By Barbara Ehrenreich
Published on The Progressive (http://progressive.org)
April 2006 Issue

Here’s the news that rocked my little world this month: We got a message that a family friend, let’s call her Lorraine, who was in an ICU, barely able to breathe on her own. In the last few weeks, there’d been some mumblings about “not feeling a hundred percent,” but no hint of anything seriously wrong. The diagnosis came back in a couple of days: fourth-stage breast cancer, which has spread to a number of other organs, including her lungs. If you know anything at all about breast cancer “staging,” you know there is no fifth stage.

Lorraine has no health insurance. We didn’t know that. In fact, we’d been content to believe that her consulting business was going as well as she said it was. In her late forties now, she’s a former accountant who never could find another decent job–also a news junkie, an avid reader, and an energetic volunteer in a number of worthy causes. But it turns out she’s been struggling with the cell phone bill and the rent. A few weeks ago, unbeknownst to us, she’d moved out of her apartment and into a free room offered by one of the nonprofits she volunteers for. The cost of a mammogram–well over $100–must have been out of reach.

President Bush, in his State of the Union address, said we should each have a “catastrophic” health insurance policy for the big ticket items like breast cancer, plus a tax-deductible savings account for the little things, like mammograms. If we have to take “personal responsibility” for our doctor visits and routine care we’ll be thrifty about it–or so the thinking goes–and the nation’s medical expenditures will stop spiking like an Ebola fever.

It’s an old idea, going back at least to the Clintons, that the problem with the American health system is that we, the consumers, just consume too much. Make us mindful of the costs by raising co-payments and other out-of-pocket costs, and we’ll stop indulging in blood workups, MRIs, prostate exams, and all those other fun things.

President Bush, meet Lorraine. Her problem wasn’t that she feasted on unnecessary care, but that like so many of the forty-five million uninsured Americans, she was’t getting any care at all. Maybe, when she first noticed the lump, she should have staged a sit-in at the nearest clinic until it sprang for a free mammogram. But her idea of “personal responsibility” was not to be a bother to anyone.

And how much does the “personal responsibility” theory even apply to the insured population? I have insurance–at enormous cost, because I’m not part of a group plan and I’m an ex-breast cancer patient myself–but that doesn’t mean I choose what care I get. It’s not my idea to have an annual mammogram and pap smear. The doctor had to threaten tears before I’d submit to a bone scan, and they’ll have to drag me in for a colonoscopy. No one aside from the rare victim of Munchausen’s syndrome goes looking for recreational medical care.

The fact is there’s a big difference between the economics of health care and that of, say, costume jewelry. We the consumers control the demand for costume jewelry; we can splurge on it or leave it alone. But we have precious little control over our demand for health care. Sure, we can exercise and refrain from smoking and sky-diving and swimming with sharks. We can eat right, too (whatever that may mean, with the dietary advice fluctuating from month to month). But it’s the medical profession that determines how often we need our blood drawn, our breasts squished, our cervices scraped, or any of the other nasty interventions they have to offer.

If the medical care we consume was under our own control, I’d say, sure, save up for it and use it wisely. But it’s no more in our control than the wind and floods we insure our homes against.

You think it’s too expensive to have universal health insurance? Let’s be hard-headed about Lorraine’s case. If she’d been diagnosed earlier, she might have gotten by with a mastectomy and a bout of chemotherapy instead of burning up Medicaid dollars in an ICU. She might be out volunteering for the needy right now, instead of lying in terror in a hospital bed.

Barbara Ehrenreich is a columnist for The Progressive. Her latest book is “Bait and Switch: The (Futile) Pursuit of the American Dream.” Her website is www.barbaraehrenreich.com.

By Matthew W. Petty
Op-Ed, The Forum (Fargo, ND)
May 4, 2006

The single-payer national health insurance system described by Josh Swanson in his April 23 opinion in The Forum is the best solution to America’s health care crisis. Unfortunately, the Massachusetts legislation Swanson describes is not single-payer, nor does it solve the health care crisis.

The Massachusetts proposal mandates that people buy their own coverage – with little or no help from employers – or pay a hefty fine. Swanson compares health insurance to auto insurance, arguing that if every driver is required to buy auto insurance, it is fair to make every person buy his or her own health insurance. But this argument ignores the critical fact that people have a choice to own a car but no choice about being an all-too-human mortal.

