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Commonwealth Fund on candidates' proposals

Commonwealth Fund on candidates' proposals

The 2008 Presidential Candidates' Health Reform Proposals: Choices for America

By Sara R. Collins, Jennifer L. Nicholson, Sheila D. Rustgi, and Karen Davis
The Commonwealth Fund
October 2008

The presidential candidates’ health care reform proposals offer fundamentally different visions of the future of health insurance in the United States. Both candidates propose reforms in which the health system would continue to be structured around private insurance markets, with a supporting role played by public insurance programs. But their plans diverge significantly on the way a reformed system should operate.

McCain would change the tax code to encourage people to buy coverage through the individual insurance market and effectively loosen state rules governing the sale of insurance by allowing people to buy policies across state lines. Obama would encourage the continuing participation of employers in the health insurance system, expand eligibility for Medicaid and the State Children’s Health Insurance Program (SCHIP), and create a new insurance market “exchange” — with consumer protections, choice of public and private health plans, and income-based premium subsidies — that would largely replace the individual market.

According to one estimate… in 10 years McCain’s proposal would reduce the number of people who are uninsured by 2 million out of a projected 67 million. Obama’s plan would reduce the number of uninsured people by 34 million in 10 years.

Executive Summary:
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=707948

Full Report:
http://www.commonwealthfund.org/usr_doc/Collins_presidentialcandhltreformprop_1179.pdf?section=4039

Comment:

By Don McCanne, MD

So these are the “choices for America.” We currently have 46 million people who are uninsured. After ten years of McCain’s plan, we would have 65 million uninsured, but ten years of Obama’s plan would leave only 33 million people without insurance. Only 33 million!?

The phrase, “both candidates propose reforms in which the health system would continue to be structured around private insurance markets,” should set off deafening alarm bells and sirens. Schemes designed around U.S.-style private insurance markets can never achieve our goal of affordable health care for everyone.

Some say that we could do it if we required everyone to participate through individual and employer mandates. With an average family policy now priced at $12,600, not including deductibles and copayments, it is unrealistic to require individuals and small businesses to purchase coverage and health care with money that they do not have. Even Sen. McCain understands that the government is going to have to ante up, but that alone is still not enough since his proposal would leave 65 million uninsured.

With a national health expenditure of $2.4 trillion, we already have enough to fund a universal risk pool that would pay for all necessary services for absolutely everyone, but only if we were to do it through a single payer national health program. If we were to attempt it using private plans that were truly effective in preventing financial hardship, and that had government subsidies that would make the premiums affordable, the inefficiencies would add close to half a trillion dollars to our national health care bill, and too many individuals would still fall through the cracks.

So what about choices for America? Which candidate? Or which health reform proposal?

In a September 30 interview with the Des Moines Register editorial board, Sen. McCain provides us with some insight to these choices: “I’ve always been a free enterprise person who thinks that families make the best choices for themselves and their future. That’s a dramatically different philosophy than my Democrat friends, in my view, who think that government is the answer. Sen. Obama wants to create a huge health care bureaucracy for America.”

Sen. Obama has said that, if starting from scratch, we would create a single payer system. That’s the health reform proposal that Americans should choose if we’re really serious about including absolutely everyone in an affordable program. And which candidate do you think would approve this message?

Video of Sen. McCain’s Des Moines Register interview:
http://www.desmoinesregister.com/apps/pbcs.dll/article?AID=/20080930/NEWS09/80930049

Private Health Insurance at Work: Hassling Cystic Fibrosis Patients

Cory Heidelberger
Madville Times, South Dakota
07/19/2008

Let’s put health care in a real, personal context:

Deron Arnold, brother of one of my wife’s old school friends, is 36, a pathologist in Minnesota. He has a wife, twin 3-year-old sons… and cystic fibrosis. That means, among other things, his body overproduces mucus, making it hard for his lungs to work.

Deron pays Blue Cross Blue Shield for his health coverage. Yesterday he got a letter from the Blue Cross Blue Shield saying that as of October 28, the company will no longer cover expenses at Fairview University Hospital in Minneapolis, where Deron plans to have his transplant. As of August 23, Blue Cross Blue Shield will stop covering physician expense at that hospital.

Deron, understandably, is in shock:

The implications of this are obviously potentially huge. I spent much of the morning on the phone in heated conversations with employees who knew about as much about it as I did. And had as much power and authority to change it. One Blue Cross employee even suggested transferring my care to Loyola…the nearest provider who could provide the same level of benefits. (For those of you who don’t know, Loyola is in Chicago.) [Deron Arnold, “In Shock,” Here in Time, 2008.07.18]

No accountability, no answers… doesn’t sound like a very effective health coverage system to me.

So now, because of an inexplicable business decision, a man with an incurable, terminal illness, who could get a phone call at any moment saying, “We have a lung; get to the hospital now,” has to devote precious time and energy to figuring out whether he can even afford to have his hospital do the operation.

Things like this don’t happen in Canada.

Another example: another friend of ours with cystic fibrosis couldn’t get her private insurer to cover the treatments that can keep cystic fibrosis in check while she attended grad school. She thus had to do what some of my readers tell me to do: leave the country. She went to Canada, to Regent College in Vancouver, British Columbia. Just like us during our stay in Canada, she paid her taxes and national health insurance premiums. Canada didn’t kick her out, or tell her she had to go to Calgary instead of Vancouver. Our friend got her treatment, and her education… in Canada.

Cystic fibrosis is hard enough. Private insurers shouldn’t make it harder. Countries with national health insurance don’t make it harder.

Commonwealth Fund on candidates’ proposals

The 2008 Presidential Candidates’ Health Reform Proposals: Choices for America

By Sara R. Collins, Jennifer L. Nicholson, Sheila D. Rustgi, and Karen Davis
The Commonwealth Fund
October 2008

The presidential candidates’ health care reform proposals offer fundamentally different visions of the future of health insurance in the United States. Both candidates propose reforms in which the health system would continue to be structured around private insurance markets, with a supporting role played by public insurance programs. But their plans diverge significantly on the way a reformed system should operate.

McCain would change the tax code to encourage people to buy coverage through the individual insurance market and effectively loosen state rules governing the sale of insurance by allowing people to buy policies across state lines. Obama would encourage the continuing participation of employers in the health insurance system, expand eligibility for Medicaid and the State Children’s Health Insurance Program (SCHIP), and create a new insurance market “exchange” — with consumer protections, choice of public and private health plans, and income-based premium subsidies — that would largely replace the individual market.

According to one estimate… in 10 years McCain’s proposal would reduce the number of people who are uninsured by 2 million out of a projected 67 million. Obama’s plan would reduce the number of uninsured people by 34 million in 10 years.

