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Don McCanne
Disputations: Is Single-Payer Health Care The Best Option? The problem with split-the-difference incremental reform.
The New Republic
July 16, 2008


Let's begin with the basic premise that our health care financing system should ensure that everyone receives the health care that they need without having to face a financial hardship. Everyone agrees that we have a very expensive system that falls far short of this goal, so it needs to be reformed.

The enthusiasm for the model of reform described by Jacob Hacker and endorsed by the Health Care for America Now (HCAN) coalition, which Jonathan Cohn wrote about in his recent New Republic piece "Single-Minded," is understandable. It is a model that attempts to align policy with politics, allegedly meeting the previously unattainable threshold of feasibility. But is it feasible, and will it even work?

Superficially, the model seems to be a workable compromise between those who believe that markets should provide health care coverage through competing private health plans, giving more control to the individual, and those who believe that a government insurance program would be more efficient and effective in ensuring that everyone has adequate health care coverage. Those on the right can support the private plans, and those on the left can purchase the competing public, Medicare-like program. Those in the middle can decide which model would become more prevalent, so goes the theory.

Anyone who really believes in this model understands that the private insurance plans would have to be very tightly regulated to reduce the profound deficiencies in our current insurance markets. The current private insurance business model depends on selling the insurers' products to the large numbers of us who are healthy, especially the healthy workforce and their healthy families, while avoiding the need to contribute to the risk pools that cover those who have greater health care needs. Those costs are largely passed on to taxpayers through government programs.

Other nations that use private plans require effective pooling between plans through various regulatory mechanisms, reducing the problem of adverse selection and ensuring that premiums or taxes are adequate to pay for the care for those with greater needs. Even if the pools are nominally segregated, they function more like a universal risk pool through mechanisms such as risk adjustment and post-claims inter-insurance transfers.

The United States has a unique problem that would make it much more difficult to require private insurers to participate in a quasi-universal risk pool. On a per capita basis, we pay far more for health care than do other nations. Average-income individuals in other nations that use private plans can still afford premiums (or their tax equivalents). In those countries, only low-income individuals require some form of government subsidy for their care.

Compare that with the United States. For healthy risk pools, such as those of employer-sponsored plans, premiums are no longer affordable for average-income individuals and families, whether paid directly by the insured, or nominally by the employer. Imagine a tightly regulated insurance market that ended adverse selection and required benefits at a level that would prevent financial hardship for those with health care needs. The private insurers would find it absolutely impossible to provide us with compliant products that had affordable premiums.

Because of our very high costs, we must accept the fact that the insurance function is no longer simply a transfer from the many who are healthy to the fewer with health care needs, but it now must also include a partial transfer from the wealthy to middle- and lower-income individuals with needs. There is no alternative to this wealth transfer, and that alone creates doubt as to whether a model of highly regulated private plans is politically feasible.

How would that transfer take place in a premium-based system? If the premium were based on income, the premiums that wealthier individuals would have to pay would be so high that it would be a non-starter. Also, we already have a system with burdensome administrative costs. Adding more administration for the purpose of adjusting premiums to match incomes would add to that burden.

We have to get over the idea that financing should be through premiums set by the actuarial value of the benefits in the insurance products. Those premiums are no longer affordable for most of us, and the complexities of income-related adjustments, whether through premium adjustments or tax credits, create an administrative nightmare. It is time that we separate the financing of the universal risk pool from the health care benefit package. The tax system provides us with the most equitable and efficient method of financing our global health care costs.

Perhaps a more compelling reason that the private insurance model no longer works is that it is very ineffective in slowing the increases in health care costs, and everyone agrees that affordability is now a major problem. Most of the current political cost-saving proposals would have very little impact on total costs. We need to address the true major cost drivers: the profound administrative excesses, the lack of an adequate primary care infrastructure, the waste of non-beneficial high-tech excesses, and the lack of a rational system of health care pricing. Even in a regulated environment, it would be very difficult for a multitude of private insurers and public programs to have much impact on these excess costs. Most economists agree that a monopsony, or single purchaser of health care products and services, would be most effective in extracting value through a negotiated realignment of incentives in our health care purchasing.

So why don't we just give up, let the private insurance market continue as is, and provide tax subsidies for those who need them, and then offer the single payer holdouts a public program to make them happy? The problem is that you would fail to gain the efficiencies and equities of the single payer model if the public program is only another option in the insurance market. It alone would not have enough purchasing power to negotiate optimal value. The public option surely would be subject to adverse selection and sink of its own weight.

So where are we on feasibility? The insurance industry wants only the healthy to ensure the success of their business model while passing much of the costs of health care on to the taxpayers. The conservatives do not want a public Medicare-like option for fear of gradual transformation into a single payer system. Many liberals do not want a free market private insurance system, but rather want private plans to be so tightly regulated that they almost function like a single payer system, though using private plans is the most expensive model of universal coverage.

This debate that is taking place within the progressive community is missing the center of the feasibility dispute. It is implied that the Hacker/HCAN progressive model would be just fine if the single payer advocates would come to their senses and join in. It ignores the fact that this model is simply not politically feasible: it loses the support of market enthusiasts because of its dependency on tight regulatory control, intrusion by a government insurance program, and the necessity of a massive infusion of tax funds.

If you are going to accept that those changes are necessary to provide adequate coverage for everyone, then you might as well go ahead and establish a much more efficient and effective single payer national health program. Some may argue that explicit calls for income transfer and bureaucratic control of spending are what limit the political feasibility of the single payer model, but the private plans/public option model would have to incorporate the same principles, and their advocates should be very frank about that upfront.

HCAN has rejected the single payer model as not being feasible because it is too disruptive. Yet their model turns the insurance industry upside down, and places the government in the dominant role. Isn't that disruptive? Besides, aren't many of the advances that we see in the technical world today due to disruptive innovations? New, improved, lower-cost technology replaces older, less effective and more expensive technology. That is certainly disruptive to the firms whose products are replaced. But isn't disruptive innovation precisely what we need in health care financing today?

