PNHP

Is San Francisco's reform a model for the nation?

Is San Francisco's reform a model for the nation?

San Francisco Health plan touted as U.S. model

By Rachel Gordon
San Francisco Chronicle
November 30, 2006

San Francisco’s groundbreaking plan to provide access to affordable medical coverage for an estimated 82,000 uninsured residents is an opportunity to create a system from top to bottom that could serve as a model of basic care for the rest of the nation.

The Health Access Program, approved by the Board of Supervisors and signed into law by Mayor Gavin Newsom, is intended for adults without health insurance who earn too much to qualify for a federal or state health care plan.

The program will cost an estimated $200 million a year, and will be funded with a combination of public funds, employer contributions and copayments by those enrolled in the program.

(Steve Falk, who heads the San Francisco Chamber of Commerce) said making sure that people have health care is a noble cause — but forcing San Francisco businesses to spend up to $1.60 per hour per employee to fund it isn’t fair.

San Francisco’s program is not like a traditional insurance plan.
Patients will be able to get care only within San Francisco, and most of that care will be delivered at the city-run San Francisco General Hospital and at the vast network of city and community clinics.

http://www.sfgate.com/cgi-bin/article.cgi?file=/c/a/2006/11/30/BAGJNMMG3L19.DTL

Comment:

By Don McCanne, MD

San Francisco’s intent to bring health care to everyone is certainly admirable. That said, there are so many complex policy flaws in our current system of financing health care that it is impossible to address them on a city-county basis (San Francisco’s unique form of government).

In a town saturated with small businesses with marginal profits, you can question the wisdom of an employer mandate. For many of these businesses, a payroll tax/premium is a financial hardship. Most policy analysts believe that the health insurance link to employment should be terminated anyway, but only after a universal program is enacted.

Another unusual feature is that this is not a safety-net public insurance program in the traditional sense; rather the safety-net coverage provided is the actual safety-net delivery system, comprised of the county hospital and a network of city and community clinics. Many of the uninsured already receive their care from these institutions.

There are many other issues not adequately addressed such as lack of coverage outside of the city, compliance with ERISA regulations, explicit two-tiered care, and, most importantly, a failure to address the true drivers of health care costs and the failure to establish a monopsonistic payer that would demand value in health care purchasing.

San Francisco’s effort is not so much health care reform as it is tax legislation. The health care delivery system remains much as it is, with only negligible changes in access. The uninsured will still have the public institutions as their source of health care. The primary change with this program is that businesses will contribute more, through taxes, to the funding of the public safety net, and individuals accessing the system will be assessed explicit cost-sharing contributions. It is unfortunate that this revenue and budgeting measure designed to benefit the city-county government is being passed off as health care reform.

The next two years presents another window of opportunity for comprehensive reform. San Francisco could accomplish much more in improving the health care of its residents by becoming a very active, high-profile, national advocate of a publicly-funded, universal program of social insurance. And the San Francisco’s throughout the nation need to join in.

HMO-Founder Calls System a Failure, Calls for Medicare for All

Book Details Health Care System Crisis

By Amy Bentley-Smith
Long Beach News, November 30, 2006
Features Editor

Dr. Robert Gumbiner, a leader in the field of managed health care in the United States, lays out his remedy for the nation’s ailing health care system in a new book he penned with his daughter, editor Alis Gumbiner.

From 3 to 4 p.m. this Saturday, Dec. 2, the Gumbiners will be signing copies of “Curing Our Sick Health Care System: A Solution to America’s Health Care Crisis” at Shore Books, 4817 E. Second St.

A longtime Long Beach resident, Gumbiner founded what would become one of the largest pre-paid Health Management Organizations (HMO) practices in the United States, FHP, in 1961. FHP would lead the way in establishing prepaid health care for the state’s Medi-Cal/Medicaid program for the low-income individuals and families, and received the first contract for federal Medicare service on the west coast.

In “Curing Our Health Care System,” Gumbiner argues that the country needs a single payer, Medicare-type system that is available to all.

“If you’re over 65 you get covered by Medicare, but if you’re under 65 you don’t. We all pay taxes,” he said, adding that giving coverage to a select group is a form of discrimination.

Such a universal system is not out of reach and could be financed with the amount of money spent on health care today, Gumbiner contends.

“I’m a firm believer that there’s enough money being spent right now with employeremployee contributions and the federal government that everyone can be covered,” Gumbiner said.

In the book, Gumbiner offers a history of the current health care system and why it is dysfunctional — mainly a result of it being too profit driven at all levels — before offering his suggestions for fixing it. He said he’s not re-inventing the wheel.

“We’ve already done most of these things,” he said of his solutions. “We just need a white knight, some politician who has the courage to go up against the prescription drug companies and for-profit hospitals and stand firm….

“I wrote it… to help the decision makers, the policy makers be better informed. There are not too many out there offering solutions.”

Available at Shore Books and online at amazon.com, “Curing Our Sick Health Care System” is Gumbiner’s third book. He previously wrote “HMO: Putting it All Together” in 1975 and “FHP: The Evolution of A Managed Care Health Maintenance Organization 1955-1992” in 1994.

Can the uninsured afford insurance?

The Uninsured And The Affordability Of Health Insurance Coverage

By Lisa Dubay, John Holahan, Allison Cook
Health Affairs
November 30, 2006

We found that 24.7 percent of the uninsured are eligible for public health insurance programs, 55.7 percent are in the “need (financial) assistance” category, and 19.6 percent are likely to be able to afford coverage on their own. There is much variation in this distribution across population groups, with 74 percent of uninsured children being eligible for existing public programs and 57 percent and 69 percent of uninsured parents and childless adults, respectively, being in the “need assistance” category. Consequently, absent a universal coverage solution, a range of policies will be needed to address the problem of uninsurance.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.26.1.w22

Comment:

By Don McCanne, MD

Studies such as this have been used by conservatives to suggest that the problem of the uninsured is not a major issue, and therefore does not require comprehensive reform. They contend that most uninsured children are technically insured because they are eligible for the Medicaid and SCHIP programs. They also contend that many uninsured adults actually can afford coverage so they should be considered as being insured even though they opt not to purchase insurance.

The conservatives imply that the only real problem is the modest number of low-income adults, mostly without children, who cannot afford coverage. They suggest that all we need to do is to make available refundable tax credits limited to the poor, and the problem of the uninsured would largely vanish.

What is the reality?

Even though many children are eligible for Medicaid and the SCHIP programs, 100 percent enrollment can never be achieved because of financial, administrative, and logistical barriers. Attrition is also inevitable because of these same barriers plus fluctuations in eligibility. The only effective way to ensure that all children are covered is to enroll them at birth in a program that is permanent and not subject to any eligibility requirement such as the payment of premiums. That is not possible as long as we continue to segregate children from low-income families into separate medical welfare programs.

What about the 20 percent of uninsured individuals who can afford coverage? In this study, the threshold of affordability was defined as 300 percent of the poverty level. At this level, a family policy would cost 17.2 percent of family income, and that does not include out-of-pocket expenses for deductibles, coinsurance and non-covered services. It also ignores those who are uninsurable because of preexisting medical problems. In considering reform, this group should not be cast aside based on the dubious claim that they have the resources to make it on their own. They should automatically be included as well.

