Frequently asked questions about the AMA proposal for reform

American Medical Association
October 2008
Q: What are the basic principles of the AMA proposal?
A: The American Medical Association (AMA) proposes that individuals and families receive financial assistance to purchase a health plan of their choice, with more generous assistance to those with lower incomes. The financial assistance could take the form of tax credits or vouchers and must be earmarked for health insurance coverage. Health insurance market regulations should be reformed to establish fair “rules of the game” that protect vulnerable individuals, without unduly driving up premiums for the rest of the population.
Q: How is the AMA proposal different or better than a single-payer system?
A: Both the AMA and the single-payer approaches emphasize the same goal of universal coverage, but they differ on how to implement it. The AMA does not believe that full government control is a workable model for the United States. Single-payer systems are plagued with an undersupply of medical personnel, long waiting periods and a lack of patient choice. Alternatively, the AMA proposal seeks to enhance patient choice and encourage patients to be conscious of health insurance costs, while also maintaining innovation in the private sector.
http://www.voicefortheuninsured.org/pdf/08-1103-FAQ-Proposal.pdf

The AMA is trying. During this presidential election season, the AMA has initiated an intensive “Voice for the Uninsured” campaign in support of their model of reform. Unfortunately, the policies behind their version of reform would fall far short of achieving the goal of affordable, comprehensive health care for everyone. Their feeble and deceptive effort to explain why their proposal is better than single payer reveals the fact that that the AMA is still controlled by those ideologically opposed to a national health program.
One of their basic principles is that “insurance market regulations should be reformed to establish fair ‘rules of the game’ that protect vulnerable individuals, without unduly driving up premiums for the rest of the population.” Presumably insurance market regulations that protect vulnerable individuals would mean that plans must prevent financial hardship for those who need health care. Even the average employer-sponsored family plan (at $12,600) may not be adequate because of deductibles and other cost sharing requirements. To be effective in protecting personal finances, these plans must be quite comprehensive and will require very high premiums.
Yet the AMA states that these plans must not unduly drive up premiums for the rest of the population. That is an impossibility. The only way you can keep premiums low is to segregate the healthy in isolated risk pools (but then these pools wouldn’t work for those who end up needing medical care because of the high cost sharing used to keep the premiums low). If you were to isolate those with high medical expenses in pools providing comprehensive coverage, the premiums would be so high that the many who are healthy would have to finance most of the costs.
Of course that is why the AMA has recommended taxpayer financed subsidies to help pay those premiums. But how could you ever make that equitable? Imagine the complexities of setting premiums in a fragmented system of unstable and inequitable risk pools, and then providing tax subsidies (credits or vouchers) that would vary with ever changing income levels. And for that we would continue to accept private insurance plans that burn up hundreds of billions of dollars in administrative waste, while remaining incapable of directing our health care dollars to where they would do the most good. Supporting a model with excess costs and greater inefficiency doesn’t make sense.
Regarding single payer, the AMA labels that as “full government control.” It is hard to know what that means when the health care delivery system remains private. About sixty percent of our health care is already financed through taxes. Single payer systems typically finance about seventy percent (though more would improve efficiency). “Full government control” is merely intended as a pejorative label that has little policy application. That label could backfire on the AMA since many Americans are now concerned that the government has not been doing enough.
The AMA states that single payer systems are “plagued with an undersupply of medical personnel.” Massachusetts has a program not unlike that supported by the AMA. Tell the people of Massachusetts that the primary care physicians that they can’t find are really there in great supply. Tell the patients behind the curtains in the upstairs hallways that we don’t have an undersupply of safety-net beds. Tell the patients on Medicaid or in Community Health Centers that we don’t have an undersupply of willing specialists. Tell the ambulance drivers who are waved past full emergency departments that we don’t have an undersupply of emergency facilities. The fact is that publicly administered programs are more capable of identifying needs and redirecting resources to where they would do the most good.
The AMA says that single payer systems cause long waiting periods. Tell that to the tens of millions of individuals in the United States who are not even allowed a place in the queue. Tell that to insured patients who may have to wait months for an appointment with a specialist. Tell that to the authors of the OECD report which demonstrated that many nations with public systems have been successful in reducing and even preventing excessive queues.
The AMA says that single payer systems cause a lack of patient choice. What does that mean? Most private insurance plans have restricted lists that take away our choice of hospitals, physicians, and other health care professionals. A single payer system gives you this free choice within the health care delivery system. Does the AMA mean a lack of choice of health plans? The only plan that you really want is a plan that allows you to access health care without being assessed a financial penalty for having health problems. Most private health plans do not do that, but a single payer system does.
The AMA states that their proposal, unlike single payer, encourages patients to be “conscious of health insurance costs.” If you look at our individual insurance market where people select their plans based on the amount of the premium, it’s easy to understand what a flawed concept this is. We have had an explosion in innovative underinsurance plans that have left patients with major medical debt, home foreclosures, and even personal bankruptcy. These people are certainly “conscious” of the financial hardship that the private plans exposed them to.
I’m the first to admit that the “Voice for the Uninsured” campaign offers real hope that the AMA has had an epiphany. But that hope will be dashed once again unless the AMA backs up their campaign with sound health policy science.

