San Diego Union Tribune
March 4, 2001
by Susan Duerksen

“Despite intense efforts to get all eligible children covered by Healthy Families insurance, children are dropping out of the federal program almost as fast as they sign up.”

Comment: “Healthy Families” is California’s version of the State Children’s Health Insurance Program (S-CHIP). The leading proposals for incremental reform call for expanding eligibility under the S-CHIP program. In spite of significant efforts, California has fallen far short of being able to enroll all eligible individuals, and will never be able to because of the inherent nature of the administration of the S-CHIP program. The statement above suggests that California is approaching a steady state in enrollment, with children rotating in and
out of the program. Although S-CHIP should be supported as a temporary, urgent stop gap, it and all of the other incremental concepts can never address the real issues that face us. We have the resources to provide comprehensive care to everyone, but we have a system that is totally incapable of allocating our resources effectively. We will never have resolution of this issue until we make the decision to establish a publicly administered, universal risk pool.

San Diego Union Tribune
March 4, 2001
by Susan Duerksen

“Despite intense efforts to get all eligible children covered by Healthy Families insurance, children are dropping out of the federal program almost as fast as they sign up.”

Comment: “Healthy Families” is California’s version of the State Children’s Health Insurance Program (S-CHIP). The leading proposals for incremental reform call for expanding eligibility under the S-CHIP program. In spite of significant efforts, California has fallen far short of being able to enroll all eligible individuals, and will never be able to because of the inherent nature of the administration of the S-CHIP program. The statement above suggests that California is approaching a steady state in enrollment, with children rotating in and
out of the program. Although S-CHIP should be supported as a temporary, urgent stop gap, it and all of the other incremental concepts can never address the real issues that face us. We have the resources to provide comprehensive care to everyone, but we have a system that is totally incapable of allocating our resources effectively. We will never have resolution of this issue until we make the decision to establish a publicly administered, universal risk pool.

This message is about a very subtle yet crucially important topic. It is long because it cannot be stated in a few words. I saved it for Saturday, since some will have time during the weekend to read it.

The New England Journal of Medicine
March 1, 2001
“Health Policy 2001”
by R.J. Blendon, D.E. Altman, J.M. Benson, and M. Brodie

Quote from article, with footnotes:

“We believe there is a reasonable chance that legislation representing a compromise between the Bush and Gore positions can be enacted that will help 4 million to 10 million of the nation’s 43 million uninsured
persons receive coverage. Such legislation might make it possible for some employed but uninsured persons to obtain coverage through tax credits that would pay for part of the cost of private health insurance
policies. The availability of medical savings accounts might also be increased. In addition, self-employed persons might receive tax incentives to encourage them to purchase insurance. Complementing these
private-sector approaches would be an increase in funds for states to expand Medicaid coverage and the State Children’s Health Insurance Program for persons with low incomes. The states could be given greater
discretion in determining how these two federal-state programs would be structured and administered.”

Comment: No footnotes? What gives? This description af a political agenda for our health care system does not really need to be referenced with footnotes as long as it begins with, “We believe that…”

This quote is from the New England Journal of Medicine, a publication noted for its academic purity. The lead authors are Robert Blendon, Sc.D., Professor at the Harvard School of Public Health, and Drew Altman, Ph.D., President and CEO of the Kaiser Family Foundation, two of the most ethical and highly respected individuals that help to bring light on the problems inherent in our health care system. Let me state up front that in no way do I question the integrity of these icons for whom I have the most profound respect. I believe that the problem that I address is a very subtle one that has received very little consideration.

What is this that they state they believe? They believe that the leading proposals have a significant chance of enactment. They base their belief on scientifically valid surveys of the American public and on the opinion of those that now control the agenda by virtue of having been elected to office. These are very reasonable conclusions.

Robert Blendon and his colleagues have a well deserved reputation for capably assessing the opinions of the public on matters of applications of health policy. They and others have shown that Americans express
greater distrust in the ability of the government to meet our social needs, and that private solutions have increasing support. But Americans do believe that the government can have a significant role in meeting the needs of the more vulnerable members of our society.

