Resource – Page 1166

Getting medical coverage to all

Posted on Thu, Mar. 13, 2003
Too many fall through the cracks of inadequate insurance programs.
By Gene Bishop
http://www.philly.com/mld/inquirer/news/opinion/local2/5378484.htm
The Philadelphia Enquirer

More than 18,000 young adults died last year in a major epidemic in the United States that managed to escape the headlines.

Those 18,000 – six times the number who were killed in the attacks on the World Trade Center – died, according to an Institute of Medicine report, because they lacked health insurance. No alert has been issued to help those who daily live in terror of becoming sick and being unable to pay.

There is the college graduate working as a waiter while trying to succeed as an artist. At work he has a seizure and is rushed to a hospital. He is discharged two days later with a prescription for medication and instructions to make an appointment to see a neurologist.

Although emergency medical assistance (Medicaid) may pay for the hospitalization, he is not eligible for Medicaid once outside the hospital because he is able to work. An appointment with a neurologist in Philadelphia could cost $250 or more, in addition to the cost of medications, blood work, and further diagnostic testing. He doesn’t have the money.

His is hardly an isolated story. As a physician who cares about access to health care, I consider myself knowledgeable about health-system problems. But having spent the last 18 months working with the Pennsylvania Health Law Project, a statewide legal services organization, I am overwhelmed. I am filled with anger as I hear story after story about Pennsylvanians who are struggling to take care of themselves or their families, but are unable to pay for doctors, hospitals or medicine.

The Health Law Project’s toll-free helpline for low-income Pennsylvanians having difficulty accessing or using the health system documents a system that is falling apart. There is the call from the social worker at a low-cost clinic. Her client has been diagnosed with a brain tumor and needs radiation therapy. The woman’s income is too high for Medicaid, and three hospitals have refused to register her for a specialist appointment because she is uninsured.

Or the man with diabetes, employed and uninsured, who sees a physician at a low-cost community health center where he pays for his medicines and physician visits. When his doctor tells him he needs an eye specialist and possible laser treatments to prevent blindness from diabetes, he doesn’t have the money. He and his lawyer make numerous phone calls trying to obtain affordable care. One hospital says it has “used up all the charity care for the year.” He becomes overwhelmed by the obstacles in his path, and the possibility of large debt. He takes his chances with his sight.

Few uninsured people come to my practice, but the underinsured are plentiful. Every day, people tell me they aren’t taking their medications because they can’t afford them. Insurance companies have shifted the cost of care to consumers.

Low-cost coverage now available to a limited number of Pennsylvanians is also inadequate. Special Care insurance, sold by Independence Blue Cross, allows four physician visits per year and doesn’t cover medications. One serious illness or accident can use up those visits. Adult Basic Coverage – funded by the tobacco settlement and run across the state by private insurers – began in July and filled its 48,000 capacity almost immediately. Even without coverage for prescriptions, mental health or drug and alcohol treatment, it has a long waiting list.

During this national “Covering the Uninsured Week,” it is time to focus again on providing universal coverage for all Americans. We already have more than enough resources in our health-care system to provide comprehensive health-care benefits to all. A national health insurance program, which would eliminate the high overhead and profits of insurance companies, offers the promise of adequate health care for all Americans.

U.S. Rep. John Conyers (D., Mich.) recently introduced a resolution calling for a national health program. On the Web, there is a national physicians’ proposal backing such a program (www.physiciansproposal.org).

As a physician in such a system, I could treat patients without checking on the rules, medication lists, or billing requirements of 10 to 20 insurers. As a patient in such a system, you or I could visit any doctor or hospital we choose, rather than the ones chosen for us by our employer, our insurer or our income. Only national health insurance allows us to expand coverage without expanding costs.

A patchwork quilt of inadequate insurance programs, each with its own set of rules and administrative costs, is not the answer. It is time to trade this torn quilt for a well-sewn blanket of universal coverage. It is time to save 18,000 lives – and save ourselves.

Living sicker, dying sooner with no health plan

By REKHA BASU
Register Columnist
03/12/2003
The Des Moines Register
http://www.dmregister.com/opinion/stories/c5917686/20705781.html

My teen-age son has a thing for Ultimate Frisbee. Such a thing that he kept on playing last week even after hurtling into a fence, splitting open his knee and getting an egg-size bump on his cheek. Later that evening, we sat in the hospital emergency room as one doctor stitched him up and another checked for a concussion.

It’s not pleasant, but it’s life: People are active. Sports come with risks. You just brace yourself for the occasional accident and feel lucky if the worst result is a superficial scar and a $75 hospital co-pay.

But it’s not that simple for everyone. The same minor accident that costs one family an evening can force another to fall behind on rent or car insurance.

