PNHP

Funds to treat breast, cervical cancer lacking

Funds to treat breast, cervical cancer lacking

The Dallas Morning News
By Connie Mabin
3/26/2002

Despite earlier promises of coverage, state lawmakers have failed to ensure funding for a program that provides breast and cervical cancer treatment for hundreds of uninsured women.

Last year, Texas lawmakers approved the state program authorized by the federal Breast and Cervical Cancer Prevention and Treatment Act of 2000.

The law allows Texas to use state and federal Medicaid money to provide free medical care to uninsured women who are found to have breast or cervical cancer but who earn too much to qualify for Medicaid. About 200 women per year were estimated to be eligible.

But in the final, hectic days of the last Legislature, budget writers quietly placed the $1.2 million program on a list of items to be funded in the $114 billion budget only if extra money could be found during the 2002-03 budget cycle.

Six months into that cycle, Comptroller Carole Keeton Rylander can’t find the money.

http://www.dallasnews.com/health/stories/032602dntexcancerfunds.a2f16.html

Comment: This may be April Fools’ Day, a day for humorous pranks, but this is perhaps the cruelest prank ever perpetrated by legislators. Funds have been provided to screen for breast and cervical cancer for low-income, uninsured women who are not eligible for other programs. But now, after their cancers are diagnosed, they are told that they are on their own. Only in America do we accept a method of funding health care that is capable of inflicting profoundly cruel and inhumane anguish.

Fortunately, in this instance the numbers of individuals involved are small enough, and there is enough altruism within the health care delivery system that most of these individuals will gain access to care. But, instead of putting these unfortunate individuals through a transitional period of terror that they may not have access to care, shouldn’t it be a matter of routine policy that access is automatic? And what about the tens of millions of other unmet medical needs that altruism alone cannot fund? Shouldn’t it be a matter of routine policy that these needs be automatically addressed by our health care delivery system?

We really do need a publicly administered and equitably funded program of comprehensive health benefits for everyone. What are we waiting for?

Health Care: We're in grave condition

The Sacramento Bee
March 24, 2002
By Keith Richman

It is time to address the fundamental health care financing problems causing our access and affordability symptoms. The Band-Aid approach can no longer cover the deep wound. California needs a master plan for health care — a practical, cost-effective blueprint for the facilities, human resources and financing needed to provide quality health care to the estimated 45 million people who will call California home in 2020.

It will take strong leadership to develop the consensus needed to make significant changes. A system that spends more than $100 billion a year on vital tasks such as improving and saving lives will not easily change. The vested interests will be strong and the emotions will be high.

Yet if we want to forestall the impending collapse of California’s health care system, we must look at the big picture and make some difficult decisions about our future.

Keith Richman, M.D. is a Republican member of the California Assembly.

http://www.sacbee.com/content/opinion/story/1936339p-2080975c.html

Comment: The California Health Care Options Project is a study of various models of health care reform that was requested by the state legislature. The study has now been completed and will soon be available for the members of the legislature. Dr. Richman will find the ideal master plan in this report when he reviews it.

One of the models studied, “Cal-Health,” is based on Dr. Richman’s own legislative proposal, Assembly Bill 32. The Lewin Group analysis of his proposal demonstrates that it would still leave five million California residents without insurance coverage, but would increase costs by about $1 billion. On the other hand, three of the proposals would provide comprehensive benefits for everyone while decreasing costs by billions of dollars.

When Dr. Richman reviews his copy of the report, we hope that he will heed his own advice and demonstrate strong leadership. We hope that he will not be deterred by strong vested interests and high emotions from doing the right thing. We hope that he will recognize the deficiencies of his own proposal and join with those that support the single payer approach. Comprehensive care for everyone at a lower cost is clearly the moral imperative.

Sumner Rosen, Professor Emeritus of Social Welfare Policy at Columbia University, responds on the problems of linking insurance to employment and the misplaced efforts of foundations. Donald Light expands on the issue and then comments on the Bush administration’s unusual approach to health policy. And Beth Capell comments on factors other than price that influence employers.

