PNHP

High deductibles are bad for children’s health

High deductibles are bad for children’s health

High-Deductible Health Plans and the New Risks of Consumer-Driven Health Insurance Products

Committee on Child Health Financing

Pediatrics (Official Journal of the American Academy of Pediatrics)
March 2007
Policy Statement

Abstract

Consumer-driven health care is the most noteworthy development in health insurance since the widespread adoption of health maintenance organizations and preferred provider organizations in the 1980s. The most common consumer-driven health plan is the high-deductible health plan, which is essentially a catastrophic health insurance plan, often linked with tax-advantaged spending accounts, with very high deductibles, fewer benefits, and higher cost-sharing than conventional health maintenance organization or preferred provider organization plans. The financial risks are significant under high-deductible health plans, especially for low- to moderate-income families and for families whose children have special health care needs. Of concern for pediatricians are the potential quality risks that are predictable in high-deductible health plans, in which families are likely to delay or avoid seeking care, especially preventive care (if it is not exempted from the deductible), when they are faced with paying for care before the deductible is met. This policy statement provides background information on the most common consumer-driven health plan model, discusses the implications for pediatricians and families, and offers recommendations pertaining to health plan product design, education, practice administration, and research.

http://pediatrics.aappublications.org/cgi/content/full/119/3/622

Comment:

By Don McCanne, MD

The American Academy of Pediatrics is to be commended for stressing the importance of protecting preventive services from the negative impact of high-deductible health plans.

Unfortunately, many of their specific recommendations are self-serving for pediatricians (full up-front payment of billed charges, debit cards, payment for telephone consultations, etc.). Conspicuously absent were specific recommendations to prevent the negative impact of high-deductibles on acute and chronic care. It is not as if they didn’t understand this in that a specific recommendation under practice management was to “prepare for greater administration/collection burdens and bad debts.”

High-deductible health plans are bad for children’s health. The Academy should be condemning these plans and supporting comprehensive solutions that would enhance the health of the nation’s children. A national health insurance program would not only cover preventive services, but it would also remove financial barriers to beneficial acute and chronic health care services.

It’s time for physicians to quit whining about how badly they’re being treated by our dysfunctional system, and start advocating for change that will meet the needs of their patients. A practice environment that works well for patients is one that works well for physicians as well.

Swiss voters reject single payer

Health reform flops at the ballot box

NZZ Online
March 11, 2007

An overwhelming majority of voters have thrown out a proposal for a single health insurance company in Switzerland, with premiums based on income and wealth.

Final results showed 71 per cent of voters rejected the reform. Turnout was close to 46 per cent, slightly above average.

There are currently 87 private insurers providing mandatory basic health care coverage for Swiss residents under a 1996 law. But health premiums have soared over the past decade.

More than 100,000 people are no longer covered because they haven’t paid their premiums.

Switzerland has the most expensive health system in Europe, according to an international comparison. It spent 11.6 per cent on health in 2005, ahead of Germany and France but behind the United States.

http://www.nzz.ch/2007/03/11/eng/article7609812.html

And…

Costs dominate health insurance debate

swissinfo
March 6, 2007

Supporters and opponents of a single health insurance company – to come to a nationwide vote next Sunday – are at odds over the financial impact of the proposal.

The initiative, backed by the political centre-left but opposed by the government and business world, wants parliament to determine the funding model. But costs have become a sore point.

In 2003 voters rejected a plan for health insurance to be funded by a rise in VAT with premiums set according to income and wealth. This would have replaced the current system of obligatory private health insurance as offered by 87 firms.

Mindful of this, the authors of this latest initiative were careful to leave the financing issue to parliament. The only requirement is that premiums are set according to a person’s “economic capacity”.

“The vote is about deciding on a radical change to the basic insurance, not about voting for a precise financial model,” Hans-Jürg Fehr, president of the centre-left Social Democratic Party, has said.

But this has led to some uncertainty about the sums involved — a situation that santésuisse, the umbrella organisation of Swiss health insurers, has been quick to exploit.

It has drawn up its own financing model, which shows that the middle class is most likely to lose out under the single insurance plan.

Earlier this year, santésuisse put its model online on the Comparis website, a comparison service which, among other things, allows the public to compare health insurance prices.

Santésuisse based its model on several hypotheses. The first was that there would be no premium rise for those on an income of more than SFr120,000 ($96,000) — to avoid health insurance acting as a form of tax on the rich. The lower limit for paying premiums was set at SFr20,000.

According to santésuisse, the new system would be mostly funded by people with incomes in between these two sums — basically the middle classes.

Secondly, it projected that costs assumed by basic health insurance would rise by ten per cent because savings options, such as excesses (i.e., deductibles), would no longer be available under a single insurance.

An excess is what an insured person decides to pay for health services before the insurance reimburses. The higher the excess, the lower the monthly premium — and the less paid out by insurers.

Santésuisse’s move caused temperatures to run high among the initiative’s supporters on the left. Whereas the Green Party wanted to keep income-based premiums, the Social Democrats drew up a model that increased the number of people eligible for premium reductions (60 per cent compared with the current 30 per cent).

Financing would come from a three per cent rise on premiums for those with incomes above SFr100,000, with no top limit. This would bring in an estimated SFr1.2 billion a year, said the party. Excesses would still be valid.

An additional SFr500 million would come from the lower administration costs arising from a single health insurance, it added.

After some resistance, the supporters of the initiative finally put their figures on Comparis as well. The public can now consult both models, but with rather different results.

According to santésuisse, a family of four from Lausanne with a taxable income of SFr90,000 would pay SFr100-SFr200 more per month. But the initiative’s model claims the same family would save around SFr300.

The differences become even larger for incomes of SFr100,000-SFr120,000.

http://www.swissinfo.org/eng/front/detail/Costs_dominate_health_insurance_debate.html?siteSect=105&sid=7525010&cKey=1173182383000

And…

Swiss spurn health insurance plan

BBC News
March 12, 2007

A row over costs in the last few days before the vote caused confusion. Supporters of the plan claimed an average family of four would save about 300 Swiss francs ($250) a month under the new scheme.

Using the same figures, Switzerland’s health insurers said the family would actually pay up to 200 francs ($150) more.

One reason (explaining the election results) may be the power of the insurance sector, and of the big pharmaceutical companies in Switzerland – both are important to the Swiss economy and both have strong lobby groups, our correspondent reports.

http://news.bbc.co.uk/2/hi/europe/6436995.stm

Comment:

By Don McCanne, MD

In evaluating health care reform proposals, one of the first questions individuals ask is, “What is it going to cost me?”

The Swiss organization representing Switzerland’s private health insurers, santésuisse, was ready with an answer. Although the measure would require that premiums would be set according to a person’s economic capacity (means tested premiums), santésuisse made the assumption that lower-income individuals would have smaller premiums or no premiums, whereas the wealthy would not have an increase in premiums. The impact of that would be to shift most of the cost of reduced premiums to the middle-income citizens.

Some would contend that this analysis was dishonest since the intent of the measure was to have means testing apply throughout the income scale. Others would contend that this analysis was appropriate because it would be unfair to require the wealthy to pay more than the full premium. Although it was a measure calling for progressive funding of health care, santésuisse found that modeling it as a welfare program provided results that supported their political agenda.

After considerable delay, the proponents of the initiative finally provided an analysis compliant with the intent of this measure, but it was too little, too late. The polls demonstrated increasing opposition, and by the time of the election, most of those who had been undecided voted against it.

As in the United States, the insurance and pharmaceutical lobbies played a major role in fending off this reform effort. But it would be a mistake to accept the results as simply a buy off of an election by vested interests with too much money and too much power.

The voters did hear the message of the proponents. The voters did understand that everyone would be covered. Middle-income individuals did hear that they would pay less if they were willing to increase taxes on the rich.

But the clearest message of all was that a government-run program would replace their private insurance plan. 71 percent of the voters didn’t like that message.

Many reading this will dispute that conclusion and contend that the polls in the United States prove that we do want to replace private plans with a single payer program of national health insurance. If that is true, then why haven’t we already enacted Medicare for All? Have the insurers and pharmaceutical firms really bought us off?

If you want to change the dynamics in the United States, then you are going to have to show the healthy workforce that their employer-sponsored coverage is bad for their finances and bad for their health. It’s true, but that’s going to be a hard sell. But that’s what you have to do.

