Michael Moore's new film is a damning indictment of the way the world's richest country looks after those who fall ill. Andrew Gumbel finds out whether his accusations are justified
June 4th, 2007
Cynthia Kline knew exactly what was happening to her when she suffered a heart attack at her home in Cambridge, Massachusetts. She took the time to call an ambulance, popped some nitroglycerin tablets she had been prescribed in anticipation of just such an emergency, and waited for help to arrive.
On paper, everything should have gone fine. Unlike tens of millions of Americans, she had health insurance coverage. The ambulance team arrived promptly. The hospital where she had been receiving treatment for her cardiac problems, a private teaching facility affiliated with the Harvard Medical School, was just a few minutes away.
The problem was, the casualty department at the hospital, Mount Auburn, was full to overflowing. And it turned her away. The ambulance took her to another nearby hospital but the treatment she needed, an emergency catheterization, was not available there. A flurry of phone calls to other medical facilities in the Boston area came up empty. With a few hours, Cynthia Kline was dead.
She died in an American city with one of the highest concentration of top-flight medical specialists in the world. And it happened largely because of America's broken health care system - one where 50 million people are entirely without insurance coverage and tens of millions more struggle to have the treatment they need approved. As a result, medical problems go unattended until they reach crisis point. Patients then rush to hospital casualty departments, where by law they cannot be turned away, overwhelming the system entirely. Everyone - doctors and patients, politicians on both the left and the right - agrees this is an insane way to run a health system.
When Elizabeth Hilsabeck gave birth to premature twins in Austin, Texas, she encountered another kind of insanity. Again, she was insured -- through her husband, who had a good job in banking. But the twins were born when she was barely six months pregnant, and the boy, Parker, developed cerebral palsy. The doctors recommended physical therapy to build up muscle strength and give the boy a fighting chance of learning to walk, but her managed health provider refused to cover it.
The crazy bureaucratic logic was that the policy covered only "rehabilitative" therapy - in other words, teaching a patient a physical skill that has been lost. Since Parker had never walked, the therapy was in essence teaching him a new skill and therefore did not qualify. The Hilsabecks railed, protested, won some small reprieves, but ended up selling their home and moving into a trailer to cover their costs. Elizabeth's husband, Steven, considered taking a new, better-paying job, but chose not to after making careful inquiries about the health insurance coverage. "When is he getting over the cerebral palsy?" a prospective new insurance company representative breezily asked the Hilsabecks. When Elizabeth explained he would never get over it, she was told she was on her own.
Everyone in America has a health-care horror story or knows someone who does. Mostly they are stories of grinding bureaucratic frustration, of phone calls and officials letters and problems with their credit rating, or of people ignoring a slowly deteriorating medical condition because they are afraid that an expensive battery of tests will lead to a course of treatment that could quickly become unaffordable.
Even when things don't go horribly wrong, it is a matter of surviving by the skin of one's teeth.
In Montana, Melissa Anderson can't find affordable insurance because she is self-employed - an increasingly common affliction. When her son Kasey came down with epilepsy two years ago, she was saved only by a recently introduced child health insurance programme specifically tailored to people who aren't poor but can't afford to pay monster medical bills. She herself remains uninsured for anything short of major care needs.
Over the past 15 years, the stories have become less about poor people without the economic means to access the system - although that remains a vast, unsolved problem - and more about the kind of people who have every expectation they will be taken care of. Middle-class people, people with jobs that carry health benefits or - as the problem worsens - people with the sorts of jobs that used to carry robust health benefits which are now more rudimentary and risk their being cut off for a variety of reasons.
This is the morass that Michael Moore has chosen to explore in his latest documentary, Sicko, which goes on release later this month. Moore spends much of the film demonstrating that there is nothing inevitable or necessary about a system that enriches insurance companies and drug manufacturers but shortchanges absolutely everyone else. His searching documentary looks at health care in France, Britain, Canada, and even Cuba - still regarded as a model system for the Third World.
Moore has his share of ghoulishly awful stories. The film kicks off with an uninsured carpenter who has to decide whether to spend $12,000 (£6,000) reattaching his severed ring finger or $60,000 to reattach his severed middle finger. Later on, Moore focuses on a hospital worker whose husband needed a bone marrow transplant to save him from a rare disease. The couple's insurance company refused to cover the transplant because it regarded the treatment as "experimental". The husband died.
Many more stories are collected in a newly published book called Sick: The Untold Story of America's Health Care Crisis, by Jonathan Cohn. A woman in California called Nelene Fox died of breast cancer after she, too, was turned down for a bone marrow transplant by her insurance company. In Georgia, a family whose infant son went into cardiac arrest were forced to take him to a hospital 45 miles away on their insurance carrier's orders. He survived, but suffered permanent disabilities that more prompt treatment might have averted. In New York, an infant called Bryan Jones - whose case was trumpeted all over the local media at the time - died of a heart defect that went undetected because his insurance company kicked him and his mother out of hospital 24 hours after his birth, too soon to carry out the tests that might have spotted the problem.
America's health system offers a tremendous paradox. In medical technology and in the scientific understanding of disease, it is second-to-none. Since doctors are better paid than anywhere else in the world, the country attracts the best of the best. And yet many, if not most, Americans are unable to reap the advantages of this. In fact, as The New York Times columnist Paul Krugman has argued, the very proliferation of research and high-tech equipment is part of the reason for the imbalance in coverage between the privileged few and the increasingly underserved masses. "[The system] compensates for higher spending on insiders, in part, by consigning more people to outsider status --robbing Peter of basic care in order to pay for Paul's state-of-the-art treatment," Krugman wrote recently. "Thus we have the cruel paradox that medical progress is bad for many Americans' health."
Having the system run by for-profit insurance companies turns out to be inefficient and expensive as well as dehumanizing. America spends more than twice as much per capita on health care as France, and almost two and a half times as much as Britain. And yet it falls down in almost every key indicator of public health, starting, perhaps, most shockingly, with infant mortality, which is 36 per cent higher than in Britain.
A recent survey by the management consulting company McKinsey estimated the excess bureaucratic costs of managing private insurance policies - scouting for business, processing claims, and hiring "denial management specialists" to tell people why their ailment is not covered by their policy - at about $98bn a year. That, on its own, is significantly more than the $77bn McKinsey calculates it would cost to cover every uninsured American. If the government negotiated bulk purchasing rates for drugs, rather than allowing the pharmaceutical companies to set their own extortionate rates, that would save another $66bn.
