The Washington Post
October 21, 2001
by Bill Brubaker

“A survey of 200 large employers released last week found that workers will pay an average of 14 percent more for company-provided health benefits next year. That’s almost four times the rate of inflation. And it follows increases of 12 percent for 2001 and 8 percent for 2000, according to the Watson Wyatt Worldwide consulting firm, which conducted the survey.”

“Corporate executives say they have no choice but to scale back benefits and pass on costs because of the sharp rise in insurers’ rates.”

Darnella Layne, 45, a cafeteria worker at Xavier University in Cincinnati:

“I couldn’t afford the premiums this year and I won’t be able to afford them next year. Last year they told me I’d have to pay almost $200 a month for a plan that insured me and my 17-year-old son. I earn $8.87 an hour and they take out a lot of taxes. It’s pitiful: If I bought that health plan I’d barely have a paycheck left.”

http://www.washingtonpost.com/ac3/ContentServer?articleid=A24859-2001Oct20&pagename=article

Comment: It is really happening. Health care costs are skyrocketing, and both employers and the insurance industry are passing those costs on to the individual employee, beneficiary, patient, consumer, or whatever label is used for the hapless, average American that is bearing the brunt of health care inflation. If the executives of our nation’s businesses and insurance companies believe that they can’t afford to absorb the increases in health care costs, just wait and see what happens when the disposable income of the average individual is consumed by this shift in health care costs. And at four times the rate of inflation!? Disaster is imminent.

Clearly there is great urgency in the need to reinforce the infrastructure of our public health system, based on the shocking realities of recent tragic events. Impairing access by making health care unaffordable would have more insidious but much greater consequences for the health of the people of our nation, not to mention causing the financial breakdown of our health care delivery system once patients are no longer able to access it. The urgent legislation that we need to fund our public health infrastructure MUST include provisions for publicly administered, universal health insurance if we are to assure the integrity and accessibility of our health care delivery system.

Personal note: With humbleness and great pride, I have been honored by Physicians for a National Health Program by being selected to serve as their president, effective in January. I fully intend to continue these messages, but I anticipate more interruptions because of conflicting commitments. Working with the dedicated individuals at PNHP has been one of the most rewarding experiences of my life. Through their efforts in analyzing and developing health policy based on ethics and equity, they have provided the beacon that will lead us to health care justice for all. It is a great honor, and indeed a pleasure, to be part of that team.

Don

Dear Don,

A number of your readers and our activists asked me to give this brief description of our current work at this time in the Quote of the Day debate.

Ken

Ken Frisof:

The stimulating debate in Quote of the Day of late has been a thoughtful mixture of politics and policy, but the underlying theme has been that this is a time for politics first, and policy second. As Donald Light noted in the most recent communication, the challenge is “to get major stakeholders to sign on to a basic principle: that every American will have access to needed health care.”

Fortunately for us, there is already a legislative vehicle that allows us to organize around this approach. House Concurrent Resolution 99, or as we are now calling it, “The Health Care Access Resolution” [HCAR] was the first joint work product of the Congressional Universal Health Care Task Force, founded in 2000 by Congressman Conyers. The Resolution was crafted by Members of Congress and their legislative aides (several of whom spent years as political organizers before joining Congressional staffs) precisely to serve as an organizing vehicle. It lists 14 attributes/principles of quality health care for all. It intentionally does not offer a policy prescription, but rather directs “Congress to enact legislation by October 2004 that provides access to comprehensive health care for all Americans.”

The first draft of a general flyer for the educational and advocacy campaign around HCAR was made ready for the Jobs with Justice National Conference on September 7-9. After a pause to reflect on the implications of the terrorist tragedy, the activists in UHCAN and other organizations working on the campaign are once more moving ahead, mindful of the changed circumstances so well described in the Quote of the Day Discussion. A new version of the general flyer, soliciting organizational endorsements and activity around HCAR is being prepared for the meetings in Atlanta later this month.