What we don't need is the feeble disruption of the old model of private health insurance by retaining it and modifying it to try to make it work in our very expensive health care environment. We need the truly beneficial disruptive innovation of replacing the obsolete model of private plans with an efficient single payer national health program.

So, the bottom line? We need reform that provides everyone the health care that they need, without financial barriers that would impede access. We can attempt to maneuver around the ubiquitous mines and trap doors of the political common ground of Hacker/HCAN, and still end up short if we survive. Or we can go straight to a proven model that would accomplish all of our financing goals--a single payer national health program.



Don McCanne is a senior health policy fellow at Physicians for a National Health Program.

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Why is Health Care for America Now Giving Up on Real Reform?
Rose Ann DeMoro
July 10, 2008

The big splash of news and internet coverage for the new Health Care for America Now coalition of labor, progressive and liberal groups is a reminder of the critical importance of health care reform. And a reminder that partial solutions, such as those proposed by the coalition, will only perpetuate, not end the health care crisis.

The groups behind the new coalition are working in concert with the Obama campaign and Democratic leaders in Congress to build "consensus" around a plan that would presumably be introduced in the first days of the next administration, and pushed through to a quick vote before opponents can mount a "Harry and Louse"-style counter attack.

But, in search of a supposedly politically viable plan, the advocates of this approach have surrendered in advance on the only overhaul that will actually cure the disease, a single-payer, expanded and improved Medicare for all reform.

Their good intentions will leave the same failed system in place, and will not even blunt the political opposition from those on the right and corporate interests who will continue to challenge anything that looks like even modest reform.

They create a false hope of systemic change that won't be, squandering the opportunity to achieve the fundamental reform so desperately needed with so many lives in the balance.

They've also missed one of the most important lessons of the failure of the Clinton plan of 1993-94 which collapsed in part due to the absence of a broad, grassroots, activist movement needed to counter the insurance industry. Only single payer engenders such a movement, the very reason the single payer bill now in Congress, HR 676, has more co-sponsors than any other reform bill with tens of thousands around the country already working to enact it.

Health Care for America Now has identified the main culprit and obstacle to genuine reform. As their inaugural ad proclaims, "Will health insurance companies ever put your health ahead of their profits? We can't trust insurance companies to fix the health care mess."

There's just one problem -- the coalition's proposal does nothing to end the actual practice of insurance companies putting their profits ahead of your health. Nor does it fix the two central components of the health care morass -- insurance company denials of care and the financial squeeze facing American families due to ever skyrocketing health care costs which is exacerbated by the escalating credit crisis.

Consider the four health care questions posed by families in the first 30-second ad: "Will they pay for his inhaler? Is my surgery covered? Can I choose my child's doctor? Will they cover the chemo?"

All are the direct result of care denials and price gouging by the insurers -- and none would be solved by the HCFAN "statement of common purpose."

How does the HCFAN coalition propose to crack down on the insurance pirates? With a "watchdog role" on the plans "to assure that risk is fairly spread" and that "insurers do not turn people away, raise rates or drop coverage based on a person's health history or wrongly delay or deny care."

You can watch someone rob your bank, but unless you stop them, the vaults are still going to be stripped bare. If you're looking for the hammer or any enforcement mechanism in the HCFAN proposal, don't bother, it's not there.

The insurers don't care if we know they are thieves, they will continue to deny and delay care because it's in their DNA. It's how they are set up to operate, it's how they make money for their shareholders, it's how they generate plush pay packages for their executives, and it's how they compete with the other insurance giants.

Nor does the HCFAN proposal contain any effective cost controls on the insurers. Their commitment to basing pricing on "ability to pay" is a recipe for merely getting the healthcare you can afford, not what you need. It also fails to assure real choice of providers beyond the limited network established by all private insurance plans.

The bone the coalition sponsors throw to single payer advocates is the false promise of a public plan side by side with private insurance. The public plan, they contend, will be so much more attractive that the private plans will just wither away. Don't count on it.

The insurance companies will always be able to lower their prices with cut rate plans with lower standards that they can aggressively market through massive advertising, tele-marketing, even door to door salesmen (as some do now) with a marketing campaign that the public plans will not have the funding to be able to match.

The private plans can then continue to cherry pick the younger and healthier patients while the sicker and older patients are dumped in the public plan, wrecking the whole idea of a risk pool and driving up the costs for the public plan to operate. The competition won't starve the private plans and cause them to wither away, they'll starve the public plan.

There's only one way to stop the insurance industry abuses -- it's to actually stop them. The rest of the world has figured this one out -- see the study in Britain earlier this year that found that the U.S. ranks last in preventable deaths among 19 industrialized nations even though we spend twice as much on health care as anyone else. Isn't it time we figured it out here as well?

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Sandeep Jauhar, M.D.
Eyes Bloodshot, Doctors Vent Their Discontent
New York Times
June 19, 2008

“I love being a doctor but I hate practicing medicine,” a friend, Saeed Siddiqui, told me recently. We were sitting in his office amid his many framed medical certificates and a poster of an illuminated lighthouse that read: “Success doesn’t come to you. You go to it.”

A doctor in his late 30s, he has been in practice for six years, mostly as a solo practitioner. But he told me he recently had decided to go into partnership with another cardiologist; his days, he said, will be “totally busy.”

“Your days aren’t busy enough already?” I asked.

The waiting room was packed. He had a full schedule of appointments, and after he was done with his office patients, he was going to round at two hospitals.

He smiled wanly. “Just look at my eyes.”

They were bloodshot.

“This whole week I haven’t slept more than about six hours a night.”

I asked when his work usually got done.

It is never done,” he replied, shaking his head. “See this pile?”

He pointed to five large manila packages on a shelf above his desk. “These are reports I still have to finish.”

