Third Edition, 2002 Lange Medical Books/McGraw-Hill By Thomas S. Bodenheimer, M.D. and Kevin Grumbach, M.D.

“Perhaps no tension within the U.S. health care system is as far from reaching a point of satisfactory equilibrium as the achievement of a basic level of fairness in the distribution of health care services and the burden of paying for those services. Despite two years of intense debate on health care reform following the 1992 presidential election, more people in the country were uninsured in 2000 than in 1994, with prospects dim for attainment of universal coverage in this century. Due to persistent financial barriers, more patients will go without early detection of potentially curable cancers, more patients with chronic diseases will be hospitalized because of lack of timely outpatient care, more hypertensive patients will forego the medications that might avert the occurrence of strokes and kidney failure, and more babies will be born prematurely and spend their first weeks of life in a neonatal intensive care unit. The poor will continue to pay a greater proportion of their income for health care than do more affluent families, and catastrophic health care costs will ravage countless middle class families.

“People providing and receiving care in the United States must work together to achieve a brighter future for the nation’s health care system. Changing the future will require that people look beyond their immediate self-interest to view the common good of a health care system that is accessible, affordable, and of high quality for all. A heightened level of public discourse will be needed, with a populace that is better informed and more actively engaged in shaping the future of their health care system. Abstract concepts in health policy will need to be discussed and debated in a manner that connects with the daily realities experienced by patients and caregivers. The attitudes and actions of physicians and other health professionals will play a major role in determining the future of health care in the United States. With leadership and foresight among the community of health professionals, our nation may yet achieve a system that allows the most honorable features of the healing professions to flourish.”

http://shop.mcgraw-hill.com/cgi-bin/pbg/searchresult.html?q=Understanding+Health+Policy&x=14&y=10

Comment: As we contemplate further deterioration in the most expensive but least efficient health care system in the modern world, there has never been a greater need to more thoroughly understand the fundamentals of health policy. Tom Bodenheimer and Kevin Grumbach, in this updated third edition of their classic text, provide a highly readable explanation of policy issues that must be understood by those who wish to help establish an equitable health care system for all of us. It is a great resource for those just learning about health policy. And for those that have more knowledge in the field, it is great for organizing thoughts and approaches to policy issues. It should be in the library of every health care reform activist.

American Medical News
January 21, 2002
Opinion
“The time is right to fix the problem of the uninsured” by Richard F. Corlin, M.D., President of the American Medical Association

“Let’s quickly summarize our AMA proposal:

“We endorse the concept that employers provide a defined contribution for the purchase of health expense coverage — rather than a defined benefit.

“Our proposal supports a system in which all Americans with health coverage are given tax credits — in amounts inversely correlated with their income — rather than excluding employer-provided health benefits from their taxable income.

“We also support the creation of opportunities for alternative health insurance markets — “voluntary choice cooperatives” — that would offer more choices for individuals than are presently available.

“Universally available medical savings accounts play an important role in this consumer-oriented system.”

“And the AMA plan would also help to develop in each and every individual a consciousness of the real costs involved in their health care choices.”

“Let me know what you think about our plan.” richard_corlin@ama-assn.org

http://www.ama-assn.org/sci-pubs/amnews/amn_02/edca0121.htm

Comment: Briefly, the impact of the AMA proposals:

Defined contribution – Results in under-funding of comprehensive coverage, leaving low-moderate and low income individuals with Spartan benefits and greater out-of-pocket expenses, impairing access to care because of lack of affordability

Tax credits – Result in severe under-funding of comprehensive coverage with the same consequences as defined contributions, and threatens the link of health insurance to employment, increasing the numbers of uninsured

Alternative health insurance markets – Creates multi-tiered health care by creating a marketplace for the Spartan plans that a defined contribution or tax credit could purchase, while opening access to all products for the affluent

Medical Savings Accounts – Removes funds from the risk pools for the sick and poor making the Spartan products even less affordable

The AMA proposal is a disaster for those with modest or low incomes. The proposal shifts too much of the responsibility of paying for care to the individuals who have the greatest medical needs. This defeats the fundamental purpose of health insurance, and that is to pool risk, providing security for everyone by shifting the costs of paying for care from the large numbers of healthy individuals to the smaller numbers of those with greater needs. Under the AMA proposal, the affluent can self-fund the deficits, assuring their own security, but modest income individuals will not be able to bear the burden of the costs of major medical problems.

