PNHP

Presidential debate – health care as a right

Presidential debate – health care as a right

The Second Presidential Debate

October 7, 2008

Tom Brokaw: Is health care in America a privilege, a right, or a responsibility?

John McCain: I think it’s a responsibility…

Barack Obama: Well, I think it should be a right for every American…

http://elections.nytimes.com/2008/president/debates/transcripts/second-presidential-debate.html

Comment:

By Don McCanne, MD

Asking whether health care is a privilege or a right often leads to a not very productive ’tis so, ’tis not debate. But when the question is asked with the added choice of responsibility, and then answered, the answers can be very revealing.

If you believe that health care should be an individual responsibility, you might design reform based on a relatively unregulated market of private health plans.

If you believe that health care should be a right, you might design reform based on social solidarity with government guaranteeing that all of us receive the care that we need.

Proposals floated during political campaigns are rarely the final definitive proposals, especially with an issue as complex as our dysfunctional health care financing system. But it is important to understand the fundamental beliefs of those who we would elect to establish new policies addressing the problems that we face. A system that honors the right for everyone to obtain the health care that they need will look very different from a system that assigns the responsibility for obtaining health care to the individual.

PBS Frontline Interview with T.R.Reid

Fall 2008

T.R. Reid is a veteran foreign correspondent for The Washington Post, a commentator for National Public Radio and the author of nine books, including three in Japanese. He is currently working on his 10th book, titled “We’re Number 37!,” in which he compares America’s health care system to others around the world. It is scheduled to be published by Penguin Press in early 2009.

How did you choose the five countries featured in this report?

Two of our choices, Britain and Japan, were pretty obvious. I had lived in both countries, I had doctors there and knew the systems. I could speak the language, sort of, in both places.

Beyond that, we were looking for examples of each of the established models of health care systems. The U.K. uses the Beveridge model; Taiwan has chosen the Canadian-style National Health Insurance [NHI] model; Germany, Japan and Switzerland use the Bismarck model. We went to three Bismarck countries on the theory that these private-sector systems are more relevant to America than a British-style National Health Service.

I got interested in Taiwan because Taiwan’s Health Ministry did what our film does; it traveled the world studying health care systems. In the end, Taiwan chose the Canadian model. We went to Switzerland because it is a ferociously free-market economy with politically powerful insurance and drug companies. But still, the Swiss managed to revamp their system, making it cheaper and fairer. We thought that might inspire Americans to believe that change is possible here, too.

You and your family lived in London and Tokyo; what was your experience with the health care systems there?

Our American family used the health care systems in Japan and Britain with considerable satisfaction. Fortunately, we never had a heart attack or cancer, but for the normal family medical problems — flu, measles, broken bones, earache, etc. — we got excellent care, with little or no waiting. During a trip to South Asia, I contracted a mysterious tropical disease that left me sick as a dog. When I got back to London, our family doctor diagnosed the problem precisely and found a fast cure.

In Japan, the prices were low; in Britain, there was no price at all. There was no bill! I loved that part of British health care.

In Japan my local government, Shibuya-ku — it’s a part of Tokyo — sent me a card every year on my birthday, urging me to get a comprehensive physical. I could go to any doctor or hospital in Shibuya, and the whole thing was free. When I did it, they checked everything — and I mean everything — that a man my age might have to worry about. This was a terrific example of preventive medicine.

In your upcoming book about health care you write about the five countries in this FRONTLINE report, as well as a few others. What are some of the good ideas America could learn from other countries?

As we say in the film, the World Health Organization studied every health care system on earth and rated the world’s richest country 37th in terms of quality and fairness. The top ranking in that survey went to France, so I went there to see what they are doing right.

The French private insurance system covers all 61 million residents of France, with excellent health results. There’s no “in-network” or “pre-authorization”; you can pick any doctor or hospital in France, and insurance has to pay the bill. Doctors are required to post their prices on the wall of the waiting room, so the mystery of American-style medical billing is removed.

Everyone in France has a green plastic card, the carte d’assurance maladie. That card has completely replaced paper billing and medical records. The result: administrative costs of 3 percent, compared to 25 percent in the U.S.

While France has achieved 100 percent digital record keeping, the U.S. is years behind on this technology. President Bush has made it a national goal to have 50 percent of American health records in digital form by the year 2014. Who would have thought that France would clean our clock when it comes to high-tech innovation?

The Austrians, who seem to do everything with a clockwork precision, have a precise, modern health care system that is a model of careful organization and cost control. But I think Austria may be too small and not diverse enough to be a model for the U.S.

Canada’s system is also pretty good. It has some notorious problems, including waiting lists, but I was impressed by Canada’s relentlessly egalitarian approach to health care.

Yes, Canada is one country in particular that many Americans think about when they think of health care. Can you talk a bit about their system: how it’s paid for, what works well, what needs fixing, and what we Americans get right and wrong when we talk about it.

Canada uses a National Health Insurance model; that means private providers but public financing. Everybody pays a premium to a single health insurer, run by the government. The Canadians call their system “Medicare,” and in fact our system of Medicare for the elderly is a good example of the Canadian-style National Health Insurance model.

Canada’s system started in a single province, Saskatchewan. The other provinces saw that it was working, and people demanded that it be expanded to the whole country. This suggests that if one American state set up a sort of Medicare-for-all system and it worked, then other states might demand the same kind of plan, and eventually we’d get a national system.

As we said in the film, the Taiwanese hired a professor at Harvard to study health care systems around the world and choose a model for Taiwan. In the end, they picked the Canadian model, on the grounds that it is cheaper and fairer than the for-profit insurance system used in the U.S.

Canada is fairly stingy in paying for health care; it spends about half of what we do, on a per capita basis. This leads to scrimping. That’s why Canadians often have to wait to see a specialist or have elective surgery. Some Canadians respond by crossing the border to buy treatment in the U.S. But most Canadians accept the delays, because they are roughly equal for everybody. A scholar there put it this way: “Canadians don’t mind waiting lines, as long as the rich Canadian and the poor Canadian have to wait about the same amount of time.”

