PNHP

Why Not Single Payer? Part 2. What's Wrong With The Clinton / Obama / Edwards Health Care Plans

Why Not Single Payer? Part 2. What's Wrong With The Clinton / Obama / Edwards Health Care Plans

Miles Mogulescu
The Huffington Post
Posted November 2, 2007 | 04:23 AM (EST)

In Part 1 of this multi-part Huffpost series on the health care debate, I criticized the leading Democratic candidates — Hillary Clinton, Barack Obama, and John Edwards — for surrendering, without firing a shot, to the insurance and drug companies by opposing universal single payer health care.

In this second installment, I elaborate on the difference between universal single payer health care and the Clinton/Obama/Edwards universal insurance mandate plans and argue that universal mandates are bad social policy.

First, let’s define our terms:

“Universal Single Payer Health Care” (aka “Medicare For All”): From the moment that you’re born until the moment that you die, you will be covered by single quasi-public non-profit health insurer that will pay for both preventative care and for all necessary medical procedures and medications. You choose whatever doctor you want to see and you and your doctor decide on the care you need. It won’t matter whether you’re employed or not or whether your employer offers health coverage. You can never be denied insurance.

“Universal Insurance Mandate:” If you like your employer’s health plan, you can keep it. If your employer doesn’t provide health insurance and you don’t qualify for Medicaid, the government will make you pay for your own health insurance out of your own pocket. If you’re too poor to afford the premiums, at tax time every year the government will give you a credit to reimburse you for part of last year’s premiums. If you’re middle class, the government tax credits may be too small to make the insurance really affordable, or you may have to buy a less expensive high deductible policy in which you have to pay for your doctor visits out of your own pocket, unless you get really sick and need major surgery or an extended hospital stay. You and your doctor will still have to fight with your insurance company on whether it will cover procedures your doctor thinks are necessary. If you try to avoid buying your own insurance or think you can’t afford it, the government will penalize you.

To be fair, the Clinton/Obama/Edwards plans have some positive points. By banning “pre-existing conditions”, they would allow people to buy insurance who are simply uninsurable now. By requiring insurance companies to charge the same premiums regardless of age or health, they would make insurance more affordable to middle aged people. (Conversely, they would make insurance more expensive for younger people.) By providing tax credits, they would help lower middle class people afford at least lower priced, high deductible “catastrophic” policies. Most of the plans include a Medicare-like public alternative that individuals may purchase and whch competes with private insurance.

But overall, a universal insurance mandate is bad public policy compared to universal single payer health care. Some of the reasons:

1. It’s a colossal waste of money. While the administrative cost of Medicare is about 2-3 percent, approximately 30 percent of private insurance premiums go to overhead, profits and executive salaries. In 1999, the last year for which I could find numbers, health care administrative costs totaled $294.3 billion or $1,059 per capita, compared to $307 per capita in Canada. With insurance premiums having climbed 87 percent in the past decade, it would be a fair guess that administrative costs now exceed $400 billion per year. That’s more than enough to cover all of the uninsured without raising taxes.

2. Universal mandates punish the middle class who make too much to receive government subsidies, but too little to afford the cost of health insurance that the government will coerce them into buying. Massachusetts passed a state universal mandate program in 2006 which proponents of a universal mandate point to as the model for a national plan. According to recent a study by the Greater Boston Interfaith Organization, the premium for the minimum insurance plan is unaffordable for households earning between 300%-500% of the poverty level. Premiums for the minimum plan are free for those earning up to 150 percent of the federal poverty level of $10,210 for individuals and $13,960 for couples. Premiums are reduced for those earning up to three times the poverty level. Those earning more than that (i.e more than $30,630 for individuals, $41,880 for couples) must pay 100 percent of the premiums themselves. Premiums range from $1464 per year for young adults to $9600 per year for those over 55. So a 55-year-old couple earning $42,000 a year would have to pay $19,200 a year in premiums, nearly 46 percent of their pre-tax income, for a plan with deductibles of $2,000 per individual and $4,000 per family and out-of-pocket expenses of up $5,000 per year for individuals and $7,500 for families. A government mandate requiring people to pay these kinds of premiums, even if a national plan had somewhat higher subsidies, is effectively a huge hidden tax increase for the middle class and a huge boondoggle for the private insurance companies to whom the government delivers large numbers of new customers.

3. The universal mandate plans assume that most people will continue to be covered by their employers and therefore they won’t have to reach into their pockets to pay the full cost of meeting the government mandate. But employer-based health insurance is a dying dinosaur. Each year fewer employers offer insurance. Between 2000 and 2006, the percentage of employers offering some type of health insurance declined from 64.2 percent to 59.7 percent and it continues to decline. Even many people whose employers now provide health insurance are underinsured — according to a Consumer Reports survey, 29 percent of people with health insurance are “under-insured,” with coverage so meager that they often postpone medical care because of cost. Moreover, as insurance premiums escalate at a far greater rate than inflation or wage increases, more and more employers increase their employee’s share of premiums, raise deductibles and co-pays and reduce benefits. If you lose your job, you lose your insurance. In the larger picture, leaving the burden of health insurance on employers makes American companies less competitive in the world economy, compared to other capitalist democracies where the government pays for health care. Recently, Toyota named the savings in health care costs as the main reason for deciding to open a new auto plant in Canada rather than the U.S.

4. Large numbers of people opting for lower-cost, high deductible plans will lead to many middle class people avoiding preventive care and necessary treatment until they are already very sick, leading to worse health outcomes and in the long-run resulting in higher costs from waiting to treat preventable diseases until they become serious. If, after paying thousands of dollars a year in premiums, a middle class family has to pay $2,000-$4,000 in deductibles before their insurance kicks in, many won’t go to the Doctor until it’s an emergency. For example, someone with a chest infection won’t seek care, thus infecting others, and possibly ending up in the hospital with pneumonia. Men won’t get their PSA checked, women won’t get pap smears and breast exams, people won’t get colonoscopies, thus leading to cancers not being found at the early treatable stage.

5. The strongest argument by progressives who support a universal mandate is that the plan would include a Medicare-like public alternative that would compete with private insurance and, because it would so clearly be superior to private insurance, would eventually evolve into a single payer system. If this plan is modeled on Medicare, it would be a fairly generous plan in which you can choose your own doctor, in which most treatments your doctor recommends are covered, and in which deductibles and co-pays are low. This means that, even after greatly reducing the administrative costs associated with private insurance, it will still be expensive compared to high deductible plans. This leads to “adverse selection.” The young and healthy would opt for the cheaper plans. The people who will buy the Medicare-like plan will be those who think their health care costs are likely to exceed their premiums — in other words, the older and sicker. Far from slowly evolving into a single payer system, as its progressive supporters like Paul Krugman argue, the Medicare-like plan is likely to become more and more expensive as time passes, making it less and less affordable and forcing more and more people back to bare bones private insurance.

End of Part 2

Coming in Part 3: Why Universal Mandates represent not just bad social policy but a losing political strategy.

The United States needs a ‘single-payer health care system

James Clancy addresses Physicians for a National Health Program in Washington

Washington (6 Nov. 2007) – Time has validated Canada’s publicly-funded national health care system and the United States should move toward a similar system, says James Clancy, president of the National Union of Public and General Employees (NUPGE).

Speaking to an American group called Physicians for a National Health Program (PNHP), Clancy said only a small minority of people in Canada favour private health care solutions such as private insurance, user fees, medical savings accounts and parallel for-profit care.

“The vast majority of Canadians have repeatedly said No to these proposals, because the principles on which these proposals rest cannot be reconciled with the values at the heart of our medicare,” Clancy said.

“The opponents of our single-payer system claim it’s a perversion of Canadian values that they can’t use their own money to purchase faster treatment from a private for-profit provider,” he added.

“But the consensus view of Canadians on this issue is clear: It’s a far greater perversion of Canadian values to accept a system where money, rather than need, determines who gets access to health care.”

Medicare defines Canada

Clancy said medicare defines the values of Canada. “Sickness doesn’t discriminate. And in Canada we’ve made the collective decision that health care shouldn’t discriminate either,” he said.

“Overwhelmingly, Canadians strongly support the core values on which our system is premised: equality, compassion and social solidarity. In fact, our medicare system is now tied to our understanding of citizenship – more than a social program, medicare to us represents a birthright and an identifying mark of Canadian-ness.”

On five occasions since national public health care was established in Canada more than 40 years ago, the system has been reviewed by high-profile political and judicial leaders, he noted. “All came to the same conclusion: single-payer, publicly-funded health care is more equitable, more efficient and more effective,” he said.

He acknowledged that problems, such as wait times, exist within the Canadian system but he said solutions also exist and will be far less costly to implement than in the U.S. Canada spends about 10% of GDP to finance its health care system, which covers all citizens. The U.S. spends roughly 15% of GDP yet leaves millions with no coverage at all, he noted.

Clancy said wait times are not caused by Canada’s single-payer system.

Health professionals

“The main source of the problem is something most countries around the world are experiencing: we’re facing a health human resources crisis,” he argued.

“There’s a serious shortage of health professionals in Canada. They’re retiring in big numbers. And we’re just not recruiting and training enough new health professionals.

To be successful in reducing those waiting lines, we’re working with Canadian governments to invest in a national strategy that will lead to a greatly expanded workforce of health care professionals.”

Clancy said the challenge is for groups such as NUPGE and PNHP to work together to bring “a single-payer system in the U.S.” while continuing to defend and expand the system that exists in Canada.

