PNHP

**Alert** – Support the MEDS Plan!

**Alert** – Support the MEDS Plan!

Today, the Congressional Progressive Caucus introduced:
The Medicare Extension of Drugs to Seniors (MEDS) Plan

It is a genuine Medicare prescription drug proposal.

Features:

*Ê All Medicare beneficiaries are eligible when they enroll in Medicare
*Ê Initially, the premium is $24/month
*Ê All necessary FDA-approved medications are covered
*Ê The plan pays 80%, with no deductible
*Ê When phased in, catastrophic coverage begins at $5000
*Ê Maximum out-of-pocket expense is $1600/year
*Ê Low income individuals would have costs subsidized
*Ê Pharmaceutical firms would be subjected to “reasonable price”
agreements
*Ê The benefit would be publicly administered

A description of the plan is available at:
http://progressive.house.gov/issues/medsplanblueprint.pdf

This plan warrants massive grass roots support!Ê Begin organizing now!

"Revitalizing Medicare: Shared Problems, Public Solutions"

By Michael Rachlis, Robert G. Evans, Patrick Lewis, & Morris L. Barer
Tommy Douglas Research Institute

“The implementation of Medicare thirty years ago was a major fork in the road for Canadian health care.Ê We could have continued to drift, as we were doing, down the road taken by the United States.Ê The road has led, as some foresaw, to ‘the most expensive and… most inadequate system in the developed world…’ (Marcia Angel, former editor, New England Journal of Medicine).Ê Instead, following the trail blazed by Tommy Douglas in Saskatchewan, we established Medicare.

“Medicare has been a great success.Ê It has achieved its primary purpose – protecting people from the financial consequences of illness and injury – and has done it for considerably less than the price paid by our American neighbours.Ê At a deeper level it has become an integral component of our national identity.”

Comment from PNHP Board member Dr. Don McCanne:Ê “This report provides a precise, accurate description of the current status of the Canadian health care system with special attention given to its problems.Ê It is must reading for those of us that have to respond to criticisms of the Canadian system as we advocate for health care justice in the United States.”

The full report is available at:
http://www.tommydouglas.ca/papers/medicare.pdf

Resistance to Attacks on Universal Health Care Mounts in Canada

by Linda Gouriluk

Health care was the number one issue for Canadians who went to the polls November 27 to elect a new government but, in Canada, the battle for universal health care is galvanizing outside the arena of electoral politics. Health care activists remain convinced they must organize the public to resist their government to save Canada’s Medicare system. While no government could expect reelection on a platform to dismantle public health care, rather than give citizens what they want on this score, the Canadian government has engaged in dissimulation regarding the preservation of Medicare for more than a decade. This has prompted hundreds of thousands of Canadians to become defenders of universal health care.

The current Liberal government’s primary method of subterfuge is to make public promises to protect Medicare while simultaneously acting to undermine it. They had taken over this role from the Conservative party after winning the 1993 election. The Liberal’s first duplicitous actions were unprecedented cuts to federal government funding of the health care system, despite loud and sustained public protests and eventually, pleas for the contrary. Starving Medicare was part of a plan for the federal government’s withdrawal from its responsibilities under the Canada Health Act, the opposite of the platform the Liberals had run upon in the 1993 election.

Like real estate agents that disparage houses to homeowners that refuse a low bid, politicians claimed Canada could no longer afford its health care system and kept on calling it costly.

The entire time that the government made this unwanted retreat from the principles of universal health care, citizens were falsely told that rising health care costs justified “reform.” Like real estate agents that disparage houses to homeowners that refuse a low bid, politicians claimed Canada could no longer afford its health care system and kept on calling it “costly.” Health care costs politicians claimed to be out-of-control were actually stable. Government reductions in healthcare spending precluded the possibility of such a claim being true. The only health care costs that went up were out -of- pocket expenses for individuals as governments “delisted” services, de-regulated pharmaceuticals and cutback drug plans.

In 1995-96, there appeared to be an attempt to gain a mandate to reform the health care system in light of what can only be called a manufactured crisis. Most likely seeking a mandate the government never received electorally, the Liberals held a series of public discussions about the supposed crisis.

The National Forum on Health conducted the discussions and released a report in 1997. It did not indicate public approval for downsizing Medicare. Although Forum literature suggested to Canadians, for the first time, that public-private partnerships and a role for the private sector ought to be examined, this was not an idea Canadians were interested in discussing. Instead, they talked about improving and enhancing the health care system and keeping a strong social safety net to address the social and economic determinants of health.

In the meantime, the Liberal government deliberately hid from Canadians its plans to sign the Multilateral Agreement on Investment (MAI) at the OECD in November of 1996. The secret agreement, kept from municipal and provincial governments and even some Federal Members of Parliament, would, said critics, undermine Canadian sovereignty as well as health care and other social programs. The secret got out and the MAI was quashed by public protests organized through an international ground swell.

The Liberals also had signed the North American Free Trade Agreement (NAFTA) which came effective on that famous day of insurrection in Chiapas, Mexico, January 1, 1994. NAFTA was a legacy of the previous Conservative government that had also failed, despite pronounced claims to the contrary, to protect Medicare in its negotiations of the Free Trade Agreement (FTA) with the United States. There was tremendous public agitation against these agreements precisely because critics felt that Canadians were going to lose good full time jobs along with Medicare. The Canadian government tried to placate protesters with more promises to protect Medicare but gradually, it has weakened this promise which so many said was lame in the first place.

According to a document recently released by the Canadian Union of Public Employees (CUPE), “Trade Minister Pierre Pettigrew won’t offer blanket, iron-clad protection of health care and education from any trade deals. This represents a dangerous retreat from Canada’s historic position.”

The government fails to inform Canadians of the implications of major restructuring of the health care system that involves inviting large private corporations, many based in the United States, to sit on new independent “private-public” bodies that now administer public funds.

Such a retreat is reflected by the fact that the government fails to acknowledge nor inform Canadians of the implications of major restructuring of the health care system that involves inviting large private corporations, many based in the United States, to sit on new independent “private-public” bodies that now administer public funds previously administered by government departments. Two examples of such bodies are the Canadian Institute of Health Information and the Canadian Health Services Research Foundation.

The passage of Bill 11, a bill establishing private, for-profit hospitals in the province of Alberta last May, is a more blatant act that reflects the federal government’s abandonment of its commitment to Medicare. While still issuing continual denials of its disregard for the Canada Health Act and the wishes and needs of Canadians, the Minister of Health has refused to intervene in regards to Bill 11.

Opponents view Bill 11 as a dangerous threat to Medicare because of NAFTA. According to Heather Smith, President of the United Nurses of Alberta (UNA), under the provisions of NAFTA, since business opportunities opened in any one province must be opened up across the country, all Canadians are in danger of two-tiered health care and queue-jumping. In the weeks before its passage, UNA nurses gathered for nightly vigils outside the Alberta Legislature. In Edmonton, a quiet parkland city where deer still wander, the peaceful nurses among others were confronted by police dressed in riot gear.