There was another recent documentary about health care around the world: Michael Moore’s Sicko. Did you have that film in mind when you set out to make this report?

I thought Michael Moore did a good job in describing the shortcomings of the U.S. system. He didn’t pay much attention to our strengths: the best medical education in the world, the most innovative research, the best equipped hospitals. He is an advocate and had a point to make.

But Sicko was disappointing when Moore went overseas. He seemed to feel that all foreign health care systems are the same, that they are all “socialized” and that they all work great for low cost. I’d say that’s simplistic and wrong. We set out to take a more careful look at the different models in different countries. We saw their problems as well as their successes.

All five of these countries have achieved universal coverage for their citizens, but all five are grappling with rising costs as well. Is this simply a worldwide problem, or is there a fundamental difference between America’s rising health care costs and those in other countries? Which countries may be better able to keep a lid on them, and why?

Health care costs are rising everywhere, largely because health care is getting better. Doctors routinely save lives now that would have been lost a decade ago. A lot of this is due to new technology, and new technologies cost money. We shouldn’t complain about this. It’s hard to imagine anything more worth our money than good health and longer, happier lives. But this is the reason all the countries we visited are struggling with rising costs for health care.

In countries where there is a single health care system — and thus a single pool of money to pay for it — it is somewhat easier to control costs. Britain’s NHS often decides, for example, that it won’t pay for kidney dialysis for a 90-year-old. That means somebody’s grandmother will die, but at least Grandma and her relatives know that the money saved is going to be used to help some sick baby or some accident victim.

Limits like that are harder to impose in the U.S. because the money saved here doesn’t necessarily help another sick person. If Aetna or United Health declines to pay for somebody’s dialysis, the money saved is likely used for dividends to the stockholders or bonuses for the executives. That’s a little harder to swallow for the relatives of the sick patient.

It was interesting to learn in the report that some of Switzerland’s drug companies make one-third of their profits in the U.S. market. Are we subsidizing these other nations’ prescription drugs, and what would happen if America clamps down on prices?

Yes, we subsidize the whole world. Americans pay more for pills than people in any other country. Sometimes, the same tablet made in the same factory costs $1 in the U.S. and 20 cents in Britain. If we could negotiate lower prices in the U.S., the drug companies would then try to raise prices overseas to make up for the lost revenues.

The pharmaceutical industry spends billions on research. Drug companies say they would have to reduce R&D if Americans paid less for their drugs, but the companies spend more on marketing than they do on research. In Switzerland, when the government started negotiating lower prices for drugs, the companies cut their marketing budgets and maintained the level of R&D.

For the first time since 1992, health care is, according to a Kaiser Foundation poll, a top-three concern for voters, after the economy and Iraq. Do you think that reform is going to happen this time?

Yes. I am confident that we’re going to do it. I think Americans are ready for fundamental change, for two reasons.

First, our system is so expensive and inefficient that we can’t afford it anymore. It’s a big competitive disadvantage for U.S. industry. Second, Americans are too decent and too generous to accept a system that leaves tens of millions of our fellow citizens without access to health care. [According to the Institute of Medicine,] about 18,000 Americans die each year because they can’t get the medical treatment that would save their lives. That’s morally unacceptable.

So I think both the fiscal and the moral imperative will drive us to major change in 2009.

You note at the end of the report that none of the 2008 presidential candidates’ plans really encompass the ideas you found abroad. Do you think there’s a distinctly American approach that can solve the problems in our system?

To me, the candidates all seem to be tinkering at the margins of a system that needs fundamental change.

What we’ve learned overseas is that successful national systems have settled on one model — be it Beveridge, Bismarck or NHI — for everybody. This is fairer, cheaper and far more efficient than our badly fragmented crazy-quilt system.

I don’t think the systems we see in our film are un-American. The British system — the Beveridge model — is the same system used by the U.S. Veterans Administration. If this is un-American, why do we use it for America’s military heroes? And the Canadian system — the National Health Insurance model — is the model for Medicare. If it were un-American, would we use it for 36 million elderly Americans?

This is not the first project you’ve done that looked at how other nations address social issues differently — and often with better results — than the United States. Has this approach drawn criticism that you’re being too hard on America?

Anybody who dares say that other countries do anything better than America is liable to be called unpatriotic.

I wrote a book, Confucius Lives Next Door, pointing out that East Asian countries in the Confucian cultural sphere have much lower crime rates than the U.S., more stable families, almost no single mothers. And when I went on talk radio to promote this book, the hosts would say, “You hate America,” or, “Well, if Asia is so much better, why don’t you just move there?”

In fact, facing up to your country’s problems and trying to fix them is a sign of love for your country. The person who really cares about his college, his company or his country is the person who recognizes its shortcomings and tries to improve things. And one excellent way to do that is to study how other colleges, companies and countries have dealt with the same problem.

There are many cherished elements of American life that we copied from other countries: the Interstate Highway System (Germany), text messages (Finland), sushi (Japan), and American Idol (Britain). So it can’t be unpatriotic to suggest that we could cure our ailing health care system by borrowing ideas from overseas.

This report is about health care, but it’s also a travelogue of sorts. What was the most memorable moment from your travels in making this report?

I heard Big Ben toll the hours; I rode the bullet train past Mount Fuji; I ate leberwurst mit sauerkraut in Berlin; I flew a fighting kite on a beach in Taiwan; I strolled the breezy shore of Lac Léman with the president of Switzerland. All in all, a lovely trip.