“If we continue to fight with passion and conviction and hold out for what we want, we’ll do more than make a difference in health care. We’ll create a world of which we can all be truly proud. Working together – we can make that happen,” he said.

Why Not Single Payer? Part 2. What’s Wrong With The Clinton / Obama / Edwards Health Care Plans

Miles Mogulescu
The Huffington Post
Posted November 2, 2007 | 04:23 AM (EST)

In Part 1 of this multi-part Huffpost series on the health care debate, I criticized the leading Democratic candidates — Hillary Clinton, Barack Obama, and John Edwards — for surrendering, without firing a shot, to the insurance and drug companies by opposing universal single payer health care.

In this second installment, I elaborate on the difference between universal single payer health care and the Clinton/Obama/Edwards universal insurance mandate plans and argue that universal mandates are bad social policy.

First, let’s define our terms:

“Universal Single Payer Health Care” (aka “Medicare For All”): From the moment that you’re born until the moment that you die, you will be covered by single quasi-public non-profit health insurer that will pay for both preventative care and for all necessary medical procedures and medications. You choose whatever doctor you want to see and you and your doctor decide on the care you need. It won’t matter whether you’re employed or not or whether your employer offers health coverage. You can never be denied insurance.

“Universal Insurance Mandate:” If you like your employer’s health plan, you can keep it. If your employer doesn’t provide health insurance and you don’t qualify for Medicaid, the government will make you pay for your own health insurance out of your own pocket. If you’re too poor to afford the premiums, at tax time every year the government will give you a credit to reimburse you for part of last year’s premiums. If you’re middle class, the government tax credits may be too small to make the insurance really affordable, or you may have to buy a less expensive high deductible policy in which you have to pay for your doctor visits out of your own pocket, unless you get really sick and need major surgery or an extended hospital stay. You and your doctor will still have to fight with your insurance company on whether it will cover procedures your doctor thinks are necessary. If you try to avoid buying your own insurance or think you can’t afford it, the government will penalize you.

To be fair, the Clinton/Obama/Edwards plans have some positive points. By banning “pre-existing conditions”, they would allow people to buy insurance who are simply uninsurable now. By requiring insurance companies to charge the same premiums regardless of age or health, they would make insurance more affordable to middle aged people. (Conversely, they would make insurance more expensive for younger people.) By providing tax credits, they would help lower middle class people afford at least lower priced, high deductible “catastrophic” policies. Most of the plans include a Medicare-like public alternative that individuals may purchase and whch competes with private insurance.

But overall, a universal insurance mandate is bad public policy compared to universal single payer health care. Some of the reasons:

1. It’s a colossal waste of money. While the administrative cost of Medicare is about 2-3 percent, approximately 30 percent of private insurance premiums go to overhead, profits and executive salaries. In 1999, the last year for which I could find numbers, health care administrative costs totaled $294.3 billion or $1,059 per capita, compared to $307 per capita in Canada. With insurance premiums having climbed 87 percent in the past decade, it would be a fair guess that administrative costs now exceed $400 billion per year. That’s more than enough to cover all of the uninsured without raising taxes.

2. Universal mandates punish the middle class who make too much to receive government subsidies, but too little to afford the cost of health insurance that the government will coerce them into buying. Massachusetts passed a state universal mandate program in 2006 which proponents of a universal mandate point to as the model for a national plan. According to recent a study by the Greater Boston Interfaith Organization, the premium for the minimum insurance plan is unaffordable for households earning between 300%-500% of the poverty level. Premiums for the minimum plan are free for those earning up to 150 percent of the federal poverty level of $10,210 for individuals and $13,960 for couples. Premiums are reduced for those earning up to three times the poverty level. Those earning more than that (i.e more than $30,630 for individuals, $41,880 for couples) must pay 100 percent of the premiums themselves. Premiums range from $1464 per year for young adults to $9600 per year for those over 55. So a 55-year-old couple earning $42,000 a year would have to pay $19,200 a year in premiums, nearly 46 percent of their pre-tax income, for a plan with deductibles of $2,000 per individual and $4,000 per family and out-of-pocket expenses of up $5,000 per year for individuals and $7,500 for families. A government mandate requiring people to pay these kinds of premiums, even if a national plan had somewhat higher subsidies, is effectively a huge hidden tax increase for the middle class and a huge boondoggle for the private insurance companies to whom the government delivers large numbers of new customers.

3. The universal mandate plans assume that most people will continue to be covered by their employers and therefore they won’t have to reach into their pockets to pay the full cost of meeting the government mandate. But employer-based health insurance is a dying dinosaur. Each year fewer employers offer insurance. Between 2000 and 2006, the percentage of employers offering some type of health insurance declined from 64.2 percent to 59.7 percent and it continues to decline. Even many people whose employers now provide health insurance are underinsured — according to a Consumer Reports survey, 29 percent of people with health insurance are “under-insured,” with coverage so meager that they often postpone medical care because of cost. Moreover, as insurance premiums escalate at a far greater rate than inflation or wage increases, more and more employers increase their employee’s share of premiums, raise deductibles and co-pays and reduce benefits. If you lose your job, you lose your insurance. In the larger picture, leaving the burden of health insurance on employers makes American companies less competitive in the world economy, compared to other capitalist democracies where the government pays for health care. Recently, Toyota named the savings in health care costs as the main reason for deciding to open a new auto plant in Canada rather than the U.S.

4. Large numbers of people opting for lower-cost, high deductible plans will lead to many middle class people avoiding preventive care and necessary treatment until they are already very sick, leading to worse health outcomes and in the long-run resulting in higher costs from waiting to treat preventable diseases until they become serious. If, after paying thousands of dollars a year in premiums, a middle class family has to pay $2,000-$4,000 in deductibles before their insurance kicks in, many won’t go to the Doctor until it’s an emergency. For example, someone with a chest infection won’t seek care, thus infecting others, and possibly ending up in the hospital with pneumonia. Men won’t get their PSA checked, women won’t get pap smears and breast exams, people won’t get colonoscopies, thus leading to cancers not being found at the early treatable stage.

5. The strongest argument by progressives who support a universal mandate is that the plan would include a Medicare-like public alternative that would compete with private insurance and, because it would so clearly be superior to private insurance, would eventually evolve into a single payer system. If this plan is modeled on Medicare, it would be a fairly generous plan in which you can choose your own doctor, in which most treatments your doctor recommends are covered, and in which deductibles and co-pays are low. This means that, even after greatly reducing the administrative costs associated with private insurance, it will still be expensive compared to high deductible plans. This leads to “adverse selection.” The young and healthy would opt for the cheaper plans. The people who will buy the Medicare-like plan will be those who think their health care costs are likely to exceed their premiums — in other words, the older and sicker. Far from slowly evolving into a single payer system, as its progressive supporters like Paul Krugman argue, the Medicare-like plan is likely to become more and more expensive as time passes, making it less and less affordable and forcing more and more people back to bare bones private insurance.

End of Part 2

Coming in Part 3: Why Universal Mandates represent not just bad social policy but a losing political strategy.

Why would Big Business defend ERISA?

Big Business launches healthcare lobby group

By Jeffrey Young
The Hill
November 6, 2007

As state legislatures, Congress and the presidential candidates turn up the volume on national healthcare reform, more than 50 of America’s largest corporations and most powerful lobbying organizations are joining forces in a campaign to protect their stake in the status quo.

The newly formed National Coalition on Benefits will spend the next two months working to convince members of Congress that the health benefits they provide their workers, through a federal exemption for state insurance regulations, are an essential component of the current system that should not be undermined in any reform initiatives.

The corporations making up this umbrella group include some of the largest employers in the country, from AT&T to Xerox; trade associations, such as the U.S. Chamber of Commerce and the Business Roundtable; and health insurance companies like Aetna and UnitedHealth Group.

“Our statement is: This is the one part of the healthcare system that’s working,” said Andrew Mekelburg, vice president of federal government relations for Verizon Communications.

Under the Employee Retirement Income Security Act of 1974 (ERISA), companies that bear the full costs of their health benefits, as opposed to purchasing an insurance package for their workers, are exempt from state regulations of health insurance. Most large companies offer ERISA-regulated health plans because, among other reasons, this approach permits the companies to offer uniform benefit packages to employees in all 50 states. Otherwise, the firms would have to comply with varying insurance requirements, such as mandates that certain services be covered, from state to state.

Democratic candidates such as Sen. Hillary Rodham Clinton (N.Y.) and former Sen. John Edwards (N.C.) have proposed requiring individuals to purchase coverage and/or requiring employers to provide it. Republican candidates such as former New York Mayor Rudy Giuliani and former Massachusetts Gov. Mitt Romney have called for changing the tax treatment of health benefits and for greater state flexibility.

Either of these approaches could include changing ERISA, Mekelburg said. “Both of them aren’t quite the right answer.”

“I don’t think there’s much potential for a lot of states doing their own thing in the absence of federal [legislation],” said Paul Ginsburg, president of the Center for Studying Health System Change, a nonpartisan research institution.

Ginsburg said that these companies have legitimate concerns about the costs associated with allowing states to circumvent ERISA or with levying new federal requirements on their benefit plans. “It’s not just reluctance to change,” he said.

Nevertheless, Ginsburg expressed concern that if such powerful interests stake out a strong position against the healthcare reform proposals emerging from the presidential candidates and Congress, it could have the effect of stifling the political debate before it really begins. “That’s the most worrisome,” he said.