Astonishingly, there hasn't been a serious debate about health care in the United States since Bill Clinton, with considerable input from his wife Hillary, tried and failed to overhaul the system in 1994. That, though, may be about to change as the 2008 presidential race heats up. Everyone acknowledges the system is broken. Everyone recognizes that 50 million uninsured - including almost 10 million children - is unacceptable in a civilized society.
Even the old, classically American free-market argument - that "socialized" medicine is somehow the first step on a slippery slope towards godless communism - doesn't hold water, because in the absence of a functioning private insurance regime the government ends up picking up about 50 per cent of the overall costs for treatment anyway. The indigent rely on a government program called Medicaid. The elderly have a government program called Medicare. And perhaps the most efficient part of the whole system is the Veterans' Administration, a sort of NHS for former servicemen.
Rather like London and Paris in the 19th century, where the authorities belatedly paid attention to outbreaks of cholera once the disease started affecting the rich and middle classes, so the American health crisis may be coming to a head because of the kinds of people who are suffering from its injustices.
Corporate chief executives, for a start, are gagging under the ever-increasing costs of providing coverage to their employees. Starbucks now spends more on health care than it does on coffee beans. Company health costs, as a whole, are at about the same level as corporate profits. In a globalized world where US businesses are competing with low-wage countries such as India and China, that is rapidly becoming unacceptable.
That explains, perhaps, why the chief executive of Wal-Mart, Lee Scott, has made common cause with America's leading service sector union - more commonly a bitter critic of Wal-Mart's labor practices - in calling for a government-run universal health care system by 2012. It's going to be a tough battle. The insurance and pharmaceutical industries bankroll the campaigns of dozens of congressmen and have so far been brutally efficient in protecting their own interests. The Clintons were defeated in 1994 in part because of the power of the industry lobbies. Doing better this time will take singular political courage.
In the meantime, we will hear ever more crazy stories like the one told by Marijon Binder, a former nun in Chicago who ended up being sued by a Catholic hospital for $11,000 because her two-night stay for a heart scare was not considered a worthy charity case. Binder, who works as a live-in companion to a disabled old woman, wrote on all her admission forms that she had no insurance and, in her telling at least, was reassured the hospital would take care of her anyway.
After a year and a monstrous bureaucratic fight that went nowhere, a civil judge promptly absolved her of responsibility for her bill - a lucky outcome, for sure. Binder said: "The whole experience was very demeaning. It made me feel very guilty; it made me feel like a criminal." She is, though, alive and solvent. Not everyone in this system catches the same break.
December 15, 2007
New York Times
By DAVID U. HIMMELSTEIN and STEFFIE WOOLHANDLER
IN 1971, President Nixon sought to forestall single-payer national health insurance by proposing an alternative. He wanted to combine a mandate, which would require that employers cover their workers, with a Medicaid-like program for poor families, which all Americans would be able to join by paying sliding-scale premiums based on their income.Nixon’s plan, though never passed, refuses to stay dead. Now Hillary Clinton, John Edwards and Barack Obama all propose Nixon-like reforms. Their plans resemble measures that were passed and then failed in several states over the past two decades.
In 1988, Massachusetts became the first state to pass a version of Nixon’s employer mandate — and it added an individual mandate for students and the self-employed, much as Mrs. Clinton and Mr. Edwards (but not Mr. Obama) would do today. Michael Dukakis, then the state’s governor, announced that “Massachusetts will be the first state in the country to enact universal health insurance.” But the mandate was never fully put into effect. In 1988, 494,000 people were uninsured in Massachusetts. The number had increased to 657,000 by 2006.
Oregon, in 1989, combined an employer mandate with an expansion of Medicaid and the rationing of expensive care. When the federal government granted the waivers needed to carry out the program, Gov. Barbara Roberts said, “Today our dreams of providing effective and affordable health care to all Oregonians have come true.” The number of uninsured Oregonians did not budge.
In 1992 and ’93, similar bills passed in Minnesota, Tennessee and Vermont. Minnesota’s plan called for universal coverage by July 1, 1997. Instead, by then the number of uninsured people in the state had increased by 88,000.
Tennessee’s Democratic governor, Ned McWherter, declared that “Tennessee will cover at least 95 percent of its citizens.” Yet the number of uninsured Tennesseans dipped for only two years before rising higher than ever.
Vermont’s plan, passed under Gov. Howard Dean, called for universal health care by 1995. But the number of uninsured people in the state has grown modestly since then.
The State of Washington’s 1993 law included the major planks of recent Nixon-like plans: an employer mandate, an individual mandate for the self-employed and expanded public coverage for the poor. Over the next six years, the number of uninsured people in the state rose about 35 percent, from 661,000 to 898,000.
As governor, Mitt Romney tweaked the Nixon formula in 2006 when he helped devise a second round of Massachusetts health care reform: employers in the state that do not offer health coverage face only paltry fines, but fines on uninsured individuals will escalate to about $2,000 in 2008. On signing the bill, Mr. Romney declared, “Every uninsured citizen in Massachusetts will soon have affordable health insurance.” Yet even under threat of fines, only 7 percent of the 244,000 uninsured people in the state who are required to buy unsubsidized coverage had signed up by Dec. 1. Few can afford the sky-high premiums.
Each of these reform efforts promised cost savings, but none included real cost controls. As the cost of health care soared, legislators backed off from enforcing the mandates or from financing new coverage for the poor. Just last month, Massachusetts projected that its costs for subsidized coverage may run $147 million over budget.
The “mandate model” for reform rests on impeccable political logic: avoid challenging insurance firms’ stranglehold on health care. But it is economic nonsense. The reliance on private insurers makes universal coverage unaffordable.
With the exception of Dennis Kucinich, the Democratic presidential hopefuls sidestep an inconvenient truth: only a single-payer system of national health care can save what we estimate is the $350 billion wasted annually on medical bureaucracy and redirect those funds to expanded coverage. Mrs. Clinton, Mr. Edwards and Mr. Obama tout cost savings through computerization and improved care management, but Congressional Budget Office studies have found no evidence for these claims.