As a physician, I could empathize. I too often feel overwhelmed with paperwork. But my friend’s discontent seemed to run much deeper than that. Unfortunately, he is not alone. I have been hearing physician colleagues voice a level of dissatisfaction with medical practice that is alarming.

In a survey last year of nearly 2,400 physicians conducted by a physician recruiting firm, locumtenens.com, 3 percent said they were not frustrated by nonclinical aspects of medicine. The level of frustration has increased with nearly every survey.

“It will take real structural change in the work environment for physician satisfaction to improve,” Dr. Mark Linzer, an internist at the University of Wisconsin who has done extensive research on physician unhappiness, told me. “Fortunately, the data show that physicians are willing to put up with a lot before giving up.”

Not long ago, fed up with what he perceived as a loss of professional autonomy, Dr. Bhupinder Singh, 42, a general internist in New York, sold his practice and went to work part time at a hospital in Queens.

“I’d write a prescription,” he told me, “and then insurance companies would put restrictions on almost every medication. I’d get a call: ‘Drug not covered. Write a different prescription or get preauthorization.’ If I ordered an M.R.I., I’d have to explain to a clerk why I wanted to do the test. I felt handcuffed. It was a big, big headache.”

When he decided to work in a hospital, he figured that there would be more freedom to practice his specialty.

“But managed care is like a magnet attached to you,” he said.

He continues to be frustrated by payment denials. “Thirty percent of my hospital admissions are being denied. There’s a 45-day limit on the appeal. You don’t bill in time, you lose everything. You’re discussing this with a managed-care rep on the phone and you think: ‘You’re sitting there, I’m sitting here. How do you know anything about this patient?’ ”

Recently, he confessed, he has been thinking about quitting medicine altogether and opening a convenience store. “Ninety percent of doctors I know are fed up with medicine,” he said.

And it is not just managed care. Stories of patients armed with medical knowledge gleaned from the Internet demanding antibiotics for viral illnesses or M.R.I. scans for routine symptoms are rife in doctors’ lounges. Malpractice worries also remain at the forefront of many physicians’ minds, compounded by increasing liability premiums that have forced many into early retirement.

In surveys, increasing numbers of doctors attest to diminishing enthusiasm for medicine and say they would discourage a friend or family member from going into the profession.

The dissatisfaction would probably not have reached such a fever pitch if reimbursement had kept pace with doctors’ expectations. But it has not.

Doctors are working harder and faster to maintain income, even as staff salaries and costs of living continue to increase. Some have resorted to selling herbs and vitamins retail out of their offices to make up for decreasing revenue. Others are limiting their practices just to patients who can pay out of pocket.

There are serious consequences to this discontent, the most worrisome of which is that it is difficult for doctors who are so unhappy to provide good care.

Another is a looming shortage of doctors, especially in primary care, which has the lowest reimbursement of all the medical specialties and probably has the most dissatisfied practitioners.

Last year, residency programs in family practice took only 1,096 graduating medical students, the fewest in the last two decades. The number increased just slightly this year. Students who do choose internal medicine increasingly are forgoing primary care for subspecialty practices like cardiology and gastroenterology.

“For me it’s an endless amount of work that I can never get through to do it properly,” said Dr. Jeffrey Freilich, 38, a primary-care physician on Long Island. “I’m a bit compulsive. As an internist, I have to worry about working up so many conditions — anemia, thyroid problems and so forth. There is no time to do it all in a day.

“On top of all that, there are all the colonoscopies and mammograms you have to arrange, and all the time on the phone getting preauthorizations. Then you have to track the patient down. And none of it is reimbursed.”

Many primary-care physicians have stopped seeing their patients when they are hospitalized, relying instead on hospitalists devoted to inpatient care. Internists have told me that it is prohibitively inefficient to drive to a hospital, find parking, walk to the wards, examine a patient, check laboratory tests and vital signs, talk to a nurse and write orders and a note — for just a handful of cases. They cannot afford to leave their offices long enough to do it.

The upshot is that the doctor who knows a patient best is often uninvolved in her care when she is hospitalized. This contributes to the poor coordination and wanton consultation that is so common in hospitals today.

“Years ago you had one or two doctors,” a hospitalized patient told me recently. “Now you’ve got so many people coming in it’s hard to know who’s who.”

A 10.6 percent cut in Medicare payments to physicians is scheduled to take effect on July 1. Further cuts are planned in coming years. Many doctors have told lawmakers that if the cuts go through, they will stop seeing Medicare patients. But reimbursement cuts are only a small part of doctors’ woes today.

“I was naïve,” Saeed Siddiqui said. “When I was a resident I thought it was enough to take good care of patients. But the real world is totally different.”

Dr. Sandeep Jauhar, a cardiologist on Long Island, is the author of a new memoir, “Intern: A Doctor’s Initiation.”

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Editorial
The High Cost of Health Care
The New York Times
November 25, 2007

The relentless, decades-long rise in the cost of health care has left many Americans struggling to pay their medical bills. Workers complain that they cannot afford high premiums for health insurance. Patients forgo recommended care rather than pay the out-of-pocket costs. Employers are cutting back or eliminating health benefits, forcing millions more people into the ranks of the uninsured. And state and federal governments strain to meet the expanding costs of public programs like Medicaid and Medicare.

Health care costs are far higher in the United States than in any other advanced nation, whether measured in total dollars spent, as a percentage of the economy, or on a per capita basis. And health costs here have been rising significantly faster than the overall economy or personal incomes for more than 40 years, a trend that cannot continue forever.

It is the worst long-term fiscal crisis facing the nation, and it demands a solution, but finding one will not be easy or palatable.

The Causes

Varied and Deep-Rooted. Contrary to popular beliefs, this is not a problem driven mainly by the aging of the baby boom generation, or the high cost of prescription drugs, or medical malpractice litigation that spawns defensive medicine. Those issues often dominate political discourse, but they have played relatively minor roles in driving up medical spending in this country and abroad. The major causes are much more deep-seated and far harder to root out.

