The Washington Post
May 27, 2002

By Bill Brubaker

Anthony Welters grew up in a one-room tenement in Harlem, sleeping behind a curtain with his three brothers, he says.

Today, he lives in a five-bedroom, seven-bathroom house on five acres in McLean. He has a 75-acre farm in the Blue Ridge Mountains. For a change of pace, there is a 5,000-square-foot house in Aspen, Colo., recently assessed at $3 million.

Welters, 47, made his fortune in health insurance, serving a specialized market.

The market is the poor.

Federal and state audits concluded in the early and mid-1990s that ineffective oversight by Pennsylvania officials had enabled Welters and his partners to make too much money from their taxpayer-supported business.

The audits said the Welters group had paid itself millions of dollars in management fees — paid to other companies they controlled — and millions more in bonuses.

Welters’s health-insurance business expanded to New York in 1994 and New Jersey in 1996. In both states, the HMO was known as Managed Healthcare Systems (MHS).

In New York, state investigators discovered something was not right about two clinics that MHS retained to serve patients in the borough of Brooklyn.

They determined that from 1995 to 1997 the clinics were being staffed largely by “unsupervised physician assistants or nurse practitioners,” New York state Attorney General Eliot Spitzer announced in May 2000.

The investigation also found that patients were “consistently complaining that they were having difficulty getting services or being seen by a doctor.”

MHS “failed to take any corrective action or properly oversee” the clinics.

Spitzer announced a settlement in which MHS repaid more than $2 million to the Medicaid program for services the clinics never provided.

In October 2000 MHS changed its name to AmeriChoice of New York.

Anthony Welters, Chairman of AmeriChoice Corp.:

“What [should] a person who takes a $200,000 investment and turns it into a billion-dollar company . . . receive? I don’t know. But I know this: I’m not going to apologize for it.”

http://www.washingtonpost.com/wp-dyn/articles/A14254-2002May26.html

Comment: Medicaid’s chronic under-funding threatens access to care for the low-income individuals covered by this program primarily because many providers will not participate at rates that frequently do not even pay overhead expenses. Several state governments have turned over their Medicaid funds to private corporations to administer these programs. Mr. Welters exemplifies how well these plans fulfill their corporate responsibility to their shareholders and executives.

In 2002 we are already spending over $5500 per capita for health care in the United States. Pool that into a single fund, eliminate the middleman thieves, establish a program of public administration, and we would have affordable, comprehensive care for everyone.

Until we do that, those of us that sit back and do nothing must concede the wisdom of the words that William Shakespeare assigned to Puck: “Lord, what fools these mortals be!”

Felix Schwarz, MA, MPH, Executive Director of the Health Care Council of Orange County, comments on Dr. Munoz’s article on mental health carve outs:

For years we have been fighting for “parity” for mental health coverage. I am now telling my mental health advocate friends, as forcefully as I can, that we should no longer seek parity in a broken health care system. We should try to fix the system as a whole — to include mental health coverage in a universal, single payer, fair and rational system that does not try to “carve out” mental health, or carve up the patient population to leave out those whose needs for health care are greatest!

National Center for Policy Analysis
April 2, 2002
Opinion Editorial

by The Honorable Pete du Pont, Policy Chairman of NCPA

“Under our current system, if a health insurance company raised prices and reduced benefits, consumers would switch in droves. But, when there is only one game in town, consumers would have to accept whatever costs and benefits were offered. Without the incentives created by competition, a single-payer system would likely exemplify the innovation, compassion and efficiency of the Internal Revenue Service in no time.”

http://www.ncpa.org/edo/pd/2002/pd040202.html

Comment: Some would consider using false innuendoes and false analogies to be the equivalent of lying. At best, they reflect the desperation of an ideologue who is unable to find logical arguments to oppose a rational concept.

National health insurance or single payer reform has been demonstrated to be the most credible option that would assure affordable, comprehensive health care for everyone. The single payer message is very powerful. It has resumed its rightful position back in the national debate on reform. Opponents are now coming out in force with their false rhetoric to attempt to beat back the anticipated groundswell of support. Be prepared.

