PNHP

Audience at health care forum backs single-payer proposal

Audience at health care forum backs single-payer proposal

By David Montero
Rocky Mountain News
October 5, 2007

BOULDER – There may be five proposals being considered to reform health care in Colorado, but only one seemed to satisfy most of the 150 gathered at the Millennium Hotel on Thursday night.

That proposal was the so- called single-payer system.

One after another, they strode to the microphone – breast cancer survivors, parents of children with autism and even a few people with no illnesses – all asking members of the Blue Ribbon Commission for Health Care Reform to radically restructure the current system.

People like William Starr, a healthy 84-year-old Boulder resident.

“I have the feeling that this is all a put-on if you’re making a fifth proposal that is backing the insurance companies when there is only one proposal that fits what your guiding principles were,” Starr said, advocating the single-payer system.

The public comment sessions were set up by the commission to gather public input on how to change the way health care is delivered for state residents.

Four separate proposals sponsored, respectively, by a powerful union, a consortium of underwriters, health care industry officials and the single-payer plan went through several drafts and changes this year and could be forwarded to state lawmakers this winter for consideration. A fifth proposal is currently in its first draft and won’t be reviewed by the commission until the middle of the month.

Regina Hathorne, a 55-year- old Boulder resident, said the proposed cap of $50,000 for catastrophic care was “laughable” when put into context of what is considered catastrophic.

“This country is currently experiencing economic racism when it comes to health insurance,” she said. “The question is do we all deserve the same health insurance? It’s a huge change in society’s values.”

The five proposals appear to be a stab at that, with Gov. Bill Ritter urging the state to find a way to cover the more than 780,000 Coloradans currently without health insurance.

Though the tide at the Boulder meeting was decidedly toward single-payer, commissioners were quick to point out that the sentiment might be different as they solicit public comments throughout the state.

And at least one speaker, Brian Schwartz, proposed getting government out of health care entirely – calling Medicaid a “failure” and an example of why single-payer won’t work. Instead, he advocated the free-market system.

“Should we have single-payer food and housing?” he asked. “Didn’t we settle that with Soviet Russia and North Korea? Why is health care different?”

The Garden Hose Health Care Brigade

Matthew Holt
San Francisco
Oct. 4, 2007

It’s been a strange old week for me in healthcare. Half was spent working with new Health 2.0 technology companies who are trying change every conceivable aspect of the patient and physician relationship. The rest was spent hanging out with a bunch of right wing lunatics. In the background the major healthcare policy stories of the last few weeks have been Sen. Hillary Clinton’s announcement – at last! – of her plan for universal coverage, and President George Bush’s vetoing of the children’s health insurance program.

So, I guess it’s my job to try to make sense of all of this. And, well, I can. But not in ways you may like.

The politics of the moment is very strange indeed.

On the one hand, a deeply unpopular president has gone against moderate members of his own party by vetoing a bill to help “the children” by expanding government-backed health care for young Americans. If there is a more powerful sound bite for Democratic candidates during the next year, I haven’t seen it. Nor have you.

On the other hand, the Democrat presidential candidates have come up with a series of proposals that the Republicans have already dismissed as socialized or, worse, French. This despite the fact that the French health care system is commonly known as one of the best in the world and is actually one that Americans would rather like.

Meanwhile, inside the beltway and on WMUR, the only TV station that matters in Manchester, N.H., a myriad of interest groups are now focusing on the uninsured. The American Cancer Society is spending all of its publicity budget for the next year on the uninsured, while Physicians for a National Health Program (an advocate of the single-payer system) is attacking Democratic candidates because they all leave a role for private insurance companies in their policy proposals. The American Medical Association (AMA) is plastering the Washington DC Metro subway with exhortations to listen to the voice for the uninsured, hoping, I guess, that you’ll conveniently forget the AMA’s role in stopping any sort of national universal insurance program for the past century or so.

What this all comes down to is an open, raging and actually somewhat interesting philosophical battle about how best to provide insurance coverage. Which is how I found myself on a stage – with someone calling himself an “Objectivist” in that fine Ayn Rand tradition – speaking to an audience of knee-jerk libertarians. The Objectivist wasn’t very objective, but boy did he object to virtually everything done on behalf of the community. Why? In his philosophy anything done on behalf the community is, by definition, something done to somebody against their will. I have met plenty of people who want to abolish Medicare and Medicaid, without providing any substitute (and they are mostly young and rich). But this is the first time I’ve met someone wanting to abolish the publicly-funded fire department in favor of a garden hose brigade. My pleas that he support his contention that the private sector works better in healthcare than the public sector with actual data were roundly ignored so, faced with this sort of audience, I couldn’t help but feel some sympathy for the struggle any politician will have to get some level of common understanding of the real health care problems confronting America.

It’s quite possible to have a rational conversation with a libertarian and eventually convince them that a free market in health insurance is not the same as a free market in home insurance. After all, the health insurance seller is – through medical records and queries about your health, habits and well-being – able to see which house is already a simmering fire before they write an insurance contract. Yes – that’s what health insurance underwriting actually does–what do you think those “family history” questions are all about?. But if that objectivist doesn’t care that the sick person with the (figurative) house on fire is going to suffer, or agree that that somehow society should help them out, it’s pretty hard to understand how you come up with a solution that will keep them happy.

Which gives Democrats a two-faced dilemma if they really want to change the current system. First, can they get enough Americans with a shared general understanding of the problems facing the entire healthcare system so they can actually win an election on the issue? Democrats main chance of taking back the White House and keeping the Congress rests on people’s belief that they are better for domestic policy, particularly healthcare. Which is why the Republicans are playing to the gallery and decrying all things French (except wine, cheese, and in the case of Mrs. Rudolph Giuliani, handbags).

Assuming the Democrats get over that hurdle, then they actually have to try to get something passed. Now it gets really tricky.

