Stanford School of Medicine
Stanford Medicine Magazine
Winter 2005
Letter from the Dean

It’s hard to fathom why our nation, with its great financial and intellectual capital, has a health-care system that’s so far from world class. Much of the trouble comes from the belief that health care must be run like a business – as if personal health were a commodity. This notion, promoted over the past two decades by our leaders in Washington, posits that the free market will restrain costs and bring high-quality care to all. Obviously, this strategy has failed miserably.

I do not believe that modifications around the edges of our health-care quagmire are going to do it. We need sweeping change. I personally favor a single-payer model incorporating support for medical training, innovation and discovery. But I’m not convinced that our political leaders can muster the will to overcome the obstacles from special interests with stakes in supporting the status quo.

Philip A. Pizzo, MD
Dean, Stanford University School of Medicine

http://mednews.stanford.edu/stanmed/2005winter/letter.html

The Commonwealth Fund
March 8, 2005
News Release
New Health Care Opinion Leaders Survey: Uninsured Rate Could Be Reduced
by Half in Ten Years

The proportion of Americans without health insurance can and should be reduced to 8 percent in ten years, less than half the current rate, according to the Commonwealth Fund Health Care Opinion Leaders survey, an online survey of widely-recognized experts in health care practice and policy.

Three-quarters (75%) of respondents say that employer-sponsored insurance should not be permitted to decline. There was also wide support from respondents for a range of policy efforts to improve coverage. About four-fifths (82%) favor incentives for employers to provide insurance that meets minimum standards, and tax credits or other subsidies for low-wage workers (79%). Other popular policy options included requiring employers who do not provide health benefits to pay into a fund to insure workers and their families (70%), allowing employers to buy into Medicaid or CHIP for their employees (60%), and employer mandates to help finance benefits (52%).

Respondents expressed lower rates of support for replacing employer coverage with a single-payer plan, with about two-fifths supporting (42%) or opposing (40%) this policy.

In contrast, three-fifths (62%) of respondents oppose making HSAs the centerpiece of efforts to cut health care costs (combined with making high- deductible plan coverage more widely available).

http://www.cmwf.org/usr_doc/HCOL_survey2_release.pdf

The survey questions and results:
http://www.cmwf.org/usr_doc/HCOL_survey2_topline.pdf

Comment: The good news about this survey is that health care opinion leaders support protecting the coverage that we do have, and they support improving coverage. The bad news is that this survey was designed to support the current path of incrementalism, an approach that has been ineffective in expanding coverage.

As an example, the very first question: “Health care costs, market pressures, and public and private policies are changing insurance coverage in the U.S. For each of the following, please indicate what you would see as both an achievable and a desirable target or goal for policy action for the next ten years: (1) The proportion of under-65 population that has no health insurance (now about 18%).”

The median answer given was a goal of 8% without insurance. Thus the survey begins with a concession on the part of the respondents that 100% coverage is not an achievable goal. Obviously that makes it very easy to reject 100% solutions as lacking political feasibility.

The third question: “About 160 million Americans get health insurance coverage through their employers who spend more than $400 billion on such benefits. Would you favor or oppose each of the following options for such coverage in the future? Please consider each option in isolation.” (Seven options are offered, in randomized order.) One option: “Employer coverage should be replaced with a single-payer plan, with current employer premium contributions redirected to help pay for coverage.”

Results: 42% in favor, 40% opposed, and 17% not sure. But this was not a question about abolishing the current fragmented system of funding care, including employer-sponsored coverage, and replacing it with a single,
publicly-administered program. Instead, this was a question about preference for a universal insurance program in which employers must bear much of the burden of the funding of health care for everyone. It makes the assumption that employer sponsorship would continue to be the mainstay of health care funding, thereby losing the support that much of the business community would have for a single payer system.

The political consequences of rejecting a 100% solution before beginning negotiations are exemplified by the comments of Charles Kahn in an accompanying commentary. He is the president of the Federation of American Hospitals, an advocacy organization for investor-owned hospitals. He is also the “strange bedfellow” of Ron Pollack, the executive director of Families USA. Although of different ideological persuasions, they had joined together to drive consensus on the development of public policy to address the problem of the uninsured.

Kahn’s comments:

“Up to this point, it has been my belief that the best way to proceed on this front is to bring together people with varying ideas about health policy and to work within the current context.”

