PNHP

A doctor’s voice: A national health insurance plan makes more sense

A doctor’s voice: A national health insurance plan makes more sense

By PETER MAHR
Hillsboro (Ore.) Argus, Oregonlive.com
December 30, 2009

As a family physician I must write to convey my frustration and indignation with the Senate health care bill.

It is an immense bill offering minor advances in the access to health care for Americans via private insurance, the expansion of Medicaid and the increase in money for community clinics. But in cementing the role of private insurance as the vehicle for Americans to access necessary health services, the bill wastes billions of dollars a year due to the inefficiency and profit motive inherent in this system.

Furthermore, the bill will still leave millions without any insurance and even more people underinsured. Those who have insurance with affordable premiums will find the cost-sharing (deductibles, co-pays and out-of-pocket expenses) onerous. Those with insurance offering adequate access to health services will pay premiums that are unaffordable.

Finally, by taxing Americans four years in advance of the initiation of subsidies for the purchase of insurance, this bill underestimates the true cost to our country. In the end the bill will mandate that all of us buy into and subsidize the inefficient and expensive private health insurance financing system we have today.

My frustration doubles when I realize that there is a viable, efficient and affordable alternative to health care financing that could be enacted tomorrow. With a system of national health insurance, we could cover 100 percent of Americans at a dramatically reduced cost for families, businesses and our country. Under a national health insurance plan everyone pays into the insurance pool via progressive income or payroll taxes.

Let’s call this our premiums. Then, when we are sick and go to the doctor or have a surgery, the doctor or hospital gets paid from the money in the pool. It is not socialized medicine: Doctors and hospitals continue treating patients as before. They remain private and autonomous.

Since a national health insurance system eliminates the profit motive, as well as the advertising and executive pay associated with private insurance and slashes burdensome and expensive administration on the doctor and hospital level, it would finance access to health care for all while reducing costs dramatically.

Finally, my frustration will pale in comparison to the American people’s anger when they find out what the Senate bill means for them. In the Senate bill, the Congressional Budget Office estimates that a family of four with a household income of $54,000 would be expected to pay 17 percent of their income, or $9,000, on health care costs. On the other hand, a family of four making the median income of $56,000 would pay just $2,900 under a national health insurance plan.

If the American people knew that we could organize our health care financing in an efficient, fair and affordable manner, and reduce their family’s health care costs by a third, they would jump at the chance. If they find out after the fact, when they are paying taxes to subsidize a private insurance system that does not meet their health care needs and puts their personal finances at risk, they will surely be looking for someone to blame.

Are you paying attention, senators?

Peter Mahr of Southeast Portland is a family physician with Physicians for a National Health Program.

http://www.oregonlive.com/opinion/index.ssf/2009/12/a_doctors_voice_a_national_hea.html

Single-Payer's Last Stand in the States?

By Greg Kaufmann
Published by The Nation
January 1, 2010

The Progressive Caucus (CPC) is the largest caucus in Congress with 82 members—it dwarfs the often-hyped Blue Dog Democrats with its 52 yapping pups.

Yet the CPC has struggled to get the respect and attention it has strived for—prior to this Congress, it seemed like the mainstream media wouldn’t even refer to it by name, instead using vague descriptions like “the liberal wing of the party.” 

That’s because getting the talented but diverse Caucus to unite and show its legislative muscle has often been described—even by its own members—as herding cats. 

This might be the moment for the Caucus to change all that in dramatic fashion.

The House healthcare bill passed by just five votes—220 to 215. Surely the CPC’s 81 House votes (the 82nd member is a Senator, CPC founder Bernie Sanders) should be viewed as just as powerful as the votes of Ben Nelson or Joe Lieberman in the Senate.

But will a strong majority of the CPC unite around a single provision and insist that it be included in the final bill exchange for their support?

One item worth rallying around—and it hasn’t received a lot of attention—is waiver language that would permit states to implement alternatives to insurance market exchanges, including single-payer systems.

The Senate bill allows states to apply for such waivers in 2017, but that’s arguably too late. States would be required to establish (and invest in) the insurance market exchanges in 2014, making it difficult to develop and provide resources for any alternative model. TheHouse bill doesn’t have any waiver language at all, though CPC members—including CPC co-chairs RaĂșl Grijalva and Lynn Woolsey, and Congressman Dennis Kucinich—fought successfully for similar language in the House Committee on Education and Labor version.

Canada’s healthcare system evolved from a program first established in Saskatchewan. Will states in the US have a similar opportunity to serve as incubators and prove that single-payer can provide comprehensive coverage and reduce costs? The CPC has the power to insist on it—if it chooses to do so.

http://www.thenation.com/blogs/notion/510767/single_payer_s_last_stand

Single-Payer’s Last Stand in the States?

By Greg Kaufmann
Published by The Nation
January 1, 2010

The Progressive Caucus (CPC) is the largest caucus in Congress with 82 members—it dwarfs the often-hyped Blue Dog Democrats with its 52 yapping pups.

Yet the CPC has struggled to get the respect and attention it has strived for—prior to this Congress, it seemed like the mainstream media wouldn’t even refer to it by name, instead using vague descriptions like “the liberal wing of the party.” 

That’s because getting the talented but diverse Caucus to unite and show its legislative muscle has often been described—even by its own members—as herding cats. 

This might be the moment for the Caucus to change all that in dramatic fashion.

The House healthcare bill passed by just five votes—220 to 215. Surely the CPC’s 81 House votes (the 82nd member is a Senator, CPC founder Bernie Sanders) should be viewed as just as powerful as the votes of Ben Nelson or Joe Lieberman in the Senate.

But will a strong majority of the CPC unite around a single provision and insist that it be included in the final bill exchange for their support?