I’ve said repeatedly on this site that I think things aren’t bad enough yet for enough Americans to clamor for a change in the health care system. Although most American have horrible health insurance, the majority of them don’t know it. And they have no idea that the medical care they are receiving is massively suboptimal. Getting that particular message across is very difficult. Who wants to hear that their doctor is a dope? Or that, by extension, they’re dope for having a bad doctor? No one. So Hillary Clinton, Sen. Barack Obama’s and to a lesser extent former Sen. John Edwards’ proposals all stress that they’re not trying to change employer-based health insurance, which most Americans have and, it seems, tolerate. Instead, the politicians say they are merely trying to add a little wraparound for those people for whom employer-based health insurance is not available.

When you burrow into the details of the proposals – and you can be assured that the lobbyists for the healthcare industry will – it becomes clear that at some stage employers and insurance companies, not to mention the Medicare program, will have to start acting very differently. No rational end payer – put in the situation of not be able to easily get out of covering people who are sick and therefore expensive – is going to just let the healthcare system continue on in cruise control as it is done for the past 50 years or so. The folks who pay the bills are going to demand changes. And changes aren’t going to be much loved by the folks who have been running health care for the past half-century. That means that despite their high-fallootin’ rhetoric about the uninsured, the AMA (not to mention the drug companies, hospitals and everyone else with a nose in the trough) is going to find itself in stark opposition to much of what health care reform will mean.

The question then is pretty basic: Is the disgust of the American public with the healthcare system enough to overcome the healthcare industry’s inertia? My guess is that much more pain and education is required. The group that I spoke with last week had no comprehension of the concept of spreading risk and cost for health care across the community or society. Worse, the discussion was also hijacked by several outright loonies who thought that all problems in American health care were due to illegal immigrants – as if there’s a rash of elderly cancer patients swimming across the Rio Grande. There’s lots of fear-mongering – on the left and the right – and gets in the way of genuine efforts for change.

Perhaps what’s needed is a real down-and-dirty political operative like Otto von Bismarck, President Lyndon Johnson or even – God help us – Dick Cheney who knows how to focus attention on selling healthcare reform the way they sold the idea of invading other countries: As some kind of patriotic duty. If you question that you’re some kind of traitor.

Failing that, I can see Sen. Hillary Rodham Clinton spending two presidential terms trying – really trying – to have a sensible conversation about healthcare reform with an objectivist who wants to abolish the fire department so we can all put out mountain fires with our garden hoses.

What Sicko doesn't tell you…

Michael Moore's film hails the NHS and condemns US healthcare. But behind the scenes the UK government has already started adopting the American model of health provision.

Allyson Pollock
Monday September 24, 2007
The Guardian

Viewers of Michael Moore’s new film will come away convinced that the public healthcare system in this country is superior to its privatised American counterpart, where more than 50 million people are without any kind of care at all. But does the government agree? Or has it instead been taking ideas from the very system revealed in Sicko to be so iniquitous?

The film is very much made for a US audience. Moore does not go into the huge changes that are taking place in European healthcare – and the new, privatising project going on here. It might surprise many British people who see the film to know that, for example, the British government has for years been in contact with Kaiser Permanente, one of the big US healthcare corporations, and is actively trying to remodel the NHS along American lines. All the reforms carried out by the government over the past few years have been aimed at that.

In 1995, civil servants from the Department of Health, fresh from visits to the US, thought they had found the future of the NHS. They invited Kaiser Permanente to look at whether it could deliver health services as part of the new Private Finance Initiative in the NHS. The PFI is a building programme of public infrastructure that brings with it a long-term debt that the government takes out from a private company. But as the medical director of Kaiser Permanente, which is both an insurer and healthcare provider, told me at the time in her marbled headquarters in California, the NHS was not yet ready for Kaiser. Such a system, built on public ownership, control and accountability, was closed to commercial companies. And it was the same story for the whole of Europe. But Kaiser Permanente, which, along with the rest of the US healthcare industry, was known as one of the “darlings of Wall Street” because it made so much money, was restless. It wanted to make more, and had its eye on the rich pickings of European tax funds. And where better to begin than by conquering the UK’s “socialised” NHS, so long the model for much of the world?

Kaiser Permanente didn’t have long to wait. In 1997, the Labour administration swept away the last remaining obstacles to PFI and, in so doing, established the laboratory for the great market experiment in public services.

The accumulated neglect and backlog in maintenance and repair became an excuse to sell off NHS land and assets at knockdown prices. The NHS is now a tenant in hospitals it once owned, leasing back buildings and services from private sector landlords at astronomical rents that are currently consuming £500m a year and will increase exponentially. The diversion of scarce funds from hospital revenues to bankers and shareholders has starved the NHS of cash, and the result has been a major downsizing. For almost every PFI hospital built, three hospitals close. Bed closures and staff reductions occur on an unprecedented scale.

Back in 1997, the NHS had major capacity problems. Waiting lists kept rising, accident and emergency wards were overflowing, public discontent was growing and staff morale plummeting. Tony Blair found a solution one night in 2000 as he was leaving the smart River Cafe. He was introduced to Tim Evans, external affairs director of the Independent Health Care Association, the body that represented the private healthcare industry, who convinced him that the private sector had all the answers.

But the Labour government knew that a public sector NHS was close to the heart of most Britons, and a spin operation was required. So, from the start of the Labour government, ministers dismissed the NHS as Stalinist, a 1940s relic of socialism, bureaucratic and rigid. Then, in 2002, the highly respected British Medical Journal published a paper purporting to show that Kaiser Permanente (them again) was more efficient than the NHS. Within hours, hundreds of emails had poured into the BMJ exposing the flaws in the paper, from the misleading nature of the claims to the authors’ links to the company. But the BMJ’s editor, Richard Smith, declined to retract the paper, correct it or publish a proper scientific rebuttal.

