By Howie Wolf
Originally published April 16, 2006
Boulder Camera

A brilliant and widely read book by Malcomb Gladwell called “The Tipping Point” calls our attention as to why there are so many changes in our society which seem to happen unexpectedly and suddenly. The sudden rise in popularity of “Hush Puppies” in the ’50s was an example.

Then Gladwell shows that not only fashion trends, but social movements and reform also may reach a “tipping point” wherein it is realized by the populace that something needs to give. The civil rights movement of the ’60s is an example of how a longstanding wrong reached the point when most of society could not tolerate racial inequality. Recently across our country people are marching in protest of impending anti-immigration legislation in Washington. Tipping points are being reached.

There is clearly a growing movement in our nation regarding health-care reform. We are spending far more for health care per capita and of our GDP than any industrialized nation. We have 46.8 million uninsured and many millions more underinsured. This means lack of access to care or delay in seeking care which translates into the grim reality that an estimated 18,000 Americans will die annually. Those who lack health insurance make around 50 percent of all bankruptcies, but 70 percent were “insured” when their medical condition began.

We do have outstanding health care being delivered in our country, and scientific advances abound. But these aren’t affordable for the uninsured.

Our co-pays and premiums are rising dramatically for those of us “lucky enough” to have insurance. Sadly for many Americans it is a choice of medication or food or a heating bill. Trying to understand most EOBs (Explanation of Benefits) reports from insurance companies is usually a complex task. Worse, there is no accountability, and insurance companies rake off 15 percent to 30 percent of our premiums to keep their companies rolling, which includes CEO salaries in the $20 million-per-year range. Most medical facilities must employ extra people to do the communicating with each insurance company with their varied rules and formularies. Payment to providers is made with predictable delays and dramatic cuts.

As a family physician who has practiced in this county for more than 43 years, I have seen the realities of what it is like for my patients who lack insurance and who face frightening medical doctor bills. An ethical and moral dilemma probably occurs with any provider who treats patients lacking insurance; we simply cannot offer the same services, treatment or medicine to the underinsured person.

Something needs to be done! Most national legislators seem uninterested in significant reform. The insurance and pharmaceutical lobbies have supported those in Congress who resist change. Indeed, the Medicare part D you’ve been hearing about is not only complex, but will be useful and money-saving for but a few Americans, while reaping nice profits for insurance and pharmaceutical companies.

Consider the savings that could have been achieved had prescription drug prices been a negotiable item, but that option was deliberately omitted. It was unconscionable how they swung this deal, leaving many seniors with costly choices. Why should a senior have to pay more than three to four times more for Lipitor than what Pfizer’s charges the VA Health care system?

Over 60 percent of all Americans favor a single-payer universal system, similar to the Canadian model. We would prefer a system that is affordable, accountable and accessible and includes preventive care and management of costly resources. Countries which have universal care can cover everybody – and have preventative care as well – at less cost than we are now paying. Their outcomes – longevity, maternal and infant mortality figures – are better than ours. Many of us who are activist in health care reform believe that – until the masses -including the uninsured and underinsured – create enough power to reach the “tipping point,” we’re stuck with the status quo.

Perhaps politicians will “listen better” when the streets swell with millions of people – as with the recent crowds demanding immigrants’ rights – but this time demanding health care for all. We are the only industrialized country without a universal system. Most systems are funded publicly but run privately. Canada’s operating cost is 2 percent to 3 percent compared to the 15 percent to 30 percent in our country.

I have learned that incremental reform will not do. A major fix is needed. Yes, the Health Savings Accounts are nice for those who have youth, money and good health. But for those who become very sick, the costs can be unaffordable, plus they do nothing to address the uninsured. Tying health insurance to employment seems absurd. People often get laid off, lose their insurance, and COBRA costs are out of sight. Employers get stuck because fewer of them can afford the rising rates. Why should employers carry the burden of health insurance anyway?

Are we close to reaching the “tipping point” with health care?

Howie Wolf, M.D., is a Boulder physician.