Smith pledged that UNA, with coalition group, Friends of Medicare, will “make every effort to preserve our universal and equitable health system.” They have been joined by Canadians in other provinces and by the Canadian Health Coalition (CHC), a coalition of labour and citizen groups including the Canadian Labour Congress (CLC), the Canadian Federation of Nurses Unions (CFNU) and the National Action Committee on the Status of Women (NAC). They called upon the federal government to instruct the lieutenant governor of Alberta to delay Royal Assent of Bill 11 until the passage of emergency Federal legislation to stop the bill. But Prime Minister Chretin thwarted his own Minister of Health, Allan Rock, by siding with the Alberta government.

Concern about a lack of democracy in Canada has escalated since the passing ofÊ Bill 11.

The Canadian Health Coalition has posted on its web site a “Working Understanding” agreed to by the Federal Government with Alberta in 1996. (www.healthcoalition.ca/working understanding.html ). The document illustrates the forked-tongue syndrome plaguing Canada over this issue. One “key” principle cited is to “Ensure access to a full range of appropriate, universal, insured health services, without charge at point of service.” Another reads: “Ensure a strong role for the private sector in health care, both within and outside the publicly funded systems.” Such contradictory statements have generated public mistrust. Concern about a lack of democracy in Canada has escalated since the passing of Bill 11.

“The government has no mandate to trade away what we hold most sacred.” Judy Darcy, President of the largest union in Canada. Canadian Union of Public Employees President, Judy Darcy, has declared to the half million CUPE membership, and to Canadians via the CUPE web site, that “The government has no mandate to trade away what we hold most sacred (universal health care).”

No Mandate, No Democracy

Government can’t get a mandate to dismantle universal health care in Canada butÊ an alliance between the federal government (and some provincial governments) and the private sector is becoming more clear not just by the formation of so-called public-private partnerships and increased rhetoric to support such partnerships but through attempts to get at least the appearance of a mandate by means other than the electoral process.

Province by Province Strategy

Last spring, before Alberta passed Bill 11, the Province distributed copies of the proposed law (which contained falsehoods and contradictions) to each Alberta household. The provincial government spent millions of dollars promoting the bill, clearly an attempt to garner public support that never materialized.

In October, the Saskatchewan government sent out an information package to 400,000 households in the province. Entitled “Caring for Medicare,” this twelve page brochure is for use at public forums intended to discuss the so-called health care crisis. This brochure also points misleadingly to out-of-control health care costs. Written in a breezy tone, the transfer of control of public assets to private corporate entities is depicted as harmless.

Colleen Fuller, author of Caring for Profit: How Corporations are Taking Over Canada’s Health Care System says, “When public officials talk about privatization, they suggest a benign process but they are talking about corporate controlled health care. If this happens in Saskatchewan, hospital services will be lost and so will outpatient programs. Certain services will disappear in rural areas such as obstetrics, gynaecology, physiotherapy and occupational therapy programs.”

The “Caring for Medicare” brochure is excerpted from a longer version posted on the Saskatchewan government web site. Its distribution, along with the passage of Bill 11 and the federal government’s lack of intervention, has led to plans for a confrontationÊ meant to stop the attacks on Canada’s health care system.

Showdown in Saskatchewan

The Health Care Union Council, a Saskatchewan coalition between unions such as the Saskatchewan Union of Nurses (SUN), the Saskatchewan Government Employees Union (SGEU) and the Service Employees International Union (SEIU) aims to reverse the erosion of the present system that occurred over the last decade. They also plan to do what Tommy Douglas did at the inception of universal health care in Canada: use Saskatchewan as the beach head for a country-wide campaign. The goal is an Rabout faceS in a new effort to do what Canadians have wanted all along, to expand and improve CanadaUs health care system.

According to Rosalee Longmoore, President of SUN, “It is essential that the role of the federal government remain paramount in the funding, planning and administration of Medicare.” She admonishes the government for selling out the health care system to corporate interests. “It’s imperative that the province and the federal government quit compromising the rights of citizens to control their public services by capitulating to legislation such as Alberta’s Bill 11, NAFTA and the General Agreement on Trade in Services (GATS). These are written as irrevocable invitations to import costly, inefficient American for-profit health care delivery corporations.”

The Council has wrote a five page declaration that demands that governments recognize that equality rights are essential to good health. Says Barb Byers, President of the Saskatchewan Federation of Labour, “Comprehensive health policy must be linked with policies to reduce poverty and unemployment.” The declaration says that achieving “health for all” means increased opportunities for education, housing, paid maternity leave, family income support and increased minimum wages, among other things. The declaration and an action plan was adopted unanimously on November 2 in Regina by the Saskatchewan Federation
of Labour.

It’s understandable why the “Caring for Medicare” document has provoked a confrontation in Saskatchewan. Frustration has mounted over a decade. The immediate catalyst comes from the casual suggestion in the package that Canadians just give up on universal health care. This “possible choice” was presented as a legal, benign and somewhat economically pressing policy option in “Caring for Medicare.” Yet this effectively means not just turning over care of Canadians’ bodies to profit corporations, emulating health care American-style but giving American corporations access to their bodies as a market. Adult Canadians consider Medicare to be a defining feature of Canada’s national identity.

Members of First Nations and Quebecois, substantial numbers of whom do not identify themselves as Canadian, also bitterly resent the suggestion that they give up the right to universal health care. The right to health care is a right under the United Nations Declaration of Universal Human Rights, something the Americans still refuse to sign but which is deeply embedded in the moral standards of most residents of Canada.

The “Caring for Medicare” packet reads: “It is time to move toward a private health care system, which allows people to buy the services they need and want, when the public system cannot meet those needs and wants.” Nowhere in the package is there any mention of how much US health care corporations will profit from such a change.

Although the long version of the package mentions higher mortality rates in the US, it fails to mention the logical corollary that Canadians are in store for death rates comparable to the US if they “Americanize” their system. The pronounced lack of financial and moral analysis in the package as well as the failure to connect interrelated facts is a major cause of alarm for the Saskatchewan universal health care advocates. Canadians are in store for death rates comparable to the US if they “Americanize” their system.

The author of the package is Kenneth Fyke, a National Advisor on the Canadian Institute for Health Information (CIHI), chaired by Michael Dector. Dector is vice president of US-based APM, Inc., a firm that advises hospitals on how to partner with corporations. CIHI is a major privatization project in Canada whereby huge amounts of public monies are used, according to Fuller, to generate health information that primarily serves commercial interests. CIHI covers roles previously played by government departments such as Health Canada and Statistics Canada. These departments used to provide information to the public as a free service.

Since 1994, relying on consultants to shape Canada’s health policy has been a part of a general dramatic shift in public procedures and policy that increasingly exclude the public. CIHI and outcomes measurement is an example. CIHI is funded by 180 partners including private companies such as IBM, Hewlet-Packard, Smarthealth, a subsidiary of the Royal Bank, SHL Systemhouse, a subsidiary of US-based telecommunications giant, MCI, Walmart, Glaxo Wellcome, 3M, and Data General. Measuring outcomes was originally suggested by doctors, nurses and citizens concerned about accountability in the health care system. Outcomes measurement could reveal when unnecessary surgeries were performed e.g. cesarean sections, gall bladder removal, hysterectomies, or, when certain health problems went unnoticed (e.g. environmental illness).

“The direction of outcomes measurement in North America has been influenced more by insurance and pharmaceutical industries than by concerns about accountability.” according to Fuller. CIHI sells back health information to the governments as well as to private corporations. Fuller is concerned that community groups such as women health networks or the disability movement are not only not consulted about research parameters but they cannot afford to purchase information they need in order to assess and suggest health
policies.

