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J. Gruber on rationing and national health insurance

J. Gruber on rationing and national health insurance

America’s Health Insurance Plans
2006 National Policy Forum
3/7/2006

Prospects and Implications of Tax Policy for the Health Care Industry Jonathan Gruber, Ph.D., professor of economics, Massachusetts Institute of Technology; co-editor, Journal of Health Economics; and associate editor, Journal of Public Economics

Carlton Dennis: Just a follow-up question, a different question on rationing. You mentioned that, and earlier speakers talked about universal health care. What’s your view on that? I know at the end of your talk you mentioned that we probably would have to go to some type of rationing.

Jonathan Gruber, Ph.D.: There are two questions there. Let me start with the second one, which is: do we need to do rationing? I don’t actually believe we do. Basically, I think what health economists have really concluded is two things which at first seem contradictory but in fact aren’t, which is: first of all – and this conclusion is most associated with the work of my colleague David Cutler at Harvard – first of all, over time, our health care dollars have been effective spent on average. That is, no one wants to have 1950s health care at 1950s prices. The health care we’re buying today is much better than it used to be. And if you use typical values of quality of life years and things like that, on net, we’re better off now than we were, even though we’re spending more. At the same time, I could, today, look back and say, “Of the 15 percent of GDP we spend on health care, I bet we could knock five percent of it out and people would be no less healthy.”

Now, how are those two things consistent? They’re consistent because it’s easy to look backwards. It’s hard to look forward. So it’s consistent because looking backwards, we can say, “Gee, a lot of this stuff we do is wasteful. Let’s get rid of it.” But we don’t know, of the new innovations, which are going to be wasteful and which aren’t. Rationing, putting a cap on, is just as likely to cut out the positive innovations as it is the negative innovations. And that’s the problem. In other words, if we rationed in 1950 and said, “Health care should not be more than five percent of GDP,” we would be much worse off as a country today. Likewise, if we today said, “Health care should not be more than 15 percent of GDP,” I predict we’d be much worse off as a country in 2100. I think we need to find another solution, other ways to try to get at this than rationing because I think rationing is just too blunt an instrument, given the overall positive advances.

Now, that said, universal national health insurance, there are two components to that. One is universal coverage. Universal coverage can be done making all of you happy. You can have universal coverage for the private health insurance industry. That’s what we’re proposing in Massachusetts. There would be a central pool through which private insurers would offer policies. But, we would mandate that everyone in the state be covered. Okay? So that’s universal coverage with the private insurance sector.

National health insurance means wiping you all out. I just personally don’t see that as even worth discussing, for political reasons. As well, I think there are some real economic arguments. At least I think there are economic cases to be made on either side. But the truth is, I just don’t think, politically, we’re just ever going to be in a place where we can seriously consider national health insurance, Canadian-style health insurance. I just don’t think it’s worth our brain cells worrying about it.

Dan Leonard: Thank you for that, by the way.

Jonathan Gruber, Ph.D.: Well, I’ve made enough enemies today.

Dan Leonard: Yeah, right.

Jonathan Gruber, Ph.D.: I figured I’d make a few friends. [Laughter]

Dan Leonard: Redeeming yourself.

http://www.kaisernetwork.org/health_cast/uploaded_files/
030706_ahip_taxpolicy_transcript.pdf

Comment: By Don McCanne, M.D.

On rationing:

In yesterday’s Quote of the Day, Marmor and Mashaw stated, “…social insurance programs have been and can be adjusted over time to meet fiscal, demographic, and technological challenges. They are not dinosaurs from another age, but evolving programs whose core principles can be expressed through a number of adaptations.”

Gruber stated, “I think we need to find another solution, other ways to try to get at this than rationing because I think rationing is just too blunt an instrument, given the overall positive advances.”

In the single payer model, the global budget for health care is adjusted for inflation, demographic changes, and the introduction of reasonable, beneficial technological innovations. One of the more important reasons that we want to continue to support technological innovation is that new technology theoretically promises higher quality at a lower cost, often replacing out-dated and more expensive technology. A major problem is that some of the technology is new, and, instead of replacing old technology, it expands the range of diagnostic and therapeutic possibilities.

This is precisely why we need a monopsonistic, single-payer purchaser of health care. We would be in a position to demand value for new technology. If it increases the health care budget, then we would want to be certain that it is worth the increased spending. Another reason is that a monopsonistic purchaser would be in a position to finally address the “Wennberg variations,” by reducing allocations for non-beneficial excesses in technological services that have been well documented.

In framing the debate on reform, we should walk away from arguments over the “blunt instrument of rationing,” and begin to discuss how we can better spend our health care dollars.

On the politics of national health insurance:

Professor Gruber was certainly an audience pleaser at this national meeting of the private insurance industry. He reassured them that they will continue to thrive, using the stale political-feasibility argument. He may be protecting the insurers’ brain cells by telling them not to worry about it, but we can assure them that they have plenty to worry about. The Quote of the Day two days ago on medical-loss ratios led to this conclusion: “You would think that anyone with a modicum of business sense would believe that keeping (the private insurance industry) in charge is no longer feasible.”

For those interested, previous Quote of the Day messages are posted at https://pnhp.org/news/quote_of_the_day.php

Marmor and Mashaw on social insurance

Understanding Social Insurance: Fairness, Affordability, and the ‘Modernization’ of Social Security and Medicare
By Theodore R. Marmor and Jerry L. Mashaw
Health Affairs
March 21, 2006

In our view, the fate of Social Security and Medicare should be neither stasis because of political gridlock nor transformative change because of anxieties about the future. Both are crucial parts of the U.S. social contract and respond to deeply held notions of fairness and collective responsibility. But they should not be immune to sensible adjustment to reflect changed circumstances. To see why, we need to understand why basic social insurance arrangements have been so remarkably durable both in the United States and elsewhere.

