PNHP

Lewin report on the public option

Lewin report on the public option

The Cost and Coverage Impacts of a Public Plan: Alternative Design Options

Prepared by John Sheils Randy Haught
The Lewin Group
April 6, 2009
President Obama has proposed to create a “public plan” that would compete for enrollment with the private insurance industry.
The public plan is difficult to evaluate because no one has specified in legislation how it would work.
Consequently, in this paper, we present impact estimates under several variations on the public plan model.
If Medicare payment levels are used in the public plan, premiums would be up to 30 percent less than premiums for comparable private coverage. On average, the monthly premium in the public plan for a typical benefits package would be $761 per family compared with an average of $970 per family in the private market for the same coverage.
If the public plan is opened to all employers as proposed by Senators Clinton and Edwards, at Medicare payment levels we estimate that about 131.2 million people would enroll in the public plan. The number of people with private health insurance would decline by 119.1 million people.
Medicare premiums would be lower than private premiums because of the exceptional leverage Medicare has with providers. Medicare pays hospitals about 30 percent less than private insurers pay for the same service. Physician payments are about 20 percent less than under private coverage. Also, because Medicare has no allowance for insurer profits or broker/agent commissions, administrative costs for this population are about one-third of administrative costs in private health plans.
Assuming Medicare reimbursement rates and eligibility for all individuals and employers, provider net income would decline under this public plan proposal, even after accounting for reduced uncompensated care and increased utilization for the newly insured. Net hospital revenues would fall by $36 billion (4.6 percent), and physician net income would fall by $33 billion (6.8 percent).
http://www.lewin.com/content/publications/LewinCostandCoverageImpactsofPublicPlan-Alternative%20DesignOptions.pdf

No details have been released by either Congress or the administration about the specifics of a potential public insurance option that could be offered in competition within a market of private health plans. Nevertheless, to provide an analysis of how such a plan might work, The Lewin Group used certain assumptions to prepare this simulation.
Under this analysis, hospitals would be paid 30 percent less than the reimbursement rates of private insurers, and physicians would be paid 20 percent less. Using these and other assumptions, premiums for the public plan would be 30 percent less than comparable coverage by private plans.
Supporters of the public option are likely to claim that it is an essential component of reform since it will lower the cost of insurance while expanding coverage to over 100 million more people.
Opponents of the public option are already claiming that the government would be an unfair competitor to the private plans because of its ability to dictate rates that are lower than what the private plans must charge.
This simulation may very well also increase the opposition by physicians and hospital administrators because of concern about the possibility of shifting large numbers of patients from the private plans to the government plan with its considerably lower reimbursement rates. In the heat of the debate, it may be forgotten that these fee reductions were an assumption made by the authors of this report for simulation purposes, and not a feature of any actual legislative proposal.
Unfortunately, this study only fuels a debate that has diverted us from the discussion that we should be having. Instead of arguing over a controversial, yet-to-be-defined measure that cannot possibly lead to the efficiencies, equity and effectiveness of the single payer model, we should be discussing what actually would work – true single payer reform.

Lewin report on the public option

The Cost and Coverage Impacts of a Public Plan: Alternative Design Options

Prepared by John Sheils Randy Haught
The Lewin Group
April 6, 2009

President Obama has proposed to create a “public plan” that would compete for enrollment with the private insurance industry.

The public plan is difficult to evaluate because no one has specified in legislation how it would work.

Consequently, in this paper, we present impact estimates under several variations on the public plan model.

If Medicare payment levels are used in the public plan, premiums would be up to 30 percent less than premiums for comparable private coverage. On average, the monthly premium in the public plan for a typical benefits package would be $761 per family compared with an average of $970 per family in the private market for the same coverage.

If the public plan is opened to all employers as proposed by Senators Clinton and Edwards, at Medicare payment levels we estimate that about 131.2 million people would enroll in the public plan. The number of people with private health insurance would decline by 119.1 million people.

Medicare premiums would be lower than private premiums because of the exceptional leverage Medicare has with providers. Medicare pays hospitals about 30 percent less than private insurers pay for the same service. Physician payments are about 20 percent less than under private coverage. Also, because Medicare has no allowance for insurer profits or broker/agent commissions, administrative costs for this population are about one-third of administrative costs in private health plans.

Assuming Medicare reimbursement rates and eligibility for all individuals and employers, provider net income would decline under this public plan proposal, even after accounting for reduced uncompensated care and increased utilization for the newly insured. Net hospital revenues would fall by $36 billion (4.6 percent), and physician net income would fall by $33 billion (6.8 percent).

http://www.lewin.com/content/publications/LewinCostandCoverageImpactsofPublicPlan-Alternative%20DesignOptions.pdf

Comment:

By Don McCanne, MD

No details have been released by either Congress or the administration about the specifics of a potential public insurance option that could be offered in competition within a market of private health plans. Nevertheless, to provide an analysis of how such a plan might work, The Lewin Group used certain assumptions to prepare this simulation.

Under this analysis, hospitals would be paid 30 percent less than the reimbursement rates of private insurers, and physicians would be paid 20 percent less. Using these and other assumptions, premiums for the public plan would be 30 percent less than comparable coverage by private plans.