And tax credits for the poor? Much has been written about the deficiencies of tax credit proposals, but perhaps the most important is that the credits would be used to purchase plans with affordable premiums, which equates with plans that prevent access to care because of the lack of affordability of out-of-pocket costs. We don’t need affordable insurance premiums; we need affordable health care.

All of the uninsured need to have comprehensive health care coverage. Moreover, all of the underinsured need to have their coverage brought up to a level that removes significant financial barriers to care. That leaves out one group: the wealthy. But we really need to include them as well since they would be crucial to a system of equitably financing a universal health insurance program.

Instead of a range of policies that collectively fall far short of reform goals, we need an effective, one-size-fits-all national health insurance program that makes comprehensive care affordable for all of us.

Advocates reject privatized coverage

Healthcare for Children: Will the HMOs leave them uncovered?

by KIP SULLIVAN
Pulse of the Twin Cities

The last election affected Governor Tim Pawlenty the way Marley’s ghost affected Scrooge. Pawlenty–the governor who cut 38,000 people from MinnesotaCare in 2003, who early in 2005 referred to MinnesotaCare as “welfare health care” and demanded that 40,000 more Minnesotans be kicked off it, and who shut down the state in the summer of 2005 to enforce that demand–that governor announced one week after his narrow re-election that he wanted to “chart a path toward universal health insurance.”

Image by Mark Limvere-Robinson “We should start with covering all kids,” he said. Pawlenty’s U-turn on this issue, coupled with the DFL takeover of the House and the recent endorsements of universal coverage by the insurance industry, has raised the odds that the Legislature will conduct a serious debate about universal health insurance in 2007.

Amid the good news, there is some bad news: A trap awaits proponents of universal coverage. The trap works like this: Politicians who normally oppose expansion of government-financed health insurance agree to support expansion of existing programs or the creation of new ones, but only on the condition that the expanded or new program be privatized; that is, that the tax dollars going into the program go directly to HMOs, not to doctors and hospitals.

Funneling the money through HMOs raises the total cost of the program by roughly 15 percent. After they cut patient spending by 5 percent, the HMOs add 20 percent in administrative costs, including advertising, lobbying executive salaries and, in the case of for-profit insurers, profit.

Some liberals, thinking it’s more important to take the money being offered by the conservatives than to argue about whether it is spent efficiently, bite on the offer. President George Bush deployed this trap to enact the horribly complex Medicare Part D program, which began on Jan. 1, 2006. Early in 2003 Bush proposed adding drug coverage to Medicare but only on the condition that it be privatized; that is, that seniors pay premiums to insurance companies if they wanted the extra drug coverage. AARP and some Democrats fell into the trap.

The result was the deplorable Medicare Part D program. It offers meager drug coverage. The worst defect is that the coverage punks out at $2,250 and does not resume until annual drug expenses reach $5,100. This scrawny coverage is costing the taxpayer twice as much as it would have if the drug coverage had been simply added to the traditional, “unprivatized” Medicare program. Not surprisingly, fixing the huge defects in the program is turning out to be difficult. The sole reform the Democrats are talking about now that they’ve taken control of Congress, is giving Medicare the authority to negotiate drug prices with the drug manufacturers. They are not talking about ousting the insurance companies from Part D.

Setting the trap in Minnesota
The insurance industry has spent much of the last six months setting a similar trap for universal-coverage advocates. Last July the CEO of HealthPartners, Minnesota’s third largest plan, announced in an op-ed for the Star Tribune that HealthPartners supported universal coverage as long as it was privatized. Last September two Blue Cross Blue Shield executives made similar announcements. On Nov. 13, the day before Governor Pawlenty announced his conversion, America’s Health Insurance Plans (AHIP, the trade group for the national insurance industry) released a proposal in Washington, D.C., calling for universal coverage of children within three years and 95 percent coverage of adults within 10 years, all to be paid for with tax dollars funneled through insurance companies (see AHIP’s Web site at www.ahipbelieves.com). Then, on Nov. 25, the Star Tribune published an op-ed by the Minnesota Council of Health Plans, which represents Blue Cross and seven of the more tightly managed health insurance companies in Minnesota, announcing they too support universal coverage, starting with kids.

CartoonThe insurance industry has not explained why it chose 2006 to bait the trap, but it’s a good bet the timing is explained by the enactment of a Massachusetts law last April that its advocates claim will halve that state’s uninsured rate, from 11 percent in 2004 to about 5 percent by 2010. That law, which requires that Massachusetts residents buy health insurance by July 1, 2007, and which provides tax-financed subsidies to lower-income residents so they can afford to obey the new law, was showered with favorable publicity across the country largely because it was passed by a Democrat-controlled legislature and signed by a Republican governor.

Although the law is going to fail because it is so costly (that’s what you get when you funnel tax dollars through insurance companies), the fact that it passed with bipartisan support has been interpreted by pundits and many politicians as a sign that the pressure for universal coverage is higher than ever and significant expansion of coverage, if not universal insurance, is coming soon.

In fact, Governor Pawlenty’s Nov. 14 announcement of his new-found belief in universal health insurance was delivered during his keynote address at a conference at the University of St. Thomas, sponsored by David Durenberger’s National Institute of Health Policy, at which the main topic of discussion was the Massachusetts law (see the Institute’s website, nihp.org, for details). Pawlenty invited Massachusetts Gov. Mitt Romney to speak at that conference with him. Romney could not come but was represented by Timothy Murphy, Massachusetts’ Secretary of Health and Human Services, the agency that oversees implementation of the new law. By participating in this event and inviting Romney, and by mentioning during his speech his support for a requirement that individuals buy health insurance, Pawlenty made it clear the Massachusetts model appeals to him.

In sum, the favorable response to the Massachusetts legislation from the media and many politicians signified that the universal coverage train might at long last be leaving the station. It is reasonable to infer that the insurance industry decided, probably around the spring of this year, that if they wanted to influence the train’s direction they had better jump on board with some proposals of their own. And, not surprisingly, their proposals promise universal coverage but only on the condition that those who want it accept a privatized version.

Insurers promote the Massachusetts law
The HealthPartners and Blue Cross proposals closely resemble the new Massachusetts law. Both insurers propose to treat health insurance like auto insurance–you have to buy it or pay a fine. This requirement, known as an “individual mandate” (to be distinguished from an “employer mandate” which makes employers buy health insurance for their employees), would be enforced with annual financial penalties. In Massachusetts, the penalty is on the order of $1,500 to $2,000 per person.

Recognizing that the average working stiff cannot afford to fork over $11,000 and up per family per year to the insurance industry, the Massachusetts law and the HealthPartners and Blue Cross proposals call for tax-financed subsidies for residents who make less than three times the federal poverty level (about $60,000 for a family of four and about $30,000 for an individual). Blue Cross estimates these subsidies will cost $1 billion a year in Minnesota.