The paper had done its work. Its propaganda was cited and repeated everywhere by academics and policy-makers and, most crucially, by the government in its white papers and documents, including the Wanless Report. The much-despised US healthcare industry, of which Kaiser Permanente is a part, was to be the new model for Britain.

Not long after publishing the article, Smith left the BMJ for a lucrative post as chief executive of the UK subsidiary of the US health corporation UnitedHealth. There he joined its new European president, Simon Stevens, formerly adviser to every Labour health secretary, and Tony Blair, since 1997. The flow of ideas, from him and many others like him, was all one-way: from the US to the UK.

As adviser to Alan Milburn, health secretary from 1999 to 2003, Stevens and his American colleagues helped to shape the NHS Plan 2000. It promised to provide more money, doctors, nurses, beds and capacity. But in the event the funds were directed at building a new parallel system that would be owned and operated not by the people but by the private sector on behalf of shareholders.

Using the mantra of choice, the market was thus disguised. In primary care the government negotiated a new GP contract that would allow commercial companies to run GP services. There are now more than 30 corporations running GP services in England.

It was choice that was used to bring in the highly controversial ISTC (independent sector treatment centre) programme, spearheaded by Texan Ken Anderson, which provides mini- factories for elective surgery. Anderson headed the new commercial directorate of the Department of Health and quickly set about awarding £6bn worth of contracts to healthcare corporations, thereby undermining elective surgery, diagnostics, radiology and pathology provision in the NHS.

Local people from Portsmouth to Scarborough have been protesting against ISTCs draining scarce NHS funds, which has led to service closures and staff redundancies to balance the books. There is not an area of the country where services are not being cut and closed. Protests against the closures of accident and emergency departments and hospital services are happening in Surrey, East and West Sussex, Kent, Worcester, Manchester, Leeds, Durham and Huddersfield; and against the 150 community hospitals in places such as Norfolk, Cambridge, Leicester, Devon, Marlborough and Bromley. The NHS, the government says, has had unprecedented levels of funding – so where has all the money gone if it isn’t into services? Is it really all down to bad managers and greedy doctors and nurses?

All markets need systems for pricing, billing and invoicing. Labour has introduced those: the electronic patient record, part of the £1bn IT disaster. The NHS too is being transformed from within. Foundation trusts such as University College London Hospitals Trust have been given new powers to enter joint ventures with commercial companies such as the Hospital Corporation of America and to spend millions of pounds on advertising campaigns, PR agents, mega-departments of finance and accounting, press officers, management consultants and profits. As in the US, billions of pounds, probably approaching 20% of annual NHS funds – estimated to be £20bn in England in a year – are being squandered on what are called the transaction costs of the market.

Earlier this year the US chief executive officer of UnitedHealth, Bill McGuire, was sacked along with other board members for repricing share options. His annual $126m package was not enough for him. Meanwhile more than 50 million Americans, including 10 million children, go without care – in the richest country in the world. Is this what we want?

Allyson Pollock is author of NHS plc: The Privatisation of Our Healthcare and professor and head of the centre for international public health policy at the University of Edinburgh.

What Sicko doesn’t tell you…

Michael Moore’s film hails the NHS and condemns US healthcare. But behind the scenes the UK government has already started adopting the American model of health provision.

Allyson Pollock
Monday September 24, 2007
The Guardian

Viewers of Michael Moore’s new film will come away convinced that the public healthcare system in this country is superior to its privatised American counterpart, where more than 50 million people are without any kind of care at all. But does the government agree? Or has it instead been taking ideas from the very system revealed in Sicko to be so iniquitous?

The film is very much made for a US audience. Moore does not go into the huge changes that are taking place in European healthcare – and the new, privatising project going on here. It might surprise many British people who see the film to know that, for example, the British government has for years been in contact with Kaiser Permanente, one of the big US healthcare corporations, and is actively trying to remodel the NHS along American lines. All the reforms carried out by the government over the past few years have been aimed at that.

In 1995, civil servants from the Department of Health, fresh from visits to the US, thought they had found the future of the NHS. They invited Kaiser Permanente to look at whether it could deliver health services as part of the new Private Finance Initiative in the NHS. The PFI is a building programme of public infrastructure that brings with it a long-term debt that the government takes out from a private company. But as the medical director of Kaiser Permanente, which is both an insurer and healthcare provider, told me at the time in her marbled headquarters in California, the NHS was not yet ready for Kaiser. Such a system, built on public ownership, control and accountability, was closed to commercial companies. And it was the same story for the whole of Europe. But Kaiser Permanente, which, along with the rest of the US healthcare industry, was known as one of the “darlings of Wall Street” because it made so much money, was restless. It wanted to make more, and had its eye on the rich pickings of European tax funds. And where better to begin than by conquering the UK’s “socialised” NHS, so long the model for much of the world?

Kaiser Permanente didn’t have long to wait. In 1997, the Labour administration swept away the last remaining obstacles to PFI and, in so doing, established the laboratory for the great market experiment in public services.

The accumulated neglect and backlog in maintenance and repair became an excuse to sell off NHS land and assets at knockdown prices. The NHS is now a tenant in hospitals it once owned, leasing back buildings and services from private sector landlords at astronomical rents that are currently consuming £500m a year and will increase exponentially. The diversion of scarce funds from hospital revenues to bankers and shareholders has starved the NHS of cash, and the result has been a major downsizing. For almost every PFI hospital built, three hospitals close. Bed closures and staff reductions occur on an unprecedented scale.

Back in 1997, the NHS had major capacity problems. Waiting lists kept rising, accident and emergency wards were overflowing, public discontent was growing and staff morale plummeting. Tony Blair found a solution one night in 2000 as he was leaving the smart River Cafe. He was introduced to Tim Evans, external affairs director of the Independent Health Care Association, the body that represented the private healthcare industry, who convinced him that the private sector had all the answers.