Individual researchers and reporters may also be at a disadvantage. They may need to rely on government departments for information but these departments have been greatly reduced as a part of the dramatic shift mentioned above. “If you are a member of CIHI’s ‘Core Plan’ (which costs between $8,000 and $160,000 annually) you don’t have to pay for bits of information such as the Annual Hospital Survey for which a non-member would pay about $500.” says Fuller.

Fuller concludes, “With respect to one of the most important debates in the country how to protect medicare and remove profits from our health care system QCIHIUs role is limited and conservative. The participation of global corporations precludes a more useful role for CIHI.”

The Canadian Health Services Research Foundation (CHSRF) was given $65 million in start-up funds in 1996. A public-private operation, CHSRF is described on its web site as structured “to promote partnership and sharing.” The site invites partners to join and this requires a financial committment. Their goal is to “Invest between $200 and $300 million in health services research over the next five years and build an endowment to sustain operations for the long term.” The language used by the CHSRF promotes privatization and ignores entirely negative consequences of this. By “putting knowledge to work” the foundation intends to improve the health care system by weighing “costs and benefits” and aims to “organize health services to maximize value for every dollar invested.”

The web site provides this imperative: “Achieving this goal is not just the government’s business – not when private health spending accounts for more than a quarter of the country’s health bill – and not when a variety of organizations are concerned with health research. This is everybody’s business.”

The posting also reads: “The Foundation is an investment in maintaining the best health services in the world.” This claim requires some scrutiny since the Foundation reflects the will of the Canadian government when it comes to health care. If health care in Canada is going to go the way of corporate controlled health care as in the United States, then the question arises, does the US have the best health care system?

During the 1990’s corporate medicine in the United States has clearly failed to deliver adequate health services to that nation’s population. Over 40 million have no health insurance. Deaths due to hospital error caused by cost-cutting hence profit-making activities such as short staffing and using faulty monitoring equipment run at 100,000 deaths annually. Health insurance costs 4 to 10 times more than in Canada but covers less. Pharmaceutical drugs are relied upon in leau of disease prevention programs and often cost four, five or more times as much as they do in Canada.

In order to generate profits, American health corporations have resorted to crime and been successfully charged with criminal offenses.

According to American doctor, Deborah Richter, President of Physicians for a National Health Program (PNHP). In order to generate profits, American health corporations have resorted to crime and been successfully charged with criminal offenses. Major corporations such as Tenet and Columbia HCA were charged hundreds of million of dollars in fines for fraud and other offenses. An especially bizarre case was NME (later called Tenet) which was caught paying bounty hunters to capture psychiatric patients for forced “treatment”. NME then released their patients/prisoners on the day their insurance ran out. “Many of them were children who were denied contact with family members.” says Richter.

Richter had two patients, a brother and a sister, young people with low paying work and no health insurance. They couldn’t afford needed medication for diabetes. Rather than quit work and social life to go on welfare to get health benefits denied to the working poor, they chose to live as long as they could without proper medication. They both died painfully in their early twenties.

Canadian, Kevin Taft co-authored with Gillian Stewart, Clear Answers: The Economics and Politics of For-Profit Medicine published this year. He found that “…there was a striking consistency in studies of health economics: study after study, decade after decade and in country after country has found that health care is a market failure.” What this means is that according to economic theory, caring for our health simply isn’t profitable. The corollary of this is that if profit is made, then it is at the expense of our health. Taft asks, “If, as the research consistently shows, for-profit medicine cannot be described as being in the public interest, then in whose interest is it?”

The story of Richter’s patients brings tears to the eyes of nearly all who hear her tell the story. This tragic story gives the answer to another question raised by Taft and Stewart. “Trust is at the heart of the debate of public versus private health care. People in need of health care must be able to trust that their weakness will not be exploited. Will we be able to trust for-profit clinics and hospitals to serve our needs above their own?”

Canadians are resisting attacks on their health care system now as attacks on the public good Q as attacks against humanity. Some Canadians are unaware of the situation but substantial numbers of health care advocates are armed with knowledge, and now a moral outrage has ignited in Saskatchewan.

Saskatchewan advocates want to rid their province of so-called private-public partnerships that will otherwise pave the way for corporate controlled health care, especially by American corporations that are capable of a swift takeover. A major contract in Health District Number One with US-based Marriott will not be renewed due to public outcry.

Since Saskatchewan still has a high degree of public control over it’s resources, it’s citizens have an excellent chance of successful resistance. In a world of concentrated corporate and financial control, Saskatchewan is a new kind of battleground that bears watching by the outside world.

“Trading Health Care Away? GATS, Public Services and Privatisation”

by Sarah Sexton

Even before its meeting in November this year in Qatar, the WTO has already begun talks to expand one of its agreements – the General Agreement on Trade in Services or GATS.

Services are now a significant part of the economies of industrialised countries and are governed by complex domestic regulations. These countries are now trying to revise the Agreement to increase international trade in services. If they are successful, GATS could be used to overturn almost any legislation governing services from national to local level.

Particularly under threat from GATS are public services – health care, education, energy, water and sanitation, for instance. A revised GATS could give the for-profit sector further access and could make existing privatisations effectively irreversible.

Experience in the United States and several Latin American countries, where health services have been run for profit over the past decade or so, suggests that the result will be a decline in accessibility to health care worldwide.

This briefing outlines the growth in services in recent years, the main provisions of GATS and its proposed revisions, and some key corporate aims in extending the Agreement. It details how public services may not in fact be excluded from GATS.

It considers what may happen if private companies are enabled to capture the most profitable components of publicly-provided and -funded health care services: a two-tier health system in which a reduced public sector has to cope with the elderly, chronically sick and the poor who most need health care and who can least afford it..

Sarah Sexton/Larry Lohmann/Nicholas HildyardÊ
THE CORNER HOUSEÊ
PO Box 3137Ê
Station RoadÊ
Sturminster NewtonÊ
Dorset DT10 1YJÊ
BRITAINÊ
Tel: +44 (0)1258 473795 Fax: +44 (0)1258 473748 Email Ê
Website: http://cornerhouse.icaap.org/

“Revitalizing Medicare: Shared Problems, Public Solutions”

By Michael Rachlis, Robert G. Evans, Patrick Lewis, & Morris L. Barer
Tommy Douglas Research Institute

“The implementation of Medicare thirty years ago was a major fork in the road for Canadian health care.Ê We could have continued to drift, as we were doing, down the road taken by the United States.Ê The road has led, as some foresaw, to ‘the most expensive and… most inadequate system in the developed world…’ (Marcia Angel, former editor, New England Journal of Medicine).Ê Instead, following the trail blazed by Tommy Douglas in Saskatchewan, we established Medicare.

“Medicare has been a great success.Ê It has achieved its primary purpose – protecting people from the financial consequences of illness and injury – and has done it for considerably less than the price paid by our American neighbours.Ê At a deeper level it has become an integral component of our national identity.”

Comment from PNHP Board member Dr. Don McCanne:Ê “This report provides a precise, accurate description of the current status of the Canadian health care system with special attention given to its problems.Ê It is must reading for those of us that have to respond to criticisms of the Canadian system as we advocate for health care justice in the United States.”