Jonathan Gruber on the RAND HIE

What is Insurance?

by Jonathan Gruber

wbur.org (Boston’s NPR)
Commonhealth (a blog)
March 9, 2007

The debate over health care reform implementation in Massachusetts has become focused on the critical issue of defining the level of “minimum creditable coverage”, the minimum level of insurance generosity that will satisfy the individual mandate. This is not a decision that can be avoided; without such a definition, the mandate has no teeth.

But this decision has become needlessly controversial because the debate has moved away from the fundamental goal of insurance: to insure individuals against unexpected medical risk.

This definition of insurance has nothing to do with the typical American conception of health insurance. Most Americans think of health insurance as medical prepayment: you pay an up-front premium and in return all of your medical expenses are covered (what experts refer to as “first dollar coverage”). But such a system has an inherent flaw: any time something is free, it will be overused. This should not be a controversial statement to anyone who has ever gone to an all-you-can-eat buffet. Having paid at the door, you always end up eating more than if you were paying for each item your ordered.

But isn’t medical care different from food? Don’t individuals only use medical care when they really need it? The answer to this question is clearly no. There is substantial evidence of overuse of medical care by the insured. The classic piece of evidence for this proposition is the famous RAND Health Insurance Experiment (HIE) in the 1970s. In this experiment, individuals were randomly assigned to insurance plans that were more or less generous, ranging from first dollar coverage to policies where indivduials paid 95% of the cost of their medical utilization. Once individuals had spent $1000 (about $4000 in today’s dollars), however, they were fully insured — so no one was going uninsured in these plans.

The lessons of the HIE are clear, yet have been conveniently misinterpreted by parties on both sides of the debate. I review these lessons in a paper prepared for the Kaiser Family Foundation, available at http://www.kff.org/insurance/7566.cfm. First, medical care is price sensitive: those who paid nothing for their care used about one-third more than those who paid almost the full cost at the point of service. Second, on average, the extra medical care consumed by those who received care for free had no beneficial impact on health: individuals in the first dollar coverage plan were no more healthy, on average, than those in the full cost plan. Third, there is some evidence (although it is not very precise) that there were some health benefits for low-income, chronically ill populations; most of this benefit was found in screening for chronic illness and maintaining treatments for that illness. The 25 years of research since the results of the HIE were reported have done nothing to overturn these central conclusions, although no study has so carefully studied the health impacts of insurance generosity.

At the same time, there is a large literature in health services research which shows that having insurance, relative to having none, is important for health outcomes. The resolution between these seemingly conflicting results is that it matters whether individuals have some insurance, but, given insurance coverage, for the typical person it does not really matter how generous that insurance is. Once again, coming back to the buffet analogy, it is clearly harmful to not allow individuals to eat — but less critical that you allow them to eat as much as they want.

These results have two clear implications for health policy. First, it is vital that we provide health insurance coverage to the uninsured as a means of improving their health. Second, that insurance need not be as generous as first dollar coverage. There is no clear benefit to covering all medical costs, and a clear cost in terms of encouraging excessive use of medical care. Insured individuals should therefore bear some of the costs of their medical care utilization, but with a limit when costs rise to a sizeable share of income. In addition, insurance should provide reduced cost sharing for prevention and maintenance of chronic illness.

This suggests that the structure of the minimum creditable coverage plans that are being discussed makes a lot of sense. All of the plans being considered provide some up front medical care that individuals can use to get preventative care and be evaluated for more serious medical disease. If individual are found to be chronically ill, they can then buy up to more generous plans that are more appropriate to their health status.

Ideally, insurance plans would be more flexibly designed to accommodate the lessons of the HIE, for example offering different levels of out-of-pocket costs by income level or by illness level. There is some exciting work being done now on designing such “value-based insurance plans”, whereby co-payments are targeted to the needs of the particular individual being insured. But such plans are still in their infancy, so that today the choice remains between offering first-dollar coverage or a plan where individuals pay more of their costs up front. The evidence is clear that the latter design provides real insurance, in the true sense of the word.

Jonathan Gruber, Professor of Economics at MIT and member of the Connector Board

http://blogs.wbur.org/commonhealth/?p=23#comments

Comment:

By Don McCanne, MD

Dr. Gruber states that the RAND Health Insurance Experiment (RAND HIE) has been “conveniently misinterpreted by parties on both sides of the debate.” He then takes one side, stating that the lessons are that “medical care is price sensitive,” that “on average, the extra medical care consumed by those who received care for free had no beneficial impact on health, but that “there were some health benefits for low-income, chronically ill populations.” It would be incorrect to characterize this as a misinterpretation, because these statements are, “on average,” true.

But there is another side as to the importance of the findings of the RAND HIE, which also should not be characterized as a misinterpretation.

It is crucial to understand the nature of the population studied. The subjects were a gainfully employed workforce and their families, who were observed for a few years. Thus this was a study of relatively healthy workers and their healthy families during healthy years of their lives. Being employed, they had discretionary income sources that could be used for health care cost sharing.

The intrinsic validity of this study can be applied to similar healthy populations with reliable incomes, but it does not have extrinsic validity in a system of “universal coverage.” A system that would cover everyone must take into consideration the entire market basket of health problems, from conception to death. Even if sectors are segregated based on age (Medicare), income (Medicaid), employment (employer-sponsored coverage), or whatever, the remaining uninsured have a multitude of problems which result in their being uninsured in the first place. The RAND HIE conclusions would apply “on average” only to the employer-sponsored group, but not to these others, and certainly not to the uninsured.

There is also considerable question as to the overall impact on total health care spending. Although the 80 percent of us who are healthy would reduce utilization, we consume only 20 percent of health care. A modest reduction of only one-fifth of our health care bill would not have a major impact. The 20 percent of individuals who use 80 percent of health care, the group that was not studied in the RAND HIE, have little opportunity to selectively decline health care that seems necessary because of their health care problems.

Besides, is the RAND HIE “on average” conclusion satisfactory? Individuals in the RAND HIE with hypertension had a 10 percent higher death rate when cost sharing was required. The families of those who died receive little consolation in the fact that these deaths did not change the statistics of the overall beneficial outcomes of this healthy population.

Is health care about the majority of us who are healthy, or is it about prevention and management of disorders that can lead to disability or death?

Since we are not static beings, how can we possibly determine which of us will remain healthy and be well served by a private insurance plan which has an affordable premium because it doesn’t cover expenses that we won’t be facing anyway? But the real question is the reciprocal. Which of us will develop major medical problems that will require affordable access to health care made possible only by selecting a more comprehensive plan, but with premiums that we can’t afford?

So what is the real lesson of the RAND HIE? Cheap insurance works for healthy people. Period.

Since the RAND HIE was completed in the 1970s, there has been a plethora of studies in the health policy arena. The studies on cost sharing have clearly indicated that erecting financial barriers to care maim and kill people with health care needs.

The fundamental flaw with using private health plans to expand coverage to everyone is that private plans work only for healthy subsets such as employer-sponsored group plans. If those with health care needs are to be included with reasonable levels of coverage, the premiums become unaffordable.

Healthy individuals are now segregated into low risk pools (e.g., employer-sponsored) which, regardless, have become so expensive that they are now barely affordable. If we are to have universal coverage, these healthy individuals must also contribute to the pools covering the high-cost, high-risk individuals, even though that isn’t affordable either. Rather than compounding the nightmare of administrative inefficiencies, it would be much simpler to combine everyone into a single risk pool that is equitably funded and therefore affordable for everyone.

Single payer would do it. But in his efforts to make the antiquated private plans work, Dr. Gruber states, “… we can’t insist everyone who has no insurance get the policy that optimizes their health.” Further, “Let’s get them into the system and get them real insurance, and then maybe they’ll be interested in buying something better.” (The Boston Globe, March 5)

Why don’t we start out with something better? Real insurance. Single payer.

Additional Comment:

By Leonard Rodberg, PhD, Chair, Department of Urban Studies, Queens College/CUNY, responds to the comments on the RAND HIE made by Jonathan Gruber, Professor of Economics, MIT:

Prof. Gruber, like many other American economists, should remove his chauvinist blinders and take a look at the rest of the world where there has been a real world “experiment” going on for years, one that is far more extensive than the very limited Rand HIE. Countries around the world offer what we would call “first dollar coverage”, that is, little or no financial barrier to seeing a doctor. The results: (i) no overuse of medical services and (ii) lower spending than the US. The conclusion might be that eliminating cost-sharing would actually save us money!