Sumner M. Rosen, Ph.D.:

It’s been clear for a long time that the employer base for health coverage will shrink irreversibly. Cost data like this tell part of the story; the more important part is the erosion of the employer-employee linkage as job tenure shortens and multiple jobs over one’s working life become the dominant pattern. Employers will continue to shrink the core and expand the periphery of the work force through downsizing, contracting out and a host of other moves amply documented in the business press. That RWJ persists in this futile effort is discouraging evidence of failure to learn from substantial and growing evidence that new initiatives are needed. The right wing virus of ideological resistance to a federal program appears to have infected people and institutions that should know better.

Donald Light, Ph.D.:

Besides trying to get free-riding employers to offer affordable health insurance, the other great white hope of foundation board members is CHIP and its extensions. They have poured tens of millions of private money into trying to make this new public patch, in the patchwork quilt of public health insurance programs, work. It would be instructive to hear from Ted Marmor and others why they think CHIP and other patches have low uptake and costly problems, while Medicare did not and does not.

Closely related to this question is another approach: just do it. Today’s NYTimes article announces that President Bush simply decided that Medicare would cover the wide-ranging, messy and costly care that patients with Alzheimer’s disease need. It’s a rather major advance for a tragic group that are an insurer’s nightmare. It’s “incremental reform” but without even the trappings of “reform.” No debate. No bill. He just did it. What are the implications of this for participants and readers of this listserve?

Beth Capell, Ph.D.:

It would be terrific if one of our academic colleagues did a state-by-state comparison on this topic.

Such a comparison would show that in California, where premiums are lower than almost anywhere else in the country, employers are substantially less likely to offer coverage, particularly to low-income workers, than elsewhere in the country where premiums are higher. This is also true within California: Bay Area employers facing higher premiums are more likely to offer coverage than Los Angeles employers whose relatively low premiums reflect a ferociously competitive market for both plans and providers.

Similarly, in California, in the early-mid 1990s when premiums were level or declining, employers shifted cost to workers and the number of uninsured remained stubbornly the same or increased–while in the late 90’s as premiums in California increased, the number of uninsured declined and employers ceased shifting costs to workers—because of the tight labor market. Again, price of premiums was not directly and simply related to levels of uninsurance or worker share of premium.

While employers may claim that price is a major factor, experience suggests otherwise. Other factors, such as the nature of the labor market and the rate of unionization, are better explanatory factors for underlying trends.

Price is merely the polite term for employer freedom to ignore the need of working people for affordable health care.

Health Care: We’re in grave condition

The Sacramento Bee
March 24, 2002
By Keith Richman

It is time to address the fundamental health care financing problems causing our access and affordability symptoms. The Band-Aid approach can no longer cover the deep wound. California needs a master plan for health care — a practical, cost-effective blueprint for the facilities, human resources and financing needed to provide quality health care to the estimated 45 million people who will call California home in 2020.

It will take strong leadership to develop the consensus needed to make significant changes. A system that spends more than $100 billion a year on vital tasks such as improving and saving lives will not easily change. The vested interests will be strong and the emotions will be high.

Yet if we want to forestall the impending collapse of California’s health care system, we must look at the big picture and make some difficult decisions about our future.

Keith Richman, M.D. is a Republican member of the California Assembly.

http://www.sacbee.com/content/opinion/story/1936339p-2080975c.html

Comment: The California Health Care Options Project is a study of various models of health care reform that was requested by the state legislature. The study has now been completed and will soon be available for the members of the legislature. Dr. Richman will find the ideal master plan in this report when he reviews it.

One of the models studied, “Cal-Health,” is based on Dr. Richman’s own legislative proposal, Assembly Bill 32. The Lewin Group analysis of his proposal demonstrates that it would still leave five million California residents without insurance coverage, but would increase costs by about $1 billion. On the other hand, three of the proposals would provide comprehensive benefits for everyone while decreasing costs by billions of dollars.

