The hard truth about health care: Government works

By Ezra Klein
The Washington Post, June 7, 2011

Everyone in Washington claims to want the same thing lately: a “serious conversation” about health-care costs. So let’s have one.

Republicans have a plan that has been tried repeatedly but that has never worked. Democrats have a plan that might work in theory, but it is untested at the scale they’ll need for it to work in practice. And both parties are too scared to talk about the only plan that has worked.

But before we get to that plan, I want to tell you about a graph.

I found it buried inside a Kaiser Family Foundation brief entitled “Health Care Spending in the United States and Selected OECD Countries.” Inauspicious, maybe. But it should change the way we think about health-care costs. Because what it shows is that we’ve failed. Failed to control costs. Failed to restrain the growth of government.

And it shows something else, too: Where we’ve failed, others have succeeded.

Everyone knows — or should know — that the United States spends much more than any other country on health care. But the Kaiser Family Foundation broke that spending down into two parts, the government’s share and the private sector’s share (both measured as a percentage of total gross domestic product), then compared the results with figures from 12 other countries that are members of the Organization for Economic Cooperation and Development. And here’s the shocker: Our government spends more on health care than the governments of Japan, Australia, Norway, the United Kingdom, Spain, Italy, Canada or Switzerland.

Think about that for a minute. Canada has a single-payer health-care system. The government is the only insurer of any note. The United Kingdom has a socialized system, in which the government is not only the sole insurer of note but also employs most of the doctors and nurses and runs most of the hospitals. And yet, measured as a share of the economy, our government health-care system is the largest of the bunch.

And it’s worse than that: Atop our giant government health-care sector, we have an even more giant private health-care sector. Altogether, we’re spending about 16 percent of the GDP on health care. No other country even tops 12 percent. Which means we’ve got the worst of both worlds: huge government and high costs.

This is where a “serious conversation” on health-care costs would start — with what has worked, and what we can learn from it. Instead, it’s where our conversation about health-care costs never quite goes.

The Republican plan, in fact, heads in the opposite direction: The GOP outsources Medicare to private insurers and gives senior citizens checks that cover less and less of the cost of insurance every year. Republicans hope that when faced with more cost pressure and more options, seniors will be able to exert the sort of consumer pressure that lowers prices while retaining, or even improving, quality.

What they’ve got in mind already exists in Medicare. “Our premium-support plan is modeled after the Medicare Part D prescription-drug program,” Paul Ryan (R-Wis.) told me. But Part D hasn’t controlled costs. Instead, premiums have risen by 57 percent since 2006, and the program is expected to see nearly 10 percent growth in annual costs over the next decade.

Moreover, this isn’t the first time we’ve tried to let private insurers into Medicare to work their magic. The Medicare Advantage program, which invited private insurers to offer managed-care options to Medicare beneficiaries, was expected to save money, but it ended up costing about 120 percent of what Medicare costs.

The Democratic plan, conversely, quietly recognizes that government-run health-care systems that are willing to throw their weight around can control costs. So the plan is to have Medicare try to pay for quality, not volume.

The first step is figuring out what quality is. So Medicare has been collecting vast amounts of hospital data on patients’ experiences, the delivery of pre-operative antibiotics, the prevalence of medical imaging and other topics. Come October, the hospitals posting good numbers will get a bonus from the Affordable Care Act; those posting bad numbers will face a penalty. Next year, the bonus and penalty will get bigger. Democrats have also created and funded a center to start testing the effectiveness of various drug, device and surgical treatments.

As for the inevitable political blowback, Democrats created the Independent Payment Advisory Board, a panel of 15 Senate-confirmed health-care experts who can make tough, cost-cutting reforms to Medicare in Congress’s stead. To be stopped, Congress needs to vote the board down, and the president needs to sign off on lawmakers’ opposition. That creates ample room for Congress to hand the IPAB the decisions it doesn’t want to make on its own.

Could it work? Sure. But it’s a gamble. It’s easy to imagine that strategy improving quality without cutting costs. That’d leave us with a better health-care system than we have now but the same budget problems. Another danger is that Congress could override the IPAB, rendering it useless as a tool for cost control.

But that’s the choice we’ve been left with: a plan that has never worked or a plan that’s never been tried. As for the approach that’s helped every other industrialized country achieve universal coverage at about half our costs? Well, we’re still not ready to talk about that.

http://www.washingtonpost.com/blogs/ezra-klein/post/the-hard-truth-about-health-care-government-works/2011/05/19/AGcE95KH_blog.html?wprss=ezra-klein

McKinsey report on employer-sponsored insurance

How US health care reform will affect employee benefits

By Shubham Singhal, Jeris Stueland, and Drew Ungerman
McKinsey Quarterly, June 2011

US health care reform sets in motion the largest change in employer-provided health benefits in the post–World War II era. While the pace and timing are difficult to predict, McKinsey research points to a radical restructuring of employer-sponsored health benefits following the 2010 passage of the Affordable Care Act.

Many of the law’s relevant provisions take effect in 2014. Our research suggests that when employers become more aware of the new economic and social incentives embedded in the law and of the option to restructure benefits beyond dropping or keeping them, many will make dramatic changes. The Congressional Budget Office has estimated that only about 7 percent of employees currently covered by employer-sponsored insurance (ESI) will have to switch to subsidized-exchange policies in 2014. However, our early-2011 survey of more than 1,300 employers across industries, geographies, and employer sizes, as well as other proprietary research, found that reform will provoke a much greater response.

Overall, 30 percent of employers will definitely or probably stop offering ESI in the years after 2014.

Among employers with a high awareness of reform, this proportion increases to more than 50 percent, and upward of 60 percent will pursue some alternative to traditional ESI.

A transformed employer market

Health care reform fundamentally alters the social contract inherent in employer-sponsored medical benefits and how employees value health insurance as a form of compensation. The new law guarantees the right to health insurance regardless of an individual’s medical status. In doing so, it minimizes the moral obligation employers may feel to cover the sickest employees, who would otherwise be denied coverage in today’s individual health insurance market. Reform preserves the corporate tax advantages associated with offering health benefits—except for high-premium “Cadillac” insurance plans.

Starting in 2014, people who are not offered affordable health insurance coverage by their employers will receive income-indexed premium and out-of-pocket cost-sharing subsidies. The highest subsidies will be offered to the lowest-income workers. That reduces the social-equity advantage of employer-sponsored insurance, by enabling these workers to obtain coverage they could not afford on today’s individual market. It also significantly increases the availability of substitutes for employer coverage. As a result, whether to offer ESI after 2014 becomes mostly a business decision.

