PNHP Newsletter Spring 2008 FOR A NATIONAL HEALTH PROGRAM » 29 E. MADISON, SUITE 602, CHICAGO, IL 60602 » WWW.PNHP.ORG » SPRING 2008 NEWSLETTER

Open Letter to the Majority of Physicians Support Single Payer Presidential Candidates A majority (59 percent) of physicians in the U.S. support "govern- ment legislation to establish national health insurance," up from 49 “Political calculus favors mandates or tax incentives, which accommodate percent five years ago, according to a study published in the Annals insurers, drug firms, and other medical entrepreneurs. But such reforms are eco- of Internal Medicine in April (reprinted on page 17). The survey, by nomically wasteful and medical dangerous. The incremental changes suggested by PNHP Board Member Dr. Aaron Carroll, corroborates the results of most Democrats cannot solve our problems; further pursuit of market-based recent surveys in New Hampshire, Minnesota, and Massachusetts strategies, as advocated by Republicans, will exacerbate them. What needs to be that found 64-67 percent of physicians in support of single payer in changed is the system itself.” - excerpt from the Open Letter those states. PNHP is spearheading a campaign to garner 10,000 sig- natories for a letter and advertisement urging the candidates to sup- PNHP 2008 Annual Meeting and Leadership Training port single payer national health insurance as the sole hope for San Diego, October 24-25, 2008 affordable, comprehensive coverage. The campaign is endorsed by Drs. Marcia Angell and Arnold PNHP will repeat its popular Leadership Training course in Relman, editors emeriti, New England Journal of Medicine, and health policy, politics, and activism October 24 in conjunction with many other prominent physicians. PNHP'ers are encouraged to cir- the Annual Meeting October 25 in San Diego. Over 500 physicians culate the letter via snail mail or e-mail at www.pnhp.org/letter. and medical students have participated in the program and gained the knowledge base and confidence to speak out in support of health PNHP Media Update care reform. Space is limited; to register call 312-782-6006. Both events will be held the Westin Horton Plaza. To reserve a room The New York Times, Globe, Newsday, Chicago Sun-Times, ($225 single/double), call 800-937-8461 before September 26. Star, Des Moines Register, Atlanta Constitution, New Hampshire Union Leader, LA Times and many other publications have IN THIS ISSUE featured op-eds and letters by PNHP'ers in support of single payer in Democrats’ Plan Not A Health Reform ...... 3 recent months. Thanks to Drs. Bud Goodrich, James Mitchiner, Hoosier Doctor’s Rx for Change ...... 4 Jeremiah Schuur, John Daley, Richard Dillihunt, Kenneth Brummel- ACP Endorses Single Payer ...... 5 Smith, Michael Kaplan, David Kerns, Miles Weinberger, Donald Warning about Massachusetts’ Reform ...... 6 Mitchell and other PNHP'ers for your media outreach. If your op-ed is Yes, We Can All be Insured...... 7 published, please send a copy to [email protected]! Tikkun magazine’s January issue featured PNHP Past President Dr. Data Update...... 8 John Geyman’s article on the presidential candidates' health plans Physicians Support Single Payer...... 17 (online at http://www.pnhp.org/2008plans). 1.8 Million Veterans are Uninsured ...... 20 Letters ...... 21 American College of Physicians (ACP) Scientific American: U.S. Number Two...... 23 Endorses Single Payer Long Waits are Really ...... 32 Survey of U.S. and Canadian Surgeons...... 33

The 124,000-member ACP endorsed single payer for the first time in Special Section on Health Care Finance December, citing international and other evidence that showed that sin- The $150 Billion Swindle ...... 34 gle payer was efficient and affordable. For details, see page 5. Drs. Henry Kahn, Andy Coates, and Oliver Fein are among the Market-based System Raises Health Costs ...... 35 PNHP'ers invited to speak to ACP chapters on the heels of their Competition in a Publicly-Funded System...... 38 endorsement of single payer. Dr. Henry Kahn was "warmly thanked" Two-Tiered Health Care in Australia ...... 42 by the Georgia ACP for defending the ACP's new position. ’s Sustainability Paradox ...... 43 PNHP'ers Dr. Olveen Carrasquillo, Dr. Linda Prine and others Private Health Insurance in Europe ...... 46 helped garner endorsements of single payer from the National Hispanic Medical Association and the New York Academy of Family Presidential Politics and Health Reform ...... 49 Practice (NYAFP). The NYAFP is taking the lead in promoting sin- Immigrants and Health Care ...... 54 gle payer within the American Academy of Family Practice. Chapter Reports...... 58 PNHP Board of Directors, 2008 PNHP Membership Drive Update

Officers Welcome to 981 new members who have joined PNHP in the last Ana Malinow, M.D. (TX), President year! PNHP now has over 15,000 members. We invite new (and long- John Geyman, M.D. (WA), Immediate Past President time) PNHP members to participate in our activities and take the lead Oliver Fein, M.D. (NY), President-Elect on behalf of PNHP in their community. Quentin Young, M.D. (IL), National Coordinator, Treasurer PNHP’ers in Alabama, Florida (Tallahasee), Puerto Rico, Michigan Steffie Woolhandler, M.D. (MA) Secretary (Ann Arbor), (Columbus), Oregon (Corvalis), Connecticut, Arizona, Minnesota, and New York (Rochester and Ithaca) are starting Regional and At-Large Delegates or reinvigorating PNHP chapters in their areas. Garrett Adams, M.D. (KY); Jay Bhatt (medical student, PA) John Bower, M.D. (MS); Olveen Carrasquillo, M.D. (NY) 362 Unions and 89 Members of Aaron Carroll, M.D. (IN); Andrew Coates, M.D. (NY) Gerald Frankel, M.D. (WA); Joseph Jarvis, M.D. (UT) Congress Endorse HR 676 David McLanahan, M.D. (WA); Greg Silver, M.D. (FL) Robert Zarr, M.D. (DC) 33 state chapters of the AFL-CIO and 362 other union groups in 48 states have endorsed HR 676, The National Health Insurance Act. The Past Presidents number of Congressional co-sponsors for single payer legislation con- Claudia Fegan, M.D. (IL); Bob LeBow, M.D. (deceased, ID) tinues to grow, with 89 as we go to press. PNHP’s DC chapter chair Don McCanne, M.D. (CA); Glenn Pearson, M.D. (CO) Dr. Robert Zarr helped garner four co-sponsors on a visit to Capital Deb Richter, M.D. (VT); Cecile Rose, M.D. (CO) Hill with lead sponsor Rep. John Conyers last fall. For a list of spon- Johnathon Ross, M.D. (OH); Jeffrey Scavron, M.D. (MA) sors, see page 45. Gordon Schiff, M.D. (MA); Susan Steigerwalt, M.D. (MI) Isaac Taylor, M.D. (deceased); Quentin Young, M.D. (IL) What PNHP Members Can Do

Honorary Board Member 1. Submit an Op-ed or Letter to the Editor to your local newspaper, Rose Ann DeMoro, Ph.D. California Nurses Association medical specialty journal, or alumni magazine. Dr. Don McCanne encourages PNHP’ers to “recycle” his single payer Board Advisors “Quote of the day” messages into letters and op-eds for local Walter Tsou, M.D. (PA); Karen Palmer, M.P.H (Canada) publication. Subscribe at [email protected]. Sindhu Srinivas, M.D. (PA); David Grande, M.D. (PA) Jaya Agrawal, M.D. (MA); Simon Ahtaridis, M.D. (MA) 2. Set up a Grand Rounds or other conference on health care reform Bree Johnston, M.D. (CA); Sal Sandoval, M.D. (CA) at your hospital, , or professional society (e.g. the local chapter of the American College of Physicians). The PNHP Subscriptions: The PNHP newsletter is published by PNHP, a tax- 2008 slide show is available to members on-line at exempt, not-for-profit organization. 29 E Madison Street, Suite 602, www.pnhp.org/slides under the password “malinow”. Chicago, IL 60602. 312-782-6006. Subscriptions are included in membership dues ($120 regular, $40 low-income, $20 student). 3. Offer to advise candidates for Congress or other public office on Visit the PNHP website at www.pnhp.org. health policy using research and educational resources from PNHP. Call the PNHP national office if you need assistance. Editors: The PNHP Newsletter is edited by PNHP co-founders Drs. David Himmelstein and Steffie Woolhandler, and Executive Director Dr. Ida Hellander. It's Easy to Add PNHP to Your Will.

National Office Staff: PNHP's headquarters in Chicago is staffed by You just add a sentence to your will that says, “I bequeath the follow- Executive Director Dr. Ida Hellander, Communications Director ing ______(dollar amount, property, or stocks) to the non-profit Mark Almberg, Webmaster/Research Associate Dave Howell, organization Physicians for a National Health Program of Chicago, Organizer Todd Main and Office Manager Matthew Petty. Courtney Illinois. Their FEIN # is 04-2937697, and their mailing address is 29 Morrow and Roberto Ramos staff the New York and California E. Madison, Suite 602, Chicago, IL 60602.” chapters of PNHP, respectively.

2 DECEMBER 15, 2007 I Am Not a Health Reform By DAVID U. HIMMELSTEIN an individual mandate for the self-employed and expanded and STEFFIE WOOLHANDLER public coverage for the poor. Over the next six years, the number of uninsured people in the state rose about 35 per- n 1971, President Nixon sought to forestall single-payer cent, from 661,000 to 898,000. national health insurance by proposing an alternative. As governor, Mitt Romney tweaked the Nixon formula IHe wanted to combine a mandate, which would in 2006 when he helped devise a second round of require that employers cover their workers, with a Massachusetts health care reform: employers in the state Medicaid-like program for poor families, which all that do not offer health coverage face only paltry fines, but Americans would be able to join by paying sliding-scale fines on uninsured individuals will escalate to about premiums based on their income. $2,000 in 2008. On signing the bill, Mr. Romney declared, Nixon’s plan, though never passed, refuses to stay dead. “Every uninsured citizen in Massachusetts will soon have Now Hillary Clinton, John Edwards and all affordable health insurance.” Yet even under threat of fines, propose Nixon-like reforms. Their plans resemble meas- only 7 percent of the 244,000 uninsured people in the state ures that were passed and then failed in several states over who are required to buy unsubsidized coverage had signed the past two decades. up by Dec. 1. Few can afford the sky-high premiums. In 1988, Massachusetts became the first state to pass a Each of these reform efforts promised cost savings, but version of Nixon’s employer mandate — and it added an none included real cost controls. As the cost of health care individual mandate for students and the self-employed, soared, legislators backed off from enforcing the mandates much as Mrs. Clinton and Mr. Edwards (but not Mr. or from financing new coverage for the poor. Just last Obama) would do today. Michael Dukakis, then the state’s month, Massachusetts projected that its costs for subsi- governor, announced that “Massachusetts will be the first dized coverage may run $147 million over budget. state in the country to enact universal health insurance.” The “mandate model” for reform rests on impeccable But the mandate was never fully put into effect. In 1988, political logic: avoid challenging insurance firms’ strangle- 494,000 people were uninsured in Massachusetts. The hold on health care. But it is economic nonsense. The number had increased to 657,000 by 2006. reliance on private insurers makes universal coverage unaf- Oregon, in 1989, combined an employer mandate with an fordable. expansion of Medicaid and the rationing of expensive care. With the exception of , the Democratic When the federal government granted the waivers needed presidential hopefuls sidestep an inconvenient truth: only to carry out the program, Gov. Barbara Roberts said, a single-payer system of national health care can save what “Today our dreams of providing effective and affordable we estimate is the $350 billion wasted annually on medical health care to all Oregonians have come true.” The number bureaucracy and redirect those funds to expanded cover- of uninsured Oregonians did not budge. age. Mrs. Clinton, Mr. Edwards and Mr. Obama tout cost In 1992 and ’93, similar bills passed in Minnesota, savings through computerization and improved care man- Tennessee and Vermont. Minnesota’s plan called for uni- agement, but Congressional Budget Office studies have versal coverage by July 1, 1997. Instead, by then the number found no evidence for these claims. of uninsured people in the state had increased by 88,000. In 1971, New Brunswick became the last Canadian Tennessee’s Democratic governor, Ned McWherter, province to institute that nation’s single-payer plan. Back declared that “Tennessee will cover at least 95 percent of then, the relative merits of single-payer versus Nixon’s its citizens.” Yet the number of uninsured Tennesseans mandate were debatable. Almost four decades later, the dipped for only two years before rising higher than ever. debate should be over. How sad that the leading Vermont’s plan, passed under Gov. Howard Dean, called Democrats are still kicking around Nixon’s discredited for universal health care by 1995. But the number of unin- ideas for health reform. sured people in the state has grown modestly since then. David U. Himmelstein and Steffie Woolhandler are professors of The State of Washington’s 1993 law included the major medicine at Harvard and the co-founders of Physicians for a National planks of recent Nixon-like plans: an employer mandate, Health Program. REPRINTED BY PERMISSION 3 | SATURDAY, FEBRUARY 9, 2008 | Prescription for change Hoosier doctor leads drive to fix ailing health system By Daniel Lee - shows Medicare overhead spending was 3.1 per- quality of care and controlling costs. cent of its budget, compared with 26.5 percent "We believe a single-payer health-care system Dr. Rob Stone was a teenager in Southern for investor-owned Blue Cross and Blue Shield would hinder progress in these areas by eliminat- when he felt the call to become a physi- plans. ing competition and restricting patient choice cian. Another slide -- with information from the and could require patients to endure long wait It began during a stint as a counselor at a camp Employer Health Benefits Annual Survey and times for care while possibly reducing the quality in Tell City for children with disabilities. An Ivy Bureau of Labor Statistics -- showed that from of health care," WellPoint spokesman Jim Kappel League education and career as a doctor followed. 2000 to 2006 health insurance premiums rose 87 said in an e-mail. Then, decades later, came a second calling: He percent while workers' earnings rose 18 percent. In its recent earnings report, WellPoint touted became an agitator for changing the nation's About 47 million Americans, including that it lowered its administrative expenses to 14.5 health-care system. 750,000 Hoosiers, are without health insurance. percent of premium revenue in 2007 from 15.7 Stone, an emergency room physician at It's a complex and uphill battle. percent in 2006 even as it added 708,000 mem- Bloomington Hospital, has emerged as one of bers. Indiana's most outspoken advocates for making The company also pointed to flaws in other insurance accessible to all. He is co-founder and nations' health-care systems. director of Hoosiers for a Commonsense Health "In Canada, which has a single-payer system, Plan, which contends that the current system is the average wait between a general practitioner too profit-driven, too inefficient, and leaves too referral and a specialty consultation at times has many people without affordable access to health been longer than 17 weeks." care. Stone stands by his position. He recalls a HCHP -- made up of doctors, nurses, social patient who refused to seek treatment for chest workers, patients and others -- is an affiliate of pains that turned out to be a heart attack. He the national Physicians for a National Health finally sought treatment for a second attack, only Program. DANESE KENON / THE STAR because the first attack left him disabled -- but From its founding in September 2005, HCHP Passion for public service: Bloomington doctor now eligible for government coverage. has grown from a small band of advocates to a Rob Stone consults with Lori Wilbur, Bloomington, The physician has scaled back his work at statewide citizens group with dozens of active at the Volunteers in Medicine of Monroe County Bloomington Hospital to two shifts a week to volunteers and an e-mail list of more than 1,500. clinic. Stone, co-founder of Hoosiers for a devote more time to HCHP. He volunteers at a Stone, 55, said his motivation stems from his Commonsense Health Plan, donates time to the clinic for the uninsured and serves on the hospi- clinic that serves the uninsured. many years of seeing the struggles of patients tal's board and as chief of its medical staff. He also needing care. is a partner of his physician practice, Unity "It started dawning on me just how crazy our " 'Single payer' is not a phrase that is rolling off Physician Group. current system is, and the cost shifting and the anyone's lips in the presidential race, with the Stone and his wife, Karen Green Stone, who crazy patchwork quilt of payer sources, just how exception of Dennis Kucinich," said Alwyn heads HCHP's education committee, live in a insane the system seems to be," Stone said. "That, Cassil, director of public affairs for the Center for home that Stone built outside Bloomington. coupled with watching as the ER became more Studying Health System Change, a Washington, Their home is unofficial headquarters for the and more of the safety net for the uninsured." D.C.-based research group. state organization. Stone brings that message to Indianapolis Many Americans, she said, tend not to be He is finding many people who are willing to today during a public forum titled interested in what they consider a government listen. "Understanding the Health Care Crisis: Problems solution to the health-care crisis. Cassil said hos- "Dr. Stone put together an incredible amount and Solutions," which runs from 9 a.m. to noon at pitals, insurers, device makers and many doctors of information. It was very eye-opening," said Indianapolis First Friends, 3030 Kessler Blvd., benefit from the current system. Beth Henricks, a tax consultant and Geist-area East Drive. But Stone does have some allies. Physicians for resident who saw Stone's presentation to a group One of Stone's favorite targets is Indiana's a National Health Program was founded by two of executives several months ago in Indianapolis. largest health-care insurance provider, Harvard professors of medicine, David "When I see somebody who's that passionate, Indianapolis-based WellPoint, a $61 billion Himmelstein and Steffie Woolhandler, and has that's really appealing to me." health insurance giant that provides coverage to grown to more than 14,000 members. Stone's point that the already 35 million people in America. "They're a very dedicated, committed group," has a "single-payer" program in Medicare that "WellPoint epitomizes our system," he said. Cassil said. covers millions seemed to make sense, said "They're it." Groups like Stone's, while small in the number Henricks, whose company First Advantage has Stone's PowerPoint presentation lays out his of physicians who take part, are credible advo- faced annual health insurance premium increases case. A Medicare-type program for all is better cates because they're out on the front lines of of 20 percent to 25 percent in recent years. than the current system, he says. Medicare is cur- medicine and often stand to lose income if the "Medicare works pretty well, and it's been rently for the elderly. reforms they seek ever become reality, Cassil said. around for a long time, so why not pattern some- One slide -- with information attributed to the For its part, WellPoint sees having a competi- thing after Medicare?"

REPRINTED BY PERMISSION International Journal of Health Services in 2005 - tive, free-market system as key to improving the http://www.hchp.info/

4 29 East Madison Street, Suite 602 Chicago, Illinois 60602-4404 Telephone 312.782.6006 Fax 312.782.6007 [email protected] www.pnhp.org Nation’s Largest Medical Specialty Group Endorses Single Payer Health Reform Says U.S. should learn from other nations’ health systems

For Immediate Release: December 11, 2007

After careful evaluation of the health systems of 12 other nations, the American College of Physicians (ACP), the nation’s largest medical specialty society and second largest medical association (124,000 members), endorsed single payer national health insurance as “one pathway” to universal coverage. The ACP represents specialists in internal medicine.

“This new proposal by the ACP brings single payer into the mainstream,” said Dr. C. Anderson Hedberg, President Emeritus of the ACP. “It’s the logical next step.”

Although ACP has advocated universal coverage since 1990, and had their own proposal for reform since 2002 based on a “pluralistic” model, this is the first time they have endorsed single payer national health insurance.

“There’s really only one choice for universal health care at a cost we can afford, and that’s single payer, Medicare for All,” said Dr. Marcia Angell, former editor-in-chief of the New England Journal of Medicine. “There is simply no way to cover everyone in a pluralistic system and control costs.”

“This changes the political landscape for the presidential candidates, who now will need to take a fresh look at single payer. It recognizes the political feasibility of single payer as well as its importance as a leading option for health care reform” said Dr. Quentin Young, a “Master” in the ACP and National Coordinator of Physicians for a National Health Program (PNHP).

PNHP is a 15,000 member organization headquartered in Chicago that has advocated for single payer national health insurance since 1986. The group’s peer-reviewed research and reform proposals in support of single payer are on-line at www.pnhp.org.

The ACP said their recommendation is based on a large and growing body of evidence that the U.S. health system is per- forming poorly compared to nations with single payer national health insurance:

“Single-payer systems generally have the advantage of being more equitable, with lower administrative costs than sys- tems using private health insurance, lower per capita health care expenditures, high levels of consumer and patient satis- faction, and high performance on measures of quality and access.” (ACP Position Paper, Annals of Internal Medicine, 1 Jan 2008, p. 55-75)

“The ACP endorsement of single payer is an important step forward for the medical profession,” said Dr. John Geyman, author of “The Corrosion of Medicine: Can the Profession Reclaim its Moral Legacy” and Past President of PNHP. “Instead of ideology and unbridled self-interest, they are putting patients’ needs first.”

“Of all the forms of inequality, injustice in health care is the most shocking and most inhumane.” –Rev. Martin Luther King Jr.

5 Early Outcomes from Massachusetts’ Health Care Reform An Open Letter to the Nation from Massachusetts Physicians

We write to alert colleagues and the nation to the afford premiums for even the skimpiest coverage; the disturbing early outcomes of Massachusetts’ widely- lowest cost plan offered for a couple in their fifties costs heralded approach to health care reform. Although we $8,200 annually, and carries a $2,000 per person wish that the current reform could secure health insur- deductible. ance for all, its failings reinforce our conviction that only Moreover, the state’s cost for subsidies is running a single payer program can assure patients the care they $147 million over the $472 million budgeted for fiscal need. year 2007. Meanwhile, collections from fines on employ- In 2006, our state enacted a law designed to extend ers who fail to provide coverage are 80% below the orig- health coverage to virtually all state residents. Political inal projections. The funding gap will widen in future leaders in other states as well as several Democratic years as health care costs escalate and insurers raise pre- presidential candidates have embraced this model. miums. Already, state officials speak of making up the Massachusetts’ law mandates that uninsured individu- shortfall by forcing patients to pay sharply higher co- als must purchase private insur- pays and deductibles, and by ance or pay a fine. The law estab- While patients, the state and slashing funds promised to safety lished a new state agency to net hospitals. ensure that affordable plans were safety net providers struggle, While patients, the state and available; offered low income resi- private insurers have pros- safety net providers struggle, pri- dents subsidies to help them buy pered under the new law, vate insurers have prospered coverage; and expanded Medicaid under the new law, and the costs coverage for the very poor. and the costs of bureaucracy of bureaucracy have risen. Blue (Immigrants are mostly excluded have risen. Blue Cross, the Cross, the state’s largest insurer, from these subsidized programs.) state’s largest insurer, is is reaping a surplus of more than Moneys that previously funded $1 million each day, and awarded free care for the uninsured were reaping a surplus of more its chairman a $16.4 million shifted to the new insurance pro- than $1 million each day retirement bonus even as he con- gram, along with revenues from tinues to draw a $3 million salary. new fines on employers who fail to offer health benefits to All of the major insurers in our state continue to charge their workers. In addition, the federal government provid- overhead costs five times higher than Medicare and ed extra funds for the program’s first two years. eleven-fold higher than Canada’s single payer system. Starting January 1, 2008 Massachusetts residents face Moreover, the new state agency that brokers private fines if they cannot offer proof of insurance. Yet as of coverage adds its own surcharge of 4.5% to each policy December 1, 2007 only 37% of the 657,000 uninsured had it sells. gained coverage under the new program. These individ- A single payer program could save Massachusetts uals often feel well served by the reform in that they more than $9 billion annually on health care bureaucra- now have health insurance. However, 79% of these cy, making universal coverage affordable. But because newly insured individuals are very poor people enrolled the 2006 law deepened our dependence on private in Medicaid or similar free plans. Virtually all of them insurance, it can only add coverage by adding costs. were previously eligible for completely free care funded Though politically feasible, this approach is already by the state, but face co-payments under the new plan. proving fiscally unsustainable. The next economic In effect, public funds for care of the poor that previous- downturn will push up the number of uninsured just as ly flowed directly to hospitals and clinics now flow the tax revenues needed to fund subsidies fall. through insurers with their higher administrative costs. The lesson from Massachusetts is that we still need Among the near poor uninsured (who are eligible for real health care reform: single payer, non-profit national partial premium subsidies) only 16% had enrolled in the health insurance. new coverage. And barely 7% of the uninsured individu- als with incomes too high to qualify for subsidies had Signed by Dr. Rachel Nardin and 250 other physicians in enrolled according to the official state figures. Few can Massachusetts.

6 JULY 30, 2007 ISSUE Yes, We Can All Be Insured By Jane Bryant Quinn Health insurers hate this model, which care and mortality, we lag behind Canada would end their gravy train. So they’re and Europe. Many individuals do indeed Prepare to be terrorized, shocked, trying to tar single-payer as a kind of get superior care, but so do people in sin- scared out of your wits. No, not by medical Voldemort, ready to destroy. gle-payer countries, and at lower cost. jihadists or dementors (you do read Here are some of their canards, and my They have long waiting times. No “Harry Potter,” right?), but by the evil replies: advanced country has waiting periods for threat of … universal health insurance! Universal coverage costs too much. emergency surgery or procedures that are The more the presidential candidates talk No—what costs too much is the system urgently needed. The United States has it up, the wilder the warnings against it. we have now. In 2005, the United States shorter waits than Canada and England Cover everyone? Wreck America? Do you spent 15.3 percent of gross domestic prod- for elective surgery. Still, queues are know what care would cost? uct on health care for only some of us. developing here, at the doctor’s door. In a But the public knows the American France spent 10.7 percent and covered study of five developed countries, the health-care system is breaking up, no everyone. The French comparison is good Commonwealth Fund looked at how matter how much its backers cheer. For because its system works very much like many sick adults had to wait six days or starters, there’s the 46 million uninsured Medicare-for-all. The other European more for an appointment. By this meas- (projected to rise to 56 million in five countries, all with universal coverage, ure, only Canada’s record was worse than years). There’s the shock of the underin- spent less than France. ours. But waits depend on how well a sys- sured when they learn that their policies Why are U.S. costs off the charts? tem is funded, not with the fact that it’s exclude a costly procedure they need— Partly because we don’t bargain with single-payer. Many countries that cover forcing them to run up an unpayable bill, providers for a universal price. Partly everyone, including France, Belgium, beg for charity care or go without. And because of the money that health insurers Germany and Japan, report no issue with think of the millions who plan their lives spend on marketing and screening people waits at all. around health insurance—where to in or out. Medicare’s overhead is just 1.5 There’s no problem; people get care work, whether to start a business, when percent, compared with 13 to 16 percent even if they’re uninsured. They don’t. to rretire, even whom to marry (there are in the private sector. John Sheils of the They get emergency treatment but little “benefits” marriages, just as there are Lewin Group, a health-care consultant, else. As a group, the uninsured are sicker, “green card” marriages). It shocks the says that the health insurers’ overhead suffer more from chronic disease and conscience that those who profit from came to $120 billion last year, of which rarely get rehabilitation after an injury or this mess tell us to suck it up. $40 billion was profit. By comparison, it surgery. They also die sooner—knowing I do agree that we can’t afford to cover would cost $54 billion to cover all the that, withh insurance, they might have everyone under the crazy health-care sys- uninsured. lived. tem we have now. We can’t even afford all Eeeek, your taxes would go up! Right now, Congress is trying to bring the people we’re covering already, which Maybe not, if Sheils is right. Both the 3.3 million uninsured children into the is why we keep booting them out. But we Congressional Budget Office and the State Children’s Health Insurance have an excellent template for universal General Accounting Office have testified Program. President George W. Bush says care right under our noses: good old that the United States could insure every- he’ll veto the expansion as “the wrong American Medicare. When you think of one for the money we’re spending now. path for our nation.” He objects to “gov- reform, think “Medicare for all.” But even if taxes did rise, you might still ernment-run health care” (like Medicare?) Medicare is what’s known as a single- come out ahead. That’s because your and says that SCHIP “deprives Americans payer system. In the U.S. version, the gov- Medicare plan would probably cost less of … choice” (like the choice to go unin- ernment pays for health care delivered in than the medical bills and premiums sured?). Buzzwords like “government the private sector. There’s one set of com- you’re paying now. run” are supposed to summon up mon- prehensive benefits, with premiums, co- We get world-class care; don’t tamp- sters like “” that pays and streamlined paperwork. You er with it. On average, we don’t. apparently still lurk under our beds. If can buy private coverage for the extra International surveys put France in first these terror tactics work, prepare for costs. place. On almost all measures of health another 46 million uninsured. REPRINTED BY PERMISSION