In 1971, New Brunswick became the last Canadian province to institute that nation’s single-payer plan. Back then, the relative merits of single-payer versus Nixon’s mandate were debatable. Almost four decades later, the debate should be over. How sad that the leading Democrats are still kicking around Nixon’s discredited ideas for health reform.
David U. Himmelstein and Steffie Woolhandler are professors of medicine at Harvard and the co-founders of Physicians for a National Health Program
An op-ed piece in the Providence Journal about huge pay packages for corporate CEOs mentioned the breath-taking $124.8 million total compensation of United Health Group (parent of United Healthcare) CEO William McGuire. This figure can also be found in the Forbes Special Report on CEO compensation. Here one can find that other managed care CEOs got less fabulous, but still formidable compensation, e.g., Howard Phanstiel, PacifiCare, 3.38 million; Edward Hanway, Cigna, $13.3 million; John Rowe, Aetna, $22.2 million; and Larry Glassrock, Wellpoint, $25.0 million.
McGuire's compensation was so large as to take a measurable part of this large company's net income (5%). Or to look at it from a stock-holder's (and hence, an company owner's) viewpoint, had McGuire, who is an employee, been only paid a cool million, and this money had been distributed as a dividend, it would amount to about a $0.20 per share dividend. (The current dividend is $0.03 per share.) (See company data available from Forbes as well.)
To look at it from a United employee's viewpoint, had McGuire, who is an employee, been only paid a cool million, and this money had been distributed to employees, each of the 40,000 employees could have received a bonus larger than $3000.
To look at it from the viewpoint of the health care system, the $124.8 million total compensation of a single United employee could pay the salaries of 833 general internists at current typical salaries. Or the $124.8 million could run one reasonable size community hospital for a year.
United Health Group's mission statement is "the company directs its resources into designing products, providing services and applying technologies that improve access to health and well-being services; simply the health care experience; promote quality; and make health care more affordable." (See this fact sheet.) Rather, it seems to be directing a good chunk of its resources into salaries of top management employees. How a $124.8 million CEO salary can be reconciled with a mission to "make health care more affordable" is completely beyond me.
United Health Group's mission statement is "the company directs its resources into designing products, providing services and applying technologies that improve access to health and well-being services; simply the health care experience; promote quality; and make health care more affordable." (See this fact sheet.) Rather, it seems to be directing a good chunk of its resources into salaries of top management employees. How a $124.8 million CEO salary can be reconciled with a mission to "make health care more affordable" is completely beyond me.
By Michael Kaplan
December 3, 2007
Along with most residents of Massachusetts, I assumed that the Massachusetts Health Reform Law was going to allow my daughter to keep her health insurance coverage after she graduated from college. The Connector Authority specified that for two years of post- dependency status, a young adult could remain on a family policy. What a relief that was. She graduated this May and is in those early stages of becoming self-supporting.
When my wife's employer, Berkshire Health Systems, informed us that my daughter's coverage would end on Dec. 31 of this year, I was shocked. It turns out that the law requires only companies that pay health insurance premiums to give the extra two years of coverage. Those companies that self-insure are governed by federal law under ERISA and are not bound by this requirement. Self-insured companies pay the health insurance companies to administer the benefit, not to insure them. So our Blue Cross Blue Shield policy seems like an insurance policy, but it is not. Berkshire Health Systems insures itself, as do national companies that employ across state lines. Many large local employers are self-insured as well. These large companies do not have to pay the extra cost to cover dependents for those two more years.
Small businesses are generally not able to take on the financial risk required to self-insure, so those companies that provide insurance to employees do have to pay the extra premiums. Whatever happened to the relief that small business was supposed to get from this reform law? Ask any small business owner and you will learn that health insurance costs for employees may have risen by as much as 50 percent since this law was passed!
My daughter has been able to get two part-time jobs, but of course she has not been offered health insurance. I am told that she may qualify for Commonwealth Care that the Connector offers under the new law.
Although the Commonwealth Care subsidized insurance is not tied to employment, coverage would be lost if she either started earning above a threshold amount or moved from Massachusetts, both likely events for a young graduate. And as a consequence of the loophole exempting many big employers from covering their employees' children for two post-college years, Commonwealth Care is likely to include more young people than expected.
This will create higher expenses for the state than originally projected, worsening the cost problem that that casts a shadow over the entire program.
Jon Kingsdale, executive director of the Connector Authority, recently said, "If we continue with double-digit inflation [in health insurance premiums] I don't think health reform is sustainable." However, there is nothing in the new law that works to control these sky-rocketing costs.
As a physician and healthcare activist for many years, I was aware that this reform law was not a panacea and did nothing to control the rapidly rising costs of private insurance that force both employers and their employees to pay more in premiums, with the insured also paying more in higher copayments and deductibles. While the reform widened the safety net for some poor families, this safety net will shred if there is not a massive infusion of new money from the state or federal governments.
Two important lessons can be learned. First, we need to sever the connection between healthcare and employment. People need continuous, portable coverage that is affordable, comprehensive, and equitable. Second, we cannot depend on the private insurance industry to provide this for us.
Piece-meal reform such as the new law will not work. Both employers and the public support the concept of single-payer healthcare. Big business is starting to realize that a single payer system will be the only affordable way to cover everyone. When will our politicians understand that their political futures will depend on supporting this kind of comprehensive reform?
Michael Kaplan is a family physician and a member of Physicians for a National Health Plan and the board of directors of the Universal Health Care Education Fund.
January 3rd, 2008
by Ed Kent
[It is pretty obvious that the U.S. alone of the developed nations is wasting massive sums on a sub par medical system incorporating private insurance company profits while denying proper medical care to many millions. Many who have studied abroad during the past 50 years have benefited as foreigners from the medical systems of the host countries where they have been studying — my wife and I both did in Britain when we were students at Oxford in 1957-8 and two of my children have so benefited in Britain and Italy. Let us hope we can now defeat the right wing propaganda against “socialized” medicine originally designed by doctors intent on preserving higher incomes but now even impacting upon doctors, themselves, as this report sent on by one of my doctor classmates indicates. Ed Kent]
An Open Letter to the Nation from Massachusetts Physicians:
Early Outcomes from Massachusetts’ Health Care Reform
We write to alert colleagues and the nation to the disturbing early outcomes of Massachusetts’ widely-heralded approach to health care reform. Although we wish that the current reform could secure health insurance for all, its failings reinforce our conviction that only a single payer program can assure patients the care they need.