Supporters of the public option are likely to claim that it is an essential component of reform since it will lower the cost of insurance while expanding coverage to over 100 million more people.

Opponents of the public option are already claiming that the government would be an unfair competitor to the private plans because of its ability to dictate rates that are lower than what the private plans must charge.

This simulation may very well also increase the opposition by physicians and hospital administrators because of concern about the possibility of shifting large numbers of patients from the private plans to the government plan with its considerably lower reimbursement rates. In the heat of the debate, it may be forgotten that these fee reductions were an assumption made by the authors of this report for simulation purposes, and not a feature of any actual legislative proposal.

Unfortunately, this study only fuels a debate that has diverted us from the discussion that we should be having. Instead of arguing over a controversial, yet-to-be-defined measure that cannot possibly lead to the efficiencies, equity and effectiveness of the single payer model, we should be discussing what actually would work – true single payer reform.

Universal health coverage in spotlight at L.A. forum

But the White House-organized event is light on details

By Lisa Girion and Noam Levey
Los Angeles Times
April 7, 2009

Reporting from Washington and Los Angeles — Even as President Obama toured Europe his administration pressed its healthcare reform campaign Monday in Los Angeles with a forum co-hosted by Gov. Arnold Schwarzenegger, who lost his bid in California to make many of the changes now on the table in Washington.

Reform is overdue, the governor said. “No one can look at our healthcare system and say that the system is fair or a good return on what we spend, and this consensus can help us pass significant bipartisan reforms into law.”


Andy Evano of the California School Employees
Association leads chanting by protesters
outside the forum.

A wide array of forum participants, including hospital and insurance company executives and the mother of a teenager who died from a preventable hospital-acquired infection, gave voice to the grow- ing desire for change. But the presentation was light on details.

Universal coverage — health insurance for all Americans — was widely touted, but there was no discussion of how to achieve that goal.

The forum, the fifth in a series the White House organized around the country over the last month, comes as senior Democrats on Capitol Hill move ahead on drafting legislation to be introduced later this spring to overhaul the nation’s healthcare system.

The president and his congressional allies have pledged that the bill will expand coverage to some 46 million uninsured people, rein in costs and improve the quality of care.

The White House billed the five forums as a way to get public input. But the invitation-only event in Los Angeles was clearly programmed to showcase the broad goals Obama has said he wants included in the legislation, including an emphasis on prevention, as well as secure and affordable coverage for everyone, regardless of age or preexisting conditions.

Schwarzenegger, who hosted the event with Washington Gov. Chris Gregoire, marveled at the White House support for reform. “Isn’t it nice to have a president who is passionate about healthcare?” Schwarzenegger said. “I love it.”

In making his case for a healthcare overhaul, Schwarzenegger took a swipe at the insurance company practice of canceling members’ coverage after they get sick over purported application misstatements about preexisting conditions. “That is unacceptable,” the governor said.

Schwarzenegger’s $14.9-billion proposal intended to provide medical insurance for nearly all Californians died in the state Senate last year.

Outside the forum, the California Nurses Assn., Physicians for a National Health Program and other groups drew hundreds to a rally in support of the so-called single-payer option, which would put government in charge of organizing and purchasing healthcare and leave the private insurance market in tatters.

Deborah Burger, co-president of the California-based nurses union, a Schwarzenegger foe, said she feared that the single-payer approach would not be considered in Washington because of heavy lobbying by the insurance industry. She said the forum, where no single-payer proponent spoke, was just more “window dressing.”

With the forums concluded, the action now shifts to Washington, where members of Congress also are working toward universal coverage through legislation that would modify the current private insurance market rather than replace it.

Congressional leaders are crafting a budget resolution that could allow Democrats to pass major healthcare legislation this year with a simple majority in the Senate, rather than the 60-vote supermajority necessary to head off a Republican filibuster.

House Democrats and some in the White House are pushing for this approach, though some senior Senate Democrats are more wary of employing a tactic that is sure to provoke a Republican revolt. Congress will take up the budget resolution when lawmakers return from spring recess in two weeks.

Doc organization pushes 'Medicare-for-all' system

By Andis Robeznieks
Modern Healthcare
April 6, 2009

Sarcastically describing them as “brilliant,” Physicians for a National Health Program National Coordinator Quentin Young warned that the legislative proposals currently being considered to improve access to healthcare are “a catastrophe in the making” and would rival the collapse of the financial markets.

Speaking at an outdoor rally today in downtown Chicago’s Federal Plaza, Young advocated for a publicly funded, privately operated “Medicare-for-all” health system, and he mocked proposals to mandate that everyone buy private insurance or face a fine.

The rally was timed to coincide with the White House forum on healthcare reform taking place in Los Angeles and was co-sponsored by the California Nurses Association/National Nurses Organizing Committee. Young noted that single-payer advocates were denied a seat at the table at today’s forum and that–in Los Angeles–“thousands were protesting outside because they could not get inside.”

Another source, however, estimated a smaller crowd. A news release issued by the Leadership Conference for Guaranteed Healthcare, a coalition that includes both the PNHP and CNA, noted that “hundreds” had gathered around a giant table representing how single-payer advocates had been shut out of the forum.

