PNHP

Francis Fukuyama on the decline of the middle class

Francis Fukuyama on the decline of the middle class

The Future of History: Can Liberal Democracy Survive the Decline of the Middle Class?

By Francis Fukuyama
Foreign Affairs, January/February 2012
Something strange is going on in the world today. The global financial crisis that began in 2008 and the ongoing crisis of the euro are both products of the model of lightly regulated financial capitalism that emerged over the past three decades. Yet despite widespread anger at Wall Street bailouts, there has been no great upsurge of left-wing American populism in response. It is conceivable that the Occupy Wall Street movement will gain traction, but the most dynamic recent populist movement to date has been the right-wing Tea Party, whose main target is the regulatory state that seeks to protect ordinary people from financial speculators. Something similar is true in Europe as well, where the left is anemic and right-wing populist parties are on the move.
The Absent Left
One of the most puzzling features of the world in the aftermath of the financial crisis is that so far, populism has taken primarily a right-wing form, not a left-wing one.
In the United States, for example, although the Tea Party is anti-elitist in its rhetoric, its members vote for conservative politicians who serve the interests of precisely those financiers and corporate elites they claim to despise. There are many explanations for this phenomenon. They include a deeply embedded belief in equality of opportunity rather than equality of outcome and the fact that cultural issues, such as abortion and gun rights, crosscut economic ones.
But the deeper reason a broad-based populist left has failed to materialize is an intellectual one. It has been several decades since anyone on the left has been able to articulate, first, a coherent analysis of what happens to the structure of advanced societies as they undergo economic change and, second, a realistic agenda that has any hope of protecting a middle-class society.
The main trends in left-wing thought in the last two generations have been, frankly, disastrous as either conceptual frameworks or tools for mobilization. Marxism died many years ago, and the few old believers still around are ready for nursing homes. The academic left replaced it with postmodernism, multiculturalism, feminism, critical theory, and a host of other fragmented intellectual trends that are more cultural than economic in focus. Postmodernism begins with a denial of the possibility of any master narrative of history or society, undercutting its own authority as a voice for the majority of citizens who feel betrayed by their elites. Multiculturalism validates the victimhood of virtually every out-group. It is impossible to generate a mass progressive movement on the basis of such a motley coalition: most of the working- and lower-middle-class citizens victimized by the system are culturally conservative and would be embarrassed to be seen in the presence of allies like this.
****
Elites in all societies use their superior access to the political system to protect their interests, absent a countervailing democratic mobilization to rectify the situation. American elites are no exception to the rule.
That mobilization will not happen, however, as long as the middle classes of the developed world remain enthralled by the narrative of the past generation: that their interests will be best served by ever-freer markets and smaller states. The alternative narrative is out there, waiting to be born.
(Francis Fukuyama is a Senior Fellow at the Center on Democracy, Development, and the Rule of Law at Stanford University.)
http://www.foreignaffairs.com/articles/136782/francis-fukuyama/the-future-of-history

In this essay, Francis Fukuyama describes the historical background of the middle class, bringing us to the troublesome present in which the stability of the middle class is in question. He suggests that we need a new political and economic ideology that “could provide a realistic path toward a world with healthy middle-class societies and robust democracies.”
The views of Fukuyama are not without controversy. Indeed, he has changed his own views over time (e.g, his views on neoconservatism and the Iraq invasion). Nevertheless, his writings are quite provocative and are helpful in broadening conceptualizations of societal problems and their potential solutions.
It is difficult to provide enough content in a few excerpts to provoke gainful contemplation on how we should approach the middle-class crisis – a crisis which is important to understand if we ever hope to ensure health care justice for all. For that reason, the entire article should be downloaded, savored and shared. Although Foreign Affairs charges $2.95 for the article (link above), this one is worth giving up today’s latte.
When you read it, consider what you already know in disciplines such as economics, political science, and sociology, but do not be bound by them in your contemplation. We have to get beyond simplistic, rigid analyses such as boxing solutions into either a government approach or a private market approach. That type of thinking has resulted in our polarized political gridlock that has prevented us from moving forward with health care reform that would best serve not only the middle class, but everyone.
Think in the broadest terms about what new political and economic ideology might lead us in the right direction. According to Fukuyama, “The alternative narrative is out there, waiting to be born.”
Fukuyama is famous for proposing that liberal democracy represents “The End of History” but not the end of events. Let’s see if we can create the events that would make our democracy work for the betterment of us all, by contemplating “The Future of History” and then acting on our thoughts.

Insurers Profit From Health Law They Fought

Insurers Profit From Health Law They Fought

By Sarah Frier
Bloomberg, January 5, 2012

Insurance companies spent millions of dollars trying to defeat the U.S. health-care overhaul, saying it would raise costs and disrupt coverage. Instead, profit margins at the companies widened to levels not seen since before the recession, a Bloomberg Government study shows.

Insurers led by WellPoint Inc. (WLP), the biggest by membership, recorded their highest combined quarterly net income of the past decade after the law was signed in 2010, said Peter Gosselin, the study author and senior health-care analyst for Bloomberg Government. The Standard & Poor’s 500 Managed Health-Care Index rose 36 percent in the period, four times more than the S&P 500.

“The industry that was the loudest, most persistent critic of this law, the industry whose analysts and executives predicted it would suffer immensely because of the law, has thrived,” Gosselin said. “There is a shift to government work under way that is going to represent a fundamental change in their business model.”

The report compares the 18 months before and after the overhaul became law, Gosselin said. The companies studied are Wellpoint; UnitedHealth Group Inc. (UNH), of Minnetonka, Minnesota; Aetna Inc. (AET), of Hartford, Connecticut; Humana Inc. (HUM), in Louisville, Kentucky; and Philadelphia-based Cigna Corp. (CI)

The companies saw their average operating profit margins expand to 8.24 percent in the six quarters since the overhaul became law, compared with 6.88 percent for the 18 months before it was passed.

