PNHP

Howard Dean on single payer

Howard Dean on single payer

10 Questions for Howard Dean

TIME
May 22, 2008

Question: As a former physician, what are your thoughts on the Democratic candidates’ health-care plans vs. a single-payer system?

Howard Dean: I think while someday we may end up with a single-payer system, it’s clear that we’re not going to do it all at once, so I think both candidates’ health-care plans are a big step forward. Certainly compared to Senator [John] McCain, who represents a big step backward.

http://www.time.com/time/magazine/article/0,9171,1808614,00.html

Comment:

By Don McCanne, MD

Let’s assume that in 2009 we will have a Democratic president, a solid Democratic majority in the House of Representatives, and sixty filibuster-proof Democrats in the Senate. We also know that, amongst Democrats, there is tremendous support for the single payer model of health care reform. That’s all we need to enact a single payer national health program. Right?

Sorry. The Democrats are already assuming that they will be in control, and the message from them is very clear. “Although single payer may be the best way to finance health care, we can never get there in one step,” is the gospel (small g) as recited by the majority of veteran Democratic legislators (with the notable exception of John Conyers and the supporters of HR 676). The majority of Democrats believe that it would be impossible to skip the next step of first using our existing programs to expand coverage to (almost) everyone.

The consensus is that, above all, we must protect the vested interests if we are to achieve this next “big step forward.” “Vested interests” is not code language; it is the private insurance industry (and to some extent, the pharmaceutical firms, which will not be discussed here).

In health care financing, the private insurers are not the solution to our problem; the private insurers are the problem. (I would apologize to President Reagan, except in his version he got it wrong.)

Those who missed yesterday’s Quote of the Day (Memorial Day) should check it out. It discussed John Geyman’s new blog and his new book on why the private insurance industry is on a death march, and why we shouldn’t resuscitate it. The “big step forward” of the Democrats will only prolong and expand the suffering and financial hardship of our fellow Americans.

We must understand the fundamental issues if we are to avoid the big misstep forward into the health care chasm. We must leap over the chasm for a safe landing on the solid foundation of a single payer national health program.

Yesterday’s Quote of the Day from John Geyman:
https://pnhp.org/news/2008/may/geymans_do_not_resu.php

Click on the following link for information about John Geyman’s book on why the health insurance industry is (and should be) dying. You can pre-order it now to receive a copy as soon as it is printed, thereby qualifying you as an authority in the national dialogue on reform.

http://www.commoncouragepress.com/index.cfm?action=book&bookid=396

America already has several models for health-care reform

By Christine B. Helfrich
The Salt Lake Tribune
05/23/2008

The May 11 Salt Lake Tribune editorial endorsed the Hillary Clinton plan for health-care reform and on May 12 gave support to the Bennett/Wyden Senate proposal.

The Tribune sought to reassure us that these plans would not be a single-payer, government-financed plan but would “force insurance companies to compete on price, benefits and quality.”

Let’s be clear, universal coverage, as discussed by the current presidential candidates and the Bennett/Wyden plan, does not mean equal coverage.

Let’s look at the much-maligned term “socialized medicine.” As op-ed writer Stas Mintowt-Czyz (“Look to England’s example for ways to solve America’s health-care problem,” Opinion, May 18) points out, this system works quite well in England.

The government both provides and pays for the health care. Hospital doctors are paid salaries, and office-based health-care providers are paid based on the number of patients they see. In fact, our own Veterans Health Administration is also government-owned and the physicians are government employees. Apparently socialized medicine is acceptable for our veterans.

In Canada health care is provided in the “social insurance” model, which means health-care providers are self-employed but the government pays for the services in the private health-care delivery system.

The Canadians call their system “Medicare” and coincidentally this is exactly how our U.S. system of Medicare works.

So, if we have successful models of socialized medicine and social insurance operating in our country, why is it such a leap to consider covering all Americans under a single system? I fear our presidential candidates have been intimidated by the “Harry and Louise” misinformation campaigns of the 1990s.

Next time you visit your health-care provider, ask how many office employees are required for the billing and preauthorization of insurance claims. This administrative burden is estimated to consume 12 percent of insurance premiums. Another 20 percent is consumed by private insurance industry administration, marketing and profits.

UnitedHealth Group CEO Stephen Hemsley recently told investors, “We will not sacrifice profitability for membership.” Do we really think the private insurance industry is going to step forward to care for our uninsured with chronic health problems?

In fact, the current position of AHIP, the national trade association representing 1,300 health insurance companies, is that private industry should not cover individuals with significant health-care needs because that drives premiums so high that they are priced out of the market. AHIP prefers that taxpayer-funded programs pay for the 80 percent of health care used by the 20 percent who have chronic or serious health-care needs.

Those of us with employer-subsidized health insurance may be unaware of some of the deficiencies of our own insurance plans. You may have a plan that allows $120 per month for prescription drugs. This sounds generous until you get a cancer diagnosis and discover that you need $13,000 (Gleevec) a month, or $150,000 (Avastin) a year, or $100,000 (Herceptin) a year for drugs delivered in an outpatient setting. And you thought hospitalization insurance was your biggest concern?

Did you know that more than half of the insurance plans offered to college students offer benefits of $30,000 or less? Hope your college kid doesn’t need a bone marrow transplant for leukemia.

If we replaced all of our public and private insurance plans with a single national health insurance plan we could eliminate $350 billion in wasteful administrative and marketing expenditures.

The United States already has a successful program that covers 40 million people and allows us to choose our health-care providers and facilities and it manages this with only 3 percent overhead for administrative expense. This health-care plan is called Medicare. Don’t we all deserve Medicare?

CHRISTINE B. HELFRICH is an employee of the University of Utah.