One item worth rallying around—and it hasn’t received a lot of attention—is waiver language that would permit states to implement alternatives to insurance market exchanges, including single-payer systems.

The Senate bill allows states to apply for such waivers in 2017, but that’s arguably too late. States would be required to establish (and invest in) the insurance market exchanges in 2014, making it difficult to develop and provide resources for any alternative model. TheHouse bill doesn’t have any waiver language at all, though CPC members—including CPC co-chairs RaĂșl Grijalva and Lynn Woolsey, and Congressman Dennis Kucinich—fought successfully for similar language in the House Committee on Education and Labor version.

Canada’s healthcare system evolved from a program first established in Saskatchewan. Will states in the US have a similar opportunity to serve as incubators and prove that single-payer can provide comprehensive coverage and reduce costs? The CPC has the power to insist on it—if it chooses to do so.

http://www.thenation.com/blogs/notion/510767/single_payer_s_last_stand

Good news on spending growth is bad news

Health Spending Growth At A Historic Low In 2008

By Micah Hartman, Anne Martin, Olivia Nuccio, Aaron Catlin and the National Health Expenditure Accounts Team
Health Affairs
January 2010
In 2008, U.S. health care spending growth slowed to 4.4 percent—the slowest rate of growth over the past forty-eight years. The deceleration was broadly based for nearly all payers and health care goods and services, as growth in both price and nonprice factors slowed amid the recession. Despite the slowdown, national health spending reached $2.3 trillion, or $7,681 per person, and the health care portion of gross domestic product (GDP) grew from 15.9 percent in 2007 to 16.2 percent in 2008. These developments reflect the general pattern that larger increases in the health spending share of GDP generally occur during or just after periods of economic recession. Despite the overall slowdown in national health spending growth, increases in this spending continue to outpace growth in the resources available to pay for it.
Health care spending by households grew 4.3 percent in 2008, a deceleration from 5.9 percent growth in 2007. Despite the slowdown, households’ health spending growth in 2008 still outpaced adjusted personal income growth of 2.7 percent.
http://content.healthaffairs.org/cgi/content/abstract/29/1/147

Although some members of the media are celebrating the lowest rate of health care spending growth in almost half of a century, a full reading of this report is sobering.
While Congress has been desperately searching for policies to slow the rate of health care spending, not even one of the worst mechanisms for reducing spending – clobbering our economy with a recession – was capable of preventing a further encroachment of our national health expenditures (NHE) on our total gross domestic product (GDP), increasing from 15.9 percent to 16.2 percent of the GDP.
It is difficult to imagine a more effective mechanism of controlling spending than to wallop our paychecks, even if not a first choice of the policy makers. Median household income fell 3.6 percent between 2007 and 2008. Yet household health care spending in 2008 still grew by 4.3 percent, even more than the 3.8 percent inflation rate for that year (which declined to 1.8 percent in 2009).
If a major hit to the economy is not going to bring our NHE under control, then how can we expect the pilot programs and the other weak cost-containment measures in the bills currently in conference to have any real impact?
The only provision that could have a major impact is the proposed Independent Medicare Advisory Board (Sec. 3402 of the Senate bill), but only if its provisions were to apply to our entire NHE. But they won’t. It’s purpose is to “reduce the per capita rate of growth in Medicare spending.” Its independent power to set the rules for Medicare spending is not extended to control over the private insurance plans.
Physicians and hospital administrators are already concerned about Medicare reimbursement rates. With spending growth in the private sector continuing to outpace the growth of the economy, it might be expected that many health care providers would walk away from the close-to-frozen prices established by the public programs, in a quest for the more lucrative rates in the private sector.
The problem of intolerable increases in our health care spending must be addressed, not just for the government, but for all of us – individuals and businesses. The current legislation feeds the rapacious appetite of the private insurance industry while threatening the stability of our most prized public health program – Medicare.
What if we had an improved Medicare program that covered everyone? An independent Medicare advisory board would certainly put the skids on spending, but not to the extent of threatening the stability of the program. Besides, don’t we want our representatives to stand up for us to be sure that our health care is not priced out of our reach? It already is for many of us, and will still be for all too many under the bills before Congress. It wouldn’t be under a single payer Medicare for all program.

Uwe Reinhardt on whether community rating is fair

Is ‘Community Rating’ in Health Insurance Fair?

By Uwe E. Reinhardt
The New York Times, Economix
January 1, 2010

One controversial feature of the health reform bill winding its way through Congress is “community rating.” The term has a mellow ring but is apt to be divisive.

“Community rating” refers to the practice of charging a common premium to all members of a heterogeneous risk pool who may have widely varied health spending for the year. It inevitably makes chronically healthy individuals subsidize with their insurance premiums (rather than through overt taxes and transfers) the health care used by chronically sicker individuals.

The purpose of any insurance, of course, is to do precisely that: redistribute the financial burden from the unlucky to the lucky members of a risk pool.

(Professor Reinhardt then provides calculations for an example of two cohorts, A and B, representing populations segregated into two pools with different risks, as is characteristic of our price-competitive market for individually sold health insurance.)

Would it be “fair” that the healthy individuals of cohort A pay a pure insurance premium of only $2,450 a year, while the sicker citizens in cohort B must pay $6,600? This is, after all, how health insurance now is priced in most states for individuals.

Or does “fairness” require that the two groups be merged into one large national risk pool A & B, whose risk profile is shown in the right-most column of the table. If each member of this merged pool is to pay the same pure premium, then the latter will have to be $4,525 to break even. Such a premium would be said to be “community rated” over these two distinct risk pools.

Relative to their premium in a perfectly risk-segregated market, the community-rated premium of $4,525 will cost members of low-risk cohort A $2,075 more and the sicker members of cohort B $2,075 less than they would have paid in a risk-segregated market. Is that “fair”?

