PNHP

Journalism professor on reporting about Canadian health system

Journalism professor on reporting about Canadian health system

Universal Health Care For Elephant, Mouse

By Gene Costain
Tampa Bay Online
January 26, 2009

Ben Jonson was a cantankerous, 17th century British dramatist who despised the early days of journalism because he thought it was overrun with propagandists and charlatans.

I’m no modern-day cynic, but the record of news coverage on universal health care has been rife with ideological cant and tall tales. In my view, journalists have formed a kind of parasitic osmosis with powerful interests that impairs robust debate.

My meager standing for wading in is that in the past 25 years I’ve lived half of that time in Canada and the other half here in the last Western refuge of commoditized medicine.

I have been making mental notes on the accumulated fallacies and misnomers about the Canadian universal system. Your neighbor to the north has always been a great case study, because the country is a near mirror image of America on many levels.

My first memory of family struggle over medical bills was in 1962, when my mother was about to give birth to the last of seven kids. The single-payer system – in which all health care providers bill a single entity – was still a few years away. Just before she went into the hospital to deliver, I overheard an anxious conversation she had with my father about how they were going to pay the anticipated $300 hospital bill. My working-class father supported us on a salary of $55 a week. Within a few years, that financial anxiety vanished, and all they had to deal with was a small plastic card, with the added bonus of virtually no paper trail.

My move to America in 1996 meant facing a small pile of bureaucratic paper before starting my doctorate in Tennessee. During my adult life in Canada, a little card was my official point of contact with the health care bureaucracy. Forget about annoying co-pays, a new concept for me. The relative wonder of it all captured my imagination, and for years I’ve been monitoring debates about the issue in a vain search for balance, especially as it relates to some of the good things you don’t hear about the Canadian system.

Let me frame this in a larger context. The late Canadian Prime Minister Pierre Trudeau said that living next door to America was like a mouse sleeping with an elephant. Canada has one-tenth of the U.S. population, and its citizens are largely resigned to (but secretly admire) the large American pachyderm. Despite the similarities, Americans have missed out on an honest depiction of what Canadians think about their system.

There is one key element in the Canadian story that Americans rarely hear about in their media. Polls show that Canadians would not trade their single-payer system for all the tea in Indonesia. Most Canadians say their health care is their most valued citizenship asset. That is not hyperbole: For years, Gallup polls have chronicled this high regard for the system. It makes you wonder why we don’t often get this view here – after all, there are plenty of Canadians sunning themselves in these parts.

One of the most persistent challenges is that there are long waiting lines for some services in Canada; my experience is that both systems are virtually indistinguishable. An informal consensus of family and friends in Canada, including my aging mother, is that the medial service is good to great. I have honestly not heard of one major medical service horror story.

But who is to blame for Americans not receiving these political, cultural and news representations? One reason is that journalists here are like reporters in other nations, they root around in their backyards for sources and social insight.

As the debate returns this year, we may get a more expansive rendering of the story because everyone agrees the system is broken. But it won’t happen unless more journalists, filmmakers and bloggers chip in with a more balanced rendering of this Byzantine story. It might make the cynical ghost of Ben Jonson happy.

(Gene Costain is a University of Tampa journalism professor.)

http://www2.tbo.com/content/2009/jan/24/co-universal-health-care-for-elephant-mouse/

And…

Health Care in Canada

Canadian Institute for Health Information
2008

Physician migration

Information on health care workers’ migrations into and out of Canada, and into and out of individual professions, is difficult to capture. However, data on physicians show that the number of physicians leaving and returning from abroad declined over the five years to the end of 2006, with those emigrating declining by more than half (56.9%) and those returning dropping by 18.2%. In the three years to the end of 2006, physicians returning to Canada outnumbered those who left.

Wait time

While it is difficult to compare jurisdictions’ progress in reducing wait times, it is possible to compare jurisdictions’ surgery rates in the priority areas. Overall, rates in these areas rose by 8% more than the expected increase from population growth and aging between 2004-2005 and 2006-2007.

Diagnostic imaging

Over the three years ended in 2006-2007, the number of MRI and CT exams in Canada rose by 42.9% (to 31.2 per 1,000 population) and 27.9% (to 103.3 per 1,000 population), respectively. During the same period, the increase in the number of exams was greater than in the number of scanners, for both MRI and CT. In the case of MRI, a 27% growth in the number of scanners led to a 47% growth in the number of exams. In the case of CT, a 12% growth in the number of scanners led to a 32% growth in the number of exams.

http://secure.cihi.ca/cihiweb/products/HCIC_2008_e.pdf

Comment:

By Don McCanne, MD

The data base that most of us use for our routine thoughts is that which is stored in our memories. When we have need for other information, we know that there are other resources to which we can turn, but for most of our rote activities, memory is presumed to be adequate and reliable.

Almost every resident of the United States can tell you several things about the Canadian health care system. The problem is that much of it is wrong.

How did it happen that our memories/knowledge of the Canadian system are so distorted? One of the more important reasons is that we have little exposure to the routine functioning of the Canadian health care system. It’s not that the information isn’t available. The Canadian Institute for Health Information is a highly credible resource for such information. You can learn quite a bit just by reading their 2008 report, Health Care in Canada.

So why hasn’t our media reported any of this information? Quite simply, it is boring. There is no mention of problems such as the number of uninsured, bankruptcy due to medical debt, or care denied because of the inability to pay for it, because those problems don’t even exist in Canada. The reports are of a system that is functioning well, but is not perfect, so measures that are being taken to improve their system are also reported. What U.S. journalist would waste their time with that, and which editor would approve it in the first place?

Another reason that our views are so distorted is that, for decades, several conservative and libertarian organizations opposed to public insurance have spoon fed the U.S. media with reports of problems in the Canadian system that happen to make good copy. Although those reports are often embellished, most do have a factual basis even if they don’t represent the mainstream functioning of their system. They are great fodder for our journalists who themselves have misperceptions about Canadian health care because they also are exposed to these highly selected, exceptional stories that do not include the boring stories of the routine.

A couple of examples of distortions were pulled out of the CIHI report. Everyone knows that physicians are fleeing Canada based on innumerable stories here, yet the reality is that more physicians are returning to Canada. Wait times for elective (not emergency) surgery have been an issue, but this report shows that the problem is being addressed with some success. The availability of diagnostic imaging also is improving significantly.

We hear stories of journalistic misbehavior, which are all too frequent, but they are not balanced with stories of the day in and day out routine of journalism. Responsible journalism is the norm in this nation, but we don’t hear much about it, thus our view of journalists may be inappropriately jaded. What journalists here often don’t realize is that, like most of the rest of us, their views of the Canadian health system are highly distorted by the selective reporting of others who are also driven by these same distortions that dwell in our cumulative memories.

Our thinking is based on what we know, but not on what we don’t know, and we won’t even know what it is that we don’t know unless our journalists start doing some more intensive research, even if it is very boring.

Health care forum looks at single-pay insurance

By Robert Wolfington III
Marshall (Minn.) Independent
January 24, 2009

MARSHALL – Dr. Michael DeBrule said he has seen a lot of his patients have to pass on important procedures because their insurance wouldn’t cover it.

“There are a lot of un-insured people that I can’t help even if I wanted to; even if I waved my surgical fees, they would still have $4,000 at the hospital (and other fees).”

DeBrule, along with supporters of a national single-pay insurance plan, discussed its feasibility and explained how it would work during a town hall forum Thursday night at the Marshall Area YMCA.