The short answer is, first, that the core features of social insurance arrangements are both economically sensible and socially and politically acceptable. Social insurance is part of the essential social glue that holds an individualistic polity together and that makes the economic risks of a market economy tolerable. Second, however fundamental to the U.S. social fabric, social insurance programs have been and can be adjusted over time to meet fiscal, demographic, and technological challenges. They are not dinosaurs from another age, but evolving programs whose core principles can be expressed through a number of adaptations.

But some mutations are species-altering. In our view, much of the current enthusiasm for “modernizing” Social Security and Medicare has precisely that species-altering ambition. These reforms emphasize not protection against common economic risks in a changing world, but individualized risk bearing through increased responsibility and rewards for personal choice and increased “marketization” of social provision. We do not deny for a moment the value of personal choice, individual responsibility, and market competition. Indeed, supporting a society based on a viable vision of those values is the fundamental function of social insurance. But social insurance programs designed to maximize personal choice and promote market competition will simply not deliver adequate social insurance protections. To see why, we need to explore the basic structure of social insurance and its capacity to face contemporary challenges-that is, its capacity to modernize while continuing to play its fundamental social role.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w114

Comment: By Don McCanne, M.D.

Even if you are already an authority on social insurance, this article is well worth reading. Marmor and Mashaw provide an effective framework on which to have a rational dialogue on social insurance. You will not only be able to explain why we should and how we can preserve the social insurance roles of Social Security and Medicare, but you will also be able to extrapolate the principles and thereby be able to explain why we need a program of social insurance to cover health care for everyone.

Even if you are not a subscriber to Health Affairs, for the next two weeks this article can be downloaded free of charge. You should do so now.

Medical-loss ratios of largest for-profit insurers

Health plans make more, spend less in 2005
By Jonathan G. Bethely
American Medical News
March 6, 2006

If physicians needed any more indication of tightening reimbursement, how about this – not only did profits for the biggest health plans go up last year, but those plans also continued to cut the percentage of revenue they spend on care.

The medical-cost ratio – also called the medical-loss ratio or medical-care ratio – is the key number for health plans in terms of their level of profitability. That ratio, simply, is the percentage of dollars the companies spend on health care.

Whereas 10 years ago many plans had medical-cost ratios in the high 80s or 90s, now the highest percentage among large, publicly traded health insurers is Health Net, at 83.9%. Aetna, which had a medical-cost ratio well into the 90s when CEO John Rowe, MD, took over in 2000, recorded a ratio of 76.9% in 2005, Dr. Rowe’s final full year before his retirement. That was the lowest medical-cost ratio for the nation’s largest publicly traded plans.

Medical-loss ratios for 2005 (Source: Company 10-K, year-end filings with the Securities and Exchange Commission):

76.9% – Aetna
82.3% – Cigna
83.9% – Health Net
83.2% – Humana
78.6% – UnitedHealth Group
80.6% – WellPoint

http://www.ama-assn.org/amednews/2006/03/06/bisd0306.htm

Comment: By Don McCanne, M.D.

Clearly, one-fifth of health insurance premium dollars are not being spent on health care, but are consumed by the insurers. What does not show up in these numbers is the cost of the administrative burden that these insurers place on the health care delivery system. The billing and insurance related functions for physicians and hospitals burn up another 12 percent or so of the premium dollar (Kahn et al, Health Affairs, Nov/Dec 2005). Add these together, and that is about one-third of the premium dollar.

We are very concerned about the continued escalation of health care costs. New technology and pharmaceuticals are adding to the spending on physicians, hospitals, laboratories and other health care services. We fret about these expenditures within the two-thirds of the insurance premium that actually makes it down to the health care system, yet we are ignoring the one-third that is wasted on administrative services that provide no health benefit for the patient.

We are enriching this industry for providing coverage for the healthy workforce and their young, healthy families, and for covering the healthy sub-sector of the individual insurance market. We taxpayers are footing the bill for the population subgroups with greater health care needs.

We certainly are not receiving much value from the insurers – letting them have the easy stuff at a very high cost. Wouldn’t it be more logical to target their waste, rather than slowing spending growth by making health care unaffordable for those who do have needs?

Why do we keep hearing that eliminating this industry isn’t feasible? You would think that anyone with a modicum of business sense would believe that keeping them in charge is no longer feasible.

Kinsley's reform we should try before we go single payer

Before We Go ‘Single Payer’: Insurance Reforms We Should Try
By Michael Kinsley
The Washington Post
March 17, 2006

The small fraction of people involved in auto accidents in any year is responsible for almost all of the cost of auto insurance. You insure against the risk of being in that group.

What’s different about health insurance is the opposite: Much of it isn’t insurance at all but a subsidy. The value of the subsidy is the difference between what the individual pays and what the insurance would cost in the free market. If people were buying health care or insurance with their own money, they might or might not spend too much — whatever “too much” is — but no one else would need to care if they did.

A subsidy has to take from someone and give to someone else. Everybody can’t subsidize everybody. Or, to put it another way, society cannot give the average citizen better health care than the average citizen would choose to buy on his or her own.

There are the makings of a deal here. Better-off or better-insured people could be told, individually or as a group: Give up your health care subsidy and you may opt out of any rationing-type restrictions that the system imposes. And if a few smaller reforms like that don’t work, maybe it will be time for single-payer.

http://www.washingtonpost.com/wp-dyn/content/article/2006/03/16/AR2006031601311.html

Comment: By Don McCanne, M.D.

What are the policy issues behind Kinsley’s proposed reforms? The wealthy are already free of rationing-type restrictions since they can purchase whatever care they want. The only real substance in his proposal seems to be that tax policy should not be used to subsidize the purchase of insurance. That would partially address only one flaw in our current system of funding health care: the regressive tax policies of employer-sponsored plans.

We don’t need to rehash here all of the flawed policies of our current system, which Kinsley fails to address, to understand that the $2.1 trillion that we are already spending is more than enough to provide comprehensive health care benefits for everyone.