The Chicago rally was attended by about 30 people, and the California Nurses Association was represented by Frank Borgers, who told how the Los Angeles forum was being hosted by “our friend–not so much–Gov. Schwarzenegger.” Borgers also mocked proposals mandating the purchase of private insurance as “foolhardy” and “doomed.”

“The nation cannot afford to subsidize private health insurance,” Borgers said.

Young described the current political climate as a good-news/bad-news proposition, explaining that public support for a single-payer system has never been stronger, but that insurance companies have been working harder than ever to maintain their control. “They have not been asleep at the wheel,” he said.

Young also noted the “bitter realities” facing the city of Chicago’s healthcare system, including how the 553-bed University of Chicago Medical Center was working to redirect a significant number of its emergency department visitors to other facilities and how the 364-bed Michael Reese Hospital and Medical Center–whose staff he joined in 1952–is closing down.

University of Chicago Medical Center spokesman John Easton defended his institution’s program to reduce emergency room traffic and described it as an effort to find medical homes for patients who use the hospital’s emergency department as their main source of primary care rather than for treatment of true medical emergencies.

Doc organization pushes ‘Medicare-for-all’ system

By Andis Robeznieks
Modern Healthcare
April 6, 2009

Sarcastically describing them as “brilliant,” Physicians for a National Health Program National Coordinator Quentin Young warned that the legislative proposals currently being considered to improve access to healthcare are “a catastrophe in the making” and would rival the collapse of the financial markets.

Speaking at an outdoor rally today in downtown Chicago’s Federal Plaza, Young advocated for a publicly funded, privately operated “Medicare-for-all” health system, and he mocked proposals to mandate that everyone buy private insurance or face a fine.

The rally was timed to coincide with the White House forum on healthcare reform taking place in Los Angeles and was co-sponsored by the California Nurses Association/National Nurses Organizing Committee. Young noted that single-payer advocates were denied a seat at the table at today’s forum and that–in Los Angeles–“thousands were protesting outside because they could not get inside.”

Another source, however, estimated a smaller crowd. A news release issued by the Leadership Conference for Guaranteed Healthcare, a coalition that includes both the PNHP and CNA, noted that “hundreds” had gathered around a giant table representing how single-payer advocates had been shut out of the forum.

The Chicago rally was attended by about 30 people, and the California Nurses Association was represented by Frank Borgers, who told how the Los Angeles forum was being hosted by “our friend–not so much–Gov. Schwarzenegger.” Borgers also mocked proposals mandating the purchase of private insurance as “foolhardy” and “doomed.”

“The nation cannot afford to subsidize private health insurance,” Borgers said.

Young described the current political climate as a good-news/bad-news proposition, explaining that public support for a single-payer system has never been stronger, but that insurance companies have been working harder than ever to maintain their control. “They have not been asleep at the wheel,” he said.

Young also noted the “bitter realities” facing the city of Chicago’s healthcare system, including how the 553-bed University of Chicago Medical Center was working to redirect a significant number of its emergency department visitors to other facilities and how the 364-bed Michael Reese Hospital and Medical Center–whose staff he joined in 1952–is closing down.

University of Chicago Medical Center spokesman John Easton defended his institution’s program to reduce emergency room traffic and described it as an effort to find medical homes for patients who use the hospital’s emergency department as their main source of primary care rather than for treatment of true medical emergencies.

McClellan asks, "What would be the point?"

Democrats seek compromise on health care plan

By Ricardo Alonso-Zaldivar
The Washington Post
April 2, 2009
Democrats are seeking a compromise on a bigger government role in insurance coverage as part of President Barack Obama’s proposed health care overhaul.
At issue is whether middle-class workers and families should have the option of a government-sponsored plan that would compete with private insurers.
Sen. Charles Schumer, who is working on the issue for the Senate Finance Committee, said Thursday one potential compromise is based on insurance plans that most states already offer their employees. Obama’s health secretary nominee, Kansas Gov. Kathleen Sebelius, likes the idea.
Schumer, D-N.Y., said such a plan would avoid expanding a federal program like Medicare and that a private insurer possibly could run it. Sebelius already administers that type of plan in Kansas.
The insurance lobby fears that a federally backed plan could drive companies out of business.
“We are taking a look at the different state employee plans to get a better understanding of how they operate,” said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans.
GOP lawmakers “are going to need to know what’s in the fine print,” said Craig Orfield, a spokesman for Sen. Mike Enzi, R-Wyo., a leading lawmaker in the debate.
“My goal is to find a plan that would be acceptable to large numbers of senators,” Schumer said in an interview. “Right now, the private insurers are totally opposed, but maybe there’s room.”
In California, the state sponsors three medical network plans for employees and retirees. These plans are offered alongside traditional insurance plans. The state-sponsored plans, administered by Anthem Blue Cross, account for about one-fourth of the 1.3 million people in the state employee health program, said Karen Perkins, a spokeswoman for the California Public Employees Retirement System, known as CalPERS.
The idea of using the state employee plans as a model came last month from two policy experts, Len Nichols and John Bertko.
“We were just trying to avoid nuclear war,” said Nichols, director of health policy for the nonpartisan New America Foundation. “We saw advocates of Medicare for all pushing to put the country into Medicare. And we saw the right using that to push the moderates out of engagement in the health reform debate.”
Schumer said he is looking at Nichols’ idea as a possible compromise and is beginning to sound out other Democrats and policy experts. He has room to maneuver because Obama and many Democrats did not spell out what they mean by a “public” insurance option.
But Schumer said other Democrats insist that option should look like Medicare, in which the government directly sets benefits and payment rates.
Mark McClellan, a health policy expert who ran Medicare under President George W. Bush, said Nichols’ proposal was “well meaning,” but that the government is much bigger than any state, so the effects of a federally backed plan on the insurance market would be far greater.
“At this point, I don’t know many Republicans who are confident a public option could work without making it look like another private sector choice,” said McClellan. “And then what would be the point?”
http://www.washingtonpost.com/wp-dyn/content/article/2009/04/02/AR2009040202804.html