Dr. Ann Settgast, co-chairwoman of the Minnesota chapter of Physicians for A National Health Program, said a single-pay insurance program would provide care for all U.S. citizens, while at the same time save money compared to the current multi-payer system.

“The cost savings in single-payer comes from getting rid of the administrative waste in a multi-payer system,” said Settgast. “You have providers filling hundreds of insurers, that is a lot more inefficient then if we are billing one payer.”

Settgast said a single-payer system would provide more flexibility in choices for health care.

“If you were a patient in a single-payer system nothing would change very much for you assuming you currently have health insurance,” said Settgast. “About 46 million people in America right now don’t have any health insurance, and for them we would bring them into the system.

“For someone who already has health insurance, the only thing that would change is you would have a different insurer, except your insurance card would be the national insurance,” she said.

Settgast said there is criticism of moving to a single-payer system because of the loss of jobs from insurance providers.

“One complaint you hear commonly is people would lose their job,” said Settgast. “That’s true, there is some superfluous work going on in the administrative sector. There are provisions in the state and national bills to allow for job retraining and also employment benefits for people who lose their jobs through this.”

Settgast said a single-payer system would simplify a system that is complicated.

“There would be no role for private insurance, so the main transition would not be as expensive as it would be disruptive,” said Settgast. “There would be some administration needed within a single-payer system, but you certainly wouldn’t need the vast bureaucracy that we have right now to run this multi-payer system.”

Settgast said PNHP is a national organization with 15,000 physician members advocating for a single-payer system.

Settgast said Minnesota has 2,000 physician members who support a single-payer system.

Settgast said the forum Thursday was an opportunity to address concerns from people including quality of care.

“A lot of our role is re-assuring people about maintaining high quality under a single-payer system, talking about where the cost savings would come from and how we can cover everyone,” said Settgast.

http://www.marshallindependent.com/page/content.detail/id/507329.html

Tell Sen. Baucus single-payer should be on the table

By GENE FENDERSON
Great Falls Tribune
January 5, 2009

In presenting his national health-care plan, “A Call to Action — Health Reform 2009,” Sen. Max Baucus said, “My door is open and I seek partners with ‘can-do’ spirits and open minds.'”

Earlier though, in the health-care forums he held around Montana, Sen. Baucus stated very strongly that a single-payer health-care plan “is off the table”.

Believing that the senator’s “door is open,” I maintain that a single-payer system must be on the table because it can help save our present and future economic well being as a state and nation.

The estimated cost of our present health-care system is $2.3 trillion dollars per year, more than 16 percent of our gross national product, compared to less than 9 percent of GNP in other industrialized countries.

I estimate the total amount spent on health care in Montana at $5.5 billion a year, including both private and public sectors. Well over $1 billion of that is spent on exorbitant administrative fees and cost shifting (people with insurance being billed higher charges to offset some of the losses from providing care to people who are underinsured or uninsured because they cannot personally afford it, their employer cannot afford it, or they don’t think they need it and do not want to pay for it).

We don’t really have a “system.” What we have is a confused maze of coverage types and providers — Medicare, Medicare Advantage, Medicaid, SCHIP, military, veterans administration, Indian Health Service, federal employee coverage, health savings accounts, community health centers, private insurance, dental insurance, vision insurance, medical coverage in auto insurance and more.

Unfortunately, the Baucus plan simply adds even more layers of confusion to this hodgepodge, which is already driving costs up and up for all Americans. We can do better. We must do better. That is why a single-payer system must be on the table.

What do we need? A basic, simple plan that charges all individuals who can afford it and all employers their fair share. One that covers all Americans, rich and poor, healthy and ill, young and old. A plan with no one refused coverage, no exclusions for pre-existing conditions, absolute choice of providers, total portability, no bankruptcies due to health-care bills, and an overall cost comparable to other industrialized nations.

A plan that will also provide our primary caregivers a standard of living that will attract and retain them.

What would work? A plan modeled on Medicare.

Medicare works well. It has overhead of 2.2 percent compared to 15 percent to 20 percent or higher for private insurers, even some nonprofit insurers.

Medicare has kept millions of Americans out of poverty, protected their hard earned savings and their homes, and allowed them to live with dignity.

Medicare includes supplemental insurance plans which help hold down over-utilization. A comprehensive American Medicare Plan could cover all Americans with a simple enrollment process based on proof of citizenship.

Existing systems serving specific populations (the military, veterans, and American Indians residing on their reservations) could continue to cover these populations. At their option, Indian tribes could choose to be covered by the American Medicare Plan.

A comprehensive American Medicare Plan could be implemented over a 10-year period allowing the system to expand in stages.

An incremental approach also allows insurance companies to change their product lines and services in a systematic, orderly fashion. Coverage would start the first two years by enrolling children and young people through age 25, by far the cheapest group to insure.

The second two-year group to enroll would be adults age 26 through 36, then the next two-years, those 37 through 47, the final two-year group would be those 48 through 64, the most expensive group.

As each adult group (those ages 26 through 64) enrolled in the comprehensive American Medicare Plan, they would also select a supplemental plan.

A person whose employer provided a supplemental plan as a benefit would automatically be covered under that plan, in addition to the American Medicare Plan.

Union members whose health and welfare trust offered a supplemental plan would be enrolled in that plan. Others could choose a supplemental plan from those offered by the government or by private insurers.

The American Medicare Plan would be paid for through an employer payroll tax calculated on a sliding scale of wages and number of employees, helping to level the playing field among all employers. Payroll tax credits would apply, as they do now. Full coverage for children from age 0 to young adults age 25 and people earning less than two hundred percent of the poverty level would be paid for from these revenues.

Adults making more than 200 percent of poverty would pay the normal Medicare fee and their own supplemental plan premium, based on a sliding scale. These costs would also be tax deductible for the individual.

This is just the outline of a uniquely American single-payer plan that could work, but only if Sen. Baucus puts a single-payer approach to health reform back on the table and opens the door to discuss all the options.

We need real change in health-care and we need it now. Please join me in urging Sen. Baucus, all of our congressional delegation and President-elect Obama to keep single-payer on the table and a part of the discussion.

Gene Fenderson was a board member for a Montana Taft-Hartley Health-care Trust Fund for 25 years and continues to participate in the health plan. Write to him at gfenderson@imt.net.

http://www.greatfallstribune.com/apps/pbcs.dll/article?AID=/200901050500/OPINION/901050304

Who Does Senator Baucus Listen To

Unions for Single Payer Health Care
January 25, 2009

Montana Senator Max Baucus, Chairman of the Senate Finance Committee, has said that in writing his new healthcare legislation “everything is on the table” except single payer. One wonders if Senator Baucus has been reading his home state newspapers or just listening to the lobbyists for the private insurance industry. (www.Opensecrets.org).

After Baucus ruled single payer “off the table” in his search for an “American” solution to the healthcare crisis, Montana’s newspapers have carried several articles calling for Senator Baucus to put single payer back on the table.

Writing in “The Great Falls Tribune” under the headline “Tell Sen. Baucus Single-payer Should Be On the Table,” Gene Fenderson, who served for twenty-five years as a union trustee of a Taft-Hartley joint healthcare fund, wrote: “I maintain that a single-payer system must be on the table because it can help save our present and future economic well being as a state and nation.” Fenderson criticized the Baucus plan directly saying: “Unfortunately, the Baucus plan simply adds even more layers of confusion to this hodgepodge, which is already driving costs up and up for all Americans. We can do better. We must do better. That is why a single-payer system must be on the table.”