In 2006, our state enacted a law designed to extend health coverage to virtually all state residents. Political leaders in other states as well as several Democratic presidential candidates have embraced this model.
Massachusetts’ law mandates that uninsured individuals must purchase private insurance or pay a fine. The law established a new state agency to ensure that affordable plans were available; offered low income residents subsidies to help them buy coverage; and expanded Medicaid coverage for the very poor. (Immigrants are mostly excluded from these subsidized programs.) Moneys that previously funded free care for the uninsured were shifted to the new insurance program, along with revenues from new fines on employers who fail to offer health benefits to their workers. In addition, the federal government provided extra funds for the program’s first two years.
Starting January 1, 2008 Massachusetts residents face fines if they cannot offer proof of insurance. Yet as of December 1, 2007 only 37% of the 657,000 uninsured had gained coverage under the new program. These individuals often feel well served by the reform in that they now have health insurance. However, 79% of these newly insured individuals are very poor people enrolled in Medicaid or similar free plans. Virtually all of them were previously eligible for completely free care funded by the state, but face co-payments under the new plan. In effect, public funds for care of the poor that previously flowed directly to hospitals and clinics now flow through insurers with their higher administrative costs.
Among the near poor uninsured (who are eligible for partial premium subsidies) only 16% had enrolled in the new coverage. And barely 7% of the uninsured individuals with incomes too high to qualify for subsidies had enrolled according to the official state figures. Few can afford premiums for even the skimpiest coverage; the lowest cost plan offered for a couple in their fifties costs $8,200 annually, and carries a $2,000 per person deductible.
Moreover, the state’s cost for subsidies is running $147 million over the $472 million budgeted for fiscal year 2007. Meanwhile, collections from fines on employers who fail to provide coverage are 80% below the original projections. The funding gap will widen in future years as health care costs escalate and insurers raise premiums. Already, state officials speak of making up the shortfall by forcing patients to pay sharply higher co-pays and deductibles, and by slashing funds promised to safety net hospitals.
While patients, the state and safety net providers struggle, private insurers have prospered under the new law, and the costs of bureaucracy have risen. Blue Cross, the state’s largest insurer, is reaping a surplus of more than $1 million each day, and awarded its chairman a $16.4 million retirement bonus even as he continues to draw a $3 million salary. All of the major insurers in our state continue to charge overhead costs five times higher than Medicare and eleven-fold higher than Canada’s single payer system. Moreover, the new state agency that brokers private coverage adds its own surcharge of 4.5% to each policy it sells.
A single payer program could save Massachusetts more than $9 billion annually on health care bureaucracy, making universal coverage affordable. But because the 2006 law deepened our dependence on private insurance, it can only add coverage by adding costs. Though politically feasible, this approach is already proving fiscally unsustainable. The next economic downturn will push up the number of uninsured just as the tax revenues needed to fund subsidies fall.
The lesson from Massachusetts is that we still need real health care reform: single payer, non-profit national health insurance.
by Mark Dunlea
Governor Spitzer and state lawmakers seek an evidence-based plan that will bring comprehensive health care to all of the people of New York State, a result that almost everyone would like to see.
Unfortunately, the Spitzer administration, along with many health care reformers, continually assert, without providing any evidence, that the best way to universal health care is a series of incremental steps that build upon existing programs to bring targeted populations of the uninsured into the “health care” system.
Incrementalists argue that the public opinion polls showing overwhelming public support - not just for a comprehensive government universal health care financing system but also for radical reform - are misleading. They contend that if one digs deeper, one finds that those with health insurance (”those who actually vote”) would rather keep the shrinking (and often already inadequate) coverage they have than see the entire system changed. They murmur that it is not “politically feasible” for our leaders to stand up to the power of the private health insurance industry and big pharma. They redefine the public’s desire for choice in doctors to hospitals to instead be choice among which insurance company to contract with. They confuse access to comprehensive health care with expanding health insurance.
Yet the experience in the various states that have tried a variety of “incremental approaches” objectively shows that it will not work. “Bold, new experiments in moving our state to universal health care” have invariably withered away over time, often in only a few years.
For instance, the media coverage over the new “universal” health care system in Massachusetts generally failed to mention similar pronouncements from Governor Dukasis two decades previously that fell apart in a few years. Because Massachusetts expanded its subsidies for insurance premiums for low-income people, over 160,000 of those eligible signed up this year. But only 7% of the nearly 250,000 who must buy unsubsidized insurance — or face a fine of $2,000 in 2008 — purchased private health insurance this year. Thus the plan will end its first year at least $147 million over budget, with Massachusetts preparing to cut payments to doctors and hospitals and ramp up out-of-pocket costs for patients. And nearly 500,000 in Massachusetts remain uninsured. Yet the leading Democratic Presidential contenders now embrace Massachusetts’ mandate for individual purchase of health insurance.
Maine’s patchwork approach to universal health care - the Dirigo plan - is not working. Nor have the plans in Vermont, Minnesota, Washington and Oregon. Tennessee’s noteworthy TennCare program to help the poor and uninsured is in the process of being dismantled. NY has added targeted programs such as Child Health Plus and Family Health Plus yet more than 5 million New Yorkers annually lack health insurance.
This fall Vermont launched “Catamount Health,” a plan to cover all Vermonters by subsidizing private health insurance from MVP and Blue Cross Blue Shield with a combination of tobacco tax money, Medicaid money and new taxes on employers who don’t offer health insurance. But as the plan takes its first steps, the inadequate insurance for those who have it, with soaring co-pays, huge deductibles and unaffordable prescription drugs has put the crisis in health care back into the legislative agenda for 2008, front and center.
In contrast, the experiences in the rest of the industrial world provide ample evidence that a comprehensive approach to universal health care will succeed. Not only do the other major industrial countries spend far less on health care than we do, they cover everyone with better health outcomes, even though we have among the best medical professionals, infrastructure and equipment in the world.
Incremental approaches evade the fundamental problems that are causing the ongoing crisis in our health care system. Real change requires addressing the entire structure of financing — in which employer-based private health insurance dominates. Without facing this, the problem of costs cannot be solved. Most of the money spent on health care in New York comes from government (federal and state) spending, yet private health insurance dominates the system. As Governor Spitzer has pointed out, NY’s system of health care financing is often not directly tied to the services being provided, its complexity and irrationality a result of the backroom deal making at the State Capitol.