The progressives in the House of Representatives have stated that they “will only support comprehensive health care reform legislation which includes a public plan option on a level playing field with private health insurance plans.” (http://cpc.grijalva.house.gov/index.cfm?ContentID=351&ParentID=0&SectionID=66&SectionTree=66&lnk=b&ItemID=349)
The Republicans will not support a government-run plan that competes “unfairly” with the private health plans. Specifically, they will not support a Medicare-like option.
But look at the wording of the statement from the Progressive Caucus. The public plan option must be “on a level playing field with the private plans.” The model that meets that definition is a PPO that is sponsored by the government but administered by private insurers, with a firewall separating the PPO from the government. Thus the government option will be simply another PPO, with all of its perverseness, competing in a market of private plans. The line in the sand drawn by the Progressive Caucus was washed away by their carefully worded release.
Mark McClellan has it right. The only hope for gaining the support of Republicans is to make the government option “look like another private sector choice, and then what would be the point?”
With the concession of the progressives, the strategy for a Medicare-like public option has already failed. Moving forward with what amounts to another private PPO with a government seal of approval means that the private insurance industry will maintain control of health care financing for the majority of Americans.
We have in the making yet one more example of where the Republicans will extract enough concessions from the Democrats to ruin the legislation, and then when it comes time to vote, the Republicans will vote against it anyway.
The Democrats have to give up the fantasy of a bipartisan solution since Congressional bipartisanship is a total fiction. The Democrats have to move forward with honest health care reform that works for everyone. They shouldn’t look for help from the party of NO.

McClellan asks, "What would be the point?"

Democrats seek compromise on health care plan

By Ricardo Alonso-Zaldivar
The Washington Post
April 2, 2009

Democrats are seeking a compromise on a bigger government role in insurance coverage as part of President Barack Obama’s proposed health care overhaul.

At issue is whether middle-class workers and families should have the option of a government-sponsored plan that would compete with private insurers.

Sen. Charles Schumer, who is working on the issue for the Senate Finance Committee, said Thursday one potential compromise is based on insurance plans that most states already offer their employees. Obama’s health secretary nominee, Kansas Gov. Kathleen Sebelius, likes the idea.

Schumer, D-N.Y., said such a plan would avoid expanding a federal program like Medicare and that a private insurer possibly could run it. Sebelius already administers that type of plan in Kansas.

The insurance lobby fears that a federally backed plan could drive companies out of business.

“We are taking a look at the different state employee plans to get a better understanding of how they operate,” said Robert Zirkelbach, a spokesman for America’s Health Insurance Plans.

GOP lawmakers “are going to need to know what’s in the fine print,” said Craig Orfield, a spokesman for Sen. Mike Enzi, R-Wyo., a leading lawmaker in the debate.

“My goal is to find a plan that would be acceptable to large numbers of senators,” Schumer said in an interview. “Right now, the private insurers are totally opposed, but maybe there’s room.”

In California, the state sponsors three medical network plans for employees and retirees. These plans are offered alongside traditional insurance plans. The state-sponsored plans, administered by Anthem Blue Cross, account for about one-fourth of the 1.3 million people in the state employee health program, said Karen Perkins, a spokeswoman for the California Public Employees Retirement System, known as CalPERS.

The idea of using the state employee plans as a model came last month from two policy experts, Len Nichols and John Bertko.

“We were just trying to avoid nuclear war,” said Nichols, director of health policy for the nonpartisan New America Foundation. “We saw advocates of Medicare for all pushing to put the country into Medicare. And we saw the right using that to push the moderates out of engagement in the health reform debate.”

Schumer said he is looking at Nichols’ idea as a possible compromise and is beginning to sound out other Democrats and policy experts. He has room to maneuver because Obama and many Democrats did not spell out what they mean by a “public” insurance option.

But Schumer said other Democrats insist that option should look like Medicare, in which the government directly sets benefits and payment rates.

Mark McClellan, a health policy expert who ran Medicare under President George W. Bush, said Nichols’ proposal was “well meaning,” but that the government is much bigger than any state, so the effects of a federally backed plan on the insurance market would be far greater.