With this background, what are the current proposed solutions? Any form of universal, comprehensive reform is totally off the table. It is nowhere in sight. Supporters of universal coverage such as Ron Pollack and Jim McDermott are now seeking solutions that are compatible with the background laid down by the studies of Blendon, et al. Ron Pollack of Families USA has joined with Chip Kahn of the Health Insurance Association of America to propose the Medicaid and S-CHIP expansions, along with tax credits, as mentioned in the “We believe” statement above. Democrat Jim McDermott and Republican Jim McCrery are proposing refundable tax credits as a compromise that might increase coverage of the uninsured.

There are serious problems with the proposals under consideration. Tax deductions and tax credits are not really health care legislation but really are tax proposals. Most of the benefit would accrue to those that already have health care coverage. Low income individuals do not benefit unless they are given a refundable tax credit that approximates the cost of health care coverage, an extremely unlikely prospect in the current political climate. Medical savings accounts are a favorite of conservatives since they benefit the healthy and wealthy, leaving out the sick and poor. Medicaid has been chronically underfunded and the S-CHIP program has Spartan benefits. Expanding these programs for low income individuals perpetuates muti-tiered health care. Legislation expanding the role of private health plans perpetuates the administrative waste and flawed health policy characteristic of these plans. Even if all of these proposals were adopted, at best we would still be leaving over three-fourths of the uninsured without coverage.

Every informed person agrees that we have enough resources to provide comprehensive care for everyone. A publicly administered, universal program would correct most of the defects in funding and allocating
health care In America. So why has this concept been totally rejected and kept out of public forums and press coverage of health care reform?

Simply, those that have control the agenda, whether the media, public forums, legislative hearings, or whatever, repeatedly cite the studies that show that Americans do not want the government involved in their
health care. Innumerable presentations in print, at forums, or wherever, specifically cite the Harvard University/Kaiser Family Foundation/Washington Post studies that confirm that concept. This perception is so pervasive that even Al Gore said, “We don’t want one-size-fits-all,” and Sen. Clinton supports the “small steps” of incrementalism. Consequently, all current proposals are limited to incremental expansions.

Although these polls demonstrate that anti-government rhetoric has permeated and molded the opinions of our society, do they show an accurate picture? Do Americans really want government out of their health care system? I often ask audiences, “How many here would like to see Medicare abolished and not replaced with any other program?” Rarely do any hands go up. If Medicare had been established as a universal program, I sincerely believe that the support would be the same, considering the great resources that we have that would be available to everyone.

When issues are carefully explained, then individuals make decisions based on their values rather than on the rhetoric. Unfortunately, the nation is poorly informed on the real issues involved. For instance the NEJM article contained the statement, “Two thirds or more of both Republicans and Democrats favor the use of tax credits to help the uninsured buy private health insurance.” This response is expected. It really sounds like a good idea. But suppose, before you ask that question, you explain the issue. You point out that a tax credit proposal will have to be a bipartisan compromise. The Democrats will prevail in seeing that the tax credit is refundable so that it will provide cash to the low income individual to enable the purchase of health care coverage. The Republicans will prevail in insisting that the amount of the credit will be modest because “we cannot afford to pay for” a generous tax credit. Studies have confirmed that such a proposal will not be adequate to make coverage affordable for most of the uninsured, but it will provide a tax subsidy for the more affluent who already have insurance. Now, let’s ask a more accurate question. Instead of asking, “Do you favor the use of tax credits to help the uninsured buy private health insurance?”, let’s ask, “Do you favor the
use of tax credits for purchasing private health insurance, a proposal that would provide a generous tax subsidy for the more affluent, and might allow a very limited number of lower income individuals to
purchase insurance?” I believe that the results would have been dramatically different. A very important question that we should ask ourselves is whether we should consider the opinions of Americans when
we make policy decisions, if those decisions are going to be based on perceptions of rhetoric rather than on a clear understanding of the fundamental issues involved.

