PNHP

L.A. County slashes doctors' reimbursement rate

L.A. County slashes doctors' reimbursement rate

L.A. County slashes doctors’ reimbursement rate

By Molly Hennessy-Fiske and Ron-Gong Lin II
Los Angeles Times
February 17, 2010
Emergency room doctors and on-call specialists treating poor, uninsured patients at private hospitals in Los Angeles County saw their reimbursement rate slashed by county supervisors Tuesday.
The rate cut could lead private hospitals to close emergency rooms and send more patients to crowded county hospitals, officials said.
L.A. County reimburses doctors 27% of estimated fees for patients’ first three days of care at private hospitals under the Physician Services for Indigents Program. Supervisors voted unanimously Tuesday to reduce the rate to 18% as of July 1.
The county had expected to pay doctors with $9 million from the state’s Emergency Medical Services Appropriation. But state lawmakers eliminated the fund, and as the number of uninsured grows, private doctors are expected to file more claims than ever with the county this year, Meyer said.
More than half of Los Angeles County’s 72 hospitals are operating at a deficit and two are in bankruptcy, Lott said (Jim Lott, executive vice president of the Hospital Assn. of Southern California). Countywide, 11 hospitals have closed since 2002, all of which had emergency rooms, he said.
http://articles.latimes.com/2010/feb/17/local/la-me-supes-uninsured17-2010feb17

“The County” – a hospital to which emergency patients with no money and no insurance are shipped. Most of us remember when The County was always the provider of last resort.
No longer. Any hospital with an emergency room, for humane reasons, must now provide emergency services to any person who presents with a bona fide emergency, regardless of the ability to pay. Unfortunately, the change in attitude of some occurred only after it became a criminal offense to fail to recognize that “ship ’em to The County” fell short of a humane response. The fact that this legislation was needed should not reflect on the great many dedicated professionals who have always been ready to help, without any regard to the financial status of the patient.
But what about paying for this care? Should the private hospitals and physicians write this off as charity? When operating at a deficit with bankruptcy around the corner, that won’t work. Should the county, as the health care provider of last resort, pay for at least the costs of the care? State and local governments are struggling with deficits in their budgets. The 18 percent payment by Los Angeles County’s Physician Services for Indigents Program obviously won’t cover costs. And the state certainly is not helping by eliminating their Emergency Medical Services Appropriation.
There is a way we could do this. We could establish a single payer national health program – an improved and expanded Medicare that includes everyone. Under such a system, even those physicians who have had difficulty understanding a humane health care system would change their response. When that emergency call comes in that always means another paying patient, it will become natural for those physicians to say, “Ship ’em here!”

L.A. County slashes doctors’ reimbursement rate

L.A. County slashes doctors’ reimbursement rate

By Molly Hennessy-Fiske and Ron-Gong Lin II
Los Angeles Times
February 17, 2010

Emergency room doctors and on-call specialists treating poor, uninsured patients at private hospitals in Los Angeles County saw their reimbursement rate slashed by county supervisors Tuesday.

The rate cut could lead private hospitals to close emergency rooms and send more patients to crowded county hospitals, officials said.

L.A. County reimburses doctors 27% of estimated fees for patients’ first three days of care at private hospitals under the Physician Services for Indigents Program. Supervisors voted unanimously Tuesday to reduce the rate to 18% as of July 1.

The county had expected to pay doctors with $9 million from the state’s Emergency Medical Services Appropriation. But state lawmakers eliminated the fund, and as the number of uninsured grows, private doctors are expected to file more claims than ever with the county this year, Meyer said.

More than half of Los Angeles County’s 72 hospitals are operating at a deficit and two are in bankruptcy, Lott said (Jim Lott, executive vice president of the Hospital Assn. of Southern California). Countywide, 11 hospitals have closed since 2002, all of which had emergency rooms, he said.

http://articles.latimes.com/2010/feb/17/local/la-me-supes-uninsured17-2010feb17

“The County” – a hospital to which emergency patients with no money and no insurance are shipped. Most of us remember when The County was always the provider of last resort.

No longer. Any hospital with an emergency room, for humane reasons, must now provide emergency services to any person who presents with a bona fide emergency, regardless of the ability to pay. Unfortunately, the change in attitude of some occurred only after it became a criminal offense to fail to recognize that “ship ’em to The County” fell short of a humane response. The fact that this legislation was needed should not reflect on the great many dedicated professionals who have always been ready to help, without any regard to the financial status of the patient.

But what about paying for this care? Should the private hospitals and physicians write this off as charity? When operating at a deficit with bankruptcy around the corner, that won’t work. Should the county, as the health care provider of last resort, pay for at least the costs of the care? State and local governments are struggling with deficits in their budgets. The 18 percent payment by Los Angeles County’s Physician Services for Indigents Program obviously won’t cover costs. And the state certainly is not helping by eliminating their Emergency Medical Services Appropriation.

There is a way we could do this. We could establish a single payer national health program – an improved and expanded Medicare that includes everyone. Under such a system, even those physicians who have had difficulty understanding a humane health care system would change their response. When that emergency call comes in that always means another paying patient, it will become natural for those physicians to say, “Ship ’em here!”

“Medicare for All: Still the One”

Remarks by Kip Sullivan
Conference call hosted by Healthcare-NOW! 
February 16, 2010

INTRODUCTION

It’s easy enough to explain why the “public option” was defeated. It’s a lot harder to explain why it rose to prominence in the first place. Even in the watered down form in which it was adopted by Democrats, the PO was probably no more politically feasible than single-payer was, but it was a lot harder to explain. And the watered down form wouldn’t work, and it probably wouldn’t even have survived.