The full report is available at:
http://www.tommydouglas.ca/papers/medicare.pdf

COSATU STATEMENT ON THE HIGH COURT CASE BY PHARMACEUTICAL COMPANIES

COSATU Communications Department – 2001-01-15
Ê
The democratic parliament passed the Medicines and Related Substance Control Amendments Act in 1997 as means to facilitate access to cheap medication. This was in view of the exorbitant cost of medicines in South Africa, especially in the case of HIV/AIDS related drug.

The act allows for parallel importation of generic drugs and issuing of compulsory license. From its inception, the legislation was strenuously opposed by opposition parties and the pharmaceutical companies on the grounds of protecting intellectual property rights. The Act has been in limbo due to the court challenge brought by the pharmaceutical companies which is now due to be heard in March 2001 in the Pretoria High Court.

COSATU regards the court case by the pharmaceutical companies as a serious stumbling bloc to the transformation of the health care system. It is also tantamount to profiteering at the expense of the health of the majority of South Africans who currently face prohibitively expensive cost of drugs. COSATU reaffirms its support to the Medicines and Related Substance Control Amendment Act particularly the objective to ensure cheaper drugs.

The drug company’s patents cannot be allowed to hold at ransom the health of our nation. COSATU therefore calls for the acceleration of the court case. Further, COSATU calls on the democratic forces to mobilise against this contemptuous action by the pharmaceutical companies.

PNHP Comments on AAFP Reform

Lanny Copeland, MD
Chair, Task Force on Universal Coverage
American Academy of Family Physicians
2512 Westgate Blvd, #6
Albany, GA 31707

American Academy of Family Physicians
Attn: Health Care Coverage
11400 Tomahawk Creek Parkway
Leawood, Kansas 66211-2672

Dear Dr. Copeland,

Physicians for a National Health Program (PNHP) applauds the efforts of the AAFP Task Force on Universal Coverage in coming up with a draft proposal that is thoughtful, innovative, and bold.

We find the “guidelines” to be especially relevant and on target. In addition, we are extremely pleased that this proposal is truly for universal coverage, not for incremental steps or merely reducing the numbers of the uninsured.

The following comments on the Draft Proposal have been put together by family physicians in PNHP who have many years of caring for the uninsured and advocating for health care reform.� Some, like me, have worked with the uninsured in community and migrant health centers for over 20 years.� Other authors have worked in inner city hospitals and clinics or other parts of our tattered “safety net” for the sick poor.

While these comments come from a family physician perspective, they represent the views of our organization as a whole. PNHP has 9,000 members and includes physicians from every state and specialty, and a growing number of medical students determined to work for a system better for their future patients.
We hope that our comments will help improve the proposal. We have also e-mailed a copy of our comments to unicov@aafp.org.

We would be pleased to meet with you to discuss these comments or, more generally, strategies to promote real health care reform over the coming period. The struggle for universal health care is going to be a long and hard one and we share your belief that family physicians should play a leading role.

Sincerely,

Bob LeBow, MD
Coordinator, PNHP Family Practice Working Group
Past President, PNHP
Medical Director, Terry Reilly Health Services
Boise, Idaho
Phone: (208) 466-7869
E-mail: Rlebow@micron.net

Comments on the American Academy of Family Physicians’ (AAFP) Draft Health Care Coverage Proposal

Executive Summary:

* The AAFP Task Force deserves much credit for a proposal that is truly universal.
* PNHP agrees that the U.S. health care system is fundamentally flawed and has fragmented funding and delivery systems.
* The draft proposal’s support for the concept of balancing individual needs and community resources is appropriate. The U.S. already spends over $4,000 per capita for health care, more than enough to provide care to all.
* The draft proposal’s support for tax-based financing of health care is appropriate. However, PNHP would support expanding tax-based financing to cover all medically necessary care, including the draft proposal’s “middle tier” of care. A separate “middle tier” of services would perpetuate disparities in access to care and fragmentation in the funding and delivery of care.
* PNHP agrees that “all people” in the U.S. should be covered, regardless of legal status.
* PNHP agrees that administrative costs should be minimized (see below).
* The draft proposal preserves a role for private insurance for a “middle tier” of benefits. In addition to perpetuating fragmentation, it sharply limits administrative savings (to less than 10% of the savings possible). It also perpetuates fraud and abuse as private insurers evade payment and attempt to shift costs to patients and government. PNHP suggests that the role of private insurance should be limited to “extra” services that are not medically necessary, such as private hospital rooms and cosmetic surgery. Sale of parallel private insurance that duplicates benefits for medically necessary care should be proscribed.
* Thus, PNHP suggests the proposal cover “all medically necessary” health care, not just “basic” and catastrophic coverage.
* PNHP feels that all federal programs should be comprehensively included in the plan, especially Medicare and the VA, in order to improve benefits for seniors and veterans, and to allow for more effective cost-containment mechanisms system-wide (e.g. globally budgeting hospitals – which also reduces overhead).
* PNHP agrees that no co-payments should be charged for primary and preventive services, but encourages AAFP to eliminate co-pays for all medically necessary care. Co-pays do not control costs, are expensive to administer, and reduce access to health care for the poor and the sick.
* Finally, PNHP believes that AAFP should ban or place a moratorium on investor-owned, for-profit health care providers. Investor-ownership pits physicians against patients; care for patients against shareholder profits (every dollar spent on clinical services is a “loss” to the profit-seeking entity).

On the Findings:

* We agree wholeheartedly with the “findings,” especially as to the Task Force’s conclusion that the insurance-based “philosophy” based on risk-avoidance is fundamentally flawed and must be changed, and that the degree of fragmentation of our current financing and delivery system is a significant barrier to addressing the problems. We also agree that system-wide change is needed, that the goal must be truly universal coverage, and that the “social good” concept is valid.

* As regards the four conceptual approaches, the “employer mandate” model as outlined resembles the solution recently proposed by Karen Davis, President of the Commonwealth Fund. We believe that this option would be very costly and perpetuate systems that are increasingly failing and expensive.

* The “individual mandate” approach again does little to reform our broken system. It leaves control over health care in the hands of the private insurance industry, and (given our experience with the uninsured) is totally unrealistic to reach those most in need.

* PNHP has always been a supporter of single-payer (“one risk pool”) as the fair-est, most equitable and cost-effective way to finance universal coverage. We realize there are political challenges to this solution because of the opposition of the powerful HMO/insurance and pharmaceutical lobbies. However, we believe that by educating and mobilizing the public that these special interests can overcome. Also, these industries cynically use their vast resources (garnered from our health care premiums) to oppose any and all reforms, so pursuing a less comprehensive strategy does not confer any real advantage. Finally, with HMO premiums rising in the double digits, belying the myth of HMO “efficiency,” the possibility of gaining business support for the most cost-effective reform (“one risk pool”) is a distinct possibility.

* “Single Purchaser”- or vouchers- would do nothing to cure the ills of our present system. Cherry-picking andinsurance company control (based on the pricing of the product) would continue to prevail.

On the Guidelines:

Question: Are these the guidelines that we should follow in developing a plan for universal coverage?

