Resource – Page 1082

Long-time PNHP Board Member Carol Kirschenbaum Passes Away

Dr. Carol B. Kirschenbaum passed away peacefully in her home comforted by her husband Dennis and sister Susan early Thursday morning. Her passing concluded a courageous eight-year struggle with cancer, which was only the last in a long list of battles Carol fought and led. Born in Brooklyn, graduated from Bayside High and from Queens college, Carol came to Durham NC to train as a Physician Assistant (PA) in 1979 at age 29, following a brief career as a Special Education instructor. Carol actively cultivated and enjoyed close relationships with dear friends and family providing strength, support, love and many good times. She is survived by her mother, Pearl and brother Howard as well as her husband, sister and six nieces.

Carol practiced medicine first as a PA within UNC hospitals working in the Radiation Oncology unit. She was encouraged to continue her medical training towards an MD after her mentors witnessed her dedication to patient comfort and well-being. She trained at UNC-CH in medical school and also for her residency in Internal Medicine. During these years, Carol was actively involved in political and cultural events in the Triangle, founding Progressive Jewish Network, working on various Middle East and Central American Peace Committees, traveling to Nicaragua, working on medical relief to both Nicaragua and Palestine and as a board member of NC-Occupational Safety and Health Project along with other causes for social and racial justice.

Carol and Dennis met in late 1990. They married within the year having quickly recognized their soulmates in commitment to community, the outdoors and celebrations with friends and family. They enjoyed backpacking, swimming, camping and kayaking. They shared a special love for cross-country skiing, enjoying one pilgrimage north every year to enjoy the serene beauty of the quiet snow-covered woods. Most of these activities were continued and appreciated even more after Carol’s diagnosis of ovarian cancer.

As a physician Carol’s dedication to her patients was unparalleled. She was the only physician in our state who was trained in treating patients with lymphedema. Indeed, Dr. Kirschenbaum frequently saw patients who had not found care in neighboring states. Several of her patients for whom she was the primary physician had complex medical conditions, some severely obese. Many of these patients were “unprofitable, time-consuming patients” and had previously had little success in finding quality care. Carol advocated for the needs of patients with lymphedema and served for many years on the subcommittee for Lymphedema with the NC Cancer Care Commission.

During the most recent decade of her life Carol had been a leading proponent of universal health care in our state, as an organizer, first, for the NC chapter of Physicians for a National Health Program (PNHP) and then as a founding member and President of the North Carolina Committee to Defend Health Care (NC-CDHC). She saw NC-CDHC grow gradually into a vital statewide organization. Dr. Kirschenbaum was on the National Board of PNHP for several years, where she lobbied for recognition of the work being done at the state level and to establish a Right to Health Care, similar to the Right to Education (primary and secondary). Carol’s life continues to inspire those who witnessed her dedication to society’s least fortunate and underprivileged. Find out more about NC-CDHC at www.NCdefendhealthcare.org

Together with her husband a new national project was initiated to support and improve communication between all the organizations working for universal health care at the state level in 21 states. That project, Project EINO, based at www.EverybodyInNobodyOut.org has also become a major proponent nationally for the Right to Health Care at www.RightToHealthCare.org .

MEMORIAL FUND:

It is Carol’s wish that donations be made in her honor to “NC-CDHC” to be split between the state work and the national project. Please mark the check “Honoring Dr. K”. Such donations should be mailed to NC-CDHC/ 1815 MLK Pkwy #2, PMB #142 / Durham, NC 27707.

FUNERAL:

The funeral will be held at 10a.m. on Sunday at the Howerton-Bryan funeral home 1005 W. Main Street, Durham, NC. Following the funeral service a procession will take place to Markham Memorial Gardens.

SHIVA (BRIEF VISITS WITH FRIENDS AND FAMILY):

Family will be present at 306 Monticello Ave, Durham for Shiva. During the “shiva” friends and the entire community of Carol and Dennis’ contacts are invited to drop by and visit (no permissions, or scheduling is performed, in fact enter premises without knocking, or find your way around to back of house if weather is nice).

Shiva will be Sun, Mon, Tues 2-8 and Weds 12-4 (June 19 – June 23). If you wish, you can bring some fresh fruit, or salad to share.

306 Monticello is 3 blks from the corner of University Dr. and Cornwallis Ave in Durham. Proceed one short block SE on Cornwallis past the signal light that is Univ Dr, taking first right on small side street (Stuart), go 1/2 block to first street on left (Monticello Ave), go down almost two blocks to 306 – on left and only house on Street with a split rail fence in front yard.

Honoring Dr. K

Carol Kirschenbaum’s vision lives on
By Bob Geary
altweeklies.com
June 22, 2005

The best thing about writing for the Indy is the chance, on a pretty regular basis, to talk to people who are generous of spirit and engaged in the hard work of trying to make the world a better place for the rest of us, not just for themselves. Even so, Dr. Carol Kirschenbaum stands out in my recollection. I met her five years ago, when she first went to the General Assembly with a simple idea–that “appropriate health care on a regular basis” should be everyone’s right in North Carolina. Carol was a fighter with a gentle soul. She was ahead of her time–we trust that’s the case, anyway–in seeing medicine as a gift to share, not something to be put up for bid. She knew her own time might be limited, and the goal beyond her own reach. But she kept on, with determination and a smile.

When I learned that Carol died last week at age 55, ending her eight-year battle with ovarian cancer, I re-read my story about her, called “Dr. K’s Cure.” We could run it again today, if we just changed a few numbers. North Carolina had almost 1 million people with no health insurance five years ago. Now we have 1.4 million. For those with insurance, premiums were increasing by almost 10 percent a year then. Now it’s double-digit increases, or else big co-pays and deductibles.