Why would the AMA support such a cruel proposal? Two considerations come to mind. Physicians wish to escape from the restrictions on fees and services that have been characteristic of the age of managed care. Many physicians believe that the AMA proposals will remove constraints on their fees and services. They are content to care for more affluent patients, whereas those that cannot afford their services can be someone else’s problem. Thus the proposal is very self-serving for physicians. The other reason that we can speculate is that the AMA leadership is saturated with political conservatives that ideologically prefer the wealth-oriented policies of the Heritage Foundation (www.heritage.org) to the patient-oriented policies of Physicians for a National Health Program (www.pnhp.org).

Most physicians really do care about patients. Please honor Dr. Corlin’s request to let him know what you think about the AMA plan. His e-mail address is above.

PNHP’s Comments on the Draft of the American College of Physicians -American Society of Internal Medicine Seven-Year Plan to Provide Affordable Coverage for All Americans

By Quentin Young, Don McCanne and Ida Hellander

Overview and Summary of Problems with Corporate Control of Medicine

Despite good intentions, the ACP-ASIM proposal for providing health care coverage for all cannot possibly meet that goal – and delays real reform by seven painful years in which the number of uninsured is expected to rise by 10 million or more. Further, while acknowledging that other problems with our health care system must be addressed, the ACP-ASIM proposal actually perpetuates these problems by keeping intact a system in which greatly flawed health financing and corporate control over health care is an integral part:

– The dominant impediment to decent health care for all is, and has been for two decades, the rapid domination of all aspects of the health system -hospitals, physicians’ practices, nursing homes, etc. – by profit-oriented venture capital. No reform is possible without the correction of this historic shift. The ACP-ASIM proposal is silent on this issue.

– The costs of a multi-payer, for-profit insurance system are so exorbitant as to preclude decent health access for all, not to mention the increasingly neglected sectors of long-term care, mental health services, and prescription drug coverage

– Crucial ethical issues – patient choice, physician’ autonomy, physicians’ ethical responsibility to care for the sick regardless of race, income, or insurance status, “first do no harm”, etc. – are being seriously degraded by the current system. The ACP-ASIM draft does not address the linkage between the delivery system and the systematic denial of services and degradation of medical ethics.

– The ACP-ASIM proposal fails to reject incremental strategies, precisely at the historical moment when employers are bailing out of their workplace insurance commitments and governments are slashing their medical and other health programs. Clearly, single payer national health insurance emerges not any longer as the best solution, but as the only solution!

– The reality that health care is a public good, not a for-profit, investor-owned commodity, has shaped the health programs of all democratic, advanced industrial nations. The ACP-ASIM draft does not examine the lessons our country can learn from the superior achievements – fiscally and medically – of other countries (Canada, Sweden, Norway, etc.).

The single-payer solution:

Universal coverage will never be achieved until we have one single system with an effective method of budgeting and cost control. And quality in health care will not be achieved until we have universal coverage with an effective method of health planning. These are inseparable, and the attempt to take on expanding coverage without reforming the fundamental structure of the health financing system would be like running our government without the Constitution.

Comment: Our response further describes the deficiencies in the ACP-ASIM proposal. By failing to address important policy issues, the ACP-ASIM proposal can never lead to an equitable, affordable system of health care for everyone. We propose an alternative which will accomplish that goal -the single payer solution.

The entire response is available at: https://pnhp.org/pressreleases.html and click on “PNHP’s Comments on the ACP-ASIM Proposal for Health Reform (MS Word document).”

The ACP-ASIM proposal is available at: http://www.acponline.org/hpp/seq_plan01.htm?hp and click on “draft.”