Executive Summary:
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=707948

Full Report:
http://www.commonwealthfund.org/usr_doc/Collins_presidentialcandhltreformprop_1179.pdf?section=4039

Comment:

By Don McCanne, MD

So these are the “choices for America.” We currently have 46 million people who are uninsured. After ten years of McCain’s plan, we would have 65 million uninsured, but ten years of Obama’s plan would leave only 33 million people without insurance. Only 33 million!?

The phrase, “both candidates propose reforms in which the health system would continue to be structured around private insurance markets,” should set off deafening alarm bells and sirens. Schemes designed around U.S.-style private insurance markets can never achieve our goal of affordable health care for everyone.

Some say that we could do it if we required everyone to participate through individual and employer mandates. With an average family policy now priced at $12,600, not including deductibles and copayments, it is unrealistic to require individuals and small businesses to purchase coverage and health care with money that they do not have. Even Sen. McCain understands that the government is going to have to ante up, but that alone is still not enough since his proposal would leave 65 million uninsured.

With a national health expenditure of $2.4 trillion, we already have enough to fund a universal risk pool that would pay for all necessary services for absolutely everyone, but only if we were to do it through a single payer national health program. If we were to attempt it using private plans that were truly effective in preventing financial hardship, and that had government subsidies that would make the premiums affordable, the inefficiencies would add close to half a trillion dollars to our national health care bill, and too many individuals would still fall through the cracks.

So what about choices for America? Which candidate? Or which health reform proposal?

In a September 30 interview with the Des Moines Register editorial board, Sen. McCain provides us with some insight to these choices: “I’ve always been a free enterprise person who thinks that families make the best choices for themselves and their future. That’s a dramatically different philosophy than my Democrat friends, in my view, who think that government is the answer. Sen. Obama wants to create a huge health care bureaucracy for America.”

Sen. Obama has said that, if starting from scratch, we would create a single payer system. That’s the health reform proposal that Americans should choose if we’re really serious about including absolutely everyone in an affordable program. And which candidate do you think would approve this message?

Video of Sen. McCain’s Des Moines Register interview:
http://www.desmoinesregister.com/apps/pbcs.dll/article?AID=/20080930/NEWS09/80930049

Gov. Schwarzenegger again vetoes single payer bill

Schwarzenegger vetoes universal health care

By Aurelio Rojas
The Sacramento Bee
September 30, 2008
For the second time in three years, Gov. Arnold Schwarzenegger on Tuesday vetoed legislation that would have established a government-run universal health care system.
Senate Bill 840 by Sen. Sheila Kuehl, D-Santa Monica, would have set up a single-payer system in which the state would assume the role that private insurance companies now play.
http://www.sacbee.com/111/story/1278412.html

And…

GOVERNOR VETOES MANY HEALTH CONSUMER BILLS

By Anthony Wright
Health Access Weblog
October 1, 2008
Some of the bills vetoed:
SB 840 (Kuehl) SINGLE PAYER: Would establish a process to create a single-payer health care system in California that would enable all residents to have health coverage.
SB 973 (Simitian) PUBLIC INSURER: Would create a statewide public insurer, connecting existing regional, county-based health care plans, to compete with private health care plans and provide consumers more affordable coverage choices.
SB 1440 (Kuehl) CAPPING ADMINISTRATION AND PROFIT: Would set a minimum medical loss ratio — requiring every insurer to spend at least 85 percent of premiums on patient care.
AB 2 (Dymally) HIGH-RISK POOL: Would have reformed the Managed Risk Medical Insurance Program (MRMIP), which provides coverage for “un-insureables” who have “pre-existing conditions.” Efforts would make the high risk pool more affordable and available and eliminate the annual $75,000 cap on benefits.
AB 1945 (De La Torre) INDEPENDENT REVIEW: Would establish an independent review process if an insurer wants to rescind coverage, and raises the standard in existing law so that coverage can only be rescinded if a consumer willfully misrepresents his health history.
AB 1887 (Beall) MENTAL HEALTH PARITY: Would require health plans to provide coverage for all diagnosable mental illnesses.
AB 1962 (De La Torre) MATERNITY COVERAGE: Would require all individual insurance policies to cover maternity services.
http://www.health-access.org/blogger.html

This was Gov. Schwarzenegger’s year for comprehensive healthcare reform in California. By the end of this year all Californians were going to have affordable health care.
He previously vetoed Sen. Kuehl’s single payer legislation, dismissing it as socialized medicine. He then embarked on a “post partisan” process of bringing all stakeholders together to create a comprehensive model of reform with “shared responsibility.” The extensive negotiations resulted in a legislative product that neither the Republicans not the Democrats could support, and it died in committee.
Many legislators then wanted to separate out some of the beneficial features of the package and introduce them as individual bills. Gov. Schwarzenegger had said that the delicate compromises necessitated by the political process required that the legislators accept either the entire package or none of it. He stated that he would veto individual measures because they served some interests and not others. He has proven that, in this matter at least, he is a man of his word.
He was given a second opportunity to approve a plan that would accomplish his stated goal: affordable health care for everyone. He once again vetoed Sheila Kuehl’s single payer bill, placing his personal ideology above the health of the people.
He did sign a bill requiring restaurant chains to post the number of calories of food items on their menus. Not much for the Year of Health Reform.

Gov. Schwarzenegger again vetoes single payer bill

Schwarzenegger vetoes universal health care

By Aurelio Rojas
The Sacramento Bee
September 30, 2008

For the second time in three years, Gov. Arnold Schwarzenegger on Tuesday vetoed legislation that would have established a government-run universal health care system.

Senate Bill 840 by Sen. Sheila Kuehl, D-Santa Monica, would have set up a single-payer system in which the state would assume the role that private insurance companies now play.

http://www.sacbee.com/111/story/1278412.html

And…

GOVERNOR VETOES MANY HEALTH CONSUMER BILLS

By Anthony Wright
Health Access Weblog
October 1, 2008

Some of the bills vetoed:

SB 840 (Kuehl) SINGLE PAYER: Would establish a process to create a single-payer health care system in California that would enable all residents to have health coverage.

SB 973 (Simitian) PUBLIC INSURER: Would create a statewide public insurer, connecting existing regional, county-based health care plans, to compete with private health care plans and provide consumers more affordable coverage choices.

SB 1440 (Kuehl) CAPPING ADMINISTRATION AND PROFIT: Would set a minimum medical loss ratio — requiring every insurer to spend at least 85 percent of premiums on patient care.

AB 2 (Dymally) HIGH-RISK POOL: Would have reformed the Managed Risk Medical Insurance Program (MRMIP), which provides coverage for “un-insureables” who have “pre-existing conditions.” Efforts would make the high risk pool more affordable and available and eliminate the annual $75,000 cap on benefits.

