PNHP

The Taming of the Queue IV

The Taming of the Queue IV

The Taming of the Queue IV: New Frontiers of Wait Time Measurement, Monitoring and Management

Prepared by: Tom McIntosh, Ph.D. and Patrick Fafard, Ph.D.
Canadian Policy Research Networks
Conference Report
May 2007

Introduction

Not many conferences attended mostly by researchers and policy-makers can boast having had the Prime Minister come for lunch. But Prime Minister Stephen Harper made a lunchtime appearance at the 4th annual Taming of the Queue conference in Ottawa on April 4, 2007 to announce, along with federal Minister of Health Tony Clement, agreements between the federal government and the 13 provinces and territories with regard to meeting specific wait time targets in exchange for targeted federal funds. Without a doubt, the announcement caused more than a ripple through the crowd of participants, many of whom had attended all or most of the previous Taming of the Queue conferences, as it served to highlight both the progress that has been made on the wait time issue and how much work still remains to be done.

What follows then (in the full report) are summaries of the presentations made to the Taming of the Queue IV conference that focus not only on the broader themes noted above, but also attempt to distil the key lessons that came from each specific line of analysis. The actual presentations themselves are also available on the Web site of Canadian Policy Research Networks (www.cprn.org) along with those from past conferences and past conference reports.

Closing Comments and Key Messages

In their closing comments, the conference co-chairs re-emphasized the positive messages that were heard throughout the conference that real progress was being made in terms of measuring, monitoring, managing and, ultimately, reducing wait times in different parts of the system in different parts of the country. But there also remained some very hard work left to be done. Indeed the final sessions of the conference, in going beyond the “big five,” in some ways returned the conference to where it had begun with the first Taming of the Queue – to areas where the work is only just beginning. The advantage of course is that work on reducing wait times for primary care, mental health and children’s services will be greatly enhanced by the hard work already done in those areas that have benefited from so much research and political attention in recent years.

Finally, it is clear that the success stories related over the course of the two days of the conference also very much reinforced an idea that has been central to the work on wait times since the issue first began to receive attention from researchers and politicians. Successful wait time strategies require champions willing to take on leadership roles and persevere in the face of sometimes strong opposition. Champions are required within the bureaucracy to sustain commitments to build new systems for monitoring and managing lists within the professions (especially within the medical profession), to break down resistance to change and to inculcate a new culture inside health care institutions and within governments, in order to ensure that there are adequate resources to both begin and carry through with the transformations required.

http://www.cprn.org/documents/48031_en.pdf

Comment:

By Don McCanne, MD

The opponents of single-payer national health insurance claim that intolerable waiting times for health care would be inevitable. They use the experience in Canada as proof.

Canada has had problems with excessive queues, but, as this report demonstrates, they are being addressed, and with considerable success.

While Canada moves forward with queue management and fine tuning of capacity, we continue to hang our heads in shame over the financial barriers we place in front of tens of millions of Americans, which prevent access to the most generously funded health care system ever known. And we refuse to act because a humane system that covers everyone might expose us to the alleged threat of preventable queues?!

Where are our champions?

Health insurance after divorce

Continued health insurance bill after divorce gets OK

By The Associated Press
UnionLeader.com
June 7, 2007

The (New Hampshire) House voted yesterday to extend health insurance coverage to people who lose their insurance when their marriages break up.

The bill would require insurance companies to let divorced spouses remain on the ex-spouse’s policies for up to three years or until one spouse remarries.

Anthem Blue Cross and Blue Shield and the Association of American Health Insurance Plans (AHIP) opposed the bill.

http://www.unionleader.com/article.aspx?headline=Continued+health+insurance+bill+after+divorce+gets+OK&articleId=6fa18f95-9212-4857-b024-d32e6d1cb5b5

Comment:

By Don McCanne, MD

Everyone should have health insurance coverage, automatically and permanently. It is wrong to require a link to extraneous qualifiers such as employment, location of residence, membership in organizations, age, or, in this instance, continuation of marriage to an individual with employer-sponsored coverage. Requiring such links satisfies the business model of the private insurers, but does so at the cost of leaving many without coverage. This remains one of the most serious flaws in our expensive, fragmented, and highly inequitable method of financing health care.

With the private insurance industry in charge, you would think that they would want to try to rectify the injustices in our system, especially when there is an increasing demand for reform. But, no. AHIP, the national trade association for the private insurance industry, and Anthem Blue Cross/Blue Shield opposed even this minuscule effort to temporarily reduce loss of coverage after divorce.

Our goal is to enable everyone to access the health care that they need without suffering financial hardship. In spite of their rhetoric, by their actions the private insurance industry has demonstrated repeatedly that they are not interested in helping us achieve this goal. They reject all reform proposals that don’t match their business model.

