidies for private health insurance are inefficient – because they distort signals about the real price of insurance and generate transaction costs – and inequitable, as they tend to benefit higher income groups.

* Private health insurers lack efficiency incentives and tend to incur higher administrative costs than statutory health insurance. Publicly-funded systems are generally more successful in controlling cost inflation than mainly privately-funded systems.

* Private health insurance can increase choice for some, but not to the extent that is often suggested, and under certain circumstances it may even restrict choice.

Cost sharing

Cost sharing is widely used in western European health systems to moderate demand and/or raise revenue. However, the theoretical case for cost sharing is weak, particularly when applied to health care arising from referral or prescription. The evidence shows that:

* Cost sharing shifts costs to individuals and leads to significant reductions in the use of health care.

* Cost sharing reduces the use of both appropriate and inappropriate health care, which has negative implications for equity and efficiency.

* Cost sharing is not an effective means of containing costs.

* Differential charges can be used to encourage more cost-effective patterns of health care use.

* Because cost sharing creates financial barriers to access, it should be accompanied by mechanisms to protect heavy users of health care and lower income groups.

* Exemption systems require administrative capacity, may generate significant transaction costs and may limit cost sharing’s ability to raise revenue.

http://www.euro.who.int/document/e83334.pdf

Comment:

By Don McCanne, MD

Even though released three years ago, this primer on private health care funding of Western European countries is especially informative for the dialogue on health care reform now taking place in the United States.

The report demonstrates that both private health insurance and patient cost sharing have a negative impact on equity, efficiency and affordable access to care. Some contend that we have to accept these perversities in order to contain health care costs. But one of the most important findings in this report is that neither is effective controlling cost inflation.

I omitted the policy recommendations that were presented in this report. They recommend greater regulation of the private insurance industry, and more careful design of cost sharing. Even though they (inadvertently?) presented a very compelling case for eliminating private insurance and cost sharing, being from the London School of Economics, it appears that they would try to make private funding work.

Regardless, this is an excellent primer on the flaws of financing health care through private insurance and cost sharing. It is well worth downloading and retaining as an important resource in our national dialogue on reform.

Just ignore their policy recommendations and substitute ours: Let’s design our national health insurance program so that it provides comprehensive benefits for everyone, funded equitably, while removing financial barriers to care. Let’s contain costs through patent-friendly supply side mechanisms. Then we could send the private insurers on their way, and they can take their perversities with them.

"Speechless" ads from Iowa

Click here for Press Release.

From The Washington Post’s The Fix:

WINNERS

California Nurses Association (and Physicians for a National Health Program): The group aired two television ads during the debate — calling out Obama and Clinton in particular — that emphasized the need for real reform on health care. It was a huge platform for the group and is like to win them and their cause more notice in the coming days. Plus, The Fix is a sucker for cardboard cutouts of politicians in ads.

A great editorial from the Des Moines Register:

In search of vision on health care
Editorial | Des Moines Register
What’s needed: a president with the vision and passion to reform this country’s health-care system the way Johnson and Congress eventually did. It’s up to Iowans – who are in the unique position of being visited by droves of presidential candidates – to demand that kind of vision and passion from our visitors. [More]

Ask me about single payer guaranteed health care for everyone!

“Speechless” ads from Iowa

Click here for Press Release.

From The Washington Post’s The Fix:

WINNERS

California Nurses Association (and Physicians for a National Health Program): The group aired two television ads during the debate — calling out Obama and Clinton in particular — that emphasized the need for real reform on health care. It was a huge platform for the group and is like to win them and their cause more notice in the coming days. Plus, The Fix is a sucker for cardboard cutouts of politicians in ads.

A great editorial from the Des Moines Register:

In search of vision on health care
Editorial | Des Moines Register
What’s needed: a president with the vision and passion to reform this country’s health-care system the way Johnson and Congress eventually did. It’s up to Iowans – who are in the unique position of being visited by droves of presidential candidates – to demand that kind of vision and passion from our visitors. [More]

Ask me about single payer guaranteed health care for everyone!