AB 1945 (De La Torre) INDEPENDENT REVIEW: Would establish an independent review process if an insurer wants to rescind coverage, and raises the standard in existing law so that coverage can only be rescinded if a consumer willfully misrepresents his health history.

AB 1887 (Beall) MENTAL HEALTH PARITY: Would require health plans to provide coverage for all diagnosable mental illnesses.

AB 1962 (De La Torre) MATERNITY COVERAGE: Would require all individual insurance policies to cover maternity services.

http://www.health-access.org/blogger.html

Comment:

By Don McCanne, MD

This was Gov. Schwarzenegger’s year for comprehensive healthcare reform in California. By the end of this year all Californians were going to have affordable health care.

He previously vetoed Sen. Kuehl’s single payer legislation, dismissing it as socialized medicine. He then embarked on a “post partisan” process of bringing all stakeholders together to create a comprehensive model of reform with “shared responsibility.” The extensive negotiations resulted in a legislative product that neither the Republicans not the Democrats could support, and it died in committee.

Many legislators then wanted to separate out some of the beneficial features of the package and introduce them as individual bills. Gov. Schwarzenegger had said that the delicate compromises necessitated by the political process required that the legislators accept either the entire package or none of it. He stated that he would veto individual measures because they served some interests and not others. He has proven that, in this matter at least, he is a man of his word.

He was given a second opportunity to approve a plan that would accomplish his stated goal: affordable health care for everyone. He once again vetoed Sheila Kuehl’s single payer bill, placing his personal ideology above the health of the people.

He did sign a bill requiring restaurant chains to post the number of calories of food items on their menus. Not much for the Year of Health Reform.

MS Patient Falls Into American Insurance Gap

By Joanne Silberner
National Public Radio
July 24, 2008

Just outside the storybook English village of Buckland, 55-year-old Briton Linda Oatley is getting ready for something she considers torture.

Oatley is in a mirror-lined room filled with cheerful blue workout mats, big red and orange exercise balls, weight racks and other devices. Wheelchairs and canes are lined up along the walls.

She was diagnosed with multiple sclerosis in 1999, and she now comes to the Chilterns MS Centre once a week for physical therapy.

On the day of our visit, she’s in a group class. She’s lying on her back, with an orange exercise ball under her knees. Her physical therapist wants Oatley to keep the ball still while she lifts her right leg off.

She groans as she lifts her leg off the large ball.

“It’s hard for me to do; it stretches me because this is where my problem is, in the hip, and it hurts to do this action,” she says, gritting her teeth. “It’s a tough exercise for me.”

Oatley’s Medical Bills

Oatley pays the equivalent of $30 a week for her physical therapy sessions at the center. And it’s a donation, not a fee. The Chilterns MS Centre is run by a charity, with some government funding.

But Oatley has never seen a bill for the rest of her medical care, such as her prescription drugs, doctors’ appointments, MRIs and lab tests. That care is paid for by Britain’s National Health Service. It’s a government-run system, funded by income taxes, that provides health care to all residents.

After Oatley’s workout session, she grabs a cup of tea. Sitting on a bench outside the center, she describes what happened to her nearly 10 years ago.

“I felt these odd sensations, in both legs actually,” she recalls. “This is weird, but it felt warm on the inside, and when I would take a bath or a shower, the hot water felt cold and the cold water felt hot.”

She made an appointment with her general practitioner, who promptly referred her to a specialist.

“He recommended, that very day, an MRI scan, a pulmonary function test, an X-ray and a blood test,” she says. “And so all that was done that afternoon, and I went back the very next week for the results.”

The tests showed multiple sclerosis, a chronic, degenerative disease that affects the central nervous system.

A Delay In Treatment

When Oatley was first diagnosed, there were several new drugs available in the United States that were thought to slow or stop the disease, at a cost of thousands of dollars per month.

But in the United Kingdom, the National Health Service was waiting for more data on the effectiveness of the medications. So Oatley paid for one of the drugs, Copaxone, herself at first. Then the NHS approved the drug for her type of MS.

At that point, the NHS gave her Copaxone free and delivered her prescription to her home every month.

“And they gave me my money back,” she adds. “So they reimbursed me the 5,000 pounds I had spent. How cool is that? I thought I’d died and gone to heaven.”

Medically, she’s happy with what she’s getting now: twice-yearly appointments with a neurologist and prescription drugs delivered free to her home.

And if she has a flare-up, she can go to the doctor without a wait.

Her only gripe is that the NHS provides only a limited amount of physical therapy, and that’s why she’s at the Chilterns MS Centre.

Waiting For Help

Oatley’s situation is a stark contrast to that of Americans diagnosed with MS who have limited or no health insurance. They have to wait more than two years before Medicare, the federal health insurance plan, will pay for treatment. When Congress and the president expanded Social Security and Medicare to the disabled in 1973, they put a two-year waiting period onto Medicare to keep costs down.

Oatley is appalled to hear this. It would be overwhelming, she says, to be diagnosed with such a potentially devastating disease — and then to be left on your own to figure out how to pay for medical care.

“I wouldn’t know where to start,” she says. “I would think it would be just so mentally debilitating. I think I would have topped myself. That’s a euphemism for killing yourself.”

She asks, what do Americans in that situation do?

Those without insurance often find themselves in a two-year waiting period.

Jeffrey Rubin, a 41-year-old living in northeast Philadelphia, was diagnosed with MS in 2006. Two years later, he spends most of his days in a rented house, taking care of his 4-year-old daughter, Taryn.

He and Taryn read together and practice numbers and the alphabet, until his three other children come home. But there are no trips to the park. Even with a cane, Rubin can walk only half a block.

Rubin’s Medical Bills

Rubin’s medicines are lined up on a high shelf in his kitchen.

He takes about nine medications for his disease. Every day he injects Copaxone, which slows down the course of the disease. It costs about $2,000 a month. He takes a twice-a-day pill for his back. That prescription costs more than $200 a month. A drug for migraines costs $400 a month. A lot of the medicines make him feel even more tired, so he takes one to help keep him awake — that costs $1,000 for a month’s supply.

When Rubin was in his late 30s, he felt pretty comfortable with his life. He supervised quality control at a medical packaging company. He had health insurance. His wife, Kristin, was a homemaker, and they had bought a house a few blocks from where he went to high school.

He had his first MS attack Memorial Day weekend in 2006. He was working a midnight shift, when suddenly a big black circle appeared in the middle of his visual field. The left side of his body went numb; the right side was riddled with pain. He went to the hospital, and while he recovered somewhat from the attack, he was no longer strong enough to work.

He eventually lost his job, and he couldn’t pay for his health insurance on his own.