Well let’s present them with the reform proposal that we really do need: single-payer national health insurance. They’ll certainly reject that, but so what? We’ll be far better off without them.

Blue Cross of California's $1 billion leak

WellPoint dividend is questioned

By Lisa Girion
Los Angeles Times
May 26, 2007

State regulators are investigating whether a $950-million dividend Blue Cross of California sent to its Indianapolis-based parent violates an agreement the companies made to limit such payments to keep premiums down and maintain the quality of healthcare benefits, officials said Friday.

Officials said the parent, healthcare giant WellPoint Inc., should have taken no more than $141 million out of California. They called the higher amount excessive, particularly as Blue Cross, which serves more than 7 million state residents, has continued to raise premiums.

The state Department of Managed Health Care also is considering expanding its probe to determine whether there are any other potential violations of the three-year agreement, part of a deal to win the agency’s approval for a corporate marriage that created the nation’s largest health benefits provider.

The merger came about when an Indianapolis-based company then known as Anthem Inc. purchased Thousand Oaks-based WellPoint, which used the Blue Cross license in California, and adopted its name.

Cindy Ehnes, director of the Department of Managed Health Care, said she was shocked to learn of the $950-million payday for WellPoint, whose total profit last year was $3.1 billion on $57 billion in revenue.

“We are concerned that it reflects a viewpoint of California being its own ATM machine, while, at the same time, Californians are struggling to get health insurance for their families,” Ehnes said in an interview.

“Health insurance is a competitive industry that does not exhibit excessive profit margins,” WellPoint spokeswoman Shannon Troughton said.

http://www.latimes.com/business/la-fi-wellpoint26may26,0,3060723.story?coll=la-home-business

The agreement (Undertakings):
http://www.dmhc.ca.gov/library/reports/news/BCCunder112404.pdf

Comment:

By Don McCanne, MD

If you read the “Undertakings” agreement you will see that it reflects an appropriate distrust of the private insurance industry, that it might not fulfill its responsibilities to its beneficiaries to see that they receive adequate coverage at a reasonable value. No such document would need to be created in a publicly-funded and publicly-administered insurance program. It represents yet more administrative waste resulting from keeping the private plans in play.

By law, the for-profit, private insurance corporations have a primary responsibility to maximize shareholder value. For Blue Cross of California, that means not only do profits need to be maximized, but they also need to be transferred out of the state to the parent corporation, WellPoint, where the funds are used for additional administrative functions, capital acquisitions, or distributed as dividends. None of these provide any benefit for the beneficiaries of the Blue Cross of California plans.

Regardless of what WellPoint does with the funds, nearly $1 billion is being sucked out of Blue Cross of California thereby causing either an increase in premiums or a reduction in benefits, or both. This only increases the financial burden for patients at a time that health care affordability is rapidly diminishing.

Why do our politicians continue to insist that we need employer mandates and/or individual mandates to purchase private insurance plans when this industry is serving us so poorly? Shouldn’t reform be designed to take care of the health of patients rather than the health of superfluous, middleman private insurance corporations? Why on earth do we need to keep asking this question?

Blue Cross of California’s $1 billion leak

WellPoint dividend is questioned

By Lisa Girion
Los Angeles Times
May 26, 2007

State regulators are investigating whether a $950-million dividend Blue Cross of California sent to its Indianapolis-based parent violates an agreement the companies made to limit such payments to keep premiums down and maintain the quality of healthcare benefits, officials said Friday.

Officials said the parent, healthcare giant WellPoint Inc., should have taken no more than $141 million out of California. They called the higher amount excessive, particularly as Blue Cross, which serves more than 7 million state residents, has continued to raise premiums.

The state Department of Managed Health Care also is considering expanding its probe to determine whether there are any other potential violations of the three-year agreement, part of a deal to win the agency’s approval for a corporate marriage that created the nation’s largest health benefits provider.

The merger came about when an Indianapolis-based company then known as Anthem Inc. purchased Thousand Oaks-based WellPoint, which used the Blue Cross license in California, and adopted its name.

Cindy Ehnes, director of the Department of Managed Health Care, said she was shocked to learn of the $950-million payday for WellPoint, whose total profit last year was $3.1 billion on $57 billion in revenue.

“We are concerned that it reflects a viewpoint of California being its own ATM machine, while, at the same time, Californians are struggling to get health insurance for their families,” Ehnes said in an interview.

“Health insurance is a competitive industry that does not exhibit excessive profit margins,” WellPoint spokeswoman Shannon Troughton said.

http://www.latimes.com/business/la-fi-wellpoint26may26,0,3060723.story?coll=la-home-business

The agreement (Undertakings):
http://www.dmhc.ca.gov/library/reports/news/BCCunder112404.pdf

Comment:

By Don McCanne, MD

If you read the “Undertakings” agreement you will see that it reflects an appropriate distrust of the private insurance industry, that it might not fulfill its responsibilities to its beneficiaries to see that they receive adequate coverage at a reasonable value. No such document would need to be created in a publicly-funded and publicly-administered insurance program. It represents yet more administrative waste resulting from keeping the private plans in play.