Beth Capell, Ph.D. on Pete du Pont’s rhetoric:

Du Pont’s arguments are real ones that need to be effectively rebutted–they reflect beliefs deeply held by many Americans that a government-run operation for any purpose is not as good as a private-run operation. This is perhaps the toughest hurdle faced by those of us who support single payer.

His argument also speaks of the importance of the market, of competition, of choice, of consumer power.

The error here is the notion that the most important social value for health care is giving individuals choice and preserving the private market rather than assuring a basic level of service for everyone.

Choice, competition and the market work against people who need health care but have only modest incomes. But these are deeply held values in this country and the force of the belief in them must be respected.

It is entirely possible for people to hold beliefs and values that have conflicting implications–all of us do it: I want to save money, I want to go on vacation; I want to lose weight, boy, that dessert looks great; I want consumer choice in health care, I want to be sure that I can get the care I need when I need it.

The problem in this country is that policy does not yet include the principle that every one of us should be able to get health care when we need it. It exists for people with insurance (that’s what the Patient Bill of Rights was about.) This principle exists for seniors, for pregnant women and for children. Here in California we are in the midst of a debate over whether it includes parents.

Fighting for the principle that every one of us should be able to get health care when we need it is fundamental.

The San Diego Union-Tribune
May 22, 2002

By Rodrigo Munoz, a psychiatrist and president of the San Diego County Medical Society

… San Diegans will continue to be on the short end of the stick when it comes to accessing critical mental health services. That is because of the little-known but powerfully disruptive practice called a “carve-out,” which allows insurers to skirt around the laws on mental health parity and deliver the least amount of care for the greatest financial return.

On paper, carve-outs are simple to understand. Insurance industry giant XYZ Health is given the contract to insure the employees of a large corporation, probably by tendering the lowest premium bid. XYZ Health promptly subcontracts with a for-profit company to handle the mental health claims under the insurance policy, severing the mental health benefit from the rest of the policy, usually for as little as 25 cents per member, per month.

If you ask how any company could turn a profit when it is being reimbursed a quarter a month for each member of the insurance plan that might seek treatment, you’re onto something. The only way that these firms (called “behavioral health companies” in industry jargon) can make money is by making it virtually impossible for those in need to get treatment.

These companies make it hard for people to see a psychiatrist in the first place, limit the number of times a patient can see a psychiatrist, limit the amount of time they will pay for the psychiatrist to see the patient to 20 minutes and force people out of the hospital before they can safely go home, with no adequate follow-up provided. This is a clear violation of the mental health parity law, but they get away with it, because the benefit has been “carved out.”

The saddest thing is that many patients and even the employers who pay the bill don’t realize that the HMO they have entrusted with their business and their health has washed its hands of a piece of it. They only find out that XZY Health is out of the picture when they go to access treatment, unsuccessfully.

Treatment for disorders of the brain should not be carved out and away from the insurance benefit any more than diseases of the kidneys, eyes or heart. “Separate but equal” is no more tolerable in health care than it was in public education. Unless we end the practice, we will have to substitute the word “parody” for “parity” when discussing mental health treatment in San Diego.

http://www.signonsandiego.com/news/uniontrib/wed/opinion/news_mz1e22health.html

Los Angeles Times
May 23, 2002
By Nicholas Riccardi and Garrett Therolf

Under the most optimistic plan, the county would have to close the emergency room at Harbor-UCLA Medical Center near Torrance, eliminate trauma services at King/Drew….

The deficit stems largely from the fact that the county health system treats many of the nearly 3 million uninsured patients in Los Angeles County. Over the years, the county has lost funding while the number of uninsured people has grown.

Dr. Brian Johnston, past president of the Los Angeles County Medical Assn.and an emergency room physician:

“They should put out a public announcement in some of these communities that if something bad happens to you, you are on your own. That’s a very busy trauma center. What’s going to happen to those people?”

http://www.latimes.com/news/printedition/front/la-052302health.story?coll=la%2Dhome%2Dtodays%2Dtimes

Comment: Most Americans are concerned about the problems of the uninsured. They do believe that measures should be taken to assure access to care for everyone. But they are uncomfortable about increasing taxes to pay for public programs for the medically indigent. And those that have health care coverage and comfortable incomes have even greater concerns about proposals to replace their health plans with some type of government program. For these reasons there is very little pressure on legislators to seriously address the problems of the uninsured and under-insured. Most would prefer to keep their current secure status in health care even though they regret the problems of the less fortunate.