He recalls thinking, “I don’t have the money. I’m already paying, of course, my mortgage, utilities. What am I going to do? I don’t know what to do now. Everything just came closing down.”

Seeking Assistance

He asked for money from his elderly parents and borrowed money from friends. Neighbors and strangers dropped off food. His doctors gave him drug samples, but not enough. He came up with strategies to make his drugs last longer, but that worried him.

“If I don’t take all my medications, who knows what’s going to happen?” Several studies have shown that stress can make MS worse.

Rubin did get Medicaid, state medical assistance, but none of his doctors belonged to the program. When he went to fill his prescriptions, the pharmacies said he wasn’t covered. He stopped paying his mortgage so he could pay some of his medical bills. Then the mortgage company claimed his house.

Finally, he declared bankruptcy.

After a fight with the Social Security Administration and a letter from one of his senators, Rubin finally qualified for government disability payments from Social Security. But he still isn’t eligible for government health insurance through Medicare.

Rubin is one of 250,000 people with disabling conditions such as MS, cancer or schizophrenia who are stuck in this waiting period without insurance, according to an estimate from the Commonwealth Fund.

Recently, Kristin Rubin got a job with the charter school the kids attend, and the family now has health insurance through her job. But the insurance comes with co-payments, and since Jeff gets a lot of care, the co-payments add up.

He admits he once contemplated suicide — as a way to ease the financial burden on his wife.

Tallying The Scorecard

So the scorecard comes to this.

Linda Oatley of Buckland, England, had several months’ delay in getting coverage for a new treatment. She also has to pay a small fee for weekly physical therapy. Overall, she’s happy with the National Health Service.

“In the end, if you ask the right questions, go to the right places, you can get the care you need from the get-go,” she says.

And the scorecard for Jeff Rubin? A year and a half of cutting drug dosages, a repossessed house and bankruptcy.

A few years ago, he wouldn’t have supported a British-style system, with its slower drug approvals and limited ability to pick your own doctors.

Now, he feels differently. He says his healthy friends might not agree, but the free care from the start that Linda Oatley got and the ability to focus on his illness and not his finances sound pretty good.

“Unless you fall into this type of situation, you just don’t understand it,” he says.

Rubin’s two-year waiting period is up in December, at which point he’ll receive health coverage from Medicare.

Produced by Vikki Valentine

Cognitive dissonance in U.S. health care

By Maggie Mahar
THCB (The Health Care Blog)
September 19, 2008

http://www.thehealthcareblog.com/the_health_care_blog/2008/09/cognitive-disso.html

Princeton economist Uwe Reinhardt is well known as one of the bluntest–and wittiest–critics of U.S. Healthcare. Last week, we both spoke at a conference organized by Princeton’s Policy Research Institute on “Access to Universal Health Care: New Jersey, the Nation and the Globe. As usual, I learned something from Professor Reinhardt.

Earlier this year, New Jersey Governor Jon Corzine received a somewhat startling letter from Princeton economist Uwe Reinhardt. The missive was appended to a report from the “New Jersey Commission on Rationalizing Health Care Resources,” a Commission that Corzine had asked Reinhardt to chair.

In the letter, Reinhardt expresses “some personal observations on the inconsistent expectations Americans have of their health system,” describing “these inconsistencies” as “a form of cognitive dissonance.” Reinhardt goes on to explain that, in his view, these inconsistencies reflect “certain deeply ingrained traits in American culture that stand in the way of a rational health care system.”

He concludes: “In short, Governor Corzine, in my professional view, the extraordinarily expensive, often excellent just as often dysfunctional, confused and confusing American health system is a faithful reflection of the minds and souls making up America’s body politic.”

After reading the letter, Governor Corzine had one question: “You’re not going to publish this in the report, are you?”

In fact, the letter did appear at the front of the report. And last week, at a conference on “Access to Universal Health Care: New Jersey, the Nation and the Globe” sponsored by Princeton’s Policy Research Institute, Reinhardt circulated said letter. It served as a good companion to Reinhardt’s speech, which compared what we euphemistically call our health care “system” to systems in other parts of the world.

Reinhardt began his talk by considering the fact that, in the U.S. insurance is often tied to one’s job. “No one–in his wildest dreams–Drunk!!–would design a health care system based on employment,” Reinhardt declared, barely containing his outrage at such a truly bone-headed idea. After all, the unintended–but inevitable–consequence of an employer-based system is this: if you lose your job, you also lose your health insurance–at exactly the worst possible time.

In his letter to Corzine, the Princeton economist elaborates: “the reluctance of Americans to countenance government financing of health care outright…has led them instead to prefer inherently temporary private health insurance tied to a particular job with a particular company (and then to look helplessly for rescue by federal or state governments, when, in their 50s and early 60s, they may find themselves structured out of their jobs and the health insurance that came with it and unable to afford coverage in the private insurance market for individuals). When,” he asks, “will it dawn on the American voter that, in an age of fierce global competition and ever novel disruptive technology, any individual American corporation is a fragile institution and, at best, a highly unreliable source of health insurance…?” This is especially true for those forced into early retirement.

Reinhardt is right. A great many Americans do not want “Big Government” interfering with their health care. Unless they lose their insurance and then they expect “their government” to bail them out.

In theory, our government will come to your rescue if you’re poor enough, offering Medicaid and SCHIP to millions of families and children who simply do not have the money to purchase their own health insurance. We take care of our poor–or at least that is what we like to tell ourselves.

In fact, Reinhardt points out, a 2008 brief by the National Institute for Health Care Management Foundation reveals that 12 million Americans who are uninsured are eligible for public programs–but are not enrolled. Of these, more than half are children.

Why aren’t they enrolled? In many cases, the application process is filled with roadblocks which can include 14-page application forms.

“And this is deliberate,” Reinhardt added, quoting a Harvard economist who has suggested that “the way to manage entitlement programs is to harass people.”

The problem, Reinhardt explains in his letter to Corzine, is that we are of two minds about providing care for the poor. While “many Americans do believe that health care is a social good that should be available to all socio-economic classes on roughly equal terms…just as many other Americans believe that health care is essentially a private consumer good–like clothes, food and shelter–whose procurement and financing is primarily the individual’s responsibility, and they routinely (and quite incorrectly) deride the former school of thought as ‘socialists.'”

The way we pay health care providers who take Medicaid patients illustrates just how conflicted we are. Doctors who treat these patients are paid much less then they would be if they were treading Medicare patients. In other words “Americans tell providers that the value of their work is lower when applied to uninsured patients or to patients insured by Medicaid.” Reinhardt observes. As a result, Medicaid patients often have difficulty finding a provider. A 2007 study published by the Commonwealth Fund reports that when Community Health Centers (CHCs) try to refer Medicaid patients to a specialist for “high tech services,” 16 percent of those patients “never” or “rarely” are able to obtain access. When it comes to Medicaid patients referred by CHCs for hospital admission, nearly 12 percent find the door blocked.