When Dr. Richman reviews his copy of the report, we hope that he will heed his own advice and demonstrate strong leadership. We hope that he will not be deterred by strong vested interests and high emotions from doing the right thing. We hope that he will recognize the deficiencies of his own proposal and join with those that support the single payer approach. Comprehensive care for everyone at a lower cost is clearly the moral imperative.

Sumner Rosen, Professor Emeritus of Social Welfare Policy at Columbia University, responds on the problems of linking insurance to employment and the misplaced efforts of foundations. Donald Light expands on the issue and then comments on the Bush administration’s unusual approach to health policy. And Beth Capell comments on factors other than price that influence employers.

Sumner M. Rosen, Ph.D.:

It’s been clear for a long time that the employer base for health coverage will shrink irreversibly. Cost data like this tell part of the story; the more important part is the erosion of the employer-employee linkage as job tenure shortens and multiple jobs over one’s working life become the dominant pattern. Employers will continue to shrink the core and expand the periphery of the work force through downsizing, contracting out and a host of other moves amply documented in the business press. That RWJ persists in this futile effort is discouraging evidence of failure to learn from substantial and growing evidence that new initiatives are needed. The right wing virus of ideological resistance to a federal program appears to have infected people and institutions that should know better.

Donald Light, Ph.D.:

Besides trying to get free-riding employers to offer affordable health insurance, the other great white hope of foundation board members is CHIP and its extensions. They have poured tens of millions of private money into trying to make this new public patch, in the patchwork quilt of public health insurance programs, work. It would be instructive to hear from Ted Marmor and others why they think CHIP and other patches have low uptake and costly problems, while Medicare did not and does not.

Closely related to this question is another approach: just do it. Today’s NYTimes article announces that President Bush simply decided that Medicare would cover the wide-ranging, messy and costly care that patients with Alzheimer’s disease need. It’s a rather major advance for a tragic group that are an insurer’s nightmare. It’s “incremental reform” but without even the trappings of “reform.” No debate. No bill. He just did it. What are the implications of this for participants and readers of this listserve?

Beth Capell, Ph.D.:

It would be terrific if one of our academic colleagues did a state-by-state comparison on this topic.

Such a comparison would show that in California, where premiums are lower than almost anywhere else in the country, employers are substantially less likely to offer coverage, particularly to low-income workers, than elsewhere in the country where premiums are higher. This is also true within California: Bay Area employers facing higher premiums are more likely to offer coverage than Los Angeles employers whose relatively low premiums reflect a ferociously competitive market for both plans and providers.

Similarly, in California, in the early-mid 1990s when premiums were level or declining, employers shifted cost to workers and the number of uninsured remained stubbornly the same or increased–while in the late 90’s as premiums in California increased, the number of uninsured declined and employers ceased shifting costs to workers—because of the tight labor market. Again, price of premiums was not directly and simply related to levels of uninsurance or worker share of premium.

While employers may claim that price is a major factor, experience suggests otherwise. Other factors, such as the nature of the labor market and the rate of unionization, are better explanatory factors for underlying trends.

Price is merely the polite term for employer freedom to ignore the need of working people for affordable health care.

To Offer or Not to Offer: The Role of Price in Employers' Health Insurance Decisions

Health Services Research

Authors: M. Susan Marquis and Stephen H. Long

Principal Findings:

Changes in price affect decisions to offer insurance: however, even a 40 percent reduction in premiums would lead only to a 2 to 3 percentage point increase in the share of employers offering insurance. Employers of low-wage workers are substantially less likely to offer health insurance than other employers.

Conclusions:

Policies to reduce the number of uninsured that focus on increasing the supply of employment-based insurance are unlikely to have the intended effect unless coupled with policies to help low-wage workers afford insurance.

http://www.hsr.org/ArticleAbstracts/Marquis365.cfm

Comment provided by Prof. Donald W. Light:

In a detailed study of private employers, Marquis and Long found that 51.5% of small employers offer health insurance (many with high co-premiums that workers feel they cannot afford), but they also found that only 58.1% of all other employers offered health insurance. This is a strikingly low number for a system based on employers in a large, affluent nation.