The PO was so tiny when Democrats introduced it in June 2009 that it is fair to say it was moribund upon arrival if not dead on arrival. It was placed on life support when Sen. Reid struck it from the Senate bill in November, and it was finally put out of its misery by the election of Scott Brown in MA in January of this year.

The PO wasn’t politically feasible in 2009 for the obvious reason that it was opposed by the same people who would have opposed a single-payer system. Perhaps as importantly, the PO wasn’t politically feasible because the people who promoted it weren’t serious enough about it to make it a condition of their support for the Democrats’ bill.

So it’s pretty easy to explain why the PO fell. What’s not so easy to explain is why a lot of smart people thought the PO was such a good idea to begin with and why, if they thought it was such a good idea, they didn’t make it their bottom line. When the campaign for the PO began in 2005, it wasn’t at all clear that the leaders of the campaign intended to throw the PO overboard if that’s what it took to get Congress to pass an insurance industry bailout (by which I mean the individual mandate and the subsidies to make the mandate affordable). But by June 2009, it was clear the leaders of the PO campaign had NO intention of making a big, powerful PO a condition that Democrats had to meet. And by Xmas Eve 2009, it was clear the PO campaign had no intention of even making a TINY, ineffective PO a precondition for its support.

It appears, in short, that the leaders of the PO campaign saw an insurance industry bailout as more important than the PO. Many leaders of the PO campaign may even have seen the PO as merely a fig leaf to induce progressives (both inside and outside of Congress) to think it was ok to support a bailout.

The modern version of the PO was brought to us by Jacob Hacker. And it was promoted by Health Care for America Now and the Herndon Alliance. The Herndon Alliance has received much less publicity than HCAN, but it played a seminal role in the development of the PO campaign. So, to understand why the proponents of the PO supported it, but not enough to make it a non-negotiable demand, it helps to review the thinking of Hacker and of the founders of HCAN and the Herndon Alliance.

I doubt I’ll have enough time to describe both Hacker’s thinking and that of the Herndon Alliance and HCAN leaders. I think what I’ll do is describe Hacker’s original version of the PO, his rationale for it, what happened to the PO after it arrived in Congress in 2009, and how Hacker accommodated himself to the degradation of the PO. And then, if I have any time left over, I’ll talk briefly about the Herndon Alliance and HCAN. If I don’t have time to talk about HCAN and the Herndon Alliance, that’s ok. Their thinking pretty much mirrored Hacker’s. Like Hacker, they saw single-payer as politically infeasible; they started out supporting a big PO as a more politically feasible substitute for single-payer; and they didn’t object when congressional Democrats unveiled a microscopic form of the PO in June.

THE ORIGINAL HACKER PROPOSAL

Hacker first proposed what he called Medicare-Plus in a paper he wrote in 2001. He published another version of his idea in 2007. In that second paper, he called his idea Health Care for America. The label “public option” didn’t appear till early 2009.

Hacker’s idea, basically, was to have the federal government create a health insurance company that would sell health insurance to the nonelderly. Hacker assumed this company would enjoy all the efficiencies of Medicare and would therefore be able to undersell the insurance industry. Hacker never used the word “company” or “business” to describe the federal program he had in mind. Instead, he repeatedly described his proposed public entity as a program that would be “like Medicare.” Hacker’s refusal to use appropriate terminology contributed greatly to the confusion that became rampant among PO advocates by 2009.

There is, of course, a huge difference between what Hacker was proposing and Medicare. Medicare is a single-payer program – it’s the only insurer of basic medical services for Americans over 65 and the disabled. Because it is a single-payer insuring such a large population, and moreover a population with above-average medical needs, Medicare enjoys advantages that the insurance industry will never enjoy, including huge size, low overhead, and an ability to induce docs and hospitals to accept below-industry reimbursement rates.

The public company Hacker was proposing would have to compete with 1,500 other insurance companies within the multiple-payer jungle. The public company he was proposing would NOT be a single-payer – it would be just one insurance company among hundreds. It’s therefore far more accurate to refer to what Hacker was proposing as a company, a corporation, or a business that would be set up by the government. It was ALWAYs misleading for Hacker to refer to his proposed entity as a government program like Medicare, and it was EXTREMELY misleading for him and his acolytes to continue doing so after the Democrats adopted a microscopic version of the PO.

However, the early version of the PO that Hacker proposed DID have the potential to become a Medicare-for-all program for nonelderly Americans. In his 2001 and 2007 papers, Hacker said he wanted to give his public insurance company several very important advantages that would have allowed the company to start out with enormous size and to grow even larger early in its life. Hacker proposed five advantages or criteria for his original PO:

(1) It had to be prepopulated (he would have shifted Medicaid and SCHIP enrollees and all or some of the uninsured into the PO);
(2) Subsidies would go only to the PO;
(3) It would be open to all non-elderly Americans;
(4) It would have the authority to use Medicare rates (this was not as important as the first three criteria); and
(5) The insurance industry had to offer the same coverage.

According to an analysis of Hacker’s 2007 paper by the Lewin Group, Hacker’s original PO would have enjoyed premiums 23% below those of the insurance industry and would have enrolled 129 million people, or about half the non-elderly population. According to the Lewin Group, Hacker’s original version of the public company would grow rapidly, from insuring half the non-elderly in 2008 to two-thirds of the non-elderly within a decade. Conversely, the insurance industry’s share of the non-elderly market would shrink from half to 35% within ten years.