“It’s so different from the spirit that I’ve seen over the past year for all these ‘strange bedfellow’ coalitions” promoting reform, Ginsburg said.

http://thehill.com/business–lobby/big-business-launches-healthcare-lobby-group-2007-11-06.html

National Coalition on Benefits (press release):
http://www.coalitiononbenefits.com/News/Read.aspx?GUID=A2A35C03-9DE1-4ED7-95E3-E880A1F8EE57

Comment:

By Don McCanne, MD

What is going on here? Big Business is being strangled with escalating health care costs. General Motors, a member of this coalition, is in the process of dumping its health benefits program into a union controlled VEBA (voluntary employees’ beneficiary association).

With the escalating push toward comprehensive reform, Big Business has an opportunity to dump its health benefits headache onto others through individual mandates to purchase private plans, or onto a national health insurance program. Why should they want to protect ERISA and their self-funded health benefit programs?

An old rule is that when something doesn’t seem right, start by looking at the money involved.

Obviously, adoption of a national health insurance program would shift the financing of health care to the tax system. But what about an individual mandate to purchase private plans? Private health insurance that provides adequate financial protection is now so expensive that average-income individuals can no longer afford it. An individual mandate would require a massive infusion of taxpayer funds in the form of vouchers or tax credits. No matter the model, any program that is truly universal and is effective in preventing financial barriers to care will require a massive infusion of tax funds.

Who will pay those taxes? Moderate- and low-income individuals can no longer pay their share. Small businesses are also finding it very difficult to fund health benefits. Innovative tax policies such as taxes on tobacco or on casino gambling can’t even make a dent in the amount needed. Obviously Big Business is looking at this, and what is their perception?

Members of the policy community across the political spectrum agree that we need to end the employer link to health insurance. The conservatives believe that it is time to place individuals in charge of their own coverage, although the conservative Heritage Foundation understands that this is a non-starter unless individual plans are heavily tax subsidized.

Liberals oppose the unfair regressive tax policies that support employer-sponsored plans and recognize that a more equitable method of health care financing must be adopted. The problem for the liberals is that they have been unable to sway the anti-tax populous into supporting public funding. So where can they find the money? Ah, Big Business is loaded with dough. So including an employer mandate would allow us to tap those funds even if it depends on perverse tax policies. But gaining the support of business by agreeing to limit corporate tax increases likely would not not work since payroll taxes then would have to be increased, still increasing business overhead. (Though economists agree that payroll taxes are part of the employees’ benefit packages, they are still part of the employers’ overhead expenses. It is likely that payroll taxes would play a role in the future financing of health care, but the extent should be set by policies designed to make the tax system as equitable as possible.)

OK. Let’s concede that Big Business will have to be a major player in health care financing. They already are carrying a heavy burden with their self-funded ERISA-protected plans. Since a universal public insurance program would reduce administrative waste, wouldn’t they prefer to change to a program that would save them at least some of their costs?

From the perspective of administrative waste, the self-insured plans of large businesses are the most efficient programs provided by the private sector. Big Business rightfully would be suspicious of claims that a single payer system would provide enough savings to offset their loss of control over their employees’ health benefit programs.

But there’s a much greater issue. Who are the employers insuring? Their own healthy workforce and their young healthy families. They are paying for a large sector of our population that happens to have the least expensive health care needs. Imagine shifting Big Business to a universal program, whether public insurance or mandated private plans, that includes the higher-cost sectors of our population. They do have the legacy costs of their retirees, but that still doesn’t approach the costs of introducing all high-risk individuals into the universal risk pool.

Single payer advocates may claim that we’ll save Big Business money, but if you were a corporate health benefits manager, would you believe it? “I think that we’ll just stick with our self-funded program, thank you.”

Policy lesson: We desperately need a universal risk pool that is equitably funded. Equitable… fair… fair for everyone. Low- and moderate-income individuals can no longer afford their pro rata share and will need help from the wealthier sector of our society. We can gain the support of much of that sector if the members are convinced that the system would be truly equitable, and we need to show them now how that would work. Nailing Big Business alone to the wall is not equitable.

Giuliani's Prostate Cancer Figure Is Disputed

By JULIE BOSMAN
The New York Times
Published: October 31, 2007

In a radio advertisement playing in New Hampshire and in speeches along the campaign trail, Rudolph W. Giuliani has cited statistics to cut at the heart of his Democratic rivals’ health care proposals, which he has derided as European-style “socialist” plans that will lower the standard of care in the United States.

“I had prostate cancer five, six years ago,” Mr. Giuliani, aRepublican presidential candidate, said in a speech that has been turned into the radio commercial. “My chance of surviving prostate cancer — and, thank God, I was cured of it — in the United States? Eighty-two percent. My chance of surviving prostate cancer in England? Only 44 percent under socialized medicine.”

Mr. Giuliani’s Democratic rivals would argue that they are not advocating government-run health care in their plans to extend coverage to the uninsured. But, beyond that, the 44 percent figure that Mr. Giuliani has been citing is in dispute.

The Office for National Statistics in Britain says the five-year survival rate from prostate cancer there is 74.4 percent. And doctors also say it is unfair to compare prostate cancer statistics in Britain with those in the United States because in the United States the cancer is more likely to be diagnosed in its early stages.

“Certainly, if you intensively screen for prostate cancer, you will find early disease,” said Dr. Ian M. Thompson, chairman of the department of urology at the University of Texas at San Antonio. “And simply because you find it earlier, you will always have longer survival after the disease is diagnosed.”

Maria Comella, a spokeswoman for Mr. Giuliani, said yesterday that the 44 percent figure came from an article in City Journal, a publication of the Manhattan Institute, a conservative research organization.

“The citation is an article in a highly respected intellectual journal written by an expert at a highly respected think tank which the mayor read because he is an intellectually engaged human being,” Ms. Comella said in an e-mail message.

That article, titled “The Ugly Truth About Canadian Health Care,” was written by Dr. David Gratzer, a senior fellow at the Manhattan Institute and an adviser to the Giuliani campaign.

In an interview, Dr. Gratzer said the statistic came from the Commonwealth Fund, a nonprofit group in New York specializing in health care policy issues, but he acknowledged that it was seven years old and “crude.”

But the Commonwealth Fund said yesterday that Dr. Gratzer had misused its research by calculating a five-year survival rate based on data on prostate cancer incidence and mortality rates in the United States and Britain.

“Five-year survival rates cannot be calculated from incidence and mortality rates, as any good epidemiologist knows,” the group said in a statement.

Dr. Gratzer dismissed the Commonwealth Fund’s statement, saying the group had “an ideological bias.” Asked if Mr. Giuliani would continue to repeat the statistic, and if the advertisement would continue to run, Ms. Comella responded by e-mail: “Yes. We will.”

Gina Kolata contributed reporting.

THE CLAIM: GIULIANI’S PROGNOSIS WOULD BE WORSE IN BRITAIN and THE FACTS

The Washington Post
Wednesday, October 31, 2007; Page A06

“I had prostate cancer, five, six years ago. My chances of surviving prostate cancer — and thank God I was cured of it — in the United States: 82 percent. My chances of surviving prostate cancer in England, only 44 percent under socialized medicine.”

— Rudy Giuliani, New Hampshire radio advertisement, Oct. 29, 2007

The former New York mayor has had experience battling prostate cancer, but he’s confused about the stats, according to several experts we consulted.

THE FACTS

As factual support for the presidential candidate’s claim, his campaign cited an article by David Gratzer that appeared in the City Journal, published by the Manhattan Institute, a conservative New York think tank, slamming the Canadian and British systems of “socialized” medicine. The article provides no sources for its assertions about five-year survivability rates for prostate cancer.

Experts from the National Cancer Institute and the urology departments at Johns Hopkins University and the University of Kansas agreed that Giuliani’s figures were way out of date, if they were ever accurate at all. The latest official figures for five-year “survivability” rates for prostate cancer are about 98 percent in the United States and 74 percent in England.

More important, the survivability figures tell us little about the differences in the quality of treatment received by prostate cancer patients in the United States and Britain. Doctors in each country have different philosophies about how to treat the disease, and these differences have greatly influenced the survivability statistics.

In the United States, there has been a big emphasis since the 1990s on early screening through prostate-specific antigen (PSA) testing. Five-year survivability rates have increased simply because the slow-developing disease is being diagnosed at a preliminary stage. If the diagnosis is made early, the chance of surviving for five years is close to 100 percent. Britain is several years behind the United States in the widespread use of PSA testing.

Another way of comparing treatment of prostate cancer in the United States and Britain is to look at the mortality rates. Here the two are much closer. About 25 men out of 100,000 are dying from prostate cancer every year in both countries. The likelihood of dying from prostate cancer is roughly comparable in the two countries, despite different treatment philosophies.

J. Brantley Thrasher, chairman of the Department of Urology at the University of Kansas, said it is “impossible to say” on the basis of the statistics whether a prostate cancer patient has a better chance of surviving under a “capitalistic” or “socialistic” medical system. American doctors tend to be more “interventionist” and more likely to advocate surgery than their counterparts in Britain or Canada, where greater emphasis is put on “active surveillance.” In the United States, a patient with a good health-care plan is “more empowered to make decisions” for himself.