This is the legacy of racism. As Henry J. Aaron and Jeanne M. Lambrew point out in Reforming Medicare: Options, Tradeoffs and Opportunities, Southern Congressmen refused to vote for the 1965 legislation that created both Medicare and Medicaid if physicians and hospitals were going to be paid as much to treat the poor as they were paid when treating the elderly. These Congressmen wanted to preserve medical apartheid. (Most Southerners over the age of 65 were white: a combination of poverty and a lack of healthcare ensured that few African-Americans lived that long.) Ultimately President Johnson had no choice but to cave to the legislators’ demands. What is both shameful and startling is that forty-three years later, this wrong still has not been righted.

But, as Reinhardt notes in his letter, our feelings are confused on this issue. Thus, even while signally to providers that we don’t value their work as highly when they are treating the poor, we don’t want to make the distinction explicit.

“A ‘rational’ health system responsive to this powerful economic signal [of lower pay for Medicaid providers] would be openly two-tiered,” Reinhardt writes in his letter to Corzine, “with bare-boned facilities devoted strictly to Medicaid patients and the uninsured…and much more luxurious, better equipped and better staffed facilities for commercially insured patients whose insurers are willing to pay higher fees.”

But in the U.S. a “citizenry which signals its preference for a class-based health system through the payment mechanism, soothes its conscience by holding physicians and hospitals to strictly egalitarian standards when it comes to the treatment of patients of all socio-economic classes.”

Since this is an unfunded mandate, many doctors reject all Medicaid patients; others take only a few. Hospitals, too, have found ways to avoid charity cases, “stabilizing the patient” who stumbles into the ER, as the law demands, but refusing to admit him as an outpatient so that he can receive the services the ER doctor recommends.

In other countries, where there is widespread agreement that equal healthcare for all is a right, our sharply tiered system is viewed as unacceptable. “If you want to kill a health care proposal, whether in Taiwan or Germany” Reinhardt told his audience last week, “all you need to say is, ‘if you do this, you’ll wind up with the U.S. system.’ It’s amazing,” he mused, “how they manage to avoid adopting ‘the best health care system in the world.'”

Why don’t we just raise fees for Medicaid providers? “We would have to pay higher taxes,” says Reinhardt. “We can’t have the Chinese temporarily pay for it” (the way China and other countries fund so much of our deficit spending by buying our bonds.)

When we try to think about health care markets and regulation, we also experience “cognitive dissonance.” For many Americans, Reinhardt notes, “it is an article of faith that private commercial markets are inherently more efficient than government will ever be. At the same time…the same Americans seem troubled and unwilling to accept for health care–and now even for mortgages–the harsh verdicts of the ‘free markets’ among which are:

(1) That a market allocates resources not to individual most in need of them, but to those who have the most money to bid high prices for them.

(2) That individuals or institutions, including hospitals, unable to fend for themselves in the competitive market’s free-for-all–among them hospitals in low-income neighborhoods–should be allowed to wither away; and

(3) That in the free-for-all of the marketplace, not only the quick-witted and better-informed, but also the morally more flexible participants often will take advantage of less quick-witted and less well-informed market participants who are naive enough to trust the morally flexible.”

Free market enthusiasts often speak as if “the market” is a benign intelligence, hovering over the marketplace to ensure that gains and losses are fairly distributed. In fact, the market is not fair–nor is it unfair. It is amoral, totally indifferent to whether individuals are getting their just desserts. The most virtuous man may lose the roll of the dice by investing too early, or too late. Often he is duped by those Reinhardt describes as “morally flexible,” truly believing that his mortgage broker has his best interests at heart. When it comes to healthcare, a seven-year-old who needs a $100,000 cancer drug may not get it; if an 89-year-old has the cash, the drug is his.

Because most Americans are unwilling to accept what Reinhardt rightly describes as “the harsh verdicts of the market,” they believe that the government should protect the weak. On the other hand, they don’t want the government to disrupt free markets which, they insist, are “efficient.” The result, says Reinhardt, is “a bewildering system of half-hearted competition and half-hearted regulation” of health care.

When it comes to health insurance, Reinhardt writes, once again “confusion reigns.” On the one hand, “many Americans decry as outright un-American the idea of mandating the individual to procure adequate health insurance coverage for at least catastrophically expensive care.” Those same youthful libertarians, however, would “bristle at the idea that…a hospital should have the right to withhold from them for want of ability to pay, costly life-saving medical interventions, should [they] be seriously injured or become critically ill…These unfunded mandates on hospitals effectively ask hospitals to provide uninsured individuals with the catastrophic health insurance they are free not to procure, at the expense of insured patients…”

“Just as inconsistently,” Reinhardt notes, many Americans believe that insurers have no right to refuse to sell insurance to individuals suffering from “pre-existing conditions.” Everyone has a right to buy insurance, they say. But many of these Americans also believe that the government has no right to insist that everyone purchase insurance. We should be able to wait until we are sick, and then buy insurance when we need it.

Of course if everyone followed this rule, only the sick would purchase insurance and it would become exorbitantly expensive. This is precisely what happened in New Jersey when, as part of the “New Jersey Individual Health Coverage Program,” the state passed legislation requiring that insurers sell policies to everyone in a given community at the same price. After the law was passed in 1993, more and more healthy individuals decided to forego insurance. They would buy it when they became ill, secure in the knowledge that insurers would have to sell it to them. As a result, Reinhardt observes, enrollment in
New Jersey’s Individual Health Coverage Program plummeted. In 1995 186,130 New Jersey citizens had been enrolled in the program; nine years later 84,968 were covered–and since so many were sick, premiums had spiraled two to three-fold.

New Jersey’s experience illustrates why we cannot insist that insurers sell policies to everyone, young or old, sick or healthy at a reasonable price–unless we also insist that everyone must join the pool by purchasing a policy. Only then will insurance be affordable.

In other words, markets need rules. But before we can draw up regulations, we have to agree on our goals. If we, as a nation, believe that health care is not a right, but a consumer good, then a multi-tier system makes sense. But we should be honest about this and say the poor deserve only so much care–and no more.

Alternatively, if we agree with the Supreme Court of Taiwan, which has ruled that healthcare is a “right”–a pure social good, to be available to all on equal term–then we all must contribute, based on our ability to pay, to a insurance pool that provide equal protection for all citizens.

Until we do this, true health care reform will remain a figment of our collective but deeply divided American imagination.