Fenderson concluded: “We need real change in health-care and we need it now. Please join me in urging Sen. Baucus, all of our congressional delegation and President-elect Obama to keep single-payer on the table and a part of the discussion.”

http://www.greatfallstribune.com/apps/pbcs.dll/article?AID=/200901050500/OPINION/901050304

As if to add emphasis to Fenderson’s argument, a second article, this time in the Helena Independent Record, reported on results of meetings held throughout Montana at the urging of President Obama’s healthcare transition team. The meetings were to report to the transition team what ordinary citizens think about healthcare reform.

“The consensus of (our group) was that we did not see a lot of change coming unless we went to a single-payer, universal health system,” said Deborah Hanson of Miles City, who organized a meeting of local citizens at the behest of Obama’s transition team. “That was sort of a general consensus – knowing, of course, that may not happen.”

“The Miles City meeting, held Dec. 21 at Hanson’s home, was one of several in Montana and thousands held across the nation during the last two weeks of December.”

http://www.helenair.com/articles/2009/01/07/top/53lo_09017_healthcare.txt

Meanwhile, back in Washington, Senator Baucus was attending a lavish pre-inaugural ball at a posh nightclub where he told Brian Ross of ABC News that “lobbyists just want what’s best for America.” Baucus also had praise for the drug, insurance and other lobbyists who paid for the party, saying: “They really care about our country.”

http://abcnews.go.com/Video/playerIndex?id=6694754

So the question remains. Who does Senator Baucus listen to?

Call, write or Fax Senator Baucus and tell him single payer should be on the table and should be given a full and fair hearing by the Senate Finance Committee.

Senator Max Baucus
511 Hart Senate Office Bldg.
Washington, D.C. 20510
(202) 224-2651(Office)
(202) 224-9412 (Fax)

Conyers To Introduce Universal Healthcare Bill Today

Ryan Grim
The Huffington Post
January 26, 2009

John Conyers plans to introduce his universal healthcare legislation today, a Conyers aide tells the Huffington Post. The bill – known last session as H.R. 676 – is a favorite of healthcare reformers who back a single-payer system.

The bill, which will again be H.R. 676, is one of the more elegant to be introduced in the House, clocking in at just a few pages.

The plan is simple: everyone is eligible for a version of Medicare under a new U.S. National Health Insurance Program.

The program would effectively put private insurers out of business. What to do with all those employees? Hire them, says Conyers’ bill.

“The Program shall provide that clerical, administrative, and billing personnel in insurance companies, doctors offices, hospitals, nursing facilities, and other facilities whose jobs are eliminated due to reduced administration (1) should have first priority in retraining and job placement in the new system; and (2) shall be eligible to receive 2 years of unemployment benefits.”

Conyers, a Michigan Democrat and chairman of the Judiciary Committee, last introduced his bill, which garnered 93 cosponsors, in February 2007. It was referred to committee but never given a hearing.

If the 647-page House stimulus bill was too much to get through, try Conyers’ out.

Gawande's pseudo-pragmatism

Getting There from Here: How should Obama reform health care?

by Atul Gawande
The New Yorker
January 26, 2009
People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse — especially for those who already have dependable coverage and access to good doctors and hospitals.
Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.
Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have.
Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.
Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area — even if prices, taxes, and competition are stiffer.
Some people regard the path-dependence of our policies as evidence of weak leadership; we have, they charge, allowed our choices to be constrained by history and by vested interests. But that’s too simple. …consider a health-care example: the 2003 prescription-drug program for America’s elderly.
On January 1, 2006, the program went into effect nationwide. The result was chaos. There had been little realistic consideration of how millions of elderly people with cognitive difficulties, chronic illness, or limited English would manage to select the right plan for themselves. Even the savviest struggled to figure out how to navigate the choices: insurance companies offered 1,429 prescription-drug plans across the country. People arrived at their pharmacy only to discover that they needed an insurance card that hadn’t come, or that they hadn’t received pre-authorization for their drugs, or had switched to a plan that didn’t cover the drugs they took. Tens of thousands were unable to get their prescriptions filled, many for essential drugs like insulin, inhalers, and blood-pressure medications. The result was a public-health crisis in thirty-seven states, which had to provide emergency pharmacy payments for the frail. We will never know how many were harmed, but it is likely that the program killed people.
This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.
Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.
Massachusetts, where I live and work, recently became the first state to adopt a system of universal health coverage for its residents.
The results have been remarkable. After a year, 97.4 per cent of Massachusetts residents had coverage, and the remaining gap continues to close.
The Massachusetts plan didn’t do anything about medical costs, however, and, with layoffs accelerating, more people require subsidized care than the state predicted. Insurance premiums continue to rise here, just as they do elsewhere in the country. Many residents also complain that eight per cent of their income is too much to pay for health insurance, even though, on average, premiums amount to twice that much.
For years, about one in ten of my patients — I specialize in cancer surgery — had no insurance. Even though I’d waive my fee, they struggled to pay for their tests, medications, and hospital stay.
For the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage.
It will be no utopia. People will still face co-payments and premiums. There may still be agonizing disputes over coverage for non-standard treatments. Whatever the system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation — which is to say, a health-care system that works. And there are ways to get there that start from where we are.
http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande

Atul Gawande is a highly respected physician who has a well deserved reputation as a gifted writer. This commentary should not be construed as an attack on him; rather, it is an attack on his message. On his writing skills I give him an A, but on his content, a D-.
This article represents what I believe to be a misuse of framing. Gawande uses overly simplistic framing, but then bends, breaks or even replaces his frames as he develops his theme.
Gawande uses the linear polarity that I condemned in a recent qotd comment. In the four dimensional model that I described, he places single payer at one end of a linear polarity, free marketeers at the other end, and pragmatists in the middle.
His stated goal is a health care system that works, a goal that most of us share. Single payer is not only a financing system, but it is an administrative system that is specifically designed to make our health care system work for all of us. It is a system designed to address our problems not only in breadth, not only in depth, but throughout the three dimensions of all parameters, and over the fourth dimension of time. It is a system that is not “on the left” as he states, but, by design, it constitutes the health care universe in its four dimensions.
The free marketeers do not provide us with a universal system, but rather would disassemble much of what we have. They would have us each attend to our own needs, paying for whatever health care we need, or purchasing private health plans, even if the premiums alone are 16 percent of our income. No serious student of health policy would ever consider that to be a system that would work for all of us. At least Gawande is correct when he places the free marketeers out “on the right.”
What about the pragmatists? Of course, pragmatism is the theme of Gawande’s article. He cites path dependency as the natural model to achieve reform. Use what we have, and build on it to bring us closer to our goals.
But what is it that we do have? We have an expensive, dysfunctional health care delivery system that needs extensive repair along with adoption of efficiencies so that we can pay for it. Within the health care delivery system, we need to build on what is working, and replace that which isn’t.
But what else is it that we have? We have a health care financing system that is wasting tremendous resources, while impairing access to much needed health care, and exposing individuals to financial hardship or even financial ruin. Gawande’s major error in framing is that he conflates our health care delivery system with our health care financing, as if they were one and the same. Since we need to build on our existing delivery system, he includes as a given that building on our current fragmented financing system is an integral part of the process.
Look at the example that he gave us: the Medicare drug benefit. By the model of path dependency that he supports, drug coverage should have been added to Medicare as yet another benefit in the program, and it would have served us very well. Instead, it followed another path dependent road – our dependency on private health plans to cover prescription drugs. As Gawande states, this decision has likely killed people. Yet he insists that building on a financing system dependent on private insurers is essential because it’s path dependent.
He leaves us with an example of a successful application of path dependent reform – the Massachusetts “system of universal health coverage.” He glosses over the point that their system is not universal, although he does concede that the plan has done nothing to control costs, even though humane cost containment is an absolute imperative of any reform program.
But then it is hard to dispute Gawande’s perception that the Massachusetts plan is a success. After all, his surgical fees are being paid.
The pragmatic approach to financing reform is to follow a path dependent program that works, and discard those that don’t. With improvements, Medicare would work well for all of us; private health plans would work for those of us who are relatively healthy and have good incomes, like Dr. Gawande.