But the Labour government knew that a public sector NHS was close to the heart of most Britons, and a spin operation was required. So, from the start of the Labour government, ministers dismissed the NHS as Stalinist, a 1940s relic of socialism, bureaucratic and rigid. Then, in 2002, the highly respected British Medical Journal published a paper purporting to show that Kaiser Permanente (them again) was more efficient than the NHS. Within hours, hundreds of emails had poured into the BMJ exposing the flaws in the paper, from the misleading nature of the claims to the authors’ links to the company. But the BMJ’s editor, Richard Smith, declined to retract the paper, correct it or publish a proper scientific rebuttal.

The paper had done its work. Its propaganda was cited and repeated everywhere by academics and policy-makers and, most crucially, by the government in its white papers and documents, including the Wanless Report. The much-despised US healthcare industry, of which Kaiser Permanente is a part, was to be the new model for Britain.

Not long after publishing the article, Smith left the BMJ for a lucrative post as chief executive of the UK subsidiary of the US health corporation UnitedHealth. There he joined its new European president, Simon Stevens, formerly adviser to every Labour health secretary, and Tony Blair, since 1997. The flow of ideas, from him and many others like him, was all one-way: from the US to the UK.

As adviser to Alan Milburn, health secretary from 1999 to 2003, Stevens and his American colleagues helped to shape the NHS Plan 2000. It promised to provide more money, doctors, nurses, beds and capacity. But in the event the funds were directed at building a new parallel system that would be owned and operated not by the people but by the private sector on behalf of shareholders.

Using the mantra of choice, the market was thus disguised. In primary care the government negotiated a new GP contract that would allow commercial companies to run GP services. There are now more than 30 corporations running GP services in England.

It was choice that was used to bring in the highly controversial ISTC (independent sector treatment centre) programme, spearheaded by Texan Ken Anderson, which provides mini- factories for elective surgery. Anderson headed the new commercial directorate of the Department of Health and quickly set about awarding £6bn worth of contracts to healthcare corporations, thereby undermining elective surgery, diagnostics, radiology and pathology provision in the NHS.

Local people from Portsmouth to Scarborough have been protesting against ISTCs draining scarce NHS funds, which has led to service closures and staff redundancies to balance the books. There is not an area of the country where services are not being cut and closed. Protests against the closures of accident and emergency departments and hospital services are happening in Surrey, East and West Sussex, Kent, Worcester, Manchester, Leeds, Durham and Huddersfield; and against the 150 community hospitals in places such as Norfolk, Cambridge, Leicester, Devon, Marlborough and Bromley. The NHS, the government says, has had unprecedented levels of funding – so where has all the money gone if it isn’t into services? Is it really all down to bad managers and greedy doctors and nurses?

All markets need systems for pricing, billing and invoicing. Labour has introduced those: the electronic patient record, part of the £1bn IT disaster. The NHS too is being transformed from within. Foundation trusts such as University College London Hospitals Trust have been given new powers to enter joint ventures with commercial companies such as the Hospital Corporation of America and to spend millions of pounds on advertising campaigns, PR agents, mega-departments of finance and accounting, press officers, management consultants and profits. As in the US, billions of pounds, probably approaching 20% of annual NHS funds – estimated to be £20bn in England in a year – are being squandered on what are called the transaction costs of the market.

Earlier this year the US chief executive officer of UnitedHealth, Bill McGuire, was sacked along with other board members for repricing share options. His annual $126m package was not enough for him. Meanwhile more than 50 million Americans, including 10 million children, go without care – in the richest country in the world. Is this what we want?

Allyson Pollock is author of NHS plc: The Privatisation of Our Healthcare and professor and head of the centre for international public health policy at the University of Edinburgh.

Being drugged into prevention

Chronic illness costs the economy more than $1 trillion a year

By Victoria Colliver
San Francisco Chronicle
October 3, 2007

Americans who have common chronic health conditions cost the U.S. economy more than $1 trillion a year, a figure that could jump to nearly $6 trillion by 2050 unless people take steps to improve their health, a study released Tuesday found.

According to the report by the Milken Institute, a Santa Monica think tank, the economic impact of chronic illness goes far beyond the expense of treating disease. It takes an even greater toll on economic productivity in the form of extra sick days, reduced performance by ill workers and other losses not directly related to medical care.

But veering onto a path that emphasizes changing lifestyles along with prevention and early detection of disease could reduce the number of illnesses by 40 million cases and save $1.6 trillion by 2023, the report said.

“The public is telling us the No. 1 domestic issue is health,” said Dr. Richard Carmona, former U.S. surgeon general and now chairman of the Partnership to Fight Chronic Disease, in a news conference in Washington on Tuesday releasing the report.

“The data to stay the course is not a particularly attractive option,” said Ken Thorpe, executive director of the Partnership to Fight Chronic Disease and a professor at Emory University.

The study was funded in part by a grant from the Pharmaceutical Research and Manufacturers Association of America, the drug industry’s trade group. The Milken Institute declined to reveal the amount of the grant.

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2007/10/03/BUDKSGJLP.DTL

Milken Institute: “An Unhealthy America: The Economic Impact of Chronic Disease:”
http://www.chronicdiseaseimpact.com/

Comment:

By Don McCanne, MD

Uh-oh. Are we being dragged (drugged) into a process that places our health care system in the hands of the pharmaceutical industry?

PNHP continues its campaign to reform health care financing in America so that everyone will have affordable access to comprehensive, high quality health care services. Implicit in that is improving the health care delivery system through improved allocation of our health care dollars.

But there is a debate within the policy community as to the best approach for containing costs.