For Dr. Gruber’s original statement and our responses:
http://blogs.wbur.org/commonhealth/?p=23#comments

The Health Care Monster Returns: Even Republicans acknowledge its ravages, but what's the best way to slay the beast?

by David Moberg
In These Times
03/7/07

Like the creature from the Black Lagoon, the health insurance monster has returned, creeping back onto the public stage. After President Clinton’s jury-rigged pen to contain the monster collapsed in 1994, it never really went away. Political leaders tried to ignore the beast or deal piecemeal with its ravages, but it pushed more unsuspecting civilians into the uninsured pit, devoured more family budgets, squeezed even giant corporations’ ability to compete globally, and raised fear and insecurity among the populace.

Now its depredations have become too loathsome to ignore for even cautious politicians and business executives — who still are inclined to see the monster as one of their own. After a rebuff in the fall elections, when voters ranked health care as one of their top concerns, President Bush offered a plan that almost certainly would not deliver his promise of “quality, affordable health care for all Americans.”

Recently, chief executives like Lee Scott of Wal-Mart — under attack for its skimpy health insurance coverage of employees — and Steve Burd of Safeway — which endured a long strike by southern California grocery workers to cut their health insurance — joined progressive leaders like Service Employees Industrial Union (SEIU) President Andy Stern, head of the nation’s largest health workers union, to call for major changes in the health care system. Under fire from both other labor unions and many citizen health care groups for joining with strange bedfellows on behalf of very broad principles, Stern argues that “the most essential change is to get everyone in a system where they have health care,” then work to improve it.

Although the war in Iraq is likely to dominate the already energetic Democratic presidential primary race, health care is emerging as the leading domestic issue in both parties. Shortly after announcing his candidacy, John Edwards laid out a comprehensive health care plan. Barack Obama said that the nation should provide universal insurance coverage by the end of the next president’s term, though so far he has mostly advocated for minor and politically easy reforms, like computerizing health records. Republican candidate Mitt Romney signed a flawed plan for universal health care when he was governor of Massachusetts, and California Gov. Arnold Schwarzenegger, after vetoing statewide single-payer legislation passed last year, has his own health insurance plan.

There’s reason for hope when leaders across the political spectrum recognize the problem. But there’s no guarantee that such agreement will lead to a good solution. For more than a decade, conventional wisdom has dictated that only incremental steps should be taken. Now more politicians are willing to consider bolder steps — but the right is still determined to push its agenda. And many progressive reformers are cautious about pursuing their ideals, as they continue to nurse scars from the fight business interests waged against the Clinton plan.

“Overwhelmingly, people are trying to find incremental responses instead of a national response,” says Marilyn Clement, national coordinator of Healthcare-NOW, a coalition advocating a public insurance program as the single payer of health care bills. “They are still putting forward the same proposals as last summer, such as ‘The first step is to get national health care for children.’ Well, that’s good, but we won the election. It’s time to escalate our hopes.”

The first crucial step is to define the problem. For many people, it’s the rising number of Americans without health insurance, now nearly 47 million. But equally problematic is the decline in quality and scope of coverage for those who have insurance. And much of the public ranks the cost of health care as their top medical and economic concern. Focusing primarily on insuring everyone won’t necessarily solve those problems. Indeed, the skyrocketing cost of health care is the main reason that the ranks of the uninsured continue to grow. Faced with rising insurance premiums, businesses have been trying to cut costs by evading responsibility for providing health insurance, leading Stern to declare that “the employer-based health care system is dead.”

But the more fundamental problem is our reliance on private, for-profit corporations to provide health insurance — the real monster in this saga. They’re the main reason for rising costs (making health insurance in the United States about twice as expensive as in most industrial countries), for the growing number of uninsured, and for the inferior health results for the average American. In 2004, the United States spent $6,100 per capita on health care, compared to $2,250 per capita on average by the countries in the Organization for Economic Cooperation and Development, which have national health insurance programs. Because public expenditures cover 60 percent of American health care costs, U.S. taxpayers are paying more than the cost of national health insurance, but not receiving it.

“How much can a new system depend on private insurance companies to provide affordable, good health care for everyone?” asks Roger Hickey, co-director of Campaign for America’s Future, a Washington, D.C.-based progressive advocacy group. “That should be the debate.”

Now the country is faced with two radically different proposals for reform. The first, pushed by conservatives and embraced by Bush in his new plans, would make individuals more responsible for buying their own health insurance. While giving them tax breaks to help pay the premiums, it would push them in the direction of lower-cost, less comprehensive plans (partly by taxing employer-provided insurance as income). As part of this strategy, conservatives have also undermined Medicare, first, by subsidizing private insurance companies to provide Medicare insurance and, second, by establishing a prescription program only available through private insurers.

The Bush strategy would be a boon for wealthy and healthy individuals, as well as employers and insurance companies, but it would ultimately leave most Americans paying more for less health security. The harsh edges of the plan could be softened — by regulating the insurance companies’ attempts to charge more or deny coverage to people seeking insurance, or by offering tax credits or direct subsidies to the poor instead of tax deductions. But these changes still embody what economist Jared Bernstein, of the progressive think tank the Economic Policy Institute, calls YOYO (“You’re On Your Own”) economics.

The diametrically opposite alternative is to recognize that “we’re in this together” (WITT, in Bernstein’s schema) and move towards social insurance, or a plan like Medicare. In this case, the federal government — through a public agency — would provide comprehensive insurance. It would be financed directly by progressive taxes on individuals and business, unlike the current system, which provides $200 billion a year in economically regressive and largely unrecognized tax deductions to subsidize employer-based health insurance. The public insurance agency would then bargain with health care providers, drug companies and others to control prices and improve quality of care.

The Bush YOYO strategy assumes that when health care consumers — otherwise known as patients — confront costs of medical care, they’ll consume less, and overall medical costs will go down. But Americans already spend more out-of-pocket on health care and use doctors and hospitals less than citizens of almost every other industrialized country. Yet, while the overall health cost in the United States is much higher, the outcomes — by virtually every measure of health — are worse. U.S. health care costs more mainly because of private insurance: Overhead at insurance companies runs close to 20 percent of total revenues, compared to less than 4 percent for Medicare. When the extra administrative costs imposed on providers are counted, the overall overhead that private insurance imposes on the system eats up about one-third of what Americans spend on health care. Eliminating those costs, as proposed by Rep. John Conyers (D-Mich.) and supported by Ohio Rep. and Democratic presidential candidate Dennis Kucinich, could finance most of a Medicare expansion to cover all Americans much more comprehensively than the program does now.

MOST PROGRESSIVE REFORMERS acknowledge that Medicare for everyone would best slay the health crisis monster, but many strategists worry that trying to eliminate the private insurers will provoke a withering counterattack. Consequently, many current proposals try, as Hillary Clinton did in 1993, to preserve a more regulated role for the insurance companies and at the same time expand public programs, on the model of Medicare, to provide a competitive alternative to private insurers.

Edwards’ plan would require employers to cover employees or help pay for their insurance (what’s widely known as “pay or play”). Everyone would have to buy insurance, taking advantage of tax credits, expanded programs such as Medicaid and the State Children’s Health Insurance Program, or new regional “health markets” that would provide a choice of competitive private plans and a public plan. Along the same lines, but with a simpler design and more robust public component, Yale political scientist Jacob Hacker proposes that everyone not in Medicare be covered either by insurance at work or a public insurance pool, including both regulated private plans and a Medicare-like plan.

Both these proposals move in the direction of Medicare for all, but strike a compromise with the existing system, losing the potential for better efficiency and more equity in the bargain. Why not push for universal Medicare (aka, a “single payer” plan)? Proponents of compromises say Medicare for all is a political non-starter. Americans, they argue, are suspicious of government, like choices and often like the private insurance they already have. And besides, they say, the insurance industry — along with most business interests and political conservatives — would launch a scorched earth campaign against such a proposal.

“There are a lot of dedicated, smart people who have made the judgment that taking some steps toward a comprehensive system with a public health care plan is better than waiting for the perfect system,” says Hickey, whose organization supports Hacker’s proposal. The labor movement, which was divided over support of a single-payer system in the ’90s, seems even more cautious now. “The political will isn’t there now, but it could get there for single-payer,” says AFL-CIO health care lobbyist JoAnn Volk. A close union ally adds, “Most of the labor movement has already accommodated to the reality that we’re not going to get a pure single-payer system. They have made the judgment that it’s just not within the range of possibility.”

SEIU’s Stern — who has argued that the United States needs an “American” plan, and not a foreign model like Canada’s single-payer system — says, “First we should create [a health care system] in which everyone is covered, then we can figure out how to rationalize it. It will cost more money than if we did it the other way [i.e, pursing the best alternative], but I think we have more chance of getting it done. The perfect cannot be the enemy of the good.”