Ask Anna Dianas of Des Moines. Her $7-an-hour job for a non-profit group provided no health insurance. Her husband, who does seasonal construction work, gets none either. They couldn’t afford to buy it and don’t qualify for any government program. So when her husband split his head open in a soccer collision, a hospital visit similar to ours set a struggling family back $500.

“We barely make it,” Dianas sighed. She racked up another $3,000 in hospital bills after she got chest pains and an EKG at a free clinic was abnormal.

Dianas was one of the people showcased Monday by the organizers of Cover the Uninsured Week, as panelists brainstormed about the health-care crisis and Lt. Gov. Sally Pederson read a proclamation urging solutions.

Dianas will soon get coverage thanks to a job change. But that still leaves more than 230,000 Iowans without insurance. Eighty-six percent of them work. They live with untreated illnesses, turn up at clinics created for the poor, rely on the good graces of doctors to slip them free samples of medicine. They live sicker and die younger, says Families USA, a consumer organization.

People variously lay the blame on: premiums that shot up 30 percent in three years; rising co-pays and deductibles; struggling small businesses unable to cover their workers; costly medical technology and drugs; poor federal reimbursement rates for Medicaid and Medicare; and an aging population using more services. You could also look further, to the loss of manufacturing jobs with union protection that ensured health benefits. In America, 1.4 million people lost their coverage in 2001; 41 million are uninsured.

For all its wealth, ours is the only industrialized country without a national health-care program, says Senator Tom Harkin. “We have the best hospitals, the best personnel and yet we can’t cover people.”

Working people often are caught in a Catch-22 because their jobs don’t come with benefits, but they are paid too much even for their kids to get government help. That’s Lorri Swigart’s problem. She’s a full-time property manager earning around $2,000 a month. Her income puts her 16-year son, who has juvenile diabetes, above the guidelines for Hawk-I, the state’s medical program for low-income children. His insulin-related expenses alone run $150 to $175 per month. She takes heart medicines.

They lost their coverage in January after she got divorced, and when she finally found an insurer that would cover them, it cost too much. “You just put things off for as long as you can,” she said. “You don’t go to the dentist, or you have a tooth pulled vs. a root canal or a cap. I just went to the dentist. I want to save my tooth but it’s $1,500 vs. $75.”

If something catastrophic led one of them to be hospitalized, she says, she’d have to file for bankruptcy. Medical bills are in fact a leading cause of bankruptcy.

Chances are that someone you know has no medical coverage. My friend Kim Davenport, who lives in Dallas County, works as a waitress and discontinued her employer-supported plan when the premium shot up to $700 a month. Her husband is self-employed, so there’s no coverage for them or their two teenage daughters.

“I’m just hoping nothing happens, that’s all,” she said.

Poignant as these stories are, they’re not presented for your pity, but your outrage. Something is terribly wrong when working Americans have to worry about a sports injury delaying the rent.

There is a solution, but no political will for it: a nationalized health-care system like Canada’s, which spends less per person and covers everyone (see Andie Dominick’s Feb. 14 Register essay). Canadians have a higher life expectancy, and their overall taxes are not higher.

President Bush decried such a system in his State of Union speech, and insurance-industry advocates are fond of spreading horror stories about waits for service and lack of choice in doctors. But there’s not much choice in health care for many Americans now.

The good news is that political will can be forced. If you doubted that, just look at how Des Moines schools capitulated to a public outcry last week within 24 hours of floating a proposal to merge 40 high school sports teams into eight. Imagine if such energy were channeled into demands for a better health-care system.

This national solution is best, but for whom?

Seattle Post-Intelligencer
March 12, 2003
National solution best for health care
By Mary O. McWilliams

Here, in the midst of Cover the Uninsured Week, it is important that this be said: All Americans should be covered by health insurance.

To that end, I offer the following principles to guide the debate. These ideas center on the values of individual responsibility, collective accountability and equality.

* Coverage for all is a national public policy matter.

* We should focus on adding to the coverage that exists today.

* We must acknowledge that solutions will have a cost.

* We need a basic set of health benefits as the floor.

* This is a collective responsibility.

* Government-sponsored programs must be adequately funded.

* We must improve the current system.

* Consumers must have a direct relationship with the cost of care.

It is to be hoped that these concepts will further spark a meaningful debate, which must continue in earnest beyond the focus of this week.

Mary O. McWilliams is president of Regence BlueShield.

http://seattlepi.nwsource.com/opinion/112031_regence12.shtml

Comment: During Cover the Uninsured Week, there is a unified voice stating clearly that everyone should be covered by health insurance. Listening to the various interests, it almost sounds like we finally agree that we must have a universal, egalitarian system. But then there are always the details.