Following is a quote from a message received from Professor Kenneth Thorpe:

“The former (health reform) is true reform, and is focused on generating better value in the health care system – better outcomes at the same or lower spending. The second issue (health care financing reform) is a political one, focused largely on moving money around the health care system. Absent a clear bold focus on the first issue, moving on the health care financing reforms has historically proven problematic.”

Yesterday’s Quote of the Day from Kenneth Thorpe and his colleagues advocated, quite appropriately, for efforts to reduce the prevalence of chronic disease. But then the focus of the article was on “treated prevalence” based on medication use.

Here is another excerpt from the Thorpe, et al Health Affairs article used as the source for yesterday’s message:

“The impact of more aggressive treatment on patient outcomes is important to consider as well. The use of cholesterol and blood pressure medications has increased sharply in the United States over the past twenty years, while hypertension and hyperlipidemia prevalence has declined. Other recent estimates indicate that the additional spending associated with higher rates of medication treatment for hypertension yield overall net reductions in health care spending. Whether more intensive use of medication treatment for other conditions, such as the metabolic syndrome, yields overall reductions in spending remains unknown.”

Dr. Thorpe continues to strongly advocate for disease management as a key to reducing health care spending. His report released yesterday seems to imply that medications are one of the most important parts the solution for reducing the prevalence of chronic disease.

The very same day, the Milken Institute released a report sponsored, at least in part, by PhRMA (Pharmaceutical Research and Manufacturers of America, an advocacy organization). An excerpt from this report:

“The rapid growth of chronic disease is costing us lives, quality of life, and prosperity. The current health-care debate rightly focuses on the extension of coverage to the uninsured and the design of a financing mechanism that is both fair and efficient. We suggest that the nature of services provided — the failure to invest in prevention and early intervention — deserves equal place in the debate.”

Investing in early intervention in chronic disease equates with selling more drugs for hypertension, hypercholesterolemia, early diabetes, appetite suppression in obesity, slowing the progression of arthritis, etc., etc. Just imagine the potential market for the pharmaceutical firms.

A serious concern is that disease management seems to have come to mean pharmaceutical intervention. If we were really concerned about health care spending and about improved population health, we would back up from an emphasis on pharmaceutical intervention to an emphasis on prevention, especially good nutrition and exercise.

I have great respect for Dr. Thorpe, and I approve of his message on the importance of making efforts to reduce the prevalence of chronic disease (though I emphatically disagree with his apparent dismissal of the importance of health care financing reform). It is unfortunate that the Partnership to Fight Chronic Disease, of which Kenneth Thorpe is Executive Director, has included PhRMA as a partner organization. This does not serve to empower his message.

Two letters on single payer in Newsday

Newsday
Letters to the Editor
September 30, 2007

“A healthy debate” [Editorial, Sept. 23] dismisses single-payer systems because “they would give consumers very little choice.” That is dead wrong. The same choice seniors now enjoy under Medicare – free choice of doctor and hospital – would continue under a single-payer system, or Medicare for all. Most private insurance companies confine choice to their own list of participating doctors and hospitals.

We now spend on health care twice as much per capita as any other country, enough to cover everyone and preserve the choice that counts.

Dr. James S. Bernstein
Rockville Centre

Regarding your editorial, you are absolutely correct that none of the health care proposals so far offered by the leading presidential candidates really address the serious problems of cost and access.

On one crucial point you err: These plans offer consumers only a “choice” of health plan, something that few if any consumers care about. What they don’t offer is the choice consumers want: the ability to choose their doctors and their hospitals. Instead, the private insurers on whom these plans depend increasingly limit just such choices. A single-payer plan such as that offered by Rep. Dennis Kucinich (D-Ohio) is, contrary to your assertion, the only plan that would offer consumers the real choice they want.

Leonard Rodberg

Editor’s note: The writer is professor and chairman of the Urban Studies Department at Queens College and co-director of Community Studies of New York Inc.

High chronic disease prevalence and high spending

Differences In Disease Prevalence As A Source Of The U.S.-European Health Care Spending Gap

By Kenneth E. Thorpe, David H. Howard, Katya Galactionova
Health Affairs
October 2, 2007

Abstract:

The United States spends more on health care than any European country. Previous studies have sought to explain these differences in terms of system capacity, access to technologies, gross domestic product, and prices. We examine differences in disease prevalence and treatment rates for ten of the most costly conditions between the United States and ten European countries using surveys of the noninstitutionalized population age fifty and older. Disease prevalence and rates of medication treatment are much higher in the United States than in these European countries. Efforts to reduce the U.S. prevalence of chronic illness should remain a key policy goal.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.6.w678

And…

Health Spending In OECD Countries In 2004: An Update

By Gerard F. Anderson, Bianca K. Frogner and Uwe E. Reinhardt
Health Affairs
September/October 2007

To summarize, the United States continued to have much higher real health care spending per capita and as a percentage of GDP in 2004 than all other OECD countries. However, the availability of health care resources and the actual use of services in the United States were below those of most industrialized countries. The average annual growth rate in real health care spending per capita in the United States was actually similar to the OECD median growth rate between 1994 and 2004. Chronic disease prevalence and mortality were high in the United States compared to other OECD countries, which may be associated with the fact that a large proportion of the U.S. population was overweight or obese.

http://content.healthaffairs.org/cgi/content/abstract/26/5/1481?ck=nck

Comment:

By Don McCanne, MD

Are we spending so much more on health care than the other OECD nations because we have a much higher prevalence of chronic disease in older individuals, or are we spending much more merely because our prices are higher?

The study by Thorpe, et al looked at the treated prevalence of disease (as a product of disease prevalence and medication use) and concluded that “we cannot directly calculate the link between higher treatment rates and spending, but we show that U.S. health care spending would be lower if treatment rates were reduced to European levels.”