ALTHOUGH A SMALL but rebounding movement for some form of Medicare-for-all exists, some progressive groups that would be its natural partisans are reluctant to commit themselves to a specific plan. William McNary, president of USAction, a national group of statewide citizen organizations, notes that many of their allies are splintering over proposals. “Things are fracturing,” he says, “it would be best for us to line up behind principles,” and not a plan. Jim Dean, chairman of Democracy for America, a liberal movement within the Democratic Party, thinks the United States is ripe for universal health care, but worries about both infighting over the best plan and the specter of corporate attacks. He wonders, “Can we figure out a way to talk about this so as not to get bogged down, sway, with “Harry and Louise” commercials [that the insurance industry used against President Clinton’s plan]?”

But there’s no guarantee that insurance companies won’t launch a war against these compromises, especially any that curtail insurance industry profits. And corporations that support universal health insurance will almost certainly oppose any plan that doesn’t seriously reduce their financial responsibility, which would threaten to shift costs to individuals. “Everyone says they’re for universal health care,” says Don Bechler, chair of the California Universal Health Care Organizing Project. “But the fundamental question is, ‘Who pays?’ Is [universal health care going to be] a sliding scale health care plan where everyone is entitled to first class health care, or a flat tax to sell junk insurance?”

When Clinton tried to finesse such political opposition by making insurance companies central to his plan, he suffered merciless attacks. No plan worth having will win without a massive grassroots organizing and education campaign. And Medicare for all is the one most likely to do so, while simultaneously strengthening progressives politically.

The American people are at least open to the argument. In a 2003 Washington Post poll, one of the few to pose alternatives fairly, 62 percent of respondents said they would prefer a universal health insurance program like Medicare, run by the government, to the current health insurance program. And support for the Medicare program remained nearly as high even if it limited the choice of doctors or led to waiting lists for non-emergency procedures.

Eventually, Medicare-for-all advocates might have to settle for a compromise. But the opportunity for major change in the health care system doesn’t come around very often. Since any change will require a massive effort, why not fight for the best?

California Nurses Association/NNOC Joins AFL-CIO following Endorsement of Single Payer Healthcare, Affiliation Unites 325,000 RNs in Federation

For Immediate Release
March 9, 2007

The California Nurses Association, and its national arm, the National Nurses Organizing Committee was granted a charter Thursday to join the AFL-CIO, uniting 325,000 registered nurses into the leading voice of America’s working people. CNA/NNOC represents 75,000 RNs in all 50 states.

Significantly, the affiliation came two days after the Federation adopted a sweeping new healthcare policy statement endorsing a single-payer type system premised on “updating and expanding Medicare benefits” to all Americans.

Rose Ann DeMoro, executive director of CNA/NNOC, said it was thrilled to be joining the AFL-CIO and also praised the Federation’s embrace new healthcare policy.

“We look forward to being a part of a Federation that has distinguished itself as the national voice of working people in the U.S., and is the leading national champion for all Americans on a broad range of critical issues, including jobs, retirement security, economic opportunity, workplace safety, civil rights, civil liberties, and public safety.”

The AFL-CIO’s new policy statement on healthcare symbolizes that leadership role, DeMoro said. CNA has been actively campaigning for enactment of bills in Congress, HR 676, and California, SB 840, that represent the type of reform endorsed by the AFL-CIO.

In statements after the policy was adopted, United Steelworkers President Leo Gerard, chair of the AFL-CIO’s Legislation Committee, welcomed the new policy as “a roadmap to universal coverage” and the Federation’s health policy specialist Gerald Shea specifically cited HR 676.

Labor has been at the center of a growing grassroots movement to enact HR 676. The bill has been endorsed by 245 union organizations in 40 states including 64 Central Labor Councils and Area Labor Federations and 17 state AFL-CIOs.

CNA/NNOC, DeMoro noted, “is especially pleased to be a part of the 325,000 RNs now represented by the AFL-CIO who will have such a prominent voice in that effort.” RNs, she said “who are at the heart of our healthcare system, have an especially unique role to play with all of labor and our many community allies to transform our current dysfunctional system to achieve guaranteed, universal healthcare for all, based on an improved and expanded Medicare.”

In addition to building “a stronger movement to end the nation’s national healthcare nightmare,” DeMoro praised other positions taken by the AFL-CIO, including mobilizations to:

* Enact the Employee Free Choice Act, recently passed by the House, to protect the democratic rights of workers to form unions

* Support the United Steelworkers’ Goodyear workers in their efforts to protect the health and welfare of their members

* Protect public health and defend public healthcare workers, as in the current fight by AFSCME and CNA/NNOC to overturn budget cuts in Chicago

* Overturn the attempt by the Bush Administration to privatize Social Security

* Confront moves by the Bush Administration’s labor board to erode workers’ rights, as in the “Kentucky River” challenge to the union representation rights of registered nurses

* Challenge globalization and the de-industrialization of America

* Defeat some of the most reactionary members of Congress and state legislators in the 2006 elections

“As CNA/NNOC is steeped in analytical work which is central to our advocacy for RNs and patients, we particularly appreciate the creative leadership of the AFL-CIO in developing and promoting an alternative economic model to the disastrous policies espoused by a number of politicians that have eroded the safety net and security of so many Americans.”

“CNA/NNOC is excited to be joining the AFL-CIO and all appropriate bodies of the federation at this critical juncture, and the opportunities we have to build a militant, united labor movement that is so essential to the future of our nation and the international labor movement,” DeMoro said.

For more information about CNA/NNOC, see www.calnurses.org.

The Health Care Monster Returns: Even Republicans acknowledge its ravages, but what’s the best way to slay the beast?

by David Moberg
In These Times
03/7/07

Like the creature from the Black Lagoon, the health insurance monster has returned, creeping back onto the public stage. After President Clinton’s jury-rigged pen to contain the monster collapsed in 1994, it never really went away. Political leaders tried to ignore the beast or deal piecemeal with its ravages, but it pushed more unsuspecting civilians into the uninsured pit, devoured more family budgets, squeezed even giant corporations’ ability to compete globally, and raised fear and insecurity among the populace.

Now its depredations have become too loathsome to ignore for even cautious politicians and business executives — who still are inclined to see the monster as one of their own. After a rebuff in the fall elections, when voters ranked health care as one of their top concerns, President Bush offered a plan that almost certainly would not deliver his promise of “quality, affordable health care for all Americans.”

Recently, chief executives like Lee Scott of Wal-Mart — under attack for its skimpy health insurance coverage of employees — and Steve Burd of Safeway — which endured a long strike by southern California grocery workers to cut their health insurance — joined progressive leaders like Service Employees Industrial Union (SEIU) President Andy Stern, head of the nation’s largest health workers union, to call for major changes in the health care system. Under fire from both other labor unions and many citizen health care groups for joining with strange bedfellows on behalf of very broad principles, Stern argues that “the most essential change is to get everyone in a system where they have health care,” then work to improve it.

Although the war in Iraq is likely to dominate the already energetic Democratic presidential primary race, health care is emerging as the leading domestic issue in both parties. Shortly after announcing his candidacy, John Edwards laid out a comprehensive health care plan. Barack Obama said that the nation should provide universal insurance coverage by the end of the next president’s term, though so far he has mostly advocated for minor and politically easy reforms, like computerizing health records. Republican candidate Mitt Romney signed a flawed plan for universal health care when he was governor of Massachusetts, and California Gov. Arnold Schwarzenegger, after vetoing statewide single-payer legislation passed last year, has his own health insurance plan.

There’s reason for hope when leaders across the political spectrum recognize the problem. But there’s no guarantee that such agreement will lead to a good solution. For more than a decade, conventional wisdom has dictated that only incremental steps should be taken. Now more politicians are willing to consider bolder steps — but the right is still determined to push its agenda. And many progressive reformers are cautious about pursuing their ideals, as they continue to nurse scars from the fight business interests waged against the Clinton plan.

“Overwhelmingly, people are trying to find incremental responses instead of a national response,” says Marilyn Clement, national coordinator of Healthcare-NOW, a coalition advocating a public insurance program as the single payer of health care bills. “They are still putting forward the same proposals as last summer, such as ‘The first step is to get national health care for children.’ Well, that’s good, but we won the election. It’s time to escalate our hopes.”

The first crucial step is to define the problem. For many people, it’s the rising number of Americans without health insurance, now nearly 47 million. But equally problematic is the decline in quality and scope of coverage for those who have insurance. And much of the public ranks the cost of health care as their top medical and economic concern. Focusing primarily on insuring everyone won’t necessarily solve those problems. Indeed, the skyrocketing cost of health care is the main reason that the ranks of the uninsured continue to grow. Faced with rising insurance premiums, businesses have been trying to cut costs by evading responsibility for providing health insurance, leading Stern to declare that “the employer-based health care system is dead.”