7 Data Update UNINSURED AND UNDERINSURED X Almost 40 million (20 percent) Americans can't afford or access needed health care according to a report from the X The number of Americans without health insurance Centers for Disease Control and Prevention (CDC). One-fifth jumped by 2.2 million to 47.0 million people (15.8 percent of of Americans can't afford one or more of the following servic- the population) in 2006 (the most recent year for which es: medical care, prescription medicines, mental health care, data is available). There are now more uninsured in the U.S. dental care, or eyeglasses. Data were collected in a survey of than at any time since the passage of Medicare and roughly 100,000 individuals (Centers for Disease Control and Medicaid in the mid-1960's. the National Center for Health Statistics, 12/03/07). The proportion of people covered by employer-spon- sored private coverage fell from 69.0 percent in 2000 to 59.7 89.6 million U.S. residents younger than age 65 (34.7 percent in 2006. Government employees account for about percent of the non-elderly population) lacked health one-fourth of all people with employer-sponsored coverage. insurance at some point during 2006-2007, according The number of uninsured children rose by 611,000 to 8.7 to data from the Census Bureau's annual Current million in 2006, 11.7 percent of all children. With private Population Survey (CPS) and the Survey of Income and employer-sponsored coverage deteriorating rapidly, the Program Participation (SIPP). Most uninsured individ- number of uninsured children has fallen only 17 percent uals lacked coverage for many months: nearly two- since SCHIP was enacted in 1997, from 10.74 million thirds (63.9 percent) were uninsured for six months or (adjusted to be comparable to current figures) to 8.66 mil- more; and more than half (50.2 percent) were unin- lion. Over 6.6 million children were covered by SCHIP in sured for nine months or more. The study also found 2006. that 79.3 percent of residents who lacked health insur- 15.3 million Hispanics (34.1 percent) were uninsured in ance were from working families, with 70.6 percent 2006, up 1.3 million from 2005. 7.6 million Blacks (20.5 employed full time and 8.7 percent employed part time. percent) were uninsured in 2006, up 600,000 from 2005. ("Wrong Direction: One Out of Three Americans Are In Massachusetts, often cited as a model for health reform, Uninsured", Families USA, 9/21/07). the number of uninsured increased from 583,000 in 2005 (9.2 percent) to 657,000 in 2006 (10.4 percent). (The X 29 percent of low- and middle-income households with Massachusetts estimate predates full implementation of credit card debt report that medical bills are a contributor to the 2006 health reform law). their current balances. Households reporting medical debt 90.9 million Americans (30.6 percent) were covered by have higher levels of credit card debt than those without government programs or the VA in 2006. This included 40.3 medical debt - $11,623 versus $7,964. Researchers surveyed million people with Medicare (13.6 percent), 38.3 million 1,150 adults with family incomes between 50 percent and 120 with Medicaid (12.9 percent), 10.6 million (3.6 percent) percent of local median income ("Borrowing to Stay Healthy: with VA/military and 1.7 million in other programs (under 1 How Credit Card Debt Is Related to Medical Expenses", percent) (United States Census Bureau, "Health Insurance Access Project, 01/16/07). Coverage 2006"). X Forty percent of Americans are inadequately insured, Maine's widely-touted 2003 health reform plan has according to a survey by Consumers Reports. The group sur- expanded the number of people with coverage by only veyed 2,905 Americans aged 18-64 and found that 29 percent 11,000, less than 10 percent of the 136,000 uninsured in of those with health insurance coverage (24 percent of the Maine in 2002, according to a recent study. 83 percent total U.S. population) were underinsured, while 16 percent of Maine businesses that don't insure their workers were uninsured. cite the high monthly cost of premiums for The underinsured reported two or more (out of six) spe- DirigoChoice, the state-subsidized plan which costs cific problems with their plans, such as inadequate prescrip- $336 per single employee, just $30 less than other plans tion drug coverage (63 percent). In the past 12 months, many in the state. In addition, revenues for subsidies for of the underinsured reported having to postpone needed low-income families (which are supposed to come medical care due to costs (56 percent), having to use their from fees paid by private insurers and providers based savings to pay medical expenses (33 percent), making job- on their savings on uncompensated care) have fallen related decisions based mainly on health care needs (21 per- short of projections by over 50 percent. (Lipson et al, cent), having outstanding medical debts to doctors or hospi- Mathematica, Commonwealth Fund, 12/05/07). tals exceeding $5,000 (17 percent), or postponing home or car

8 repairs due to medical costs (38 percent). In addition, 71 per- County") in Chicago is facing another $108 million in cuts cent said they are dissatisfied with their household's share of after being forced to close clinics and lay off 1,000 doctors, out-of-pocket medical expenses, 34 percent said their retire- nurses, and other health workers to save $100 million last ment decisions were adversely affected by health expenses, year. Without new funding, the County will have to close a and only 37 percent reported being financially able to handle center that treats one-third of the area's HIV patients, all 12 an unexpected major medical expense in the next 12 months. neighborhood clinics, and two public hospitals, Provident (Consumer Reports, August 6, 2007). and Oak Forest. Only Stroger Hospital and the facility that treats jail inmates will remain, and officials admit that there's X Uninsured patients aged 18 to 64 years are 1.6 times more "no way" they'll be able to take care of all the people who have likely than patients with private insurance to die within 5 "no insurance and no other means." years of being diagnosed with cancer, according to a study by About 300 public hospitals have closed in the past 15 researchers with the American Cancer Society (ACS). The years, including LA's Martin Luther King Jr.–Harbor uninsured were less likely to receive timely screening tests Hospital and Washington's, DC General Hospital. The and more likely to be diagnosed with advanced stage disease nation's 1,300 public hospitals account for two percent of all than patients with private coverage. Patients with Medicaid hospitals but provide 25 percent of the nation's uncompen- coverage also fared poorly, partly because many beneficiaries sated care (New York Times, 1/8/08, Los Angeles Times, receive coverage only after diagnosis. (Ward et al, 2/14/08, Cain's Chicago Business, 2/8/08). Association of Insurance with Cancer Care Utilization and Outcomes, CA Cancer J Clin, January, 2008). COSTS

X About 122,000 Medi-Cal beneficiaries in California will lose X Health spending in the U.S. in 2006 was up 6.7 percent to their health coverage and join the ranks of California's 6.8 mil- $2.1 trillion, $7,076 per person, 16.0 percent of GDP. The lion uninsured if Governor Schwarzenegger's proposal that Centers for Medicare and Medicaid Services projects that in patients be required to file eligibility forms four times a year 2008 health care spending will be $2.4 trillion, or $7,868 per passes. Medi-Cal is the state's Medicaid program. The plan, capita, and consume 16.6 percent of GPD. (CMS, Health which would affect 4.5 million of the 6.5 million Medi-Cal ben- Affairs 2/26/08). eficiaries, would allow the state to dump people who no longer meet eligibility requirements faster, shifting an estimated $92 The average premium for family coverage in 2007 million a year in medical bills to patients. Schwarzenegger was $12,106, with workers paying an average of $3,281 proposes cutting another $1 billion from the program by reduc- of the cost. The average premium for individual cover- ing benefits and cutting payments to providers by 10 percent. age was $4,479 with workers paying an average of $694 Medicaid accounts for 22 percent of spending by state govern- of the cost. Health insurance premiums grew 78 per- ments (Chorneau, San Francisco Chronicle, 02/25/08, National cent between 2002 and 2007, compared with cumula- Governors Association, June 6, 2007). tive inflation of 17 percent and cumulative wage grow of 19 percent over the same period ("Employer Health X Safety-net hospitals are facing deep deficits and service Benefits, 2007" Kaiser Family Foundation, 9/07). cuts across the country. LA County is proposing to reduce services at its six outpatient centers, which provide about X The Center for Medicare and Medicaid Services (CMS) 400,000 patient visits per year, to close a $195 million deficit. estimates that in 2017 health spending will be $4.3 trillion, Two-thirds of their patients are uninsured. and the share of health spending by federal and state govern- In Atlanta, Grady Hospital is in deep financial trouble, and ment's will increase 3 percentage points, from 46 percent in its Joint Commission accreditation is at risk. Grady provides 2006 to 49 percent in 2017 (these figures exclude coverage for 850,000 outpatient visits and more than 30,000 hospitaliza- government employees and tax subsidies to employers). Part tions a year (only 8 percent covered by private insurance), of the increased spending by government will be due to an and trains one in four Georgia physicians. It has the region's increase in enrollment in private Medicare plans, which cost only Level 1 trauma center and ambulance fleet. Yet besides 12 percent more than traditional Medicare (for details, see owing $71 million to creditors, it faces a $53 million deficit the Medicare section of the Data Update, below). (Health this year and is $366 million behind in needed capital Affairs and Kaiser Daily Health Policy Report, 2/26/08). improvements, such as replacing the trauma ward x-ray machine (which broke two years ago), and equipment for X "Cherry picking" is profitable to insurers because 1 percent cardiac catheterization and MRIs. The wait for elective of the population accounts for over 20 percent of health orthopedic procedures is, according to one doctor, "infinity." spending, while the sickest 10 percent account for over 60 Cook County's Stroger Hospital (previously "Cook percent of health spending. In contrast, the half of the popu-

9 lation with the least health spending accounts for only three X Ford and General Motors have turned over responsibility percent of spending (Trends in Health Care Costs and for retirees' health care costs to the United Auto Workers. Spending, Kaiser Family Foundation, September 2007). The corporations will pay a fixed amount in cash, stocks and assets into a Voluntary Employee Benefits Association X The Federal Employees Health Benefit Program (FEHBP) (VEBA) trust under the supervision of the UAW to cover is often cited as a model for health care reform. But represen- retirees' health care costs. Ford will pay off its estimated $31 tatives from the Government Accountability Office (GAO) billion in retiree health care liabilities with a lump sum of testified to Congress that the apparent success of the pro- $23.7 billion and GM will pay off its estimated $46.7 billion gram in holding premium increases under 2 percent in 2007 in liabilities with a lump sum payment of $26.5 billion is misleading. Premiums would have risen an average of 9 (Kaiser Daily Health Policy Report, 12/04/07, GM Expects percent if reserves had not been used to reduce premiums Further Cost Cuts, AP, 01/17/08). (accounting for 5 percentage points of the difference) and benefits had not been cut (Testimony by John Dicken, GAO, X Out-of-pocket costs for maternity care are higher in con- 5/18/07, Kaiser Daily Health Policy Report, 5/21/07). sumer-driven health plans than in traditional plans, accord- ing to a study by the Georgetown Health Policy Institute. Health care expenses that exceed 10 percent of pre- The group modeled cost-sharing for different birth scenarios. tax family income is one measure of "underinsurance." For an uncomplicated delivery, out-of-pocket costs ranged More than 61 million Americans are in families that will from $1,455 in a traditional plan to $7,884 in a CDHC plan in spend more that 10 percent of their pre-tax income on the individual market. Similarly, out-of-pocket costs with a health care (up from 37.1 million in 1996) and 13.5 mil- C-section ranged from $2,244 in the traditional plan to lion are in families that spend over 25 percent of their $9,818 in a CDHC plan. (Maternity Care and Consumer- pre-tax income on health care. More than four out of Driven Health Care, Karen Pollitz, Mila Kofman, Alina five people (82.4 percent) in families spending more Salganicoff, Usha Ranji, Kaiser Family Foundation, 6/12/07). than 10 percent of their pre-tax income on health care costs have health insurance. Similarly, three-fourths Single Payer Would Save Money in (75.8 percent) of those spending more than 25 percent Colorado, Kansas, New Mexico of their pre-tax income on health care costs have health insurance, according to a Families USA report based on Three new fiscal studies of single payer at the state level data from the Bureau of Labor Statistics' Consumer show that it would be possible to cover everyone and save Expenditure Survey (Too Great a Burden: America's money on total annual health spending. Savings are pro- Families at Risk, Families USA 12/20/07). jected for Colorado ($1.4 billion), Kansas ($869 million), and New Mexico ($178 million) by the consulting firms of X Eight percent of adults ages 19 to 64 who are privately Lewin, Schramm-Raleigh, and Mathematica, respectively. insured all year, or 8.5 million people, are covered through Each firm also evaluated several other options for reform; the individual insurance market, according to a Princeton all cost more for less coverage. survey of 1,878 privately insured adults age 19-64. Only a third (34 percent) rate their coverage as excellent or very good, compared with 54 percent of those enrolled in SOCIOECONOMIC INEQUALITY employer plans. Two of five adults (43%) covered through the individual market spent more than 10 percent of their X Hospitals charged uninsured and "self-pay" patients 300 incomes on premiums and out-of-pocket medical expenses, percent of their Medicare- allowable costs and 250 percent of compared with one of four (24%) of those insured through the amount private insurers paid for the same services in employer plans. (S. R. Collins, J. L. Kriss, K. Davis, M. M. 2004. The gap between rates charged to self-pay patients and Doty, and A. L. Holmgren, Squeezed: Why Rising Exposure those charged to other payers for hospital care has widened to Health Care Costs Threatens the Health and Financial dramatically since the mid-1980's. Researchers looked at Well-Being of American Families, The Commonwealth hospitals because there is better data on their charges, not Fund, September 2006) because hospitals necessarily overcharge the uninsured more 11 percent of all applicants for individual insurance cover- or less than other providers. (Anderson G, "From Soak the age in 2006, and 30 percent of those applicants between the Rich to Soak the Poor: Recent Trends in Hospital Pricing" ages of 60 and 64, were not offered a policy (at any price) Health Affairs 26, No.3 2007). after a review of their medical conditions, according to a sur- vey by America's Health Insurance Plans (New York Times X The Cleveland Clinic, Nebraska Medical Center, and other 12/19/07). hospitals now require that patients pay out-of-pocket costs

10 before surgery. In a February, 2008 letter to physicians, X Marketing expenditures by drug companies grew from Cleveland Clinic CEO Fred DeGrandis, wrote that the clinic $11.4 billion in 1996 to $29.9 billion in 2005. Spending on "started this new "point-of-service" policy because it offers direct-to-consumer advertising increased three-fold over the more convenience for patients and decreases the number of same period, to $4.2 billion, 14 percent of total marketing days that bills remain in receivables." "Scheduled patients are expenditures (New England Journal of Medicine, 08/06/07) notified when they pre-register that applicable co-pays will be due at the time of service. In addition, signs regarding the Drug companies have raised the prices on medications new co-payment collection initiatives are posted throughout needed by low-income seniors, and on "unique" medica- the hospital…We encourage your office staff to communicate tions with no therapeutic substitute, in response to the the expectation of co-pays when instructing patient about passage of Medicare Part D, according to a study pub- upcoming tests and procedures." Although the memo notes lished in Health Affairs. Seniors who are "dual-eligible" that "no patient will be turned away or denied treatment for for Medicaid account for about 29 percent of Part D failure to make their co-payment," placing the hospital in the enrollees, and a higher share of drug utilization. roll of toll-keeper undoubtedly causes many patients to forgo Previously, drug companies were required to give necessary care (Cleveland Clinic memo and Omaha World Medicaid their "best price" on medications for this popu- Herald, 3/26/08). lation, but this is no longer the case now that low- income seniors have been shifted into private Part D drug X For decades, Mississippi and neighboring states with large plans. Several drug giants reported rosy gains based on black populations and persistently high poverty rates made this shift in their annual reports. Additionally, prices on steady progress in reducing infant death. But, in recent years, unique brand-name drugs used disproportionately by the death rate has risen in Mississippi and several other states. the elderly had major price increases during the first half In Mississippi, infant deaths among blacks rose from 14.2 per of 2006. "The enhanced market power of the manufactur- thousand in 2004 to 17.0 per thousand in 2005 and from 6.1 per er created by Part D" is a threat to Medicare's financial thousand to 6.6 among whites. The national average in 2005 stability, concluded the report (Frank and Newhouse, was 13.7 for blacks and 5.8 for whites (Eckholm, "Infant Deaths Health Affairs, Jan/Feb 2008). Rise in South" New York Times, 04/22/07). X Overall prescription drug prices rose 8.2 percent in 2006, PHARMACEUTICALS, INC slightly slower than in 2005. However, prices of some cate- gories of drugs increased much faster. The cost of drugs used X Bristol-Myers Squibb will pay a $515 million fine to settle to treat diabetes went up 15.5 percent in 2006 - the second charges that it illegally inflated wholesale prices and promot- year of double digit increases for these products. One tech- ed its products for unapproved uses. The U.S. government nique drug companies use to boost revenues and reduce uses average wholesale prices, as reported by drug makers, to generic substitution is to steeply hike the price of a drug that set reimbursement rates for medicines used by federal health is about to go off patent, prompting patients to switch to a programs, including Medicare and Medicaid (Bloomberg, newer product made by the firm that still has a long patent 09/28/07). life (St. Louis Post Dispatch, 04/26/07, Kaiser Daily Health Policy Report, 2/21/08). Drug and insurance companies spent a combined $2.2 billion lobbying Congress between 1998 and 2007. X Prescription drug spending will increase to $1,537 per per- Pharmaceutical companies and their trade associations son by 2017, up from $761 per person in 2007. Out-of-pocket spent $1.2 billion, more than any other industry. spending on prescription drugs will remain about 18 percent Insurance companies and their trade associations came of total drug costs. The share covered by private insurance in second in lobbying expenditures over the decade, at will shrink from about 41 percent to 33 percent over the $978 million. Drug makers dispatch over a thousand decade, while the share covered by public insurance will agents to lobby congressional committees and adminis- increase from 40 percent to 49 percent in 2017 (Baltimore tration offices each year. They succeeded in making Sun, 2/26/07). Medicare Part D a windfall for the drug companies by prohibiting Medicare from negotiating drug prices, and X AstraZeneca will pay a $215 million fine in Alabama for in blocking drug re-importation. (OpenSecrets.com inflating prices to that state's Medicaid program. The Lobbying Database, 02/11/08 and Ken Dilanian, Montgomery County Circuit Court jury found AstraZeneca Senators Who Weakened Drug Bill Got Millions from liable for misrepresentation and fraudulent concealment Industry, USA Today, 05/14/07). (Kaiser Daily Health Policy Report, 2/28/08).

11 Eli Lilly faces a $1 billion fine to settle civil and criminal in Florida to defraud the state of $35 million over five years. The charges stemming from the company's marketing of the company is also under investigation by New York, Georgia and drug Zyprexa. Zyprexa has serious side effects including Connecticut officials. (Wall Street Journal, 11/3/07). diabetes and death and is approved only to treat people with schizophrenia and severe bipolar disorder. But com- UnitedHealth Group and Corporate Crime pany documents show that from 2000-2003, Lilly encour- aged physicians to prescribe the costly medication to peo- Former UnitedHealth CEO William McGuire will pay ple with age-related dementia as well as people with mild $468 million to avoid trial on charges that he manipulated bipolar disorder and depression (New York Times, stock options. McGuire resigned in 2006 with stock 1/31/08). options valued at $1.6 billion UnitedHealth, the nation's largest private insurer with 27 million enrollees, faces fines up to $1.33 billion due to a CORPORATE MONEY AND CARE failure to make timely payments on thousands of Pacificare claims in California. UnitedHealth bought Pacificare for X Health industry CEO's were richly rewarded in 2006. $9.2 billion in 2006, adding three million subscribers. The According to firms' SEC filings, the insurance executives with California Department of Insurance uncovered 133,000 the highest total compensation included Wellpoint's Larry alleged violations of state laws after widespread com- Glasscock ($23.9 million), Cigna's Edward Hanway ($21.0 mil- plaints by patients and providers. Separately, the state lion), Coventry's Dale Wolf ($12.9 million), Aetna's Ronald department of Managed Health Care is seeking $3.5 mil- Williams ($19.8 million), Unitedhealth Group's William lion in fines for claims denials (Girion, LA Times, 1/2/08) McGuire ($12.0 million), and Health Net's Jay Gellert ($5.2 mil- UnitedHealth Group is under investigation by the New lion). The highest compensated drug company CEOs included York Attorney General for activity at its subsidiary Miles White at Abbot Laboratories ($26.9 million) and Richard Ingenix, which compiles the data that much of the insur- Clark at Merck ($10.3 million) (Executive PayWatch Database, ance industry uses to determine "usual and customary" AFL-CIO). and "reasonable" charges. Because their limits are usually far below what providers actually charge, patients are California's Health Net Inc. will pay $9 million in puni- financially liable for a high proportion of any out-of-net- tive damages for canceling the insurance policy of a work care. Ingenix is alleged to manipulate the data to woman battling breast cancer while she was in the middle artificially lower fees. 16 insurers have been subpoenaed in of treatment. The firm claimed that the patient weighed the probe, including Aetna, Cigna, Wellpoint, and other more than she reported on her insurance application, and insurance giant (Wall Street Journal, 2/14/08). failed to report a heart condition. The firm will also pay a fine of $1 million for misleading the state about bonuses X California regulators are seeking $12.6 million in fines from tied to policy cancellations or "rescission." The firm avoid- Blue Shield, one of the state's largest health plans, for 1,262 ed payment of $35.5 million in medical expenses by revok- alleged violations of claims handling laws and regulations that ing around 1,600 policies between 2000 and 2006, offering resulted in more than 200 people losing their medical coverage. its senior cancellations analyst more than $20,000 in The charges are based on an investigation of the firm's "Life and bonuses based, in part, on her meeting or exceeding annu- Health" unit which covers about 167,000 people. California al targets for revoking policies. Health Net made more Insurance Commissioner Steve Polzner called the allegations than $2 billion in profits in 2007 (LA Times, 11/09/07, ABC "serious violations that completely undermine the public's trust News, 2/25/08). in our healthcare delivery system and are potentially devastating to patients". The state's HMO regulator is conducting a separate X Blue Cross and Blue Shield of Massachusetts' CEO William investigation into the company's managed care unit with 2.3 Van Faase received a whopping $16.4 million retirement pack- million members (Lisa Girion, LA Times, 12/13/07). age when he stepped down as CEO in 2006. Faase stayed on as chairman and received another $3 million the same year, includ- X One reason U.S. corporations have not embraced single payer ing $500,000 in base pay and $2.46 million in bonuses (Boston national health insurance is because they have health-industry Globe, 01/24/08). executives on their boards. The AFL-CIO filed a report with the Security and Exchange Commission (SEC) alleging that Board X Tampa-based health insurer Wellcare is under investigation members of 21 of the largest non-health related U.S. companies for Medicaid fraud in Florida and other states. Almost all of the have "violated their fiduciary duties to shareholders by barring firm's $4 billion in revenues comes from federal and state gov- the purchase of generic drugs instead of name brands, and ernments. The firm allegedly inflated its mental healthcare costs blocking companies whose boards they sit on from supporting

12 federal legislation that could have saved shareholders billions of Private Plans Hurt Medicare dollars." The 21 firms have Board members who also serve on the boards of pharmaceutical and other health-related companies Medicare Advantage plans cost the government 12 per- (e.g. United Health Group, Aetna, Tenet, Pfizer, Johnson and cent more per beneficiary than traditional Medicare, Johnson, PhRMA, Abbott, Eli Lilly, Merck, etc) (AFL-CIO according to a new report by the Government release, 10/05/07). Accountability Office (GAO), an investigative arm of Congress. The report says, "Medicare spends more per MEDICARE beneficiary in Medicare Advantage than it does for benefi- ciaries in the original Medicare fee-for-service program, at X Patients with diabetes or cardiovascular disease who are an estimated additional cost to Medicare of $54 billion uninsured prior to gaining Medicare coverage need more costly from 2009 through 2012." The GAO also found that many and intensive care over subsequent years than if they have been people in private plans face higher costs for home health previously insured, according to a study of 5,158 retirement-age care, in-patient hospital care, and certain cancer drugs and adults between 1992 and 2004. Uninsured patients with a his- mental health services. Overhead in Medicare Advantage tory of diabetes, hypertension, heart disease, or stroke diagnosed plans is 13 percent, compared to 3 percent in traditional before age 65 required 13 percent more doctors visits and 20 per- Medicare (New York Times, 2/28/08). cent more hospitalizations, and had 51 percent higher total med- About 20 percent of the 44 million Medicare benefi- ical expenditures, between the ages of 65 and 72 than did previ- ciaries - 9 million people - are now in private Medicare ously insured adults. (J M McWilliams et al, Use of Health Advantage plans. Enrollment in private plans is expect- Services by Previously Uninsured Medicare Beneficiaries, New ed to increase to 27.5 percent in 2017. A Congressional England Journal of Medicine, July 12, 2007). effort to curb the Medicare overpayment to private plans was defeated in the face of heavy lobbying from X Medicare coverage leads to a dramatic improvement in health the insurance industry (Health Affairs and Kaiser Daily for previously uninsured individuals according to a study of Health Policy Report, 2/26/08). 5,006 adults with and without insurance coverage over 55 years The Medicare Advantage program is dominated by two of age. For every 100 uninsured adults with heart disease or dia- giant firms, UnitedHealth and Humana. UnitedHealth, betes before age 65, the researchers found that with Medicare the nation's largest insurance company, received roughly coverage they had 10 fewer major cardiac complications, such as 15 percent of its projected pre-tax profit of $7.5 billion in heart attack or heart failure, than would be expected by age 72 2007 from Medicare. Humana derives about two thirds of (McWilliams et al, Health of Previously Uninsured Adults After its profit from the Medicare Advantage program, with an Acquiring Medicare Coverage, JAMA, 12/26/07). annual gross margin of about $1,650 per Humana benefici- ary (Goldstein, Bloomberg, 10/29/07 and Freudenheim, X Median out-of-pocket spending among Medicare beneficiar- New York Times, 12/5/07). ies was 15.5 percent of income in 2003. The 25 percent of bene- Since mid-2007 Medicare has imposed fines of more ficiaries with the highest spending spent at least 29.9 percent of than $770,000 on 11 Medicare Advantage insurers for their income on health care, while 39.9 percent spent more than marketing violations and failure to provide timely notice a fifth of their income on health care (Neuman et al, The to beneficiaries about changes in costs and benefits. Increasing Financial Burden of Health Care Spending 1997-2003, According to testimony from the Wisconsin Health Affairs, Nov/Dec 2007). Commissioner of Insurance, "states have consistently reported … complaints of high-pressure sales tactics and X The average monthly premium for a Medicare Part D drug tactics that could be considered unethical, at best, and plan will increase 17 percent, from $27.39 in 2007 to $31.99 in fraud, at worse" (Congressional Testimony, Wisconsin 2008, if enrollees don't change plans. Nearly one in five enrollees Insurance Commissioner Sean Dilweg, 5/22/07 and Pear, will experience an annual increase of at least $120 (Changes New York Times, 10/7/07). Ahead for Medicare Drug Program, Kevin Freking, AP, 11/03/07). Medicare Advantage plans do not provide higher Medicare Part D plans are reducing coverage for high-cost quality or more cost-effective care than traditional drugs. Since 2006, the number of Medicare Part D Prescription Medicare, according to the Congressional Budget Drug Plans using "specialty tiers" that allow the insurers to Office. Additionally, the Medicare Payment Advisory charge co-insurance of 33 percent has increased more than five- Commission (Med-PAC) reports that beneficiaries in fold, from four to 21. Over 3 million seniors with Medicare Part the traditional program are less likely to report prob- D fell into the "donut hole" in 2007. ("Medicare Part D 2008 Data lems in access to specialty care. (Testimony, Spotlight: Specialty Tiers," The Henry J. Kaiser Family Congressional Budget Office Director, Senate Foundation, December 2007). Committee on Finance, 4/11/07).

13 X Hospitals participating in a Medicare pay-for-perform- socialized medicine would be an improvement, while 70 per- ance pilot program were not significantly more likely than cent of Republicans say it would worsen health care. There non-participating hospitals to provide better treatment for is a lack of agreement about what parts of the U.S. health sys- acute myocardial infarction, according to a three year study tem are "socialized medicine," such as Medicare (60 percent (Glickman et al, JAMA, 06/06/07). say they think of Medicare this way), the VA (47 percent) and "managed care plans such as HMOs" (30 percent) (LA POLLS/PUBLIC OPINION Times, 2/25/08).