What the law says

Reform requires all employers with more than 50 employees to offer health benefits to every full-timer or to pay a penalty of $2,000 per worker (less the first 30). The benefits must provide a reasonable level of health coverage, and (except for grandfathered plans) employers will no longer be able to offer better benefits to their highly compensated executives than to their hourly employees. These requirements will increase medical costs for many companies. It’s important to note that the penalty for not offering coverage is set significantly below these costs.

The subsidies will cap the amount lower- and middle-income individuals and families will have to spend on health coverage, to 9.5 percent of household income for those at 400 percent of the federal poverty level and less for those at lower income levels. The subsidies will keep the cost of insurance coverage from the exchanges below what many employees now pay toward employer-sponsored coverage, especially for those whose earnings are less than 200 percent of the federal poverty level.

A bigger effect than expected

As we have seen, a Congressional Budget Office report estimated that only 9 million to 10 million people, or about 7 percent of employees, currently covered by ESI would have to switch to subsidized exchange policies in 2014. Most surveys of employers likewise show relatively low interest in shifting employees from traditional ESI.

Our survey found, however, that 45 to 50 percent of employers say they will definitely or probably pursue alternatives to ESI in the years after 2014. Those alternatives include dropping coverage, offering it through a defined-contribution model, or in effect offering it only to certain employees. More than 30 percent of employers overall, and 28 percent of large ones, say they will definitely or probably drop coverage after 2014.

Our survey shows significantly more interest in alternatives to ESI than other sources do, for several reasons. Interest in these alternatives rises with increasing awareness of reform, and our survey educated respondents about its implications for their companies and employees before they were asked about post-2014 strategies. The propensity of employers to make big changes to ESI increases with awareness largely because shifting away will be economically rational not only for many of them but also for their lower-income employees, given the law’s incentives.

https://www.mckinseyquarterly.com/How_US_health_care_reform_will_affect_employee_benefits_2813

And…

Getting Insurance at Work

Posted by Nancy-Ann DeParle
The White House Blog, June 8, 2011

You might have seen reports about a study from McKinsey and Company claiming that a significant number of employers will stop offering insurance to their workers in 2014. Unfortunately, the study misses some key points and doesn’t provide the complete picture about how the Affordable Care Act will strengthen the health care system and make it easier for employers to offer high quality coverage to their employees.

The McKinsey Study is an Outlier

The Rand Corporation: “The percentage of employees offered insurance will not change substantially, but a small number of employees in small firms (defined as those with under 100 employees in 2016) will obtain employer-sponsored insurance through the state insurance exchanges.”

The Urban Institute: “Some have argued that the Patient Protection and Affordable Care Act would erode employer-sponsored insurance (ESI) by providing incentives for employers to stop offering coverage. Others have claimed that most businesses would face increased costs as a result of reform. A new study finds that overall ESI coverage under the ACA would not differ significantly from what coverage would be without reform.”

Mercer: “In a survey released today by consulting firm Mercer, employers were asked how likely they are to get out of the business of providing health care once state-run insurance exchanges become operational in 2014 and make it easier for individuals to buy coverage. For the great majority, the answer was ‘not likely.'”

The Bottom Line

A central goal of the Affordable Care Act is to reduce the cost of providing health insurance and make it easier for employers to offer coverage to their workers. We have implemented the law at every step of the way to minimize disruption and maximize affordability for businesses, workers, and families. And we agree with experts who project that employers will continue to offer high quality benefits to their workers under the new law. This one discordant study should be taken with a grain of salt.

(Nancy-Ann DeParle is the Assistant to the President and Deputy Chief of Staff.)

http://www.whitehouse.gov/blog/2011/06/08/getting-insurance-work

Comment:

By Don McCanne, MD

Republicans contend that this new McKinsey study shows that the provisions of the Affordable Care Act (ACA) will cause a massive transfer of employee health coverage from employer-subsidized plans to new government-subsidized plans that will be made available through the state insurance exchanges. Democrats contend that the ACA program design will prevent this shift. This either/or debate misses the point. The massive shift to government-subsidized private plans will occur under ACA. The uncertainty is only in how fast that will be.

This discussion is important because one of the main strategies was to establish policies that would ensure the perpetuation of the employer role in funding health care, thereby avoiding the necessity of infusing yet more taxpayer funds into health care. Ultimately, a taxpayer-financed system would be more equitable and efficient, but, until we have that, the employer funds are an important transitional resource to help fund our health care.

As the financing responsibility shifts more to the government, there is also a responsibility for the government to demand greater value in its health care purchasing. That will be difficult under ACA since a government-managed exchange of private health plans does not provide effective means of eliminating the administrative and clinical waste that typifies our dysfunctional U.S. system of financing health care.

The rate of employer-sponsored coverage continues to decline. The quality of employer-sponsored health plans continues to deteriorate as more and more costs are shifted to employees, making the plans less desirable. The opportunity offered to employers by the safety-valve of the state insurance exchanges will cause an acceleration in the decline of employer-sponsored coverage as employers realize that shifting to a government-financed program simply represents a wise business decision for them.

Once the government is stuck with the bill for these private exchange plans, maybe the light will finally go on. Why are we paying so much for these inadequate and wasteful plans when we could have a more efficient and effective program with better benefits – a single payer national health program? Fortunately, the emergence of this epiphany will not be a matter of whether, but how soon.

Barbara Starfield

Barbara Starfield, M.D., Focuses on Primary Care and Health Care Reform

By James Arvantes
American Academy of Family Physicians, September 2, 2009

Barbara Starfield, M.D., M.P.H., is a renowned researcher, scholar and author. A distinguished professor with appointments in the departments of Health Policy and Management and Pediatrics at the Johns Hopkins University Bloomberg School of Public Health and School of Medicine in Baltimore, she is known throughout the world for her work in demonstrating the value of primary care.

Starfield, who also is the director of the Johns Hopkins University Primary Care Policy Center, has repeatedly presented evidence demonstrating how primary care can enhance health care access, improve quality and outcomes, and reduce costs. Her efforts have served to strengthen and solidify the argument for a primary care-based health care system in this country.

Q. What, in your view, is wrong with our current health care system?

A. The thing that is wrong with our current health care system is that it is not designed to produce the best effectiveness, efficiency and equity in health services because it is too focused on things that are unnecessary and of high cost rather than arranging services so that the most needed services are provided when needed and with high quality.