Carol’s legislation, which sought a referendum to amend the state constitution, was House Bill 1396 then. Now it’s HB 1358. The amendment, modeled after a similar provision about public education, would read: Health care is an essential safeguard of human life and dignity, and there is an obligation for the State to ensure that every resident is able to realize this fundamental right. Not later than July 1, 2007, the General Assembly shall provide by law a plan to ensure that by July 1, 2011, every resident of North Carolina has access to appropriate health care on a regular basis.

The politics of health care being how they are, Carol’s amendment is going nowhere in the legislature of 2005, just as it went nowhere in 2000. This country, alone among the so-called advanced nations of the world, still sells health care in the marketplace while treating the poor–belatedly, inadequately–out the back door. It was immoral then, as she said. It’s immoral now.

Carol Kirschenbaum wasn’t your typical doctor. For one thing, she worked as a special education teacher and then a physician’s assistant at UNC Hospitals before going to medical school at UNC-CH in her 30s. As her husband and partner, Dennis Lazof, wrote in an eloquent obituary (you can read it at www.ncdefendhealthcare.org/obit.htm ), she stood out to her mentors from the start for her dedication to patient comfort and well-being. She never lost that. Though her cancer eventually limited her ability to practice, she continued for as long as she could to care for a number of “unprofitable” and time-consuming patients who suffered from a disease called lymphedema that other doctors steer clear of.

As the founder of the N.C. Committee to Defend Health Care, Carol stepped into the debate over reforming medicine in the wake of the Clinton reform-lite disaster of 1993-94, when Democrats tried to get this country’s insurance companies to act a little more like healers and less like heels. She was convinced that only a single-payer system–a public system, that is, paid for by you and me–could rationalize the piecemeal services, and lack of services, that the health-care industry has created for us. But that would be step two, she thought. And maybe somebody else could think of a better idea. Step one was embracing health care as something we’re all equally entitled to have, regardless of income or place of employment. That’s what the amendment’s about.

Dennis was sitting shiva with family and friends Monday night at their home in Durham. He, too, is a gentle soul, and the talk was about good times and how they fell in love. When shiva ended, I asked him if Carol had been discouraged by the lack of progress toward reform. Not at all, he said. She was optimistic. Dennis, too, who was Carol’s partner in everything including NC-CDHC and a broader, national initiative of his own devising that you can read about on the Web site, thinks a breakthrough is coming.

Why? First, more and more people see that the current system doesn’t work. Huge sums of money are wasted as “providers” try to avoid the sickest, poorest patients. So support for change is growing “at a grassroots level.” Second, businesses recognize that skyrocketing insurance costs, and the uncertainty of coverage for their employees, is making them unstable. If you doubt that, ask any small business owner. For that matter, ask General Motors.

It won’t be long, Dennis believes, before business starts to call for universal public health care in the same way that, a century ago, it called for universal public education. “That started with a call in one state too, and then it spread to other states,” he said. “That’s how reform happens.”

Carol was very sick the last year, and he was her primary caregiver, so their work for the NC-CDHC lately was “weak,” he said. But the good news is, others have stepped forward to provide leadership and raise money. The committee has much more support now than ever, and is on the verge of being staffed full-time, he said, from an office that is not in their house.

It’s Dennis’s hope that Carol’s life, and death, will inspire a renewed push for reform. Donations to NC-CDHC will be split between work at the state level and the national project. Checks should be marked “Honoring Dr. K” and mailed to NC-CDHC, 1815 MLK Parkway #2, PMB #142, Durham, NC 27707.

It’s time to bypass employers and try a single-payer health care system

Let’s let employers get out of the medical care business
By Jack E. Lohman
Milwaukee Journal Sentinel online
Posted: July 3, 2005

After spending 35 years in the health care industry, I never thought I’d be supporting more government involvement in medicine. But, clearly, our private system is broken.

Double-digit increases in health care costs are driving manufacturing jobs out of the country. That will continue if the system is not fixed.

Today, more Big Three autos are being made in Ontario than in Detroit. General Motors’ planned cuts of 25,000 jobs expose a trend that has been in progress for years:

GM spends $6,500 per year per employee in the United States for health care. But as it builds more of its cars in Canada, its costs will decrease to an $800 per employee per year tax to help cover that country’s single-payer system.

The sticker price on every GM vehicle includes $1,500 for health care, compared with $186 for Toyota.

What else can we reasonably expect but exodus?

It is by historical accident that employers provide medical coverage, and 40% of business leaders now want out of it. Canada’s single-payer system makes the most sense, although we can eliminate their wait times.

Even with its legendary wait times – which are short to non-existent when urgent procedures are required – Canada’s life expectancy is two years longer than ours, its infant mortality 35% lower, and all with 40% less in costs.

Turning health care administration over to one payer, as Medicare did, would keep the independence of physicians and hospitals and still allow patients full physician selection. It’s just a different way of paying the bill.

It would reduce administrative costs from a typical 30% to Canada’s 8%. Medicare’s is less than 4%. Using Medicare’s rules and fee schedule would ensure fair reimbursement, although increasing its rates slightly would make it fairer and still be less costly than what we have today.

Excessive and unnecessary testing easily adds 25% to our exorbitant health care costs, and that misuse must be curtailed.