PNHP’s Comments on the Draft of the American College of Physicians -American Society of Internal Medicine Seven-Year Plan to Provide Affordable Coverage for All Americans

By Quentin Young, Don McCanne and Ida Hellander

Overview and Summary of Problems with Corporate Control of Medicine

Despite good intentions, the ACP-ASIM proposal for providing health care coverage for all cannot possibly meet that goal – and delays real reform by seven painful years in which the number of uninsured is expected to rise by 10 million or more. Further, while acknowledging that other problems with our health care system must be addressed, the ACP-ASIM proposal actually perpetuates these problems by keeping intact a system in which greatly flawed health financing and corporate control over health care is an integral part:

– The dominant impediment to decent health care for all is, and has been for two decades, the rapid domination of all aspects of the health system -hospitals, physicians’ practices, nursing homes, etc. – by profit-oriented venture capital. No reform is possible without the correction of this historic shift. The ACP-ASIM proposal is silent on this issue.

– The costs of a multi-payer, for-profit insurance system are so exorbitant as to preclude decent health access for all, not to mention the increasingly neglected sectors of long-term care, mental health services, and prescription drug coverage

– Crucial ethical issues – patient choice, physician’ autonomy, physicians’ ethical responsibility to care for the sick regardless of race, income, or insurance status, “first do no harm”, etc. – are being seriously degraded by the current system. The ACP-ASIM draft does not address the linkage between the delivery system and the systematic denial of services and degradation of medical ethics.

– The ACP-ASIM proposal fails to reject incremental strategies, precisely at the historical moment when employers are bailing out of their workplace insurance commitments and governments are slashing their medical and other health programs. Clearly, single payer national health insurance emerges not any longer as the best solution, but as the only solution!

– The reality that health care is a public good, not a for-profit, investor-owned commodity, has shaped the health programs of all democratic, advanced industrial nations. The ACP-ASIM draft does not examine the lessons our country can learn from the superior achievements – fiscally and medically – of other countries (Canada, Sweden, Norway, etc.).

The single-payer solution:

Universal coverage will never be achieved until we have one single system with an effective method of budgeting and cost control. And quality in health care will not be achieved until we have universal coverage with an effective method of health planning. These are inseparable, and the attempt to take on expanding coverage without reforming the fundamental structure of the health financing system would be like running our government without the Constitution.

Comment: Our response further describes the deficiencies in the ACP-ASIM proposal. By failing to address important policy issues, the ACP-ASIM proposal can never lead to an equitable, affordable system of health care for everyone. We propose an alternative which will accomplish that goal -the single payer solution.

The entire response is available at: https://www.pnhp.org/pressreleases.html and click on “PNHP’s Comments on the ACP-ASIM Proposal for Health Reform (MS Word document).”

The ACP-ASIM proposal is available at: http://www.acponline.org/hpp/seq_plan01.htm?hp and click on “draft.”

The New York Times
January 12, 2002
Letters

To the Editor:

Re “On an Icy Night, Little Room at the Shelter” (Jan. 5):

Very simply stated, in the year 2002 here in the United States, everyone should have a warm and safe place to sleep. There is no excuse for its being any other way.

HAROLD LANGUS Poughkeepsie, N.Y.

http://www.nytimes.com/2002/01/12/opinion/L12HOME.html

Comment: Very simply stated, in the year 2002 here in the United States, everyone also should have health care. There is no excuse for its being any other way.

The New York Times
January 11, 2002
by Robin Toner

“Federal officials confirmed this week that health care costs are climbing faster than they have in years, creating new strains on employers, individuals and government programs that cover the elderly and the poor.”

“… the proportion of people who believe that ‘radical change’ is needed in the health care system has risen, said the Republican pollster Bill McInturff.”

“Not surprisingly, administration officials insist that Mr. Bush will embrace, in his budget, a series of credible health care proposals not unlike what he offered last year – tax credits to help the uninsured buy coverage, particularly people recently laid off, and a new prescription drug proposal for the elderly, tied to an overhaul of Medicare.”

Mark McClellan, a senior White House health care adviser and member of the Council of Economic Advisers:

“The president’s definitely been interested in rising costs. His direction to us has been, if anything, to redouble our efforts to find approaches to keeping coverage affordable.”

http://www.nytimes.com/2002/01/11/politics/11HEAL.html

Comment: Affordable for whom? The answer is that the administration wants to make health care affordable for the payers, specifically employers and the government. But their two primary proposals, tax credits and Medicare premium support, shift the costs to the patients, making care unaffordable for low to moderate income individuals. At the same time, these proposals protect the profits of the private health plans, again at the expense of the beneficiaries.