The concept that I want to make clear is that these studies do not only show us where Americans believe they stand on health care reform, but they are also driving the political agenda for reform. I emphasize that
that these are opinions on where Americans believe they stand, but they are not opinions on where they would stand if they understood the full implications of the policy behind the rhetoric. The rhetoric is even influencing the pollsters. They are asking questions about private versus government. Is Medicare private or government? It is a publicly funded program that uses the private and public health care delivery
system. Such dual choice questions are frequently inappropriate.

The Harvard/Kaiser/WP poll asks, “Do you favor a national health plan, financed by taxpayers, in which all Americans would get their insurance from a single government plan?”. There are many problems with the
phrasing of this inquiry, but the term “government” assures a negative response, based on reflexive rejection of the rhetorical implications, but not based on a comprehensive knowledge of the policy issues involved. Indeed, this one question has been used repeatedly to support the position that Americans do not want national health insurance (even though they do support Medicare.) It is being used to keep the consideration of comprehensive reform off of every agenda.

Polls could be designed that would ferret out the true values of Americans. Those are the polls that should be used to establish policy. The current polls, which are based more on rhetoric, are being used by each interest to further their own political agendas. In the case of health care, they are being used to dismiss, without
consideration, a rational, ethical approach to reform: a publicly administered, universal risk pool. In reforming health care, we need to understand the position of Americans, but their position on their values, not on their rhetoric.

Don McCanne
mccanne1@home.com

Ventura County Star
March 1, 2001

“Thousand Oaks-based Blue Cross of California announced a program this week aimed at enabling small businesses to subsidize employee health care coverage at defined rates.”

“Under the program, employers pay a fixed dollar amount per employee per month toward the cost of health care coverage. Employees are responsible for costs above the employer’s contribution.”

Comment: So Blue Cross is creating a program that will make employee health insurance affordable for small employers who cannot afford (or have elected not to pay for) the costs of existing health plans. But what is happening here?

Blue Cross is the largest and one of the most successful insurers in California. They often set trends in insurance coverage. This plan is the first one of this nature, but we can expect other companies to follow.

Since the premium paid by the employer is the same for each employee regardless of age, number of dependents or other risk factors, this is a DEFINED CONTRIBUTION proposal. The dollar amount set by the employer will be as little as $80 per employee. Each employee can then chose from a menu of Blue Cross plans, the higher the level of benefits, the more expensive the plan. The greatest defect with defined contribution plans is that low income employees will be able to afford only bare bones coverage if even that. Defined contribution plans inevitably result in multiple tiers of health care, boutique medicine for high
income individuals and limited access and impaired outcomes for those with lower incomes.

Blue Cross, since converting to a for-profit company, has refined its business models for coverage. The traditional concept of a defined contribution plan is to allow the employee a given amount of funds to be used to select from a wide variety of health plans in the marketplace. Blue Cross has figured out a way to capture this under-served market by offering employers the advantage of a fixed contribution plan, but, at the same time, locking the employees into a menu of plans offered only by Blue Cross. Employers can assuage their guilt at a low cost,
employees will get only mediocrity but with significant out-of-pocket expenses, and Blue Cross will walk away with the dough.

Isn’t it time that we dump these marketplace health plan parasites, and replace them with a publicly administered, universal risk plan?

The Economic Policy Institute
Paycheck Economics, Vol. 1, No. 4

“One attractive option that could provide insurance to the uninsured while maintaining high-quality care for those who have insurance is to expand Medicare to the entire population. The Medicare benefits package would first need to be fully modernized to include prescription drugs, preventive care, improved mental health and substance abuse services, and better cost sharing.

“There are advantages to this plan besides providing universal high-quality care. Having Medicare as a single insurer or “single payer” would greatly streamline the paperwork done by physicians, hospitals and other providers. Multiple investigators, from experts at the U. S. General Accounting Office to professors at Harvard University, have estimated that these savings would pay all the costs of providing insurance to the 44 million Americans without it.

