Resource – Page 693

Critique of the co-chairs’ health care proposals for the National Commission on Fiscal Responsibility and Reform

By Don McCanne, M.D.

The projected increases in Medicare spending are of concern to all of us. Although we need to slow the rate of growth in spending, we should do so not only without impairing the program, but by actually enhancing the benefits. Let me explain.

The co-chairmen have advanced proposals that address federal budget deficits related to Medicare, but unfortunately they have done so to the detriment of the Medicare beneficiaries. I spoke to this briefly in my Quote of the Day yesterday (Nov. 10).

They propose an increase in Medicare cost sharing to promote greater consumer sensitivity to health care costs. Medicare is already a relatively Spartan program, paying roughly only half of health care costs for our seniors and those with long-term disabilities. Medicare beneficiaries face significant financial barriers to care, sometimes preventing them from receiving essential health care services. Some with greater health care needs even face bankruptcy because of the high out-of-pocket costs. Shifting more costs from the federal government to patients might reduce the federal budget, but it plays havoc with personal budgets. Cost sharing is merely a polite term for what it really is — cost shifting onto the backs of patients.

Because of the potential financial burden, many Medicare beneficiaries purchase Medigap plans. They provide one of the lousiest values in health insurance, having very high premiums for very modest benefits. The co-chairmen propose that the benefits be reduced further by requiring deductibles, again to create greater consumer sensitivity to costs. If they were really interested in saving money, they would recommend folding the Medigap benefits into the traditional Medicare program, thereby saving the profound administrative waste that characterizes these private Medigap plans. Although that improves patients’ budgets without changing the federal budget, policies should be designed to benefit the patients rather than appease the anti-government ideologues.

In many areas of the country physicians are concerned about their relatively low Medicare payment rates, and the lack of a “doc fix” is a very real threat for patients. Our primary care infrastructure is already crumbling, and imposition of the scheduled fee reductions will cause many more physicians to exit the Medicare program. The recommendation to prevent the fee reductions for physicians by imposing fee reductions on physicians is truly disingenuous. Physicians understand simple math when it comes to their paychecks. Patients also understand what it means when physicians’ practices are closed to new Medicare patients.

The co-chairmen propose strengthening the pending Independent Payment Advisory Board (IPAB). The board is being given the task of reducing payments in the traditional fee-for-service Medicare program, and has been provided with considerable leverage to impose those changes. Reducing fees in the Medicare program without changing fees paid by private insurers will surely motivate physicians to drop Medicare patients in favor of those privately insured. Strengthening IPAB will only compound this differential. We do need an IPAB that has a mission not to simply reduce payments, but rather to set payments based on value. We need to pay the right amount, not necessarily the least amount. But, to be effective, an IPAB would have to have influence over the entire health care delivery system. That would be possible only with a single payer system, but not with our current fragmented system of financing health care.

Another disingenuous recommendation is to reward physicians for meeting spending targets by reducing their rates further. Disgruntled physicians lack incentives for high quality performance. A “back-up-sequester” (when IPAB recommendations are not adopted) to increase premiums or reduce provider payments is punitive to both patients and physicians and could further impair patients’ access to care.

The proposed premium support system for Medicare (basically vouchers for private plans) is strictly another manifestation of the great risk shift – an assault on individuals and families (Hacker). It defeats the solidarity behind social insurance programs.

Although the deficit commission is fixated on the federal budget, what really matters in health care is that our total spending is brought under control – both private and public. If we are paying a reasonable amount for all health care combined, then it really doesn’t matter that most of it would appear in the federal budget. It’s still our money whether we pay it directly or pay it as taxpayers.

It would be much more efficient and equitable if our national health expenditures were funded through progressive tax policies. We could do that very easily if we simply improved Medicare and then provided it for everyone, as PNHP’s congressional fellow, Dr. Margaret Flowers indicated in her testimony before the commission months ago. At least we would have stabilized the health care component of our federal budget.

https://pnhp.org/blog/2010/11/11/more-on-the-deficit-commission’s-co-chairs’-proposal/

Yesterday’s Quote of the Day, listing the health care proposals of the Co-Chairmen:
https://pnhp.org/news/2010/november/deficit-commission-co-chairs-proposal

Deficit commission: Co-Chairs' proposal

Co-Chairs' Proposal (Draft Document)

National Commission on Fiscal Responsibility and Reform
November 10, 2010

Reducing Health Care Costs (page 31)

## Medium Term: Fully offset the cost of the “Doc Fix” by asking doctors and other health providers, lawyers, and individuals to take responsibility for slowing health care cost growth. Offsets include:
* Pay doctors and other providers less, improve efficiency, and reward quality by speeding up payment reforms and increasing drug rebates
* Pay lawyers less and reduce the cost of defensive medicine by adopting comprehensive tort reform
* Expand cost-sharing in Medicare to promote informed consumer health choices and spending
* Expand successful cost containment demonstrations
* Strengthen IPAB
* Recommend additional health savings (illustrative examples to follow)
## Long Term: Contain growth in total federal health spending to GDP+1% after 2020 by establishing a process to regularly evaluate cost growth, and take additional steps as needed if projected savings do not materialize