Incremental approaches have done little to nothing to control costs, while adding more people to the system, thus causing more financial strain on both the government and private sectors, especially in bad economic times. The various stakeholders such as hospitals and insurance companies often actually extract more resources as a result of the political negotiations over expanding access to health care (i.e., ok, you can cover more people but we need to extract higher payments in exchange).
Costs increase over time as health care costs in general continue to rise above the rate of inflation and more people utilize the new programs. Thus states find that they simply cannot afford incremental improvement, and so they must manage an incremental retreat. They end up pushing the costs of the health crisis problem back onto individuals by raising premiums, co-pays and deductibles, through roadblocks to limit participation in government programs and by whittling away at health services.
Perhaps the most fundamental difference between the US and the rest of the industrial world is that we allow health care to be treated as a commodity that is bought and sold on the open market, with the profit motive as a major factor. Access to health care is often based on the ability to pay rather than on need. The profit motive propels the US towards a “sick care” system, even though it is more expensive to cure people once they are ill rather than keeping them healthy. Incremental approaches fail to address these basic problems.
By definition, incremental approaches fall far short of universal coverage. The incremental approach also mistakenly often defines “universal” as everyone having access to health insurance, when what we need is a system that offers comprehensive care to all. Having everyone “in” one system provides a variety of ways to save costs, both within and without the health care system (e.g., reduction in costs impacted by health care such as workers’ comp and automobile insurance.)
Take for instance computerized medical records, something that everyone agrees we need. In a fragmented for-profit system individual “players” such as HMOs won’t make such common-sense investments since the immediate bottom line, not the long-term interests of the patient or society, prevail. In contrast, a true universal health care system will need to build in incentives for the use of computerized records, in order to allow medical providers demonstrate their efforts to keep the population healthy and to systematically address areas of high cost such as chronic illnesses.
The incremental approach often underestimates the number of uninsured and the problems they face. Every one has heard there are 47 million uninsured in America but few realize that the Census Bureau defines that number by those who lack insurance for the entire year. Perhaps twice as many go without health insurance for some time during any one-year. Thus it is impossible for a program that expands subsidies for private insurance to offer true health security to those who unexpectedly find themselves uninsured.
Further, those who are uninsured but live in medically under-served areas may finally find a way to pay for health care, for instance under New York’s Family Health Plus, but that fact by itself will not necessarily bring health care facilities or providers any closer to their door. And they may remain unable to find doctors in their communities willing to accept the reimbursement rates provided (e.g., Medicaid for certain services such as dental care.) Then there is the problem of people who have inadequate insurance. A 2003 Commonwealth study estimated that 16 million adults have inadequate insurance. In September 2007 Consumer Reports found that 29 percent of people with health insurance have coverage so meager they often avoid necessary medical care because of costs, that 43 percent of people with insurance feel unprepared to cope with a costly medical emergency, and that 20 percent were so dissatisfied with their HMO or PPO that they hoped to switch plans.
Worse, most people don’t realize they have inadequate insurance until they need it. Private insurance companies increase their profits by denying services to those they insure. As a result, high health care bills now account for a majority of bankruptcy filings, yet 3 out of 4 such individuals had health insurance when they become ill.
Thus at least a third of the American population suffers from a lack of adequate health insurance.
Incremental efforts, by definition, fail to offer comprehensive health solutions. We need a plan for health care that will provide all necessary medical care. This means emergency, primary and preventive care, necessary specialty care including prenatal care, acute hospital care, rehabilitative services, home care, nursing home care, dental care, mental health care, eye care. Look at nursing home care. Medicaid is in crisis, entangling our nursing homes and our county governments. Incremental expansions may be much more likely to exacerbate than to alleviate such problems.
Most experts who study health care admit that a single payer Medicare for all Style program does best at achieving the goals of providing quality, affordable health care to all. Single payer means one entity pays all bills but it doesn’t run the delivery system ( e.g., doctors, hospitals). Single payer proposals, by eliminating the cost and bureaucracy of private health insurance, manage to bring everyone in while actually saving costs. Single payer has been rated best by every state that has undertaking the comprehensive cost-benefit analyses of universal health care that New York is presently starting. The single payer proposals are almost always the only ones that meet the goal of actually bringing the entire population into the health care system (i.e., universal coverage.)
Yet many elected officials and health care reformers contend that single payer is not politically feasible, largely due to the opposition of special interests starting with the private health insurance companies that would no longer be needed. Many argue that the massive amounts of money spent by the insurance industry to defeat the Clinton health care plan in 1994, highlighted by their Harry and Louise ads, shows that they can’t be defeated. This argument however ignores that Clinton explicitly rejected a single payer approach, deciding instead to try to buy the support of the various stakeholders by throwing money at them in her proposal. The result was so complex and convoluted that many single payer advocates agreed that it should be defeated. The lesson arguably is not that a single payer proposal has no chance but rather that half-baked, flawed incremental approaches are doomed to failure.
Proponents of incrementalism tend to avoid the reality that the special interests oppose many of their proposals anyway, since most involve a reduction of their market share and funding. So right from the start incrementalists have weakened the impact of potential reforms without receiving any concessions in return from the major opponents. Incrementalists accommodate rather than resolve the fundamentally negative impact of private health insurance on health care delivery; indeed, the “reforms” that have been enacted have invariably strengthened rather than curtailed private insurance companies. Incrementalism unfortunately also undercuts the momentum for more comprehensive, effective reforms.
Others argue that moving to a single payer system - despite its positive impacts across the board on issues such as cost, coverage, access, choice, etc. - would be too disruptive, starting with the hospitals, doctors and insurance companies.. More “time” is needed to allow everyone to “adjust” to the new reality. However, little evidence has been presented to back up this assertion.
It should be noted that a number of industrial countries do have multipayer systems. What they don’t have is our system of private health insurance, where doctors are forced to navigate a maze of companies, many of them for profit, with their own rules and paperwork. As much as a third of every health care dollar touched by private insurance firms goes to pay for their existence, paperwork and profit. In America, despite the fact that more than 60% of health care costs are now paid directly for by the government (e.g., Medicare and Medicaid), we allow private health insurance to dictate much of the terms of the health care system. In all other industrial countries, the health care system is determined through their system of representative democracy. If private insurance is allowed, it plays a minor supplemental role, operating under strict rules determined by the government, with no role for profit.