Fraser: Canadian patients worse off than uninsured Americans

The Hidden Costs of Single Payer Health Insurance

A Comparison of the United States and Canada

by Brett Skinner, Mark Rovere, and Marisha Warrington
Fraser Institute
September 2008
In practical terms, Canadian patients are unable to buy quicker access or better care than what the government health insurance program provides. In this sense, Canadian patients on waiting lists are worse off than uninsured Americans who may legally use their own money or credit to buy health care if they lack insurance coverage.
The Canadian single-payer system is an example of what not to do in health care. The fact is that single-payer systems are probably the worst way to achieve universal health insurance coverage. If Canada is currently witnessing the failure of its own single-payer health insurance system, why would Americans want to adopt such a system for themselves?
Nevertheless, the problem of the uninsured needs to be solved before a “tipping point” is reached and Americans have a Canadian-style health policy disaster foisted upon them by single-payer advocates who are not fully disclosing all the facts about health care in Canada.
The evidence indicates that the best approach to achieving universal health insurance coverage is to make people prioritize their own income toward the purchase of their own health insurance, not to make some taxpayers buy health insurance for everyone through a redistributive, government health insurance monopoly.
http://am.eri.ca/researchandpublications/publications/6216.aspx

This report will be used by the opponents of single payer health reform in the United States. You should be aware of it so that you can dismiss it as a resource lacking credibility.
The Fraser Institute supports “a free and prosperous world through choice, markets and responsibility.” The quote from their report leaves no doubt as to their ideological preferences for relying on individual responsibility, and rejecting government health insurance.
This report itself is typical of the Fraser Institute in that it presents a very dishonest case in support of their ideology (while accusing U.S. single payer advocates of not fully disclosing all the facts about health care in Canada, a blatantly untrue assertion). Although the report is rife with distortions and untruths, only one example will be discussed here since the compromise in methodology is representative of the others.
The U.S. Census Bureau reported that the uninsured rate of the U.S. population was 15.8 percent in 2006. The Fraser Institute adjusted the number down to 7.9 percent by excluding those who could have been insured, even though they weren’t. (Those who were uninsured for part of the year were also excluded from the Census Bureau numbers; thus the numbers, just as easily, could have been adjusted upwards to represent the total uninsured for all or part of the year.)
Although 100 percent of Canadians are insured, they classified 6.0 percent as “effectively uninsured” because they were unable to establish a relationship with a primary care physician (a problem that we also have in the United States, though no adjustment was made for that).
Thus they conclude, “Based on these figures, the estimated percentage of the population that was ‘effectively’ uninsured for non-emergency, necessary medical services at any given time during 2007 was roughly the same in both countries: 7.9% in the United States, versus 6.0% in Canada.”
Zero percent uninsured in Canada is the same “effectively uninsured” rate as 15.8 percent uninsured in the United States!? In full self-confidence, you can tell the single payer opponents that they can take their Fraser report and… (censored).

Additional comment from a reader: I believe the important thing to keep your eye on in this discussion is OUTCOMES. At the end of the day, this is the measure of whether our system is succeeding or failing. As we found in our research for the American Human Development Report, with $3,326 per person per year, Canada is buying an average of 2.5 additional years of life for their citizens, as compared with our annual expenditure per person of $6,401 on healthcare– nearly double! Canadian life expectancy at birth is 80.4 years, ours is 77.9. Again, looking at other important measures of bang for the buck, Canada has lower infant and child mortality rates than the U.S., far lower rates of low birth weight babies and more. A focus on outcomes seems to be me to be the way to cut through the ideologically-charged discussion of “nanny government” and socialized medicine. I’m attaching a nice editorial board piece that just came out in the Seattle Post-Intelligencer using this argument: http://seattlepi.nwsource.com/opinion/380652_healthed.html.
Thx for excellent work following the news and research on this critical issue,
Sarah Burd-Sharps, Co-Director
American Human Development Project

Fraser: Canadian patients worse off than uninsured Americans

The Hidden Costs of Single Payer Health Insurance

A Comparison of the United States and Canada

by Brett Skinner, Mark Rovere, and Marisha Warrington
Fraser Institute
September 2008

In practical terms, Canadian patients are unable to buy quicker access or better care than what the government health insurance program provides. In this sense, Canadian patients on waiting lists are worse off than uninsured Americans who may legally use their own money or credit to buy health care if they lack insurance coverage.

The Canadian single-payer system is an example of what not to do in health care. The fact is that single-payer systems are probably the worst way to achieve universal health insurance coverage. If Canada is currently witnessing the failure of its own single-payer health insurance system, why would Americans want to adopt such a system for themselves?

Nevertheless, the problem of the uninsured needs to be solved before a “tipping point” is reached and Americans have a Canadian-style health policy disaster foisted upon them by single-payer advocates who are not fully disclosing all the facts about health care in Canada.

The evidence indicates that the best approach to achieving universal health insurance coverage is to make people prioritize their own income toward the purchase of their own health insurance, not to make some taxpayers buy health insurance for everyone through a redistributive, government health insurance monopoly.

http://am.eri.ca/researchandpublications/publications/6216.aspx

Comment:

By Don McCanne, MD

This report will be used by the opponents of single payer health reform in the United States. You should be aware of it so that you can dismiss it as a resource lacking credibility.

The Fraser Institute supports “a free and prosperous world through choice, markets and responsibility.” The quote from their report leaves no doubt as to their ideological preferences for relying on individual responsibility, and rejecting government health insurance.

This report itself is typical of the Fraser Institute in that it presents a very dishonest case in support of their ideology (while accusing U.S. single payer advocates of not fully disclosing all the facts about health care in Canada, a blatantly untrue assertion). Although the report is rife with distortions and untruths, only one example will be discussed here since the compromise in methodology is representative of the others.

The U.S. Census Bureau reported that the uninsured rate of the U.S. population was 15.8 percent in 2006. The Fraser Institute adjusted the number down to 7.9 percent by excluding those who could have been insured, even though they weren’t. (Those who were uninsured for part of the year were also excluded from the Census Bureau numbers; thus the numbers, just as easily, could have been adjusted upwards to represent the total uninsured for all or part of the year.)

Although 100 percent of Canadians are insured, they classified 6.0 percent as “effectively uninsured” because they were unable to establish a relationship with a primary care physician (a problem that we also have in the United States, though no adjustment was made for that).

Thus they conclude, “Based on these figures, the estimated percentage of the population that was ‘effectively’ uninsured for non-emergency, necessary medical services at any given time during 2007 was roughly the same in both countries: 7.9% in the United States, versus 6.0% in Canada.”

Zero percent uninsured in Canada is the same “effectively uninsured” rate as 15.8 percent uninsured in the United States!? In full self-confidence, you can tell the single payer opponents that they can take their Fraser report and… (censored).

