PNHP

The State of Health Insurance in California: Recent Trends, Future Prospects

The State of Health Insurance in California: Recent Trends, Future Prospects

UCLA Center for Health Policy Research
March 2001

by E. Richard Brown, PhD, Ninez Ponce, PhD, & Thomas Rice, PhD

“The state’s strong economic growth has enabled more families and individuals to obtain job-based insurance, resulting in a lower uninsured rate for the first time in several years. But the future prospects for this trend continuing seem uncertain at best. The economy
appears to be cooling, accelerated in California by the energy crisis – a trend that may be undermining the major factor in the state’s recently expanding coverage. And there is clear evidence that health insurance premiums are going to rise by double digits in 2001, making health insurance coverage less affordable at the very time when the labor
market is likely to slacken. When the economy does contract and health insurance costs rise, more Californians will almost certainly become uninsured.”

“In the longer run, California and the nation need to extend to all residents affordable coverage that provides good access to high quality health care that enhances people’s health. Although there are costs to ensuring that all residents have coverage, there are great costs associated with a large portion of our population remaining uninsured – lost earnings, lost school days, lost potential, and lost life.”

The full report is available at:
http://www.healthpolicy.ucla.edu/FullReport.html

A Conservative Convert To Socialized Medicine by David Burgess

http://www.iht.com/articles/12871.html
http://www.commondreams.org/views01/0309-03.htm

PARIS – What’s the old joke? A conservative is a liberal who has just been mugged? Well, I am a conservative who has just been “mugged” by the socialized French health system, and, to my astonishment, I’m a believer. I have lived in France for nearly 19 years. Until about two years ago I was very cross about the amount I had to pay in taxes and in “social charges,” which finance the medical system, in which a pauper gets about the same medical care as a millionaire.

Let me take you quickly through my experience of being gravely ill in France.

For 20 years or so I had been a gobbler of antacids in one form or another, and in October 1998 I began to have trouble swallowing. I assumed it was an ulcer and took the appropriate medicine, but it didn’t go away. At the end of the year I was referred to a doctor who performed an endoscopy, in which, under anesthetic, a tube is inserted in the throat, allowing the doctor to have a look around and do a biopsy. He found that I had a malignant tumor at the base of my esophagus, where it meets the stomach, that had virtually closed the passage.

The doctor lost no time. He called my local hospital, which fortunately was one of the four in the Paris area that could do the operation that I needed, and reserved me a bed for the next day.

At the hospital, within an hour or two of my arrival, my surgeon, who has the title of professor, as he is head of the department of digestive surgery, paid me a visit. He outlined the operation I would have, and, in answer to my question, said the mortality rate for the kind of cancer that I had was about 85 percent within the first three years. But, he said, “Don’t worry, we’re going to beat it.”

Foolishly, I suppose, I believed him. Now, more than two years later, I still do; he has lots of charisma.

After my operation, which lasted more than 10 hours, I was in the hospital another three weeks, then home, where a nurse came by each day to give me the shots I needed, check and dress my surgical wounds and make sure that I wasn’t losing weight. Then back to the hospital for three days of chemotherapy every three weeks – four treatments in all.

I was operated on in mid-January 1999, went back to work part-time in mid-May, and returned to work full-time in September. (For those of you who are less than enthusiastic at the prospect of going to work in the morning, there is nothing like a serious illness to adjust your outlook.) Why does socialized medicine seem to work in some places and be a disaster elsewhere? Anyone who reads the British press is assaulted daily with tales of how cancer patients have to wait months for an appointment with an oncologist, or a candidate for a hip or knee replacement has to wait years. In France, such delays can be measured in days or, at most, weeks.

Why the difference? Take a deep breath. These are the numbers, provided by the French and British health ministries and translated into dollars (bear in mind that Britain and France have roughly the same populations). French total expenditure on health in 1999 was $109.5 billion. In Britain it was about $78.02 billion. Per capita, it was $1,800 in France and $1,312 in Britain. As a percentage of the gross domestic product, it was 8.5 percent in France and 5.9 percent in Britain.