By law, the for-profit, private insurance corporations have a primary responsibility to maximize shareholder value. For Blue Cross of California, that means not only do profits need to be maximized, but they also need to be transferred out of the state to the parent corporation, WellPoint, where the funds are used for additional administrative functions, capital acquisitions, or distributed as dividends. None of these provide any benefit for the beneficiaries of the Blue Cross of California plans.

Regardless of what WellPoint does with the funds, nearly $1 billion is being sucked out of Blue Cross of California thereby causing either an increase in premiums or a reduction in benefits, or both. This only increases the financial burden for patients at a time that health care affordability is rapidly diminishing.

Why do our politicians continue to insist that we need employer mandates and/or individual mandates to purchase private insurance plans when this industry is serving us so poorly? Shouldn’t reform be designed to take care of the health of patients rather than the health of superfluous, middleman private insurance corporations? Why on earth do we need to keep asking this question?

John Geyman on disease management

Disease Management: Panacea, Another False Hope, or Something in Between?

By John P. Geyman, MD
Annals of Family Medicine
May/June 2007

Disease management is being promulgated by many policy makers, legislators, and a burgeoning new disease management industry as the next major hope, together with information technology and consumer-directed health care, to bring cost containment to runaway costs of health care. Many expect quality improvement as well. The concept is being aggressively marketed to employers, health plans, and government in the wake of managed care’s failure to contain costs. There is widespread confusion, however, about what disease management is and what impact it will have on patients, physicians, and the health care system itself. In this article I give a current snapshot of disease management by briefly addressing (1) its rationale and growth, (2) its track record concerning costs and quality of care, and (3) its impacts on primary care.

There are two basic types of disease management programs–those based on primary care and integrated within a managed care organization (eg, Group Health Cooperative and Kaiser Permanente), and commercial vendors to which employers and health plans may outsource their disease management functions. The former has been well accepted within the medical community as an important advance in the care of chronic disease. Group Health Cooperative and Kaiser Permanente have pioneered new approaches to chronic disease management based upon a new paradigm, the Chronic Care Model. For example, primary care teams are provided support in the form of electronic diabetes registries, evidence-based guidelines, patient self-management support, and decentralized on-site consultation with a diabetes expert team (a physician and a nurse specialist).

Commercial disease management programs are quite different. As carved-out programs, they are not integrated with primary care, are for-profit ventures, and are marketed to employers and health plans primarily as a cost-containment strategy. With sophisticated information systems, disease management companies focus on patient education and more-effective patient self-management, especially by use of telephone calls, mailings, and the Internet. Commercial disease management programs often provide minimal communication with primary care physicians, and reception of these programs by physicians is frequently antagonistic. Physicians may at times receive telephone calls from several nurses in distant call centers about the same patient with multiple chronic conditions.

Disease management on a Chronic Care Model based in primary care is an important advance in the care of a growing part of the population. With training, reengineering of practice functions, and adequate funding, the elements of this model can be adapted to many primary care settings, as Group Health Cooperative has already shown in many community health centers across the country. With a strong link to primary care, quality of care can be improved, but cost savings cannot be assumed. Costs may actually increase as better quality of care is provided to patients previously undertreated for chronic conditions. There is no solid evidence yet that commercial for-profit disease management vendors will save money and improve care of chronic illness on a long-term basis. It is much more likely that the current enthusiasm among employers and insurers for outsourced disease management programs will end up as just one more policy failure, undermining primary care and delaying increasingly urgent health care reform.

http://www.annfammed.org/cgi/content/full/5/3/257

Comment:

By Don McCanne, MD

This article could not be timelier. In response to growing concerns about the affordability of health care, the political arena is awash with proposals to control health care spending. Unfortunately, because of the timidity of the politicians in confronting the powerful vested interests that are wasting so much of our resources, they are turning to pseudo-solutions such as the commercial variety of disease management.

The private health insurance industry has been aggressive in its marketing of innovative products that shift risk from insurers to taxpayers and to patients with greater health care needs. While abandoning the risk pooling function, they have been selling us more and more administrative services. The commercial disease management programs compound this administrative waste, while introducing yet another disruptive, intrusive element into the clinical arena.

Yet the deficiencies in chronic disease management are very real. But rather than wasting more resources on third party managers, the solution is to reinforce our rapidly deteriorating primary care infrastructure. A strong primary care base provides the ideal environment in which to develop an effective chronic disease model. Barbara Starfield and others have demonstrated that this would not only improve quality of care, but would also address the issue of affordability by ensuring more cost-effective care.