The renewed popular recognition of the vital role of government in promoting well-being is a valuable opening for the forces for health care justice and equity. HCAR provides a congressionally-originated vehicle through which we can reach out to the organizations and politicians of mainstream America and seek endorsement and cosponsorship of our core principles.

If you would like to participate, please e-mail your contact information to uhcan@uhcan.org. We will e-mail material once the revised version is available, in the last week of October.

A description of House Concurrent Resolution 99 is available at: http://www.uhcan.org/files/strategies/taskforce.html

Comment: There are many individuals and organizations dedicated to health care equity, and there are even more ideas floating out there on the preferred agenda for reform. But there is one agenda item that we must all place first and that is that we are going to have to agree to work together.

Margaret Heldring, Ph.D., Executive Director, America’s HealthTogether:

Dear Dr. McCanne:

I write to introduce America’s HealthTogether, following on Karyn Gill’s initial introduction. Thank you for your apparent interest!

America’s HealthTogether is committed to universal health care, health care justice, and health promotion. I understand you have seen our website and so know we are proud of the extraordinary group of people working together. Bob LeBow, a member of our Advisory Committee, is a past president of PNHP. You can see I have cc’d him on this email.

We would like to do all that we can to move this shared agenda. We are poised to function as conveners. We would be fully open to sharing this role with others, such as Arthur Caplan (I have admired his work!). We think that the more frequently we demonstrate collaboration, the more we model it and help support a culture that values it – a necessary value for universal health care!

Please be in touch and share this information as you would like. We look forward to pulling together!

Sincerely, Margy Heldring

America’s HealthTogether: http://www.healthtogether.org

Comment: Again, we share the goal of health care equity. Let’s all work together to achieve it.

(Note: Due to other commitments, the Quote of the Day messages will not resume until about October 23.)

Joel Segal, Legislative Assistant for Congressman John Conyers:

Dear Friends,

With 44 million uninsured, ( I use to be one of those for many years), the time has come for a unified universal health care movement that is motivated by compassion, love, and empathy for those whose lives are ruined by our current for profit health care system.

We need health care activists to write their respective Members of Congress letters, make phone calls, e-mail, fax, etc. about the need for universal health care. First, contact the legislative assistant in charge of health care. You can even write pre-fabricated letters. BELIEVE ME…THEY DO MATTER. WHEN WE GET LETTERS AND PHONE CALLS, WE MUST TELL OUR BOSS! IF YOUR MEMBER OF CONGRESS IS NOT ON THE UNIVERSAL HEALTH CARE TASK FORCE, PLEASE URGE THAT THEY SIGN ON.

ORGANIZE TOWN MEETINGS & HEARINGS TO HEAR FROM THOSE WHO SUFFER DAY IN AND DAY OUT WITH OUR HEALTH CARE SYSTEM. WE CAN HELP GET MEMBERS OF CONGRESS TO ATTEND.

THANKS,

Joel Segal Legislative Assistant for Congressman John Conyers 202 225-5126

The New York Times
October 7, 2001
Letters

To the Editor:

While some of the disappearance of the federal surplus (front page, Oct. 1) may be attributable to slowing economic growth and the unaccountable amounts of money Congress is unquestioningly throwing at the military and intelligence complex, surely the largest factor is the huge, irresponsible Bush tax cut largely benefiting the rich that Congress passed earlier this year.

If those of us down in the valley are expected to make sacrifices for our new war on terrorism in the form of increased everyday inconveniences, more fragile civil liberties, a slowing economy and increased federal expenditures that will come out of our future Social Security and Medicare benefits, surely we can ask those living in the houses on the hill to sacrifice their newly acquired tax relief, which they didn’t need anyway.

Mark Hannay New York

Comment: Why is a letter on distributive tax policy being circulated as a quote of the day for health care reform? Mark Hannay is the Director of Metro New York Health Care for All Campaign, and an ardent supporter of health care equity. Issues of distributive tax policy are fundamental to the societal values that we must be supporting if we ever hope to inject equity into our health care system.