Q. Why is that the case?

A. It is the case because the country has not put sufficient emphasis during the past 50 years on a good infrastructure of primary care. Primary care everywhere in the world is most of the care, for most of the people, most of the time. We have done a reasonably good job at making (sub)specialty care available, but a lot of (sub)specialty care is not necessary if you have good primary care. So we end up with a very expensive system that does things unnecessarily. If we followed what the evidence shows, we could do a whole lot better with a much better infrastructure of what we call primary health care.

Q. What must health care reform accomplish for it to be successful?

A. For health care reform to be successful, the system must focus on providing more primary care to more people. We know exactly what we mean when we say primary care. It is not just having a family physician or internist. It is providing services that achieve four functions. First of all, care has to be accessible, and we know that our care is not very accessible compared to countries that do much better than we do on health.

Second, care has to be person-focused over time. Now, instead of focusing care on meeting peoples’ needs, professionals define the needs — usually in terms of having a specific disease — and then forget about the people while dealing with the disease. We know from evidence that if you don’t deal with people’s problems, people are much less likely to get better. We are focusing on diseases that are professionally defined needs. We are not focusing on people-defined needs. Unless we address people-defined needs, we are not going to get good health outcomes.

The third characteristic is comprehensiveness. Instead of referring so much unnecessarily to (sub)specialists, we have to reserve (sub)specialist care for things that (sub)specialists are really needed for — the less common and complicated things — and take much better and more care of most health needs within a primary care setting.

The fourth characteristic is coordination. People have to go elsewhere for (sub)specialized services every now and then and that is good care, not bad care. When they do go, the care they receive elsewhere has to be coordinated with their ongoing care.

We know exactly what primary care is, we know exactly why systems organized around it do a better job. It is not a secret, it is not rocket science, but we don’t do it.

Q. If this obvious, why isn’t it done?

A. It is not done because there are enormous numbers of people and organizations who profit from the way health care is organized now. A lot of health policy is explicitly made by medical academia. Medical academia and teaching hospitals decide what to teach, and that is often not what the needs are in the community. Most graduates leave their training thinking that the biggest needs in the population are complicated diseases. They don’t appreciate the way problems present in the community, and they really don’t know how to deal with them because they have been trained in institutions that focus on relatively unusual problems. We are not doing a good job of training a cadre of professionals to provide the infrastructure for health services.

In addition, powerful, vested interests are keeping the system the way it is, and … they don’t want to change the system because they believe they have too much to lose. As health needs change in populations, providers should be changing to adapt their mission to the new realities of disease management and health promotion.

http://www.aafp.org/online/en/home/publications/news/news-now/professional-issues/20090902starfield-q-a.html

And…

Email
June 12, 2011

Dear colleagues,

I have very sad news. Barbara Starfield, professor of Health Policy and Management, died Friday evening of an apparent heart attack while swimming — an activity that she dearly loved.

Our School has lost one of its great leaders. Barbara was a giant in the field of primary care and health policy who mentored many of us. Her work led to the development of important methodological tools for assessing diagnosed morbidity burden and had worldwide impact. She was steadfast in her belief that a quality primary care system is critical to the future of health care in this country and worldwide and received numerous accolades for her work in this important area…

Michael J. Klag, MD, MPH
Dean, Johns Hopkins Bloomberg School of Public Health

Comment:

By Don McCanne, MD

Barbara Starfield made a difference. The momentum she created is so intense that it cannot be broken, but will carry us forward until we finally bring to reality our dream of a high-performance health care system based on a patient-oriented primary care infrastructure. We’ll all be better off for her efforts.

Barbara Starfield

Barbara Starfield, M.D., Focuses on Primary Care and Health Care Reform

By James Arvantes
American Academy of Family Physicians, September 2, 2009

Barbara Starfield, M.D., M.P.H., is a renowned researcher, scholar and author. A distinguished professor with appointments in the departments of Health Policy and Management and Pediatrics at the Johns Hopkins University Bloomberg School of Public Health and School of Medicine in Baltimore, she is known throughout the world for her work in demonstrating the value of primary care.

Starfield, who also is the director of the Johns Hopkins University Primary Care Policy Center, has repeatedly presented evidence demonstrating how primary care can enhance health care access, improve quality and outcomes, and reduce costs. Her efforts have served to strengthen and solidify the argument for a primary care-based health care system in this country.

Q. What, in your view, is wrong with our current health care system?

A. The thing that is wrong with our current health care system is that it is not designed to produce the best effectiveness, efficiency and equity in health services because it is too focused on things that are unnecessary and of high cost rather than arranging services so that the most needed services are provided when needed and with high quality.

Q. Why is that the case?

A. It is the case because the country has not put sufficient emphasis during the past 50 years on a good infrastructure of primary care. Primary care everywhere in the world is most of the care, for most of the people, most of the time. We have done a reasonably good job at making (sub)specialty care available, but a lot of (sub)specialty care is not necessary if you have good primary care. So we end up with a very expensive system that does things unnecessarily. If we followed what the evidence shows, we could do a whole lot better with a much better infrastructure of what we call primary health care.

Q. What must health care reform accomplish for it to be successful?

A. For health care reform to be successful, the system must focus on providing more primary care to more people. We know exactly what we mean when we say primary care. It is not just having a family physician or internist. It is providing services that achieve four functions. First of all, care has to be accessible, and we know that our care is not very accessible compared to countries that do much better than we do on health.

Second, care has to be person-focused over time. Now, instead of focusing care on meeting peoples’ needs, professionals define the needs — usually in terms of having a specific disease — and then forget about the people while dealing with the disease. We know from evidence that if you don’t deal with people’s problems, people are much less likely to get better. We are focusing on diseases that are professionally defined needs. We are not focusing on people-defined needs. Unless we address people-defined needs, we are not going to get good health outcomes.

The third characteristic is comprehensiveness. Instead of referring so much unnecessarily to (sub)specialists, we have to reserve (sub)specialist care for things that (sub)specialists are really needed for — the less common and complicated things — and take much better and more care of most health needs within a primary care setting.

The fourth characteristic is coordination. People have to go elsewhere for (sub)specialized services every now and then and that is good care, not bad care. When they do go, the care they receive elsewhere has to be coordinated with their ongoing care.

We know exactly what primary care is, we know exactly why systems organized around it do a better job. It is not a secret, it is not rocket science, but we don’t do it.