Majority of Physicians Support Single Payer 65 percent of Americans agree that the "United States should adopt a universal health insurance pro- A majority (59 percent) of physicians in the U.S. gram in which everyone is covered under a program like now support government legislation to establish Medicare that is run by the government and financed national health insurance, up from 49 percent five years by taxpayers" according to a recent AP/Yahoo Poll. ago, according to a new national survey. Similarly, Although the term "single payer" is less well known opposition by physicians to national health insurance than "Medicare", a majority, 54 percent, say they con- has dropped from 40 percent in 2002 to under one- sider themselves "a supporter of a single-payer health third (32 percent) of physicians in 2007, and fewer care system, that is a national health plan financed by physicians are "neutral" (9 percent in 2007 vs. 11 percent taxpayers in which all Americans would get their in 2002). Only 14 percent of physicians who oppose insurance from a single government plan." (AP/Yahoo national health insurance are in favor of more incre- poll, 12/28/07). mental reforms. Psychiatrists are the most supportive (83 percent), followed by emergency medicine doctors (69 percent), pediatricians (65 percent), internists (64 INTERNATIONAL percent), family practitioners (60 percent), and general surgeons (55 percent). (Carroll and Ackermann, X The United States ranks last in preventable death rates "Support for National Health Insurance among among 19 industrialized countries, resulting in about 101,000 American Physicians: Five Years Later" Annals of excess deaths per year. In addition, while other nations Internal Medicine, 4/1/08). improved dramatically during the study period, 1997 to 2002, the US improved only slightly. The study compared X In New Hampshire, 67 percent of all physicians, and 81 "amenable mortality" rates, deaths before the age of 75 from percent of all primary care physicians, support single payer causes that are potentially preventable with timely and effec- ("favor a simplified payer system in which public funds, col- tive healthcare, and found that if the United States had lected through taxes, are used to pay directly for services to matched the rate achieved by the three top-performing coun- meet the basic healthcare needs of all citizen") (New tries (France, Japan, and Australia) it would have had 101,000 Hampshire Medical Society, December 2007). fewer deaths per year by the end of the study period. On aver- age, "amenable mortality" in the 18 other countries fell by 16 X A survey of small and mid-sized businesses by the percent, whereas it fell by only 4 percent in the United States National Small Business Association found that 60 percent (E. Nolte and C. M. McKee, "US Has Most Preventable Deaths favor a "federally-funded, government administered health Among 19 Nations," Heath Affairs, January/February 2008). care system financed through higher taxes" (National Small Business Association 4/07). Despite much higher health spending per capita in X The term "socialized medicine" has lost much of its stigma 2004 ($6,102 vs. $2,552), the United States has fewer in the U.S., according to a recent Harris poll of over 2,000 health care resources per capita than the international adults. Of the 67 percent of Americans who say they at least average for 30 industrialized nations in the Organization "somewhat" know what "socialized medicine" means, 45 per- for Economic Cooperation and Development (OECD). cent say it would make the U.S. health care system better, The U.S. has fewer doctors (2.4 vs. 3.2 per thousand compared to 39 percent who say it would make it worse. population), fewer doctor visits (3.9 vs. 6.1 per capita), Four-fifths (79 percent) say "socialized medicine" means that fewer RNs (7.9 vs. 8.1 per thousand), fewer acute care "government makes sure everyone has health insurance" and beds (2.8 vs. 3.8 per thousand) and shorter hospital 73 percent say it means "government pays most of the cost of stays (6.5 vs. 8.2 days) than the OECD international health care" Only one-third (32 percent) say it means "gov- average (Anderson et al, Health Affairs, Sept/October ernment tells doctors what to do." Politics matter: 70 per- 2007). cent of Democrats and 45 percent of Independents say that

14 X Japan has a larger proportion of seniors than the U.S. yet is 24 percent of patients in the United Kingdom and 16 percent more effective at controlling drug costs. The Japanese gov- of German patients. Thirty-seven percent of all U.S. adults ernment trimmed prescription drug prices by an average of and 42 percent of those with chronic conditions had skipped 5.2 percent in its latest drug price review. The government is medications, not seen a doctor when sick, or foregone recom- also stepping up efforts to promote generic medications mended care in the past year because of costs-rates well (Reuters, 12/18/07). above all the other countries surveyed. 34 percent of Americans said that the US health system needs to be "rebuilt X More Canadian-trained physicians moved back to Canada completely," compared to 15 percent in the UK and 12 percent in 2007 (192) than left the country (133), according to the lat- in Canada (Mahon et al, Commonwealth Fund, 11/01/07). est data from the Canadian Institute for Health Information. Overall, 207 physicians left Canada in 2007, while 238 RECENT RESEARCH FINDINGS FROM PNHP'ERS returned from abroad, for a net gain of 31 (CIHI, Canada's (press releases and full-text on-line at www.pnhp.org/press). Health Care Providers, 2007). X Waits for emergency care nationwide increased 36 per- International Evidence on cent between 1997 and 2004. Among all patients, the aver- Mandating Health Insurance Coverage age wait increased to 30 minutes. Even the severely ill are waiting longer. Waits for patients suffering heart attacks Switzerland and the Netherlands are sometimes increased 150 percent, to 20 minutes, and a quarter of heart cited as nations that successfully attained universal attack victims in 2004 waited 50 minutes or more before coverage by mandating that individuals buy private seeing a doctor ("Waits To See An Emergency Department insurance. Yet, Switzerland's mandate program result- Physician: U.S. Trends And Predictors, 1997-2004" Wilper ed in "only a minute increase in coverage from the peri- A, Woolhandler S, Lasser K, McCormick, Cutrona, Bor D od before the mandate, when 98-100 percent of the pop- and Himmelstein DU, Health Affairs, March/April 2008; ulation held coverage." Additionally, "private health 27(2):w84-w95). insurers" in Switzerland are nothing like American insurance companies. They are non-profit and do not X Most free drug samples go to wealthy and insured set premiums, benefits, or fees to providers. Princeton patients, not to the needy. More than three-quarters of sam- economist Uwe Reinhardt describes them as de facto ple recipients were insured all year. Conversely, less than "quasi-governmental agencies." one-fifth were uninsured for all or part of 2003, and less than Dutch researchers estimate that the 2006 reform one-third had low incomes (under $37,000 for a family of that allowed their non-profit regional sickness funds four). Free drug samples are distributed according to mar- to convert to for-profit status and new insurers to keting criteria, not as a safety-net for patients. There are also begin marketing private coverage in the Netherlands safety concerns. Vioxx and Celebrex were among the most has left hundreds of thousands of Dutch uninsured. widely distributed samples in 2002, and they turned out to About 241,000 people are not enrolled in a health plan have lethal side effects ("Characteristics of Recipients of Free and another 240,000 have already defaulted on their Prescription Drug Samples: A Nationally Representative premiums, including a higher proportion of seniors, Analysis." Cutrona S, Himmelstein DU, Woolhandler S, et al, the unemployed and single parent families, out of a AJPH, Feb 2008). population of 16.4 million. There was one positive outcome of the 2006 reform: The government negoti- X There is no evidence that "disease management" (DM) pro- ated generic drug prices with the pharmaceutical grams are effective in controlling health costs, according to a industry, and reported that "for the first time in comprehensive review. The rush to embrace DM as a panacea decades, our expenditure on medicines has fallen is reminiscent of the rush into managed care in the 1990's, thanks to this agreement." (Glied et al, Health Affairs which was a dismal failure. There are two types of DM pro- Nov/Dec 2007, personal communication, Hans grams. The first is non-profit chronic care programs that are Maarse, 12/7/07). integrated with primary care. These can improve quality, but in many cases raise costs. The second type is the for-profit X U.S. patients are more likely than patients in seven other model of DM promoted heavily by pharmaceutical compa- industrialized nations to say they experienced medical nies. There's scant evidence that commercial DM programs errors, went without care because of costs, and that the improve quality or save money after accounting for program health care system needs to be rebuilt completely. Among costs ("Disease Management: Panacea, Another False Hope, U.S. patients with 2 or more chronic medical conditions, 32 or Something in Between?" Geyman J, Annals of Family percent reported a medical error in the last two years, versus Medicine, May/June 2007).

15 PNHP Past President Dr. John Geyman's new book, What's Wrong with Hacker's (and Clinton's, "The Corrosion of Medicine: Can the Profession Reclaim and Obama's) Health Plan? its Moral Legacy?" (Common Courage Press, 2008) is available from the PNHP national office for $20. Hacker considers single payer reform unrealistic (N Engl J Med 2007;357:733-5). Instead he'd make employers cover employees, with an expanded HILLARY CLINTON ON SINGLE PAYER Medicare-like program competing with private insurers. X This February, fourth-year Yale medical student Liza Unfortunately, his political calculus ignores eco- Goldman questioned Hillary Clinton about her support for sin- nomic reality. As we detailed in The Journal, single gle payer on the rope line after a campus appearance. Goldman payer could cut administration from 31% of health told Clinton, "I'm sure you know that single-payer would save spending to 16.7% - equivalent to savings of $324 bil- billions of dollars and thousands of lives." Clinton responded in lion in 2007, enough to cover the uninsured and agreement but said, echoing her disastrous 1993 health reform upgrade coverage for most others. Hacker's plan - effort, "It's not politically feasible." So Goldman offered her a like all multi-payer plans - forfeits bureaucratic sav- hypothetical: "Would you sign it if it came across your desk?" ings. It perpetuates private insurers whose overhead "She said yes, and shook my hand," Goldman reports. (Goldman averages 14.1% (vs. 1.3% for Canada's program), and is the daughter of Dr. Sarah Huertas Goldman, chair of PNHP's the wasteful eligibility and billing paperwork they Puerto Rico chapter.) foist on providers. Hence, his coverage expansion Candidates are followers, not leaders. If we build a power- means increased costs. Incremental reform efforts in ful movement for single payer national health insurance, they several states, though politically successful, have all will step to the head of it. In the meantime, having Democratic foundered on this problem. candidates like Clinton and Obama who acknowledge the Hacker also naively assumes that insurers would superiority if not desirability of single payer is a very profound allow fair competition with Medicare. For decades gain for advocates of fundamental health care reform. Our chal- HMOs have cherry-picked healthy Medicare patients lenge is to move the debate in the direction that their own and gained subsidies that allow them to flourish admissions are taking them (contributed by Quentin Young, despite costs 12% above traditional Medicare's. MD, PNHP Volunteer National Coordinator). Single payer reform is anathema to insurers but would benefit most Americans. Uniquely among reform options; it's affordable.

by David U. Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

IMMIGRANTS continued from page 57

16 Results: Of 5000 mailed surveys, 509 were returned as undeliv- Annals of Internal Medicine erable and 197 were returned by physicians who were no longer practicing. We received 2193 surveys from the 4294 eligible partic- ipants, for a response rate of 51%. Respondents did not differ sig- nificantly from nonrespondents in sex, age, doctoral degree type, or specialty. A total of 59% supported legislation to establish national CLINICAL OBSERVATIONS health insurance (28% “strongly” and 31% “generally” supported), 9% were neutral on the topic, and 32% opposed it (17% “strongly” Support for National Health Insurance among and 15% “generally” opposed). A total of 55% supported achieving U.S. Physicians: 5 Years Later universal coverage through more incremental reform (14% Background: The increasing costs of health care and health in- “strongly” and 41% “generally” supported), 21% were neutral on the surance have concerned Americans for some time (1). The number topic, and 25% opposed incremental reform (14% “strongly” and of uninsured Americans increased by 2.2 million to 47 million in the 10% “generally” opposed). A total of 14% of physicians were op- most recent census. This is the largest increase reported by the U.S. posed to national health insurance but supported more incremental Census Bureau since 1992 (2). In a 2002 survey of physicians, we reforms. More than one half of the respondents from every medical reported that 49% supported government legislation to establish na- specialty supported national health insurance legislation, with the tional health insurance (3). exception of respondents in surgical subspecialties, anesthesiologists, Objective: To determine whether physician opinion has changed and radiologists. Current overall support (59%) increased by 10 per- in the 5 years since the 2002 survey and assess physicians’ support for centage points since 2002 (49%). Support increased in every subspe- government legislation to establish national health insurance and cialty since 2002, with the exception of pediatric subspecialists, who their support for achieving universal coverage through more incre- were highly supportive in both surveys (Figure). mental reform. Conclusion: Most physicians in the United States support gov- Methods: We randomly sampled 5000 physicians from the ernment legislation to establish national health insurance. Support is American Medical Association Masterfile. We sent each physician a high among physicians in all but some of the procedural specialties. survey asking 2 questions: 1) In principle, do you support or oppose government legislation to establish national health insurance? and 2) Aaron E. Carroll, MD, MS do you support achieving universal coverage through more incre- Ronald T. Ackerman, MD, MPH mental reform? Question 1 was identical to the one we used in our Indiana University School of Medicine 2002 study (3). Respondents answered using a 5-point Likert scale. Indianapolis, IN 46202 We also gathered data on physician membership organizations and demographic, personal, and practice characteristics. Potential Financial Conflicts of Interest: None disclosed.

Figure. Support for government legislation to establish National Health Insurance in 2007 and 2002, by specialty.

Psychiatry

Pediatric subspecialties

Emergency medicine

General pediatrics

General internal medicine

Medical subspecialties 2007 Pathology 2002 Family medicine

Medical Specialty OB-GYN

General surgery References Surgical subspecialties 1. Kaiser Health Tracking Poll: Election 2008, Conducted October 2007. vol. 4. Menlo Park, CA: The Henry J. Kaiser Family Foundation; 2007. Accessed at www.kff Anesthesiology .org org/kaiserpolls/pomr032907pkg_v2.cfm on 6 March 2008. 2. DeNavas-Walt C, Proctor BD, Smith J. U.S. Census Bureau. Income, Poverty, and Radiology Health Insurance Coverage in the United States: 2006. Washington, D.C: U.S. Gov Printing Office; 2007. Accessed at www.census.gov/prod/2007pubs/p60-233.pdf on 6 0 10 20 30 40 50 60 70 80 90 100 March 2008. 3. Ackermann RT, Carroll AE. Support for national health insurance among U.S. physicians: a national survey. Ann Intern Med. 2003;139:795-801. [PMID: Support National Health Insurance, % 14623616]

2002 data are not available for pathology and radiology because of lack of response in those categories. OB-GYN ϭ obstetrics and gynecology.

566 1 April 2008 Annals of Internal Medicine Volume 148 • Number 7 www.annals.org REPRINTED BY PERMISSION

17 Friday, February 15, 2008 Asking about single-payer By Dr. Susanne King 4) Can we afford single-payer, if that means 8) How would single-payer be financed? covering 47 million uninsured people? Currently about 60 percent of our health care often talk with people about health care We already pay enough for comprehensive system is financed by public money (our taxes), reform, advocating for single-payer health coverage for everyone. We just don't get cov- 20 percent by private employers, and 20 per- I care as the only answer to problems that erage for everyone, because 31 percent of our cent by individuals. With a state or national include 47 million uninsured people in the health care spending goes for administration single-payer health program, the public money United States, and an even greater number of through the patchwork of private for-profit would be retained. One option for financing underinsured; the economic pressure on busi- insurance companies. Potential savings from single payer would be a payroll tax on employ- nesses; and the rising costs of health care for eliminating the waste and astonishing profits ers (approximately 7 percent) and an income our country, states, towns and individuals. of insurance companies (like Massachusetts' tax on individuals (approximately 2 percent). Here are the questions people most frequent- Blue Cross/Blue Shield's 2006 compensation The payroll tax would replace all other employ- ly ask. of over $16 million to its retiring CEO William er expenses for employee health care. The Van Faasen), has been estimated at $350 bil- income tax would take the place of all current 1) What is single-payer health care? lion per year. insurance premiums, co-pays, deductibles, and "Single-payer" refers to the administration of any other out-of-pocket payments. the health care funds by one payer, rather 5) Won't there be waiting lines For the vast majority of people, a 2 percent than the current multiple insurance compa- or rationing with single-payer? income tax is less than what they now pay for nies. This payer could be either the state or The United States currently rations care based insurance premiums and out-of-pocket pay- the federal government. Every other industri- on ability to pay, and 18,000 Americans die ments such as co-pays and deductibles, par- alized country in the world has national every year because they lack health insurance. ticularly for anyone who has had a serious ill- health insurance. Canada has a single-payer system, and their ness or has a family member with a serious ill- waiting times for care are shorter than com- ness. Many small employers now have to pay 2) Is this socialized medicine? monly believed. In 2005, the median wait for 25 percent or more of payroll for health insur- No, because hospitals would still be privately specialists or elective surgery was four weeks. ance, and large employers now pay roughly owned, rather than owned by the government, Canadians live longer and are more satisfied 8.5 percent. Everyone would have more com- and doctors would still be in private practice. with their health care than Americans, while prehensive coverage: in addition to medical "Single-payer" refers to the taking in and pay- paying half as much per person. care and drugs, benefits would include mental ing out of the health care dollars, which would health care, dental care, and long-term care. replace the current role of private insurance 6) Won't our aging population break companies. Traditional Medicare is a single- the bank in a single-payer system? 9) Who would run a single payer plan? payer system that has been in place for many Japan and Europe both have a higher percent- It is a myth that with national health insur- years. age of elderly citizens, yet they spend much ance the government will be making the med- less on health care than we do, and have bet- ical decisions. The government would only be 3) Doesn't Medicare have big problems? ter outcomes. Universal access through a sin- the administrator of the health care funds. Traditional Medicare has worked very well gle-payer system prevents more advanced In a publicly financed, universal health care for patients, and they have been happy with it. stages of illness, and will pay for long-term system, medical decisions are left to the patient However, the intrusion of private insurance care rather than costly hospitalization. and doctor, and the public has a say in how the companies into the administration of system is run. Cost containment measures will Medicare, first with the introduction of pri- 7) Some people like their insurance; be publicly managed by an elected and appoint- vate HMOs in the 1980s, and then by why should they change? ed body. This body, in consultation with med- President Bush with subsidies to the insur- Our current system is tied to employment; ical experts in all fields of medicine, will decide ance companies for drug plans, has wrought people change or lose jobs, which disrupts on the benefit package, negotiate doctor fees havoc with the program. their coverage. Others find their coverage and hospital budgets, and be responsible for The insurance companies now see fails when they get sick: 75 percent of the health planning and the distribution of expen- Medicare as a cash cow, creating an economic one million Americans experiencing medical sive technology. Right now, insurance compa- burden on the program, to the tune of billions bankruptcy each year were insured when nies make many health care decisions behind of dollars per year. Subsequently payments to they got sick. And insurance premiums go closed doors, and their interest is in profits, not doctors, the actual providers of care, have up every year, for policies that cover less and

REPRINTED BY PERMISSION been cut. less. ASKING continued on page 19 A slightly modified version of this article appeared in the Berkshire Eagle 18 COLORADO Valley Courier

lion (by the second quarter of 2005) which, if But I’um not dead yet! annualized, would come to $13 billion by the end of 2005! That amounts to a 1,300 percent By C. Rocky White, M.D. to their patients to "draw out the evil humors." increase in profits at a time when many They were applying modern science to the Americans had to declare bankruptcy because he rising sun cut through the fog reveal- practice of medicine in light of what they of medical bills and 2,700 people a day became ing a squalid little medieval English vil- knew. As the understanding of diseases uninsured! T lage. The undertaker was making his changed, so did the treatments - thank God. When Bill McGuire, CEO of UnitedHealth gruesome morning rounds collecting the vic- Likewise, as the practice of medicine has Group, stepped down from his post last tims of the Plague who had not survived the changed, our ideas about how to pay for it will December amidst an investigation by the night. have to change as well. The health insurance Securities Exchange Commission, he was col- He led his cart through streets shouting, industry naturally evolved in the 20th century lecting a salary of $8 million a year with accu- "Bring out your dead!" to protect people from the ever-increasing cost mulated United stock options of $1.6 billion. A door opened and a family tossed an old of modern medicine. With time, some very For most for-profit insurance companies, man onto the cart. The cart started again. shrewd businessmen began to see that a lot of anywhere between 15 and 30 cents of every dol- Suddenly the undertaker stopped. money was changing hands in this business. lar you spend on premiums is wasted on "Be quiet and sit still back there," the under- More and more health insurance companies bureaucracy and multi-million dollar CEO taker barked. became investor-owned, for-profit organiza- salaries. While millions of Americans will be "But I'um not dead yet!" the old man replied. tions that grew, merged and grew again, giving sitting at their kitchen tables tonight trying to "I don't care, be still," said the undertaker. rise to the multi-billion dollar behemoths that decide between keeping their health insurance "BUT I'UM NOT DEAD YET!" the old man dominate public health care policy today. or paying for school lunch for their children, repeated. As I have said in the past, I'm a strong these guys will be trying to decide whether to "Shut up!" the undertaker shouted. believer in a free market system and competi- panel their new yacht in Bermuda with Ok, it was just a Monty Python skit and I tion and there is nothing wrong with profit- Brazilian Mahogany or English Oak. forgot what happens next (really, kids, this was motivating ingenuity. However, health care Despite the self-serving arguments of conser- humor in the 1970s), but this scene reminds us does not lend itself to Wall Street economics vative Wall Street backers in Washington, the that our health care system isn't dead -- yet. and human lives are not a commodity to be for-profit health insurance industry is not in the Also, the medieval setting reminds us of just traded on the open market. business of providing you with quality, equi- how far we have come since the dark ages and In the United States from 2000 to 2005, the table and affordable health care. They are in the that medicine, like society, is evolving and con- real buying power income of primary care business of making money -- and lots of it. stantly in a state of flux. physicians fell about 5 percent, the number of Just as doctors have learned that using Thankfully, medicine has come a long ways people covered by employer-sponsored insur- leeches to "drain the evil humors" from a dying and the medieval practice of bloodletting and ance fell from 69 to 60 percent of the work- patient only hastened their demise, we must using leeches has been assigned to the history force, and the uninsured rate went from 40 to face the reality that our health care system books - sort of. 45 million. (although not dead yet) is sick and pale and A leech is a water-dwelling parasite that Yet in that same timeframe, according to only the leeches are getting fat. attaches itself to another creature, sucking the Weiss Ratings, the accumulated earnings of the The way we finance health care will have to host's blood for nourishment. Up until the last 500 or so for-profit insurance companies that change -- it's only common sense for the com- century, many physicians would attach leeches they track increased from $1 billion to $6.5 bil- mon good. REPRINTED BY PERMISSION

ASKING continued from page 18 insurance companies. In addition, doctors Senate bill 703. Federal legislation is HR 676, now provide care for which they don't get now supported by 88 congressmen, including our health care. reimbursed, when patients are unable to pay Rep. John Olver. because they are uninsured or underinsured. In Canada, single-payer health was intro- 10) Won't doctors dislike a More and more physician groups are support- duced province by province, rather than at single-payer system? ing single-payer. Physicians for a National the national level. Support for single-payer Most doctors are very dissatisfied with the Health Program now has 15,000 members. health care is increasing as people learn about current system, because of its administrative the benefits of this solution for our broken burden, and because insurance companies 11) How would we get to a health care system. create hurdles to providing care doctors think single payer system? If you wish to learn more, visit the Web their patients need. Physicians would like to There are bills in the state legislatures and in sites www.pnhp.org, www.masscare.org, or make medical decisions with their patients, Congress. Single-payer legislation for our www.sickocure.org. without the intrusion of the profit-motivated state is the Massachusetts Health Care Trust, Susanne L. King, M.D., is a Lenox practitioner.

19 Thursday, June 21, 2007

Study Finds 1.8 Million Veterans Are Uninsured Figure Has Grown by 290,000 Since 2000, Professor Tells House Veterans Panel

By Christopher Lee sured. whether to open VA hospitals’ doors to Washington Post Staff Writer Woolhandler is a well-known advo- so-called Priority 8 veterans, who have cate of guaranteeing access to health no service-connected disabilities and As the nation struggles to improve care for all Americans through a govern- whose earnings generally are above 80 medical and mental health care for mil- ment-run national health insurance percent of the median income where itary personnel returning from program. Republican lawmakers seized they live. Doing so would add signifi- Afghanistan and Iraq, about 1.8 million on that association to question whether cantly to VA’s caseload and costs — U.S. veterans under age 65 lack even she was trying to advance that goal estimates range from $366 million to basic health insurance or access to care with her study. $3.3 billion annually — and some veter- at Veterans Affairs hospitals, a new “The difficulty would be that ans groups and lawmakers are con- study has found. because of your desire for universal cerned that it would make it harder for The ranks of uninsured veterans have veterans with serious service-related increased by 290,000 since 2000, said health problems to get timely care. Stephanie J. Woolhandler, the Harvard About 12.7 percent of Only about half of the 1.8 million Medical School professor who present- uninsured veterans are classified ed her findings yesterday before the non-elderly veterans — or Priority 8, Woolhandler said. The rest House Committee on Veterans Affairs. may technically be eligible for some VA About 12.7 percent of non-elderly veter- one in eight — lacked care but live too far from its facilities for ans — or one in eight — lacked health health coverage in 2004, it to be a real option, she said. coverage in 2004, the most recent year Rep. Steve Buyer (Ind.), the commit- for which figures are available, she said, the most recent year for tee’s ranking Republican, said Veterans up from 9.9 percent in 2000. Veterans Affairs should focus on its “core con- 65 and older are eligible for Medicare. which figures are available stituency” — veterans with service- About 45 million Americans, or 15 related health problems, the indigent percent of the population, were unin- and those with “catastrophic” disabili- sured in 2005, the Census Bureau health care, that could influence how ties. “Some say the government is reports. you felt about veterans,” Rep. Cliff obliged to provide essentially free “The data is showing that many veter- Stearns (R-Fla.) said. health care for life to anyone who ans have no coverage and they’re sick and Woolhandler said the data are served even a year or two,” he said. “I need care and can’t get it,” Woolhandler sound. She has firsthand experience intend to protect the core constituency said. with the issue as well, she said, because first.” Woolhandler’s findings are based on as a physician she has seen uninsured But Rep. Bob Filner (D-Calif.), the data from two national surveys — the veterans with untreated high blood committee’s chairman, said taking care Current Population Survey administered pressure, diabetes and other conditions. of veterans is a continuing cost of war. by the Census Bureau and the National “It breaks my heart,” she said. “The “All veterans should have access to Health Interview Survey administered by VA should be an important safety net ‘their’ health-care system,” he said. the Department of Health and Human for my patients, and it’s not.” “This is rationing health care to veter- Services. Veterans who said they had nei- Nearly 8 million veterans were ans, those who have served our nation. ther health insurance nor veterans or mil- enrolled in the VA health system in And I think it’s unacceptable for a

REPRINTED BY PERMISSION itary health care were counted as unin- 2006. The focus of the hearing was nation of our wealth and our ability.”

20 LETTER TO THE EDITOR: APRIL 15, 2007 What's the one Thing Big Business and the Left Have in Common?

Is this what our country has come to? Leading C.E.O.’s, public good that should be treated as a public responsibility. despairing of their ability to limit rising health-care costs and We should be expanding and improving the Medicare program, unwilling to bear these costs themselves any longer, will now which we know provides reliable, cost-effective coverage and back legislation that would place every individual and family at has been doing so for more than 40 years. Public Medicare-for- the mercy of private insurance companies like UnitedHealth, All, not private for-profit insurance, is the only path to a future Wellpoint and the other insurance giants. Do they think John that will truly provide access to health care for all Americans. and Jane Doe can achieve what Safeway and General Motors cannot, namely, affordable health care for all of us? Oliver Fein, M.D. Leonard Rodberg, Ph.D Instead of moving backward to the time before there was New York Flushing, N.Y. employer-based or group health insurance, when people were on their own to get health care any way they could, we should (The authors are, respectively, chairman and research director of the New be moving forward, recognizing that health care is a necessary York chapter of Physicians for a National Health Program) REPRINTED BY PERMISSION

SATURDAY, JUNE 2, 2007

Single-Payer System a Bargain Dr. David Scrase, the chief operating tals are funded through a global budget. costly sick patients) poses a serious con- officer of Presbyterian Health Care That means that the hospital receives an flict of interest for the Presbyterian system. Services, shows that he does not under- annual payment based upon the previous In a single-payer statewide health insur- stand the Canadian single-payer system year's operating costs. ance system, New Mexico's many skilled when he criticizes the findings of the This is how we fund public schools, fire and dedicated physicians, clinicians, nurs- Mathematica Policy Research Inc. report departments, and police departments. We es and health workers would be freed from on New Mexico's options for universal don't pay the fire department on a per fire the time consuming, costly, and frustrating health care. basis, so why should we pay hospitals administrative hassles of a multi-payer The Journal quoted Scrase: "The based upon how many appendices they system. They would be freed up to prac- Canadian system pays doctors a flat rate remove? By eliminating per patient billing, tice their professions and provide the best and owns hospitals, which means it does a huge amount of money is saved. care for their patients. not incur the cost of negotiating and Under a single-payer national health The preliminary report from the administering different payments from dif- insurance system, Scrase's Presbyterian Mathematica Policy Research Inc. shows ferent sources." Hospital would continue to operate as a that by reducing admininistrative overhead This is not true. According to the non-profit hospital. The Presbyterian costs, a single-payer system can insure Canadian Government Web site, "The Health Plan, an insurance company, would every New Mexican and actually save majority of Canadian hospitals are operat- no longer be allowed to sell insurance for $178 million. ed by community boards of trustees, vol- the same services that are covered by the This is a bargain that New Mexicans untary organizations, or municipalities." In public insurance plan. should not pass up. We will never get a other words, most Canadian hospitals are Having a system that combines a hospi- better offer! not-for-profit, just like Presbyterian tal (whose mission is to take care of sick Hospital. patients) and a managed care insurance BRUCE G. TRIGG, M.D. Under a single-payer system, all hospi- company (whose goal is to avoid insuring Albuquerque REPRINTED BY PERMISSION

21 LETTERS SUNDAY, JULY 8, 2007 Canadian and U.S. Health Services – Let's Compare the Two The introduction of private insurance or private-for-profit Undoubtedly there are similar anecdotes describing difficulties health care for medically necessary services is not the answer to in accessing care experienced by the 44 million Americans who challenges in the Canadian health-care system. In a systematic lack health insurance. However, in making a rational compari- review of 38 studies published in Open Medicine in May, 17 son of the Canadian and American health systems it is more rea- leading Canadian and U.S. researchers confirmed the Canadian sonable to contrast service levels and costs of the systems rather system leads to health outcomes as good, or better, than the than trading anecdotes. U.S. private system, at less than 50% of the cost. Canadians pay about 9% of national GDP to insure 100% of Unwanted side-effects of competitive health care include a citizens in our single-payer system, compared with more than drain of highly trained professionals from the public system and 14% of GDP to insure 85% of Americans. The Kaiser Family “cream skimming” of patients by private clinics who choose the Foundation reports that the average compound annual growth healthiest patients, leaving the most complex to the increasingly rate in U.S. health insurance costs has been 11.6% over the past overburdened public system. five years. It is therefore not surprising that polling by Kaiser In June 2006, the Canadian Medical Association reviewed all found that 75% of Americans were worried or very worried the evidence from other jurisdictions and concluded that pri- about the amount they would need to pay for health insurance vate insurance for medically necessary physician and hospital in the future and that 63% were worried or very worried about services does not improve access to publicly insured services; not being able to afford health-care services. does not lower costs or improve quality of care; can increase There is no question that restriction of supply with sub-opti- wait times for those who are not privately insured; and, could mal access to services has contributed to the lower cost of exacerbate human resource shortages in the public system. health care in Canada. However, a new approach of targeting Medicare is not only more equitable, but more efficient and investments to reduce waiting times combined with transpar- produces higher quality health care than the alternatives. This ent reporting of wait times is having a substantial impact on conclusion is supported by the best national and international access in the Canadian system. Dr. Gratzer wrote about pro- evidence, including reports from the World Health longed waits for treatment in Ontario but did not refer readers Organization and the Organization for Economic Co-Operation to the public Web sites that detail Ontario waiting times for and Development. cancer surgery, chemotherapy, radiation, cataract, heart, arthro- So what should Canada do about patients who do not receive plasty and imaging procedures: timely access to essential medical care? Numerous expert (http://www.health.gov.on.ca/transformation/wait_times/wai reports, including the 2002 Royal Commission on the Future of t_mn.html and http://www.cancercare.on.ca) Health Care in Canada, have already told us we need to restore Canadians spend about 55% of what Americans spend on and strengthen Medicare, not decimate it. health care and have longer life expectancy, and lower infant In May the Canadian Centre for Policy Alternatives reported mortality rates. Many Americans have access to quality health that successful initiatives in team-based care and improved care. All Canadians have access to similar care at a considerably administration produced dramatic cuts in waiting times for sur- lower cost. In “Sicko,” Michael Moore has apparently exaggerat- gery in B.C. Alberta, Saskatchewan and Ontario, without any ed the performance of the Canadian health system — there is no need for competition. doubt that too many patients still stay in our emergency depart- ments waiting for admission to scarce hospital beds. However, Danielle Martin Mr. Moore’s description of the advantages of the Canadian sys- Board Chair tem in the film is more accurate than the jaundiced view of our Canadian Doctors for Medicare system proposed by Dr. Gratzer. Toronto www.canadiandoctorsformedicare.ca Robert S. Bell, M.D. President and CEO University Health Network Toronto The commentary by David Gratzer (“Who’s Really Sicko?”editorial page, June 28) presents an extremely prejudicial (The letter was also signed by Carolyn Baker, R.N., president view of the publicly funded Canadian health system. It high- and CEO, St. Joseph’s Health Centre, Toronto, and Catherine lights the unfortunate story of a man from Ontario who had dif- Zahn, M.D., executive vice-president of Clinical Programs and

REPRINTED BY PERMISSION ficulty accessing a head MRI scan for a malignant brain tumour. Practice, University Health Network, Toronto.)