For vaccines, underinsurance worse than no insurance

Gaps in Vaccine Financing for Underinsured Children in the United States

By Grace M. Lee, MD, MPH; Jeanne M. Santoli, MD; Claire Hannan, MPH; Mark L. Messonnier, PhD; James E. Sabin, MD; Donna Rusinak; Charlene Gay; Susan M. Lett, MD, MPH; Tracy A. Lieu, MD, MPH
JAMA
August 8, 2007

Children who are uninsured or who have public health insurance, such as Medicaid, can receive vaccines free of charge through the Vaccines for Children (VFC) program.

Only 34% of states had a health insurance mandate that required insurers to follow current ACIP or American Academy of Pediatrics recommendations for children and adolescents. Seventeen percent of states had a health insurance mandate that did not require insurers to cover all recommended vaccines and 49% of states did not have any health insurance mandate.

Limitations in both federal (section 317) and state vaccine financing were reported as the dominant barriers to states’ providing vaccines to underinsured children. Lack of section 317 funding was cited as a barrier for 81% (Tdap) to 100% (pneumococcal conjugate) of state immunization programs that were not able to provide vaccines to underinsured children. State funding was either limited or unavailable for vaccine purchase for 94% or more of programs that were not able to provide vaccines to underinsured children.

The public sector safety net for offering vaccine to underinsured children seems to be under considerable strain. Past studies have suggested that many private clinicians refer underinsured children to public health clinics for vaccination. Unfortunately, a growing number of states are no longer able to provide expensive vaccines, such as the meningococcal conjugate vaccine, to underinsured children in the public sector. Furthermore, the proportion of vulnerable US children whose insurance plans either do not cover vaccines or require families to pay out-of-pocket for preventive care is likely to grow. A recent article by the American Academy of Pediatrics found that 20% of employers are offering catastrophic health insurance plans (high-deductible health plans), up from only 5% in 2003, and only 30% of these plans covered preventive care before the deductible was met. These trends are of concern because inadequate insurance coverage has been associated with forgone health care among families who lack resources.

Despite the ability of vaccines to prevent illness and death, our current system of vaccine financing has resulted in a gap for underinsured children.

http://jama.ama-assn.org/cgi/content/full/298/6/638

Comment:

By Don McCanne, MD

The crisis in the affordability of private health insurance can only result in an expansion in the current epidemic of underinsurance. If insurers are to maintain a market for their products, they must continue to find innovative methods of not paying for health care.

Vaccines for children are so important that we have in place public policies that ensure that children covered by public insurance programs and children without any health insurance at all will still receive their immunizations. Our public policies also presume that vaccines will be provided on a private basis for privately insured children. The response of the private insurers confirms that this latter assumption is not valid, especially considering that the cost to fully vaccinate a child in the public sector is $1170.

There is a fundamental difference between public insurance and private insurance. Public insurance is founded on policies that help to ensure that people receive the health care that they need, when they need it. That includes vaccines for children. Private insurance is founded on policies that ensure success in a competitive marketplace that trades off lower insurance premiums for limiting access to care that people need. That includes limiting affordable access to childhood vaccines.

Leaving policy decisions under the control of the private stewards of a competitive market of underinsurance will result in adverse outcomes such as the preventable deaths of untold numbers of children for lack of vaccines. Isn’t it time for us to dismiss the private stewards and hire our own public stewards who really do care about the health of our children, and the health of the rest of us?

See SICKO! And Learn about Private Health Insurance

by Paul Sorum, MD
Daily Gazette (Schenectady, NY)
July 29, 2007

You should see Michael Moore’s SICKO. You will both laugh and cry. You will feel disgusted both with our health care system and with Moore. It is, in Moore’s typical style, outrageous, one-sided, and contrived.

But its fundamental message–that the private health insurance industry is dangerous to our health–will resonate loudly with patients and physicians. Here is why:

* Private insurers impose on medical practitioners and their patients a huge financial and psychological burden of rules, paperwork, delays, and denials. Even their attempts to improve “quality” scores increase this burden.

* Private insurers add enormous extra costs to our already skyrocketing medical expenditures. These include both insurers’ administrative costs–the salaries of their highly-paid executives and armies of employees, their marketing expenses, and (in the case of for-profit insurers) their profits–and the billing-related costs imposed on providers. In 2001, we spent $351 per capita on administrative costs, while the Canadians spent only $54 and the French only $48.