The authors also found once again that the continued efforts by the Robert Wood Johnson Foundation and others to increase the number of employers offering coverage by supporting lower premiums does not work. Even if offered a 40 percent reduction in premiums, only a few percent more employers said they would offer health insurance. These efforts to shore up an inherently partial system, which provides limited and variable coverage at very high prices to employers as well as to employees, have been tried for over 15 years. It seems time for the boards of Kaiser Family Foundation, RWJF, and others to face the data and turn to more equitable and efficient approaches.

Source: “To offer or not to offer.” Health Services Research 2001;36:937-958.

To Offer or Not to Offer: The Role of Price in Employers’ Health Insurance Decisions

Health Services Research

Authors: M. Susan Marquis and Stephen H. Long

Principal Findings:

Changes in price affect decisions to offer insurance: however, even a 40 percent reduction in premiums would lead only to a 2 to 3 percentage point increase in the share of employers offering insurance. Employers of low-wage workers are substantially less likely to offer health insurance than other employers.

Conclusions:

Policies to reduce the number of uninsured that focus on increasing the supply of employment-based insurance are unlikely to have the intended effect unless coupled with policies to help low-wage workers afford insurance.

http://www.hsr.org/ArticleAbstracts/Marquis365.cfm

Comment provided by Prof. Donald W. Light:

In a detailed study of private employers, Marquis and Long found that 51.5% of small employers offer health insurance (many with high co-premiums that workers feel they cannot afford), but they also found that only 58.1% of all other employers offered health insurance. This is a strikingly low number for a system based on employers in a large, affluent nation.

The authors also found once again that the continued efforts by the Robert Wood Johnson Foundation and others to increase the number of employers offering coverage by supporting lower premiums does not work. Even if offered a 40 percent reduction in premiums, only a few percent more employers said they would offer health insurance. These efforts to shore up an inherently partial system, which provides limited and variable coverage at very high prices to employers as well as to employees, have been tried for over 15 years. It seems time for the boards of Kaiser Family Foundation, RWJF, and others to face the data and turn to more equitable and efficient approaches.

Source: “To offer or not to offer.” Health Services Research 2001;36:937-958.

U.S. Government Should Implement Single-Payer Insurance System, Ivins Says

Kaiser Daily Health Policy Report
March 28, 2002

The United States should replace the nation’s “broken” health care system with a single-payer system that would provide universal health coverage, syndicated columnist Molly Ivins writes in… (a syndicated) opinion piece. Ivins writes that although the U.S. health care system “works” for individuals with health insurance, for the uninsured, the “system is an insane nightmare.” Since the failure of former President Clinton’s national health care plan in 1994, lawmakers “have been trying to move the ball incrementally” on legislation to help the uninsured, Ivins writes. However, she says that the U.S. health care “system is moving faster than they can move to fix it. A patients’ bill of rights is not the answer. It won’t provide health insurance for a single additional individual.” Ivins recommends that the United States should move to a not-for-profit health care system. She backs a plan proposed by Dr. Rudolph Mueller in his new book, “As Sick As It Gets: The Shocking Reality of America’s HealthCare,” which would allow the federal government to conduct a “one-time fair buyout” of “all for-profit or investor-owned provider and insurance organizations.” Ivins concludes, “Every time we start to get serious about reform, the right wing starts screaming, ‘Socialized medicine, socialized medicine.’ And then we’re all supposed to run, screaming with horror. But if you want to see horror in action, try the emergency room of any large public hospital in this country” (Ivins, Tallahassee Democrat, 3/27).

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=10318

The full article, released on March 26, is available at the Creators Syndicate: http://www.creators.com/opinion_show.cfm?columnsName=miv

The Rise of For Profit Medicine

By Uwe E. Reinhardt

FROM THE perspective of someone whose social ethic was forged first in Europe and then in Canada, the current brouhaha over ”boutique medicine” in the United States is amusing.