For me, the best moment came at a new hospital in the fishing village of Jinshan, on the east coast of Taiwan. We went there with Professor Bill Hsiao of Harvard, the guy who designed Taiwan’s new health care system. In the hospital lobby, we met a woman, Mrs. Lee. She told me that her mother got breast cancer in the 1980s, when Taiwan had no [national] health care system and Jinshan had no hospital. Her mother died. In the late 1990s, the daughter, Mrs. Lee, also got breast cancer. By then, Jinshan had the new hospital and a health care system that gave Mrs. Lee treatment. She is now completely recovered.

I pointed out Professor Hsiao. I said, “Right over there is the guy who set up the health care system that treated your cancer.” So Mrs. Lee walked shyly over to Bill Hsiao; she gave him just a tiny, almost imperceptible bow. I thought it was a moving way for someone to say, “Thank you for saving my life.”

How Do You Think Your Healthcare is Trading?

By Donna Smith
Community Organizer
California Nurses Association

CHICAGO — If you think the companies that collect your health insurance premiums and pay your health care claims have been insulated from the economic crisis, think again. And if you think the health insurance industry that is suffering right alongside the financial services industry isn’t going to need a bail-out too, think yet again. Only the bail-out we will give the health insurance industry will be much more insidious and potentially far more dangerous to us all.

I wanted to inform myself about the stock performance of the big boys in the for-profit health insurance market, and here’s what I found this morning on Business Week’s website:

Stock performance, over the past month:

Aetna — down 25.03%

CIGNA — down 23.15 %

Humana — down 20.16%

Unitedhealth Group — down 27.95%

Wellpoint — down 20.59%

In fact, I couldn’t find one health insurance company traded on the stock exchange that looked very healthy right now. On its own, that’s not an indictment of the health insurance industry because so many businesses — if not most businesses — are losing money on Wall Street right now.

While the financial services industries were the first to the trough for bail-out, they won’t be the only private interests standing in line for some of our taxpayers’ funds. But when the private, for-profit health insurance industry comes calling, it will do so by raising premiums, denying claims and seeking to cover more Americans who won’t actually need to use many medical services. There are limited ways for the health insurance giants to recoup losses, and we are the way — our money, our ability to get the care we need and our lives depend on getting healthcare out of this folly.

We all know it. Healthcare isn’t like widgets or tires or hammers and nails. Healthcare is a human right. When we are sick, when our neighbor is sick, when our parent is sick, when our child is sick, and yes — even when our enemies are sick — we must have access to medical care. To see a doctor or other healthcare professional when we need it (and before it has become a crisis) is the way a humane and just society behaves.

But under the current, market sensitive and market driven pressures, healthcare morphs into a sort of odd blend of wealth-care for those who can still afford it as approved by for-profit insurance companies with enough resources to pay the claims. We can argue all we want to about the art of medicine, but when Unitedhealth Group drops nearly 30 percent in value in just one month, there isn’t any art to what they’ll be doing to the practice of medicine.

As a patient, I do not want my healthcare subject to the whims and the momentary fortunes of the stock market. I do not want to gamble on my healthcare or my children’s or my grandchildren’s. And I certainly don’t think the CEOs of those big corporations will want to take reductions in compensation or allow shareholders to suffer. Ronald Williams at Aetna, Edward Hanway at Cigna, Michael McCallister at Humana and Stephen Hemsley at Unitedhealth Group surely want to retain their millions in compensation even if that means denying me my prescription or my treatment or raising my premiums.

Any corporate losses resulting from the massive drops in value to the private health insurance industry in the current stock market environment will be absorbed by policy holders. You and me. Our employers. Our neighbors. Our families. Our health is in the hands of the stock market not those of our doctors and other healthcare professionals. And right now, my healthcare is worth a lot less than it was on Labor Day.

The only alternative to gambling with our healthcare in this volatile way is to make sure public funding backs up the healthcare system.

And I don’t know about other taxpayers — but I suspect many will feel as I do — I don’t want the funds I earn and the funds my taxes put in the public coffers to be used to pay for yet another corporate bail-out at my expense. I’ll gladly pay for my healthcare through a public fund but not their wealthcare. How does the saying go? Been there. Done that.

I do not want to pay monthly premiums and on top of those premiums to fund a bail-out to shore up health insurance company CEO compensation or shareholder dividends. And I cannot invest in the stock market by paying my health insurance premiums on time and wait for the market recovery in the estimated five to 10 years to recoup the investment. I might get sick and need actual healthcare.

I want the funds I contribute to healthcare to be used for healthcare. Period.

Health Care Systems – Four Basic Models

An excerpt from correspondent T.R. Reid’s book on international health care, titled “The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care.” There are about 200 countries on our planet, and each country devises its own set of arrangements for meeting the three basic goals of a health care system: keeping people healthy, treating the sick, and protecting families against financial ruin from medical bills. But we don’t have to study 200 different systems to get a picture of how other countries manage health care. For all the local variations, health care systems tend to follow general patterns. There are four basic systems:

The Beveridge Model

Named after William Beveridge, the daring social reformer who designed Britain’s National Health Service. In this system, health care is provided and financed by the government through tax payments, just like the police force or the public library. Many, but not all, hospitals and clinics are owned by the government; some doctors are government employees, but there are also private doctors who collect their fees from the government. In Britain, you never get a doctor bill. These systems tend to have low costs per capita, because the government, as the sole payer, controls what doctors can do and what they can charge. Countries using the Beveridge plan or variations on it include its birthplace Great Britain, Spain, most of Scandinavia and New Zealand. Hong Kong still has its own Beveridge-style health care, because the populace simply refused to give it up when the Chinese took over that former British colony in 1997. Cuba represents the extreme application of the Beveridge approach; it is probably the world’s purest example of total government control.