American Medical Association
October 2008

Q: What are the basic principles of the AMA proposal?

A: The American Medical Association (AMA) proposes that individuals and families receive financial assistance to purchase a health plan of their choice, with more generous assistance to those with lower incomes. The financial assistance could take the form of tax credits or vouchers and must be earmarked for health insurance coverage. Health insurance market regulations should be reformed to establish fair “rules of the game” that protect vulnerable individuals, without unduly driving up premiums for the rest of the population.

Q: How is the AMA proposal different or better than a single-payer system?

A: Both the AMA and the single-payer approaches emphasize the same goal of universal coverage, but they differ on how to implement it. The AMA does not believe that full government control is a workable model for the United States. Single-payer systems are plagued with an undersupply of medical personnel, long waiting periods and a lack of patient choice. Alternatively, the AMA proposal seeks to enhance patient choice and encourage patients to be conscious of health insurance costs, while also maintaining innovation in the private sector.

http://www.voicefortheuninsured.org/pdf/08-1103-FAQ-Proposal.pdf

Comment:

By Don McCanne, MD

The AMA is trying. During this presidential election season, the AMA has initiated an intensive “Voice for the Uninsured” campaign in support of their model of reform. Unfortunately, the policies behind their version of reform would fall far short of achieving the goal of affordable, comprehensive health care for everyone. Their feeble and deceptive effort to explain why their proposal is better than single payer reveals the fact that that the AMA is still controlled by those ideologically opposed to a national health program.

One of their basic principles is that “insurance market regulations should be reformed to establish fair ‘rules of the game’ that protect vulnerable individuals, without unduly driving up premiums for the rest of the population.” Presumably insurance market regulations that protect vulnerable individuals would mean that plans must prevent financial hardship for those who need health care. Even the average employer-sponsored family plan (at $12,600) may not be adequate because of deductibles and other cost sharing requirements. To be effective in protecting personal finances, these plans must be quite comprehensive and will require very high premiums.

Yet the AMA states that these plans must not unduly drive up premiums for the rest of the population. That is an impossibility. The only way you can keep premiums low is to segregate the healthy in isolated risk pools (but then these pools wouldn’t work for those who end up needing medical care because of the high cost sharing used to keep the premiums low). If you were to isolate those with high medical expenses in pools providing comprehensive coverage, the premiums would be so high that the many who are healthy would have to finance most of the costs.

Of course that is why the AMA has recommended taxpayer financed subsidies to help pay those premiums. But how could you ever make that equitable? Imagine the complexities of setting premiums in a fragmented system of unstable and inequitable risk pools, and then providing tax subsidies (credits or vouchers) that would vary with ever changing income levels. And for that we would continue to accept private insurance plans that burn up hundreds of billions of dollars in administrative waste, while remaining incapable of directing our health care dollars to where they would do the most good. Supporting a model with excess costs and greater inefficiency doesn’t make sense.

Regarding single payer, the AMA labels that as “full government control.” It is hard to know what that means when the health care delivery system remains private. About sixty percent of our health care is already financed through taxes. Single payer systems typically finance about seventy percent (though more would improve efficiency). “Full government control” is merely intended as a pejorative label that has little policy application. That label could backfire on the AMA since many Americans are now concerned that the government has not been doing enough.