Overall, with a few exceptions, yes. PNHP agrees that:

* (a) the current U.S. health system is fundamentally flawed, and that we as a society have a moral imperative to provide ethical care to individuals while providing responsible stewardship of community resources;
* (c) a uniform, outcome-based package of health services will be available to all, though we have a problem with the word “basic” (see below);
* (d) we will fund only evidence-based, high-quality, and cost-efficient health care services;
* (f) the system should balance the needs of the individual patient with the greater good of the community as a whole, and there need to be fiscal limitations;
* (g) sufficient funds for public health, research, and education are available to meet the nations’ needs;
* (h) administrative costs should be minimized.

On (b) and (e) – and we will elaborate later – PNHP has a problem with the concept of “basic health services” as it applies in the draft proposal. We feel that the lack of coverage for the “in between” or “middle tier” services (specialist and hospital services not covered in the “catastrophic” part) are the weak point of this proposal. We will address this item below.

Program Elements and Fiscal Implications:

Question: What do you think of the overall approach and of the individual elements?

* PNHP strongly supports changing the source of funding from an employment-based system to a tax-based one. Current incentives in employment-based funding are based on costs rather than on the genuine health needs of employees. Small employers and the self-employed are also unduly penalized. A tax-based system would be simpler, more equitable, and easier to administer. Universal coverage would be much more difficult to attain without a tax-based system.

* Element I: “Basic health services”: This is the part of the proposal with which PNHP has the greatest problem, especially given our members’ extensive experience dealing with health care for the uninsured. Our comments are elaborated in several points below.

* PNHP agrees fully that there should be no co-payments or deductibles for “basic” services. We also advise that there be no co-payments for all medically necessary services, not just “basic” care. As the Rand study and other studies have shown (Rasell, “Cost Sharing in Health Insurance: A Re-examination,” NEJM April 27, 1995) co-payments are true barriers to care – especially preventive care. We have seen patients delay or defer needed care, or not fill a prescription, because of co-payments and means-tested nominal fees (as low as $5 – $10). Patients often feel ashamed to come in when they can’t pay a minimum charge – yet we would all agree that our poor, sick patients are the very ones we want to see most.

* The draft proposal defines “basic” as those “services…that most people need at some point in their lifetime”: Would this also include the care our poor uninsured patients need, such as a cardiac catheterization, surgery to correct a prolapsed uterus or repair a torn knee ligament, neurological evaluation and treatment for a complex seizure disorder, cataract surgery, etc.? We’re afraid our most vulnerable patients would continue to fall through the cracks.

* Those of us who have worked in the “safety net,” e.g. in community and migrant health centers, feel that we’re fairly well able to cover the primary (or “basic”) health care needs of our patients, but when it comes to secondary care, which in the proposal seems to be defined as specialist care short of something catastrophic, we usually have to beg, borrow, and steal (so-to-speak) to get care for our patients. We don’t see our patients as being able to go out on the market and purchase a plan or insurance to cover these “middle tier” needs, especially when they have multiple pre-existing conditions. Should we leave these patients (and their “in-between” needs) at the mercy of the for-profit insurance industry? We believe that this approach won’t achieve the AAFP’s goal of universal coverage. It will leave millions of patients underinsured, resulting in predictably delayed care, with larger expenses – and totally avoidable patient suffering — in the long run. It will perpetuate multi-tiered care, where one patient will get a needed hip replacement, while the next patient, who is poor and without “middle tier” coverage, is sent home with a walker.

* PNHP believes that it makes more sense to cover all medically necessary care with a seamless, comprehensive benefit package. While the for-profit HMO/insurance and pharmaceutical industries will oppose this reform (as they do all reforms – witness the $30 million television advertising campaign the drug companies recently ran opposing a prescription drug benefit in Medicare), we believe physicians should place the interests of our patients first.

* As family physicians, we are trained to look at patients holistically. We don’t see a patient’s chronic mental illness as part of “catastrophic” coverage, their “pap” smear as “basic” and their congestive heart failure as “middle tier”. We take care of the whole person during a visit. It’s contrary to the philosophy of family medicine (and an administrative nightmare – see below) to create arbitrary categories.

* Should a plan cover all people as described above?: Absolutely. The plan should apply to all people in the U.S., including those who are undocumented. We have a commitment as physicians to care for every person when they need care. For public health reasons and to reduce the threat of treatable conditions becoming catastrophic it also makes sense to cover everyone.

* The draft proposal defines “basic” as services “most people” would need. What about the “basic” care people with rare conditions need to prevent complications? One of us has three patients with Fabry’s disease, a fairly rare genetic disorder with severe consequences. Would they be excluded from new treatments (which could be expensive) as they become available? If they have a heart attack at age 40, their treatment would be covered under catastrophic coverage, but what about their “middle tier” medical care until then? There are hundreds of similar examples. We believe it would be simpler, and more ethical, to cover “all medically necessary services,” and have an administrative body (with representatives from the NIH, the CDC, the public and the medical profession) define a seamless benefits package and meet periodically to evaluate new treatments and technology.

* Would the individual’s financial participation – through co-payments, for example – discourage appropriate utilization of basic health services or simply discourage inappropriate utilization?: As we noted above, the medical literature and our experience show that such payments do discourage appropriate utilization and lead to delayed care. If we want appropriate access to primary care and (especially) prevention, co-payments are a mistake. We feel there should be less worry about inappropriate utilization. In primary care, those “inappropriate utilization” episodes are opportunities for prevention and improved continuity of care. Education with better patient information (a public health approach) is the path to take, not co-payments, to discourage inappropriate utilization.

* What process should be used to define basic benefits? We have already discussed the problems with both the definition and use of a “basic benefits” approach to health care reform. We gave some examples (above) which highlighted the vagueness and ambiguity of the “what most people need” criterion for basic benefits. The definition of “catastrophic” and “middle tier” care is just as problematic. Is all inpatient care considered catastrophic? How about a hernia repair as an outpatient? Colonoscopy for someone with positive stool hemoccults? An infertility work-up? Arthroscopy or an MRI ordered by an orthopedist for an injured knee? Would people who could not afford to buy private insurance (i.e. because of a low wage job or pre-existing conditions) for this “in-between” category be denied these kinds of procedures?

* It is more profitable for an insurer to cherry-pick patients in subtle ways than to provide care, even if rates are risk-adjusted. Also, insurers will exploit the arbitrary nature of the definition of “middle tier” to shift costs to patients and the government. This part of the draft proposal leaves the health system wide-open to continued fraud and abuse.

* PNHP feels we need to cover “all medically necessary” measures that are proven to be effective, not just “basic benefits” with a catastrophic caveat as this plan proposes. Otherwise, we will find ourselves in a quagmire of ambiguity, with little or no improvement from our current fragmented systems of health care financing and delivery. Moreover, the proposal could be interpreted as very self-serving for family practitioners, as it seems to indicate that the basic coverage would ensure payment for primary care practitioners, but (generally) not specialists. What if a gastroenterologist does EGD instead of a family practitioner? Would that be covered by the “basic” plan?

* As regards administrative savings, the savings projected by Lewin are tiny ($7.8 billion, less than ten percent of the $100 billion in administrative savings projected under single payer by the GAO and the CBO). These savings could be much greater, and the system much more effective and seamless, if everyone didn’t have to re-enter the insurance market to buy their “in-between” or “middle-tier” insurance.