The Bismarck Model

Named for the Prussian Chancellor Otto von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. Despite its European heritage, this system of providing health care would look fairly familiar to Americans. It uses an insurance system — the insurers are called “sickness funds” — usually financed jointly by employers and employees through payroll deduction. Unlike the U.S. insurance industry, though, Bismarck-type health insurance plans have to cover everybody, and they don’t make a profit. Doctors and hospitals tend to be private in Bismarck countries; Japan has more private hospitals than the U.S. Although this is a multi-payer model — Germany has about 240 different funds — tight regulation gives government much of the cost-control clout that the single-payer Beveridge Model provides. The Bismarck model is found in Germany, of course, and France, Belgium, the Netherlands, Japan, Switzerland, and, to a degree, in Latin America.

The National Health Insurance Model

This system has elements of both Beveridge and Bismarck. It uses private-sector providers, but payment comes from a government-run insurance program that every citizen pays into. Since there’s no need for marketing, no financial motive to deny claims and no profit, these universal insurance programs tend to be cheaper and much simpler administratively than American-style for-profit insurance. The single payer tends to have considerable market power to negotiate for lower prices; Canada’s system, for example, has negotiated such low prices from pharmaceutical companies that Americans have spurned their own drug stores to buy pills north of the border. National Health Insurance plans also control costs by limiting the medical services they will pay for, or by making patients wait to be treated. The classic NHI system is found in Canada, but some newly industrialized countries — Taiwan and South Korea, for example — have also adopted the NHI model.

The Out-of-Pocket Model

Only the developed, industrialized countries — perhaps 40 of the world’s 200 countries — have established health care systems. Most of the nations on the planet are too poor and too disorganized to provide any kind of mass medical care. The basic rule in such countries is that the rich get medical care; the poor stay sick or die. In rural regions of Africa, India, China and South America, hundreds of millions of people go their whole lives without ever seeing a doctor. They may have access, though, to a village healer using home-brewed remedies that may or not be effective against disease. In the poor world, patients can sometimes scratch together enough money to pay a doctor bill; otherwise, they pay in potatoes or goat’s milk or child care or whatever else they may have to give. If they have nothing, they don’t get medical care. These four models should be fairly easy for Americans to understand because we have elements of all of them in our fragmented national health care apparatus. When it comes to treating veterans, we’re Britain or Cuba. For Americans over the age of 65 on Medicare, we’re Canada. For working Americans who get insurance on the job, we’re Germany. For the 15 percent of the population who have no health insurance, the United States is Cambodia or Burkina Faso or rural India, with access to a doctor available if you can pay the bill out-of-pocket at the time of treatment or if you’re sick enough to be admitted to the emergency ward at the public hospital. The United States is unlike every other country because it maintains so many separate systems for separate classes of people. All the other countries have settled on one model for everybody. This is much simpler than the U.S. system; it’s fairer and cheaper, too.

Note – Reid’s “Beveridge” model corresponds to what PNHP would call a single payer national health service (UK); “Bismark” model refers to countries that PNHP would say use non-profit “sickness funds” or a “social insurance model” (Germany); and “National health insurance” corresponds to single payer national health insurance (Canada, Taiwan). Reid’s “out-of-pocket” model is what PNHP would call “market driven” health care. Some countries have mixed models (e.g. Sweden has some features of a national health service such as hospitals run by county government; but other features of national health insurance such as physicians being paid on a FFS basis). This explains why Reid might classify the Scandinavian systems as “Beveridge” while PNHP classifies them as “single payer national health insurance.”

What reform does business want?

Business Cool Toward McCain’s Health Coverage Plan

By Kevin Sack
The New York Times
October 6, 2008
American business, typically a reliable Republican cheerleader, is decidedly lukewarm about Senator John McCain’s proposal to overhaul the health care system by revamping the tax treatment of health benefits, officials with leading trade groups say.
The officials, with organizations like the U.S. Chamber of Commerce, the Business Roundtable and the National Federation of Independent Business, predicted in recent interviews that the McCain plan, which eliminates the exclusion of health benefits from income taxes, would accelerate the erosion of employer-sponsored health insurance and do little to reduce the number of uninsured from 45 million.
Officials with eight business trade groups contacted by The New York Times predicted the McCain plan would raise costs and force some employers to stop providing health benefits.
A recent survey of 187 corporate executives by the American Benefits Council and Miller & Chevalier, a consulting firm, found that three-fourths felt the repeal of the tax exclusion would have a “strong negative impact” on their workers. Only 4 percent said they would provide additional pay to fill any gaps.
http://www.nytimes.com/2008/10/07/us/politics/07health.html?pagewanted=all

Where does American business really stand on health care reform?
Employers remain very concerned about rising health care costs. Because of our failure to reform our health care financing system, employers have been responding by shifting more responsibility to their employees. There has been an increase in the use of high-deductible health plans, which slow the rate of premium increases for the employer, but makes health care less affordable for the employees by requiring greater out-of-pocket payments when health care is accessed. Many employers now have decided not to offer health plans; the rate of coverage through employer-sponsored plans has continued to decline, especially amongst small businesses.
The McCain proposal is designed to relieve employers of the responsibility of providing employer-sponsored plans, both by eliminating the tax benefit for the employees and by offering individuals tax credits for purchasing plans in the individual market. It is not only the Obama camp that recognizes the erosion of health coverage that this would cause, the business community recognizes it as well. Most American businessmen are concerned about the welfare of their employees. They really don’t want a solution that would have a “strong negative impact” on their employees.
So would business be more supportive of the Obama proposal? The most important component of his proposal is to offer a market of quality plans similar to those used by federal employees. But isn’t that what they have now? Isn’t that precisely why the business community is seeking relief? Even Barack Obama understands that these plans are too expensive, and many would still have to go without coverage.
The American business leadership certainly understands the single payer model. One of the most important principles for a successful business is to reduce waste, and that is precisely what the single payer model does, by design. Adopting a single payer system would allow us to cover everyone, and would allow us to finance it equitably through a single universal risk pool.
When we desperately need sound business principles to drive health care financing, it really seems silly to digress into a not-very-intellectual debate over free markets and the government, as if they were two distinct entities between which a choice had to be made. Nebulous debates lead to nebulous results (and is probably the reason why conservatives keep drawing us into that debate).
Some leaders in the business community must be ready to support sound business principles in revamping our highly flawed health care financing system. An intellectual debate over ideology might make for an interesting pastime, but first we have to get our dollars in order. Every businessman understands that.