So what should the political leaders of this imaginary country do? It would be interesting to have your reaction. It is, after all, the very question our political leaders are tackling this moment.

Should you choose to respond, would you indicate your age?

(You can post a response by clicking on “Post a Comment” at the end of the full article at the following link. You can also recommend specific responses.)

http://economix.blogs.nytimes.com/2010/01/01/is-community-rating-in-health-insurance-fair/

Posted response of Don McCanne, San Juan Capistrano, CA (response # 9):

One of the more obvious examples of this dilemma is the disagreement as to the premiums that should be charged for the healthier population in their twenties as opposed to the less healthy population, on average, in their fifties and early sixties. Congress has already decided that strict community rating through a single premium for everyone will not apply to age differences, but they remain conflicted as to how much of a transfer will occur from the younger healthier individuals to the older less healthy individuals. They seem to believe that the concept of such a transfer is “fair,” but they are not in agreement as to what level of transfer exceeds their concept of fairness.

My wife and I are in our seventies and benefit from Medicare, a program in which there is a transfer to us from those in their twenties, many of whom are uninsured. Is that fair?

Of course the issue is further complicated by our nation’s very high health care costs since there is a need to transfer from the wealthy to lower income individuals, if, in fact, we agree that we should have a financing system that allows everyone to have the essential health care that they need. The many other complexities introduced by our fragmented health financing system, using public and private sources, complicates the process of finding the right premium for the right coverage, for the right amount of cost sharing, with the right amount of subsidies to support the premiums and the cost sharing.

With our unique health financing system already overburdened with profound administrative waste, it doesn’t seem rational to try to expand coverage by assigning inevitably inequitable premiums to benefit packages within fragmented private plan risk pools. That just adds to the complexities, inequities and administrative waste.

It would be much more efficient and equitable to remove the risk bearing function from the private insurers, thereby eliminating premiums, and replace our dysfunctional health care financing system with a single universal risk pool covering everyone. Each person would pay into the pool their fair share, based on ability to pay, by funding it through progressive taxes.

This could easily be accomplished through an improved Medicare for all. But some may not consider this fair either if they reject the concept of social solidarity, the concept on which community rating is based.

Health care 'overhaul'? The devil's in the details

By Andrew Coates
Rochester City Newspaper
December 29, 2009

As health insurance reform inches towards the president’s desk, the airwaves and editorial pages fill with spin. “Health-care overhaul,” the headlines say. “Still a government takeover of health care,” the Republicans in Congress say. “The culmination of a struggle begun by Theodore Roosevelt,” Vice President Biden says.

Against so much political posturing, Representative Eric Massa has proven himself unique in Congress: someone who sticks to the facts. Last month when he courageously voted against the House bill, he said it would strengthen, not weaken, the hand of the private insurers. The insurance industry is the problem, not the solution, he explained. As the legislation nears final reconciliation, Massa’s analysis remains solid.

The crux of the legislation in Congress is compulsory private insurance. Under the “individual mandate,” a long-held wish of the insurance companies, the government will coerce people to become and remain their paying customers.

If you’re uninsured and you don’t buy health insurance, the Senate bill allows a fine of up to 2 percent of your income, assessed by the IRS. (It’s 2.5 percent in the House bill.) Pay the fine and you’re free to remain uninsured.

If you simply can’t afford a policy, according to the Senate bill, you can avoid paying the fine by applying for a “hardship waiver.” Get the waiver and you’re free to remain uninsured.

Since the legislation does nothing to make insurance affordable, tax money will subsidize private insurance premiums for those who earn up to 400 percent of the federal poverty level. But those earning up to 400 percent of the poverty level would still have to pay up to 9.8 percent of their income for insurance (under the Senate bill). This taxpayer gift to insurance companies will amount to as much as $476 billion – half a trillion dollars – over a decade.

The Senate formula also pushes the onus of health costs onto individual families by imposing a 40 percent tax on high-cost health plans, an incentive to reduce coverage. This will especially impact residents of states with high insurance costs, like our own state; union members with comprehensive benefits; companies that employ women (whose group insurance costs are higher), and plans that cover older employees (whose insurance costs are higher).

The Senate bill also encourages skimpy coverage by allowing the most basic plans to cover only 60 percent of actual health costs on top of growing of out-of-pocket expenses. Prescription drug costs have gone up 9 percent this year. Meanwhile, the insurance industry itself has estimated premium hikes of 79 to 111 percent over the coming decade.

In addition to millions of new customers for insurance companies, the legislation seeks an enormous expansion of Medicaid, with new enrollment of millions of people by expanding eligibility to those who earn up to 150 percent of the federal poverty level. But we know from bitter experience that having Medicaid is no guarantee of access to care, nor will it reduce disparities in care.

If private insurance will remain a defective product and Medicaid will remain a poor program for poor people and the legislation will not reign in costs – where is the reform?

But perhaps most startling is that the major features of the legislation would not begin until 2013, after the next presidential election, and then would take effect gradually over six years more. Such a proposal hardly seems worthy of the name “overhaul” when we remember that Medicare passed in 1965 and was up and running in 1966.

Last month when he voted against the House bill, Congressman Massa explained that he had studied the entire bill and that he understood the health care needs of his district. As the Congressional process lumbers forth, with the pending legislation ever more insurance-industry-friendly, Eric Massa has emerged as a portrait of leadership, courage, and honesty.

It’s time to scrap this pro-insurance-company legislation and start over. A good starting point would be the improvement and expansion of Medicare to cover every person in the United States.