” Not only would it be more efficient, but such a system would also help keep costs low, thus slowing the growth in future health care spending overall. An enhanced Medicare program for all Americans -“Medicare for All” – is the best way to provide universal high-quality health care.”

Note: This excellent eight page analysis of Medicare explains the program, its problems, wrong solutions such as HMOs and vouchers, and the “right regimen for healing Medicare.” It can be downloaded at: http://www.epinet.org/Paycheck/medicare.pdf

The New York Times
February 28, 2001
Letters

Re “Governors Offer ‘Radical’ Revision of Medicaid Plan” (front page, Feb. 26):
As it now stands, the vast majority of the nation’s physicians do not accept Medicaid clientele because the fee structure does not begin to cover office overhead. When about $50 per visit is needed to allow just for rising malpractice insurance premiums and about $12 is issued by Medicaid per visit, the arithmetic is revealing. Thus, the Medicaid recipients end up, if anywhere, in public hospitals or so- called Medicaid mills with lesser facilities and substandard care.

The United States remains the world’s only industrial power without a universal health care plan. Manipulating the same inadequate Medicaid budget to cover more people with lesser reimbursements is pointless. The answer is making health care a right instead of a privilege.

DON SLOAN, M.D.

New York, Feb. 26, 2001

The Medicare Modernization and Solvency Act of 2001

In the current political climate comprehensive reform will not be on the agenda. Instead, attempts will be made to reduce support of existing programs, especially Medicare. We need to protect Medicare and improve the benefits offered.

Today, the Ways and Means Health Subcommittee held a hearing on Medicare reform. To provide an alternative to proposals that would threaten Medicare, Congressman Stark has introduced The Medicare Modernization and Solvency Act of 2001. It would expand benefits, control out-of-pocket expenses, and assure solvency of the program. It is not perfect, but it is vastly superior to other current proposals.

A summary of the bill:
http://www.house.gov/stark/documents/107th/medreformsumm.html#Anchor-47857

Judith Feder, Ph.D., Professor and Dean of Policy Studies, Georgetown University, in testimony before the committee today, presented an approach to protecting and improving Medicare based on sound policy.

Her testimony should be downloaded and saved, and should be used as an educational resource to provide guidance on rational Medicare reform.
It is available at:
http://waysandmeans.house.gov/health/107cong/2-28-01/2-28fede.htm

A Conference Sponsored by The Annenberg Public Policy Center of the University of Pennsylvania and The Atlantic Monthly
February 27, 2001
“Bipartisan Paths to Expanded Health Coverage: Prospects for 2001 and Beyond”

Hon. Jim McCrery (R-LA):

Regarding explaining health care reform to audiences:
“The easiest one to explain would be a single payer system. It makes a lot of sense.”

Regarding covering the uninsured:
“The single payer system solves that problem. It covers everyone.”

Regarding employer health plan costs:
“It solves that problem because you don’t have to pay for it anymore, as an employer. The government pays for it.”

Comment: This conference was to introduce the McDermott-McCrery concept of tax credits as a possible bipartisan solution to covering the uninsured. It was clear that major problems with this proposal have not been resolved, and probably will not be. Remarkable to me was the fact that Jim McCrery, a conservative Republican, repeatedly made references to the great strengths of the single payer proposal. He seemed to be convinced that, if we do not take some other urgent action, then we will end up with “more government control with a single payer system.” So it is the perfect system except that the government is in charge. Can someone explain to him that publicly administered systems, such as Medicare, are vastly more efficient than are the middleman, marketplace health plans? Doesn’t that mean that single payer is as close to perfect as is possible?

The two hour conference included Jim McDermott, Jim McCrery, Matt Miller, Uwe Reinhardt, Judy Feder, and Gail Wilensky. It can be viewed at your convenience at:
http://www.kaisernetwork.org/healthcast/annenberg/feb01

Don McCanne
mccanne1@home.com

Uwe Reinhardt:

If anyone would like to take me on in a debate “RESOLVED: THAT U.S. HEALTH CARE OF THE 1980s WAS BETTER THAN US HEALTH CARE OF THE 1990s,” I’ll gladly take the negative of the debate, because I love to win debates, and this one I would win hands down. My opponents would not even have a fighting chance. Any takers? Try me and make my day!