What reform does business want?

Business Cool Toward McCain's Health Coverage Plan

By Kevin Sack
The New York Times
October 6, 2008

American business, typically a reliable Republican cheerleader, is decidedly lukewarm about Senator John McCain’s proposal to overhaul the health care system by revamping the tax treatment of health benefits, officials with leading trade groups say.

The officials, with organizations like the U.S. Chamber of Commerce, the Business Roundtable and the National Federation of Independent Business, predicted in recent interviews that the McCain plan, which eliminates the exclusion of health benefits from income taxes, would accelerate the erosion of employer-sponsored health insurance and do little to reduce the number of uninsured from 45 million.

Officials with eight business trade groups contacted by The New York Times predicted the McCain plan would raise costs and force some employers to stop providing health benefits.

A recent survey of 187 corporate executives by the American Benefits Council and Miller & Chevalier, a consulting firm, found that three-fourths felt the repeal of the tax exclusion would have a “strong negative impact” on their workers. Only 4 percent said they would provide additional pay to fill any gaps.

http://www.nytimes.com/2008/10/07/us/politics/07health.html?pagewanted=all

Comment:

By Don McCanne, MD

Where does American business really stand on health care reform?

Employers remain very concerned about rising health care costs. Because of our failure to reform our health care financing system, employers have been responding by shifting more responsibility to their employees. There has been an increase in the use of high-deductible health plans, which slow the rate of premium increases for the employer, but makes health care less affordable for the employees by requiring greater out-of-pocket payments when health care is accessed. Many employers now have decided not to offer health plans; the rate of coverage through employer-sponsored plans has continued to decline, especially amongst small businesses.

The McCain proposal is designed to relieve employers of the responsibility of providing employer-sponsored plans, both by eliminating the tax benefit for the employees and by offering individuals tax credits for purchasing plans in the individual market. It is not only the Obama camp that recognizes the erosion of health coverage that this would cause, the business community recognizes it as well. Most American businessmen are concerned about the welfare of their employees. They really don’t want a solution that would have a “strong negative impact” on their employees.

So would business be more supportive of the Obama proposal? The most important component of his proposal is to offer a market of quality plans similar to those used by federal employees. But isn’t that what they have now? Isn’t that precisely why the business community is seeking relief? Even Barack Obama understands that these plans are too expensive, and many would still have to go without coverage.

The American business leadership certainly understands the single payer model. One of the most important principles for a successful business is to reduce waste, and that is precisely what the single payer model does, by design. Adopting a single payer system would allow us to cover everyone, and would allow us to finance it equitably through a single universal risk pool.

When we desperately need sound business principles to drive health care financing, it really seems silly to digress into a not-very-intellectual debate over free markets and the government, as if they were two distinct entities between which a choice had to be made. Nebulous debates lead to nebulous results (and is probably the reason why conservatives keep drawing us into that debate).

Some leaders in the business community must be ready to support sound business principles in revamping our highly flawed health care financing system. An intellectual debate over ideology might make for an interesting pastime, but first we have to get our dollars in order. Every businessman understands that.

In Pennsylvania, churches back single payer

By Morton Mintz
Nieman Watchdog
Commentary
October 05, 2008

Morton Mintz relays comments by the director of Public Advocacy of the Pennsylvania Council of Churches holding that health care “is very much an issue for the faith community.”

Are there good questions that reporters could ask of religious leaders in their communities about the morality of a system that leaves 46 million Americans without health insurance, millions more with inadequate coverage, and, because of the economic crisis, guarantees big increases in these numbers? Are there also good questions about that same system that reporters could put to businessmen in their communities? Indeed there are, as I learned at a health care conference at Franklin & Marshall College in Lancaster, Pa., on Sept. 18.

Few others were privileged to have had the same learning experience, the conference having received zero news coverage until seven days later, when a report by columnist Jeff Hawkes ran in the local paper, the Intelligencer Journal.

The conference sponsor, Progressives4Pennsylvania, seeks to make Pennsylvania the first state to adopt the form of universal health insurance known as single-payer. It is essentially Medicare for all, meaning that everyone – not just elders – would get private care paid for by the government, and with administrative costs far lower than those of private insurance. It is not socialized medicine, in which a national government, Great Britain’s being a case in point, owns and operates the health care system. (Disclosure: I was one of 15 panelists, my topic being press coverage – and non-coverage – of universal health care systems, particularly single-payer in Canada.)

The focus of this article is on the panelist whose remarks suggest questions for religious leaders. She is the Rev. Sandra L. Strauss, an ordained Minister of Word and Sacrament in the Presbyterian Church (USA) who holds a Master of Arts in Public Policy Studies from Duke University. But she spoke as Director of Public Advocacy for the Pennsylvania Council of Churches, which endorses single-payer for her state.

Does the Council’s counterpart in, say Ohio, endorse single-payer, and if it does, why, and if it does not, why not?

She said early on that “health care is very much an issue for the faith community.” Do ministers, priests and rabbis in, say South Carolina, agree or disagree, and why?

Such obvious questions flow in abundance from her full but brief prepared text, which follows:

I begin by sharing a few words from the Rev. Dr. Martin Luther King, Jr.: “Of all forms of inequality, injustice in health care is the most shocking and inhumane.” Sadly, it seems that not only have inequalities continued, they appear to be growing worse.

A colleague in another state asked his constituents the following question: What does it mean for us, as members of Christ’s body in the world, to carry on Jesus’ work of bringing hope and healing to all?