Andrew Coates practices medicine in Albany, where he is assistant professor of medicine and psychiatry at AlbanyMedicalCollege. He is a member of the board of directors of Physicians for a National Health Program.

http://www.rochestercitynewspaper.com/news/opinion/2009/12/COMMENT-Health-care-overhaul-The-devils-in-the-details/

Health care ‘overhaul’? The devil’s in the details

By Andrew Coates
Rochester City Newspaper
December 29, 2009

As health insurance reform inches towards the president’s desk, the airwaves and editorial pages fill with spin. “Health-care overhaul,” the headlines say. “Still a government takeover of health care,” the Republicans in Congress say. “The culmination of a struggle begun by Theodore Roosevelt,” Vice President Biden says.

Against so much political posturing, Representative Eric Massa has proven himself unique in Congress: someone who sticks to the facts. Last month when he courageously voted against the House bill, he said it would strengthen, not weaken, the hand of the private insurers. The insurance industry is the problem, not the solution, he explained. As the legislation nears final reconciliation, Massa’s analysis remains solid.

The crux of the legislation in Congress is compulsory private insurance. Under the “individual mandate,” a long-held wish of the insurance companies, the government will coerce people to become and remain their paying customers.

If you’re uninsured and you don’t buy health insurance, the Senate bill allows a fine of up to 2 percent of your income, assessed by the IRS. (It’s 2.5 percent in the House bill.) Pay the fine and you’re free to remain uninsured.

If you simply can’t afford a policy, according to the Senate bill, you can avoid paying the fine by applying for a “hardship waiver.” Get the waiver and you’re free to remain uninsured.

Since the legislation does nothing to make insurance affordable, tax money will subsidize private insurance premiums for those who earn up to 400 percent of the federal poverty level. But those earning up to 400 percent of the poverty level would still have to pay up to 9.8 percent of their income for insurance (under the Senate bill). This taxpayer gift to insurance companies will amount to as much as $476 billion – half a trillion dollars – over a decade.

The Senate formula also pushes the onus of health costs onto individual families by imposing a 40 percent tax on high-cost health plans, an incentive to reduce coverage. This will especially impact residents of states with high insurance costs, like our own state; union members with comprehensive benefits; companies that employ women (whose group insurance costs are higher), and plans that cover older employees (whose insurance costs are higher).

The Senate bill also encourages skimpy coverage by allowing the most basic plans to cover only 60 percent of actual health costs on top of growing of out-of-pocket expenses. Prescription drug costs have gone up 9 percent this year. Meanwhile, the insurance industry itself has estimated premium hikes of 79 to 111 percent over the coming decade.

In addition to millions of new customers for insurance companies, the legislation seeks an enormous expansion of Medicaid, with new enrollment of millions of people by expanding eligibility to those who earn up to 150 percent of the federal poverty level. But we know from bitter experience that having Medicaid is no guarantee of access to care, nor will it reduce disparities in care.

If private insurance will remain a defective product and Medicaid will remain a poor program for poor people and the legislation will not reign in costs – where is the reform?

But perhaps most startling is that the major features of the legislation would not begin until 2013, after the next presidential election, and then would take effect gradually over six years more. Such a proposal hardly seems worthy of the name “overhaul” when we remember that Medicare passed in 1965 and was up and running in 1966.

Last month when he voted against the House bill, Congressman Massa explained that he had studied the entire bill and that he understood the health care needs of his district. As the Congressional process lumbers forth, with the pending legislation ever more insurance-industry-friendly, Eric Massa has emerged as a portrait of leadership, courage, and honesty.

It’s time to scrap this pro-insurance-company legislation and start over. A good starting point would be the improvement and expansion of Medicare to cover every person in the United States.

Andrew Coates practices medicine in Albany, where he is assistant professor of medicine and psychiatry at AlbanyMedicalCollege. He is a member of the board of directors of Physicians for a National Health Program.

http://www.rochestercitynewspaper.com/news/opinion/2009/12/COMMENT-Health-care-overhaul-The-devils-in-the-details/

Uwe Reinhardt on whether community rating is fair

Is ‘Community Rating’ in Health Insurance Fair?

By Uwe E. Reinhardt
The New York Times, Economix
January 1, 2010
One controversial feature of the health reform bill winding its way through Congress is “community rating.” The term has a mellow ring but is apt to be divisive.
“Community rating” refers to the practice of charging a common premium to all members of a heterogeneous risk pool who may have widely varied health spending for the year. It inevitably makes chronically healthy individuals subsidize with their insurance premiums (rather than through overt taxes and transfers) the health care used by chronically sicker individuals.
The purpose of any insurance, of course, is to do precisely that: redistribute the financial burden from the unlucky to the lucky members of a risk pool.
(Professor Reinhardt then provides calculations for an example of two cohorts, A and B, representing populations segregated into two pools with different risks, as is characteristic of our price-competitive market for individually sold health insurance.)
Would it be “fair” that the healthy individuals of cohort A pay a pure insurance premium of only $2,450 a year, while the sicker citizens in cohort B must pay $6,600? This is, after all, how health insurance now is priced in most states for individuals.
Or does “fairness” require that the two groups be merged into one large national risk pool A & B, whose risk profile is shown in the right-most column of the table. If each member of this merged pool is to pay the same pure premium, then the latter will have to be $4,525 to break even. Such a premium would be said to be “community rated” over these two distinct risk pools.
Relative to their premium in a perfectly risk-segregated market, the community-rated premium of $4,525 will cost members of low-risk cohort A $2,075 more and the sicker members of cohort B $2,075 less than they would have paid in a risk-segregated market. Is that “fair”?
So what should the political leaders of this imaginary country do? It would be interesting to have your reaction. It is, after all, the very question our political leaders are tackling this moment.
Should you choose to respond, would you indicate your age?
(You can post a response by clicking on “Post a Comment” at the end of the full article at the following link. You can also recommend specific responses.)
http://economix.blogs.nytimes.com/2010/01/01/is-community-rating-in-health-insurance-fair/