“At this point, I don’t know many Republicans who are confident a public option could work without making it look like another private sector choice,” said McClellan. “And then what would be the point?”

http://www.washingtonpost.com/wp-dyn/content/article/2009/04/02/AR2009040202804.html

Comment:

By Don McCanne, MD

The progressives in the House of Representatives have stated that they “will only support comprehensive health care reform legislation which includes a public plan option on a level playing field with private health insurance plans.” (http://cpc.grijalva.house.gov/index.cfm?ContentID=351&ParentID=0&SectionID=66&SectionTree=66&lnk=b&ItemID=349)

The Republicans will not support a government-run plan that competes “unfairly” with the private health plans. Specifically, they will not support a Medicare-like option.

But look at the wording of the statement from the Progressive Caucus. The public plan option must be “on a level playing field with the private plans.” The model that meets that definition is a PPO that is sponsored by the government but administered by private insurers, with a firewall separating the PPO from the government. Thus the government option will be simply another PPO, with all of its perverseness, competing in a market of private plans. The line in the sand drawn by the Progressive Caucus was washed away by their carefully worded release.

Mark McClellan has it right. The only hope for gaining the support of Republicans is to make the government option “look like another private sector choice, and then what would be the point?”

With the concession of the progressives, the strategy for a Medicare-like public option has already failed. Moving forward with what amounts to another private PPO with a government seal of approval means that the private insurance industry will maintain control of health care financing for the majority of Americans.

We have in the making yet one more example of where the Republicans will extract enough concessions from the Democrats to ruin the legislation, and then when it comes time to vote, the Republicans will vote against it anyway.

The Democrats have to give up the fantasy of a bipartisan solution since Congressional bipartisanship is a total fiction. The Democrats have to move forward with honest health care reform that works for everyone. They shouldn’t look for help from the party of NO.

Are we safer than Natasha Richardson?

By Laura S. Boylan, M.D.
Commondreams.org
Monday, April 6, 2009

In an example of the circus of fear and hyperbole surrounding the health care debate, opponents of government involvement in health care are exploiting Natasha Richardson’s tragic death from a skiing accident.

The New York Post reports “Canadacare May Have Killed Natasha.” The blogosphere has headlines like “Canada’s Killer Healthcare.”

Here are the bare facts: Natasha Richardson died from an epidural hematoma, a condition that requires urgent evaluation and surgical treatment. When treated early enough, this injury is rarely fatal. It is, therefore, reasonable to ask how different health care systems handle this sort of emergency.

Ms. Richardson’s initial refusal of an ambulance cost about two hours. With 20/20 hindsight we know this was a bad decision. However, it’s also true that “feeling OK” after a minor head injury is, in fact, a powerful predictor of a good outcome. But bad things do happen. Patients with an epidural hematoma may initially feel and look well, this is referred to as a “lucid interval.”

After the ambulance was summoned for a second time, only 3 hours and 40 minutes elapsed before Ms. Richardson arrived at a neurotrauma center in Montreal. On the way she was evaluated and stabilized at a community hospital with modern imaging facilities. Apparently, however, it was still too late.

Many have asserted that Ms. Richardson would have fared better in the United States. This is far from certain. With epidural hematomas, it’s all in the timing. The intervention required is one of the simplest in neurosurgery.

Helicopter airlift, or the lack thereof, has been a focus of criticism of Ms. Richardson’s care. An immediately available helicopter might have helped Ms. Richardson if used to transfer her directly from the resort to Montreal. It’s hard to know. However, it does not follow that the profusion of medical helicopter services in the United States makes Americans safer.

As reported by the Institute of Medicine, neurosurgeons are often unavailable to provide emergency and trauma care in the U.S. Detailed data on patients referred to specialty hospitals for emergency neurosurgical evaluations is available for Cook County, Illinois. This county, which includes Chicago, is densely populated. Total time elapsed from arrival to a community hospital to arrival at the specialty hospital averaged 11 hours. The comparable time period for Ms. Richardson, who had an accident in rural Quebec, was less than 3 hours. In Cook County most patients would still be awaiting an imaging study at the first hospital.

The Austin American-Statesman reported in 2002 that a man with a vertebral fracture after a fall waited 8 hours in an Austin emergency room before being airlifted to Temple because no local neurosurgeon was available. In Temple, he waited two days for surgery and was eventually billed over $4,000 for the helicopter. In the end, it turned out that there had, in fact, been a neurosurgeon available in Austin; however, he worked at a hospital in a competing network. This is just one case, but it does illustrate how business incentives distort quality in our health care system.

U.S. helicopter medical evacuation services are extensive, but tend to address market rather than public health imperatives. Helicopters are concentrated in urban rather than rural areas. Alarming fatality rates due to accidents during medical helicopter evacuations have led to headlines such as in “Critics Say Emergency Medical Helicopters Are Overused and Offer Few Benefits to Patients” (Wall Street Journal 2005).

It’s different in Canada. In Quebec, while there is no helicopter service there is a fixed wing air ambulance service. Fixed-wing craft require a landing strip but are much faster. In addition to being used for long distance emergencies in this vast province, several times a week Quebeckers from remote regions are flown to the city to obtain non-emergency medical care not available locally. All of this is free to patients, who are covered by Canadian medicare. Other provinces do have helicopter evacuation services, and these have a better safety record than their U.S. counterparts.

A really good emergency medical system addresses the continuum of care from prevention to pre-hospital care to rehabilitation. Nova Scotia, a not-wealthy largely rural Canadian province, has created a model program of integrated services, which others have aimed to reproduce.