Paying for the “Doc Fix” (page 32)

## Pay doctors, other health providers, and drug companies less and improve efficiency and quality
* Replace cuts required by SGR through 2015 with modest reductions while directing CMS to establish a new payment system, beginning in 2015, to reduce costs and improve quality.
* Require rebates for brand-name drugs as a condition of participating in Medicare Part D.
## Increase cost-sharing in Medicare
* Eliminate first-dollar coverage in Medigap plans.
* Replace existing cost-sharing rules with universal deductible, single coinsurance rate, and catastrophic cap for Medicare Part A and Part B.
## Pay lawyers less and reduce the cost of defensive medicine
* Enact comprehensive medical malpractice liability reform to cap non-economic and punitive damages and make other changes in tort law.

Savings Beyond the Doc Fix (page 34)

## Expand Successful Cost-Containment Demonstration Projects by 2015
## Identify an additional $200 billion savings in federal health spending
## Strengthen the Independent Payment Advisory Board (IPAB)
* Include all providers (no carve-outs) and recommendations on benefit design and cost-sharing.
* Improve savings targets to 1.5% starting in 2015.
* Eliminate the trigger that could turn off IPAB in 2019.
* Allow cost-savings recommendations even when spending does not exceed the target growth rate.
* Allow proposals that apply reforms to health plans in the exchange.
* Require affirmative Congressional approval of recommendations or alternative savings, with a “back-up sequester” increasing premiums and reducing provider payments if IPAB recommendations (or equivalent savings) are not adopted.

Long-Term Health Care Savings (page 36)

## Set global target for total federal health expenditures after 2020 (Medicare, Medicaid, CHIP, exchange subsidies, employer health exclusion), and review costs every 2 years. Keep growth to GDP+1%.
## If costs have grown faster than targets (on average of previous 5 years), require President to submit and Congress to consider reforms to lower spending, such as:
* Increase premiums (or further increase cost-sharing)
* Overhaul the fee-for-service system
* Develop a premium support system for Medicare
* Add a robust public option and/or all-payer system in the exchange
* Further expand authority of IPAB

http://www.fiscalcommission.gov/sites/fiscalcommission.gov/files/documents/CoChair_Draft.pdf

Comment:

By Don McCanne, Md

Today, behind closed doors, the chairmen of President’s Obama’s deficit commission, Erskine Bowles and Alan Simpson, presented to the other members of the commission their draft proposal for reform. The selections above, from their report, apply to health care.

The reception by the committee members is expressed well by Lori Montgomery of The Washington Post:

“Commission members, who include a dozen sitting members of Congress, emerged from the morning session in a Capitol Hill hearing room praising the seriousness of the effort but voicing deep reservations about the details.”

http://www.washingtonpost.com/wp-dyn/content/article/2010/11/10/AR2010111004029.html

Obviously, some of these proposals are very deleterious. It is not as if the commission didn’t receive suggestions for far better policies to address costs while actually improving our health care system, though they have chosen to ignore them. Following is a quote from the testimony of Margaret Flowers, M.D. of Physicians for a National Health Program:

“The alternative scenario of a national improved Medicare for All will save lives and save money. National improved Medicare for All will place our nation on the path of becoming one of the best health systems in the world – something of which we can all be proud. This commission has the ability to recommend creating a financially sustainable universal health system. I urge the members of this commission to recommend addressing the deficit through adopting this most popular approach: national improved Medicare for All. Don’t cut Medicare. Protect it, improve it and expand it to cover everyone.”

http://www.fiscalcommission.gov/meetings/public-forum/6/Margaret_Flowers_6_30_2010.pdf

Video version (in 6 of 7 at 27:30):
http://www.fiscalcommission.gov/meetings/public-forum/

Deficit commission: Co-Chairs’ proposal

Co-Chairs’ Proposal (Draft Document)

National Commission on Fiscal Responsibility and Reform
November 10, 2010

Reducing Health Care Costs (page 31)

Paying for the “Doc Fix” (page 32)

Savings Beyond the Doc Fix (page 34)

Long-Term Health Care Savings (page 36)

http://www.fiscalcommission.gov/sites/fiscalcommission.gov/files/documents/CoChair_Draft.pdf

Comment:

By Don McCanne, Md

The reception by the committee members is expressed well by Lori Montgomery of The Washington Post:

http://www.washingtonpost.com/wp-dyn/content/article/2010/11/10/AR2010111004029.html

http://www.fiscalcommission.gov/meetings/public-forum/6/Margaret_Flowers_6_30_2010.pdf

Video version (in 6 of 7 at 27:30):
http://www.fiscalcommission.gov/meetings/public-forum/

Single Payer System Takes Center Stage in Vermont

Healthcare Technology News
Tuesday, November 9, 2010

Vermont’s new governor-elect Peter Shumlin makes the case for a single payer system first and foremost as an economic issue based on the trajectory of cost increases for the state, employers and individuals. Shumlin campaigned on a platform that calls for implementation of a single payer system, with benefits that follow the individual and are not a requirement of the employer. The system would reimburse based on outcomes rather than fee for service using technology for medical records and payment. It would also eliminate private insurers and their administrative costs.