We don’t need “radical change” that shifts costs to those who are in the greatest need of health care services, thereby expanding financial barriers to care. Instead, we need radical change that establishes equity in our health care system and contains costs through mechanisms that improve allocation of our resources. We need a universal program of social insurance which utilizes global budgeting. And we need it now.

Health Affairs
January/February 2002
by Richard Kronick and Todd Gilmer

“Among persons with income between 100 percent and 200 percent of FPL (federal poverty level), public coverage reduced the number of uninsured persons and crowded out some private insurance. The partial successes achieved by these programs should be kept in perspective: Even after program implementation, approximately 30 percent of low-income adults in the four states were uninsured.”

“If expanded programs of subsidized insurance for low income adults are to greatly reduce the numbers of uninsured persons, they must be designed, implemented, financed, and marketed more successfully than were the programs we studied. Such programs have the potential to reduce private coverage, particularly as they are extended to persons with incomes above the federal poverty level. As has been discussed elsewhere, crowding out of private coverage will result in welfare-improving enhancements for low-income persons but does reduce the program’s target efficiency. Given the pressing problems created by the existence of close to forty million uninsured persons, we think that designing programs to maximize participation should be an overriding policy goal. However, in a voluntary market programs that are attractive enough to enroll large numbers of uninsured persons inevitably will be attractive enough to enroll large numbers of persons who would have had private insurance in the program’s absence.”

Comment: This study demonstrated the important principle that programs of public insurance, such as Medicaid and S-CHIP, may “crowd out” private insurance. That is, these publicly funded programs for lower income individuals may displace health insurance coverage that is currently funded privately (albeit with tax advantages). For individuals with private coverage that shift into the public programs, the costs for this coverage is shifted to the taxpayers even though it does not result in a reduction in the rolls of the uninsured.

There is a much more important principle which this study demonstrates. These programs of public insurance, Medicaid and S-CHIP, after fully implemented, still exclude significant numbers of low income individuals. Further, since states must contribute a component to the funding of these programs, during difficult economic times they are subjected to the guillotine of the budget cutters. Since they are chronically under-funded anyway, these program cuts can be disastrous for our health care delivery system.

There are four lessons here:

(1) Public insurance programs for low income individuals partially miss the target population, insuring the already insured, at the expense of taxpayers.

(2) A program of social insurance should have separate sources of funding that are not admixed with the general budget that is highly subject to political machinations. Although the status of the economy will affect delegated funding for a health care program, problems with funding should not be compounded by injecting the potential for a greater element of political chicanery.

(3) Existing public insurance programs fail to patch many of the holes in the health care safety net, leaving unacceptable voids in health care coverage.

(4) Incremental approaches, most of which include some form of public programs for low income individuals, will never provide the comprehensiveness and equity that is missing from our system. Only fundamental restructuring of health care funding can accomplish that. We desperately need a universal program of social insurance.

NULL

Health Affairs
January/February 2002
by Katharine Levit, Cynthia Smith, Cathy Cowan, Helen Lazenby , and Anne Martin
(The authors are in the National Health Statistics Group, Office of the Actuary, at the Centers for Medicare and Medicaid Services in Baltimore.)

“Historical spending trends through 2000 along with historical medical inflation and employment reports for the first half of 2001 indicate that the acceleration in health care costs will likely continue. This stands in stark contrast to recent reports of an increasingly sluggish U.S. economy. Pressure will mount on both public and private payers to finance accelerating health care costs out of decelerating incomes and revenues. Increased job layoffs in the slowing economy will lead to a less competitive job market, reducing private employers’ incentive to shoulder rising health care costs, potentially increasing the number of uninsured persons. Competition may force employers to shift a larger share of rising costs to workers, who may no longer be able to afford accelerating out-of-pocket costs. Fewer employers may offer health insurance, and the recently unemployed are often left without coverage. Shrinking tax revenues will likely force government to evaluate health care priorities at a time when the need for coverage is rising. These national health spending estimates may well mark the end of an era of reasonably affordable health care cost growth.”

The Des Moines Register
January 4, 2002
A single-payer national plan makes more and more sense by Register Editorial Board

“Americans should consider establishing a national health-insurance system that covers everyone.”