22 SCIENTIFIC AMERICAN - MAY 03, 2007 WE'RE NUMBER TWO: Canada Has as Good or Better Health Care than the U.S.

By Christopher Mims disparate pool of 38 papers examining every- results corresponds to variations in the size of thing from kidney failure to rheumatoid an effect across the studies being reviewed. Whether it is American senior citizens arthritis.) In other words, of the studies surveyed, driving into Canada in order to buy cheap pre- Overall, the results favored Canadians, who some showed slightly better outcomes for the scription drugs or Canadians coming to the were 5 percent less likely than Americans to Canadian system and some showed slightly U.S. for surgery in order to avoid long wait die in the course of treatment. Some disorders, better outcomes for the U.S. approach, mak- times, the relative merits of these two nations’ such as kidney failure, favored Canadians ing it hard to draw any conclusion other than health care systems are often cast in terms of more strongly than Americans, whereas oth- that, on balance, the two systems seem to anecdotes. Both systems are beset by balloon- ers, such as hip fracture, had slightly better yield only slightly different outcomes. ing costs and, especially with a presidential outcomes in the U.S. than in Canada. Of the election on the horizon, calls for reform, but a 38 studies the authors surveyed, which were Money Doesn’t recent study could put ammunition in the winnowed down from a pool of thousands, 14 Necessarily Buy Health hands of people who believe it is time the U.S. favored Canada, five the U.S., and 19 yielded The study’s authors highlight the fact that per ceased to be the only developed nation with- mixed results. capita spending on health care is 89 percent out universal health coverage. higher in the U.S. than in Canada. “One thing Gordon H. Guyatt, a professor of epidemi- Mortality Isn’t the Only that people generally know is that the admin- ology and biostatistics at McMaster Measure That Matters istration costs are much higher in the U.S.,” University in Hamilton, Ontario, who coined Not all experts agree with the implication Groome notes. Indeed, one study by the term “evidence-based medicine,” collabo- that the Canadian system is better than the Woolhandler published in The New England rated with 16 of his colleagues in an exhaus- U.S. system, however, or with the researchers’ Journal of Medicine in 2003 found that 31 per- tive survey of existing studies on the out- methodology. Vivian Ho, who is the James A. cent of spending on health care in the U.S. comes of various medical procedures in both Baker III Institute for Public Policy chair in went to administrative costs, whereas Canada the U.S. and Canada. Their work appears in health economics at Rice University in spent only 17 percent on the same functions. the inaugural issue of the new Canadian jour- Houston and has spent time living and con- Ho believes, however, that there are also nal Open Medicine, and comes at a time when ducting research in both the U.S. and Canada, inefficiencies in the Canadian system. In her many in Canada are debating whether or not argues that the study’s focus on mortality own work on hip fracture, she found that to move that country’s single-payer system could be misleading. Canadian hospitals held patients for longer toward for-profit delivery of care. The ulti- “When we look at health systems we look periods because there was no incentive to dis- mate conclusion of the study is that the at other things than death,” Ho explains. In charge them. “These patients are easier to take Canadian medical system is as good as the her own research on hip fracture, which was care of,” she explains, “and that helps [hospi- U.S. version, at least when measured by a sin- cited in Guyatt’s study, she found that the tal administrators] justify their budget.… I gle metric—the rate at which patients in time a patient had to wait before surgery— think there is room for economic incentives either system died. which was significantly longer in Canada [in the Canadian system].” “Other people knew that Canadians live than the U.S. because of a shortage of operat- “Personally,” Ho adds, “my view is that the two to two and a half years longer than ing rooms—made only a 1 percent difference Canadian system is good for Canada and the Americans,” says Steffie Woolhandler, an in terms of mortality. American system is good for America. Neither author on the paper and an associate profes- “But certainly if you ask people waiting in side should switch, because the systems are a sor of medicine at Harvard Medical School, the hospital,” Ho notes, “They’re going to say function of the population—the Canadian citing a phenomenon that many attribute to I’d rather have the U.S. system.… Waiting population believes much more in maintain- differences in lifestyle between the two coun- means there’s a significant amount of distress ing social safety nets.” tries. “But what was not known was once you for an elderly patient, and also higher compli- This research may already be having an got sick, was the quality of care equivalent in cations for pneumonia because you have the impact on policy debate: According to the two countries.” patient immobile for so long.” Woolhandler, Ohio democratic congressman Patti Groome, an epidemiologist at Queens and presidential candidate Dennis Kucinich Americans Less Likely University Cancer Research Institute in has plans to circulate the results of this study to Survive Treatment Kingston, Ontario, said she believes that over- to Congress. Woolhandler herself would like According to Woolhandler, by looking at all the paper was balanced. “But when you get to see this study play a part in a slightly differ- already ill patients, the researchers eliminated into [the] meat of [the] paper they can’t sort ent debate—one over whether it it is better to any Canadian lifestyle advantage and just out what’s going on.… There’s way too much be sick and insured in the U.S. or in Canada. examined the degree to which the two sys- heterogeneity in these studies to come to a “I’d like to see politicians giving up on this tems affected patient deaths. (Mortality was conclusion about these systems.” In meta- mythology that the quality of care for sick the one kind of data they could extract from a analyses such as this one, “heterogeneity” in people in the U.S. is unique.” REPRINTED BY PERMISSION

23 SUNDAY February 10, 2008

wvgazette.com UNIVERSAL HEALTH CARE: U.S. could outdo Canadians

By Elizabeth Kurczynski the United States. dozens of separate insurance com- and Allen Chauvenet In the past, Barack Obama has panies. Physicians would be paid a said that a single-payer plan is the set amount for specific services, and s physicians who treat chil- best health plan, but he now says would no longer have to employ dren with blood diseases and that it is not politically feasible. In billing clerks to fill out many differ- Acancer at Women and other words, our elected represen- ent complex insurance forms to Children's Hospital, we frequently tatives feel that the insurance and receive reimbursement at a reduced see families with either inadequate drug lobbying interests are too rate. insurance coverage or no coverage powerful to fight. But these are the Administrative costs in our cur- at all. These are almost always people we elect to support our rent health-care system are working families with one or both interests nationally! between 30 and 40 percent of our parents who have a steady job. Thousands of physicians and total health-care costs, whereas a These families are part of the 47 many organizations such as the single-payer plan such as Canada's million Americans and the 322,000 American College of Physicians and system, Medicaid, Medicare or the in West Virginia with no health The Charleston Gazette have Veterans Administration health- insurance coverage. Even families endorsed a single-payer universal care system, has only about 3 per- with "good" coverage are paying health plan. Physicians for a cent administrative costs. This dra- more per year with much higher co- National Health Plan is a national matic savings would be enough to payments and deductibles, since group that has been working for a provide complete coverage for the cost of health insurance for a single-payer plan for the past 20 everyone in the United States. family is now over $12,000 per year. years (PNHP.org). We have a Many polls have clearly shown Most Americans realize that our Mountaineer Chapter of PNHP here that at least 65 percent of health-care system is in crisis. All of in Charleston. Every other Western Americans want national health the presidential candidates propose country covers everybody. We can insurance, and over 97 percent of incremental changes that would do it, too. Canadians like their health-care offer more people the opportunity Such a system would be similar system and would not want a U.S.- to "buy" coverage, or offer families to the Canadian health system, but style system. How have we let our small grants to help them buy a better funded, since the Canadians system get to the point where it is cheaper insurance plan that pro- pay less than $4,000 per person for run by for-profit insurance compa- vides only adequate coverage for health care. A single-payer system nies whose goal is to deny care and those who are healthy. How many would be supported by tax dollars - to make more money for their Wall can afford $12,000 a year? about 6 percent for businesses, and Street stockholders? Our Dennis Kucinich is the only can- about 2 percent for individuals, less Mountaineer chapter of Physicians didate who favors a nationwide sin- than we currently pay. But the sys- for a National Health Plan would gle-payer health plan, which would tem would be privately run, and like all West Virginians to learn provide coverage for everyone for patients could choose their own about a better alternative that can all health-care needs, including physicians and hospitals. provide universal care, and elimi- drugs. Everyone who votes should Everything would be covered, nate the inequality and injustice in know that this plan exists. It is an including doctors, hospital stays, our current system. affordable alternative to more long-term care, mental health, den- insurance. It could cover everyone tal and vision care and prescription Kurczynski and Chauvenet are both for no more money than the $7,500 drugs. Hospitals would be given a pediatricians and professors with per person per year that we are cur- lump sum for the year, and would WVU in Charleston.

REPRINTED BY PERMISSION rently spending for health care in not have to negotiate with and bill

24 FINANCIAL TIMES TUESDAY JULY 3 2007 A future of public healthcare for all to contract, a health score will summarise of disparities between rich and poor. Our my overall healthcare risks. Each year, focus is on equal opportunities, not on Stephen Cecchetti with new information on my weight, equal outcomes. blood pressure and the like, my score will Granted, Americans accept greater conomists believe in markets. be refined. inequality than the citizens of many other Market-determined prices allo- The fact that we will all have health countries do. Not so for healthcare. cate scarce resources efficiently, scores has profound implications for insur- Members of wealthy societies share the encouraging individuals to put ance; or, more accurately, for the failure of view that their members are entitled to E market-based insurance. If I have the infor- high-quality medical care. Social justice them to their best possible uses. This improves the welfare of -everyone. But mation revealing that I am likely to be demands that the rich and poor among us there are times when private markets healthy, living a long life with a low cost of all receive roughly comparable treatment. break down, and insurance is one of them. medical care, then I am going to forgo Over the past decade there have been When markets fail, the government insurance for everything except treat- several attempts to reform the American inevitably has to step in to provide insur- ments arising from accidents that are com- healthcare system. The US spends nearly ance. The future is one in which healthcare pletely unforecastable. 15.5 per cent of gross domestic product on will fall into this same category. Even in Alternatively, if my insurance company medical care, roughly 50 per cent more countries like the US, the government, not can obtain my health score, then, in the than countries such as France, Germany the market, will ultimately control the same way that lenders use my credit score and the Netherlands. And, as measured by level and cost of the medical care we will to calibrate the interest rate they might life expectancy and infant mortality, receive. offer on a loan, they will adjust my health Americans’ health outcomes are worse A single-payer, publicly run health-care insurance premium based on their precise than those in much of the industrialised system is the inevitable consequence of the world. Something has to change. But nearly continuous scientific revolution in A single-payer, publicly run change is politically and socially difficult, molecular genetics that began a half centu- health-care system is the so in designing the new system we should ry ago. One day it is James Watson, one of make changes that are likely to last. the discoverers of the structure of DNA, inevitable consequence of the Looking into the future, we see that being handed the complete genetic code nearly continuous scientific technology will force private health insur- inside his own cells. The next day revolution in molecular genetics ance to disappear at the same time that the researchers tie yet another chronic disease social pressure to provide equal access to to the presence of specific patterns on indi- that began a half century ago care will remain. This makes it inevitable vidual chromosomes. Then, a few days that healthcare systems everywhere will after that, we find out that scientists are estimate of the cost of my future medical provide universal coverage and be publicly learning to make stem cells from skin cells. care. And, importantly, a clever insurance run. Governments will replace markets, The time is fast approaching when we company that is precluded from learning ensuring that the poor and uninsurable will have an inexpensive test that is capa- my health score directly will find a pricing receive medical treatment at the same time ble of revealing a person’s genetic propen- scheme that leads me to reveal it to them that the healthy are forced to participate in sity to contract a broad array of chronic through the choices that I make. a comprehensive system. diseases. That means that we will be able The fact that private insurers can accu- Unfortunately, we shall be forced to accurately to assess the cost of treatment rately compute customer premiums to restrict access to the most expensive treat- over their lifetime. reflect expected future payouts means that ments, but even so everyone is going to I grant that there are a number of things the insurance market will break down. receive adequate healthcare. The operation about my medical future that I would Insurance is about shifting risk, pooling replacing my disintegrating brain and rather not know. For example, I am not large groups of undifferentiated individu- overworked liver with the new ones anxious to learn about my genetic predis- als. When either the insurer or the insured grown from my skin cells may not be cov- position to develop Alz-heimer’s disease can forecast future events, accurately dis- ered; but then again, maybe it will. or my propensity to contract heart disease tinguishing one person from another, the Regardless, I am off to my wine cellar to or type two diabetes. rationale for insurance disappears. ponder the best way to design a publicly While I may shy away from knowing In thinking about the provision of med- run, single-payer healthcare system. the details, I am interested in the medical ical care, it is important to realise that we equivalent of my credit score – call this my view it differently from other goods and The writer is a professor of global finance at the “health score”. Without revealing the services. When it comes to housing, cars, Brandeis International Business School and a co-

specifics of any future diseases I am likely vacations and the like we are fairly tolerant director of the US Monetary Policy Forum REPRINTED BY PERMISSION

25 Press-Telegram

Long Beach, California SUNDAY, JANUARY 27, 2008 25 cents (plus tax) U.S. should have Medicare for all ages

By Robert Gumbiner the increasing number of people in their doing nothing. In fact, they create their late 80s and 90s that we have to worry work. Having managed two insurance here is a somewhat illogical argu- about. companies in addition to a large HMO, I ment being made against By the same token, we could expand can tell you that it costs at least 15 per- Texpanding Medicare to include Medicare to provide health care to cent or more to market your product all citizens and taxpayers in the U.S., everyone, using a simple payroll deduc- and another 10 percent to run the com- which is that Social Security and tion (from employees) and contribution pany, even if you are fully funded and Medicare are going to go broke. This (from employers). We know that people spreading the risk. This means 25 per- argument makes no sense. For one thing, will agree to pay more if they get more. cent to 30 percent of “health care cost” is if this were true, how could the federal In the Scandinavian countries people are going directly to the insurance compa- government keep borrowing from Social willing to pay more because they get nies and is not contributing anything to Security and Medicare? The fact is, more social services, including health health care. Right now, Medicare avoids Medicare has the money and the federal government doesn’t. Having managed two insurance companies in addition to a Another argument used to muddy the waters is that health care costs more large HMO, I can tell you that it costs at least 15 percent or than Medicare can afford to pay. The more to market your product and another 10 percent to run answer to this problem is simple: collect the company. This means 25 percent to 30 percent of “health more money. When the cost of living goes up, we expect to pay more for goods care cost” is going directly to the insurance companies. and services. Twenty years ago, a house might cost $50,000 or $150,000; that care coverage. People in this country can this added 25 to 30 percent, paying same property now costs $800,000. So understand this simple equation. They something like 4 to 6 percent, all in, for why should we expect to pay the same would be agreeable to pay another 4 claims adjustments outsourced to com- amount of money for Medicare health percent payroll deduction if it meant 100 panies like Blue Cross. It is time for care that we were paying 20 years ago? percent coverage and no financials wor- insurance companies to get out of the In addition, let’s pay more attention ries. health care business. to controlling the costs and better edu- This is a simple plan that can work, We brought the tobacco companies cation of the providers in the cost of but the public is being led down the gar- under control for the greater good of the their procedures. Give the providers, i.e. den path by a bunch of unknown, talk- American public; we can do the same doctors and hospitals, some responsibil- ing heads. The propaganda machines for with the insurance and pharmaceutical ities for cost control. the insurance and pharmaceutical com- companies that shamelessly exploit the True, when 80 million baby boomers panies are trying their old-fashioned American public. join the 40 million people currently cov- scare techniques on the American pub- How is it that American pharmaceu- ered by Medicare, the budget may be lic, claiming that Medicare is going tical companies can sell their same prod- stretched thin. But since Medicare will broke, so forget about using it to estab- uct for 30 percent, 40 percent or 50 per- be spreading the risk over 120 million lish national universal health care. cent less in Canada and Mexico and people, in the future it will work. Garbage! make money? Doesn’t that mean they Remember, a lot of those new people are It will just take another three or four are making 30 percent, 40 percent or 50 accessing Medicare at 66 years of age percentage points - whatever it costs - percent more than they need to make off and those are winners for the Medicare out of payroll. People will be delighted the American public? It is a crime. It’s program because they are healthier than to pay it in order to get full coverage. ridiculous. Why doesn’t Congress do the average. These younger people will The biggest opponents to expanding anything about it? be feeding in over the next 20 to 30 Medicare are the insurance and pharma- years, and using less care initially. ceutical companies. Insurance compa- Robert Gumbiner, M.D., is founder and former

REPRINTED BY PERMISSION Actually, Medicare may work better; it’s nies are parasitical. They get paid for CEO of FHP International.

26 MONDAY, JULY 16, 2007 The Waiting Game PAUL KRUGMAN

eing without health insurance is no A recent article in Business Week put ance company was stalling; I had an big deal. Just ask President Bush. “I it bluntly: “In reality, both data and anec- option, which I didn’t know I had, to Bmean, people have access to health dotes show that the American people are avoid all the approvals by going to ‘Tier care in America,” he said last week. “After already waiting as long or longer than II,’ which would have meant higher co- all, you just go to an emergency room.” patients living with universal health-care payments.” This is what you might call callous- systems.” He adds, “I don’t know how many ness with consequences. The White A cross-national survey conducted by people my insurance company waited to House has announced that Mr. Bush will the Commonwealth Fund found that death that year, but I’m certain the num- veto a bipartisan plan that would extend America ranks near the bottom among ber wasn’t zero.” health insurance, and with it such essen- advanced countries in terms of how hard To be fair, Mr. Kleiman is only sur- tials as regular checkups and preventive it is to get medical attention on short mising that his insurance company medical care, to an estimated 4.1 million notice (although Canada was slightly risked his life in an attempt to get him to currently uninsured children. After all, worse), and that America is the worst pay more of his treatment costs. But it’s not as if those kids really need insur- place in the advanced world if you need there’s no question that some Americans ance — they can just go to emergency care after hours or on a weekend. who seemingly have good insurance rooms, right? nonetheless die because insurers are try- O.K., it’s not news that Mr. Bush has ing to hold down their “medical losses” no empathy for people less fortunate Debunking — the industry term for actually having than himself. But his willful ignorance to pay for care. here is part of a larger picture: by and another health On the other hand, it’s true that large, opponents of universal health care Americans get hip replacements faster paint a glowing portrait of the American care myth. than Canadians. But there’s a funny system that bears as little resemblance to thing about that example, which is used reality as the scare stories they tell about constantly as an argument for the superi- health care in France, Britain, and We look better when it comes to see- ority of private health insurance over a Canada. ing a specialist or receiving elective sur- government-run system: the large majori- The claim that the uninsured can get gery. But Germany outperforms us even ty of hip replacements in the United all the care they need in emergency on those measures — and I suspect that States are paid for by, um, Medicare. rooms is just the beginning. Beyond that France, which wasn’t included in the That’s right: the hip-replacement gap is the myth that Americans who are study, matches Germany’s performance. is actually a comparison of two govern- lucky enough to have insurance never Besides, not all medical delays are cre- ment health insurance systems. face long waits for medical care. ated equal. In Canada and Britain, delays American Medicare has shorter waits Actually, the persistence of that myth are caused by doctors trying to devote than Canadian Medicare (yes, that’s puzzles me. I can understand how peo- limited medical resources to the most what they call their system) because it ple like Mr. Bush or Fred Thompson, urgent cases. In the United States, has more lavish funding — end of story. who declared recently that “the poorest they’re often caused by insurance compa- The alleged virtues of private insurance Americans are getting far better service” nies trying to save money. have nothing to do with it. than Canadians or the British, can wave This can lead to ordeals like the one The bottom line is that the opponents away the desperation of uninsured recently described by Mark Kleiman, a of universal health care appear to have Americans, who are often poor and professor at U.C.L.A., who nearly died of run out of honest arguments. All they voiceless. But how can they get away cancer because his insurer kept delaying have left are fantasies: horror fiction with pretending that insured Americans approval for a necessary biopsy. “It was about health care in other countries, and always get prompt care, when most of us only later,” writes Mr. Kleiman on his fairy tales about health care here in

can testify otherwise? blog, “that I discovered why the insur- America. REPRINTED BY PERMISSION

27 REPRINTED BY PERMISSION promises of affordable insurance, the only continue to rise. Despite the governor's able for most Illinoisans while costs would Decent coverage would remain unafford- of remedying our state's health crisis: capita cost (or less). ized world better health for half our per- that has afforded the rest of industrial- universal public health insurance, a system insurance companies with Medicare-like vate insurance route. Arnold Schwarzenegger in offering the pri- Gov. Mitt Romney and California Carolina Sen. John Edwards, Massachusetts has joined President Bush, former North ings to cover everyone. Sadly, Blagojevich generate), or scrap them and use the sav- nies (and the huge systemic waste they reform: preserve private insurance compa- more than we're spending now. vide health care for all Illinoisans no ers altogether would save enough to pro- ger benefits. But eliminating private insur- taxes to pay insurance companies for mea- wrong prescription. Blagojevich would hike Unfortunately, he has come up with the sured and underinsured is commendable. his focus on our state's millions of unin- bered as Illinois' "health care governor," and Eliminating private health insurance our only good option APRIL 30, 2007 The Blagojevich approach has little hope The better approach would be to replace Illinois has only two options for health Rod Blagojevich wants to be remem- AND QUENTIN YOUNG, M.D. BY NICHOLAS SKALA COMMENTARY care. The paperwork they inflict on doctors enhance profits but divert resources from utilization review and other activities that sums on marketing, billing, underwriting, out the sick, private insurers waste vast therefore profitable) patients and screen tion. In their drive to enroll healthy (and spending this year will go for administra- Nearly a third of our $2.3 trillion in health spend less than half per person we do. form of public health insurance, yet most rather than sustain, private health insurers. support. But this plan would terminate, and Mike Boland has garnered considerable duced by Representatives Mary Flowers The state single-payer bill (HB 311) intro- gle-payer system: "Medicare for All Illinois." coverage and lower costs is through a sin- paper-thin coverage. more comprehensive plans into the new, more and middle-class families from costs continue to rise, employers will push would remain unable to get care and as name only. Beleaguered Illinois families costs after that. in, and still pony up 20 percent of hospital deductible payments before insurance kicks have to spend $7,164 in premium and 56-year-old making $30,000 annually will state to experiment with such a scheme, deductibles. In Massachusetts, the first them down with huge co-payments and way to get inexpensive policies is strip Every other developed nation has some The only way to simultaneously expand Such skimpy plans are insurance in people of Illinois. need leaders committed to the health of all and even aspirants to the presidency. We giants continues to intimidate lawmakers tion from insurance and drug industry nomically viable reform option. Yet opposi- the future. ing that the new benefits are sustainable in long-term cost control mechanism, ensur- duplication, it also would establish a stable, planning and the elimination of wasteful the people in Illinois. Through rational to provide comprehensive benefits for all than $13 billion a year, enough new money Medicare for All" -- could save Illinois more single public payer -- a kind of "Improved streamlining our health finances through a other industrialized countries. shorter life expectancy than people in most Americans have higher infant mortality and lower rates of nearly every chronic disease. sized spending. Brits and Canadians have den. tals and doctors face little paperwork bur- for 1 percent overhead. And Canada's hospi- nies, Canada's single-payer program runs 20 percent overhead of insurance compa- more each year. In contrast to the roughly and hospitals costs hundreds of billions A single-payer system is the only eco- Harvard researchers have shown that Illinoisans get scant return for our out- Dr. Quentin Young is national coordinator of Physicians for a National Health Program Nicholas Skala is co-founderof Health Care for All Illinois; .

28 TUESDAY APRIL 1, 2008 Dr. Quentin Young, a Chicago legend, to retire

By PHIL KADNER national health insurance since 2002, the cost. when a similar survey was conducted. Local governments, such as Cook His patients have included Martin Surveys were randomly mailed to County and the state of Illinois, find Luther King Jr., Mike Royko, Studs 5,000 doctors, and 2,103 were themselves cutting other costs to Terkel and members of the Chicago 7 returned. meet the public’s health care needs. conspiracy trial, but after 61 years in Psychiatrists (83 percent), pedi- The amount of money budgeted for private practice, Dr. Quentin Young is atric subspecialists (71 percent), Medicaid in Illinois is now larger than hanging up his stethoscope. emergency medicine physicians (69 the amount of money budgeted for Young, a physician in Chicago’s percent) and general pediatricians public education, although about half Hyde Park community who from (65 percent) seemed to be the most of that cost is picked up by the feder- 1972-81 was chairman of the enthusiastic about national health al government. Department of Medicine at Cook insurance, while those practicing Young contends that while other County Hospital, was King’s doctor radiology (30 percent) and anesthesi- industrialized countries control med- during the civil rights leader’s ill- ology (38 percent) registered the low- ical costs through single-payer uni- fated stay in Chicago. est amount of support for such a pro- versal health care plans, the profiteers He was with him when King was gram. here (primarily health insurance com- hit in the head with a rock while Young, 84, is a founding member of panies) continue to drive up costs. marching through Gage Park and also the Chicago-based Physicians for a Because their primary motive is to visited King in his Chicago home National Health Program and believes make money, not to provide the best when he came down with a respirato- the results signify an important shift in health care for patients, insurers’ ry infection. the public debate. decisions often are detrimental to pol- “I stretched a 15-minute visit for a “People trust their doctors,” Young icyholders. cold into an all-afternoon affair just so said. “If their doctor tells them that Yet many Americans still believe I could talk to the man,” Young national health insurance is not a good health care here is better than any- recalled. “It was a unique opportuni- thing, they tend to believe that’s prob- place else in the world. But they seem ty.” ably true. If their doctor now starts to be living in denial, ignoring the fact I have done the same whenever saying it is something that would be that health care here is not going to I’ve had the chance to talk to Young, good for the country, then average peo- remain as it is. a liberal renegade who has lived by ple will be more likely to support it.” Costs will continue to rise. the credo: “If the majority agrees The survey, conducted by Employers, facing a potential recession, with you, you are probably in the researchers at Indiana University, is are going to have to cut their costs. wrong.” being touted as the largest ever Health insurance companies will Young, for the first time in his 20- among doctors on the issue of health continue to make a profit through year fight for national health insur- care financing reform. higher premiums and by taking con- ance, finds himself in the majority. An estimated 47 million Americans trol of patient treatment out of the A survey to be published today in have no health insurance, and another hands of family doctors. the Annals of Internal Medicine, a 50 million are believed to be underin- Young, who is giving up his med- medical journal, indicates that a sured. ical practice, will devote all of his majority of U.S. physicians (59 per- At the same time, health insurance energies to reforming health care. cent) support national health insur- costs are rising at a rate of about 7 per- “I tell people that I will refuse to die ance, 32 percent oppose it, and 9 per- cent a year, twice the rate of inflation. until there is national health care,” he cent are neutral. Employers are struggling to pay laughed. The findings, according to a news health insurance premiums for their Phil Kadner can be reached at pkad- release, reflect a 10-percentage-point employees, often reducing coverage [email protected] or (708) 633-

increase in physician support for or asking workers to pick up more of 6787 REPRINTED BY PERMISSION