Almost all economists would agree that the main driver of high medical spending here is our wealth. We are richer than other countries and so willing to spend more. But authoritative analyses have found that we spend well above what mere wealth would predict.

This is mostly because we pay hospitals and doctors more than most other countries do. We rely more on costly specialists, who overuse advanced technologies, like CT scans and M.R.I. machines, and who resort to costly surgical or medical procedures a lot more than doctors in other countries do. Perverse insurance incentives entice doctors and patients to use expensive medical services more than is warranted. And our fragmented array of insurers and providers eats up a lot of money in administrative costs, marketing expenses and profits that do not afflict government-run systems abroad.

Does It Matter? If citizens of an extremely wealthy nation like the United States want to spend more on health care and less on a third car, a new computer or a vacation home, what’s wrong with that? By some measures, Americans are getting good value. Studies by reputable economists have concluded that spending on such advanced treatments as cardiac drugs, devices and surgery; neonatal care for low-birth-weight infants; and mental health drugs have more than paid for themselves by extending lives and improving their quality.

But if health care spending continues on its same trajectory, the United States will reach the point — probably several decades from now — where every penny of the annual increase in gross domestic product would have to go for health care. There would be less and less money for other things, like education, environmental protection, scientific research and national security, that may be equally or more important to the well-being of society.

Governmental budgets will face the crisis even sooner. States are already complaining that they have to crimp other vital activities, like education, to meet soaring Medicaid costs. And federal spending on Medicare and Medicaid is surging upward at rates that will cause the deficit to soar. That means politicians will have to raise taxes, severely cut a wide range of other governmental programs, or chop back the health programs themselves.

The question is: What can be done to lower both the high level of health care spending and its high rate of increase from year to year?

The Solutions

Geography. Pioneering studies by researchers at Dartmouth have shown enormous disparities in expenditures on health care from one region to another with no discernible difference in health outcomes. Doctors in high-cost areas use hospitals, costly technology and platoons of consulting physicians a lot more often than doctors in low-cost areas, yet their patients, on average, fare no better. There are hints that they may even do worse because they pick up infections in the hospital and because having a horde of doctors can mean no one is in charge.

If the entire nation could bring its costs down to match the lower-spending regions, the country could cut perhaps 20 to 30 percent off its health care bill, a tremendous saving. That would require changing the long- ingrained practices of the medical profession. Public and private insurers might need to refuse coverage for high-cost care that adds little value.

Stick to What Works. The sad truth is that less than half of all medical care in the United States is supported by good evidence that it works, according to estimates cited by the Congressional Budget Office. If doctors had better information on which treatments work best for which patients, and whether the benefits were commensurate with the costs, needless treatment could be junked, the savings could be substantial, and patient care would surely improve. It could take a decade, or several, to conduct comparative-effectiveness studies, modify relevant laws, and change doctors’ behavior.

Managed Care. For a brief period in the 1990s it looked as if health maintenance organizations competing for patients and carefully managing their care might bring down costs and improve quality at the same time. The H.M.O.’s did help restrain costs for a few years. The problem was, doctors and patients hated the system, management became much looser, and the upsurge in costs resumed. Managed care techniques are creeping back into some health plans, especially for services apt to be overused, but too heavy a hand would most likely produce another backlash.

Information Technologies. The American health care system lags well behind other sectors of the economy — and behind foreign medical systems — in adopting computers, electronic health records and information-sharing technologies that can greatly boost productivity. There is little doubt that widespread computerization could greatly reduce the paperwork burden on doctors and hospitals, head off medication errors, and reduce the costly repetition of diagnostic tests as patients move from one doctor to another. Without an infusion of capital, the transition from paper records is not apt to happen very quickly.

Prevention. Everyone seems to be hoping that preventive medicine — like weight control, exercise, better nutrition, smoking cessation, regular checkups, aggressive screening and judicious use of drugs to reduce risks — will not only improve health but also lower costs in the long run. Preventive medicine actually costs money — somebody has to spend time counseling patients and screening them for disease — and it is not clear how soon, or even whether, substantial savings will show up. Still, the effort has to be made. The Milken Institute recently estimated that the most common chronic diseases cost the economy more than $1 trillion annually, mostly from lost worker productivity, which could balloon to nearly $6 trillion by the middle of the century.

Disease Management. Virtually all policy experts want more careful coordination of the care of chronically ill patients, who account for the largest portion of the nation’s health care expenditures. Although that should improve the quality of the care they get, coordination may not cut costs as substantially as people expect. In some initial trials it has cut costs, in others not.

Drug Prices. Compared with the residents of other countries, Americans pay much more for brand-name prescription drugs, less for generic and over-the-counter drugs, and roughly the same prices for biologics. This page believes it would be beneficial to allow Medicare to negotiate with manufacturers for lower prescription drug prices and to allow cheaper drugs to be imported from abroad. The prospect for big savings is dubious.

Who Picks Up the Tab?

Pay Providers Less. With doctors dreadfully unhappy under the heavy hand of insurers, it would seem shortsighted to make them even unhappier by cutting their compensation to levels paid in other countries. But many experts believe it should be possible to tap into the vast flow of money sluicing through hospitals, nursing homes and other health care facilities to find savings.

Emphasize Primary Care. In a health system as uncoordinated as ours, many experts believe we could get better health results, possibly for less cost, if we changed reimbursement formulas and medical education programs to reward and produce more primary care doctors and fewer specialists inclined to proliferate high-cost services. It would be a long-term project.

Skin in the Game. The solution favored by many conservatives is to force consumers to shell out more money when they seek medical care so that they will think harder about whether it is really necessary. The “consumer-directed health care” movement calls for providing people with enough information about doctors and treatments so that they can make wise decisions.