Q. If this obvious, why isn’t it done?

A. It is not done because there are enormous numbers of people and organizations who profit from the way health care is organized now. A lot of health policy is explicitly made by medical academia. Medical academia and teaching hospitals decide what to teach, and that is often not what the needs are in the community. Most graduates leave their training thinking that the biggest needs in the population are complicated diseases. They don’t appreciate the way problems present in the community, and they really don’t know how to deal with them because they have been trained in institutions that focus on relatively unusual problems. We are not doing a good job of training a cadre of professionals to provide the infrastructure for health services.

In addition, powerful, vested interests are keeping the system the way it is, and … they don’t want to change the system because they believe they have too much to lose. As health needs change in populations, providers should be changing to adapt their mission to the new realities of disease management and health promotion.

http://www.aafp.org/online/en/home/publications/news/news-now/professional-issues/20090902starfield-q-a.html

And…

Email
June 12, 2011

Dear colleagues,

I have very sad news. Barbara Starfield, professor of Health Policy and Management, died Friday evening of an apparent heart attack while swimming — an activity that she dearly loved.

Our School has lost one of its great leaders. Barbara was a giant in the field of primary care and health policy who mentored many of us. Her work led to the development of important methodological tools for assessing diagnosed morbidity burden and had worldwide impact. She was steadfast in her belief that a quality primary care system is critical to the future of health care in this country and worldwide and received numerous accolades for her work in this important area…

Michael J. Klag, MD, MPH
Dean, Johns Hopkins Bloomberg School of Public Health

Still Paying Through the Nose, Labor Campaigns for Single Payer

By Andy Coates
Labor Notes, June 8, 2011

A year after President Obama signed his health care reform with strong support from the labor movement, advocates of a single-payer system might be tempted to ask, “How’s that working out for you?”

At last weekend’s conference of the Labor Campaign for Single Payer, a Plumbers and Pipe Fitters delegate pointed out that his members are paying $12.31 per hour for their health benefits.

The activists marshaled their forces once again in D.C. last weekend, where campaign coordinator Mark Dudzic reported progress on the group’s mission: “to establish and expand within labor the idea that labor has got to lead this fight” for single payer, or improved and expanded Medicare-for-All.

Indeed, the conference began June 3 at AFL-CIO headquarters and heard from President Richard Trumka himself. Trumka spoke of the reluctance of the AFL-CIO Executive Council to embrace single payer but pointed to disappointment with the president’s Affordable Care Act at the council.

He recalled meetings 20 years ago when he fought for single payer on the council and Karen Ignagni, then assistant to the AFL-CIO president, was “doing her damnedest” to thwart the effort. (Today Ignagni is CEO of America’s Health Insurance Plans, the lead lobby for health insurance corporations.)

Trumka referred to single payer as “the only way to cure the health care problem.” He proposed that labor should “continue to educate about Canada. It’s a big myth about Canada. I go there all the time. You sit down with someone over coffee and ask them: ‘Tell me about your health care.’ They say: ‘Oh, it’s a godsend.’ We need to get that message out.”

The AFL-CIO president also continued to gesture toward political independence for labor, saying, “We should strengthen our support for our friends and do less for our acquaintances.”

As signs of progress, Dudzic noted the federation’s financial support for the Labor Campaign, participation by Vice President Arlene Holt Baker in a press conference announcing single-payer legislation, and the fact that the AFL-CIO sent staffer Nick Unger to help the single-payer efforts in Vermont. (Unger was the same staffer who in 2009-2010 campaigned for single-payer activists to embrace the public option.)

Dudzic also reported progress within the Labor Caucus for Single Payer, a group of nine internationals chaired by Greg Junemann of the Professional and Technical Engineers. Dudzic suggested several unions in which single-payer activists should “insist that our leaders follow the direction of the members.”

Without the White House

The deafening silence coming from the White House was a recurring theme as participants discussed the state-by-state assault on labor, ongoing unemployment, and the relentless rise in the costs of care. Stuart Acuff of the Utility Workers counseled, “Our job is not to follow Obama. Our job is to hold Obama accountable.”

Although the chances of passing a single-payer bill this year are less than remote, delegates welcomed Representative Jim McDermott of Washington by conference call and Representatives John Conyers and Dennis Kucinich, co-sponsors of HR 676, in person. HR 676, which calls for a publicly financed, privately delivered health care system, has been introduced every year since 2003.

McDermott, a psychiatrist, recently introduced a single-payer House companion to one introduced by Senator Bernie Sanders of Vermont.

Delegates agreed to support both the McDermott and Conyer bills, yet took note that HR 676 covers the undocumented, forces for-profit hospitals to convert to non-profit status, and requires federal, instead of state-by-state, administration.

On more immediate efforts in the states, delegates heard a panel from Vermont, where the Act for a Universal and Unified Health System was signed into law May 26. Mari Cordes of the Vermont Nurses/AFT recalled that only two years ago single-payer advocates were called “bomb throwers” by Vermont legislators for sticking to a cause labeled “too hard” and “not possible.”

Jill Charbeonneau, president of the Vermont AFL-CIO, cautioned that the legislation was the first in a series of steps toward single payer—”a skeleton this year,” followed by a year-long process of defining the scope of health benefits under the plan, followed by a second to third year process “to decide how to finance the system,” and ultimately a need for waivers from the federal government.

A video excerpt from the Vermont Workers Center illustrated the grassroots campaign, predicting: “If Vermont Leads, the Rest of the Nation Will Follow.” On a panel about the effort in California, Cindy Young of the California Nurses Association laid out a multi-year strategy for achieving single payer in that state.

Don Tremontozzi, a local president who is running for the No. 2 job in the Communications Workers national union, described how his members phone-banked for single payer in Vermont this spring.

“Once it was, ‘I want what the unions have,’” Trementozzi said. “Now it’s, ‘Why should you have 100 percent coverage?’ We need to get to the public.”

He roused the room with a call to defend the existing benefits companies are trying to claw back.

Drawing parallels between his union’s upcoming contract negotiations with Verizon and talks now under way with General Electric, Trementozzi said, “Yesterday at the CWA headquarters Verizon made a presentation about how costly health care is. These companies make billions in profits! They pay their CEOs millions!”

Trementozzi said “these companies act like they make no money at all” when they come crying to jack up insurance rates and cut health benefits for retirees.