The study by Anderson, et al looked at physician visits per capita, acute care bed days, and average length of inpatient stay and concluded that “the United States had 30 percent fewer inpatient hospital days and 36 percent fewer physician visits per capita than the OECD median in 2004.”

So is our higher health care spending due to higher prices or higher treatment rates? Or does it really matter?

What matters more is that we do have a very high prevalence of chronic disease, and we have a very high level of health care spending that has failed to provide better health outcomes than in other OECD nations. So what can we do about it?

The most important measure is prevention. The two most important modalities, good nutrition and exercise, are not really much in the purview of the health care delivery system, but are more complex societal issues. Public and private resources must be directed to improving diet and exercise and other preventive measures, but that topic will not be addressed here.

Given that we do have high spending and a high prevalence of chronic disease, what is the best approach to managing these problems? Some would suggest that we need to reform the health care delivery system to improve chronic disease management. Others suggest that we need to reform health care financing so that our resources are more appropriately directed.

Well, we need to do both. If we can get a handle on the financing, then we can rebuild our primary care infrastructure that would provide the appropriate environment for clinical disease management, whether acute or chronic.

Just don’t wait around for the private insurance industry to do that for us.

Stories from the marketplace

Bristol-Myers Will Settle U.S. Government Drug Probe

By Lisa Rapaport and Beth Jinks
Bloomberg.com
September 28, 2007

Bristol-Myers Squibb Co. completed an agreement to pay $515 million to settle U.S. allegations it overcharged the government for drugs and promoted medicines for unapproved uses.

The settlement resolves federal charges the company inflated the average wholesale price of some drugs, and investigations into allegations Bristol-Myers promoted medicines for non-approved uses. The U.S. government uses average wholesale prices, as reported by drugmakers, to set reimbursement rates for medicines used by federal health programs, including Medicare and Medicaid.

Bristol-Myers in 2005 settled a previous probe involving allegations it boosted sales by encouraging distributors to buy more medicine than they could sell.

http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aGFYdv1vtWnU

And…

Court rules Medicare plans can be sued for nonpayment

By Amy Lynn Sorrel
American Medical News
October 8, 2007

The Texas Supreme Court… on Aug. 31 ruled that a group of Texas hospitals can sue Aetna in state court for allegedly failing to reimburse them.

In Christus Health Gulf Coast v. Aetna, five hospital groups had contracted with North American Medical Management of Texas to provide Medicare services to members of an Aetna subsidiary that participated in the Medicare Advantage program. NAMM went bankrupt in 2000 and stopped paying the hospitals, so the facilities turned to Aetna for reimbursement, court records show. Aetna said it already had paid NAMM for the services, and the health plan declined the hospitals’ claims.

The TMA’s Wilcox said the high court decision strengthens an Aug. 27 state trial court ruling holding PacifiCare liable for payment problems.

PacifiCare in the late 1990s contracted with a group of IPAs that eventually went bankrupt and failed to pay thousands of claims owed to doctors under its Medicare Advantage plan, Wilcox said. The insurer argued that it was not responsible for the unpaid claims, so the TMA and several physician groups sued in 2003.

http://www.ama-assn.org/amednews/2007/10/08/gvsd1008.htm

And…

New retail health clinic model puts doctors out front

By Pamela Lewis Dolan
American Medical News
October 8, 2007

While retail-based health clinics generally rely on nurse practitioners and physician assistants to see patients, another model is emerging that staffs entirely with physicians.

Despite the increase in overhead, that new model works, say clinic operators, because of its expanded scope and greater marketing potential. And some big names and deep pockets are jumping behind the concept.

One of the model’s early adopters is Jacksonville, Fla.-based Solantic, which recently expanded its stand-alone clinic chain to include clinics located inside Wal-Mart stores.

Solantic is also gaining attention because of one of the names behind it. Richard Scott, who founded Solantic in 2002, gained notoriety for taking two struggling Texas hospitals and creating, through mergers and acquisitions, the Columbia/HCA Healthcare Corp., which became the largest for-profit hospital chain in the world.

However, a massive Medicare fraud investigation cost Scott his job as Columbia/HCA’s CEO and president. Scott was never charged with wrongdoing, though other executives were, and HCA — which dropped the Columbia name — agreed to pay $1.7 billion in civil penalties and damages to settle the case.

http://www.ama-assn.org/amednews/2007/10/08/bisb1008.htm

And…

Medtronic, Again Questioned Over Payments to Doctors, Is Subject of Senator’s Inquiry

By Reed Abelson
The New York Times
September 27, 2007

Medtronic, which reached a $40 million settlement last year with the federal government over accusations that the company had paid illegal kickbacks to doctors for using its spinal devices, has continued to pay doctors millions of dollars in consulting fees, according to a lawyer representing a whistle-blower involved in the case.

In the case that led to last year’s settlement, the Justice Department accused Medtronic of paying kickbacks through what government officials described as “sham consulting agreements, sham royalty agreements and lavish trips to desirable locations” offered to doctors from 1998 to 2003.

http://www.nytimes.com/2007/09/27/business/27letter.html?ref=health

Comment:

By Don McCanne, MD

What do these stories have in common? They are examples of the marketplace at work, and it is our health care system and those it serves that are the victims.

Much of the current debate on reform centers around the issue of whether the free market or the government would provide the more efficient approach to financing health care.

These stories demonstrate that good business practices, designed to improve profits, are amoral or sometimes even immoral methods of allocating our health care dollars. The health care system is manipulated by businesses to achieve maximal return on investment. The for-profit private insurance industry adheres to these principles.

In contrast, government has the sole responsibility to use its public resources to promote the public good. Taxpayer-funded health insurance programs use their purchasing power to achieve maximal health care value for the beneficiaries of the public program.

If we were to establish our own national health insurance program we would be in a much better position to demand that the health care industry be injected with a heavy dose of business ethics.