The chorus of calls for incremental reform has fallen badly out of tune with respect to what the people of New York want for their health care system and hopelessly out of tempo with what people need for their personal health and security. When Governor Spitzer weighs the evidence he will find that only a single payer system can provide affordable, comprehensive health care for all New Yorkers.
Mark Dunlea is Executive Director of the Hunger Action Network of New York State and a long-time advocate of single payer health care.
Columbus Dispatch, Wednesday, January 9, 2008
By Froma Harrop
Crowding out sounds like a bad thing. The Bush administration uses that fearsome term in denying recent requests by Louisiana, Ohio, Oklahoma and, no doubt, other states to expand Medicaid to families not considered poor. Bush argues that opening the government program to middle-class people would prompt many to drop their private coverage.
Where's the problem?
It's not about justice. For-profit insurers drop families when a member becomes sick, and Washington looks the other way.
It's not new. When Medicare was created, the government health plan replaced a lot of private insurance coverage bought by the elderly.
And it's not about preserving quality health care. You don't hear Medicare beneficiaries clamoring for a return to private coverage, do you?
Not just a few medical providers, meanwhile, would love to see the private insurers "crowded out." The following story illustrates why:
St. Joseph Health Services is a Catholic nonprofit that cares for many poor people in Rhode Island. Last year, UnitedHealthcare of New England tried to cut the hospital group from its provider network. The reason? After years of seeing little or no increases in payments for services, St. Joseph had demanded that the insurer raise its reimbursement levels.
UnitedHealthcare played hardball. It proceeded to threaten its customers with a huge 58-percent compounded increase in premiums if it had to start writing bigger checks to St. Joseph.
During the angry standoff, St. Joe's chief revealed these interesting numbers: In 2006, the former chief executive officer at UnitedHealth Group (the parent company in Minneapolis), William McGuire, made $124 million. That was 1.5 times the entire payroll of St. Joseph's 2,000 employees. That's right, one pooh-bah at one insurance company pulled in 150 percent of what everyone at St. Joe's three health-care facilities made put together -- not only the nurses, orderlies, administrators and floor-swabbers, but also the executives and surgeons. Everyone!
William McGuire may be a familiar name. Last month, he was forced to give back $418 million worth of UnitedHealth stock options on top of nearly $200 million in options he already surrendered. That was punishment for joining in an unseemly scheme to backdate the options.
Waste no tears on "Dollar Bill." McGuire holds another $875 million in options, though a judge has frozen them, pending further review. And as top boss at UnitedHealth from 1991 to 2006, he raked in $500 million, which he definitely keeps.
You see, health care has become just another racket by which clever operators can scoop up fortunes. There's a ton of money to be made nickel-and-diming doctors and hospitals while making sure you don't sell insurance to sick people -- and that's the legal part. Once government offers coverage, it's game over for the manipulators -- and more of our health-care dollars go for health care.
And so here's another way to look at the "crowding out" issue. Rather than create unfair competition for insurance executives, government can be seen as freeing the public and medical caregivers from their claws.
That's not to say that private interests shouldn't play a role. A Canadian-style single-payer system, where government is the only insurer, has problems that allowing private-coverage options would ease. The best government-run systems, such as France's, are multipayer. They allow participation by private insurers, but keep them on a leash.
The Bush administration's fight to keep moderate-income families out of Medicaid resembles its successful battle last year to stop the expansion of the State Children's Health Insurance Program. It used the crowding-out argument back then.
But when you see the insurers in action, crowding out doesn't seem so evil or even the right term for what's happening. Throwing out may be more like it.
Froma Harrop writes for Creators Syndicate.firstname.lastname@example.org
New York Times
May 4, 2008 By REED ABELSON and MILT FREUDENHEIM
The economic slowdown has swelled the ranks of people without health insurance. But now it is also threatening millions of people who have insurance but find that the coverage is too limited or that they cannot afford their own share of medical costs.
Many of the 158 million people covered by employer health insurance are struggling to meet medical expenses that are much higher than they used to be often because of some combination of higher premiums, less extensive coverage, and bigger out-of-pocket deductibles and co-payments.
With medical costs soaring, the coverage many people have may not adequately protect them from the financial shock of an emergency room visit or a major surgery. For some, even routine doctor visits might now take a back seat to basic expenses like food and gasoline.
“It just keeps eating into people’s income,” said James Corbin, a former union official who works for the local utility in Tucson.
Mr. Corbin said that under their employer’s health plan, he and his co-workers are now obliged to pay up to $4,000 of their families’ annual medical bills, on top of about $1,600 a year in premiums. Five years ago, they paid no premiums and were responsible for only about $2,000 of their families’ medical bills.
“That’s a big jump,” Mr. Corbin said. “You’ve just lost a month’s pay.”
Already, many doctors say, the soft economy is making some insured people hesitant to get care they need, reluctant to spend a $50 co-payment for an office visit. Parents “are waiting longer to bring in their children,” said Dr. Richard Lander, a pediatrician in Livingston, N.J. “They say, ‘The kid isn’t that sick; her temperature is only 102.’ ”
The problem of affording health care is most acute for people with no insurance, a group expected to soon exceed 48 million, but those with insurance say they too are feeling the pain.
Since the recession of 2001, the employee’s average cost of an annual health care premium for family coverage has nearly doubled to $3,300, up from $1,800 while incomes have come nowhere close to keeping up. Factor in other out-of-pocket medical costs, and the portion of the average American household’s income that goes toward health care has risen about 12 percent, according to the consulting and accounting firm Deloitte, and is now approaching one-fifth of the average household’s spending.
In a recent survey by Deloitte’s health research center, only 7 percent of people said they felt financially prepared for their future health care needs.
Shirley Giarde of Walla Walla, Wash., was not prepared when her husband, Raymond, suddenly developed congestive heart failure last year and needed a pacemaker and defibrillator. Because his job did not provide health benefits, she has covered them both through a policy for the self-employed, which she obtained as the proprietor of a bridal and formal-wear store, the Purple Parasol.