Earlier this year, Harvard Economics Professor William Hsiao, an expert on health care systems, was commissioned by the Vermont legislature to develop implementation plans for healthcare system options including a single payer system. In a New York Times interview, Hsiao contends that “you can have universal coverage and good quality health care while still managing to control costs. But you have to have a single-payer system to do it.”

Vermont would require a waiver from the federal government to implement a single payer program. Shumlin is already lobbying President Obama about this waiver. According to Shumlin, “the waivers is the easy part. The hard part is designing a single payer health care system that works and that delivers quality health care, gets insurers off our providers’ backs, has a reimbursement system that makes sense. … I believe if we design that system, we can sell it.“

There is solid evidence to back up Shumlin’s belief. Exit polls tallied 59% of Vermont voters either backing national health care reform as-is (16%) or backing expansion of reform (43%). And with the Vermont executive and legislative branches firmly controlled by one political party, there is the very real opportunity for a viable single payer system to be enacted.

According to Shumlin, “in Vermont, the cost of health care is estimated to increase by $1 billion from 2010 to 2012. For the average Vermont family of four that’s a $7,000 increase on top of the $32,000 that we now spend for health care coverage each year. Our rate of increase exceeds the national average. It is not sustainable. Health care costs are crippling our economy, hampering business growth, driving up property taxes, and bankrupting too many individuals. These costs must be brought under control. The only way to do this is for the state of Vermont to lead the nation in comprehensive health care reform. 47,000 Vermonters have no insurance. When these Vermonters become sick, they are faced with a choice—seek the care they need and risk bankruptcy, or avoid care and face debilitating health or even death. When they do choose to seek care, it is the insured that pay for it. This is an unacceptable choice in a civilized society. It also imposes ethical dilemmas on health care professionals trying to treat the uninsured. Unfortunately, this problem isn’t confined to the uninsured. Tens of thousands of Vermonters are underinsured. All too often Vermonters don’t get the care they need because of unaffordable deductibles, co-pays, and coinsurance.”

Privatizing Medicaid is wrong way to go

By ROBERT PUTSCH
Independent Record (Helena, Mont.), November 5, 2010

The IR’s Oct. 14 headline caught me off guard: “Gov mulls privately run Medicaid.” Is this the same governor who in August 2009, welcomed President Obama saying: “Did you know that, just 300 miles north of here … they offered universal health care 62 years ago?”

Gov. Schweitzer certainly understands that the Canadians didn’t accomplish universal care by privatizing health care programs that are publicly funded. Thanks to excellent coverage by reporter Mike Dennison it appears that the state is considering a five-county Medicaid demonstration project and it includes a proposal from Centene Corp.

So what’s going on? To begin with, Medicaid, at $315.2 billion per year in 2005, covering 60.4 million people, has become the nation’s largest public health insurance program. This caught the attention of health insurance companies. United Health Group and Wellpoint and smaller companies such as Centene all want a cut of the pie.

Centene, in fact, is listed by Goldman Sachs as one of the country’s fastest growing Medicaid HMOs. John Geymen, in his book “Do Not Resuscitate,” says “two of these companies (WellCare and Centene) have grown 300 to 400 percent since their IPOs all within the last six years.” As if to emphasize Geyman’s point, Centene joined the Fortune 500 list this summer.

And these details leave me wondering. How can a company that specializes in managed Medicaid plans and CHIP become a darling of Wall Street?

After all, Medicaid has often been targeted in budget cuts around the country and is widely regarded as being underfunded. Beyond that, all of the money going into Medicaid is tax financed. We’re not arguing here about what percentage of the money is tax based — Medicaid is 100 percent funded by state and federal taxes.

By that measure, Centene is a publicly funded “private” corporation. Geyman once again hits the nail on the head: “Privatization of public programs has clearly been a bonanza for private insurers.”

Listed on the New York Stock exchange as CNC, Centene’s CEO is Michael Neidorff, who earns (according to Reuters) $6.1 million a year and has $9.5 million in stock options. Wall Street likes the company’s ability to generate profits. On July 27, Centene’s CEO laid out the following company policy: “Protecting our earnings stream is crucial and we will continue to be bottom-line focused.”