Gawande's pseudo-pragmatism

Getting There from Here: How should Obama reform health care?

by Atul Gawande
The New Yorker
January 26, 2009

People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse — especially for those who already have dependable coverage and access to good doctors and hospitals.

Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.

Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have.

Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.

Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area — even if prices, taxes, and competition are stiffer.

Some people regard the path-dependence of our policies as evidence of weak leadership; we have, they charge, allowed our choices to be constrained by history and by vested interests. But that’s too simple. …consider a health-care example: the 2003 prescription-drug program for America’s elderly.

On January 1, 2006, the program went into effect nationwide. The result was chaos. There had been little realistic consideration of how millions of elderly people with cognitive difficulties, chronic illness, or limited English would manage to select the right plan for themselves. Even the savviest struggled to figure out how to navigate the choices: insurance companies offered 1,429 prescription-drug plans across the country. People arrived at their pharmacy only to discover that they needed an insurance card that hadn’t come, or that they hadn’t received pre-authorization for their drugs, or had switched to a plan that didn’t cover the drugs they took. Tens of thousands were unable to get their prescriptions filled, many for essential drugs like insulin, inhalers, and blood-pressure medications. The result was a public-health crisis in thirty-seven states, which had to provide emergency pharmacy payments for the frail. We will never know how many were harmed, but it is likely that the program killed people.

This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.

Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.

Massachusetts, where I live and work, recently became the first state to adopt a system of universal health coverage for its residents.

The results have been remarkable. After a year, 97.4 per cent of Massachusetts residents had coverage, and the remaining gap continues to close.

The Massachusetts plan didn’t do anything about medical costs, however, and, with layoffs accelerating, more people require subsidized care than the state predicted. Insurance premiums continue to rise here, just as they do elsewhere in the country. Many residents also complain that eight per cent of their income is too much to pay for health insurance, even though, on average, premiums amount to twice that much.

For years, about one in ten of my patients — I specialize in cancer surgery — had no insurance. Even though I’d waive my fee, they struggled to pay for their tests, medications, and hospital stay.

For the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage.

It will be no utopia. People will still face co-payments and premiums. There may still be agonizing disputes over coverage for non-standard treatments. Whatever the system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation — which is to say, a health-care system that works. And there are ways to get there that start from where we are.

http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande

Comment:

By Don McCanne, MD

Atul Gawande is a highly respected physician who has a well deserved reputation as a gifted writer. This commentary should not be construed as an attack on him; rather, it is an attack on his message. On his writing skills I give him an A, but on his content, a D-.

This article represents what I believe to be a misuse of framing. Gawande uses overly simplistic framing, but then bends, breaks or even replaces his frames as he develops his theme.

Gawande uses the linear polarity that I condemned in a recent qotd comment. In the four dimensional model that I described, he places single payer at one end of a linear polarity, free marketeers at the other end, and pragmatists in the middle.

His stated goal is a health care system that works, a goal that most of us share. Single payer is not only a financing system, but it is an administrative system that is specifically designed to make our health care system work for all of us. It is a system designed to address our problems not only in breadth, not only in depth, but throughout the three dimensions of all parameters, and over the fourth dimension of time. It is a system that is not “on the left” as he states, but, by design, it constitutes the health care universe in its four dimensions.

The free marketeers do not provide us with a universal system, but rather would disassemble much of what we have. They would have us each attend to our own needs, paying for whatever health care we need, or purchasing private health plans, even if the premiums alone are 16 percent of our income. No serious student of health policy would ever consider that to be a system that would work for all of us. At least Gawande is correct when he places the free marketeers out “on the right.”

What about the pragmatists? Of course, pragmatism is the theme of Gawande’s article. He cites path dependency as the natural model to achieve reform. Use what we have, and build on it to bring us closer to our goals.

But what is it that we do have? We have an expensive, dysfunctional health care delivery system that needs extensive repair along with adoption of efficiencies so that we can pay for it. Within the health care delivery system, we need to build on what is working, and replace that which isn’t.

But what else is it that we have? We have a health care financing system that is wasting tremendous resources, while impairing access to much needed health care, and exposing individuals to financial hardship or even financial ruin. Gawande’s major error in framing is that he conflates our health care delivery system with our health care financing, as if they were one and the same. Since we need to build on our existing delivery system, he includes as a given that building on our current fragmented financing system is an integral part of the process.

Look at the example that he gave us: the Medicare drug benefit. By the model of path dependency that he supports, drug coverage should have been added to Medicare as yet another benefit in the program, and it would have served us very well. Instead, it followed another path dependent road – our dependency on private health plans to cover prescription drugs. As Gawande states, this decision has likely killed people. Yet he insists that building on a financing system dependent on private insurers is essential because it’s path dependent.

He leaves us with an example of a successful application of path dependent reform – the Massachusetts “system of universal health coverage.” He glosses over the point that their system is not universal, although he does concede that the plan has done nothing to control costs, even though humane cost containment is an absolute imperative of any reform program.

But then it is hard to dispute Gawande’s perception that the Massachusetts plan is a success. After all, his surgical fees are being paid.

The pragmatic approach to financing reform is to follow a path dependent program that works, and discard those that don’t. With improvements, Medicare would work well for all of us; private health plans would work for those of us who are relatively healthy and have good incomes, like Dr. Gawande.

For healthcare, single-payer system is best

It's the only way to ensure accessible, affordable quality care

By Dr. Stephen Kemble
Honolulu Advertiser
January 23, 2009

Economic analysis has repeatedly shown that administrative overhead is far greater for competing private health plans than for a publicly financed single-payer system. Administrative costs are about 31 percent of the healthcare dollar in the U.S., 15 percent in countries with single-payer plans.

Other industrialized countries spend far less per capita than we do on healthcare, provide universal coverage, and their doctors and hospitals spend far less money and time on administration. Public plans do not need to pay for marketing, negotiating with employers, underwriting (techniques for avoiding or charging more for insuring sicker patients), multiple private bureaucracies, reserves or profits.

A single-payer funding system is the only option that can assure quality and access at an affordable cost. We cannot continue an insurance system that profits by denying or avoiding paying for care.

President Obama has proposed banning underwriting by private health insurers (standard benefits and same premiums regardless of health status), and allowing an expanded Medicare-like public plan to compete with private plans. This would remove the perverse incentives of plans to avoid covering the sick, but it would not reduce the excess cost and complexity for both providers and patients in a system of competing plans.

Obama’s proposed plan also continues and expands Medicaid, a program so broken that Medicaid patients can no longer find a doctor who will see them.

National polls show most Americans favor a universal national healthcare program, along the lines of “Medicare for All.”

Most doctors also favor a single-payer plan, but justifiably fear “Medicare for All” because they have experienced claims processing problems and senseless, burdensome policies with Medicare. Fees are often irrational and inadequate, especially for primary care and “cognitive” specialties that emphasize listening to and thinking about patients and their issues, rather than high-tech procedures.

We have a shortage of primary-care doctors, and few medical students are now willing to enter primary-care careers. Medicare’s “Sustainable Growth Rate” formula is slated to slash physician fees by 30 percent over the next five years, so it has become very difficult to find a doctor accepting new Medicare patients.