To accomplish this, incentives need to be realigned to encourage the improvement and expansion of the primary care infrastructure. This would be a simple task for the public administrators of a single national health insurance program. Crafting reform that leaves the private insurance industry in play would only direct more resources to their primary product: ever more wasteful administrative services. We need to take care of our patients, not our insurers.

Teamsters, United Auto Workers, Call for Single Payer

Speakers want universal health care, differ on running, paying for it

By Sheena Harrison
Crain’s Detroit Business
June 4, 2007

MACKINAC ISLAND — While business and union leaders agreed that health care should be available for all Americans, they differed on who should pay the tab for health coverage.

United Auto Workers International President Ron Gettelfinger and James Hoffa, general president of the International Brotherhood of Teamsters, both advocated creating a universal, single-payer health care system in separate speeches at the Detroit Regional Chamber’s Mackinac Policy Conference.

Meanwhile, Intel Chairman Craig Barrett and Pitney Bowes Executive Chairman Michael Critelli said employers will play a crucial role in creating a health care system that covers all people, encourages healthy living and lower health care costs. They argued that employers are best able to effect change because they are more invested in the productivity of their employees than insurance companies or government entities are.

“Ask yourself if you went to a government-paid plan whether they would care whether you got back to work,” Critelli said.

Audience members agreed universal health care is a good goal, but seemed to side with Barrett and Critelli’s views that it should not be a federal initiative.

“I don’t think a single-payer system will change the system in a way it needs to be changed,” said Jan Whitehouse, senior vice president with the Greater Detroit Health Council Inc. and head of the council’s Save Lives, Save Dollars program.

“We agree everybody ought to have health insurance. We don’t agree it should be a government-run program” said Rob Fowler, president and CEO of the Lansing-based Small Business Association of Michigan and chairman of the Michigan Health Insurance Access Advisory Council.

Hoffa and Gettelfinger addressed health care as part of speeches Wednesday night and Thursday morning that encouraged unions and businesses to work together for common goals.

Barrett and Critelli offered their suggestions Thursday morning during a session on how businesses can lead a transformation of the U.S. health care system. Their session included examples of how their companies have lowered costs and improved quality of care for their employees.

For example, Critelli said Pitney Bowes offers in-house clinics that provide care at no cost to employees, and cafeterias that serve appropriate portions and sell nutritious foods at lower prices than less-healthy items.

As a result, Pitney Bowes has been able to reduce its diabetes care costs by about 6 percent and asthma care costs by 15 percent. Other companies could benefit by taking similar steps to promote employee health, Critelli said.

“In America, we’re paying for a disease-care system, not a health care system,” Critelli said. “We must begin to pay for prevention.”

Barrett said technology also should play a larger role in reducing costs and providing better care for patients. He advocated the use of telehealth systems, which monitor vital signs from the patient’s home and can alert health providers to problems before a patient faces a health emergency.

Electronic health records and prescriptions also would help reduce costs by reducing errors in paperwork and allowing providers and patients to access their information at any time, Barrett said.

“Wherever you are in the world, you should have access to your health records,” Barrett said.

Both Barrett and Critelli said providers and patients should take more responsibility in changing the health care system. They advocated paying providers based on their performance in resolving patient conditions, rather than paying for individual services, similar to the GDAHC’s Save Lives, Save Dollars program.

Ken Matzick, president and CEO of Royal Oak-based William Beaumont Hospitals, said the chairmen offered good suggestions that can be implemented in Southeast Michigan though he didn’t think the ideas could effect large-scale change in the health care system.

Fact-checking the Democratic Candidates on Health Care

infoZine Staff
Kansas City infoZine
Tuesday, June 05, 2007

Politics: The National coordinator of Physicians for a National Health Program

Washington, D.C. – Institute for Public Accuracy – infoZine – National coordinator of Physicians for a National Health Program, Quentin Young, M.D. ( info@pnhp.org ) said yesterday: “It was ironic to hear Clinton talk about standing up to the the insurance companies. She’d tried to work them into her plan, which is a large part of why it failed. The biggest insurance companies actually backed her plan for a time while the smaller ones opposed it.

“Edwards is giving a false impression when he says that there’s no way to have universal coverage without raising taxes. We could cover everyone with a single payer system for the same amount of money that we’re paying now. This would mean money going to a single payer — like Medicare is run now — instead of the insurance companies. For about 95 percent of people it would mean less total costs. However, neither Clinton, Edwards or Obama are adopting such a plan, probably because it would clash with the interests of the insurance and drug companies, who are major funders.” www.pnhp.org

Study: Little Evidence that "Disease Management" Programs Control Health Costs

Presidential Candidates Peddling Unproven Reform

For Immediate Release
Tuesday, June 5, 2007

Contacts:
John Geyman, MD (360) 378-6264
Deb Richter, MD (802) 224-9037
Quentin Young, MD (312) 782-6006

There is little evidence that “disease management” (DM) programs are effective in controlling health care costs, according to an article published in the May/June issue of Annals of Family Medicine which reviews recent studies of the programs. Yet all of the leading Democratic presidential candidates have made the programs — which aim to reduce health care costs and/or improve care quality by helping patients manage chronic conditions such as diabetes and heart disease — a plank of their health reform platforms, and a number of states (such as Vermont) have made DM a central component of state-level reform.

