Single-payer system is best reform approach

By DANIEL P. WIRT, M.D.
Houston Chronicle
Feb. 8, 2009

The data and evidence are clear: To a scientific certainty, only a single-payer “Medicare-for-All” system of health care financing will solve the serious cost and access problems and achieve good, affordable health care for all in the United States. As a scientist and physician, this is my conclusion after studying the data for years. The data are voluminous, stretching back to World War II, and come not only from the United States, but from all other industrialized countries. Except for the United States, all industrialized countries have some form of universal health care.

Americans are increasingly afraid that they can’t afford to get sick, and with good reason. About half of all personal bankruptcies are caused by medical expenses, and 76 percent of these individuals had health insurance when they got sick or injured. Those of us with insurance are paying a greater share of the premium and more deductibles and co-pays as well. Thus, not only do we have 46 million Americans without health insurance, but at least an equal number who are seriously underinsured. With the recent economic downturn, the ranks of those who are uninsured and underinsured are growing. Many are faced with choosing between paying for medicine and needed health care and paying for food and housing. A typical story is: get sick or injured, lose your job, lose your health insurance, go bankrupt.

A majority of physicians (59 percent) and an even higher proportion of Americans (at least 62 percent) support single payer national health insurance or “Medicare-for-All”. In spite of this, virtually all we are hearing about today are mandate plans that would require everyone to buy the same private for-profit insurance that is already failing us. The for-profit insurance companies and their plethora of plans make for a terribly complex, fragmented, costly and inefficient system. Administrative overhead consumes about 31 percent of health care dollars in the United States, and the for-profit insurance companies are responsible for half of this, or 15 percent of $2.4 trillion. This money, more than $350 billion per year, provides no health care: it is consumed by enormous administrative costs, profits for investors and shareholders, and large salaries for managers of these for-profit insurance companies.

All of the incremental reform programs proposed – tax subsidies, health savings accounts, individual or employer mandates, increased regulation of for-profit insurance companies – keep these proverbial foxes in the henhouse and are doomed to fail to control costs and provide universal access. Competition among the foxes does not benefit the chickens, the patients, the doctors or the hospitals. The for-profit insurance companies fundamentally reduce choice – your preferred doctor or hospital is “out-of-network”? Too bad, we won’t pay, says your insurance company.

The data are in. Incremental reforms, mostly mandate schemes which retain the for-profit insurance companies, have been tried in seven states over the past two decades: Massachusetts, Tennessee, Washington, Oregon, Minnesota, Vermont, Maine. In all of these states the reforms have failed to contain costs. In all but Massachusetts, they have failed to reduce the number of uninsured. In Massachusetts, there has been a modest decrease in the number of uninsured, falling from 13 percent of adults in 2006 to 7.1 percent of adults in 2007, but at the cost of a substantial increase in public spending (spending for “Commonwealth Care” was $629.8 million in fiscal year 2007, $1089.2 million in fiscal year 2008 and $1317.7 million in fiscal year 2009). Most of the gain in Massachusetts has come from expanding Medicaid and subsidizing the purchase of private insurance; very few people have signed up for the unsubsidized private insurance. Not to mention that 7.1 percent uninsured is unacceptably high. Far from controlling costs, these mandate plans will add hundreds of billions of dollars to the nation’s health care costs.

The United States spends about twice as much per capita on health care as other industrialized countries. Yet it is a myth that the United States has the best health care in the world. The United States ranks near the bottom of industrialized countries in terms of important morbidity and mortality outcomes (for example, life expectancy and infant and maternal mortality).

About 18,000 American adults die unnecessarily every year due to lack of insurance (Institute of Medicine, 2002). As reported in the Archives of Internal Medicine in 2003, repair of an aortic aneurysm cost $8,647 in Canada and $13,432 in the U.S.

What accounted for the substantial difference? Most of the difference was due to much greater overhead costs in the U.S. The surgeons and surgical facilities are top-notch in Canada. The surgeons are very well paid. The difference is that Canada has adopted a true insurance system for financing health care, one that spreads risk across a broad population: a publicly funded single-payer national health insurance plan that eliminates the parasitic, investor-owned “insurance” companies that make profits by enrolling the healthy, screening out the sick and denying claims.

Single-payer national health insurance for financing health care is NOT “socialized medicine.”

Under a single-payer, “Medicare-for-All” system, delivery of health care remains private. The providers of health care remain private. Patients choose any doctor and any hospital.

Parenthetically, replacing the wasteful for-profit insurance companies with a single-payer national health insurance program for financing health care in the United States would save enough money (more than $350 billion) to not only achieve universal coverage, but allow the coverage to expand and be more comprehensive.