I should mention that I am not yet out of the woods. My markers, blood tests that indicate the presence of cancer, started to rise last summer, and since the end of September I have again been in chemotherapy. The markers have dropped consistently, showing that the therapy is working. The treatment is debilitating. I expect to resume work part-time from April or May until the summer vacation, and full-time thereafter.

Last summer, I asked a friend of mine, a dean at a medical school in New England, what the cost of my care would have been in the United States. “About $700,000,” she said. I haven’t seen a bill. Well, that is not quite true. I got a bill for 43 francs (about $6.50). I’m not sure what it was for, but I paid it.

I no longer complain about my taxes.

Copyright © 2001 the International Herald Tribune

Bipartisan Paths to Expand Health Coverage: Prospects for 2001 and Beyond

February 27, 2001
Washington, DC

Gail Wilensky:

“… it doesn’t ignore the fact that making people more cost conscious, which I think Congressman McCrery, you ought to make sure is in every paragraph that you talk about your healthcare plan; it’s a very important issue that will drive change.”

Uwe Reinhardt:

“Whenever I hear cost-consciousness as an economist I ask myself — I read yesterday in ‘The Wall Street Journal’ that Paul O’Neill’s income last year was $56 million the Treasury’s Secretary. Now I ask myself, how do I want him to be cost conscious about healthcare? How do I do
that when the guy’s annual income is $56 million; what am I gonna charge, am I gonna charge 20 million for the bypass? Because that’s roughly what it would be to put him on power with the waitress, so when you say you want to make people more cost conscious you really should
speak plain English. You want to ration by income class.”

“So when you talk about cost consciousness, you’re really saying the lower middle class should get less healthcare, and maybe they should, but say so.”

Employers Say They Lack Data on Quality of Health Care

The Washington Post
March 8, 2001
by Bill Brubaker

Susan Pisano, a vice-president of the American Association of Health Plans:

“There is quite a lot of information that is available about the performance of America’s health plans.”

Comment: Unfortunately, most of the information currently available about the quality of health plans is of almost no value.

The majority of health plans are network model plans which contract with the health care providers at large. When quality parameters of different plans are measured, the same overlapping group of providers is being measured. When the same physician is being evaluated by each of the many plans with which he or she contracts, differences in sampling results have virtually no meaning.

The quality measurements designed by the health plan industry are usually designed to produce positive marketing messages. Patient satisfaction surveys are subject to the bias that, “Managed care is terrible overall, but I am very satisfied with my doctor and my health plan.”

Measurements of rates of favorable interventions, such as percentages of pap smears or retinal examinations in diabetics, have demonstrated that integrated staff model plans can improve the levels of these parameters
when compared to the loosely structured and overlapping network models. A deficiency of this approach is that providers are aware of the relatively few parameters that will be measured. The quality improvement programs are then often directed primarily to these very limited areas.

Other significant efforts are being made to improve quality assessment, and we will have better measurements. However, there is a much greater need to design a system that will promote quality in the first place. Although we have had many technological advances, measurements have shown that they have not had much impact in improving outcomes, compared to their cost, primarily because our system has been incapable determining and promoting the optimum use of this technology. Standards of practice vary tremendously between communities and between individual practitioners. Integrated staff model organizations have demonstrated that better standards of practice can be recognized and encouraged, and
errors, such as incompatible medications, can be greatly reduced. In this modern age of information technology we now have the opportunity to integrate our entire health care system. Structural design is the key
to quality. With a rational system in place, quality assessment can be elevated to a more noble purpose, and that is to provide a basis for continuing improvement in our health care structure.

As long as we continue with our fragmented health care system, quality improvement will remain only a dream. Let’s defragment our system by starting with a foundation of a publicly administered, universal risk pool. We have the resources for high quality care for everyone. Let’s start using our resources wisely.