Prof. Donald Light responds to Gordon, Caplan, Griss and Oberlander:

Jeoffry Gordon and Art Caplan have, with somewhat different agendas, articulated well the special opportunity and need to address the long-standing, inherent inadequacies in “our lousy health care system.” Bob Griss has added still more reasons why this effort would be timely. While I agree with Jon Oberlander about the obstacles, the way around them, I think, is to get major stakeholders to sign on to a basic principle, to “simply state that every American will have access to [needed health] care.” Art is right to keep it vague, and from my international experience, the mistake would be for us experts to figure out just how. The only way around the serious obstacles that Oberlander describes is to get this basic consensus and then ask, “OK, how would you like to do it?” Then, let the small employers, the large employers, the health insurance companies, the for-profit health plans and hospitals, the public hospitals and health centers and the non-profit ones start working on an answer.

It won’t be easy, and one needs a neutral, prominent strong convenor. Let Art Caplan and the Center for Bioethics be the convenor. Bring together a hand-picked group of leaders from across the industry and sectors, close the doors, and have a sustained meeting on how to do it. Of course, it will take several such 2 or 3-day meetings. And if a plan of consensus arises, there will be subsequent back-sliding and the need to shore it up while widening the circle.

A real danger is that one group of us experts or another will oppose anything they come up with. If they go for universalizing Medicare, our experts will tell them five reasons why they’re doing it the wrong way, while the powerful pro-market coalition will tell them government-run programs always fail. If they go for a Karen Davis mix (quite interesting), nearly every faction of experts will pick apart one part or another. Advocates of a national health care program (at least, as they envision Britain’s NHS) will oppose almost anything the major stakeholders come up with. Maybe this means that in the meantime, we should have a parallel meeting to see if experts and advocates for universal health care can agree on a plan!

Aside from this recommendation, the first thing that advocates for universal health care need to do is to persuade the small employers, that fierce lobbying group that did serious damage to the Clinton proposal. On one hand, they are hurting the most (or not participating), they feel they have the most to lose, and they are the source of most workers without the partial, flawed voluntary health insurance that other employers offer. On the other hand, you can’t win without understanding their issues, taking in their value and language,and responding effectively. If we can persuade them that universal health insurance is a good deal for them, the large employers will be no problem, and together they constitute the clientele of the insurance industry, their agents and the health benefits industry.

Below are a set of REFORM RULES I circulated about two years ago and they may be helpful in thinking about strategies:

REFORM RULES FOR UNIVERSAL HEALTH CARE ACCESS (or “What is likely to Pass?”)

1. No nation has attained universal health insurance that has not built on the existing health care institutions.

Overlay or Add-on or Reconfiguration

2. Short of revolution, no universal health reform has passed over the opposition of more than one major power block.

Which one will you take on? Which one “has to go”?

What plan will gain the support of the other major power blocks? (Think of the huge battle over a few “patients’ rights.”)

3. Successful coalitions are not usually “made” but rather assembled out of existing large organized parties and groups.

The New York Times
October 7, 2001
Letters

To the Editor:

While some of the disappearance of the federal surplus (front page, Oct. 1) may be attributable to slowing economic growth and the unaccountable amounts of money Congress is unquestioningly throwing at the military and intelligence complex, surely the largest factor is the huge, irresponsible Bush tax cut largely benefiting the rich that Congress passed earlier this year.

If those of us down in the valley are expected to make sacrifices for our new war on terrorism in the form of increased everyday inconveniences, more fragile civil liberties, a slowing economy and increased federal expenditures that will come out of our future Social Security and Medicare benefits, surely we can ask those living in the houses on the hill to sacrifice their newly acquired tax relief, which they didn’t need anyway.

