By Dr. Oliver Fein
The Progressive
September 10, 2009

President Obama sold single-payer health care short in his speech to Congress. It’s actually the only sensible solution to our health care crisis.

Obama said that a single-payer health care system would require us to “build an entirely new system from scratch.”

Not true.

We already have a working single-payer system.

For more than 40 years, single payer has served millions of American patients in the form of traditional Medicare. In essence, single payer is an improved Medicare for all.

Obama touted his plan as a way to reduce the escalating costs of health care in this country. But he’s exaggerating the amount of waste and inefficiency he can wring out of Medicare and Medicaid. And the Congressional Budget Office estimated that his plan would actually end up costing hundreds of billions of dollars.

But if we implemented single payer, the savings would be enormous. Medicare incurs approximately 3 percent in administrative overhead annually, compared to at least five times that figure in private insurance plans. If you factor in all the bureaucracy and paperwork inflicted on physicians and hospitals by the insurance industry, the administrative waste in our present system amounts to $400 billion annually.

By replacing the for-profit insurance companies with a streamlined Medicare for all, that $400 billion could be put back where it belongs: providing health care. The new system would basically pay for itself.

Insurance companies play no constructive role in providing health care. They do not give you a physical exam; they do not perform your surgery. What they do instead is fight claims, issue denials and screen out the sick, diverting huge sums away from much-needed care.

The savings rendered by cutting out private insurance companies and establishing a single-payer plan would be sufficient to cover everyone who lacks insurance now and to upgrade insurance for everyone else.

Our nation spends twice per person on health care as other industrialized countries do, but our health outcomes are significantly worse.

What gives? How can we spend more and get less than the rest of the world?

The answer is that most these countries have taken a fundamental step that we haven’t: the elimination of U.S.-style, for-profit private health insurance.

We should take that step.

Obama should have proposed a single-payer plan in the first place. Not that the path would have been politically easy. But single payer would have been easier to defend than the expensive, overly bureaucratic, patchwork mess that he is trying to sell to the American public.

It’s time for Congress acknowledge what patients and doctors across the country already know, that single-payer Medicare for all is the only way to achieve affordable and effective health care.

Dr. Oliver Fein is professor of clinical medicine and public health at Weill Cornell Medical College in New York. He is also president of Physicians for a National Health Program (www.pnhp.org).

By George S. McGovern
Washington Post
Sunday, September 13, 2009

For many years, a handful of American political leaders — including the late senator Ted Kennedy and now President Obama — have been trying to gain passage of comprehensive health care for all Americans. As far back as President Harry S. Truman, they have urged Congress to act on this national need. In a presentation before a joint session of Congress last week, Obama offered his view of the best way forward.

But what seems missing in the current battle is a single proposal that everyone can understand and that does not lend itself to demagoguery. If we want comprehensive health care for all our citizens, we can achieve it with a single sentence: Congress hereby extends Medicare to all Americans.

Those of us over 65 have been enjoying this program for years. I go to the doctor or hospital of my choice, and my taxes pay all the bills. It’s wonderful. But I would have appreciated it even more if my wife and children and I had had such health-care coverage when we were younger. I want every American, from birth to death, to get the kind of health care I now receive. Removing the payments now going to the insurance corporations would considerably offset the tax increase necessary to cover all Americans.

I don’t feel as though the government is meddling in my life when it pays my doctor and hospital fees. There are some things the government does that I don’t like — most notably getting us into needless wars that cost many times what health care for all Americans would cost. Investing in the health of our citizens will enhance the well-being and security of the nation.

We know that Medicare has worked well for half a century for those of us over 65. Why does it become “socialized medicine” when we extend it to younger Americans?

Taking such a shortsighted view would leave nearly 50 million Americans without health insurance and without the means to buy it. It would leave other Americans struggling to pay the rising cost of insurance premiums. These private insurance plans are frequently terminated if the holder contracts a serious long-term ailment. And some people lose their insurance if they lose their jobs or if the plant where they work moves to another location — perhaps overseas.

We recently bailed out the finance houses and banks to the tune of $700 billion. A country that can afford such an outlay while paying for wars in Iraq and Afghanistan can afford to do what every other advanced democracy has done: underwrite quality health care for all its citizens.