One for-profit HMO pays its CEO $7.2 million annually, and he holds $720 million in company stock. That is patient money that is not being used for patient care. Independent physicians and hospitals are not totally free of extravagances, which also drives costs up.

Who would pay for a single-payer system? The same people who are paying for it today: Taxpayers.

We all pay for the present health care system, which costs some $1.6 trillion each year. And 100% of this money comes from we the people, through taxes, premiums, co-pays, deductibles, purchases, employer tax breaks and the other methods we use for collecting money.

When we buy a product, that company adds its health care costs to the price, and we pay at the cash register. What we are really talking about changing is how we collect and use the same money.

At the federal level, the health care, insurance and pharmaceutical industries are doing everything in their power to block progress toward an efficient system. While getting rid of our moneyed political system would fix this and many other societal problems, that isn’t going to happen soon. Politicians like the flow of campaign cash just as it is.

In the meantime, the states can act to keep jobs at home.

We can establish our own single-payer system by contracting with the same company that administers the Medicare system. With the savings, we could replace BadgerCare and Medicaid and cover all Wisconsin families.

It all makes sense for the public, but that may be its downfall.

Jack E. Lohman of Colgate is a former CEO of an independent diagnostic testing facility in Milwaukee and is executive director of www.WiCleanElections.org .

High prices contribute to high costs

Health Spending In The United States And The Rest Of The Industrialized World
By Gerard F. Anderson, Peter S. Hussey, Bianca K. Frogner and Hugh R. Waters
Health Affairs
July/August 2005

Do Americans have access to a greater supply of health care resources?

Surprisingly, Americans have access to fewer health care resources than people in most other OECD countries, measured in three major categories:
hospital beds per capita, physicians and nurses per capita, and magnetic resonance imaging (MRI) and computed tomography (CT) scanners per capita.

How much savings are possible through waiting lists?

Waiting lists could explain part of the difference in health spending between the United States and other OECD countries. However, there are several reasons to believe that they explain little of the difference.

First, not every OECD country experiences waiting lists, although every country spends much less than the United States on health care. The OECD Waiting Times project identified twelve OECD countries that considered waiting times for elective surgery to be a high priority but also identified seven countries besides the United States that did not perceive that they had a problem with waiting times. Health spending in the twelve countries with waiting lists averaged $2,366 per capita, while in the seven countries without waiting lists, it averaged $2,696-both much less than U.S. spending of $5,267 per capita.

A second reason is that the procedures for which waiting lists exist in some countries represent a small part of total health spending. Using U.S. survey data, we calculated the amount of U.S. health spending accounted for by the fifteen procedures that account for most of the waiting lists in Australia, Canada, and the United Kingdom. Total spending for these procedures in 2001 was $21.9 billion, or only 3 percent of U.S. health spending in that year.

From the Discussion:

Although malpractice litigation is a growing problem in the United States as well as in Australia, Canada, and the United Kingdom, there is limited evidence that it is responsible for much of the difference in health spending levels between the United States and these countries. In all four countries, malpractice litigation costs for claims against physicians are small compared with total health spending.

Another piece of conventional wisdom about why U.S. health care costs are so much higher than other countries’ is also probably overstated. It is common for people to wait for nonemergency medical procedures in some OECD countries, but these procedures do not contribute much to health spending.

In the United States, the procedures that necessitate waiting lists in other countries would account for only 3 percent of health spending.

The finding that litigation and waiting lists do not explain most of the higher U.S. health spending is perhaps not surprising considering previous research showing that the prices of care, not the amount of care delivered, are the primary difference between the United States and other countries.

These higher prices are increasingly making health care unaffordable for many Americans. Equally troubling, the more-costly U.S. health care has not resulted in demonstrably better technical quality of care or better patient satisfaction with care. Future U.S. policies should focus on the prices paid for health services and on improving the quality of those services.

http://content.healthaffairs.org/cgi/content/abstract/24/4/903

And…

Outcomes and Cost of Coronary Artery Bypass Graft Surgery in the United States and Canada
By Mark J. Eisenberg, MD, MPH; Kristian B. Filion, BSc; Arik Azoulay, BComm, MSc; Anya C. Brox, BSc; Seema Haider, MSc; Louise Pilote, MD, MPH, PhD
Archives of Internal Medicine
July 11, 2005

Coronary artery bypass graft surgery (CABG) requires substantial resources in Canada and the United States. However, patients undergoing CABG at US hospitals incur approximately twice as much cost compared with those at Canadian hospitals, with little difference in clinical outcome and despite shorter average LOS (length of stay). The difference in total in-hospital costs is almost equally attributable to differences in direct and overhead costs between the Canadian and US hospitals. This cost differential primarily reflects higher resource prices for products and labor and higher overhead costs in the United States resulting from a nonsocialized medical system.

http://archinte.ama-assn.org/cgi/content/abstract/165/13/1506

Comment: So why are health care costs so much higher in the United States than in other industrialized nations? Clearly, prices are higher.

Why are prices higher? Often the reason given is that we offer more high tech care than do other nations. But these studies suggest that we don’t, and, even if we did, we are not purchasing any improvement in quality outcomes. Although the costs of malpractice litigation and defensive medicine are frequently cited as a major contributor, these account for an almost negligible amount of the higher prices in the United States. Neither does the aging of the population account for a significant portion of the international variations in spending.

The authors tend to dismiss the administrative waste inherent in our system as being only a minor contributor to increased U.S. health spending. But numerous other studies confirm that the administrative burden is excessive and can be reduced with significant savings. Another potential source for savings by which all nations could benefit would be to identify and adjust supply side excesses (over-utilization) which fail to improve outcomes.