Medicare D drug coverage is intolerably complex and difficult. Hospitals are being driven into bankruptcy by the uninsured and below-cost reimbursement from Medicare and Medicaid, so they shift as much of their costs as possible onto commercially insured patients. A single-payer “Medicare for All” plan would require serious attention to correcting the flaws in the current Medicare program.

Tom Daschle, the incoming Secretary of Health and Human Services, has proposed creation of a Federal Health Board, analogous to the Federal Reserve Board in the financial arena, charged with developing rational healthcare policies that serve the public interest. This board would be responsible for designing and updating the healthcare fee structure, scope of practice issues, allocating funds for medical training and education, public health and quality improvement programs.

A single-payer program would greatly reduce administrative costs and hassles for doctors and hospitals, and control out-of-pocket medical expenses.

Health coverage would be fully portable and not tied to employment. There would be no fragmentation or denial of care when insurers dispute responsibility for an illness or injury.

Most of medical malpractice costs are tied to current and future healthcare expenses, so if all healthcare were fully covered by a universal system, malpractice costs would be slashed. So would worker’s compensation and auto insurance costs. Injured parties would not feel forced to sue for fear their healthcare might not otherwise be covered.

A well-designed universal health plan can contain costs and maintain access and quality by serving patients and the providers of healthcare, instead of industry “middle men.”

Gawande’s pseudo-pragmatism

Getting There from Here: How should Obama reform health care?

by Atul Gawande
The New Yorker
January 26, 2009

People fear the unintended consequences of drastic change, the blunt force of government. However terrible the system may seem, we all know that it could be worse — especially for those who already have dependable coverage and access to good doctors and hospitals.

Many would-be reformers hold that “true” reform must simply override those fears. They believe that a new system will be far better for most people, and that those who would hang on to the old do so out of either lack of imagination or narrow self-interest. On the left, then, single-payer enthusiasts argue that the only coherent solution is to end private health insurance and replace it with a national insurance program. And, on the right, the free marketeers argue that the only coherent solution is to end public insurance and employer-controlled health benefits so that we can all buy our own coverage and put market forces to work.

Neither side can stand the other. But both reserve special contempt for the pragmatists, who would build around the mess we have.

Every industrialized nation in the world except the United States has a national system that guarantees affordable health care for all its citizens. Nearly all have been popular and successful. But each has taken a drastically different form, and the reason has rarely been ideology. Rather, each country has built on its own history, however imperfect, unusual, and untidy.

Social scientists have a name for this pattern of evolution based on past experience. They call it “path-dependence.” Paul Krugman received a Nobel Prize in Economics in part for showing that trade patterns and the geographic location of industrial production are also path-dependent. The first firms to get established in a given industry, he pointed out, attract suppliers, skilled labor, specialized financing, and physical infrastructure. This entrenches local advantages that lead other firms producing similar goods to set up business in the same area — even if prices, taxes, and competition are stiffer.

Some people regard the path-dependence of our policies as evidence of weak leadership; we have, they charge, allowed our choices to be constrained by history and by vested interests. But that’s too simple. …consider a health-care example: the 2003 prescription-drug program for America’s elderly.

On January 1, 2006, the program went into effect nationwide. The result was chaos. There had been little realistic consideration of how millions of elderly people with cognitive difficulties, chronic illness, or limited English would manage to select the right plan for themselves. Even the savviest struggled to figure out how to navigate the choices: insurance companies offered 1,429 prescription-drug plans across the country. People arrived at their pharmacy only to discover that they needed an insurance card that hadn’t come, or that they hadn’t received pre-authorization for their drugs, or had switched to a plan that didn’t cover the drugs they took. Tens of thousands were unable to get their prescriptions filled, many for essential drugs like insulin, inhalers, and blood-pressure medications. The result was a public-health crisis in thirty-seven states, which had to provide emergency pharmacy payments for the frail. We will never know how many were harmed, but it is likely that the program killed people.

This is the trouble with the lure of the ideal. Over and over in the health-reform debate, one hears serious policy analysts say that the only genuine solution is to replace our health-care system (with a single-payer system, a free-market system, or whatever); anything else is a missed opportunity. But this is a siren song.

Yes, American health care is an appallingly patched-together ship, with rotting timbers, water leaking in, mercenaries on board, and fifteen per cent of the passengers thrown over the rails just to keep it afloat. But hundreds of millions of people depend on it. There is no dry-docking health care for a few months, or even for an afternoon, while we rebuild it. Grand plans admit no possibility of mistakes or failures, or the chance to learn from them. If we get things wrong, people will die. This doesn’t mean that ambitious reform is beyond us. But we have to start with what we have.

Massachusetts, where I live and work, recently became the first state to adopt a system of universal health coverage for its residents.

The results have been remarkable. After a year, 97.4 per cent of Massachusetts residents had coverage, and the remaining gap continues to close.

The Massachusetts plan didn’t do anything about medical costs, however, and, with layoffs accelerating, more people require subsidized care than the state predicted. Insurance premiums continue to rise here, just as they do elsewhere in the country. Many residents also complain that eight per cent of their income is too much to pay for health insurance, even though, on average, premiums amount to twice that much.

For years, about one in ten of my patients — I specialize in cancer surgery — had no insurance. Even though I’d waive my fee, they struggled to pay for their tests, medications, and hospital stay.

For the past year, I haven’t had a single Massachusetts patient who has had to ask how much the necessary tests will cost; not one who has told me he needed to put off his cancer operation until he found a job that provided insurance coverage.

It will be no utopia. People will still face co-payments and premiums. There may still be agonizing disputes over coverage for non-standard treatments. Whatever the system’s contours, we will still find it exasperating, even disappointing. We’re not going to get perfection. But we can have transformation — which is to say, a health-care system that works. And there are ways to get there that start from where we are.

http://www.newyorker.com/reporting/2009/01/26/090126fa_fact_gawande

Comment:

By Don McCanne, MD

Atul Gawande is a highly respected physician who has a well deserved reputation as a gifted writer. This commentary should not be construed as an attack on him; rather, it is an attack on his message. On his writing skills I give him an A, but on his content, a D-.

This article represents what I believe to be a misuse of framing. Gawande uses overly simplistic framing, but then bends, breaks or even replaces his frames as he develops his theme.

Gawande uses the linear polarity that I condemned in a recent qotd comment. In the four dimensional model that I described, he places single payer at one end of a linear polarity, free marketeers at the other end, and pragmatists in the middle.

His stated goal is a health care system that works, a goal that most of us share. Single payer is not only a financing system, but it is an administrative system that is specifically designed to make our health care system work for all of us. It is a system designed to address our problems not only in breadth, not only in depth, but throughout the three dimensions of all parameters, and over the fourth dimension of time. It is a system that is not “on the left” as he states, but, by design, it constitutes the health care universe in its four dimensions.

The free marketeers do not provide us with a universal system, but rather would disassemble much of what we have. They would have us each attend to our own needs, paying for whatever health care we need, or purchasing private health plans, even if the premiums alone are 16 percent of our income. No serious student of health policy would ever consider that to be a system that would work for all of us. At least Gawande is correct when he places the free marketeers out “on the right.”

What about the pragmatists? Of course, pragmatism is the theme of Gawande’s article. He cites path dependency as the natural model to achieve reform. Use what we have, and build on it to bring us closer to our goals.

But what is it that we do have? We have an expensive, dysfunctional health care delivery system that needs extensive repair along with adoption of efficiencies so that we can pay for it. Within the health care delivery system, we need to build on what is working, and replace that which isn’t.