If Medicare needs a few modifications in order to serve all Americans, we can make such adjustments now or later. But let’s make sure Congress has an up or down vote on Medicare for all before it adjourns this year. Let’s not waste time trying to reinvent the wheel. We all know what Medicare is. Do we want health care for all, or only for those over 65?

If the roll is called and it goes against those of us who favor national health care, so be it. If it is approved, the entire nation can applaud.

Many people familiar with politics in America will tell you that this idea can’t pass Congress, in part because the insurance lobby is too powerful for lawmakers to resist.

As matters now stand, the insurance companies claim $450 billion a year of our health-care dollars. They will fight hard to hold on to this bonanza. This is a major reason Americans pay more for health care per capita than any other people in the world. The insurance executives didn’t cry “socialism” when their buddies in banking and finance were bailed out. But to them it is socialism if the government underwrites the cost of health care.

Consider the campaign funds given to the chairman and ranking minority member of the Senate Finance Committee, which has jurisdiction over health-care legislation. Chairman Max Baucus of Montana, a Democrat, and his political action committee have received nearly $4 million from the health-care lobby since 2003. The ranking Republican, Charles Grassley of Iowa, has received more than $2 million. It’s a mistake for one politician to judge the personal motives of another. But Sens. Baucus and Grassley are firm opponents of the single-payer system, as are other highly placed members of Congress who have been generously rewarded by the insurance lobby.

In the past, doctors and their national association opposed Medicare and efforts to extend such benefits. But in recent years, many doctors have changed their views.

In December 2007, the 124,000-member American College of Physicians endorsed for the first time a single-payer national health insurance program. And a March 2008 study by Indiana University — the largest survey ever of doctors’ opinions on financing health-care reform — concluded that 59 percent of doctors support national health insurance.

To have the doctors with us favoring government health insurance is good news. As Obama said: “We did not come to fear the future. We came here to shape it.”

George S. McGovern, a former senator from South Dakota, was the Democratic nominee for president in 1972.

By Lara Wright, M.D.
Guest Commentary
Contra Costa Times
09/12/2009

I AM a family physician who has firsthand experience about the need for health insurance reform. In 1999, after completing a residency in family practice, I was diagnosed with a brain tumor. Fortunately, I had use COBRA to continue my health benefits for 18 months. When my diagnosis was made, I still had health insurance, as well as supportive family, friends and colleagues who worked in health care.

Even with so much help, I experienced much difficulty navigating the health insurance system. As someone with a history of a brain tumor, my options for insurance after my COBRA coverage expired were minimal and expensive. Many of the options would cover all medical problems except those relating to the brain tumor.

The difficulties with health insurance compounded the stress for me and my family in dealing with treatment of and recovery from my brain tumor.

During the next few years, I worked as a patient advocate for a health insurance plan. In that job, I sometimes heard patients referred to as “product lines,” a surprising and disturbing experience.

Now, 10 years later, I again work as a doctor. The prognosis from my rehabilitation physician immediately after my surgery included a lifetime of permanent disability. Thankfully, I have far exceeded the prognosis of my physician. Instead of receiving benefits, I am able to work, treat patients and pay taxes.

I work in a county clinic, where I see patients who are faced with the difficult decision to pay for rent and food for their families, or pay for their health care. Many are unable to afford health insurance and risk running up hospital bills for emergency care that will drive them into debt and possibly into bankruptcy.

A recent study shows that more than half of personal bankruptcies are linked to medical bills, and 75 percent of people filing those bankruptcies had health insurance when they got sick.

The insight into my patients’ experiences with illness combined with my own experiences as a patient and patient advocate give me a unique perspective on our medical and insurance systems.

My experiences have led me to realize that the best solution is single-payer health care, an improved Medicare for All. This alternative has been largely neglected in the present health reform debate.

The California Senate and Assembly have twice passed a single-payer health insurance plan, but Gov. Arnold Schwarzenegger vetoed it both times. On the national front, HR 676 and SB 703 are two bills in the U.S. House and Senate that include single-payer health insurance plans, funded by the government but delivered through the existing private and public hospital system.

A recent study showed that 59 percent of physicians now support a national health insurance program. Such a system would meet their patients’ needs best, as well as eliminate many of the wasteful administrative costs with the current private health insurance industry. Moving to a single-payer system would enable our nation to save $400 billion annually, enough to provide comprehensive, quality care to all.