Ms. McWilliams believes in a national solution, as long as that solution protects her industry, funds it more generously, and allows it to shift the burden of actually funding health care to the individual patients, to “encourage cost- and quality-conscious purchasing.” What will her position be if it is decided to reduce expensive administrative excesses by eliminating middleman health plans and adopting a single public payer?

Cover the Uninsured Week should not only end with a resolve to cover everyone, but it should also end with a resolve to put the interests of patients above all others. Without such a resolve we will flounder and founder.

Real terror: no health insurance

March 12, 2003
BY CINDY RICHARDS
The Chicago Sun-Times

For 30 years, Rebecca Sawyer-Spoon and her husband, Joe, lived the American dream. They ran a small business, paid their taxes and prospered. Now, she’s a statistic.

Sawyer-Spoon is one of the 41 million Americans without health insurance, even though she works full time and brings home a comfortable, middle-class living.

She was one of several victims of the Great American Health Debacle to speak during a moving town meeting Monday at the Harold Washington Library, one of a score of events being staged this week in Chicago–and hundreds being staged across the country–as part of ”Cover the Uninsured Week.” The week is supposed to raise awareness of the growing number of working Americans who either can’t get health insurance or can’t afford the insurance they could get. The message, however, is getting lost amid the media scramble to cover the war on terror.

”Why isn’t health care considered protection by the government? We feel so much more terrorized in our daily lives by our lack of access to health care than we do by foreign terrorist attacks,” said Sawyer-Spoon, a resident of rural Downstate Charleston.

The Spoons had health insurance until their provider went out of business. She had been diagnosed with a mild case of asthma, and her husband was diagnosed with high cholesterol. Their pre-existing conditions precluded them from finding other insurance.

Now, when she goes to the doctor to renew her asthma prescription, Sawyer-Spoon said, ”I won’t let him touch me.” What if he found some other health problem?

She could get the necessary treatment and then file bankruptcy to avoid paying for it. That’s what doctors suggested Chicagoan Frances Camberis do when she was diagnosed with a fibroid tumor and spent four uninsured days in the hospital. She hadn’t been able to get health insurance, Camberis said, ”because I’m fat.” The bill for that hospital stay was $28,000. She liquidated her retirement plan to pay it.

Not only do the uninsured wait to get necessary treatment, ensuring that they will need more costly care, they pay more for the care they get. A study released last week by the Service Employees International Union shows people who pay medical bills themselves are charged more for the same services. Large insurance companies, large employers and the federal government (which pays for 60 percent of health care through Medicare and Medicaid) use their buying power to negotiate better rates from doctors and hospitals.

All in all, it was a rather depressing two hours. Having been a statistic in the past–my union’s health insurer collected our premiums but never paid our providers and ended up in receivership, leaving hundreds of us uninsured and hounded by bill collectors–this is a subject near and dear to my heart. During the time I was uninsured, a nasty cold turned into pneumonia, which triggered asthma. I doubt I will ever be able to buy an individual health insurance policy again.

While Monday’s meeting was long on emotion, it was woefully short on solutions. Sen. Dick Durbin (D-Ill.) opened the session by lamenting the lack of leadership on this issue in Washington, then headed off to catch a plane before explaining why he hasn’t stepped up to the plate. Rep. Rahm Emmanuel (D-Ill.), who worked in the Clinton White House the last time health care topped America’s political agenda, will introduce a bill soon that would expand coverage for lower-income Americans.

But this is no longer a lower- income problem. It is a mainstream problem. The flagging economy is sapping employers’ ability to offer health insurance, the high cost of technology and malpractice insurance is raising the cost of health care, and the risk aversion of insurers is leaving more and more Americans unable to get coverage at any cost. Even those of us who have health insurance today have no guarantee we’ll still have it tomorrow should a layoff, the death of an insurance-providing spouse or even a costly illness mean the end of our insurance benefits.

This is the terror President Bush should be fighting.

The hidden cost of a fragmented health insurance system

United States Senate Special Committee on Aging
March 10, 2003
Testimony of Karen Davis, President, The Commonwealth Fund

Time for Change: The Hidden Cost of a Fragmented Health Insurance System

Executive Summary

We have entered the 21st century encumbered by a health system that is not up to the challenge of ensuring a healthy and productive nation. Set in motion over 50 years ago, the system is costly, complex, and confusing. Most important, it is failing to achieve the twin objectives of health insurance: to ensure that people have access to needed medical care and to protect them from the financial burdens of costly medical bills.