But the more fundamental problem is our reliance on private, for-profit corporations to provide health insurance — the real monster in this saga. They’re the main reason for rising costs (making health insurance in the United States about twice as expensive as in most industrial countries), for the growing number of uninsured, and for the inferior health results for the average American. In 2004, the United States spent $6,100 per capita on health care, compared to $2,250 per capita on average by the countries in the Organization for Economic Cooperation and Development, which have national health insurance programs. Because public expenditures cover 60 percent of American health care costs, U.S. taxpayers are paying more than the cost of national health insurance, but not receiving it.

“How much can a new system depend on private insurance companies to provide affordable, good health care for everyone?” asks Roger Hickey, co-director of Campaign for America’s Future, a Washington, D.C.-based progressive advocacy group. “That should be the debate.”

Now the country is faced with two radically different proposals for reform. The first, pushed by conservatives and embraced by Bush in his new plans, would make individuals more responsible for buying their own health insurance. While giving them tax breaks to help pay the premiums, it would push them in the direction of lower-cost, less comprehensive plans (partly by taxing employer-provided insurance as income). As part of this strategy, conservatives have also undermined Medicare, first, by subsidizing private insurance companies to provide Medicare insurance and, second, by establishing a prescription program only available through private insurers.

The Bush strategy would be a boon for wealthy and healthy individuals, as well as employers and insurance companies, but it would ultimately leave most Americans paying more for less health security. The harsh edges of the plan could be softened — by regulating the insurance companies’ attempts to charge more or deny coverage to people seeking insurance, or by offering tax credits or direct subsidies to the poor instead of tax deductions. But these changes still embody what economist Jared Bernstein, of the progressive think tank the Economic Policy Institute, calls YOYO (“You’re On Your Own”) economics.

The diametrically opposite alternative is to recognize that “we’re in this together” (WITT, in Bernstein’s schema) and move towards social insurance, or a plan like Medicare. In this case, the federal government — through a public agency — would provide comprehensive insurance. It would be financed directly by progressive taxes on individuals and business, unlike the current system, which provides $200 billion a year in economically regressive and largely unrecognized tax deductions to subsidize employer-based health insurance. The public insurance agency would then bargain with health care providers, drug companies and others to control prices and improve quality of care.

The Bush YOYO strategy assumes that when health care consumers — otherwise known as patients — confront costs of medical care, they’ll consume less, and overall medical costs will go down. But Americans already spend more out-of-pocket on health care and use doctors and hospitals less than citizens of almost every other industrialized country. Yet, while the overall health cost in the United States is much higher, the outcomes — by virtually every measure of health — are worse. U.S. health care costs more mainly because of private insurance: Overhead at insurance companies runs close to 20 percent of total revenues, compared to less than 4 percent for Medicare. When the extra administrative costs imposed on providers are counted, the overall overhead that private insurance imposes on the system eats up about one-third of what Americans spend on health care. Eliminating those costs, as proposed by Rep. John Conyers (D-Mich.) and supported by Ohio Rep. and Democratic presidential candidate Dennis Kucinich, could finance most of a Medicare expansion to cover all Americans much more comprehensively than the program does now.

MOST PROGRESSIVE REFORMERS acknowledge that Medicare for everyone would best slay the health crisis monster, but many strategists worry that trying to eliminate the private insurers will provoke a withering counterattack. Consequently, many current proposals try, as Hillary Clinton did in 1993, to preserve a more regulated role for the insurance companies and at the same time expand public programs, on the model of Medicare, to provide a competitive alternative to private insurers.

Edwards’ plan would require employers to cover employees or help pay for their insurance (what’s widely known as “pay or play”). Everyone would have to buy insurance, taking advantage of tax credits, expanded programs such as Medicaid and the State Children’s Health Insurance Program, or new regional “health markets” that would provide a choice of competitive private plans and a public plan. Along the same lines, but with a simpler design and more robust public component, Yale political scientist Jacob Hacker proposes that everyone not in Medicare be covered either by insurance at work or a public insurance pool, including both regulated private plans and a Medicare-like plan.

Both these proposals move in the direction of Medicare for all, but strike a compromise with the existing system, losing the potential for better efficiency and more equity in the bargain. Why not push for universal Medicare (aka, a “single payer” plan)? Proponents of compromises say Medicare for all is a political non-starter. Americans, they argue, are suspicious of government, like choices and often like the private insurance they already have. And besides, they say, the insurance industry — along with most business interests and political conservatives — would launch a scorched earth campaign against such a proposal.

“There are a lot of dedicated, smart people who have made the judgment that taking some steps toward a comprehensive system with a public health care plan is better than waiting for the perfect system,” says Hickey, whose organization supports Hacker’s proposal. The labor movement, which was divided over support of a single-payer system in the ’90s, seems even more cautious now. “The political will isn’t there now, but it could get there for single-payer,” says AFL-CIO health care lobbyist JoAnn Volk. A close union ally adds, “Most of the labor movement has already accommodated to the reality that we’re not going to get a pure single-payer system. They have made the judgment that it’s just not within the range of possibility.”

SEIU’s Stern — who has argued that the United States needs an “American” plan, and not a foreign model like Canada’s single-payer system — says, “First we should create [a health care system] in which everyone is covered, then we can figure out how to rationalize it. It will cost more money than if we did it the other way [i.e, pursing the best alternative], but I think we have more chance of getting it done. The perfect cannot be the enemy of the good.”

ALTHOUGH A SMALL but rebounding movement for some form of Medicare-for-all exists, some progressive groups that would be its natural partisans are reluctant to commit themselves to a specific plan. William McNary, president of USAction, a national group of statewide citizen organizations, notes that many of their allies are splintering over proposals. “Things are fracturing,” he says, “it would be best for us to line up behind principles,” and not a plan. Jim Dean, chairman of Democracy for America, a liberal movement within the Democratic Party, thinks the United States is ripe for universal health care, but worries about both infighting over the best plan and the specter of corporate attacks. He wonders, “Can we figure out a way to talk about this so as not to get bogged down, sway, with “Harry and Louise” commercials [that the insurance industry used against President Clinton’s plan]?”

But there’s no guarantee that insurance companies won’t launch a war against these compromises, especially any that curtail insurance industry profits. And corporations that support universal health insurance will almost certainly oppose any plan that doesn’t seriously reduce their financial responsibility, which would threaten to shift costs to individuals. “Everyone says they’re for universal health care,” says Don Bechler, chair of the California Universal Health Care Organizing Project. “But the fundamental question is, ‘Who pays?’ Is [universal health care going to be] a sliding scale health care plan where everyone is entitled to first class health care, or a flat tax to sell junk insurance?”

When Clinton tried to finesse such political opposition by making insurance companies central to his plan, he suffered merciless attacks. No plan worth having will win without a massive grassroots organizing and education campaign. And Medicare for all is the one most likely to do so, while simultaneously strengthening progressives politically.

The American people are at least open to the argument. In a 2003 Washington Post poll, one of the few to pose alternatives fairly, 62 percent of respondents said they would prefer a universal health insurance program like Medicare, run by the government, to the current health insurance program. And support for the Medicare program remained nearly as high even if it limited the choice of doctors or led to waiting lists for non-emergency procedures.

Eventually, Medicare-for-all advocates might have to settle for a compromise. But the opportunity for major change in the health care system doesn’t come around very often. Since any change will require a massive effort, why not fight for the best?

Humana shifts risk to competitor

Feds probe Humana over Rx drug patients

By Jeffrey Young
The Hill
March 8, 2007

Federal officials are investigating whether one health-insurance company that sells prescription-drug coverage to Medicare beneficiaries inappropriately diverted its most expensive customers to a competitor.

Sierra Health Services, which offers Medicare Part D prescription-drug plans under the brand name SierraRx, alleges that Humana Inc. telephoned its highest-cost customers and recommended they purchase coverage from Sierra instead.

Sierra President and Chief Executive Anthony Marlon delivered the bad news: “As we looked at the first month’s results, it became apparent that the pharmacy costs on this product were much higher than we and our independent actuaries had projected.”

Sierra will discontinue the money-losing plan next year, Marlon assured the analysts.

According to Marlon, “We believed our level of adverse selection was in part due to certain high-utilizing members being referred to us by another PDP provider. We did not agree to these referrals.”