The critics of boutique medicine deem it un-American to let the individual’s health care experience vary by ability to pay. Yet it seems only natural in a country that countenances boutique education and the enduring tradition of rationing by income the health care of some 7 million uninsured children and 12 million elderly Medicare beneficiaries without coverage for prescription drugs.

The boutique physicians protest that they merely seek to restore the overall quality of health care to the allegedly high level it had before the onset of managed care – which is in itself a hypothesis, not a fact. If they sincerely believe in their theory, they must be arithmetically challenged.

There are, in the Boston area, only so many physicians and so many patients. Suppose half of those physicians switched to boutique medicine and reduced their patient loads to spend more time with patients who can afford their fees. Former patients now price-rationed out of these physicians’ practices would then either have to go without care or be loaded onto the 50 percent of physicians not yet engaged in boutique medicine.

Either way, the quality of these patients’ health care would deteriorate. In effect, boutique physicians do not enhance the overall quality of care. Wittingly or not, they merely redistribute superior quality toward patients thought to deserve it, because they can and will pay for it.

Boutique physicians are perfectly in keeping with certain sacred tenets of normative economic theory. For decades economics professors have drummed into students the ”marginal productivity theory of income,” according to which a person’s position in our nation’s income distribution largely reflects that person’s marginal contribution to society. From that theory it is but a small step to the ethical doctrine that wealthy persons ”deserve” better housing, education, justice, and, yes, health care than do persons of lesser means. It is their reward for their superior social contribution.

This doctrine extends even to a person’s financial wealth, whether inherited or however else begotten. To illustrate, if a person possesses $100 million and invests it in the economy, his or her marginal social contribution is said by economists to exceed by many multiples that of, say, a soldier in the 101st US Airborne Division fighting for America in the mountains of Afghanistan or of a firefighter standing ready daily to risk his or her life for fellow citizens. It is so, say economists, because the marginal social contribution made by the millionaire’s capital is judged by ”the American people” (i.e., the market) to be far above the soldier’s or firefighter’s, whose modest salaries represent the valuations put upon their marginal contributions to society. Consequently, according to economic doctrine, the financier’s family deserves higher quality of the basic things in life.

Nobel Laureate economist Milton Friedman has articulated the implication of this doctrine for health care more clearly than anyone else. During the health reform debate of the 1990s, Friedman proposed the complete abolition of the federal Medicare program for the elderly and the state-federal Medicaid program for the poor. A better approach, in his view, would be for families to have only catastrophic health insurance, with an up-front, out-of-pocket deductible of $20,000 per year or 30 percent of the family’s income during the last two years, whichever is lower. At the time of his writing, the median pretax family income in the United States was $35,000, which means that he had in mind a $10,500 deductible for such a family.

Friedman’s vision for American health care has made substantial inroads into the medical profession – perhaps even to Boston’s boutique physicians. For example, when I questioned in the Journal of the American Medical Association whether, as a matter of national policy, children of low-income families in this country should be offered the same health care experience as that enjoyed by children of well-to-do parents, this was decried as ”socialism” by a good number of irate physicians. Physicians inclined to answer my question in the affirmative remained silent. Friedman’s disciple, Richard A. Epstein, distinguished law professor of the University of Chicago, answered my question with a crisp ”No!” and went so far as to call the very idea of equality ”perverse.”

Recent health insurance reforms embraced by the American Medical Association are in line with Friedman’s vision for health care, as are many of the novel health insurance products now on the drawing boards of the private health insurance sector. Boutique medicine is merely a natural and rather innocent expression of that ethic.

Some folks in Boston may as yet feel uncomfortable with that approach to medicine. Their children and grandchildren will view it as American as apple pie – as we now do boutique education.

Uwe E. Reinhardt is a professor of economics and public affairs at Princeton University.