There are five types of costs inflicted by our fragmented health insurance system:

* Costs of a growing number of uninsured

# 41 million Americans in 2001 fell through the cracks of the American health care system because they were not lucky enough to be covered by employer-based coverage, Medicare, Medicaid, or the Children’s Health Insurance Plan

* Health and economic consequences of gaps in health insurance coverage

# 18,000 deaths of adults ages 25 to 64 occur each year as a result of the absence of health insurance coverage – making it the sixth-leading cause of death in this age group, ahead of HIV/AIDS or diabetes

* Cost-shifting that occurs in a fragmented financing system, especially as health care costs accelerate

# 70 million American workers are covered by their own employer; 20 million by a family member’s or previous employer; 30 million are not covered by an employer

# Our “pass the buck” system of health insurance perpetually shifts costs from one employer to another, employers to workers, federal government to state governments and back, and to safety-net hospitals serving the uninsured

# Far more energy goes into shifting costs than enhancing efficiency or quality of health care; insurance companies are profitable by attracting favorable risks, not through innovative incentives to improve quality and efficiency

* Costs of churning in health insurance coverage, as people’s economic and personal circumstances change

# Churning results in frequent gaps in insurance. Sixty-two million – one of four – were uninsured during 2000; 75 million were uninsured in 2000 and 2001. These people were at high risk of not getting care when needed and facing unaffordable medical bills when care could not be postponed.

# The U.S. spent $111 billion in 2002 on private insurance and government administrative costs – not including administrative costs incurred by hospitals and other health care providers or by individuals as they enroll, disenroll, and re-enroll and change insurance coverage and plans.

* Costs of complexity from a pluralistic system of health insurance without an integrating framework and consensus on basic principles

# Cost of large numbers of individuals eligible for but not enrolled in public programs

# Cost of lost productivity, health, anxiety, sick days, and valuable time of uninsured patients spent seeking care

# Cost of resources wasted on administration – jobs underwriting, screening, and verifying eligibility; new administrative apparatuses to cover narrow target groups of eligible individuals; costs of enrolling and disenrolling for public and private insurers and for individuals

# Costs of inefficient and low-quality care – high costs in emergency rooms for preventable conditions and hospitalizations; costs of differing standards of care depending on insurance status

# The U.S. spends twice as much per capita on health care as other industrialized OECD nations and is the only one to fail to cover everyone

There has to be a better way:

* Automatic and affordable coverage for all

(Truncated. See “Comment” for the solution suggested.)

http://www.cmwf.org/programs/insurance/davis_senatecommitteetestimony_622.pdf

Comment: Karen Davis has provided the rationale for ending our fragmented health insurance system. The obvious conclusion is that we need a single, publicly-funded and publicly-administered insurance program. But here is the solution that Karen Davis offers:

“We have built an incredibly complex, costly, and confusing health insurance system. We need a single guiding framework for coverage. It can include multiple sources of financing, multiple choices of public and private coverage, and multiple benefit packages, but it needs to be integrated within a single framework. Certainly, we should have a system that preserves innovation, flexibility, and choice, but some standardization will be required to cut through the maze of complexity in our current system. Reaching consensus on the parameters of choice versus standardization is an important part of public debate on this issue.”

It is astounding to see the efforts that are being made to avoid a program of social insurance but instead to build on our current fragmented system. To present compelling arguments on why the fragmented system does not and cannot work, and then to suggest that we build on it, defies all logic.

Need stitches on that gash? Try living without health insurance

By Jamie Smith. Jamie Smith lives in Pearl River, N.Y

March 11, 2003
Chicago Tribune

I don’t have health insurance.

Unlike many of the 40 million Americans without health insurance, I could get coverage fairly easily. I am a speech pathologist by training, and it would not be hard for me to get a job with health benefits. But I have three small children, and when the oldest was a baby I decided to do what it took to stay home. What it takes is living without good health insurance.

We live, the five of us, on my husband’s modest income. We live simply, in a small apartment. We have no car and we eat a lot of lentils. Mostly, we prefer it that way. I like lentils. The problem is health care.

We practice preventive medicine as far as possible. I breastfeed; I childproof; I serve my family nutritious food; I am a hand-washing fanatic. But breastfed babies can still get ear infections. Toddlers can split their heads open on a worrisome array of innocuous-looking objects. And 4-year-olds can still get pneumonia, vitamin C and hand-washing notwithstanding.

We have almost always had some sort of coverage–cheap policies with high deductibles from companies you never heard of. But we have never gotten a dollar back from one of these policies. We buy them just in case–just in case somebody gets cancer, or falls out of a window, or gets hit by an uninsured driver. When we received the notice that the premium for our last policy was rising by 35 percent, I went rampaging around my apartment. “I could have stood on the roof and flung the money into the wind for all the good this policy has done me, and now they want more money for the useless thing?” And then I paid the bill.

Just in case.

I follow the newspaper coverage of the health-care crisis. The articles are all too familiar. “Doctors raise charges for patients without insurance,” the paper tells me, as I observe grimly that I have been charged $140 for a 10-minute well-child exam. An insurance company has the clout to announce that it will pay only a third of that amount; the uninsured patient who tries that strategy will quickly find himself in the hands of a collection agency.