Viewpoints: The Health Care Debate – Dr. David Himmelstein

Physicians for a National Health Program Co-Founder David Himmelstein – Posted May 21
Listen (mp3 | wma)

www.kaisernetwork.org/health_cast/health2008hc.cfm?hc=2599#physicians

David Himmelstein, co-founder of Physicians for a National Health Program, which advocates for a universal, single-payer national health program, and Associate Professor of Medicine at Harvard Medical School, talks with the Foundation’s Jackie Judd about how a single payer model will lead to universal coverage, the obstacles to achieving it and the implications of such a plan on health care providers and the insurance market.

Transcript

JACKIE JUDD: Dr. David Himmelstein is the co-founder of Physicians for a National Health Program, thank you for joining us on Health08.org today.

DAVID HIMMELSTEIN: Thanks for having me.

JACKIE JUDD: Let me ask you a question that we are asking everyone else as part of this interview series and that is in your organization’s view, identify the single biggest problem facing the health care system today.

DAVID HIMMELSTEIN: Well, the greatest problem is the large number of people who are uninsured and have great difficulty in getting any care at all, and related to that is a growing number of Americans who have insurance but also cannot afford care because of gaps in their coverage. So our view is that the lack of access to care is most acute for the uninsured, but growing for the insured as well – this is the biggest problem we face.

JACKIE JUDD: I know when you co-founded the organization about two decades ago now, it was founded on a single issue and that issue was to create a single-payer plan. Is that the remedy you still see today, all these many years later?

DAVID HIMMELSTEIN: Very much so. In fact, we think the evidence is much more striking than it was two decades ago that nothing else can get us to universal coverage at a cost the nation can afford. That is the only viable solution.

JACKIE JUDD: And for people who are uninitiated, describe how the single-payer plan works.

DAVID HIMMELSTEIN: Single-payer national health insurance would be very simple. Basically government would be the insurer for all Americans in a single, public plan that would be paid for out of taxes, much as the Medicare program is today, but instead of covering just the elderly it would cover everybody for all necessary medical care. Unlike Medicare, we would include full prescription drug coverage, much more extensive outpatient coverage and home care coverage than Medicare does at present, and nursing home care as well.

The other things that we would do differently than Medicare is that instead of paying hospitals on a piecework basis, patient by patient, we would use what’s called global budgets for hospitals and other institutions. So as a fire department is currently paid, they get one check a month to cover all of their work and we think that is a much more rational way to pay hospitals, clinics, nursing homes that are institutional providers of care in our system. So it would tremendously simplify the billing apparatus for those institutions.

JACKIE JUDD: And so all private insurance goes away, all insurance through employers goes away?

DAVID HIMMELSTEIN: That is right. Virtually all insurance. You might still have a very small private insurance market for things like private rooms when they are not medically indicated, some of the luxuries that are not medically necessary but that a few wealthy individuals might want, could remain privately insured. But for the vast majority of medical services, private insurance would disappear.

JACKIE JUDD: Why does the organization believe that this is the only remedy when it would cause such disruptions to what so many people are currently accustomed to.

DAVID HIMMELSTEIN: First, for patients and doctors and nurses the disruptions would in fact be miniscule. Every patient would have complete coverage from the patient’s point of view. You would have an insurance card that would be good at any doctor, any hospital, any clinic in the country. You could go and get your care and the disruption of actual care would be zero. For doctors it would tremendously simplify our billing, virtually all of us who bill Medicare are familiar with the kind of billing that would be involved.

So the disruption for the actual delivery of care would be minimal. But it’s a huge disruption for the insurance industry, that is actually the biggest thing. And for employers it is a disruption. I think for many of them it would be a welcome disruption because it would relieve them of the burden of providing coverage and of administrating coverage for their workers.

The reason that we think that this politically difficult step is worth taking is that first you get enormous potential administrative savings, so by cutting out the insurance companies who are now the middlemen, you save something like $80 billion a year just on their overhead alone, so for every dollar we pay in to a private insurance plan, we only get about 87 cents worth of care out and the rest pays for the administrative costs of the plan and the CEO’s income and the other things.

We know that Medicare can do that same job for 3 percent. The Canadian national health insurance program runs for 1 percent overhead. So we could save $80 billion just on insurance overhead, but also private insurance inflicts on providers, on hospitals and doctors and nursing home a mountain of paperwork that we ought to be able to do away with.

Again, if you pay a hospital like a fire department, they don’t have to bill for each aspirin and band-aid, you cut out a tremendous administrative burden on hospitals and similarly for doctors offices. If they are billing one program with one set of rules, you simplify my colleagues and my administrative work and we have done detailed studies on that published in the New England Journal of Medicine and the potential savings are on the order of about $350 billion each year. That is enough to cover all of the uninsured and to upgrade coverage for the rest of us so that we would have first-dollar coverage, no co-payments and deductibles, without any increase in health spending at all.

That is the only way you can actually give people terrific coverage and not drive up the cost. And other things it then makes possible is much improved quality improvement possibilities, because you have got the data for the health system in one place, you can monitor practice patterns and look at where problems are. It also gives you leverage to negotiate prices with the drug industry and medical suppliers and to do many other things that need doing in our health care system. It really creates the infrastructure to move forward and also frees up the funds to solve the acute crisis.

JACKIE JUDD: In other countries that have some parts of what you have just described, you will often hear complaints about care being rationed, about a long waiting list to get some kind of service that an individual patient feels he or she needs, that a doctor is compelled to see more patients than is reasonable in order to get their incomes up. Would all of that happen here?