Maria Comella, deputy communications manager for the Giuliani campaign, sent us the following e-mail explaining the mayor’s mistake without quite acknowledging it:

“Mayor Giuliani is an avid reader of City Journal and found the passage in the Gratzer article himself. He cited the statistics at a campaign stop, and the campaign used a recording from that appearance in the radio ad. The citation is an article in a highly respected intellectual journal written by an expert at a highly respected think tank which the mayor read because he is an intellectually engaged human being.”

THE PINOCCHIO TEST

Giuliani is simply wrong when he claims that his chances of surviving prostate cancer are almost twice as high in the United States as in England, under a “socialized” medical system. We award Giuliani four Pinocchios.

To find out the winner of the Fact Checker’s first Geppetto award, and coverage of Tuesday night’s Democratic debate, visit

The serial exaggerator strikes again

By Steve Benen
The Carpet Bagger Report
Posted October 30th, 2007 at 9:15 am

At this point, it appears Rudy Giuliani is just daring the national media. Following up on yesterday’s item, the candidate who can barely go a day without making a wildly misleading exaggeration, has unveiled a new radio ad with a truly audacious whopper, even by Giuliani’s low standards.

OK, Rudy Giuliani has just released an ad claiming that the survival rate from prostate cancer is much higher in America than in Britain, thus proving the failure of socialized medicine.

The problem is that his claim is just plain false. In fact, mortality rates from prostate cancer are almost the same in America and Britain.

So, will this get as much attention as, say, the Edwards haircut or the Hillary laugh? Will it get any coverage at all? Bear in mind that health care is the central domestic issue of this election — and Rudy has just showed that he doesn’t know a thing about it.

It’s really not that complicated. Giuliani, in his campaign spot, claims that the survival rate for prostate cancer patients in the U.S. is 82%, while in England, it’s 44%. Giuliani argues that a universal-coverage system necessarily leads to worse care and more deaths.

But Giuliani doesn’t know what he’s talking about, and his claims were easily debunked.

Keep in mind, this wasn’t just an off-hand comment Giuliani made on the stump. This was a carefully crafted pitch, and put on the air. Giuliani didn’t just flub the facts in response to a voter’s question; he’s intentionally trying to deceive the public with a misleading ad.

And how has the media responded to the leading Republican candidate getting caught lying in a campaign ad? So far, by largely ignoring it.

Reader R.K. alerted me to a discussion on yesterday’s Hardball, where MSNBC’s Chris Matthews showed the ad in its entirety. Matthews and his guests then scrutinized the ad for quite a while. How many mentioned that the ad’s central claim was demonstrably false? None.

Matthews got the discussion started by saying, “Boy, that is classic Live Free or Die, self reliance, the Granite State. Perry, this is like main lining right into that psychology of New Hampshire, which is leave me alone. I don’t trust socialism. Is it going to work in these days, when people are really challenged on health care?”

Perry Bacon discussed the ad in the context of other candidates’ healthcare pitches. Jill Zuckman talked about the ad in the context of taking on Hillary Clinton. Matthews repeatedly asked whether the ad would “work,” by which he meant, win support from voters.

It didn’t occur to any of them to even question Giuliani’s central claim, better yet point out that it’s completely wrong.

As for digging into the policy details a little more, Ezra did a handful of good posts on the subject yesterday, but included a gem last night when he noted the circumstances of Giuliani’s life-saving cancer treatment.

…Giuliani’s case for the superiority of our “free market” health care system goes something like this: While on health insurance provided by New York state, he was treated, using a surgery developed by Europeans, for prostate cancer, a disease that most commonly afflicts those covered by the federal government’s single-payer health care system. Take that, Europe/national health insurance.

Yep, Giuliani is that clueless.

In an effective political system, this would be a fairly big deal. A leading candidate produces an ad (one of a small number created by the campaign) with an obvious falsehood. If reporters cared half as much about this as haircuts, cackles, and cleavage, the process might actually function.

Getting the Facts Right: Why Hillarycare Failed

By Vicente Navarro
Professor of Health and Public Policy
The Johns Hopkins University
10/24/07

In his article “The Hillarycare Mythology” (The American Prospect, October 2007, pp. 12-18), Paul Starr, a senior health policy advisor to President Bill Clinton and a leading figure in Hillary Rodham Clinton’s White House task force on health care reform, analyzes the origins, development, and final outcome of the Clinton administration’s health care reform — referred to by Republicans as “Hillarycare.”

Starr dates the origins of Bill Clinton’s commitment to health care reform to the special congressional election held in Pennsylvania in November 1991, when Harris Wofford won against all odds by making reform of the health care sector a major campaign issue. According to Starr, this event triggered a great deal of interest in health care reform; even the American Medical Association (AMA) and the Health Insurance Association of America (HIAA) supported some types of reform such as an employer mandate to provide health benefits coverage. As noted by the editor of JAMA, “there was an air of inevitability about health care reform.” It was this surge of interest that candidate, and later President, Clinton tried to capitalize on by developing a proposal to provide universal health care coverage for all Americans (meaning all U.S. citizens and residents).

Once elected, Bill Clinton established the 500 member White House task force, led by Mrs. Clinton, to work on the details of a proposal developed within a framework defined by the President. According to Starr, the proposal failed when President Clinton presented it to the U.S. Senate after completion of, rather than before, the budget discussions. The Senate did not support the proposal, because it would require extra revenues (making senators susceptible to Republican charges of fiscal irresponsibility) and particularly because — again, according to Star — the proposed benefits coverage was too extensive and too large for many senators to swallow. The final message of Starr’s article is that it was President Clinton’s fault, rather than Hillary’s, that the reform proposal failed.
Starr reproduces a widely held interpretation of the failure of the Clinton health care reform that (limiting the analysis to the relationship between the President and Congress) attributes this failure to a calendar error ­– bad timing — and to the excessive generosity of the proposed health care benefits. I believe there is a need to correct such an interpretation of the events that led to the death of the reform proposal and to challenge the assumptions behind the interpretation. This is important because we might face a similar situation very soon. The majority of the U.S. population is dissatisfied with the funding and organization of the health care sector, and this dissatisfaction has reached unprecedented levels. Once again, all indicators show that people want change. But we could face another failure unless some major changes take place in the U.S. — changes that, I admit, are unlikely to occur with the current correlation of forces in the country and in the Democratic Party.

Let’s start with some corrections to Starr’s assumptions. The commitment of the Democratic Party and candidate Bill Clinton to universal health care coverage for all citizens and residents started much earlier than Starr suggests. It began in the presidential primary campaigns of 1988, when Jesse Jackson (for whom I was senior health advisor), running for the Democratic nomination, made a commitment to universal, comprehensive health care benefits coverage a central component of his platform. This proposal was dismissed by the Democratic Party establishment as “too radical,” but it had already mobilized large sectors of the party’s grassroots (especially labor unions and social movements) to support Jackson, with more than 40% of the delegates at the Democratic Party Convention in Atlanta. This shook the Democratic establishment and stimulated responses from Governor Clinton, Senator Al Gore, and Congressman Richard Gephardt to block this rise of the left in the Democratic Party, which they did by establishing the Democratic Leadership Council, among other interventions. (Gore and Gephardt have changed since then; Bill Clinton hasn’t.) (I describe these effects of Jackson’s health proposals on the Democratic Party in “The 1988 Presidential Election,” in The Politics of Health Policy: The U.S. Reforms 1980–1998, Blackwell, 1994. pp. 99-110.) To control this growth of the left, something had to be done. And as liberals always have done when faced with the left, they recycled its progressive proposals, adopting much of their narrative but emptying them of their content. This is what Clinton did in his 1992 campaign. He used the title, narrative, and symbols of Jesse Jackson’s campaign, calling his platform “Putting People First” (the title used by Jackson in 1988) and including the call for universal health care benefits. As the perceptive Financial Times wrote, “Clinton [has borrowed] extensively from Jesse Jackson 1988. He sounds like a Swedish social democrat.” While borrowing the language and the symbols, however, Clinton changed the content dramatically.

Whereas Jackson had called for a single-payer program similar to that in Canada, Clinton chose the opposite pole of the political spectrum: managed care competition. Managed care competition basically meant the insurance companies exercised full control over health care providers, with doctors working in group practices called Health Maintenance Organizations (HMOs). As stated by Paul Elwood, a leading member of the White House task force, “insurers-controlled HMOs, under managed care competition will stimulate a course of change in the health care industry that would have some of the classical aspects of the industrial revolution — conversion to larger units of production, technological innovation, division of labor, substitution of capital for labor, vigorous competition and profitability as the mandatory condition of survival” (“Heath Maintenance Strategy,” Medical Care, 9 (1971), p. 291). This industrial revolution in medical care would indeed have revolutionized the practice of medicine.

It is important to note that the idea of managed care competition was first proposed as a solution to the irrationality of the U.S. health care sector by Alain Enthoven, personal advisor to U.S. Secretary of Defense Robert McNamara during the Vietnam War. Enthoven was in charge of developing the “body count” as an indicator of military efficiency. After the Vietnam fiasco, Enthoven retired to the Rand Corporation, choosing to focus his intellectual efforts on the reform of U.S. health care. A strong ideologue and market fundamentalist, and completely ignorant of the mechanics of the medical care sector, Enthoven thought the best way to control out-of-control costs in the health sector was to increase competition in the sector, letting health insurance companies compete for consumers — meaning patients — based on the price of services. The problems with such a naïve and unrealistic scenario are many. First, patients do not determine the cost or price of medical care services. Second, patients have very little choice in the U.S. health care sector: employers choose which plans are available to employees. Third, the market does not exist in the health care sector. Fourth, the insurance industry’s financial viability depends on its ability to discriminate against heavy care-users. I could go on and on detailing just how wrong Enthoven’s proposals were.