The insurance industry and its allies are going out of their way to make sure Minnesotans understand they are not promoting a single-payer system. (Under such a system, tax dollars bypass insurance companies and flow directly to clinics and hospitals. See sidebar for a definition of “single-payer”). “Please know that universal coverage does not mean ‘single-payer,'” said Blue Cross’ CEO, Mark Banks, in his speech to the St Paul Chamber of Commerce on Sept. 13. “I’m going to repeat that statement,” he continued, “because too many people instantly reject the idea of universal coverage because they reject the idea of a single-payer system. Universal coverage does not mean single payer.”

Governor Pawlenty’s office has likewise issued statements distinguishing Pawlenty’s interest in expanding coverage from interest in a single-payer system.

Unfortunately, Pawlenty and the health insurance industry are not the only powerful players in this debate who are insisting that any significant expansion of tax-financed health insurance be privatized. The Minnesota Medical Association (which represents a majority of Minnesota doctors) took that position in a report published in January 2005. “Pawlenty aligns policy with MMA” said the MMA website (www.mmaonline.net) on Nov. 15, 2006, the day after Pawlenty’s announcement. The Children’s Defense Fund, which has been fighting for better coverage for children for two decades, is lobbying for legislation to insure all kids but on the condition that the parents of these children enroll them in HMOs.

DFL leadership has been part of the problem
In addition to the insurance industry, the MMA, some advocates for children, and Governor Pawlenty, the forces demanding that any new tax dollars for expanded coverage be routed through HMOs includes the handful of DFL legislators who have set health care policy for their party as chairs of the health policy and health finance committees in the House and Senate over the last two decades. The influence of these DFLers can be seen in Minnesota’s three public health insurance programs–MinnesotaCare, Medical Assistance (MA), and General Assistance Medical Care (GAMC). All three programs were privatized during periods when the DFL controlled the Legislature. MA and GAMC were privatized gradually beginning in 1985; MinnesotaCare was privatized overnight in 1996. That’s right. Thanks to the support of DFL “leaders” on health policy, HMOs have been inserted into all three of these programs.

When Blue Cross and HealthPartners come to the Legislature next year to propose universal coverage (either for the entire population or for kids only) on the condition that the coverage is privatized, they will come with the backing of some powerful groups and some powerful politicians, notably Gov. Pawlenty and some senior DFL legislators. If you were a betting person and knew nothing about the grassroots movement for a single-payer, you’d bet that the Blue-Cross-HealthPartners-MMA-Pawlenty alliance, with help from DFL “leaders,” will succeed in embedding insurance companies in any program to expand health insurance coverage, if not next year, then over the long haul.

The single-payer movement grows
But two developments over the last two years have placed speed bumps, and perhaps serious barriers, in the path of the privatization juggernaut. First, two single-payer coalitions have geared up to prevent the growing momentum for universal health insurance from being parlayed by the insurance industry into momentum for privatization. These coalitions–the Minnesota Universal Health Care Coalition (MUHCC) and the Greater Minnesota Health Care Coalition (GMHCC)–have undertaken a campaign to “deprivatize” MinnesotaCare, MA and GAMC. Their research indicates Minnesota could cut the cost of those three programs by 10 to 20 percent if the HMOs were booted from those programs. The arguments presented by the MUHCC-GMHCC campaign to roll back privatization will obviously apply as well to any proposal to expand privatized coverage, either to all children or to all Minnesotans.

The second development that will impede the privatization freight train is the election results. The November election not only gave the DFL greater control over the Legislature, it brought into office new legislators who support single-payer or who, at minimum, do not accept the HMO propaganda that privatization of state programs is a good idea. Several of these new legislators have been appointed to the health committees.

The MUHCC-GMHCC deprivatization campaign began formally in August 2004 with a meeting between MUHCC representatives and then-DFL House Minority Leader Matt Entenza (St. Paul). MUHCC asked Entenza for help determining whether any research existed indicating that the privatization of state programs had worked as the HMOs and their DFL and Republican allies had said it would. Entenza agreed to write a letter posing that question to Kevin Goodno who at that time was the commissioner of the Department of Human Services (DHS), the agency that runs MinnesotaCare, MA and GAMC. In December 2004, Goodno replied that DHS had never done any research to address that question.

With Commissioner Goodno’s admission in hand, MUHCC and GMHCC, with help from Rep. Entenza, drafted legislation to remove Medica, HealthPartners, Blue Plus and the other HMOs from the three state health insurance programs. The bill was introduced in the House by Rep. Neva Walker (DFL-Minneapolis) (Keith Ellison was among the five co-authors) and in the Senate by Senator Leo Foley (DFL-Anoka). The House bill got a short hearing in the House health committee last March. When Rep. Walker and two speakers (including the author of this article) were done testifying, Goodno and three HMO representatives testified against the bill. Not one of the four opponents of the bill attempted to rebut Rep. Walker’s evidence that privatization had raised the cost of state programs by 10 to 20 percent.

But thanks to opposition to the bill by the Republicans and the senior Democrat on the committee, Rep. Walker did not ask for a vote. Because of similar opposition on the Senate health committee (including the senior Democrat), MUHCC and GMHCC did not ask for a hearing in the Senate.

MUHCC’s and GMHCC’s expectations for the 2007 legislative session are higher than they were for the 2006 session largely because the pro-HMO, pro-privatization DFL leadership in both houses has been diluted by legislators who are single-payer advocates or, at minimum, supportive of single-payer and deprivatization and skeptical of the claims made for HMOs. This is especially true in the Senate where Senator John Marty (DFL-Roseville) will chair the Senate Health Policy Committee. Marty authored legislation to create a single-payer health care system in the mid-1990s when most of his colleagues were swept up in the mania for HMOs, and he spoke openly about his support for a single-payer system during his 1994 campaign for governor.

Massachusetts: The Ghost of Christmas Future
The heightened interest in universal health insurance, the takeover of the Minnesota House by DFLers, and Pawlenty’s ostensible conversion from opponent of public programs to supporter has created a more promising climate for all advocates of universal health insurance. The issue is not whether universal coverage will be discussed seriously in the 2007 session, but whether universal coverage advocates inside and outside the Legislature will fall into the privatization trap.

The issue is whether they’ll endorse privatization in exchange for a significant step toward universal coverage thereby making maintenance of existing coverage more difficult, because coverage will be so costly and render any future expansions of coverage more difficult.

The struggle Massachusetts now is going through to implement its new “universal health insurance” law serves as a warning to universal coverage advocates in Minnesota who believe that expanding access to health insurance is so important it is worth sacrificing real cost containment to get it. The comments of Massachusetts Governor Romney after he signed the law on April 12 illustrate this risk. Romney, who will probably announce his presidential ambitions soon, told the New York Times, “This is really a landmark for our state because this proves … that we can get health insurance for all our citizens without raising taxes ….

The old single-payer canard is gone.” Romney is a healthy man in his 50s. He will live to eat his words. The law Romney signed will not provide “health insurance for all [Massachusetts] citizens … without raising taxes.” Even the law’s most delirious supporters were saying during the debate over the bill in the Legislature that it would cut Massachusetts’ uninsured rate from 11 percent in 2004 to 1 percent by 2010. Shortly after it was enacted, its proponents were saying the uninsured rate would fall to 5 percent by 2010.