* Soaring health premiums–caused in part by private insurers’ administrative waste–are causing employers to reduce or drop health insurance benefits and preventing individuals from purchasing adequate insurance. Not only are 47 million (15% of the population) currently uninsured and many more millions inadequately insured, but these numbers are rising inexorably.

* As long as health insurance is a market commodity, private insurers must reduce their costs as much as possible, i.e., must spend as little as possible of their premiums on actual health care. Even if individual medical directors and other employees are virtuous and well-meaning, they must avoid sick patients and deny care if their companies are to survive in the market.

* Private insurers cannot make the health of the population their top priority. They must, like other businesses, focus on short-term results, not on the long-term health of their enrollees (especially since these people are likely to change insurers and eventually switch to Medicare). Moreover, in marketing their products to select groups, they fragment the population and undermine our already-fragile sense of social solidarity: they reinforce people’s short-sighted inclination to refuse to pay for those with more health needs, and fewer means, than themselves. They encourage healthy people to forget that they might one day suffer major illness and injury and that they and society as a whole benefit if all people are as healthy as possible.

So what does Moore offer us as a solution? He takes us to other developed countries–Canada, Britain, France–where private insurers have greatly reduced roles. These countries have, of course, more problems than Moore shows us; no system can be perfect. But they provide high-quality health care to all residents, at half our cost. They have high levels of patient satisfaction (yes, in spite of complaints in Canada and Britain about waiting lines). They interfere in patient-physician decision-making less than do US managed care companies. Their health systems are based on the principle that all residents should have the health care they need.

But would a publicly-financed system be, in some way, un-American? As Moore points out, we already use public funding for other social goods like schools and fire protection. And we already have in this country a health program that is publicly funded, liked by patients, and efficient: Medicare. Recently, for-profit Blues spent 26.5% of premiums on administrative costs, commercial carriers 19.9%, not-for-profit Blues 16.3%, and Medicare only 3.1%. If we expand Medicare to provide comprehensive coverage for everyone, we will, therefore, not only improve the health of our population and eliminate the scandal of the uninsured, but also end up saving money!

What then should you do? See SICKO and bring our elected officials with you. Convince them that Americans’ health is too important to leave in the hands of the private insurance industry. Convince them that, like the Canadians, British, and French, we should provide our people with the health care they need, not what they can pay for.

Paul Sorum lives in Schenectady, is a primary care physician in Latham, and chairs the Capital District chapter of Physicians for a National Health Program.

Consumer Reports Health Care Survey

Consumer Reports
August 6, 2007

Summary of Key Findings

A survey of the health care experiences of 2,905 nationally representative respondents was conducted in May, 2007. We focused on respondents’ experiences of the past 12 months. The population sampled was U.S. residents between the ages of 18 to 64 who were covered by neither Medicare nor Medicaid.

Our findings indicate that there are three tiers of health care consumers in the United States: the adequately-insured, who account for 59% of all Americans in the population sampled; the underinsured, who represent 24% of all Americans sampled; and the uninsured, who comprise 16% of our sample.

From a list of possible complaints about their health plans, respondents were asked to indicate which characterized their plans. Our initial factor analysis identified 6 specific, highly-correlated items that collectively defined our scope of coverage dimension. An additive scale was constructed from these items. We found that at the plateau of two complaints, the health care experiences of insured respondents diverged sharply. Those insured respondents with two or more complaints have been identified as the underinsured. To illustrate the depths of these concerns, 63% of the underinsured indicated their health plan does not adequately cover prescription drug costs.

Our principal finding is that the underinsured represent a large segment of the American population between the ages of 18 to 64: 29% of all persons with health plans, and 24% of the population as a whole. Although the travails of the uninsured have been widely-documented, our observation is that the uninsured represent only one segment of those lacking adequate health insurance. When we add together the uninsured (16%) with the underinsured (24%), we find two-fifths of a nation burdened by health care jitters.

Here is a sample of the experiences of the underinsured in the past 12 months:

56% postponed needed medical care because of costs

33% had to dig deep into their savings to pay medical expenses

34% of those 50+ said decisions about retirement were adversely affected by health care expenses

21% made job-related decisions based _mainly _on health care needs.