Posted response of Don McCanne, San Juan Capistrano, CA (response # 9):
One of the more obvious examples of this dilemma is the disagreement as to the premiums that should be charged for the healthier population in their twenties as opposed to the less healthy population, on average, in their fifties and early sixties. Congress has already decided that strict community rating through a single premium for everyone will not apply to age differences, but they remain conflicted as to how much of a transfer will occur from the younger healthier individuals to the older less healthy individuals. They seem to believe that the concept of such a transfer is “fair,” but they are not in agreement as to what level of transfer exceeds their concept of fairness.
My wife and I are in our seventies and benefit from Medicare, a program in which there is a transfer to us from those in their twenties, many of whom are uninsured. Is that fair?
Of course the issue is further complicated by our nation’s very high health care costs since there is a need to transfer from the wealthy to lower income individuals, if, in fact, we agree that we should have a financing system that allows everyone to have the essential health care that they need. The many other complexities introduced by our fragmented health financing system, using public and private sources, complicates the process of finding the right premium for the right coverage, for the right amount of cost sharing, with the right amount of subsidies to support the premiums and the cost sharing.
With our unique health financing system already overburdened with profound administrative waste, it doesn’t seem rational to try to expand coverage by assigning inevitably inequitable premiums to benefit packages within fragmented private plan risk pools. That just adds to the complexities, inequities and administrative waste.
It would be much more efficient and equitable to remove the risk bearing function from the private insurers, thereby eliminating premiums, and replace our dysfunctional health care financing system with a single universal risk pool covering everyone. Each person would pay into the pool their fair share, based on ability to pay, by funding it through progressive taxes.
This could easily be accomplished through an improved Medicare for all. But some may not consider this fair either if they reject the concept of social solidarity, the concept on which community rating is based.

The New York Times doesn't get it

This editorial from today’s edition of The New York Times makes their case for supporting the current health reform legislation before Congress. The responses of Don McCanne, MD are in red and bracketed with ***.

The Case for Reform

Editorial
The New York Times
December 29, 2009

Reforming this country’s broken health care system is an urgent and essential task.

*** Absolutely! ***

Given all of the fabrications and distortions from Republican critics, and the squabbling among Democratic supporters, it is no surprise that many Americans still have doubts.

*** Unfortunately, the Republicans are handicapped by their ideological opposition to government solutions for social problems. Their proposal for a free market of cheap underinsurance products sold across state lines would only make problems worse by further impairing the effectiveness of our current inadequate and inequitable risk pools. The squabbling of the Democrats is based on a disagreement over whether to take the bold step of providing a truly effective universal public insurance program, such as an improved Medicare for everyone, or to take what some believe to be the politically expedient step of trying to modify our current dysfunctional system, even though it means falling far short of the goals of universality and affordability. ***

President Obama and Democratic leaders have a strong case. They need to make it now.

*** They have a very weak case. President Obama and the Democratic leadership chose to try to modify our current dysfunctional system, leaving tens of millions without insurance and perpetuating the financial hardships faced by many who need health care. ***

Here are compelling reasons for all Americans to root for the reform effort to succeed and urge Congress to complete the job:

THE HEALTH OF MILLIONS OF AMERICANS

The fact that 46 million people in this country have no health insurance should be intolerable. Every other major industrial country guarantees health coverage to its citizens, yet the United States, the richest of them all, does not.

*** The current proposal would leave close to 20 million people without insurance, a number that is destined to increase as health care costs continue to rise. Supporting a policy that ensures that so many will continue to be without health insurance is what should not be tolerated. A public insurance program is designed to automatically cover everyone. ***

Claims that the uninsured can always go to an emergency room for charity care ignore the fact that American taxpayers pay a high price for that care. And it ignores the abundant evidence that people who lack insurance don’t get necessary preventive care or screening tests, and suffer gravely when they finally do seek treatment because their diseases have become critical.

*** The modest marginal cost of providing care for additional patients in the emergency room is not a major issue. The crucial problem is the deterioration of our primary care infrastructure that is required to provide individuals with a source of seamless continuing care. The proposed legislation does take some important steps toward addressing this serious deficiency, but they would be much more effective with a single, unified financing system integrated with our health care delivery system. ***

The American Cancer Society now says the greatest obstacle to reducing cancer deaths is lack of health insurance. It is so persuaded of that fact that two years ago, instead of promoting its antismoking campaign or publicizing the need for cancer screening, it devoted its entire advertising budget to the problem of inadequate health insurance coverage.

*** We previously commended the American Cancer Society for taking this forward-thinking position. ***

We consider it a moral obligation and sound policy to provide health insurance to as many people as possible. While the pending bills would fall short of complete coverage, by 2019, the Senate bill would cover 31 million people and the House bill 36 million who would otherwise be uninsured under current trends.

*** It is both a moral obligation and sound policy to provide health insurance for everyone, which a universal public insurance program would do. The design of the current proposal is both immoral and unsound because it leaves an intolerable number of individuals uninsured – a number close to two-thirds of the population of Canada. We may criticize Canada’s queues, but we would be outraged if they prohibited two-thirds of their population from even having a place in the queues. Why is there no outrage here when we would leave a similar number without coverage? ***

MORE SECURITY FOR ALL

Horror stories abound of people — mainly those who buy individual policies — who were charged exorbitant premiums or rejected because of pre-existing conditions or paid out for years and then had their policies rescinded when they got sick.

Such practices would be prohibited completely in three or four years under the reform bills. Before that, insurers would be barred from rescinding policies retroactively and the bills would establish temporary high-risk pools to cover people with pre-existing conditions.