Aren’t you growing weary of the before-we-go-to-single-payer-let’s-try-(insert-deficient-policy-here) approach to reform?

Health care reform does too little, say activists

Times Argus
Originally published Feb 15, 2006

MONTPELIER ā€” Even as the House Health Care Committee worked inside on a health reform bill that would provide care to more Vermonters, a group of activists stood on the Statehouse steps demanding a more comprehensive approach.

Members of a group dubbed Concerned Vermonters for Universal Health Care complain that the plan being written by the committee falls far short of the goal of ensuring that every resident of the state has access to quality care at an affordable price.

They accused the committee of caving in to Gov. James Douglas, who has advocated a much more modest approach to expanding access and reducing costs, in the hope of enact-ing something this year.

“They’ve crafted a bill that (Douglas) would have no choice but to sign,” said Deb Richter, a physician who supports a taxpayer-financed single payer system similar to how health care is funded and delivered in Canada.

That’s a sentiment shared by many critics of the House’s work this year. Critics believe the House has drafted an initiative similar in approach to the governor’s that will not achieve the priorities that Democrats set out in the elections of 2004.

The bill would expand insurance coverage to some of the people who do not currently have it. But it does not purport to cover everyone and it still may not meet with the governor’s approval because Democrats have made it clear that they will need to tap a tax source to pay for it. Douglas has said he does not believe there’s any need for new taxes to pay for health care.

Democrats respond that his plan, which would require people to take insurance provided by their employers if it’s available, is little different from a tax. It would cost an estimated $45 million to those employers.

Advocates for health care reform say neither the House nor the governor is getting it right. “The House bill may help a few Vermonters. But all Vermonters need help,” read one sign held by the roughly 100 activists who demonstrated outside the Statehouse in a brisk wind on Tuesday.

It is true that the Health Care Committee’s bill would not require people who do not currently have health insurance to buy it. But it was designed to make insurance more affordable by creating a tiered system of premiums based on people’s income. The committee’s goal is to draw people into the insurance system through the subsidized premiums.

The committee also is aiming to improve the care that is delivered by adopting the governor’s chronic care initiative, which coordinates the care given to people suffering from heart disease, diabetes, and other types of ongoing diseases.

The chronic care initiative would be expanded to state employees and people enrolled in public health insurance.

Although critics welcome the initiative, they argue that much more needs to be done if the bill can accurately be described as health care reform.

Dr. Marvin Malek of Barre said a Canadian-style system would be real reform and he and others at the rally urged the Health Care Committee to continue working until they were able to get closer to such an ideal.

“We have to keep letting the Legislature know we can do better,” he said.

Critics challenge health reform plan

By Nancy Remsen
Free Press (Burlington, VT)
Originally Published February 15, 2006

MONTPELIER — Dr. Deborah Richter hoisted a megaphone and addressed a group of 50 supporters of universal health care gathered Tuesday outside the Statehouse to protest the health reform plan drafted by the House Health Committee.

“Go back to the drawing board and consider a different bill,” Richter bellowed toward the windows of the state capitol. She and the other demonstrators object to the limited scope of the committee’s reform plan, which calls for expanding state-subsidized health coverage to many of the state’s uninsured and promoting better management of chronic diseases among all Vermonters.

The recently organized Concerned Vermonters for a Universal Health Care System prefers the bill the House Health Committee recommended last year, which set out a roadmap to move all Vermonters to a government-financed health care system. Gov. Jim Douglas derailed the broader reform proposal with a veto last spring.

The House Health Committee expects to wrap up work on its new health reform bill this week.

Richter, who has a family medicine practice in Cambridge, blamed politics for the committee’s scaled-back proposal: House Democrats are trying to accommodate the demands of the Republican governor and avoid another veto in an election year.

“They have crafted a bill he would have no choice but to sign,” she told the crowd.

Inside the Statehouse, however, representatives of the Douglas administration found plenty to criticize in the latest draft of the House Health Committee’s bill.

Joshua Slen, director of the state Office of Vermont Health Access, posed the biggest challenge to the bill when he questioned the way the committee proposed to pay for the new Catamount Health program for the uninsured and the bill’s chronic care initiatives. The cost of the proposal isn’t set because the committee continues to study options that change how many uninsured could be expected to enroll.

The House bill specifies that the new programs would be paid for in part with dollars the state will receive under its new agreement with the federal government for funding Medicaid. This is the funding source Slen questioned.

Under the Global Commitment for Health agreement, the federal government has promised Vermont $4.7 billion over five years for state-subsidized health care. State officials project the Medicaid will require at least $4.2 billion in those years. Slen said the administration has plans for another $300 million, and he wants to hold at least $100 million in reserve in case Medicaid costs are higher than projected. The committee has been considering using $70 million from this fund.

“My recommendation to the governor has been we can’t be in a position that eats into that cushion,” Slen said.

Some committee members weren’t convinced of the administration’s math or Slen’s conclusion that their plan would consume the cushion. They had their own financial experts reviewing the numbers.

A parade of other witnesses, mostly advocates with special interests, offered the committee their comments on the bill.

“You did a good job setting the stage to move forward,” said Richard Davis, executive director of the Campaign for Health and a registered nurse.

He praised the comprehensive health coverage that would be offered to the uninsured and the plan to better manage treatment of people with chronic diseases such diabetes.

Davis questioned the requirement that someone who has insurance now would have to go a year without insurance before becoming eligible for Catamount Health. “I don’t understand that, if you want to promote access.”

Dr. Marvin Malek questioned the committee’s assumptions about how much money might be saved with the bill. “I don’t see administrative savings,” he said, noting that it wasn’t the single-payer system he advocated.

“If you are expecting there will be a lot of savings because of chronic care management, I’m not optimistic,” Malek added. He and others warned the system might not reap financial benefits from revamping chronic care for years.