Not surprisingly, managed care was the proposal chosen by the insurance industry and by employers. As Bill Link, Executive Vice President of Prudential and one of the highest-paid CEOs in the country, stated: “for Prudential, the best scenario for reform — preferably even to the status quo — would be enactment of a managed competition proposal.” Link envisioned the corporatization of U.S. medicine, breaking the long dominance of health care providers in the medical care sector. As Enthoven wrote in an article co-authored with Richard Kronick, another leader of the White House health care reform, “what about traditional fee-for-services individual and single specialty group practices? We doubt that they should generally be compatible with economic efficiency. . . . Some would survive in private solo practice without health plan contracts, serving the well-to-do.” It could not have been put more clearly: managed care competition was corporate assembly-line capitalism for the masses and their health care providers, with free choice and fee-for-service medicine for the elites.

This proposal was actively promoted in the White House task force by the staff of Democratic Representative Cooper and members of the so-called Jackson Hole Group, who even distributed the group’s manuals on implementing managed care competition to task force members. They were particularly active in the Governance of the Health System (chaired by Richard Curtis, who had been an official of the HIAA) and Global Budgeting working groups. Outside the task force, managed care competition was actively promoted by the insurance companies. Mr. Weinstein, a disciple of Enthoven and a member of the editorial board of the New York Times (a third of the Times board members then had connections with insurance companies), wrote nine editorials in support of managed care competition.

Paul Starr sold managed care to candidate Bill Clinton. Of course, Starr and another leader of the White House task force, Walter Zelman, were aware of some drawbacks of this scheme, and they modified it to allow for some form of regulation of the ill-defined market forces — without specifying, however, who would do the regulating. They spoke of Health Alliances that would regulate the rate of growth of premiums and would allow, in theory, for consumer choice of health plans, with large employers operating on their own outside the regulatory process but still within the framework of managed care competition (with budget constraints); health insurers and health care providers could be integrated in the same organization, or Health Plans. While managed care competition was the proposal favored by insurers and large employers, it was not favored by health care providers. Providers had already had enough experience with insurance companies to know that they could be more intrusive, abusive, and nasty than government. And managed care was certainly not the choice of the grassroots of the Democratic Party — labor unions and social movements.

Concerned that managed care was not backed by the majority of the progressive base of the Democratic Party, Jesse Jackson, Dennis Rivera (then president of Local 1199, the foremost health care workers union), and I went to see Hillary Clinton. We complained about the commitment to managed care competition without due consideration of a single-payer proposal supported by large sectors of the left in the Democratic Party. We emphasized the need to include this proposal among those to be considered by the task force. Mrs. Clinton responded by asking Jackson and the Rainbow Coalition to appoint someone to the task force with that point of view. And this is how I became a member of the White House task force. I later found out that there was considerable opposition from senior health advisors, including Starr and Zelman, to my becoming part of the task force. According to a memo later made public and published in David Brock’s nasty book The Seduction of Hillary Clinton, Starr and Zelman disapproved of my appointment “because Navarro is a real left-winger and has extreme distaste for the approach we are pursuing”– which was fairly accurate about my feelings, but I must stress that my disdain for managed competition and the intellectuals who supported it did not interfere with my primary objective: to make sure that the views of the single-payer community would be heard in the task force. They were heard, but not heeded. I was ostracized, and I had the feeling I was in the White House as a token — although whether as a token left-winger, token radical, token Hispanic, or token single-payer advocate, I cannot say. But I definitely had the feeling I was a token something.

It was at a later date, when some trade unions and Public Citizen mobilized to get more than 200,000 signatures in support of a single-payer system, that President Clinton instructed the task force to do something about single-payer. From then on the battle centered on including a sentence in the proposed law that would allow states to choose single-payer as an alternative if they so wished. In Canada, after all, single-payer started in one province (Saskatchewan) and later spread to the whole nation. I have to admit that I made that proposal with considerable misgivings, since the insurance companies can also be extremely influential at the state level. For example, Governor Schaeffer (a Democrat) of Maryland had asked insurance companies to interview the various candidates for state insurance commissioner. Still, including this proposal was a step toward giving single-payer a chance in the U.S.

It is interesting that in my debates with Alain Enthoven, he dismissed my proposals with the comment that “the U.S. Political System is incapable of forcing changes in such powerful constituencies as the insurance industry.” Such candid admission of the profoundly undemocratic nature of the U.S. political system was refreshing. The splendid opening of the U.S. Constitution, “We the people . . . ,” should be amended with a footnote reading “and the insurance companies.” Actually, Enthoven’s statement came very close to Marx and Engels’ Communist Manifesto, which defines democracy as a class dictatorship in which the corporate class controls the state. Empirical support in the U.S. for that statement is strong. But the statement is not 100% accurate. I lived under a dictatorship in my youth (in Franco’s Spain) and I recognize a dictatorship when I see one. The U.S. is not a dictatorship. People in the U.S. do have a voice. Marx and Engels (and Enthoven) were not completely right: U.S. history shows that people’s mobilizations can win the day. But, while not a dictatorship, U.S. democracy is profoundly undermined by the enormous influence of the economic and corporate lobbies, components of the corporate class. I documented this in Medicine Under Capitalism, published in the 1970s. And things have become much worse during the Reagan–Bush Sr.–Clinton–Bush Jr. era. The huge limitations of U.S. democracy are evident in the difficulty with which the importance of people’s voice gets noticed. And this is why the Clinton proposal failed. He did not include in his plans any effort to mobilize people in support of the reform. Quite to the contrary. He allied himself with the major forces responsible for the sorry state of the U.S. medical care sector — the health insurance industry. The insurance companies ultimately opposed the final proposal because of its regulatory components, added by Starr and Zelman. But, apart from these components, the insurance companies would have continued to manage the health care system.

Starr’s explanation of why the reform failed is dramatically insufficient. The failure had little to do with timing, with when and where President Clinton presented the proposal. It had to do with how the Clintons related to the progressive constituencies, including labor and social movements. No universal, comprehensive coverage will ever be achieved in the U.S. without an active mobilization of the population (especially progressive forces) so as to balance and neutralize the enormous resistance from some of the most important financial lobbies in the nation. Starr’s social engineering approach, lacking any understanding of the dynamics of power, explains failure as a consequence of problems of the electoral calendar or the types of benefits offered.

In reality, the Clinton administration ignored the majority of the country’s progressive forces from the very beginning of its mandate. President Clinton made his first priority a reduction of the federal deficit (a policy not even included in his program), approved NAFTA (against the opposition of the AFL-CIO, the social movements, and even the majority of the Democratic Party), and committed himself to perpetuation of the for-profit health insurance system — the primary cause of the country’s inhumane medical care system. When NAFTA was approved, Clinton signed the death certificate for the health care plan, and for the Democratic majority in Congress. The number of people who voted Republican in 1994 was no larger than in 1990 (the previous non-presidential congressional election year). The big difference was in the Democratic vote. Abstention by working-class voters increased dramatically in 1994 and was the primary reason why Democrats lost their majority in Congress. This is a point that Starr ignores. The Gingrich Revolution of 1994 was an outcome of voter abstention, particularly among the working class, who were fed up with President Clinton. But NAFTA was also the death knell for health care reform. One could see this in the White House task force. NAFTA empowered the right, and weakened and demoralized the left.

A continuing shift to the right (erroneously called the center) has been the Democratic Party’s strategy for the past 30 years, abandoning any commitment to the New Deal and the establishment of universal entitlements that make social rights a part of citizenship. David Brock writes in his book “that Navarro had told Mrs. Clinton that if the President went ahead with a managed care competition plan, it would cost the election to the Democratic Party.” Brock’s credibility as a reporter is extremely limited, but on that point he was right. I told Mrs. Clinton that the only way of winning, and of neutralizing the enormous power of the insurance industry and large employers, was for the President and the Democratic Party leadership to make the issue one of the people against the establishment. It was a class war strategy that the Republicans most feared. My good friend David Himmelstein, a founder of Physicians for a National Health Program, told Mrs. Clinton the same thing. And as I judged by her response, she seemed to think we did not understand how politics works in the U.S. The problem is, we understood only too well how power operates.

This, then, is why the Clintons failed. And unfortunately, Hillary Clinton will fail again if she lacks the courage to confront those responsible for the predicament in the nation’s health care system. The insurance-controlled system imposes enormous pain on the population. It is not just that 46 million people are now without health insurance, but the system also fails the huge numbers of people who have insufficient coverage and don’t discover this until they need it. This cruel system has been supported by large employers because it gives them oppressive control of the labor force. When workers lose their job, they lose not only their income but also health benefits coverage — for themselves and their families. The alliance of two of the most powerful forces in this country — insurance and large employers — is at the root of the problem.

A final observation. Love of country is measured by the extent to which one promotes policies that support the well-being and quality of life of the population and, most particularly, the working and middle classes that make up the vast majority of the population. Judged by this standard, most super-patriotic, right-wing forces fail miserably on the love-of-country front. People in this nation die due to lack of health care. The estimates vary from 18,000 to 100,000 a year, depending on how you measure preventable deaths. But even based on the most conservative number of 18,000 (from the conservative Institute of Medicine), this is six times the number of people killed on September 11, 2001, by Al Qaeda. And these deaths continue year after year. The deaths on 9/11 are rightly seen as the result of enemy action. But why do the 18,000 deaths each year go unnoticed? Why aren’t they seen as the outcome of hostile forces, whose love for their country is clearly nil? Mark Twain said, “You cannot love people and then go to bed with those who oppressed them.” Why is it so difficult to understand such a basic truth?