One other important factor that partially explains our high prices is that they are correlated with higher U.S. incomes and higher cost of living.

While we can be thankful about our nation’s wealth, most of us are quite upset about our excessive health care prices, especially when we can do something about it. We can begin by instituting administrative simplification and negotiated pricing through a single, universal health insurance program.

Bigger and Better

When it comes to providing broad-based social-insurance programs, it’s the government that’s rational and the market that’s dumb
By Jacob S. Hacker
The American Prospect
Issue Date: 05.06.05

Remember those bumper stickers during the early-1990s ﬁght over the Clinton health plan? “National Health Care? The Compassion of the IRS! The Efﬁciency of the Post Ofﬁce! All at Pentagon Prices!” In American policy debates, it’s a ﬁxed article of faith that the federal government is woefully bumbling and expensive in comparison with the well-oiled efﬁciency of the private sector. Former Congressman Dick Armey even elevated this skepticism into a pithy maxim: “The market is rational; government is dumb.”

But when it comes to providing broad-based insurance — health care, retirement pensions, disability coverage — Armey’s maxim has it pretty much backward. The federal government isn’t less efﬁcient than the private sector. In fact, in these critical areas, it’s almost certainly much more efﬁcient.

To grasp this surprising point, it helps to understand how economists think about efﬁciency. Although politicians throw the word around as if it were a blanket label for everything good and right, economists mean something more speciﬁc. Or rather, they usually mean one of two speciﬁc things: allocational (or Pareto) efﬁciency, a distribution that cannot be changed without making somebody worse off; or technical efﬁciency, the most productive use of available resources. (There’s a third possibility, dynamic efﬁciency, but we’ll take that up in a moment.)

When the issue is health insurance or retirement security, allocational efﬁciency is really not what’s under discussion. Nearly everyone agrees that the private market won’t distribute vital social goods of this sort in a way that citizens need. Before we had Social Security, a large percentage of the elderly were destitute. Before we had Medicare, millions of the aged (usually the sickest and the poorest) lacked insurance. If we didn’t subsidize medical care — through tax breaks, public insurance, and support for charity care — some people would literally die for lack of treatment. Market mechanisms alone simply can’t solve this problem, because private income is inadequate to pay for social needs. This is one of the chief reasons why government intervenes so dramatically in these areas by organizing social insurance to pay for basic retirement and disability, medical, and unemployment coverage, and by extensively subsidizing the cost of these beneﬁts, especially for the most vulnerable.

What’s usually at issue, instead, is technical efﬁciency: Are we getting the best bang for our necessarily limited bucks in these areas? The notion that the private market is, by deﬁnition, better at delivering such bang for the buck is the main rationale offered for increasing the already extensive role of the private sector in U.S. social policy. Thus, Medicare vouchers or partly privatized Social Security would supposedly engage the discipline of competition and lead to more efﬁcient use of resources.

Liberals usually retort that social policies have other goals besides efﬁciency, most notably distributive justice. That’s true enough, and it’s another major reason why we should be profoundly skeptical of unqualiﬁed paeans to the private sector. In theory, it might be possible to design social-insurance programs that rely on the private sector but do everything that current programs do. In practice, however, privatized approaches almost invariably change the distribution of who gets the beneﬁts, because they tend to erode common pools and subsidies (indeed, that’s what their advocates often want). Yet there’s no reason for advocates of social programs to cede the ground on efﬁciency while raising broader concerns of this sort, because in health and social policy, what is most just is also, in a great many cases, most efﬁcient as well.

Broad-based insurance, after all, is not like widgets. In the ﬁercely competitive market of economics textbooks, multiple sellers appeal to multiple buyers who have good information about the comparative merits of relatively similar products. Competition squeezes out inefﬁciencies and yields optimal outcomes. But “markets” for social insurance don’t work like this. In particular, information in these markets is both scarce and unequally distributed. This leads, in turn, to all sorts of familiar distortions on both sides of the transaction. Consumers, for example, can saddle private insurers with “adverse selection,” which occurs when only high-risk folks buy insurance. The “moral hazard” problem crops up when people are insured against costs that are partially under their control, and then engage in risky behavior. On the producer side, health-insurance companies can take steps to avoid costly patients, and purveyors of retirement products can gull unwary retirees in order to enrich insiders. All of this is why insurance aimed at achieving broad and necessarily social objectives has never worked well, or indeed at all, without some government support and regulation. And it’s also why it often makes sense for that support to take the form of public insurance.

Notice I say “insurance.” The real issue in the big-ticket areas of U.S. social policy isn’t public versus private services. It’s public versus private insurance. Medicare buys essentially all its services from the private sector, and no one wants that to change. What some want to change is the degree to which Medicare is in the insurance business, and it’s here that all the efﬁciency advantages of the public sector become clear.

Perhaps the most obvious is the advantage that neither side wants to talk about: compulsion. In the realms of public policy under discussion, however, compulsion is often necessary to make the market work. Think about what would happen if younger and healthier senior citizens were allowed to opt out of Medicare for private coverage: The broad risk-pool of the program would collapse.

Broad programs also have another big advantage: They are ridiculously inexpensive to administer. The typical private health insurer spends about 10 percent of its outlays on administrative costs, including lavish salaries, extensive marketing budgets, and the expense of weeding out sick people. Medicare spends about 2 percent to 3 percent. And Social Security spends just 1 percent. Even low-cost mutual funds have operating costs greater than that.