29 PNHP Action Fund Contributors We acknowledge with great appreciation our recent donors

Foundations Dr. John Rolland Dr. Bernard Grossman Todd W. Schaffner Dr. David E. Eibling Dr. Robert M. Peck Anonymous Dr. Johnathon Ross, MPH Dr. Kevin Grumbach Dr. Michael J. Schermer Dr. Monika M. Eisenbud Dr. Richard K. Pelz Louis & Anne Abrons Drs. Evan Seevak & Dr. Wayne Hale Dr. Louis M. Schlickman Dr. Carl Englebardt Dr. Muhammad Ali Pervaiz Foundation Sarah R. Pearson Dr. Peter Hammond Dr. Barton D. Schmitt Dr. Dan C. English Dr. Richard D. Quint, MPH Jewell Foundation- Dr. Greg M. Silver Dr. James Hart Dr. Diana Schott Dr. Alice Faryna Dr. David L. Rabin, MPH Dr. Deborah J. Schumann Richard Stithem Dr. Ann Harvey & Dr. Jeremiah Schuur Dr. Karl Felber Dr. Julia F. Ragland The Philanthropic Dr. Bruce T. Taylor Francesca Dr. Jerrold P. Schwartz Martha F. Ferger Dr. Raymond A. Raskin Collaborative-Matt & Dr. Jonathan Walker Cunningham, RN Dr. Ewell G. Scott Dr. Debbie Fibel Dr. Ann E. Reitz Suzanne Case Dr. Miles Weinberger Dr. Michael J. Hauan, Dr. Janet K. Seeley Dr. Marshal P. Fichman Dr. Deborah A. Richter Seymour & Sylvia Dr. Marquita West MPH, MTS Dr. Catherine M. Dr. Margaret Flowers Dr. H.T. Robertson Rothchild 2004 Charitable Dr. Mary E. Wheat Dr. Robert E. Hirschtick Sharkness Dr. Susan Frayne Leonard Rodberg, Ph.D. Foundation Dr. Robert B. White Dr. & Mrs. E. Beaumont Dr. Carol Shores, PhD Dr. Suzanne Frye, MPH Dr. R. P. Channing Rodgers Drs. Richard Whittington & Hodge Tess Siegel Dr. Jay H. Gold Dr. David Rush Leaders Jane L. Coleman Dr. Neil A. Hoffman Dr. Joseph Rogers Dr. Liz Goldman Dr. Ivan M. Safonoff $5,000 or more Irving & Evelyn Wolfe Dr. Floyd Huen Simpson, Sr. Dr. Mari & Al Goldner Dr. David R. Samson Dr. Ida G. Braun Dr. Polly Young & William Dr. Charles W. Huff Dr. David Slobodkin, MPH, Dr. Gary Greenberg Dr. Salvador Sandoval Dr. Michael J. Lichtenstein Veale Friends of Dr. Kenneth FACP Dr. Elliott Gritz Dr. Sanjaya Saxena Steven & Tami McCanne Hupart Dr. James Warren Smith Dr. William R. Handley Dr. Maria Schmidt National Union of Public Sponsors Dr. Edward N. Johnson Dr. M. Gregg Steadman, Dr. Susan Hardt Dr. Carol Schneebaum & General Employees $500-$999 Dr. Leonard W. Kaplan FACS. Dr. Robert F. Harris Dr. Amy R. Schwartz Dr. David C. & Ann C. Trigg Drs. Simon Ahtaridis & Dr. Ellen Z. Kaufman Dr. Rob Stone Dr. Steven Harris Dr. Martin Seltman Dr. Quentin Young Jaya Agrawal Dr. Robert Keisling Myles Sussman, Ph.D. Dr. Noel S. Harrison Dr. Ann Settgast Dr. William H. Albers Dr. Maureen Kelly Dr. William Tarran Drs. Denise & Robert Hart Dr. Jim Shaughnessy, MPH Benefactors Dr. Pamela Alsum John & Barbara Kennedy Dr. Byron C. Tucker Dr. Alan I. Hartstein Dr. John Shepard $2,500-$4,999 Dr. Kathryn M. Anastos Rachel Kreier, Ph.D. Dr. William Ulwelling, MPH Dr. Judith Herman Dr. Carlton Shmock Dr. John P. Geyman Leora Barish Dr. Elizabeth Kurczynski Dr. Barbara Waldman Dr. Sonya Hintz Dr. Jerry Sielaff Dr. Don McCanne Dr. Keith Barton Dr. Julia Kyle Dr. James Walsh Dr. Ralph F. Hudson Dr. Lonnie D. Simmons Dr. Anne Scheetz Dr. Richard Bayer Dr. Alice Landrum Dr. Marilyn S. Ward Dr. Rocio Huet Dr. Norman Sissman Drs. Gordon Schiff & Dr. Daniel D. Bennett Dr. David S. Lee Dr. Henry Weisman Dr. James Clark Huff Dr. Linda Skory Mardge Cohen Dr. Daniel Berkenblit Dr. Helena Leiner Dr. Seth D. Weissman Dr. Gary Huffaker Dr. Susan Smile Dr. Christopher Stack Dr. Robert Bertcher Dr. Allan Lewis Dr. Andy Wilper Dr. Karin Jacobson Dr. Gordon W. Smith Kay & Walter Tillow Drs. Gene Bishop & Dr. John G. Long Dr. Garen Wintemute, MPH Dr. Joseph Jarvis, MSPH Dr. Wesley Sowers Andrew Stone Dr. Stephen Lucas Dr. Michael S. & Mary Ann Dr. Gary & Ines Johanson Drs. Kirsten Staples & Patrons Dr. Theodore & Undine Dr. Maria-Laura Mancianti Wolkomir, BSN, CNLC Dr. Michael Kaiser Harold Van Lonkhuyzen $1,000-$2,499 Bistany Dr. Barry M. Massie Karen Anne Woodbury David Keahey, PA-C, MSPH Dr. Lorraine Stehn Dr. James E. Alexander Jr. Dr. David Bor & Henrietta Dr. Charlea Massion Dr. Susan Wu Dr. Alan Kenwood Dr. Peter Steinglass Dr. Ray Bellamy Barnes Dr. Charles R. Mathews Dr. Paul Zenker Dr. Tanya Kern Dr. David S. Stewart Dr. Gary B. Birnbaum Drs. Laura Boylan & Friends of Keith B. McCall, Dr. Michael A. Keshishian Dr. Leo Stornelli Dr. John D. Bower Daniel Labovitz Ph.D. Friends Dr. David Kosh Dr. Fred Strauss Dr. Richard C. Braun Dr. Howard Brody Drs. Chris Cassel & Mike $300-$499 Dr. Richard Kvam Dr. Robert E. Sullivan Dr. Tamara Brenner Dr. John Buckley McCally George A. Abbott Dr. Tim Lambert Dr. Stephen F. Tarzynski, Dr. Nancy Brown Dr. Stephen M. Bullard Dr. Lon McCanne Dr. Parks M. Adams, Jr. Dr. Suzanne Laurel MPH Dr. William Cromartie Dr. Christopher Butler Dr. Mary McCord, MPH, & Dr. Michael Adler Dr. Benjamin S. Lerman Dr. Robert F. Thompson Dr. Matthew D. Davis Dr. Philippe V. Cardon Alex Okun Dr. Russ Altman Dr. Ralph Levin Dr. Robert Titzler Dr. Herman A. Dobbs, Jr. Dr. Peggy Carey Dr. Mick McGarvey Dr. Richard Arnold Alan Lezak Dr. John Treanor Todd Evans Dr. Charles C.J. Carpenter Dr. Dianne McQueen Dr. Margaret Atterbury Dr. Philip K. Lichtenstein Dr. Walter H. Tsou Dr. Robert M. Factor, Ph.D. Friends of T. John Dr. Jeffrey Meffert Dr. Virginia Baker Dr. Tom Lieb Dr. Alkinoos Vourlekis Drs. Linda & Gene Farley Carpenter Dr. Lawrence A. Melniker Drs. Sidney Bender & Dr. James Loehr Drs. Benjamin & Eugenia Dr. Claudia M. Fegan Dr. Francis Carter Dr. Roger Mendelson Marjorie Luckey Dr. Thomas A. Madden Wainfeld Drs. Carl W. & Merle J. Drs. John A. Cavacece & Dr. Armin D. Meyer Dr. John Benziger Dr. Jeffrey Maisels Dr. David O. Warner Fieser Bonnie L. Taylor Dr. Alan D. Miller, MPH Dr. William J. Bickers Dr. Marvin Malek Dr. Howard J. Weisman Dr. Bob Fine Dr. Natasha Chriss Dr. Carol A. Miller Dr. David W. Bishop Drs. Beth Marcus & Jeff Dr. Hubert N. Williston Dr. Gerald Frankel Dr. Ronald L. Clarke Dr. Susan A. Miller Dr. LeClair Bissell Rang Dr. William R. Winn Dr. Elizabeth E. Frost Dr. Scott Clarke Dr. Robert Mishell Dr. Steve Boster Dr. Laurel B. Mark Dr. Carol Winograd Dr. Avrum V. Gratch Dr. William Cochran Dr. James Mittelberger, Dr. Charles Brackett, MPH Dr. Steve Maron Dr. Robert J. Wyatt Marjorie Greer Dr. Stephen N. Cohen MPH Dr. Basil A. Bradlow Dr. Joseph T. Mason Dr. Charlotte Zitrin Dr. Linda J. Griffith Dr. June Cooperman Dr. Rachel Nardin Drs. Harold & Norma Brown Dr. John D. Matthew Dr. Andrew Zweifler Dr. Henry T. Haye Dr. Trevor J. Craig Dr. Thomas B. Newman Dr. Kenneth Brummel- DeAnn McEwen, RN Dr. Elizabeth K. Hersh Dr. William Crockett Dr. Christine Newsom Smith Dr. David McLanahan Supporters Dr. Eiluned Hogenson Dr. Michael S. Diamond Stan Ovshinsky Dr. W. Richard & Mary Dr. Suzanne Meyer $250-$299 Dr. Aarchan Joshi Dr. Peter Dull Dr. George Pauk Burack Dr. Harold Morse Dr. Robin E. Abaya Dr. Julian Kadish Dr. Sally Mae Ehlers Dr. Rachel A. Perla Dr. Linda Burden Dr. Carter V. Multz, FACP, Lynda Abdoo Dr. Henry S. Kahn Dr. Eric L. Esch Dr. Richard L. Phelps Dr. James F. Burdick FACR Drs. James W. & Mary Agna Dr. Michael S. Kaplan Drs. Krista Farey & Vishu Dr. William Pope Dr. Laurence Burns Michael Nathanson, Ph.D. Dr. Richard Allen Dr. Roy Korn, Jr. Lingappa Dr. Thomas G. Pretlow Dr. Carla Campbell, M.S. Dr. Elizabeth Naumburg & Dr. Walter J. Alt Dr. Jeffrey C. Lamkin Dr. Oliver Fein Dr. Peter Pryde Dr. Cory D. Carroll Carl Hoffman Dr. Ralph J. Alvarez Dr. Craig B. Leman Dr. Harvey Fernbach, MPH Dr. Colin Raitiere Dr. Winston Cavert Dr. David E. Ness Dr. John A. Ameriks Dr. Robert Lichtenstein Dr. Howard Fields Dr. R. Stephen Rankin Dr. Janice J. Cederstrom Dr. Audrey Riker Newell Dr. Chris Anderson Dr. Fredrick J. Lieb Dr. Jean L. Forest Dr. Douglas Robins Dr. Gerald Charles Dr. Barbara Newman, MPH Dr. Ron Anderson Dr. Michael Mann Dr. Charissa Fotinos John H. Rodgers Dr. Elinor Christiansen Dr. Lisa Nilles Dr. David Ansell Dr. Appleton Mason, III Drs. John & Mary Frantz Don & Judy Rogers Dr. Thomas Clairmont, Jr. Dr. Susan M. Nowak Dr. Edward Anselm Dr. Patricia J. Middleton Ann Friedman Dr. Aaron M. Roland Dr. Lloyd K. Comstock Dr. William L. Nyhan, PhD Ed Anthony Dr. Donald Mitchell Dr. Paul J. Friedman Dr. Ursula Rolfe Dr. Judith A. Dasovich, Dr. Joseph P. O'Bryan Dr. Andrea Arena John Mullen, III Dr. John T. Garland Dr. John B. Rust FACP Dr. James V. Ortman Dr. Valerie Arkoosh Dr. Uberto T. Muzzarelli Dr. Nancy Greep Dr. James E. Sabin Dr. David Dassey, MPH, Dr. Pantea Pahlavan Dr. Jeff Arp-Sandel Dr. Richard Pierson, Jr. Dr. Karen E. Grimmell Dr. Dennis Sanchez FACP Dr. Robert H. Palmer Dr. Regan Asher

30 Dr. Steve Auerbach, MPH Mel Packer Dr. Susan H. Houseman Dr. William B. Lloyd Dr. Susan M. Racine Dr. Sarah Stadler Dr. Richard Lee Backman Dr. David DeGrand Dr. Bobby D. Howard Dr. Lawrence Loo, FACP Dr. Robert E. Rakel Dr. Dale Stark Dr. Neal A. Baer Dr. J. Greg Dent Dr. Sarah Huertas- Dr. Panna Lossy Dr. Barbara Ramsey Dr. Donald W. Dr. Dennis Baker Dr. Norman A. Desbiens Goldman David Lotto Dr. Elizabeth Rand Stechschulte, Jr. Dr. Victoria Balkoski & Dr. John Diamond Dr. Susan T. Iannaccone Dr. Susan Love Drs. Bonnie & Peter Dr. Gerald Stein, FACP Paul Winkeller Dr. Ward E. Dickey Dr. Peter A. Ingraldi Dr. Jerome Lowenstein Reagan Dr. Robert Stern Dr. John Ball Dr. Richard C. Dillihunt Dr. Kenji Irie Dr. Richard G. Lucarelli Dr. Stephen C. Reichl Dr. David E. Steward Dr. David Ban Dr. Robert Doepke Dr. Ross Isaacs Dr. Howard Lucas Dr. Bridget Reidy Dr. Eileen Storey Dr. Eileen Barrett Dr. Susan R. Donaldson Dr. James S. Jacobsohn Dr. W. Richard Ludwig Dr. King Reilly Dr. David P. Stornelli Dr. James E. Barrett Dr. Martin Donohoe Dr. Mark E. Jacoby Dr. Yee-Bun Benjamin Lui Dr. Lewis Reisman Dr. Cosimo N. Storniolo Dr. Robert A. Barron Dr. Patricia Downs Berger Dr. David F. Jaffe Dr. Joan MacEachen Dr. Mark Remington, PhD Dr. William Strauss Dr. Sara Bartos Dr. Daniel Doyle Dr. Daniel A. Jardini Dr. David Macpherson Dr. Philip G. Rhodes Dr. Alvin Hal Strelnick Dr. Jerome Bass Dr. Henry T. D'Silva Dr. Stephen J. Jay Dr. Bruce Madison Dr. Charles M. Richardson Dr. Wayne S. Strouse Dr. Susan C. Bayer Dr. Jerry Earll Dr. Alan Johnson Dr. Mario L. Maiese, Dr. Roberta Richardson Dr. David M. Strutin Dr. Kathleen M. Beaver Dr. Anne D. Ehrlich Dr. David M. Johnson FACC, FACOI Dr. Wendy Ring, MPH Dr. James Sullivan Dr. William R. Beavers Dr. Doug Einstadter Dr. Paul Johnson Dr. Richard I. Malkin Dr. Eugene Rondeau Dr. Arthur J. Sutherland III Dr. John C. Beck Dr. Mark P. Eisenberg Dr. William R.K. Johnson Dr. Jeffrey Mandel Dr. Barry N. Rosenbaum Dr. Eliza Sutton Dr. Carol Beechy Dr. Sherif Emil Dr. Scott Johnston Arky & George Markham Dr. David Rosenberg Dr. Rosemary Tambouret Dr. Ann Behrmann Jessica Eng Dr. Thomas Jones Dr. James E. Marks Dr. Katherine Rosenfield Dr. Ed Taylor Dr. Robert Benner Dr. Linda Engelstad Vanessa Jones, RN Dr. Jeffrey B. Marvel Dr. Jeffrey S. Ross Dr. Susan Jane & Diego Dr. Steven Berk, PharmD. Dr. Stanley L. Erney Dr. Peter G. Joseph Dr. Robert A. Maslansky Dr. Steven K. Rothschild Taylor Dr. Shivarama Bhat Susan Ervin-Tripp, Ph.D. Dr. Nicholas Kafoglis Fred & Marjie Mautner Dr. Patrick Rowe Dr. W. Jape Taylor Dr. Edward Birdsong Dr. David Espey Dr. Scott Kale Dr. Martin Mayer, MPH Dr. Fred H. Rubin Dr. Stewart Teal Dr. Jonathan S. Bishop Dr. Richard Evans Dr. Matthew Kapklein Dr. Marianne Clinton- Dr. Christopher T. Ruskey Dr. John R. Teerlink Dr. Philip G. Black Dr. Joshua Fenton Dr. Jeffrey Kaplan McCausland Dr. Sarah Ryterband Dr. James Theis Dr. Gregory Blaschke Dr. Sarah J. Fessler Dr. Norman Kaplan Dr. Peter McConarty Dr. Prantik Saha Dr. Howard K. Thompson, Dr. Bruce Block Dr. James D. Finkelstein Dr. Marvin Karno Dr. Lisa McDermott Dr. Douglas A. Sallis Jr. Dr. Thomas Bodenheimer Dr. Daniel J. Finn Dr. Richard Katz Dr. Greg McHolm Carol Salter, RN Dr. Lowery L. Thompson Dr. Patricia Lynn Borman Dr. Kevin Fiscella Drs. Joel Kaufman & Dr. Michael D. McNeer & Dr. Richard Salzer Dr. Sara Thompson Dr. J. Wesley Boyd, Ph.D. Dr. Anne A. Fitzpatrick Anna Wald Debbi Young Dr. Marcosa J. Santiago Dr. Steven J. Thorson Dr. Linda A. Wimer Brakel Dr. Michael W. Foutz Dr. Faris Keeling Dr. Ann Medinger Dr. Carolyn Sax Dr. Diane M. Timberlake Dr. S. Jeanne Bramhall Dr. Aaron Fox Dr. Chris Keenan Dr. David Mehr Dr. Marcus L. Scarbrough Dr. Glennah I. Trochet Dr. Rachel Bramson Dr. Constance Fox Dr. Robert I. Keimowitz Dr. Richard Menet, MPH Dr. Jeffrey Scavron Dr. George L. Tucker Dr. David Bressler Dr. Hugh M. Foy Dr. Stephen R. Keister Dr. Michael Merhige Margery S. Schab Dr. John Tulley Dr. Allan Brett Dr. Alfred Franzblau Dr. Dana Kent & Bill Dr. Randolph V. Merrick Dr. Stanley G. Schade Dr. E.H. Uhlenhuth Dr. Eric Brezina Dr. Josh Freeman Monning, J.D. Dr. Chris Meyer Dr. Michael Schatz Dr. Eric Unzicker Dr. Rambie L. Briggs Dr. Diana Galindo Dr. David Kessler Dr. Arthur Milholland Marty Schiffenbaurer, Ph.D. Dr. Richard U'Ren Dr. Charles Browning Tony Garr Dr. Thomas A. Kessler Dr. Aaron Miller Dr. Peter Schlesinger Dr. Marilyn J. Vache Dr. Bryan Bruns Dr. Francisco J. Garriga Dr. Jeffrey Kin Drs. Cynthia H. Miller & Dr. Evelyn D. Schmidt Dr. John Van Buskirk Drs. Daniel Brustein & Dr. John J. Geren Dr. Kathy L. Kinder Matt Leinung Dr. Gregory Linn Schmidt Drs. Charles Van Der Joan Trey Dr. Godfrey S. Getz Dr. Lambert N. King Dr. Edward Miller Dr. David E. Schmitt Horst & Laura Svetkey Dr. David Buch Dr. Juan C. Gil Dr. Lucy Jane King Dr. Laurie Miller & Dr. Janet Schmitt Dr. Cornelia van der Ziel Dr. David Buck, MPH Dr. George M. Gill Dr. Mary King Kolby Vaughan, PA-C Drs. Miriam Schocken & Dr. Bonnie Van Uitert Dr. Timothy L. Burke Dr. Edward B. Gilmore Jerry & Nannie Kirk Dr. Patricia A. Miller Gerald Green Dr. Kathryn A. Vaughn- Dr. William Burke Dr. David Ginsburg Dr. Melvin Kirschner, MPH Dr. Marlene M. Mirassou Dr. Timothy Scholes Rosenberg Dr. Robert Burns Dr. Linda Gochfeld Dr. Lindsey Kiser Dr. Joy Mockbee Dr. Mike Schroering Dr. Janie Vestal Dr. Roger W. Bush Dr. Joe Goldenson Dr. John H. Kissel Dr. Deborah C. Molrine Dr. Melvyn B. Schupack Dr. Robert Wells Vizzard Dr. Peter L. Campbell Dr. Steven R. Goldfarb Dr. Ernest W. Klatte Dr. Francis Mondimore Dr. Richard E. Schweitzer Dr. Harold Vonk Dr. Jane E. Carleton Dr. Wayne L. Goldner Dr. Deborah Klein Dr. Jose Oscar Morales, Dr. Don Scott Dr. Mark R. Vossler Dr. Thomas Carlstrom Dr. Linda Good Dr. Richard L. Klein FACNP Dr. Ralph D. Scoville Dr. Howard Waitzkin Dr. John Carson Dr. Jeoffry B. Gordon, MPH Dr. Frank Kline, PhD Dr. Daniel Morgenstern Dr. Richard R. Sefi Barbara Walden Dr. Sarah Carter Dr. Raymond F. Graap Dr. Alex Klistoff Drs. Rudolph & Diane Claudia Seldon Dr. Corinne A. Walentik, Dr. Graham Chelius Dr. Charles Granatir Dr. Thomas R. Kluzak Mueller Dr. Peter Seymour MPH Dr. Art Chen Frances Gray Dr. Theodore Koerner Dr. James Murakami Dr. Robert Shadel Dr. Debra Walter Alden Chiu Dr. David Andrew Green Dr. Carolyn Koffler Dr. Jody Naimark Dr. Ehsan Shahmir Dr. Ann Tyler Watlington Drs. Rich & Charlene Clark Dr. William R. Greene Dr. H. Alexander Krob Burton & Marlene Nanus Drs. Eve Shapiro & Paul Dr. Sarah K. Weinberg Dr. Robert R. Clark Dr. Gregg Greenough James A. Kruer, Jr. Dr. Marius Nefliu Gordon Drs. Michael J. & Dr. Murray Claytor Dr. Elizabeth Greyber Dr. Sachi Kuhananthan Drs. Mary & Peter Nelson Linda and Mark Shapiro Patrice G. Whistler Drs. David Clement & Dr. Frances Griffiths Dr. David Kuo Dr. Steven Nussbaum Drs. Katheen & Gerald A. White, M.S., Elizabeth Weiss Dr. N. Thorne Griscom Dr. Pauline L. Kuyler Dr. David W. Oberdorfer, Todd Shapley-Quinn FAAPM Dr. James A. Clever Dr. William N. Grosch Frank & Emily La Croix FACS Dr. Karen Sheehan Dr. Harry C. White Dr. Andrew D. Coates Dr. Rick Guthmann Dr. William M. Landau Dr. P. Blair Odland Dr. L. Thomas Sheffield Dr. Arnold Widen, FACP Dr. James A. Cockey Dr. Matthew Gutwein Drs. Barbara & Joel Lazar Dr. Kathleen M. Ogle Dr. Hilary C. Siebens Dr. John L. Wiese Dr. Ronald Codario Dr. Lauro S. Halstead Dr. Alexander Leaf Dr. Katrina Olson Dr. Sandra M. Siler Dr. Kathryn A. Williams Dr. Ellen Cohen Dr. Michael Hamant Dr. Martha Leas Dr. Kelly Orringer Drs. Julie & Ken Dr. Stephen Williamson Dr. Allan Converse Dr. Ann Ewalt Hamilton Gail LeBow Dr. Genevieve Pagalilauan Silverstein Dr. Bruce Wilson Drs. Paul & Fiona Cook Dr. John V. Hartline Dr. Michael C. Lee Dr. Henriette Parkman Dr. Barry Charles Simon Dr. Rochelle L. Wilson Dr. Scott Cooper Dr. Kevan L. Hartshorn Dr. Jim Leggett Dr. Glenn Pearson Dr. Anne Simons Dr. Gordon Winchell Dr. Lawrence E. Cormier Dr. Susan Hasti Dr. Chris Leininger Dr. Eric Morgan Peck Andrew Singer Dr. Jeffrey Winston Dr. Anne C. Courtright Health Care for All - Oregon Dr. Rosanne M. Leipzig Dr. Eleni Pelecanos-Matts Dr. Baldeep Singh Dr. Daniel Wirt Dr. Stephen E. Cox Dr. Esther Hedberg Dr. Robert Lerner Dr. James Peterson Dr. Charles Singleton Dr. Theresa Woehrle Dr. Jill Crandall Dr. Matthew Hendrickson Dr. Lawrence Levy Dr. Thomas K. Pettus Drs. Michael Slater & Dr. Faith Wolberg Dr. Jewel Crawford Dr. Eva Hersh Dr. Joseph R. Lex, Jr. Dr. Victoria L. Pillard Shoshana Elkin Waskow Dr. Oliver Wolcott Dr. Johanthan Cree Dr. B. Mark Hess Dr. John Lichtenstein Dr. Matthew A. Pius Dr. Gregory Smith Dr. William M. Woodhouse Dr. Sarah Cross Dr. Roger Hicks Dr. David Lieb Dr. Jean Pointon Dr. Joseph H. Smith Dr. Richard J. Wyderski Dr. Jessica M. Crosson Dr. Eugene Z. Hirsch Dr. Judy Lieberman Dr. Daniel Pomerantz Dr. Scott P. Smith, MPH Dr. John D. Wynn Dr. Brian Crownover Drs. Marie Hobart & Bill Dr. Jerome Liebman Dr. Mark Prange Dr. Susan Soboroff Dr. Nabeel R. Yaseen, Ph.D. Dr. James E. Dalen, MPH Kadish Susan Lilienfield, Ph.D. Dr. Donald W. Price Dr. Lynn Soffer Dr. Robert Zarr, MPH Dr. John P. Daley Drs. Thomas & Grace Dr. Jiin T. Lin, MPH Dr. Marshall F. Priest Dr. Moneer A. Sohail Dr. Ruth Ann Zent Dr. Lawrence J. D'Angelo Holmes Dr. Ronald M. Lind Dr. Kirk Prindle Dr. David Solosko & Dr. Benson Zoghlin Dr. William E. Davis Dr. Tomas Holmlund Dr. Jonathan Lindgren Dr. David & Rita Priver Sandra Kniess Dr. Leon N. Zoghlin Dr. John Anthony Day, Jr. Drs. Neil Holtzman & Dr. Larry Lipscomb Dr. Munro H. Proctor, MPH Dr. Antal E. Solyom, Ph.D., Dr. Barry Decker Barbara Starfield Dr. John Littlefield Dr. Michael Puisis MA Thanks also to anyone whose Emily DeFerrari, CNM & Dr. Chad Hood Dr. Keith Littlewood Dr. Ronald E. Pust Dr. Margaret Sowerwine name we may have missed.

31 TUESDAY, JULY 10, 2007 ON HEALTH CARE REFORM: Long Waits Are Really SiCKO

By DEBORAH BURGER from funding cuts by conservative national or provincial governments, or hat country endures such long from the siphoning off of resources by waits for medical care that private providers. But precisely because W even one of its top insurers the Canadian system is publicly adminis- has admitted that care is "not timely" and tered, Canadians are able to force their people "initially diagnosed with cancer elected officials to fix problems, or get are waiting over a month, which is intol- voted out of office. erable?" Throughout Canada, there are multi- If you guessed Canada, guess again. ple pilot programs that have succeeded The answer is the United States. in slashing wait times. Canada's latest Scrambling for a response to the pop- statistics show that median wait times ular reaction to Michael Moore's for elective surgery in Canada is now "SiCKO" and a renewed groundswell for three weeks -- that's less time than a publicly financed, guaranteed single- Aetna's chief medical officer says payer health care solution, such as Americans typically wait after being SB840, the big insurers and their diagnosed with cancer. Paul Lachine/NewsArt.com defenders have pounced on Canada, Canada also has no waits for emer- pulling out all of their old tales of peo- he spent much of his time trying "to find gency surgeries. It also doesn't have 44 ple waiting years in soup kitchen-type appointments for people with doctors." million people who are uninsured lines for medical care. Brennan's comments went unreported because everyone has a national health- But, here's the dirty little secret that in the major media. But some reports are care card guaranteeing health care from they won't tell you. Waiting times in the now beginning to break through, any doctor or hospital they choose. And United States are as bad as or worse spurred by the debate "SiCKO" has it doesn't burden those with insurance than Canada. And, unlike the United spawned. with rising deductibles or co-pays. A States, in Canada no one is denied need- Business Week reported (www.busi- study reported by Health Affairs, a poli- ed medical care, referrals or diagnostic nessweek.com/technology/content/jun20 cy journal, for example, found that out- tests due to cost, pre-existing conditions 07) that "as several surveys and numer- of-pocket costs to U.S. consumers or because it wasn't pre-approved. ous anecdotes show, waiting times in the jumped 76 percent this year over last U.S. waiting times are the elephant in United States are often as bad or worse year alone. the room few critics care to address. But, as those in other industrialized nations -- Canada also surpasses the United listen to what the chief medical officer of despite the fact that the United States States in a broad array of health barome- Aetna had to say in March. spends considerably more per capita on ters, including life expectancy, infant Speaking to the Aetna Investor's health care than any other country." mortality rates, adult mortality rates, Conference 2007, Troy Brennan let these A Commonwealth Fund study of six deaths due to HIV/AIDS, mortality rates pearls drop: highly industrialized countries for cardiovascular diseases and years of The U.S. "health care system is not (www.commonwealthfund.org), the life lost to injuries and diseases, accord- timely." United States and five nations with ing to data from the World Health Recent statistics from the Institution national health systems (Britain, Organization and the Organization of of Healthcare Improvement document Germany, Australia, and Economic Co-operation and "that people are waiting an average of Canada) found waiting times were Development. about 70 days to see a provider." worse in the United States than in all the No wonder some people are so afraid "In many circumstances, people initial- other countries except Canada . we'll learn the real comparative story ly diagnosed with cancer are waiting There's something else you probably about Canada's system -- and our own. over a month, which is intolerable." don't hear about Canada. Substantial In his former stint as an administrator progress is being made. Deborah Burger, R.N., is president of the

REPRINTED BY PERMISSION and head of a physicians' organization, Most of the wait-time problems derive California Nurses Association.