Critics say single-payer health insurance is socialized medicine. Not so, single-payer is insurance for everyone. A good example of socialized medicine is the Veterans Affairs: hospitals are owned by the government and doctors and nurses are on the federal payroll.

Under single-payer, however, doctors and hospitals remain largely private. You go to whichever doctor or hospital you choose. Instead of private insurers, a nonprofit government agency pays all the bills, similar to how traditional Medicare operates today. Private insurance includes wasteful administrative costs, sometimes up to 20-30 percent, a significant portion of which is spent to deny care that is not covered and decide who will make for a profitable consumer, or “product line.”

The United States is the only developed country without a national health insurance plan. The U.S. ranks number 29 in infant mortality and number 30 in expected life span among countries in the world, while far outspending all other countries.

We desperately need real health insurance reform. The best option is single-payer Medicare for All.

Wright is a member of Physicians for a National Health Program (www.pnhp.org), an organization of 17,000 doctors and health professionals who support single-payer national health insurance. She practices in Contra Costa County.

By PAULINE W. CHEN, M.D.
New York Times
September 10, 2009

I was born, raised and live in the United States, but recently a neighbor asked me, “What are you?”

As the daughter of Taiwanese immigrants, I have gone through this line of inquiry my entire life, so I understood that while well-intentioned, my neighbor’s question carried the assumption that I was not, at least in his eyes, entirely American.

On that day, however, I decided not to elaborate on my family’s immigration history. Instead, I threw the question back to him, hoping in part that he would tell me about the countries from which his family originated.

“Well,” I said, “tell me first, what are you?”

“I’m an American!” he replied without a moment’s thought. But then he asked once again, “So what are you?”

According to a recent editorial in The New England Journal of Medicine, my neighbor is not the only one who holds erroneous assumptions about the meaning of “American.” Dr. Allan S. Brett, a professor of medicine and bioethicist at the University of South Carolina, argues that politicians and pundits from both sides of the aisle are now doing the same, using incorrect beliefs about “American values” as a smokescreen in the health care reform debate. Phrases like “uniquely American” have become high praise, while “Canadian” and “British” are fighting words or frank defamation.

As Dr. Brett writes, “[T]he underlying premise is that an identifiable set of American values point incontrovertibly to a health care system anchored by the private insurance industry. . . .Discussions dominated by references to uniquely American individualism, uniquely American solutions, or narrowly defined conceptions of choice tell us more about the political and economic interest of the discussants than about the interest of the Americans they claim to represent.”

I spoke to Dr. Brett recently and asked him about the notion of “American values,” the assumptions made in the health care debate, and what system, if any, might come close to representing what is American.

Q. What assumptions do public figures have when they use the term “American values”?

A. They assume several things. First, that you can take just about any American walking down the street and reliably make an inference about what their views will be and what they deem important in health care. But anyone with his or her eyes open knows just how heterogeneous we’ve become in this country.

They also assume that these “American values” can be predictably translated into organizational structures. But that’s not true. One cannot assume, for instance, that if a person prizes liberty and freedom, he or she will prefer private insurance. Instead, maybe what that person wants is freedom from worries about what will happen should he or she suddenly became ill. Maybe that person wants the liberty to accomplish what he or she wants to accomplish. Those goals are better served by a seamless health care system where the individual doesn’t have to worry about what is coming from around the corner.

The concept of American values is used to tell people what they should be wanting rather than objectively trying to understand what Americans are all about.

Q. What about freedom of choice in health care? Isn’t that uniquely American?

A. There are three types of choice in health care.

The first is the choice of your preferred physician. In the most popular health plans, the choices are virtually unlimited; people can chose whom they want to see and where they want to go. But a single-payer system, for example, does not necessarily change that, since all the facilities and practices as we know them today are left in place. In fact, if you take away all the insurance restrictions we have today on whom you can see, your choice is increased.

A second type of choice is the freedom to choose a health care plan. We do want to choose our hospitals and doctors. But do we really look forward every November to choosing between one of five plans with permutations and combinations of physicians, providers in network and providers out of network? What people really want is a user-friendly system to get what they need.

Finally, the third kind of choice has to do with deciding on whatever tests and treatments you might want as a patient. But that element of choice has to be carefully handled no matter what kind of system we have because those choices affect cost. Over the last 10 to 20 years, the pendulum has swung toward patient autonomy — which is a good thing — but it has also swung to the point where doctors sometimes feel they must give patients whatever they want without thinking critically about the risks and benefits. That has led to a huge proportion of money being spent on care that is not only marginally beneficial but is also of no benefit at all. I think that if we had a way to eliminate that — which means using our clinical decision-making skills and saying no when appropriate — we would have more money to spend on care that does matter and that makes a difference.