“Considering the scant evidence of cost savings from “disease management” programs, it is astounding that the candidates have rushed to embrace and promote them as panaceas,” said Dr. John Geyman, Professor Emeritus of Family Medicine at the University of Washington and author of the article. “One is reminded of the similar rush to embrace managed care in the 1990s, which was also a dismal failure.”

Dr. Geyman points out that much of the best data casts doubt on the ability of DM to control costs:

* A 2005 report by Dr. David Eddy and colleagues on the long-term effect of DM on diabetes costs concluded that “Even for the most optimistic picture…the net effect on diabetes-related costs would be an increase of about 25 percent.”

* A 2006 analysis calculated that DM programs would need to decrease hospital admissions by 10 percent to 30 percent to cover program fees alone.

* A 2004 Congressional Budget Office survey of 57 DM programs concluded: “there is insufficient evidence to conclude that disease management programs can generally reduce overall health spending…”

In the Annals article, Dr. Geyman identifies two types of DM programs. The first is nonprofit chronic care programs integrated with primary care. These programs can include evidence-based treatment guidelines, and on-site consultations with expert doctors and nurses, and electronic disease registries. Programs of this type have been found to achieve improved care quality, but in many cases raise costs.

The second type is rapidly-growing, for-profit DM programs which are carved-out and separate from primary care. This corporate model is marketed to employers and health plans as a way to cut costs. The development of commercial DM programs has been spearheaded by the pharmaceutical industry since the early 1990s. Such programs also produce profits for DM vendors and related industries (for instance, DM companies will call patients and suggest drugs they should ask their doctors to prescribe). These programs find it difficult to provide sustained improvement in quality of care because of their uncoordinated nature and disconnect from primary care. Studies of the impact of commercial DM programs, many of which are funded and conducted by industry, have been limited by short-term follow-up, focus on single chronic diseases without accounting for co-morbidity or program costs, and publication bias.

“Management of chronic disease is best accomplished by physicians and other health professionals working closely with patients in primary care settings,” said Dr. Geyman. “Corporate disease management programs are contradictory to this relationship. How can a person in a distant commercial call center recommend the best diabetes drugs to a frail Medicare patient she has no relationship with, especially since such patients typically have several chronic diseases, not just one?”

Moreover, some physicians have reported adverse problems from corporate DM vendors, which sort through patients’ insurance claims data looking for potential customers. Three patients of Dr. Deborah Richter, a family physician in Vermont, were contacted by DM firms and mistakenly told they had diseases they didn’t have.

“These DM companies are so focused on making a profit that they will put anyone with a symptom on their list. Two of my patients received letters erroneously telling them they had chronic diseases, scaring the daylights out of them. Another was harassed on a weekly basis by a DM company “nurse” about a condition she didn’t have. She was afraid to come see me because she thought I had sent this person.”

Despite the lack of evidence as to DM programs’ ability to control costs and problems associated with them, Hillary Clinton, John Edwards, and Barack Obama have all endorsed DM programs as part of their health reform plan. In addition, states such as Illinois, Pennsylvania and Vermont have all proposed taking up DM programs.

“‘Disease management’ is only the latest in a series of panaceas that have been offered as a way to avoid facing the real problems in our health system: private insurance companies,” said Dr. Quentin Young, National Coordinator of Physicians for a National Health Program. “The only way to control health care costs is to evict wasteful private insurers and create a single-payer national health program which can streamline our patchwork payment system and rein in costs through rational budgeting. Until we have leaders that are willing to take on these big problems and the powerful interests that create them, there is little hope for solving our health care crisis.”

Article Link (PDF): https://pnhp.org/dm.pdf

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Physicians for a National Health Program is an organization of 14,000 physicians that support single-payer national health insurance. PNHP is headquartered in Chicago and has chapters and spokespeople across the U.S. To contact a physician-spokesperson in your area, contact nick@pnhp.org or call 312-782-6006. www.pnhp.org.

Defining affordability of health care

Setting A Standard Of Affordability For Health Insurance Coverage

by Linda J. Blumberg, John Holahan, Jack Hadley, and Katharine Nordahl
Health Affairs
June 4, 2007

The definition of affordability for individuals and families of different incomes or circumstances is a critical decision in implementation and is relevant to any state or federal reform requiring individual premium or cost-sharing contributions, or both. This analysis was done to assist the policy design process in Massachusetts and delineates an empirically based approach to setting affordability standards.