But when Raymond had his medical problems, Ms. Giarde discovered that her insurance would cover only $22,000, leaving them with about $100,000 in unpaid hospital bills.
Even though the hospital agreed to reduce that debt to about $50,000, Ms. Giarde is still struggling to pay it in part because the poor economy has meant slumping sales at the Purple Parasol. Her husband, now disabled and unable to work, will not qualify for Medicare for another year, and she cannot afford the $758 a month it would cost to enroll him in a state-run insurance plan for individuals who cannot find private insurance.
She recently refinanced her car, a 2002 Toyota Highlander, to help pay for her husband’s heart medicines, which cost some $400 a month.
Experts say that too often for the underinsured, coverage can seem like health insurance in name only adequate only as long as they have no medical problems.
“There’s a real shift in the burden of health care to people who happen to be sick,” said Paul B. Ginsburg, the president of the Center for Studying Health System Change, a research group in Washington.
Companies and policy makers have yet to focus on what the faltering economy means for employees’ medical care, said Helen Darling, president of the National Business Group on Health, a Washington association of about 200 large employers.
“It’s a bad-news situation when an individual or household has to pay out-of-pocket three, four or five times as much for their health plan as they would have at the time of the last recession,” she said. “Americans have been giving their pay raise to the health care system.”
Sage Holben, a 62-year-old library technician with diabetes who is active in her local union in St. Paul, says that in 2003 union members agreed to a two-year freeze on wages to protect their health care coverage. But for the union, which will begin talks on the next contract this fall, it may be difficult to continue that trade-off, Ms. Holben said. “It’s at the point where we’re losing, anyway,” she said.
“I live paycheck to paycheck,” said Ms. Holben, who makes close to $40,000 a year at Metropolitan State University.
When she took the job in 1999, she says, the health benefits required no co-payments for doctor visits. Now, her out-of-pocket cost per visit is $25, and she pays $38 a month for her diabetes medicine. She has not been to the eye doctor in two years, even though eye exams are crucial for people with diabetes and she knows she needs new glasses. Nor does she monitor her blood sugar as regularly as she should because of the cost of the supplies.
“It’s not an extravagant expense,” she said. “It just adds up.” And it comes atop the increasing cost of utilities, gasoline and food and the few hundred dollars of repairs her 1994 Chevrolet Cavalier needs.
Many employers do recognize that their workers are struggling financially even as they are asking them to pick up more of their health-care bills.
“It makes the work we have to do even more challenging,” said Anne Silverman, the vice president in charge of benefits in North America for the publishing company Reed Elsevier. “Employees are being stretched in terms of their disposable income.”
Even so, more companies may see themselves as having little choice but to require employees to pay even more of their health expenses, said Ted Nussbaum, a benefits consultant at the firm Watson Wyatt Worldwide. And when a weak economy undermines job security, he said, workers may simply have to accept reduced benefits.
While Mr. Nussbaum and other consultants say it is unlikely that significant numbers of employers will simply drop coverage for their workers, the weak economy could prompt more of them to push for so-called consumer-driven plans. Such plans tend to offset lower premiums with higher annual deductibles.
And while these plans often allow employees to put pre-tax savings into special health care accounts, they typically end up forcing the worker to assume a bigger share of overall medical costs. About six million people are now enrolled in these medical plans.
Among employers, the hardest pressed may be small businesses. Their insurance premiums tend to be proportionately higher than ones paid by large employers, because small companies have little bargaining clout with insurers.
Health costs are “burying small business,” said Mike Roach, who owns a small clothing store in Portland, Ore. He recently testified on health coverage at a Senate hearing led by Ron Wyden, Democrat of Oregon.
Last year, Mr. Roach paid about $27,000 in health premiums for his eight employees. “It’s a huge chunk of change,” he said, noting that he was forced to raise his employees’ yearly deductible by 50 percent, to $750.
Around the nation, some workers are simply priced out of their employee health plans.
After Brian Falacienski of Milton, Fla., was laid off last year from his job as a surveyor for a construction company, he found another position. But the cost of his new health plan $800 a month for coverage with a $1,000 annual deductible was beyond the means of Mr. Falacienski, 38, who is married and has a 2-year-old daughter.
His wife, Marianne, started researching individual insurance policies and was able to find policies for her husband and daughter offering basic, if minimal, coverage, costing $161 a month for father and daughter. But Ms. Falacienski, 32, who has arthritis and the severe digestive disorder Crohn’s disease, is now uninsured. Because of her conditions, she said, four major insurers rejected her.
“I even applied for Medicaid,” she said, “but I wasn’t low-income enough.”
Copyright 2008 The New York Times Company
By Milton Fisk and Kay Mueller
April 24, 2008
Government subsidies and outsourcing may be good for business without always being good for the public. Medicare outsources the administration of its prescription drug program, Medicare D, to private insurers. Medicare Advantage — Medicare C — subsidizes managed care insurance plans for seniors choosing them. Several current presidential aspirants — Clinton and Obama — would subsidize the purchase of insurance for the low-income uninsured. Each of these plans offers private insurers protection against a less wasteful plan, one that does without private insurers.
Involving the insurers in the Medicare drug and Advantage plans is a needless drain of Medicare funds.
The drug companies charge much more for the drugs used under Medicare D than they do for the same drugs bought by Medicaid. The law forbids Medicare to negotiate prices of Medicare D drugs with the pharmaceuticals. Medicaid bargains a 30 percent discount on drugs while the insurers running Medicare D bargain only a 5 to 10 percent discount. Medicare C’s Advantage Plan turns over managed care to private insurers, paying them 10 to 12 percent more than Medicare pays for seniors in its regular program.
Suppose one of those presidential aspirants wins. What would the subsidies they want cost? They want subsidies to help at least the poorest two-thirds of the 47 million uninsured buy insurance.
The insurers would be in for a windfall injection — from the government and low-income individuals — of about $150 billion each year. Any industry would love this. But would it serve the public interest?
The answer comes from looking at how to get quality health care to the uninsured for much less. The private insurers operate with enormous overhead. Profit is an essential part of it, since without it, investors turn away.
Then there is marketing, lobbying, paperwork, computer systems, colossal salaries for upper level managers and the expense of constantly merging and reorganizing. In sum, overhead accounts for roughly 25 percent of premium income, while overhead for Medicare is five times less!