Hopefully, thinking about how these outfits make tons of money and attract the attention of Wall Street makes you as uncomfortable as it does me. It begs another question: How do companies squeeze profits out of an underfunded public program,?

Massachusetts’ experience is instructive. In 2009 Massachusetts transferred 30,100 green-card-holding immigrants from its state-subsidized insurance program to a Centene subsidiary, CeltiCare. CeltiCare was paid $1,500 per enrollee for a plan that covered less than the one it replaced; $1,500 is well below Kaiser’s projections for adequate care. Eight months after the plan became active, a brief study in the Aug. 5 New England Journal of Medicine accused Centene of “rationing by inconvenience.”

Medicaid managed care plans profit by cutting costs, by exclusionary contract language, and by denying care. In New Jersey, private Medicaid plans enrolled large numbers of low-income families and then denied up to 30 percent of their claims for hospital care. Both Montana and Massachusetts undertook earlier attempts to provide private Medicaid funding in mental health with disastrous results.

But there’s another key item I haven’t mentioned. It’s called the medical loss ratio. Centene’s is variously reported as 81-82 percent. That means that they spend either 81 or 82 cents on every dollar on actual care. The company gets to keep the rest. So if Montana continues down this path, the state will see 18 to 19 cents of every tax dollar spent on Medicaid feed Centene’s bottom line.

Finally, Centene began its involvement in Montana quite a while back. They undertook renovations at the old American Legion baseball park in Great Falls and it’s now called Centene Stadium. They then announced the development of a data processing center in Great Falls. That deal was worked out and had the attention of both state and local development authorities. Makes one wonder whether the current privatization proposal is about health care for families living on the margin or about employment and business. Think about it. What’s the deal here?

The Schweitzer administration and Legislature should focus on building a robust and functional state-managed Medicaid program. At the very least, a state-run program doesn’t have to add a profit motive to the costs of serving children and families in Montana. Beyond that, I liked the rest of Gov. Schweitzer’s comments to the crowd greeting President Obama at the Gallatin Field Airport hangar. He reminded them that the Canadians had recently selected the “father” of Canada’s single-payer health care system, former Saskatchewan Premier Tommy Douglas, as the greatest Canadian.

Remember, Medicaid covers four of 10 births in the U.S. and provides care for one in every three children. Montana can ill afford to expose at-risk families to denials and the profit-making focus of yet another health insurance company.

Robert Putsch, a retired physician and a clinical professor emeritus of medicine at the University of Washington School of Medicine and member of Physicians for a National Health Program, a national organization dedicated to the extablishment of a single-payer sytem, lives year round in Canyon Creek.

Taiwan's Health Reforms: Lessons for the U.S. and Maine

Speaking in Maine
The Maine Public Broadcasting Network, Oct 19, 2010

Listen to the talk by Dr. William Hsiao given at Bates College (mp3)

Taiwan’s Health Reforms: Lessons for the U.S. and Maine

Speaking in Maine
The Maine Public Broadcasting Network, Oct 19, 2010

Listen to the talk by Dr. William Hsiao given at Bates College (mp3)

Deficit commission: Co-Chairs’ proposal

Co-Chairs’ Proposal (Draft Document)

National Commission on Fiscal Responsibility and Reform
November 10, 2010

Reducing Health Care Costs (page 31)

## Medium Term: Fully offset the cost of the “Doc Fix” by asking doctors and other health providers, lawyers, and individuals to take responsibility for slowing health care cost growth. Offsets include:
* Pay doctors and other providers less, improve efficiency, and reward quality by speeding up payment reforms and increasing drug rebates
* Pay lawyers less and reduce the cost of defensive medicine by adopting comprehensive tort reform
* Expand cost-sharing in Medicare to promote informed consumer health choices and spending
* Expand successful cost containment demonstrations
* Strengthen IPAB
* Recommend additional health savings (illustrative examples to follow)
## Long Term: Contain growth in total federal health spending to GDP+1% after 2020 by establishing a process to regularly evaluate cost growth, and take additional steps as needed if projected savings do not materialize

Paying for the “Doc Fix” (page 32)

## Pay doctors, other health providers, and drug companies less and improve efficiency and quality
* Replace cuts required by SGR through 2015 with modest reductions while directing CMS to establish a new payment system, beginning in 2015, to reduce costs and improve quality.
* Require rebates for brand-name drugs as a condition of participating in Medicare Part D.
## Increase cost-sharing in Medicare
* Eliminate first-dollar coverage in Medigap plans.
* Replace existing cost-sharing rules with universal deductible, single coinsurance rate, and catastrophic cap for Medicare Part A and Part B.
## Pay lawyers less and reduce the cost of defensive medicine
* Enact comprehensive medical malpractice liability reform to cap non-economic and punitive damages and make other changes in tort law.

