PNHP

Children harmed by static SCHIP eligibility

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.

Consumer Reports on the underinsured

Are you really covered?

Why 4 in 10 Americans can’t depend on their health insurance

Consumer Reports
September 2007

You might think that you don’t have to worry about paying for medical care if you have health insurance. But you would be wrong.

From escalating medical debt to postponed retirement, our exclusive national survey of working-age adults shows the depth of jitters even for those lucky enough to have insurance through their jobs or families:

* 29 percent of people who had health insurance were “underinsured,” with coverage so meager they often postponed medical care because of costs.

* 49 percent overall, and 43 percent of people with insurance, said they were “somewhat” to “completely” unprepared to cope with a costly medical emergency over the coming year.

* 20 percent of people said they were so disappointed with their HMO or PPO that they wanted to switch plans.

* 16 percent had no health plan at all, including many working respondents whose jobs didn’t offer insurance, or who couldn’t afford the premiums or deductibles of the available plan.

Insured but not covered

Our survey found evidence of the increasing frailty of our system of health insurance almost everywhere we looked.

Between 2001 and 2005, the percentage of middle-income families – those who earn between $40,000 and $80,000 for a family of four – who had job-based health coverage dropped by 4 percentage points. Half lost benefits because their employers dropped health insurance altogether or quit offering dependent coverage. But 15 percent gave up their employer-based insurance because they could no longer afford the premiums.

But even those who have managed to hang on to insurance have found it more difficult to pay their medical bills.

In our survey, the median household income of respondents who were underinsured was $58,950, well above the U.S. median; 22 percent lived in households making more than $100,000 per year.

An explanation isn’t difficult to find: Health plans are offloading more and more expenses onto consumers. Co-pays and deductibles have risen steadily in the past several years.

This combination of deductibles and co-pays can quickly add up to serious bills in the case of a major illness. A 2006 study found that 10 percent of insured patients with cancer had out-of-pocket expenses of more than $18,500.

How to pay?

Consumers faced with higher health costs have to find the money somewhere, and many in our survey found that tough to do. Overall, 37 percent said their health insurance and checking accounts together weren’t enough to pay for their medical expenses over the previous year. But 59 percent of underinsured respondents fell in that category. They had to raid their retirement accounts, run up credit-card balances, and borrow from friends and family to pay their medical bills. Twenty-seven percent said they were still in debt to doctors and hospitals, and 3 percent said medical bills had forced them to declare bankruptcy.

Almost 4 in 10 underinsured respondents deferred needed auto or home repairs. Almost 3 in 10 said they made decisions such as changing jobs, postponing retirement, or changing their marital status mainly to preserve access to health insurance.

But the most worrisome result of underinsurance is reduced access the health care itself. Forty-three percent of underinsured respondents said they had postponed going to the doctor because they couldn’t afford it, and 28 percent had put off filling prescriptions.

http://www.consumerreports.org/cro/index.htm (subscription required)

Comment:

By Don McCanne, MD

Private health plans work for people who do not and never will need health care. But what if medical needs arise? How well do they work?

Thirty-seven percent of privately-insured consumers with higher health costs found that their insurance plus their checking accounts were not enough to pay for their medical expenses over the previous year. And for the underinsured, that rose to fifty-nine percent.

Yet most of our politicians want to build on private insurance plans to provide coverage for everyone, but they do recognize that premiums are no longer affordable for average-income individuals. So what do they recommend? Let’s make premiums affordable by reducing further the coverage provided by the private plans.

What will happen then? Health care will remain affordable for those with insurance plus very large balances in their checking accounts. The rest of us with insurance will have to “raid our retirement accounts, run up credit-card balances, and borrow from friends and family.”

Listen up, Politicians! PRIVATE PLANS WON’T WORK! Get over it!

H.R. 676 would tax rich, give health care to all

Saul Friedman | Gray Matters
Newsday
August 4, 2007

The middle-aged fellow who takes care of my yard had a stroke some weeks ago, but he doesn’t know how it affected him or whether another one may be coming.

That’s because he hasn’t had the $1,600 cash for the MRI he needs. He could not get health insurance, even if he could afford the huge premium, because he was not in the best of shape, and he can’t get it now because of his pre-existing condition – the stroke. So he hopes for the best.

That is not an unusual story. I haven’t yet seen “Sicko,” but I don’t need filmmaker Michael Moore to tell me (and most of us) that while American health care can be the best if you can get it, the health care distribution system is also the most backward, costly, unfair and inequitable in the civilized world.

The single most important reason: The multibillion dollar power of the private insurance industry stands in the way of genuine change.

The facts are well known, and unique to the United States. More than 43 million Americans, most with jobs, have no health insurance and no protection against illness or accident. More than nine million children are without health care coverage. People who are under 65 and have been laid off from jobs cannot get coverage unless they pay outrageous premiums.