As this question suggests, health care is very much an issue for the faith community. As Protestant Christians–the constituency I represent–our concerns are shaped by the biblical principles of stewardship and justice.

It seems that our nation’s economic and political institutions, by and large, have not been good stewards of the resources that our society allocates to health care. We fail to be good stewards of our nation’s health care resources when Americans spend two to three times as much per person as other industrialized countries-and our overall health outcomes are worse!

In addition, disparities in health care coverage raise serious questions about the overall justice of our present system. All persons are precious in the eyes of God. No person’s well-being can be reduced to a price and bought and sold without moral and ethical considerations. Persons are more than “consumers” of the goods and services produced by the health care system: all are entitled to care, respect, and compassion, regardless of their state of health, their medical history, their personal circumstances, or their ability to pay.

As Christians, we believe that all creation is sacred, precious and worthy of being safeguarded. We believe that we are called to pursue justice and to practice love and compassion. We believe that we have a responsibility for stewardship, especially for stewardship of those resources that protect the well-being of human lives.

Finally, we believe that we are called to action to advocate and work for the well-being of poor and marginalized persons, as summed up by these words from the prophet Isaiah: “Seek justice, rescue the oppressed, defend the orphan, plead for the widow.” Orphans and widows were considered the most vulnerable members of the society of Isaiah’s time-and at the time of Jesus. This includes advocating for access to comprehensive and affordable health care for ALL persons, access not based solely on wealth, population, or other arbitrary determinant. Health care coverage must be for everyone. The religious conscience will accept nothing less.

The Pennsylvania Council of Churches has chosen to support the only proposal that addresses both of these concerns for Pennsylvania-the Family and Business Health Security Act, which would provide for a publicly administered system that covers all Pennsylvanians, but also maintains individual choice of comprehensive, privately delivered health care.

In closing, I want to remind all of you here that Jesus was a healer–and healing was one of the most important aspects of Jesus’ ministry. The gospels are replete with stories of Jesus healing the sick, raising the dead, restoring sight to the blind and hearing to the deaf, and making lame persons walk. He cared deeply for the spiritual welfare of all as well. He empowered others “to proclaim the kingdom of God and to heal” (Luke 9:2). He never refused to heal someone because they could not pay, and obviously preexisting conditions were his specialty. It seems to me that Jesus would provide for the health and well-being of all persons.

While I can’t claim that Jesus would endorse this legislation, I suspect that He would be happy to know that we are working, as He did, to provide health and healing for everyone…because I doubt that He would settle for anything less.

Some memorable context for the Rev. Strauss’s remarks came from a fellow panelist, a physician from the Department of Family and Community Medicine at Lancaster General Hospital. Here’s columnist Hawkes’s account:

Dr. Thomas Gates also joined the call for universal health care, having seen how the uninsured suffer when they put off treatment.

Citing an Institute of Medicine report, Gates said an uninsured person is twice as likely as an insured one to require a hospital stay for a preventable illness such as pneumonia or diabetes. Uninsured cancer patients delay care, resulting in a 50 percent higher chance of dying from the disease. Uninsured patients in general, he said, have a hospital mortality rate three times that of the insured because they delay going to the emergency room.

Gates has seen firsthand the problems. He recalled the time an uninsured blue-collar worker, a family man in his mid-20s, was admitted at Lancaster General Hospital after avoiding care until he was too weak to stand.

When the man arrived at the ER, he was diagnosed with new-onset diabetes and blood sugar levels off the chart [2,500]. His organs failed, and within 24 hours he was dead.

“His death certificate, I’m sure, says complications from diabetes,” Gates said. “But in reflecting on this, it would be just as accurate and just as true to say he died from lack of health care insurance.”

Morton Mintz is a senior adviser to the Nieman Watchdog project of the Nieman Foundation for Journalism at Harvard University.

Beware 'siren song' of privatizers, U.S. doctor tells Canadians

FOR IMMEDIATE RELEASE:
Oct. 7, 2008

Contact:
Mark Almberg, Physicians for a National Health Program, (312) 782-6006, mark@pnhp.org

Canada’s publicly funded health insurance program known as medicare “is one of the best health care systems in the world,” a leading U.S. health policy expert says, but is being threatened by government underfunding and by those who would partially privatize it under the guise of reducing wait times for elective medical procedures.

Dr. Marcia Angell, a senior lecturer at Harvard Medical School, writes in the Oct. 21 issue of the Canadian Medical Association Journal (CMAJ) that Canada’s health expenditures are half those in the United States – US$3,326 per person versus US$6,697. Yet, in sharp contrast to the U.S., Canada’s health system guarantees essential medical care to all of the country’s residents.

In addition, Angell says, since the full implementation of medicare in 1972, Canada’s medical outcomes have surpassed those of the U.S. “The life expectancy of Americans is now 2.5 years shorter than that of Canadians,” she writes. “Infant mortality rates are higher in the U.S., as is preventable mortality (death before the age of 75 from diseases that are amenable to treatment).” Americans also visit their doctors much less often than their Canadian counterparts.

Saying the only plausible explanation for the U.S. spending more and getting less than Canada is that the U.S. system is “enormously inefficient,” an inefficiency that stems from relying “primarily on private, largely investor-owned corporations to provide health care.”

These for-profit health insurance companies, hospitals, and “satellite businesses that have sprung up around the health care industry” like drug-management companies, utilization review companies and billing agencies siphon off about 31 percent of all health care spending in the U.S. for administrative costs, marketing and profits, she says.

By contrast, she writes, Canada’s public system and the U.S. Medicare system incur administrative costs of 2 percent or less.

The main charge leveled against Canada’s system is that it requires excessive wait times, particularly for elective procedures, Angell says.

Waiting times are a concern, she says. Some waits were lengthened when Canada adopted a 1984 law that essentially abolished user fees and extra charges. To compensate, system administrators tried to contain costs by controlling the supply of services like imaging and the use of surgical facilities, leading to longer waits.

