The New York Times
January 3, 2002
by The Associated Press

“Discount prescription drug cards now available to older Americans offer only meager savings, particularly in urban areas, government figures suggest.”

“The administration countered that the GAO study is proof that the Bush plan is needed. By attracting more seniors, the Bush discount cards will allow companies to negotiate much more substantial savings, said Thomas Scully, administrator of the Centers for Medicare and Medicaid Services.”

Thomas Scully, CMS administrator:

“The voluntary drug cards that exist in the market for seniors don’t deliver any savings. Seniors are not organized at all. They’re the only people in the country who pay over-the-counter prices.”

http://www.nytimes.com/aponline/health/AP-Medicare-Drug-Cards.html

And from the National Journal:

“… with congressional election campaigns in full swing, Novelli (Bill Novelli, executive director of AARP) says that his group will aggressively remind lawmakers that prescription prices are still high, that millions of seniors have no help with those costs, and that the problem is getting worse. ‘We’re going to go in for the biggest possible package that we can,’ said Novelli. ‘We’re going to go for it.'”

Comment: And before the next elections, will we see Bush discount cards? Or a real Medicare prescription benefit? And will we be allowed in on the conversation when Mr. Scully explains to Mr. Novelli precisely what he meant when he said that seniors are not organized at all?

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The New York Times
Letters
December 28, 2001

To the Editor:

Disputes between companies and the families of the World Trade Center victims over health care coverage (front page, Dec. 26) reflect more than corporate penuriousness. They reflect America’s failure to adopt a national health care system that covers all Americans, one that is affordable and financed fairly, based on ability to pay.

The more than 40 million uninsured Americans can surely empathize with the victims’ families because they, too, need health care coverage. It’s time for our government to face this issue, not to be put off by the lobbying and campaign contributions of the insurance companies and others in the health care industry who insist that coverage exists to assure profits for companies rather than care for consumers.

RHODA H. KARPATKIN
New York, Dec. 26, 2001

http://www.nytimes.com/2001/12/28/opinion/L28INSU.html

Comment: Rhoda Karpatkin understands. She is the immediate past president of Consumers Union and has been an outspoken advocate of health care equity.

(December 1, 2001)

Excerpts from a survey sponsored by the California Nurses Association, California Medical Association, American Small Business Alliance, and the Foundation for Taxpayer and Consumer Rights:

III. Your Views on the Future of Health Care

26. Currently, there are approximately 7 million Californians without health insurance. Do you believe in a universal health care system where all Californians should be guaranteed health care coverage – regardless of their employment or income status – or do you think the current system works fine?

58% – Support universal coverage 28% – Current system works fine 14% – Declined to state

27. Would you prefer a system that would guarantee benefits for all workers and dependents and establish set costs for health insurance premiums, but would require all businesses to participate?

48% – Yes 47% – No 5% – Declined to state

28. Would you prefer a system whereby employers no longer dealt with insurance companies directly, but instead gave employees paid vouchers to purchase health insurance on their own?

32% – Yes 63% – No 5% – Declined to state

29. Would you prefer a system where health insurance is not linked with employment, and instead all businesses pay to a health care fund a fixed percentage based on the company’s size?

35% – Yes 55% – No 9% – Declined to state

30. Would you support this if it guaranteed that all your workers and their dependents were covered, and it would cost your business less than it pays now in health care costs?

70% – Yes 22% – No 8% – Declined to state

32. Which would you prefer? A. Health insurance plans would be administered by not-for profit organizations whose mission is to provide quality care at a reasonable cost. B. Health insurance plans be run by for-profit private corporations that answer to shareholders.

55% – Not-for-profits (A) 9% – Private corporations (B) 22% – Both (A&B) 7% – Other 6% – Declined to state

33. Do you support or oppose each of the following as a way to improve access to health care for the uninsured?

A health system, financed by taxpayers, in which all Californians would get their insurance from a single plan.

37% – Support 59% – Oppose 4% – Decline to state

Requiring businesses to cover and help pay the cost of private health insurance for their employees.

45% – Support 51% – Oppose 4% – Decline to state

Increasing government funding to expand community health clinics that serve the poor.

70% – Support 24% – Oppose 6% – Decline to state

Offering uninsured Americans income tax deductions, tax credits or other financial assistance to help them purchase private health insurance on their own.