32 ABSTRACT Canada-trained pediatric surgeons: a cross-border survey of satisfaction and preferences Sherif Emil a,*, Jean-Martin Laberge b aDivision of Pediatric Surgery, University of California–Irvine Medical Center, Orange, CA 92868-3298, USA b Division of Pediatric Surgery, McGill University Faculty of Medicine, Montreal, Quebec, Canada www.elsevier.com/locate/jpedsurg Objectives: The American and Canadian health care delivery systems impact pediatric surgical practice differently. We conducted a survey of Canada-trained pediatric surgeons practicing in the United States and Canada to compare their levels of satisfaction and to assess their health care system preferences. Methods: Pediatric surgeons who graduated from Canadian training programs between 1983 and 2002 were invited to complete a web-based questionnaire. They rated their satisfaction on a scale ranging from 1 (most) to 5 (least) with issues pertaining to quality of life, compensation, work environment, academics, and patient care. Surgeons who had experience in both the American and Canadian systems marked their preferences for each system as it impacted the same areas. Results: Sixty surgeons (65% practicing in the United States and 35% in Canada) of 94 eligible participants (64%) responded to the survey. Surgeons in the United States were more satisfied with their overall workload and patient care issues, whereas those in Canada were more satisfied with the system of health care reimbursement and the medicolegal environment. Among 38 surgeons who had experience in both systems, 26% had an overall preference for the Canadian system, 24% did for the American system, and half had no preference. Conclusions: Canada-trained pediatric surgeons practicing in the United States are more satisfied with patient care issues, whereas those practicing in Canada are more satisfied with the medicolegal environment and the system of health care reimbursement. There is no overwhelming preference for either system among surgeons who had experience in both. © 2007 Elsevier Inc. All rights reserved.

Table 1 Satisfaction levels of pediatric surgeons practicing in the United States and Canadaa United States Canada P Quality of life I am satisfied with my overall workload. 2.1 2.6 .049 I am satisfied with the amount of time I have for my family. 2.6 3.2 NS I am satisfied with my overall quality of life. 2.1 2.4 NS Financial compensation and reimbursement I am satisfied with the opportunity I have for financial advancement. 2.3 2.6 NS I am satisfied with the overall system of health care reimbursement. 3.8 2.6 b.001 I am satisfied with my net after-tax income. 2.4 2.7 NS I am satisfied with the amount of paperwork required for fee and salary collection. 3.4 2.3 b.001 Work environment I am satisfied with the amount of administrative responsibilities. 2.6 2.4 NS I am satisfied with the medicolegal environment. 3.9 2.0 b.001 I am satisfied with the opportunity I have for professional advancement. 2.0 2.0 NS I am satisfied with my work environment. 2.1 2.2 NS Academic activities I am satisfied with my academic status. 2.2 2.0 NS I am satisfied with my academic progress. 2.3 2.5 NS I am satisfied with the amount of teaching I provide. 2.1 2.2 NS I am satisfied with the amount of clinical research I perform. 2.6 3.0 NS I am satisfied with the amount of basic science research I perform. 2.6 2.9 NS I am able to obtain research funding if needed. 3.0 2.9 NS I am able to find researchers to collaborate with if needed. 2.3 2.6 NS Patient care I am satisfied with the quality of surgical care children receive in the system. 1.7 1.9 NS I am satisfied with the quality of surgical care I am able to provide my patients. 1.4 1.9 .017 I am satisfied with the amount of technological resources available to me. 1.6 2.5 b.001 I am able to provide my patients emergency services without impediment. 1.5 2.6 b.001 I am able to provide my patients elective services without impediment. 1.7 3.0 b.001 My patients are able to undergo elective operations within a reasonable period. 1.5 2.8 b.001 I feel patients are treated equitably without regard to their financial status. 1.8 1.4 .028 I feel patients and their families are satisfied with the health care system. 2.3 2.3 NS Overall I am satisfied with the overall system of health care delivery. 2.8 2.5 NS I prefer the system in which I practice to that of Canada/the United States. 2.6 2.2 NS NS indicates not significant. a Respondents rated their level of agreement with each statement on a scale ranging from 1 (strongly agree)to5(strongly disagree), with a lower value denoting a higher level of agreement with the statement. REPRINTED BY PERMISSION 33 Modern Healthcare SEPTEMBER 17, 2007 The $150 billion swindle The case against Medicare Advantage is Medicare Advantage fee-for-serv- ice plans—which are the fastest- overwhelming; when will D.C. get wise? growing segment of the program and receive the highest rate of By Todd Sloane of power in Washington, scrap- extra payments—don’t provide ping Medicare Advantage will be care coordination, often charge If it is hard to argue an indefen- to the advantage of almost every- higher copayments and don’t offer sible proposition, the Bush one. In 2003, we were sold a bill of much in the way of extra benefits. administration is showing no goods on how handing some extra The CMS admits it has failed to obvious signs of distress. It con- money to insurers in the short keep track of extra benefits tinues to vow that it will go to the term would produce long-term offered to beneficiaries and, mat to protect the Medicare savings to the program, while according to a recent report from Advantage program, even in the allowing insurers to deliver more the Government Accountability face of overwhelming evidence services at lower premiums. Office, it also has failed to ade- that it mainly serves the needs of A new analysis by the quately keep track of much of any- shareholders and health insur- Congressional Budget Office gives thing else. The CMS is required ance executives, at a breathtaking the lie to that notion. It shows each year to audit one-third of cost to taxpayers. that the Medicare Advantage pay- Medicare Advantage plans to see In another era this would have ment structure would preclude if they are providing the benefits astounded conservatives, who any such savings unless insurers they say they are, but the GAO prized fiscal restraint over every- can deliver services at half the cost found the percentage of plans thing else. This White House has of fee-for-service Medicare. In the audited has been going down made a religion out of the concept dry language of CBO Director sharply, to just 14% in 2006. of privatizing Medicare and Peter Orszag, such an outcome is In one year of audits they per- rewarding its business cronies. “implausible.” formed, the CMS identified about As of this writing, it seems that Instead, the CBO projects that $34 million in government pay- some House Democrats are signal- extra payments to Medicare outs that could have been used by ing retreat on using major cuts in Advantage would amount to $150 the plans to provide extra bene- this managed-care boondoggle to billion over the next decade. fits to beneficiaries. And that was finance an array of changes to the For this, what do we get? An in 2003, before the huge addition- Medicare program, part of their American Medical Association al payments mandated by the broader plan to extend the State survey found that more than half Medicare Modernization Act of Children’s Health Insurance of physicians said their Medicare 2003. The CMS told the GAO it Program. As we have argued, this Advantage patients had been had no plans to pursue financial retreat is not a bad thing—for denied coverage of services that recoveries because the agency now. Better to send Bush a clean fee-for-service Medicare routinely lacked authority to do so. The SCHIP bill—financed by an picks up. The Medicare Rights GAO said the law clearly spells increase in tobacco taxes and Center finds that access to needed out such power. backed by a bipartisan, veto-proof care is often hindered by overly One could joke that maybe the majority—than to see a veto sus- strict rules on pre-authorization CMS could privatize its enforce- tained, harming children in the by the private plans. A Kaiser ment activity, but with $77 bil- process. Family Foundation report found lion being wasted on the program But down the road, probably that seniors in poor health may be this year alone, it is no laughing matter. REPRINTED BY PERMISSION when there is a different balance charged more for coverage.

34 REPRINTED BY PERMISSION

35 36 37 Competition in a publicly funded healthcare system

Are the UK and other countries right to adopt a market based model for improving their health services? Steffie Woolhandler and David Himmelstein believe that the appropriate response to the US experience with such policies is quarantine, not replication

Why would anyone choose to emulate the US health- Steffie Woolhandler associate hospitals. Similarly, for-profit dialysis firms rushed in care system? Costs per capita are about twice the professor of medicine after the government made everyone with end stage Organisation for Economic Cooperation and Devel- David U Himmelstein associate renal disease eligible for Medicare in 1972. professor of medicine, Department opment average. Forty seven million people are com- of Medicine, Cambridge Hospital, Until the 1970s, private insurers (mostly founded pletely uninsured. Many others with insurance face Harvard Medical School, and controlled by doctors and hospitals) and Medi- high out of pocket costs that hinder care and bankrupt Cambridge, MA, USA care exerted minimal oversight of care and payment more than a million annually.1 Mortality statistics lag Correspondence to: D U rates. But soaring costs prodded employers and gov- Himmelstein, 1493 Cambridge behind those of most other wealthy countries, and Street, Cambridge, MA 02139, USA ernment to assert more control. In the private sector, even for the insured population, clinical outcomes and david_himmelstein@hms. managed care and health maintenance organisations patient satisfaction are mediocre.23 harvard.edu (HMOs)}most of which were controlled by investors This dismal record arises, we contend, from health Accepted: 8 November 2007 rather than health providers and vigorously intervened policies that emphasise market incentives. Even as the in clinical care}rapidly gained a foothold. public share of health spending in the US has risen In the mid-1980s, Medicare also began encouraging to 60% (box) investor owned firms have eclipsed the elderly people to enrol in private HMOs. Government public, professional, and charitable bodies that previ- paid the private plans a fixed monthly premium for each ously managed the financing and delivery of care. The person who switched from traditional (fee for service) development and effect of US policies that mix public Medicare, with the HMO taking over responsibility for funding and private management has wider relevance purchasing (or, rarely, providing) care. This arrangement because politicians in Europe and beyond are pushing was touted as a means to bring market efficiency to the analogous schemes. public programme and to broaden patients’ choices. Unfortunately, the first crop of Medicare HMOs Failure of private contracting in Medicare yielded mainly scandal—for example, a major political The combination of tax funding and market oriented donor whose plan enrolled thousands of aged patients delivery is exemplified by the US Medicare programme, in Florida (and collected tens of millions of government which has a budget more than double that of the entire dollars) but neglected to contract with doctors or hos- NHS. Until 1965, many US employers offered private pitals to care for them. He fled prosecution, eventually health cover, but elderly, poor, and disabled people seeking refuge in Spain.4 were mostly uninsured and forced to rely on threadbare Subsequently, Medicare applied stricter regulations. government institutions or charity. In 1965, Congress The government set the HMOs’ payment at 95% of established the Medicare social insurance programme the average monthly cost of care for a patient in tra- for elderly people. Private hospitals gained a vast new ditional Medicare, with the expectation of 5% savings market, and investors soon took note, launching for- through improved efficiency. Patients who chose an profit chains that now account for 15% of US acute care HMO—attracted by free spectacles, lower copay- ments, and other benefits not covered under traditional } Tax financed health spending in US Medicare were free to return to traditional Medicare • Official figures for 2005 peg government’s share of total health expenditure at 45.4%, but whenever they wished. this excludes: HMOs recognised an opportunity in the skewed Tax subsidies for private insurance, which cost the federal treasury $188.6bn (£92bn; distribution of health costs. Most patients use little €129bn) in 2004 and predominantly benefit wealthy taxpayers care}indeed 22% of elderly people cost Medicare Government purchases of private health insurance for public employees such as police nothing at all each year}while the fraction who are officers and teachers. Government paid private insurers $120.2bn for such coverage in 2005: severely ill account for the lion’s share of expenditures. 24.7% of the total spending by US employers for private insurance Astute HMO executives quickly realised windfall profits • Government’s true share amounted to 9.7% of gross domestic product in 2005, 60.5% of through cherry picking—recruiting healthier than aver- total health spending or $4048 per capita (out of total expenditure of $6697) age older people who brought hefty premiums but used • By contrast, government health spending in Canada and the UK was 6.9% and 7.2% of gross little care}and returning sick patients, and their high domestic product respectively (or $2337 and $2371 per capita) medical bills, to the traditional Medicare programme— • Government health spending per capita in the US exceeds total (public plus private) per 5 capita health spending in every country except Norway, Switzerland, and Luxembourg disrupting care for millions.

REPRINTED BY PERMISSION HMO marketing departments devised selective

1126 BMJ | 1 DECEMBER 2007 | VOLUME 335 38 recruitment schemes to attract healthy people. These By the late included free fitness club memberships, complementary 1990s private recruiting dinners at times and places inaccessible to frail elderly people, and advertisements painted on health plans the bottoms of swimming pools. HMOs used financial were selectively incentives to encourage doctors to persuade sick patients enrolling healthy to leave the HMO—for example, deducting payments to specialists from the primary care doctor’s own capitation people and payment. Hence, a general practitioner could raise her removing sick income by advising patients needing hip replacement ones to leave the HMO, and even convince herself that such advice might benefit patients by freeing them of HMO restrictions on the choice of surgeon and hospital. HMOs concentrated on ensuring convenient and attractive care for the modest needs of healthy (and profitable) older people. Meanwhile, expensive, ill patients fared poorly. Stroke patients, those need- ing home care, and others with chronic illnesses got skimpy care, had bad outcomes, and fled HMOs.5-8 And when all else failed and an HMO found itself saddled with too many unprofitably ill patients in a particular county, executives simply closed up shop in that area and returned the patients to traditional Medicare. By the late 1990s, private HMOs’ selective enrol- 2% higher death rates and 19% higher costs than non- ment of healthy elderly people and removal of sick profit hospitals.14 15 Despite spending less on nurses people had raised annual Medicare costs by about and other clinical staff, investor owned hospitals spend $2bn.9 Yet despite this subsidy, HMOs couldn’t effec- more on managers.16 tively compete with traditional Medicare. The bur- If the failings of private contracting in the US are den of administrative costs}about 15% in the largest underappreciated, so is the major success story of Medicare HMO10 compared with 3% in traditional recent US health policy: the Veterans Health Admin- Medicare}was too great to overcome. Many HMOs istration system. This network of hospitals and clinics couldn’t sustain the extra benefits they had offered at owned and operated by government was long derided the outset to attract members. as a US example of failed Soviet-style central planning. As enrolment fell, HMOs lobbied hard for govern- Yet it has recently emerged as a widely recognised ment rescue, and Congress upped their payments. leader in quality improvement and information tech- Currently, Medicare pays private plans $77bn annu- nology. At present, the Veterans Health Administration ally; the cost of caring for the eight million Medicare offers more equitable care, of higher quality, at compa- members who have switched to HMOs is 12% above rable or lower cost than private sector alternatives.17 the cost of caring for comparable patients in traditional Medicare.11 Costsofmarketforces Medicare’s HMO contracting programme, originally Health care’s shift from a public service to a busi- touted as a market based strategy to improve the pub- ness model has raised costs, partly by stimulating the lic programme’s efficiency, has evolved into a multi- growth of bureaucracy. The proportion of health funds billion dollar subsidy for private HMOs. Moreover, devoted to administration in the US has risen 50% in the massive financial power amassed by these firms the past 30 years and now stands at 31% of total health (largely at government expense) is a political roadblock spending, nearly twice the proportion in Canada.18 to terminating this failed experiment. Meanwhile, administration has been transmogrified from the servant of medicine to its master, from a Is private really better? handful of support staff dedicated to facilitating patient Other US experiments in using public money to buy care to a vast army preoccupied with profitability. care from private firms have also disappointed. Costs Recent trends elsewhere indicate that the US expe- for the private insurance that government purchases rience is not unique. The advent of internal markets for public employees have risen even faster than Medi- sharply increased administrative costs in the UK19 and care’s.12 According to comprehensive meta-analyses, New Zealand.20 The overheads of Canadian private investor owned renal dialysis centres (funded almost insurers are 10 times higher than those of public pro- entirely by the special Medicare programme that vincial health insurance programmes.18 In Australia, covers everyone needing long term dialysis) have tax subsidies for private insurance have directed 9% higher mortality than non-profit centres despite money through private firms, whose overhead is 12% equivalent costs13; and investor owned hospitals—which (versus 3.5% in the public programme)21; the private receive most of their funding from public coffers—have hospitals favoured by current policies are about 10%

BMJ | 1 DECEMBER 2007 | VOLUME 335 1127 39 costlier than public ones.22 As Germany’s insurance for referrals; claimed excessive sums from Medicare; plans have adopted an increasingly business-like mode and that its hospitals performed hundreds of unneces- of operation, administrative costs have soared, rising sary cardiac procedures.27-29 63.3% between 1992 and 2003; meanwhile doctors For-profit executives’ incomes also drain money complain about an avalanche of paperwork.23 from care. When Columbia/HCA’s chief executive Two factors are at work. Firstly, fragmenting the officer resigned in the face of fraud investigations into funding stream, with multiple payers rather than a the company, he left with $324m in company stock. single government one, necessarily adds complexity Tenet’s chief executive exercised stock options worth and redundancy. Secondly, high administrative costs $111m shortly before resigning under pressure from are intrinsic to the commercial mode (in medical care investors in 2003. The head of HealthSouth (the domi- as elsewhere). Each party to a business transaction nant provider of rehabilitation care, mostly paid for must maintain its own detailed accounting records, not by Medicare) made $112m in 2002, the year before primarily for coordination but as evidence in case of his indictment for fraud (charges of which he was later disputes.24 Moreover, investors and regulators demand acquitted) and four years before his conviction on unre- verification by independent auditors, generating yet Overcrowded lated bribery charges.30 another set of records. Thus the commercial record Even chief executives of untainted firms have reaped replicates each clinical encounter in paper form before, US emergency enormous rewards. Former Harvard geriatrician John during, and after it takes place in the examining room. departments Rowe earned $225000 a day (including Sundays and The sense of mutual obligation and shared mission to turn away an holidays) in his 65 months running Aetna health insur- which medicine once aspired becomes irrelevant, even ance company.31 Bill McGuire made $1.6bn after giving a liability. Hence, the decision to unleash market forces ambulance once up pulmonary medicine to run UnitedHealthcare.32 is, among other things, a decision to divert healthcare a minute, on While private contracting has benefited executives dollars to paperwork. average and shareholders, it has increased costs and worsened quality because health care cannot meet the funda- Market failure mental requirements for a functioning market. It is Market theorists argue that although competition fashionable to view patients as consumers, but seri- increases administration, it should drive down total ously ill people (who consume most care) cannot shop costs. Why hasn’t practice borne out this theory? around, reduce demand when suppliers raise prices, Investor owned healthcare firms are not cost mini- or accurately appraise quality. They necessarily rely misers but profit maximisers. Strategies that bolster on their doctor’s advice on which tests and treatments profitability often worsen efficiency. US firms have to “purchase.” found that raising revenues by exploiting loopholes or Even for sophisticated buyers like government, lobbying politicians is more profitable than improving the “product” of health care is notoriously difficult to efficiency or quality. Columbia/Hospital Corporation evaluate, particularly since doctors and hospitals cre- of America (HCA)}the biggest US private hospital ate the data used to evaluate and reward them. When operator}deliberately submitted inflated bills and Tenet hospitals did heart surgery on healthy patients, expenses to the government, structured business the surgical outcomes appeared first rate. Even for deals so that Medicare picked up the cost of corporate honest firms, careful selection of lucrative patients expenses, and paid doctors in return for patient refer- and services is the key to success. Conversely, meet- rals.25 Tenet, the second largest hospital firm, has a ing community needs often threatens profitability and long history of legal problems. In the 1980s (when the hence institutional survival. In the past decade 425 firm was known as National Medical Enterprises) it emergency departments}magnets for both very sick gave doctors kickbacks to boost referrals and improp- and uninsured patients unable to pay}have closed. erly detained psychiatric patients in order to fill beds, Overcrowded US emergency departments turn away resulting in legal settlements totalling nearly $700m.26 an ambulance once a minute, on average.33 More recently, Tenet paid hundreds of millions of dol- Finally, a real market would require multiple inde- lars in fines to resolve claims that it offered kickbacks pendent sellers, with free entry into the marketplace. Yet many hospitals exercise virtual monopolies; half Hallmarksofmarketbasedreforms of Americans live in regions too sparsely populated to • Market reforms aim to bring medicine into the realm of commerce, where commodities support real medical competition. (homogeneous goods or services) are bought and sold for profit • The first stage of this process is to divide the medical enterprise into discreet, saleable units What’s driving privatisation? (commodities), creating buyers and sellers—for example, separating responsibility for financing and providing care or moving from global hospital budgets to fixed payment for a Evidence from the US is remarkably consistent; public specific procedure funding of private care yields poor results. In practice, • Once medical commodities are defined, the sellers (medical providers) are forced to public-private competition means that private firms carve compete, giving rise to financial winners and losers out the profitable niches, leaving a financially depleted • Because most medical commodities are heterogeneous (patients differ) providers can gain public sector responsible for the unprofitable patients advantage by market segmentation—for example, caring for a relatively healthy subgroup of and services. Based on this experience, only a dunce patients with a particular diagnosis could believe that market based reform will improve • Profitable providers attract investors and amass the financial (and political) power to expand efficiency or effectiveness. Why do politicians}who are their opportunities, while unprofitable ones are driven from the market anything but stupid}persist on this track?

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40 Such reforms offer a covert means to redistribute 3 Guyatt G, Devereaux P,Lexchin J, Stone S, Yalnizyan A, Himmelstein D, et al. A systematic review of studies comparing health outcomes wealth and income in favour of the affluent and pow- in Canada and the United States. Open Med 2007;1(1). www. erful. Privatisation trades the relatively flat pay scales openmedicine.ca/article/view/8/1. 4 Freedberg S. Miami mystery. Paid to treat elderly, IMC moved in worlds of in government for the much steeper ones in private spying and politics. New York Times 1988 Aug 9:1. industry; the 15-fold pay gradient between the highest 5 Morgan RO, Virnig BA, DeVito CA, Persily NA. The Medicare-HMO revolving door} the healthy go in and the sick go out. NEnglJMed and lowest paid workers in the US government gives 1997;337:169-75. way to the 2000:1 gradient at Aetna. 6 Shaughnessy PW, Schlenker RE, Hittle DF. Home healthcare outcomes under capitated and fee-for-service payment. Health Care Fin Rev But even more important, privatisation of publicly 1994;16:187-222. funded health systems uses the public treasury to cre- 7 Retchin SM, Brown RS, Yeh SCJ, Chu D, Moreno L. Outcomes of stroke patients in Medicare fee for service and managed care. JAMA ate profit opportunities for firms needing new markets. 1997;278:119-24. US private insurers used to focus on selling coverage 8 Ware JE Jr, Bayliss MS, Rogers WH, Kosinski M, Tarlov AR. Differences to employer sponsored groups and shunned elderly in 4-year health outcomes for elderly and poor, chronically ill patients treated in HMO and fee-for-service systems. Results from the medical people as uninsurable. Now, with employers cutting outcomes study. JAMA 1996;276:1039-47. health benefits, insurers have turned to public treasur- 9 Risk selection and risk adjustment in Medicare. In: Annual report to congress. Washington, DC: Physician Payment Review Commission, ies for new revenues. And why stop at selling insur- 1996. ance? Why not tap into the trillions spent annually on 10 PacifiCare announces changes for Secure Horizons Medicare HMO health plans in 2002. Medicare HMO Data Report, 2001. www. care in hospitals and doctors’ offices? medicarehmo.com/mrepnr04b.htm. 11 Congressional Budget Office. Statement of Peter R Orszag, director, on Lessons for other countries the Medicare advantage programme, June 28, 2007. www.cbo.gov/ ftpdocs/82xx/doc8265/06-28-MedicareAdvantage.pdf. Market fundamentalists conjure visions of efficient 12 Davis K, Cooper BS, Capasso R. The federal employee health benefits program: a model for workers, not Medicare. New York: Commonwealth medical markets partnered with government over- Fund, 2003. www.cmwf.org/usr_doc/davis_fehbp_677.pdf. sight and funding to assure fairness and universality. 13 Devereaux PJ, Schünemann HJ, Ravindran N, Bhandari M, Garg AX, Choi PTL, et al . Comparison of mortality between private for-profit and private But regulation is overmatched. Incentives for optimal not-for-profit hemodialysis centers: a systematic review and meta- performance align imperfectly, at best, with the real analysis. JAMA 2002;288:2449-57. 14 Devereaux PJ, Choi PTL, Lacchetti C, Weaver B, Schünemann HJ, Haines goals of care. Matrices intended to link payment to T, et al. A systematic review and meta-analysis of studies comparing results instead reward entrepreneurs skilled in clever mortality rates of private for-profit and private not-for-profit hospitals. circumvention. Their financial and political clout CMAJ 2002;166:1399-406. 15 Devereaux PJ, Heels-Ansdell D, Lacchetti C, Haines T, Burns KEA, grows; those who guilelessly pursue the arduous work Cook DJ, et al. Payments for care at private for-profit and private not- of good patient care lose in the medical marketplace. for-profit hospitals: a systematic review and meta-analysis. CMAJ 2004;170:1817-24. Health systems in every nation need innovation 16 Woolhandler S, Himmelstein DU. Costs of care and administration and improvement. But remedies imported from com- at for-profit and other hospitals in the United States. NEnglJMed 1997;336:769-74. merce consistently yield inferior care at inflated prices. 17 Oliver A. The Veterans Health Administration: an American success Instead we prescribe adequate dosing of public funds; story? Milbank Q 2007;85:5-35. 18 Woolhandler S, Campbell T, Himmelstein DU. Costs of health care budgeting on a community-wide scale to align invest- administration in the United States and Canada. NEnglJMed ment with health priorities and stimulate cooperation SUMMARY POINTS 2003;349:768-75. 19 Health Policy Network of the NHS Consultants’ Association, NHS among public health, primary, and hospital care; The US has long combined Support Federation. In practice: The NHS market in the United Kingdom. encouragement of local innovation; explicit empow- public funding with J Public Health Policy 1995;16:452-91. private healthcare 20 Coney S. Relentless unraveling of New Zealand’s health-care system. erment of patients and their families; intensive audit Lancet 1996;347:1825. for improvement, not reward or blame; a system based management and delivery 21 WillcoxS. Promoting private health insurance in Australia: Do Australia’s on trust and common purpose; and leadership not by Extensive research shows latest health insurance reforms represent a policy in search of evidence? that its for-profit health Health Affairs 2001;20(3):152-61. corporations but by “imaginative, inspired, capable 22 Duckett SJ, Jackson TJ. The new health insurance rebate: An inefficient institutions provide and...joyouspeople,invitedtousetheirmindsand way of assisting public hospitals. Med J Australia 2000;172:439-42. inferior care at inflated 23 Hyde R. An end to Germany’s bureaucratic nightmare? Lancet their wills to cooperate in reinventing the system, itself prices 2006;367:1717-8. 24 Braverman H. Labor and monopoly capital: the degradation of work in ...becauseofthemeaningitaddstothelives and the US experience shows 34 the twentieth century. New York: Monthly Review Press, 1974. peace it offers in their souls.” that market mechanisms 25 Department of Justice. Largest health care fraud case in US history We thank Howard Waitzkin for useful comments. undermine medical settled: HCA investigation nets record total of $1.7 billion. Press release, 26 June, 2003. www.usdoj.gov/opa/pr/2003/June/03_civ_386. Contributors and sources: SW and DUH work as primary care doctors at institutions unable or htm. an urban public hospital. Stimulated by their patients’ difficulties in obtaining unwillingtotailorcareto 26 Eichenwald K. $100 million settlement seen in Tenet suits. New York care, they began research into the inadequacies of US health care. In 1986 profitability Times 1997 Jul 30:D1. 27 Department of Justice. Tenet Healthcare Corporation to pay US more than they cofounded Physicians for a National Health Program (www.PNHP.org), Commercialisation $900 million to resolve False Claims Act allegations. Press release, 29 which advocates non-profit national health insurance in the US. Both authors drives up costs by June, 2006. www.usdoj.gov/opa/pr/2006/June/06_civ_406.html. participated equally in all aspects of this work, which draws on their research, diverting money to profits 28 Eichenwald K. How one hospital benefited from questionable surgery. New York Times 2003 Aug 12. experience as clinicians in the US healthcare system, and extensive literature and fuelling growth review. Both serve as guarantors. 29 Eichenwald K. Tenet Healthcare paying $54 million in fraud settlement. in management and New York Times 2003 Aug 7. Competing interests: None declared. financial bureaucracy 30 Reeves J. The Scrushy case: Health South founder begins 7-year Provenance and peer review: Not commissioned; externally peer reviewed. sentence. Houston Chronicle 2007 Jun 30. The poor performance of 31 Dash E. Executive pay: a special report. Off to the races again, leaving 1 Himmelstein DU, Warren E, Thorne D, Woolhandler S. Illness and injury US health care is directly many behind. New York Times 2006:Apr 9(section 3):1-9. as contributors to bankruptcy. Health Aff (Milwood) 2005;(suppl web attributable to reliance on 32 Anders G. As patients, doctors feel pinch, insurer’s CEO is worth a exclusive):w5-63-w5-73. billion. Wall Street Journal 2006 Apr 18:A1. 2 Davis K, Schoen C, Schoenbaum SC, Doty MM, Holmgren AL, Kriss JL, et market mechanisms and 33 Committee on the Future of Emergency Care in the United States al. Mirror, mirror on the wall: an international update on the comparative for-profit firms and should Health System. Hospital-based emergency care: at the breaking point. performance of American health care. New York: Commonwealth Fund, warn other nations from Washington, DC: National Academies Press, 2006. 34 Berwick DM. Improvement, trust, and the health care workforce. 2007. www.commonwealthfund.org/publications/publications_ this path Qual show.htm?doc_id=482678. Saf Health Care 2003;12:2-6.