Survey Report: Time May Be Right for a Single-Payer Health Care System

By Marianne Mattera
Managing Editor
MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor at the University of Pennsylvania School of Medicine.
September 28, 2007

Presidential candidates might consider proposing a health care reform package that relies on a single-payer system, if results of a MedPage Today poll reflect the country’s mood.

When we asked visitors if it is time for the U.S. to adopt a single-payer health care system, 56% said, Yes, the current system cannot be fixed by half-way measures.

The 696 respondents represented most of the key segments of the health care equation — including physicians, nurses, nurse practitioners and physician assistants, pharmacists, health care administrators, and patients.

Economics was a big factor in the decision of many who voted for one source of financing. One respondent summed up the rationale: “The system is broken. A single payer system would save taxpayers millions of dollars when the middle men [in the insurance system] are cut out. There are too many rules, too many deductibles, too many games doctors have to play. The paperwork is a nightmare for doctors and patients alike.”

Another agreed, noting that the excess between cost of care and insurance profit would pay for all the uninsured.

Even physicians, who have traditionally opposed anything that smacks of national health insurance — as a single-payer plan would imply — came down heavily in the Yes column. They chose that option two-to-one over an answer that recognized that a single-payer system could mean “the end of whatever physician autonomy and patient choice still remains in this country.”

One doctor spelled out why he and his colleagues feel that way: “The only way to fix the system is single payer. Under the current system, choice of provider is limited by which provider is covered by [the patient’s] insurance. This combined with [insurers’] drug formularies already limits choices in care.”

Overall, only 20% of respondents were worried about maintaining choice and autonomy. Another 24% said there should be more players involved in the financing mechanism, but there should be a plan to cover the uninsured.

Those who voted No had strong opinions, though. Said a nurse practitioner with 30 years in health care, “I’ve seen the failures in multiple government-run programs and talked to doctors who fled the Canadian system because their patients were being denied care. There is no way government should run health care.”

One physician noted that the United States is a capitalist society and the only role of government is to maintain a level playing field. “It is the right of individuals and groups of individuals acting as ‘legal persons’ or corporations to trade capital goods, labor, land and money,” he said.

A colleague who supports a single-payer system, however, looks at competition from another angle. “The current health care environment takes away the competitiveness of our industries in the global arena. We need a basic universal health care system for all.”

Although universal coverage doesn’t necessarily translate into a single-payer system, that doctor is right about the timing of this debate, he said, “I am glad that this question on health care reform comes up now, before a new president is elected.”

Single-payer health plan best for taxpayers

By Kathy Waller
The Coloradoan
October 1, 2007

The numbers are in, and every citizen needs to pay attention.

The U.S. Census Bureau recently released data on health insurance coverage in the United States. For 2006, 47 million Americans were uninsured, an increase of 2.18 million from the previous year. In other words, one in 6 Americans does not have any health insurance. In every other industrialized country in the world, the number of uninsured is zero.

The increase in the number of uninsured Americans from 2005 to 2006 is the biggest jump reported by the Census Bureau since 1992. There are now more uninsured people in the United States than at any time since the passage of Medicare & Medicaid in the mid-1960s.

Strikingly, nearly all of the increase in uninsured over the past year (2.02 million of the 2.18 million) was concentrated among middle-class Americans making over $50,000 per year.

More than half of the newly uninsured (56.4 percent) are full-time workers. Maybe this is because the average health-insurance premium for a family of four is just over $12,000 per year (not including deductibles and co-pays). Hardworking, middle-class Americans are now feeling the distress of being uninsured. Many of us are only one illness or accident away from financial ruin.

More numbers: Private health insurance companies made $40 billion in profit last year, while it would cost $54 billion to cover all of the uninsured.

In Colorado, there are 792,000 uninsured, including 180,000 children.

Now for some good news. Here in Colorado, the 208 Commission (a bipartisan group created by the state Legislature) solicited input and requested health-care reform proposals from the people of the state. Of 31 proposals submitted, they narrowed the choices to four and sent them to an independent health-care analysis group to determine the potential impacts on health spending and coverage in Colorado.

Three of the proposals are based upon combinations of public and private health insurance, some with mandates requiring individuals and/or employers to purchase health insurance. The fourth proposal is a single-payer plan, pooling the risk of all residents into a single fund, minimizing the administrative costs and eliminating the profit motive from health insurance (a fifth proposal, also a combination of public and private insurance, was created by the commission; it was sent for analysis later and the results are still pending).

The results were released last month, and the numbers are astounding. The three plans that give private insurance a continued role are estimated to cost the state between $595 million and $1.3 billion, and still leave between 109,000 and 467,000 people without adequate health insurance. The single-payer plan will save the state $1.4 billion and everyone will be covered.

Let’s repeat that for emphasis. The single-payer plan will provide coverage for everyone and save more than a billion dollars for Colorado taxpayers. The other plans cost millions of dollars and still leave hundreds of thousands of people uninsured.

We have a unique opportunity in Colorado to show the rest of the country how to achieve efficient, affordable, universal health coverage. Single-payer is the only plan that makes sense. To learn more and get involved, visit www.healthcareforallcolorado.org and www.pnhp.org. From medical, moral and economic perspectives, we just can’t afford to sit around and wait for the numbers to get even worse.

Kathy Waller, MD, MPH, lives in Fort Collins.

Oprah Winfrey Talks To Michael Moore About Sicko And Health Care Insurance Industry

Submitted by Dan Wilson
Best Syndication
September 27, 2007

Michael Moore visited Oprah Winfrey on Thursday to talk about the health insurance industry. His movie Sicko has stirred a debate, and even Oprah admitted that it opened her eyes to the issue. The movie is a warning to the vast majority of Americans who believe they are protected because they have health insurance. The movie does not concern the 50 million without coverage.