DAVID HIMMELSTEIN: Well, we currently spend about twice as much per person as, for instance, Canada does and if we were to cut our budget down to the Canadian level, half, we would have to limit certain expensive high technology kinds of care. If we are willing to go on spending at our current level, we ought to be able to deliver really terrific care to every American without any significant limitations on that care.
Now, that said, it is also true that we are doing large volumes of procedures that probably do no good for patients. So many of the coronary artery stents that are put in are clearly unnecessary. A lot of the spine surgery doing no good and some of the knee surgeries, many of the CT scans and other diagnostic procedures delivering high radiation doses are not actually improving our patient’s outcome.

We ought to be limiting, to some extent, the care we are giving because at present the financial incentive in our system are really creating some terrible practices. But, we ought to limit those things because that could improve the quality, not because the finances are not there.

In terms of doctors, if you ask Canadian and American doctors, for instance, how happy are you with your practices and this has been done with surgeons who have practiced on both sides of the border, generally they are happier with practice in Canada than in the U.S. Sure, there are problems, but they are generally smaller than ours. And I think the issue of how much doctors ought to make is going to be a contentious issue under any health system.

At present American doctors are making about $200,000 per doctor per year, that is after they pay their malpractice costs and office expenses, and I think that is a plenty good income. The budgeting we have done for single-payer national health insurances, you could continue paying doctors at that level without really any problem under the kind of system we are proposing.

JACKIE JUDD: I would like you to talk for a moment or two about what the big obstacles are to achieving this vision. Certainly it has been talked about for many decades in this country. Earlier in the interview you described it as politically difficult, but it is also culturally difficult, isn’t it?

DAVID HIMMELSTEIN: I think it is culturally difficult for the insurance industry because we are saying we you are not doing anything useful in the health care system and we have no place for you and that is the major obstacle. We are taking a $500-billion-dollar-a-year industry and saying you no longer have a place in our national life. And they have tremendous financial clout and political clout that goes along with it.

The second major obstacle is the drug industry, because they are very well aware that when you have got a single payer, you have got the clout to bargain with the drug industry. So in Canada the reason they have lower drug prices is because provincial drug plan have bargaining power and have driven those prices down. If we had a national health insurance program with a single payer we would drive drug prices down. Now they still make a profit in Canada, but they do not make nearly the huge profits that they make in the U.S. So for the drug industry, national health insurance would be a hit on their profits.

I think for most other Americans it is not a big cultural shift. Your own group, Kaiser, has done surveys that have shown about 60 percent of Americans favor a Medicare-like program paid for out of taxes covering all Americans, and 59 percent of doctors favor a single-payer national health insurance program in a recent random sample survey of American doctors.

I think the people in this country, doctors, patients, clearly nurses; the American Nurses Association favors it as do the California Nurses Association/National Nurses Organizing Committee. The people on the ground are ready for national health insurance, but powerful players in our health system and in our political life are dead set against it.

JACKIE JUDD: I have a final question and that is if, as we move into 2009, a new administration and there is serious consideration of changes in the current health care system, short of adopting a single-payer plan which does not seem in the cards at the moment. What would your priorities be? If there could be one smaller change, what would it be?

DAVID HIMMELSTEIN: It is very hard for me to tell you that because I am not a political person, I am a doctor, I am a primary care doctor and I generally view my role as telling my patients and my community the truth and helping them to make decisions as I do with my patients. If one of my patients has a serious cancer, and I have a cure for it that I can offer them, I offer that to them and they say to me, what about aspirin, what about Tylenol, what about narcotics, I need to tell them those may dull the pain for a little while, but they will not cure the cancer and we do have a cure. So think short of national health insurance those other things fall short.

In Massachusetts we have had a reform that is far short of national health insurance that includes government essentially providing free insurance coverage for people below the poverty level and then partial subsidies up to 300 percent of the poverty level and then above 300 percent you are supposed to buy it yourself.

What we have said to our patients and our colleagues here is we are happy that the patient under 150 percent of poverty are getting free coverage and that is a step forward, but also we must warn that that system will not work and that we have been that route before, this is the fourth time we have tried a mandate-like system, the three previous ones have failed because cost continued to rise, the recessions that came strapped the state budget with high costs for subsidizing the growing number of poor just as the tax revenues went down. And they were then repealed and we bounced back to more uninsured than before those programs were ever passed.

What I hear is that lesser reforms cannot possibly work and that we build up expectations and then disappoint them and give them the impression that it is impossible to fix the health care system. I guess that said, the one lesser reform that I could imagine working is to say we are going to do a single payer for inpatient hospital care.

So one could imagine that that is the way they did it initially in Canada is to say we will cover every American for inpatient care, we will pay hospitals on a global budgeted basis and we will take that out of the private insurance market. For the drug industry that is probably a little less noxious for the insurance industry, it leaves them with some business, but I am skeptical that they would be prepared to see that without a huge fight because they would see where that leads as it lead in Canada.

People said we are doing this for the hospitals; it makes sense to do it for all care. And it would distort care because it would say to the uninsured; you are insured, but only on the inpatient side. We would start doing all kinds of irrational things driven by that. But that is about the only incremental step I would see.

JACKIE JUDD: Thank you very much Dr. David Himmelstein.

DAVID HIMMELSTEIN: Thank you.

Health care for veterans should be a priority

By Jonathan Walker
Fort Wayne Journal Gazette
Monday, May 26, 2008

If you spend much time reading the news in Fort Wayne, you would get the impression that “Veterans Don’t Deserve Health Care” reflects how we feel about our veterans. For instance, there have been numerous reports about veterans trying to maintain the inpatient services at the Fort Wayne VA Medical Center so that they don’t have to drive to Indianapolis to obtain care. And veterans are not the only ones having trouble with health care. The family members of active-duty soldiers are given an insurance plan that is so bad that it can be hard to find a doctor. I have a patient who is married to a soldier in Iraq, and she has to drive from LaGrange to Huntington to see the only primary care doctor who will accept patients on the plan.