Those who know how government works will reject universal coverage

American Medical News
Published by the American Medical Association
March 12, 2001
Letters to the Editor

Daniel Joyce, M.D., Niles, Mich.:

“… when the government provides something like health insurance to everyone, people tend to look at it as their right to health insurance versus appreciating the wonderful gift that is being provided to them. I see this all the time in the government programs. The people who are provided these wonderful things are often very ungrateful. If charitable organizations provide the same assistance out of the generosity of their heart, people then realize that it isn’t their right and appreciate the kindness as it should be appreciated.”

Comment: The American Medical Association professes to serve the public interest in health care matters. Its leadership could do that now by instructing its members on the basic fundamentals of health policy. But before that is possible, the leaders themselves will have to take a crash course in health policy to learn why tax credits and medical
savings accounts, which they support, will never serve the public interest. If the AMA would shift to advocating for patients instead of physicians, the organization would find that they would be supporting a practice environment that is in the best interests of both patients and physicians.

Following are the comments of Tom Mainor, pastor of the Shady Grove Presbyterian Church in Memphis, TN. He has served the Presbyterian Church USA in health care ministries and has a very strong background in health policy.

Needed: clarification of the nature of single payer approaches

Don, et. al.

I am convinced that the frequent caricature of the single payer health care financing as “government-run medicine” needs to be challenged on every level. It side-tracks and mis-describes the effect of a single payer approach.

For example, single payer approaches can involve multiple not-for-profit payer sources, such as Medicare/Medicaid, Blue Cross/Blue Shield, Tenn Care, and such efforts as the Mayo Clinic, Kaiser Permanente, Seattle Puget Sound and other regional or national efforts.

Using a regional budgeting approach, e.g. looking at the kind of services delivered by local and regional hospitals, a budget providing full funding for hospitals, minus the costs normally associated with collection and financing, would provide first rate care for a predetermined population. The hospitals would know what they would receive, receive incremental payments monthly for providing services, and thus be able to better serve the populations they have already been serving. The savings in billing costs and administrative costs could be re-directed into preventive health strategies…

Getting too detailed, but, for example, our MED, the regional hospital here–which not only serves western Tennessee, but also eastern Arkansas, northern Mississippi, the boot heel of Missouri and western KY–is frequently required to take in patients from those other jurisdictions in spite of the knowledge that, say, Mississippi will not reimburse the MED, the University of Tennessee or Tenn Care for the care. Because we are on the Mississippi, I-40/I-55, as well as being a major distribution center, we also have persons being served who come from far away. With regional funding, based upon patient load and acuity, such hospitals could render far better services.

My contention is that we spend far too much for health care without organizing it in such a way as to make the dollars make sense, health-wise. Regional strategies, tied in with revitalized health departments, NIH, the Centers for Disease Control, etc, would be
health-and-cost-effective. With the increase in global warming, the diseases such as West Nile Virus and expanding areas of malaria, AIDS, Ebola and others are going to require a much more effectively integrated health system to do the job that public health did in the early 1900s, in addition to providing the sophisticated technologies at reasonable prices.

We need to realize public profits on drugs that we helped fund, and the pharmaceutical industries charge excessively for. Brazil is an example, currently. The issue is also raising its head in southern Africa and else where.

Then, there is the fair return on investment on behalf of communities which have contributed the building of hospitals through a variety of means, including taxes. These are being bought up for a song by the health conglomerates to the detriment of many large and small community hospitals.

Health care is too important to the well-being of the nation to be left to the vagaries of the market place. It clearly does not increase services in places of greatest need. And the charges on advances in medical technology are outrageously high, and because of the paper trails created, there is rampant overcharging, duplication of charges and other waste.