*** Although private insurers have been appropriately condemned for using trivial reasons to rescind policies, many rescissions were for the legitimate reason (legitimate in a business sense) that individuals who were uninsured and then developed serious problems purchased coverage without reporting their newly acquired problem – a form of fraud. That defeats the insurance function of pooling all of the healthy in with the sick. The proposal before Congress still permits rescissions for fraud. This problem would totally disappear in a public financing system in which enrollment for life is automatic. Also, the experience with high-risk pools to date has been very dismal. The need for high-risk pools would be eliminated by a single public universal risk pool. ***

The legislation would also allow unmarried dependent children to remain on their parents’ policies until age 26 (the Senate version) or age 27 (the House version).

*** What do they do at 26 or 27? Would everyone at that age have a great job with generous employer-sponsored benefits? If not, would they be eligible for plans in the exchange, and could they afford their portion of premiums and out-of-pocket expenses that is estimated to be about 20 percent of their income? Again, this problem would disappear in an equitably-financed public program in which everyone is automatically enrolled for life. ***

If reform legislation is approved, employees enrolled in group coverage at work would also be more secure. If workers are laid off — an all too common occurrence these days — and need to buy policies on their own, insurers would be barred from denying them coverage or charging exorbitant premiums for health reasons.

*** Just like COBRA, laid-off employees who no longer have a paycheck must then pay the full insurance premium that was formerly heavily subsidized by their employers. Partial subsidies are not adequate for a person with no paycheck. Even if eligible for the backup of Medicaid, shifting in and out of programs is disruptive to care. ***

CUTTING COSTS

Americans are justifiably concerned about the rising cost of health insurance and of the medical care it covers. The reform bills won’t solve these problems quick
ly, but they would make a good start.

*** The reform bills do not solve the problem of rising costs, and they don’t even make a good start. The proposals for accountable care organizations and bundling of payments create nightmare logistical problems that are dismissed as something we can figure out later. The excise tax on higher-premium plans will result in diminished benefits, shifting more of the financial responsibility to those individuals who need care and are already burdened with excessive out-of-pocket expenses. As health care costs continue to increase, more plans will be pared of benefits in order to avoid the excise tax. Making essential health care less affordable is a perverse policy proposal. Strengthening the power of an independent MedPAC-like board to reduce spending only within the Medicare program threatens to diminish the support of those in the health care delivery system who already feel threatened by what they perceive to be already low reimbursement rates. Price discrimination is a major problem in our dysfunctional financing system, but it cannot be adequately addressed by a payment advisory board limited to Medicare. Although the current proposal would look at the private sector, it would have no power nor even the ability to slow cost increases in the private sector. Under a universal public financing program, the board would be able to recommend measures to improve resource allocation for our entire health care delivery system, while balancing the demands of patients, health care providers and taxpayers. ***

Despite overheated Republican claims that the reforms would drive up premiums, the Congressional Budget Office projected that under the Senate bill the vast majority of Americans (those covered by employer policies) would see little or no change in their average premiums or even a slight decline. Those who buy their own policies would pay somewhat more — but for greatly improved coverage.

*** Except for a few regulatory requirements for the insurance industry, most Americans will see no improvement. They will continue to be burdened with ever higher health care costs, reflected in higher premiums and greater out-of-pocket cost sharing. Being guaranteed the right to buy insurance is of little consolation for those who can’t pay for it. Those in the individual market are often uninsured because they can’t afford the stripped-down plans currently available. Requiring greater benefits makes these plans even less affordable. The inadequacy of the proposed subsidies which are limited to plans purchased through the exchange will provide little consolation for those who are not eligible for or who cannot afford the plans in the exchange. A universal public system equitably financed based on ability to pay would eliminate the need for individual or employer-sponsored private plans. ***

Most people who would be buying their own policies would qualify for tax subsidies to help pay their premiums, which could reduce their costs by thousands of dollars a year. And small businesses would qualify for tax credits to defray the cost of covering their workers.

*** The primary reason to propose tax subsidies is to keep the insurance industry alive. It is much less efficient than establishing a single universal risk pool financed by equitable taxes. Furthermore, the proposed subsidies would leave all but the wealthiest of us exposed to a potential obligation to pay about 20 percent of our incomes for health care. That is a burden that most would find very difficult to bear. ***

The inexorably rising cost of hospital and medical care is the underlying factor that drives up premiums, deductibles and co-payments. No one yet has an answer to the problem.

*** Balderdash! All sane economists agree that a single payer monopsony would solve the problem. Conservative economists might not like a government solution, but they agree that it would actually work. It’s time for the practitioners of the dismal science of economics to engage in normative economics. These are not only numbers we’re dealing with; they are about the lives and well being of people. ***

But the bills would launch an array of pilot projects to test new payment and health care delivery systems within Medicare. These include, for example, incentives to coordinate hospital and post-hospital care to head off needless readmissions, better coordination of care for the chronically ill, and incentives for doctors to provide a patient’s total care for a flat fee instead of charging for each test or service provided.

*** Continual improvement in health care delivery is an important goal, but it is in no way unique to the current legislative proposal. A single payer monopsony would have a greater capability of realigning incentives for optimal care. ***

The Senate bill would set up an independent board to spur the use of programs that save money or improve care — subject to Congressional veto. Optimists believe the savings might come quickly but this could still take many years. Without passing a reform bill, there is little chance of success.

*** See the first comment under “cutting costs.” ***

THE TIME HAS COME

For decades, presidents from both parties have tried in vain to reform the health care system and cover the uninsured. Still many Americans wonder, given the deep recession, whether it makes sense to do it now. The first thing to keep in mind is that the C.B.O. says that the reform bills are paid for over the next 10 years and would actually reduce future deficits.

The need is clear and the political timing is right with the Democrats controlling the White House, the Senate and the House. If this chance is squandered and Republicans gain seats, as expected, in the midterm elections, it could be a decade or more before reformers have another opportunity. Americans shouldn’t have to wait any longer.