Wait times also increased in the 1990s, when the Canadian system was badly underfunded. The funding became a political issue, and while subsequent funding improved the situation, today “waiting times are still too long for certain elective procedures, such as hip and knee replacements, and it takes time for increased funding to be translated into more facilities and specialists.”

But waiting lists for these procedures are no reason to abandon what clearly amounts to a superior overall system of delivering health care, a system that provides essential health care to all based on medical need, not ability to pay, Angell says. Canadian medicare still remains popular with the public, she notes.

Those who say that privatizing part of Canada’s system will reduce wait times have produced little evidence to back up their claim, she says. In fact, Angell believes the pressure to partially privatize the Canadian system has more to do with “the desire of businesses and some specialists to profit from the system, just as they do in the U.S.,” combined with a desire on the part of federal and provincial governments to shift more health care costs onto individual patients.

Such steps toward privatization would backfire, she says, since “for-profit care is nearly always more expensive and often of lower quality.”

Instead, she urges better funding for Canada’s medicare. “The wisest course for Canada is to expand and reinforce its public system, not undermine it,” Angell says.

Angell, the former editor-in-chief of The New England Journal of Medicine, notes that many Americans also appreciate the merits of a national health insurance system: “Polls have shown that about two-thirds of Americans would prefer a Canadian-style system, as would three-fifths of doctors.”

An early release version of Dr. Angell’s paper (“Privatizing health care is not the answer: lessons from the United States,” Marcia Angell, CMAJ, www.cmaj.ca, Oct. 21, 2008) can be found here: www.pnhp.org/Canada_medicare.

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Physicians for a National Health Program, a membership organization of over 15,000 physicians, supports a single-payer national health insurance program. To contact a physician-spokesperson in your area, call (312) 782-6006 or visit www.pnhp.org/stateactions.

Medical causes of home mortgage foreclosures

Get Sick, Get Out: The Medical Causes of Home Mortgage Foreclosures

By Christopher Tarver Robertson, Richard Egelhof, & Michael Hoke
Health Matrix
Vol. 18:65 2008
In recent years, there has been national alarm about the rising rate of home foreclosures, which now strike one in every 92 households in America, and which contribute to even broader macroeconomic effects.
These factors — loose lending, irresponsible borrowers, a flat real estate market, and rising interest rates — have together become the “standard account” of home foreclosure.
Policymakers and scholars may be surprised to learn that even in the midst of this spike, one of the largest causes of home foreclosures was none of the above. We studied homeowners going through foreclosure in four states and found that medical crises contribute to half of all home foreclosure filings. If these patterns hold nationwide, medical causes may put as many as 1.5 million Americans in jeopardy of losing their homes each year.
Half of all respondents (49%) indicated that their foreclosure was caused in part by a medical problem, including illness or injuries (32%), unmanageable medical bills (23%), lost work due to a medical problem (27%), or caring for sick family members (14%). We also examined objective indicia of medical disruptions in the previous two years, including those respondents paying more than $2,000 of medical bills out of pocket (37%), those losing two or more weeks of work because of injury or illness (30%), those currently disabled and unable to work (8%), and those who used their home equity to pay medical bills (13%). Altogether, we found that about 7 in 10 of our respondents either self-reported a medical cause of foreclosure, or experienced one of these indicia of medical disruptions in the years before foreclosure.
Altogether, these findings suggest that the standard account of mortgage foreclosure is missing a large portion of the story. Mortgage foreclosures are not just the results of bad loans, bad properties, or bad borrowers. Instead, many mortgage foreclosures are the result of unpredictable medical disruptions that impact both the incomes and the expenses of family finances.
http://works.bepress.com/cgi/viewcontent.cgi?article=1001&context=christopher_robertson

The authors of this study indicate that the results are only preliminary, primarily due to limitations in methodology. Although we cannot quantify precisely the extent of the problem, the qualitative conclusion is certainly valid. Just as with personal bankruptcy, medical debt in both insured and uninsured individuals contributes to loss of homes through mortgage foreclosures.
This past month has demonstrated to all of us the importance, for our entire economy, of establishing policies that would ensure that default of home mortgages would be a relatively rare event. Eliminating medical debt certainly would not prevent all home loan defaults, but it would prevent a great many of them, even if we cannot yet precisely quantify how many.
Simply changing to a more efficient, single payer national health program would be one of the least expensive measures that we could undertake to help reduce home mortgage foreclosures.
Almost everyone would like to see measures that would reduce the negative impact of our financial crisis that was precipitated by mortgage-bcked securities. Some of us also would like to see that everyone has affordable access to health care, even if it is only an additional benefit of a financial rescue package.

Medical causes of home mortgage foreclosures

Get Sick, Get Out: The Medical Causes of Home Mortgage Foreclosures

By Christopher Tarver Robertson, Richard Egelhof, & Michael Hoke
Health Matrix
Vol. 18:65 2008

In recent years, there has been national alarm about the rising rate of home foreclosures, which now strike one in every 92 households in America, and which contribute to even broader macroeconomic effects.

These factors — loose lending, irresponsible borrowers, a flat real estate market, and rising interest rates — have together become the “standard account” of home foreclosure.

Policymakers and scholars may be surprised to learn that even in the midst of this spike, one of the largest causes of home foreclosures was none of the above. We studied homeowners going through foreclosure in four states and found that medical crises contribute to half of all home foreclosure filings. If these patterns hold nationwide, medical causes may put as many as 1.5 million Americans in jeopardy of losing their homes each year.

Half of all respondents (49%) indicated that their foreclosure was caused in part by a medical problem, including illness or injuries (32%), unmanageable medical bills (23%), lost work due to a medical problem (27%), or caring for sick family members (14%). We also examined objective indicia of medical disruptions in the previous two years, including those respondents paying more than $2,000 of medical bills out of pocket (37%), those losing two or more weeks of work because of injury or illness (30%), those currently disabled and unable to work (8%), and those who used their home equity to pay medical bills (13%). Altogether, we found that about 7 in 10 of our respondents either self-reported a medical cause of foreclosure, or experienced one of these indicia of medical disruptions in the years before foreclosure.