Dr. Ronald Stewart, who championed the program first as a legislator and then as minister of health, engineered the replacement of fragmented private services with a unified public system in the 1990s. Innovation has thrived with a profusion of influential research papers on, for example, medically appropriate helicopter triage, head injury treatment guidelines, and detailed reports of clinical characteristics and outcomes of all surgical interventions on injuries of the sort Ms. Richardson had. The average wait time for neurosurgical emergency treatment in Nova Scotia, by the way, is less than in Cook County.

I have worked for years in a variety of different sorts of U.S. health care facilities including inner city hospitals, private academic referral centers, rural community hospitals and the Department of Veterans Affairs. A uniform truth, alas, is that financial incentives play a major role in who gets what care and when. We have scarcity in the midst of excess, to the detriment of patients on both receiving ends.

If you are uninsured and socially undesirable you can die in Manhattan from an epidural hematoma, despite rapid arrival to an emergency room and what must surely be one of the world’s densest concentrations of medical subspecialty care. I’ve seen it. Trauma patients are disproportionately uninsured and are considered a high medicolegal liability risk.

Our entire emergency care system is overwhelmed, in large part, due to lack of universal access to other health care. As a result, all Americans are left to rely on a distorted emergency system. When it comes to effective clinical emergency care we should emulate Canada’s single-payer system, not congratulate ourselves on helicopter availability in Aspen.

Laura S. Boylan is clinical associate professor of neurology, New York University School of Medicine; attending neurologist, Department of Veteran’s Affairs; and board member, Physicians for a National Health Program – Metro NY.

Dr. Boylan’s institutional affiliations are provided for identification purposes only; the views expressed are hers alone.

Why "chocolate or vanilla"? Put Single Payer on the table!

by Claudia Chaufan
www.opednews.com
April 3, 2009

With 100,000 monthly foreclosures, 700,000 jobs lost every month, and the number of uninsured, underinsured, and deaths for lack of health insurance not getting any smaller, if the time for healthcare reform is not now, when then? And private health insurers know this too well, which is why they claim to have become “team players”, and to support “change”. But the question remains: which change?

As New York Times reporter Robert Pear recently noted, the only two options receiving any serious consideration in the halls of power of Washington D.C. are a “public option” (Medicare-like plan) or no public option, both within a “tightly-regulated-healthcare-marketplace”. In other words, our house is burning, and Washington, once again, gives us two options, “vanilla or chocolate”, both of which involve “comparative-shopping” (as if with health insurance, much like with Ipods, we could increase our market power if we wait for the next sale!).

That private insurers are fighting the public option on the grounds that competing with government is “unfair” should come to nobody’s surprise: clearly, they are in the business for the money, not to provide a social service to the American people. And they win when they collect premiums and deny payments for health care, and when they dump “bad customers” (sick, old, poor, or “not-wealthy-enough-to-pay-for-our-products”) on taxpayers.

And from their point of view of course, a government-financed, privately-delivered, healthcare plan is “unfair competition:” who can compete against a publicly financed option — whose goal is to eliminate financial barriers to health care — with its demonstrable administrative efficiency, capacity to set high quality standards, and huge market power that could dramatically reduce the absurd prices Americans pay for services and goods (e.g. pharmaceuticals) that cost a fraction elsewhere?

And defenders of the public option, the “other side” of the “chocolate-or-vanilla” equation, are also very familiar with the strengths of publicly-financed systems, such as single payer. Indeed, renowned Berkeley professor Jacob Hacker has extolled the virtues of a Medicare-like plan, and argued that including it is critical to successful healthcare reform.

What is less clear is why Hacker, who clearly understands the advantages of social insurance (what his Medicare-type “option” is) — advantage, that is, from the point of view of prospective patients — when compared to for-profit liability insurance (what private for-profit plans are), would suggest a Medicare-like plan only as an “option”, and in so doing undermine its critical strengths – by chipping away its administrative efficiency, weakening its market leverage, and forcing it to compete against folks whose ultimate goal is not to meet a social need, but to make a buck, the bigger the better.

Why would Hacker not recommend extending the benefits of Medicare to all Americans (what Congressman John Conyers’ HR676 bill proposes for the nation and Senator Mark Leno’s SB 810 proposes for California), while extricating the profit motive, which created the current mess, from health insurance altogether?

To this, Hacker replies that Americans are “deeply divided” when it comes to health insurance — after all, have we not been struggling with this while the rest of the world moved on? — and that “polls” (two exactly, one of them conducted by himself) indicate that Americans prefer “choice”, not only of doctors but also of insurance plans (hmm…does it follow that pushing single payer off the table represents “the people’s will”?). And that anyway, Americans don’t trust government (very well…does it follow that we trust insurance CEOs more than our elected officials?).

This coming Monday April 6th, in Los Angeles, Californians will host the last of five, White-House-sponsored, highly scripted Healthcare Forums. So far, key legislators and their corporate friends have gone out of the way to exclude single payer from the “menu of options” (unsuccessfully as it turned out). It is up to Californians to say “enough:” why settle for less than all other industrialized nations in the world have?

No more “shopping” for our rights. Let us demand single payer. Now.