“Premiums rising,” the headlines say. Don’t I know it.

I used to think that was just the way things were–until we moved to Scotland for two years. While the National Health Service has many flaws, it was a revelation to see how well universal coverage could work. When my oldest son fell and needed stitches, I took him to our local children’s hospital. We were treated promptly and professionally; he has a tiny white scar and pleasant memories of the hospital. We chose to have our second child while we were living there, and I was struck again and again by the wisdom of the British system of perinatal care: cheaper, safer, smarter, accessible to any pregnant woman regardless of the vagaries of her employer’s benefits plan.

When we returned to the U.S. I found myself questioning the third-party payer system. Why do we pay so much money to insurers, who make a profit based on how little of it is passed along to the people who provide the services?

What if we cut out the middleman? Why have for-profit entities been afforded so much decision-making power?

Back in the U.S. my second son fell into an end table on a Saturday afternoon.

As I surveyed the gash on his forehead, I found myself wondering how much an emergency room visit would cost and how big his scar would be if we didn’t go–hating myself for making the calculation, making it anyway. A friend had been billed $1,000 to repair a comparable injury. We stayed home. With shaking hands and butterfly bandages I brought the edges of the cut together. But I am no doctor. His scar is not conspicuous but it is present. And every time I see it I feel guilty.

I know I am far from alone in my frustration. Every time health insurance comes up in conversation, more questions surface about the long-term cost of the third-party payer system. How many children lose out on having a sibling because of the cost of maternity coverage? How many people abandon the dream of owning a business because of the cost of providing health coverage for a family? How many retirement-age employees slog on at work to provide health insurance for a spouse?

In the busy pediatric clinic where I worked before my first child was born, almost all the receptionists who became pregnant returned to work after their maternity leaves. The pay was meager (especially given the cost of child care) but the benefits were good; they needed the insurance.

After his second post-doctoral research position, my husband decided to switch career directions and get off the academic track. I was relieved at the prospect of having health benefits, but I found myself with more questions.

Would it be unethical to participate in a system which is so fundamentally unjust? Would I really have the gumption to decline health benefits on ethical grounds? I didn’t need to worry; another headline intervened–“Employers cutting dependent coverage.” My husband’s company offers no benefits to dependents. I could buy insurance if I paid 15 percent of his monthly take-home pay to do so.

I declined. You can buy a lot of lentils with that amount of money. But the questions remain: Is it right to participate in a profoundly unjust system?

How many people have to demand other options before other options become available?

I’m still waiting for answers.

Your responses to my apology for the poetry spam

Although I had stated that I would limit postings on this list to health policy issues, because of the volume of responses received, I am unable to respond individually to your comments on my “weak apology” for the anti-war poetry. Thus this message.

Simply stated, my faith has been restored.

Although somewhat narrowly focused, I believe that the comment on a sign at peace demonstrations in Los Angeles, graciously forwarded to us by Anne Marie Staas Niedorf, expresses the sentiment and priorities of most of us:

SADDAM DIDN’T CLOSE MY HEALTH CLINIC

Risk segmentation is bad for your health system

Economic and Social Research Institute February 2003 Issues in Coverage Expansion Design

Coping with Risk Segmentation: Challenges and Policy Options by Elliot K. Wicks, Ph. D.

A factor that complicates almost all proposals to extend health insurance coverage is how to cope with risk segmentation in the small-group and individual insurance markets. Experience in these markets shows that if market forces are left to operate unfettered, people seeking private health insurance will be segregated into small risk pools that reflect their expected risk of incurring medical expenses and charged premiums accordingly. Premiums will vary widely across the spectrum of expected risk, and risk will not be widely shared. These are problems that generally do not plague large employers, because they are large enough to form their own risk pools and self-insure; that is, costs are sufficiently spread among higher-risk and lower-risk employees within the group. So the discussion that follows applies to health insurance for small employers and individuals buying coverage on their own.

Risk segmentation and the consequent wide variation in premiums create at least two kinds of problems. First, some high-risk people are not able to afford coverage. Second, the wide premium spread requires some people to pay much more than others for identical coverage, which many would consider inequitable.

Alternative Ways to Deal with Risk Selection

Prevent Risk Selection

Approach 1: Require insurers, in setting premiums, to community rate everyone.

Approach 2: Require everyone in some subset of the population who purchases coverage to buy from a common source and have each insurer base premiums on the experience of all its enrollees in the pool – for example, require all small employers to buy from a purchasing cooperative or insurance exchange.

Approach 3: Instead of charging people premiums, use public financing, as with the Medicaid and Medicare systems.