We have an American system that works. It’s Medicare. It’s not perfect, but Americans with Medicare are far happier than those with for-profit insurance. Doctors face fewer hassles in getting paid, and Medicare has been a leader in keeping costs down. And keep in mind that Medicare insures people with the greatest health care needs: people over 65 and the disabled. We should improve and expand Medicare to cover everyone. In contrast to the for-profit insurance companies, Medicare has a very low overhead – about 3 percent.

Unfortunately, the for-profit insurance companies have been infiltrating Medicare in the form of “Medicare Advantage” plans, substantially raising costs when compared to traditional Medicare.

A single-payer “Medicare-for-All” system is embodied in a bill currently in the U.S. House of Representatives, H.R. 676, sponsored by U.S. Rep. John Conyers, D-Mich., and cosponsored by 93 other members of Congress.

Its features are: automatic enrollment for everyone; comprehensive services covering all medically necessary care and drugs; free choice of doctor and hospital, who remain independent and negotiate their fees and budgets with a public or nonprofit agency; processing and payment of bills by a public or nonprofit agency; promotion of job growth and the entire U.S. economy by removing the excessive burden of health care costs from businesses; coverage for everyone without spending any more than we are now.

The growth in health care costs must be addressed if any proposal is to succeed. Single-payer offers real tools to contain costs: budgeting, especially for hospitals, planning of capital investments (to avoid wasteful duplication and concentration of expensive technology), and an emphasis on primary care and coordination of care. Mandate plans offer only false hopes: competition among for-profit insurance companies, computerization and chronic disease management. Competition among the shrinking number of for-profit insurance companies has already failed to contain costs and, in the absence of single-payer and reformed primary care (so that everyone has a primary care home), computerization and chronic disease management will raise costs, not lower them.

Business leaders are well on their way to understanding how the current system makes their businesses uncompetitive with businesses in industrialized countries that have cost-effective health care systems not based on profit.

Finally, the most important group is patients. We are all sometimes patients. All patients must rise up and remove the foxes from the henhouse.

Foxes are not evil, but their nature is such that they must not be allowed in the henhouse.

Wirt is a pathologist at Memorial Hermann Northeast Hospital in Humble.

http://www.chron.com/disp/story.mpl/editorial/outlook/6251537.html

By Avram Goldstein
Bloomberg News
February 4, 2009

Just as President Barack Obama prepares to overhaul the U.S. medical system, providers of U.S.- backed health plans for the elderly are raising prices.

Humana Inc., Health Net Inc. and other providers increased 2009 premiums by 13 percent on average, or more than five times as much as last year, for people who use the Advantage version of Medicare, according to Avalere Health, a consulting company in Washington. The elderly say higher costs for the Advantage plans, which add features such as drug coverage to Medicare, are reducing money for groceries and utilities.

Obama has vowed to control spending in the $2.6 trillion U.S. health-care system while extending coverage to more people, and, during his campaign, criticized the costs of Advantage plans to taxpayers. The premium increases, charged directly to the elderly rather than the government, are further evidence that insurers’ need for profits is ballooning patients’ expenses and reducing the efficiency of care, said Arnold Relman, former editor of the New England Journal of Medicine.

“Medicare Advantage is a rip-off,” said Relman, 85, who is also a professor emeritus at Harvard Medical School in Boston, in a telephone interview on Jan. 23. “I cannot see that they do anything better than public insurance does, and they do a lot of things worse.”

Medicare will spend 14 percent more this year, on average, for Advantage enrollees than for beneficiaries with basic coverage, according to a staff report in December by the Medicare Payment Advisory Commission, an independent agency that advises Congress.

Obama’s Stance

Obama considers the government payments “excessive,” said Jen Psaki, a spokeswoman now on the White House staff, in a Jan. 5 e-mail. During his campaign Obama promised to cut subsidies to Advantage by as much as $15 billion a year, or about 15 percent from last year’s total of $100 billion.

In addition, insurers collected about $5 billion in Advantage premiums from consumers last year, said Thomas Scully, the former top administrator of the U.S. Centers for Medicare & Medicaid Services, with headquarters in Baltimore.

Scully, who helped design the Advantage program, said that he doesn’t consider the premiums excessive and that Advantage is less expensive than alternatives. Scully is a lawyer for the New York private equity firm Welsh, Carson, Anderson & Stowe, and for the Atlanta law firm Alston & Bird.

“I don’t think you’re going to see a mass exodus from Medicare Advantage,” Scully said in a Jan. 9 interview.

Bundling Options

Medicare is the U.S. health plan for the disabled and those over 65. Basic Medicare, with a monthly fee of $96, lets patients use any U.S. doctor or hospital. Beneficiaries can also buy separate private policies to cover prescription drugs and expenses exempted from standard benefits. Advantage, which covers 10.5 million people, bundles those options.