Savings Beyond the Doc Fix (page 34)

## Expand Successful Cost-Containment Demonstration Projects by 2015
## Identify an additional $200 billion savings in federal health spending
## Strengthen the Independent Payment Advisory Board (IPAB)
* Include all providers (no carve-outs) and recommendations on benefit design and cost-sharing.
* Improve savings targets to 1.5% starting in 2015.
* Eliminate the trigger that could turn off IPAB in 2019.
* Allow cost-savings recommendations even when spending does not exceed the target growth rate.
* Allow proposals that apply reforms to health plans in the exchange.
* Require affirmative Congressional approval of recommendations or alternative savings, with a “back-up sequester” increasing premiums and reducing provider payments if IPAB recommendations (or equivalent savings) are not adopted.

Long-Term Health Care Savings (page 36)

## Set global target for total federal health expenditures after 2020 (Medicare, Medicaid, CHIP, exchange subsidies, employer health exclusion), and review costs every 2 years. Keep growth to GDP+1%.
## If costs have grown faster than targets (on average of previous 5 years), require President to submit and Congress to consider reforms to lower spending, such as:
* Increase premiums (or further increase cost-sharing)
* Overhaul the fee-for-service system
* Develop a premium support system for Medicare
* Add a robust public option and/or all-payer system in the exchange
* Further expand authority of IPAB

https://www.nytimes.com…

The reception by the committee members is expressed well by Lori Montgomery of The Washington Post:

http://www.washingtonpost.com…

http://www.fiscalcommission.gov…

Video version (in 6 of 7 at 27:30):
http://www.fiscalcommission.gov…

Free clinic is vital till single-payer health care system arrives

By Andrew D. Coates
The Daily Gazette (Schenectady, N.Y.), Nov. 7, 2010

The Schenectady Free Health Clinic provides high-quality care to some 2,600 patients, about 18 percent of Schenectady County’s uninsured, free of charge. The need for the clinic is increasing.

The Census Bureau recently reported a one-year 10 percent increase in the uninsured – to 50.7 million people, or 16.7 percent of our population. A jump of 4 million people is alarming. Harvard researchers recently showed that for every 1 million with diminished access due to no health insurance, roughly 1,000 people die.

Daunting out-of-pocket expenses, co-insurance payments, co-pays and high deductibles, together with unaffordable premiums, weigh upon everyone. Our nation spends, per person, more than twice what any other nation spends for health care.

Yet for all the money, our health outcomes remain mediocre. Among many health indicators the United States continues to rank dead last among developed nations. In life expectancy our rank in the world is now number 49.

Awareness of the ongoing health care crisis led the Capital District chapter of Physicians for a National Health Program to sponsor a fundraiser for the Schenectady Free Health Clinic on Oct. 29. As physicians we know intimately that preventable tragedy can result when money causes a person to postpone or forgo necessary care.

Because perverse financial incentives so often undermine the practice of medicine, we also recognize the Schenectady Free Health Clinic as an oasis of compassionate care. The event brought over one hundred people together to celebrate the best of our community, including its physicians, people who refuse to forget those most in need. We are pleased to report over $8,500 in new donations for the clinic.

But is something wrong with this picture? Health care crisis? Free clinic? Aren’t we supposed to be “status post health reform”?

The omnibus bill signed by President Obama earlier this year promises to decrease the number of uninsured starting in 2014. Even so, the Congressional Budget Office estimates that if the new health law works just as planned, 10 years from now there will still be about 23 million people with no health insurance.

The cornerstone of the reform is compulsory private health insurance. Curiously, although passed by Democrats, the individual mandate was first proposed by GOP leaders (including George H.W. Bush) and first enacted in 2006 in Massachusetts under Republican Gov. Mitt Romney. The legislation President Obama signed will make it federal policy in 2014.

From the Massachusetts experience we know that the individual mandate can neither control costs nor cover everybody. Because health insurance is simply not affordable for millions who will be required to purchase it, under the new law federal taxpayers will give an estimated $447 billion by 2019 to private insurance companies to subsidize premium payments for those with low incomes.

The reform also aims to add some 16 million people to Medicaid by increasing income eligibility to 133 percent of the federal poverty level (excluding all undocumented immigrants and also legal immigrants who have lived here for six years or less).

Overall, regrettably, reducing by half the number of uninsured while expanding the influence of private insurance companies, means we still need free health clinics. Health reform worthy of the name should eliminate that need.

At the fundraiser for the Schenectady Free Health Clinic, Dr. Paul Sorum, founder of the local chapter of Physicians for a National Health Program, made a spirited appeal. He pointed out that the Schenectady free clinic reminds us all of the way medicine ought to be practiced. Everyone should have access to comprehensive, quality care, with no payments for individual services, he explained, for user fees undermine the doctor-patient relationship.