Extending the auto insurance argument to social policy fails to address real crises. For example, no one wo uld suggest ending homelessness and hunger by mandating that all homeless people buy a house and all hungry people buy food.

Requiring the uninsured to purchase health insurance will simply result in a proliferation of health insurance policies not worth the paper they are printed on. A 2005 Harvard study shows that three-quarters of people bankrupted by illness had health insurance when they first became ill. That percentage could skyrocket if the country adopted a Massachusetts-style individual-mandate law thanks to cheap and skimpy insurance policies.

Swanson is correct that many studies show single-payer to be the most cost-effective solution to the health care crisis. Unfortunately, the Massachusetts plan only adds to the health care system’s administrative waste. Massachusetts’ health care system already devotes $13.3 billion to billing, marketing, and other administrative costs. If the state devoted the same percentage as Canada’s single-payer system to bu reaucracy, the state’s health care system could save $9.5 billion annually, enough to cover all that state’s uninsured and to improve coverage for everyone else.

The Massachusetts health care proposal purports to provide health insurance to nearly all state residents. In reality the proposal promotes shoddy coverage with more holes than Swiss cheese. Insurance will remain unaffordable even with tax subsidies, forcing state residents to spend as much as 20 percent of their income for health insurance. The proposal will do nothing to stop employers from dropping coverage for workers, control costs, or reduce paperwork.

Nations with single-payer systems (e.g., Canada, Sweden, Norway, Germany, etc.) have better health outcomes while spending less per capita. Adopting a true single-payer system is the real solution to America’s health care crisis.

Petty is a 2001 graduate of Fargo’s Shanley High School and a 2005 graduate of Northwestern University with a bachelor’s degree in social policy and specialization in health policy. He is currently office manager and research associate with Physicians for a National Health Program, a 14,000-physician-member national nonprofit organization based in Chicago. E-mail matt@pnhp.org.

To view Medicare Watch’s February 2006 newsletter, click here. (PDF file)

By Sara R. Collins, Ph.D., Karen Davis, Ph.D., Michelle M. Doty, Ph.D., Jennifer L. Kriss, and Alyssa L. Holmgren
Commonwealth Fund, April 26, 2006

Overview

Watch a multimedia presentation about the findings, with audio and slides, by lead author Sara R. Collins, Ph.D., senior program officer and director of the Fund’s Program on the Future of Health Insurance.

Gaps in health insurance coverage\a problem that has long afflicted lower-income U.S. families\is increasingly becoming an all-American problem. Findings from the Commonwealth Fund Biennial Health Insurance Survey show that, while lack of insurance continues to be highest among families with incomes under $20,000, uninsured rates for moderate- and middle-income earners and their families are rising, putting their health and financial security at risk. The survey finds that most of these individuals reside in working families: Of the estimated 48 million American adults who spent any time uninsured in the past year, 67 percent were in families where at least one person was working full time. In addition, survey respondents were asked about problems with medical bills and accrued medical debt; difficulties in accessing needed health care; problems managing chronic conditions; utilization of routine preventive care, like mammograms and colonoscopies; and coordination and efficiency of care.

Executive Summary

National health care spending is climbing by more than 7 percent per year, outpacing economic growth by a substantial margin. As health care costs have climbed, so has the number of people without health insurance in the United States, even during a period of overall economic growth. In 2004, according to U.S. Census data, nearly 46 million people of all ages were uninsured, an increase of 6 million over 2000. This combination of eroding health insurance coverage and rapidly rising health care costs raises concerns about the ability of U.S. families to obtain timely medical care, protect their finances from catastrophic health care costs, and save for retirement.

The Commonwealth Fund Biennial Health Insurance Survey, a nationally representative survey of 4,350 adults age 19 and older, presents new information on the health insurance coverage of Americans and the health and financial consequences families face when they experience breaks in insurance. The survey, conducted between August 2005 and January 2006, finds that while the lowest-income families have always been most at risk of not having insurance coverage, more moderate- and middle-income earners and their families are also in jeopardy. In addition, one of five of all adults under age 65 is currently paying off debt from medical bills incurred in the past. Those who lack insurance are particularly affected by this burden. The survey also finds that uninsured people with chronic health conditions like diabetes and asthma are much more likely to skip medications for their conditions and go to an emergency room or hospital than are those who are insured.