“There are almost 11 million people who have chosen to participate in Medicare Advantage because they feel they’re good plans,” said Richard Barasch, chief executive officer of Universal American Corp., an insurer in Rye Brook, New York, in a telephone interview. “Medicare Advantage is a great value to them.”

The Advantage premiums paid by Blair Law and his wife, Mary, soared to $50 a month this year, up from zero under the policy’s initial terms.

“These guys have you by the short hairs,” said Blair Law, 77, a retired construction-company executive now living in Fort Myers, Florida, in a telephone interview. “They know you’re disinclined to shift to another plan, so they keep ratcheting the cost up.”

Rebates End

In 2007, the Laws joined an Advantage plan provided by Universal Health Care Corp. of St. Petersburg, Florida. Initially, the plan charged no monthly premium, and the insurer rebated the couple’s basic-Medicare premiums, according to the Laws. The rebate ended last year, and this year the company began charging the couple an additional $50 a month.

Pinched for funds, Law said he doesn’t eat as much beef as before, uses less air conditioning, and will cut back travels to see relatives across the country.

“That’s a real hardship,” Law said.

Universal Health Care Chief Executive Officer Akshay Desai didn’t respond to a request for comment. Many Advantage policies had no monthly payments first, according to analysts.

The absence of premiums was a “come-on” to spur enrollment for many insurers and was “unsustainable,” said Uwe Reinhardt, a professor of political economy at Princeton University in New Jersey. Advantage plans serve about 23 percent of Medicare enrollees, up from about 12 percent in 2003, according to Medicare officials.

Insurers’ ‘Dream’

“The insurers’ dream was that maybe 80 percent of the elderly would enroll in Medicare Advantage and then traditional Medicare would just die, and these private health plans could do what they want,” Reinhardt, whose specialty is health-care issues, said in a telephone interview on Jan. 23.

Investors, favorable toward price increases yet wary of the threat of cuts in U.S. subsidies, aren’t sure if there is money to be made in stocks of Advantage providers, said Carl McDonald, an analyst with Oppenheimer & Co. in New York. Most of the companies, in any case, also have other profit centers, and their fate isn’t tied wholly to Advantage.

On average, the almost 200 companies selling Advantage policies raised prices 13 percent this year for enrollees, to $41.40 a month, according to Avalere Health. In 2008, premiums rose 2.5 percent, Avalere found.

Doubling Premiums

Humana, based in Louisville, Kentucky, more than doubled average premiums for its Advantage clients, to $30 from $14, the largest percentage jump identified in the Avalere analysis conducted for Bloomberg News. Universal American had the second- largest rise among publicly traded companies, moving up average monthly premiums 44 percent to $39. Health Net, of Woodland Hills, California, increased the monthly fee 24 percent to $51.

In calculating the averages, Avalere compared premiums for plans offered in both 2008 and 2009 and weighted each company’s average increase by membership.

Health Net, Humana and other insurers also are requiring elderly plan members to pay more for ambulance rides and hospital stays or raise the amount people must spend before 100 percent coverage kicks in, according to Medicare data.

Humana, with 1.44 million Advantage members on Dec. 31, said yesterday it expects to add no more than 75,000 people to the plans this year, after gaining 293,000 last year. Health Net said yesterday its Advantage enrollment may fall as much as 2 percent this year, from 295,000 at the end of last year.

UnitedHealth

Not all companies are raising premiums. UnitedHealth Group Inc. dropped what it said were unprofitable Advantage plans for the chronically ill and increased out-of-pocket costs in other Advantage plans. The company, based in Minnetonka, Minnesota, is the largest Advantage provider, with 1.6 million members.

UnitedHealth is counting on competitors’ premium increases to drive the elderly to its policies, said Simon Stevens, former head of the insurer’s Medicare plans, in an e-mail. The company added at least 97,000 customers for policies that began on Jan. 1, according to U.S. government figures.

Meanwhile, Martha Baker, 74, said her Health Net plan increased her share of costs for ambulance care and other services this year. Her premium also went up, to $38 a month from zero.

“What’s disheartening is, I’m a person who has never taken from the system,” said Baker, who retired after directing the women’s ministry at a Tucson, Arizona, church. “I’ve always paid into it, and now it seems to be failing me.”

To contact the reporter on this story: Avram Goldstein in Washington at agoldstein1@bloomberg.net.

Experiences of Cancer Patients Illustrate Potential Problems With Private Health Coverage For People With Life-Threatening Illnesses

Kaiser Family Foundation
News Release
February 5, 2009

WASHINGTON, DC — Cancer patients can face severe challenges in paying for life-saving care — running up large debts, filing for personal bankruptcy and even delaying or forgoing potentially life-saving treatment — even when they have private health insurance, according to a new report by the Kaiser Family Foundation and the American Cancer Society.