“I still have great hope for this approach… But after many years of coalition building and consensus development, the number of uninsured Americans continues to grow, dramatically. Rather than risk inactivity and allow this number to escalate, perhaps we should adapt this approach to better reflect current political reality.”

“Republicans, who control the White House and both Houses of Congress, dominate the current political landscape. Therefore, if health policy advocates want to see progress on the uninsured, we have to look to President Bush and the GOP majority to take the lead.”

“Rather than trying to achieve a sufficiently broad consensus, there is a compelling argument to be made that, to begin reducing the number of uninsured Americans, we instead ought to reach for what is already within our grasp.”

“I recognize that tax credits and expanded health savings accounts are not the preferred policy approaches for some members of our ‘strange bedfellows’ coalition. However, these are the approaches most likely to be approved by Congress. Given the rising number of uninsured Americans, we owe it to them, and to ourselves, to work to pass what can be passed, and then allow these approaches sufficient time to work.”

http://www.cmwf.org/publications/publications_show.htm?doc_id=262376

Further comment: When you wake up in the morning and find your bedfellow gone, you suddenly realize that your self-esteem left with him. But all is not lost. There is no better way to recover your self-respect than to pick yourself up, reject the siren song of incrementalism, and move forward with great certitude toward a fully achievable 100% solution in health care.

Fortunately, we can find more inspirational guidance in another commentary by Michael Rodgers, interim president of the Catholic Health Association:

“Most important, those working to amplify the voice of the uninsured and the marginalized are well served to remember that the cause for which they fight is nothing short of a moral imperative.

“We are a fortunate nation with plentiful resources and a community spirit rooted in equality and fairness. Now it is our monumental but unavoidable task to express the need for change, to mobilize the nation behind it, and to once and for all meet our obligation not just to the sick specifically, but to one another generally.”

http://www.cmwf.org/publications/publications_show.htm?doc_id=260394

Health Affairs
March/April 2005
Overcoming Disparities In U.S. Health Care
By William H. Frist

…the best way to eliminate health disparities is through improvements in the care we deliver to each patient, emphasizing patient dignity and empowerment.

Patients must be central to our efforts to improve health care. For instance, a person with a chronic illness such as diabetes must essentially “own” that illness if he or she is to have any hope of effectively managing it. Providers can help with high-quality treatment and the best recommendations, but patients must act on those recommendations. They must stop smoking, eat right, exercise, take their medication, and monitor their blood sugar, based on their own volition and usually outside of the clinical setting. Public policies must encourage patients to embrace personal responsibility.

Policies that promote dignity and personal responsibility will help decrease individuals’ risky behavior. The major causes of death among African Americans, for instance, are heart disease, cancer, stroke, accidents, and diabetes. Most of these are chronic diseases rather than acute illnesses, and all of these causes of death are at least arguably preventable.

Further, the top three can be reduced by decreasing tobacco use alone. We must
promote policies that help people address individual behavior, such as smoking.
Some have voiced concerns that health care is somehow different: that the
therapeutic relationship between doctor and patient should not be subject to
competitive forces. Further, many argue that quality chasms and health disparities cannot be fixed by fostering competition. Certainly, competition does not provide all of the answers. We will need a strong safety net and vigorous attention to vulnerable populations. But all of our immediate health care system problems-rising costs, questionable quality, patient safety, rising numbers of uninsured people, and, yes, health disparities-are interrelated and can be improved by empowering patients and providers.

We simply cannot afford to forgo the lower costs and increased quality and value that the right kind of competition will drive.
http://content.healthaffairs.org/cgi/content/abstract/24/2/445

Health Affairs
March/April 2005
The Role Of The Federal Government In Eliminating Health Disparities
By Edward M. Kennedy

The state of U.S. minority health is an embarrassment to the nation. Minority communities are struggling with rising numbers of uninsured citizens, festering epidemics, and lower health care quality, all of which mean increased rates of diseases and preventable deaths. To end the minority health crisis, Congress and the Bush administration need to step up to the plate by increasing health insurance coverage and investing in cultural competence, workforce diversity, minority data collection and reporting, and overall public health. Greater resources should be given to the HHS Office for Civil Rights and Office of Minority Health, both of which lead the fight to reduce disparities. All of these efforts must be integrated into the larger effort to increase access and improve quality of care, since we face not only a minority problem, but a national problem. In addition, the country must be mindful that health is inextricably tied to educational opportunities for children, job security and living wages for families,
safe and affordable community housing, and pension stability and social security
for seniors. Elimination of disparities in health depends in part on progress in each of these critical areas.