There would most likely be some savings. A classic experiment by Rand researchers from 1974 to 1982 found that people who had to pay almost all of their own medical bills spent 30 percent less on health care than those whose insurance covered all their costs, with little or no difference in health outcomes. The one exception was low-income people in poor health, who went without care they needed. Any cost-sharing scheme would have to protect those unable to bear the burden.

And consumer-driven plans have limitations. Most health care spending is racked up by a small percentage of individuals whose bills are so high they are no longer subject to cost sharing; they will hardly be deterred from expensive care they desperately need. Moreover, few consumers have the competence or knowledge to second-guess a doctor’s recommendations.

Single Payer. Deep in their hearts, many liberals yearn for a single-payer system, sometimes called Medicare-for-all, that would have the federal government pay for all care and dictate prices. Such a system would let the government offset the price-setting strength of the medical and pharmaceutical industries, eliminate much of the waste due to a multiplicity of private insurance plans, and greatly cut administrative costs.

But a single-payer system is no panacea for the cost problem — witness Medicare’s own cost troubles — and the approach has limited political support. Private insurers could presumably eliminate some of the waste through uniform billing and payment procedures.

* * *

By now it should be clear that there is no silver bullet to restrain soaring health care costs. A wide range of contributing factors needs to be tackled simultaneously, with no guarantee they will have a substantial impact any time soon. In many cases we do not have enough solid information to know how to cut costs without impairing quality. So we need to get cracking on a range of solutions. The cascade of knowledge flowing from the human genome project, new nanotechnologies and the advent of treatments tailor-made for individual patients may well accelerate, not mitigate, the rise in medical spending. If we want the benefits, we will need to make them affordable.

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David Lazarus
Nation's Healthcare Crisis Gets Personal
Los Angeles Times
October 7, 2007

I write a lot about healthcare reform. Now it's personal.
 
I was diagnosed this past week with diabetes. As of Friday, I was injecting myself with insulin, something I'll be doing four or five times a day, every day, for the rest of my life. Without the injections, I'll likely die.
 
Scared? You're damn right I'm scared. What's going to happen to me? What's going to happen to my family?
 
I got past the shock pretty quickly and am now stuck somewhere between denial and anger. Depression will soon arrive, followed eventually by acceptance. Something to look forward to.
 
This is an uncertain time for me, but I know this much: I'm more convinced than ever that our medical system is a mess and that a single-payer insurance program is the only realistic way we can achieve universal coverage, promote preventive treatment and make healthcare affordable to all.
 
And if contracting diabetes is frightening for a relatively well-insured person like myself, what must it be like for any of the 47 million Americans who lack health insurance?
 
According to the American Diabetes Assn., nearly 21 million U.S. adults and kids have the disease -- 7% of the population. About 15 million of this number have been diagnosed. The rest have no idea that they're afflicted.
 
With obesity rates soaring, as many as 54 million others are strongly at risk of contracting diabetes in the future.
 
In my case, diabetes struck not because I stuff my face with Big Macs and fried chicken, which I don't. I take good care of myself and am not overweight -- considerably less so since unexpectedly dropping about 15 pounds over the past couple of months.

No, it's almost certain I got nailed because a genetic time bomb finally exploded.
 
My father, Paul N. Lazarus III, who produced the movies "Westworld" and "Capricorn One," has Type 1 diabetes and is now nearly blind. My younger brother has Type 1 and is doing well enough. My aunt had Type 1 before it blinded and then killed her.
 
The doctors say diabetes -- almost certainly Type 1 -- has been lurking in my DNA since I was a child, waiting for its time to strike.
 
But why now? I've lived 46 fairly healthy years, except for certain pharmaceutical pursuits during college. I don't drink. I don't smoke. I exercise as regularly as I can. What did I do wrong?
 
Probably nothing. The stress of my recent move to L.A. and starting a new job didn't help, but it's not to blame. This was going to happen no matter what.
 
I had a good idea something was wrong when I noticed that my weight kept going down no matter what I ate, and that I was consumed with a thirst of biblical proportions (accompanied by a commensurate increase in bathroom breaks).
 
I visited my doctor and had a blood test. The bad news came just days later. I was immediately referred to a specialist, whom I'll call Dr. B.
 
Dr. B was great -- knowledgeable, sensitive, empathetic. Problem was, Dr. B didn't take insurance.
 
Excuse me? I said.
 
Dr. B explained that it just wasn't cost-effective for him to seek reimbursement from insurance companies. It was too much hassle, he said, and he didn't get paid enough for his efforts. Dr. B said an increasing number of doctors were cutting ties with insurers for the same reasons.
 
If I wanted to see him at his private practice, which was most convenient to my home, each visit could cost me hundreds of dollars -- not the most appealing prospect when one's facing a chronic disease.
 
Dr. B said I could try to deal with insurance reimbursements on my own, but that's the last headache I wanted to inflict on myself at this point.

So I had to quickly find a doctor who would take insurance. My insurer's website had a directory of possible choices, but you're essentially pulling a name out of a hat -- not the best way to make decisions when your blood-sugar level is three or four times normal.
 
This led me to Dr. W, who was equally knowledgeable if perhaps a bit lacking in the empathy department. He also had what seemed to me unconventional ideas about how diabetes can be treated with certain drugs and a rigidly monastic diet of his own devising.
 
This ultimately led me to Dr. D at UCLA's Gonda (Goldschmied) Diabetes Center, whom I'm very fortunate to have found. Not only does he know what he's doing, but he also has the resources of a world-class medical facility that focuses exclusively on what's trying to put me under dirt.
 
It was Dr. D who finally made the call that I needed to start insulin injections, and it was he who made sure I knew how to handle that first, life-changing moment when needle touched skin.
 
Clearly I'm receiving the best available treatment, and I'd rather be here than anywhere in the world.
 
But the quirks and complexities of the insurance system border on madness. Through my employer, I have about as much insurance coverage as anyone. Yet that wasn't good enough for Dr. B.
 