Here is where critics of social insurance usually pull out their trump card — the claim that social insurance is not just inefﬁcient but unaffordable. Maybe social insurance is, in some sense, efﬁcient; but, these critics argue, its inexorable growth will lead the United States to ﬁnancial ruin. And it is true that the growth of social insurance isn’t slowed by the usual market brake of consumer willingness to pay. (If it were, as just emphasized, it wouldn’t work.) But that doesn’t mean that there are no brakes at all. If it did, the federal government would now be a leviathan, rather than — as is the case — about as large as it was in the early 1970s. Americans don’t decide individually how much of their income to devote to social insurance. But, through their elected representatives, they do decide — in a rough way, of course — how much of the nation’s income to devote. Spending has trade-offs, in the form of higher taxes and forgone priorities, and those trade-offs are visible in people’s tax bills and everyday lives, and in public debate. Anyone who has followed recent political ﬁghts knows that politicians are not evading the rising costs of social programs.

What’s more, the government has another advantage when it comes to holding down costs: It is a powerful negotiator. Medicare pays doctors and hospitals less per service than does the private sector, and its costs have grown more slowly than private health plans over the last 30 years, despite huge technological advances in care for the aged. Medicaid is even more austere (some might say too austere): Its payments are well below private levels, and it negotiates bargain-basement prices on prescription drugs — something Medicare has been barred from doing. The main reason that Medicaid’s costs are rising so rapidly is not that it pays exorbitantly for services but that it covers a lot more children and families than it used to, a good thing in an era in which private coverage has plummeted. Lest government’s use of its countervailing power to hold down prices seems illegitimate, it’s worth remembering that this is exactly what HMOs and other big health plans were supposed to do — but Medicare and Medicaid do it better.

To be sure, public insurance could still dampen what economists call dynamic efﬁciency, that is, innovation and improvements in quality. But in some areas, like sending out retirement checks, it’s not clear where the innovation will come from, while in others, like micromanaging providers, it’s not clear that the private sector’s “innovations” are really worth emulating. Many of the innovations have to do with discriminating against people at risk of getting sick, micromanaging doctors, and shifting out-of-pocket costs onto patients. Proﬁt-motivated entrepreneurs quickly realize that the most effective way to minimize costs is to get rid of the people most likely to need care. This may be efﬁcient from their perspective, but it’s obviously not efﬁcient for society.

Plus, when it comes to the most basic and important form of dynamic efﬁciency — namely, quality control and improvement — the public sector is arguably as capable as the private sector, and probably more so. As Phillip Longman has argued in an important Washington Monthly article on veterans’ health care, the Department of Veterans Affairs (VA) has used its central power to create a model evidence-based quality-improvement program. Although the Medicare program still has a long way to go to match the VA, no one disputes that it conducts more rigorous reviews of technology and treatments than private health plans do. Indeed, private plans use Medicare’s criteria for covering treatments as their standard of medical necessity. Information about quality is a classic public good — everyone beneﬁts from it, but few have strong incentives to supply it. A large insurer with extensive data on its patients and considerable power to reshape market practice is arguably best positioned to provide such a good.

And this is simply to focus on efﬁciency. As noted already, the public sector runs circles around the private sector in terms of equity, the other major rationale for social insurance. If the current functions of social insurance were just turned over to the private market, vast numbers of people simply wouldn’t be able to afford anything as good as Social Security and Medicare. Conservatives like to argue that everything provided in the Social Security package — the annuity, disability, and life-insurance coverage — could just be purchased in the private market. It could, but at far greater cost for most Americans, and many applicants would be deemed “uninsurable.” All of which suggests that the claim that social programs are “inefﬁcient” is often just a politically correct way of saying that they don’t follow the usual market logic of giving the most to those with the greatest means.

Liberals frequently stress the equity argument but buy into the efﬁciency critique because they recognize, correctly, that the market is usually tremendously efﬁcient. But they shouldn’t accept that premise when it comes to social insurance. Well-functioning markets are indeed efﬁcient for ordinary commerce, but well-designed social insurance is almost always more efﬁcient than its market counterparts when it comes to dealing with the basic social risks that capitalism invariably produces. It’s high time for liberals to say what logic, evidence, and the lived experience of citizens all show: The efﬁciency attack on social insurance, far from a self-evident truth, is usually an attack on the ideal of social insurance itself — the notion that everyone, regardless of income or likelihood of need, should be covered by a common umbrella of protection. And, ultimately, social insurance is good for the efﬁciency of society as a whole, not just because it provides much-needed protections at a reasonable cost, but also because it allows people to deal with what FDR once called the “hazards or vicissitudes” of modern capitalism without draconian restraints on the free play of the competitive market.

So the next time someone complains to you about the compassion of the IRS, the efﬁciency of the post ofﬁce, all at Pentagon prices, tell them you’d be happy with the efﬁciency of Social Security, the compassion of Medicare, all at Medicaid prices.

Jacob S. Hacker, a political scientist at Yale and New America Foundation fellow, is the author of The Divided Welfare State, as well as of the forthcoming books The Great Risk Shift and, with Paul Pierson, Off Center: The Republican Revolution and the Erosion of American Democracy.

The Public-Private Mix for Health

The Nuffield Trust
The Public-Private Mix for Health
Edited by Alan Maynard

This book, written over 20 years after the publication of a similar collection of essays, examines again the complexities, frustrations and progress of healthcare systems in a leading group of rich countries. Like its predecessor, it offers few panaceas, but the insights of its authors show that the political and economic challenges of healthcare reform are now better articulated, if still largely unmet. The resilience of some of the obstacles to efficient reform articulated over 20 years ago and examined here again demonstrates the power of public and private interest groups in resisting changes that will benefit the patient. The ongoing battle between funders, providers and consumers is the business of healthcare, like many other markets. The characteristic of healthcare, however, is its resistance to change and the preservation of inefficient practices by management techniques appropriate for Dickensian times.