No matter what system we ultimately decide upon, there will have to be mechanisms in place to insure that we spend money wisely.

Q. So is there anything that is uniquely “American” about our way of approaching health care?

A. Yes. We are unique almost worldwide in that we deny health care coverage to a proportion of our population.

I do not believe there are pivotally important distinctions between our “American values” and those of other Western European and North American countries, and certainly not the kind of distinctions that would prevent us from sorting out our health care system. I don’t think we are as unique as politicians make us out to be. Even if we were that unique, the important thing is to get health care right and not to harp on the uniqueness of the system we come up with.

Q. How would you envision a health care system that is imbued with “American values”?

A. In virtually every opinion poll conducted in recent years, a majority of Americans favor government guaranteed health insurance. While a single-payer system isn’t the only way for the government to guarantee coverage for all, I think one way to think of such a system is to consider it “Medicare for all.”

But such a system would have to be accompanied by a really hard look, led by medical experts and members of the community, at what works and what doesn’t, an assessment of how we can best budget our health care dollars to achieve the best possible health care outcomes. Such a system would take time and there would be hard choices, and not everyone would be happy. But we might come closer than we are to representing the interests of most Americans.

The Missoulian
Letter to the editor
Thursday, September 10, 2009

Amidst the give and take of the health care reform discussion is an underlying basic moral imperative: Does a wealthy country like the United States have an ethical obligation to provide access to health care to everybody?

If the U.S. made the moral choice to provide universal coverage, like other industrialized nations, then we too could design a fair, efficient and high-quality health care system for all Americans.

So the first question that must be answered by policy makers is, “Do we want to live in a society that lets tens of thousands of our neighbors die each year, and hundreds of thousands face financial ruin, because they can’t afford medical care when they are sick?”

Once answered that morally everybody should have a basic human right to health, aided through a system of health care, that is comprehensive, simple to administer, of lower cost, and universally available, we can move to the next step.

The concept of a unified system that works the same for everybody doesn’t necessarily equate to a single-payer system, although this seems to be the simplest and best. There are multi-payer systems that provide fairness and the administrative simplicity of a single payer structure: all patients treated the same and all the payers follow a coordinated set of rules and forms, and all providers fees adhere to a unified payment schedule. A unified system makes it easier to use digital record keeping. It eliminates cost shifting and an incentive for preventive health measures.

The fragmented system we have hasn’t worked. Financing health care must be a non-profit endeavor. A unified system creates a powerful political dynamic for managing cost. Universal coverage enhances health care results by improving the overall health of a nation. Incomplete coverage is a key reason 22,000 die every year from diseases that could have been treated if they’d had health insurance.

Because administrative costs and unnecessary care, combined with perverse incentives, are the major causes of the expense, the concept of a single payer system is mandatory. This is an anathema to free-market people, who are misleading the public by negative advertising, with denigration by politicians and others, labeling it “socialized medicine,” and “government interference.”

To get the truth out, there should be a new intense advertising campaign to educate the public about the benefits of this approach. A single payer system could be run by a federal board, independent of the government, appointed by the president and confirmed by the Senate. It could function with assistance of health care experts and be immune to political interference. Regional entities under the board’s aegis could manage the delivery of health care. Unnecessary care could be monitored so the link between income and generated procedures and tests could be curbed. There are many options for reimbursement to providers: capitation, global payments, salary system, pay for episodes of care, rewards for improved outcomes, and pay according to episodes of care. It’s interesting that 30 % of U.S. physicians are already on salary. Tort reform must also be addressed to eliminate the high cost of liability insurance, through a review panel of peers for malpractice claims.

All of this could be done by not spending any more than what we do now. It is more likely there would be a huge reduction in health care spending. It just doesn’t make sense to continue the partisan pursuit of complicated individual interests. Everyone needs to proclaim that there exists a moral imperative; that it does mean providing access to health care for everyone. It is relatively common sense to then formulate a government funded, unified system, with nonprofit financing and coverage for every citizen – a single-payer system.

Richard A. Damon, MD
Bozeman