27% had outstanding medical debts still owed doctors or hospitals, and 17% were carrying medical debts of $5,000 +

38% postponed home or car maintenance or repairs due to medical expenses

71% indicated they were dissatisfied with their household’s share of out-of-pocket medical expenses

37% said they were at all prepared to financially handle unexpected major medical expenses they might face in the next 12 months.

In short, these data warrant a more expansive discussion about health care policy in the U.S. Recognition of the problems of the 16% who are uninsured acknowledges only part of the story. Respecting the burdens of an additional 24% with inadequate health plans compels a more thorough assessment of what ails the health care system.

Unlike the uninsured, who stand out as distinctly less affluent, less educated, and less white than the insured population, the underinsured are not demographically distinct from their adequately-insured compatriots. Their median income of $58,000 is about twice as great as the median incomes of the uninsured. They are just as white, and nearly as well-educated, just as likely to work full-time and to work in large or medium-sized companies. They could well be the neighbors of the adequately insured.

There is luck-of-the draw eeriness about these findings. Most riveting are the responses to a survey item asking respondents whether their current health plan is better or worse than the plan they had prior to it. One-quarter of the underinsured qualified to answer. Only 30% of them rated their current plan as better, and 51% worse, than their previous plan. These are disturbing findings consistent with our knowledge of the persistent pressure on employers to offer less comprehensive benefits to meet the rising costs of their health insurance premium payments.

Children harmed by static SCHIP eligibility

Dynamics In Medicaid And SCHIP Eligibility Among Children In SCHIP's Early Years: Implications For Reauthorization

By Anna S. Sommers, Lisa Dubay, Linda J. Blumberg, Fredric E. Blavin, and John L. Czajka
Health Affairs
August 7, 2007

In 2004 approximately six million children were eligible for public health insurance through Medicaid or the State Children’s Health Insurance Program (SCHIP) but remained uninsured at least part of the year. These numbers reflect one of the biggest challenges facing the public health insurance system for children today: how to reduce the number of uninsured eligible children and increase continuous coverage for children enrolled. These issues are a major policy concern because the uninsured are more severely ill when diagnosed and receive less therapeutic care than the insured, resulting in higher mortality. Parents of uninsured children report worrying all the time that their children will get hurt and need medical care. Children with discontinuous coverage are more than thirteen times as likely to delay care as are children who are continuously insured.

Only nine states and the District of Columbia administer SCHIP solely as a Medicaid expansion, relying on the same benefits and provider networks but applying different eligibility rules. In all other states, certain populations are enrolled in a separate SCHIP program, with more limited benefits and a different provider network, and some families are required to pay copayments and premiums.

Churning in and out of public coverage is a well-documented burden in Medicaid. In addition, about two million children move between Medicaid and SCHIP each year. Less well understood is the underlying eligibility dynamics of children, which could be of a much larger magnitude than is apparent from studying enrolled populations. In 2002, thirty-six million children were eligible for either program during the year. Because eligibility depends on a child’s age, family income, and assets, and, in SCHIP, access to private coverage, a change in any of these factors can trigger changes in eligibility.

In this study we analyze eligibility dynamics in Medicaid and SCHIP for children over the period 1996-2000. (Changes in the Census Bureau’s Survey of Income and Program Participation after 2000 made it impossible to continue tracking past that date.)

Study Results

Over the full course of the four-year panel, 66 percent of all children (fifty-nine million) were eligible for either Medicaid or SCHIP at some point during the panel. By comparison, point-in-time estimates are much lower and show that 33 percent of all children in the first wave of the panel and 46 percent in the last wave were eligible for either program.

More than one-third of all children who were ever eligible for Medicaid during the panel were also eligible for SCHIP in other waves, while nearly three-fourths of all children who were ever eligible for SCHIP during the panel were also eligible for Medicaid in other waves.

Overall, 32 percent of all eligible children were eligible for both Medicaid and SCHIP during the course of the panel, representing about one-fifth of all children, or almost nineteen million children. Another 57 percent were eligible only for Medicaid, and 12 percent were eligible only for SCHIP. About one in five children (18 percent) were always eligible for either Medicaid or SCHIP in every wave of the panel, while 48 percent of all children were eligible for only some waves, and the remaining third were never eligible.