Richter addressed the committee, too, before joining the noon rally. She told the panel they were repeating the mistake made by lawmakers in the 1990s by recommending repairs rather than reform of a broken health care system.

“Nothing in the bill offers cost relief in the near future,” she said. “It will result in more uninsured. And the bill makes no provisions for the under-insured.”

The committee will consider today how to react to all the comments it heard about the bill.

Vice Chairman Malcolm Severance, R-Colchester, observed late Tuesday, “We heard a lot today we have to listen to very carefully.”

Health care: the single payer vision

Letter
Louisville Courier-Journal
Friday, February 17, 2006

America has wonderful hospitals, clinics, and doctors. We conduct brilliant research. But there is a missing link: access to health services.

Some day, however, financial barriers to health care in America will be removed, and, finally, we will provide health care for all. Every resident will have affordable, high quality comprehensive health care. Infant mortality rates will fall, immunization rates and life expectancy will rise, and the World Health Organization will rank the efficiency of American health care first, instead of 37th. Health care will be disengaged from employment, freeing millions of health care hostages to pursue jobs they want, rather than jobs they take for health benefits.

Self-employment and entrepreneurship will become financially feasible. American business and manufacturing again will be competitive with countries that have national health plans. Without health benefits as a hiring issue, small businesses will compete equally with large ones for good employees. Medical bankruptcies — now half of all bankruptcies, and especially affecting the middle class — will vanish. Ninety-five per cent of Americans will pay less for health care than they do now.

Malpractice issues will diminish. Physicians will spend more time with patients and people will choose physicians and hospitals freely, rather than being forced into a market network. Money will not change hands between patients and providers, again improving doctor-patient relationships and leading to fewer claims. Since 60 percent of current settlement costs are for future medical care and everyone already will have medical care, settlements will go down and professional liability insurance costs will go down proportionately. Overhead in doctors’ offices will plummet because of vastly simplified billing to a single payer. Primary care physicians will be valued and reimbursed accordingly.

There will be no Medicaid crises, no unreimbursed care for doctors, hospitals or other providers, and no cost-shifting. Health-related issues associated with natural disasters, such as hurricane Katrina, or pandemic influenza, will be managed seamlessly.

A national electronic medical record system will detect medical errors quickly. Half a million Kentuckians are uninsured, 85,000 in Jefferson County. The dire straights of unhealthy Kentuckians have been dramatically portrayed in The Courier-Journal. Uninsured people forego doctor visits and necessary medicine; they postpone medical attention until illness is far advanced, more expensive to treat, and some cannot be helped.

Eighteen thousand Americans — six 9/11 bombings — die every year because they cannot afford medical care.

Privatization of traditional Medicare is a Trojan horse bringing more pain to a critically ill American health care system. Health insurance companies increase profits by raising premiums, reducing benefits, shifting costs to consumers, and providing coverage for only the healthiest.

The Medicare Prescription Drug Act specifically prohibits negotiation for volume discounts and requires private administration. It is an example of the difficulties of mixing profit-taking with health care delivery. It provides lucrative profits to insurance and pharmaceutical industries; but a high cost is borne by the American people. Dr. Oliver Fein, New York City internist, says: “I was outraged when one of my patients required hospital admission after stopping her medications, because she couldn’t afford the $45.57 co-payment demanded by [her new plan].” Health Savings Accounts, tax credits, consumer-directed health care, voucher sytems, etc. are Band-Aids for a failed experiment in health care delivery; they cannot control costs effectively, and they will not provide comprehensive universal affordable health care.

We have the highest health costs in the world, more than twice that of other developed nations that provide care to all of their citizens. We spend more, but we get less. We have the money now to provide excellent health care for everyone. A bill in the U.S Congress, HR 676, describes the details of a single payer national plan. The majority of American citizens support a national health program, and data indicate that the majority of physicians do so as well. We need non-profit single payer health care reform now.

GARRETT ADAMS, M.D., M.P.H.
State Coordinator
Physicians for a National Health Program — Kentucky
Louisville 40206

Louisville Courier-Journal: Readers' Forum

Originally published February 13, 2006

READERS’ FORUM

Providing health care for everyone: ‘Everybody in, nobody out’

I’m writing to thank state Rep. Joni Jenkins and her colleagues who raised their voices in support of HCR 40, a resolution that urges Congress to pass House Resolution 676, the United States National Health Insurance Act, which provides a system of universal single-payer health care insurance.

HR 676 is a publicly funded, privately delivered plan to address the current immoral system, which rations care to those who can afford it. The health care meltdown is accelerating, threatening families, stifling job growth and squeezing funds for education and housing. The solution is HR 676: Everybody in, nobody out.

The deep-pocketed interests that profit from the current collapsing system demonize the single-payer alternative as a form of socialized medicine, which it is not. The current system is bankrupting families, but not industry CEOs and their collaborators.
Ten years ago, Taiwan moved from a system similar to our current system to a single-payer model. Coverage was expanded from less than 60 percent to 97 percent of Taiwan’s residents. What’s the deal? Taiwan can figure this out, but we can’t?

Our current system leaves 46 million out, and millions more underinsured. George Washington wrote: “The admiration of justice is the firmest pillar of government.” Rather than shuffle and make excuses, Jenkins and HCR 40 supporters have taken a giant step forward for justice.

MARK McKINLEY
Louisville 40204

‘The right thing to do’

Thank you for the Jan. 30 article on single-payer health insurance. Most everybody knows someone who needs medical treatment but cannot afford it.

Before thinking that health insurance for all Americans is too good to be true, read U.S. Rep. John Conyers’ bill, HR 676, which outlines the financing. With the money that can be saved from the administrative costs and advertising of privately owned insurance companies, the U.S. government could provide health care services to all, as do Britain and Canada.