Despite differences in culture, history and resourcing, the nature and performance of healthcare systems worldwide are very similar. Political debates about healthcare reform are dominated by covert ideological arguments, and the policies these debates produce are generally ill-focused in terms of resolving well-evidenced common performance and incentive problems. As a consequence, the political necessity is created for the next often-irrelevant ‘redisorganisation’ of structures, epitomised nicely in the behaviour of successive Dutch and British governments, both having adopted, abandoned and readopted reforms in the past 15 years. Such changes usually fail to define the causes of inefficiencies in performance and pay scant attention to how better systems of incentives can be implemented to remedy performance problems.

http://www.radcliffe-oxford.com/books/bookdetail.asp?ISBN=1+85775+701+7

Comment: If you wish to be a serious participant in the national dialogue on health care reform, this book is an absolute must-read.

The United States has a unique position amongst the wealthier nations. We have the most expensive health care system, yet we are the least effective in ensuring affordable access to care. Everyone agrees that we need change, but we fail to move forward with reform because we are locked up in the debate as to whether the private or public sector would serve us better.

Before this book discusses the relative roles of the public and private sectors in the health systems of various nations, it discusses the pervasive role of ideology in the optimization of the public-private mix. Although the debate over the public-private mix is often framed as a linear spectrum with libertarians and authoritarians at either end, the authors instead describe the libertarian-egalitarian polarity. Much of the political process of reform is driven by these ideological positions.

The problem is that the debate over ideology is the wrong debate. Instead the dialogue should be over the best mechanisms to provide efficiency, control of expenditures, and ensuring equity in funding and access. No system will be purely public or private, so decisions should be made on changes that will improve the functioning of the system based on understanding of the impact of various well-described policies. Effective solutions would invariably have the support or opposition of ideologues, but the ideology should not control the process. Health policy science has advanced dramatically in the past couple of decades, and we have the knowledge on how to make the systems work.

Many lessons of the public-private mix can be learned from the discussions in this book of the systems of the United Kingdom, United States, Canada, France, Scandinavia, Germany, New Zealand and Australia. Single payer supporters will be particularly interested in the chapters on the United States by Uwe Reinhardt and on Canada by Robert Evans. But we should not allow our egalitarian, single payer ideology to deter us from reading the other chapters which help to clarify the advantages and the deficiencies of various government and market solutions.

As Professor Maynard states, “Political debates about healthcare reform are dominated by covert ideological arguments, and the policies these debates produce are generally ill-focused in terms of resolving well-evidenced common performance and incentive problems.”

It’s time to end our policies of “redisorganization” and move forward with rational reform. Optimizing patient care is too important of a process to worry about the response of ideologues, whether or not they’re pleased with the results.

Rick Mayes on the elusive quest for national health insurance

Book Review by Don McCanne
The New England Journal of Medicine
July 7, 2005

Universal Coverage: The Elusive Quest for National Health Insurance

(Conversations in Medicine and Society.) By Rick Mayes. 207 pp. Ann Arbor, University of Michigan Press, 2004. $26.95. ISBN 0-472-11457-3.

Observers of the U.S. health care scene cannot help but be perplexed by the enigma of a system of funding health care that leaves so many patients financially vulnerable, in spite of per capita spending on medical care that is almost twice that of the average industrialized nation. We tend to look for relatively simplistic explanations of this phenomenon, but most theories are too narrowly focused to provide adequate enlightenment. In contrast, in this book, Rick Mayes provides a political history of the reform movement that demonstrates why it seems almost improbable that national health insurance ever could have reached the threshold of political feasibility.

Mayes begins with President Franklin Roosevelt’s decision to abandon his attempt to include national health insurance in his Social Security legislation. Roosevelt feared that the opposition of the politically influential American Medical Association would doom his entire program, a risk that he dared not take. Mayes then describes several other critical junctures at which comprehensive reform again seemed feasible but failed each time, primarily because of a lack of the requisite political alignment of influential interests. The one notable exception was the success during the Johnson administration in enacting the Medicare and Medicaid programs. Mayes ends with a description of the politically inept effort of the Clintons, which never could have produced a consensus.

Perhaps the most important contribution to understanding why the quest for universal coverage remains elusive is Mayes’s description of the various incremental measures that were effective in increasing coverage but, ironically, solidly institutionalized the reforms and thus made it more and more difficult to enact a universal system. Even Social Security, as one of the most popular government programs ever, was a factor, since Medicare was a logical expansion of the provision of security in retirement. Labor’s eventual support of employer-sponsored coverage, with the acquiescence of business interests, firmly secured the position of the insurance industry as a major player in health care funding. Medicaid nominally fulfills the commitment to provide coverage for patients in poverty, and many believe that tweaking this program would provide the final major increment of bringing in low-income people who currently do not qualify for Medicaid.

Although Mayes does fill in the blanks in confronting the complexities of health care reform, nevertheless it is clear why many observers believe that refinement of our current institutions would be adequate and that a comprehensive national health insurance program is not necessary.

Such complacency ignores the fact that many of the tens of millions of people without coverage do suffer adverse health outcomes and even death.