But what else is it that we have? We have a health care financing system that is wasting tremendous resources, while impairing access to much needed health care, and exposing individuals to financial hardship or even financial ruin. Gawande’s major error in framing is that he conflates our health care delivery system with our health care financing, as if they were one and the same. Since we need to build on our existing delivery system, he includes as a given that building on our current fragmented financing system is an integral part of the process.

Look at the example that he gave us: the Medicare drug benefit. By the model of path dependency that he supports, drug coverage should have been added to Medicare as yet another benefit in the program, and it would have served us very well. Instead, it followed another path dependent road – our dependency on private health plans to cover prescription drugs. As Gawande states, this decision has likely killed people. Yet he insists that building on a financing system dependent on private insurers is essential because it’s path dependent.

He leaves us with an example of a successful application of path dependent reform – the Massachusetts “system of universal health coverage.” He glosses over the point that their system is not universal, although he does concede that the plan has done nothing to control costs, even though humane cost containment is an absolute imperative of any reform program.

But then it is hard to dispute Gawande’s perception that the Massachusetts plan is a success. After all, his surgical fees are being paid.

The pragmatic approach to financing reform is to follow a path dependent program that works, and discard those that don’t. With improvements, Medicare would work well for all of us; private health plans would work for those of us who are relatively healthy and have good incomes, like Dr. Gawande.

Current political status on reform

Great Expectations — The Obama Administration and Health Care Reform

By Jonathan Oberlander, Ph.D.
The New England Journal of Medicine
January 22, 2009
Health care reform is back. For the first time since 1993, momentum is building for policies that would move the United States toward universal health insurance. President Barack Obama has made health care a central part of his domestic agenda, and key members of Congress have promised to introduce ambitious health care reform legislation in 2009.
The lessons of 1993 and 1994 are also well understood in Congress. Two key Senators — Max Baucus (D-MT), chair of the Finance Committee, and Edward Kennedy (D-MA), chair of the Health, Education, Labor, and Pensions Committee — are developing legislation that largely tracks the Obama plan. Consequently, this time around, congressional Democrats may be more unified around a health care reform strategy. Baucus’s support for reform is crucial, given the importance of financing issues, and Kennedy’s staff has been holding meetings with stakeholders in an effort to build consensus. Both senators are determined to move quickly, fearing that delay could dissipate momentum, as it did in 1993.
Financing health care reform in this fiscal climate will be an extraordinary political challenge, deep divisions persist in Congress, and many thorny problems are nowhere near resolution. Throughout the past century, reformers pursuing comprehensive change in the U.S. health care system have failed to overcome similar barriers. But the fact that reform has failed before does not mean it is fated to fail forever. As the election of Barack Obama vividly reminds us, history is not always repeated. Sometimes it is made.
http://content.nejm.org/cgi/content/full/360/4/321

And…

Which Way to Universal Healthcare?

By Ezra Klein
In These Times
January 19, 2009
Ezra Klein: Your opening statements demonstrate a congruency in values, but obviously your approaches are different. It seems to me you each balance the politics and the policies of the issue differently. So, let me start with you, Steffie: How does single payer pass the Senate Finance Committee?
Steffie Woolhandler (PNHP): Well, you build a popular movement among the American people, much in the way that Obama was able to succeed by building a popular movement. If you’d asked me five years ago, what was more likely, passing single-payer or electing a black president, I probably would’ve said single-payer and you probably would’ve, too. But the thing that changed was a kind of populist sentiment in this country, and that’s what it’s going to take.
Ezra Klein: Richard, a lot of what you said today has been reliant on the idea of the public plan, but my congressional reporting suggests that one plausible outcome for your plan is that when you try to get to 60 votes in the Senate, the public plan gets bargained away. Is the public plan a bottom line? If the public plan vanishes, but the rest of the plan is structurally similar to your principles, is that a plan that’s beneath the level of acceptability? Is that a plan that therefore merits opposition?
Richard Kirsch (HCAN): We haven’t as a coalition had a discussion yet about how we look at this whole plan when it passes, and what’s acceptable and what is not.
We’re a long way policy-wise and politically — although maybe not that long on the calendar, potentially only nine or so months — of seeing something enacted. But we’re not there yet, so we’re just going to fight in every way for the best system that is achievable.
http://www.inthesetimes.com/article/4159/which_way_to_universal_healthcare/

Jonathan Oberlander is one of the nation’s more astute observers of the politics of health care reform. After a long dry spell of pessimism, he is finally able to justify a very cautious note of optimism, though it still risks being a fleeting message. The most reassuring component of his message is that Congressional Democrats, especially Sen. Baucus and Sen. Kennedy, are rapidly moving forward with comprehensive reform in a process designed to prevent as much as possible the errors of the past.
So the politics is in motion, but with which policies?
Although there is a growing populist sentiment for single payer reform, that has not translated into political action. Congress is moving forward with reform based primarily on covering more individuals with private health plans. Many of those supporting public insurance have decided that the politics require that we must follow the lead of the Washington politicians regardless of the Medicare-for-all populism. Thus they are pushing for a public insurance option in a market of private plans.
Ezra Klein is quite correct when he states that “my congressional reporting suggests that… when you try to get to 60 votes in the Senate, the public plan gets bargained away.” And what is the strategy to prevent this outcome? Richard Kirsch of the HCAN coalition states, “We haven’t as a coalition had a discussion yet…” and “We’re a long way policy-wise and politically…” and “we’re not there yet…”
The boat has left the dock and is leaving behind the better-than-Medicare option, and the HCAN coalition hasn’t solidified either the policies or the politics, other than to agree on abandoning single payer.
Is there any way that we can convert Medicare-for-all populism into political action? In his NEJM article, Professor Oberlander states, “Finally, in Barack Obama, health care reform has a president who could effectively use the bully pulpit to rally the public behind change.” Populism got President Obama to where he is. Can’t we take it one step further?

Current political status on reform

Great Expectations -- The Obama Administration and Health Care Reform

By Jonathan Oberlander, Ph.D.
The New England Journal of Medicine
January 22, 2009

Health care reform is back. For the first time since 1993, momentum is building for policies that would move the United States toward universal health insurance. President Barack Obama has made health care a central part of his domestic agenda, and key members of Congress have promised to introduce ambitious health care reform legislation in 2009.

The lessons of 1993 and 1994 are also well understood in Congress. Two key Senators — Max Baucus (D-MT), chair of the Finance Committee, and Edward Kennedy (D-MA), chair of the Health, Education, Labor, and Pensions Committee — are developing legislation that largely tracks the Obama plan. Consequently, this time around, congressional Democrats may be more unified around a health care reform strategy. Baucus’s support for reform is crucial, given the importance of financing issues, and Kennedy’s staff has been holding meetings with stakeholders in an effort to build consensus. Both senators are determined to move quickly, fearing that delay could dissipate momentum, as it did in 1993.

Financing health care reform in this fiscal climate will be an extraordinary political challenge, deep divisions persist in Congress, and many thorny problems are nowhere near resolution. Throughout the past century, reformers pursuing comprehensive change in the U.S. health care system have failed to overcome similar barriers. But the fact that reform has failed before does not mean it is fated to fail forever. As the election of Barack Obama vividly reminds us, history is not always repeated. Sometimes it is made.

http://content.nejm.org/cgi/content/full/360/4/321

And…

Which Way to Universal Healthcare?