Federal and state funding of existing health care programs would involve a modest payroll tax on all employers of 3.3 percent, a 5 percent health tax on the top 5 percent of income earners, and a small tax on stock and bond transfers.

HR 676 would give us more ownership for health care. We could afford it and would be able to choose our own doctors. Morally, it is the right thing to do, and it makes good business sense. . . .

If you want this, ask your Kentucky state representative and senator to vote yes on HRC 40, which endorses the U.S. House bill, HR 676.

JILL HARMER
Louisville 40205

‘We’re all in this together’

In the Jan. 9 Readers’ Forum, single-payer health insurance was endorsed by a local Democratic club. As major corporations . . . crash under their commitments to employees, health insurance and pensions are of equal interest to Republicans.

Thanks to economy of scale, the cost to employers to provide health insurance was less than equivalent salaries, and it guaranteed a healthier workforce. Employees, in turn, bought it as a money-saver.

Today, our national piecemeal attempts to provide health insurance through employers are collapsing. The wonderfully proficient medical treatment available has made the gamble of health care insurance a game too expensive to get into.

Originally, employee pensions looked profitable if company profits increased to cover the eventual cost or if valued employees worked longer to collect the deferred compensation. Employees trusted management to hold part of their pay as savings for old age.

Today, so many companies are going bankrupt or ending up without the projected resources that even the U.S. Treasury can’t cover the needed pensions. . . . Republicans and Democrats, we’re all in this together.

PRUDENCE TODD MOFFETT
Masonic Home, Ky. 40041

Is medical care lacking but equal?

Who Is at Greatest Risk for Receiving Poor-Quality Health Care?
By Steven M. Asch, M.D., M.P.H., Eve A. Kerr, M.D., M.P.H., Joan Keesey, B.A., John L. Adams, Ph.D., Claude M. Setodji, Ph.D., Shaista Malik, M.D., M.P.H., and Elizabeth A. McGlynn, Ph.D.
The New England Journal of Medicine
March 16, 2006

We have previously reported that Americans receive about half of recommended health care and that there is remarkably little geographic variation in this rate. The present study demonstrates that the differences among population subgroups in the quality of health care, even when they are statistically significant, are small in relation to the gap between actual and optimal performance. These results underscore the profound and systemic nature of the quality-of-care problem.

We found that health insurance status was largely unrelated to the quality of care among those with at least minimal access to care. Although having insurance increases the ease of access to the health care system, it is not sufficient to ensure appropriate use of services or content of care. Indeed, within systems where access to care is more equitable, disparities in quality due to race or ethnic group or to other characteristics are often reduced or even reversed, but substantial gaps between observed and optimal quality remain.

To make substantial improvements in the quality of health care available to all patients, we must focus on large-scale, system-wide changes. Our previous study of the quality of care delivered in the Veterans Affairs health system illustrates some of the potential for improvement. In that system, with one of the country’s most mature electronic medical-record systems, decision-support tools at the point of care, automated order entry, routine measurement of and reporting on quality, and financial incentives for performance, we found that participants received 67 percent of recommended care, a considerably better rate than the 55 percent observed in the current study.

We have previously shown substantial deficits in the quality of care nationally and in metropolitan areas with very different market profiles. In this study, we have now shown that individual characteristics that often have a protective effect do not shield most people from deficits in the quality of care. As the Institute of Medicine has concluded, problems with the quality of care are indeed widespread and systemic and require a system-wide approach.

http://content.nejm.org/cgi/content/full/354/11/1147

Working Paper (technical appendix to “Who Is at Greatest Risk for Receiving Poor-Quality Health Care?”): http://www.rand.org/pubs/working_papers/2006/RAND_WR174-1.pdf

And…

Medical Care Lacking but Equal
By Rob Stein
The Washington Post
March 16, 2006

Blacks and Hispanics tend to receive slightly better day-to-day medical care than whites when they see a doctor, a large and surprising study has found, sparking new debate about the impact of race on health in America.

The study, the most comprehensive examination of the quality of primary care in the United States, found no significant differences among patients from different ethnic groups or incomes once they get to see a doctor, but a slight trend toward better care for blacks and Hispanics.

The researchers stressed, however, that other disparities in health care do exist. Poor people and minorities, for example, are less likely to see a doctor in the first place and they receive far less expensive care. In addition, the minor variations among racial groups found in the study are swamped by the low level of care everyone gets, they said.

“The obsession with racial disparities is a distraction from what we really need to do, which is improve health care for everyone,” said Sally Satel, who studies health care at the American Enterprise Institute, a conservative think tank. “This shows us that, if anything, minority groups actually have even somewhat better outcomes.”

http://www.washingtonpost.com/wp-dyn/content/article/2006/03/15/AR2006031502120.html

Comment: By Don McCanne, M.D.

To understand what was measured in this study, you should glance at the technical appendix at the link above. Some of the quality indicators listed are clearly high priority items and most of those do have a very high mean score for compliance. Some items are low priority, and it would be unreasonable to expect them to be included in every medical record for the given clinical event. Some are controversial and should not be included as arbitrary measures of quality. Many others may be addressed during the clinical interaction but might be included in the record only if the clinician were compulsive about detailed charting even though the item is of only nominal significance.

If you were to go through the list and weight the relative importance and effectiveness of each quality indicator, the scores would be much higher than the 55 percent reported. Nevertheless, we can do better, and we should attempt to do so.

A major concern about this study is that the overestimation of quality impairment was used to demonstrate that the lack of insurance or the presence of unfavorable sociodemographic factors had little bearing on these quality parameters. Thus, Sally Satel of AEI makes the outrageous statement that “minority groups actually have even somewhat better outcomes.” In fact, their broad sweep of what they define as recommended care was so broad, and so bluntly focused, that it obliterated well documented differences in access and outcomes.

Innumerable studies have proven that health disparities and the lack of insurance maim and kill people. This study should not deter us in the least from continuing our fight for health care justice.