In my view, the Lewin Group grossly underestimated how much damage Hacker’s original version of the PO would do to the insurance industry. I think a public insurer with half the non-elderly population and premiums at 23 percent below the industry’s would have quickly destroyed the insurance industry. Twenty-three percent is an enormous differential. To put 23 percent in perspective, consider that HMOs in the 1980s had premiums only 5-10% lower than the traditional non-managed-care insurance companies they eventually displaced. Even though most Americans didn’t want to be in HMOs, employers all over the country pushed their employees into HMOs in order to take advantage of that 5-10 percent pre
mium differential. And that was two decades ago when premiums took less of a bite out of everyone’s pocket. Can you imagine how fast employers would dump their existing insurance company today for a 23 percent cut in their premium, especially if the PO were as kind and gentle as PO advocates say it would be?

It’s hard to believe that someone as informed about health policy as Hacker didn’t know his original PO had the potential to become a single-payer for the non-elderly. Let me read to you a portion of a transcript of a phone conference call sponsored by EPI on January 11, 2007 in which two participants, Ezra Klein (a blogger for the Washington Post) and Bob Kuttner (co-editor of the American Prospect), asked Hacker why he thought his proposal would succeed any better than Clinton’s 1993 Health Security Act. Klein says, “What you’ve proposed here is much more fundamentally dangerous to the actors who killed it [ie, the Clinton bill] the last time around.” Kuttner, who must have seen an early draft of the Lewin report, says, “[Y]ou’re setting in train a gradual process whereby the whole system gradually shifts from 50/50 [meaning, 50 percent are in the public program and 50 percent are insured by the insurance industry] to 60/40 to 70/30. So after a couple of generations, almost everybody is in the quasi-Medicare program. Is that the intent?”

Hacker denied that was his intent. He agreed that the PO would start out at 50 percent, but then it would basically just get stuck there despite its enormous cost advantages over the private insurance industry. Here’s what Hacker said: “[Lewin] did not forecast a huge shift over just a 10-year period. I think it was a shift of two percentage points over that period. So, at that rate, we’d have everyone within Medicare in about 250 years.”

But Hacker was wrong. As I’ve already told you, when the Lewin Group released its analysis of Hacker’s proposed program a year after this conversation took place, they projected a 34% increase in the PO’s enrollment over a decade, not 2%. And as I said, I think Lewin was being way too conservative.

Hacker’s answer to Klein and Kuttner illustrates the strange state of denial Hacker and other PO advocates induced in themselves as they tried to sell the PO as a politically feasible alternative to single-payer even though it would, in its original form, do a lot of damage to the insurance industry and would probably have led to a single-payer for the non-elderly.

But Hacker’s confusion (and the confusion of other PO leaders) over whether the PO would be more feasible than a single-payer was MINOR compared to the confusion that set in when congressional Democrats adopted a microscopic version of Hacker’s original PO. When the Democrats released their draft legislation in June 2009, it was clear they had stripped out four of the five criteria for the public company that Hacker had specified in his original papers.

The only criterion the Democrats kept was the one requiring insurance companies to offer the same coverage as the PO. The other four criteria –
• the one calling for prepopulation of the PO,
• the one requiring that only the PO get subsidies,
• the one requiring that the PO be available to all non-elderly Americans, and
• the one authorizing Medicare’s reimbursement rates

– all four of those criteria were gone. Now it was crystal clear to anyone who understood what Hacker had originally proposed that the PO the Democrats had adopted was so small it wouldn’t affect the insurance industry. The Congressional Budget Office said the Senate version of the PO would insure no one; it said the House version would insure 10 million, and then later scaled that back to 6 million.
Now that the PO had been shriveled down from 129 million people to zero to 6 million, PO advocates faced not only the same old political feasibility problem (the insurance industry and the Republicans continued to scream about the tiny PO as if it were a big PO or a single-payer), but they also faced a huge logistical problem. A PO that represented no one on the day it opened for business wouldn’t be able to crack most insurance markets in the US, and might not even be able to survive.

This is where Hacker’s habit of always comparing the PO to Medicare became extremely misleading. When Medicare commenced operations on July 1, 1966, it represented nearly all seniors. With the exception of a few hospitals in the south that temporarily resisted integrating their facilities, all clinics and hospitals in America immediately began accepting Medicare enrollees even though there was no law requiring them to do so. The reason all clinics and hospitals did that is that Medicare represented an enormous constituency on day one and providers didn’t want to walk away from so many patients and so much money.

The tiny PO the Democrats incorporated into their bills was no Medicare. It would represent no one on the day it opened for business. It would have to do what NO insurance company has done in the last three or four decades, which is to create a new, successful insurance company in every state in the US. In fact, I’m pretty sure no insurance company has expanded into even ONE new market in the last three decades by building a new insurance company from scratch. For the last three decades, insurance companies that wanted to expand their empires have done so by BUYING their way into new markets. That is, they bought an existing insurance company.

But Hacker and other PO advocates blithely ignored this issue. They ignored it because they continued to talk about the Democrats’ PO as if it were the same huge PO Hacker had originally proposed. I might add that the CBO totally ignored this issue as well. The CBO never examined the issue of whether the PO would be able to crack even one US market, much less all of them. I think the CBO was being extremely generous to the House version of the PO when they said it would insure 6 million people.

Nevertheless, as inexplicably rosy as it was, the CBO’s reports on the PO sealed its fate. The poor PO was already hated by the right wing and the insurance industry. It was being promoted by people who cared more about an insurance industry bailout than the PO. And now the CBO was revealing the truth about the Democrats’ version of the PO – that it was laughably small and for that reason was going to save little or no money.

When Democrats throughout Congress, especially those in swing districts, asked themselves why they should vote for something as controversial as a PO when the darn thing wouldn’t save any money, PO advocates had no answers.