By Ezra Klein
In These Times
January 19, 2009

Ezra Klein: Your opening statements demonstrate a congruency in values, but obviously your approaches are different. It seems to me you each balance the politics and the policies of the issue differently. So, let me start with you, Steffie: How does single payer pass the Senate Finance Committee?

Steffie Woolhandler (PNHP): Well, you build a popular movement among the American people, much in the way that Obama was able to succeed by building a popular movement. If you’d asked me five years ago, what was more likely, passing single-payer or electing a black president, I probably would’ve said single-payer and you probably would’ve, too. But the thing that changed was a kind of populist sentiment in this country, and that’s what it’s going to take.

Ezra Klein: Richard, a lot of what you said today has been reliant on the idea of the public plan, but my congressional reporting suggests that one plausible outcome for your plan is that when you try to get to 60 votes in the Senate, the public plan gets bargained away. Is the public plan a bottom line? If the public plan vanishes, but the rest of the plan is structurally similar to your principles, is that a plan that’s beneath the level of acceptability? Is that a plan that therefore merits opposition?

Richard Kirsch (HCAN): We haven’t as a coalition had a discussion yet about how we look at this whole plan when it passes, and what’s acceptable and what is not.

We’re a long way policy-wise and politically — although maybe not that long on the calendar, potentially only nine or so months — of seeing something enacted. But we’re not there yet, so we’re just going to fight in every way for the best system that is achievable.

http://www.inthesetimes.com/article/4159/which_way_to_universal_healthcare/

Comment:

By Don McCanne, MD

Jonathan Oberlander is one of the nation’s more astute observers of the politics of health care reform. After a long dry spell of pessimism, he is finally able to justify a very cautious note of optimism, though it still risks being a fleeting message. The most reassuring component of his message is that Congressional Democrats, especially Sen. Baucus and Sen. Kennedy, are rapidly moving forward with comprehensive reform in a process designed to prevent as much as possible the errors of the past.

So the politics is in motion, but with which policies?

Although there is a growing populist sentiment for single payer reform, that has not translated into political action. Congress is moving forward with reform based primarily on covering more individuals with private health plans. Many of those supporting public insurance have decided that the politics require that we must follow the lead of the Washington politicians regardless of the Medicare-for-all populism. Thus they are pushing for a public insurance option in a market of private plans.

Ezra Klein is quite correct when he states that “my congressional reporting suggests that… when you try to get to 60 votes in the Senate, the public plan gets bargained away.” And what is the strategy to prevent this outcome? Richard Kirsch of the HCAN coalition states, “We haven’t as a coalition had a discussion yet…” and “We’re a long way policy-wise and politically…” and “we’re not there yet…”

The boat has left the dock and is leaving behind the better-than-Medicare option, and the HCAN coalition hasn’t solidified either the policies or the politics, other than to agree on abandoning single payer.

Is there any way that we can convert Medicare-for-all populism into political action? In his NEJM article, Professor Oberlander states, “Finally, in Barack Obama, health care reform has a president who could effectively use the bully pulpit to rally the public behind change.” Populism got President Obama to where he is. Can’t we take it one step further?

Which Way to Universal Healthcare?

Two leading reformers debate the role of private insurers

By Ezra Klein
In These Times
January 19, 2009

Steffie Woolhandler and Richard Kirsch talk it out.

The numbers have never been this grim. Almost 50 million Americans are uninsured. The average annual premium for a family is nearing $13,000, and racing upward at rates that wages can’t hope to match. If nothing changes, by 2050, government healthcare spending will consume 37 percent of the gross domestic product, and private health spending will be far more. There will be little left for education or wages or leisure.

Economists have a dictum they call Stein’s Law, and it is simple: If something cannot go on forever, they say, it won’t.

Our health system cannot go on in this fashion forever. It will break the back of the federal budget and crush individual consumers. But between “cannot” and “will not” lies an ocean of impediments and questions.

Some of those barriers seem to be dissolving before the moral force of the issue. For the last eight years, our government lacked either the will or the interest to act on health reform. After Jan. 20, 2009, that will no longer be true.

President-elect Barack Obama has not only stated his intention to reform healthcare, he has also staffed his administration with eager reformers, notably former Senate Majority Leader Tom Daschle, who has written a book calling for comprehensive healthcare reform and who will serve as the administration’s “health czar,” as well as its Health and Human Services secretary.

But if the incoming administration has the will, few are sure of the way. It’s an old debate, and a consequential one. As the saying goes, the status quo is everyone’s second choice. And when you have reformers squabbling over what they want, and industry uniting to defeat what they don’t want, the outcome is never progressive.

In an attempt to encourage dialogue in advance of the legislative battles to come, In These Times invited representatives from two leading reform groups–Steffie Woolhandler, co-director of Physicians for a National Health Program, and Richard Kirsch, the national campaign manager for Health Care for America Now (HCAN)–to talk out their differences. An edited transcript of their conversation follows.

Why don’t we begin with each of you giving us the “elevator pitch” of what your groups are advocating for? Steffie?

Steffie Woolhandler: Our group of more than 15,000 physicians supports single-payer national healthcare insurance. We support that because it’s the only way to affordably cover all Americans. That’s because single-payer allows you to generate huge administrative savings by going to a more simplified payment structure.

If you don’t go with single-payer and you continue with the current system of multiple-payers and the participation of private insurance, you continue to have tremendous administrative waste. And then the only way to get more coverage is to spend more money, and that quickly becomes economically unfeasible.

Just so we’re clear on terms, when you say “single payer,” how stringent are you being? Are you talking just what Canada and England do, or are you also considering Germany and France, which have nonprofit involvement? Do they count as single-payer?

SW: Germany clearly would not count as single-payer. They have multiple payers. But there are other nations that have, or have had, some form of single-payer systems, not just Canada or England. For a while, Australia had single-payer, for instance, and Taiwan has a single-payer system.

Richard?

Richard Kirsch: Health Care for America Now’s goal is to have a guarantee of quality, affordable healthcare for everyone in the nation. And we’ve come together as a coalition that includes 480 organizations that represent community groups, labor, healthcare providers and faith-based groups, among a whole variety of organizations on a common set of principles: That everyone should be covered. That the coverage should be affordable based on people’s income. That the benefits should meet people’s needs. That the coverage should be affordable to employers. And that, in order to do this, we need to have really strict regulation of the private health insurance industry, so that it can’t continue to have a business model that drops people when they need healthcare.

We also need to give people a choice of healthcare coverage. So, in addition to keeping their own healthcare coverage, they have the choice of a public health insurance plan. Private insurance isn’t the only choice. The primary goal is to look at healthcare as a public good.

The reason healthcare in this country costs so much more than in any other country is because we’re the only country that treats healthcare as a commodity.

Your opening statements demonstrate a congruency in values, but obviously your approaches are different. It seems to me you each balance the politics and the policies of the issue differently. So, let me start with you, Steffie: How does single payer pass the Senate Finance Committee?

SW: Well, you build a popular movement among the American people, much in the way that Obama was able to succeed by building a popular movement. If you’d asked me five years ago, what was more likely, passing single-payer or electing a black president, I probably would’ve said single-payer and you probably would’ve, too. But the thing that changed was a kind of populist sentiment in this country, and that’s what it’s going to take.

So, Richard, what’s your response? In particular, why do you let corporate insurers remain in your system?

RK: First of all, our goal is to get all folks covered. A lot of people in America have their healthcare taken care of by private insurers.

My wife’s a cancer survivor. She got really good care and some not-good care, and none of that had to do with the insurance. The not-good care had to do with a doctor who wasn’t so good, but the insurance covered both the good doctor and the bad doctor.