America's quality care is going to the dogs

Toronto Star
Mar. 5, 2006
Canadian taxpayers should have full access to the system – and doctors – they pay for By Linda McQuaig

The wonderful thing about the Canadian system is that it operates on a higher principle than the marketplace; access is determined by human need, not money. We can improve it without tampering with this profoundly important principle.

The baffling question is why (Alberta Premier Ralph) Klein wants to be remembered for moving us closer to the U.S. system, where a rich person’s dog can get better medical treatment than tens of millions of Americans.

http://www.thestar.com/NASApp/cs/ContentServer?pagename=thestar/Layout/Article_Type1&c=Article&cid=1141426212450&call_pageid=968256290204&col=968350116795

Comment: We’ll probably have to continue to accept inadequate health care for low-income American dogs, but how can we continue to accept that for our people?

Los Angeles Times notes momentum of single payer

Why pick on Wal-Mart?
Editorial
Los Angeles Times
March 2, 2006

Although healthcare spending is expected to jump to $4 trillion in the next decade – to 20% of the nation’s gross domestic product – the number of uninsured is increasing by more than a million people a year, and Americans are no healthier than citizens of countries that spend half what we do. That’s the definition of bad medicine.

Fortunately, the public appears to be growing so tired of the problem that national healthcare reform is all but inevitable. Proposals range from a comprehensive overhaul to minor tweaks. More moderate reforms could simply increase the number of low-income adults eligible for existing public programs. And even after President Clinton’s disastrous healthcare reform proposals a decade ago, momentum is growing again for a “single payer” government agency that would insure everyone in the country.

http://www.latimes.com/news/printedition/opinion/la-ed-walmart02mar02,1,4847708.story

Comment: By Don McCanne, M.D.

Although the primary thrust of this editorial was to criticize the Wal-Mart targeted employer mandates as inadequate and misdirected measures, the significance of this excerpt cannot be understated.

This is not an endorsement of single payer, but rather it is a much more important comment on the momentum of the single payer movement. The editorial staff of one of the nation’s leading newspapers has observed that “momentum is growing again for a ‘single payer’ government agency that would insure everyone in the country,” and they have done so without adding the heretofore obligatory phrase, “but it is not politically feasible.”

Single payer is looking more and more like the only option that will work. Feasibility becomes a moot point when it is ever more clear that you just have to go ahead and do it.

Interview with Dr. David Himmelstein

Healthcare for All: The Campaign for Single-Payer Health Insurance in Massachusetts and the United States
Multinational Monitor
Originally published December 2000
Volume 21, Number 12

INTERVIEW

David Himmelstein is an associate professor of medicine at Harvard Medical School and co-founder of Physicians for a National Health Program. The author of numerous studies and books, he is a leader in the movement for universal health care. He was also an author of the recently defeated Question 5, a Massachusetts initiative that would have delivered universal health care for the citizens of the Commonwealth.

Multinational Monitor: Why does the United States need universal health care?

David Himmelstein: Forty-three million people in the United States have no health insurance at all, and tens of millions more have such inadequate coverage that if they were seriously ill, they would be bankrupted. Millions of Americans don’t get the care they need. And simultaneously, we are throwing away huge resources on useless bureaucracy, outrageous profits, outright fraud and unnecessary overtreatment for many patients. We need a thorough revision of our system to deliver the care to the people.

We now have the most expensive health care system in the world. We pay money to middlemen – private insurance companies and HMOs – who do nothing useful. These private insurers act on behalf of employers to limit care to patients and simultaneously extract profits for themselves and other health care providers.

MM: But the insurance companies do provide coverage to tens of millions of people in the United States, right?

Himmelstein: They pass some of the money paid in premiums along to the doctor or to the hospital, but they charge an extraordinary fee for doing that. The average private insurer in this country takes about 13 to 14 percent of the total premium dollar for their overhead.

By contrast, Medicare runs for about 2 percent overheard. The Canadian national health insurance program runs for less than 1 percent overhead.

In the sense that the private insurance companies spread risk and carry out the insurance function, that’s a useful function. But they do it in an extraordinary inefficient way that enriches themselves and their business partners.

MM: You support a Canadian-style single payer system?

Himmelstein: Right, but a national health service like Britain’s would be fine, also.

MM: What’s the difference between Canadian and British systems?

Himmelstein: Canada has provincial health insurance plans. In each province, everybody is covered under a single government-run health insurance plan. You pay your taxes, and your taxes go to cover everybody. That plan then negotiates with all of the hospitals in the province on what each of their budgets is going to be. Instead of paying for hospital care band aid by band aid, aspirin tablet by aspirin tablet, they negotiate with the hospital their entire budget for the year, and they pay them one check a month for that budget.

Doctors submit all of their bills to the public plan, and get paid on a fee-for-service basis. The fees are negotiated between the doctors and the provincial health plan.

In Canada, the doctors have remained in private practice, though they are paid by the public system. Hospitals have remained mostly private, although again, they receive their payments from the public insurance system.

In Britain, the hospitals are owned by the government. The specialists are employed on salary by government as employees of the hospitals.

MM: Why not fix the system here in the United States?

Himmestein: We ought to fix the current system, but there is nothing that will work short of national health insurance.

We have had a series of patchwork reforms over the last 20 years now, and we have more uninsured people today than we had 20 years ago. And despite the economic boom, we have made no dent in the number of people who are uninsured.

We passed the children’s health insurance program two or three years ago, but there are as many uninsured children now as there were two or three years ago, because health care costs keep rising, and fewer people can afford private coverage. The public expansions don’t keep pace with the cutbacks in private coverage most years.

Basically, as a private insurance firm, the way you make money is to avoid sick people. There has been no effective way of policing that.

The problem is that unless you require that either an employer buy coverage for an employee, or that an individual buy coverage, there is no way of making universal coverage in a private insurance system. Moreover, poor people are least likely to be able to afford medical care, and are often the sickest people in the society.