Personal bankruptcies are increasing because of medical debt. And as Moore’s documentary shows, the 250 million Americans with insurance can’t count on coverage when they’re really and expensively sick. Any of these facts would be considered outrageous almost anywhere else in the world.

Forget the silly and mostly inaccurate nitpicking about Moore’s facts. We know from personal experience and from all we’ve read that his and our diagnosis of the American health care distribution system is correct. According to every poll, more than 70 percent of us know it needs to be fixed with a system that covers every American if they need it – whether it’s for the flu, a broken bone or a long battle with cancer.

How do we do this? So far, most of the Democratic presidential candidates favor giving most of the role of providing health care to insurance companies in partnership with employers and the federal government. How much government would be involved remains an issue. (The Republican candidates would provide tax breaks to buy insurance with little or no government involvement.)

The most important reason the candidates involve insurance companies is the fear that their power, along with other financial interests of the medical-industrial complex, would kill any universal coverage that doesn’t include a major role for the insurance industry.

But “Sicko” calls for an end to private health insurance (except for such services as cosmetic surgery) because, Moore says, insurance companies have an inherent conflict of interest. Their first obligation, under law, is to earn as much as possible for their shareholders. And that means they are obligated to spend as little as possible on health care, by limiting coverage to younger, healthy people or refusing as many claims as they can get away with, or restricting the services doctors and hospitals may provide. If your doctor can’t spend time with you, there’s an insurer in the room.

That’s why Moore was able to find 25,000 people with tales of insurance denials, some of them fatal. And that’s why Moore favors a publicly financed “single-payer” system, run by the government and with no role for the insurance companies.

But as my mail shows, there are misconceptions about what a “single-payer” system is. It is not the British model, in which health care providers work for the health service. That is not what advocates of single-payer system envision for the United States.

Indeed, the United States already has a couple of government-run, taxpayer-supported single-payer systems – Medicare, for persons over 65 and the disabled, and the Veterans Affairs health system, which provides doctors, hospitals, drugs and even long-term care for eligible veterans. Doctors and other medical personnel work for themselves. And both systems work remarkably well, despite this administration’s efforts to undermine them.

You would think, then, that a single-payer system that expands Medicare to cover every American, and not just the old and disabled, would be logical and reasonable. But Rep. Dennis Kucinich of Ohio is the only Democratic candidate to endorse the idea.

In addition, while surveying the possibilities for universal health coverage, most of the press and even the authoritative Kaiser Family Foundation’s new health care Web site, have failed to mention the only legislative proposal, endorsed by Kucinich and Moore, for a single-payer universal health plan: H.R. 676, the National Health Insurance Act, or “the Expanded and Improved Medicare for All Act.”

But one of the most influential voices for seniors, Jane Bryant Quinn, has endorsed what she called, in Newsweek, “an excellent template for universal care right under our noses; good old American Medicare. When you think of reform, think ‘Medicare for all.'”

That’s the intent of H.R. 676, introduced in 2005 by Rep. John Conyers (D-Mich.), with nearly 80 co-sponsors. It would be financed by tax increases on the wealthiest Americans plus appropriations and premiums to guarantee free medically necessary health care, drugs, and long-term care to every American. But most of the cost would be offset by the end of private insurance costs. Like Medicare before HMOs were permitted, insurance companies would be prohibited from selling policies that duplicated the benefits provided under the act.

The cost would be much less than the $12 billion a month we’re spending on Iraq because it would eliminate the need for employer contributions, Medicaid, the State Children’s Health Insurance Program and other state programs.

Radical? Judge for yourself. Medicare for All, which could be phased in gradually and administered within states as Medicare is, has been endorsed by 15,000 doctors, even more nurses and 20 state labor federations. If you have access to a computer, visit the Web site of Physicians for a National Health Plan (pnhp.org) and see what it says about a single-payer plan. And read Conyers’ bill by searching on your computer or at the library for H.R. 676.

WRITE TO Saul Friedman, Newsday, 235 Pinelawn Rd., Melville, NY, 11747-4250, or by e-mail at saulfriedman@comcast.net.

Medicare for all would help America

Judy Dasovich, M.D
The Springfield News-Leader
Ozarks Opinions
Saturday, August 4, 2007

In your 7/25 article, Jordan Valley Community Health Center Executive Director Brooks Miller stated that “We believe we all need to pay something.” At the Kitchen Medical and Dental Clinic we see patients every week who start out at Jordan Valley but cannot afford the minimum $30 per visit. Even patients who can afford the initial fee bring us their prescriptions, which they cannot afford. This $30 doesn’t cover specialty care or testing, such as a treadmill or a CAT scan or a visit to the cardiologist.

Here is the typical scenario: People get sick, then they can’t work so they lose their jobs and their medical insurance. They have a hard time paying their bills. Under these circumstances, $30 per visit for only the basics becomes prohibitive. These are the patients who come to us after finding that the Jordan Valley safety net is full of large holes. They may not have money but they’re still sick.