The fundamental reason the Massachusetts law will never come close to insuring all citizens is that it cannot contain cost. It is just flat out impossible to insure more people for the same amount of money if you don’t cut costs somewhere. The Massachusetts law promises to cut costs by issuing “report cards” on clinics and hospitals, which is supposed to cause quality to go up and costs to go down. For several reasons, including the difficulty of measuring quality of medical care and the high cost of doing so repeatedly for numerous medical services, this promise is going to fail. Since Romney and his Democratic allies ruled out a deprivatized system, and since their so-called cost containment strategy can’t work, they have no way to reduce costs other than to reduce coverage and/or encourage the insurance companies to ration health care. Given the average citizen’s hostility to HMO attempts to ration care, it is unlikely (although by no means impossible) that costs will be cut substantially through HMO rationing. That leaves reduced coverage as the path of least resistance.

Reduced coverage appears to be the strategy Massachusetts is adopting, willy-nilly. According to a blog maintained by Health Care For All (the citizen group in Massachusetts that led the campaign for the law Romney is so proud of and that Minnesota insurers find so attractive), the agency that is implementing the Massachusetts plan is now discussing allowing insurance companies to sell policies with very high deductibles and scrawny coverage. Moreover, that agency is now discussing permitting residents who buy these stripped down policies to offer them as proof of having obeyed the individual mandate. To be specific, the agency is considering letting insurers sell policies with deductibles of $2,500 to $3,000 for individuals (presumably these numbers are much higher for families) and limited coverage (for example, generic drugs only) (see http://blog.jcfama.org?p-648#comments). As bad as this coverage is, agency staff predict the premium will be $2,500 to $3,000 a year.

In short, Massachusetts appears to be moving toward a system in which only 95 percent and perhaps fewer of its people are insured, and many of these will be “insured” with very leaky coverage. Even so, whether this can be done without raising taxes remains to be seen. The tax-financed subsidies are going to have to be high if all residents are going to be able to afford their $2,500-$3,000 per person premium.

Health Care for All and other advocates of universal coverage in Massachusetts have paid a high price for “universal” coverage. Advocates of universal coverage in Minnesota should think long and hard before they cut a similar deal here. Let’s insure all kids as a first step toward universal coverage. But let’s leave insurance companies out of the loop. Let’s then insure all other Minnesotans with a single-payer system.

Make corporate executives sensitive to their own health carecosts?

The Wall Street Journal
November 28, 2006
Letters

Should Corporate Chiefs Get Lifetime Health Care?

In your Nov. 20 editorial “AHIP Hop” on the health-insurance proposal recently unveiled by America’s Health Insurance Plans (AHIP), you lament the fact that “individuals generally aren’t sensitive to the price of their treatment decisions.” For that reason, you have long supported high-deductible health insurance that puts patients’ “skin in the game,” to use the colorful metaphor for “high deductibles.”

Economists, who generally believe that fiscal incentives drive human behavior, can resonate with this prescription, but as one such I would ask: What does it tell us about the health-insurance coverage of highly paid corporate executives? Does it not imply that these executives should never have the corporation buy health insurance of any sort for them, lest these executives become too insensitive to the cost of their health care?

Instead, we find that corporate executives routinely insist that their companies purchase for them and their spouses generous health insurance for life, and many of them even insist that the company cover all out-of-pocket expenses built into such policies.

Is that at all defensible on the “skin in the game” theory you espouse?

Uwe E. Reinhardt
Professor of Political Economy
Princeton University
Princeton, N.J.

http://online.wsj.com/public/us

Comment:

By Don McCanne, MD

Corporate executives, of course, are sensitive to health care costs – of their employees. But the question they should be asking themselves is, “Should we be controlling health care spending by making beneficial services for our employees unaffordable, or should we act like the businessmen we are and support structural reform of health care financing that would make the comprehensive health benefits that we receive affordable for everyone?”

Corporate executives are businessmen, aren’t they?

Three More CLC's in Two states Endorse HR 676

Two labor councils in northern New Jersey, and one in central Indiana, have endorsed HR 676, national single payer healthcare legislation, introduced by Congressman John Conyers (D-MI). Fifty-three central labor councils, including six in New Jersey, have now endorsed HR 676.

After the White River Central Labor Council in Bloomington, IN endorsed HR 676, Jackie Yenna, council president said, “The time has come for all Americans to be able to have health care. I trust our newly elected congress will work with us to pass HR 676”.

The Passaic County Central Labor Council in Clifton, NJ endorsed HR 676 at its October meeting.

In Jersey City the Hudson County Central Labor Council, whose members include more than a thousand health care workers in 8 hospitals, acted at its November meeting. Its resolution states: “The system of managed care…has proven itself detrimental to the health of the patients it serves…and damaging to the United States’ healthcare system.” The resolution also declares: “That the Hudson County Central Labor Council AFL-CIO when endorsing a candidate for public office will look to said candidate to endorse HR 676…”

#30#

HR 676 now has 77 congressional co-sponsors in addition to John Conyers. It would institute a single payer health care system in the U.S. by expanding a greatly improved Medicare system to every resident.

HR 676 would cover every person in the U. S. for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental, mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care, chiropractic and long term care. HR 676 ends deductibles and co-payments. HR 676 would save billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.

HR 676 has been endorsed by 212 union organizations including 53 Central Labor Councils and Area Labor Federations and 15 state AFL-CIO’s (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, & NC).

For further information, a complete list of union endorsers, or a sample endorsement resolution, contact:
Kay Tillow
All Unions Committee For Single Payer Health Care-HR 676
c/o Nurses Professional Organization (NPO)
1169 Eastern Parkway, Suite 2218
Louisville, KY 40217
(502) 636 1551
Email: nursenpo@aol.com
11/29/06

DrSteveB's single payer blog on Daily Kos

Single Payer National Health Insurance

Part I – Introduction
Blog by DrSteveB
Daily Kos
November 27, 2006

This is the beginning of a series of diaries to explain what single payer national health insurance is, and what it is not.

In discussing this issue, the most important piece of information to hold on to, is that:

EVERY OTHER DEVELOPED COUNTRY IN THE WORLD ALL THE OTHER WESTERN CAPITALIST DEMOCRACIES EVERY SINGLE ONE

…has SOME form of universal health coverage for their citizens. Only the United States does not.

They differ from each other in how they do this, and the mechanisms and details do matter… Canada is different from the U.K., is different from France is different from Germany, Japan, Austalia, Taiwan, etc… But only the United States does not have something. Remember that whenever somebody says, “yes… but…”

http://www.dailykos.com/story/2006/11/27/114614/15

Comment:

By Don McCanne, MD

Many have suggested that we need a blog on single payer health care reform. Well, it’s here.

DrSteveB, a single payer supporter, has established a health care blog on Daily Kos, the largest center-left political blog in the United States.

Although you won’t be able to read it in detail now (at this posting there were 432 comments), you should glance at it and save the link for future reference. Whether or not you have an interest in blogs, it is important to be aware of DrSteveB’s efforts and be able to direct to his site others who do want to see a single payer-friendly blog.