MM: How many uninsured people are there in the United States?

Himmelstein: Forty three million – that’s about 15 percent of the population.

MM: What happens when an uninsured person gets sick? Who pays?

Himmelstein: It depends on where they are and exactly what they are sick with. It varies from community to community. If you are sick enough to be in imminent danger of dying, then a hospital is required to stabilize you or risk a fine from the federal government. Several dozen hospitals get that kind of fine every year, so it does happen that even very sick people are denied care.

If a hospital treats an uninsured patient, the hospital tries to collect from you, and if they can’t collect from you, then they write it off as free care. In some states, there are some state funds available to subsidize that care, in others not. In some cities there are some public hospitals available to help subsidize that care and others not.

If you are not very ill, in some places, you may not be able to get any care. In other places, there are some systems of care for the uninsured, either locally subsidized or at reduced rates.

There are 300,000 people refused care in hospital emergency rooms every year because they can’t pay.

MM: Under a system of national health insurance, what happens to the insurance companies?

Himmelstein: They are eliminated.

The total health budget in the United States is about $1.2 trillion. About $300 billion is administration, and you could probably eliminate about $175 billion of it with rational health insurance system.

It is very clear that if you streamline the system and took the administrative waste out of it, you could give Cadillac care to everybody in the country for what we are now spending. The General Accounting Office has studied the question, and confirmed that. The Congressional Budget Office found that. A right-wing consulting firm made estimates that are in line with that.

MM: Can national health insurance supporters in the United States overcome public distrust of government?

Himmelstein: Most Americans have some distrust of government. One of the organizations they like even less than government is private insurance companies. And those are the only two options for running our health insurance system.

Surveys show that universal coverage is enormously popular. If you give a reasonable description of a Canadian-style health care system, about 55 to 60 percent say they support that.

MM: So why doesn’t the United States have a national health insurance system?

Himmelstein: First, national health insurance means a major redistribution of income. At present, the poorer you are, the larger the proportion of your income you spend for medical care. And if you go to a tax-funded national health insurance plan, presumably you are going to fund it out of a vaguely progressive tax. And rich people are going to pay a higher proportion of their income and poor people are going to pay a lower proportion of their income. It implies a substantial redistribution of income.

Second, national health insurance attacks a major concentration of corporate power. Some of the largest and richest firms in the country are health care firms. You are putting out of business HMOs and health insurance companies.

And you are severely affecting the profits of others. The drug industry, which has been the most profitable industry among the Fortune 500, would be faced by a single national purchaser of their drugs. And they wouldn’t get away with the rip-off prices that are routine for them now.

The government will say to the drug companies, “We are not willing to pay for the $12 billion a year that you spend to miseducate doctors.” That’s the marketing and sales force, which they would presumably have to justify as a cost, if they were bargaining with the government. The drug companies would not be in a position to justify those costs.

MM: Question 5 was a universal health care proposition on the ballot in Massachusetts in November. What would it have done?

Himmelstein: It would have done three things.

First, it would have required our state legislature to pass universal coverage by July 1, 2001 and implement it by July 1, 2002. The system was required to eliminate barriers to care. It had to maintain a free choice of provider for patients. It had to minimize incentives for overcare and undercare.

Question 5 didn’t specify how universal coverage should have been carried out. And clearly, if it had passed, there would have been a major debate in our state about exactly how to do it.

It would have set up a commission to advise the legislature on how it ought to have been done. And on the commission would have been several advocates of a Canadian single payer system.

MM: Why weren’t you explicit about how the single payer system would have worked?

Himmelstein: Under the laws in Massachusetts, you can’t appropriate money with a ballot initiative. We couldn’t actually put in place a new tax structure to fund health care and specify that degree of detail. Second, specifying a system in detail would have required many pages of detailed text. We knew we were going to be tremendously attacked by the insurance industry and others. And we thought that the possibility of having a reasonable debate about the detailed structure of the system was almost nil given the political system in our state.

For tactical reasons, we decided that the first step was to say, “There needs to be universal coverage, and here are some broad outlines. Let’s set up a commission that includes a majority of single payer advocates. And then within six months, let’s proceed to the next step.”

There were two other clauses. One would have banned conversions of hospitals and HMOs to for-profit businesses. The other would put in place some restrictions on HMOs immediately. They would have to spend at least 90 percent of premiums on medical care. It would also have required them to allow patients to go to any doctor licensed in the state. And it would have outlawed financial incentives to doctors to restrict care.

MM: Who in the state supported Question 5?

Himmelstein: Question 5 was initially proposed by an ad hoc group of doctors, nurses, psychologists and other health professionals. We went around and started to build a broader coalition with some friends and colleagues who had some more political sophistication that we did.

They rounded up a number of groups that were going to support it, including the AFL-CIO and some consumer advocacy groups including Health Care for All, which has Families USA as its Washington, D.C. counterpart.

The groups collected the signatures to get the thing on the ballot – 120,000 signatures. Those signatures were collected last fall. And this spring we collected another 15,000. Under Massachusetts law, you have to collect two sets of signatures.

The legislature started to panic about this initiative being on the ballot. And the HMO industry did as well.

A patient protection bill, which had been stalled by the HMO lobby in the legislature for three years, suddenly began to move. And it was clear the HMOs had instructed the legislative leaders that they needed that thing to pass, and they wanted the ballot initiative to be removed. A last minute deal was struck between the HMOs and the major groups that had signed on to the initiative. The patient protection bill would become law and in exchange, the initiative would be pulled off the ballot at the last moment.

That left only the League of Women Voters and the original ad hoc group of doctors, nurses and other individual professionals supporting it. We were left with no organization, no money and little political savvy.

MM: What did the patient protection act do?

Himmelstein: It put in place the right to appeal if an HMO denied you care. It put in place a structure to regulate for-profit conversions of hospitals and HMOS. It set up a commission to advise the legislature on universal coverage, although there was no mandate that the legislature had to do anything about it.