We believe people should receive health care based on need, not ability to pay. As many leaders in the Springfield health care community pointed out, this problem is too big for any one group to handle alone. I believe that Medicare for all will be the most effective and affordable solution. In this form of universal care, the delivery system (hospitals, doctors, etc.) stays in the hands of private business. It is the insurance piece that is handled by the government. Currently, Medicare overhead is less than 3 percent, while private insurance averages about 12-15 percent and can be higher. Patient satisfaction with Medicare insurance is higher than it is with private insurance. Traditional Medicare doesn’t exclude people for pre-existing conditions or cancel their insurance once people become ill. Medicare insurance also allows patients the freedom of choice advocated by Donald Tucker in his 7/28 News-Leader article. They can choose any doctor or hospital they want. Medicare for all is similar to the system that gets interstate highways built — federal tax dollars pay private business to produce a common good.

It’s time to put aside reliance on incomplete safety nets like emergency rooms, free clinics, and taxpayer-funded health care centers like Jordan Valley that turn sick people away. Contact the people that work for you in Washington today.

Judy Dasovich, M.D., is volunteer medical director at the Kitchen Medical and Dental Clinic.

A strike for better healthcare

By Stephen J. Bergman
The Boston Globe
August 5, 2007

SOON AFTER HMO/managed care came to Massachusetts in the late ’80s, I got a call from a patient I had admitted to the 28-day alcohol unit at the hospital. He said that he was being discharged after three days because that was all that the HMO would now pay for alcoholism. He said the HMO representative told him to go out and get drunk again and they would readmit him.

How did this happen? Managed care let it be known through massive advertising that either doctors join up, or be left out — we would lose patients to HMO doctors. This seemed strange: Doctors did the work; without us, there was no “care” to manage. If we stuck together, we could get what we wanted from the insurance industry. Instead, doctors elbowed each other out of the way to make sure they would “get in.” We lost our clout in setting standards for good care for patients, and a work environment that would allow it.

Now, healthcare in America is a national disgrace. Forty-five million are uninsured, most are underinsured — one illness away from bankruptcy, poverty, or homelessness. Our private healthcare system is worse for patients and doctors and better for the insurance industry. Even the insured are suffering. Their doctors are rushed, mistakes are made, good care is hard to find. Private health insurance spends about 30 percent on administrative costs; government-run Medicare spends 3 percent. The single-payer national model seems inevitable.

Yet it has not happened. The health insurance industry is profitable, and a well-funded lobby. Only one of the presidential candidates (Dennis Kucinich) is sponsoring a single-payer system — the others are just whistling past the grave of medical care. However, elements of change are arising — scholars, politicians, media, pundits, and the public, and now Michael Moore, in his new documentary “Sicko,” pointing out the relative inadequacies of our system. But one piece, a vital piece, has been missing.

Change will not originate from the top. In any hierarchical system, the only threat to the dominant group is the quality of connection among the subordinate group. This is true of race, gender, class, ethnicity, and sexual preference. In three great movements of my lifetime — women’s rights, civil rights, and the ending of the Vietnam War — change came from my generation seeing an injustice and believing that by organizing together at the grass-roots level we could right an obvious wrong. And now?

I propose a doctors strike (or a healthcare workers strike, but I can only speak as a doctor). First, doctors would recruit enough colleagues to pledge that if, in two years (say, by July 4, 2009), there is not a federal law for a single-payer, universal coverage health system, we will go on strike.

At first we will be dismissed as idealistic or ungrateful nuts advocating that horror of horrors, “socialized medicine.” We may not have many members, and the insurance industry will mobilize in a way that makes the ads against the Clinton health bill look like musical comedy.

Six months pass; we remind the public that in 18 months we will go on strike. Our ranks increase — patients, realizing that it is in their interest to directly support the strike, join us — and more attention gets paid. Twelve months until the strike, we are growing in membership — other healthcare workers join, maybe even a company like General Motors that is sick and tired of paying more for health insurance than for the steel for their cars — and we spell out exactly what we won’t provide and the resulting chaos in our hospitals, emergency rooms, outpatient clinics, etc. Perhaps those in the government start to notice.

At six months, with tens of thousands pledging to strike, we may be taken quite seriously — the public understands that the consequences of a strike would be disastrous. What irony: To protect patients, doctors have to go on strike!

I predict that it will never come to that. We will put real health insurance on the books.

We are the ones who do the work. If we care for our patients, and for our Hippocratic ideals, we have no choice but to try. Our efforts, in sync with the rising tide of public and political movements, might just lift us all, leading America into the fold of those rich nations who put first things first: the health security of their citizens.

*Stephen J. Bergman, *under the pen-name “Samuel Shem,” is author of the novels “The House of God” and “Mount Misery” and co-author of the play “Bill W. and Dr. Bob.”

(c) Copyright 2007 Globe Newspaper Company.