I have to wonder where else my private-sector insurance will fail me in years ahead.
 
And what happens if I get fired tomorrow? With a preexisting condition, I'm virtually uninsurable in the individual insurance market. Will diabetes leave my family destitute?
 
In the past, I always wrote about the uninsured in a largely abstract way
-- a faceless mass of millions of people confronted with a broadly defined medical challenge. I know better now.
 
The terrifying possibility of my own loss of coverage gives me an acute sense of what the uninsured must deal with, the dreadful awareness that you and your loved ones are only one medical misstep from catastrophe.
 
That's unacceptable for any person who lives in the wealthiest, most advanced nation in the history of the world.
 
I'll have a lot more to say about this in the future, especially as my own situation takes shape. But this much at least is evident:
 
* Universal coverage must be our goal, and it must allow ready access to all aspects of the medical system at affordable prices.
 
* The emphasis must be on treatment, not bureaucracy. As it stands, researchers at Harvard University estimate that about a third of the $2 trillion in annual healthcare spending is squandered on bureaucratic overhead.
 
* Employer-based healthcare is obsolete. As costs continue climbing, businesses can no longer meet their historical obligation of being the primary provider of coverage to American families.
 
* Quality medical treatment is a right, not a benefit.
 
Unfortunately, nearly all healthcare-reform proposals on the table center on expanding the existing system and pushing the uninsured into high-cost individual policies that will make private insurers even more profitable.
 
That can't be the answer.
 
Single-payer isn't perfect. Critics say it can involve long waits for treatment and can stifle innovation.
 
My belief is that Americans can get it right. We can learn from the examples of other nations and refine things so that our healthcare is second to none. It won't be easy. Then again, how much worse could it be than the way things are now?
 
As of this moment, I'm completely dependent on the U.S. healthcare system to keep me alive. I, and you, shouldn't have to settle for anything but the best.

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New York Times Editorial
World's Best Medical Care?
August 12, 2007

Many Americans are under the delusion that we have "the best health care system in the world," as President Bush sees it, or provide the "best medical care in the world," as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.

Michael Moore struck a nerve in his new documentary, "Sicko," when he extolled the virtues of the government-run health care systems in France, England, Canada and even Cuba while deploring the failures of the largely private insurance system in this country. There is no question that Mr. Moore overstated his case by making foreign systems look almost flawless. But there is a growing body of evidence that, by an array of pertinent yardsticks, the United States is a laggard not a leader in providing good medical care.

Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. More recently, the highly regarded Commonwealth Fund has pioneered in comparing the United States with other advanced nations through surveys of patients and doctors and analysis of other data. Its latest report, issued in May, ranked the United States last or next-to-last compared with five other nations —Australia, Canada, Germany, New Zealand and the United Kingdom—on most measures of performance, including quality of care and access to it. Other comparative studies also put the United States in a relatively bad light.

Insurance coverage. All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients. The United States, to its shame, has some 45 million people without health insurance and many more millions who have poor coverage. Although the president has blithely said that these people can always get treatment in an emergency room, many studies have shown that people without insurance postpone treatment until a minor illness becomes worse, harming their own health and imposing greater costs.

Access. Citizens abroad often face long waits before they can get to see a specialist or undergo elective surgery. Americans typically get prompter attention, although Germany does better. The real barriers here are the costs facing low-income people without insurance or with skimpy coverage. But even Americans with above-average incomes find it more difficult than their counterparts abroad to get care on nights or weekends without going to an emergency room, and many report having to wait six days or more for an appointment with their own doctors.

Fairness. The United States ranks dead last on almost all measures of equity because we have the greatest disparity in the quality of care given to richer and poorer citizens. Americans with below-average incomes are much less likely than their counterparts in other industrialized nations to see a doctor when sick, to fill prescriptions or to get needed tests and follow-up care.

Healthy lives. We have known for years that America has a high infant mortality rate, so it is no surprise that we rank last among 23 nations by that yardstick. But the problem is much broader. We rank near the bottom in healthy life expectancy at age 60, and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care. The good news is that we have done a better job than other industrialized nations in reducing smoking. The bad news is that our obesity epidemic is the worst in the world.

Quality. In a comparison with five other countries, the Commonwealth Fund ranked the United States first in providing the "right care"

for a given condition as defined by standard clinical guidelines and gave it especially high marks for preventive care, like Pap smears and mammograms to detect early-stage cancers, and blood tests and cholesterol checks for hypertensive patients. But we scored poorly in coordinating the care of chronically ill patients, in protecting the safety of patients, and in meeting their needs and preferences, which drove our overall quality rating down to last place. American doctors and hospitals kill patients through surgical and medical mistakes more often than their counterparts in other industrialized nations.

Life and death. In a comparison of five countries, the United States had the best survival rate for breast cancer, second best for cervical cancer and childhood leukemia, worst for kidney transplants, and almost-worst for liver transplants and colorectal cancer. In an eight-country comparison, the United States ranked last in years of potential life lost to circulatory diseases, respiratory diseases and diabetes and had the second highest death rate from bronchitis, asthma and emphysema. Although several factors can affect these results, it seems likely that the quality of care delivered was a significant contributor.

Patient satisfaction. Despite the declarations of their political leaders, many Americans hold surprisingly negative views of their health care system. Polls in Europe and North America seven to nine years ago found that only 40 percent of Americans were satisfied with the nation's health care system, placing us 14th out of 17 countries. In recent Commonwealth Fund surveys of five countries, American attitudes stand out as the most negative, with a third of the adults surveyed calling for rebuilding the entire system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada.

That may be because Americans face higher out-of-pocket costs than citizens elsewhere, are less apt to have a long-term doctor, less able to see a doctor on the same day when sick, and less apt to get their questions answered or receive clear instructions from a doctor. On the other hand, Gallup polls in recent years have shown that three-quarters of the respondents in the United States, in Canada and in Britain rate their personal care as excellent or good, so it could be hard to motivate these people for the wholesale change sought by the disaffected.