Commercial business now accounts for less than half of the companies’ combined revenue for the first time in at least two decades, according to the study. That’s partly a result of the companies’ growing investments in plans that provide services to Medicare and Medicaid patients, the report said.

http://www.bloomberg.com/news/2012-01-05/health-insurer-profit-rises-as-obama-s-health-law-supplies-revenue-boost.html

The full text of the report:
http://media.bloomberg.com/bb/avfile/r5leWxypfaX4

Peter Gosselin discusses his report, “Despite Predictions, Health Insurers Prosper Under Overhaul” (5 minute video):
http://www.youtube.com/watch?v=4rMOz5E5Du8

Comment:

By Don McCanne, MD

Peter Gosselin’s Bloomberg Government report, “Despite Predictions, Health Insurers Prosper Under Overhaul,” is further confirmation that, as long as we leave the private insurers in charge, they will always find a way to stick it to us, as we now witness a dramatic increase in insurers cornering taxpayer-financed health insurance programs – Medicare and Medicaid – not to mention the private plans that taxpayers purchase for government employees on all levels.

These trends are very healthy for the private insurance industry, but they’re enough to make us sick.

Crowdfunding for medical expenses in U.S.

With medical expenses the leading cause of personal bankruptcies in the United States, an increasing number of desperate Americans are turning to websites to raise money to pay for medical bills of relatives and friends

By Julia Sisler
CMAJ (Canadian Medical Association Journal), Jan. 5, 2012

Forget about fundraising with signs and spaghetti dinners. When a friend or relative needs help paying medical bills, many Americans are turning their social network into a safety net through a growing number of online fundraising platforms.

But some observers say these websites are a symptom of the failing health care system in the United States — and hardly a solution.

Websites like GiveForward, IndieGoGo, GoFundMe and YouCaring have been launched in the U.S. over the past five years. GiveForward is the only site primarily focused on medical campaigns, and co-founder Ethan Austin says he’s seen people raise US$50,000 in a day.

“This is such a gigantic need, we didn’t really anticipate how big it was,” he says.

The concept is an extension of community fundraisers often held when people get sick. The websites help users connect their campaign to social media like Twitter and Facebook to solicit donations from family, friends and even strangers. It’s a kind of “crowdfunding” — where many people chip in to fund a cause or project — that took off on sites like KickStarter for entrepreneurs. Most crowdfunding sites take a percentage of the money raised by each campaign, usually between 3 percent and 7 percent.

Since its launch in 2008, GiveForward campaigns have raised over US$8.8 million, and about 7,600 campaigns have been completed, Austin says. Other fundraising sites accept campaigns for categories such as tuition, mission trips, start-ups or art projects. But at GoFundMe, the largest percentage of campaigns are health-related, and at YouCaring the majority of donations are in the area of medical expenses, according to their founders.

Austin says the popularity of these websites shows how desperate many Americans are when a relative or friend gets sick. “People don’t want to be seen as a charity case. But we’re all in the same boat, unless you’re Warren Buffett or Bill Gates or someone who’s mega-rich, we all could use a little extra help when someone gets sick.”

Medical expenses are the leading cause of bankruptcy in the United States, according to a study that indicated about 62 percent of personal bankruptcies in 2007 were reportedly due to medical bills, even though most of those people had insurance — up from about 46 percent in 2001 (Am J Med 2009;122[8]:741-46).

The average amount of money raised for a GiveForward health campaign is US$2,650, though some have topped US$80,000.

Ultimately, the growth of these websites is sad, but not surprising, given that simply tens of millions of Americans don’t have insurance, says Dr. Ida Hellander, director of health policy for the Physicians for a National Health Program, a nonprofit organization which advocates for universal health care.

“I wouldn’t even say it’s a band-aid — it’s sort of a desperate attempt to help a few people,” she says. “It shows how desperate people are, and it shows the magnitude of the crisis and the fact that the political will is not there to help people.”

Many Americans are driven to fund-raise on the Internet because they do not have, or have inadequate, health insurance, she says. “It’s certainly no solution, and it’s probably not even a solution for the person raising the money — it just might help with this week’s bill.”

Many of the campaigns on GiveForward and other sites appear to be aimed at generating funds for an emergency, a specific treatment or recommended diagnostic tests. Rarely do they appear aimed at chronic illnesses or long-term care.

The growth of crowdfunding sites points to the need for a broader cultural change in America than is possible through the use of crowdfunding, Hellander adds. “It reflects the unethical and immoral health care system that pushes its citizens to have to essentially beg for money on the Internet.”

Others are concerned about the impact Internet fundraising will have on the U.S. health care system.

It could slow progress toward a solution, says Rebecca Dresser, Daniel Noyes Kirby Professor and professor of ethics in medicine at the Washington University Law School in St. Louis, Missouri. “You might say to the extent it [a fund-raising website] relieves the burden, it takes pressure off society and people in government to have a more effective health care system.”

Crowdfunding sites should raise questions, like any decision about giving money, Dresser contends. True friends are different than Facebook friends, she points out, and you should trust that your money will go towards a real medical condition before donating. “If you’re trying to use your resources wisely, you should think about — what are alternative beneficiaries of my money? … Do I trust this person? I would want to find out — what is your medical situation? What has the doctor recommended?”

There is always the possibility of abuse of Internet fundraising, as evidenced by the case of Ashley Kirilow of Burlington, Ontario, who in 2010 faked having cancer and used a Facebook page to help raise thousands of dollars.

But Austin says there’s only been one case of fraud at GiveForward in the past three years, and the site holds donations in an escrow account until a campaign is over, so staff have time to investigate questionable Web pages and return monies to donors if necessary. Other websites forward monies to the recipient as soon as they’re raised but encourage users to identify and flag suspicious campaigns.

Dresser suggests it might be more effective to donate that money to a registered charity or a nonprofit group that has a systematic way of distributing funds.

DOI:10.1503/cmaj.109-4084

Julia Sisler, is based in Ottawa, Ont., Canada.

http://www.cmaj.ca/site/earlyreleases/5jan12_crowdfunding-for-medical-expenses.xhtml

Single-payer for all

By Nicholas Anton, M.D.
Letters, The Press Democrat (Santa Rosa, Calif.), Jan. 4, 2011

The Ryan-Wyden proposal to fix Medicare, which your editorial supported as a “bipartisan” solution (“A bipartisan take on fixing Medicare,” Saturday), is far from the “good” that is the “enemy of the perfect.”

Competition in the health insurance market already exists for those less than 65 years old, and it has done nothing to lower costs. Private for-profit insurance companies do have “systemic inefficiencies” (15 percent to 20 percent overhead) “that contribute mightily to rising costs.” Those same insurance companies fought aggressively to keep the public option (read Medicare for those under 65) out of the Affordable Care Act knowing they couldn’t compete with it.