It gets worse. A recent study in the American Journal of Public Health indicated that almost 2 million veterans are uninsured, along with almost 4 million of their family members. This means that one in every eight uninsured Americans is a veteran or a member of a veteran’s household. You may have thought that veterans can automatically be treated at a VA hospital, but this is not the case. Veterans who have a service-connected injury can get care, but uninjured veterans face a “means test” before they are allowed into the VA system. They have to make less than 80 percent of the local median income before they are eligible, which explains why there are so many uninsured veterans – they make too much to be eligible for the VA (or Medicaid) but not enough to afford their own insurance. This rule was implemented in 2003 to save money.

Unfortunately, even if the VA was allowed to cover every veteran, it would still leave about half the uninsured veterans without care because they do not live near a VA hospital. Think about that for a minute. Although the VA can provide excellent care, it is impossible to have a VA hospital near every veteran. There are laws that make it illegal for an insurance company to force patients to drive an excessive distance just to stay in the network, yet we think nothing of making veterans drive long distances to get the care to which they are entitled.

It seems strange that a society that prides itself on “supporting the troops” would treat our veterans so poorly when it comes to health care. It so happens that if you become sick and lose your insurance, you will eventually become eligible for Medicare and Medicaid, assuming you can survive long enough to go bankrupt. You have to hit bottom first, but then you can get free medical care anywhere.

It would be so simple to expand these programs to veterans and their family members – so they never have to hit rock-bottom. It would even be cheaper than leaving them uninsured: A 2004 Kaiser Commission study found that the uninsured cost society twice as much compared to the cost of simply giving them insurance in the first place.

Veterans should have unfettered access to the best care we can give them. We should be ashamed that so many of them go without the care they deserve.

Jonathan D. Walker, M.D., is a member of Hoosiers for a Commonsense Health Plan. He wrote this for The Journal Gazette.

Geyman's Do not resuscitate the insurance industry

The Most Basic Question in the Health Care Reform 'Debate'

Posted by John P. Geyman, M.D.
Professor Emeritus of Family Medicine
University of Washington

PNHP Blog
Inaugural posting
May 23, 2008

Adapted from my book Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It (2008), with permission of the Publisher, Common Courage Press

The most basic question underlying the so-called debate over reform of U.S. health care is being dodged by most participants, policymakers, and politicians. As health care costs spiral out of control and exclude more and more millions of Americans from even the most rudimentary health care services, what debate we have deals with incremental tweaks as delusional and false hopes of reform. The air is filled with claims and hopes for a long and growing list of ‘reforms’ — for starters, these include employer and individual mandates, expanding prevention programs, chronic disease management, pay-for-performance, state high-risk pools, association health plans, information technology, tax credits/vouchers, and more. Within this cacophony of noise, the big issue is being missed.

What then is the big question? It is whether or not we should continue with private multi-payer financing of health care. Although private health insurance served the public interest in its earlier years, those times have long since passed. The industry has been transformed over the last 50 years to a largely investor-owned industry within which profits to shareholders and CEOs trump service to patients and the public.

The industry’s track record speaks for itself. It is on a death march. The costs of insurance premiums alone have become unaffordable for tens of millions of Americans, and are increasing several times faster than costs-of-living and median family incomes. Insurance covers less and less of total health care costs. Access to affordable health care has become a major concern affecting all middle-class Americans, with no relief on the horizon. Private insurers go to great lengths to avoid coverage of sick individuals and even high-risk groups. As the employer-based market shrinks, they seek out new lucrative markets in generously subsidized public markets, especially Medicare and Medicaid, for revenue growth. This industry is unsustainable, as some insiders are starting to fear. Even Wall Street analysts are beginning to see dark clouds on the industry’s horizon.

The industry’s 60-year report card is in, and it has failed the public interest. It is now time to require an efficient, equitable, and sustainable financing system that can enable universal coverage of all Americans for necessary health care by spreading risk across our entire population. Subsequent commentaries will focus on the many ways in which private health insurance cannot meet that challenge.

https://pnhp.org/news/2008/may/the_most_basic_quest.php

“Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It” by John Geyman, Common Courage Press:
http://www.commoncouragepress.com/index.cfm?action=book&bookid=396

Comment:

By Don McCanne, MD

Today, Memorial Day, we commemorate the U.S. men and women who perished while in military service for our country. Somehow it doesn’t seem right that this day has become associated with hazardous sporting events, travel with excess fuel consumption, picnics with the requisite beer, and a surge in slaughter on our highways. It seems much more appropriate to contemplate what our men and women were fighting for. After all, they did give their lives for us.

They were defending America. They were defending a nation that has learned to balance our freedom to achieve our personal goals through individual liberty, with our sense of community through social solidarity in making this a better nation for all of us.

The balance between individual freedom and social solidarity is a dynamic. Our policies can be used to improve both sides of that balance, or they can be used create an inappropriate imbalance, often resulting in impairment of both sides. We don’t always get it right.

The nation understands that there is something wrong with the provision of one of our most fundamental needs – health care. On this Memorial Day we should commemorate those who gave to our nation all that they possibly could. We can make our own humble contribution by resolving to do all that we can to make this a better nation. Making our health care system work for all of us would provide the balance we are seeking by using solidarity to enhance the role of the individual through better health.

John Geyman’s new book could not be more timely. There is a surge in activity to move forward with political solutions to our health care crisis. There is a loud call to end the policy debate and move forward with UNITY behind models that build on private insurance plans. But Geyman shows us that private plans are rapidly deteriorating in their ability to provide the health care needs of the individual and in their ability to provide affordable, comprehensive health care financing for the nation. Instead of improving both sides of the balance, health plans are weighting down the scales and causing both sides to crash.