BMJ | 1 DECEMBER 2007 | VOLUME 335 1129

41 (Editor's note: The following entry from Dr. Don McCanne's single payer "Quote of the Day" concerns the negative impact a decade of private health plans has had on Australia's single payer national health insurance system. In 2007 the government spent $3 billion in taxpayer funds to subsidize 1/3 of the cost of private health insurance, but claimed penury when it came to adequately funding public hospitals. To subscribe to the “Quote of the Day,” drop a note to to Dr. McCanne via e-mail [email protected]. Australia’s Medicare and Private Health Plans: A Model of Two-Tiered Care The private life of health care Commentary by Don McCanne, MD

By Ruth Pollard and Mark Metherell Australia’s experiment with a public Medicare program The Sydney Morning Herald and private insurance plans has provided a very important April 6, 2007 policy lesson for the United States: Establishing policies that encourage the purchase of private insurance while In just 10 years, the health system many were dreading has simultaneously limiting the funding of public insurance will arrived. Spurred by the Federal Government’s campaign to push inevitably result in a two-tiered system. More affluent indi- Australians into private health insurance and exacerbated by dif- viduals will have the best care money can buy, whereas ficulties in finding care in public hospitals, the balance has tipped those remaining in an underfunded public program will in favour of private hospitals. Our system is now a genuinely two- have impaired access and impaired health outcomes. Keep tiered model: the wealthy and privately insured get timely health in mind that impaired health outcomes means chronic suf- care and the rest, unless they are critically ill, can wait. fering and death. In the past decade, a clear division of labour has evolved: public The private Medicare Advantage insurance options in our hospitals are now dominant in emergency surgery and medicine, Medicare program are intended to reproduce this same two- while private hospitals rule in elective surgery, accounting for 55.7 tiered system in the United States. Currently the Medicare per cent of all operations. Advantage plans are provided with more taxpayer funds so “Since 1982-83, Australia’s hospital system has witnessed a that they can attract individuals by providing better bene- massive shift of activity to the private sector,” Bill Nichol, an assis- fits. Once the private plans are well established, the govern- tant director in the federal Department of Health, writes in the ment can start reducing the funding of both the traditional study. program and the private plans. But the private plans will be “The private sector’s role has increased to dominant player” in able to continue to offer greater benefits merely by increas- several categories of care, including eye, cancer, ear, nose and ing premiums and cost sharing. Thus more affluent individ- throat and the male and female reproductive systems, Nichol says. uals will select the private plans whereas individuals with The worrying thing is that many seem to have thrown up their more modest means will be relegated to the underfunded arms in despair, a kind of “Oh, well” about the death of equity in public program. Without a surge in political activism, this the health system. outcome is inevitable. Bruce Armstrong, the director of research at the Sydney Cancer There is an even more important lesson from the Centre and a professor of public health at the University of Australian experience. We now have a consensus that we Sydney, believes there has been no attempt to prevent a two-tier must reform health care in America. The two main options health system from developing. are to either establish an equitable national health insur- “Equity is a real issue – a proportion of the Australian popula- ance program, or build on the current fragmented system to tion which is not inconsequential is not going to get that care achieve universality. Numerous attempts at patching our because if you go to a private hospital you need private health current system have fallen short, so some politicians and insurance and even then, there [are] always going to be gap pay- policymakers are now supporting a public Medicare-like ments.” program as a safety-net alternative. Because health care A disturbing trend to emerge despite the establishment of costs are a leading concern of virtually everyone, efforts will Medicare in 1983 is the widening disparity between the well-off be made to keep the funding of the Medicare-like option to and the poor in mortality rates from avoidable diseases. The a minimum. Imagine a minimally funded program that Australian way of death means the prosperous are significantly attracts people with low incomes and with significant less likely to die from avoidable disease than those on low health care needs; talk about stretching resources. Anyone incomes. who can buy their way out of that program will. Like In 1986 the rate of death from “avoidable” causes such as treat- Australia, a two-tiered system would be inevitable. able and preventable conditions like heart disease among the As Professor Braithwaite says, “The real question is, is have-nots was 50 per cent higher than for the haves. By 2002 that this the health system that we want, that people desire?” difference had stretched to a twofold gap, according to research published in the International Journal of Epidemiology. REPRINTED BY PERMISSION AUSTRALIA continued on page 43

42 AUSTRALIA continued from page 42 the private insurance rebate, acknowledges this point, says Professor Jeffrey states are bearing a larger share of public Braithwaite, the director of the Centre for hospital costs. Clinical Governance Research at the The report concludes that “advantaged But he says that if there is an equity prob- University of NSW. people have obtained a disproportionate lem, it’s for state governments to fix. “It may “This is a health system responding to benefit of health care, contributing to sound like I am playing the blame game, but policy measures - those measures are the widening relative health inequalities”. state governments are responsible for pub- caps in the public hospital system and the “A universal health-care system does not lic hospitals,” Abbott says. incentives provided in the private system,” guarantee equality in health-care-related He would welcome further growth in he says. outcomes,” says the article, whose lead private insurance, which he suggests many “The real question is, is this the health author was Rosemary Korda of the National more people could afford given that more system that we want, that people desire?” Centre for Epidemiology and Population than 1 million people on incomes of less Health at the Australian National than $20,000 pay for cover. http://www.smh.com.au/news/national/the-private-life-of- University. health-care/2007/04/05/1175366414296.html?page=fullpage# “No doubt having private health insur- Australian Health Review - Abstract (Nichol): The Health Minister, Tony Abbott, hav- ance confers additional benefits [like avoid- http://www.aushealthreview.com.au/publications/articles/issu ing presided over multibillion-dollar infu- es/ahr_31_1_0407/ahr_31_1_s004.asp ing public waiting lists], but you do have to International Journal of Epidemiology - Abstract (Korda et al): sions into the private sector through pay for it,” Abbott says. http://ije.oxfordjournals.org/cgi/content/abstract/dyl282v1 Medicare payments to private doctors and It was inevitable that we would end up at ‡USUcU›VÿdPUeadÿTUIPÿVœVaP` USc adP VfVaURSUgReRaœÿbUIUcX

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"&%17 –  % 1!  7%%"% % 127"-ÿ3 %   ÿ'  % 4"&3%$ % % -ÿÿ"%!' ÿ&"%!-"%3 0-1 % '%"- % " % 7- "%  "%-Gn7  Rep Kildee, Dale E. [MI-5] 7 7ÿ!ÿ-% "%3 !% "% ÿ3  !%  -à 2 HR 676 Rep Kilpatrick, Carolyn C. [MI-13] Rep Kucinich, Dennis J. [OH-10] %-  7"-ÿ7- "%   ÿ7"ÿ% % 4-"-ÿ& 7 7  Co-Sponsors Rep Lantos, Tom [CA-12] ÿ' "%"%3 %  & 7  %4  -%1h%"%!% 7"- Rep Lee, Barbara [CA-9] (110th Congress Co-Sponsors) Rep Lewis, John [GA-5] "% "-ÿ "" j 7 %% !% % 4-"-ÿ&7 7ÿ! Rep Loebsack, David [IA-2] -% "%3 "%ÿ 7 o %"  n  - 7ÿ!- -ÿÿ-"3%"&"!% 4 Rep Abercrombie, Neil [HI-1] Rep Lynch, Stephen F. [MA-9] Rep Baca, Joe [CA-43] 7"37 7%ÿ"%ÿC%†!%!  7 % "%!--ÿ"% Rep Maloney, Carolyn B. [NY-14] Rep Baldwin, Tammy [WI-2] Rep McDermott, Jim [WA-7] -% "%3 7%ÿ%"ÿ4-%' ÿ% 19! ˜"%% 7 ""$ Rep Becerra, Xavier [CA-31] Rep McGovern, James P. [MA-3]  - %3 7ÿ& 7"-ÿ%"%!"  "37 ' -%' ÿ ÿ3 Rep Berman, Howard L. [CA-28] Rep McNulty, Michael R. [NY-21] Rep Bishop, Sanford D., Jr. [GA-2] Rep Meehan, Martin T. [MA-5] 7 -!" 4ÿ7- % "% - "%ÿ "" "%3 & 73 7ÿ"% Rep Brady, Robert A. [PA-1] Rep Meeks, Gregory W. [NY-6] 7 7ÿ!ÿ0%" -1 ™  %3 % -ÿ 7 7 7 Rep Brown, Corrine [FL-3] Rep Miller, George [CA-7] Rep Capuano, Michael E. [MA-8] Rep Moore, Gwen [WI-4] !ÿ-% "%3!%% 3  !%  - '!-ÿ& 7 Rep Carson, Julia [IN-7] Rep Moran, James P. [VA-8] -- "%'" " 40%-%1 Rep Christensen, Donna M. [VI] Rep Nadler, Jerrold [NY-8] Rep Clarke, Yvette D. [NY-11] Rep Napolitano, Grace F. [CA-38] Rep Clay, Wm. Lacy [MO-1] Rep Norton, Eleanor Holmes [DC] 27"-ÿ "! ÿ7- '% %" 1 Rep Cohen, Steve [TN-9] Rep Olver, John W. [MA-1] Rep Cummings, Elijah E. [MD-7] Rep Pastor, Ed [AZ-4] Š‹% ”&'&”ŒŽ”Ž•A % ! 1 Rep Davis, Danny K. [IL-7] Rep Payne, Donald M. [NJ-10] Rep Delahunt, William D. [MA-10] Rep Rangel, Charles B. [NY-15] (’)‹01‘'% ”Ž• 6 7%„ 2ÿe"% F %"ÿA4 i&&e%3 % Rep Doyle, Michael F. [PA-14] Rep Richardson, Laura [CA-37] ˜% ˜ 4 & 7" 737 & !  % -ÿ% & -ÿ& 7"-ÿ "! 1 Rep Ellison, Keith [MN-5] Rep Roybal-Allard, Lucille [CA-34] Rep Engel, Eliot L. [NY-17] Rep Rush, Bobby L. [IL-1] Rep Farr, Sam [CA-17] Rep Ryan, Tim [OH-17] Rep Fattah, Chaka [PA-2] Rep Sanchez, Linda T. [CA-39] ó ‡ Rep Filner, Bob [CA-51] Rep Sanchez, Loretta [CA-47] Rep Frank, Barney [MA-4] t1C52-„B! % 7 +' "!f+"% ÿ6% &!16 8-ÿ' !!--!6%&"%3 7 Rep Schakowsky, Janice D. [IL-9] Rep Green, Al [TX-9] Rep Scott, David [GA-13] ' ÿ% ' "!ÿ% "% ÿ7 7ÿ!1i  GC %"% 5 "!  --!" "%j Rep Grijalva, Raul M. [AZ-7] xrrk1%" ' G1! 1!w ""wC5 wC% % ""3-w6%-" C  Rep Scott, Robert C. "Bobby" [VA-3] Rep Gutierrez, Luis V. [IL-4] Rep Serrano, Jose E. [NY-16] w5"E -w&wxrrkw' !!-- x1& !!-- xrr‡ÿ5 xv†1 Rep Hare, Phil [IL-17] x1 5 -% ˜ 1™  7ÿ-4-  48ÿ&"1˜ ' % 5 " g2% lxrr€ÿA%txjn! Rep Solis, Hilda L. [CA-32] Rep Hastings, Alcee L. [FL-23] Rep Sutton, Betty [OH-13] Gq1 Rep Hinchey, Maurice D. [NY-22] q1 n"-%i1ƒ 7  " -  ÿ&%„ ' ÿ% 7 7ÿ!à ˜ ' % 5 " g2% l Rep Thompson, Bennie G. [MS-2] xrryÿtjn! Gt‡1 Rep Hirono, Mazie K. [HI-2] Rep Tierney, John F. [MA-6] y1 C7 %3"%3 7 7ÿ!ÿ-4-  -- "%'" " 4G%- %"%3 7 7ÿ-4-  $ Rep Honda, Michael M. [CA-15] Rep Towns, Edolphus [NY-10] &%!& "%3 !% "-1i  G27 C %&%! — ÿ&C%jxrry1 Rep Jackson, Jesse L., Jr. [IL-2] Rep Udall, Tom [NM-3] %" ' G17 713%1'1!w-!-w' "! "%-wC%&%! — x1& Rep Jackson-Lee, Sheila [TX-18] Rep Waters, Maxine [CA-35] !!-- xrr‡ÿ5 xv†1 Rep Jefferson, William J. [LA-2] Rep Watson, Diane E. [CA-33] €1 5 !e"%%%ÿiC127" 7  "!ÿ&7 7ÿ!1C5 ixrryjt‡tGkrq$y1 Rep Johnson, Eddie Bernice [TX-30] Rep Weiner, Anthony D. [NY-9] Rep Johnson, Henry C. "Hank," Jr. Rep Welch, Peter [VT] [GA-4] Rep Wexler, Robert [FL-19] Rep Jones, Stephanie Tubbs [OH-11] Rep Woolsey, Lynn C. [CA-6] Rep Kaptur, Marcy [OH-9] Rep Wynn, Albert Russell [MD-4] Rep Kennedy, Patrick J. [RI-1] Rep Yarmuth, John A. [KY-3]

For a list of 24 Congressional candidates who support single payer see http://www.sickocure.org/single_payer_candidates.php

rs tu v uwxyÿ45{|}~~ v €€‚ ‰{ dependants (about 5% of the population). C o m p l e m e n t a ry VHI provides cover for s e rvices excluded or not fully covered by the state, particularly cover for statutory user charges, as in Croatia, Denmark, France and Slovenia. Supplementary VHI p rovides cover for faster access and i n c reased consumer choice and is Private health insurance and access available in most EU member states. VHI may increase access to health care to health care in the European Union for those who are able to purchase an adequate and affordable level of private cover. At the same time it is likely to Sarah Thomson and Elias Mossialos present barriers to access, particularly for older people, people in poor health and people with low incomes. The greater the Private or voluntary health insurance (VHI) a c c o rding to whether its role, in relation to role of VHI in providing access to effec- does not play a significant role in many health s t a t u t o ry health insurance (SHI), is substitu- tive health services that are a substitute systems in the European Union (EU), either tive, complementary or supplementary. for or complement to those provided by in terms of funding or as a means of gaining Substitutive VHI provides cover that would the government, the larger the impact it access to health care. In most EU member o t h e rwise be available from the state. It is will have on access to health care. states it accounts for less than 5% of total p u rchased by those who are excluded fro m Access to health care within VHI expenditure on health and covers a relatively p a rticipating in some or all aspects of the SHI markets is heavily dependent on the small proportion of the population (see Table scheme – for example, Dutch residents with an regulatory framework in place and the 1). The exceptions to this trend are France, annual income over 30,700 a year and their dependants (around a quarter of the popula- way in which insurers operate. It may be Germany and the Netherlands. tion) – or by those can choose to opt out of affected by how premiums are rated, VHI fulfils diff e rent roles in diff e rent con- that SHI scheme, such as German employees whether they are combined with cost texts. In the EU context it can be classified with annual earnings over 45,900 and their sharing, the nature of policy conditions, the existence of tax subsidies to encour- Table 1 age take up or cross-subsidies to the Levels of VHI coverage as a percentage of the total population in the EU, 2000 or latest available year statutory health care system and the Country Substitutive Complementary Supplementary characteristics of those who purchase it. It may also be affected by whether or not Austria* 0.2% 18.8% (inpatient 12.9%) benefits are provided in cash rather than Belgium 7.1% 30–50% in kind, the way in which providers are Denmark* None 28% paid and the extent to which policies are Finland*** None None Children <7: 34.8% purchased by groups – usually employers Children 7–17: 25.7% – rather than individuals. Adults: 6.7% France** Marginal (frontier workers) 85% (2000 estimate 94%) Due to information failures in VHI Germany* 9% 9% (mainly) markets, insurers need to find ways of assessing an individual’s risk of ill health Greece None 10% in order to price premiums on an actuari- Ireland None 45% ally fair basis. However, accurate risk Italy* None 15.6% assessment is technically difficult and Luxembourg None 70% (mainly) expensive to administer. Consequently, Netherlands* 24.7% (+ 4.2% WTZ) >60% Marginal insurers have strong incentives to select Portugal** None 12% risks – that is, to attract people with a Spain* 0.6% 11.4% lower than average risk of ill health and Sweden* None 1.0–1.5% deter those with a higher than average UK None 11.5% risk. Some regulatory measures will increase insurers’ incentives to select * 1999, ** 1998, *** 1996 Source: Mossialos and Thomson (2004)1 risks – for example, requiring insurers to REPRINTED BY PERMISSION offer community-rated premiums – while others, such as risk adjustment mecha- nisms, aim to reduce these incentives.

46 Table 2 However, even if explicit risk selection is Conditions usually excluded from VHI cover in the European Union, 2001 prohibited by requiring insurers to offer open enrolment and to cover pre-existing Country Usual exclusions conditions, insurers may engage in covert forms of risk selection. Austria Individual: pre-existing conditions usually excluded (but not from group policies); insurers cannot reject applications but may charge higher premiums and/or introduce Insurers in European VHI markets are cost-sharing arrangements for people with chronic illnesses generally subject to a low level of regula- Belgium Mutual: psychiatric and long-term care (lump sum) tion. In most non-substitutive VHI mar- Mutual: psychiatric care (co-payment) kets regulation is exclusively concerned Commercial: pre-existing conditions, infertility treatment, sporting injuries with ensuring that insurers remain solvent rather than issues of consumer Denmark Pre-existing conditions protection. Ireland is the only country in Finland Pregnancy and childbirth, infertility treatment, alcoholism, herbal remedies, treatment which insurers are required to offer open covered by statutory health insurance enrolment, community-rated premiums France Excluding any disease is forbidden by law, although it can be authorized in individual and lifetime cover and are subject to a policies under certain conditions: the disease has to be clearly stated and the insurer risk equalization scheme (see the article has to prove that the patient had the disease before purchasing the policy on Ireland). Elsewhere insurers are permitted to reject applications for cover, Germany Pre-existing conditions are excluded if they were known at the time of underwriting exclude or charge higher premiums for and were not disclosed by the insured; declared pre-existing conditions are covered pre-existing conditions, rate premiums but generally result in higher premiums according to risk, provide non- Greece Pre-existing conditions standardized benefit packages and offer annual contracts. Benefits are usually Ireland Open enrolment provided in cash – that is, insurers reim- Italy Individual: pre-existing conditions, chronic and recurrent diseases, mental illness, alco- burse individuals for their health care hol and drug addiction, cosmetic surgery, war risks, injuries arising from insurrection, costs. In loosely regulated VHI markets natural disasters etc; also often excludes dental care not caused by accident/illness older people, people in poor health and Group : pre-existing conditions such as diabetes, drug and alcohol addiction, HIV/AIDS, people with low incomes are likely to severe mental health problems such as schizophrenia, voluntary termination of find it difficult to obtain affordable cov- pregnancy and war risks erage. People in poor health may not be Luxembourg Mutual: open enrolment (but no cover for treatment excluded from Statutory Health able to purchase any cover (see Table 2). Insurance) Commercial: pre-existing conditions G o v e rnments intervene more heavily in markets for substitutive VHI in Germ a n y Netherlands Some dental plans may require people to have their teeth restored before acceptance and the Netherlands where, as a result of Portugal Individual: pre-existing conditions, long-term chronic illnesses (such as diabetes, multi- risk selection by insurers, older people ple sclerosis and asthma), HIV/AIDS, haemodialysis, self-inflicted injuries, and people with chronic illnesses have psychiatric treatments, check-ups, dental care, outpatient drugs, not been able to purchase suff i c i e n t and non-evidence based treatment; dental care, delivery costs and outpatient drugs are c o v e r. Risk selection by insurers has also only covered by the most expensive policies contributed, to some extent, to the Spain HIV/AIDS, alcoholism and drug addiction, dental care (often available for a supplemen- financial instability of the SHI scheme, tary premium), prosthesis, infertility treatment, orthopaedics etc; some insurers do not which covers a dispro p o rtionate amount have general restrictions but may reject certain conditions; most insurers offer extra of older people in both countries. benefits for a supplementary premium eg organ transplants, second opinion, family Changes in regulation to prevent furt h e r planning, assistance during trips, treatment abroad, certain prosthesis; only one insurer destabilization of SHI in the Netherlands offers homeopathy or spa treatment in 1986 and in Germany in 1994 and 2000 Sweden Emergency care, long-term care, HIV/AIDS, some other communicable diseases, mean that some people with re l a t i v e l y diseases and injuries as a result of the use of alcohol or other intoxicating substances, low incomes no longer have access to pre-natal care, child birth (normal or with complications), termination of pregnancy, s t a t u t o ry coverage and must rely on infertility treatment, vaccinations substitutive VHI. For this reason insure r s in both countries are re q u i red to pro v i d e UK Pre-existing conditions, GP services, accident and emergency admission, long-term chronic illnesses such as diabetes, multiple sclerosis and asthma, drug abuse, self- older people with standardized benefit inflicted injuries, outpatient drugs and dressings, HIV/AIDS, infertility, normal packages – providing similar benefits to pregnancy and child birth, cosmetic surgery, gender reassignment, preventive s t a t u t o ry coverage – for a premium treatment, kidney dialysis, mobility aids, experimental treatment and drugs, organ regulated by the government. Insurers in transplants, war risks and injuries arising from hazardous pursuits G e rmany are also re q u i red to offer Source: Mossialos and Thomson (2004)1 lifetime substitutive VHI cover. In the

47 Table 3 VHI tends to incur higher management A comparison of administrative costs among voluntary and statutory insurers, 1999 and administrative costs than SHI, partly Country Voluntary Statutory because pool size is smaller, but mainly (% of premium income) (% of public expenditure on health) due to the extensive bureaucracy Austria 22% (early 1990s) 3.6% (2000) required to assess risk, set premiums, design benefit packages and review, pay Belgium 25.8% (commercial individual) 4.8% or refuse claims (see Table 3). Insurers 26.8% (commercial group) also incur additional expenses through France 10–15% (mutuals) 4–8% advertising, marketing, distribution, rein- 15–25% (commercial) surance and the need to generate a profit Germany 10.2% 5.09% (2000) or surplus. Within the EU context, these additional costs cannot be justified on Greece 15–18% (commercial life insurers) 5.1% the grounds that insurers are innovative Ireland 11.8% (Vhi Healthcare 2001) 2.8% (1995) in devising mechanisms to contain costs. 5.4% (Vhi Healthcare 1997) In practice, EU insurers are more likely Italy 27.8% (2000) 0.4% (1995) to compete on the basis of risk selection than through competitive purchasing. Luxembourg 10–12% (mutuals) 5.0% Most attempts to contain costs operate Netherlands 12.7% 4.4% on the demand side, through cost shar- Portugal About 25% - ing. Transaction costs have not been low- ered as a result of increased liberalization Spain About 13–15% 5.0% of VHI markets in the EU since 1994. In UK About 15% 3.5% (1995) Ireland higher levels of advertising United States About 15% About 4.0% following liberalization have actually increased transaction costs. Source 1 : Mossialos and Thomson (2004) Overall, VHI requires careful regulation to ensure access to health care, guarantee Netherlands younger people with ernment introduced a law on universal consumer protection and stimulate substitutive VHI are re q u i red to cro s s - health coverage (CMU) in 2000, extend- efficiency gains. The existence of VHI is subsidize the premiums of older people ing free complementary VHI coverage to likely to create barriers to access and and all policy holders must make an people earning less than 550 (US$ 645) may reduce equity and efficiency in the annual contribution to the SHI scheme. per month (see the article on page 4). health system as a whole. Furthermore, Complementary VHI covering cost Supplementary VHI often provides faster unless there are clear boundaries between sharing is likely to present barriers to access to health care by enabling people the public and the private sector, VHI access for people with low incomes, to bypass waiting lists in the public sec- may distort the allocation of public particularly those with incomes just tor. It can also provide access to a wider resources for health care, to the above the threshold for any exemptions range of providers. However, if supple- detriment of those who are insured by from cost sharing that may exist. It is mentary VHI does not operate indepen- statutory health insurance. both inequitable and inefficient for gov- dently of the statutory health system, it REFERENCES ernments to establish a price mechanism may distort the allocation of public Vo l u n t a ry through cost sharing and then negate the resources for health care, which may 1. Mossialos E, Thomson, S. Health Insurance in the European Union. effect of price for those who can afford restrict access for those who are publicly to purchase complementary VHI. insured. This could happen if boundaries Copenhagen: The European Observ a t o ry Complementary VHI is most prevalent between public and private provision are on Health Systems and Policies, 2004. in France, where it covered 85% of the not clearly defined, particularly if capaci- population in 1998. Research shows that ty is limited, if providers are paid by Elias Mossialos is Professor of Health Policy at the London School of Economics the likelihood of being covered by com- both the public and the private sector & Political Science and a Research plementary VHI is highly dependent on and if VHI creates incentives for health Director of the European Observatory on social class, income levels, employment care professionals to treat public and Health Systems and Policies. status, level of employment and age. private patients differently. Governments Furthermore, the quality of coverage in some countries, for example, Ireland, Sarah Thomson is a Research Officer in provided by complementary VHI have found that the existence of VHI can Health Policy at LSE Health and Social increases significantly with income. In reduce access for publicly funded Care at the London School of Economics order to address the inequalities in access patients and are taking steps to clarify & Political Science and a Research to health care arising from unequal access the boundaries between public and Officer at the European Observatory on to complementary VHI, the French gov- private provision of health care. Health Systems and Policies.