To sum up: The PO rose to prominence because powerful Democratic constituency groups thought single-payer was not feasible but the PO was. They were wrong. The PO failed politically, and it failed as a policy idea. Politically, it turned out to be no more feasible than single-payer. As a policy, it was a disaster. The tiny PO adopted by Democrats would have accomplished nothing other than to embarrass all of us who believe government must play a prominent role in insuring the uninsured

Is Medicare "close enough" to universal?

Measuring Coverage for Seniors in Medicare Part A and Estimating the Cost of Making It Universal

By Michael Birnbaum and Elizabeth M. Patchias
Journal of Health Politics, Policy and Law
February 2010

Medicare’s Part A Coverage Gap in the Context of National Health Care Reform

The fact that 1.6 million seniors in the United States — 5 percent of the elderly population — are without full federal Part A coverage is a significant policy issue. While Medicare is widely understood to cover the entire elderly U.S. population, this is at best a substantial exaggeration of Medicare’s reach and perhaps a mischaracterization whose broad acceptance preempts a national debate about Medicare eligibility policy and clouds the existing debate on universal coverage.

Will a national discussion on Medicare eligibility get at least a little traction? At this point it seems unlikely because of a powerful counterargument that Medicare is close enough to universal and that seniors without the full federal Part A benefit have other public programs and sources of government funding to support their health care needs, with some ultimately gaining Medicare Part A through their state Medicaid programs. This argument is valid and empirically strong, but it hangs on a normative question: when we are dealing with Medicare eligibility policy in the context of a national discussion about universal coverage, should we settle for “close enough” and accept that, when people fall through the cracks of Medicare’s eligibility framework, Medicaid and the states will be there as a last resort?

http://jhppl.dukejournals.org/cgi/content/abstract/35/1/49?etoc

And…

Projected Impact of Senate Health Reform Bill; Estimates of Alternative Designs

RAND
February 16, 2010

The (RAND) study finds that health care legislation passed by the Senate in December would cut the number of uninsured Americans to 25 million by 2019 (a 53 percent decrease).

http://www.rand.org/news/press/2010/02/16/

Comment:

By Don McCanne, MD

At what level do we say that the rate of coverage under a universal program is “close enough”? For Medicare Part A, we’ve already answered that question. Covering 95 percent of those over age 65 is “close enough,” leaving 1.6 million seniors out of the Part A program (primarily hospital care).

We now hear from our politicians that the Senate reform bill awaiting approval in the House is “close enough” to universal coverage, cutting the number of uninsured in half, leaving only 25 million without coverage, according to this new RAND report.

Many suggest that we abandon the term “single payer” and use “Medicare for All” instead. Universal coverage under single payer means 100 percent – everyone is included automatically, not 95 percent like Medicare Part A.

When we choose to use the Medicare rhetoric because it would resonate better with some audiences, we should refer to it as “improved Medicare for All.” That’s simply code language for replacing Medicare’s numerous flawed policies with a bona fide single payer program – a program that removes financial barriers to health care for absolutely everyone.

During the health reform dialogue, when someone says, “close enough,” you know that person is supporting flawed policies. Jump in immediately, protesting that “close enough” isn’t good enough when we have better policies that will get all of us all the way there.

Is Medicare “close enough” to universal?

Measuring Coverage for Seniors in Medicare Part A and Estimating the Cost of Making It Universal

By Michael Birnbaum and Elizabeth M. Patchias
Journal of Health Politics, Policy and Law
February 2010

Medicare’s Part A Coverage Gap in the Context of National Health Care Reform

The fact that 1.6 million seniors in the United States — 5 percent of the elderly population — are without full federal Part A coverage is a significant policy issue. While Medicare is widely understood to cover the entire elderly U.S. population, this is at best a substantial exaggeration of Medicare’s reach and perhaps a mischaracterization whose broad acceptance preempts a national debate about Medicare eligibility policy and clouds the existing debate on universal coverage.

Will a national discussion on Medicare eligibility get at least a little traction? At this point it seems unlikely because of a powerful counterargument that Medicare is close enough to universal and that seniors without the full federal Part A benefit have other public programs and sources of government funding to support their health care needs, with some ultimately gaining Medicare Part A through their state Medicaid programs. This argument is valid and empirically strong, but it hangs on a normative question: when we are dealing with Medicare eligibility policy in the context of a national discussion about universal coverage, should we settle for “close enough” and accept that, when people fall through the cracks of Medicare’s eligibility framework, Medicaid and the states will be there as a last resort?

http://jhppl.dukejournals.org/cgi/content/abstract/35/1/49?etoc

And…

Projected Impact of Senate Health Reform Bill; Estimates of Alternative Designs

RAND
February 16, 2010

The (RAND) study finds that health care legislation passed by the Senate in December would cut the number of uninsured Americans to 25 million by 2019 (a 53 percent decrease).

http://www.rand.org/news/press/2010/02/16/

Comment:

By Don McCanne, MD

At what level do we say that the rate of coverage under a universal program is “close enough”? For Medicare Part A, we’ve already answered that question. Covering 95 percent of those over age 65 is “close enough,” leaving 1.6 million seniors out of the Part A program (primarily hospital care).

We now hear from our politicians that the Senate reform bill awaiting approval in the House is “close enough” to universal coverage, cutting the number of uninsured in half, leaving only 25 million without coverage, according to this new RAND report.

Many suggest that we abandon the term “single payer” and use “Medicare for All” instead. Universal coverage under single payer means 100 percent – everyone is included automatically, not 95 percent like Medicare Part A.

When we choose to use the Medicare rhetoric because it would resonate better with some audiences, we should refer to it as “improved Medicare for All.” That’s simply code language for replacing Medicare’s numerous flawed policies with a bona fide single payer program – a program that removes financial barriers to health care for absolutely everyone.