Key findings of the survey include:

Rising Numbers of Uninsured Individuals Are in Moderate- and Middle-Income American Families

Two of five (41%) working-age Americans with incomes between $20,000 and $40,000 a year were uninsured for at least part of the past year\a dramatic and rapid increase from 2001 when just over one-quarter (28%) of those with moderate incomes were uninsured (Figure ES-1).

Adults with incomes under $20,000 were still the most likely to be uninsured: more than half (53%) had spent time uninsured in the past year.

Most people who are uninsured are in working families. Of the estimated 48 million American adults who had any time uninsured in the past year, 67 percent were in families where at least one person was working full time.

Many Americans Report Medical Bill Problems and Medical Debt

One-fifth (21%) of working-age adults, both insured and uninsured, currently have medical debt they are paying off over time and more than two of five (44%) of these individuals are carrying $2,000 or more in debt.

More than one-third (34%) of adults ages 19 to 64 either had medical bill problems in the past year or were paying off accrued medical debt. Problems include not being able to pay bills, being contacted by a collection agency about unpaid medical bills, or having to change way of life to pay bills.

Three of five (62%) of all adults with medical bills or debt problems said they or their family member were insured at the time the debt was incurred.

More than half (51%) of uninsured adults reported medical debt or bill problems. Of those, nearly half (49%) used up all their savings to pay their bills. Two of five were unable to pay for basic necessities like food, heat, or rent because of medical bills.

Rates of medical bill problems and debt were high among people in both lower-income and higher-income households who experienced a time uninsured. Indeed, rates were highest among those with higher incomes. Nearly three of five (59%) adults with incomes of $40,000 or more reported difficulties with medical bills or accrued debt. Forty-six percent of adults with higher incomes were paying off unpaid medical bills over time, with over half (54%) of these individuals carrying $2,000 or more in medical debt.

People with Gaps in Coverage Have Difficulty Managing Chronic Conditions

An alarmingly high proportion\59 percent\of uninsured adults who had a chronic illness, such as diabetes or asthma, did not fill a prescription or skipped their medications because they could not afford them.

More than one-third (35%) of uninsured adults who had a chronic condition went to an emergency room or stayed overnight in the hospital in the past year because of their condition\about two times the rate of people with chronic health problems who were insured all year (Figure ES-2).

Individuals with Gaps in Coverage Are Much Less Likely to Get Preventive Care

Only 18 percent of uninsured adults ages 50 to 64 had a colon cancer screen in the past five years, compared with 56 percent of adults insured all year.

Less than half (48%) of uninsured women ages 50 to 64 had a mammogram in the past two years, compared with 75 percent of women who were insured all year.

Few adults without medical insurance receive dental care: only 35 percent of those uninsured at the time of the survey had a dental exam in the past year, half the rate of those who were insured for the full year.

People with Gaps in Coverage Experience Inefficient Care

Nearly one-quarter (23%) of adults who reported spending any time uninsured in the past year said test results or medical records were not available at the time of a scheduled appointment, compared with 15 percent of continuously insured adults.

Nearly one of five (19%) adults with any time uninsured said he or she had been given a duplicate test, twice the rate of duplication reported by continuously insured adults.

It is clear from the findings of this survey and from prior research that the health care\and ultimately the health and productivity\of the U.S. population is being damaged as the nation’s insurance problem continues to grow. Real solutions that build on group forms of coverage already in place, including employer plans, Medicare, Medicaid, the State Children’s Health Insurance Program, and state and federal employee benefits plans, will help to fill insurance gaps with meaningful, affordable coverage that helps link families and providers. Preventive care routines, like cancer screenings, blood pressure and cholesterol tests, dental exams, as well as care for chronic conditions, should be the shared reality of all Americans.

Citation:
S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, and A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, The Commonwealth Fund, April 2006

Copyright 2006 © • The Commonwealth Fund |

Shredding the Social Contract: The Privatization of Medicare
by John Geyman, 322 pp, with illus, paper, $16.95, ISBN 1-56751-376-X, Monroe, Me, Common Courage Press, 2006.

JAMA. 2006;295:1950-1951.

In Shredding the Social Contract, John Geyman examines the development of the largest social insurance program in the country\Medicare\identifies the multitude of influences that have led to the current state of the Medicare program, and suggests that national health insurance (NHI) may be the only solution to its problems.