Humana counters that it merely passed along information to its customers about a competing product that might better suit their needs, and said federal regulators approved its actions.

Humana redesigned its Complete product (Part D drug benefit) for 2007 by eliminating brand-name doughnut hole coverage and raising the premium to about $80.

All Part D plans are required to send letters by Oct. 31 to beneficiaries explaining any changes in their drug coverage for the coming year, which Humana did.

Humana went one step further. In December 2006, Humana customer-service representatives contacted an undisclosed number of Complete customers by telephone.

During the call, Humana employees again explained that the brand-name doughnut hole coverage was being cut out. They also told beneficiaries that other insurance companies were offering that benefit in 2007, including Sierra Health Services.

“Our goal was to make sure these people continued to have access to prescription coverage,” Humana’s director of media and public relations, Dick Brown, said. Humana also asserts that CMS (Centers for Medicare and Medicaid Services) approved the script the company used for these calls.

Brown would not explain, however, whether the company contacted each of the more than 400,000 Complete customers with the same information or if Humana targeted the calls to a subset of these beneficiaries such as those with the highest drug costs, as Sierra implied.

http://thehill.com/leading-the-news/feds-probe-humana-over-rx-drug-patients-2007-03-07.html

Comment:

By Don McCanne, MD

Getting rid of high-cost patients is a very wise business move for an investor-owned insurer. But what about the interests of the patients?

In the business world, premium increases due to adverse selection are known as the death spiral, which results in withdrawal of those insurance products from the market. Humana escaped from its death spiral by forcing a new death spiral on a competitor. As a result, comprehensive Part D coverage will no longer be available for those with very high drug costs. The business model works for the investors, but not for the patients.

A drug program in the traditional Medicare program would never have been designed to deprive those with the greatest needs of their drug benefits. To the contrary, it would have been designed to be certain that patients would have affordable access to the drugs that they need.

The complicity of our public stewards is consistent with the current administration’s goal to shift public insurance to the private sector. Maybe we need new public stewards. After all, patients deserve more than to be pawns for passive investors.

Uninsured are focus of forum

Some 860,000 Hoosiers lack health coverage.

By Jennifer L. Boen
Fort Wayne News-Sentinel
Thu, Mar. 08, 2007

The stories told by the uninsured and underinsured reverberate in the mind of emergency room doctor Robert Stone, who works in Bloomington: People delay care because they don’t have health insurance or skip or stop taking medications because they can’t afford them. A less serious medical problem becomes catastrophic because of the delays or lack of medication.

Nationally, 46.6 million people are uninsured, according to 2005 U.S. census data; 860,000 of those are Hoosiers. Many health-care providers, consumers and their families are calling for a change and will address the problem at a public forum on Monday titled “Citizen’s Hearing on Healthcare for All.”

Stone, who co-founded Hoosiers for a Commonsense Health Plan, is keynote speaker at the event. The organization is promoting the health-care reform agenda laid out by Physicians for a National Health Program. The groups seek universal, comprehensive coverage for everyone through a single-payer health insurance system that is publicly financed but privately delivered. Rather than employer-based health insurance, all people would participate in a plan that would give access to all — similar to the way Medicare works for people 65 and older.

“This is not socialized medicine,” with doctors and hospitals government-owned, Stone said.

A Medicare-like system for all would require raising taxes, but those taxes would take the price of premiums, which continue to escalate for employers and employees, he said.

A 2003 study by Harvard Medical School and the Canadian Institute for Health Information found 31 percent of U.S. health-care dollars are spent on administration and overhead, compared to 17 percent in Canada.

“Medicare runs about 3 percent overhead,” compared to insurance companies’ 20 percent to 30 percent overhead, Stone said.

Park Center President/CEO Paul Wilson calls U.S. health care a “non-system.” “The confusion and fragmentation is so expensive and so wasteful. It’s a real tragedy we spend so much money on health care, and we leave so many people out.

“We see huge numbers of people who don’t have any insurance or don’t have mental-health coverage,” Wilson said about the community mental health center. “What we’ve developed in this country is all kinds of stopgap measures. People in their most vulnerable time running across town to the (township) trustee’s office, or to a church for help.”

The ASK clinic is one of several free clinics in Allen County.

“The numbers here just keep going up,” said ASK director Eve Bratton. “It used to be the generational poor we saw. Then it became people laid off from their jobs. Now we’re seeing people still in college and people among the middle class. We’re seeing sicker people. It’s not uncommon for me to see blood pressures of 260/120 (normal pressure is 120/80), because people can’t take their medicine, and they delay care.

“The health-care system is absolutely collapsing, and people are falling through the safety net,” Bratton said.

Dr. Matthew Farber is an ophthalmologist and surgeon with Allen County Retinal Surgeons. “In talking with physicians, some say things such as, ‘I don’t know if people are going to be happy waiting for care as in Canada,’ which has a single-payer system.

But the reality, Farber says, is even though U.S. health-care spending was nearly $2 trillion in 2004 and is expected to reach $4 trillion by 2015, “In the end, it’s not as if people live longer here,” compared to Canada.

Americans want new medicines and life-saving technologies, yet also want to preserve the free-market system and competition. For example, three medicines are used to treat glaucoma, Farber said. All are costly, and the companies who make them “don’t compete by trying to get a bigger (sales) share by lowering the price. Sure we want the pharmaceutical industry to come up with new therapies, but in the end, there can be only so much spent on pharmaceuticals.”

For too long, the health-care system has not promoted or reimbursed doctors for preventive medicine. Now a growing epidemic of diabetes, chronic lung disease, high blood pressure and other conditions, along with the largest segment of the population entering their senior years, is overwhelming the system.

“There aren’t any easy answers,” Farber said, “but the current system isn’t working. We have to get Congress to be willing to stand up and try and improve things.”

The economic ramifications of health-care costs are far-reaching, Stone said. Big industries wanting to compete internationally find themselves at a disadvantage because of American health insurance costs. People running small businesses cannot afford to pay premiums. Wilson says he has found 7,200 health insurance plans exist in the United States. “It’s bizarre, craziness. I suppose we could have a more wasteful system — but I don’t know how.”

Book Review: Solving the Health Care Problem

Solving the Health Care Problem:
How Other Nations Succeeded and Why the United States Has Not
By Pamela Behan
171 pp. Albany, State University of New York Press, 2006.
$60. ISBN 978-0-7914-6837-1.

Reviewed by Danielle Ofri, M.D., Ph.D.
New York University School of Medicine
For the New England Journal of Medicine

Status quo is a powerful determinant of both belief and behavior. Many of the things we do and the things we believe in transpire because they are what we have always done or believed. This is why incumbents win elections, why we always choose the same flavor of yogurt, why we take the same route to work, why we prescribe the same antihypertensive medications. For most Americans, our health care system is the way it is simply because this is the way it has been. The logic of changing doctors when you change insurance, changing insurance when you change jobs, and paying out of pocket when you do not have a job makes some sort of sense because this is simply the way things are.

A visitor from Mars, or Europe perhaps, would find this status quo shocking, much the way American tourists abroad are sometimes shocked to find that they are not supposed to dispose of toilet paper in some toilets. In this regard, Pamela Behan has something of an outsider’s view of America. The title of her book, Solving the Health Care Problem, assumes that the lack of national health insurance is the biggest problem in U.S. health care, which is what you learn once you read the book. This is surely what most Europeans would call the biggest problem in U.S. health care. But I’m sure that many Americans, even thoughtful ones, might think that other issues — the cost of prescription drugs, inequitable funding for research, Food and Drug Administration oversight — are the biggest problems. Even the book’s subtitle — How Other Nations Succeeded and Why the United States Has Not — assumes that the adoption of national health insurance is the definition of success in solving the biggest health care problem. I happen to agree with Behan that national health insurance is what the United States needs, but the title of her book and her approach make assumptions that might put off some of the intellectuals and policymakers who play an influential role in the future of American health care.

The book lays out a very specific methodology to answer the question that the subtitle poses. It chooses Canada and Australia as countries that are relatively similar to the United States, and it traces the paths these societies traveled to achieve national health insurance. Then it sketches the (unsuccessful) path that the United States has traveled. Approaching the problem as if it were a case-control study, the author attempts to compare these three experiences and calculate the differences, with the goal of explicating what the United States would need to do to obtain that holy grail.

Readers from the medical community are well aware of the limitations of case–control studies involving groups of human beings — even large, well-selected groups. But to compare three societies, with incalculable historical, political, and social differences that could conceivably outweigh their similarities, in the expectation of a clear finding is a tall order indeed. Aside from speculation, however, there are not many other research options out there, so Behan offers what is probably the most careful analysis that can be performed.