The sometimes eligible children represent 73 percent of children who were eligible at any point, while the always eligible constitute 27 percent. About half of the sometimes eligible became SCHIP-eligible, compared with 29 percent of the always eligible. Eligibility for public coverage is often characterized by interruptions in eligibility. All of the sometimes eligible were ineligible for both programs in at least one wave, and 56 percent had two or more distinct spells of eligibility. Overall, 41 percent of all eligible children had multiple spells of eligibility.

Many eligible children–42 percent–faced at least some period of uninsurance while eligible, although only 7 percent remained uninsured for the entire period they were eligible. Forty-four percent of eligible children were covered by Medicaid or SCHIP during at least one eligible wave, while 66 percent were covered by private insurance.

Churning in and out of public coverage has historically been blamed on administrative barriers; however, fluidity in eligibility is an important contributor that affects a broader population of children.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.5.w598v1

Comment:

By Don McCanne, MD

Let’s see. What is it they keep telling us? We don’t want to disrupt what is working by throwing out our existing private insurance plans and public programs, but instead we to need to fix what isn’t working. And we should begin by getting all children insured.

As we consider using our current financing system to expand coverage to everyone, the children are the easy part of that problem. Children are a relatively healthy subset of our population with a low incidence of chronic disease and catastrophic medical events (though they do occur and that, plus preventive services, are why coverage for children is so important). But the fact remains that children are very inexpensive to insure.

So what is the debate taking place in Washington right now? The politicians agree that the State Children’s Health Insurance Program (SCHIP) should be renewed, but the debate is over whether only very poor children should be included, or should children from moderately-low income families who might be eligible for private, employer-sponsored coverage also be allowed to participate?

So why don’t we just use SCHIP and/or Medicaid to insure only low-income children, and then mandate parents or their employers to purchase private insurance for the rest of the children?

This study confirms once again that arbitrary standards of eligibility are not static, but are a dynamic. Though federal and state legislators can change the eligibility requirements, creating some instability in program enrollment, much greater instability results from the changing status of the participants. Eligibility related to personal circumstances continues to change not only for the Medicaid and SCHIP programs, but also for employer-sponsored plans and for compliance with underwriting standards in the individual market. Being above the threshold for public program qualification, ineligible for employer-sponsored coverage (if offered at all), and not having the income to pay premiums in the individual market inevitably results in the additional category of uninsurance.

Further, the dynamic of changing eligibility results in fragmentation of care because of variations in the networks of approved providers under the multiple public and private programs. This denies these children of the crucial benefit of having a stable medical home.

If the politicians are serious about initiating comprehensive reform by covering all children, they must come up with a proposal that enrolls all children automatically and permanently. Watching them stumble around with the SCHIP program proves that building on our public and private plans will never get us there, and unfortunately most seemed resigned to that fact that we can’t do it.

But what about Medicare? For that sector of our population isn’t that a program that covers essentially everyone, automatically and permanently? Why can’t we do that for children? For that matter, why can’t we do that for everyone?

Oh, that’s right. We can’t do that because we would have to throw out what is working for some, even though it means that we can never fix our system so that it works for everyone. It’s too bad that the way we frame our political rhetoric is much more important to us than adopting policies that actually would prevent suffering and death.

More Than a Prayer for Single Payer

The American Prospect talks to the co-founder of Physicians for a National Health Program about why a single-payer system remains not only the most desirable reform goal in the United States, but an achievable one.

Roger Bybee
The American Prospect
August 6, 2007

The notion of a Canadian-style “single-payer” health system — essentially, replacing costly private insurers with a government body or bodies to pay for healthcare — has long been dismissed by elite politicians and pundits. But the popular response to Michael Moore’s new documentary “Sicko” is adding fuel to an already-smoldering fire of resentment over the domination of the current health system by for-profit insurers, in addition to that system’s high cost (double any other nation’s) and poor performance (37th overall in quality, according to the World Health Organization).

Dr. Steffie Woolhandler, with her partner, Dr. David Himmelstein, co-founded Physicians for a National Health Program. Both are practicing physicians as well as professors at Harvard Medical School. They have written widely on issues of health care reform, including the book Bleeding the Patient: The Consequences of Corporate Health Care (with Dr. Ida Hellander). A native of Shreveport, Louisiana, Dr. Woolhandler earned her medical degree at the LSU-New Orleans Medical School.