“I say, ‘Over my dead body!’” Trementozzi said. “When a company makes billions and pays no taxes—we won’t stand for it!”

Andrew Coates, M.D., is a member of the executive board of the Public Employees Federation, AFL-CIO, of New York State. He is an assistant professor of medicine and psychiatry at Albany Medical College, and also serves as secretary of the Capital District chapter of Physicians for a National Health Program (www.pnhp.org).

http://labornotes.org/2011/06/still-paying-through-nose-labor-campaigns-single-payer

Medicare for All: The Only Solution to Big Pharma

By Stuart Jeanne Bramhall, M.D.
Open Salon blogs, June 7, 2011

In my view, the only solution to the mess “corporatization” has made of the U.S. health care system is to follow the example of other industrialized countries and establish a single, nationally funded health program, like the American Health Security Act of 2011 that Senator Bernie Sanders and Representative McDermott introduced last month.

Three decades of cost studies, including research by the Congressional Budget Office and America’s foremost health policy experts, show this could be accomplished quite easily by expanding Medicare. Under the Medicare program, doctors, hospitals and labs bill the federal government (instead of a private insurance company) for health services to seniors and the disabled. Expanding this program to all age groups would result in a streamlined, efficient system comparable to the Canadian Medicare program, in which doctors, hospitals, labs and pharmacies bill the government for the health services they deliver. U.S. health providers, who currently bill hundreds of different private insurance plans, would simply bill Medicare for all patients, as they currently do for their 65+ patients.

This would immediately take nearly a trillion dollars out of America’s $3 trillion health care bill, as it would massively reduce the cut private insurance companies take for profit, CEO salaries, marketing, administration and billing. Under the current system, this administrative waste siphons off 31 percent of every health care dollar. In contrast to the 3.6 percent it costs to administer the Medicare program (see this 2003 study).

Reducing the Cost of Prescription Drugs

The experience in other industrialized countries is that this model also drastically reduces the cost of prescription drugs. The purchasing power enjoyed by a single agency purchasing medications for millions of citizens forces pharmaceutical companies to agree to major cost concessions. In fact it is the one true example in health care delivery where market competition leads to price reductions – especially when four or five manufacturers are producing eight virtually identical drugs for the same condition. The main reason prescription drugs are so much cheaper in Canada and Europe than the U.S. is because of the bulk discounts their hard bargaining has won from drug companies (in the U.S., the Pentagon and Veterans Administration use their purchasing power to negotiate similar bulk discounts).

It Works in New Zealand

This model works exceptionally well in New Zealand, where the government has set up a semi-autonomous corporation called PHAMAC to contain prescription drug costs (which are one of the main reasons developed countries are blowing out their health budgets). This model works exceptionally well in New Zealand, where the government has set up a semi-autonomous corporation called PHAMAC to contain prescription drug costs (which are one of the main reasons developed countries are blowing out their health budgets). See the 2004 Australian Health Review.

In New Zealand, medications on PHARMAC’s approved medication list are subsidized, with the patient paying a $3 co-pay. The formulary consists mainly of generic drugs, where they are available, and for brand name drugs where the manufacturer has agreed to a volume discount. If the drug company won’t agree to a discount, the drug doesn’t appear on the PHARMAC formulary. One example is Pfizer, which refuses to discount the price of the antidepressant Zoloft. Because patients must pay the full cost of a Zoloft prescription at the pharmacy, it’s very rarely prescribed in New Zealand.

Obviously there are exceptions. If credible medical research indicates a new, non-discounted drug fills a distinct clinical need, it will be included on the formulary as a “special authority” drug. This means the prescription will only be subsidized if the doctor fills out a “special authority” application certifying that the patient meets specific diagnostic criteria and has failed to respond to one or two comparable drugs on the formulary.

The Envy of the Industrial World (and under attack – see * below)

Thanks to PHARMAC New Zealand, unlike most of the industrial world, has been relatively successful in limiting the growth of prescription costs to the rate of inflation – despite a significant increase in demand. As the Australian Health Review describes, its formation in 1993 was followed by near constant litigation from drug companies, which meant that legal costs accounted for 18 percent of its budget in early years. Drug companies complain that New Zealand is failing to pay its fair share of research costs, a claim I find pretty self-serving, given record profits the pharmaceutical industry recorded in 2010 (averaging more 15-20% of revenue), as well as the billions devoted to “me-too” drugs and marketing (see my last blog), criminal penalties for fraudulent business practices and exorbitant CEO salaries.

Especially as the taxpayers funded the research, at the National Institutes of Health and Veterans Administration, for some of the pharmaceutical industry’s most profitable drugs (for example, Taxol and several HIV drugs). After covering the lion’s share of the costs (i.e. research), the federal government turned these discoveries over to drug companies to be mass produced – and earn them billions of dollars in profits.

*A recent Wikileaks cable release reveals New Zealand’s National-led government is contemplating scrapping PHARMAC as a condition of a new free-trade agreement with the U.S. See this story.

Dr. Stuart Jeanne Bramhall, past president Health Care for All Washington, currently resides in New Zealand. In October 2002, Dr. Bramhall accepted a locum tenens position as a consultant psychiatrist in Christchurch, New Zealand, after third-party reimbursement problems caused her Seattle practice of 25 years to become insolvent.

http://open.salon.com/blog/stuartbramhall/2011/06/06/medicare_for_all_the_only_solution_to_big_pharma

Out-of-Pocket Costs for Some Cancer Patients Top $700 Monthly

By Katherine Hobson
The Wall Street Journal, June 6, 2011

The cost of cancer treatment is high and, according to the National Cancer Institute, growing. And at the individual level, the financial burden can be very heavy, even for patients with insurance.

A new study from Duke University Medical Center and Dana-Farber Cancer Institute covers 216 cancer patients, mostly older females with breast cancer. It found their self-reported, out-of-pocket, cancer-related costs averaged $712 a month. Some 30% of respondents said their expenses were a “significant burden” and 11% called them a “catastrophic problem.”

All but one of those surveyed had insurance, mostly Medicare, and 83% had prescription-drug coverage.

There are some caveats to the findings. Most of the patients found their way to the study via the HealthWell Foundation, a nonprofit group that provides financial assistance for out-of-pocket health-care costs, mostly prescription-related. (The rest of the study participants were being treated at Duke.) Most of the study participants had a household income of less than $40,000.

So the findings may not represent the experience of all cancer patients.