*** Most of the major features of this legislation are not scheduled to begin for years, yet we are told that it is urgent that we pass this bill within the next several weeks. The urgency is not based on sound health policy but is based on the political goal of proving President Obama and the Democrats with a political victory well in advance of the next elections. That might be good politics, but it is an unforgivable neglect of duty that is being committed by our public stewards. The policies of a single payer Medicare for all program are much less complex than the dysfunctional model being foisted off on us with the misnomer of reform. Because of the toll of financial hardship, physical suffering and even death, there is urgency in the need to act. But we can act now and have the program fully up and running long before the dates proposed in the current legislation. The New York Times says that we are squabbling, by definition arguing about trivial matters. Racking up a political victory on the scorecard is trivial. Doing that while glibly accepting a system that will leave so many broke and uninsured is unconscionable. ***

NYT editorial, The Case for Reform: http://www.nytimes.com/2009/12/30/opinion/30wed2.html

The New York Times doesn’t get it

This editorial from today’s edition of The New York Times makes their case for supporting the current health reform legislation before Congress. The responses of Don McCanne, MD are in red and bracketed with ***.

The Case for Reform

Editorial
The New York Times
December 29, 2009

Reforming this country’s broken health care system is an urgent and essential task.

*** Absolutely! ***

Given all of the fabrications and distortions from Republican critics, and the squabbling among Democratic supporters, it is no surprise that many Americans still have doubts.

*** Unfortunately, the Republicans are handicapped by their ideological opposition to government solutions for social problems. Their proposal for a free market of cheap underinsurance products sold across state lines would only make problems worse by further impairing the effectiveness of our current inadequate and inequitable risk pools. The squabbling of the Democrats is based on a disagreement over whether to take the bold step of providing a truly effective universal public insurance program, such as an improved Medicare for everyone, or to take what some believe to be the politically expedient step of trying to modify our current dysfunctional system, even though it means falling far short of the goals of universality and affordability. ***

President Obama and Democratic leaders have a strong case. They need to make it now.

*** They have a very weak case. President Obama and the Democratic leadership chose to try to modify our current dysfunctional system, leaving tens of millions without insurance and perpetuating the financial hardships faced by many who need health care. ***

Here are compelling reasons for all Americans to root for the reform effort to succeed and urge Congress to complete the job:

THE HEALTH OF MILLIONS OF AMERICANS

The fact that 46 million people in this country have no health insurance should be intolerable. Every other major industrial country guarantees health coverage to its citizens, yet the United States, the richest of them all, does not.

*** The current proposal would leave close to 20 million people without insurance, a number that is destined to increase as health care costs continue to rise. Supporting a policy that ensures that so many will continue to be without health insurance is what should not be tolerated. A public insurance program is designed to automatically cover everyone. ***

Claims that the uninsured can always go to an emergency room for charity care ignore the fact that American taxpayers pay a high price for that care. And it ignores the abundant evidence that people who lack insurance don’t get necessary preventive care or screening tests, and suffer gravely when they finally do seek treatment because their diseases have become critical.

*** The modest marginal cost of providing care for additional patients in the emergency room is not a major issue. The crucial problem is the deterioration of our primary care infrastructure that is required to provide individuals with a source of seamless continuing care. The proposed legislation does take some important steps toward addressing this serious deficiency, but they would be much more effective with a single, unified financing system integrated with our health care delivery system. ***

The American Cancer Society now says the greatest obstacle to reducing cancer deaths is lack of health insurance. It is so persuaded of that fact that two years ago, instead of promoting its antismoking campaign or publicizing the need for cancer screening, it devoted its entire advertising budget to the problem of inadequate health insurance coverage.

*** We previously commended the American Cancer Society for taking this forward-thinking position. ***

We consider it a moral obligation and sound policy to provide health insurance to as many people as possible. While the pending bills would fall short of complete coverage, by 2019, the Senate bill would cover 31 million people and the House bill 36 million who would otherwise be uninsured under current trends.

*** It is both a moral obligation and sound policy to provide health insurance for everyone, which a universal public insurance program would do. The design of the current proposal is both immoral and unsound because it leaves an intolerable number of individuals uninsured – a number close to two-thirds of the population of Canada. We may criticize Canada’s queues, but we would be outraged if they prohibited two-thirds of their population from even having a place in the queues. Why is there no outrage here when we would leave a similar number without coverage? ***

MORE SECURITY FOR ALL

Horror stories abound of people — mainly those who buy individual policies — who were charged exorbitant premiums or rejected because of pre-existing conditions or paid out for years and then had their policies rescinded when they got sick.

Such practices would be prohibited completely in three or four years under the reform bills. Before that, insurers would be barred from rescinding policies retroactively and the bills would establish temporary high-risk pools to cover people with pre-existing conditions.

*** Although private insurers have been appropriately condemned for using trivial reasons to rescind policies, many rescissions were for the legitimate reason (legitimate in a business sense) that individuals who were uninsured and then developed serious problems purchased coverage without reporting their newly acquired problem – a form of fraud. That defeats the insurance function of pooling all of the healthy in with the sick. The proposal before Congress still permits rescissions for fraud. This problem would totally disappear in a public financing system in which enrollment for life is automatic. Also, the experience with high-risk pools to date has been very dismal. The need for high-risk pools would be eliminated by a single public universal risk pool. ***

The legislation would also allow unmarried dependent children to remain on their parents’ policies until age 26 (the Senate version) or age 27 (the House version).

*** What do they do at 26 or 27? Would everyone at that age have a great job with generous employer-sponsored benefits? If not, would they be eligible for plans in the exchange, and could they afford their portion of premiums and out-of-pocket expenses that is estimated to be about 20 percent of their income? Again, this problem would disappear in an equitably-financed public program in which everyone is automatically enrolled for life. ***

If reform legislation is approved, employees enrolled in group coverage at work would also be more secure. If workers are laid off — an all too common occurrence these days — and need to buy policies on their own, insurers would be barred from denying them coverage or charging exorbitant premiums for health reasons.