With market-based health care, too many lose out

Letters to the Editor
St. Petersburg Times
Published November 3, 2007

As Rudy Giuliani and the other candidates predictably trot out the scare tactics regarding universal, national health care programs, they would do well to remember these facts:

1. Everyone is covered, period. There are no pre-existing conditions, insurance ratings or other tricks to deny coverage.

2. Health insurance does not evaporate with the loss or change of a job, nor is it different if you are injured at work, in a car accident, disabled, below the poverty level or if something happens to you at home or abroad.

3. Medical decisions are made by the patient and doctor, not an insurance company or government bureaucrat.

4. Medical care is the same for everyone, regardless of race, socioeconomic status or employment.

5. Bankruptcy from medical bills, or living in fear of it, does not exist.

6. We pay far too much now and receive far too little in exchange.

If “market-based” health care is so wonderful, how did it lead us to the miserable state of health care in this country today? Our leaders seem to have forgotten the fundamental truth of market systems: There are always “winners” at the expense of “losers.” Will we, as a nation, continue to accept our fellow citizens as health care losers in order for health insurance companies to be the big winners?

I, for one, cannot.

Greg Silver, M.D.
Palm Harbor

Speaker's conclusions on health care wrong

Letter to the Editor
Palm Beach Daily News
Sunday, November 04, 2007

I found the article on [HSA Consulting Services president] Roy Ramthun’s health-care talk in (the Oct. 24) Shiny Sheet very interesting but I must take issue with his conclusions. One of these is that “. . . liberals promote covering the uninsured, but that involves taking subsidies away from those who have coverage. They want to cover everybody first and then deal with the cost.”

I am a liberal and am very active in a national campaign with the 14,000-member Physicians For a National Health Program. What we support is Medicare for everyone. It is expressed in the Conyers Bill, HR676, and calls for covering everyone without taking subsidies away from anyone.

It is the only proposal that carefully considered costs during the preparation of the legislation. According to a thorough study published in the New England Journal of Medicine, eliminating all of the middlemen now milking the health care system would result in a saving of at least $350 billion, enough to more than cover all of the uninsured. These figures come from government sources.

As it is now, costs are rising so outrageously that the 47 million without insurance have nightmares, worried over being hit with a serious medical condition. Too many of them find reality nightmarish when they actually are hit. In the words of Dr. Marcia Angell, for years editor in chief of the New England Journal and now a Harvard Medical School professor, “We can no longer afford not to have single-payer universal health care.

DR. H. DAVID PRENSKY
Palm Beach

Single solution

One universal health care system answers all the questions

By TIM JOSEPH
Times Union
First published: Sunday, November 4, 2007

Gov. Eliot Spitzer has formed a task force to examine how to achieve universal health care access in New York. There are two fundamentally different approaches that can be taken to solve the problem.

One is to build on the current patchwork of employer-provided insurance, Medicare, Medicaid, Child Health Plus, Family Health Plus, individual pay as you go, indigent care provided by emergency rooms, etc. This approach involves making the health care system more complicated by adding patches to cover people currently left out.

The other approach is to replace the current system with a single government-managed health insurance system, sometimes called “single payer” or “Medicare for all.”

As an elected county leader, I find that a tremendous amount of my time, and my county’s budget, is devoted to one or another aspect of health care for some segment of our citizens. Nearly all of that time is devoted not to delivering health care, but to sorting out who will pay for it.

A big advantage of a single-payer system, compared with our current patchwork, is that it resolves this issue once and for all, and thus offers substantial savings in administrative costs.

Every estimate I’ve seen of those savings overlooks the myriad hidden costs associated with our current system. Here are just a few of those costs I encounter every day:

My county, like every county in the state, has an Office for the Aging. We have a 10-person staff. The largest part of their work consists of helping seniors navigate the health care system, find programs available to help them, and plan how they will manage health care costs now and in the future.

Our personnel department includes a full-time benefits manager who is mostly occupied with assisting employees in dealing with the health insurance program. Those employees lose productive work time consulting with the benefits manager and fighting insurance company denials, which can take hours from the workday.

When we negotiate with our employee unions, health care is always the biggest topic. We have a health care consultant on retainer to help us examine and cost out plan changes that we present to our unions in an attempt to control costs. At least two-thirds of the staff time devoted to collective bargaining is spent on health care issues.

We devoted hundreds of hours of staff time to developing and publicizing a discount prescription card available to all county residents to reduce drug costs for those without insurance.

We have a $400,000 state grant to form a health insurance consortium among local governments to purchase employee health care as a larger group. We will hire a consultant to help us form that consortium and find a suitable plan. Various county staff devotes substantial time to this project.

We have staff in our mental health, public health and social services departments devoted to collecting fees from private insurers to reduce the public cost of programs that deliver various health services.

We have people waiting in jail whom judges are prepared to release to drug or alcohol treatment programs as soon as we can assure payment to the treatment center. Staff in local agencies and our Department of Social Services work on getting these inmates into health care programs, mainly Medicaid, that will cover treatment. Meanwhile, we pay the cost of incarceration.

Our economic development staff encounters aspiring entrepreneurs who would like to start their own businesses, but are tied to a job by the health insurance benefits. Meanwhile, new businesses often have trouble attracting the employees they need, because they cannot yet offer a health plan.

We have staff who don’t like their jobs and perform at less than the desired level, but who remain because they need the health insurance.

Nurses and other health care professionals routinely leave direct service to take jobs in insurance companies, contributing to our severe shortage of nurses and physicians.

This is just a partial list of the many ways county government and local economies spend time and money dealing with the question of who will pay for health care.

None of these costs are ever included in comparisons between single-payer and other health care systems, but every one of them would go away if there was a single, simple and consistent answer to the question, “Who will pay?”

Only a single-payer system will accomplish that.

Tim Joseph in chairman of the Tompkins County Legislature.

Why a Single-payer Health Care System Would Be Good for Counties

by Paul Clay Sorum, MD; Professor of Medicine and Pediatrics, Albany Medical College, Albany, New York; and Chair, New York Capital District Chapter of Physicians for a National Health Program
The Journal of County Administration
October 2007

What can save counties from impending heath insurance driven financial disaster? A single-payer health care system!

“The problem for counties is the soaring health care responsibilities and costs that already consume much of their budgets. County governments have a responsibility for the health of all their residents, especially for those at the margins. Many expend substantial taxpayer dollars on Medicaid, county hospitals, nursing homes, health departments, and other health costs. They provide health insurance for their current employees and retirees. All these costs are rising faster than people’s incomes and property values. County governments desperately need, therefore, a means of fulfilling their responsibilities without causing serious financial problems for county taxpayers.

The first step of a solution is to recognize the need to provide adequate health coverage to all residents of all counties. Almost all health reformers, interest groups, and politicians agree that everyone should have health insurance. If people do not have health insurance, they do not get preventive care, they delay seeking treatment for illnesses, they use the emergency rooms more frequently than those with insurance,and counties end up paying in different ways for the unpaid and higher bills.1 The cost of the health forgone because of uninsurance has been estimated at $65 to $130 billion.2

Not everyone is willing, however, to provide coverage sufficient for people’s health needs. The number of “underinsured” is rising as employers offer reduced coverage. The barebones basic packages envisioned by the Massachusetts reforms, the donut hole in Medicare part D, the high deductible policies increasingly offered to employees–all these leave millions of people underinsured, unable to pay all the co-payments on their medications, at risk of allowing their illnesses get worse, and of going bankrupt if they get seriously injured or sick. Consumer Reports reported that in May 2007 that “29 percent of people who had health insurance were ‘underinsured,’ with coverage so meager they often postponed medical care because of costs.”3 Even the Reader’s Digest is alarmed: in its recent poll, “two-thirds of adults 21 and older said they feel they ‘can’t afford to be sick.'”4

The second step of a solution is to decide how to go about providing this adequate coverage. Reform plans fall into two categories, proposing either to utilize the private insurance companies–through tax credits or vouchers, individual mandates, employer mandates, and/or expansions of public programs for the poor–or to set up a “single-payer” system. In this issue, I will explain why private insurance companies cannot provide the solution and a single-payer system can. In the next issue, I will explain how a single payer system would work and how it can be instituted.

Private insurers add enormous costs to our already skyrocketing medical expenditures. These include both insurers’ administrative costs–the salaries of their highly-paid executives and armies of employees, their marketing expenses, and (in the case of for-profit insurers) their profits–and the billing related costs imposed on providers. In California, billing and insurance-related functions for insurers and providers represent 20-22 percent of privately insured spending in California acute care settings.5 In the US, we spent in 2001 $351 per capita on administrative costs, while the Canadians spent only $54 and the French only $48.6

The health premiums charged by private insurers are soaring, owing in part to their administrative waste and profits. Premiums have increased 78 percent since 2001, while wages increased 19 percent and inflation was 17 percent. For employment-based insurance, they averaged $12,106 for a family of four in 2007 and $4,479 for a single person.7 As a consequence, employers, especially small employers, are dropping health insurance benefits–60 percent of companies offered them in 2007 versus 69 percent in 2000, and only 45 percent of companies with 3-9 employees in 2007 versus 57 percent in 2000–and individuals have difficulty in paying on the open market for adequate insurance (especially since premiums are higher for non-employment-based insurance). Thus, in spite of the widespread conviction that people need health insurance, not only has the number of uninsured risen to nearly 47 million (15.8 percent of the population) 8, but the number who are inadequately insured is rising even faster.9 So the counties’ health burdens are increasing. Even if counties self-insure for their own employees, they may buy health administrative services and pay for health care in markets inflated by the unneeded expenses of the private insurance companies that dominate these markets.