During the health reform dialogue, when someone says, “close enough,” you know that person is supporting flawed policies. Jump in immediately, protesting that “close enough” isn’t good enough when we have better policies that will get all of us all the way there.

Hearts and Minds

DON’T MOURN – ORGANIZE

By Clyde Winter
December 15, 2009

http://clydewinter.wordpress.com/2009/12/15/dont-mourn-organize/

I’m not his only friend, by a long shot. Skip is respected and well liked by a whole lot of people. He was a fellow seaman and a millwright, a member of the Masters, Mates and Pilots Union, the Carpenter’s Union, an organizer for justice and human rights and the IWW. He loved family and friends, and he valued and respected life and people.

He was working as a millwright when he got sick, and the illness and treatment made him unable to continue working, which, of course, cost him the health insurance coverage he had at the time he became ill. Months of recuperation and healing followed, but when he experienced symptoms that caused him to again seek medical help, he was turned down flat due to his lack of private wealth and the lack of health insurance, which was caused by his lack of current employment, which was caused by his previous illness and treatment. This left him a healthcare “choice” between realizing that he was at the end of his rope, or hanging on to “Hope”. Any “Hope” he had might have been based partly on the fact that he was just months away from becoming eligible for Medicare.

On the day he became eligible, Skip showed up at the hospital, which immediately admitted him, considering his signs, symptoms, and history. He was soon released from the hospital. But that wasn’t good news. There was nothing the doctors and nurses and technicians could do for him, because the delay in getting “eligibility” to receive health care had been too long. So he died soon afterward. A couple weeks ago.

I campaigned one day at the Ozaukee County Fair during the summer of 2008. (I ran as an Independent in 2008 for the state senate against a career politician Republican incumbent who had never before faced an opponent in a general election, despite his notorious voting record.) I approached a family that was just getting up from a picnic table and cleaning up after brats and a soda, and introduced myself. “What do you think is the most important issue in this election?”, the young father asked me. “I guess I’d have to say the health care crisis”, I replied. “We know something about that”, he said. And he (and his wife) proceeded to tell me what they knew, with their ten year old daughter quietly and carefully listening.

He was a machinist by trade, his family covered by health insurance that was the “choice” of his employer, with the fine print written in the policy the “choice” of the insurance company. Co-pays and deductibles, coupled with the cost of providing for a family and preparing for future educational expenses, encouraged him to make the usual “choice” to forgo comprehensive regular physical exams and preventive care, since he felt fine and healthy as usual, until the day he felt he had no “choice” but to see a doctor. The news was not good, and the treatment necessary was extensive and expensive due to the late diagnosis.

The insurance policy exemptions and co-pays and “reviews” resulted in substantial cost not being covered by insurance, and in the family quickly depleting all savings and credit. (The treatment was such that the father could not continue working, and since they, like virtually all working families in similar circumstances, could not afford to “choose” to make COBRA payments, the family no longer had health insurance.) They were informed by the hospital administrators that in order to continue the treatment plan, they would have to “choose” to sign a payment plan. Well, a payment plan does not even have the slim legal protections that remain for personal bankruptcy. A payment plan is whatever you agree to. And the administrators wanted everything this family owned in order to continue with the treatment plan.

You may be surprised that the husband and father actually had to think it over. The treatment, after all, was not an elective option – it was a life or death “choice”. But despite this, he was unable to immediately sign the papers, although his life was clearly at stake. Could you have signed the payment plan knowing that it would render your family homeless and deeply in debt for the foreseeable future? That if you lost the gamble and died, you would die knowing that your wife and children would be destitute and without even a place to live?

While the family was considering their awful healthcare “choice”, the hospital sent a social worker with some counsel and some brochures. They were gently and courteously informed by the nice hospital employee about the hospice care program that was available to them.

At this point in the narration that I was hearing amid the milling crowd at the County Fair, the wife (who had said little to this point) could see that I hadn’t yet quite gotten it. Though she didn’t “make a scene”, there was no mistaking her deep anger, when she told me, with her husband and daughter listening, she had thrown the social worker out of their home. “You have no business talking about hospice care to us”, she told the social worker. “Hospice care is for when there is no hope for further medical treatment. Hospice care is not an ‘option’ instead of the health care he needs.”

I was stunned. I had studied and written about the health care crisis in America for years, but that was the moment when I learned that hospice care is being offered and provided in the United States, not because it is medically indicated, but because it is financially indicated. In other words, if you can’t pay for the life-saving health care you need, you are offered end-of-life care, instead. And subsequent conversations with experienced medical professionals have confirmed that is not uncommon.

That was not a decision by a mythical government death panel. That was a decision by a very real corporate death panel. And those corporate death panels make those decisions routinely, every day in America. Five Americans die every hour, day and night, day after day, because of those decisions by those corporate death panels, simply because we do not have comprehensive health care guaranteed for all, which would cost us less, per capita, (with no co-pays and no deductibles) than the current for-corporate-profit healthcare system we currently have. Got it? We are all paying more for this, right now, than it would cost to strengthen and extend Medicare for everyone, for life.

My friend Skip was in a similar fix that this working family had been, though in his case, hospice care was not prematurely offered. Skip just had the misfortune of the gatekeepers opening the healthcare door to him too late.