The AMA states that single payer systems are “plagued with an undersupply of medical personnel.” Massachusetts has a program not unlike that supported by the AMA. Tell the people of Massachusetts that the primary care physicians that they can’t find are really there in great supply. Tell the patients behind the curtains in the upstairs hallways that we don’t have an undersupply of safety-net beds. Tell the patients on Medicaid or in Community Health Centers that we don’t have an undersupply of willing specialists. Tell the ambulance drivers who are waved past full emergency departments that we don’t have an undersupply of emergency facilities. The fact is that publicly administered programs are more capable of identifying needs and redirecting resources to where they would do the most good.

The AMA says that single payer systems cause long waiting periods. Tell that to the tens of millions of individuals in the United States who are not even allowed a place in the queue. Tell that to insured patients who may have to wait months for an appointment with a specialist. Tell that to the authors of the OECD report which demonstrated that many nations with public systems have been successful in reducing and even preventing excessive queues.

The AMA says that single payer systems cause a lack of patient choice. What does that mean? Most private insurance plans have restricted lists that take away our choice of hospitals, physicians, and other health care professionals. A single payer system gives you this free choice within the health care delivery system. Does the AMA mean a lack of choice of health plans? The only plan that you really want is a plan that allows you to access health care without being assessed a financial penalty for having health problems. Most private health plans do not do that, but a single payer system does.

The AMA states that their proposal, unlike single payer, encourages patients to be “conscious of health insurance costs.” If you look at our individual insurance market where people select their plans based on the amount of the premium, it’s easy to understand what a flawed concept this is. We have had an explosion in innovative underinsurance plans that have left patients with major medical debt, home foreclosures, and even personal bankruptcy. These people are certainly “conscious” of the financial hardship that the private plans exposed them to.

I’m the first to admit that the “Voice for the Uninsured” campaign offers real hope that the AMA has had an epiphany. But that hope will be dashed once again unless the AMA backs up their campaign with sound health policy science.

Medical Tourism Causes Complications

By Christina L. Madden
Carnegie Council
Policy Innovations
October 27, 2008
Approximately 750,000 Americans traveled overseas for medical treatment in 2007, and the number of so-called medical tourists could increase to more than 15 million in 2017.
Overall the effects of medical tourism are mixed. On the one hand, the industry can boost a developing country’s gross domestic product and investment in health facilities. Upgrades in a country’s hospitals also tend to decrease external brain drain, as top physicians find local jobs instead of leaving for employment in developed nations.
In many cases, however, medical tourism threatens to exacerbate unequal access to quality health care in developing countries. Although relatively cheap by most Western standards, the private hospitals that treat foreigners are out of reach for the majority of people, and the revenue they bring in rarely makes its way to the public sector.
External brain drain is often replaced by internal brain drain, as doctors leave public health care centers to work in private hospitals.
Medical tourism is not an alternative to significant reform of the U.S. health care industry. Aside from the negative effects on public health overseas… medical tourism is not predicted to reduce the country’s health spending by more than 1 to 2 percent.
By introducing global competition to an industry that’s long been considered immune to outsourcing, medical tourism may up the ante on reforming coverage, cost, and quality at home.
http://www.policyinnovations.org/ideas/briefings/data/000083

Previous studies have shown that one of the reasons that health care is so expensive in the United States is that, quite simply, our prices are very high. Since other nations have been demonstrated to be capable of selectively providing high quality care at much lower prices, it is not surprising that medical tourism has become an attractive option for those paying the bills, including cash-paying patients, some insurers and some employers.
For those who believe that health care financing should be a function of markets, medical tourism would have a prominent place in the menu of options. For those who believe that health care systems should provide everyone with the best options available in an egalitarian system, both for us in the United States and for the people of other nations, medical tourism is a troublesome development.
As this article describes, medical tourism is further impairing public health programs in developing nations. In our quest for a high performance system in the United States, we must be very careful to avoid the unintended consequence of inflicting damage on the health systems of other nations.

By Christina L. Madden
Carnegie Council
Policy Innovations
October 27, 2008

Approximately 750,000 Americans traveled overseas for medical treatment in 2007, and the number of so-called medical tourists could increase to more than 15 million in 2017.

Overall the effects of medical tourism are mixed. On the one hand, the industry can boost a developing country’s gross domestic product and investment in health facilities. Upgrades in a country’s hospitals also tend to decrease external brain drain, as top physicians find local jobs instead of leaving for employment in developed nations.

In many cases, however, medical tourism threatens to exacerbate unequal access to quality health care in developing countries. Although relatively cheap by most Western standards, the private hospitals that treat foreigners are out of reach for the majority of people, and the revenue they bring in rarely makes its way to the public sector.