The presidential aspirants who promote this kind of insurer protection plan recognize the waste involved. So what is their response? They would make subsidies contingent on reducing overhead. Sen.Clinton’s plan says premiums are not to be dedicated to “excessive profits and marketing.” This might reduce overhead from 25 percent down to 15 or 20 percent of premium income — still three or four times more than Medicare’s overhead. How can anyone stand before the public and say they want to waste billions of taxpayers’ dollars just to protect the insurers?
It is not right to use the uninsured as an excuse for making the insurers richer. We don’t need the insurers to provide the uninsured with health care.Those proposing insurance protection plans spread the view that we shouldn’t help the uninsured unless the corporations make a buck out of it. Whatever happened to the public interest?
This guest column was written by Milton Fisk and Kay Mueller, who are members of the research committee of Hoosiers for a Commonsense Health Plan. Fisk is also an author of a book on health care reform
New York Times
March 27, 2008
By MARCI ALBOHER
If there is one thing that separates the self-employed from those employed by others, it is their preoccupation with health insurance.
I was reminded of this on Feb. 14, when I wrote a post on the Shifting Careers blog asking small-business owners and would-be entrepreneurs what they were doing about health insurance. Within hours, scores of people posted comments about their own experiences and, if they had managed to find good resources, shared those. I have been reading e-mail messages and trying to make sense of the subject ever since. In short, it is not pretty out there.
A 43-year-old woman wrote about going without insurance in the first year of her business. “I lived in terror of needing a doctor visit or worse yet, lab tests or something more,” she said. She then moved to an H.M.O. for sole proprietors through a local chamber of commerce. The cost of that plan, which she said was $171 a month in 2001, has now risen to $500 a month. At the same time, she wrote, co-payments have increased and services have been cut.
That woman’s experience reflected the exasperated tone of several of the other writers. Many entrepreneurs seem to find health insurance after doing a lot of research, though they generally pay more than they think they should. Some who are in good health bet on remaining that way and forgo health insurance or get policies with low premiums and high deductibles, choosing to insure themselves for mostly catastrophic illness. Some are lucky enough to have a well-insured partner.
The unluckiest are those with chronic illnesses or the dreaded pre-existing condition that results in a denial of coverage. Many of these people abandon dreams of entrepreneurship altogether because they need jobs that come with a health plan and they cannot find a way to self-insure.The comments also revealed that the health care system is a state-by-state patchwork, with options varying based on where you live. A 60-year-old owner of a mail order business from Illinois wrote that she was unable to get insurance until about 10 years ago when Illinois started a high-risk pool with Blue Cross Blue Shield.
A woman in business with her 57-year-old husband wrote to say that her husband is presently uninsured because, as a diabetic with high blood pressure, she cannot find an insurance company in Florida that will cover him. The stories go on. There were reports from Americans happily insured while living in Europe and Canada. And, of course, there were numerous pleas to Washington.
Jennifer Jaff, a reader who happens to be an expert on health insurance issues, shared a valuable tool, healthinsuranceinfo.net. The site, maintained by the Georgetown Health Policy Institute, shows a map of the country and after clicking on a state, a document is downloaded that covers everything from what kinds of programs are available to small-business owners to whether there is a high-risk pool available for those who have been rejected by insurance providers. These primers are comprehensive and frequently updated, and they are a great place to start, especially if you have been wondering about the meaning of jargon that peppers insurance providers’ descriptions of their offerings.
Many readers shared recommendations based on where they buy their insurance. Popular sources were local chambers of commerce, the Small Business Service Bureau (sbsb.com), AARP (aarp.org) (for those over 50), industry-specific trade associations like a bar association or the Institute of Electrical and Electronics Engineers. In states that permit it, small-business owners can also start a group with as little as one member. In that case, a good insurance agent comes in handy.
For the reasonably healthy who know what they are looking for, ehealthinsurance.com got fairly good reviews. The site, which has the feel of an Expedia or Orbitz for purchasing health insurance, allows you to compare a variety of policies offered through about 70 insurance providers. One caveat, pointed out by several readers, is that ehealthinsurance.com does not serve consumers in all states. Rhode Island, Vermont, Massachusetts, Maine and North Dakota are excluded. The company also covers only individuals. So if your company has employees, you will need to explore other options, like starting a group if your state permits that.
Another possibility for consultants and independent workers is the Freelancers Union, which won consistently good reviews in the reader comments. But the union also has some limitations. It operates in only 30 states, and you have to work in one of the industries or occupations it serves. While healthy business owners have to incur high costs and navigate a maze of choices, the truly unhealthy face the biggest challenges.
To learn more about options for those whose health is getting in the way of their self-employment, I spoke with Ms. Jaff, the woman who directed me to healthinsuranceinfo.net. Ms. Jaff, a lawyer who has worked on legal issues surrounding health care in both the public and private sector, now runs Advocacy for Patients With Chronic Illness (advocacyforpatients.org), a nonprofit organization in Farmington, Conn., that advises and advocates on behalf of the chronically ill. She says she works with about 1,000 patients a year, handling everything from battles to get insurance companies to pay for treatments prescribed by patients’ doctors to helping people figure out the best coverage.
Ms. Jaff speaks from experience. She suffers from Crohn’s disease, a condition so severe that she does not leave her house during flare-ups except to get to a doctor’s appointment or to the hospital. She wanted to find something she could do out of her home and as she went through the challenge of finding her own health insurance, she discovered what she calls “a community of patients in desperate need of help.”
Ms. Jaff qualified for the Municipal Employees Health Insurance Program, offered by Connecticut to cover small-business owners as part of a plan for state employees. She knew about the plan, which she recommends to all small- business owners in Connecticut, from her days as a lawyer in the attorney general’s office. Even with her extensive experience, Ms. Jaff has not been able to find the holy grail — good coverage at a great price. When she started on this insurance, her premium was $400 a month. Last year, the monthly payment went up to $800.
“I don’t know if people who don’t have chronic illnesses can really understand this,” she said. “But I have worked full time my entire adult life — generally 15 to 18 hours a day. I have paid into the system for all those years. And there is only one thing that could bankrupt me, and it is my health. I could lose every penny I own from one serious hospitalization without insurance. So I chose the plan that would give me the most possible coverage because the year I don’t is going to be the year I get really sick.”