Fraud and abuse, high prices, payments for unnecessary and ineffective treatments and medical malpractice all contribute to rising costs. Only a single-payer system for all has the clout to address these issues while lowering costs and improving quality.

Senate Bill 810, currently working its way through the legislative process, would provide such a system for all Californians.

Dr. Nicholas Anton resides in Santa Rosa.

http://www.pressdemocrat.com/article/20120104/OPINION/120109829

Insurers Profit From Health Law They Fought

Insurers Profit From Health Law They Fought

By Sarah Frier
Bloomberg, January 5, 2012
Insurance companies spent millions of dollars trying to defeat the U.S. health-care overhaul, saying it would raise costs and disrupt coverage. Instead, profit margins at the companies widened to levels not seen since before the recession, a Bloomberg Government study shows.
Insurers led by WellPoint Inc. (WLP), the biggest by membership, recorded their highest combined quarterly net income of the past decade after the law was signed in 2010, said Peter Gosselin, the study author and senior health-care analyst for Bloomberg Government. The Standard & Poor’s 500 Managed Health-Care Index rose 36 percent in the period, four times more than the S&P 500.
“The industry that was the loudest, most persistent critic of this law, the industry whose analysts and executives predicted it would suffer immensely because of the law, has thrived,” Gosselin said. “There is a shift to government work under way that is going to represent a fundamental change in their business model.”
The report compares the 18 months before and after the overhaul became law, Gosselin said. The companies studied are Wellpoint; UnitedHealth Group Inc. (UNH), of Minnetonka, Minnesota; Aetna Inc. (AET), of Hartford, Connecticut; Humana Inc. (HUM), in Louisville, Kentucky; and Philadelphia-based Cigna Corp. (CI)
The companies saw their average operating profit margins expand to 8.24 percent in the six quarters since the overhaul became law, compared with 6.88 percent for the 18 months before it was passed.
Commercial business now accounts for less than half of the companies’ combined revenue for the first time in at least two decades, according to the study. That’s partly a result of the companies’ growing investments in plans that provide services to Medicare and Medicaid patients, the report said.
http://www.bloomberg.com/news/2012-01-05/health-insurer-profit-rises-as-obama-s-health-law-supplies-revenue-boost.html
The full text of the report:
http://media.bloomberg.com/bb/avfile/r5leWxypfaX4
Peter Gosselin discusses his report, “Despite Predictions, Health Insurers Prosper Under Overhaul” (5 minute video):
http://www.youtube.com/watch?v=4rMOz5E5Du8

Peter Gosselin’s Bloomberg Government report, “Despite Predictions, Health Insurers Prosper Under Overhaul,” is further confirmation that, as long as we leave the private insurers in charge, they will always find a way to stick it to us, as we now witness a dramatic increase in insurers cornering taxpayer-financed health insurance programs – Medicare and Medicaid – not to mention the private plans that taxpayers purchase for government employees on all levels.
These trends are very healthy for the private insurance industry, but they’re enough to make us sick.

Enhancing physician recruitment for rural hospitals

Increasing Graduate Medical Education (GME) in Critical Access Hospitals (CAH) Could Enhance Physician Recruitment and Retention in Rural America

By Imam M. Xierali, PhD, Sarah A. Sweeney, BS, Robert L. Phillips Jr., MD, MSPH, Andrew W. Bazemore, MD, MPH and Stephen M. Petterson, PhD
Journal of the American Board of Family Medicine, January-February 2012

Critical Access Hospitals (CAHs) are geographically isolated, small rural hospitals that are typically the sole source of care for their community, providing not only acute care but a broad spectrum of basic health services. There was a robust increase of CAH designations from 50 in 1998 to 1,310 in 2009.

Rural communities struggle to recruit and retain health care providers. In 2008, 81% of rural counties were or contained areas designated as Primary Care Health Professional Shortage Areas. Encouraging evidence shows that residents trained in a rural setting are much more likely to continue to serve in rural or underserved settings. Analysis of Medicare hospital cost report data suggests that very few CAHs ever have reported intern and resident training. As rural hospitals and as hospitals without prior graduate medical education (GME) programs, CAHs are eligible for starting or becoming funded members of GME training programs.

Increasing the capacity for CAHs to create and expand training programs could improve access to care in rural communities and strengthen existing rural training programs, many of which are threatened or closing. Recent policies promoting primary care training, such as the teaching health center program, also mean opportunity for CAHs to play an important role in GME expansion. Though this role for CAHs requires no legislative changes, CAHs will face additional hurdles related to accreditation and staffing.

http://www.jabfm.org/content/25/1/7.full

And…

Critical Access Hospital (CAH) Graduate Medical Education (GME): Too Little, and Maybe Too Late

By Frederick M. Chen, MD, MPH
Journal of the American Board of Family Medicine, January-February 2012

In the context of national scrutiny on graduate medical education (GME) from both the Medicare Payment Advisory Commission and the Joint Select Committee on Deficit Reduction, Xierali et al, bring our attention to the ongoing needs of rural underserved communities and the potential role of critical access hospitals (CAHs) in training the rural physician workforce. Their analysis demonstrates the minuscule number of CAHs that have reported resident training within their walls. The literature shows that physician training in rural settings is successful in producing rural physicians but also is endangered with the number of rural training tracks and rural residencies in free-fall over the past 10 years.

Although CAHs may be an untapped resource for GME, there are significant barriers to their success. Xierali et al point out the challenges of accreditation and staffing. CAHs, like RTTs, are by definition located in small communities that tend to be under-resourced for physician faculty and other medical education needs. Often the loss of a single physician in these settings results in the loss of the training site.

Financing is always an important consideration. Though CAHs may be eligible for Medicare GME payments because they are free of the resident cap, many CAHs have a low percentage of Medicare inpatients, resulting in payments that are insufficient to cover the costs of residency training. On the other hand, this has not precluded urban hospitals from claiming the time that residents spend in CAHs. Though this enables some residency training time in CAHs, the flow of funds, if any, from the urban hospital to the CAH is unknown, except to hospital financial officers.

Enabling and encouraging more residency training in rural settings is a priority if rural communities are to have adequate access to health care. New training models that encourage community-based training also encourage CAHs to participate in physician training. However, changes to GME financing are needed if CAHs are going to be able to play a larger role in rural physician training.

http://www.jabfm.org/content/25/1/6.full?etoc

Comment: 

By Don McCanne, MD

Critical Access Hospitals serving rural communities provide an opportunity to train physicians who would more likely stay in these communities, many of which are designated as Primary Care Health Professional Shortage Areas.