“A single-payer, national health-insurance system would give the government more clout to control costs. It would free Americans from the fear of losing health care when they lose their jobs. It would free businesses from scrambling to find health coverage for their workers, at ever higher costs.”

“The current health-care hodgepodge in this country is a failure.”

http://www.dmregister.com/news/stories/c5917686/16786298.html

The Washington Post
January 6, 2002
by David S. Broder

” …. as long as somewhere between 39 million and 44 million Americans are without health insurance of any kind, it will be impossible to solve the problems of cost and quality in the health care system. It is also clear that tinkering around the edges cannot, for long, withstand the adverse trends that are at work, let alone reverse them. This is an issue that cannot wait for the war on terrorism to end. It needs attention from the president and Congress. And it needs it now.”

http://www.washingtonpost.com/wp-dyn/articles/A64872-2002Jan4.html

The Boston Globe
January 4, 2002
by Diane E. Lewis

Mark Abate, a health care and group benefits consultant at William M. Mercer Inc., noted that “some employers were considering a market-driven approach in which employees would receive catastrophic or high deductible insurance for unexpected health care expenses and a health care spending account for more routine expenses. In all, 29 percent of companies with 20,000 or more workers and 17 percent of all of the companies polled indicated they were somewhat or very likely to establish that plan within two years.”

http://www.boston.com/dailyglobe2/004/business/Surveys_say_companies_health_care_costs_will_rise+.shtml

Comment:

To see how these plans may work, we can look at an example provided by the Pacific Business Group on Health for their new “Breakthrough Plan with Definity Health”:

“An employee is seriously injured, and her medical expenses total $20,000. The first $1,000 is paid by the employee’s PCA and applied toward the deductible. The employee pays the next $500 of the plan deductible. After a total of $1,500 has been spent on primary medical services, the deductible is met and the health coverage feature covers all remaining costs. If the employee chooses preferred network providers, co-payments and deductibles are likely to be low. If she chooses providers from outside the network, her cost-share will be somewhat higher, but care will still be provided. At the end of the calendar year, the employer will establish a new PCA with a $1,000 contribution.”

(Note that the $1500 deductible used in this example is much smaller than many analysts expect will be the norm.)

Source: http://www.pbgh.org/breakthrough/default.asp

Caveat emptor!

These plans are being promoted as a pain free method of meeting medical expenses. First the savings account is depleted, and then the patient pays the remainder of the plan deductible. After that, the “health coverage feature covers all remaining costs.” But look at what is omitted by this “catastrophic coverage” that “covers all remaining costs.” If the patient is lucky enough to have had contracted network providers care for her serious injuries (often a chance occurrence), then she will still have to pay “co-payments and deductibles.” If the providers are outside of the network, she will be responsible for all uncovered costs. Those that have used PPO products are aware of the severe financial penalties for using out-of-network providers.

A visit to the website of WellPoint’s Blue Cross of California is revealing (http://www.bluecrossca.com/index.asp) . WellPoint has been an innovator in insurance products that has helped to place it in the leadership role as a business model for health care coverage. Blue Cross of California offers only one product to complement medical savings accounts, and that is an EPO or exclusive provider organization. This plan has the same restrictions as PPOs except that there is virtually no coverage for services by providers outside of the exclusive provider list. Don’t make the mistake of going to the “wrong” doctor or “wrong” hospital! A new version is to be introduced soon and you can be assured that it will be another very successful business product for WellPoint.

Although considerable concern has been expressed over the large deductibles of these MSA-catastrophic plans, the catastrophic backup being offered should be sounding all alarms. And yet these plans are destined to become the standard based on the initial response of business interests!

Let’s put at end to policies that are designed solely to create successful business models for the insurance industry, and let’s instead adopt policies that are designed to establish equity in access and coverage for patients.

Kip Sullivan responds to the message on catastrophic plans for MSAs:

“What the press isn’t telling the public is that Definity and other defined contribution plans are using managed care tactics. A Definity official told me Definity uses utilization review and profiling, but not gatekeeping. Of course, choice of doc is limited. An article in HR Today indicates Vivius uses capitation. I suspect that means Vivius also uses UR. I would say we have gone from bad to worse if we go from manage-care plans with low deductibles to managed-care plans with large deductibles.”