Health Council of Canada Releases Report on Wait Times and Guarantees

Toronto June 26, 2007 — While there has been significant progress to improve and manage centralized information on wait times for targeted health care procedures, the data needed to see changes over time and compare wait times on a national level is not available from all jurisdictions, the Health Council of Canada says in its wait times report, released today.

Wading through Wait Times: What Do Meaningful Reductions and Guarantees Mean? reviews progress by provinces and territories in reducing wait times for non-emergency care from a patient’s perspective through a true story about Frank, a hip replacement patient.

This report is a look at one of the key public concerns about health care, set in the context of the national commitment to achieve meaningful reductions in wait times in five priority areas — cancer, heart, diagnostic imaging, joint replacements and sight restoration — by March 31, 2007.

“Clearly there has been progress, and we can see many areas where jurisdictions are doing more and reporting in more accessible ways to citizens,” said Dr. Jeanne Besner, Chair, Health Council of Canada. “Reporting wait time information to citizens on the Internet has been no small task. These information systems have considerable potential to improve patients’ experiences with waits for care.”

Approximately one in 10 Canadians sees a health care specialist each year, with many patients reporting delays in accessing care. On average, Canadians reported waiting four weeks to see a specialist, according to surveys done in 2003 and 2005. Although provinces and territories report wait times in different ways, information shows median wait times for non-emergency care have clearly declined for some services. For example:

* In British Columbia the wait time for cataract surgery has been reduced to 7.6 weeks from 9.9 weeks;
* In Ontario the wait time for radiation for cancer care has been reduced to 4.4 weeks from 6.4 weeks;
* In Alberta the wait time for hip replacement has been reduced to 12 weeks from 16 weeks and for knee replacement has dropped to 17 weeks from 22 weeks.

These and other positive developments come at the same time the volume of services has increased in targeted areas. For some services, in some parts of the country, more people are getting care more quickly.

While the information now available for wait times is not sufficient for Canada-wide monitoring, having this data in the public realm is a significant step forward and means wait lists are beginning to be managed centrally in a fair and logical way. Until recently most surgeons kept their own waiting lists and data were rarely compiled at the provincial, regional or hospital level. Unfortunately, gaps remain in the availability of wait times information and the Health Council of Canada continues to call for accelerated investments in the development of comparable data systems across the country.

Developed, in part, through interviews with leaders of innovative programs (see backgrounder), Wading through Wait Times identifies a number of factors that are critical for success in reducing health care wait times. They are:

* Support from government leaders;
* Strong program leadership;
* Full-time program staff;
* Information systems to centralize and track waiting lists;
* Adequate funding for information systems and program leadership;
* A comprehensive approach to all the changes required to reduce wait times.

In addition to reporting on progress in reducing wait times for care as agreed to in the 2004 10-Year Plan to Strengthen Health Care, this update provides Canadians with information on the new patient wait time guarantees.

“Ideally, the best guarantee is one that rarely, if ever, needs to be invoked,” said Councillor Les Vertesi, an emergency physician from British Columbia. “Jurisdictions have chosen to implement guarantees for services they already provide, or are well on their way to delivering, within the guaranteed time frame.”

As Wading through Wait Times concludes, international experiences with wait time guarantees may be instructive, but they cannot tell us what impact Canadians can expect from these policies until they are coupled with reliable and comparative data. Guarantees may play a valuable role in resolving Canada’s wait time problem. But unless access also improves for other health services, the guarantees by themselves may fall short of meeting the expectations of Canadians.

Visit www.healthcouncilcanada.ca to download Wading through Wait Times: What Do Meaningful Reductions and Guarantees Mean? and the backgrounder highlighting regional success stories in reducing wait times.

Background

The Health Council of Canada, created by the 2003 First Ministers’ Accord on Health Care Renewal following the recommendations of the Romanow and Kirby reports, is mandated to monitor and report on the progress of health care renewal in Canada. The 26 Councillors were appointed by the participating provinces, territories and the Government of Canada and have expertise and broad experience in community care, Aboriginal health, nursing, health education and administration, finance, medicine and pharmacy.

The economics and morality of Sicko

'Sicko' economics, round 2

David Felix
Bangor Daily News
August 1, 2007

John Goodman summarizes his critique of Michael Moore’s documentary on health care reform as follows: “So what are we to make of Moore and his ‘documentary’? Economists, like other scientists, study reality in order to adapt to it. Artists, by contrast, selectively focus on some facts and ignore others in order to recreate reality.” Bad economics is thus Goodman’s basic charge against “Sicko.”

This charge prompted me, an economist, to see the documentary. My conclusion? Moore is far less guilty of flawed economics and disregard of relevant facts than is Goodman. Moore is also straightforward about his values and ideology, whereas Goodman masks his as scientific economics. This impels me to defend my profession by exposing the falsity of his claims, and some of the salient facts that he ignores.