Private health insurers must, according to the logic of the free market,contribute to uninsurance and underinsurance. As long as health insurance is a market commodity, private insurers must promise prospective enrollees as much as possible, but also reduce costs as much as possible, i.e., must spend as little as possible of their premiums on actual health care. Even if individual medical directors and other employees are virtuous and well meaning, they must avoid sick patients and deny care if their companies are to survive in the market.

Furthermore, private insurers cannot, unlike county governments, make the health of the population a top priority. They must, like other businesses, focus on short-term results, not on the long-term health of their enrollees (especially since these people are likely to change insurers and eventually switch to Medicare). In addition, in marketing their products to select groups, they fragment the population and undermine our already-fragile sense of social solidarity: they reinforce people’s short-sighted inclination to refuse to pay for those with more health needs, and fewer means, than themselves. They encourage healthy people to forget that they might one day suffer major illness and injury and that they, and the county as a whole, benefit if all county residents are as healthy as possible.

Private health insurers do not, therefore, provide the solution to the crisis in health expenses faced by county governments. But a public single-payer system, similar to but more inclusive than Medicare, is the solution with public financing but largely private delivery of health care.10 All legal residents would have an insurance card entitling them to basic but comprehensive care, i.e., access to the health services that would provide significant benefit to them. The structure of the single-payer system will be discussed in the next issue. The counties would continue to play a role in delivering health care, through their clinics and hospitals, but would no longer be burdened with paying for this care.

Critics will argue, however, that a single-payer system, an expanded Medicare for All, would not be desirable. These criticisms are found not only in the distorted charges of political candidates, but also in the serious and reasoned arguments of single-payer opponents in scholarly articles and in public forums, such as in Albany, NY, the series of four forums on “The Pros and Cons of Medicare for All” sponsored by public radio WAMC in spring 200611. It is necessary to address the three major criticisms.

First, opponents of a single-payer system assert that it would amount to “socialized medicine,” to “government run medicine,” with health care decisions made by government bureaucrats rather than by physicians. This set of charges distorts the reality of what is proposed.

* Medicare for All is not socialized medicine. In socialized systems, the physicians and other providers are government employees; in Medicare for All, they would remain as they are now, mostly private practitioners, paid not by salary but by fee for service.

* Physicians and patients in countries with national health insurance have greater freedom of decision making than do physicians in the U.S.; in Medicare for All, medicine would be macro-managed; in current managed care, medicine is increasingly micro-managed, as insurance companies strive to reduce their own costs (and thereby increase the psychological as well as financial costs to patients and providers). Second, opponents of a singlepayer system point to Canada and the United Kingdom and charge that it will result in underfunding and waiting lists.

* In fact, single-payer systems do not necessarily result in waiting lists; they are not a problem in, for example, France and Japan.

* Even if they are a problem in Canada and the United Kingdom, the extreme cases are not typical (just as the cases in the U.S. documented in, for example, Michael Moore’s movie, SiCKO, are atypical); the waiting lists involve noncritical care; and lists are being reduced through government efforts to increase capacity, even as the number of Americans without health insurance increases.12

* Not only do those of us with health insurance often face delays to getting certain services, but those without insurance or money face uncalculated waiting times.

* Even if our own capacity is strained as health coverage becomes universal, the American public, the American voters (most of whom currently have insurance) will not put up with longer waiting lists and will insist on increasing our capacity. Third, opponents charge that national health insurance will causes taxes to rise and will bankrupt the country by increasing health care expenses.

* What should interest individuals is not how much they pay for health care in income taxes, but how much they pay in all taxes–sales, property, payroll, and income–plus over-the-counter health expenses. The question is, therefore, what happens to overall costs.

* The only way to achieve universal access to comprehensive health care without increasing costs is to adopt a single-payer system. The reduction in administrative costs of insurers and providers and the elimination of marketing costs and insurance company profits would save far more money than would be spent on providing health coverage for the currently uninsured. On the national level, Hadley and Holahan estimated in 2001 that the cost of the additional health services that would be used if the uninsured were provided insurance would be $33.9 to $68.7 billion.13 Woolhandler, Campbell, and Himmelstein calculated in 1999 that reducing our administrative costs to those of Canada would have saved $209 billion14. In his critique, Henry Aaron argued for a lower figure, $159 billion, but still far more than the estimated additional costs.15 On a state level, the Lewin Group has made estimates of the cost of various plans for universal coverage in numerous states from California to Mississippi; consistently, the single-payer plans save money, the others cost money.16

We must, however, be realistic. Even if having a single-payer health care system would seem beneficial to county governments and residents across America, what would it actually look like, and would it truly be possible to institute such a system? These are the questions to be addressed in the next issue.

Endnotes

1. Ayanian JZ et al. Unmet health needs of uninsured adults in the United States. JAMA. 2000;284:2061-9. Institute of Medicine. A Shared Destiny: Community Effects of Uninsurance. Washington: National Academies Press, 2003. Ross JS, Bradley EH, Busch SH. Use of health care services by lowerincome and higher-income uninsured adults. JAMA. 2006;295:2027-36. County-level estimates of uninsured in 2000 by the US Census Bureau are available at http://www.census.gov/ hhes/www/sahie/statecntyest2000.html, accessed September 24, 2007.

2. Miller W, Vigdor ER, Manning WG. Covering the uninsured: what is it worth? Health Aff. 2004.

3. Are you really covered? Why 4 in 10 Americans can’t depend on their health insurance. Consumer Reports. August 2007. Available at http://www.consumerreports.org/cro/health-fitness/health-care/health-insurance-9-07/ overview/0709_health_ov.htm, accessed September 24, 2007.

4. Howley K. “I can’t afford to get sick”: Think your insurance has you covered? Just wait till you need it most. Reader’s Digest. April 2006: 57-70. Article and poll available at www.rd.com/healthcare, accessed September 24, 2007. A lower estimate of nearly 16 million people ages 19-64 underinsured in 2003 is given by the Commonwealth Fund: Schoen C, Doty MM, Collins SR, Holmgren Al. Insured but not protected: how many adults are underinsured? Health Aff. 2005;w5-289-302.

5. Kahn JG, Kronick R, Kreger M, Gans DN. The cost of health insurance administration in California: estimates for insurers, physicians, and hospitals. Health Aff. 2005;24:1629-39.

6. OECD Health Data. Accessed by David Himmelstein.

7. Kaiser Family Foundation. Employer Health Benefits 2007 Survey. Available at http://www.kff.org/ insurance/7672/index.cfm, accessed September 24, 2007.

8. US Census Bureau: http://www.census .gov/hhes/www/hlthins/hlthin06.html, accessed September 24, 2007.

9. See the references in notes 3 and 4 above.

10. The single-payer system most commonly proposed is described, with multiple links, on the website of the Physicians for a National Health Program: www.pnhp.org.

11. Sorum PC. The pros and cons of “Medicare for All”: a series of public forums on health reform. Health Law Journal 2007;12: 24-37. Audio available at www.wamcarts.org (click on “Archives”).

12. Canadian Institute on Health Affairs. Waiting for health care in Canada: What we know and what we do not know. 2006. Available at http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=AR_1385_E&cw_topic=1385, accessed September 25, 2006. Statistics Canada. Access to health care services in Canada,January to December 2005. Ottawa: Minister of Industry, 2006. Available at http://cansim2.statcan.ca/cgi-Hadleywin/cnsmcgi.pgm?Lang=E&SP_Action=Result&SP_ID=2967&SP_TYP=2&SP_Sort=-0, accessed September 24, 2007.

13. Hadley J, Holahan J. Covering the uninsured: how much would it cost? Health Aff. 2003;W3:250-65.

14. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med. 2003;349:768-75.

15. Aaron HJ. The costs of health care administration in the United States and Canada–questionable answers to a questionable question. N Engl J Med. 2003;349:801-3.

16. Available at http://www.lewin.com/ NewsEvents/Publications/. Look in the category “uninsured & safety net.” Accessed September 16, 2007.

Giuliani’s Prostate Cancer Figure Is Disputed

By JULIE BOSMAN
The New York Times
Published: October 31, 2007

In a radio advertisement playing in New Hampshire and in speeches along the campaign trail, Rudolph W. Giuliani has cited statistics to cut at the heart of his Democratic rivals’ health care proposals, which he has derided as European-style “socialist” plans that will lower the standard of care in the United States.

“I had prostate cancer five, six years ago,” Mr. Giuliani, aRepublican presidential candidate, said in a speech that has been turned into the radio commercial. “My chance of surviving prostate cancer — and, thank God, I was cured of it — in the United States? Eighty-two percent. My chance of surviving prostate cancer in England? Only 44 percent under socialized medicine.”

Mr. Giuliani’s Democratic rivals would argue that they are not advocating government-run health care in their plans to extend coverage to the uninsured. But, beyond that, the 44 percent figure that Mr. Giuliani has been citing is in dispute.