Additional comment from a reader: I believe the important thing to keep your eye on in this discussion is OUTCOMES. At the end of the day, this is the measure of whether our system is succeeding or failing. As we found in our research for the American Human Development Report, with $3,326 per person per year, Canada is buying an average of 2.5 additional years of life for their citizens, as compared with our annual expenditure per person of $6,401 on healthcare– nearly double! Canadian life expectancy at birth is 80.4 years, ours is 77.9. Again, looking at other important measures of bang for the buck, Canada has lower infant and child mortality rates than the U.S., far lower rates of low birth weight babies and more. A focus on outcomes seems to be me to be the way to cut through the ideologically-charged discussion of “nanny government” and socialized medicine. I’m attaching a nice editorial board piece that just came out in the Seattle Post-Intelligencer using this argument: http://seattlepi.nwsource.com/opinion/380652_healthed.html.

Thx for excellent work following the news and research on this critical issue,

Sarah Burd-Sharps, Co-Director
American Human Development Project

Thinking big on health

Editorial
Bangor Daily News
Sept. 24, 2008

Maine’s former Sen. George Mitchell, who led a recent conference in Portland, is one of many who are pressing for a bipartisan solution to the nation’s mounting health care crisis. The time for action should come under a new Congress and a new president.

The meeting was the third of four regional forums organized by Sen. Mitchell and three other former senate majority leaders (Republicans Howard Baker of Tennessee and Bob Dole of Kansas and Democrat Tom Daschle of South Dakota). The group plans to present a consensus proposal early next year.

A similar effort is headed by Sen. Edward M. Kennedy, chairman of the Committee on Health, Education, Labor and Pensions, with emphasis on the need for a universal health care system. While fighting an aggressive brain tumor, he has directed his aides to hold meetings to build bipartisan support for a major initiative.

Still another proposal in the works is a universal health care plan put forward by Sens. Ron Wyden, D-Oregon, and Robert Bennett, R-Utah. Their Healthy Americans Act would replace the current employer-based system with government oversight and subsidies of private health care plans that individuals select. It would guarantee coverage as good as that which federal employees receive. Funding would come from a tax of from 3 percent to 26 percent on employers. The Congressional Budget Office and the Joint Committee on Taxation say that the plan could take full effect in 2014, would break even the first year and create budget surpluses in successive years.

A doctors’ organization, Physicians for a National Health Program, has been pressing for single-payer national health insurance. It points out that the United States now spends twice as much as other industrialized nations on health care, while Americans lag in life expectancy and infant mortality rates and 47 million lack health coverage. It argues that 31 percent of the nation’s health care cost now goes into the private insurance bureaucracy and paper-work and that a single-payer plan would save more than $350 billion a year.

These and other proposals may seem like a hodgepodge of competing ideas, but the time has come for agreement and creation of a new system that will serve efficiently the health needs of all Americans. It should be universal, ending the expensive resort to emergency rooms by the uninsured and under-insured. It should break the connection between health benefits and employment, which came about by accident in World War II, when benefits were a way to avoid government caps on pay raises. It should draw on the experience of other countries.

Sen. Mitchell wisely acknowledged the divisive influence of entrenched pressure groups and conflicting political philosophies. But a fresh look at the crisis could sweep aside those problems and reach a national agreement. The cost, the uncertainty, the shortcomings of the present system are too much to bear. And that’s not to mention the burden of paperwork on doctors, clinics, hospitals and consumers.

http://www.bangornews.com/detail/51357.html

America Needs A New New Deal

By KATRINA VANDEN HEUVEL and ERIC SCHLOSSER
Wall Street Journal
SEPTEMBER 27, 2008

The Bush administration has proposed the most expensive government spending plan in American history, allocating as much as $700 billion to a Wall Street bailout. The proposal was attacked by members of both parties, who immediately began negotiations to find an alternative. The Bush plan was not only a political blunder; it was also a complete repudiation of the administration’s own economic policies. It could not be justified by any of the core beliefs governing free enterprise and the free market.

As with the decision to invade Iraq, the administration sought to commit the federal government to massive spending without a clear exit strategy. Most important, it drew upon the New Deal’s legacy of government intervention in the marketplace — without any of the New Deal’s fundamental concern for the well-being of ordinary Americans.

This year happens to be the 75th anniversary of the New Deal, a revolution in governmental philosophy that began with the Emergency Banking Act of 1933. That first piece of New Deal legislation was a hurried response to the worst banking crisis in U.S. history — until now.

President Franklin Delano Roosevelt outlined the problem clearly in his first fireside chat, a week after taking office. “We had a bad banking situation,” Roosevelt said. “Some of our bankers had shown themselves either incompetent or dishonest in the handling of people’s funds. They had used the money entrusted to them in speculations and unwise loans . . . It was the government’s job to straighten out this situation and do it as quickly as possible.”

President Roosevelt’s banking plan ended the panic. But it did much more than that. In Roosevelt’s words, it “reorganized, simplified, and made more fair and just our monetary system.”

Compare those aims and that achievement with what the Bush administration proposed. Having championed the free market, small government and deregulation for years, the administration asked taxpayers to assume the costs of Wall Street’s poor investments — while allowing Wall Street to hold on to the good ones.

The size and scale of the Bush administration’s proposal are mind-boggling. During the New Deal, the Roosevelt administration spent about $250 billion (in today’s dollars) on public-works projects, building about 8,000 parks, 40,000 public buildings, 72,000 schools and 80,000 bridges. The entire cost of all the New Deal programs (in today’s dollars) was about $500 billion. The secretary of the Treasury now wants to spend perhaps twice that amount, simply to prevent a financial collapse.

Of course, something must be done — and quickly. “Government intervention is not only warranted,” President George W. Bush said last week. “It is essential.” With those nine words, he contradicted the governing philosophy of the Republican Party for the past 30 years.

According to President Roosevelt, the New Deal had three fundamental aims: relief, reform and reconstruction. On Wednesday night, President Bush described his far more expensive but far less inclusive spending plan as merely a “rescue effort.” Mr. Bush’s proposal — to hand over $700 billion to Wall Street banks without any Congressional oversight, without any means to prevent conflicts of interest, or without any measures to help ordinary Americans — was disgraceful.

What we really need is a new New Deal: a systematic approach to the financial and economic problems of the U.S.

Firstly, we need relief for ordinary Americans. At the moment, four million households are behind on their mortgage payments and facing foreclosure. Some estimates suggest that an additional two million may face eviction next year.

On Wednesday in this newspaper, Sen. Hillary Clinton called for a revival of the Home Owner’s Loan Corporation (HOLC). Organized in the early months of the New Deal, the HOLC avoided widespread foreclosures by purchasing troubled mortgages from banks and then reissuing them with more favorable terms. It proved a tremendous success — for homeowners, taxpayers and banks.