62% – Support 34% – Oppose 4% – Decline to state

The full survey is available at: http://www.businesshealthsurvey.org/survey/results_dec2001.pdf

Comment: Although this survey is not scientifically valid, it does give an impression of the trends in the thoughts of small business owners on health care reform after September 11. A few tentative conclusions are warranted.

* Business owners believe that the problems of the uninsured need to be addressed. * They remain concerned about their own costs in health care. * They are concerned about the intrusion of private, for-profit corporations. * They seem to understand the defective policies behind vouchers, but fail to understand similar implications of tax policies such as tax credits. * They believe that funding of community clinics is a solution for low income individuals (though no assessment was made as to whether they understood the inadequacies of this as a sole approach). * They remain unconvinced that a tax-payer supported “health system” using a “single plan” provides a satisfactory solution for achieving universal coverage.

This survey suggests that we no longer need to expend much more effort on educating the public on the problems that exist in health care, but that there is a pressing need to educate the public on the policy implications of the various approaches to reform.

BMJ 2001;323:1440-1441
December 22-29, 2001
Editorials

“The newly qualified doctors of Imperial College School of Medicine recently adopted a ceremony in which they declare their commitment to assume the responsibilities and obligations of the medical profession. The decision to create a declaration ceremony was widely supported by the final year students and it reflects a recent resurgence in interest in medical oaths in the United Kingdom.”

“The increasing complexity of healthcare arrangements and interagency collaboration, and the need to look at rationing resources, has forced the medical profession to re-examine its core values. In view of this, and with public confidence in doctors diminishing and morale at an all time low, it is perhaps unsurprising that the concept of an entire year of newly qualified doctors freely declaring their intentions to act ethically and professionally proved popular with both staff and students at Imperial College.”

An excerpt from the “Declaration of a new doctor”:

“I will strive to change laws that are contrary to my profession’s ethics and will work towards a fairer distribution of health resources.”

For the entire declaration: http://bmj.com/cgi/content/full/323/7327/1440?eaf

Comment: With only 6% of their GDP devoted to health care, these young British physicians have a significant challenge in being certain that their resources are distributed fairly. Their efforts need to be directed to increasing the budget for health care.

With access to 14% of our GDP, our young physicians should have relatively negligible challenges in distributing our health care resources fairly, if it weren’t for the intrusive health plans with their fragmented coverage. The real challenge is to change the laws to provide a system of public administration and universal coverage that would enable fair distribution of our abundant resources. Striving for these changes would represent the finest of our Hippocratic traditions.

World Health Organization Press Release
December 20, 2001
Commission on Macroeconomics and Health

“A drastic scaling up of investments in health for the world’s poor will not only save millions of lives but also produce enormous economic gains, say experts in a landmark report presented today to the World Health Organization (WHO).

“A group of leading economists and health experts maintain that, by 2015-2020, increased health investments of $66 billion per year above current spending will generate at least $360 billion annually. About half of this will be as a result of direct economic benefits: the world’s poorest people will live longer, have many more days of good health and, as a result, will be able to earn more. The other half will be as a consequence of the indirect economic benefits from this greater individual productivity. It will mean a total economic gain of at least US $360 billion per year – a six-fold return on the investment.”

http://www3.who.int/whosis/cmh/cmh_press/e/who_hq_20Dec2001.pdf

For the entire report, “Macroeconomics and Health: Investing in Health for Economic Development”: http://www3.who.int/whosis/cmh/cmh_report/e/report.cfm?path=cmh,cmh_report&language=english

Comment: This report demonstrates that it makes economic sense to invest in the health care of the people of poor nations. Although it is disconcerting for health care professionals to see spending on health care reduced to a mere formula for calculating dollar return on investment, there actually is good news here.

Currently, the 60 poorest countries spend $13 per person per year on health care. For comparison, the United States spends $4500 per person per year. The report shows that increasing the level of spending in poor countries to $38 per person would be adequate to fund essential health interventions.

As health care professionals, our first concern is preserving the maximum number of quality years of life possible, referred to by economists as disability-adjusted life years. This modest increase in spending in poor countries would save 330 million years of quality life for the 8 million lives saved each year.

Whether you are an economist looking at the dollar return, or a health care professional looking at the real value in improved health, this is an investment that the world must make.