If our current fragmented system of financing health care were replaced with a single payer national health program – an improved Medicare for all – the coordinated allocation of our health care funds could ensure that these training programs for rural physicians would be adequately funded, not to mention ensuring the perpetuation of Critical Access Hospitals wherever they are obviously needed.

Enhancing physician recruitment for rural hospitals

Increasing Graduate Medical Education (GME) in Critical Access Hospitals (CAH) Could Enhance Physician Recruitment and Retention in Rural America

By Imam M. Xierali, PhD, Sarah A. Sweeney, BS, Robert L. Phillips Jr., MD, MSPH, Andrew W. Bazemore, MD, MPH and Stephen M. Petterson, PhD
Journal of the American Board of Family Medicine, January-February 2012
Critical Access Hospitals (CAHs) are geographically isolated, small rural hospitals that are typically the sole source of care for their community, providing not only acute care but a broad spectrum of basic health services. There was a robust increase of CAH designations from 50 in 1998 to 1,310 in 2009.
Rural communities struggle to recruit and retain health care providers. In 2008, 81% of rural counties were or contained areas designated as Primary Care Health Professional Shortage Areas. Encouraging evidence shows that residents trained in a rural setting are much more likely to continue to serve in rural or underserved settings. Analysis of Medicare hospital cost report data suggests that very few CAHs ever have reported intern and resident training. As rural hospitals and as hospitals without prior graduate medical education (GME) programs, CAHs are eligible for starting or becoming funded members of GME training programs.
Increasing the capacity for CAHs to create and expand training programs could improve access to care in rural communities and strengthen existing rural training programs, many of which are threatened or closing. Recent policies promoting primary care training, such as the teaching health center program, also mean opportunity for CAHs to play an important role in GME expansion. Though this role for CAHs requires no legislative changes, CAHs will face additional hurdles related to accreditation and staffing.
http://www.jabfm.org/content/25/1/7.full

And…

Critical Access Hospital (CAH) Graduate Medical Education (GME): Too Little, and Maybe Too Late

By Frederick M. Chen, MD, MPH
Journal of the American Board of Family Medicine, January-February 2012
In the context of national scrutiny on graduate medical education (GME) from both the Medicare Payment Advisory Commission and the Joint Select Committee on Deficit Reduction, Xierali et al, bring our attention to the ongoing needs of rural underserved communities and the potential role of critical access hospitals (CAHs) in training the rural physician workforce. Their analysis demonstrates the minuscule number of CAHs that have reported resident training within their walls. The literature shows that physician training in rural settings is successful in producing rural physicians but also is endangered with the number of rural training tracks and rural residencies in free-fall over the past 10 years.
Although CAHs may be an untapped resource for GME, there are significant barriers to their success. Xierali et al point out the challenges of accreditation and staffing. CAHs, like RTTs, are by definition located in small communities that tend to be under-resourced for physician faculty and other medical education needs. Often the loss of a single physician in these settings results in the loss of the training site.
Financing is always an important consideration. Though CAHs may be eligible for Medicare GME payments because they are free of the resident cap, many CAHs have a low percentage of Medicare inpatients, resulting in payments that are insufficient to cover the costs of residency training. On the other hand, this has not precluded urban hospitals from claiming the time that residents spend in CAHs. Though this enables some residency training time in CAHs, the flow of funds, if any, from the urban hospital to the CAH is unknown, except to hospital financial officers.
Enabling and encouraging more residency training in rural settings is a priority if rural communities are to have adequate access to health care. New training models that encourage community-based training also encourage CAHs to participate in physician training. However, changes to GME financing are needed if CAHs are going to be able to play a larger role in rural physician training.
http://www.jabfm.org/content/25/1/6.full?etoc

Critical Access Hospitals serving rural communities provide an opportunity to train physicians who would more likely stay in these communities, many of which are designated as Primary Care Health Professional Shortage Areas.
If our current fragmented system of financing health care were replaced with a single payer national health program – an improved Medicare for all – the coordinated allocation of our health care funds could ensure that these training programs for rural physicians would be adequately funded, not to mention ensuring the perpetuation of Critical Access Hospitals wherever they are obviously needed.

Arnold Relman on saving the U.S. medical system

In Dire Health

By Arnold S. Relman
The American Prospect, Jan-Feb/2012

Most people assume that insurance is an essential part of the health-care system. Some think it should be provided through public programs like Medicare, while others prefer to see it purchased from private insurance companies, but the majority believe that insurance is needed to help pay the unpredictable and often catastrophic expenses of medical care. That is why so much public policy focuses on extending coverage to as many people as possible and controlling its cost. I think this emphasis on insurance is mistaken. We would have a much better and more affordable health-care system if the reimbursement of medical expenses through public or private insurance plans was replaced by a tax-supported universal access to comprehensive care, without bills for specific services and without insurance plans to pay those bills.

Insurance is not simply a mechanism for spreading financial risks and paying for medical care. Because it usually tries to limit payments to providers, insurance often is an intrusive third party in the doctor-patient relationship and, particularly with private insurance, restricts the freedom of doctors and patients to select the services, specialists, and facilities they want to use.

Furthermore, all insurance plans have administrative expenses, and most private plans take profits that add to the cost of their premiums. The billing and collecting operations that are an integral part of any insured health system are a major expense for doctors and hospitals as well.

For-profit insurance companies, which control most of the private market, are the greatest problem. They have a direct conflict of interest with their customers, because a plan’s net income is increased by avoiding coverage of patients with serious illness (who, of course, are most in need of insurance), restricting access to services, and limiting coverage of expensive medical services.

There is, however, a practical alternative to health insurance and the fee-for-service system with which it is usually associated: a not-for-profit system in which a public single payer provides universal access to comprehensive private care delivered by primary-care physicians cooperating with medical specialists in group-practice arrangements.

I do not underestimate the complexity of the changes I am proposing. The odds against it are daunting. Congress might not even begin to debate major reform until the health system is near collapse. But what seems clear is that the best – possibly the only – hope for achieving universal, affordable care lies in the eventual elimination of private insurance and fee-for-service payment and in the creation of a tax-supported system based on group practice. Although this proposal makes good medical, social, and economic sense, its ultimate fate will be decided in the political arena. It cannot become a reality without an informed and aroused public bolstered by the medical profession’s strong support for the reform.