Rep. Dennis Kucinich Tackles Health Care

By Joshua Scheer

Rep. Dennis Kucinich speaks with Truthdig contributor Joshua Scheer* about the state of health care in America, his bill with Rep. John Conyers to provide universal coverage and why progress is inevitable.

Edited Transcript:

Truthdig: What kind of healthcare [do] congressmen get – what kind of healthcare do you have?


AP Photo / Robert F. Bukaty
Rep. Dennis Kucinich, D-Ohio, gestures during his speech to the
Democratic National Convention at the FleetCenter in Boston
Wednesday, July 28, 2004.

Kucinich: Well, we pay for our health care. I mean, our health care is deducted from our salary. You know, we can opt for what kind of plan we want. The more comprehensive coverage you have, the more you pay. The solution to the nation’s health care problem is not to deny members of Congress health care coverage. It’s to make sure every American has the access to quality health care, and the only way to do that is for Congress to pass a bill that would provide for universal not-for-profit health care for all Americans. There’s a bill called “Medicare for all,” and this bill in this current Congress is HR-676 – the Conyers/Kucinich bill.

Truthdig: That bill – it’s Conyers and you? Do you think it’s going to pass?

Kucinich: There are 75 members of Congress signed on in support of the bill. We recognize that there are 46 million Americans who don’t have health insurance, and there are another 50 million Americans who are under-insured; that the cost of healthcare has gone out of the reach of a large number of Americans, and so there’s only one real solution, and that is to make health care not-for-profit. I mean health care should be established as a basic right in a democratic society. Every industrialized democracy has health care for its people…You know when I traveled the country as a candidate for president, the two issues that came up most consistently were health care and the integrity of the election process. Health care is one issue that unites Americans across party lines, across income lines. Because every person realizes that a single illness in a family can wipe out that family financially. So health care and the accessibility and affordability of health care is central to the government’s responsibility to provide – to promote the general welfare.

When you look at the fact that there are 46 million Americans without health insurance – another 50 million under-insured – when you see that businesses are cutting back sharply on health care benefits – at the bargaining table labor is faced with giving up their hard-fought health care benefits, when you see that trade, meaning in this case jobs that move out of our country – there is an acceleration of jobs going out of the country because workers not paid benefits in a number of countries where the jobs move to. Chief among those benefits is health care. Health care is central – it’s a central question – and it defines who we are as a nation and what we can become as a nation. We are already paying for a universal system of care, we’re just not getting it…Close to two trillion dollars a year is spent for health care in America, but one out of every four dollars goes for the activities of the for-profit system: corporate profits, executive salaries, advertising, marketing, the cost of paperwork – anywhere from 15-30 percent as compared to Medicare’s 3 percent. And so a for-profit health care system is crushing everyone, except the insurance companies. It’s crushing workers, who may actually be working 40 hours a week and not have health care coverage. It’s crushing businesses, particularly small businesses, who are finding that they cannot afford health care for their employees. It’s causing major manufacturers to renege on commitments they made to their workers years ago and to retirees years ago for health care.

The high cost of health care and health care for profit has transformed American society and has been a powerful engine for accelerating the wealth of the nation upwards. And so what I’ve advocated with John Conyers is HR-676: universal single-payer not-for-profit health care, which provides that everyone’s covered for everything and we’re already paying for a universal standard of care, we’re just not getting because – if you took that almost $500 billion a year and put it into health care in the form of a universal system, we would have enough money for all basic medical care, plus dental care, vision care, mental health care, long term care, prescription drugs and even broader coverage. We’re already paying for this. We’re not getting it. We need to have the end of health care for profit in the United States, and the beginning of a health care system which helps those who don’t work or can’t work, which helps workers, small businesses, manufacturers – this could be – this single move towards health care for all can bring about a dramatic shift in the American economy and in the lives of every man, woman and child in the United States.

Truthdig: If I’m interested in the plan and I want to know more and make my voice heard, how do you suggest going about that?

Kucinich: You have to start by talking to people in your family and your neighbors, because everybody is affected by this. I mean this is a moral question. Martin Luther King says of all the forms of inequality, injustice in health care is the most shocking and inhumane. And when you have – I think it was 82 million people spent part of 2002 and 2003 without health insurance, and when you understand that the uninsured include – half of the uninsured are people who are employed…certainly people have to talk to their congressman, but already there are over 14,000 physicians for national health care who are advocating this plan. The American manufacturers are starting to take a more careful look at how health care can benefit their industries, when you see that Canada, for example, has long maintained a competitive advantage in various manufacturing sectors vis a vis the United States because they provide health care. And all of Europe has had a competitive advantage against the United States because they provide health care. When you understand that, for example, you remember General Motors? They had a big big debate a few years ago about their health care costs – they spent five billion dollars in 2003 for health care – that was like $1,200 per car, and when you see how GM has gotten into financial trouble, one of the reasons is their health care costs. And all these Americans…don’t have health insurance because their employer either dropped their coverage or people can’t afford the insurance.

And you look at medical bankruptcies, Josh, there are millions of bankruptcies in America now and about half of them are related to the cost of medical care. And people are filing bankruptcy – I think it was in 2001, there was a study that three-quarters of those who filed [for] medical bankruptcy had health insurance at the start of – at the onset of the illness. This is a huge problem for middle class families because people are postponing needed care, they’re having trouble paying their bills, they aren’t getting the drugs they need, the collection agencies are on top of people…A lack of access to health care is one of the reasons why the United States has had higher infant mortality rates as compared to Germany and Australia, Norway, Sweden and Canada, you know, lower life expectancy, less continuity of care.

People are having difficulty getting needed care. I mean think about this, life expectancy in Sweden and Italy and Canada and France and Germany and the UK – it’s all higher than the US. And this despite the fact that we spend over $2 trillion a year. So…throughout my district, I’ve been holding town hall meetings on the issue of health care and discussing this with people, my constituents…As a candidate I was promoting this, and we had some real challenges that have to be overcome in the congress in order to make it possible for people to get the care that they need…This really is the single most important economic issue confronting the United States right now.

Truthdig: You’ve said the money’s already there…there’s not going to be a problem paying for this…

Kucinich: Well yes, now here, a woman whose name is Dr. Marcia Angell…a few years ago…when Conyers and I introduced our bill, she said that – and this is a woman who was the editor of “the New England Journal of Medicine” – she said that she’d estimate that no more than fifty cents of the health care dollar actually reaches the providers. So if you’re talking about a little more than $2 trillion, where does the rest of the money go? And where it goes is to, you know, you look at some of the executive compensation where people running these health care companies are making tens of millions of dollars a year, when you look at the fraud that’s involved in the system, the drug company profits, how people are paying so much more for drugs than they should be – look at the crooked deal that resulted in…Medicare being strapped with a law that forces them to pay whatever the drug companies ask for for drugs…the Medicare part D drug plan forbids the government from negotiating lower prices with the drug companies, and it banned the Canadian import of drugs and it paid only 30% of that first fifty-one-hundred dollars – the so-called “doughnut hole” – and forced coverage through private plans.