The approach to defining affordability explored in this paper focuses on people’s actual spending on health care (health insurance premiums and out-of-pocket expenses), at various income levels. This approach has the strength of reflecting people’s actual purchasing decisions, thereby revealing what they are both willing and able to spend, albeit in the context of a voluntary health insurance system.

Total medical costs.

Nongroup coverage: The median individuals and families with nongroup coverage across all incomes spent 16.9 percent and 14.7 percent of income, respectively, on health insurance and out-of-pocket costs. The median values for those with incomes of 300-499 percent of poverty were 10.4 percent (single) and 11.6 percent (family).

Total spending for employer coverage: At the median, spending was 12.3 percent and 15.1 percent for individual and family coverage, respectively. For those with incomes of 300-499 percent of poverty, these figures were 12.6 percent and 17.4 percent, respectively (mean: 13.2 percent and 18.2 percent).

Role of out-of-pocket liability: Because of the highly skewed distribution of health care spending and the large potential variation in plans’ actuarial values, affordability must take out-of-pocket liability into account in addition to premiums. Our analysis shows that total medical spending, including premiums and out-of-pocket expenses, can be very high as a percentage of income, particularly for those with incomes below 300 percent of poverty and for those with high medical needs. Thus, any effective standard for affordability must consider both out-of-pocket costs and premiums. (This is) an important consideration for the enforcement of an individual mandate, because cost-sharing requirements can be overly burdensome for middle-income people as well, depending upon the out-of-pocket exposure associated with insurance and the intensity of required medical care.

Postscript

The affordability standard set by the (Commonwealth Health Insurance Connector Authority in Massachusetts) does not explicitly take potential out-of-pocket exposure into account. As a result, people with persistently high out-of-pocket costs will face much higher financial burdens as a percentage of income than what our data indicate are typically borne nationally by those at 300-499 percent of poverty.

The Massachusetts approach is to exempt from the mandate all those who cannot obtain the minimum level of coverage at an affordable level.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.4.w463

Comment:

By Don McCanne, MD

Although there is no accepted economic definition of affordability, this paper makes an attempt to set an affordability standard for health care by defining what people are willfully paying for health insurance premiums plus out-of-pocket expenses in our voluntary private health insurance market. Presumably, the uninsured are individuals who find these costs to be unaffordable, and many objective studies confirm that the great majority of the uninsured simply do not have the funds to pay these costs.

The results of this study confirm what we already knew. We are spending a lot for health care – a median of about 15 percent of income for family coverage in both the individual and group private insurance markets, including out-of-pocket expenses. For many families, this constitutes a financial hardship, but they continue with coverage because they recognize the importance of being able to pay for health care when they need it. Many are hanging on, hoping that we will soon provide relief by reforming our method of financing health care.

But the picture is actually worse than this study would indicate. This study was of individuals already insured in the private market. These are the healthiest individuals in our society – the healthy workforce and their young healthy families. If risk pools limited to the healthiest are consuming 15 percent of family income, just think what the costs of funding the pool would be once coverage is universal and includes those with high-cost medical problems.

Also, 15 percent of income is the median amount for a family. The healthiest half pays less, but the other half pays more, and the few with significant health care needs pay much more. Yet one of the most important functions of insurance is to protect the finances of precisely these individuals. We could do that by establishing one single universal risk pool and funding it equitably.

But no. Our politicians insist that the private plans be left in play. Like Massachusetts, we will have to agree that, even with a mandate, we will not require coverage for average-income individuals who cannot afford it.

A brief excerpt from the debate last night of the Democratic presidential candidates:

SEN. OBAMA: But on this issue of mandatory versus non-mandatory, (people are ?) not going around trying to avoid buying health care coverage. And in fact, if you look at auto insurance, in California there’s mandatory auto insurance. Twenty-five percent of the folks don’t have it. The reason is because they can’t afford it.

So John and I, we’re not that different in this sense; that I’m committed to starting the process. Everybody who wants it can buy it and it’s affordable. If we have some gaps remaining, we will work on that. You take it from the opposite direction, but you’re still going to have some folks who aren’t insured under your plan, John, because some of them will simply not be able to afford to buy the coverage they’re offered.

Another brief excerpt:

MR. BLITZER: Hold on one second. I promised Congressman Kucinich.

Go ahead.

REP. KUCINICH: I reject this whole approach. And the American people should know that with half the bankruptcies in the country connected to people not being able to pay their doctor bills or hospital bills, premiums, co-pays and deductibles going so far through the roof — 46 million Americans, no health care; another 50 million underinsured, there is only one way to get health care coverage for all Americans, and that is to have a universal single-payer, not-for- profit healthcare system, Medicare for All. Wolf, I’ve written the bill — it’s H.R. 676 — with John Conyers, supported by 14,000 physicians.