But how secure is the current status of the affluent? What does it mean to shut down trauma centers? The Institute of Medicine report released this week revealed that an uninsured auto accident victim is more likely to die than a patient with insurance, even though they both were transported to emergency facilities. If merely the insured status makes a difference, then what would be the impact of shutting down the trauma center? Obviously, they are both at much greater risk of dying if they have to be transferred to an over-crowded facility on the other side of a heavily congested city. The affluent may be relatively complacent, but they shouldn’t be.

Currently in California there are proposals to increase funding of trauma care systems by tax increases. But Gov. Davis’ office responded that it is unlikely that the tax increase proposals would receive enough support from the state legislature to pass. Even if they did pass, would this small patch in the gigantic voids in our system really bring us health security?

The $1.5 trillion that we are already spending is enough to fund all care for everyone, but we lack an efficient system to properly direct those funds. The solution is simple. Enact National Health Insurance now.

Institute of Medicine
National Academy Press
May 21, 2002

“… the overall mortality risk for uninsured adults, estimated here to be on the order of 18,000 excess deaths among uninsured adults annually, is comprised of elevated mortality rates across many disease categories. All of these excess deaths among uninsured adults occur among relatively young Americans, those under the age of 65.”

http://books.nap.edu/books/0309083435/html/index.html

Comment: Headline news:

18,000 YOUNG ADULTS KILLED

You didn’t see this headline? Of course not. That’s merely the number of young adults that die each year because they don’t have health insurance. And besides, if we emphasized this tragedy, we would probably have to report the follow-up stories that demonstrate that these young adults (and everyone else) could have had life-saving insurance at no net additional cost to us. We won’t publish those stories. Instead, bland stories on the policy issues of the Institute of Medicine are the order of the day (not to mention that the media wouldn’t want to risk losing advertising revenue from the private health plans). Then the administration wouldn’t be pressured to renew its protest that it’s un-American to have the government interfere with the health insurance marketplace. And we won’t have to see our administration’s typical rhetoric that “18,000 young Americans gave their lives for a free America, protecting the principles that make America the great nation that it is.”

Since 9/11, our government is turning the world upside down because of the tragic loss of life that day. Yet just since 9/11, FOUR TIMES AS MANY YOUNG ADULTS HAVE DIED because of the lack of insurance. Each two months of inaction duplicates the loss of that tragic day. And our government remains silent. Our leaders won’t even discuss real solutions because, “We don’t want ‘the government’ involved in our health insurance.”

Why does America tolerate this rhetoric? It’s sick! Our health care system is sick! And our political leaders are doing nothing to cure the problems!

It’s time to grab the placards and take to the streets! Let’s go!

AARP May 21, 2002

“More people age 50 to 64 are uninsured today than in the past. Individuals who are accustomed to feeling secure about their health coverage are increasingly at risk of not having needed protection. Medicare beneficiaries are frequently without adequate coverage, especially for prescription drugs. Vulnerable subgroups of people age 50 and older continue to experience problems in accessing health care services.”

Implications for Policy (Paraphrased and abridged)

1. Consider socioeconomic conditions in addition to clinical conditions.

2. Expand not just life but also health.

3. Use the public health system to alter the impact of individual behavior and personal choices on health and disability.

4. Address the lack of long-term coverage and the inadequacy and instability of health care coverage for those over 50.

5. Make better use of resources.

6. Improve the quality of health and long-term care systems.

7. Develop a national health information infrastructure.

http://www.aarp.org/beyond50/

Comment: This new report from AARP describes many of the problems with our health care system, especially the impact on those over age 50. There are no surprises in this report. Particularly, AARP has once again failed to surprise us in that they are adhering to their policy position that “good health is better.”