American Medical News
December 24/31, 2001

Number of applications to medical schools:

1996-1997 school year – 46,968 2001-2002 school year – 34,859

“Experts cite loss of physician autonomy and the high cost of medical education as two reasons for the decline.”

http://www.ama-assn.org/sci-pubs/amnews/pick_01/prca1224.htm

Comment: Opponents to national health insurance frequently claim that adoption of a program of government insurance would result in a decline in the number of qualified applicants for medical school. If the number of qualified applicants is to be used as a parameter of the quality of our system, then it is quite clear that we can no longer accept the status quo.

It probably is true that individuals who place the highest value on the opportunity to maximize income may not be attracted to a system in which compensation is adequate but not excessive. But then our health care system is not well served by those individuals that continually manipulate the system to maximize profit.

We would better be served by individuals that maximize the dignity and value of human life, and who are quite content to practice medicine in an environment in which the medical decisions lie within the physician-patient partnership, while financial decisions are removed from the day-to-day medical considerations.

A publicly administered program of universal health insurance would assure potential physicians of a favorable practice environment and adequate compensation, thereby assuring the rest of us that there will always be a generous pool of qualified medical school applicants.

The Washington Post
December 19, 2001
by Glenn Kessler and Juliet Eilperin

“The stimulus bill has been mired in disputes between Democrats and Republicans over the best mix of tax cuts and spending, but the biggest hurdle in recent days has involved health insurance. The issue has prompted a fierce philosophical debate, with Republicans pushing individual tax credits and Democrats arguing to keep such credits within the employer-based system.”

“House-Senate negotiators had met for barely an hour last night when Rep. Bill Thomas (R-Calif.), chairman of the negotiations, left to go to a vote. Participants said he then phoned the negotiating room and informed the other negotiators he was terminating the meeting and not returning.”

Rep. Bill Thomas:

“There are people who are employed and do not get health insurance. If we get a structure, it ought to be available to them when they are working. Why would it be available to them only when they are not working?”

http://www.washingtonpost.com/wp-dyn/articles/A62608-2001Dec18.html

Comment: Whether the tax benefit of purchasing insurance coverage accrues to the employer or to the employee seems like a minor issue, especially when considering that most economists consider health coverage to be part of the employee’s compensation package anyway. Besides, as Rep. Thomas points out, tax credits could also assist employed but uninsured individuals to purchase health care coverage. What could be wrong with this? Well, plenty.

Employers are looking for ways to escape the burden of escalating costs of their health benefit programs. Many are switching to partial payment through defined contribution approaches to coverage, if not outright terminating employee coverage. Granting tax credits to employees will encourage employers to shift the responsibility of purchasing health care coverage to the employee in order to take advantage of the tax benefit. Since tax policy carries the endorsement of our government, employers would be relieved of much of the guilt they might have by making this change.

By converting to the equivalent of vouchers or cash, employers will have fulfilled their responsibility, and employees are left to fend for themselves in the health care marketplace. The defined contribution received by the employee would be inadequate to purchase comprehensive coverage, and so the employee is left with either an inadequate plan, or very likely, pocketing the allowance and taking a chance on not having catastrophic health care losses. Thus tax credits for individuals will severely damage or destroy the link between health care coverage and employment, resulting in dramatic increases in the numbers of uninsured and under-insured.

There are other issues. Individuals in the health insurance market are vulnerable, having to pay higher premiums than with group coverage, and not being able to obtain affordable coverage if they have pre-existing disorders. This is great for insurance industry profits, but terrible for beneficiary-patients.

By making the patient the decision maker in health care purchasing, tax credits support the consumerism movement in health care. As we have seen previously, consumerism shifts costs to those that need care, threatening affordability and access for those with major acute and chronic disorders.

Individual tax credits are being supported by conservatives as the answer to the covering the uninsured. But it is very clear that the credits will never, never be large enough to assure affordability of health care coverage. Credits will be used primarily by those who now receive coverage through their employment or by those who can afford to purchase coverage on their own. As targeted tax policy, it entirely misses the target.

In the future, the linkage between health care coverage and employment should be terminated as we place everyone into a universal program of health insurance. But until then, it is absolutely essential that we continue with policies that encourage maximum employer participation in the health benefit programs for the employees. Failing to do so will only increase the numbers of the uninsured and under-insured.