Also disconcerting is the fact that the newer, ubiquitous, innovative insurance products are no longer adequate to ensure either financial security or health security. But Mayes does give us hope. Although he acknowledges that critical junctures are rare, he notes that they do occur, especially in response to unmet social needs. Perhaps the deterioration in insurance coverage that has taken place may have brought us much closer to our next critical juncture than most of us realize.

Don R. McCanne, M.D.
Physicians for a National Health Program Chicago, IL 60602 don@mccanne.org

http://content.nejm.org/cgi/content/full/353/1/103-a

Big Brother: Leave the decision-making to us

By Dan Kurland
Charleston Gazette (Charleston, WV)
May 13, 2005

May 1-8 was Cover the Uninsured Week, a time to focus on the broader health-care crisis. Writer Alwin Hawkins sums up the situation fairly well: “Everything I see we can do to fix the problem is either politically, ethically or financially disastrous.” But that’s probably not what you wanted to hear.

Health care is funded in a la-la world of cost-shifting. Uncompensated care is covered by overcharging those who actually pay. Charity care is partially reimbursed by the government. Everyone thinks someone else is paying. No one realizes that whether insurance is based on individual contributions, employer contributions, or government programs, in the end individual citizens pay all health-care costs out of pocket, in higher prices and lower wages, or in taxes. And insurance companies, like casinos, never lose.

Oh, for a while there seemed to be a glimmer of hope. HMOs tried to restore fiscal restraint, and the Clintons, bless their hearts, thought by satisfying everyone they could satisfy everyone. But it just wasn’t that simple. Vested interests just don’t play nice with others. It’s against their nature and their interests.

So here we sit, watching retirees lose pension benefits, the employed endure higher premiums and co-pays, and businesses cut back benefits. Defined contributions replace defined benefits, and why shouldn’t they? Costs have skyrocketed. Why make promises you can’t keep? It’s not business’s fault that prices went up, or that workers want affordable health care.

As more people drop from the lists of the insured, states seek ways to insure the growing number of uninsured. Not by subsidizing insurance, of course. There’s no money for that. Instead they look to low-cost private insurance packages. But low cost implies low coverage. Fewer services, higher co-pays, higher deductibles and lower maximum benefits. Yet everyone benefits: The uninsured are offered coverage, the insurance industry gets a new product to sell, and providers are protected against the rising costs of uncompensated care. Without insurance companies, after all, how would people get health care? (Hint: the public education system.)

As states create new initiatives to insure the uninsured, reduced federal Medicaid funding forces those very same states to uninsure the otherwise Medicaid-insured. There’s a war going on, and tax cuts to save. We must keep our priorities straight.

And keep our values straight as well. People can make up their own minds when they buy a car, why not a heart transplant (read: consumer-directed choice)? They can save for a vacation, why not a bypass (read: health savings account)? Must government always tell us what to do? Smoking, drinking, Big Macs and Barcaloungers. Wait long enough and there’ll be a pill for obesity. We all know it. Trust me. Wait. You’ll see the ad on TV.

We have moved from physician-based health care to pill-based health care, from a needs-based (I feel sick) to a market-inspired (…may last for four hours…) health-care system. We take pills for diseases we never imagined we had, whether there is clinical evidence to support their value or not. Everything is marketing. Once physicians start owning imaging centers, they obviously need volume (patients) to amortize their investment. Economic necessity clearly cannot be denied.

Of course, in time it will all catch up with us. Skyrocketing prices and continuing unhealthy lifestyles will lead to fewer insured and more uncompensated care and increased financial strain on the health-care industry. Providers will be forced to turn away Medicaid patients because below- cost reimbursement policies are sucking them dry. Whoops! That’s already happening! Government will have to step in to save failing hospitals to assure medical care.

When people are dying on the streets — or worse, health-care companies are going south on the stock market — others might actually take to the street and demand something be done.

When providers no longer have economic and political leverage, real changes can be made. We’ll be free to replace doctors with nonphysician health-care providers for preventive procedures, to insist on doctor-pharmacist collaboration in disease management, and to reimburse home care instead of hospital care. We’ll have the will to limit each patient to a single transplant, to ban Cheetos, to forbid Game Boys, and to prohibit low-probability end-of-life care. We’ll be free to legislate that school buses drop our children a half mile from schools to assure they get their exercise, and that all school lunches have two vegetables (not counting ketchup).

At least we won’t have to make the hard decisions. They’ll have been made for us.

Kurland is health action coordinator of Covenant House and creator of the Web site www.criticalreading.com

Bush & Congress agree on reform – "Patient Navigator"

Bush Signs ‘Patient Navigator’ Bill To Help People Make Medical Decisions
Kaiser Daily Health Policy Report
June 30, 2005

President Bush on Wednesday signed into law a bill that will establish a “patient navigator” system to help patients with chronic illnesses make medical decisions, CongressDaily reports (Rovner, CongressDaily, 6/30).

The law authorizes $25 million in grants over five years to establish patient navigator programs to aid uninsured patients in low-income and rural communities nationwide. Under the system, counselors will help patients evaluate their treatment options, enroll in clinical trials, obtain referrals and apply for financial assistance (Kaiser Daily Health Policy Report, 6/24). Rep. Robert Menendez (D-N.J.), who co-sponsored the legislation with Rep. Deborah Pryce (R-Ohio), said, “This is a textbook example of how the legislative process should work” (CongressDaily, 6/30).

http://www.kaisernetwork.org/daily_reports/rep_hpolicy.cfm

Comment: Is this a textbook example of the way the legislative process should work?