MR. BLITZER: All right.

REP. KUCINICH: And you know what? What Senator Clinton, Senator Edwards, Senator Obama are talking about, they’re talking about letting the insurance companies stay in charge. They’re talking about continuing a for-profit health care system. (Applause.) And I think —

MR. BLITZER: All right. Hold on. No applause.

REP. KUCINICH: — we need a president who’s ready to challenge that. And I’m ready to challenge the insurance companies.

MR. BLITZER: All right. Let’s go to the next question.

http://www.nytimes.com/2007/06/03/us/politics/03demsdebate_transcript.html?pagewanted=all

Michael Moore's "Sicko" to Premiere in Sacramento on June 12 with California Nurses Association and Physicians for a National Health Program

For immediate release:
June 1, 2007

Contacts:
Quentin Young, MD: (312) 782-6006
Nicholas Skala: (312) 782-6006

Moore will testify at legislative briefing and rally with single payer activists

Film maker Michael Moore’s new documentary “Sicko” will premiere on Tuesday, June 12 in Sacramento with Physicians for a National Health Program, the California Nurses Association/National Nurses Organizing Committee, and other supporters of single payer national health insurance. “Sicko” opens nationwide in theaters on June 29.

California is a key state for health care reform. One-in-four state residents is uninsured, costs are skyrocketing, and outrage has erupted over the recent $950 million dividend paid by the state’s Blue Cross plan to their new owner, the Indianapolis insurance giant Wellpoint, on top of the $600 million awarded to top executives involved in the 2004 merger.

Debate at the state level mirrors that of the national scene, which boils down to a choice between just two paths for health reform. One path (supported by Schwarzenegger, Massachusett’s Mitt Romney, and Democratic presidential candidates Barack Obama and John Edwards) is to continue to rely on the wasteful private insurance industry and tinker with tax policy, public subsidies, and other changes favoring insurers. Such reform is administratively complex, would fail to cover all the 46 million uninsured, and adds costs to a health system already the most expensive in the world. States that have tried this path (Hawaii in 1974, Oregon in 1989, Massachusetts in 1988, and Maine in 2003) have more uninsured than before the plans passed.

The other path for reform is single payer, as proposed by Sen. Sheila Kuehl, chair of the California Senate’s Health Committee. Kueh’s bill (SB 840) would replace private insurers with a single comprehensive plan to cover all Californians. The savings on administrative overhead would allow the state to cover everyone and save an additional $7 billion per year, according to the prestigious Lewin consulting firm. On the national level, single payer would save over $350 billion on paperwork costs, enough to cover all the nation’s uninsured. National legislation based on the proposal, HR 676, the Conyers/Kucinich bill, has over 70 co-sponsors.

Single payer gained the support of both houses of the California legislature last year, and is favored by a majority of “likely voters” and 70 percent of “likely Democratic primary voters” in the polls. “Our campaign with physicians and nurses across the country in conjunction with the release of “Sicko” will boost the visibility of the single payer option for reform,” said Dr. Quentin Young. “It’s the only cure for our Sicko health system.”

Michael Moore will testify at a legislative briefing for the co-authors of SB 840 from noon to 1:30 p.m. in State Capitol Room 4203. The briefing will be followed by a big rally with Moore sponsored by the California Nurses Association (CNA). CNA, Physicians for a National Health Program, and other single payer supporters will rally on the West Steps of the Capitol and then a special premiere of “Sicko” for RNs, doctors and invited guests.

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Physicians for a National Health Program was founded in 1986 and has over 14,000 members and chapters across the U.S. PNHP has physician spokespeople in every state. For contact information, write info@pnhp.org or see our web site at www.pnhp.org

Sen. Obama, Please No More Deck Chairs on the Insurance Industry Titanic

By Rose Ann DeMoro
The Huffington Post
May 29, 2007

The first misconception in the health care debate is the portrait of all of us as “consumers” of health care.

If we are ever going to build a genuinely humane society, we need to discard the notions of consumerism when it comes to the most basic factor of our humanity — our health.

We already have that expectation when it comes to our personal safety with publicly guaranteed police and fire services. But somehow our health, our life, has become a commodity.

Sen. Barack Obama’s healthcare plan, announced today, is yet the latest to perpetuate the present misguided system that sacrifices all of us to this concept.

Mirroring others before him, Obama’s plan rests on expanding the girth of the private insurance industry, largely through federal subsidies to help uncovered low and moderate income individuals and families buy insurance.

While Obama would not force all individuals to buy insurance, in contrast to the John Edwards plan or Massachusetts-Arnold Schwarzenegger model, he would require all children have to health insurance; presumably the kids themselves will not be paying the premiums.