By Marcia Angell
Originally published April 17, 2006

IF GOVERNOR Romney thinks the state’s new plan for universal health coverage will carry him to the White House, he should think again. This Rube Goldberg contraption won’t even get him off the ground because it doesn’t touch the underlying problem — our reliance on multiple private insurance companies.

Private insurers compete not by offering better healthcare, but by avoiding high-risk individuals, limiting services for those they do cover, and, whenever possible, shifting costs to other payers or to individuals in the form of high deductibles and copayments. It’s a chaotic and fragmented system that requires a mountain of paperwork, which is one reason premiums are so high. Those employers who still offer health benefits react by capping their contributions, so that workers pay more out of pocket and bear the full brunt of premium increases. Massachusetts does better than most states, but healthcare in Massachusetts is also the most expensive in the nation.

If this system is left essentially intact, as it is under the new plan, expanding coverage will inevitably increase costs. That is common sense: Coverage and costs have to move in tandem if the system stays the same. Furthermore, the plan does nothing to keep costs from growing. For years, premiums have been rising much faster than the consumer price index. At current rates, even if the state were able to cover its proposed contributions to the plan at launch, it wouldn’t be able to keep up with soaring prices.

But already it’s clear that the governor and legislators don’t know how to pay for it even at launch. One legislator told Boston Globe columnist Joan Vennochi: ”We don’t yet know what it’s really going to cost us or where we’re going to get the money from. To some extent you might call it a Hail Mary pass.” The essence of this faith-based plan is to squeeze employers and individuals, with a relatively small state contribution. But employers who don’t offer health insurance can get away with paying a penalty of only $295 per employee per year — in a state where health insurance for individuals costs about $7,200 per year.

Individuals not covered by employers and whose income is at least 300 percent of the federal poverty level (now about $30,000) will have to buy their insurance or pay income tax penalties. Romney thinks premiums can be held to $2,400 a year with a cap of $2,100 on deductibles, but that is wildly implausible. If premiums are higher than that and continue to escalate faster than income, this will amount to fining people because they can’t afford health insurance, which, in effect, will punish them twice — an unsavory prospect.

Those individuals whose income is less than 300 percent of poverty level would receive state subsidies. That will require an enormous bureaucracy to determine what insurance is adequate and ”affordable” and who can really afford it, and there will be incessant legal and regulatory wrangling. The legislation calls for a new state agency, the Commonwealth Health Insurance Connector, to oversee insurance plans, and that is just the beginning.

Like the Medicare prescription drug benefit, the Massachusetts healthcare plan is a complicated morass that might limp along for a while, but will never cover all the people it is meant to cover, and will become increasingly unaffordable. Most likely, it will meet the same fate as the much celebrated 1988 legislation to provide universal coverage in Massachusetts, which shriveled and died with scarcely a whimper.

The only answer is to change the system entirely, so that we can expand coverage while controlling costs. Romney said, ”The old single-payer canard is gone.” No, it isn’t. Sooner or later, that is exactly what we’ll need if we’re really serious about universal healthcare. There’s no other way.

Dr. Marcia Angell is a senior lecturer in social medicine at Harvard Medical School and former editor-in-chief of the New England Journal of Medicine.

Copyright 2006 Globe Newspaper Company

http://www.boston.com/news/globe/editorial_opinion/oped/articles/2006/04/17/healthcare_plan_needs_dose_of_common_sense/

DID YOU KNOW THAT:

•Most uninsured people will now have to buy their own insurance without any or with very little financial support?

•The Bill will not help the underinsured or those with poor quality insurance, including those on Medicare paying high out-of-pocket costs?

•It will not attempt to reduce the costs of health insurance for individuals and businesses paying the highest prices in the world?

DID YOU KNOW THAT:

•40 percent of the uninsured in Massachusetts, the 292,000 who earn more than three times the poverty level income, will be forced to purchase their own health insurance without any help or subsidies from the state? Bad insurance for someone earning three times the poverty level will cost them 20 percent of their total income.