These are among the countless examples of the complete nonsense embodied in the appallingly ignorant or crass suggestion that anyone can get health care by just going to the emergency room. The primary thing an emergency room is expected to do is make a preliminary assessment, and stabilize your vital signs, if possible. (Now, that responsibility is neither simple nor trivial, but it also does not include an awful lot of necessary medical care.) The for-profit hospital doesn’t have to admit you or keep you, and the ER doesn’t set your broken bones or treat your cancer, diabetes, or other affliction, or provide good primary or specialized care . And even if you don’t think you know anyone who has suffered or even died from this denial of needed health care for financial reasons, or has suffered medically induced destitution and bankruptcy, it happens every day, every hour, in America.

You have undoubtedly heard the analysis of health care reform which maintains that there are two very different reasons that people support
health care reform. Allegedly, one, is that people altruistically would like everyone to have health care (this is often expressed in extremely compromised form as “everyone should be able to access affordable health insurance”). Two, is that people would selfishly, for practical reasons, like to control health care costs (this is often expressed as “everyone wants their health insurance to cost less”). This two-edged analysis is intentionally misleading, narrow, and short-sighted. It falsely implies that resolving the health car crisis places personal interest in opposition to social justice. It falsely implies that people who do not have health insurance have entirely different needs and interests than people who currently have health insurance. It sets up a false opposing tension between the goal of everyone getting the health care they need, against the goal of reducing and controlling health care costs.

Despite the constantly repeated lies, the truth is that it costs less to provide everyone the comprehensive health care they need, than it costs to ration health care to people on the basis of what the administrators figure each individual deserves. The way that our health care is administered in the United States has virtually every family playing Russian roulette with its members’ health, its financial security and solvency, and our longevity, with the ground rules set by the increasingly greedy, powerful, and arrogant sickness business corporations. The only difference between you and me in this game of Russian roulette is the number of chambers that each of us has loaded at any moment in our lives. If you have health insurance and employment today, you may not have it tomorrow. If you have health insurance when you need it, your mother, your child, your cousin, your friend may not. If you, or others, have health insurance, you won’t know what it doesn’t cover till you need it. The insurance you, or any member of your family has now may change with little or no warning in the future, without regard to what you want or need. Mandating private, for-profit health insurance for everyone does not solve these problems. It merely increases insurance corporation profits. Providing comprehensive health care for everyone does solve these problems.

I have tried to illuminate the health care crisis, and to clearly define the solution to that crisis, in a series of essays and leaflets over the last seven years. If you have not followed those articles, or you do not yet comprehend why strengthening Medicare, eliminating the co-pays and deductibles, and expanding Medicare to cover everyone in America, for life, is actually less costly per capita, provides superior health care outcomes for us, eliminates personal bankruptcies due to sickness and injury, and improves the economic competitiveness of businesses that are willing to employ American workers (compared to the current administration of health care by for-profit insurance corporations) please read some of those articles, and familiarize yourself with at least some of the valuable references provided in most of them.

The most despicable, ominous thing that has happened with regards to the current health care reform effort in Congress has been that the evidence and the simple proposal for Enhanced Medicare for All has not even been allowed a public hearing or a vote in the Congress this year. You may disagree with me that strengthened Medicare for all is the best solution to the health care crisis, but virtually everyone with any knowledge of the issue, and of the principles of representative democracy, can agree that it should certainly have been publicly discussed and given full and open hearings by our legislative representatives. The reason that it didn’t is simply that corporations control our U.S. government.
If you agree with me, contact your U.S. Senators and Representative, by personal visit, by phone, and/or by the internet, and urge them to sponsor, support, and vote for Enhanced Medicare for All, HR 676. Don’t wait, do it now. But the most important thing for us to do is to organize and inform every other American, one by one, about this health care crisis, and about how the corporations are exploiting us, how our government is serving the corporations, not the people, and about the simple, best solution which will be best for all the people when we finally end the for-profit insurance corporations’ control and exploitation of the health care we all need.

ENHANCED MEDICARE FOR ALL

EVERYBODY IN, NOBODY OUT
COMPREHENSIVE HEALTH CARE – ONE FOR ALL AND ALL FOR ONE

PEOPLE DON’T NEED HEALTH INSURANCE, PEOPLE NEED HEALTH CARE!

President Obama: the Answer is Medicare for All

By Healthcare-NOW!
February 17, 2010

Once again the president and congress are not including any discussion of the only real solution to America’s health care problems – expanding and improving Medicare to cover everyone in America.

Medicare for All would meet each of the goals President Obama set for health reform in his State of the Union Address, “But if anyone…has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know.”

The President’s goals and our responses:

1. Expand coverage and provide more Americans health care – Improved Medicare for All will provide comprehensive medical, mental, dental, vision and prescription coverage to all people (everybody in, nobody out) living in the United States from birth to death without gaps. No system based on private insurance can make the same guarantee.

2. End insurance company abuses – Improved Medicare for All will remove the expensive and bloated private insurance bureaucracy from our health care system and effectively end their profit-driven practices of denying and restricting coverage. All people in America will enjoy the same sense of security that those with traditional Medicare currently feel in knowing that necessary care will be covered and that their coverage cannot be taken away. Medicare is accountable to the public, rather than to investors.

3. Control health care costs – Improved Medicare for All is the only solution with built-in cost controls. There will be immediate savings of $400 billion per year simply by removing the high administrative and marketing costs that come with having over 1,300 different private insurance plans. Additional savings will arise through negotiations for fair pharmaceutical prices as Walmart does now.

4. Decrease the deficit – Improved Medicare for All is the only solution which will put the brakes on our health care costs which are spiraling out of control. Further positive effects on the economy will occur as businesses are relieved of the financial burden of paying for health benefits allowing them to focus on building their business, raising wages and competing in the global market. Having less volatility in health care prices will allow businesses to hire more employees, thereby spurring job growth.