* Another part of the administrative waste in this proposal is that it maintains the Medicaid and CHIP programs to assure that this group has the “in-between” coverage. If the benefits package was seamless, these programs could be largely eliminated, increasing the administrative savings that could be used for clinical care. The sub-question of “Should physician payments be reduced to reflect lower administrative costs?”: Yes, without a doubt, as long as the administrative office/etc. costs are truly diminished. It is doubtful that this would be the case if multiple systems of payment (many private insurance plans, basic plan, Medicaid, CHIP, Medicare, CHAMPUS) are retained.

Element 2: The Oversight Body:

What model of public/private oversight would be appropriate?: Oversight is critical at both the federal and state level. There should be representation from the public, public health, physicians, government agencies such as the CDC and the NIH, allied health professionals, and academic health centers. There should be substantial (perhaps half) representation that is non-medical, from the public. It could be modeled like a utility regulatory board, with decision-making authority, not just advisory status. And it should be empowered with setting and enforcing global budgets. PNHP is opposed to oversight by investor-owned interests, because that would be like “the wolf guarding the henhouse.”

Element 3: Programs left in place:

Should some existing federal programs…remain as separate programs…or should these programs be eliminated? [And status of Medicaid] …as part of the universal coverage plan?

* PNHP believes that all federal programs should be folded into any proposal for universal coverage. The administrative savings could be increased if there were integration of the government health programs into the AAFP health plan, but probably only if the AAFP plan were expanded to cover “medically necessary and effective” treatment instead of “basic” and catastrophic services.

* There would be public resistance to integrating government programs into the AAFP proposal if the beneficiaries were offered worse benefits. Similarly, people in comprehensive private health plans might also object. As mentioned above, PNHP feels that the AAFP proposal should be upgraded to include a more comprehensive set of benefits, thus facilitating inclusion of people from federal programs as well as private plans. Also, allowing patients to choose and stay with their physicians is a major advantage of this proposal over existing health plans, but only if it includes choice and coverage of specialty care as well as primary care. Secure, comprehensive coverage that allows choice of physician would be attractive to the public and could be used to “sell” the program (for-profit HMOs would of course be opposed as they hope to expand their profits and share of the Medicaid/Medicare market).
* There have been many complaints from people about the current CHAMPUS and Indian Health Service programs. They seem to be insufficient and could probably be integrated into the AAFP plan without much complaint, and with added benefit to the people in these plans. The same could apply for the VA. To retain their usefulness for their beneficiaries, these programs could offer “extra” services not covered in the AAFP plan, such as social services, long-term care and rehabilitation, home visits by health teams, etc.

* The Medicaid program should be integrated into the AAFP plan, again with expanded benefits. Why duplicate bureaucracies, especially one like Medicaid with a separate bureaucracy in every state and beneficiaries who cycle in and out of the program, sometimes on a monthly basis? Continuity of care would be better with a seamless benefits package. Also, there wouldn’t be the administrative nightmare of trying to determine which care is covered by Medicaid vs. the “basic” plan. Conversely, a Medicaid agency could be maintained to deal with “extra” benefits not covered under the AAFP plan, be it eyeglasses, durable medical equipment, transportation, etc., and these benefits could vary from state to state.

* PNHP believes Medicare should be included in any universal coverage plan. Medicare is in sore need of improved benefits. Shouldn’t we be addressing the problems of Medicare if we’re really interested in improving access for everyone? We see Medicare patients every day who postpone care, take medications every other day instead of every day, and cut corners because they can’t afford the care we prescribe for them. Seniors spend close to 25% of their total income on health care despite Medicare. Can we ignore this? Can we really talk about “universal coverage and access” unless we deal with Medicare? Yes, it’s a big political football, but the public supports Medicare, and it already has a funding mechanism. The AAFP plan is much superior to Medicare with regard to primary care, especially with respect to co-payments. But Medicare largely covers the “middle tier” care not in the current proposal. Integrating Medicare into “one risk pool” (such as a more comprehensive and seamless AAFP plan) or vice versa would also allow for more effective cost-containment (and administrative savings) system-wide.

* Consolidation of federal and state programs would allow increased administrative savings, much in excess of the Lewin estimate – savings that could be used to fund clinical health care. As a point of reference, the outgoing CEO of Aetna recently confirmed that administrative costs in the U.S. health system are about 25 percent of all health care costs (although we’re tempted to think that if he admits to 25 percent, the truth is probably closer to 35 percent). We could cut that by half or more if we truly rationalized our payment system. Additional optional services could remain at the discretion of each state or program.

Element 4: Catastrophic Coverage:

Yes, in the absence of a truly comprehensive and seamless plan, there should be catastrophic coverage. One of the great inequities of our current system is the incredible financial burden a family must endure if they should be so unlucky to have a catastrophic health event. This burden currently applies in the U.S. not only to the uninsured, but to the underinsured as well. People in other countries shake their heads in disbelief that we tolerate such a situation.

* Should co-payments for catastrophic coverage be uniform or means-tested?
Neither. Co-payments and deductibles should be eliminated, especially in the case of chronic or catastrophic illness. Co-payments in these cases penalize the sick at the worst possible time in their lives. Not only are the patients too sick to work, but family members may also have to reduce their working hours to act as unpaid caregivers.

* Should catastrophic protection be provided in this way? PNHP feels strongly that there should be no out-of-pocket expenses for any necessary and effective medical care. Our experience with our low-income patients tells us that cost sharing is a burden. Even means-tested and capped out-of-pocket expenses are a major obstacle to access for families with little disposable income. Also, co-pays are administratively unwieldy and do not control health care costs.

Element 5: The “in-between” or “middle tier” services:

We gave examples in the section on “basic” coverage on how ambiguous and difficult the distinction of “middle tier” services would be. In addition, maintaining a separate tier covered by private insurers opens the door to fraud and abuse, as insurers “cherry pick” the healthy and cost shift expenditures for the sick onto patients and the government. Why perpetuate a system that is broken? Why keep a large portion of medical services under the old fragmented payment system with multiple tiers of care? The affluent will buy expensive plans; those who cannot afford them will scrape by with bare bones coverage, millions will continue to go without contrary to the goal of “universal coverage”. What will insurers charge a person with angina to cover their “middle tier” of health care – and what lengths will they go to to deny coverage for any services they actually use. Finally, as we pointed out above, if we only endorse “basic” (primary) care as part of the plan, we family physicians could be perceived as self-serving

* [As an employer]… how likely would you be to offer…coverage [for non-covered]…services? The link between employment and insurance is a historical accident that should not be maintained. This is a major flaw in the AAFP draft proposal, and should be remedied in the final version. Private employers pay for private insurance for less than half (43%) of Americans, and millions of Americans are uninsured because of the unfortunate link between insurance and employment. As family physicians, we know all too well the devastation caused by lack of insurance in our low-income patients – despite the fact that they are working two or three jobs.

* Those of us involved in purchasing insurance for our employees would try to price a plan, but it would be the same kind of game we play now, more or less at the mercy of the insurance companies, with ever more complex co-payments and deductibles. Once a plan is purchased, the insurer then denies paying for care, creating problems that are time consuming to resolve for us and our employees (and creates hassles for their physicians). With the basic and catastrophic parts in effect, why perpetuate the agony, increased complexity, and costly overhead of a “middle tier”?

* Besides sharply limiting administrative savings, maintaining a separate “middle tier” limits effective cost containment. As much as the guarantee of rising costs and a slice of the health care spending pie pleases insurers (and presumably this part of the proposal is intended to fend off their opposition) the HMO/insurers and drug companies will oppose the plan just as fiercely as they have other reforms.