*** Just like COBRA, laid-off employees who no longer have a paycheck must then pay the full insurance premium that was formerly heavily subsidized by their employers. Partial subsidies are not adequate for a person with no paycheck. Even if eligible for the backup of Medicaid, shifting in and out of programs is disruptive to care. ***

CUTTING COSTS

Americans are justifiably concerned about the rising cost of health insurance and of the medical care it covers. The reform bills won’t solve these problems quickly, but they would make a good start.

*** The reform bills do not solve the problem of rising costs, and they don’t even make a good start. The proposals for accountable care organizations and bundling of payments create nightmare logistical problems that are dismissed as something we can figure out later. The excise tax on higher-premium plans will result in diminished benefits, shifting more of the financial responsibility to those individuals who need care and are already burdened with excessive out-of-pocket expenses. As health care costs continue to increase, more plans will be pared of benefits in order to avoid the excise tax. Making essential health care less affordable is a perverse policy proposal. Strengthening the power of an independent MedPAC-like board to reduce spending only within the Medicare program threatens to diminish the support of those in the health care delivery system who already feel threatened by what they perceive to be already low reimbursement rates. Price discrimination is a major problem in our dysfunctional financing system, but it cannot be adequately addressed by a payment advisory board limited to Medicare. Although the current proposal would look at the private sector, it would have no power nor even the ability to slow cost increases in the private sector. Under a universal public financing program, the board would be able to recommend measures to improve resource allocation for our entire health care delivery system, while balancing the demands of patients, health care providers and taxpayers. ***

Despite overheated Republican claims that the reforms would drive up premiums, the Congressional Budget Office projected that under the Senate bill the vast majority of Americans (those covered by employer policies) would see little or no change in their average premiums or even a slight decline. Those who buy their own policies would pay somewhat more — but for greatly improved coverage.

*** Except for a few regulatory requirements for the insurance industry, most Americans will see no improvement. They will continue to be burdened with ever higher health care costs, reflected in higher premiums and greater out-of-pocket cost sharing. Being guaranteed the right to buy insurance is of little consolation for those who can’t pay for it. Those in the individual market are often uninsured because they can’t afford the stripped-down plans currently available. Requiring greater benefits makes these plans even less affordable. The inadequacy of the proposed subsidies which are limited to plans purchased through the exchange will provide little consolation for those who are not eligible for or who cannot afford the plans in the exchange. A universal public system equitably financed based on ability to pay would eliminate the need for individual or employer-sponsored private plans. ***

Most people who would be buying their own policies would qualify for tax subsidies to help pay their premiums, which could reduce their costs by thousands of dollars a year. And small businesses would qualify for tax credits to defray the cost of covering their workers.

*** The primary reason to propose tax subsidies is to keep the insurance industry alive. It is much less efficient than establishing a single universal risk pool financed by equitable taxes. Furthermore, the proposed subsidies would leave all but the wealthiest of us exposed to a potential obligation to pay about 20 percent of our incomes for health care. That is a burden that most would find very difficult to bear. ***

The inexorably rising cost of hospital and medical care is the underlying factor that drives up premiums, deductibles and co-payments. No one yet has an answer to the problem.

*** Balderdash! All sane economists agree that a single payer monopsony would solve the problem. Conservative economists might not like a government solution, but they agree that it would actually work. It’s time for the practitioners of the dismal science of economics to engage in normative economics. These are not only numbers we’re dealing with; they are about the lives and well being of people. ***

But the bills would launch an array of pilot projects to test new payment and health care delivery systems within Medicare. These include, for example, incentives to coordinate hospital and post-hospital care to head off needless readmissions, better coordination of care for the chronically ill, and incentives for doctors to provide a patient’s total care for a flat fee instead of charging for each test or service provided.

*** Continual improvement in health care delivery is an important goal, but it is in no way unique to the current legislative proposal. A single payer monopsony would have a greater capability of realigning incentives for optimal care. ***

The Senate bill would set up an independent board to spur the use of programs that save money or improve care — subject to Congressional veto. Optimists believe the savings might come quickly but this could still take many years. Without passing a reform bill, there is little chance of success.

*** See the first comment under “cutting costs.” ***

THE TIME HAS COME

For decades, presidents from both parties have tried in vain to reform the health care system and cover the uninsured. Still many Americans wonder, given the deep recession, whether it makes sense to do it now. The first thing to keep in mind is that the C.B.O. says that the reform bills are paid for over the next 10 years and would actually reduce future deficits.

The need is clear and the political timing is right with the Democrats controlling the White House, the Senate and the House. If this chance is squandered and Republicans gain seats, as expected, in the midterm elections, it could be a decade or more before reformers have another opportunity. Americans shouldn’t have to wait any longer.

*** Most of the major features of this legislation are not scheduled to begin for years, yet we are told that it is urgent that we pass this bill within the next several weeks. The urgency is not based on sound health policy but is based on the political goal of proving President Obama and the Democrats with a political victory well in advance of the next elections. That might be good politics, but it is an unforgivable neglect of duty that is being committed by our public stewards. The policies of a single payer Medicare for all program are much less complex than the dysfunctional model being foisted off on us with the misnomer of reform. Because of the toll of financial hardship, physical suffering and even death, there is urgency in the need to act. But we can act now and have the program fully up and running long before the dates proposed in the current legislation. The New York Times says that we are squabbling, by definition arguing about trivial matters. Racking up a political victory on the scorecard is trivial. Doing that while glibly accepting a system that will leave so many broke and uninsured is unconscionable. ***

NYT editorial, The Case for Reform: http://www.nytimes.com/2009/12/30/opinion/30wed2.html