Although AARP does not wish to offend its large and politically diverse membership base, that does not mean that it cannot lay before us health care policy which would seriously address the problems described. A universal, publicly administered, national health insurance program, with appropriate support of the public health system, would correct the problems without significantly increasing global health care costs. The California Health Care Options Project demonstrated that Medicare beneficiaries (and indeed everyone), under the universal models, would receive greatly expanded benefi ts while virtually eliminating financial barriers to care, and global health care costs actually would be reduced.

Is AARP so intimidated by its conservative members that maintaining silence on reform that reflects progressive thought has priority over an open and frank discussion of real solutions to our problems? The AARP membership must become informed on the options. The spectrum from progressive to conservative positions can be presented, but decisions need to be made by an informed public. AARP can provide the leadership in this process. Or is it really better to continue the politically safe approach of remaining silent on the truth and continuing with the very sick status quo?

May 2002
“Sicker and Poorer: The Consequences of Being Uninsured” By Jack Hadley, Ph.D., Principal Research Associate, The Urban Institute

… this report focuses primarily on the relationship between health insurance and health outcomes, which has been addressed by a surprisingly large number of studies over the past 25 years, as well as the link between health and educational attainment and economic opportunity.

This review shows that there is a substantial body of research consistent with a model postulating positive relationships between health insurance, use of medical care, health, income, and education. However, as noted at the outset, none of these studies is definitive, nor are their findings universal. The literature also includes studies that have failed to find a positive relationship between good health and having health insurance or using more medical care.

While all of these studies suffer from methodological flaws of varying degrees, two general observations appear warranted. The first is the fairly remarkable degree of consistency across the studies that support the underlying conceptual model of the relationship between health insurance and health. Studies of different medical conditions, conducted at different times, using different data sets and statistical methods have produced quantitative estimates of the effects of having health insurance or using more medical care that are both consistent with each other and fall within a relatively narrow range. This degree of quantitative agreement across studies reinforces the implications of any single study taken by itself.

The second general observation, holding aside issues of potential methodological weaknesses, is that many of the studies that failed to find a positive association between health insurance or medical care use and health do not obviously generalize to the current population of uninsured nonelderly adults and their families. Casual empirical observations of pre-Medicare/Medicaid data in the U.S., studies of inefficient medical care use by the elderly or privately insured, and studies of birth outcomes may not be directly relevant to assessing the health benefits of extending health insurance to those who are currently without insurance coverage. Even if one accepts as valid the findings of the more methodologically sound studies that suggest little or no health benefit from additional medical care use by well-insured populations, it does not necessarily follow that the uninsured would not benefit both from health insurance coverage and from greater medical care use. Holding both points of view would not be inconsistent. In fact, it would seem to be both inappropriate and unfair to argue on the basis of these studies that the uninsured should be penalized, i.e., denied help in obtaining insurance coverage, because of the inefficient or excessive use of medical care by the well insured.

This report concludes that a compelling case has been made that having health insurance does lead to improved health by means of better access to medical care. Furthermore, the available research on the links between health insurance, health status, and an individual’s productivity begins to provide a reasonable basis for future economic analyses of the benefits of health insurance to the nation as a whole.

The next step for health services research is to estimate the size of the economic benefits of continuous health coverage. Estimates of the size of the potential economic benefits should become a prominent part of policy debates over expanding health insurance coverage. These estimates may help shift the current focus from the direct costs of health insurance expansions to the question of how much is likely to be saved by expanding coverage, and ultimately to policy decisions based on a truer sense of the net cost to the nation to cover all Americans.

(The comments above include excerpts from the Executive Summary and excerpts from the Full Report that have been commingled .)

http://www.kff.org/content/2002/20020510/

Comment: This comprehensive review of the extensive research on the consequences of being uninsured is a very valuable resource that confirms that the lack of insurance has major negative impacts. This report can be used to refute the arguments of those that use isolated studies to suggest that the uninsured do receive the care that they really need. They clearly do not.

The White House
May 17, 2002

President George W. Bush:

… the myth is somehow that if seniors are given choice, low income seniors will not benefit; that if we provide more options for our senior citizens to tailor plans that meet their needs, that somehow the low income will be left behind.