Helping low-income, uninsured individuals find free programs or locations for financial assistance is certainly not bad policy. But at an average of $100,000 per state per year, there are not enough funds to pay for one individual per state, plus the overhead required for that individual to function.

Unfortunately, this is a textbook example of how our “bipartisan” legislative process is failing us miserably. Political solutions exist which would provide affordable access to comprehensive health care for everyone, without spending more than we do already. Yet the politicians continue to turn their backs, pretending that they didn’t hear us.

We don’t need money from Congress; we need authorization for structural reform of health care financing. Now that we’re ready to build a splendiferous new financing structure for health care, our Congress can’t seem to come up with much more than the equivalent of a construction-project outhouse on an empty lot. Surely the legislative process can work better than that.

Bush & Congress agree on reform – “Patient Navigator”

Bush Signs ‘Patient Navigator’ Bill To Help People Make Medical Decisions
Kaiser Daily Health Policy Report
June 30, 2005

http://www.kaisernetwork.org/daily_reports/rep_hpolicy.cfm

Comment: Is this a textbook example of the way the legislative process should work?

"Medicare Health Accounts"

Medicare Health Accounts: A New Policy Option to Help Adults Save for Health Care Expenses Not Covered by Medicare Findings from the Commonwealth Fund Survey of Older Adults
By Sara R. Collins, Karen Davis, Sabrina K. H. How, and Alyssa L. Holmgren
The Commonwealth Fund
June 30, 2005

While Medicare was designed to protect people over age 65 from health costs and facilitate access to needed services, the program has substantial cost-sharing requirements and does not cover such high-cost services as long-term care. Medicare beneficiaries spend 22 percent of their incomes on premiums and out-of-pocket medical expenses—a figure that is projected to increase to 30 percent by 2025.

New strategies are needed to encourage people to save more for their retirement. The Commonwealth Fund Survey of Older Adults, a nationally representative sample of 2,007 adults ages 50 to 70 conducted in late 2004, asked respondents about their interest in new savings accounts that could be created within the Medicare program. Such accounts would allow people to automatically save for health costs that are not currently covered by Medicare. With Medicare Health Accounts, up to 1 percent of earnings could be deducted automatically from people’s paychecks and placed in an account in the Medicare program. The savings could then be used by people in their retirement to cover costs of long-term care, home health, and other costs not covered by Medicare.

Among older adults in households in which at least one member was working, nearly seven of 10 (69%) said they would be interested in having a Medicare Health Account.

http://www.cmwf.org/usr_doc/842_collins_olderadults_fs_06-30-2005.pdf

Comment: Medicare covers less than 50% of health care costs of Medicare beneficiaries. As costs increase both health security and financial security are declining for seniors, and everyone else.

In this survey of seniors on the declining affordability of health care, Medicare beneficiaries were asked if they supported the option of reducing the financial risk of health care: placing 1% of their paychecks in a segregated Medicare Health Account to be used when the need arises.
Without a discussion of the implications of segregated accounts nor a discussion of other options, Medicare Health Accounts, at first blush, would seem like a good idea. The strong positive response is really not surprising.

But there is a great variability in health care needs amongst Medicare beneficiaries. Some remain healthy and drop dead suddenly of a cardiac arrest. The financial burden is negligible for them. Others have very protracted and expensive end-of-life disorders and yet others have high-cost long-term care needs.

The Medicare Health Accounts would be superfluous for those with few needs, but, as described, they would likely be inadequate to provide financial security for those with greater needs.

The lesson is obvious. For insurance to work, risk must be pooled. Medicare Health Accounts segregate risk, defeating the very purpose of insurance.

Although it is suspected that these accounts have been proposed as a solution that might appease conservatives, this is very unlikely. First, conservatives want to reduce public funding of Medicare. These accounts are add-ons and do nothing to reduce the Medicare tax burden. Second, conservatives want to reduce health care spending by requiring individuals to be sensitive to more of the costs. An account dedicated exclusively to out-of-pocket expenses under Medicare largely insulates patients from the costs and defeats the strategy of the conservatives.

Once again, we come to the bottom line. Insurance should be funded by modest contributions from everyone to ensure that health care is affordable and accessible by all. Medicare segregates a high-cost sector into a separate risk pool. Employer-sponsored plans segregate a low-cost sector into a separate quasi-pool, but one that is rife with inefficiencies, inequities, and egregious waste.

Medicare beneficiaries would benefit by being placed in a low-cost pool that covers everyone. Healthy, employed individuals are already funding Medicare anyway, so they wouldn’t suffer by being included in the Medicare pool, and they would also benefit by being included in a program that reduces administrative waste and inefficiencies, and would ensure equitable access in time of need.

Incremental measures result from an effort to appease all parties, but they end up increasing costs without net improvements in coverage and affordability. All parameters are getting worse, not better. We know how to fix the system. We just need to finally decide that it’s time to do it.

“Medicare Health Accounts”

Among older adults in households in which at least one member was working, nearly seven of 10 (69%) said they would be interested in having a Medicare Health Account.

http://www.cmwf.org/usr_doc/842_collins_olderadults_fs_06-30-2005.pdf

Comment: Medicare covers less than 50% of health care costs of Medicare beneficiaries. As costs increase both health security and financial security are declining for seniors, and everyone else.

The Medicare Health Accounts would be superfluous for those with few needs, but, as described, they would likely be inadequate to provide financial security for those with greater needs.

The lesson is obvious. For insurance to work, risk must be pooled. Medicare Health Accounts segregate risk, defeating the very purpose of insurance.

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