A new HOLC should be created immediately, and with the power to keep people in their homes.

As winter approaches, millions of families will need help keeping those homes warm. During the past year, the cost of heating oil has increased about 30%. Meanwhile, the Bush administration is now trying to cut funding for the Low Income Energy Assistance Program. Instead of cutting, the federal government should more than double the current budget of $2.6 billion. That is awfully small change on Wall Street these days.

Second, we need reform. In recent years, one federal regulatory agency after another has been handed over to the industries they were created to regulate. It should come as no surprise that during the Bush administration the U. S. has witnessed the largest recall of contaminated beef in its history, thousands of deaths from unsafe prescription drugs, and one of our worst financial meltdowns.

Advocates of the free market must confront the fact that both the Great Depression and the current financial chaos were preceded by years of laissez-faire economic policies. Strictly enforced regulations not only protect consumers, they protect companies that behave ethically from those that don’t. The sale of tainted baby food in China demonstrates, once again, that when industries are allowed to police themselves, there’s absolutely no limit on what they’ll do for money.

Third, we need reconstruction, not only of America’s physical infrastructure, but also of its society. Today close to 50 million Americans lack health insurance. About 40% of the nation’s adult population is facing medical debts, or having difficulty paying medical bills. A universal health-care system would help American families, while cutting the nation’s long-term health-care costs. And a large-scale federal investment in renewable energy and public-works projects would build the foundation for a strong 21st century economy.

Contrary to the myth of the free market, direct government intervention has played a central role throughout American economic history, subsidizing the growth of the railroad, automobile, aerospace and computer industries, among others. It will take well-planned government investment to break our dependence on foreign oil and create millions of new Green jobs.

The events of the past month have proven, beyond any doubt, that the federal government must actively address America’s great social and economic problems. That necessity was recognized by Franklin Delano Roosevelt during the 1930s — and by his cousin, President Theodore Roosevelt, a generation earlier.

The opposing view, promoted by President Bush until recently, is now as bankrupt as one of our leading investment banks. A Wall Street bailout plan that relies upon the mechanisms of the New Deal, while betraying its underlying spirit, should be rejected. Federal relief should not be aimed at the top and somehow expected to trickle-down.

A new New Deal wouldn’t require another alphabet soup of federal agencies, micromanaging every aspect of the economy. It would simply ensure that federal spending is driven by the needs of every American. Anything less than this — any proposal that rewards those who created the problem and penalizes those who can least afford it — is a raw deal.

Ms. vanden Heuvel is editor of the Nation. Mr. Schlosser is author of “Fast Food Nation” (Harper Perennial, 2002).

Germany's lessons for H. Aaron and his cautious approach

Healthy Choice

By Henry Aaron
The New Republic
September 29, 2008
A lot of Democrats want universal health care to be the next president’s top priority. But it shouldn’t be.
The ‘Big Bang’ Approach to Health Reform is the Wrong Strategy.
Congress is unlikely to change how the entire U.S. health care industry operates with one bill. And if it did so, it would probably make a hash of the job. Differences among the states in the cost and style of delivery of health care approximate those of the European Union. More importantly, apart from periods after major wars or depression, democracies typically make large social and economic changes gradually, through laws enacted successively over many years.
So, rather than ‘betting the administration’ on one shot, the sensible strategy would be to enunciate a broad vision for reform and propose practical steps to move in the envisioned direction. Get them through Congress, see what works and what doesn’t, and then move forward again.
http://www.tnr.com:80/politics/story.html?id=208db068-4a74-4083-b14c-79e8b21b97ae

And…

Health Care Financing Reforms in Germany: The Case for Rethinking the Evolutionary Approach to Reforms

By Percivil M. Carrera, Karen K. Siemens and John Bridges
Journal of Health Politics, Policy and Law
October 2008
Abstract (excerpt)
In this article, we document twelve significant attempts to reform health care financing in Germany and critically appraise them according to the principles of solidarity and subsidiarity on which SHI (social health insurance) systems were built. While the reforms in the aggregate offered the prospect of addressing the challenges faced by the system, the modest results of the reforms and remaining deficiencies of the system underscore the limitations of the evolutionary approach to reforms. This suggests that reformers should consider a more revolutionary approach.
Concluding Remarks (excerpt)
An appraisal of health care financing reforms in Germany since reunification offers three lessons. First, while evolutionary reforms may be more politically feasible than radical reforms, evolutionary reforms are inadequate in addressing the issue of the sustainability of health care financing. Second, the impact of evolutionary reforms can be substantial when they extend and build on and not contradict or undermine previous measures. Finally, the biggest challenge to health care financing reform is the aversion to take the revolutionary route.
http://jhppl.dukejournals.org/cgi/content/abstract/33/5/979?etoc

The logic of Henry Aaron and other incrementalists seems to be as follows: Comprehensive reform of health care financing is not feasible because, if it were, we would have it by now; therefore we should abandon any thoughts of a single comprehensive reform package and move forward with tinkering around with various steps to see “what works and what doesn’t.” Of course, the discontinuity of this framing belies the alleged logic.
Aaron suggests that history shows us that only “major wars or depression” motivate democracies to make “large social and economic changes.” Is our current war too small, with too few U.S. casualties? Is our current recession too shallow, with too few unemployed and bankrupt? Is the home foreclosure rate too low, and the meltdown of the financial services industries too limited? Perhaps, perhaps.
If these don’t concern us enough, then what about the sputtering of the engine of the great American Dream? You know, that Dream that everyone could have a home, educational opportunities, healthy food, transportation, retirement security, and… health care. That engine has been redesigned to produce wealth transfer – a transfer of wealth from the masses who have increased our nation’s productivity, to the few who commandeered the machinery of Wall Street. Isn’t the sunsetting of the American Dream a crisis of proportions that finally would make us demand action?
If we are going to make our economy work for everyone, we are going to have to have to take “the revolutionary route” to health care financing reform. If we don’t fix our health care financing system, we will continue to see further erosion of the other elements of the American dream.
We do know how to do it, but first we are going to have to send Henry Aaron and his ilk off to their policy laboratories to tinker with their evolutionary reforms that never get us there. We can’t allow them to stand in our way any longer.
We need to throw out the current health care financing system and replace it with a system that would pay for all necessary health care services for everyone: a single payer national health program.
As Katrina vanden Heuvel and Eric Schlosser stated in today’s Wall Street Journal, “A universal health care system would help American families, while cutting the nation’s long-term health care costs… A new New Deal… would simply ensure that federal spending is driven by the needs of every American. Anything less than this — any proposal that rewards those who created the problem and penalizes those who can least afford it — is a raw deal.”
America Needs A New New Deal
http://online.wsj.com/article/SB122246953790280655.html