Part of my message today is I want to work with you to provide more choices and more savings for our seniors. (Applause.) I’m a person who trusts people. See, I trust the American people. The American people are fantastic, great citizens. We’ve got to trust people with their own choices in life. I’d rather have the American people make choices than the federal government make choices on their behalf. (Applause.)

We need a fair system of competition. We need a system that guarantees that patient protections and all of Medicare’s required benefits are included in every choice; a system that encourages additional benefits and options for better care at lower cost, including improved medical savings accounts.

That’s what we need to think about, and that’s where we ought to head here in America. The costs savings from competitive reforms are essential. They’re essential. If you notice, and the people will testify to this, that there are lower costs in Medicare plus Choice. And those cost savings in a Medicare plus Choice plan are very important for the future, for your children and your grandchildren to be able to have a Medicare system that works.

http://www.whitehouse.gov/news/releases/2002/05/20020517-8.html

Comment:

President Bush has used “lower costs” in two contexts.

Many participants in the Medicare plus Choice plans have had lower out-of-pocket expenses and more benefits than available in the traditional Medicare program. This results in a “lower cost” for the individual Medicare plus Choice beneficiary. This has been possible because the Medicare plus Choice plans have been practicing virtuous selection by marketing their plans specifically to the healthy, thereby avoiding higher costs of chronically ill patients.

On the other hand, studies have confirmed that the Medicare plus Choice plans have higher costs per beneficiary than for comparable beneficiaries in the traditional Medicare program, primarily because of higher administrative costs. Competition of Medicare plus Choice options not only failed to reduce costs but actually failed to prevent increases in costs. This is an irrefutable fact. But when President Bush says, “The cost savings from competitive reforms are essential,” and “… a fair system of competition… a system that encourages additional benefits and options for better care at lower cost,” he is using “lower cost” in the context that the private plan options will reduce costs for the Medicare program. That is simply not true.

Since the private plans will always have higher administrative costs than the publicly administered program, the only ways to reduce costs for the program are to restrict benefits and/or to increase patient cost-sharing. Thus, President Bush’s version of Medicare modernization will allow options that provide only minimal benefits or higher out-of-pocket expenses or a combination thereof. If Medicare beneficiaries want more coverage, they will have to pay higher premiums. What will happen to low income seniors? They will have impaired access because of financial barriers erected under his proposal. And yet, President Bush states that it is a “myth… that somehow the low income will be left behind,” when given “more options to tailor plans.” The only options affordable will leave low income individuals behind.

We need to understand the problems with our health care system and the effect that various policy decisions would have on access, equity and costs. President Bush should lead the quest for the truth by dismissing his health care ideologues and bringing in serious health policy analysts that will provide an objective assessment of all options for reform. He trusts us. He trusts us with our choices. He’d rather have the American people make choices than have the federal government make choices on their behalf. He should trust us to tell him what choice we want in health care reform once we have an honest presentation of all of our potential options.

Health Affairs
May/June 2002

Surprisingly few Canadians travel to the United States for health care, despite the persistence of the myth.

by Steven J. Katz, Karen Cardiff, Marina Pascali, Morris L. Barer, and Robert G. Evans

A tip without an iceberg?

This study was undertaken to quantify the nature and extent of use by Canadians of medical services provided in the United States. It is frequently claimed, by critics of single-payer public health insurance on both sides of the border, that such use is large and that it reflects Canadian patients’ dissatisfaction with their inadequate health care system. All of the evidence we have, however, indicates that the anecdotal reports of Medicare refugees from Canada are not the tip of a southbound iceberg but a small number of scattered cubes. The cross- border flow of care-seeking patients appears to be very small.

Our telephone survey of likely U.S. providers of wait-listed services such as advanced imaging and eye procedures strongly suggested that very few Canadians sought care for these services south of the border. Relative to the large volume of these procedures provided to Canadians within adjacent provinces, the numbers are almost undetectable. Hospital administrative data from states bordering Canadian population centers reinforce this picture. State inpatient discharge data show that most Canadian admissions to these hospitals were unrelated to waiting time or to leading-edge-technology scenarios commonly associated with cross- border care-seeking arguments. The vast majority of services provided to Canadians were emergency or urgent care, presumably coincidental with travel to the United States for other purposes. They were clearly unrelated either to advanced technologies or to waiting times north of the border. This is consistent with the findings from our previous study in Ontario of provincial plan records of reimbursement for out-of-country use of care. Additional findings from the current study showed that a small amount of cross-border use was related to proximal services, primarily in rural or remote areas where provincial payers have made arrangements to reimburse nearby U.S. providers. Finally, information from a sample of “America’s Best Hospitals” revealed very few Canadians being seen for the magnet referral services they provide.