I could go on. Sorry, didn’t mean to get wound up. But, clearly, there are many options out there beyond the current waste of precious lives and resources. Doctors ought to be able to treat patients according to medical standards, with hospital and peer review. Not second-guessed by someone at a health maintenance organization who gets rewarded for denial of care…

Thanks for the ventilation opportunity…

Tom Mainor

Subject: John Foster responds to John Gilman

Even the best and brightest don’t really get the skinny!

Spending more Federal dollars to “BUY SERVICES” simply invites drug companies and other vendors to get richer faster. Their prices will all go up.

But not in Medicare where the rules have evolved nicely over the many years, and cost increases have been moderate..

Only a single payer can control the cost of services, which is why, for example, Canadians get cheaper drugs.

Extending Medicare INCREMENTALLY would be a rational way towards a universal plan.

JOHN T. FOSTER(RETIRED ADMINISTRATOR)
Keene, NH

Subject: Susan Swan comments

Susan Swan, MSN, MPH, a Canadian, and currently a nurse practitioner in Atlanta, comments:

Re: Comments of Tom Mainor

In addition to Rev. Mainor’s comments I think it should be pointed out that the single payer system in Canada is not “government run”. Doctors are independent, fee for service practitioners. Hospitals are independently owned and operated – ie: we have Catholic hospitals, community hospitals, university hospitals etc. They are run by
voluntary boards of directors, not political appointee’s. Lastly, we have to ask the question “Why is the government inherently incompetent”? This “incompetence” arises from the nature of bureaucracy. Any large, multi-layered institution is going to be
inefficient, government or “private”. In fact, it is safe to say that most government bureaucracies pale in comparision to Blue Cross-Blue Choice’s or Kaiser Permanente’s of the world. The American myth that profit driven organizations are by nature well-oiled, finely tuned model’s of efficiency must be must be dispensed with. Every bit of evidence points to the contrary. Profits don’t influence efficiency and
have no place in healthcare.

Response of John Gilman, M.D., Health Policy Advisor to Senator Paul Wellstone:

“With this background, what are the current proposed solutions? Any form of universal, comprehensive reform is totally off the table.” — Don McCanne

Come on Don. Affordable universal health care may be off most of Washington’s radar screens, but not ours. Senator Wellstone, Congresswoman Tammy Baldwin, and Congressman David Obey (along with Reps. Conyers, Baca, Carson, and Filner) introduced the Health Security for All Americans Act last year and will reintroduce it again this Spring. This bill would assure that all Americans have affordable comprehensive health care within 5 years of its enactment. It is supported by APHA, Families USA, AMSA, and SEIU. No, it is not a national single payer bill; but it does set the national parameters that states must meet in terms of benefits, quality and affordability, and it provides matching federal funds (on average 70% federal, 30% state) to allow states to adopt the system of their choice, including single payer. This is a practical and principled approach that is capable of putting universal health care back on the table. It deserves attention
and support from anyone concerned about reaching universal coverage.

The Washington Post
March 6, 2001
“Bush Urges Congress to Revamp Medicare”

President George W. Bush:

“I believe the framework for a bipartisan consensus about how to make sure the Medicare system fulfills its promise is at hand, and we’ve got a lot of work to do.”

Comment: Medicare remains under intense attack. The Medicare “modernization” proposal of President Bush and the “bipartisan,” anti-government members of Congress is simply a proposal to shift more
of the costs of Medicare away from the tax system and onto the Medicare beneficiaries. The current out-of-pocket expenses already impair access to care for our moderately low income retired and disabled population, simply because of lack of affordability. The “premium support” or “competitive premium” proposal will compound this problem for these lower income individuals. We need to protect and improve Medicare. We should not support the “generosity” of our leaders who would like to use Medicare to provide additional grist for the middlemen vultures of the health plans. We need to remind our leaders that vultures don’t feed on
grist, they feed on carcasses.