External brain drain is often replaced by internal brain drain, as doctors leave public health care centers to work in private hospitals.

Medical tourism is not an alternative to significant reform of the U.S. health care industry. Aside from the negative effects on public health overseas… medical tourism is not predicted to reduce the country’s health spending by more than 1 to 2 percent.

By introducing global competition to an industry that’s long been considered immune to outsourcing, medical tourism may up the ante on reforming coverage, cost, and quality at home.

http://www.policyinnovations.org/ideas/briefings/data/000083

Comment:

By Don McCanne, MD

Previous studies have shown that one of the reasons that health care is so expensive in the United States is that, quite simply, our prices are very high. Since other nations have been demonstrated to be capable of selectively providing high quality care at much lower prices, it is not surprising that medical tourism has become an attractive option for those paying the bills, including cash-paying patients, some insurers and some employers.

For those who believe that health care financing should be a function of markets, medical tourism would have a prominent place in the menu of options. For those who believe that health care systems should provide everyone with the best options available in an egalitarian system, both for us in the United States and for the people of other nations, medical tourism is a troublesome development.

As this article describes, medical tourism is further impairing public health programs in developing nations. In our quest for a high performance system in the United States, we must be very careful to avoid the unintended consequence of inflicting damage on the health systems of other nations.

Primary Health Care – Now More Than Ever

World Health Organization
October 14, 2008
The World Health Report 2008 critically assesses the way that health care is organized, financed, and delivered in rich and poor countries around the world. The WHO report documents a number of failures and shortcomings that have left the health status of different populations, both within and between countries, dangerously out of balance.
Inequities in access to care and in health outcomes are usually greatest in cases where health is treated as a commodity and care is driven by profitability. The results are predictable: unnecessary tests and procedures, more frequent and longer hospital stays, higher overall costs, and exclusion of people who cannot pay.
To steer health systems towards better performance, the report calls for a return to primary health care (PHC), a holistic approach to health care formally launched 30 years ago. When countries at the same level of economic development are compared, those where health care is organized around the tenets of primary health care produce a higher level of heath for the same investment.
This report structures the PHC reforms in four groups that reflect the convergence between the evidence on what is needed for an effective response to the health challenges of today’s world, the values of equity, solidarity and social justice that drive the PHC movement, and the growing expectations of the population in modernizing societies: reforms that ensure

• that health systems contribute to health equity, social justice and the end of exclusion, primarily by moving towards universal access and social health protection — UNIVERSAL COVERAGE REFORMS;
• reforms that reorganize health services as primary care, i.e. around people’s needs and expectations, so as to make them more socially relevant and more responsive to the changing world while producing better outcomes — SERVICE DELIVERY REFORMS;
• reforms that secure healthier communities, by integrating public health actions with primary care and by pursuing healthy public policies across sectors — PUBLIC POLICY REFORMS;
• reforms that replace disproportionate reliance on command and control on one hand, and laissez-faire disengagement of the state on the other, by the inclusive, participatory, negotiation-based leadership required by the complexity of contemporary health systems — LEADERSHIP REFORMS.

In high-expenditure health economies, which is the case of most high-income countries, there is ample financial room to accelerate the shift from tertiary to primary care, create a healthier policy environment and complement a well-established universal coverage system with targeted measures to reduce exclusion.
Even in the United States, its exceptionalism stems not from lower public expenditure… but from its singularly high additional private expenditure. The persistent under-performance of the United States health sector across domains of health outcomes, quality, access, efficiency and equity, explains opinion polls that show increasing consensus of the notion of government intervention to secure more equitable access to essential health care.
http://www.who.int/mediacentre/news/releases/2008/pr38/en/index.html
Primary Health Care – Now More Than Ever (148 page PDF):
http://www.who.int/whr/2008/whr08_en.pdf

The World Health Report 2008 provides a critical assessment of health care systems throughout the world. It describes how all nations, regardless of national wealth, can benefit by enacting reforms organized around primary health care.
In reading the various experiences of other nations, it is almost shocking to see how infrequently the most expensive health system of all, that of the United States, is mentioned as an example of how reform can work. But then it is understandable when other nations single our system out for its exceptionalism – a system with “singularly high additional private expenditure” that persistently underperforms “across domains of health outcomes, quality, access, efficiency and equity.”
For a proper perspective of what we do have and what we could have, this report should be required reading.