(Arnold S. Relman is a professor emeritus of medicine and social medicine at Harvard Medical School and the former editor of The New England Journal of Medicine.)

http://prospect.org/ (As of Jan. 3, Jan-Feb/2012 issue not yet posted online)

Comment: 

By Don McCanne, MD

It seems appropriate to begin the new year with the words of the venerable Arnold Relman. Much media attention on reform will be misdirected this year to implementation of the private-insurance-based Affordable Care Act and to its challenge in the U.S. Supreme Court. Dr. Relman reminds us that instead we need to move forward with informing and arousing the public in support of fundamental reform that actually would bring affordable care to all.

U.S.-trained doctor demystifies Canada’s health system

WCHL Your Health Radio, Nov. 16, 2011

The following text is an unofficial transcript of a radio broadcast titled “Demystifying the Canadian Health System” featuring Dr. Khati Hendry. She appeared on “Your Health Radio with Dr. Adam Goldstein and Dr. Cristy Page” on WCHL 1360 AM on Nov. 16. The program is produced weekly by the Department of Family Medicine at the University of North Carolina. A link to the podcast of this broadcast is available here.

Dr. Cristy Page: I’m Dr. Cristy Page and I’m joined today by guest host Dr. Rob Gwyther from the Department of Family Medicine at the University of North Carolina. On our show today we are going to talk with family physician Dr. Khati Hendry about “Demystifying the Canadian Health System.” She practiced in the United States for many years, but now she’s a practicing family physician in Canada.

Dr. Hendry is a U.S.-trained family physician like me and Rob but she has worked in British Columbia in a private family practice since 2004, so she has experienced both sides of the health care systems in the United States and Canada.

Dr. Rob Gwyther: So I’d like to start by figuring out just what you’ve done in the United States and what you’ve done in Canada so our listeners will understand what your references are.

Dr. Khati Hendry: Thanks for having me. I actually spent more time in the United States than in the Canada. I am an American, a U.S. citizen, and I did my training in the U.S. Then I got my dream job working in a community health center in Oakland, California, oh, way back when. I was there for almost 25 years.

Dr. Page: Wow, that’s real service.

Dr. Hendry: Yes, that was quite a bit, actually. So while I was there, the clinic grew, I had more responsibilities, I was the medical director there, and then I was the medical director of a whole network of community health centers in that area. I got pretty heavily involved in administration, and when other opportunities came up, and personal things like getting married and so on, I had a chance to move to Canada. So I worked in the Oakland area for 25 years and I’ve been working here for the last seven years or so as a family doctor.

Dr. Page: So you’ve really had experience that is more than just a glance at each of the health care systems.

Dr. Hendry: Yes, I feel like I’ve had a quite intimate look at a number of issues that people are concerned about on both sides.

Dr. Gwyther:  So I’d say in this country people who are physicians are pulling their hair out because they’re not satisfied with the system. Lots of patients don’t have access to this system and are not happy about that. It’s about to bankrupt the country and everybody in Washington is screaming and yelling. The Canadians, by repute in this country, have a pretty good system. People have access to the system and they seem to be more content. Is that your experience?

Dr. Hendry: That is exactly my experience. Actually, I have to say that when I moved up here and started working it felt a little bit like I had finally stopped banging my head against the wall. It felt really good to stop. [Laughs.] So, no, it’s quite a relief to be working in a system where you’re not spending most of your energy essentially fighting to make things better for your patients — fighting the insurance companies, fighting the rules and regulations, things changing underneath you all the time, worrying about patients who you can’t get what they need. It’s been an amazing journey, one that I’ve been really happy to be able to make.

When I moved [to Canada] and started working it felt a little bit like I had finally stopped banging my head against the wall. It felt really good to stop. So … it’s quite a relief to be working in a system where you’re not spending most of your energy essentially fighting to make things better for your patients — fighting the insurance companies, fighting the rules and regulations, things changing underneath you all the time, worrying about patients who you can’t get what they need.

Dr. Page: How does it relate to primary care being a family physician or being a patient receiving primary care. How would you summarize the major differences between the two systems?

Dr. Hendry: Well, as far as the medical care goes, it’s really hardly different at all. In other words, I might see someone in my office – they’re going to have same colds, they’re going to have the same problems, and I’m going to be bringing my same expertise there, be ordering the same tests for investigation, and I’ll be making my referrals. So in terms of day-to-day seeing patients, it’s not that different. What’s really different is the context in which it’s happening. It might be helpful just to give a little example. I’m right now in my office and saw patients all morning. So what happens is that they come in the door, they say hi, they have their card, their number, whatever. No one has to check for whether or not it’s still valid, or whether they changed from one plan to another, or if they have co-pays that they need, or anything. They just come in for the visit. They go down the hall and I see them. I do whatever is necessary. I don’t have to fill out any extra forms. I go to my EMR, my electronic medical records, I put down what I did, and it gets sent off by the one, part-time bookkeeper, who serves the six-physician practice, and I get money.

Dr. Page: Hm. That sounds really heavenly.

Dr. Hendry: It’s amazing. It’s amazing what you don’t do in all of that, you know? You just cut right through it. You’re taking care of patients and being concerned about their medical issues. I’m practicing medicine, not paperwork.

Dr. Gwyther: So if you talk to people in this country they sort of in knee-jerk fashion say, “Oh, we couldn’t have socialized medicine here.” We have to have our system, which is in incredible disarray. So here’s my questi
on: You, as a Canadian physician, are told what you’re going to earn and how things are going to go by the government, they become the single payer, and if you’re going to have a contest between the medical establishment and the government, that’s how things are going to be ironed out. In this country, most physicians are working for a bunch of insurance companies, and if they wanted to take them on, they’d have to take them on one a time. So which is the one that you think enables you and your patients to benefit the most?

Dr. Hendry: Well, I have to say that it’s really nice not to be spinning your wheels, dealing with a multiplicity of people to fight against, for starters. And the thing that the government tells you what you’re going to get is kind of an oversimplification. I think a lot of people don’t realize that medicare – and this is kind of ironic, but the name of the system in Canada is medicare …

Dr. Gwyther: We stole it. [Laughter.]