•The Bill raises only $170 million per year in new spending to help subsidize 748,000 uninsured people in Massachusetts? This is not enough to pay for 45,000 people. All other funds used by the Bill are a shell game, most taken out of Free Care – which provides medically necessary health services for the uninsured – and moved into more wasteful plans run by commercial insurance companies.

•This Bill, which will affect the lives of hundreds of thousands, was bought and paid for by healthcare industry lobbyists? Industry lobbyists spent over $7.5 million this year to make your health care Bill work for them. Forcing uninsured people into private insurance plans will create new business and new profits for insurers, without reforming the system of waste and discriminatory health care access for Massachusetts residents.

DID YOU KNOW THAT: every developed nation in the world offers comprehensive health care for all of its residents, except the United States? And they pay less for it? Let’s organize against these attempts to shift health care costs on to low-income people. Let’s fight for the universal, quality health care that we know is possible!

Dr. Don McCanne editorial in the San Diego Physician (PDF File)

Originally Published 4/4/2006

Countries that have national health services easily accessible to people of all ages are more likely to have better survival rates for their teenagers and young adults (TYAs) with cancer, than are countries where individuals have to pay for their own medical insurance.

This is the suggestion that arises from new research presented at the 4th International Conference on Teenage and Young Adult Cancer Medicine, in which the health care systems of the United States of America and Australia were compared.

Professor Archie Bleyer told the conference, organised by Teenage Cancer Trust, that Australia’s system of health insurance for all, regardless of age, meant that TYAs were more likely to survive cancer in Australia than they were in the USA.

Prof Bleyer, who is medical advisor at the Cancer Treatment Center, St Charles Medical Center, Bend, Oregon, said: “However, both countries have a lower survival rate for their TYAs than for their younger and older patients, proving that TYAs remain the most neglected group of cancer patients across the globe.

“Our previous research has shown that the survival of older teenagers and young adults with cancer in the United States has lagged behind progress in younger and older patients. We found that diagnosis was delayed in TYAs who either lacked health insurance or had inadequate insurance, and therefore this lack of progress might be due to the USA health care system and less expected in countries with national health insurance.

“During the past year we have compared survival of TYAs in the USA with those in Australia, a country similar in many demographics to the USA, but with health insurance provided to all citizens regardless of age.

“From 1982 to 1998, the rate of improvement in the five-year survival from invasive cancer in Australia exceeded that which occurred in the USA, such that by the late 1990s, TYAs in Australia had an overall five-year cancer survival that was higher than in the USA. The deficit begins at 16 and ends at 55, the same years that national health insurance is not available in the USA. It ranges from 5% for 18 to 25 year-olds to 12% for those aged 30 to 35. This difference suggests that the health care system in Australia, with universal health insurance, was able to provide better cancer care to its TYAs.

“The advantage for Australian TYAs was not apparent in their children or older adults with cancer. This suggests that the need for private health insurance in the USA is responsible for the worse survival of TYAs, in that children and older adults in the USA are more adequately insured than TYAs.”

In the USA the greatest improvement in survival occurred amongst patients aged over 65 for whom national health insurance is provided.
Prof Bleyer said: “Both countries, however, had a lower rate of improvement in the five-year cancer survival rate among TYAs than in either younger or older patients, albeit the relative deficit was greater in the USA than in Australia.

“These comparisons indicate that the relative lack of progress in cancer outcome among TYAs in the USA is due, at least in part to the lack of health insurance,” he said.

However, he warned that even in countries where there was national health insurance for all, this didn’t necessarily guarantee access to good diagnosis and treatment for cancer patients, and particularly not for TYAs.

“Good health care systems make a huge difference in prolonging survival and reducing deaths amongst TYAs with cancer,” he said. “The failure to improve survival amongst 15 to 29-year-olds over the last quarter of a century is striking and there are reasons that are common between different countries. These include the tendency for adolescents and young adults to wait longer before consulting a doctor about symptoms, lack of a regular and usual source of primary care, delays in diagnosis by doctors not used to seeing young people with cancer, the wide spectrum of cancers contracted by TYAs, physicians poorly trained in caring for TYAs with cancer, and, most importantly, the lack of participation in clinical trials for this age group.”