Don McCanne
mccanne1@home.com

Drug access shouldn't be reliant on industry goodwill, but be ensured by law

Government is concerned that poor people’s access to quality medicines is dependent on the goodwill of individual industry players. With the Medicines and Related Substances Control Amendment Act of 1997 – now tied up in a court battle initiated by the pharmaceutical industry – government wants to ensure its ability to provide medicines for all, for ever.

The latest SA Health Review 2000 – launched last Thursday – confirms that drug expenditure puts an unsustainable burden on state coffers as the HIV/AIDS pandemic claims more and more victims, and contributes most significantly to the inequality in access to healthcare between the private and public sector. “Public sector sales are expected to make up 24%, which translates to R59.36 per person not belonging to a medical aid scheme.ÊIn contrast, the per capita expenditure on prescription drugs in the private sector would be R800.29,” according to the Review.

The total value of drug sales is anticipated to be R8.25 billion, according to figures released to the SA Health Review Team by the Pharmaceutical Manufacturers Association.

Background to the court case

Health Director-General Dr Ayanda Ntsaluba said in a press briefing at the weekend that he took part in the 1993 health expenditure analysis which found government was making a disproportionate allocation to drugs. This, says Ntsaluba, culminated in the now disputed Act.
In January 1998, Zuma met with the pharmaceutical industry, represented by the Pharmaceutical Manufacturers Association.

Government supports activists' role in court

The government on Monday expressed support for the Treatment Action Campaign becoming a party to the court case brought by pharmaceutical companies challenging legislation making provision for cheaper medicines.

“They have to deal with matters of life and death,” MTK Moerane, counsel for the government, told the Pretoria High Court.

“It would be an injury not to admit them.”

The Pharmaceutical Manufacturers’ Association has brought an application against the state in opposition of certain sections of the Medicines and Related Substances Control Amendment Act, which it says infringes on patent rights. The PMA is acting on behalf of about 40 local and international drug companies.

The TAC, a lobby group campaigning for equal and affordable access to Aids drugs, applied to join the case as a “friend of the court’ in support of the government.

Arguing in opposition to the TAC move, PMA counsel SA Cilliers said the court case was not specifically about access to medication for HIV or Aids patients.

At issue was the constitutionality of certain sections of the Act, not cheaper Aids drugs, he contended.

Judge President Bernard Ngoepe ruled that the PMA should go ahead with its arguments as if the TAC had been allowed to join the case.

The court was earlier adjourned for about 10 minutes due to repeated power failures. – Sapa

©2001. All rights strictly reserved.

Court hearing has global implications

AIDS Drug Test Case: World’s Pharma Unions Back South Africa

ICEM Update, No. 10/2001, 5 March 2001

Countries must have the right to buy AIDS medication at an affordable price.

That call was issued in Copenhagen this morning by the leader of trade unions in the world’s pharmaceutical industry.Ê

Fred Higgs, General Secretary of the 20-million-strong International Federation of Chemical, Energy, Mine and General Workers’ Unions (ICEM), was speaking as a crucial court case opened in South Africa today.Ê

Developing countries’ access to medication is at issue in the test case between the South African government and 39 big pharmaceutical companies.Ê

To protect their patents, the major drug corporations are asking the court to stop the implementation of a South African law aimed at providing cheaper medicines. The law would permit the country’s health minister to use parallel importation of drugs, compulsory licensing and generic substitution (cut-price “copy” drugs) where necessary.

Application of this Act has already been delayed for several years by the legal wrangles. The measure is particularly important to the fight against HIV/AIDS in South Africa, which has one of the world’s highest rates of HIV infection.Ê

“As part of the ICEM’s programme to combat HIV/AIDS, we believe that South Africa and other countries must have the right to buy the appropriate pharmaceuticals at prices that they can afford,” said Higgs this morning. He was in South Africa last week at an ICEM conference where African and Asian unions adopted a programme of action on HIV/AIDS.

“We hope that the South African courts will defend South Africa’s rights in this regard,” Higgs added. “We ask ICEM-affiliated unions to express their support for the South African government’s position.”Ê

ICEM affiliates include pharmaceutical workers’ unions worldwide.