Health insurance for all is still my overarching goal, so that the basic right to health care can become a reality for all citizens.
http://content.healthaffairs.org/cgi/content/abstract/24/2/452

Comment: Perhaps the most appropriate comment comes from an article in this
same issue of Health Affairs: The Role Of Health Insurance Coverage In Reducing Racial/Ethnic Disparities In Health Care, by Marsha Lillie-Blanton and Catherine Hoffman:

“To assess whether insurance expansions could be expected to reduce racial/ethnic disparities in access to care, this paper reviews evidence from studies specifically designed to quantify the contribution of health insurance to racial/ethnic disparities in access. The studies provide evidence that a sizable share of the differences in whether a person has a regular source of care could be reduced if Hispanics and African Americans were insured at levels comparable to those of whites.”

http://content.healthaffairs.org/cgi/content/abstract/24/2/398

Pediatrics
March 2005
Changing Conclusions on Secondhand Smoke in a Sudden Infant Death
Syndrome
Review Funded by the Tobacco Industry
By Elisa K. Tong, MD; Lucinda England, MD; and Stanton A. Glantz, PhD

Prenatal and postnatal exposure to tobacco smoke adversely affects maternal and child health. Secondhand smoke (SHS) has been linked causally with sudden infant death syndrome (SIDS) in major health reports.

In 1997, PM (Philip Morris) commissioned a consultant, Frank Sullivan, to write a review, with coauthor Susan Barlow, of all possible risk factors for SIDS. The first draft concluded that prenatal and postnatal smoking exposures are both independent risk factors for SIDS. After receiving comments and meeting with PM scientific executives, Sullivan changed his original conclusions on smoking and SIDS. The final draft was changed to emphasize the effects of prenatal maternal smoking and to conclude that postnatal SHS effects were “less well established.”

Clinicians, parents, and public health officials are most vulnerable to the changed conclusions of the SIDS review. The national SIDS “Back to Sleep” campaign has been very successful in reducing SIDS rates. However, estimates of SIDS risk from SHS (odds ratios range from 1.4 to 5.1) have considerable overlap with estimates of risk from prone sleep positioning (odds ratios range from 1.7 to 12.9). With the Back to Sleep campaign well underway, efforts to address parental smoking behavior in both the prenatal and postnatal periods should be intensified.

http://pediatrics.aappublications.org/cgi/content/abstract/115/3/e356

Comment: What does the malfeasance of toxicologist consultant Frank Sullivan have to do with national health insurance? My response may be a stretch, but the issues are fundamental.

The opponents of national health insurance have framed the debate as the efficiency of the private marketplace in providing higher quality and greater value versus the inefficiency and poor value wrought by government bureaucracies. But the overwhelming preponderance of health policy literature indicates that this framing of the ideological divide is incorrect. In the financing of health care, the private bureaucracy has been profoundly inefficient, and the failure to provide adequate coverage has negatively impacted quality by leaving in place financial barriers to care.

In contrast, government bureaucracies have been much more effective in ensuring affordable access to care with greater efficiency through streamlined administration.

If the framing of the ideological divide as efficient markets versus inefficient government bureaucracies is incorrect, then how should this ideological divide be framed? One does not need to be an astute observer to recognize that the divide is between those who support freedom in the marketplace as a means to achieve maximum personal wealth versus those who support solidarity through government action to be certain that all of us have our most basic needs met first before we enjoy our hedonistic pursuits in the marketplace. This reframing of the debate over the ideological divide is not merely rhetorical, but it is fundamental because it places the issue of solidarity ahead of money in our society.

And today’s quote? The medical literature has been used in an attempt to preserve profits of the tobacco industry at a cost of loss of lives due to SIDS. What could be more fundamental than that? We have enough solidarity to be outraged by these individuals who would sacrifice infants’ lives for personal greed.

But do we have enough solidarity to act to save the lives of the 18,000 young adults who die prematurely each year due to lack of health insurance? Or is it more important to maximize the wealth of those who have learned the ways of success in the health care marketplace? This is really the way that we need to frame the debate.

Efficient free markets versus oppressive government bureaucracies? Balderdash! Let’s quit debating their ideology and start debating polices that save lives!