It resulted in windfalls, subsidies and profits for private plans and managers and – I mean there are so many things wrong with it, but [the worst] part of it was it guaranteed $150 billion in drug company profits. And, of course, it was not a surprise that the drug companies turned around and rewarded Congress handsomely with big contributions during election cycles. And you know any time you’re talking about a for-profit system, the costs are higher, there’s fraud, there’s higher overhead, there’s fewer nurses, the quality is worse, death rates are higher, you get more citations on poor quality and as far as the doctors – more and more doctors are favoring the approach that I’m talking about because they don’t want the insurance companies to be making the decisions – about the doctors, about the tests, about procedure, about length of stay, about medication – and what we’ve seen in health care has been a tremendous increase in administrators as opposed to physicians over a period of about twenty years. So, I see this change coming. It is going to happen, because there is an awareness that government has failed the American people in this regard, and it’s an economic issue, it’s a moral issue, and it’s central to who we are as a nation.

Truthdig: So for-profit medical companies have as much bureaucracy as…the government run [program]?

Kucinich: It’s not just the bureaucracy, Josh, it’s the amount of profits they make with their product. The V.A. negotiates a price for drugs with the drug companies. Under the Conyers/Kucinich bill, the government can negotiate for all the people in this country with the drug companies and benefit from high volume. I mean, if the drug companies don’t want to negotiate, the government could start making its own generic brands if it wants to, but we shouldn’t have to do that. The drug companies already negotiate with the V.A., but in Medicare part D, in order to protect over $100 million in drug company profits, the administration saw to it that cost controls were taken off. So you have to go back to: what is it the people want with health care? They want guaranteed access. They want freedom of choice as far as their doctor. They want high quality and affordability. They want to be able trust the system. And that’s not what they’re getting right now. So what I’ve been doing – John Conyers is the senior member whose name is first on the bill, but John and I have been working together and I’ve been organizing members of Congress on this, to get people to be involved in supporting this universal single-payer not-for-profit health care system and this is really an idea whose time has come, and one for which there’s broad support.

I’ve got one more thing to say about it if I may, and that is – I went to the Democratic platform committee in 2000 with Lila Garrett, Tom Hayden [and Gloria Allred] where I offered a presentation that the Democratic party take a strong stand on universal health care. My proposal, unfortunately, was rejected. I brought the same proposal embodied in the Conyers/Kucinich bill to the Democratic platform committee in 2004. Once again, the plan was rejected. Both times the plan was rejected because of the unfortunate influence of corporate interests upon the Democratic party hierarchy. And so it is urgent that the American people are aware that our political system has frustrated the emergence of health care for all because of the tremendous influence which the insurance companies and the drug companies have on our political process. It doesn’t mean that this influence is fatal, but people need to know that it exists.

Truthdig: You’ve just said it’s not fatal, but do you think this is going to hinder the Conyers/Kucinich plan this time? Or do you think you have enough support now that the Democrats are in power and they won on these kinds of issues like health care, the minimum wage and the war?

Kucinich: I see health care as being the defining domestic issue in 2008. It transcends every other issue. It relates to quality of life, it relates to economic productivity, it relates to wages, it relates to trade, it relates to our ability to have a government we can call our own. It relates to the foundational purposes of the United States of America as outlined in the very preamble to the Constitution. This really is a great cause that we should all be involved in. And so my commitment on this has been very strong, and I think that when you go out across the country as I have, and you hear from the people and you see the amount of economic jeopardy which exists because of a lack of – either a lack of access to or affordability – then you know that one must take a stand – that health care is a right, and that the current health care system is not adequate, and that we have to fulfill the purpose of our nation to promote the general welfare.

http://www.truthdig.com/interview/item/20061128_rep_dennis_kucinich_tackles_health_care/

*Interviewer Scheer worked as an entry-level staffer on Kucinich’s state Senate campaign, and was later a summer associate in his congressional office. In this weekly interview series, Rep. Kucinich gives his take on the goings-on in Congress in the wake of the Democrats’ victory.

Cigna sticks it to entertainers

Healthcare premiums to soar for entertainers

By Lisa Girion
Los Angeles Times
November 23, 2006

Hundreds of actors, artists, musicians and writers in California are facing massive increases in their health insurance premiums — a situation that could face other consumers who don’t have employer-sponsored health plans, advocates and lawmakers said.

Cigna Corp., which has sold insurance to members of the entertainment industry through their professional associations for 25 years, is raising premiums for actors and others by an average of 82%, with some hikes as high as 254%.

Under the Cigna increases, premiums on its point-of-service plan will rise to $1,022 a month for single members in the Los Angeles area beginning Jan. 1. Family point-of-service coverage would jump to
$2,485 a month.

State Sen. Sheila Kuehl (D-Los Angeles), a proponent of single-payer universal coverage, said the entertainers’ plight illustrates the vulnerability of consumers under the current “fragmented” system that is largely based on employment.

“Everyone is at risk now,” she said. “People believe that they are secure because they have a job. But, in an employer-based system, you lose your job, you lose your insurance. And even those who are paying a significant premium on their own have no guarantee this won’t happen to them in terms of their premiums being jacked up to an unaffordable place.”

Insurers disagree, saying that competition remains robust.

http://www.latimes.com/business/la-fi-insure23nov23,1,5705270,full.story?coll=la-headlines-business

Comment:

By Don McCanne, MD

A $29,820 annual premium for family coverage!? And we have “robust competition” to thank for this?

This insanity would end if only we would all agree to establish a single risk pool, covering everyone, and fund it equitably. But then there wouldn’t be a place for the robust competitors.

Will Congress reform health care?

Uninsured Americans and the new Democratic Congress Is universal coverage now more likely?

By Uwe E Reinhardt
BMJ | November 23, 2006
Editorial

In August 2003 I published a paper entitled “Is there hope for the uninsured?” My answer then was “most probably not.” As economic forecasts go, this one has been accurate so far. The question now is whether the Democrats’ ascendancy to power in Congress requires a recalibration of that dire forecast, especially in light of the recent unveiling of a proposal for universal coverage by America’s Health Insurance Plans, the national association of private health insurers in the US. My revised answer is “probably not,” although I would love to be proved wrong by subsequent events.

It is not for want of attention that so many uninsured Americans find themselves in their predicament. Their plight has been explored in a decades’ old series of conferences, town hall meetings, workshops, public hearings before Congress and state legislatures, television talk shows, and even, in recent years, exuberant nationwide observances of “cover the uninsured week.” An entire industry has sprung up in the health services research community, dedicated annually to counting and categorising the number of uninsured people, arguing over the accuracy of the various counts, and debating whether uninsured people are worse off for their lack of coverage.

An equally energetic research enterprise has sprung up to create health reform proposals designed to bring universal coverage to the US. Although some of these proposals have been crafted with scholarly detachment, they mostly embody distinct political ideologies or the pecuniary interests of groups who profit from health care. The previously mentioned health insurance proposal unveiled by the health insurance industry on 13 November 2006 is a classic example of this genre. Although America’s Health Insurance Plans would tolerate a modest expansion of government insurance programmes for poor Americans, for the most part the plan calls for federal subsidies towards the purchase of the private health insurance policies the association’s members sell. It is, like all such plans, designed to allow the originator to do well by doing good.