Higgs was speaking at the congress of the ICEM-affiliated Danish Women Workers’ Union (KAD), which is celebrating its centenary this year. Over a thousand delegates are attending the congress.

Angry protests as companies start drug battle

The battle over South Africa’s medicine legislation came to a head on two fronts in Pretoria on Monday – in the city streets and in the High Court.

As angry words flew when protesters demanding cheaper drugs delivered a memorandum, the court heard in legal argument that the issue was not about affordable and accessible drugs.

The crux of the matter was the constitutionality of the Medicines and Related Substances Control Amendment Act of 1997, the Pharmaceutical Manufacturers’ Association (PMA) contended.

Representing about 40 local and international pharmaceutical companies, it wants the court to prevent the enforcement of the act.

‘You are treating us with contempt’ The PMA’s legal representative Fanie Cilliers SC said certain sections of the act were unconstitutional. They were also in breach of the Patents Act and the country’s international
obligations.

As the case got under way, thousands of protesters opposing the PMA court action gathered in Church Square about a block away.

The demonstration was organised by the Congress of SA Trade Unions, the Treatment Action Campaign (TAC), religious bodies and a range of other organisations.

After marching past the High Court building in Vermeulen Street, the protesters proceeded on a 5km walk to the United States embassy in Arcadia.

There they were upset when senior embassy official Robert Godec refused to walk through the crowd to receive a memorandum outlining their demands.

Cilliers opposed the joining of the TAC “You are treating us with contempt,” Cosatu president Willie Madisha told Godec.

Madisha later made a brief appearance in the courtroom, where Cilliers argued that a section of the act gave the health minister the power to render lawful what the Patents Act rendered unlawful.

Another section, which provided for compulsory substitution of scheduled medicines by generic drugs, could be dangerous, and was in breach of property provisions in law, as well as the constitutional rights of equality and freedom of expression, he said.

At the start of Monday’s proceedings, Cilliers opposed the joining of the TAC as “friend of the court” in support of the government.

M T K Moerane SC, for the government, expressed his support for the TAC joining them.

“We believe the clients they represent are at the sharp end of what we regard as the unreasonable conduct of the applicants. It would be an injustice not to admit them.”

Cilliers requested time to consult his clients. The judge ruled that the matter should continue in the meantime as if TAC had been allowed to join. – Sapa

©2001. All rights strictly reserved.

Thousands march against drugs multinationals

Thousands of protesters marched from Pretoria’s Church Square around 11am on Monday to the city’s High Court where they picketed to show support for the government in its court battle against the Pharmaceutical Manufacturers’ Association, a group which represents multinational drugs companies.

The pharmaceutical firms are approaching the court in a bid to stop the country importing cheaper generic medicines, including a cost-effective anti-AIDS “cocktail”.

The marchers, filling the length of an entire street block, marched down Church and Bosman Streets on their way to the court in Vermeulen Street.

They were led by Pretoria’s Catholic Archbishop George Daniel and Bishop David Beetge of the Anglican Church.

‘We cannot allow them to succeed’ Traffic officials, police and marshals were trying their best to keep the march orderly, and several city streets had been closed.

Before leaving Church Square, the protesters were led in prayer by religious leaders.

The marchers included members of the Congress of South African Trade Unions (Cosatu) , the African National Congress, the SA Communist Party, the Treatment Action Campaign, and other unions.

“We cannot allow them to succeed, and will continue our fight. If we don’t do that it means that we allow people to die,” Cosatu’s president, Willie Madisha, said at the march.

Should the drugs firms win the case, Cosatu would approach the National Economic Development and Labour Council to push for procedures allowing the union to “mobilise around this as a socio-economic issue,” he said.

Cosatu would also approach the Constitutional Court. – Sapa

©2001. All rights strictly reserved.

Low-cost insurance program can't keep healthy enrollment

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.