Altogether, these findings suggest that the standard account of mortgage foreclosure is missing a large portion of the story. Mortgage foreclosures are not just the results of bad loans, bad properties, or bad borrowers. Instead, many mortgage foreclosures are the result of unpredictable medical disruptions that impact both the incomes and the expenses of family finances.

http://works.bepress.com/cgi/viewcontent.cgi?article=1001&context=christopher_robertson

Comment:

By Don McCanne, MD

The authors of this study indicate that the results are only preliminary, primarily due to limitations in methodology. Although we cannot quantify precisely the extent of the problem, the qualitative conclusion is certainly valid. Just as with personal bankruptcy, medical debt in both insured and uninsured individuals contributes to loss of homes through mortgage foreclosures.

This past month has demonstrated to all of us the importance, for our entire economy, of establishing policies that would ensure that default of home mortgages would be a relatively rare event. Eliminating medical debt certainly would not prevent all home loan defaults, but it would prevent a great many of them, even if we cannot yet precisely quantify how many.

Simply changing to a more efficient, single payer national health program would be one of the least expensive measures that we could undertake to help reduce home mortgage foreclosures.

Almost everyone would like to see measures that would reduce the negative impact of our financial crisis that was precipitated by mortgage-bcked securities. Some of us also would like to see that everyone has affordable access to health care, even if it is only an additional benefit of a financial rescue package.

Doctors to candidates: enact single-payer health reform

Embargoed until:
Oct. 6, 2008
5:30 p.m. EDT

Contacts:
Steffie Woolhandler, M.D.
Oliver Fein, M.D.
Mark Almberg, PNHP, (312) 782-6006, mark@pnhp.org

Over 5,000 U.S. physicians have signed an open letter calling on the candidates for president and Congress “to stand up for the health of the American people and implement a nonprofit, single-payer national health insurance system.”

Noting that the nation’s private-insurance-based model is failing by denying needed medical care to millions, wasting resources and driving up costs, the doctors say that a publicly financed system is “the sole hope for affordable, comprehensive coverage.”

“A single-payer health system could realize administrative savings of more than $300 billion annually — enough to cover the uninsured and to eliminate co-payments and deductibles for all Americans,” they write, adding that it would also slow cost increases.

Dr. Oliver Fein, a professor of clinical medicine and public health at Weill Cornell Medical College in New York and a signer of the letter, said today, “With the sudden economic downturn, more people than ever before are worried about how to pay for health care. A single-payer system — an improved Medicare for all — would lift those worries, provide care to all who need it and require no new money. It’s the only morally and fiscally responsible approach to take.”

In their letter, the physicians express disappointment that most U.S. political leaders still cling to the private health insurance industry model of financing care and “seem intent on reprising failed schemes from the past” like mandates or tax incentives.

“The incremental changes suggested by most Democrats cannot solve our problems; further pursuit of market-based strategies, as advocated by Republicans, will exacerbate them,” they say. “What needs to be changed is the system itself.”

The letter is being circulated by Physicians for a National Health Program, a single-payer advocacy group. Fein is the group’s president-elect. Excerpts from the appeal are being published in full-page advertisements in the Oct. 13 editions of The New Yorker and The Nation magazines, which arrive on newsstands this week.

Signers of the letter include some of the most prominent figures in U.S. medicine, including leaders of professional societies in internal medicine, pediatrics, family medicine, psychiatry and public health. Among them are Marcia Angell, M.D., senior lecturer at Harvard Medical School and past editor-in-chief of the New England Journal of Medicine, and Bernard Lown, M.D., professor of cardiology emeritus at Harvard and Nobel laureate.

Dr. Steffie Woolhandler, an associate professor of medicine at Harvard Medical School and a co-author of the letter, said, “Physicians have a responsibility to get to the root of a patient’s medical complaint, to make a diagnosis based on evidence. Only then can we confidently prescribe a cure, rather than offer a consoling placebo.

“Given the repeated failure of incremental reforms like the one under way in Massachusetts, which is already facing cost overruns and leaving many residents uncovered, and given the increasingly obvious failure of unfettered markets, it’s clear that neither of these traditional prescriptions for reform will work,” she said. “What’s needed instead is the only treatment that has proven its effectiveness — a single-payer plan.”

The letter’s release follows a survey in the Annals of Internal Medicine this spring that shows 59 percent of U.S. physicians support national health insurance, a jump of 10 percentage points from five years ago

Single-payer plans typically involve a single, publicly administered social insurance fund that guarantees health care coverage for everyone, much like Medicare presently does for seniors. Patients go the doctors and hospitals of their choice; health care providers largely remain private. Private health insurers are eliminated or their role is substantially reduced.

A bill in Congress, the U.S. National Health Insurance Act, H.R. 676, embodies the single-payer model. Sponsored by Rep. John Conyers Jr. (D-Mich.), it currently has over 90 co-sponsors, more than any other health reform proposal.

The ads in The New Yorker and The Nation announcing the physicians’ open letter feature Nicole Hollander’s cartoon character Sylvia writing a letter to Congress.

The full text and initiating signers of the “Open Letter to the Candidates on Single Payer Health Reform” are available at www.pnhp.org/letter/.

The complete list of signers is available at www.pnhp.org/letter/signers/.

A PDF of the full-page, four-color ad that is appearing in the pages of The New Yorker and The Nation can be found at www.pnhp.org/ad.

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Physicians for a National Health Program, a membership organization of over 15,000 physicians, supports a single-payer national health insurance program. To contact a physician-spokesperson in your area, call (312) 782-6006 or visit www.pnhp.org/stateactions.