Mark Hannay New York

Comment: Why is a letter on distributive tax policy being circulated as a quote of the day for health care reform? Mark Hannay is the Director of Metro New York Health Care for All Campaign, and an ardent supporter of health care equity. Issues of distributive tax policy are fundamental to the societal values that we must be supporting if we ever hope to inject equity into our health care system.

Prof. Donald Light responds to Gordon, Caplan, Griss and Oberlander:

Jeoffry Gordon and Art Caplan have, with somewhat different agendas, articulated well the special opportunity and need to address the long-standing, inherent inadequacies in “our lousy health care system.” Bob Griss has added still more reasons why this effort would be timely. While I agree with Jon Oberlander about the obstacles, the way around them, I think, is to get major stakeholders to sign on to a basic principle, to “simply state that every American will have access to [needed health] care.” Art is right to keep it vague, and from my international experience, the mistake would be for us experts to figure out just how. The only way around the serious obstacles that Oberlander describes is to get this basic consensus and then ask, “OK, how would you like to do it?” Then, let the small employers, the large employers, the health insurance companies, the for-profit health plans and hospitals, the public hospitals and health centers and the non-profit ones start working on an answer.

It won’t be easy, and one needs a neutral, prominent strong convenor. Let Art Caplan and the Center for Bioethics be the convenor. Bring together a hand-picked group of leaders from across the industry and sectors, close the doors, and have a sustained meeting on how to do it. Of course, it will take several such 2 or 3-day meetings. And if a plan of consensus arises, there will be subsequent back-sliding and the need to shore it up while widening the circle.

A real danger is that one group of us experts or another will oppose anything they come up with. If they go for universalizing Medicare, our experts will tell them five reasons why they’re doing it the wrong way, while the powerful pro-market coalition will tell them government-run programs always fail. If they go for a Karen Davis mix (quite interesting), nearly every faction of experts will pick apart one part or another. Advocates of a national health care program (at least, as they envision Britain’s NHS) will oppose almost anything the major stakeholders come up with. Maybe this means that in the meantime, we should have a parallel meeting to see if experts and advocates for universal health care can agree on a plan!

Aside from this recommendation, the first thing that advocates for universal health care need to do is to persuade the small employers, that fierce lobbying group that did serious damage to the Clinton proposal. On one hand, they are hurting the most (or not participating), they feel they have the most to lose, and they are the source of most workers without the partial, flawed voluntary health insurance that other employers offer. On the other hand, you can’t win without understanding their issues, taking in their value and language,and responding effectively. If we can persuade them that universal health insurance is a good deal for them, the large employers will be no problem, and together they constitute the clientele of the insurance industry, their agents and the health benefits industry.

Below are a set of REFORM RULES I circulated about two years ago and they may be helpful in thinking about strategies:

REFORM RULES FOR UNIVERSAL HEALTH CARE ACCESS (or “What is likely to Pass?”)

1. No nation has attained universal health insurance that has not built on the existing health care institutions.

Overlay or Add-on or Reconfiguration

2. Short of revolution, no universal health reform has passed over the opposition of more than one major power block.

Which one will you take on? Which one “has to go”?

What plan will gain the support of the other major power blocks? (Think of the huge battle over a few “patients’ rights.”)

3. Successful coalitions are not usually “made” but rather assembled out of existing large organized parties and groups.

Bob Griss, Director of the Center on Disability and Health, Washington, DC, responds to Drs. Gordon, Marmor, Oberlander and Caplan:

The objective opportunity is there for the emergence of National Health Insurance as Dr.Gordon reveals, but it is not a sure thing as Professors Marmor and Oberlander remind us.

Clearly, private insurers would prefer that Congress rely on COBRA continuation policies and CHIP expansions instead of creating a right to health care for everyone. But COBRA continuation does not guarantee adequate coverage, nor does it provide the leverage for cost containment or an information system that facilitates quality assurance in our fragmented health care system.