* PNHP suggests that the AAFP have Lewin price out what it would cost to fund the “middle tier” through taxes as part of a unified system that would allow for improved continuity of care and fewer barriers to access. Administrative savings would be vastly increased, and cost-containment much more effective system-wide. The overall cost of a unified system should be much lower and help avoid fragmentation of care and administrative nightmares.

* Is it appropriate to leave to individuals whether to seek coverage for this tier of benefits? Should the plan incorporate individual accountability for patients’ own health behaviors?

Part I: “Individual fiscal responsibility” is a concept that should have no place in the reform of health care. Health care is most ethically viewed as a social responsibility and a human right. The concept of the “irresponsible health care consumer” is a myth perpetuated by entrepreneurs and MBA’s seeking to profit off the $1 trillion U.S. health care “market.” As physicians, we need to debunk the myth of the patient as “greedy consumer” and the physician as “self-serving provider”. Our relationship with our patients is not the same as the widget salesman to their customer – and we must not allow it to be reduced to that. A large measure of what needs to be accomplished in reform is to restore physicians’ professionalism and eliminate the notion that a sick patient receiving care is somehow a “loss.” Health care is a social “good.” By putting forth a proposal for reform that is inclusive and comprehensive, and explicitly rejecting a corporate model of health care, the AAFP will be taking a large step in the right direction.

Part II: We affluent physicians often gripe about smokers, drinkers, drug-abusers, etc. Yet those of us with more experience realize that discriminating against people is a slippery slope. What about a physician (one of us) who bicycles in New York City or travels in malaria-infested rural West Africa? Or a person who does ice climbing or Class V rapids in a kayak? And how can we discriminate between a genetically-based mental illness and substance abuse? We should not include this type of “health behavior accountability,” but provide the kind of educational, preventive, and rehabilitative services to help deal with these behaviors.

Element 6: The financing strategy

PNHP fully agrees with tax-based financing as the most equitable and efficient way to fund health care. The requirement that all employers participate will meet with resistance from some established business groups (e.g. the Chamber of Commerce), but others are likely to show renewed interest in health care reform. With HMO premiums rising 15-30% at many businesses this year, and the growing hassle and cost of managing employee health benefits, business can’t afford to reject a proposal that will reduce their long-term costs out-of-hand.

The amount that employers and employees contribute could be changed over time. Gradually shifting more of the tax burden to income taxes (and having employers increase wages to account for their reduced contribution) would be one way to make the tax burden more progressive. PNHP supports either method.

One item that appears not to have been discussed in the proposal is the effect of the current tax-free benefit in present employer-paid health insurance. This benefit has been estimated to be a $100 billion subsidy from the government – i.e., money that would have been paid in taxes otherwise. The government could re-direct this money to pay for added services if this factor hasn’t already been taken into account.

Element 7: State Administration:

What do you think of the fund distribution and the state administration provisions of this plan? PNHP feels that state-by-state (or maybe regional) administration makes sense as long as there are national guidelines to be followed and public oversight. We support negotiated fees (by the state or regional body) with the possibility of increased payments in areas where there is a shortage of physicians.

Psst. The real scoop on Patient Assistance Programs

ZNET commentary, December 26, 2000
By Dorothy Guellec

Drug companies are giving away medications if you know how to ask. This is the best-kept secret because it is not widely known. All of the top 30 pharmaceutical companies make prescriptions available free, and these programs are horribly underutilized. PHRMA, an industry trade group, told me that 2.8 million prescriptions nationwide (not including samples) valued at about $500 million were given away in 1998.

Getting prescriptions to the people who need them is vital nowadays. Costs are rising and, contrary to the mainstream media stories, few older citizens can just hop on a bus and go to Canada for a prescription every 30 days. There are several vehicles physicians can and should use to make sure needy patients get prescriptions. “We have a responsibility to care for the poor,” said Herbert Rakatansky, MD, chair of the AMA Council on Ethical and Judicial Affairs.

I spoke with Bob Huber at Pfizer on December 9th, 2000. He told me that after the merger with Warner Lambert this summer, the combined companies’ projected earnings for this next fiscal year would be $30 billion and of that, $5 billion would go for research and development. I asked about the other $25 billion, but he just laughed.

Of the patient population most dependent on medications – those older than 65-31% lack coverage for prescription drugs. Seniors who have coverage typically use 21 prescriptions a year. About 45% of the elderly have incomes at 200% or less of the poverty line. That’s $16,000 to $18,000 a year before taxes. The average senior citizen today has 2 to 2 ½ chronic conditions, and a drug just for one chronic condition can cost between $500 and $3,000 a year if bought in the U.S. Of course one could always go to India and purchase a copycat for 1/50th the price. Trying to understand the regulations is very tricky as the pharmaceutical companies are not forthcoming, just the opposite. The drug companies will not discuss criteria; believe me I’ve tried. Patient-advocacy groups say they have seen families with incomes of $50,000 or more get free prescriptions.

Most programs require the patients to apply through their doctors. The doctors are not informed because generally it falls to the sales reps to promote the programs. In today’s climate, with the average doctor allowing 10 minutes per patient, one can understand why doctors are not aware of these benefits. To qualify, applicants must show they have no coverage for outpatient prescription drugs; that their income must be low enough that paying for medicine would pose a hardship; and that they do not qualify for Medicaid. In reality the doctor writes a two-sentence letter to the pharmaceutical company without any other documentation. Most companies supply three months at a time on a case-by-case basis.

The corporate drug programs are underutilized. I see this as political not philanthropic. They want to keep it a secret. They do it so they can tell Congress, “We give away medicine for free,” but then, they don’t tell anybody about it and make it very hard for people to apply. After researching this program for hours, I came up with one article from the Wall St. Journal and a few stories from local mid-western papers. Actually the Journal article described the program as being “difficult to apply for.”

This isn’t true. Every company has guidelines and some require lengthy paperwork, but not uniformly. There is a non-profit organization called the Medicine Program that can help to simplify the process in some cases, but I would advise patients to first try on their own. Dan Hogg of the Medicine Program said, “We just serve as the patient’s advocate.” For $5, refundable if you do not qualify for the free drugs, this non-profit organization will help with the paperwork and get them to the right pharmaceutical company. Most pharmaceutical programs look at income and expenses and do not count assets, which can often disqualify people from government programs. Last year Glaxo Wellcome gave away $28 million in drugs, it fills more than 14,000 free prescriptions each month.

The Medicine Program’s website is www.themedicineprogram.com. It appears strange that they claim to be non-profit with a com., and not org, but buyer beware I guess.

Physicians should be aware that a large number of people might have difficulty affording a drug without insurance coverage. Doctors are obligated in my opinion, to advocate for their patients. They should get involved and help to access medications. Some physicians feel that there are limits to their obligations. One said, “While physicians have a responsibility to help care for medically indigent patients in a variety of ways, using their own financial resources to make that happen is above and beyond the call of duty.” Doctors, however, agreed that their implied social contract calls on them to help needy patients. I wonder if they feel that ensuring that patients obtain prescription drugs is part of that contract.