5. Stabilize Medicare – Improved Medicare for All will finally relieve the financial stress which is placed on Medicare from providing coverage for those who have the greatest health care needs – those who are disabled or who are 65 years of age and older. Everybody, healthy and ill, will contribute to the Medicare fund throughout their lives knowing that Medicare will be there for them when they need it.

Single-payer insurance needed now

By Mark Leno
San Francisco Chronicle
Tuesday, February 16, 2010

As outraged families and small businesses react to the latest health insurance premium increases, Californians are forced to face the fact that insurance companies are not in business to provide health care to people who need it. Premium increases are just part of the concerns – pre-existing condition denials, overturned doctors’ decisions, coverage rescissions and other insurance industry abuses are sadly commonplace.

It is impossible to make a profit serving customers who are likely to cost the insurer more than the premiums they pay. This means that if any one of us gets seriously sick or injured, we become an undesirable customer to health insurers. That’s the message Anthem Blue Cross sent to millions of Californians when it increased premiums by up to 39 percent. The insurer clearly doesn’t care if it loses these customers.

Health insurance companies are defending the rate increases by blaming rising health care costs – but health care costs have increased about 6 percent a year on top of similar increases last year – not 39 percent.

It is outrageous that insurance companies blame their rate increases on consumers who are dropping coverage because they can no longer afford it. In this economy, another increase in health premiums will be the last straw for many Californians. We know health insurance companies increase premiums each year because they can. They do it because it is in their best financial interests to do so, even when some increases stifle economic growth and threaten our middle-class standard of living. Everything we buy or use has health care costs embedded in it – from the food we eat to the dry cleaning service we select. Our current health insurance system is failing us. The California Universal Health Care Act, a single-payer reform plan that I introduced last year, provides every Californian with comprehensive health care and is fully funded with money that California already spends on health care.

Senate Bill 810 builds on our current system of privately delivered health care but is funded by a single, comprehensive health insurance plan that cuts out the private insurance middle man in order to simplify administration. It puts doctors and hospitals back in charge of our health care system.

SB810 works by creating a trust fund to pool money that government, employers and individuals spend on health care each year. Instead of paying premiums to private insurers, Californians would pay into the fund, which would guarantee coverage to all Californians. Patients would be free to choose their private doctors and hospitals.

SB810 would provide relief to consumers and to California businesses, which are struggling to pay rising employee health benefits.

Americans already pay per capita for health care twice what residents of other industrialized countries pay. The United States ranks 37th among nations in health care outcomes, according to the World Health Organization.

Californians want and deserve the state-of-the-art, single-payer health-care system envisioned by SB810. Visit CaliforniaOneCare.org to learn more.

Democrat Mark Leno represents Marin and parts of San Francisco and Sonoma counties in the state Senate.

http://sfgate.com/cgi-bin/article.cgi?f=/c/a/2010/02/16/EDLL1C0UA9.DTL

This article appeared on page A – 10 of the San Francisco Chronicle

Is Medicare "close enough" to universal?

Measuring Coverage for Seniors in Medicare Part A and Estimating the Cost of Making It Universal

By Michael Birnbaum and Elizabeth M. Patchias
Journal of Health Politics, Policy and Law
February 2010
Medicare’s Part A Coverage Gap in the Context of National Health Care Reform
The fact that 1.6 million seniors in the United States — 5 percent of the elderly population — are without full federal Part A coverage is a significant policy issue. While Medicare is widely understood to cover the entire elderly U.S. population, this is at best a substantial exaggeration of Medicare’s reach and perhaps a mischaracterization whose broad acceptance preempts a national debate about Medicare eligibility policy and clouds the existing debate on universal coverage.
Will a national discussion on Medicare eligibility get at least a little traction? At this point it seems unlikely because of a powerful counterargument that Medicare is close enough to universal and that seniors without the full federal Part A benefit have other public programs and sources of government funding to support their health care needs, with some ultimately gaining Medicare Part A through their state Medicaid programs. This argument is valid and empirically strong, but it hangs on a normative question: when we are dealing with Medicare eligibility policy in the context of a national discussion about universal coverage, should we settle for “close enough” and accept that, when people fall through the cracks of Medicare’s eligibility framework, Medicaid and the states will be there as a last resort?
http://jhppl.dukejournals.org/cgi/content/abstract/35/1/49?etoc

And…

Projected Impact of Senate Health Reform Bill; Estimates of Alternative Designs

RAND
February 16, 2010
The (RAND) study finds that health care legislation passed by the Senate in December would cut the number of uninsured Americans to 25 million by 2019 (a 53 percent decrease).
http://www.rand.org/news/press/2010/02/16/

At what level do we say that the rate of coverage under a universal program is “close enough”? For Medicare Part A, we’ve already answered that question. Covering 95 percent of those over age 65 is “close enough,” leaving 1.6 million seniors out of the Part A program (primarily hospital care).
We now hear from our politicians that the Senate reform bill awaiting approval in the House is “close enough” to universal coverage, cutting the number of uninsured in half, leaving only 25 million without coverage, according to this new RAND report.
Many suggest that we abandon the term “single payer” and use “Medicare for All” instead. Universal coverage under single payer means 100 percent – everyone is included automatically, not 95 percent like Medicare Part A.
When we choose to use the Medicare rhetoric because it would resonate better with some audiences, we should refer to it as “improved Medicare for All.” That’s simply code language for replacing Medicare’s numerous flawed policies with a bona fide single payer program – a program that removes financial barriers to health care for absolutely everyone.
During the health reform dialogue, when someone says, “close enough,” you know that person is supporting flawed policies. Jump in immediately, protesting that “close enough” isn’t good enough when we have better policies that will get all of us all the way there.