Congressman Pete Stark
March 3, 2005
Stark Introduces Constitutional Amendment to Establish Right to Health Care

Today, Rep. Pete Stark (D-CA) announced his introduction of a proposed amendment to the US Constitution to guarantee health care as a right for every American. The amendment, H.J. Res. 30, is cosponsored by Rep. Jesse Jackson, Jr. (D-CA) and 27 other House members.

“The health of every American is vital to their unalienable rights of ‘life, liberty, and the pursuit of happiness,'” said Rep. Pete Stark. “To ensure these rights are fully enjoyed, we must be certain that every American can access quality health care – regardless of their income, race, education or job status. This Constitutional amendment is aimed at achieving this fundamental goal.”

Today, there are 45 million uninsured Americans, including 8 million children. Millions more are underinsured, excluded from certain types of health coverage or being quickly priced out of the health insurance market altogether. Additional disparities in access, treatment, and outcomes exist for people of color.

Facing skyrocketing costs, many employers are cutting benefits or dropping coverage for their employees, chipping away at the very foundation of health care insurance in the United States. Proposed cuts in Medicaid now endanger coverage for the over 50 million Americans that currently rely on the program for medical care.

“We face a health care crisis where equal opportunity and basic fairness in our nation are at stake,” said Rep. Stark. “I’m frustrated, as many Americans are, that the President and Congress continue to ignore the problems we face. A Constitutional guarantee of health care for all will force Congress to take action to ensure that health coverage is there for all Americans.”

H.J. Res. 30 would amend the Constitution to say “all persons shall enjoy the right to health care of equal high quality.” It would require ratification by three-fourths of the States and so-called implementing legislation must be passed by Congress to ensure compliance with the amendment.

“I firmly believe that until we can guarantee that all people have the right to equal, high-quality health care through the Constitution, the interests of the people will continue to play second fiddle to the corporate bottom-line,” said Rep. Stark. “It’s time we put the health care of the people first. Our Constitution should be amended to promote that common interest.”

http://www.house.gov/stark/news/109th/pressreleases/03-02_healthamendment.htm

Comment: We are already spending more than enough to provide high quality health care for everyone. But only the government can mandate that those funds be used to ensure that everyone has the right of access to affordable care.

We have long given lip service to the right to health care. But now it’s finally time to have a serious, definitive national debate on the constitutional right to quality health care for all. Let’s rally around H.J. Res. 30.

National Association of Community Health Centers and The George Washington University
March 2005
Growing Uninsured, Budget Cutbacks Challenge President’s Initiative to Put a Health Center in Every Poor County
By Michelle Proser, Peter Shin and Dan Hawkins

Given the Bush Administration’s new goal of expanding health centers into every poor county in the country, the National Association of Community Health Centers (NACHC) and the George Washington University identified poor counties that are “unserved” in that they lack at least one health center. A total of 929 counties around the country fit these criteria. These poor, unserved counties represent almost a third of all US counties and more than half of all poor counties.

The number of communities needing a health center far exceeds available resources. For instance, available funding for FY 2002 and 2003 allowed only one out of three qualified applications for new health center sites to be approved for funding. In FY 2004, less than one in ten of qualified applications were approved. Moreover, while inflation-adjusted federal funding between 2002 and 2003 increased by 7%, the number of uninsured patients at federally-funded health centers rose by 11%. Many health centers around the country are reporting significantly higher growth in the proportion of uninsured patients. For every one uninsured, low income patient that a health center treats, there are four others needing their services, not to mention countless others lacking access to regular primary care regardless of insurance status. Compounding the need is rising poverty.

Given these multiple factors, there are not enough health centers for the people and communities who need them. Of course, in order to improve health on the greatest scale, the preservation of insurance is equally important. Expanding both insurance coverage and the health center program are needed to improve access to care,and both approaches are in fact complementary. Health centers provide services that many other providers do not, such as enabling services, making them preferred providers for many patients.

President George W. Bush (January 27, 2005, Cleveland, OH):

“.here are some practical ways for us to deal with the rising costs in health care. One is to make sure that people who can’t afford health care have got health care available to them in a common-sense way. And that’s why I’m such a big backer of expanding community health centers to every poor county in America. We really want people who cannot afford health care- the poor and the indigent – to be able to get good primary care at one of these community health centers, and not in the emergency rooms of the hospitals across the United States of America.”

http://www.nachc.com/research/Files/poorcountiesSTIB9.pdf

Comment: In 2004, over 90% of qualified applications for community health centers were rejected because of lack of available funding. Is it fair to ask the president what he means when he says that he’s “such a big backer of expanding community health centers”?