Now is the time to publicize the advantages of National Health Insurance at the national and state levels to all of the interest groups while:

(1) Employers lay off many of their workers as the economic recession deepens, and shift their rising health insurance premiums to their remaining employees;

(2) States seek to cut benefits and increase cost-sharing in their Medicaid programs which CMS (formerly HCFA) has enabled them to do through the recently imposed HIFA waiver and the even more pernicious gutting of consumer protections in Medicaid managed care by gutting the regulations designed to safeguard the needs of the most vulnerable Medicaid recipients with disabilities; and

(3) Medicare leaves a growing number of seniors and persons with disabilities without outpatient prescription drug coverage as drug profits continue to soar driving up health care prices throughout our health care system while drug companies continue to use their lobbying power to oppose the cost containment mechanisms that Medicare uses for all other health care providers.

Bioethicist Art Caplan correctly understood that terrorism has obliterated the distinction between soldiers and civilians making it imperative that all residents have access to medically necessary health care.

Meanwhile, Representative Jan Schakowsky (D-IL) stands poised to introduce a legislative mechanism called “First Things First Act” that would roll back the tax cut for the wealthiest Americans until various social objectives are achieved to ensure the unity and productivity of our nation. Among her objectives are:

(1) Adequate responses to the needs created by the terrorist attack, including impacts on workers,

(2) Extended solvency of the Social Security and Medicare Trust Funds,

(3) Medicare prescription drug coverage,

(4) Federal funding of school modernization, and

(5) Affordable housing.

Instead of arguing whether a Republican-dominated White House and House of Representatives would ever enact a right to health care, the challenge to health care reformers is to publicize the advantages that National Health Insurance could offer to all stakeholders in society, and mobilize support from mainstream advocacy groups like AARP, labor unions, employers, religious groups, and health care providers to get behind a political strategy like “First Things First” that could pave the way for “National Health Insurance”.

Bob Griss, Director Center on Disability and Health Washington, DC Email Address: Bgrisscdh@aol.com

Quote of the Day

October 5, 2001

The response to Jeoffry Gordon’s call for a shift in strategy can be summarized best by Arthur Caplan’s statement, “Fifty years of waiting for a national health system has left tens of millions with nothing… Let’s get the damn thing done already.”

As expected, the call for moving forward with reform brought many suggestions for the specifics of reform, and many criticisms of the various proposals currently being floated. There is no consensus on the models for reform, but there is universal agreement that we must accomplish reform now.

But the precise models are not the urgent issue. Dr. Caplan is absolutely right. The urgent issue is that we must go to the negotiating tables IMMEDIATELY. We need to lay down on the table the fundamental issues of health policy – coverage, equity, affordability, access, cost containment, adverse selection, portability, continuity, etc., etc. Then we can hash out the policy applications that will address these issues.

The fights in the past have been over the concerns of special interests, such as viability of the private health plans, greed and ego needs of physicians, egalitarian issues of equality versus equity, protection of consumer advocacy litigation income, etc, etc. But these are not extraneous issues that interfere with reform; these are very real issues that must be considered as well. A few examples.

We desperately need an integrated information technology system in health care. Integration would be most effectively achieved and enforced by a public entity, but the application would be more effective through contracted vendors – opening a great opportunity for the health plans to transform themselves into something useful for our health care system. They can be relieved of the burden of risk pooling, which they are attempting to abandon anyway.

If health care as a profession is to remain attractive to some of our more gifted individuals, we will need to compensate them adequately, and we can do this by establishing collective negotiating rights for providers. And restoring the traditional physician-patient relationship will meet the ego needs of physicians. This can be done by eliminating the micromanagement of the middleman money managers, and replacing them with quality improvement programs based on assessment of applications of evidence-based medicine.

Litigation reform is in order, but accountability must be assured by allowing access to appeals and to recourse. We can restore consumer rights to patients while reducing the waste inherent in our poorly targeted litigation system.