48 Yes, We Can! Can We? THE NEXT FAILURE OF HEALTH CARE REFORM B y V I C E N T E N A V A R R O

A major problem–if not the major prob- similar cases, with the eloquence that Meanwhile, during those years, the lem–for many people living in the U.S. is characterizes all of his speeches. He fre- Democratic Party establishment dis- the difficulty of accessing and paying for quently refers to his own mother, who tanced itself from any commitment to medical care when they are sick. For had cancer and had to worry not only resolving these problems. Even though this reason, candidates in the presiden- about her illness but about paying her the 1976, 1980, 1984, 1988, and 1992 tial primaries of 2008–the Democrats medical bills. Democratic Party platforms included more often than the Republicans–have All these cases are tragic and are rep- calls for health care benefits coverage for been recounting stories about the resentative of a situation faced by mil- everyone (what is usually referred to as health-related tragedies they have lions of people in the U.S. every year. "universal health care"), that call was encountered in meetings with ordinary But, I am afraid that unless the winning usually made without much conviction. people around the country (an exercise Democratic candidate, once elected In the primaries of 1988, when I was conducted in the U.S. every four years, president (and I hope he or she will be), involved in preparing the Democratic at presidential election time). These sto- develops a more comprehensive health platform, Dukakis (the winner of the ries tell of the enormous difficulties and care proposal than any of those put for- primaries) resisted including universal suffering faced by many people in their ward in the primaries so far, we will see health care in the party platform. He was attempts to get the medical care they the same situation continue. Democratic afraid of being perceived as "too radical." need. I have been around long enough–I candidates in the 2012 primaries, and in He had to accept it, however, because was senior health advisor to Jesse the 2016 primaries, will still be referring Jesse Jackson agreed to support Dukakis Jackson in the Democratic primaries of to single mothers with chronic health (Jackson had 40% of the Democratic del- 1984 and 1988–to know how frequently conditions who cannot pay their medical egates at the Atlanta convention) only if Democratic candidates, over the years, bills. The proposals put forward by the platform included this call for uni- have referred to such cases. The only Obama and Clinton underestimate the versal care. things that change are the names and gravity of the problem in the U.S. med- Then, in 1992, Bill Clinton (who bor- faces in these human tragedies. ical care sector. The situation is bad and rowed extensively from Jackson's 1988 Otherwise, the stories, year after year, is getting worse: the number of people proposals) put the call for universal are almost the same. who are uninsured and underinsured has health care at the center of his program. In the Democratic Party primaries of been growing since 1978. But, once president, his closeness to Wall 1988, for example, candidate Michael Let's start with the uninsured, those Street and his intellectual dependence on Dukakis talked about a young single people who do not have any form of Robert Rubin of Wall Street (who mother who had two jobs and still could health benefits coverage. There were 21 became his Secretary of the Treasury) not afford medical insurance for herself million uninsured people in the U.S. in made him leery of antagonizing the and her children. In 1992, Bill Clinton 1972. By 2006, that number had more insurance industry. It was President did the same, changing the story only than doubled to 47 million. And this Clinton's unwillingness to confront the slightly. This time it was the case of a increase has been independent of eco- insurance companies that led to his fail- woman with diabetes who could not get nomic cycles. The number of uninsured ure to honor his commitment to work health insurance because of her chronic grew by 3.4 million from 2004 to 2006, toward a universal health care program condition. And now, in the 2008 primar- even as a resurgent economy raised (see my article "Why HillaryCare Failed" ies, Hillary Rodham Clinton (whom I incomes and lowered poverty rates. http://www.pnhp.org/hillarycare, worked with on the White House March 6, 2008 Health Care Reform Task Force in 1993) describes a similar case. This time it is a single woman, with two daughters, who cannot pay her medical bills because her congenital heart defect makes it impos- sible for her to get medical insurance

coverage. And Barack Obama describes REPRINTED BY PERMISSION

49 November 12, 2007). The type of reform ical care to everyone who needs it. The These deaths are so much a part of our President Clinton called for was a health U.S. spends 16% of its GNP on medical reality that they are not news. How can insurance-based model called "managed care, almost double the percentage spent this be tolerated in a country that claims care," in which insurance companies by Canada and most countries of the to be a civilized nation? remain at the center of health care. An European Union (E.U.) on providing alternative approach could have been to universal, comprehensive health care The Democratic establish a publicly funded health care coverage to their populations. We in the candidates' proposals program (which was favored by the U.S. spend $2.1 trillion on medical care, The proposals put forward by the cur- majority of the population) that would making the medical care sector one of rent Democratic candidates for presi- cover everyone, providing medical care as the largest economies in the world (if the dent, Barack Obama and Hillary Clinton, an entitlement for all citizens and resi- medical care sector were a country, will improve the situation. They will dents. This could have been achieved, rather than a massive sector within a diminish somewhat the number of those such as by expanding the federal country). And it has been estimated that not covered by health insurance and will Medicare program to cover everyone. To this spending will reach 20% of GNP in reduce the level of undercoverage. But do so, however, would have required a few years (7 years according to some, the major problems will remain unre- neutralizing the enormous power of the 12 years according to others). Lack of solved, including the problems the can- insurance companies with a massive money is not the root of the medical care didates have referred to during their mobilization of the population against problem in the U.S. We spend far, far campaigns. People will still experience them and in favor of a comprehensive and more than any other developed country, incomplete coverage, and many millions universal health care program. and far more than what we would need will continue to be uninsured and But President Clinton's loyalty to to provide comprehensive health care underinsured. Not even the mandatory Wall Street prevailed. His administra- coverage for everyone. The frequently health insurance called for by Hillary tion's top priorities were reduction of heard argument that the U.S. cannot Clinton will resolve these problems. Her the federal deficit (at the cost of reduced afford universal, comprehensive care has plan proposes that, just as a car driver in public social expenditures) and no credibility. It is a poor rationale for the U.S. must have car insurance, so a approval of NAFTA (without amending keeping the situation as it is. citizen or resident will have to have President George H. W. Bush's propos- Despite the huge amount of money health insurance. The problem with this al, which Clinton had inherited, and spent on medical care, the situation of mandate is not only–as Obama has refusing to address the concerns of the the U.S. medical care sector is a disgrace. pointed out–the matter of enforcement labor and environmental movements). Even Richard Nixon, in an unguarded (note that according to some estimates, These actions antagonized and demoral- moment, defined it as a mess. And as up to 20% of car owners drive without ized the grassroots of the Democratic noted above, it has gotten much worse car insurance), but the assumption Party. Clinton lost any power to mobi- since Nixon was president: in 2006, 47 behind the policy. The assumption is lize people for the establishment of a million Americans did not have any form that most people who are not insured are universal health care program. This of health benefits coverage, and 108 mil- "free-riders," people who could afford to frustration of the grassroots, and espe- lion had insufficient coverage. And peo- buy insurance but choose not to, and cially the working class, also led to the ple die because of this. Estimates of the choose to let someone else pay for their huge abstention by the Democratic number of preventable deaths vary, from care when they get sick. But the vast Party base in the 1994 congressional 18,000 per year (estimated by the conser- majority of people who are uninsured are elections and the consequent loss of the vative Institute of Medicine) to a more people who cannot afford to pay for it. Democratic majority in the House, the realistic level of more than 100,000 (cal- It's as simple as that. Massachusetts Senate, and many state legislatures. At culated by Professor David Himmelstein passed a mandate of this sort (under the root of this disenchantment with of Harvard University). The number Governor Mitt Romney), but 198,000 the Clinton administration was its depends on how one defines "preventa- people still remain uninsured. The subsi- unwillingness to confront the insurance ble deaths." But even the conservative dies and tax incentives proposed to help companies and Wall Street. Could that figure of 18,000 deaths per year is six the uninsured pay for health insurance happen again? times the number of people killed in the premiums under plans of this type are World Trade Center on 9/11. That event insufficient. The health care mess outraged people (as it should), but the Another proposed mandate (put for- (Nixon dixit) deaths resulting from lack of health care ward by Clinton more strongly than by Before addressing this question, let's seem to go unnoticed; these deaths are Obama) is that all employers must pro- look at the problems people face in the not reported on the front pages, or even vide insurance coverage to their employ- U.S. But first, I should stress that the on the back pages, of the New York ees–a policy proposed by President country has sufficient resources to pro- Times, Washington Post, Los Angeles Nixon back in the 1970s. But with this vide comprehensive, high-quality med- Times, or any other U.S. newspaper. proposal, unless you force employers to

50 provide comprehensive coverage at an with individual insurance: 53%). In channels through which that money is affordable cost to everyone, the problem 2006, one of every four Americans lived managed and spent. The problem is the will still not be resolved. An even greater in families that had problems in paying privatization of the funding of medicine problem with the employer mandate, medical bills. And most of them had that allows profits to boom. The insur- however, is that it continues to tie health health insurance. ance and pharmaceutical industries benefits to employment, which is a per- The inhumanity of this situation is enjoy the highest rates of profit in the verse system and a nasty one. The reason made evident by the fact that nearly 40% U.S. Just last year, insurance industry employers, in 1948, pushed to make of people in the U.S. who are dying profits reached $12 billion, and pharma- health care benefits dependent on because of terminal illness are worrying ceutical industry profits $49 billion, the employment (in the nefarious Taft- about paying for care–how their families highest in the U.S. and in the world. Hartley Act) was that this was a way of are going to pay the medical bills, now and According to Fortune Magazine, health- controlling workers. The Taft-Hartley after they die. No other developed country related industries are among the most Act forced the labor force to get health comes close to these levels of insensitivity profitable industries in the country. A care benefits through collective bargain- and inhumanity. Meanwhile, the federal lot of money is being made from people's ing agreements that are highly decen- government parades around the world as suffering. This scandalous situation is tralized and are negotiated at the place the great defender of human rights, ignor- easy to document. For example, lanzo- of employment. In the U.S., workers who ing the fact that among the developed prasol, a gastric secretion-reducing lose their jobs lose not only wages, but democratic nations, the U.S. is the most medicine widely used in the U.S., costs also health benefits coverage for them- deficient in human rights. The basic right $329 in Baltimore, U.S.A.; the same med- selves and their family. And if these of access to health care in time of need icine (same number of doses) costs $9 in workers want to keep their insurance, does not exist in the U.S. The United Barcelona, Spain! And the current Bush they have to pay prohibitive premiums. Nations Human Rights Declaration administration signed legislation for a So, a worker will think twice before includes this right in a prominent posi- program that, in theory, covers drug striking. This is one reason why the U.S. tion, but this is a declaration that the U.S. costs for elderly people, but in practice has fewer working days lost to strikes Congress has never signed. It should come this is an enormous rip-off. It forbids the than other developed countries. Until as no surprise that the world's people do government to negotiate with the drug recently, employers have been the major not believe the U.S. government is a great industry on the cost of drugs–that is, the force–besides the insurance compa- defender of human rights abroad, since it price of their products. What this means nies–for keeping the current system of does not guarantee even basic rights at is that the federal government pays the funding and managing health care. This home. prices dictated by pharmaceutical com- system, then, is based on an alliance And here again, things are getting panies. between employers and the insurance worse. The percentage of uninsured and Now, one might well ask, Why does industry. underinsured has been increasing. The this continue? Why hasn't our govern- It is this alliance that is responsible proportion of people with employer- ment done something about it? Is it that for the biggest problem of health care based health benefits coverage declined the government could not provide com- benefits: undercoverage. Most people from 67.8% among the non-elderly in prehensive health benefits coverage? It believe that because they have health 2000 to 63% in 2006–even though the certainly could. All E.U. governments insurance, they will never face the prob- economy was booming during those do so. All provide publicly funded, com- lem of being unable to pay their medical years. In the same period, the number of prehensive health care coverage to their bills. They eventually find out the adults without coverage increased by 8.7 entire population. And on this side of truth–that their insurance is dramatical- million, and from 2004 to 2006 the num- the Atlantic, Canada (which once had a ly insufficient. Even for families with the ber of children without coverage system identical to ours, health insurers best health benefits coverage available, increased by 1 million. included) also provides this entitle- the benefits are much less comprehen- ment to all its citizens. In Canada in the sive than those provided as entitlements Why does this situation 1960s, a social democratic government in Canada and in most E.U. countries. persist in the U.S.? in Saskatchewan did a very logical And paying medical bills in the U.S. is a For any society, medicine is a mirror of thing. My good friend, Dr. Samuel serious difficulty for many people. In the power relations in that society. And Wolfe, who was then Chief Health fact, inability to pay medical bills is the nowhere is the lack of human rights Officer of Saskatchewan, proposed to primary cause of family bankruptcy, and more evident than in the house of medi- the province's social democratic gov- most of these families have insurance. cine. In the U.S., insensitivity toward ernment that rather than paying premi- Furthermore, 20% of families spend human needs goes hand-in-hand with ums to insurance companies, people more than 10% of their disposable enormous profits made from that suffer- would pay earmarked taxes to a public income on insurance and medical bills ing. The root of the problem, as noted trust fund, controlled by their represen- (the percentage is even higher for those earlier, is not lack of money but the tatives. This trust fund would negotiate

51 with doctors and hospitals for the pay- money can buy (for a further discussion The possibilities ments they would receive for the care of how money corrupts the electoral sys- for major change they provided. This saved a lot of money tem, see my article "How to Read the Obama and Clinton are ready to by bypassing the insurance companies. U.S. Primaries: Guide for Europeans," admit that single-payer may be better The Saskatchewan Health Plan provid- Counterpunch, February 13, 2008). The than any other alternatives. Obama ed comprehensive care to everyone in privatization of the electoral process spoke out in favor of it at one time: the province at a much lower cost than (with most of the money that pays for before. Soon, the other provinces campaigns coming from economic, "So the challenge is, how do we adopted similar plans, establishing financial, and professional interests, and get federal government to take Canada's nationwide health plan that from 30% of the nation's highest-income care of this business? I happen to now covers everyone. The overhead for earners) corrupts the democratic be a proponent of a single payer the public system in Canada is only 4%, process. I am not implying that politi- health care program. I see no rea- compared with 30% in the U.S. insur- cians are corrupt (although some are). I son why the United States of ance industry–30% that goes to mar- am willing to admit that most are honor- America, the wealthiest country keting, administration (a lot of paper able persons. But the need to constantly in the history of the world, spend- shuffling goes on in U.S. health care), raise funds for their campaigns (election ing 14% of its Gross National and the salaries of extremely well-paid and re-election) corrupts the democratic Product on health care cannot executives and insurance lobbyists. system. And the unwillingness of most provide basic health insurance to One of the best-paid individuals in this members of Congress to change this sit- everybody. And that's what Jim is country is William McGuire, CEO of an uation makes them accomplices in that talking about when he says every- insurance company–United. He makes corruption. Such practices are illegal in body in, nobody out." $37 million a year, plus $1.7 billion in most democratic countries. "A single payer health care plan, stock options. And all of this money And people know all about this. In a universal health care plan. And comes from premiums paid by people, surveys, 68% of people believe the U.S. that's what I'd like to see. And as many of whom have insufficient cover- Congress does not represent their all of you know, we may not get age. interests, but the interests of the finan- there immediately. Because first The insurance companies have enor- cial and economic groups that fund we have to take back the White mous power, both in Washington and in political campaigns. But the establish- House, we have to take back the most state legislatures. In Maryland, for ments, including the political, media, Senate, we have to take back the example, a former governor arranged for and academic establishments, want House." (Barack Obama in 2003 candidates for Insurance Commissioner everyone to believe that the reason we before the Illinois AFL-CIO) to be interviewed by the insurance asso- don't have a universal health program ciations before he made his final selec- is that people don't want it. They But, something happened on the tion. But, insurance industry influence is would like people to believe that way to Washington. The train strongest in Washington. In the U.S., Congress legislates what people actu- derailed. Now Obama claims that his money is the milk of politics. The elec- ally want. Meanwhile, the long list of declaration was taken out of context. toral process is also privatized. And the public policies that people want but do And Hillary Clinton, in 1993, told me insurance companies pay a lot of money not get from their government is grow- that while single-payer might be the to candidates. According to the Center ing: 65% of people want a publicly most logical model, it was politically for Responsive Politics, the insurance funded health care system similar to infeasible. industry has contributed $525,188 to that in Canada, a system that in aca- I hope both candidates will recon- Hillary Clinton, $414,863 to Barack demic language is called single-payer. sider. At this time, neither candidate's Obama, and $274,724 to John McCain. In a single-payer system, the govern- proposal will resolve the health care As a consequence, not one of the candi- ment, rather than the insurance compa- crisis we are facing. And in 2012, can- dates is asking for a publicly funded sys- nies, negotiates with providers–doc- didates will still be talking about sin- tem. The major players in medical care in tors, hospitals, nurses, etc.–for the pro- gle mothers who cannot pay for med- the U.S.–insurance companies, drug vision of medical care. We already have ical care for themselves or their chil- companies, professional associations, a system of this type in Medicare (with dren. The candidates of 2008 should etc. (the list is long)–have given a lot of an administrative overhead of only 4%, be asking for government mandates money to the candidates. The splendid compared with the 30% in the insur- rather than individual mandates. It is document called the U.S. Constitution, ance system). By eliminating the huge not people who should be mandated which begins "We the people " should administrative expenses, we could pro- to get insurance. It is the government have a footnote "and the insurance com- vide comprehensive health care cover- that should be mandated to provide panies, the drug companies, " The U.S. age for everyone without spending an insurance for everyone as an entitle- Congress is indeed the best Congress extra penny. ment.

52 The need to mobilize To prevent this, there is a need to to go. And it should be obvious that Obama has been able to capitalize on the mobilize. History is not made by extraor- change will not occur unless there is a anti-establishment mood in the country. dinary figures but by ordinary people huge mobilization to complete the unfin- And he has inspired many. While I who can move mountains when they ished agenda of civil rights: a full devel- believe that large numbers of people–the believe in a cause and get organized. It opment of social rights, with the human grassroots of the Democratic Party who has happened all over the world, and it right to access to health care at the cen- support him–do want change and are has happened in the U.S. We saw it in ter. firmly anti-establishment, I am con- the establishment of the New Deal, To achieve that right, we need reforms cerned that they are putting too much Social Security, unemployment insur- more substantial than those put forth by faith in one individual. Without dimin- ance, job creation, minimum wage, and either Democratic candidate. The splen- ishing what candidate Obama has subsidized housing, among other pro- did slogan first used by the great trade achieved, the fact is that he has already grams. These were not just the outcome union leader Cesar Chavez, founder of shown himself to be adaptable to the of President Roosevelt's position, but the the United Farm Workers of America, political context. He was once against result of huge social agitation and mobi- was Yes, We Can! This should guide the the war in Iraq. But, in Congress, his lization. As usually happens in historical call for establishing the right to health votes on Iraq have been indistinguishable moments of societal change, government care. But, for that to happen, the current from those of Hillary Clinton. And in leaders were not so much leading as try- holders of the slogan must heighten their health care, his rather disappointing pro- ing to catch up with what millions of expectations and become more ambi- posal will not resolve the problems. I am people were demanding. Similarly, the tious in their proposals. This is what the very worried that once in power, he will Great Society Programs–Medicare, electorate expects from them in their not have the courage to confront the Medicaid, Environmental Protection promises of change extremely powerful lobbies primarily Agency, NIOSH, OSHA, and many other responsible for the lack of health care examples of progressive legislation–were coverage and the undercoverage of the the outcome of massive mobilizations. Dr. Vicente Navarro is Professor of American people. It happened with Bill Candidate John Kennedy's proposals for Health Policy, Public Policy, and Policy Clinton's administration and it may hap- change were rather moderate, and his Studies at the Johns Hopkins University. pen again. Contrary to what Obama and domestic policies, once he was elected, He has written extensively on econom- others have said, the main problem with were also disappointing. But the mobi- ics, health, and social policy, and has Hillary Clinton's Task Force in 1993 was lization triggered by his election was fol- been advisor to many governments and not its secrecy (although secrecy was lowed by many more, such as international agencies. His books have indeed a problem) but a conceptual Appalachian coal miners' strikes against been translated into many languages. He framework based on an insurance their working conditions, the splendid was the founder and president of the model–managed care–that was pushed civil rights movement led by Martin International Association of Health on the political, media, and academic Luther King, and the anti-Vietnam War Policy (http://www.healthp.org/), and establishments by the insurance compa- movement led by student groups. They for almost forty years has been Editor-in- nies. The ideologues of managed care all established a political climate in Chief of the International Journal of were clearly in charge of the Task Force. which progressive legislation could Health Services. He is also a founding It could happen again. occur. History, indeed, does not repeat member of Physicians for a National itself. But it offers us pointers on where Health Program. See also “Why Hillarycare Failed” http://www.pnhp.org/hillarycare

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57 PNHP Chapter Reports In Alabama, Dr. Wally Retan and other www.pnhp.org/quote_of_the_day, or sign-up co-sponsor of HR 676) and Rep. Neil PNHP'ers are active in speaking, outreach to by dropping a note to [email protected]. Abercrombie (D-HI). For a speaker or to labor and other groups, and building the state's become active, contact Dr. Leslie Hartley Gise PNHP chapter, "Healthcare for Everyone". The In Colorado, PNHP'ers are active in speaking, on Maui at [email protected] or David Friar on group is working with the local labor council writing, outreach to legislators, and in coali- Oahu at [email protected]. of the AFL-CIO, and a PNHP spokesperson tion-building. Dr. Elinor Christiansen and Dr. will give the keynote address in an upcoming Rocky White are leaders in Health Care for All Indiana's PNHP chapter, Hoosiers for a forum with the Dean of the School of Public Colorado and in promoting single payer at the Commonsense Health Plan (HCHP), has been Health and Alabama Blue Cross and Blue state level. A fiscal analysis by Lewin found active in outreach to physicians, coalition Shield. To get active or invite a speaker to your that single payer would cover all the uninsured building and statewide outreach. HCHP has group, contact Dr. Wally Retan at and save $1.4 billion annually. Dr. White is chapters in Indianapolis and Bloomington, and [email protected]. running for a seat in the state House (District four new chapters in Fort Wayne, Terre Haute, 62) on a pro-single payer, pro-education plat- New Albany, and Evansville. The group Arizona PNHP has been mobilizing support for form. Contact Dr. Christiansen at received the Indiana Public Health both HR 676 and a HB2677, a state single- [email protected]. Association's "Citizens Advocacy Award." payer bill sponsored by PNHP member Phil HCHP is active in outreach to garner co-spon- Lopes, the Arizona House Minority Leader. The Washington, DC chapter of PNHP is sors for HR 676 as well as working on legisla- PNHP members met in Phoenix with nurses active in speaking, outreach to physician and tion to study single payer at the state level (SB from the National Nurses Organizing other groups, media outreach, and acting as 218). Contact Dr. Rob Stone at Committee (NNOC) to form a new state coali- national PNHP's liaison to the Congress and [email protected] ~ www.hchp.info tion, "Arizona Medicare for All." They plan to Washington-based organizations. Activists team up with other groups to help promote met with members of the Congressional Black In Illinois, PNHP’ers are active in speaking, single payer in the state. Contact Dr. George Caucus (garnering 3 new co-sponsors for HR grassroots outreach, press work, and support- Pauk at [email protected]. 676), discussed single-payer with national lead- ing HB 311, a bill for a single payer plan in ers of the AFL-CIO, and hosted a single payer Illinois (full text on-line at PNHP's California chapter, the California booth at the Take Back America conference. www.healthcareforallIllinois.org). Dr. Quentin Physicians Alliance (CaPA) is active in speak- Dr. David Rabin is a frequent speaker to both Young and Dr. Claudia Fegan are active in ing to health professionals and the public, in medical and grassroots groups. Drs. Harvey speaking to physicians at grand rounds and lobbying for SB 840 (Keuhl's bill) and HR 676, Fernbach and Robert Zarr have been featured other conferences. Dr. Fegan spoke at the in recruiting new members at academic med- in the local media and are active in meeting annual meeting of the Student National ical centers, in chapter-building, and in media with medical student and other groups. Medical Association. Dr. Anne Scheetz and her outreach. 400 medical students participated Contact Dr. Robert Zarr at [email protected]. husband Jim Rhodes are active in outreach to in a lobby day for SB 840 in January. PNHP grassroots groups and other public National Coordinator Dr. Quentin Young tes- Georgia PNHP members have been reaching audienceWiscons across the state. Since Dr. tified against the flaws in governor out to the progressive and medical communi- Gordon Schiff moved to Boston, the chapter is Schwarzenegger's individual mandate propos- ties through public forums, grand rounds and in need of more speakers for physician audi- al, ABX 1, before Sen. Keuhl's committee; he legislative efforts. The chapter presented a sem- ences. If you are willing to give grand rounds delivered a letter from 250 physicians in inar on their state "SecureCare" plan to the on behalf of PNHP (we’ll provide slides and Massachusetts about the problems with that Georgia Progressive Summit, which includes other materials), please drop a note to state's individual mandate plan and the need trade union, civil rights, environment and peace [email protected]. for single payer. Dr. Claudia Chaufan's article groups. Chapter leader Dr. Henry Kahn has about ABX 1 is available on-line at maintained an active speaking schedule both in PNHP members in Kansas are working with www.capa.pnhp.org. Activists are developing Georgia and neighboring South Carolina. His medical students from the University of local chapters in Humboldt County, Los recent engagements have included: a graduate Kansas, labor, church, and other groups to form Angeles, Fresno and other areas. The Los nursing seminar at the University of Georgia, "Heartland Healthcare for All". First year med- Angeles group is active in outreach to business the Department of Medicine at the Tenet- ical student Elizabeth Stephens and others are (including county and city government), owned Atlanta Medical Center, and the active in speaking using the PNHP slide show. including to the Business Caucus of the Departments of Medicine and Pediatrics at the The Kansas Legislature is studying health care California Democratic Committee in Anaheim. University of South Carolina. Contact Dr. reform options. The fiscal analysis by the con- Contact CaPA's new staffer, Roberto Ramos, Kahn at [email protected]. sulting firm of Schramm-Raleigh found that at [email protected] ~ capa.pnhp.org single payer would cover everyone and reduce In Hawai'i, Dr. David Friar in Oahu is starting a health spending by $870 million annually. For PNHP Senior Health Policy Fellow Dr. Don new chapter of PNHP. PNHP activist Dr. a speaker or to become active, contact Dr. McCanne is a frequent speaker to California Leslie Hartley Gise recently spoke to the Joshua Freeman at [email protected]. medical and grassroots groups and to the Tripler Army Medical Center and the medical media. His influential and widely-read "Health school in Honolulu. She also participated in Kentucky PNHP members are active in out- Policy Quote of the Day" is archived at events with Rep. Mazie Hirono (D-HI, a new reach to faith and civic groups and to legisla-

58 tors at both the state and federal level. Kay already has 57 co-sponsors and passed out of for All North Carolina. Members who are Tillow continues to spearhead the effort to gar- the Senate Health Policy Committee in active in speaking include Dennis Lazof, Dr. ner labor support for single payer. Dr. Garrett February. Dr. Morrison Hodges, Dr. Lisa Gary Greenberg, Dr. Trevor Craig, Dr. Ernesto Adams participated in a widely-covered press Nilles, Dr. Elizabeth Frost, and Kip Sullivan de la Torre and Dr. Jonathan Kotch. State Rep. conference when Sicko premiered and is fre- have been active in speaking to community Verla Insko participated in panel discussions quently interviewed on local radio. Dr. Syed groups and in forums with Rep. Keith Ellison, on SiCKO and other events. Staffer Emily Quadri, Dr. Ewell Scott and Harriette Seiler are a sponsor of HR 676. The chapter is holding a Taylor and Dr. Claudia Prose developed useful active in speaking and writing letters to the speaker's training in February and is seeking materials for the group. The chapter co-spon- editor. Contact Garrett Adams at kyhealth- additional opportunities to speak to physi- sored three fall forums with the Pediatrics [email protected]. cians. Contact Dr. Ann Settgast at Society, the Nurses' Association, and the [email protected], Dr. Lisa Niles at Community Health Center Association, and In Massachusetts' PNHP members have [email protected], or Dr. Elizabeth Frost received two grants to fund additional out- been leading critics of the state's health at [email protected]. reach and training. Contact Dr. Jonathan reform, and continue an active campaign for Kotch at [email protected]. single payer. Chapter Chair Dr. Rachel PNHP’ers in the New York-Metro chapter of Nardin's Op Ed appeared in the Boston Globe, PNHP are active in speaking, outreach to physi- Activists resurrected an Ohio chapter of PNHP and she crafted a statement calling for more cians and medical students, press work, and in January. They plan to give grand rounds, do thoroughgoing health reform in the state, sponsoring a popular monthly forum on health outreach to the media, legislative work, and which garnered the signatures of 250 policy and politics. PNHP President-Elect Dr. participate in public debates and forums. A Massachusetts' physicians. Dr. Nardin is also Oliver Fein is a frequent speaker both locally state bill for single payer, the Health Care for active in speaking to professional and commu- and nationally. Dr. Fein, medical student David all Ohioans Act, was re-introduced in the legis- nity groups. Dr. Susanne King's pro-single Marcus, Martha Livingston and others led a lature in 2007. PNHP'ers educated state leg- payer column regularly appears in the speakers’ training for 43 medical students on islative leaders and their aides about single Berkshire Eagle, the largest paper in the west- March 8. A new book on single payer,"10 payer, and used SiCKO as an organizing tool. ern part of the state. Dr. Michael Kaplan's Op Excellent Reasons for National Health Care" Letters to the editor and op-eds by PNHP Ed critical of the health reform appeared in edited by Dr. Mary O'Brien and Martha members have appeared in publications the Boston Globe. Students in PNHP spon- Livingston is being published by The New Press statewide. For a speaker or to become active, sored a showing of SiCKO and follow-up this summer. (http://www.pnhpnymetro.org/) contact Dr. Jonathon Ross at forum for Boston-area medical students. Dr. [email protected]. Pat Berger brought a pro-single payer resolu- In Albany, PNHP’ers are frequent speakers to tion to the Massachusetts Medical Society. physician and grassroots groups. Chapter chair PNHP's Western Washington chapter is very The MMS agreed to "include single-payer Dr. Paul Sorum and Dr. Andy Coates led a well- active in speaking, outreach to the public, and health care reform as an option for achieving attended speaker’s training in October. lobbying for single payer on the national (HR universal, comprehensive, equitable, patient- Activists are involved in outreach to unions, 676/HR 1200) and state level (Washington centered, sustainable, and affordable health medical students, the League of Women Health Security Trust). The chapter is pushing care for our patients." Contact Dr. Rachel Voters, the NY branch of the American College for a fiscal analysis of WHST to show that single Nardin at [email protected]. of Physicians, and other groups. Contact Dr. payer is the only affordable option for universal Coates at [email protected]. coverage. In addition to participating in nearly In Michigan, PNHP member Dr. Jim Mitchiner a dozen panels on healthcare reform, PNHP'ers has been active in speaking, media outreach, The newly formed Finger Lakes PNHP have presented to the King County Medical and discussion of single payer within his spe- Chapter (Rochester, New York) has been Society, a program in family medicine, cialty society, the American College of active in speaking, media outreach, and lobby- on radio and at rallies. The chapter hosted a Emergency Physicians. He spoke to the ing. The chapter hosted four screenings of booth at the Washington State Medical Michigan State Medical Society House of SiCKO followed by panel discussions, and par- Association's annual meeting, is making a Delegates, the Washtenaw County Medical ticipated in a meeting with Rep. Louise brochure for physicians' waiting rooms, and is Society, and WMU's Center for the Study of Slaughter (NY-28). Chapter chair Dr. Larry supporting a medical student studying in Cuba. Ethics in Society. His pro-single payer op-ed Jacobs' pro-single payer op-eds appeared in the The chapter's annual meeting in February appeared in the Ann Arbor News, and he was Rochester Democrat & Chronicle and the focused around "The Community Effects of interviewed by the local NPR affiliate in Santa Fe Times (Jacobs’ winter home). Uninsurance." Contact Dr. David McLanahan at Kalamazoo. Contact Dr. Mitchiner at Chapter members have published letters sup- [email protected]. [email protected]. porting single-payer in the Syracuse Post Standard and other local press. Drs. Leon PNHP members Drs. Linda and Gene Farley Minnesota PNHP members are active in Zoghlin, Larry Jacobs and Emily Queenan are very active in the Coalition for Wisconsin speaking, lobbying, outreach to grassroots spoke at a seminar for medical students at the Health (CWH), the Wisconsin affiliate of groups and collecting physician endorsements University of Rochester. Contact Larry Jacobs PNHP. Canadian labor leader James Clancy for a resolution in support of HR 676. at [email protected]. spoke in Milwaukee about the advantages of Chapter members are working with Sen. John single payer in December; an excellent record- Marty and the Minnesota Universal Health In North Carolina, PNHP members are active ing of his talk is available at www.grassroot- Care Coalition on the new Minnesota Health in speaking, media outreach, leadership train- snorthshore.org/?page_id=19. For a speaker or Care Act, the state's single-payer bill, which ing, and coalition-building with Health Care to become active, contact [email protected].

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