Goodman rejects single payer universal coverage health systems, which Moore favors, because they require bureaucratic rationing of medical care, and impose longer waiting periods than do private market health systems. The rationing complaint as such is irrelevant; markets also ration, mostly by the purse. What they have been unable to do is provide universal coverage.

The incentive for private health insurance companies is to maximize profits by insuring low-risk clients and rejecting high risk ones. That incentive promotes private bureaucratic rationing of services and intensified screening of applicants. The U.S. public sector and private charities have thus been pressured to finance treatment of some sort for the rapidly rising millions of U.S. uninsured and underinsured. “Sicko” illustrates various aspects of the problem. Goodman gives it no mention whatsoever.

(David Felix then discusses numerous examples of Goodman’s distortion of the economics through major omissions.)

…what economists call deadweight losses, inefficient uses of resources that reduce national welfare. “Sicko” illustrates such losses in the U.S. system; Goodman ignores them.

Which brings us to the moral issue. The major religions advocate egalitarian distribution of social welfare theologically, whereas libertarian ideology prioritizes free markets and individual choice. Each can become enmeshed by policy conflicts between theology and economic reality.

Health reform is an exception. Moore has the easier advocacy task: his single-payer reform is supported by both “scientific” economics and widely held religious principles.

Goodman must show that socializing health insurance, even if it lowers economic costs while improving health, is morally bad. His critique avoids that question, other than hinting at a slippery slope argument. My conclusion: Moore wins over Goodman on economics and morality.

David Felix of Orono is professor emeritus of economics at Washington University in St. Louis.

http://bangordailynews.com/news/t/viewpoints.aspx?articleid=152647&zoneid=35

Comment:

By Don McCanne, MD

The economic benefit of the single payer model is firmly established in the health policy literature. That does not stop the conservative and/or libertarian think tanks from using highly selected data to create the impression that there is a compelling economic argument for rejecting single payer reform. As David Felix’s article suggests, these arguments are made to appear valid by remaining silent on the overwhelming body of information that would refute their deviously crafted premises.

In dismissing the validity of their economic theses, we can then turn to the fundamental dispute: the choice between the egalitarian concept of social insurance and the libertarian ideology of free markets. David Felix is right. This is a moral issue.

Is establishing an efficient, equitably-funded, universal insurance pool that would allow everyone to have affordable access to health care a good thing or a bad thing?

Is keeping the government out by allowing individuals the freedom to use their own personal funds to negotiate their way through insurance markets and the health care delivery system a good thing or a bad thing?

Joining together in a democratic process to be sure that everyone has health care has been considered to be a good thing by all other industrialized nations. Do those who wave the banner of freedom really still believe that they hold the high moral ground when they have emblazoned their banner with a skull and crossbones? I’ll take our banner with its stars and stripes, thank you.

Testimony by Dr. Johnathon S Ross, Past President of Physicians for a National Health Program in Support of HR 676

July 31, 2007
Toledo, Ohio

My name is Johnathon Ross. I am an internist. I practice and teach internal medicine at St Vincent Mercy Medical Center and have done so for the past 27 years. I am the medical director for the outpatient adult clinic which serves a center city population that includes a substantial number of poor and uninsured individuals. Every day I see a near miss. Every week I see a wounding. Every month or so I see a death due to our sickness care non-system that leaves 50,000 Lucas County citizens, over a million Ohioans and over 45 million Americans uninsured. A recent Friday morning was a typical clinic session where I work. Here are a few stories from just that single morning. Imagine similar ones day after day for the past 27 years and you will understand why I am here to testify today. I have changed the names for privacy but I did ask each patient if it was ok to tell their story and each agreed.

Tommy is 41. He was making his first visit following bypass surgery after suffering a massive MI. Tommy can’t read or write very well. He was working a low wage job that did not have insurance so he never saw a doctor for well care. That doesn’t matter much now since he lost his job due to his illness. He was very depressed in hospital and was started on medication for his depression and for his heart. Fortunately he was at the clinic with a family member who had paid over $100 for medication to keep him alive until his appointment with us. Thanks to CareNet, a free care program I helped to devise which helps some of the uninsured in Lucas County, he was able to see us in the clinic without charge but there was little likelihood he would be able to pay for follow up with the heart specialists let alone the bills they would soon be sending for his hospital care. One of our nurses who spends hours every day trying to help people get “free” drugs from the pharmaceutical companies looked deflated when we gave her the long list of expensive medication he needed.

Shelly works as a temp at another hospital. She doesn’t have any benefits including health insurance even though she works full time as a nurse’s aide. The irony of a health care worker who is not covered for health care is not lost on me as I see lots of nurse’s aides who work in extended care facilities with no benefits. She was seen in the emergency room for severe stomach pain. She hasn’t seen the bill yet but I suspect her stomach\ pain will get worse when she does. Her stomach still hurts and she had no money for the ulcer medicine they wrote for her. I search the free samples and manage to find about two weeks of medicine. I give her a follow-up appointment and hope for the best. Even if she was covered it can take a month or more to get a gastroenterologist to see my patients.