Stanford School of Medicine
Stanford Medicine Magazine
Winter 2005

OK, you say you want a revolution Why Americans settle for a broken health-care system
By Michelle Brandt

“The whole thing is broken,” says David Magnus, PhD, director of the Stanford Center for Biomedical Ethics. “The core problem is that we have a completely irrational way of paying for and delivering health care.”

Our national leaders haven’t adequately addressed the issues, and- despite survey after survey showing that Americans believe our health-care system needs reform – the public hasn’t taken them to task for it. Health care hasn’t
reached critical mass as a political issue, experts say, because Americans are worried about the future but not concerned enough with their current situation to clamor for change.

Yet many continue to push for reform, including medical student (Graham) Walker, who is hoping to soon begin a documentary on the health-care system.
He’s among those who feel confident that change is coming. Says another believer in change, advocate (Don) McCanne: “I personally suspect it will happen in years, rather than decades.

“We want our technology, we want great advances in health care. When we see
only the wealthy can get them, that’s not going to be acceptable.” Sociology professor (Donald) Barr agrees and predicts that increasing numbers of “horror stories” will eventually cause people to vote only for those politicians who address the health-care issue. And that’s exactly what we need to have happen: only when the public puts the pressure on legislators – and becomes entrenched in the fight like Walker and others – will the nation get real reform.

http://mednews.stanford.edu/stanmed/2005winter/healthcare-main.html

Comment: Michelle Brandt is the Media Relations Manager of the Office of Communication and Public Affairs at Stanford University Medical Center. In this article she has captured the essence of our broken system of funding care and the oxymoronic unstable inertia of reform. Although the article is somewhat long, it makes for a great Sunday read.

Congressman Pete Stark
March 3, 2005
Stark Introduces Constitutional Amendment to Establish Right to Health Care

Today, Rep. Pete Stark (D-CA) announced his introduction of a proposed amendment to the US Constitution to guarantee health care as a right for every American. The amendment, H.J. Res. 30, is cosponsored by Rep. Jesse Jackson, Jr. (D-CA) and 27 other House members.

“The health of every American is vital to their unalienable rights of ‘life, liberty, and the pursuit of happiness,'” said Rep. Pete Stark. “To ensure these rights are fully enjoyed, we must be certain that every American can access quality health care – regardless of their income, race, education or job status. This Constitutional amendment is aimed at achieving this fundamental goal.”

Today, there are 45 million uninsured Americans, including 8 million children. Millions more are underinsured, excluded from certain types of health coverage or being quickly priced out of the health insurance market altogether. Additional disparities in access, treatment, and outcomes exist for people of color.

Facing skyrocketing costs, many employers are cutting benefits or dropping coverage for their employees, chipping away at the very foundation of health care insurance in the United States. Proposed cuts in Medicaid now endanger coverage for the over 50 million Americans that currently rely on the program for medical care.

“We face a health care crisis where equal opportunity and basic fairness in our nation are at stake,” said Rep. Stark. “I’m frustrated, as many Americans are, that the President and Congress continue to ignore the problems we face. A Constitutional guarantee of health care for all will force Congress to take action to ensure that health coverage is there for all Americans.”

H.J. Res. 30 would amend the Constitution to say “all persons shall enjoy the right to health care of equal high quality.” It would require ratification by three-fourths of the States and so-called implementing legislation must be passed by Congress to ensure compliance with the amendment.

“I firmly believe that until we can guarantee that all people have the right to equal, high-quality health care through the Constitution, the interests of the people will continue to play second fiddle to the corporate bottom-line,” said Rep. Stark. “It’s time we put the health care of the people first. Our Constitution should be amended to promote that common interest.”

http://www.house.gov/stark/news/109th/pressreleases/03-02_healthamendment.htm

Comment: We are already spending more than enough to provide high quality health care for everyone. But only the government can mandate that those funds be used to ensure that everyone has the right of access to affordable care.

We have long given lip service to the right to health care. But now it’s finally time to have a serious, definitive national debate on the constitutional right to quality health care for all. Let’s rally around H.J. Res. 30.