This weekend is the beginning of John Geyman’s blog series on why private health insurance cannot meet our challenge. It is crucial that we understand the fundamentals. Without further dialogue on policy, the momentum for UNITY will move forward with the private plan model and crush our scales of reform. Geyman shows us that the private plan pathway can only lead to greater physical suffering and financial hardship. We can improve both health care for individuals and health care financing for the nation through a single payer national health program, but first we must pass the hurdle of the obsolete, dysfunctional model of private health plans.

In addition to his blog, John Geyman’s book, “Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It,” will soon be available. It will be of great importance in our advocacy work with the new administration and Congress. Everyone should have a copy. It can be pre-ordered now at the Common Courage Press website, and is very inexpensive with the publisher’s discount. Even though delivery will not be until this summer, I emphatically recommend that you order it now while you are thinking about it. At least, check out the website at this link:

http://www.commoncouragepress.com/index.cfm?action=book&bookid=396

Geyman’s Do not resuscitate the insurance industry

The Most Basic Question in the Health Care Reform ‘Debate’

Posted by John P. Geyman, M.D.
Professor Emeritus of Family Medicine
University of Washington

PNHP Blog
Inaugural posting
May 23, 2008

Adapted from my book Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It (2008), with permission of the Publisher, Common Courage Press

The most basic question underlying the so-called debate over reform of U.S. health care is being dodged by most participants, policymakers, and politicians. As health care costs spiral out of control and exclude more and more millions of Americans from even the most rudimentary health care services, what debate we have deals with incremental tweaks as delusional and false hopes of reform. The air is filled with claims and hopes for a long and growing list of ‘reforms’ — for starters, these include employer and individual mandates, expanding prevention programs, chronic disease management, pay-for-performance, state high-risk pools, association health plans, information technology, tax credits/vouchers, and more. Within this cacophony of noise, the big issue is being missed.

What then is the big question? It is whether or not we should continue with private multi-payer financing of health care. Although private health insurance served the public interest in its earlier years, those times have long since passed. The industry has been transformed over the last 50 years to a largely investor-owned industry within which profits to shareholders and CEOs trump service to patients and the public.

The industry’s track record speaks for itself. It is on a death march. The costs of insurance premiums alone have become unaffordable for tens of millions of Americans, and are increasing several times faster than costs-of-living and median family incomes. Insurance covers less and less of total health care costs. Access to affordable health care has become a major concern affecting all middle-class Americans, with no relief on the horizon. Private insurers go to great lengths to avoid coverage of sick individuals and even high-risk groups. As the employer-based market shrinks, they seek out new lucrative markets in generously subsidized public markets, especially Medicare and Medicaid, for revenue growth. This industry is unsustainable, as some insiders are starting to fear. Even Wall Street analysts are beginning to see dark clouds on the industry’s horizon.

The industry’s 60-year report card is in, and it has failed the public interest. It is now time to require an efficient, equitable, and sustainable financing system that can enable universal coverage of all Americans for necessary health care by spreading risk across our entire population. Subsequent commentaries will focus on the many ways in which private health insurance cannot meet that challenge.

https://www.pnhp.org/news/2008/may/the_most_basic_quest.php

“Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It” by John Geyman, Common Courage Press:
http://www.commoncouragepress.com/index.cfm?action=book&bookid=396

Comment:

By Don McCanne, MD

Today, Memorial Day, we commemorate the U.S. men and women who perished while in military service for our country. Somehow it doesn’t seem right that this day has become associated with hazardous sporting events, travel with excess fuel consumption, picnics with the requisite beer, and a surge in slaughter on our highways. It seems much more appropriate to contemplate what our men and women were fighting for. After all, they did give their lives for us.

They were defending America. They were defending a nation that has learned to balance our freedom to achieve our personal goals through individual liberty, with our sense of community through social solidarity in making this a better nation for all of us.

The balance between individual freedom and social solidarity is a dynamic. Our policies can be used to improve both sides of that balance, or they can be used create an inappropriate imbalance, often resulting in impairment of both sides. We don’t always get it right.

The nation understands that there is something wrong with the provision of one of our most fundamental needs – health care. On this Memorial Day we should commemorate those who gave to our nation all that they possibly could. We can make our own humble contribution by resolving to do all that we can to make this a better nation. Making our health care system work for all of us would provide the balance we are seeking by using solidarity to enhance the role of the individual through better health.

John Geyman’s new book could not be more timely. There is a surge in activity to move forward with political solutions to our health care crisis. There is a loud call to end the policy debate and move forward with UNITY behind models that build on private insurance plans. But Geyman shows us that private plans are rapidly deteriorating in their ability to provide the health care needs of the individual and in their ability to provide affordable, comprehensive health care financing for the nation. Instead of improving both sides of the balance, health plans are weighting down the scales and causing both sides to crash.

This weekend is the beginning of John Geyman’s blog series on why private health insurance cannot meet our challenge. It is crucial that we understand the fundamentals. Without further dialogue on policy, the momentum for UNITY will move forward with the private plan model and crush our scales of reform. Geyman shows us that the private plan pathway can only lead to greater physical suffering and financial hardship. We can improve both health care for individuals and health care financing for the nation through a single payer national health program, but first we must pass the hurdle of the obsolete, dysfunctional model of private health plans.