Is Medicare “close enough” to universal?

Measuring Coverage for Seniors in Medicare Part A and Estimating the Cost of Making It Universal

By Michael Birnbaum and Elizabeth M. Patchias
Journal of Health Politics, Policy and Law
February 2010

Medicare’s Part A Coverage Gap in the Context of National Health Care Reform

The fact that 1.6 million seniors in the United States — 5 percent of the elderly population — are without full federal Part A coverage is a significant policy issue. While Medicare is widely understood to cover the entire elderly U.S. population, this is at best a substantial exaggeration of Medicare’s reach and perhaps a mischaracterization whose broad acceptance preempts a national debate about Medicare eligibility policy and clouds the existing debate on universal coverage.

Will a national discussion on Medicare eligibility get at least a little traction? At this point it seems unlikely because of a powerful counterargument that Medicare is close enough to universal and that seniors without the full federal Part A benefit have other public programs and sources of government funding to support their health care needs, with some ultimately gaining Medicare Part A through their state Medicaid programs. This argument is valid and empirically strong, but it hangs on a normative question: when we are dealing with Medicare eligibility policy in the context of a national discussion about universal coverage, should we settle for “close enough” and accept that, when people fall through the cracks of Medicare’s eligibility framework, Medicaid and the states will be there as a last resort?

http://jhppl.dukejournals.org/cgi/content/abstract/35/1/49?etoc

And…

Projected Impact of Senate Health Reform Bill; Estimates of Alternative Designs

RAND
February 16, 2010

The (RAND) study finds that health care legislation passed by the Senate in December would cut the number of uninsured Americans to 25 million by 2019 (a 53 percent decrease).

http://www.rand.org/news/press/2010/02/16/

At what level do we say that the rate of coverage under a universal program is “close enough”? For Medicare Part A, we’ve already answered that question. Covering 95 percent of those over age 65 is “close enough,” leaving 1.6 million seniors out of the Part A program (primarily hospital care).

We now hear from our politicians that the Senate reform bill awaiting approval in the House is “close enough” to universal coverage, cutting the number of uninsured in half, leaving only 25 million without coverage, according to this new RAND report.

Many suggest that we abandon the term “single payer” and use “Medicare for All” instead. Universal coverage under single payer means 100 percent – everyone is included automatically, not 95 percent like Medicare Part A.

When we choose to use the Medicare rhetoric because it would resonate better with some audiences, we should refer to it as “improved Medicare for All.” That’s simply code language for replacing Medicare’s numerous flawed policies with a bona fide single payer program – a program that removes financial barriers to health care for absolutely everyone.

During the health reform dialogue, when someone says, “close enough,” you know that person is supporting flawed policies. Jump in immediately, protesting that “close enough” isn’t good enough when we have better policies that will get all of us all the way there.

Proper health care requires everybody in the same boat

By George Jolly
The Saratogian (Saratoga Springs, N.Y.)
Sunday, February 14, 2010

Health care reform has derailed and is sitting beside the tracks.

The proposals that came out of Congress are patchworks of policies which try to alleviate some of the most egregious failures of our present healthcare “non-system,” such as limiting the power of insurance companies to refuse to cover those with pre-existing conditions.

But those stalled efforts fell far short of what is needed:  Twenty-million people would remain uninsured. The system would be more complex than ever. These reforms would cost an extra trillion dollars over the next 10 years and contain no effective means of reducing the rapid rate of growth of health care expenditure. More middle-class families would face financial disaster as insurance companies issue policies inadequate in serious illness. The mandate to buy insurance would push huge sums into the hands of the already powerful private insurers.

What should be the essential features of the future American health care finance system?

– We need to have everybody participate. That is the way insurance works — you spread the risk of illness across as many people as possible.

– We need simplicity, ease of administration, ease of enrollment and a system not affected by changing jobs or being laid off.

– It should cover all necessary medical care.

– It should allow choice of physician and of hospital.

– We need to curtail rising costs. The greatest waste in the system right now is created by enormous bureaucratic complexity. Future rises in costs should be managed system wide, with input from providers and the public. It is crazy to let Congress micro-manage health care expenditure.

It should be financed through a graduated income tax, because illness doesn’t check to see if you are wealthy or poor, employed or unemployed.

Such a system already exists in our traditional Medicare.

As a citizen, I know I’m automatically included at age 65. The paperwork is minimal. I can use any doctor or hospital. It is clear what is covered and what is not. It runs with an overhead of 5 percent instead of the 15 to 25 percent of commercial insurance. Payment policy is controlled by a federal agency under a budget set by Congress.

Medicare is costly, paying for care of the oldest and sickest people in society. We have caused that by allowing private insurance to “cherrypick” the healthiest, lowest-cost working people. Every healthy person brought into “Medicare for all” will reduce the per-patient cost. Elimination of the multiplicity of insurance companies and the use of global budgeting of institutions like hospitals will result in an estimated savings of $400 billion yearly, enough to pay for all the uninsured, and improve the quality of coverage for both present and new Medicare enrollees.

Shouldn’t we expect more from our elected representatives, the Congress and the president? Shouldn’t we insist that they place the interests of the American people ahead of the special interests of insurance companies and drug companies? A workable solution won’t emerge unless each of us makes it clear to our elected officials that we want a system based on the principles listed above.

So, if no reform comes out of Washington this year, we may have been given a chance to do it right. Our first consideration ought to be a “single-payer” Medicare for all.

George Jolly is a geriatrician with Saratoga Medical Associates in Saratoga Springs.

http://www.saratogian.com/articles/2010/02/14/opinion/doc4b777ba10f13a031529704.txt