A clerk tells me that Niles is at the window and he is upset. He is out of medication and needs samples of medication for his blood pressure. He should be covered by Medicare as he is 68. He has a card but the pharmacy says it is no good. He is not sure if it is no good for all or some of his medication. He just knows that he is not supposed to miss it. We have referred him several times to the social security office and they tell him he is covered by his card. There are 50- different plans all with different formularies and there is no time today to sort out again why his card is no good. I tell the nurse to give him samples again and we will try to sort out what is wrong with his card later.
Chris has asthma low back pain and high blood pressure. She is doing ok with her current medication but isn’t sure if her re-application for Medicaid will go through in time to allow her to get the refills that she needs. She says that she might have to “spin down”. She’s not sure what this means but I am. She works a little and may have made too much money this past month to qualify for help and might need to “spend down” not “spin down” to poverty or perhaps she will do both. In any case, she will be out of medicine in about ten days. The last time she missed her asthma medicine she ended up in the ER. I give her one of my last samples of an inhaler just in case and hope I don’t need it for someone else with more immediate needs.

Arthur has insurance. He has Medicaid. This is his third visit for a rash that won’t go away. It seems there are no dermatologists in town who will take his Medicaid HMO. I try to make light of a bad situation and remark that his new private insurance under Medicaid is actually a hunting license. WE get to go hunting for specialists who will accept his plan. We decide to continue our game of musical medicines to see if one will help. At least, he has coverage for his medicines. Welcome to the best health care system in the world.

America and Ohio need affordable guaranteed High quality health care coverage that they cannot lose if they change or lose a job, whether they are rich or poor, whether they are healthy and want to stay that way or whether they are sick and want to get well. Single payer national health insurance or a similar state based plan could accomplish the goals of guaranteed coverage, quality and cost control.

Doctors would get paid for every patient, see malpractice and administrative costs drop. They could maintain continuity of patient care with less non-compliance with expensive but needed therapies. Outcomes and quality would improve. Emergency room overuse and abuse would diminish. Chronic disease management would improve.
For patients, soaring health insurance premiums are the norm and uninsured Americans now exceed 45 million. 80% of the uninsured are working people and their kids. They are not covered by their jobs or cannot afford to buy health insurance when faced with skyrocketing premiums. Managed care, with its restrictions and market competition, failed to cure rising costs but surely created hassles for doctors and patients. Those same self-interested insurers who brought us HMO’s insist that financially squeezing patients will cure the cost crisis. In reality, High deductible health plans and Health savings accounts are just another way that employers shift the cost burden onto employees, whose co-payments and deductibles soar while their coverage sinks. If doctors and patients have problems now with collections, insurance hassles, and continuity of care, just wait until HSA’s with Swiss cheese coverage become the norm. Unfortunately, there will never be an effective market for health care services. Why?

Health care is not an ordinary product that people want. Rather, it is a necessity that they must have. The consumer’s not sovereign. The doctor, not the patient, orders the care. There’s no easy exit from the market for patients. Price does not matter. When critically (and expensively) ill, you buy or die. The most expensive health care is necessary not desired. Even the best physicians are unsure at times what tests or treatments will benefit a patient. Thus, the costs of patient care are often unpredictable. It is this uncertainty and unpredictability that creates the need for insurance in the first place. Asking patients to assume more responsibility for out of pocket costs will not work. Americans already pay the highest out of pocket health care costs in the western world and this has done little to control costs. Research shows that higher out of pocket payments will reduce the number of outpatient visits but these payments fail to increase the appropriateness of the visits. Paying more does not create wiser consumers of health care. To understand the absurdity of using individual market forces to control health care costs, imagine open-heart surgery is on sale. Would you have two? The most expensive surgery or medical care is the least optional, predictable or negotiable. The sickest 10% of patients generate 73% of the health care bills at an average of about $39,000 per person yearly. They will save nothing in their HSA’s. The market for medical services fails these tests of an effective market and will fail in the guise of HSA’s.

Massachusetts is forcing uninsured working families to buy bare bones coverage from private insurers who will likely keep 15 to 40% of premiums for administrative costs and profits. This is hailed as reform but hardly seems wise, fair or efficient. It will leave these families vulnerable to large health care bills that are potentially financially fatal to working families and there seems to be little effort to improve the quality of care we all get under this so called reform.

If market forces cannot work, the proven alternative is a tax financed universal health insurance system. It may seem counter-intuitive that a tax financed universal health insurance program that covers everyone could be less expensive than a health system based on cutthroat competition between private insurance companies that leaves 45 million Americans uncovered. Yet, this has proven to be the case for every other industrial democracy. Recently, Taiwan made just such a switch and again proved it could be done. They covered everyone with little increase in cost. On the other hand, national health insurance, as proposed in HR 676, (Conyers and Kucinich) would replace private premiums with fair payroll taxes. These funds, added to current public spending, would create a single insurance pool adequate to cover all Americans with no added spending. Here in Ohio, The health Care for all Ohioans act would do the same thing for all Ohioans. How can this be true?