In addition to his blog, John Geyman’s book, “Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It,” will soon be available. It will be of great importance in our advocacy work with the new administration and Congress. Everyone should have a copy. It can be pre-ordered now at the Common Courage Press website, and is very inexpensive with the publisher’s discount. Even though delivery will not be until this summer, I emphatically recommend that you order it now while you are thinking about it. At least, check out the website at this link:

http://www.commoncouragepress.com/index.cfm?action=book&bookid=396

Gov. Crist's victory for unaffordable underinsurance

Legislature passes health plan pushed by Gov. Crist to cover uninsured

By Josh Hafenbrack
Sun-Sentinel.com
May 3, 2008

Delivering on Gov. Charlie Crist’s top election-year priority, the Florida Legislature on Friday approved a health insurance package to extend no-frills coverage to the state’s 3.8 million uninsured.

The plans — which aren’t the “Cadillac of coverage,” as Crist concedes — would cover some health screenings, doctor visits and office surgeries, but not medical attention that requires a specialist or prolonged hospital stays.

Crist called the health-care package “historic legislation” that will be a model for the rest of the nation.

http://www.sun-sentinel.com/business/sfl-flfhealth0503sbmay03,0,1207424.story

And…

New Florida Law Allows Low-Cost Health Policies

By Kevin Sack
The New York Times
May 22, 2008

With considerable fanfare, Gov. Charlie Crist traveled the length of his state on Wednesday to sign a bill aimed at providing low-cost health coverage to the uninsured by allowing the sale of stripped-down insurance policies.

… an insurance company could, for instance, choose to limit the number of days of hospitalization it will cover or place a dollar cap on reimbursing certain services.

But the best part, as Mr. Crist, a Republican, explained at news conferences in Miami, Tampa and Tallahassee, is that the law “doesn’t cost taxpayers a dime.”

Mr. Crist… said he was optimistic that uninsured Floridians would buy the plans…

“Even if it’s one person,” Mr. Crist said, “it would be a success…”

http://www.nytimes.com/2008/05/22/us/22crist.html?_r=1&ref=health&oref=slogin

Florida Senate SB 2534 “Cover Florida Health Care Access Program:”
http://www.flsenate.gov/cgi-bin/view_page.pl?Tab=session&Submenu=1&FT=D&File=sb2534er.html&Directory=session/2008/Senate/bills/billtext/html/

Comment:

By Don McCanne, MD

This weekend, Florida’s Gov. Charlie Crist travels to Sen. John McCain’s ranch in Arizona for further vetting as a member of the short list of potential nominees for vice-president. With him he takes his health reform legislative victory that can serve as “a model for the rest of the nation.”

Some model. It would reduce insurance premiums by stripping down benefits through measures such as limiting hospitalization and specialized services and by capping payments. Since this “doesn’t cost taxpayers a dime,” the premiums would still be unaffordable for most individuals currently without coverage. Obviously this model will not work for individuals who have health care needs.

But it might work for one person, and Gov. Crist says that it would then be a success. But as a model for the nation, isn’t that setting a low standard? Or maybe he means fifty people – one in each state.

WellPoint Meeting, 5/21/08

From Dr. Rob Stone in Indianapolis, IN

The WellPoint protest and meeting went very well, and I want to thank everyone who participated. We had over 50 outside the corporate offices and a nice piece in the Indy Star, and check out the great picture. http://www.indystar.com/apps/pbcs.dll/article?AID=/20080521/BUSINESS/80521049.

Five of us who own some stock went into the meeting and were able to address the board, which includes one of former President G H W Bush’s brothers William H T Bush, Sen Don Reigle, and Susan Bayh, amongst others. (The stock is right now trading around $50/share, and so you can buy 5 shares like I own and be able to attend the meeting next year!) We were polite, civil, and relentless. We made our case.

Who recalls the poem “Ozymandias” by Shelly from high school English class? (you can Wikipedia it at http://en.wikipedia.org/wiki/Ozymandias) The poem tells the story of a traveler finding a broken statue in the desert, a forgotten wreckage. On the pedestal the words appear: “My name is Ozymandias, king of kings: Look on my works, ye Mighty, and despair!” This was our message to the stockholders of WellPoint. Yes, you may seem high and mighty today, but soon you will be dust and wreckage in the desert. This is how we should be reframing the question when we hear, “But the insurance companies are so powerful. We will never be able to see real change. They will crush us.” The last lines of the poem:

“Nothing beside remains: round the decay

Of that colossal wreck, boundless and bare,
The lone and level sands stretch far away.”

Here is the question I posed to the Board and CEO, Angela Braly:

“I am a stockholder in WellPoint, and I am an emergency room doctor from down the road in Bloomington, therefore an “in-network provider” with a contract with this company, and I carry an Anthem card in my pocket as a policyholder. I bring all three perspectives to this meeting.

WellPoint has had a bad year. From California, first the court ruling about recision, or post hoc cancellation of policies, then the furor over asking doctors to rat on their patients who might have pre-existing conditions. From here in Indianapolis the scandal and dismissal of CFO David Colby. From Washington, the fines for improper and overly aggressive marketing of Medicare Advantage Plans. From Wall Street, the stock down 30% over the last 3 months. From Connecticut, the shareholder resolution that is clearly aimed at the perspective that the officers are grossly overpaid. And in my hometown of Bloomington, another in a series of bitter, protracted contract negotiations just concluded, this time with the largest physician group in the community. Lots of bad press and hard feelings.

Given that setting, imagine my distress to read in the May 19 issue of American Medical News that Angela Braly was being quoted. The article notes, as many others have, that health insurance companies are pricing themselves out of the market. Currently 47 million Americans are priced out of the market.

The article went on: “We will not sacrifice profitability for membership,” WellPoint President and CEO Angela Braly told analysts during a conference call. In trying to persuade investors that WellPoint’s problems are “fixable,” CEO Braly emphasized WellPoint’s market power, which she said gives it the ability to lean hard on its network doctors to accept lower reimbursement.

Last month a study published in the Annals of Internal Medicine reported that now 59% of physicians in this country support government legislation to establish national health insurance. That number grows every time a physician reads Ms Braly’s quote in American Medical News.