The Office for National Statistics in Britain says the five-year survival rate from prostate cancer there is 74.4 percent. And doctors also say it is unfair to compare prostate cancer statistics in Britain with those in the United States because in the United States the cancer is more likely to be diagnosed in its early stages.

“Certainly, if you intensively screen for prostate cancer, you will find early disease,” said Dr. Ian M. Thompson, chairman of the department of urology at the University of Texas at San Antonio. “And simply because you find it earlier, you will always have longer survival after the disease is diagnosed.”

Maria Comella, a spokeswoman for Mr. Giuliani, said yesterday that the 44 percent figure came from an article in City Journal, a publication of the Manhattan Institute, a conservative research organization.

“The citation is an article in a highly respected intellectual journal written by an expert at a highly respected think tank which the mayor read because he is an intellectually engaged human being,” Ms. Comella said in an e-mail message.

That article, titled “The Ugly Truth About Canadian Health Care,” was written by Dr. David Gratzer, a senior fellow at the Manhattan Institute and an adviser to the Giuliani campaign.

In an interview, Dr. Gratzer said the statistic came from the Commonwealth Fund, a nonprofit group in New York specializing in health care policy issues, but he acknowledged that it was seven years old and “crude.”

But the Commonwealth Fund said yesterday that Dr. Gratzer had misused its research by calculating a five-year survival rate based on data on prostate cancer incidence and mortality rates in the United States and Britain.

“Five-year survival rates cannot be calculated from incidence and mortality rates, as any good epidemiologist knows,” the group said in a statement.

Dr. Gratzer dismissed the Commonwealth Fund’s statement, saying the group had “an ideological bias.” Asked if Mr. Giuliani would continue to repeat the statistic, and if the advertisement would continue to run, Ms. Comella responded by e-mail: “Yes. We will.”

Gina Kolata contributed reporting.

THE CLAIM: GIULIANI’S PROGNOSIS WOULD BE WORSE IN BRITAIN and THE FACTS

The Washington Post
Wednesday, October 31, 2007; Page A06

“I had prostate cancer, five, six years ago. My chances of surviving prostate cancer — and thank God I was cured of it — in the United States: 82 percent. My chances of surviving prostate cancer in England, only 44 percent under socialized medicine.”

— Rudy Giuliani, New Hampshire radio advertisement, Oct. 29, 2007

The former New York mayor has had experience battling prostate cancer, but he’s confused about the stats, according to several experts we consulted.

THE FACTS

As factual support for the presidential candidate’s claim, his campaign cited an article by David Gratzer that appeared in the City Journal, published by the Manhattan Institute, a conservative New York think tank, slamming the Canadian and British systems of “socialized” medicine. The article provides no sources for its assertions about five-year survivability rates for prostate cancer.

Experts from the National Cancer Institute and the urology departments at Johns Hopkins University and the University of Kansas agreed that Giuliani’s figures were way out of date, if they were ever accurate at all. The latest official figures for five-year “survivability” rates for prostate cancer are about 98 percent in the United States and 74 percent in England.

More important, the survivability figures tell us little about the differences in the quality of treatment received by prostate cancer patients in the United States and Britain. Doctors in each country have different philosophies about how to treat the disease, and these differences have greatly influenced the survivability statistics.

In the United States, there has been a big emphasis since the 1990s on early screening through prostate-specific antigen (PSA) testing. Five-year survivability rates have increased simply because the slow-developing disease is being diagnosed at a preliminary stage. If the diagnosis is made early, the chance of surviving for five years is close to 100 percent. Britain is several years behind the United States in the widespread use of PSA testing.

Another way of comparing treatment of prostate cancer in the United States and Britain is to look at the mortality rates. Here the two are much closer. About 25 men out of 100,000 are dying from prostate cancer every year in both countries. The likelihood of dying from prostate cancer is roughly comparable in the two countries, despite different treatment philosophies.

J. Brantley Thrasher, chairman of the Department of Urology at the University of Kansas, said it is “impossible to say” on the basis of the statistics whether a prostate cancer patient has a better chance of surviving under a “capitalistic” or “socialistic” medical system. American doctors tend to be more “interventionist” and more likely to advocate surgery than their counterparts in Britain or Canada, where greater emphasis is put on “active surveillance.” In the United States, a patient with a good health-care plan is “more empowered to make decisions” for himself.

Maria Comella, deputy communications manager for the Giuliani campaign, sent us the following e-mail explaining the mayor’s mistake without quite acknowledging it:

“Mayor Giuliani is an avid reader of City Journal and found the passage in the Gratzer article himself. He cited the statistics at a campaign stop, and the campaign used a recording from that appearance in the radio ad. The citation is an article in a highly respected intellectual journal written by an expert at a highly respected think tank which the mayor read because he is an intellectually engaged human being.”

THE PINOCCHIO TEST

Giuliani is simply wrong when he claims that his chances of surviving prostate cancer are almost twice as high in the United States as in England, under a “socialized” medical system. We award Giuliani four Pinocchios.

To find out the winner of the Fact Checker’s first Geppetto award, and coverage of Tuesday night’s Democratic debate, visit

The serial exaggerator strikes again

By Steve Benen
The Carpet Bagger Report
Posted October 30th, 2007 at 9:15 am

At this point, it appears Rudy Giuliani is just daring the national media. Following up on yesterday’s item, the candidate who can barely go a day without making a wildly misleading exaggeration, has unveiled a new radio ad with a truly audacious whopper, even by Giuliani’s low standards.

OK, Rudy Giuliani has just released an ad claiming that the survival rate from prostate cancer is much higher in America than in Britain, thus proving the failure of socialized medicine.

The problem is that his claim is just plain false. In fact, mortality rates from prostate cancer are almost the same in America and Britain.

So, will this get as much attention as, say, the Edwards haircut or the Hillary laugh? Will it get any coverage at all? Bear in mind that health care is the central domestic issue of this election — and Rudy has just showed that he doesn’t know a thing about it.

It’s really not that complicated. Giuliani, in his campaign spot, claims that the survival rate for prostate cancer patients in the U.S. is 82%, while in England, it’s 44%. Giuliani argues that a universal-coverage system necessarily leads to worse care and more deaths.

But Giuliani doesn’t know what he’s talking about, and his claims were easily debunked.

Keep in mind, this wasn’t just an off-hand comment Giuliani made on the stump. This was a carefully crafted pitch, and put on the air. Giuliani didn’t just flub the facts in response to a voter’s question; he’s intentionally trying to deceive the public with a misleading ad.

And how has the media responded to the leading Republican candidate getting caught lying in a campaign ad? So far, by largely ignoring it.

Reader R.K. alerted me to a discussion on yesterday’s Hardball, where MSNBC’s Chris Matthews showed the ad in its entirety. Matthews and his guests then scrutinized the ad for quite a while. How many mentioned that the ad’s central claim was demonstrably false? None.

Matthews got the discussion started by saying, “Boy, that is classic Live Free or Die, self reliance, the Granite State. Perry, this is like main lining right into that psychology of New Hampshire, which is leave me alone. I don’t trust socialism. Is it going to work in these days, when people are really challenged on health care?”

Perry Bacon discussed the ad in the context of other candidates’ healthcare pitches. Jill Zuckman talked about the ad in the context of taking on Hillary Clinton. Matthews repeatedly asked whether the ad would “work,” by which he meant, win support from voters.

It didn’t occur to any of them to even question Giuliani’s central claim, better yet point out that it’s completely wrong.

As for digging into the policy details a little more, Ezra did a handful of good posts on the subject yesterday, but included a gem last night when he noted the circumstances of Giuliani’s life-saving cancer treatment.

…Giuliani’s case for the superiority of our “free market” health care system goes something like this: While on health insurance provided by New York state, he was treated, using a surgery developed by Europeans, for prostate cancer, a disease that most commonly afflicts those covered by the federal government’s single-payer health care system. Take that, Europe/national health insurance.

Yep, Giuliani is that clueless.

In an effective political system, this would be a fairly big deal. A leading candidate produces an ad (one of a small number created by the campaign) with an obvious falsehood. If reporters cared half as much about this as haircuts, cackles, and cleavage, the process might actually function.

Speaker’s conclusions on health care wrong

Letter to the Editor
Palm Beach Daily News
Sunday, November 04, 2007

I found the article on [HSA Consulting Services president] Roy Ramthun’s health-care talk in (the Oct. 24) Shiny Sheet very interesting but I must take issue with his conclusions. One of these is that “. . . liberals promote covering the uninsured, but that involves taking subsidies away from those who have coverage. They want to cover everybody first and then deal with the cost.”

I am a liberal and am very active in a national campaign with the 14,000-member Physicians For a National Health Program. What we support is Medicare for everyone. It is expressed in the Conyers Bill, HR676, and calls for covering everyone without taking subsidies away from anyone.

It is the only proposal that carefully considered costs during the preparation of the legislation. According to a thorough study published in the New England Journal of Medicine, eliminating all of the middlemen now milking the health care system would result in a saving of at least $350 billion, enough to more than cover all of the uninsured. These figures come from government sources.

As it is now, costs are rising so outrageously that the 47 million without insurance have nightmares, worried over being hit with a serious medical condition. Too many of them find reality nightmarish when they actually are hit. In the words of Dr. Marcia Angell, for years editor in chief of the New England Journal and now a Harvard Medical School professor, “We can no longer afford not to have single-payer universal health care.

DR. H. DAVID PRENSKY
Palm Beach