The liberal-progressive wing in the reform movement can continue to advocate for equity or fairness in our health care system, without misdirecting efforts to establish equality, which sometimes can be inequitable (a subject appropriate for another editorial).

All special interests have real concerns that must be addressed. Instead of attempting to achieve compromises that inevitably result in mediocrity, we should be looking for the strengths that the special interests bring, and weave them into our system, while rejecting the weaknesses that would compromise reform.

Let’s all move immediately to the negotiating tables. Let’s leave our junk policy science behind. Let’s put down on the table the real issues that need to be addressed with real policy science. Let’s bring ALL of the special interests to the table. Let’s begin with only one rule: Advocates of each position are mandated to keep foremost in mind at all times what is best for the American patient. If we create a model that is best for the patient, it will be the model that is best for any special interests that have a rightful place at the table. Those that don’t belong there will rapidly reveal themselves to the rest of us.

There is far more than enough genius amongst the recipients of this message to initiate this process. Who volunteers as the convener?

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University of California, Irvine
Graduate School of Management
Health Care Management Distinguished Speaker Program
October 2, 2001

Dr. Paul Ellwood, “The Father of HMOs”

The following comments are not absolutely verbatim quotes, but were reconstructed from notes taken by me during Dr. Ellwood’s presentation:

Dr. Ellwood stated that he has written off managed care companies. But he is ready to try refrom again. He believes that reforms will be far more complex, and that the task will be much more difficult.

He has developed a new acronym for his concepts of future reform, although he states that this is a work in progress.

His acronym: HEROIC, as follows:

H: Health system, with an emphasis on the health component rather than on financial incentives. We should consider that the new form be not-for-profit. (He mentioned that he is disgusted when a managed care executive goes to Wall Street and brags about raising premiums and reducing benefits.)

E: Evidence based medicine. Physicians must agree to follow principles of evidence based medicine. Consumers must agree that evidence based care is sufficient. As an example, they should not an MRI when evidence based medicine does not support its use.

R: Responsibility. Patents need to assume more responsibility for their own health and for the costs of health care. He did state that there is danger that the defined contribution will be too low.

O: Outcomes accountability. Outcomes accountability is absolutely necessary to assure high quality.

I: Information technology. Health care is lagging in information technology. Information technology is demanding, complex and costly. It interferes with “clinical productivity” (i.e., income generation). But information technology provides the glue that holds the health care system together.

C: Commitment. We will be able to identify individuals that will acquire specific disorders. A health care relationship will need to be sustained, with a lifetime tracking and alerting system.

He said that we can design a better health care system, but the problem is getting there. We do not want to put cost containment in front of the system that assures health. We must develop an American health system that hails who we are.

Comment: Listening to Dr. Ellwood, he was obviously very disappointed that the managed care revolution did not fulfill his dreams of quality, efficiency and integration, that would improve outcomes through evidence based health care. He is disappointed that his concepts were developed primarily into a business model rather than a health care model. He believes that we can go back and design a model that will incorporate his concepts, although the implementation will be difficult. It is interesting that in informal conversations after his presentation, a few individuals commented that he had implicitly (but not explicitly) endorsed single payer reform.

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The New York Times
October 1, 2001
Letters

To the Editor:

(editorial, Sept. 28):

An additional indirect but major economic effect of the Sept. 11 terrorist attacks may be in health care policy. The economic slowdown that had dramatically increased unemployment in August has been accelerated by the attack to the point of inducing a full-fledged recession.

Most Americans who have health insurance get it through their work. When the slowdown began, 43 million Americans had no health insurance.

As unemployment grows, the families of laid-off workers will add many more millions to the ranks of the uninsured. Perhaps when we get to 50 million or 60 million uninsured, it may at last be politically acceptable to discuss universal health insurance.
JAMES J. FLORIO
Metuchen, N.J.
The writer was governor of New Jersey, 1990-94.

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