It appears to me that the business plan that has served WellPoint so well the past 10 years now looks more like a car driving off a cliff, or maybe a dinosaur stumbling toward a tar pit. Please comment.”

Ms Braly thanked me for my question and spoke for several minutes in reply, managing to say nothing.

Rob Stone, MD

The Most Basic Question in the Health Care Reform 'Debate'

PNHP Blog, inaugural posting, date May 23, 2008

Posted by John P. Geyman, M.D.
Professor Emeritus of Family Medicine
University of Washington

Adapted from my book Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It (2008), with permission of the Publisher, Common Courage Press

The most basic question underlying the so-called debate over reform of U.S. health care is being dodged by most participants, policymakers, and politicians. As health care costs spiral out of control and exclude more and more millions of Americans from even the most rudimentary health care services, what debate we have deals with incremental tweaks as delusional and false hopes of reform. The air is filled with claims and hopes for a long and growing list of ‘reforms’ — for starters, these include employer and individual mandates, expanding prevention programs, chronic disease management, pay-for-performance, state high-risk pools, association health plans, information technology, tax credits/vouchers, and more. Within this cacophony of noise, the big issue is being missed.

What then is the big question? It is whether or not we should continue with private multi-payer financing of health care. Although private health insurance served the public interest in its earlier years, those times have long since passed. The industry has been transformed over the last 50 years to a largely investor-owned industry within which profits to shareholders and CEOs trump service to patients and the public.

The industry’s track record speaks for itself. It is on a death march. The costs of insurance premiums alone have become unaffordable for tens of millions of Americans, and are increasing several times faster than costs-of-living and median family incomes. Insurance covers less and less of total health care costs. Access to affordable health care has become a major concern affecting all middle-class Americans, with no relief on the horizon. Private insurers go to great lengths to avoid coverage of sick individuals and even high-risk groups. As the employer-based market shrinks, they seek out new lucrative markets in generously subsidized public markets, especially Medicare and Medicaid, for revenue growth. This industry is unsustainable, as some insiders are starting to fear. Even Wall Street analysts are beginning to see dark clouds on the industry’s horizon.

Private health insurance is obsolete for these kinds of reasons:

* less efficient than public financing
* fragments risk pool by medical underwriting
* increasing epidemic of underinsurance
* excessive administrative and overhead costs
* profiteering as shareholders’ interests trump patients’ needs
* pricing itself out of the market
* unsustainable and resists regulation
The industry’s 60-year report card is in, and it has failed the public interest.

It is now time to require an efficient, equitable, and sustainable financing system that can enable universal coverage of all Americans for necessary health care by spreading risk across our entire population. Subsequent commentaries will focus on the many ways in which private health insurance cannot meet that challenge.

Gov. Crist’s victory for unaffordable underinsurance

Legislature passes health plan pushed by Gov. Crist to cover uninsured

By Josh Hafenbrack
Sun-Sentinel.com
May 3, 2008

Delivering on Gov. Charlie Crist’s top election-year priority, the Florida Legislature on Friday approved a health insurance package to extend no-frills coverage to the state’s 3.8 million uninsured.

The plans — which aren’t the “Cadillac of coverage,” as Crist concedes — would cover some health screenings, doctor visits and office surgeries, but not medical attention that requires a specialist or prolonged hospital stays.

Crist called the health-care package “historic legislation” that will be a model for the rest of the nation.

http://www.sun-sentinel.com/business/sfl-flfhealth0503sbmay03,0,1207424.story

And…

New Florida Law Allows Low-Cost Health Policies

By Kevin Sack
The New York Times
May 22, 2008

With considerable fanfare, Gov. Charlie Crist traveled the length of his state on Wednesday to sign a bill aimed at providing low-cost health coverage to the uninsured by allowing the sale of stripped-down insurance policies.

… an insurance company could, for instance, choose to limit the number of days of hospitalization it will cover or place a dollar cap on reimbursing certain services.

But the best part, as Mr. Crist, a Republican, explained at news conferences in Miami, Tampa and Tallahassee, is that the law “doesn’t cost taxpayers a dime.”

Mr. Crist… said he was optimistic that uninsured Floridians would buy the plans…

“Even if it’s one person,” Mr. Crist said, “it would be a success…”

http://www.nytimes.com/2008/05/22/us/22crist.html?_r=1&ref=health&oref=slogin

Florida Senate SB 2534 “Cover Florida Health Care Access Program:”
http://www.flsenate.gov/cgi-bin/view_page.pl?Tab=session&Submenu=1&FT=D&File=sb2534er.html&Directory=session/2008/Senate/bills/billtext/html/

Comment:

By Don McCanne, MD

This weekend, Florida’s Gov. Charlie Crist travels to Sen. John McCain’s ranch in Arizona for further vetting as a member of the short list of potential nominees for vice-president. With him he takes his health reform legislative victory that can serve as “a model for the rest of the nation.”

Some model. It would reduce insurance premiums by stripping down benefits through measures such as limiting hospitalization and specialized services and by capping payments. Since this “doesn’t cost taxpayers a dime,” the premiums would still be unaffordable for most individuals currently without coverage. Obviously this model will not work for individuals who have health care needs.

But it might work for one person, and Gov. Crist says that it would then be a success. But as a model for the nation, isn’t that setting a low standard? Or maybe he means fifty people – one in each state.