There are a lot of problems with the health insurance industry and the way it functions, but it can be regulated. It’s not private insurance that makes it impossible to provide access to care to people. We should remember that, even with all the frustrations that people have with it.

SW: These private-public types of plans fail. The TennCare plan [Tennessee’s Medicaid managed care program] in 1992 did include a big public plan, so it’s not correct to say that none of these efforts have included a public plan.

Similarly, the Massachusetts reform in 1988, the Oregon reform in 1992, and the Washington reform in 1993 all included substantial employer mandates. They were never fully implemented because the economics didn’t work. If you don’t get the administrative costs under control, you can’t get advanced care.

But these proposals fail at the state level because healthcare is a countercyclical cost. States cannot deficit spend. When recessions hit, their revenues drop. But when recessions hit, more people lose their insurance and need subsidies. So at the exact moment revenues go down, costs go up. That’s why the plans unravel. But it’s not necessarily applicable to the federal level.

SW: That’s certainly true about the state level and the inability of states to deficit spend. But what the countercyclical argument doesn’t get to is the explosion of healthcare costs. And that is much more the cause of their failure, and not a specific issue about money flowing into state coffers.

RK: As Steffie may recall, I was a leader of the single-payer movement in the early ’90s. I actually co-wrote with Assemblyman Dick Gottfried–who was, and still is, the chair of the Assembly Health Committee in New York–the only fully financed single-payer bill to pass a state legislative body. (Most of the other ones that passed punted on the financing.)

I did the fiscal analysis that showed the financing. So I understand the arguments against state plans. But there is an enormous difference if we do this at the federal level. You have broad-based taxes, you can deficit spend. The financing is totally different.

Richard, one of the arguments that Steffie is making about your proposal is that of cost-control. I’m not as concerned about the administrative costs as she is, but single-payer certainly has a very coherent argument about cost-control. It’s essentially that we will use the market share of a single payer to force the system into being more cost-effective. There’s a lot of research backing this up. What is the cost-control theory of the HCAN plan?

RK: There are two things: First, having a public plan that has 100 million people in it will give you a lot of the cost-control.

But what if you don’t have that? That seems to me a very speculative part of your plan. Are there any other aspects of the plan that will control costs?

RK: Well, to say that the public plan is speculative is to say that any of this stuff is speculative, regulating the insurance industry, etc. But there are other things that control costs that might even be bigger lifts than the public plan.

We need to ask, “How do we start doing the other kind of changes in the system that we need, to control costs?” Part of it is, obviously, how do we get everybody in the system with prevention? How do we get better chronic care management? How do you create a system where providers have different incentives? How do you have a system where there’s better value?

So, yes, let’s use the public plan for its ability to have better prices for drug companies, better prices for hospitals, not have medical specialists get paid the outrageous amounts of money that they do get paid in this country–all the things Medicare tries to do.

But also, let’s start having a public discussion about the really hard decisions about what we pay for. Should we be having doctors perform lots of services that have no value? Should we be paying for drugs that have no value? Those are the hard decisions that the hospitals, the doctors, the drug companies, the medical device manufacturers are going to fight tooth and nail in both a private system and in a public system, and that’s ultimately where the price savings are going to have to come from.

Steffie, let me ask you about what is maybe the most fundamental disagreement between you two. Do you think the American people might be disturbed to lose the private healthcare they currently have and move toward a government system?

SW: Medicare is one of the most popular social programs of all time in the United States. So it’s very easy to talk in terms of Medicare, and to win people over by explaining that what we are proposing is an expanded and improved Medicare for all. Winning people over is not he problem.

Certainly, if Richard and HCAN went out with rhetoric about Medicare, they’d have no trouble signing up voters who are interested in it. But if they go out there with, “Here’s our principle: We have to have private insurance,” that’s not going to move us forward.

Okay, but to follow up: HCAN, for better or for worse, is a response to a long history of failure on the U.S. left to achieve universal healthcare. And that’s been a failure to achieve it on a single-payer basis, which is what Truman was looking at, a failure on a hybrid basis, which is more what Clinton was looking at. I agree that HCAN is a policy compromise that is suboptimal, but it does have a certain political logic behind it.

SW: Who got Obama elected? That’s obviously not the same coalition that we’d need to build a movement for national health insurance, but it shows what is possible. We’ve had a civil rights movement that completely changed the way we think about race. We’ve had a women’s movement that has won all sorts of victories. We had an antiwar movement that ended the war in Vietnam. So I don’t understand your cynicism here about how there couldn’t be a movement.

I’m not saying that there can’t be one, but I’m wondering why hasn’t there been one? The catalytic figure for the movement of Barack Obama was Barack Obama. What would be the catalytic moment or figure for your movement? Single-payer as an idea has been around for an extremely long time, but the movement hasn’t achieved a sufficient amount of power to pass it. So what has been wrong in the past that will be right in the future? Why can it succeed now when it has failed before?

SW: Right before the Clinton plan, the thing that changed was the election of Sen. Harris Wofford (D-Pa.). He was elected on a single-payer platform almost by accident. It was only one aspect of his plan, and then his opponent, Dick Thornburgh, decided to attack him as being a single-payer supporter, and Wofford was elected to the Senate based on Thornburgh’s attacks.

Now, that I could not have predicted. But in a general way, I can predict that when important elections are won and lost on this issue, then it’ll be like a lightning bolt coming from the sky. The political scene can change very, very rapidly.

RK: But Steffie, what you just said totally makes an HCAN point. Because Barack Obama was elected on a promise to fix healthcare in a certain way. One of his ads showed two extremes–government health insurance at one extreme, all private health insurance at the other extreme–and he said, “I’m not at either extreme, I’m in the middle.” What he said in his messaging at every debate was, “Under my plan, you can keep your own health insurance or you can have a choice of other health insurance.” He was elected on exactly the kind of mandate Steffie’s talking about.

That’s what the election was all about. It wasn’t for single-payer. It was for this bold promise to the American public to have a guarantee of quality, affordable healthcare from a choice of either private or public insurance and know that you’re going to get good benefits that are affordable. That’s the mandate we have.

Steffie, is there any intermediate proposal between here and single-payer that would be a step in the right direction?

SW: If you’re going to do something incremental, I would start with single-payer for hospital care. All hospitals would get their budget from a single-payer, and hospitals would no longer send bills or do health accounting to individual patients, but would be budgeted. That at least gets you a substantial amount of administrative savings and increases the fairness of the system. It also allows you to do better health planning.

There’s not a lot of talk about that as an incremental step, but that’s the one incremental step that makes sense.

Richard, a lot of what you said today has been reliant on the idea of the public plan, but my congressional reporting suggests that one plausible outcome for your plan is that when you try to get to 60 votes in the Senate, the public plan gets bargained away. Is the public plan a bottom line? If the public plan vanishes, but the rest of the plan is structurally similar to your principles, is that a plan that’s beneath the level of acceptability? Is that a plan that therefore merits opposition?

RK: We haven’t as a coalition had a discussion yet about how we look at this whole plan when it passes, and what’s acceptable and what is not.

We’re a long way policy-wise and politically–although maybe not that long on the calendar, potentially only nine or so months–of seeing something enacted. But we’re not there yet, so we’re just going to fight in every way for the best system that is achievable.

We’re glad we got President-elect Obama and more than half the newly elected members of Congress to sign our principles. Our goal is to build this movement for the set of principles that are achievable and that the President-elect got a mandate for, and to see that in law in 2009.

Ezra Klein is a staff writer at the American Prospect who blogs regularly at www.ezraklein.com.