This story ran on page A15 of the Boston Globe on 3/26/2002. (C)Copyright 2002 Globe Newspaper Company.

http://www.boston.com/dailyglobe2/085/oped/The_rise_of_for_profit_medicineP.shtmlÊ — Boston Globe Online

Health Care for All – Oregon

Folk,Ê

Here in Oregon, Health Care for All – Oregon had collected 74,748 signatures as of May 30, 67,000 signatures of voters eligible to vote are required for the initiative to appear on the ballot in Nov. 2002. Signature collection is going to go on until July 1 to be sure that there will be about 80,000 signatures so that when the state removes the ineligibles that more than 67,000 will be left. History has shown that we can count on the initiative being on the Nov. 2002 ballot with such a surplus of signatures collected. Here is a chance to have the people in our state vote into law and install into law a single payer universal health care system which our legislators can’t prevent. HCAO now has to complete the education of the voters and get out the vote in Nov. 2002. We need help and you can do that by sending money to “Health Care for All Oregon.” Please help us with as much as you can. Please include your address – no PO boxes – and what work you do with your check. NO ONE will solicit you by phone.

Our address is: HCAO, P.O. Box 51422, Eugene. OR, 97405.

You know that this only has to happen in one state and then it will leapfrog from one state to another, to another, and so on, until we have universal health care in America.

Health insurance bill's makeover turns the tide

St. Petersburg Times
March 20, 2002
By Anita Kumar

Rep. Frank Farkas scored a victory Tuesday when the House passed his controversial health insurance bill.

Farkas agreed to… increase coverage to $25,000 annually…

Farkas… said other aspects of the insurance plan would lower the cost, such as flexible deductibles, co-pays and other treatments and procedures not mandated by law but often covered by insurance companies.

The amended bill passed 113-2.

Rep. Eleanor Sobel, D-Hollywood:

“A bare-bones policy has been given meat. It is a great step forward.”

http://www.sptimes.com/2002/03/20/State/Health_insurance_bill.shtml

Comment: One technical criticism of the movie, “John Q,” was that a $20,000 cap on John Q’s coverage was almost non-existent; virtually all policies have much higher levels of coverage. Now we have a bipartisan, 113 to 2 vote that says that John Q’s fictional bare-bones policy is “a great step forward.”

What has happened to the soul of America?

Health insurance bill’s makeover turns the tide

St. Petersburg Times
March 20, 2002
By Anita Kumar

Rep. Frank Farkas scored a victory Tuesday when the House passed his controversial health insurance bill.

Farkas agreed to… increase coverage to $25,000 annually…

Farkas… said other aspects of the insurance plan would lower the cost, such as flexible deductibles, co-pays and other treatments and procedures not mandated by law but often covered by insurance companies.

The amended bill passed 113-2.

Rep. Eleanor Sobel, D-Hollywood:

“A bare-bones policy has been given meat. It is a great step forward.”

http://www.sptimes.com/2002/03/20/State/Health_insurance_bill.shtml

Comment: One technical criticism of the movie, “John Q,” was that a $20,000 cap on John Q’s coverage was almost non-existent; virtually all policies have much higher levels of coverage. Now we have a bipartisan, 113 to 2 vote that says that John Q’s fictional bare-bones policy is “a great step forward.”

What has happened to the soul of America?

CalPERS cuts losses on self-funded health plans Despite improvement over last year, the pension trustees are considering a single statewide program.

The Sacramento Bee
March 21, 2002
By Lisa Rapaport

Some of the biggest changes could come in CalPERS’ two self-insured plans, which provide benefits to 20 percent of its 1.2 million members. The pension plan has seen financial risk grow in its self-insured plans as sicker, costlier patients flock to them as HMOs abandon outlying counties and some unions with healthier members shop for coverage outside CalPERS.

In response, the pension fund might drop all of its HMO contacts in favor of a single, statewide self-insured plan.