In multi-payer systems, complexity yields high administrative costs. Each insurer, hospital and doctor must track of a myriad of contracts, discount arrangements, benefit packages, formularies, limited referral networks, and insurance regulations designed to reduce utilization. Market solutions leave this insurance and billing bureaucracy in place and add the complexity of tracking 300 million individual insurance policies.

Multiple studies confirm that the administrative simplicity of a single universal insurance pool yields hundreds of billions in savings that allow comprehensive coverage for all at current levels of spending. A tax-based public system is simple and efficient. There is simply less work to do. The data from a universal system can be used to track and evaluate care and offers the best opportunity to improve the quality of care.

Health care costs are hurting the competitiveness of our products in the world markets. Despite HMO’s, PPO’s, HSA’s, the FEHBP, CALPERS, small business insurance purchasing pools, high risk individual insurance purchasing pools, we have failed to control our health costs. American business and governmental employers are struggling with the burden of health care costs and despite almost 20 years of experimentation with these different approaches to cost control health care costs are growing at double the rate of the GDP. At the same time, the number of uninsured full time workers has soared by 10’s of millions as premiums have become more and more unaffordable. Several large industries are giving up responsibility for insuring their workers, creating insurance trusts that will be maintained by unions who not surprisingly support national health insurance. The largest U.S. employer, Wal-Mart, has come under severe criticism for its failure to cover its workers. They are targeted with state laws aimed at forcing them to insure their employees or pay special taxes to the state to help cover the uninsured. More business leaders are calling for a national solution. Some have speculated that it must be ideology alone that keeps many business leaders from supporting a national solution.

Business owners should realize that the health care system provides the maintenance on their work force just as other experts provide maintenance on their expensive and complex industrial and business machinery. It makes good sense to get the most comprehensive maintenance system for the best price. More for the same money, value, is what tax-financed universal health insurance system can provide. Those businesses avoiding the cost of insuring their employees are still the recipients of cost shifting. This occurs through higher taxes to fund indigent care and higher prices paid when doing business with companies who continue to insure their employees and pass along the costs shifted to them in the price of their products.

Conclusion

Patchwork solutions such as Medicaid expansions, individual insurance mandates, tax credits or health savings accounts are unlikely to work. They will mainly serve to enrich the insurance bureaucracy. They will fail to control costs, improve Quality and fail to cover everyone. Fundamental reform is needed.

A single payer tax financed universal health insurance system (an improved and expanded Medicare like program such as that proposed in HR 676 and the HCFAO act) will cover all Americans comprehensively at no added cost. It’s good for business and our health. Single payer national health insurance is conservative of the basic structure of the American health care system and in that it changes mainly the financing. It would ease our efforts to improve quality. It is conservative of individual freedom and responsibility in that it allows free choice of provider and eliminates financial barriers to preventive and chronic disease care.

Single payer national health insurance would cover everyone, save lives, save money, and it is the right thing to do. Counter-intuitive or not, even conservatives should support a single payer universal health insurance solution. Financially, they already are.

Johnathon S. Ross MD, MPH
Past President, Physicians for a National Health Program

'Sicko' economics, round 2

David Felix, economist
Bangor Daily News
Wednesday, August 1, 2007

John Goodman summarizes his critique of Michael Moore’s documentary on health care reform (“Sicko is no model for health care reform,” BDN, July 21), as follows: “So what are we to make of Moore and his ‘documentary’? Economists, like other scientists, study reality in order to adapt to it. Artists, by contrast, selectively focus on some facts and ignore others in order to recreate reality.” Bad economics is thus Goodman’s basic charge against “Sicko.”

This charge prompted me, an economist, to see the documentary. My conclusion? Moore is far less guilty of flawed economics and disregard of relevant facts than is Goodman. Moore is also straightforward about his values and ideology, whereas Goodman masks his as scientific economics. This impels me to defend my profession by exposing the falsity of his claims, and some of the salient facts that he ignores.

Goodman rejects single payer universal coverage health systems, which Moore favors, because they require bureaucratic rationing of medical care, and impose longer waiting periods than do private market health systems. The rationing complaint as such is irrelevant; markets also ration, mostly by the purse. What they have been unable to do is provide universal coverage.

The incentive for private health insurance companies is to maximize profits by insuring low-risk clients and rejecting high risk ones. That incentive promotes /private /bureaucratic rationing of services and intensified screening of applicants. The U.S. public sector and private charities have thus been pressured to finance treatment of some sort for the rapidly rising millions of U.S. uninsured and underinsured. “Sicko” illustrates various aspects of the problem. Goodman gives it no mention whatsoever.

Waiting time is emphasized by Goodman, although he ignores some important dimensions of the waiting issue, and presents biased treatment of others.