Dr. Hendry: So, you know, people who have Medicare in the U.S., for the most part, even though there are of course things that they might want to improve, it’s generally been a pretty popular program and it’s incredibly popular here in Canada. People give it very high marks and say they don’t want to get rid of the system, just like people don’t want to get rid of Medicare in the States. In terms of the government telling you what to do, it’s a little more complicated. There’s a Canada Health Act, and there’s a federal level in which there are certain things that need to be included in the health care systems in the provinces (provinces are our states). Each province actually has the authority to modify what that plan looks like, they just can’t go below the basic requirements. So they can add other things, tweak them, and in addition, each province negotiates with the medical association for how they’re going to pay the physicians. So physicians have quite a say in it, there’s a back and forth as these negotiations go on, and it’s not the same from province to province, but there’s an agreement on a fee structure. And I know people in the U.S. are familiar with fee structures from all the different insurance companies, but we have one fee structure.

Dr. Gwyther: And everybody goes home at the end of the day and that’s what you’re going to get, you don’t have to negotiate with five different vendors.

Dr. Hendry: Yes. If you’re going to get X amount of money, that’s what you get. And the other thing is that you get it. Or you almost always get it, I mean unless you did something egregious. They way it used to be in the States, I remember, you would submit your bill and maybe you’d get it and maybe you wouldn’t. Maybe they would have changed the goalposts, maybe you would have spent six months trying to get paid. But here, essentially, you have an agreement about what you’re going to get paid and they pay you. They don’t micromanage.

Dr. Page: It sounds like it’s cutting out a lot – you mentioned the paperwork before, and you mentioned that you have this one part-time person who’s helping to submit this for six different doctors.

Dr. Hendry: Right.

Dr. Page: Whereas in the United States we pay all this money to try to keep our practice open to have all these people who are helping with paperwork, signing for the bills, working with the insurance companies, and all this. And it sounds to me like it’s simplified a lot in your office. And has that borne out to be true for you?

Dr. Hendry: Oh, unbelievably so. And it’s much simpler also for the patients, because if I want to send someone to the hospital or a specialist I don’t have to worry about what plan they’re in, whether we have an agreement with it, or whether it switched from one day to the next. You know, you probably have this – one of those handheld Epocrates-type programs … the applications.

And it’s much simpler also for the patients, because if I want to send someone to the hospital or a specialist I don’t have to worry about what plan they’re in, whether we have an agreement with it, or whether it switched from one day to the next.

Dr. Page: Yep.

Dr. Hendry: You know, you have the 50 different formularies that you can use, special apps. There’s no need for an app here, because everyone basically has got pretty much the same plan.

Dr. Page: You can prescribe a medication and it will be paid? Or do you only have certain medications that are on the plan that you can choose from?

Dr. Hendry: Well, actually, that’s an interesting point, because the Canada Health Act provides for medically necessary services, which includes doctor visits, hospital visits, and the supporting tests and examinations. Pharmaceuticals were actually not part of that original plan. Some of the provinces, all of the provinces, have made different efforts to try to include that. But that’s one of the things that needs to be reined in, in terms of costs in Canada, is how we deal with pharmaceuticals because there isn’t a federal plan for payment. However, we don’t have a lot of different plans that tell you what you can and can’t prescribe. There’s a share of costs for most places, a few provinces do have pharmaceutical coverage, but it’s not quite as straightforward as medical services.

Dr. Gwyther: We need to take a short break, but when we return we’ll continuing talking to our guest, family physicians Dr. Khati Hendry about demystifying the Canadian health care system. We’ll be right back with Your Health.

Dr. Page: Welcome back. You’re listening to Your Health. We’ve been talking with Dr. Khati Hendry about demystifying the Canadian health care system. Dr. Hendry is a U.S.-trained family physician who spent 25 years working in the United States and has spent the last seven working in Canada. But we were talking a little about socialized medicine, or this fear that having a single-payer system is socializing medicine. And one of the things I hear a lot from people in my family and peopl
e who are concerned about any talk of that in our country is this perception that people are waiting in lines, that care is getting rationed out, and that if you want a transplant you can’t get one because of the long lines. Tell us how that bears out, or is that true?

Dr. Hendry: Well that is certainly not my experience at all. One of the things is that people have their own ideas of what it looks like. It’s very ironic. I moved to Canada and immediately I am working in a private doctors’ office. I have much more say over how I take care of my patients – more than I ever did while working in the States, where I was an employee and I had people micromanaging me, almost on a daily basis, from all the different insurance companies to the government agencies and everything else. I have to say there is much less intrusion by government or any kind of insurance agency here in Canada than there is in the United States. That’s No. 1. The other thing is that a lot of people think we are all employees of the government, and that is absolutely not true. Most of the doctors are in private practice. We have a fee scale we have agreed to through negotiations with our medical associations. So that is a single-payer source so it is publicly administered, but it’s not government officials that are running it. It’s the doctors who are running the medical system in terms of defining what we want our patients to have, and so on. The questions of lines, it really just has to do with supply and demand. If you’re in a rural area – we’re a big country, so you have a lot of rural areas – you’re not going to have immediate access to some specialists if you’re up on the Northwest Territories, for example. So obviously…

I moved [to Canada] and immediately I am working in a private doctors’ office. I have much more say over how I take care of my patients – more than I ever did while working in the States, where I was an employee and I had people micromanaging me, almost on a daily basis, from all the different insurance companies to the government agencies and everything else. I have to say there is much less intrusion by government or any kind of insurance agency here in Canada than there is in the United States.

Dr. Page: That’s true for rural America as well, right?

Dr. Hendry: Exactly. And the other thing is that there are some issues with overtreatment when you have too many specialists. Because if they’re there, they’re going to want to work, right?

Dr. Page: Yes.

Dr. Hendry: So there is a better distribution I would say throughout the country. The places where people run into trouble are either where you just have a shortage of doctors – and again that is mostly in a rural areas, not unlike many other parts of the world – or in places where you have not as many specialists as you need. And in elective areas.

Dr. Page: So what about the concern that, you know, I want my knee replacement, it’s not emergent, but I’m going to have to wait forever to get one?

Dr. Hendry: Well you won’t wait forever. I mean, you might get it next year instead of this year, but you don’t wait forever. But people are still concerned. You know, everyone is very involved in their medical care because we’re all part of the system, so people are quite vocal about it, so you certainly hear about it, but in fact if people need a knee replacement, they will get it, and they will not go bankrupt from it, and they will have it done at a reasonable time. So what have they done to deal with that — they have developed a wait-list system throughout the country, and each province has a different way of dealing with it. They’ve worked on different ways to expedite some of these elective procedures that people want to go faster. In British Columbia, for example, they have a website where you can go and see who has shorter wait times and then ask to be referred to a physician who has a shorter wait time. So people are working on it. But it’s only the elective stuff, not the emergent thing.