Use of information technology. Shockingly, despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines.

Top-of-the-line care. Despite our poor showing in many international comparisons, it is doubtful that many Americans, faced with a life-threatening illness, would rather be treated elsewhere. We tend to think that our very best medical centers are the best in the world. But whether this is a realistic assessment or merely a cultural preference for the home team is difficult to say. Only when better measures of clinical excellence are developed will discerning medical shoppers know for sure who is the best of the best.

With health care emerging as a major issue in the presidential campaign and in Congress, it will be important to get beyond empty boasts that this country has "the best health care system in the world" and turn instead to fixing its very real defects. The main goal should be to reduce the huge number of uninsured, who are a major reason for our poor standing globally. But there is also plenty of room to improve our coordination of care, our use of computerized records, communications between doctors and patients, and dozens of other factors that impair the quality of care. The world‚s most powerful economy should be able to provide a health care system that really is the best.

Following thie editorial, THeNew York Times printed 8 letters to the Editor on August 14:

To the Editor:

Re "World‚s Best Medical Care?" (editorial, Aug. 12):

As a former health care executive for a multihospital system responsible for quality management and patient satisfaction, I applaud you for the most accurate and succinct summary I've yet read regarding the status of medical care in the United States. With luck, the quality and fairness of our health care system will finally be a major issue this coming election.

It is time that our citizens woke up to the fact that our country's health care system is in crisis and is far from the best in the world as measured by any number of indicators. Every presidential candidate must clearly answer whether he or she believes that our present lack of universal health coverage is morally acceptable and how specifically the candidate proposes providing health coverage for all of our citizens, both employed and unemployed.

To say, as some of our radio talk-show hosts claim, that the United States has the best health care system in the world at the same time that our country doesn't provide universal health coverage, is simply a contradiction in terms.

Jack Scharf
Morris Plains, N.J., Aug. 13, 2007

——

To the Editor:

I opted out of the system when I was told by my then doctor's receptionist that although I felt ill, he could not see me for seven weeks. I then made the best investment ever, by enrolling in what is called a "boutique" medical practice. For a yearly fee, I have 24/7 access, and my visits average 40 minutes, just to name a few benefits.

I have chronic fatigue syndrome, which is sometimes accompanied by fibromyalgia, an illness that causes agonizing pain.

I attend a support group, and I am ashamed at the fact that I can afford to pay for health care, when the women attendees cannot work because they can't stand up, have no health insurance, no money, can‚'t buy pain medications and have no hope. World's best medical care?

Michael Golding
Fort Myers, Fla., Aug. 12, 2007

——

To the Editor:

Your editorial reminded me of my experience in Spain a few years ago. A United States citizen, I was taken very ill on a visit to the island of Tenerife. Within five minutes, an ambulance was at the door. Upon arrival at a hospital, I was admitted immediately and seen and treated by three doctors.

Upon discharge, I went to the front office to pay my bill, and was told that I owed nothing for the service, and that a taxi was waiting at the entrance to take my wife and me back to my hotel. The taxi driver subsequently declined payment from me for his services.

Eduardo Munoz Perou
Livonia, Mich., Aug. 12, 2007

——

To the Editor:

The failure of the United States to develop a national insurance program is a primary reason for the inefficient coordination of care, lack of computer sophistication and poor communication between patient and doctor that reduce the efficacy of our health care.

With no centralized, single-payer national insurance plan, each patient and provider is on his or her own in identifying and coordinating the treatment of even such common conditions as a bronchitis attack.

A national health care plan would put dollars and technology toward standardizing treatment and otherwise resolving such confusion.

Yet the insurance and drug industries continue to conduct an economically motivated campaign to thwart efforts to establish such a national health care plan, including by labeling such plans „socialized medicine."

A national health insurance plan would not be "socialized medicine," however, because under such a plan, physicians and other providers would not be government employees or entities. Instead, primary health care costs would be reimbursed by the federal government using our tax dollars.

The corporate actors who have thwarted a national health care plan merely use incendiary rhetoric and other obstructive tactics to conceal their true motive, which is to continue to make billions of dollars at the expense of the nation‚s health.

Rita Tobin
Chappaqua, N.Y., Aug. 12, 2007

——

To the Editor:

You express some dismay that the world's most powerful economy does not produce the world's best medical care. But if a nation makes the economy its ultimate bottom line, and if that economy is unabashedly skewed to favor the wealthiest top percent, it should hardly be surprising that its health care system is calibrated to function in precisely the same fashion.

Joel Brence, M.D.
Aspen, Colo., Aug. 12, 2007

——

To the Editor:

Your editorial correctly questions the adequacy of American health care. But your analysis misses a central flaw in our system: institutionalized cost shifting.

Consider the following hypothetical scenario: An elderly patient, retired from a full-time career, is injured in a collision while driving a delivery truck during part-time post-retirement employment. Who will pay the bills for his consequent treatment?

Medicare, the state workers‚ compensation fund, the group health underwriter for his former full-time employer or an automobile insurer? And if all of these "third parties" manage to wriggle out of payment, will the patient or the treating physician and hospital have to "eat" the cost of care?

Huge bureaucracies, diverting vast sums of money, have mushroomed into existence with the express mission of manipulating such quandaries to their sponsors‚ maximum advantage. These bureaucracies are bleeding us dry. It is for this reason that the United States needs a single-payer system.

Donald Mender, M.D.
Rhinebeck, N.Y., Aug. 13, 2007
The writer is an assistant clinical professor of psychiatry, Yale University School of Medicine.

——

To the Editor:

Your claim of shock at the lack of use of sophisticated information technology in the health care system is somewhat perplexing. Computers, software, networks, and Internet access all cost money. Manual records, while less desirable than electronic medical records, are a fraction of the cost in the short run.