Approach 4: Single payer without health plans that accept any risk.

A single-payer system that did not put health plans at risk – as with fee-for-service Medicare – would solve both sides of the risk segmentation problem. Enrollees would not pay premiums, and thus there would be no difference in cost associated with risk differences. And insurers would not bear risk – they would just administer the system – and thus there would be no reason to compensate them for differences in the risk of the people they enroll. There would be no risk segmentation because there would be only one insurer – government.

Allow but Offset Risk Selection

Approach 1: Allow wide (though perhaps not unlimited) variation of premium based on price, but provide subsidies to help high-risk enrollees pay the high price they will face.

Approach 2: Make risk selection unprofitable by having a very good risk-adjustment process.

http://www.esresearch.org/newsletter/february03/risk_segmentation.pdf

Comment: This report describes the policy implications of various approaches to segmenting risk. It is worthwhile reading this nine page report because you will understand the problems that arise with each approach. Understanding risk segmentation makes it clear why it is so difficult, or, actually impossible, to ensure that everyone has equitable, affordable health care coverage. But the exception is the single payer approach which is unique because there would be no risk segmentation since there would be only one insurer – the government.

Why do we waste so much effort and expense on playing the risk segmentation game, perpetuating inevitable inequities, when we can save time and money and establish equity by dumping the health plans and establishing a single payer system? Do we have an aversion to logical solutions?

Our health care system is a real pill

Posted on Thu, Jan. 23, 2003

By Molly Ivins Creators Syndicate

Bet you if I had a nickel for every time someone has started an article or a speech in the past five years by saying, “The nation’s health care system is facing a crisis,” or, “Our health care system is falling apart,” I would be a rich woman today.

I suppose I could come up with some dramatic metaphor for the crumbling, tottering, greed-rotted structure, but hey, why don’t you check out your health insurance premiums and see how you’re doing? Up by 12 percent, 22 percent, 40 percent?

Larger premiums, higher deductibles, increased payments for prescription drugs? Employer dropping your coverage? Are we having fun yet?

Our money-corrupted political system isn’t about to address the systemic problems. I think it’s almost self-evident that a single-payer system is the best answer to all the problems, but since we have to deal with political reality, let’s shelve that plan for now.

The last time anyone tried to do anything about the whole system — Hillary Clinton with a not-very-good plan back in ’93 — she was shouted down by $10 million in insurance company ads, still the record for the most money spent ever to defeat a single bill.

Now we’ve got 41.2 million Americans with no health insurance — 14.6 percent of us — which ends up costing us more than it would to pay for their insurance. We pay the world’s highest health care taxes. Our government spends $2,604 per capita, the highest of any nation, including those with national health insurance, even though only a quarter of our population is covered by government insurance.

We spend 13 percent of our GDP on health care, the highest in the world. The average in the European Union and in other developed countries is 8 percent. According to the Organization for Economic Cooperation and Development, we spend a total of $4,600 per capita for health care, more than twice the average of other countries.

We ain’t getting much bang for our buck, either. Forget the “we have the finest health care in the world” claims. In both life expectancy and infant mortality, we’re below the median for developed countries.

If you stand back and look at the fiscal crisis in the states and cities, you will see that almost all of it is driven by health care costs. Naturally, the strapped states and cities can’t think of anything to do except start knocking people off Medicaid and the Children’s Health Insurance Program (CHIP). That just means they wait and get sicker before they finally end up in the emergency rooms, costing us all more money in the long run.

Sometimes the sheer stupidity of our choices is amazing.

One chunk of this insanely complicated system that the politicians are now preparing to tackle is medical malpractice costs. “Med-mal,” as it is known in the trade, is currently the subject of a particularly fruitless hissing match between Republicans and Democrats over whether the trial lawyers or the insurance companies are to blame for astronomical increases in premiums. This is complicated by the fact that trial lawyers give money to Democrats and insurance companies give money to Republicans.

We’ve all heard of ridiculous lawsuits by trial lawyers looking for a buck. The insurance companies have well-funded campaigns to publicize idiotic suits — they do not publicize it when the suits get thrown out of court. Of course, we’ve all heard of ridiculous medical mistakes as well.

It has never been clear to me why the American Medical Association goes along with blaming trial lawyers rather than insurance companies when their malpractice rates skyrocket. The fact is that malpractice is committed by a tiny percentage of doctors — 5 percent, according to Public Citizen — and the AMA could save itself and everyone else a lot of trouble by getting rid of them.

In Texas, we’ve had zero doctor’s licenses revoked because of medical errors since 1997, despite 6,038 medical malpractice claims reported to the state, including 150 times that surgeons operated on the wrong part of the body.