As the debate over American healthcare heats up in anticipation of the 2008 presidential race (in which health reform is widely expected to be one of the central issues), Dr. Woolhandler reflects on the flawed U.S. health system, various reform proposals, and the prospects of enacting a system in the single-payer mold.

Roger Bybee: What drew you into fighting for universal healthcare as a doctor?

Steffie Woolhandler: It became obvious that there was a lot we could do for patients in terms of helping them live longer and preventing disease, but we couldn’t do any of it if they didn’t come into our offices. It became really clear that the financing system was an obvious barrier to care for our patients. Tens of millions lack insurance or have poor insurance.

Why is healthcare such an intense issue right now, following a long hiatus after the defeat of the Clintons’ plan in 1994?

There are two main factors. First, health costs have been rising for a while — they slowed down a bit in the late 90s, but have been averaging about 8 percent in increases a year in the 2000s. These cost increases are now much less tolerable because of globalization. U.S. manufacturers in particular have to compete in world markets, and they can’t just pass on higher costs to consumers via higher prices. So globalization has really made health costs a big concern for American business, and that’s one major part of the renewed interest.

The other part is that the quality of insurance coverage is going down even for the middle-class Americans, in terms of co-pays, deductibles, and uncovered services. When a middle-class family faces a major illness, they also face the danger of bankruptcy. So there’s been a shrinkage of coverage for the middle-class even as prices have increased sharply.

What pushed it off the national radar screen — or at least the elites’ political agenda — for the past 13 years?

Business was hoping managed care would solve this problem for them. Business went completely in the direction of managed care, and managed care companies promised they would take care of costs. But after a brief period where costs slowed down, costs are now rising just as fast as before managed care.

Why have HMOs and rising deductibles for workers failed to rein in costs?

What happens with HMOs is that they’re interested in making money, and the easiest way is the cherry-picking of enrollees and seeking subsidies from Congress. Holding down costs just isn’t their priority. Besides, they got a lot of pushback from hospitals and doctors over bossing them around on costs. Managed care is kaput. History has shown managed care doesn’t work.

Neither do Health Savings Accounts. Health spending works on kind of an “80/20” rule, where most spending is on a minority of people with chronic or crisis needs. So most health spending is for a relatively small group of people within a given year. With Health Savings Accounts, the front-end costs are paid, but you can’t control the costs of people who are really injured or really sick.

Also, the high-deductible Health Savings Account plan will force sicker people out of the workforce. For example, Wal-Mart and other employers are using a strategy to push older, chronically ill people out of the workforce. From a social point of view, it’s completely backward to push people with diabetes and high blood pressure out of being covered.

There’s tremendous ferment going on at the state level in terms of reform. How do you evaluate these plans that, for example, require individuals to purchase insurance policies, as in Massachusetts under Mitt Romney?

I think the Massachusetts bill, the Romney plan, is a hoax. It won’t get us to universal coverage. The fundamental assumption is that the uninsured have enough money to buy insurance policies, that they can buy their way out of the predicament. If they had the money, they’d already have insurance! They don’t have money in the first place. Someone my age, in their 50s, and making over $29,400 a year, would get no subsidy. The cost of that premium would be $4,200 a year, but along with that there’s a $2,000 deductible before any coverage begins, co-pays, and co-insurance after that first $2,000.

That kind of coverage is worthless to a low-income person. They don’t have money for the premium, and they can’t pay the $2000 out of pocket. I don’t call that insurance, I call it a hoax. You’re not going to be able to cover everyone with those kinds of premiums. And expansion of Medicaid won’t get us to universal coverage, either. We’ve had 10-plus years of experience with that.

In Illinois, Governor Rod Blagoevich is proposing a tax on business to pay for private insurance. What’s your take on that?

There is a fundamental problem with going through private insurance plans with high overhead costs. It’s not unusual for a private insurer to have 20 percent devoted to overhead and profit. So of every dollar you pay out in insurance premiums, only about 80 cents ever makes its way to a hospital or doctor.

When you put insurance companies in the middle of any kind of coverage you can engineer, you must realize that 20 percent is frittered away in overhead and profits. Quite apart from denials, it’s tremendously costly to doctors and hospitals.