Oprah asked a question that she wanted everyone to answer. She asked “Should the son of a gas station attendant have the same health coverage as the son of a CEO?” She told her audience “You need to see this movie”! When she saw the film, it completely changed the way she looked at health care.

Following Michael Moore’s last appearance, the Oprah show was inundated with thousands of emails. One caller said “while I am searching for affordable health care, my daughter may die.”

A pivotal moment in the health care debate came a few weeks ago during the Democratic Presidential debate in Chicago. Retired steel worker, Steve Skvara, asked “After 34 years with LTV steel I was forced to retire because of a disability. Two years later LTV filed bankruptcy. I lost a third of my pension and my family lost their healthcare… what is wrong with America and what will you do to change it.” Oprah had Scuvara on the set Thursday.

One of the problems Oprah brought up involved a bone marrow transplant. Stewart Eastham, a 25 year old worker in the oil and gas industry, was told by the hospital that he must bring $250,000 cash for a life saving treatment. Stewart’s insurance would only cover $150,000 of the procedure, and he needed to pay the additional $250,000.

The delay in his treatment caused Stewart to go blind in one eye. Lisa Ling decided to call his insurance company to find out what had happened with Stewarts case. She wanted to talk to the CEO of Blue Cross / Blue Shield about his case.

Civia Katz is a working mother of three. She needed a special surgery, and later her insurance company refused to pay for anything. Lisa also decided to call Civia’s insurance company.

Michele Marron was attacked by an auto immune disorder. She lost weight and needed to use on oxygen 24 hours a day because the disease had attacked her lungs. Her doctor says a stem cell transplant is the only chance for her to breath on her own. This was deemed an experimental surgery and would not be paid for by insurance. Lisa decided to call her insurance as well.

Out of all three cases, none of the insurance company’s CEOs would speak to Lisa Ling. The media representatives gave her various explanations. Only Civia received any help from her insurance company, Aetna, who said they made a mistake.

A comment came from a former hospital CEO, William Blaine of Minnesota, who said “I retired early because I had Multiple Sclerosis (MS) and could no longer work. Since retiring, my health insurance denied me critical medication and my disability insurance told me that I am no longer disabled…. I face a daily battle with my insurance companies.

“Most people can’t afford to fight these companies. I think we can’t afford not to. If this can happen to me, it can happen to anyone.”

On average, having a brain tumor will cost about $200,000 more in treatment. A stroke will cost $140,000. Leukemia can cost up to $600,000. Oprah asks “would you be covered?”

Michael Moore said that medical obligations are the number one cause of both bankruptcy and homelessness. “It is an absolute outrage,” Moore said. He said people who are sick are sometimes unable to fight the insurance companies.

Karen Ignagni, president of America’s Health Insurance Plans, made an attempt to defend the insurance companies and said that Michael Moore is right, and American needs health insurance for everyone. She represents a health insurance lobbying group.

Michael Moore doesn’t agree with that. Moore says the insurance companies are the problem. Insurance companies deny claims, cancel policies and eliminate people with pre-existing conditions. Both Hillary Clinton and John Edwards are calling for “Universal Coverage” which would force people to buy health insurance. This could actually exacerbate the problem.

But what about experimental procedures? “The National Institute of Health (NIH) should cover that as part of their research, said Professor Uwe Reinhardt of Princeton.

Reinhardt came up with the fundamental question for Oprah’s show, “Sick in America”. He asked “Should health care be more like elementary and secondary education, where every American simply has a right to it. Or do you want to treat it like a luxury like fine dining, where if you have the money you get it but if you don’t you won’t.”

Check Back Next Week For Part 2 of this Story See what others are saying and join the discussion at our Forum

Privatized "Big Brother"

Employers, Health Insurers Increasingly Use Care Managers To Review Physicians' Treatment Plans, Ensure They Conform to Evidence-Based Practices

Kaiser Daily Health Policy Report
September 25, 2007

A growing number of employers and health insurers are using care managers, or integrated health managers, who “essentially audit an employee’s health care and look for ways to both improve outcomes and save money,” the Wall Street Journal reports. According to the consulting firm Deloitte & Touche, there are more than 200 care managers in the U.S. who provide “programs designed to save employers and health plans money by reviewing employees’ health care claims and targeting high-cost cases for special management,” the Journal reports.

Care managers often review physicians’ treatment plans to ensure they are following established evidence-based practices and help coordinate care for people with serious illnesses. Based on the reviews, “the companies then may nix certain drugs or procedures,” the Journal reports.

Critics say that some of the programs “intrude into the private relationship between patients and their doctors and that they add yet another layer of bureaucracy, while saving money mostly by denying or switching specific drugs and procedures,” according to the Journal. Other critics say that care managers can be inflexible and ignore differences between individual patients and the judgment of physicians and nurses.

Cecil Wilson, immediate past chair of the American Medical Association, said, “The patient’s physician should ultimately be the one in charge,” adding that cost-saving should not be the main goal of care managers (McQueen, Wall Street Journal, 9/25).

http://www.kaisernetwork.org/Daily_reports/print_report.cfm?DR_ID=47740&dr_cat=3

Comment:

By Don McCanne, MD

Big Brother is watching you. Only he is not from the government. He is an agent of the Invisible Hand.

Intrusive micromanagement of health care today is not coming from an oppressive government, but rather it is an innovation of the free marketplace.

Rather than micromanaging health care, the stewards of a government-administered single payer system would macromanage the funds to pay for health care. Health care micromanagement decisions would be left to patients in consultation with their health care practitioners.

Of course, oversight of the spending of public funds would be essential to be certain that they are not inappropriately diverted through fraud and abuse. But that would be at arms length and not through disruptive intrusions.

Again, the private industry is foisting off on us yet more of its primary product: wasteful administrative excesses.