There’s yet another gift to the insurers, and to big employers to boot, using public funds to reimburse employers for catastrophic healthcare expenditures.

Borrowing from the Massachusetts law, Obama also sets up a National Health Insurance Exchange to guide individuals through the convoluted insurance maze, with the supposed stick that insurers would have to offer “fair and stable premiums” and meet other standards to qualify for participation. It’s not working in Massachusetts, and won’t work for Obama either.

Under Obama’s plan — and all the others before him, of course — the insurance industry continues to govern our health. No matter how many layers of transparency or sweeteners are piled on top of the system, the insurers are not going to change their intrinsic behavior, any more than you can expect an alligator to stop eating meat by giving it time outs.

In his brilliant new documentary Sicko, Michael Moore gets it completely right. The problem is not enough insurance or even making insurance “affordable.” It’s the insurance industry itself. Until we can pry our health out of the cold, cruel hands of the insurers, the system will never fundamentally change, and millions of Americans will continue to be abandoned and mistreated.

Moore explains with heart wrenching profiles of people with insurance who are nonetheless denied the care they need. None of those individuals need more insurance, they need more care. He then deconstructs the insurance based system to show us how it works, and how the industry maintains its power through the buying and selling of Congress.

And, Moore contrasts our healthcare debacle with other industrialized countries where enriching the private insurance industry is not the first focus of healthcare policy.

Obama could have easily gone down another path. He once suggested that a single-payer model, such as exists in Canada, one of the countries Moore visited which has a genuinely universal system, would be ideal, but then backed away.

Obama’s speech today was filled with recognition of the plight of those millions who face bankruptcy for high medical bills, and even concludes that “the biggest obstacle in the way of reforming this skewed system of needless waste and spiraling costs are those who profit most from the status quo – the drug and insurance companies.”

But when Obama notes “it’s time to let the drug and insurance industries know that while they’ll get a seat at the table, they don’t get to buy every chair,” he’s missed an opportunity, and made the wrong choice.

The insurance companies have not just bought the chairs, they’ve bought the table as well. Or to thoroughly mix the metaphor, we won’t cure the sickness by using public money to buy more deck chairs on the insurance industry Titanic.

There are only two approaches to healthcare reform. Keep sailing on that insurance Titanic, or enact a humanitarian system that ends the insurers’ stranglehold. There is such a proposal. It’s John Conyers’ HR 676 in Congress, or similar state versions, such as SB 840 in California. They establish a “single-payer” system in which one public entity collects and distributes all the funds and dispenses them for delivery through our current, mostly private hospitals, clinics, doctors, and other providers with guaranteed, comprehensive healthcare for all.

Michael Moore to Testify at Landmark Sacramento Legislative Briefing on "Sicko" June 12

CNA/NNOC Hosts Big Rally, Premiere for RNs, Doctors, Patient Advocates

For Immediate Release
May 30, 2007

Contact: Charles Idelson, 510-273-2246, 415-559-8991 (cell), Shum Preston, 510-273-2276

Film maker Michael Moore will testify at a landmark Sacramento legislative briefing on his stunning new documentary “Sicko” Tuesday, June 12, the California Nurses Association/National Nurses Organizing Committee announced today.

The briefing is sponsored by State Sen. Sheila Kuehl, chair of the Senate Health Committee, and author of a sweeping healthcare reform bill, SB 840. The briefing for legislative co-authors of SB 840 will be followed by a big rally with Moore and Physicians for a National Health Program on the West Steps of the Capitol and then a special premiere of “Sicko” for RNs, doctors and invited guests.

Leading up to the legislative briefing and rally, Moore, CNA Executive Director Rose Ann DeMoro, and Sen. Kuehl, will participate in an upcoming web chat about “Sicko”.

Legislative briefing with Michael Moore:

Tuesday, June 12, 12 — 1:30 p.m., State Capitol, Room 4203
CNA-sponsored rally with Moore:
Tuesday, June 12, 2 p.m., Capitol West Steps

“Sicko” is a stunning new documentary on the U.S. healthcare crisis that opens in U.S. theaters on June 29.

CNA/NNOC is working with Physicians for a National Health Program, Health Care-Now and other nurse groups across the U.S. to promote the film and build a broader movement for genuine reform, like SB 840 or HR 676 in Congress that would establish a single-payer system similar to an expanded and improved Medicare for all.

DeMoro, who attended a private screening in New York, notes that “Sicko” is “not just an indictment of an indefensible healthcare industry in the U.S. It’s a rejoinder for those who think we can fix the soulless monster by tinkering with an unconscionable system that puts us further in thrall to those who created the crisis.

“At a time when the apologists of accommodation are promoting the lowest common denominator, Moore most of all offers a vision and hope,” says DeMoro. That hope, she says, is symbolized by SB 840, which is pending before the state legislature, and HR 676.