Primary Health Care – Now More Than Ever

World Health Organization
October 14, 2008

The World Health Report 2008 critically assesses the way that health care is organized, financed, and delivered in rich and poor countries around the world. The WHO report documents a number of failures and shortcomings that have left the health status of different populations, both within and between countries, dangerously out of balance.

Inequities in access to care and in health outcomes are usually greatest in cases where health is treated as a commodity and care is driven by profitability. The results are predictable: unnecessary tests and procedures, more frequent and longer hospital stays, higher overall costs, and exclusion of people who cannot pay.

To steer health systems towards better performance, the report calls for a return to primary health care (PHC), a holistic approach to health care formally launched 30 years ago. When countries at the same level of economic development are compared, those where health care is organized around the tenets of primary health care produce a higher level of heath for the same investment.

This report structures the PHC reforms in four groups that reflect the convergence between the evidence on what is needed for an effective response to the health challenges of today’s world, the values of equity, solidarity and social justice that drive the PHC movement, and the growing expectations of the population in modernizing societies: reforms that ensure

* that health systems contribute to health equity, social justice and the end of exclusion, primarily by moving towards universal access and social health protection — UNIVERSAL COVERAGE REFORMS;

* reforms that reorganize health services as primary care, i.e. around people’s needs and expectations, so as to make them more socially relevant and more responsive to the changing world while producing better outcomes — SERVICE DELIVERY REFORMS;

* reforms that secure healthier communities, by integrating public health actions with primary care and by pursuing healthy public policies across sectors — PUBLIC POLICY REFORMS;

* reforms that replace disproportionate reliance on command and control on one hand, and laissez-faire disengagement of the state on the other, by the inclusive, participatory, negotiation-based leadership required by the complexity of contemporary health systems — LEADERSHIP REFORMS.

In high-expenditure health economies, which is the case of most high-income countries, there is ample financial room to accelerate the shift from tertiary to primary care, create a healthier policy environment and complement a well-established universal coverage system with targeted measures to reduce exclusion.

Even in the United States, its exceptionalism stems not from lower public expenditure… but from its singularly high additional private expenditure. The persistent under-performance of the United States health sector across domains of health outcomes, quality, access, efficiency and equity, explains opinion polls that show increasing consensus of the notion of government intervention to secure more equitable access to essential health care.

http://www.who.int/mediacentre/news/releases/2008/pr38/en/index.html

Primary Health Care – Now More Than Ever (148 page PDF):
http://www.who.int/whr/2008/whr08_en.pdf

Comment:

By Don McCanne, MD

The World Health Report 2008 provides a critical assessment of health care systems throughout the world. It describes how all nations, regardless of national wealth, can benefit by enacting reforms organized around primary health care.

In reading the various experiences of other nations, it is almost shocking to see how infrequently the most expensive health system of all, that of the United States, is mentioned as an example of how reform can work. But then it is understandable when other nations single our system out for its exceptionalism – a system with “singularly high additional private expenditure” that persistently underperforms “across domains of health outcomes, quality, access, efficiency and equity.”

For a proper perspective of what we do have and what we could have, this report should be required reading.

California high-risk pool for medically uninsurable helps fewer residents

By Jordan Rau
Los Angeles Times
October 28, 2008
California… is one of 35 states that arranges health coverage for people rejected by commercial companies because they have blemished medical histories.
This group — known as “medically uninsurable” — accounts for about an eighth of the 5 million Californians who lack health insurance. Most are self-employed, work for companies that don’t provide insurance or don’t have a job.
But California’s publicly subsidized high-risk pool, long one of the least generous in the country, has atrophied over the tenure of Gov. Arnold Schwarzenegger — even as the governor put the plight of the uninsured at the top of his political agenda.
Rising premiums and limited subsidies have made the Major Risk Medical Insurance Program either unaffordable, unavailable or ineffective for many of those who most need health insurance.
The program now covers about 13,000 Californians — about 2% of the medically uninsurable.
Enrollment has dropped by almost a third since Schwarzenegger became governor.
Subscribers pay two-thirds of the pool’s cost and the state about one-third. The insurers that voluntarily participate — primarily Blue Cross of California and Kaiser Permanente — break even.
Unlike most other states, which finance their programs either directly with tax dollars or with assessments on insurers, California’s subsidies have come only from the state’s tobacco tax.
Lawmakers have kept annual financing at or below $40 million a year, requiring the pool’s administrators to cap its enrollment.
One of the major obstacles is the cost of premiums, which the law sets at 125% of commercial insurance rates. More than a third of pool participants who dropped out this year told the pool’s administrators that they couldn’t afford it anymore.
Despite its cost, California’s high-risk pool is of limited use for people needing extensive medical care, such as those with cancer or chronic diseases. That is because the pool’s benefits are capped at $75,000 a year, lower than the limits of any other state’s pool.
To fix California’s pool, the Legislature this year proposed placing a $1 monthly per customer fee on insurers that sell policies directly to customers.
But in his veto message, Schwarzenegger said the fee would be passed on to customers and thus “only exacerbates their burden.”
http://www.latimes.com/news/local/la-me-uninsured28-2008oct28,0,7559850,full.story