Response of Bob LeBow, Past-President of PNHP:

What Uwe is saying reminds me very much of the feeling I have when I deal with issues at the Idaho State Legislature (and behind the scenes with the lobbyists). The Good Old Boys know they have the decisions sewn up. They talk a good line sometimes, but the deals have been made (or bought or traded) off the record. There’s a certain smugness, a mutual backscratching fraternity of the moneyed interests, a shaking of the head when the people doing the nodding really know that there is another, already decided (and likely paid-for) agenda. Yet it has been possible to get some change into the system…some issues cry out for change. Unfortunately, health care reform is so complex and easily thwarted by a few million dollars spent to create doubt. I think many of us, “dreamers that we are,” feel its our mission to do the best we can, and fight on, to get the best deal we can get for our patients, especially those most excluded from our health care system in the larger sense. There’s no doubt campaign reform would help, may even be a sine qua non of meaningful reform. I will continue to dream on, despite –maybe in spite of — Uwe’s gloomy prediction.

As for Uwe’s challenge on the 80s vs. the 90s, I would respond that it’s a mixed bag. It depends on from whose viewpoint you’re looking. From the viewpoint of people with “regular” insurance, it has to be worse in the 90s.The 90s had higher deductibles and co-pays, less choice of physician, worse continuity of care, more fragmented care, more feeling of being rushed in the doctor’s office. On the other hand, in the 90s we had improved technology, better drugs, shorter hospital stays (sometimes worse, but usually not), probably an improvement in the scientific basis of care (the good side of managed care), and (likely) fewer unnecessary procedures. For the uninsured, I have seen continuing gloom and chaos –generally toward the negative side as there was less room for cost shifting to charity care. I have a much more difficult time now getting managed-cost squeezed specialists to see my uninsured patients. Our Community Health Center funding stayed static despite the demand to see growing numbers of uninsured patients. Of course, the number of uninsured grew in the 90s. And our low-income elderly patients with Medicare have seen a double-edge sword effect in the transition from the 80s to the 90s: they have much greater out-of-pocket costs for drugs and insurance premiums (and are poorer in that sense) but (the other side) the technological advances have made their lives much more enjoyable — when they can afford these wonders. I see many more “injustices” of the system now than I did 10 years ago — perhaps because of the increasing complexity of the system…especially for patients. From the physician’s viewpoint, the 80s had to be better than the 90s, but for me, at least, I’m trying to look primarily from the vantage point of the patient. So I guess I would answer Uwe’s challenge by expressing (as outlined above) my feeling that there are pluses and minuses comparing the 80s to the
90s, but on my balance, the minuses of the 90s outweigh the pluses. It would be great to see Uwe’s arguments on why American health care is better in the 90s than the 80s. Maybe he can convince me, but I’d be willing to wager one meal at a for-profit hospital of the winner’s choice…

Joanne Landy, Executive Director Physicians for a National Health Program-NYC
Responding to Reinhardt and LeBow – Health care better in 80s or 90s?

Whether the healthcare system was better in the 80s or the 90s–this is not really the issue. Both decades were unacceptable, though, as Bob LeBow outlines, unacceptable in different ways, and in both decades with occasional rays of light peeking through the clouds. What we need is a decent universal health care system for the 00’s that’s publicly and fairly financed; what we don’t need is a sterile debate devoted to choosing between evils.

Jeannie Brewer, board member of California Physicians Alliance responds:

My 2 cents:

Well, for the uninsured and the uninsurable, both decades (80s and 90s) were bad and so are the 2000’s.

Jeannie Brewer, M.D.
among the ranks of the uninsurable

Don’s comment: You know we have a very sick health care system when a young physician, fellow CaPA board member Jeannie Brewer, is uninsurable because of a serious medical disorder.