Thus the socialized systems of Britain, Canada, Australia and New Zealand assign lower priorities and longer delays to elective (e.g., cosmetic) and non-emergency (e.g., hip replacement) surgery than to emergency (e.g., cardiac or cancer) surgery.

The U.S. has the shortest average waiting time for elective and non-emergency surgery, but is merely in the middle of the Anglo-Saxon group for emergency surgery. The same for delay in seeing a specialist.

Goodman combines the two priorities, lowering the overall U.S. waiting time to first place, which allows him to claim it indicates the extra risk of death that government rationing imposes in emergency cases.

He disregards that the U.S. is the most difficult of the Anglo-Saxon group in getting same-day doctor appointments; shares with Canada the most difficulty in getting treatment on nights and weekends; and that France, Germany, Japan and the Scandinavians have still shorter delays than the Anglo-Saxon group in almost all dimensions of waiting. Implication? Bureaucratic rationing is unavoidable in universal coverage government health programs, but longer waits are not.

Goodman’s data manipulation and his assumption that longer waits have deadly consequences imply that the U.S. should have longer life expectancy and a lower rate of infant mortality than the industrial countries with socialized medicine.

But he doesn’t test that implication, enabling him to ignore that the U.S. has the lowest life expectancy and highest infant mortality rate of the industrialized democracies. Instead, he puzzles over why national health insurance seems so popular in these countries, concluding it’s because their citizenry, unaware that they pay by taxes, think they’re getting something for nothing.

And so to another of Goodman’s major omissions. The overall cost of health, taxes and all, is far higher in the U.S. than in any of the countries with universal coverage socialized health systems. U.S. overall spending on health is pushing 16 percent of its GDP and rising, as are its millions of uninsured. The overall health spending of the countries with socialized health insurance averages around 10 percent of GDP, with none reaching 12 percent, and all providing universal coverage. We pay the most to cover the least.

Can we cover more while paying less? Kenneth Thorpe, perhaps the top U.S. health economist, was recently commissioned by a broad coalition of 90 corporations, unions and advocacy groups to answer the question statistically. His report estimates the annual cost of moving to universal coverage at $75 billion in constant U.S. dollars, but this could be more than offset by reducing administrative costs to the Canadian level, acquiring pharmaceuticals at Canadian prices, and by earlier detection and treatment of patients now priced out of the current health system.

The annual savings in 10 years would reach $125 billion, with the current health system preserved, up to $182 billion if transformed to a single payer insurance system. These numbers estimate what economists call deadweight losses, inefficient uses of resources that reduce national welfare. “Sicko” illustrates such losses in the U.S. system; Goodman ignores them.

Which brings us to the moral issue. The major religions advocate egalitarian distribution of social welfare theologically, whereas libertarian ideology prioritizes free markets and individual choice. Each can become enmeshed by policy conflicts between theology and economic reality.

Health reform is an exception. Moore has the easier advocacy task: his single-payer reform is supported by both “scientific” economics and widely held religious principles.

Goodman must show that socializing health insurance, even if it lowers economic costs while improving health, is morally bad. His critique avoids that question, other than hinting at a slippery slope argument. My conclusion: Moore wins over Goodman on economics and morality.

David Felix of Orono is professor emeritus of economics at Washington University in St. Louis.

Company endorses single-payer health care in new pact

LOCAL 376 AT COLT FIREARMS
WEST HARTFORD, CONN

Members of UAW local unions and regions across the country are working hard to win health care for all — from passing resolutions and working with local coalitions to win statewide single-payer systems to getting state legislatures to endorse a proposed congressional bill that would extend Medicare coverage to all Americans.

In Connecticut, UAW Region 9A has come up with a new tactic for building this growing grassroots movement: bargaining for universal health care, or more specifically, bargaining to get UAW employers to endorse the concept.

The region’s first victory under its new bargaining/political action strategy came with UAW Local 376’s new three-year contract with Colt Firearms in West Hartford.

With the agreement accepted in April, the 350 workers — who produce rifles and other weapons for commercial and military use — avoided paying health care premiums while getting the company to endorse Connecticut’s Healthcare4every1 campaign.

“This is a very important addition to the contract. Our health care system is in crisis,” said Bob Madore, Region 9A director. “The research and evidence shows that a single-payer system will provide universal health coverage for residents while benefiting the economy and businesses far more than building upon the current broken system.

“The position taken by Colt is socially responsible, reflects their commitment to all workers, and shows how the bargaining table can be a place for larger scale discussions about mutually beneficial economic and social change,” Madore added.

Healthcare4every1 is a project of the Universal Health Care Foundation of Connecticut, a labor-community coalition working to create a system for all state residents.

Under the agreement, Colt Defense LLC approved being listed as an endorser of the group’s campaign and allowed the foundation to publicize the company’s endorsement.

http://www.uaw.org/solidarity/07/0807/uf07.php