Handing out free samples from the manufacturers is the easiest option, but the industry opposes this – I wonder why. Of course it’s not a long-term solution for patients with chronic conditions. A more viable option is the patient assistance programs. If physicians cannot keep on top of what pharmaceutical companies offer, then its up to the patients . Can’t lose anything by asking. Pfizer Inc. is relies on the physician’s word not the patient’s tax forms.

Libby Overly was working as a home health social worker in Alabama when she recognized that the personal database she’d developed to navigate the patient assistance programs might encourage doctors to access them as well.

With the help of Richard J. Sagall, MD, she created Need Meds, an online database of companies and the free drugs they offer. Patients can also access a Directory of Drug Patient Assistance Programs by PhRMA a trade group for the pharmaceutical industry. It is a handy directory of 33 companies who provide drugs to physicians for patients who otherwise could not afford them. Of course ultimately society has the responsibility to make sure that people have access to all the health care they need.

The prestigious AARP devoted their November publication “Bulletin” to the array of problems that their sample of 11,000 members might encounter. Not once did they mention the Prescription Assistance Program. What is one to think? It is obvious that the top honchos do not want all the members of AARP asking their doctors for free medicines. A psychiatrist on a listserv wrote “many of my patients are provided medications through pharmaceutical company patient assistance programs.these provide for 2-3 month supply of meds for uninsured, low income patients. I rarely have had any patient turned down and have never had a patient taken off the program, unless of course they obtained insurance. My routine and the routine of many doctors in my clinic is to begin a patient on samples and then, once you find that the medication is working for the patient, transition them to the patient assistance program.” The natural question to wonder about is why is this doctor so well informed, and most of the others are not? Is it not incumbent upon them to know about these programs? Maybe it’s the fault of the drug reps., but if the reps can only see the nurses, or have 5 minutes with a doctor to explain a new medication, when can they promote patient assistance programs?

It finally and logically falls to the media, and the pharmaceutical companies themselves, to promote these programs vigorously. I did a very thorough search and spoke with lots of so-called informed people – they never heard of free medications from 33 of the leading companies. There are about 980 pharmaceuticals amongst all the companies, and new ones are being added all the time.

Anyone reading this is encouraged either to email me, or to insist that the doctor or someone on his or her staff research the availability of the medication. The chances are that there is at least one non-generic (expensive) drug that is available free of charge.

Dorothy Guellec
guellec@purvid.purchase.edu
Tel 914 271-5644
Fax 914 271-6188

USA Today Letter to the Editor

USA TODAY
December 20, 2000
Page 12A

Some health-insurance woes can be avoided.

The health insurance industry told the public and employers that they could provide medical care for less money, and many purchasers of medical-care insurance bought into that (”HMO: What happens after the Band-Aids run out?” Cover Story, News, Dec. 8).

What the insurance companies didn’t tell people about were the long waits for appointments, crowded waiting rooms, shortened hospital stays, delayed or limited specialist services and even actual denial of services and procedures.

Now that the insurers have squeezed the hospitals and doctors as much as they can, they are raising premiums. Medical costs are rising as medical technology improves and as the population ages and needs more medical care; but the insurance industry has cost burdens that can be avoided. Medicare operates at an administrative overhead of less than 3%. The time has come to get rid of the health-insurance industry, its multiple, redundant administrations, costly marketing, obscene executive salaries and the need for corporate profits.

By eliminating these expenses, this country could afford Medicare for all through a proven single-payer system. There would be a single set of rules to abide by. Everyone would have medical coverage, and patients would be able to choose any doctor or hospital they wanted to use.

Melvin H. Kirschner, M.D.
Family Practice
Van Nuys, Calif.

Dear Santa, Universal Healthcare this year, please?

By Joan Retsinas
The Progressive Populist

Dear Santa,

It’s time for my annual letter to you. Fresh from giving thanks for all the bounties of prosperity at Thanksgiving, I am compiling my wish list for more bounties. That is the schizoid nature of this season: gratitude followed by greed.

But I’m unabashedly making my same old request: universal health insurance — a one-card system that gives every American access to our wonderful doctors and hospitals (thank you for the wonderful doctors and hospitals). European countries have this. I want it too.

I know. I know. I’ve asked you for this before. In 1935. In 1946. In 1950. In 1965. Eight years ago. And each time I semi-graciously acknowledged that the time wasn’t right. In 1935 Social Security was a big enough holiday gift — the greediest citizen couldn’t expect you to tack on health insurance too. In 1946 you gave hospitals a mammoth boost with Hill Burton legislation — thanks to you, Congress pored millions of dollars into hospital construction throughout the nation. It was too much to expect, as some senators did, that you could give us a health insurance package too. In 1950 I put it on my wish list — you got President Truman to talk about it. But no go. In 1965 you gave us a partial gift — universal health insurance, but only for the disabled and elderly. Again, I’m grateful, but still want more. As for 1992, maybe the whole shebang — health insurance for everybody — was just too much to ask for. Greedy aspirants generally get coals in their stockings, don’t they? But it has been eight years, and I’m weighing back in with the same old same old.

This time you are my last recourse. I’ve given up on the new President — neither the Democratic nor the Republican candidate promised universal health insurance during their campaigns, and they promised lots of other goodies. Senator Bill Bradley, the only Presidential candidate to float a detailed proposal for national health insurance, didn’t survive the primaries. Congressional solons are not waxing hysterical about the persistent pool of people without insurance. Why should they? Our elected leaders all have health insurance by virtue of being in Congress. And all are wealthy enough to buy insurance on their own if their constituents dump them — a rare occurrence in American politicaldom.

So, Santa, I’m bringing my cause to you.

I know that most Americans have dropped “health care” from their annual wish lists. In a post-voting poll, a sample of voters named their key desire (aside from character, which the pollsters took off the table). Most (24%) want to save Social Security (though it is in no imminent danger); 23% care about education; 16% care about abortion; 13% about taxes, 12% about the economy (which — thank you — is roaring along superbly). Only 11% put “health care” at the top of their wish list; and some of them are asking you for prescription drug coverage.

But the 43 million of us who lack insurance are a tenacious lot. In general, we haven’t been especially good or especially bad this year — certainly not bad enough to end up waiting in hospital emergency rooms, hoping on the one hand that we are sick enough for somebody to look at us, hoping on the other hand that we aren’t truly that sick. We don’t deserve our plight. Most of us work, earning just enough to fall into that oxymoron category, “the working poor.” Either we have the bad fortune to work for employers who don’t offer health insurance as a fringe benefit. Or we can’t afford to buy the insurance that our employers do offer.

Santa, you have dropped “health care stuffers” into our holiday stockings in past year. We have COBRA, which lets us, or our families, buy insurance at our employer’s group rates if we leave the job. That helps — thank you — but few people can afford to pay even the group rates, especially people who have lost their jobs. Medicaid now enrolls children, and, in some states, their parents, whose income falls above strict Medicaid levels. That too helps. We have special funds to pay for breast cancer treatment for uninsured women diagnosed with breast cancer — again, thank you.

Those stocking stuffers, though, don’t suffice. We still want the whole shebang — a “health insurance card,” like the Medicare card all Americans get when they reach age 65. You can take back COBRA, Medicaid, and the special programs for special populations. We won’t need them anymore.

Sincerely,

An Ever-Believing Virginia

Joan Retsinas is a sociologist who writes about health care in Providence, Rhode Island.