These findings from U.S. data are supported by responses to a large population-based health survey, the NPHS, in Canada undertaken during our study period (1996). As noted above, 0.5 percent of respondents indicated that they had received health care in the United States in the prior year, but only 0.11 percent (20 of 18,000 respondents) said that they had gone there for the purpose of obtaining any type of health care, whether or not covered by the public plans.

Phantoms in the snow.

Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these “zombies”-ideas that, on logic or evidence, are intellectually dead-that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.

http://www.healthaffairs.org/freecontent/v21n3/s6.htm

Comment: This excellent study refutes the false generalizations that have been extrapolated from the embellished anecdotes of Canadian medical refugees in the United States. Debates on health care policy should be based on the best factual information available regardless of whether or not those facts support individual ideological viewpoints. This important study should be downloaded and made readily available to refute those that insist that single payer approaches should be dismissed immediately without further consideration merely because of the fictional massive medical migration from Canada into the United States.

Health Affairs
May/June 2002

Surprisingly few Canadians travel to the United States for health care, despite the persistence of the myth.

by Steven J. Katz, Karen Cardiff, Marina Pascali, Morris L. Barer, and Robert G. Evans

A tip without an iceberg?

This study was undertaken to quantify the nature and extent of use by Canadians of medical services provided in the United States. It is frequently claimed, by critics of single-payer public health insurance on both sides of the border, that such use is large and that it reflects Canadian patients’ dissatisfaction with their inadequate health care system. All of the evidence we have, however, indicates that the anecdotal reports of Medicare refugees from Canada are not the tip of a southbound iceberg but a small number of scattered cubes. The cross- border flow of care-seeking patients appears to be very small.

Our telephone survey of likely U.S. providers of wait-listed services such as advanced imaging and eye procedures strongly suggested that very few Canadians sought care for these services south of the border. Relative to the large volume of these procedures provided to Canadians within adjacent provinces, the numbers are almost undetectable. Hospital administrative data from states bordering Canadian population centers reinforce this picture. State inpatient discharge data show that most Canadian admissions to these hospitals were unrelated to waiting time or to leading-edge-technology scenarios commonly associated with cross- border care-seeking arguments. The vast majority of services provided to Canadians were emergency or urgent care, presumably coincidental with travel to the United States for other purposes. They were clearly unrelated either to advanced technologies or to waiting times north of the border. This is consistent with the findings from our previous study in Ontario of provincial plan records of reimbursement for out-of-country use of care. Additional findings from the current study showed that a small amount of cross-border use was related to proximal services, primarily in rural or remote areas where provincial payers have made arrangements to reimburse nearby U.S. providers. Finally, information from a sample of “America’s Best Hospitals” revealed very few Canadians being seen for the magnet referral services they provide.

These findings from U.S. data are supported by responses to a large population-based health survey, the NPHS, in Canada undertaken during our study period (1996). As noted above, 0.5 percent of respondents indicated that they had received health care in the United States in the prior year, but only 0.11 percent (20 of 18,000 respondents) said that they had gone there for the purpose of obtaining any type of health care, whether or not covered by the public plans.

Phantoms in the snow.

Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these “zombies”-ideas that, on logic or evidence, are intellectually dead-that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.

http://www.healthaffairs.org/freecontent/v21n3/s6.htm

Comment: This excellent study refutes the false generalizations that have been extrapolated from the embellished anecdotes of Canadian medical refugees in the United States. Debates on health care policy should be based on the best factual information available regardless of whether or not those facts support individual ideological viewpoints. This important study should be downloaded and made readily available to refute those that insist that single payer approaches should be dismissed immediately without further consideration merely because of the fictional massive medical migration from Canada into the United States.