A system of single-payer national health insurance remains the best way to provide access to care for everybody, with each person paying a fair share. Out of pocket expenses including co-pays, for necessary care, would be eliminated.

Fiscally responsible, single-payer would save about $400 billion annually, eliminating the wasteful paperwork and bureaucracy associated with multiple private insurers while creating strong cost-control tools, like bulk purchasing, needs-based planning and the elimination of profiteering from the sick.

Sooner or later a Medicare-for-all finance system will begin to heal our broken health system. Until then, Schenectady Free Health Clinic will remain vital to our community.

—
Dr. Coates practices internal medicine in Albany. He is assistant professor of medicine and psychiatry at Albany Medical College and newly elected chair of the Capital District Chapter of Physicians for a National Health Program.

http://www.dailygazette.com/news/2010/nov/07/1107_coates/

A Doctor Speaks About Healthcare, Big Business and Justice

The following article was originally posted at Health Reform Watch at the Seton Hall University School of Law, Health Law & Policy Program on Sept. 28, 2010.

By Timothy Shaw, M.D., F.A.C.S.
HEALTH REFORM WATCH, Nov. 9, 2010

Twenty years ago, upon entering private medical practice for the first time it took me about a month to realize that the United States needed “Health Care Reform.” After serving the previous fifteen years in the US Army Medical Corps, I started my first civilian medical job. I was asked to come to a hospital by another surgeon to perform an ear operation on a 3 year old boy at the same time as he would be performing an eye operation. This would save the child from two anesthetics on two different days. Since I had never worked at that hospital, and apparently in order to set me straight from the start, one of the head doctors at this hospital, came up to me in the preoperative holding area, and boldly shoved the child’s chart in my face, pointed to the child’s insurance (Medicaid (Welfare)) and shamelessly told me, “if all you are going to do, is to bring this “****” in here, then we don’t need you to come here.” The poor little guy sitting in the corner with his Mom, was smiling at us with his cute partially toothless grin, and coke-bottle glasses. He didn’t realize what one of his doctors called him because of his health insurance coverage.

Again, several months later I was called to a different hospital (one that I normally did not work at either) in the same city by an operating nurse who asked if I took Medicaid “welfare patients.” She asked me if I would come to their operating room to take a coin out of a 2 year old child’s esophagus. She informed me that their hospital doctors in my specialty did not take welfare patients and they were looking for someone to do the operation as the child had choked on a coin. “Apparently someone forgot to screen this child’s insurance before he came to the operating room.” I canceled my clinic patients and drove across town, performed an esophagoscopy and removed the coin.

Obviously, the doctors in these above scenarios did not support “the Public Option” (Medicaid).

What had happened to our Health Care System? What had changed? Where was the honor that we had in the Army Medical Corps? We treated everyone from Generals to Privates and their families with the same respect. In accordance with Geneva Conventions, we even treated enemy soldiers during the Iraq War in our Combat Support Hospitals with the same care that we treated our own.

In a significant measure the United States Private Health System had changed into “Big Business.” In some measure the humanitarian emphasis had eroded.

Although spurning the pharmaceutical industry as “conflict of interest” entities, not suitable for proper patient care, surprisingly, doctors saw no apparent conflict of interest in merging with the Health Insurance Industry. Doctors and the Health Insurance Business became so closely aligned that their DNA intertwined to form a new species. This powerful new combined-arms team became the forme fruste of our new United States Health Care Industry. Doctors armed with new found business tactics, and the Health Insurance Industry armed with the legitimacy of the Doctor’s legal authority to limit health care to patients became the de facto United States Health Care System.

The business meeting replaced the medical conference to discuss “patient care” issues. To cope with the ever burgeoning bureaucracy, more and more doctors went into administration. More doctors have their MBA’s then carry black bags and make house calls. Mergers, Acquisitions, Expansions, Contracts, Covered Lives, Marketing Strategy, Demographics, Competition Threat Forecasts, Actuarial Science, and Health Insurance became the focus of many doctors. Time was spent on avoiding insurance business risk, trying to avoid the high risk patients, finding the better payer groups, etc. Hospitals became less hospitable. Doctor’s began to discharge patients so rapidly, that in the mid 1980’s the majority of States passed consumer protection laws (”Drive By Delivery Laws”) to protect mothers/newborns from being discharged from the hospital too soon.

Currently, the U.S. health care system is outrageously expensive, yet inadequate. Despite spending more than twice as much as the rest of the industrialized nations ($7,129 per capita), the United States performs poorly in comparison on major health indicators such as life expectancy, infant mortality and immunization rates.

Expenditures in the United States on health care surpassed $2.2 trillion in 2007, more than three times the $714 billion spent in 1990, and over eight times the $253 billion spent in 1980. The reason we spend more and get less than the rest of the world is because we have a patchwork system of for-profit payers. Combined, this needless administration consumes one-third (31 percent) of Americans’ health dollars.