The report profiles 20 patients and illustrates the potential difficulties people diagnosed with cancer or other serious illnesses have in maintaining affordable health insurance and paying for their health care. The patients in the report and accompanying video were selected to illustrate typical cases from the many people who call the American Cancer Society’s Health Insurance Assistance Service, which helps families affected by cancer who encounter problems navigating the health care system.

For these patients, having private health insurance at the time of their cancer diagnosis did not protect them from high out-of-pocket costs — leaving them with large debts to cover their treatment costs and forcing some to skip or delay necessary treatments.

“The stories of people with cancer in this study and video documentary show what our earlier survey work found: that the insurance system often fails people when they need it most, when they get really sick,” said Kaiser Family Foundation President and CEO Drew Altman, Ph.D.

“Cancer patients too often find out that their insurance doesn’t protect them when they need care the most,” said John R. Seffrin, Ph.D., national chief executive officer of the American Cancer Society. “High out-of-pocket costs coupled with the high cost of insurance premiums can force cancer patients to incur huge debt, and to delay or forgo life-saving treatments.”

The report, which was released today at a briefing in Washington, D.C., highlights five key gaps in the health care system that can leave people with cancer and other life-threatening diseases in financial jeopardy as a result of their diagnosis:

* High cost-sharing, caps on benefits leave cancer patients vulnerable. The various types of cost-sharing and limits on benefits found in some insurance plans may quickly lead to high out-of-pocket costs once cancer treatment begins. For instance, Jamie Drzweicki of Miami ran up more than $75,000 in debts after her breast-cancer treatment costs exceeded her policy’s annual limit.

* Those with employer-sponsored coverage may not be protected from catastrophically high health care costs if they become too sick to work. Most people get their health coverage through their employers, which often pay most of the premiums. Under existing law, people who lose their jobs because they are unable to work generally must decide within 60 days whether to temporarily retain their employer-sponsored coverage through COBRA by paying the full premium costs. Phyllis Miller of Johnstown, Pa., who has been unable to work since having emergency surgery for late-stage colon cancer, missed the 60-day deadline and has struggled since then to afford the premiums and cost-sharing of her less comprehensive individual policy.

* Cancer patients and survivors are often unable to find adequate and affordable coverage in the individual market. Cancer survivors who have been in remission for years and have a good long-term prognosis may still have trouble finding coverage or pay higher premiums in the individual market. For instance, 10 years after Thomas Olszewski of Graham, Texas was treated for early prostate cancer, he still is unable to find affordable health coverage and pays one-fourth of his family’s income in premiums for a high-deductible plan.

* High-risk insurance pools are not available to all cancer patients, and some find the premiums difficult to afford. High-risk pools, which are designed to help cancer patients and others who are uninsurable, are not available in all states, and when they are available, they are often much more expensive than most other plans in the individual market. For example, high costs have prevented breast cancer survivor Mardel Budreau of West Lafayette, Ind. from enrolling in a high-risk pool after learning her individual insurance policy only paid $250 toward her radiation treatment.

* Waiting periods, strict restrictions on eligibility, or delayed application for public programs can leave people who are too ill to work without an affordable insurance option. Cancer patients too sick to work may qualify for Social Security Disability Insurance income and, after two years of receiving this income, may qualify for Medicare coverage. During the waiting period, patients typically have reduced incomes and may not be able to afford private insurance coverage. This happened to David Young, a truck driver from Godwin, N.C., who has not worked since being diagnosed with late-stage kidney cancer. Young became eligible for Social Security disability benefits in October 2007 but does not yet qualify for Medicare benefits.

The report, Spending to Survive: Cancer Patients Confront Holes in the Health Insurance System, was jointly authored by researchers at the Kaiser Family Foundation and the American Cancer Society. The Kaiser Family Foundation also released a separate video documentary profiling three of patients featured in the report.

The report and video are available online at www.kff.org and www.cancer.org. In addition, a webcast of today’s briefing will be available online after 5 p.m. ET today.

The Kaiser Family Foundation is a non-profit private operating foundation, based in Menlo Park, California, dedicated to producing and communicating the best possible information, research and analysis on health issues.

The American Cancer Society is dedicated to eliminating cancer as a major health problem by saving lives, diminishing suffering and preventing cancer through research, education, advocacy and service. Founded in 1913 and with national headquarters in Atlanta, Georgia, the Society has 13 regional Divisions and local offices in 3,400 communities, involving millions of volunteers across America. For more information anytime, call toll free 1-800-ACS-2345 or visit www.cancer.org.