Of course, trial lawyers do drive at least a part of med-mal costs, but if you examine the competing claims (under the Bush administration, you have to be wary of government data because it increasingly uses only insurance industry figures), the insurance industry is the primary villain. (If this were a lawsuit, the trial lawyers would figure out how much blame to assign to each of the parties to the last decimal point.)

According to The Wall Street Journal, the insurance industry folks are jacking up prices not just because their investments in the stock market have fallen dramatically but also because they fouled up their pricing practices in the early ’90s. They seriously underpriced med-mal and are now trying to recoup, and for this they blame the trial lawyers.

California is an interesting case in point. The state passed a tort reform bill, limiting what one can recover in a lawsuit, in 1975 and waited expectantly for insurance premiums to go down. They nearly tripled in the next 12 years, finally leveling off in the early ’90s. And, amazingly enough, California just happened to have passed strict insurance regulations in 1988.

Molly Ivins writes for Creators Syndicate. 5777 W. Century Blvd., Suite 700, Los Angeles, CA 90045

The consequences of medical debt

The Access Project, with other organizations February, 2003

The Consequences of Medical Debt

Summary of key findings:

* Having health insurance does not always protect individuals from out-of-pocket medical bills they cannot afford to pay. In our survey of low-income individuals in three communities, respondents with and without insurance were struggling with comparable levels of medical debt.

* Confusing and multiple bills, and the challenge of understanding what is owed and to whom, add to the problem.

* Provider practices – requiring cash payment upfront, flatly refusing care or suggesting people use other sources of care – made it harder for many respondents with medical debt to access care with any regularity. Patients often responded to these practices by not seeking care or filling prescriptions, or otherwise not complying with treatment regimens.

* Health care providers seem to be adopting more aggressive collection procedures, including turning over their accounts to collection agencies 30 to 60 days after a missed payment (instead of a more customary 150 to 210 days) and encouraging patients to pay off their medical bills with credit cards, a practice that burdens patients with not only large debts, but high interest payments as well.

* Many of the individuals we interviewed wanted to pay off their debt and had tried to negotiate payment plans, but found the terms of the plan very difficult to maintain given limited incomes and apparently inflexible hospital collection practices.

* Few respondents, in spite of very low incomes, were able to secure public assistance to defray the cost of their medical care. Many turned to family and friends for help, suggesting that communities may help relieve the burden of medical debt, but also share in it.

* Like other forms of debt, medical debt can have substantial financial consequences, including serious credit problems and, in extreme cases, personal bankruptcy. However, unlike other forms of debt, medical debt is often involuntary, the result of an event over which one has little or no control.

* Bankruptcy may offer a means to relief from medical debt and from the harassment of collection agencies and its attendant stress. This is particularly the case for the uninsured – people who are likely to have relatively fewer resources and be less able to make regular payments on their debt.

* Medical debt made it harder for respondents to achieve self-sufficiency; they were hindered in their ability to get a bank loan and other lines of credit, to save money, or to pay for basic goods and services.

* The effects of medical debt can be compounded if a health problem leaves a person unable to return to work. Because of the debt, people may be deterred from seeking the care needed to allow them to work. Job seeking may also be hindered by the fear of wage garnishments.

* Respondents told us that medical debt caused significant stress, anxiety and feelings of hopelessness. Medical debt can also be a source of embarrassment and shame, and many respondents were frustrated and angry that they were being financially punished for a medical event over which they had little control.

Health care is a business unlike most others. The customers are, by definition, in a vulnerable position by virtue of the medical problem for which they seek services. The providers of these services differ from sellers in most other markets because their product is essential and often life saving, and is governed by ethical responsibilities that exceed those that apply in typical commercial transactions. Purchases are often sudden and unplanned and, particularly for people without health insurance, may bring large financial burdens that are involuntary in the sense that they are not the result of a traditional consumer choice.

http://www.accessproject.org/downloads/med_consequences.pdf

Comment: Warning: this report is difficult to read. It is not a report of technical complexity. Rather it is a report that has a Dickensian quality, including the Tiny Tims whose suffering is compounded by medical debt, and the institutional and individual provider Scrooges with their passive automaticity when faced with the “need” to collect unpaid debts. The report is punctuated with quotations. If you cry easily, this may make you do so.

We are spending $1.66 trillion on health care this year. Our existing policies ensure that our administrative excesses will always be fully funded for the benefit of the insurers. But our policies are not designed to prevent medical debt for vulnerable patients. Yet only a very small portion of funds directed to the wasteful administrative excesses would be more than adequate to cover all medical debt. It is so tragic and so needless.

Let’s change our policies. Let’s reduce the waste by changing to an administratively efficient, public insurance program, and use the savings to provide everyone comprehensive coverage. Medical debt then could be relegated to the Dickensian novels where it belongs.

What is California HealthCare Foundation's true mission?