Some countries belatedly were waking up to this problem, he said. In the UK, the National Institute for Health and Clinical Excellence (NICE) issued new guidance for the treatment of under-19s in August 2005. “In the USA the National Cancer Institute has initiated a major review of the national status of cancer in this age group. Known as a Progress Review Group, the nation’s experts will evaluate all available data, determine the severity and potential solutions, and provide an official report of recommendations,” he said.

“In addition, the President’s Cancer Panel is working on a similar report on the survivorship of young Americans with cancer. Both efforts include a review of the role of health insurance and health care delivery systems in the new medical frontier that is TYA oncology.”

The New York Times
Published: April 9, 2006

To the Editor:
Your reports about Massachusetts’ health reform legislation treat politicians’ overblown claims as gospel.

The legislation completely ignores one-third of the uninsured, dismissing the Census Bureau’s estimate that 748,000 lack coverage in Massachusetts in favor of an estimate of 500,000 derived from a phone survey.

The linchpin of the promised coverage is a requirement that most of the uninsured buy their own coverage, and assurances that private insurers will offer affordable, comprehensive policies.

But already reports have surfaced that these new policies will be far costlier than promised, putting them out of reach of most of the uninsured and sharply raising the costs of state subsidies to help the very poor.

Predictably, rising costs will force more employers to drop coverage, while state coffers will be drained by the continuing cost increases in Medicaid. When the next recession hits, tax revenues will fall just as a flood of newly unemployed people join the Medicaid program or apply for the insurance subsidies promised in the reform legislation.

The program is simply not sustainable over the long or even short term. In contrast, a single-payer reform could save $9 billion a year on bureaucracy in Massachusetts, more than enough to cover the uninsured and to upgrade coverage for the rest of us.

David U. Himmelstein, M.D.
Steffie Woolhandler, M.D.
Cambridge, Mass., April 6, 2006
The writers, associate professors of medicine at Harvard, co-founded Physicians for a National Health Program.

Originally Published April 8, 2006

Des Moines Register Editorial Board

On Tuesday, the Massachusetts Legislature passed a bill mandating all residents purchase health insurance. The philosophy is right: Everyone should have health insurance. It should be affordable. When people are uninsured, everyone pays.

But it’s difficult to get too excited about what Massachusetts did to cover its roughly 550,000 uninsured residents. The bill requires businesses to offer insurance or face financial penalties, but it doesn’t guarantee that insurance be adequate. Individuals must buy insurance or face tax penalties, but it doesn’t define what “affordable” health insurance means. It expands health care for lower-income residents, but much of the money comes from shuffling
existing dollars.

Worst of all, it mandates residents participate in a dysfunctional system that largely ties health care to employment. Every other industrialized country in the world knows it’s a bad idea to tie health care to jobs. It kills entrepreneurial spirit, saddles business with huge costs and forces employers to choose between their bottom lines and the best health policies for workers.

The Massachusetts bill also funnels even more dollars to private insurance companies that may waste money on administration. According to a 2003 Harvard Medical School study, nearly one-third of all U.S. health-care expenditures goes to administration and bureaucracy. That includes insurance-company paper pushers and all the people doctors offices employ to navigate the thousands of insurance plans.

Massachusetts Gov. Mitt Romney, who is considering a run for president, has boasted that the plan gets everyone covered without new taxes or a government takeover.

Yet when it comes to health care, the government is hardly the enemy. Indeed, it may be the best hope.

Medicare provides uniform coverage with low administrative costs for more than 40 million seniors and disabled people. Though it needs some fixing, a Medicare-like system for everyone would be more efficient and use fewer dollars on administration than private insurance.

Given the inaction on health-care reform at the federal level, state legislatures are trying to take on the job. While the desire by Massachusetts lawmakers to cover everyone is philosophically right, the approach isn’t.

The fix has to come from a different group of lawmakers – the ones in Washington.