It may be asked why, during more than a century with so many health reform proposals on the table at any time, not one has become the law of the land, if only by accident. The answer seems to be twofold.

Firstly, unlike Europeans, Americans tend to believe that poverty is the product of free choice rather than lineage and bad luck. The persistence of that myth, despite empirical evidence to the contrary, has made it difficult to raise taxes for universal health insurance, even though the US has the lowest ratio of taxes to gross domestic product in the Organisation for Economic Cooperation and Development.

However, a more important obstacle to universal health insurance in America is that, although all politically powerful interest groups have their own preferred strategy for universal coverage, these groups always prefer the status quo as the alternative — a phenomenon known as Altman’s law (after Brandeis University economist Stuart H Altman). Because no single plan has garnered the support of a political majority, we always revert to the current non-system mix of employer, government, and self coverage or no coverage. And Altman’s law holds.

The Democrats’ ascendancy to congressional power will probably trigger another national conversation on the plight of uninsured people. But even if the Democrats mustered the courage and the votes to raise taxes or enlarge the nation’s already huge deficit for the sake of universal coverage, President Bush’s veto pen would undoubtedly nip that idea in the bud, ironically appealing to the very budget deficit for which he is largely responsible.

Thus, it is a safe bet that any flurry of activity on uninsurance will be just another instalment in the never ending series of America’s national conversations on the topic — a conversation that resembles nothing so much as the rambling of a drunken lover at a bar — big talk, little action. In health care it has become “the American way.”

http://www.bmj.com/cgi/rapidpdf/bmj.39042.375544.BEv1?hrss=1

And…

Health reform looks to the states

Bipartisan support increases for ‘test labs’ around the nation
By Guy Boulton
Milwaukee Journal Sentinel
Nov. 26, 2006

(Liberal Rep. Tammy Baldwin and conservative Rep. Tom Price) are part of a group of lawmakers and policy analysts that would use states as laboratories to test different approaches for expanding insurance coverage, improving quality and controlling costs.

The idea appeals to conservatives and liberals alike. It recognizes that states have taken the lead in health care reform. And it acknowledges that there may not be one sweeping solution that works equally well in states as dissimilar as Massachusetts and Mississippi.

It also concedes that Congress – mired in the debate over whether the solution is more government involvement or less – is unlikely to agree on the best way to reform the health care system.

The (three) bills all differ slightly. But each would encourage states to come up with ways to make the health care system work better. The proposals would be reviewed by a commission or task force. The most promising ones would be sent to Congress for fast- track approval.

The idea is for the proposals to cross the political spectrum. And, in this, the idea implicitly acknowledges one of the realities of health care reform: No one really knows the best way to expand coverage, control costs and improve quality.

“You can’t possibly know the right solution,” said Stuart Butler, a health care economist with the Heritage Foundation, a conservative policy research organization.

“You may be half right,” he said. “But it’s only by trying these ideas in practice – modifying them based on experience – that you gravitate to a right answer.”

“When you think about what it is going to take to get health care reform,” Butler added, “a key part of this is going to be trust and the ability to work together.”

Everybody’s first choice still is for everyone else to agree with them.

“But that,” he said, “isn’t going to happen.”

http://www.jsonline.com/story/index.aspx?id=535435

Comment:

By Don McCanne, MD

Is covering everyone an idea that is only half right? Is funding health care equitably so that it is affordable for each individual an idea that is only half right? Is improving efficiency by reducing administrative waste an idea that is only half right? If the right solution means that we fix the financing of health care so that it works for everyone, then we really do understand how to do that.

Apparently the Next Big Thing in health care reform is for Congress to grant the states the opportunity to achieve universal coverage. It is not as if the states haven’t been actively involved in this process. In fact, the federal government already has been giving states budget-neutral permission slips to experiment with various reforms.

Of the fifty states, after a half century of efforts, how many of them have achieved universal, affordable health care coverage? None, of course. They are busy struggling with funding issues, high-risk pools, Medicaid, regulatory oversight of private insurers, and many other policy issues that inevitably fall short on reform goals. When we already know how to fix the system, why would we insist on continuing with fifty different state laboratories to experiment further with well understood health policy science?

This is simply a process designed to further fragment our public and private insurance systems, and prevent us from ever having a universal program of social insurance such as Medicare for All. It is not a process designed to establish trust so we can work together. Rather it is a process designed to deceive. It is a decoy set up by the conservative/libertarian faction that has lured the centrists and the progressive/liberal factions.

As long as those in the center and on the left, with a false sense of compromise, sing the praises of those on the right who would constrain and limit government at the cost of a modicum of egalitarianism, we will be unable to prove wrong Uwe Reinhardt’s prophecy.

Canada's Health Care Lauded by One Who Knows

by Sol Littman
Arizona Daily Star

Ever since my wife and I chose to leave Canada and settle in Tucson, we have been amazed and angered by the distortions and misrepresentations in the American media of Canada’s government-funded, one-payer medical system. Among them is the recent op-ed article in the Arizona Daily Star by Dr. Jane M. Orient.

For most of my adult life, I worked as a journalist in Canada and took full advantage of Canada’s health-care system. My wife, daughter and grandchildren were free to choose their own primary doctors and specialists. Service was consistently kindly, prompt and concerned. If something serious was suspected, we were tested, X-rayed and examined in a matter of days. Our physicians were highly trained and the hospital facilities modem and pleasant.

Thirty years ago, I had my gall bladder removed and had to spend three or four days in hospital. When I was discharged, I was presented with the bill — a total of $5.50 for the use of the television set in my semi-private room. The Ontario Hospital Insurance Plan paid the rest.

It is important for Americans to know that people in Canada tend to live a couple of years longer than their U.S. counterparts and that Canada’s infant mortality rate is lower. This is attributed to the fact that everyone — young, old, working or unemployed — is covered for basic hospital and medical care in Canada without co-insurance or deductibles. This is in contrast to the United States, where there are more uninsured people (over 40 million) than Canadian inhabitants.

American critics of Canada’s health care are quick to cite the fact that there are lengthy waiting lists for non-emergency medical procedures. It is also true that there is considerable overcrowding in some hospitals, but this is due to the fact that emergencies are treated immediately even if it means a lineup of gurneys in the hospital corridor — a situation I have found exists in American emergency wards as well.

The Canadian system does not rely on private insurance companies. The system is run by 10 provinces and two territories. They pay the bills and set the rules. Medicare, which services the American elderly, is the closest approximation to the Canadian one-payer system, but there are important differences.
In the United States, the government pays the bills but private insurance companies that are more wasteful than the government run the system. In addition, some of our American health-care dollars go to make the insurance companies rich and play no role in actual health care.

The waiting times for some procedures are longer in Canada than in the United States, but this problem is being actively tackled by the government in the wake of a Canada Supreme Court decision that “access to a waiting list is not access to health care.” However, the decision did not abolish the one-payer system — in fact, it reinforced it by giving the Quebec government, which was the chief object of the lawsuit, 12 months to remedy the situation.