You performed a study showing that about 31 percent of health spending in America goes to administrative overhead and profit. If 20 percent is accounted for by the insurance companies, what explains the rest? Is it, as critics like Paul Krugman say, the strategy of “denial management” followed by insurance companies, where they’ve bloated their staffs so that they can challenge more claims by both providers and patients?

The remainder of the overhead comes from doctors and hospitals. Part of it is in response to “denial management,” but the big portion is just needing a high baseline level of paperwork and administrative support to deal with all the different insurers. In my little practice, you have to deal with all the different insurance companies, different co-payments, different deductibles, and different formularies [listings of approved prescriptions].

While the single-payer approach fares extremely well in polling (67 percent of Americans in a 2005 BusinessWeek poll supported a system akin to Canada’s or Britain’s), policymakers and pundits dismiss this option out of hand. Even some progressives like Ron Pollack of Families USA and SEIU President Andrew Stern have depicted the single-payer plan as being utterly out of reach. How do you respond to that perspective?

There’s not another plan that will work. All of the other proposals lack feasibility in terms of economics. The other plans simply won’t get you to universal healthcare. The key to the economic feasibility of the single-payer plan is administrative savings. We shouldn’t be pouring more money into the insurance system, but saving money on administration in order to cover everyone and provide better coverage.

There’s a fundamental problem with going to private insurers that makes universal coverage unaffordable. It doesn’t matter what the “political feasibility” is. You must start with a plan that will work.

How vital is it to unify progressives behind a single-payer plan in the coming years? How can we avoid the fracturing of progressive and liberal forces that occurred in 1993-94?

I frankly haven’t seen much fragmentation now, because a lot of people are very knowledgeable about single-payer. I’m not really that worried about fragmentation. There will be a lot of debate, but when people fully understand the economics of healthcare, there will be more support for single-payer.

John Edwards and the political scientist Jacob Hacker are advocating plans that would give all Americans a choice of traditional private insurance or enrolling in a regional single-payer plan.

We already have experience with Medicare Plus. These plans are supposed to compete on equal footing with Medicare, but private HMOs have used selective recruiting of healthier people and gone to Congress and gotten embedded into the Medicare Advantage Drug plan, and they get huge over-payments of 11 to 13 percent. The private plans won’t let Medicare compete.

It’s incumbent upon those who favor competition to show how this won’t happen if single-payer is competing with traditional insurance.

If you have two groups trying to enroll people in health plans, the bad guys will drive the good guys out of business. The bad guys will selectively recruit healthier people, and push sicker people onto the single-payer plan. Competition is not something that works with healthcare.

How do you envision closing the gap between big firms like Wal-Mart making vague commitments to universal healthcare and actual recognition that only a single-payer system can hold down costs, reach all citizens, and provide free choice of doctors?

If companies want to hold down costs, they need to support universal healthcare. Otherwise, it won’t solve the problem of healthcare for low-wage workers. The good news is that no one would miss the administrative burden that accounts for such high costs in the U.S. However, we would have to provide retraining and income support to displaced health insurance workers.

Polls of doctors in Minnesota (Feb., 2007) and Massachusetts (2004) both show a remarkable 64 percent favoring a single-payer plan. What accounts for this historic shift in the sentiment of doctors, when you think back to how the American Medical Association successfully mobilized doctors in every community to block Harry Truman’s health reform effort? This new polling seems extraordinary; both because doctors’ support for single-payer is just slightly below the general public’s and because doctors are presumably much more knowledgeable about health systems than the average citizen. How do you see things developing among doctors and the health industry?

The opposition in Truman’s era was the medical profession, and the AMA still is opposed even though a high percentage of doctors support a single-payer plan.

But now there are two other powerful forces: the health insurance industry [that emerged since the Truman plan] and the pharmaceutical companies. Under a single-payer plan, the government steps into the pharmaceutical pricing picture with a lot of bargaining power, so both of these forces feel threatened.

It’s ironic that hospitals aren’t more supportive. The health insurance industry would be put out of business, so it’s life or death for them. But hospitals would still be there. Some for-profit hospitals oppose national health insurance, and our plan calls for reconversion to non-profit status. With the non-profit hospitals, I think opposition to single-payer is mostly fear of change. I think that they can live with a single-payer national health insurance plan, so I don’t see them as our biggest enemy.