We rejected the deal because the patient protection act was more or less the same reforms they put in place in 30 other states, and those laws have had no noticeable effects on health care in those states. Instead of prohibiting conversions, it laid out how an HMO or hospital could be converted to an investor-owned organization.

Third, it set no deadlines, and no requirement for universal coverage. It just set up a commission that was not likely to act. So, we thought the deal was nothing but a sham and didn’t effectively accomplish anything.

MM: But once on the ballot, the AFL -CIO and Health Care for All could not remove the initiative?

Himmelstein: They felt they could. The negotiations on the deal were being conducted right around the time when the final signatures were due earlier this year. Our allies turned the sheets with the signatures in because the patient protection act legislation was dragging. And they thought they were turning in the signatures as a stick to put over the heads of the legislative leaders to conclude the legislative wrangling.

They turned them in to the Secretary of State. Then they tried to withdraw them. At that point, the rest of us who had been involved said, “No, you can’t withdraw them.” And the Secretary of State ruled in our favor.

MM: So, you get on the ballot. At that point, who was supporting you and who was opposing you?

Himmelstein: Our major supporters were colleagues. The biggest organization was the Massachusetts Nursing Association. The League of Women Voters was important. And individual doctors and nurses. That’s about it.

The opposition was the business community and particularly the HMOs in Massachusetts. The HMOs kicked in at least $5 million. Organizations like Raytheon and some other big businesses kicked in money. They saturated the television and radio airwaves.

MM: What was their argument?

Himmelstein: They argued that this proposal would raise costs tremendously. They commissioned a study that claimed that universal coverage would increase costs by 40 percent in Massachusetts. That is a fairly bizarre notion. We are already 30 percent above the national average in our state.

We are spending $6,000 per capita in Massachusetts on health care. The notion that we would raise that to something like $8,000 per capita is bizarre. There is no place else in the world that spends more than $2,500 per capita on health care. In the United States, we are spending $4,000 per capita.

There is no serious health policy person who believes that under universal health care we would be spending $8,000 per capita. But they commissioned studies that purported to show that and the news media covered those studies as if they were true.

There have been two serious studies of what statewide health insurance program in Massachusetts would cost. Both of those were commissioned by the Massachusetts Medical Society, by no means a left-wing organization. And both concluded that you either save money, or it might increase costs a little in the first year, and then you start to save money.

MM: They spent $5 million, you spent $60,000. They had ads all over the airwaves, you had no ads. You relied on free media. Did you get much publicity?

Himmelstein: A fair amount. The last week or two, when it became clear that we had a serious chance of winning this, the press actually began to cover it. The problem was that the folks working on the campaign for us were doing it in our spare time, after working full-time jobs. And we were not in a position to spend our days thinking up lies to tell, like the opposition was doing.

They would put out a raft of lies, which the press would report, and we would then try and counter those, but by no means have the time or resources to go after each one.

MM: What were you expecting in terms of percentage of the vote?

Himmelstein: We didn’t know what to expect. The polls showed that we were ahead 75 to 25 at the beginning. We thought we would probably go down fairly fast from there, but a week before the election, the polls showed us at 60 to 40. We started to think that we might win it, especially after Senator Ted Kennedy said he was going to vote for it. And during the last week, a few politicians began to filter to the front of the parade, since they apparently thought the thing might pass.

If we had only a minimally competent campaign, it would have passed. We lost in the end 51 to 49.

If we had signs at half the polling places in the state that said – Ted Kennedy says vote yes on Question 5 – we would have won easily. But we weren’t organized enough to do that.

MM: Are you bitter about this?

Himmelstein: No, we are tremendously energized by this. We made every conceivable mistake. We ran the most incompetent campaign possible. We were deserted by all of our allies.

And we still got 49 percent of the vote. We feel like all we need to do is do this right and we will win easily.

MM: Do you plan to do it again?

Himmelstein: Yes, in 2002.

MM: When is the United States going to get universal health care?

Himmelstein: We are going to have a major debate about this in the next three or four years. When we are going to get it is more difficult to say. We’ll have opportunities for it in a major way. The system is becoming unstable. Costs are rising very rapidly. In the early 1990s managed care firms said to employers, “We will hold down your costs if you give us control of the system.”

From 1994 to 1997, health care costs rose more slowly than they did in the late 1980s and early 1990s. And big employers closed ranks behind the existing health care system. While patients were dissatisfied, the system was fairly stable at that point.

Now, you have the re-emergence of health care inflation. And that is a major destabilizing force. Now it is clear that HMOs have not succeeded in containing costs and are not likely to. We are going to have to have some other major reform of our health care system to contain costs.

That creates divisions in corporate America and allows for an opening for debate that otherwise is difficult to create. The implementation of HMO control of the system in the early 1990s was quite brutal, not only for uninsured patients but for many insured patients. That spread a reaction among not just the poor, but many middle class people who are now dissatisfied with the system.

It creates an opportunity for a broad coalition for change. Surveys show that something like 55 to 60 percent of doctors now are in favor of national health insurance. The majority of all medical school deans in the United States have explicitly endorsed single payer health insurance.

MM: Why isn’t that support being translated into political support in Washington?

Himmelstein: No firm in the U.S. has ever advocated the nationalization of any industry. General Motors is upset that its health care costs are going up, but they are not yet ready to say that the preferred solution is the elimination of a private capitalist industry.

MM: Has legislation been introduced in Congress?

Himmelstein: Yes, regularly since 1948. But it never goes anywhere. In the early 1990s, 70 or 80 members of Congress supported it. Now there are about 20 or 30 members who actively support it. If there were a serious organizing effort, we could get back to 50 or 60 members supporting it.

But, the Congress is going to be the last place to act. We are going to need to create a major groundswell for change before Congress acts.