So what have they done to deal with [waits for certain elective procedures] — they have developed a wait-list system throughout the country, and each province has a different way of dealing with it. They’ve worked on different ways to expedite some of these elective procedures that people want to go faster. In British Columbia, for example, they have a website where you can go and see who has shorter wait times and then ask to be referred to a physician who has a shorter wait time. So people are working on it. But it’s only the elective stuff, not the emergent thing.

If you can bear with me for a second, for orthopedics — I often had a hard time getting services for my patients when I was in the States. I don’t know if that’s your experience, but it turns out that it’s not always that easy to get exactly what you want when you want it in the States either, especially in the safety-net. But here, if I have someone who really needs something, they get it. There is an orthopedist 24/7 at my hospital.

If someone has a fracture or an acute injury they go there and they’re seen that same day, and again, no one goes broke for that because they don’t have to pay extra for it. I have never, ever been in a situation here that I was in in the States where I had to have a patient make a decision about a life-threatening situation versus financial disaster.

Dr. Page: That’s a common scenario in our country.

Dr. Hendry: And you have a million examples of that. But I had a patient I thought was having a bleed into his brain, a subarachnoid hemorrhage, and was trying to convince him to go to the emergency room. He was terrified because he had no insurance and it would be expensive.

Dr. Page: That would be the United States.

Dr. Hendry: Yes, in the United States. I’ve never have that problem here. It wouldn’t be thinkable.

Dr. Gwyther: I remember seeing a movi
e where the question was asked of a couple of Canadian citizens who wanted to come to the United States for a wedding and their family and that they bought some kind of insurance for a couple of weeks so that if anything happened here they’d be taken care of. They were that afraid to come here because of the possibility of that happening.

Dr. Hendry: People are terrified of that. Absolutely you need insurance when you go. We do have snow up here, you may have heard of that [laughter], so quite a few people are snowbirds and they go south, many go to the States, and they always have insurance. And I get people coming back who had things happen in the States and still end up with thousands and thousands of dollars of debt, even after their insurance paid. If it had happened in Canada they wouldn’t have had any of that.

Dr. Gwyther: That’s absolutely amazing to me. So do family doctors play the gatekeeper role in Canada?

Dr. Hendry: Well, actually we do, in part because it’s much more family-practice friendly. Everyone is used to that’s how you get care, you see your family doctor, which, as a family doctor, I love. It’s not overly specialized in that way. But if someone wants to see a specialist, then I refer them. So yes, I’m a gatekeeper. Now you could go and see a specialist on your own if they would see you, but most of the specialists won’t do that, because they don’t get a specialist consultation fee that doesn’t come from the family doctor, so there’s nothing prohibiting them from doing it, but they prefer the family doctor send them. The other thing which is kind of interesting is that not only is it family-doctor friendly, but the pediatricians and internists in Canada are specialists, meaning that people don’t go there for their primary care, they’re referred there by the family doctors for a specific issue.

Dr. Page: Interesting. What about a medical home? Are people attached to you and your practice as a place that they receive primary care?

Dr. Hendry: Oh, completely.

Dr. Page: That’s wonderful.

Dr. Hendry: Yeah. You go to your doctor, that’s your doctor, right? And so that’s your medical home. Now there is a lot of interest in Canada in improving the medical home and making sure everyone has one, because we still do struggle with that, making sure that everyone has their own family doctor and that’s a really big issue for people. It’s being done differently in different areas. So in Ontario, for example, they’ve used a lot of multidisciplinary clinics, settings, and in that city usually there is some combination of salary and fee for service, and then in other areas, no so much. So it’s being experimented with differently across Canada. Absolutely, that’s the idea – for everyone to have their own family doctor, have a place that they go, have their medical home.

Dr. Gwyther: Do you have what’s called “pay for performance” down here up there, where if you do certain things you’ll make more money because your payers are telling you it’s the right thing to do?

Dr. Page: Or a way they monitor the quality of care?

Dr. Hendry: Not exactly the way that they have it in the U.S. There’s a lot of discussion about whether there might be some role for some of that. In my office, the closest thing I could say is that we get to that is the incentive program for family doctors to encourage us to take care of people with chronic illnesses and do maternity care and people in nursing homes, and so on. So there are special fee codes that we can submit for doing full-service family practice, essentially, which is more financially attractive than just doing walk-in clinics, or something like that. That’s not exactly pay for performance, but it is getting paid more for doing certain types of services. It’s certainly not punitive in any way. There is also some experimenting for increasing the elective surgeries in which hospitals get more money the more surgeries that they do, which is a little bit of a twist on what they’re currently doing.

Dr. Page: We are going to have to wrap up our conversation, but Dr. Hendry thank you for taking the time to talk with us and really you did demystify some of our questions and what I hear a lot of concerns about the Canadian health care system. It doesn’t sound perfect, but, gosh, the idea that you can see patients and take care of them without 12 different arguments about how to get paid sounds pretty dreamy.

Dr. Hendry: Can I just say one parting shot? And that is that one of the things I’m most impressed with is that you don’t lose your insurance. In other words, no worries about pre-existing conditions, if you lose your job, you don’t lose your insurance. If you have dependents, are married or not, or whatever, you still have the insurance. So you don’t lose it. You always have that sense that you’re taken care of and that you belong and people aren’t going to leave you in the dust or make you bankrupt. People are worried about their health and getting better. They’re not worried about the bill they’re going to get at the end of the day.

Dr. Page: Thank you for making that extra statement. It’s hard to end the conversation because there are so many questions about how it works over there, but you are good neighbors and we appreciate your taking a moment with us to demystify the Canadian health care system.

Dr. Hendry: Thank you.