But study lead author Yousuf Zafar, an assistant professor of medicine at Duke, tells the Health Blog the findings do reflect the plight of the “underinsured” cancer patient. As the WSJ’s Laura Landro wrote in an Informed Patient column on this topic, about 25 million people are considered to fall into this category, meaning they have insurance but it doesn’t cover all their medical needs, leaving them with high out-of-pocket costs.

That $712 figure includes insurance premiums and costs including lost wages and travel to appointments, as well as co-pays for medications and physician visits.

Other research has backed up the notion that the cost of insurance plus out-of-pocket costs can weigh heavy on cancer patients and survivors. A study published recently by the Journal of Clinical Oncology found that about 13% of cancer patients spend more than 20% of their income on health care and insurance premiums. A survey by the cancer-survivor advocacy group Livestrong — which, like the Duke study, is being presented at the American Society of Clinical Oncology meeting — found that 33% of post-treatment cancer survivors cited debt as a practical concern.

The consequences can affect care. The Duke study found that 26% of patients surveyed had not filled a prescription because of cost, 22% said they had filled a prescription part-way and 20% had taken less than the prescribed amount. (Another recent study found that 10% of cancer patients failed to fill new prescriptions for oral cancer drugs.)

“People forgo treatment, cuts pills in half and are often forced to choose between medications and food,” Mary Sundeen, president of the HealthWell Foundation, tells the Health Blog.

Physicians can help out by talking with their patients about the costs of care — for example, there may be a less expensive drug that works just as well, says Zafar.

Our friends over at the WSJ’s Bankruptcy Beat blog pointed out a study, also presented at ASCO, that 2.1% of cancer patients filed for personal bankruptcy in the years following a diagnosis.

http://blogs.wsj.com/health/2011/06/06/out-of-pocket-costs-for-some-cancer-patients-top-700-monthly/

N.Y. lawmakers introduce bill for single-payer health care system

By Cara Matthews
The Journal News (White Plains, N.Y.), Jun 07, 2011

Democratic lawmakers in both houses introduced a universal health care bill today, under which publicly sponsored coverage would replace coverage by insurance companies. Instead of premiums, there would be broad-based public financing of health care based on people’s ability to pay. It would be funded through a graduated income tax, and the system wouldn’t have deductibles or co-payments. Delivery of care would remain primarily private.

Assembly Health Committee Chairman Richard Gottfried and Sen. Thomas Duane, both of Manhattan, introduced the legislation, which is being co-sponsored by 62 other legislators. However, it does not have a Republican sponsor in the Senate, which is controlled 32-30 by Republicans. Democrats hold the majority in the Assembly. The legislative session is scheduled to end June 20.

“We can get better coverage, get all of us covered, and save billions by having New York provide publicly sponsored, single-payer health coverage, like Medicare of Child Health Plus but for everyone,” Gottfried said in a statement.

Vermont Gov. Peter Shumlin signed legislation May 26 to create a single-payer system in that state.

“New Yorkers need and deserve security when they are sick or injured, and should not fear for how they will pay for medical bills,” Duane said in a statement. “Primary care and access to health care should be a right. A single-payer system is not only cost-efficient, but the fair and moral choice for New York.”

The national health care law doesn’t ensure that everyone has access to quality health care or control costs, according to Mark Dunlea, co-chairman of Single Payer New York and co-chairman of the Hunger Action Network of New York State.

New York is in the process of setting up a health-insurance exchange to comply with the federal Affordable Care Act. Individuals and small businesses will be able to purchase health insurance through the exchange. Gov. Andrew Cuomo’s administration is expected to introduce legislation soon.

http://polhudson.lohudblogs.com/2011/06/07/lawmakers-introduce-bill-for-single-payer-health-care-system/

‘Health care for all New Yorkers’ bill introduced

‘New York Health’ single-payer plan for comprehensive health coverage, regardless of income

By Single Payer New York

All New York residents would receive comprehensive health coverage under “New York Health,” a universal health care bill introduced by key legislators today. Under the plan, publicly sponsored coverage would replace insurance company coverage, and premiums would be replaced by broad-based public financing based on ability to pay. The bill, A.7860/S.5425, introduced by Assembly Health Committee Chair Richard N. Gottfried and Senate Health Committee Ranking Member Thomas K. Duane, is co-sponsored by 62 other legislators.

Gottfried and Duane were joined at the Albany press conference today by Dr. Garrett Adams, national president of Physicians for a National Health Program; Shaun Flynn of the New York State Nurses Association; Mark Dunlea, co-chair of Single Payer New York and executive director of Hunger Action Network of NYS; and Laurie Wen, executive director of Physicians for a National Health Program, New York Metro chapter.

“We can get better coverage, get all of us covered, and save billions by having New York provide publicly sponsored, single-payer health coverage, like Medicare or Child Health Plus but for everyone,” Assembly Member Gottfried said.

“New Yorkers need and deserve security when they are sick or injured, and should not fear for how they will pay for medical bills. Primary care and access to health care should be a right. A single-payer system is not only cost-efficient, but the fair and moral choice for New York,” said Senator Duane.

“The current system doesn’t work for patients or health care providers, or for the employers, individuals, and taxpayers who pay for care and coverage today,” Mr. Gottfried said.

Under this plan, no one would have to give up the doctors or other providers they use. Instead of individuals and employers paying high premium costs, the coverage would be funded through a graduated tax on income, the legislators said. Deductibles would also be eliminated and co-payments would be nonexistent.

“Federal health care reform made major improvements, but it still leaves insurance companies with too much control over premiums. Premiums are unrelated to a consumer’s ability to pay. Too often, patients and their doctors are left trying to figure out what is covered and then trying to get reimbursed. New York State can do better,” Mr. Duane said.

“Health coverage should be accountable to the people of New York, not to insurance company stockholders,” said Assembly Member Gottfried. We should get the administrative and cost savings of a single-payer system – which have been documented in repeated independent studies. It should be fairly funded based on ability to pay.”

“Physicians for a National Health Program salutes Assembly Member Gottfried and Senator Duane for their vision for social justice for New Yorkers. ‘New York Health’ is model health reform legislation, not only for the people of New York but for the nation,” said Dr. Adams.

Mr. Dunlea said: “Two critical elements missing from the recent national health care package were ensuring that everyone had access to quality health care and controlling costs. That is why this state single-payer proposal is so critical. Canada’s universal health care system started at the province rather than the national level, and it will be up to states like Vermont and New York to show how to make health care an affordable right at a sustainable cost.”