Let Americans speak, and they will demand single payer now

by Claudia Chaufan
Santa Cruz Sentinel
04/05/2009

What are we to expect from the last of five White House-sponsored Regional Health Care Forums in Los Angeles on Monday? Moderators will attempt to garner support for a “public option” that will compete with private plans in a “highly regulated health care marketplace.”

Is there any reason to hope that this public option will take us from “here” the current mess to “there” eliminating financial barriers to health care universally? Sadly, there is not. And there is not because this public option will operate within the same flawed structure that led us where we are. This structure, unlike publicly financed systems such as single payer, has no capacity to control the escalating costs of health care that are eroding the fiscal and economic health of our state and our nation.

So what does single payer, a publicly financed, privately delivered, system do that a “health care marketplace,” with or without a public option, does not?

First, it pools risk, by including everybody into one single “plan” that pays for comprehensive medical care. Risk-pooling is a powerful, well-documented cost-control strategy. It purchases care on behalf of all participants, which gives the system great market leverage. An example of such leverage is the price of Lanzoprasol, a widely used drug to reduce acidity. In Spain it costs $9. In Maryland the cost is $329 for the same dose.

It also cuts administrative waste — from marketing, underwriting, claims adjusting, shareholders’ profits, and CEOs salaries, the life-blood of private health insurance — that eats up no less than 30 cents of each health care dollar in contrast to 3 to 5 cents in publicly financed systems like Medicare.

Last, it cross-subsidizes, which means that the least costly 80 percent always pays for the care of the most costly 20 percent. Nobody knows who will be on which side at any given moment, but we know that the division between the most and least costly patients gravitates toward those proportions. Cross-subsidizing also eliminates the “special categories” — the too sick, too old, or too poor — shunned by private insurers, ultimately financed by taxpayers, whether or not they qualify for those subsidies.

The second thing single payer does is financing health care through cooperative compulsory contributions, which simply means that everybody has to pay. This meets the criterion of “shared responsibility,” popular among policy experts these days. Yet because of the cooperative dimension of the obligation to pay, contributions are always a predictable proportion of income, unrelated to health status, which makes them affordable to individuals and families. And by combining public financing with private delivery, cooperative compulsory financing is the “public-private partnership” that gives people meaningful choices, not of undecipherable policies with obscure clauses or restricting “preferred providers” lists, but choices of providers, who have the healthy incentive to compete for clients by providing better services

But the Obama administration insists that Americans prefer a “public option” as part of a “menu” of insurance “choices” Maybe the president has listened to renowned Berkeley professor Jacob Hacker, who has argued for the numerous benefits of a Medicare-like plan — its low administrative overhead, its great market leverage, and its ability to set high quality standards — and the convenience of including it in a “menu” of “insurance choices.” Maybe he overlooked the obvious fact that Hacker has yet to offer a good reason to favor this “health care-marketplace-with-a-public-option” over single payer aside from a vague “Americans prefer choice,” according a poll conducted by Professor Hacker that does not ask participants whether their “love of choice” refers to plans or doctors.

Let us hope that on Monday the honest intention of the Obama administration is to let Americans speak. If so, the president might be able to hear what California Sen. Mark Leno, who recently introduced a single payer bill, the California Universal Health Care Act of 2009, noted was a growing social movement. And he might learn why single payer is not merely the only rational policy option, but also the one Americans prefer.

Claudia Chaufan, MD, PhD, is an assistant professor of sociology and health policy at the UC San Francisco. She received her doctorate in sociology at the UC Santa Cruz, where until recently she lectured.

If health insurance companies ran the postal service…

George Harris
Kansas City Star
April 2, 2009

Could health insurance companies opting to get into mail delivery make the current single deliverer postal service worse? Let’s speculate.

If medical insurance companies ran postal services, citizens would pay a monthly premium to get mail delivery. The premium would vary by age, sex and region of the country.

To enhance competition, multiple health insurance companies would compete for mail delivery business. Some companies would provide service only to citizens in cities with populations over 2 million and would deliver only to comparable cities with populations exceeding 2 million. To conserve costs, subscribers would be permitted to post mail only at selected in-network post offices.

People with preexisting high junk mail volume would pay a 300% surcharge.

Citizens with dogs would be required to get mail delivery through the state high risk mail pool.

It would cost $.42 to send a letter across town. Delivery to rural areas would cost $20. Delivery to another state would cost $40. However, the actual allowable charge paid to subcontractors would vary by company.

Any citizen with mail volume exceeding 30% of average mail delivery could be denied mail service. However, the percentage cut-off point would vary by company. Appeals of denial would be submitted to a specialist who is unemployable in any other business available in the western hemisphere. The specialist would work in an undisclosed location with no direct telephone access and would not respond to e-mail.

Pre-authorization would be obtained to mail packages with breakable objects. Requests would have to be submitted to the corporate office in Connecticut and reviewed by teams of disgruntled employees (much like the present system.)

Western Kansas, Wyoming, Nevada (except Las Vegas), the Texas panhandle and select counties of Mississippi, Alabama, Arkansas and New Mexico would not receive daily mail. 40 million people would go without regular mail delivery. However, the Federal government would legislate that emergency mail must be delivered at no cost to the citizen.