The first chapter of the book frames the basic research question in three brief pages; there is a casual mention that the last chapter “describes the study’s conclusion in layman’s terms, including the changes that may be needed to solve the problems of health care access and protection from its costs in the United States.” Were this an Agatha Christie mystery or a José Saramago novel, I wouldn’t dare peek at the last chapter. But in a book that intends to provide the all-embracing research details in the intervening chapters, nonacademicians are all but invited to skip to the plot’s climax. If suspense is important to your reading enjoyment, then stop reading this review now, because I will divulge the outcome. The answer is that in order to enact national health insurance, countries need to achieve four necessary conditions: both federal and financial authority in health care (that is, the national rather than the local government manages and funds the health care system), a multiparty system, a health care legislative legacy, and strong trade unions. Countries also need one of two sufficient conditions: labor-party power and lack of veto points (that is, the ability to block legislation — easily — from within or outside the system).

The United States comes up short on almost every one of these six counts. I found the discussion of the veto points the most interesting. For the past century, almost every legislative gesture was soundly defeated by an unelected body — the American Medical Association (AMA). Behan takes pains not to paint the AMA as the devil, since plenty of senators, representatives, and presidents added their own obstructionism. But the historical discussion reveals that the most consistent pressure came from within medicine itself.

The very nature of the American political system — the winner-take-all voting system, the free-market attitude toward lobbyists, the ability of legislators to compromise bills into nothingness — makes far-reaching social change almost impossible. The necessary and sufficient conditions needed to achieve universal health insurance seem constitutionally unachievable in American society. Behan’s sad conclusion is that “many of the chief blessings of democracy” — and health care as a right is clearly included here — “will, ironically, elude those pioneers of democracy, the American people.”

AFL-CIO statement on comprehensive reform

AFL-CIO Executive Council statement

AFL-CIO
Executive Council
March 6, 2007

The nation is once again focused on the crisis in health care and the American people are looking for a comprehensive solution, instead of the inaction and incredibly ineffective piecemeal approach of the past 10 years.

Nearly forty-seven million U.S. citizens are uninsured. Tens of millions more worry about losing the coverage they have. Workers fear changing or losing jobs because they are at risk of losing their health care coverage. American businesses that provide adequate health benefits are at a significant disadvantage, competing in the global marketplace with foreign companies that do not carry health care costs on their balance sheets. The same is true for businesses in domestic competition against employers that provide little or no coverage.

As a society, we all benefit from improvements in public health. We are a more creative, vibrant, productive and democratic nation because of it. We are all at risk of illness, injury or poor health, and we all suffer when individuals are denied needed care. The shortcomings of the American health care system–which ignores these fundamental realities–strain our nation’s social and economic fabric.

The time for talking about this crisis is past. All families deserve the security of a universal health care system that guarantees access based on need rather than income. Health care is a fundamental human right and an important measure of social justice.

As a nation, we need to exert the political will to enact comprehensive health care reform nationwide. There is strong evidence the crisis can be solved with tools at hand and at a cost that pales in comparison to the toll in human lives the current system exacts.

It is time to mobilize America behind a concrete plan to enact universal health care and the AFL-CIO commits its full resources to asserting leadership in this historic effort.

Universal health care does not mean mandating that everyone must buy a health insurance policy and then handing them the bills. Meaningful health care reform must be measured by the following tests:

Universal Coverage

* Everyone should have health care coverage, without exclusions or penalties.

* While the market has an important role to play, our government–as the voice of all of us–must play the central role in regulating, financing and providing health care.

* Coverage should be accessible through the largest possible groups that pool risk to ensure coverage regardless of gender, age, health status or other factors.

Comprehensive, Affordable Coverage

* Coverage should be affordable and comprehensive.

* Unions and employers should continue to play a role and retain the ability to supplement coverage.

Choice of Providers

* Individuals should retain the ability to select their own doctors and other health care providers.

Financing Through Shared Responsibility

* Because everyone faces the possibility of poor health, risks should be shared broadly to ensure fair treatment and equitable rates, and everyone should share responsibility for contributing to the system through progressive financing.

* A level playing field should be provided for all businesses. Every employer must participate in ensuring health coverage and no employer should be disadvantaged because of the age or health of its workforce or number of retirees.

Effective Cost Control

* Reform efforts must include effective mechanisms for controlling costs, requiring information on provider performance and enhancing efficiency.

* Investments should be made in systems and technology to reduce medical errors and costs, streamline administration and promote best practices.

* Employees who are frontline caregivers should have a protected voice in improving health care.

Do No Harm

* Until we have a comprehensive alternative for all Americans, reform efforts should not undermine existing coverage or put people at risk of unmet health care needs.

Our approach should be to build on what’s best in American health care. At the same time, we should draw from the best experiences of other countries that have achieved universal coverage at a fraction of U.S. health care costs.

One concrete plan that meets the test of comprehensive, universal health coverage would build on our nation’s successful universal health coverage plan for seniors: Medicare.

In its 40-year history, Medicare has delivered substantial advances for the health care of older Americans and people with disabilities. Medicare has guaranteed coverage, made health care more affordable, included a form of shared financial responsibility, significantly reduced administrative costs compared with those of private plans and has been the largely unheralded financer of America’s medical science advances. Medicare also has been a leader in advancing quality care and improvements in health care service delivery in the United States.

Such an approach would require updating and expanding Medicare benefits to fit the working population and children, as well as negotiating prices with physicians and providers that families–and the country–can afford. It would encourage innovation in health care services and medical technology. Employers’ responsibility for health care financing would be broadly and equitably shared, substantially reducing burdens on all businesses and reducing disadvantages currently faced in the global marketplace. In building on Medicare to move toward a universal program, we can find a practical, achievable and affordable solution to our country’s health care crisis.

We call on congressional leaders to unite behind such a plan.

Unlike our fragmented and flawed health care system, a successful universal health care system would provide benefits and cost savings for all stakeholders. The leadership to make comprehensive reform possible, then, must come from all quarters:

* Governments will have to forge the tough consensus that commits necessary public funding while paying only for care that is effective and efficient, based on the best science available.

* Employers must provide strong political support for a transition away from the current employment-based system and be willing to provide continuing financial contributions sufficient to responsibly contribute to the new funding requirements.

* Unions and other organizations that represent users of health services must make enactment of comprehensive health reform legislation a top priority and make a long-term commitment to improving health care service delivery.

* Health care providers and practitioners need to commit their leadership and lend their knowledge and experience to achieving necessary improvements in the quality and effectiveness of care, and use their considerable political clout to support the effort.

We will mobilize our members to build support for bold, meaningful and comprehensive reform and work to pass legislation that assures everyone affordable, comprehensive coverage. We will recruit employers to join us in achieving universal coverage. And we will evaluate the health proposals of candidates for president in 2008 based on the test we have outlined and their capacity to make meaningful change to meet this urgent goal.

Until comprehensive national reform is enacted, we will continue to defend the health benefits workers have fought and sacrificed to establish over the past 50 years, and we will strongly oppose President George W. Bush’s changes in the tax treatment of existing employer-provided coverage.

We also will continue to fight to preserve and expand the State Children’s Health Insurance Program (SCHIP) and Medicaid coverage, improve the Medicare drug benefit and alleviate the legacy health care costs that threaten coverage for millions of workers and retirees, as well as the health of the economy. And we will continue to push for comprehensive reforms at the state level, with the knowledge that other nations have built the political consensus for national reform by first enacting comprehensive care region by region.

http://www.aflcio.org/aboutus/thisistheaflcio/ecouncil/ec03062007.cfm

Comment:

By Don McCanne, MD

To repeat, “Universal health care does not mean mandating that everyone must buy a health insurance policy and then handing them the bills.”

It means abandoning the “incredibly ineffective piecemeal approach of the past 10 years,” and moving forward with meaningful reform that meets the tests of an equitable, efficient, high quality, affordable, comprehensive system that covers everyone.

WonderWoman: Rose Ann DeMoro

Bay Area BusinessWoman
Published: March, 2007
March 2007 Vol. 14 No. 6

Rose Ann DeMoro, executive director of the California Nurses Association (CNA), has been hailed as the “The Woman who met the Terminator’s match.” For the last 13 years, she has run the boisterous, nearly all female 70,000-member union that neutralizes its opponents, including actor-turned governor Arnold Schwarzenegger, with creative direct action, alliance building and media manipulation.