“Doctors and patients are sick of a system controlled by private insurance companies,” said Ms Wen. They don’t provide the services they overcharge us for and they make huge profits by denying care. What we need instead is a system accountable to the public, not to CEOs and shareholders. The Gottfried/Duane bill would restore the doctor-patient relationship and give doctors the freedom to take care of patients.”

In 2009, the “Partnership for Coverage” report by the New York State Health and Insurance Departments, based on an analysis by the Urban Institute, found that a single-payer plan would be the lowest-cost alternative for universal coverage, compared to plans relying on insurance companies and employment-based coverage.

Single-payer plans like New York Health would save billions of dollars, including excess insurance company administrative costs and profit; and billing and collecting for hospitals, physicians and other health care providers. Current federal, state and local expenditures for health care services – primarily through Medicare and Medicaid – would be incorporated into the New York Health Plan to help pay for the program.

Assembly Member Gottfried added, “By eliminating the need for any employer to provide health coverage for its workers, we would make New York dramatically more job-friendly, especially for small businesses, start-ups and low-margin businesses, while offering better and more secure coverage to every New Yorker.”

Single-payer health coverage is a system in which a single public or quasi-public agency pays for health care for all residents, but delivery of care is primarily private, as it is now. Patients would have freedom of choice of health care providers, and health care decisions are made by patients and their doctors, not by insurance companies. All New Yorkers would be covered for all medically necessary services, including primary, pr
eventive, and specialist care; hospital; mental health; reproductive health care; dental; vision; prescription drug; and medical supply costs.

The cost of New York Health would not be new spending, the legislators said. For most people, it will be a substantial reduction in what they are now spending. When employers and individuals aren’t “taxed” by out-of-control insurance company premiums and deductibles, most people’s take-home pay will go up.

Union Nurses Call for Single-Payer System

By Emily P. Walker
MedPage Today, June 7, 2011

WASHINGTON — Several hundred members of National Nurses United held a rally here on Tuesday to call for a single-payer healthcare system, an end to tax breaks for big corporations, and workers’ rights.

The nurses started their march in front of the White House and walked across the street to the U.S. Chamber of Commerce chanting “Hey Chamber, you can’t hide, we can see your greedy side.”

The union wants Congress to levy higher taxes on Wall Street, which would include the big companies that the Chamber of Commerce represents, Dan Rec, RN, of Jamaica Plain, Mass., explained.

The nurses then bussed over to the Capitol where they were serenaded by a singer/guitar player who belted social justice tunes, and then heard brief speeches from Sen. Barbara Boxer (D-Calif.) and Sen. Bernie Sanders (I-Vt.).

Sanders, like the 175,000-strong nurses union, is a major proponent of a single-payer healthcare system.

“If you have the money, you have good healthcare,” Rec told MedPage Today. “If you don’t have the money, it’s ‘oh well.’ It needs to be healthcare for all.”

Boxer spoke out against Rep. Paul Ryan’s plan to drastically change Medicare for those who are currently under 65, saying many in Congress don’t want to change the insurance program for the elderly.

http://www.medpagetoday.com/nursing/Nursing/26909

Nurses Union Keeps Pressure On Health Care Overhaul

By Jessica Marcy and Shefali S. Kulkarni
Kaiser Health News, June 10, 2011

Nurses converged on Washington in their fight against Wall Street this week.

Hundreds of nurses from across the country rallied to support broader access to health care and to call for higher taxes on corporations and the wealthy.

They gathered Tuesday near the White House and then picketed the U.S. Chamber of Commerce with large red banners that read: “RNs say Heal America, Tax Wall Street.” National Nurses United, the nation’s largest nurses union, sponsored the event to promote its “Main Street Contract for the American People,” a campaign that broadly calls for improved living conditions, including guaranteed health care, better wages and quality education.

They plan to rally on Wall Street later this month.

In response to the Washington rally, Blair Latoff, director of communications for the U.S. Chamber of Commerce, released the following statement: “The Chamber welcomes all voices to the debate, but the debate has to remain focused on creating American jobs and keeping our economy growing. Right now U.S. businesses are saddled with one of the highest corporate tax rates in the world, which is undercutting our global competitiveness.”

Some nurses spoke about the need for improved working conditions by increasing pay and enforcing adequate nurse-patient ratios. Many held signs that read: “I am a patient advocate” and “Medicare for all.” Participants finished the rally by gathering at a park near the Capitol, where Sen. Barbara Boxer, D-Calif., spoke about the need to protect Medicare and Sen. Bernie Sanders, I-Vt., told the crowd of red-shirted nurses that the nation needs a single payer system like that recently promoted in his own state.

Rose Ann DeMoro, executive director of National Nurses United, suggested that nurses offer a unique perspective on the struggles that patients and their families face because of the direct care they provide. “Everywhere the fallout of this system is felt, and it’s felt and experienced by the registered nurse,” she said.

Sue Gray, 51, who has been a nurse for more than 30 years and cares for cardiac surgery patients at Minneapolis Children’s Hospital, says that her own experience as a cancer patient has given her insight into the financial and emotional pressures that patients and their families experience. Diagnosed with breast cancer 12 years ago, Gray continues to work two days a week despite her cancer, which returned five years ago and has spread to her liver and bones. She does so to provide financial support and health insurance to her self-employed husband and three children.

“We really need to get some type of universal health care so that people going through my situation or families that I see at work that are struggling don’t have to worry about not getting health care,” Gray said.

Web version includes slideshow and audio of nurses’ demonstration in Washington:
http://www.kaiserhealthnews.org/Slide-Shows/2011/National-Nurses-United-Washington.aspx

Media Release: Legislation for Single Payer Medicare for All Legislation Would Make Health Care a Right, Cut Costs

Single Payer New York
Media Advisory
www.singlepayernewyork.org

For Immediate Release: June 6
For More Info: Mark Dunlea, SPNY, 212 741-8192 xt 5#
Laurie Wen, PNHP-NY Metro, 917-446-1610

Notice of News Conference

Date: Tuesday, June 7
Topic: Introduction of state legislation for a state single payer Medicare for All health care system
Time: Noon
Location: Rm. 130, LCA press room, Legislative Office Building, State and Swan St., Albany

Single payer advocates will join with leaders of the Legislative Health Committees on Tuesday June 7 at noon to announce the introduction of legislation to create a Medicare for All style universal health care system in NY.