Moreover, the other advanced nations provide comprehensive coverage to their entire populations, while the U.S. leaves 45.7 million completely uninsured and millions more inadequately covered. Spain has a constitutional law guaranteeing health care for all of its citizens. The United States is the only industrialized nation that does not have a single payer government national health plan covering all of its citizens.

More Americans die of lack of health insurance than terrorism, homicide, drunk driving and HIV combined. Lack of health insurance kills 45,000 American adults a year, according to a new study published in the American Journal of Public Health. One out of three Americans under age 65 had no private or public health insurance for some or all of 2007-2008. Even with health insurance, many Americans are a medical crisis away from bankruptcy. Research shows 62 percent of all bankruptcies in 2007 were medical, a share up 50 percent since 2001. Most of the medically bankrupt had health insurance. American Manufacturing is down, but not American Manufacturing of poor people. In Canada, where they have a single payer government managed health insurance system, bankruptcy filings due to medical bills are precisely zero (0).

Contrary to myth, the United States does not have the world’s best health care. We’re No. 1 in health care spending, but No. 50 in life expectancy, just before Albania. In Japan, people live four years longer than Americans. Canadians live three years longer. Forty-three countries have better infant mortality rates.

Our Health Care System is unjust. It is unjust in part for some of the following reasons:

Much of the medical research in our country is supported with public tax money through the National Institute of Health Grants. At present, this benefits only those lucky enough to have “good health insurance.”

Many of our hospitals were founded by the hard work of ALL citizens, not just corporate health care institutions. In the late 1800’s Catholic nuns from St. Louis hitched their horses to wagons and rode into the North West Territories armed with a Mission Statement from God to “cure the sick, care for the poor, comfort the dying” and built our first hospitals. They built these hospitals for ALL citizens, not just the patients with “good” insurance.

Our health care system is unjust because patients of minority background get less care and inadequate care compared to white patients, based on evidence published in numerous medical studies. The same arguments which justified slavery as an institution in the 1860’s are used today to justify our current for-profit health care and health care insurance industries — “we don’t want government telling us what to do; we can’t change our lifestyle and our way of life; we don’t want interference with our benefits; we don’t want you to
interfere with our economy, the jobs of the health insurance industry.” These statements are made notwithstanding the basic injustice perpetrated on others by our current health care system.

Our Health Care System is unjust because patients are discriminated against based on their ability to pay. Some doctors and dentists will not see “No insurance / Self Pay ” or Medicaid patients, even though their degrees were issued by publicly funded medical and dental schools.

Our Health Care System is unjust because Doctors charge different patients different prices for the same service based on their insurance or employer. If one would go to a gas station and be told that you have to pay $6 a gallon of gas but that your neighbor has to pay $3 because of who you work for — there would be civil war. But this is how health care is billed. Often the person without insurance is charged more for the same service.

It is unjust because patients do not have the liberty to pick their own doctor. Every time their employer switches health insurances as a business decision, the employees often have to switch doctors. This is an inefficient system, particularly for those with chronic diseases, such as cancer, asthma, etc.

Our healthcare system is unjust because of cost. A man showed me his mother’s hospital bill when she delivered him in 1937. For 5 days in the hospital, room, meals, nursing care and the delivery – $175. Today if you go to a clinic to get earwax removed by a doctor taking only two minutes – it costs almost twice that !!

It is unjust because, although many of the discoveries of medicine were not the work of American Medical/Insurance Industry, the discoveries are then used to create private profit for our present Health Care System. For example, when the Austrian Pathologist Karl Landsteiner won the Nobel Peace Prize for his 1903 discovery of the ABO Blood Groups which made blood transfusions safe, saving billions of lives, he gave his discovery to humankind, not a patent lawyer.

Our healthcare system is unjust for the reason that people without health insurance just as likely had fathers and grandfathers who laid on the sands of Normandy and Iwo Jima, and whose sons and daughters are serving and dying in the service of our country today.

Our health system is unjust because of huge profit taking. Health insurance executives don’t worry about going bankrupt from getting sick. Forbes reports that two large Health Care Corporation CEO’s made $121 million and $57 million respectively in the last five years. While The Medical /Insurance Industry, and Pharmaceutical industries make billions in private profits, our citizens are lining up at a county fair, in neglected health, with their teeth rotting from their heads, just to be seen once at a free medical/dental clinic set up in a barn with freshly swept farm animal stalls.

Health Care is an essential human service which should be part of a public trust, not sold as a for-profit commodity. It has the same essentiality as Clean Air, Clean Water, Roads, Rivers, Police and Fire Protection and should be afforded the stature of Public control.

I’ve often wondered why educated people and our leaders cannot see the injustice of our healthcare system. In a historical context however, it is inconceivable to think that the man who wrote “We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness,” could see his slaves working in his fields as he looked out his window.