Larry Levitt of the Kaiser Family Foundation:

“You have to be very big to even contemplate fully self-funding and taking the HMOs out of the equation completely. It’s hard to imagine many employers besides CalPERS pulling this off.”

http://www.sacbee.com/content/business/story/1913356p-2025433c.html

Comment: If CalPERS, the nation’s second largest provider of health benefit services (next to FEHBP), recognizes the wisdom of excluding middlemen health plans and establishing a single, statewide program for California state employees and retirees, then when will the rest of us finally recognize that a single, statewide, publicly-administered program will better serve the health care needs for all of us? Would CalPERS consider letting us join in on the initial discussions to consider whether it might be wise to establish a single payer system for the entire state? The California Health Care Options Project has established the credibility of this approach. It is time to look at all options, especially those with credibility.

Workers Feel Like Suckers

Los Angeles Times
March 20, 2002
By Ralph Frammolino

The memories will endure, but the factory that turns out 46 billion Life Savers each year won’t. Kraft Foods Inc. is closing the plant and moving its operations to Canada.

Life Savers will pay nonunion workers in Mount Royal about $12.50 an hour–$3 less than their counterparts in Holland (Michigan). With the Canadian government picking up the tab for health coverage, the savings come to about $6.5 million a year.

John Boyd, president of a Princeton, N.J., consulting firm that helps companies select plant locations:

“Labor costs dominate the equation. They account for at least 70% of all operating costs. . . . That’s the real driver in the site selection process.”

http://www.latimes.com/news/printedition/la-000020325mar20.story

Comment: When will businesses in the United States be ready for the government to assist in making American products more competitive by picking up the tab for health coverage? And when will the politicians tire of watching jobs and businesses with their tax revenues move to Canada? The lack of publicly funded health insurance in the United States may not be the only factor in this shift, but it’s a big one.

Jon Oberlander, Ph.D., Assistant Professor of Social Medicine, University of North Carolina-Chapel Hill, responds to Uwe Reinhardt’s comments on Medicare:

I agree with Uwe that single payer is thrown around far too often as a catch phrase. And I strongly believe that too many health reformers are “fundamentalists,” fixated on Canadian style single payer when other international models perform just as well–and may be a better political fit for the U.S. That is a large topic that I leave for another day.

But I do want to take up what Uwe has said about Medicare. He tells us of Medicare (along with Medicaid): “neither program is known for its ability to assure the quality of health care, and both can control costs in only the crudest ways–with a sledgehammer.” He then goes on to criticize Medicare’s regional discrepancies in payment and notes that low cost physicians in Minnesota could be punished under Medicare’s Volume Performance Standard system if physicians in Miami push up their own utilization. Is that a way to run a health system, Uwe wonders?

Judging by international experience, the answer is yes. Medicare’s tools of cost control are indeed crude but so are those in Canada, Germany, and just about any other country you look. Medicare uses the sledgehammer of setting fee schedules (or price controls, depending on your taste) but that, along with global budgets and controlling technological diffusion (which Medicare is not positioned to do) is precisely how other countries have controlled costs. Crude? Yes. Effective? Yes. So exactly what, Uwe, is the point in labeling Medicare as having crude cost control? Is there another system that works in practice rather than theory (judging by the flops at CalPERS and FEHBP, it is surely not managed competition, as much as Alain Enthoven would have us believe otherwise).

As for regional inequities in Medicare payment, I agree these are truly irrational. But it is worth pointing out that other nations such as Canada, also have collective punishment in budgets that “claw back” excess payments across all doctors. Medicare perhaps is worse–at least the Canadians are smart enough to do it on the provincial level–but collective payment reductions is not exactly an original sin. And Medicare doesn’t guarantee quality outcomes, as Uwe says. But who does? Not managed care. For all the talk of disease management and coordinated care, there is no evidence on average that HMOs improve care for Medicare beneficiaries. Too often, this is the stuff of advertising slogans, not real change in health care delivery. And the one group that fares badly under managed care over the years in Hal Luft’s review is chronically ill seniors.

At the end of the day, I’m sure we’re not far apart in agreeing that Medicare has lots of limitations and could stand for major improvement in benefit coverage etc. But I’m not sure what the point of Medicare bashing is, Uwe, if you leave out its similarities in cost control (with its limited capabilities) to other nations and in quality to the private experience here.

Best, Jon