As a result, Quebec is working hard to catch up with the rest of Canada. The average wait for a hip replacement has been reduced to four to five weeks, and knee replacements usually take six to seven weeks. This may still be too long, but if you happen to be one of the 40 million uninsured Americans, you might have to wait forever.

Why have my wife and I chosen to spend our retirement years in Tucson? We did, in fact, worry about leaving behind our Canadian health care, but climate, the availability of year-round golf and relatively good health persuaded us to take the chance.

We have found medical services in Tucson excellent, but expensive and complicated. We don’t like being at the mercy of an HMO and have yet to decipher the ins and outs of the new drug plan. We continue to long for the simplicity and efficiency of Canada’s single-payer system.

Sol Littman is a former Canadian journalist living in Tucson with his wife, Mildred.

Medicaid coverage worse than private insurance?

Insurance Coverage and Care of Patients with Non-ST-Segment Elevation Acute Coronary Syndromes

By James E. Calvin, MD; Matthew T. Roe, MD, MHS; Anita Y. Chen, MS; Rajendra H. Mehta, MD, MS; Gerard X. Brogan, Jr., MD; Elizabeth R. DeLong, PhD; Dan J. Fintel, MD; W. Brian Gibler, MD; E. Magnus Ohman, MD; Sidney C. Smith, Jr., MD; and Eric D. Peterson, MD, MPH
Annals of Internal Medicine
21 November 2006

Background: The impact of insurance coverage on the care of patients with non-ST-segment elevation acute coronary syndromes (NSTE ACS) is unclear.

Objective: To compare NSTE ACS care patterns by insurance type.

Design: Comparison of Medicaid patients younger than 65 years of age and Medicare patients 65 years of age or older with patients of similar age who have health maintenance organization (HMO) or private insurance coverage.

Setting: 521 U.S. hospitals participating in the CRUSADE (Can Rapid Risk Stratification of Unstable Angina Patients Suppress ADverse Outcomes with Early Implementation of the ACC [American College of Cardiology]/AHA [American Heart Association] Guidelines) quality improvement initiative from January 2001 through March 2005.

Patients: 37,345 NSTE ACS patients younger than 65 years of age and 59,550 patients 65 years of age or older.

Measurements: Guideline-recommended treatments, and in-hospital outcomes.

Results: Medicaid was the primary payer for 18.7% (6999 of 37,345) of patients younger than age 65 years, whereas Medicare was the primary payer for 67.5% (40,199 of 59,550) of patients age 65 years or older. Medicaid patients were statistically significantly less likely to receive short-term (less than 24 hours) medications and to undergo invasive cardiac procedures than patients covered by HMO and private insurance. They also had higher mortality rates (2.9% vs. 1.2%; adjusted odds ratio, 1.33; 95% CI, 1.08 to 1.63). Medications and invasive procedures were used to a similar extent in patients with Medicare and HMO or private insurance, and respective mortality rates were not significantly different (6.2% vs. 5.6%; adjusted odds ratio, 1.08; 95% CI, 0.99 to 1.18).

Limitations: Self-pay patients and patients without insurance were not assessed.

Conclusions: NSTE ACS patients with Medicaid (but not Medicare) as the primary payer were less likely to receive evidence-based therapies and had worse outcomes than patients with HMO or private insurance as the primary payer. The causes of these treatment differences and solutions for narrowing the gaps in quality require further investigation.

Grant Support: CRUSADE is funded by Schering-Plough Corporation. Bristol-Myers Squibb/Sanofi-Aventis Pharmaceuticals Partnership provides additional funding support. Millennium Pharmaceuticals, Inc., Cambridge, Massachusetts, also provided funding for this research.

Potential Financial Conflicts of Interest: Consultancies: M.T. Roe (Schering-Plough, Bristol-Myers Squibb, Sanofi), E.M. Ohman (Savacor, Liposcience, Responsible Biomedical, The Medicines Company, Inovise): Honoraria: J.E. Calvin (Millenium Speaker’s Bureau), M.T. Roe (Sanofi, Bristol-Myers Squibb, Schering-Plough); Stock ownership or options (other than mutual funds): E.M. Ohman (Inovise, Savacor, Medtronics Inc.); Grants received: M.T. Roe (Schering-Plough, Bristol-Myers Squibb), W.B. Gibler (Schering-Plough, Bristol-Myers Squibb, Sanofi-Aventis), E.M. Ohman (Bristol-Myers Squibb, Sanofi-Aventis, Schering-Plough, Millenium Pharmaceuticals, Eli Lilly Inc., Berlex).

http://www.annals.org/cgi/content/abstract/145/10/739

Comment:

By Don McCanne, MD

It is important to understand this study because it will be used by the opponents of government health insurance programs to “prove” that private plans provide higher quality care and improved health care outcomes compared to government programs.

Perhaps the most important point to note is that private plans were contrasted with two different government programs – Medicaid and Medicare – and the conclusions were that only Medicaid was associated with worse outcomes, and Medicare was not.

As an insurance program, Medicaid has more comprehensive benefits and much lower out-of-pocket spending than do the private plans or Medicare.

Therefore the difference cannot possibly be explained by a greater ability of private plans to eliminate financial barriers to health care, a crucial function of insurance. Unfavorable socioeconomic factors undoubtedly play a significant role. The Medicaid program is chronically underfunded, which reduces the financial incentives for physicians and hospitals to care for these patients. Also, many physicians strive to create a practice with a classier clientele. Anyone who has spent any time in the doctors’ dining room has heard countless complaints from physicians who have had another (censored) Medicaid patient dumped on them by the ER (while the more dedicated physicians at the table lose their appetite and become silent). You do not need hard data to surmise that an angry physician who wants to rid himself of his welfare patient would not be as compulsive about a checklist for ACC/AHA compliance.

The other government program studied, Medicare, rather than being a welfare program for the poor, is a program of social insurance in which almost everyone over 65 participates. Medicare patients are largely welcomed by physicians and should and do receive at least the same level of care as privately insured patients. If anything, the conclusion that should be reached based on this study alone is that private plans did not provide any advantage over Medicare even though private Medicare Advantage plans are paid on average 15 percent more than is spent on patients in the traditional Medicare program. Even though quality and outcomes on these limited measures were the same, value provided by the private plans was worse because it cost more for the same outcomes.

Why were these data pulled out of the CRUSADE study? Why were the uninsured excluded from this subset of data? Did the authors really wish to prove that Medicare could produce the same results at a lower cost?

Several of the authors have alliances with the pharmaceutical industry, and the CRUSADE study was supported by pharmaceutical company grants. The pharmaceutical industry is currently partners with the private insurance industry in combating a move toward publicly-funded and publicly-administered universal health insurance.

A cavalier quote by James Calvin, the lead author, is revealing: “On the surface, people may conclude that doctors have a bias against poor people. However, it doesn’t cost a thing to tell someone to watch the salt in their diet or to quit smoking, which is really good advice to reduce heart problems.” (http://www.southcoasttoday.com/daily/11-06/11-21-06/01health.htm)

What is that line? When they say it’s not about the money, it’s about the money.