The concept of health insurance is quite simple. When everyone pays into an insurance risk pool, the many who are healthy are subsidizing the higher costs of those with greater health care needs. Thus everyone receives whatever medical care they need without facing financial barriers to care.
Then why do we have high-risk pools? The simple answer is that health care has become so expensive that premiums for universal pools would be so high that few could afford them. So we move higher cost individuals into high-risk pools in order to keep premiums more affordable for pools of healthy individuals.
Think about the premium for a family in an employer-sponsored pool composed of the healthy workforce and their young healthy families; it now averages $12,600. If we were to add into these pools many hundreds of thousands of individuals with high health care costs, you can only imagine how high the premiums would go.
Although California has set the high-risk pool premium at 125 percent of commercial rates, they have had to cap the benefits at $75,000 to avoid yet higher premiums. Sorry, but for this high cost group, that falls far short of the insurance function of preventing financial hardship in the face of medical need. For adequate benefits, the premiums for high-risk pools would be unaffordable for all but the very wealthiest of us, as if they weren’t too high already.
If we expect to cover high-risk individuals, we do need a transfer from the healthy to the sick. California attempted to take a very small step in this direction by assessing fees on insurance plans in the individual market that would be used to help fund the high-risk pool. But Gov. Schwarzenegger didn’t want to “exacerbate the burden” on the healthy by expecting them to help fund care for the sick. Then who funds the high-risk pool?
We really need to end this game of juggling unaffordable premiums amongst fragmented, inequitable risk pools. It’s time to establish one single risk pool for all of us, and fund it equitably through progressive taxes. The private plans get in our way. We need to dump them.

California high-risk pool for medically uninsurable helps fewer residents

By Jordan Rau
Los Angeles Times
October 28, 2008

California… is one of 35 states that arranges health coverage for people rejected by commercial companies because they have blemished medical histories.

This group — known as “medically uninsurable” — accounts for about an eighth of the 5 million Californians who lack health insurance. Most are self-employed, work for companies that don’t provide insurance or don’t have a job.

But California’s publicly subsidized high-risk pool, long one of the least generous in the country, has atrophied over the tenure of Gov. Arnold Schwarzenegger — even as the governor put the plight of the uninsured at the top of his political agenda.

Rising premiums and limited subsidies have made the Major Risk Medical Insurance Program either unaffordable, unavailable or ineffective for many of those who most need health insurance.

The program now covers about 13,000 Californians — about 2% of the medically uninsurable.

Enrollment has dropped by almost a third since Schwarzenegger became governor.

Subscribers pay two-thirds of the pool’s cost and the state about one-third. The insurers that voluntarily participate — primarily Blue Cross of California and Kaiser Permanente — break even.

Unlike most other states, which finance their programs either directly with tax dollars or with assessments on insurers, California’s subsidies have come only from the state’s tobacco tax.

Lawmakers have kept annual financing at or below $40 million a year, requiring the pool’s administrators to cap its enrollment.

One of the major obstacles is the cost of premiums, which the law sets at 125% of commercial insurance rates. More than a third of pool participants who dropped out this year told the pool’s administrators that they couldn’t afford it anymore.

Despite its cost, California’s high-risk pool is of limited use for people needing extensive medical care, such as those with cancer or chronic diseases. That is because the pool’s benefits are capped at $75,000 a year, lower than the limits of any other state’s pool.

To fix California’s pool, the Legislature this year proposed placing a $1 monthly per customer fee on insurers that sell policies directly to customers.