The announcement, in the LCA news conference room in the Legislative Building, will include Dr. Garrett Adams, national President of Physicians for a National Health Program; Assembly Health Committee Chair Richard Gottfried; Senator Tom Duane, ranking minority member of the Senate Health Committee; Shaun Flynn, Director o f Government Affairs for the NYS Nurses Association; Danielle Alexander, Albany Medical College class of 2013; and representatives of the faith community.

Last month the state of Vermont became the first state to make health care a right, adopting a universal health care system that they intend to end up as a single payer system. California is also considering a single payer system; the state legislature has twice recently passed single payer only to have it vetoed by the former Governor.

Like Vermont, state legislators several years ago under the leadership of As. Gottfried commissioned an independent study of the best way for New York to provide universal health care. Like Vermont and the other states that have examined the issue, the report found that a single payer system was the most-cost effective option, covering all residents while reducing overall health care expenditures in the state by $20 billion annually by 2019. The study found that single payer would save $28 billion annually compared to the insurance mandate model that Congress adopted.

Text of the bill

As physicians change, will the AMA?

By Aaron Carroll
Washington Post, May 31, 2011
Ezra Klein blog

There was a fascinating piece in the NYT yesterday that discussed the apparent shift in politics among physicians:

Doctors were once overwhelmingly male and usually owned their own practices. They generally favored lower taxes and regularly fought lawyers to restrict patient lawsuits. Ronald Reagan came to national political prominence in part by railing against “socialized medicine” on doctors’ behalf.

But doctors are changing. They are abandoning their own practices and taking salaried jobs in hospitals, particularly in the North, but increasingly in the South as well. Half of all younger doctors are women, and that share is likely to grow.

There are no national surveys that track doctors’ political leanings, but as more doctors move from business owner to shift worker, their historic alliance with the Republican Party is weakening from Maine as well as South Dakota, Arizona and Oregon, according to doctors’ advocates in those and other states.

When I was a fellow, back at the turn of the century, a colleague and I conducted a national survey of physicians to determine their level of support for national health insurance. At the time, I was sure physicians would oppose it en masse. Surprisingly, they did not — at least not to the levels that I had thought they might.

In 2007, we repeated the survey to see whether opinions had changed. I grant you that this is not a pure tracking survey of doctor’s political leanings, but it does provide some insight on how physicians’ leanings on this one issue changed:

(Annals of Internal Medicine )

Remember this was support for federal legislation to establish National Health Insurance. That’s far more radical than the PPACA. And 59 percent of physicians supported it. That was an increase of 10 percent from what we found five years earlier, and it was statistically significant. More than half the respondents from every medical specialty supported it, with the exception of surgical subspecialties, anesthesiologists and radiologists. That means support included a majority of general surgeons, medical subspecialists and obstetricians/gynecologists.

Most significantly, in pretty much every specialty we measured in both years, support went up from 2002 to 2007.

I think that demographics likely play a part in this. I also think that this is a potential problem for the American Medical Association.

An unpublished part of our analysis showed that members of the AMA were significantly less likely to support national health insurance than were non-members. Moreover, AMA members were not like other physicians; they were more likely to be older, male and surgical subspecialists.

While still regarded as the “voice of physicians,” less than 30 percent of physicians are actually AMA members. And, as we see from above, it’s not a random sample.

The AMA has, unfortunately, been slow to react to changes before. For instance, in 1921, Congress sought to provide funding to reduce maternal and infant mortality through The Sheppard-Towner Act. The AMA fiercely opposed this piece of legislation. In defiance to what many saw as an organization that was not promoting the welfare of children, a group of motivated pediatricians separated from the pack and formed a new group, the American Academy of Pediatrics. Today the AMA is, of course, a strong supporter of efforts to reduce maternal and infant mortality. Perhaps if they had adapted faster, pediatricians would still play a larger part in the AMA.

We’ll never know for sure, but I think it’s possible that the about-face that the AMA made in support of the PPACA, after strenuously opposing health-care reform in the past, was due to recognition of the changing positions of physicians. I remember hearing many anecdotes of doctors vigorously opposed to the law, but a large survey conducted in 2009 showed that physicians, as a group, supported progressive elements of health-care reform that were eventually dropped.

At some point, the AMA has to decide whether to represent physicians or represent its members. I think that in the past few years, the AMA has tried harder to do the former. I think that they decided to adapt, and widen their tent, lest they risk alienating a majority of physicians on this issue. Whether they can continue to adapt, and maintain their influence in the face of changing demographics, remains to be seen.

Aaron Carroll is a pediatrician, health services researcher and associate professor of pediatrics at Indiana University School of Medicine. He blogs at The Incidental Economist and tweets via @aaronecarroll.

http://www.washingtonpost.com/blogs/ezra-klein/post/as-physicians-change-will-the-ama/2011/05/31/AGVTtPFH_blog.html

Single payer system a 'credible alternative' to Medicare's woes

By Dr. David Knutzen
Letters, Madison.com (Wis.), May 31, 2011

I take exception to the May 23 editorial, “Don’t let Medicare go bankrupt.” After praising Rep. Paul Ryan for a Medicare plan which would dramatically shift the increasing costs of Medicare from the government onto the recipients of Medicare, you stated: “Those who disagree with Ryan’s Medicare prescription haven’t offered credible alternatives.”

I disagree since the most credible solution to the rising costs of Medicare, and all health care, has been offered repeatedly for many years and certainly during the health care discussions leading up to the health care reform law.

It’s a single payer system similar to those used by every other industrialized country where health care for all is provided for between 8.5 percent and 11 percent of gross domestic product.

That would improve on the 17 percent to 18 percent of GDP we in the United States now pay. With that huge decrease in the cost of health care, Medicare would not be in danger of bankruptcy and other U.S. citizens would have affordable health care.

Currently, 20 percent to 30 percent of every health care dollar spent is paying for administrative costs and profits, including huge CEO remuneration for the insurance companies.

Medicare’s administrative costs are 4 percent. A single payer system would offer savings of administrative costs, provide health care for everyone and prevent Medicare from going bankrupt.

http://host.madison.com/news/opinion/mailbag/article_4aa9d250-895a-11e0-b232-001cc4c03286.html

Getting Insurance at Work

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Barbara Starfield, M.D., Focuses on Primary Care and Health Care Reform

‘Health care for all New Yorkers’ bill introduced

‘New York Health’ single-payer plan for comprehensive health coverage, regardless of income

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