The Most Basic Question in the Health Care Reform ‘Debate’

PNHP Blog, inaugural posting, date May 23, 2008

Posted by John P. Geyman, M.D.
Professor Emeritus of Family Medicine
University of Washington

Adapted from my book Do Not Resuscitate: Why the Health Insurance Industry Is Dying, and How We Must Replace It (2008), with permission of the Publisher, Common Courage Press

The most basic question underlying the so-called debate over reform of U.S. health care is being dodged by most participants, policymakers, and politicians. As health care costs spiral out of control and exclude more and more millions of Americans from even the most rudimentary health care services, what debate we have deals with incremental tweaks as delusional and false hopes of reform. The air is filled with claims and hopes for a long and growing list of ‘reforms’ — for starters, these include employer and individual mandates, expanding prevention programs, chronic disease management, pay-for-performance, state high-risk pools, association health plans, information technology, tax credits/vouchers, and more. Within this cacophony of noise, the big issue is being missed.

What then is the big question? It is whether or not we should continue with private multi-payer financing of health care. Although private health insurance served the public interest in its earlier years, those times have long since passed. The industry has been transformed over the last 50 years to a largely investor-owned industry within which profits to shareholders and CEOs trump service to patients and the public.

The industry’s track record speaks for itself. It is on a death march. The costs of insurance premiums alone have become unaffordable for tens of millions of Americans, and are increasing several times faster than costs-of-living and median family incomes. Insurance covers less and less of total health care costs. Access to affordable health care has become a major concern affecting all middle-class Americans, with no relief on the horizon. Private insurers go to great lengths to avoid coverage of sick individuals and even high-risk groups. As the employer-based market shrinks, they seek out new lucrative markets in generously subsidized public markets, especially Medicare and Medicaid, for revenue growth. This industry is unsustainable, as some insiders are starting to fear. Even Wall Street analysts are beginning to see dark clouds on the industry’s horizon.

Private health insurance is obsolete for these kinds of reasons:

* less efficient than public financing
* fragments risk pool by medical underwriting
* increasing epidemic of underinsurance
* excessive administrative and overhead costs
* profiteering as shareholders’ interests trump patients’ needs
* pricing itself out of the market
* unsustainable and resists regulation
The industry’s 60-year report card is in, and it has failed the public interest.

It is now time to require an efficient, equitable, and sustainable financing system that can enable universal coverage of all Americans for necessary health care by spreading risk across our entire population. Subsequent commentaries will focus on the many ways in which private health insurance cannot meet that challenge.

CBO Questions Savings From Digital Health-Care Records

See also: Projected Savings from Electronic Medical Records Called Illusory

By ANNA WILDE MATHEWS
The Wall Street Journal
May 22, 2008; Page A12

WASHINGTON — Official congressional analysts dealt a blow to the prospects for broad legislation to boost information technology in the health system by taking a skeptical view of the savings that would likely result.

In an analysis released late Tuesday, the Congressional Budget Office discounted earlier projections of large cost savings that could result from the adoption of technology such as digital health records, particularly questioning an estimate of $77 billion a year that appeared in a widely cited RAND Corp. analysis. The budget office has an important voice in such debates because of its role in calculating how much legislation will cost the federal government.

Although the CBO found the potential for savings under certain circumstances — particularly when information technology was combined with broader reforms — it found that the technology by itself was typically unlikely to generate sizable financial benefits. “By itself, it’s generally not sufficient” to reduce costs, said CBO Director Peter Orszag.

The finding is a challenge to advocates of health-information technology, who have generally argued that it will improve patient safety and achieve significant efficiencies, cutting down fast-growing health-care expenses.

The idea has won broad political support, with backers including all three remaining presidential candidates as well as a diverse group of lawmakers. The current Secretary of Health and Human Services, Michael Leavitt, has also pushed for greater use of technology in the health sector. The Bush administration’s National Coordinator for Health IT, Robert Kolodner, said in a statement that “cost savings is just one of the benefits of using health IT,” and the “magnitude of savings to be generated is yet to be determined.”

An array of interests have allied around health-information technology. Last year, the “Divided We Fail” health-restructuring alliance, backed by the Business Roundtable, the AARP and the Service Employees International Union, called for Congress to pass legislation encouraging its adoption. A number of technology companies have jumped into the field, including Microsoft Corp. and Google Inc., which are getting into the business of offering personal health records.

According to the budget office report, as of 2006, only 12% of doctors and 11% of hospitals had adopted health information technologies.

Richard Hillestad, a senior principal researcher at RAND who was an author of the think tank’s analysis, said he disagreed with the budget office’s argument that his group overstated the likely savings tied to health-information technology. Mr. Hillestad said he stood by the RAND projections, and indeed feels they may “actually be relatively conservative” because they didn’t take into account some potential benefits such as billing efficiencies.

Supporters of health-information technology said the CBO analysis shouldn’t kill the prospects for legislation, adding that it could even encourage broader efforts at reform. “It’s a strategy that has to be part of a whole,” said Karen Ignagni, chief executive of America’s Health Insurance Plans.

The CBO analysis didn’t focus on particular bills, and indeed, one piece of health-technology legislation that has a chance of passing this year is expected to be associated with Medicare savings in the office’s scoring. A bill sponsored by Democratic Sen. John Kerry of Massachusetts that would encourage digital prescription technology by initially offering Medicare payment bonuses to doctors, then later penalizing them if they failed to adopt it, may end up being part of a broader Medicare package that is expected to pass before July 1. The CBO analysis noted that there might be some savings if the federal government decides to mandate some form of technology, such as e-prescribing, by penalizing providers that don’t participate.

Another bill, sponsored in the Senate by Edward Kennedy, the Massachusetts Democrat, and Michael Enzi, the Wyoming Republican, would encourage broader use of technology in health care, but not mandate it. Sen. Enzi, in a statement, said “We can squabble over the potential amount of savings, but we know health IT will save lives and money. The time to act is now.”

Write to Anna Wilde Mathews at anna.mathews@wsj.com