In an investigative reporting style with generous use of quotations from policy makers, physicians, institutional providers, and beneficiaries, Geyman makes the case that Medicare’s problems pose challenges to a broad array of stakeholders. He cites research demonstrating Medicare’s impact on the federal budget and the financial health of practitioners and institutional providers; brings in information from media accounts, public documents, and scholarly journals; and offers personal accounts from beneficiaries to illustrate the obstacles that stem from hastily implementing new programs or reinterpreting existing ones. After reading these accounts, the reader comes away convinced that “fixing” Medicare will not be easy given the political, social, and economic forces molding the program’s future.

Geyman’s concern is that Medicare as an entitlement program is incrementally being eroded. The chapter on “Means Testing and Medicare” asks the question whether Medicare services should be delivered on the basis of economic need. Medicare is an entitlement program, whose benefits are to be equitably distributed to enrollees regardless of ability to pay or income level. Medicaid is a social welfare program, whose benefits are to be distributed according to means. This is an important distinction between the two programs. Yet Medicare’s prescription benefit program is being administered according to means, and thus it breaks the social contract that the US Government has with its citizens. Since a portion of Medicare is now means-tested, there may be serious consideration given to making all of Medicare means-tested, especially with the current political rhetoric predicting the insolubility of the Medicare trust funds. The inevitable question becomes, Will Social Security become the next convert to means-tested distribution of benefits?

In Geyman’s view, Medicare is being eroded in part by the economic interests of proprietary insurance and pharmaceutical companies and in part by a Congress amenable to the privatization of public services. He explains how this erosion is inherent in a system that allows private insurance companies to be fiscal intermediaries\and how it has been exacerbated by Medicare + Choice (now called Medicare Advantage), in which beneficiaries have the option to join a managed care plan that delivers Medicare services. He points out that the overhead of managed care companies administering Medicare benefits is five to nine times that of traditional Medicare. And he notes that the recently enacted prescription drug plan was designed with the pharmaceutical companies’ interests in mind, not the needs of beneficiaries. This shift toward favoring private interests is due in part to the political clout of private-sector lobbies. Their support of legislation favorable to their business interest neutralizes the interests of the middle class and outweighs the economically disadvantaged, who are socially marginalized, not inclined to vote, and in any case too poorly organized to impact legislation.

Geyman sees health care as a basic human need, not a commodity for private interests to package and sell in the marketplace. From this perspective, any reform must concentrate on the needs of the population, not the economic self-interest of managed care organizations and proprietary supplies of health care. Thus, Geyman suggests that creating NHI is the only way to repair the problems of Medicare. He suggests that a single-payer system under NHI can address the macroeconomic disadvantages of the current system. He points out that administrative overhead and profit taking account for up to 31% of the cost for direct patient care. Those without adequate insurance coverage delay seeking treatment until their condition further deteriorates and requires more costly treatment. Furthermore, incremental reforms during Medicare’s tenure have not reduced overall cost and improved access to services.

Achieving NHI will meet with resistance in the current political and economic environment. Any attempt at a universal health plan may be thwarted by political compromises that could relegate the system to proprietary interests. Furthermore, administering NHI would have the same challenges faced by Medicare. One such challenge is inherent in our federal system of governance. Each state has the authority to regulate insurance contracts and license practitioners and health facilities. Thus, states determine the supply of health care services available in a given geographic area. Would control by the states change with NHI?

Additionally, Medicare was established as a means of distributing acute, short-term medical services to the elderly, but the greatest need today is for chronic care, and that problem would still have to be solved with NHI. Furthermore, the direction of Medicare or NHI has to be resolved. Should Medicare be administered as a public program or through partnerships with proprietary interests? And whose needs should take precedence? Those of the beneficiaries or those who insure or provide health care services?

Shredding the Social Contract is easy reading for general audiences, but there is an overabundance of lengthy quotations from policy makers and scholars. Health policy experts will have little difficulty sifting through the varied sources and synthesizing the book’s essential messages. It may be more difficult for others to assess the strength of the argument made by the author. A condensed version might serve well as a catalyst to help the general public become more vigilant over the changes that are made to their entitlement program. Clearly Medicare needs fixing, and NHI would certainly be an ideal solution. The book’s implicit message, however, is that the road to NHI will be met with challenges from the stakeholders. In the meantime, Geyman’s explicit message is a wake-up call to the nation that Medicare as an entitlement program is being eroded by private interest.

Robert R. Kulesher, PhD, Reviewer
School of Allied Health Sciences
East Carolina University
Greenville, NC
kulesherr{at}ecu.edu