To right the injustices perpetrated by the British against his countrymen, Thomas Jefferson would write the words which lent justification and strength to his fellow patriots to fight the world’s most powerful army and navy. However, Jefferson’s quill had not the power to convince his countrymen to right an injustice perpetrated by themselves against another people. This would be a conflagration for another time, another generation.

Let us encourage our congresswomen and men to have the moral courage to pass legislation long overdue, to create equality in health care. They should establish a national healthcare insurance plan as a civil right of American citizenship. Let’s abandon our current “Lobbyocracy” and create a true “Democracy.” They should forgo the influence of lobbyist’s money, and “establish justice and promote the general welfare” by creating a health care system that serves and cares for the people.

Some say that we don’t want a Canadian or British style healthcare system. I say let’s make America’s healthcare system look like the United States space program compared to Britain’s or Canada’s! If we put our nation’s collective will together — Americans can do anything. Let us create a publicly funded national health insurance plan to restore to every American their dutiful respect and “unalienable rights.”

Thomas Jefferson’s last words in the Declaration of Independence ring true today: “And for the support of this declaration, with a firm reliance on the protection of Divine Providence, we mutually pledge to each other our lives, our fortunes and our sacred honor.”

Timothy Shaw, M.D. F.A.C.S.
Fitchburg, Wisconsin

http://www.healthreformwatch.com/2010/09/28/a-doctor-speaks-about-healthcare-big-business-and-justice/

Health insurers sit pretty at their customers' expense

'People aren't getting the care they need because they have to pay more out of pocket,' says the president of Consumer Watchdog.

By David Lazarus
Los Angeles Times, November 9, 2010

It’s a good time to be a health insurer.

Three of the biggest names in the insurance game reported rock-solid profits last week. Aetna said its third-quarter net income jumped 53% over the same period last year, to $497.6 million. WellPoint, parent of Anthem Blue Cross in California, said its profit rose 1.2% to $739.1 million. Health Net posted a net income of $62.7 million, compared with a loss of $66 million a year earlier.

Angela Braly, chief executive of WellPoint, attributed the company’s strong performance to “disciplined administrative expense control.”

Aetna CEO Ronald Williams was more expansive. He cited “a reduction in utilization of healthcare services after the surge we saw in 2009, combined with appropriate pricing and effective medical quality and cost management.”

Well, that sounds fine and dandy until you parse what exactly he’s saying.

That “reduction in utilization of healthcare services” basically means fewer people went to the doctor. Did we all suddenly become healthier? Not likely.

Jamie Court, president of Consumer Watchdog, a Santa Monica advocacy group, said Americans are skipping doctor visits because they’ve switched to plans with higher deductibles or their employers have jacked up co-pays.

“People aren’t getting the care they need because they have to pay more out of pocket,” he said.

This raises an interesting question about the looming reform of the nation’s healthcare system, under which everyone will be required to have insurance. If available coverage is too pricey for people to use, will Americans be any better off, health-wise?

While most insurance policies will cover catastrophic events, it’s entirely possible that healthcare costs will be too high for the sort of routine care or preventive treatment that can head off illnesses before they become debilitating.

Then there’s that bit from Williams about “appropriate pricing.” What’s that mean?

“Rate increases,” answered Sabrina Corlette, a research professor at the Georgetown University Health Policy Institute. “It means higher rates, as well as more aggressive underwriting that excludes people for certain conditions or charges them higher premiums.”

In September, the California Department of Insurance approved a 19% rate increase for 65,000 Aetna policyholders.

This followed rate hikes of as much as 29% for Anthem Blue Cross, Blue Shield and Health Net, affecting more than 1 million policyholders.

According to the Kaiser Family Foundation, workers now pay 47% more for family health coverage they receive through their jobs than they did five years ago, while wages have gone up only 18%.

And what about “effective medical quality and cost management”?

Court at Consumer Watchdog said this is just another way of saying that insurers are denying more claims. “It’s code for some bureaucrat somewhere telling people that a treatment isn’t necessary,” he said.

The average health insurance agent now receives more than 200 requests annually from clients to provide assistance in pursuing a claim, according to a survey released this month by the National Assn. of Insurance and Financial Advisors, an industry group.

Most agents say they have to contact an insurer at least twice on behalf of a client, the survey found. Eleven percent say they have to make six or more calls in trying to help resolve a claim.

“The most effective cost management for insurers is to decline services,” said Ron Pollock, president of the advocacy group Families USA. “And when there’s a dispute, it’s often very difficult to get a satisfactory result from an insurance company.”

It’s a good time to be a health insurer. For patients, clearly, not so much.

http://www.latimes.com/health/la-fi-lazarus-20101109,0,1116186.column

Health insurers sit pretty at their customers’ expense

‘People aren’t getting the care they need because they have to pay more out of pocket,’ says the president of Consumer Watchdog.