Arnold Relman on saving the U.S. medical system

In Dire Health

By Arnold S. Relman
The American Prospect, Jan-Feb/2012
Most people assume that insurance is an essential part of the health-care system. Some think it should be provided through public programs like Medicare, while others prefer to see it purchased from private insurance companies, but the majority believe that insurance is needed to help pay the unpredictable and often catastrophic expenses of medical care. That is why so much public policy focuses on extending coverage to as many people as possible and controlling its cost. I think this emphasis on insurance is mistaken. We would have a much better and more affordable health-care system if the reimbursement of medical expenses through public or private insurance plans was replaced by a tax-supported universal access to comprehensive care, without bills for specific services and without insurance plans to pay those bills.
Insurance is not simply a mechanism for spreading financial risks and paying for medical care. Because it usually tries to limit payments to providers, insurance often is an intrusive third party in the doctor-patient relationship and, particularly with private insurance, restricts the freedom of doctors and patients to select the services, specialists, and facilities they want to use.
Furthermore, all insurance plans have administrative expenses, and most private plans take profits that add to the cost of their premiums. The billing and collecting operations that are an integral part of any insured health system are a major expense for doctors and hospitals as well.
For-profit insurance companies, which control most of the private market, are the greatest problem. They have a direct conflict of interest with their customers, because a plan’s net income is increased by avoiding coverage of patients with serious illness (who, of course, are most in need of insurance), restricting access to services, and limiting coverage of expensive medical services.
There is, however, a practical alternative to health insurance and the fee-for-service system with which it is usually associated: a not-for-profit system in which a public single payer provides universal access to comprehensive private care delivered by primary-care physicians cooperating with medical specialists in group-practice arrangements.
I do not underestimate the complexity of the changes I am proposing. The odds against it are daunting. Congress might not even begin to debate major reform until the health system is near collapse. But what seems clear is that the best – possibly the only – hope for achieving universal, affordable care lies in the eventual elimination of private insurance and fee-for-service payment and in the creation of a tax-supported system based on group practice. Although this proposal makes good medical, social, and economic sense, its ultimate fate will be decided in the political arena. It cannot become a reality without an informed and aroused public bolstered by the medical profession’s strong support for the reform.
(Arnold S. Relman is a professor emeritus of medicine and social medicine at Harvard Medical School and the former editor of The New England Journal of Medicine.)
http://prospect.org/ (As of Jan. 3, Jan-Feb/2012 issue not yet posted online)

It seems appropriate to begin the new year with the words of the venerable Arnold Relman. Much media attention on reform will be misdirected this year to implementation of the private-insurance-based Affordable Care Act and to its challenge in the U.S. Supreme Court. Dr. Relman reminds us that instead we need to move forward with informing and arousing the public in support of fundamental reform that actually would bring affordable care to all.

Employer-based health care flawed

By Ken Saffier, M.D.
Letters, Contra Costa Times, Dec. 29, 2011

The Dec. 11 Times article, “Cost of health benefits soaring,” accurately describes an increasingly intolerable situation for those fortunate to have employer-based insurance.

Employees and businesses pay more for less coverage as the insurance industry seeks to maximize profits.

Other developed countries cover their population by some form of social health insurance and have a competitive advantage.

In the United States, we don’t have the best health care system in the world. Even with so-called reform, it’s expensive.

Some 23 million won’t be covered, and those who do have it increasingly get a flawed product that favors the insurance industry, not patients.

How many people with inadequate employer-based insurance with higher deductibles and co-pays will delay needed care and join the uninsured 45,000 who die annually due to lack of health care?

As a physician working in our county health system, we see increasing numbers of workers and their families who have lost their jobs and insurance.

We desperately need single-payer, improved Medicare for all.

Dr. Ken Saffier resides in Richmond, Calif.

http://www.contracostatimes.com/news/ci_19634109

A future with high deductibles for everyone

High-deductible health plans on rise

By Tom Wilemon
The Tennessean, December 27, 2011

Corporate employers, small businesses and nonprofit organizations are increasingly requiring their workers to spend between $1,200 and $5,000 before filing a health insurance claim.

Nearly three in four employers will offer at least one of these plans next year, according to a survey by the National Business Group on Health, a nonprofit association that represents large employers.

Helen Darling, its president, predicts that by 2016 the majority of all health plans will have high deductibles.

http://www.tennessean.com/article/20111227/NEWS07/312270017/High-deductible-health-plans-rise

Comment: 

By Don McCanne, MD

The National Business Group on Health (NBGH) is composed of the nation’s largest employers, predominantly Fortune 500 companies. They provide health coverage for over 50 million workers, retirees and their families. When NBGH’s president, Helen Darling, says that three years from now the majority of all plans will have high deductibles, you can bank on it.

Although this development is independent of the measures in the Affordable Care Act (ACA), it has greater consequences than any other feature of ACA, merely based on the number of people who will be impacted – not just the Fortune 500 company employees, but virtually everyone else as well.

Most workers and their families obtain their health care coverage through their employment. With large employers leading the way, high deductible plans will become the national standard. For median-income households, the deductible is large enough to create a financial hardship should a family member have significant health care needs. Thus, under-insurance is becoming the new norm, not only for employer-sponsored plans, but also for the low actuarial value plans to be offered through the state insurance exchanges.

The rationale usually given for high deductibles is to make patients more sensitive to the costs of health care so that they will use less of it. This has been shown not only to decrease the use of beneficial health care services, but it also potentially exposes people to financial hardship when they develop problems for which health care is absolutely essential.

So the question is, does this really save enough money to warrant these adverse consequences? Let’s look at the RAND HIE and also the experiences of other nations.

The RAND Health Insurance Experiment demonstrated that health care use was reduced by 30 percent in patients with cost sharing as compared to first dollar coverage, supposedly without resulting in harm (though low-income people were harmed). But that study was limited to healthy workers and their young healthy families during a few healthy years of their lives. It does not apply to the relatively unhealthy 20 percent of people who use 80 percent of our health care dollars – care that is not influenced by deductibles. Reducing spending by 30 percent on healthy people who use very little care – perhaps an office visit or two – is not going to reduce our national health expenditures significantly.

Many other nations have first dollar coverage with no deductibles, yet spend far less than we do, and with no evidence of significant overuse of medical services. There are far more effective and much more patient-friendly methods of controlling spending than the use of deductibles and other cost sharing, as these nations have demonstrated.

The Affordable Care Act is not providing us the framework that would ensure affordable care for everyone. Trying to modify the Act to make it work better won’t help because the financing infrastructure is so fundamentally flawed that legislative tweaking cannot repair it. Though getting rid of deductibles would be an improvement, it wouldn’t reduce our high costs, but would merely shift them, making insurance premiums even less affordable.

For this new year, we really have our work cut out for us. The public at large needs to understand the irreparable flaws in the ACA model of reform. People need to know that we can control spending while making health care accessible and affordable for everyone. We can do this by enacting a far better way to finance health care – a single payer national health program: an improved Medicare for all.