But in his veto message, Schwarzenegger said the fee would be passed on to customers and thus “only exacerbates their burden.”

http://www.latimes.com/news/local/la-me-uninsured28-2008oct28,0,7559850,full.story

Comment:

By Don McCanne, MD

The concept of health insurance is quite simple. When everyone pays into an insurance risk pool, the many who are healthy are subsidizing the higher costs of those with greater health care needs. Thus everyone receives whatever medical care they need without facing financial barriers to care.

Then why do we have high-risk pools? The simple answer is that health care has become so expensive that premiums for universal pools would be so high that few could afford them. So we move higher cost individuals into high-risk pools in order to keep premiums more affordable for pools of healthy individuals.

Think about the premium for a family in an employer-sponsored pool composed of the healthy workforce and their young healthy families; it now averages $12,600. If we were to add into these pools many hundreds of thousands of individuals with high health care costs, you can only imagine how high the premiums would go.

Although California has set the high-risk pool premium at 125 percent of commercial rates, they have had to cap the benefits at $75,000 to avoid yet higher premiums. Sorry, but for this high cost group, that falls far short of the insurance function of preventing financial hardship in the face of medical need. For adequate benefits, the premiums for high-risk pools would be unaffordable for all but the very wealthiest of us, as if they weren’t too high already.

If we expect to cover high-risk individuals, we do need a transfer from the healthy to the sick. California attempted to take a very small step in this direction by assessing fees on insurance plans in the individual market that would be used to help fund the high-risk pool. But Gov. Schwarzenegger didn’t want to “exacerbate the burden” on the healthy by expecting them to help fund care for the sick. Then who funds the high-risk pool?

We really need to end this game of juggling unaffordable premiums amongst fragmented, inequitable risk pools. It’s time to establish one single risk pool for all of us, and fund it equitably through progressive taxes. The private plans get in our way. We need to dump them.

‘Hallway medicine’ seen as a way to unclutter ERs

By Carla K. Johnson
Houston Chronicle/AP
October 26, 2008
It may not sound like ideal health care, but hospital officials nationwide are being urged to consider hallway medicine as a way to ease emergency department crowding, and some are trying it.
Leading the way is Stony Brook University Medical Center at Stony Brook, N.Y., where a study found that no harm was caused by moving emergency room patients to upper-floor hallways when they were ready for admission.
Holding patients in ERs can cause deaths, doctors say. In a 2007 survey of nearly 1,500 emergency doctors, 13 percent said they personally experienced a patient dying as a result of boarding in the emergency department. The survey was conducted by the American College of Emergency Physicians.
The new study found slightly fewer deaths and intensive care unit admissions in the hallway patients, compared with the standard bed patients. That was no surprise… because the protocol calls for giving the first available rooms to the sickest patients. Intensive care patients never go to hallways.
http://www.chron.com/disp/story.mpl/health/6079406.html

The United States has 2.9 hospital beds per 1000 individuals. The median number of beds for OECD nations is 3.7 (OECD, 2002). Not only do we have fewer beds, the distribution is less even than in other nations with their more egalitarian systems. The supply of beds tends to be quite adequate in affluent regions, but is inadequate in other areas, especially those served by safety-net institutions.
In many hospitals, emergency departments have had to accept queues in “holding” – patients who have been admitted but for whom there are no beds available on the hospital floors. When the holding area is full, it has been common practice to admit patients to the hallways of the various services, not as policy but as a temporary inconvenience. The significance of this study is that hallway admissions now are being recommended as explicit hospital policy.
Hospitals also need policies to provide surge capacity – the ability to admit much larger numbers of patients in the event of major epidemics or catastrophic events. Can you imagine how these hospitals would respond to such a surge in patients? Not very well.
How is it that we have lower capacity and worse distribution of our hospital beds than do other nations that spend much less on health care than we do? Quite simply, they use equitable, egalitarian systems for health care financing and health system planning. Of course, this is code language for stating that they depend on government involvement in their financing and health system planning.
Other nations do sometimes have queues, especially for less urgent problems, often labeled as rationing. So their systems are not perfect. Some merely need to spend more money, and others need to replace their public stewards with individuals who have more egalitarian values.
In the United States, we spend more than enough money, primarily on those with the means to pay, and they get good care (except for an excess of detrimental high-tech services).
In contrast, for less affluent individuals, we do not even supply them with enough beds. But at least we don’t ration. We merely hide them behind the curtains in the upstairs hallways.