Given the power of the insurers, hospitals, and the rest of the medical-industrial complex, how optimistic do you feel about reaching the goal of universal care, free choice of doctors, and cost containment?

I’m really optimistic, because the current system can’t keep going. There will be increasing pressures from employers and state and federal governments for change because of the soaring costs. The American people do have the power to make change, and private interests cannot hold back change forever and for all time. So I’m optimistic!

Roger Bybee is a Milwaukee-based writer and progressive activist, who formerly edited the official labor weekly Racine Labor. He has written for a number of state and national publications and websites on issues such as health care reform and corporate globalization.

Single-payer care deserves debate

Expanding Medicare best alternative to current system

Drew Richardson
The News Leader
Columnist

The last time I wrote about filmmaker Michael Moore’s latest opus, “Sicko,” I stated that I believed the documentary succeeded in characterizing the dire circumstance of our broken health care system. Between the approximately 45 million uninsured Americans, the underinsured and the insecurely insured, most of our citizens are at some financial risk stemming from a medical catastrophe. This is in spite of America’s present large health care expenditures, costs that are rapidly outpacing general inflation and employee income. Even the business community has come to realize that it cannot support the interests of one business–the health insurance and broader health care industry–to the detriment of all other businesses. But what of proposed solutions?

Let’s look for a minute at the broad implications of various proposed plans for promulgating health care change in this country.

Although many plans on the table boast of universal health care, some merely have all citizens having some form of mandated health insurance. Only one piece of currently proposed federal legislation advocates universal and unrestricted access to health care. There is a big difference between having health insurance and having universal access to health care. The latter is what is referred to as a single-payer health care system and is essentially what Canada, Great Britain, France and Cuba (depicted in Moore’s film) have. Examples of the former category include such domestic plans as the Wyden Healthy Americans Act, the Stark/Edwards/Hackler Plan, and the Kennedy/Dingell Medicare for all (this latter is largely public with an optional private plan). Proponents of such plans talk of reasoned transition, shared responsibility, efficiency and consumer choice. Critics suggest that these plans suffer most importantly from offering no real structural change and therefore no reform to the present system. They leave the bureaucracy and upwardly spiraling costs of the insurance/health care industry largely intact. To add insult to injury, the hated complexities and downsides of means testing, co-pays, deductibles, exclusions, denials and appeals are all still there. Furthermore, these critics argue that, from a tactical and practical point of view, that the Rush Limbaughs of the world and the powerful and inflexible pharmaceutical and health insurance industries will not see these plans as any more acceptable than fully developed and pure single-payer health care.

So what is single-payer health care? Essentially it involves expanding the present Medicare system to cover everyone and eliminating private insurance (with the claimed accompanying savings of hundreds of billions of dollars). Additional features would include the absence of means testing, no concern for pre-existing conditions, the restoration of independent doctors and hospitals who negotiate with Medicare and would be chosen freely by consumers and one public agency processing and paying bills.

Because it would be unneeded with this system in place, the present Medicaid program for the indigent and its associated administrative costs would be eliminated. Proponents suggest that costs could be contained and quality maintained through more efficient review by the single insurer. Costs would be financed through a progressive income tax. Such a plan is represented in proposed legislation contained in House Resolution 676 that currently has 73 cosponsors in the House of Representatives.

Unfortunately, an opinion column is really no more satisfactory a vehicle than a movie for defining and contrasting health care proposals. Although I hope the former serves to challenge the mind and instill enthusiasm for more detailed consideration, my commentary must end with a recommendation for formal debate to occur at the Valley’s major universities. These would include large audiences and participating proponents representing notions ranging from a defense of the status quo to the most far-reaching plan of change. Representatives from the communities of consuming individuals and businesses should be included.

As I have said before, I believe we must move forward with ready dispatch, but I also believe we need serious thought replete with all the components of rigorous and open debate allowing for a full defense and critique of all ideas put forth. I believe voters in 2008’s presidential and congressional elections will demand such.

Dr. Drew Richardson is a retired FBI agent and cardiovascular physiologist. He teaches forensic science at James Madison University. Contact him at dr0404@hotmail.com.