Illegal aliens would receive mail at no charge at emergency mail stations.

Citizens away from home would pay out of network rates to send mail.

Postal employees would become independent contractors and would be prohibited from forming guilds to maintain payment levels from companies. Average incomes would decline 45%.

The CEO of one former health insurance company (now postal delivery service) would make $1.5 billion by selling his stock in the company. The average pay of CEO’s would be $400 million annually.

Citizens would receive group mail delivery rates by applying through their employer and could join the group at time of employment or on predetermined sign-up dates without regard for preexisting mail volume overages. The cost of letter delivery to a citizen who belongs to a group would be discounted as much as 75%.

In some states, groups could comprise 2 or more unrelated people, not living in the same household. In all other states a group be be required to comprise 30 to 40 people.

The Federal government would legislate that citizens leaving a group would be able to take his/her postal privileges with him for a period not to exceed 18 months. However, the health insurance company could charge any fee it desired.

Advocates for a single company to organize mail delivery to everyone at a sensible rate would be branded as socialists and sent to Canada. However, shipment would be delayed because no one could calculate the postage.

http://voices.kansascity.com/node/4186

Something is Rotten at PBS

By RUSSELL MOKHIBER
April 2, 2009

Last year, former Washington Post reporter T.R. Reid made a great documentary for the PBS show Frontline titled Sick Around the World.

Reid traveled to five countries that deliver health care for all — UK, Japan, Switzerland, Germany, Taiwan — to learn about how they do it.

Reid found that the one thing these five countries had in common — none allowed for-profit health insurance companies to sell basic medical coverage.

Frontline then said to Reid — okay, we want you to go around the United States and make a companion documentary titled Sick Around the America.

So, Reid traveled around America, interviewing patients, doctors, and health insurance executives.

The documentary that resulted — Sick Around America — aired Monday night on PBS.

But even though Reid did the reporting for the film, he was cut out of the film when it aired this week.

And the film didn’t present Reid’s bottom line for health care reform — don’t let health insurance companies profit from selling basic health insurance.

They can sell for-profit insurance for extras — breast enlargements, botox, hair transplants.

But not for the basic health needs of the American people.

Instead, the film that aired Monday pushed the view that Americans be required to purchase health insurance from for-profit companies.

And the film had a deceptive segment that totally got wrong the lesson of Reid’s previous documentary — Sick Around the World.

During that segment, about halfway through Sick Around America, the moderator introduces Karen Ignagni, president of America’s Health Insurance Plans, the lead health insurance lobby in the United States.

Moderator: Other developed countries guarantee coverage for everyone. We asked Karen Ignagni why it can’t work here.

Karen Ignagni: Well, it would work if we did what other countries do, which is have a mandate that everybody participate. And if everybody is in, it’s quite reasonable to ask our industry to do guarantee issue, to get everybody in. So, the answer to your question is we can, and the public here will have to agree to do what the public in other countries have done, which is a consensus that everybody should be in.

Moderator: That’s what other developed countries do. They make insurers cover everyone, and they make all citizens buy insurance. And the poor are subsidized.

But the hard reality, as presented by Reid in Sick Around the World, is quite different than Ignagni and the moderator claim.

Other countries do not require citizens buy health insurance from for-profit health insurance companies — the kind that Karen Ignagni represents.

In some countries like Germany and Japan, citizens are required to buy health insurance, but from non-profit, heavily regulated insurance companies.

And other countries, like the UK and Canada, don’t require citizens to buy insurance. Instead, citizens are covered as a birthright — by a single government payer in Canada, or by a national health system in the UK.

The producers of the Frontline piece had a point of view — they wanted to keep the for-profit health insurance companies in the game.

TR Reid wants them out.

“We spent months shooting that film,” Reid explains. “I was the correspondent. We did our last interview on January 6. The producers went to Boston and made the documentary. About late February I saw it for the first time. And I told them I disagreed with it. They listened to me, but they didn’t want to change it.”

Reid has a book coming out this summer titled The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care (Penguin Press, August 2009.)

“I said to them — mandating for-profit insurance is not the lesson from other countries in the world,” Reid said. “I said I’m not going to be in a film that contradicts my previous film and my book. They said — I had to be in the film because I was under contract. I insisted that I couldn’t be. And we parted ways.”

“Doctors, hospitals, nurses, labs can all be for-profit,” Reid said. “But the payment system has to be non-profit. All the other countries have agreed on that. We are the only one that allows health insurance companies to make a profit. You can’t allow a profit to be made on the basic package of health insurance.”

“I don’t think they deliberately got it wrong, but they got it wrong,” Reid said.

Reid said that he now wants to make other documentaries, but not for Frontline.

“Frontline will never touch me a again — they are done with me,” Reid said.

Reid says that “it’s perfectly reasonable for people to disagree about health policy.”

“We disagreed, and we parted ways,” Reid says.

It might be perfectly reasonable for people to disagree about health policy.

But it’s not perfectly reasonable to mislead the American people on national television in the middle of a health care crises when Congress is shaping legislation that will mean life or death for the for-profit health insurance industry.

http://atheonews.blogspot.com/2009/04/something-is-rotten-at-pbs.html