What is California HealthCare Foundation’s true mission?
By Don McCanne

Following is a description of the California HealthCare Foundation from their own website:

“The California HealthCare Foundation, based in Oakland, is an independent philanthropy committed to improving California’s health care delivery and financing systems. Formed in 1996, our goal is to ensure that all Californians have access to affordable, quality health care.

“CHCF’s work focuses on informing health policy decisions, advancing efficient business practices, improving the quality and efficiency of care delivery, and promoting informed health care and coverage decisions.

“CHCF commissions research and analysis, publishes and disseminates information, convenes stakeholders, and funds development of programs and models aimed at improving the health care delivery and financing systems.”

And California HealthCare Foundation’s stated mission:

“Mission statement: to expand access to affordable, quality health care for underserved individuals and communities and to promote fundamental improvements in the health status of the people of California.”

Understanding the origin of California HealthCare Foundation (CHCF) is important. During the decades that Blue Cross of California was a non-profit entity, it received favorable tax treatment not available to for-profit insurers. When Blue Cross of California converted to a for-profit entity, becoming a subsidiary of WellPoint, it was decided that the accrued value of the tax subsidy should not be granted gratis to the new shareholders of WellPoint, but should utilized for the benefit of Californians since this vested interest rightfully belonged to them. It was decided that this could be accomplished by establishing the California HealthCare Foundation and the California Endowment. The funds would then be used to improve the health care system in California, benefiting the underserved, and, in fact, benefiting all Californians by “improving the delivery and financing systems.”

Mark D. Smith, MD, MPH, President and Chief Executive Officer of California HealthCare Foundation, has infused foundation funds into research and reports on health plans, managed care, insurance markets, MediCal and other aspects of our current system. But he has often expressed his view that a single, universal health insurance program is not an option for reform. In spite of the California Health Care Options Project study that demonstrated that single payer reform could provide affordable, comprehensive coverage for all Californians (a goal of CHCF), he seems to continue to exclude that option from CHCF activities.

Yesterday we saw an interesting example of this apparent bias. The Kaiser Daily Health Policy Report sends out summaries of important policy issues, published by The Advisory Board Company. One item yesterday included reference to a New York Times article on employers’ concerns about health care costs, along with reference to the USA Today editorial debate on two views of controlling health care costs. It ended with my comment that we need to throw out the wasteful, ineffective health plans and spend the money on patients instead.

The items of national interest are often repeated in their entirety in California Healthline, a similar publication of the California HealthCare foundation, also published by The Advisory Board Company. The article above was no exception except for one remarkable difference. The New York Times segment was carried, but the USA Today segment on controlling costs by replacing health plans with a public program was deleted and another USA Today story on reducing costs by exercising and eating well was substituted. Is it not unreasonable to ask what happened? Why was a statement highly unfavorable for health insurers such as Blue Cross deleted?

The health care crisis in California, and, indeed, in the nation has reached proportions such that reform is mandated. This is the time to be examining all options for reform. An informed state and national discourse are essential. The California HealthCare Foundation should be front and center as a resource on policy issues. And since they are utilizing funds that originated from California taxpayers, they have an ethical obligation to be certain that their process is as open and unbiased as possible.

It is reasonable to ask a few questions.

* Does Blue Cross/WellPoint still exert any control over this process that has deliberately excluded options that would remove Blue Cross as a player in the health care system?

* Do members of the board of directors have any conflicts of interest that might cause them to fail in their ethical obligation to support the interests of Californians and their health care system?

* Does Mark Smith have either an ideological bias, or a vested interest in California health plans, especially Blue Cross, that might disqualify him from administering ethically the California HealthCare Foundation in the interests of all Californians?

* Why did The Advisory Board Company take the unusual step of changing a portion of this one article for publication in California Healthline?

* What is California HealthCare Foundation’s true mission?

These and other questions I believe are quite reasonable. I don’t have the answers. Perhaps those in the media receiving this message may want to try to discover the answers. If you have friends interested in investigative reporting, you may want to forward this message to them.

The rest of us must intensify our efforts to demand fairness and openness in the process. We must be sure that the reform we end up with will be in the best interests of all patients.

About CHCF: http://www.chcf.org/aboutchcf/

Kaiser Daily Health Policy Report on the New York Times article on employers’ health care costs, and on the USA Today debate on managing costs (requires registration): http://www.kaisernetwork.org/daily_reports/print_report.cfm?DR_ID=16431&dr_c at=3

California Healthline on the New York Times article on employers’ health care costs, and on a substitute USA Today article on reducing costs by exercising and eating well (requires registration, and limited to California residents): http://www.californiahealthline.org/members/basecontent.asp?contentid=48118& collectionid=3&contentarea=23810

What is California HealthCare Foundation’s true mission?