Under DeMoro’s helm, the CNA has tripled in size, and has become a major political player in the state. Now it’s taking its influence across the country, organizing RNs in 40 states and pushing for legislation making federally funded healthcare available for everyone.

DeMoro believes that she benefited from the courage of some strong and influential women in a period of time, the late ’60s and early ’70s when the country was questioning its political priorities and woman were demanding their rightful place at the table — giving her the capacity to fight and advocate for the too often undervalued women in the nursing profession.

After earning her degree in Women’s Studies from Southern Illinois University, DeMoro moved to Santa Barbara where she started working toward a PhD in sociology. But she abandoned her studies to cut her teeth in union organizing.

Fast-forward 20 years to the early ’90s when each nurse in California had ten or twelve patients and service was so terrible that some were calling 911 from their hospital beds. That’s when DeMoro took over the reigns of the nurses’ union and started pushing for a minimum nurse-to patient ratio.

She launched a huge 10-year fight against fierce opposition from powerful HMOs that climaxed with the enactment of the nation’s first nurse-to-patient safety law. Then Schwarzenegger, elected in November 2004, almost immediately tried to scrap the law. In response, DeMoro targeted Schwarzenegger in one of the most aggressive and colorful labor campaigns in decades.

The nurses also took the lead in forming a coalition with California’s other powerful unions enraged over Schwarzenegger’s call for a special election in November 2005 which featured ballot initiatives that would curtail their power. Schwarzenegger’s union-taming initiatives went down to massive defeat, and days later his administration quietly dropped its court battle to block the nurse-patient ratio law.

DeMoro and the CNA are not only grassroots heroes in California. Nurses nationwide are asking DeMoro for help in challenging the growing power of corporate hospital chains and other states’ anti-worker initiatives.

What’s the most important thing you learned in school — or in the “school of hard knocks?”

History does not reward timidity in bringing about social justice to the health care arena.

What has been your biggest challenge?

Fighting the misbegotten notion that our current health care un-system can be repaired through piece meal incrementalism of profit-based private health insurance.

What’s your favorite quotation?

“If there is no struggle there is no progress — power concedes nothing without a demand. Find out just what any people will quietly submit to and you have found out the exact measure of injustice and wrong which will be imposed upon them, and these will continue till they are resisted.” — Frederick Douglass.

What achievement are you most proud of?

Playing a significant part in the reconceptualization of the lost historic role of the RN from bedside patient advocate to social advocate.

What’s your advice to girls and/or women who are interested in the Health Care profession?

Now is the singularly best historical moment to enter the profession and demonstrate that advocating for one’s patients is inseparable from advocating for social justice.

What does it take to be an effective activist for change?

To rebel against “conventional wisdom” that maintains the ‘dynamic status quo,’ to find courage to follow your beliefs to advocate for change when it seems hopeless. To be collective, creative, inclusive — and relentless.

AFL-CIO Endorses Medicare for All

AFL-CIO Executive Council statement
Health Care
March 06, 2007
Las Vegas

The nation is once again focused on the crisis in health care and the American people are looking for a comprehensive solution, instead of the inaction and incredibly ineffective piecemeal approach of the past 10 years.

Nearly forty-seven million U.S. citizens are uninsured. Tens of millions more worry about losing the coverage they have. Workers fear changing or losing jobs because they are at risk of losing their health care coverage. American businesses that provide adequate health benefits are at a significant disadvantage, competing in the global marketplace with foreign companies that do not carry health care costs on their balance sheets. The same is true for businesses in domestic competition against employers that provide little or no coverage.

As a society, we all benefit from improvements in public health. We are a more creative, vibrant, productive and democratic nation because of it. We are all at risk of illness, injury or poor health, and we all suffer when individuals are denied needed care. The shortcomings of the American health care system–which ignores these fundamental realities–strain our nation’s social and economic fabric.

The time for talking about this crisis is past. All families deserve the security of a universal health care system that guarantees access based on need rather than income. Health care is a fundamental human right and an important measure of social justice.

As a nation, we need to exert the political will to enact comprehensive health care reform nationwide. There is strong evidence the crisis can be solved with tools at hand and at a cost that pales in comparison to the toll in human lives the current system exacts.

It is time to mobilize America behind a concrete plan to enact universal health care and the AFL-CIO commits its full resources to asserting leadership in this historic effort.

Universal health care does not mean mandating that everyone must buy a health insurance policy and then handing them the bills. Meaningful health care reform must be measured by the following tests:

Universal Coverage

* Everyone should have health care coverage, without exclusions or penalties.

* While the market has an important role to play, our government–as the voice of all of us–must play the central role in regulating, financing and providing health care.

* Coverage should be accessible through the largest possible groups that pool risk to ensure coverage regardless of gender, age, health status or other factors.

Comprehensive, Affordable Coverage

* Coverage should be affordable and comprehensive.

* Unions and employers should continue to play a role and retain the ability to supplement coverage.

Choice of Providers

* Individuals should retain the ability to select their own doctors and other health care providers.

Financing Through Shared Responsibility

* Because everyone faces the possibility of poor health, risks should be shared broadly to ensure fair treatment and equitable rates, and everyone should share responsibility for contributing to the system through progressive financing.

* A level playing field should be provided for all businesses. Every employer must participate in ensuring health coverage and no employer should be disadvantaged because of the age or health of its workforce or number of retirees.

Effective Cost Control

* Reform efforts must include effective mechanisms for controlling costs, requiring information on provider performance and enhancing efficiency.

* Investments should be made in systems and technology to reduce medical errors and costs, streamline administration and promote best practices.

* Employees who are frontline caregivers should have a protected voice in improving health care.

Do No Harm

* Until we have a comprehensive alternative for all Americans, reform efforts should not undermine existing coverage or put people at risk of unmet health care needs.

Our approach should be to build on what’s best in American health care. At the same time, we should draw from the best experiences of other countries that have achieved universal coverage at a fraction of U.S. health care costs.

One concrete plan that meets the test of comprehensive, universal health coverage would build on our nation’s successful universal health coverage plan for seniors: Medicare.

In its 40-year history, Medicare has delivered substantial advances for the health care of older Americans and people with disabilities. Medicare has guaranteed coverage, made health care more affordable, included a form of shared financial responsibility, significantly reduced administrative costs compared with those of private plans and has been the largely unheralded financer of America’s medical science advances. Medicare also has been a leader in advancing quality care and improvements in health care service delivery in the United States.

Such an approach would require updating and expanding Medicare benefits to fit the working population and children, as well as negotiating prices with physicians and providers that families–and the country–can afford. It would encourage innovation in health care services and medical technology. Employers’ responsibility for health care financing would be broadly and equitably shared, substantially reducing burdens on all businesses and reducing disadvantages currently faced in the global marketplace. In building on Medicare to move toward a universal program, we can find a practical, achievable and affordable solution to our country’s health care crisis.

We call on congressional leaders to unite behind such a plan.

Unlike our fragmented and flawed health care system, a successful universal health care system would provide benefits and cost savings for all stakeholders. The leadership to make comprehensive reform possible, then, must come from all quarters:

* Governments will have to forge the tough consensus that commits necessary public funding while paying only for care that is effective and efficient, based on the best science available.

* Employers must provide strong political support for a transition away from the current employment-based system and be willing to provide continuing financial contributions sufficient to responsibly contribute to the new funding requirements.

* Unions and other organizations that represent users of health services must make enactment of comprehensive health reform legislation a top priority and make a long-term commitment to improving health care service delivery.

* Health care providers and practitioners need to commit their leadership and lend their knowledge and experience to achieving necessary improvements in the quality and effectiveness of care, and use their considerable political clout to support the effort.

We will mobilize our members to build support for bold, meaningful and comprehensive reform and work to pass legislation that assures everyone affordable, comprehensive coverage. We will recruit employers to join us in achieving universal coverage. And we will evaluate the health proposals of candidates for president in 2008 based on the test we have outlined and their capacity to make meaningful change to meet this urgent goal.

Until comprehensive national reform is enacted, we will continue to defend the health benefits workers have fought and sacrificed to establish over the past 50 years, and we will strongly oppose President George W. Bush’s changes in the tax treatment of existing employer-provided coverage.

We also will continue to fight to preserve and expand the State Children’s Health Insurance Program (SCHIP) and Medicaid coverage, improve the Medicare drug benefit and alleviate the legacy health care costs that threaten coverage for millions of workers and retirees, as well as the health of the economy. And we will continue to push for comprehensive reforms at the state level, with the knowledge that other nations have built the political consensus for national reform by first enacting comprehensive care region by region.