The continually decreasing reimbursement rates to health care providers from both government and private insurers require the prioritization of financial resources to direct patient care. Until financial incentives are forthcoming, significant investment in information technology by both institutional and private health care providers will continue to be an unaffordable luxury.

Ira S. Novich, M.D.
New Rochelle , N.Y., Aug. 12, 2007

——

To the Editor:

Also consider that elderly people can lose their homes and assets to pay for medical care. A 62-year-old friend of mine took a $60,000 mortgage out to pay for her husband's chemo before he died. Hard to do at that age. This doesn't happen in other countries.

Ivan Beggs
Canton, Ohio, Aug. 13, 2007

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Jane

Bryant Quinn
We Can Afford Universal health Care
Newsweek
July 30, 2007

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

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Atul Gawande
Sick and Twisted
The New Yorker
July 23, 2007

The documentary filmmake Michael Moore has more than few insufferable traits. He i manipulative, smug, and self-righteous. He has no interest i complexity. And he mocks the wea as well as the powerful. (Recall hi derision, in “Roger and Me,” for a impoverished woman in Flint Michigan, who slaughtered rabbit to make ends meet.) For all that, hi movie about the American health-care system, “Sicko,” is revelation. And what makes this especially odd to say is that the movie brings to light nothing tha the media haven’t covered extensively for years

Few will be surprised, surely, to learn that insurance companies routinely deny people individual coverage, or jack up applicants’ rates, if they have diabetes or are obese or produced a weird blood-test result in the sixth grade. It’s just that a lot of us haven’t met those people, or seen what happens to them afterward. Moore makes sure that we do.

Their travails are by turns depressing, blackly comical, and infuriating. There’s the twenty-two-year-old who was denied reimbursement for her cervical-cancer treatment because someone at her insurance company thought that she was “too young” to have the disease; the seventy-nine-year-old on Medicare who works picking up trash at his local Pathmark store to pay for the medicines that he and his wife need; the thirty-something-year-old who matter-of-factly sews up a trickling five-inch gash in his leg with kitchen thread, because he doesn’t have insurance to cover an emergency-room visit.

These have become ordinary tales in America. Just this year, in my own surgical practice, I have seen a college student who couldn’t afford the radiation treatment she needed for her thyroid cancer, because her insurance coverage maxed out after the surgery; a breast-cancer patient who didn’t have the cash for the hormone therapy she needed; and a man denied Medicare coverage for an ambulance ride, because the chest pain he thought was caused by a heart attack wasn’t—it was caused by a tumor. The universal human experience of falling ill and seeking treatment—frightening and difficult enough—has been warped by our dysfunctional insurance system.

“Sicko” doesn’t really offer solutions. Yes, it visits France. But it doesn’t discuss the difficulties of reforming a system that encompasses sixteen per cent of the economy. It doesn’t investigate the tradeoffs that universal health care will inevitably require. It’s an outrage machine. Moore hopes that once people grasp the inhumanity of our system we will replace it. But will we? The movie is so effective in depicting the inhumanity that it makes our failure to act seem baffling. Moore blames the familiar villains: insurance companies, pharmaceutical-industry lobbyists, politicians. But plenty of countries have private insurance—not to mention politicians and lobbyists—and nonetheless have health-care systems that cover all their residents, at a lower cost, and with higher levels of satisfaction. Israel, the Netherlands, and Switzerland all provide universal coverage through multiple private insurers and, like Moore’s France, spend between half and three-quarters of what we do. The finger of blame points to an obstacle different from the one the movie suggests: us.

Our health-care morass is like the problems of global warming and the national debt—the kind of vast policy failure that is far easier to get into than to get out of. Americans say that they want leaders who will take on these problems. Large majorities profess support for fundamental change. Yet when it comes to specific solutions we balk. A big reason is the cost. Even though universal health coverage can reduce the system’s over-all expense—for instance, by granting everyone access to preventive care and to prompt, consistent treatment for chronic illnesses—any plausible approach will shift substantial costs from the private sector to taxpayers. The cheapest proposals circulating would still require more than a hundred billion dollars a year in public funds—around a thousand dollars per American household. Taxing millionaires or cutting “waste, fraud, and abuse” won’t pay for that. Then we get bogged down in the innumerable, wearying complexities: whether abortions will be covered, whether states will be allowed to design their own systems, what’s an acceptable co-payment for drugs—and on and on. Finally, Americans are deeply skeptical about government, and it doesn’t take much to sow doubts about expanding its role.

Health care confronts us with a difficult test. We have never corrected failure in something so deeply embedded in people’s lives and in the economy without the pressure of an outright crisis. The welfare reforms of 1996 made changes that profoundly affected people’s lives, but only those of the poor, which was why voters supported the experiment. We adopted rules to protect clean water, clean air, and endangered animal species, but the costs seemed small and were largely hidden from taxpayers.

In the past few months, John Edwards and Barack Obama have put forward coherent proposals to achieve universal or near-universal coverage. For the first time in a decade and a half, the prospects for reform seem genuinely promising. But the fight is about to begin. For example, Rudy Giuliani recently outlined a tax-credit-based health plan that would come nowhere near covering everyone; for one thing, he would let insurers continue to exclude people with preëxisting conditions. Its main purpose, it seems, is to let him attack other proposals as involving a big government takeover of medical care.

If, in 2009, we actually swear in a President committed to universal health care, the fight will turn ugly. The plan most likely to gather broad support will look something like the Edwards/Obama approach, which would subsidize health insurance for everyone who does not receive coverage through work or through existing programs. It would provide a choice of private insurance options, as in the Netherlands, and would probably add a Medicare-like government option as well. And it would require Americans to obtain coverage for, at a minimum, their children.

People on the right will attack the plan as a tax-and-spend nightmare, because it will have to include some mixture of increases in business and personal-income taxes. And they’ll say that it dictates your medical choices and gives government too much control. People on the left—Moore included—will attack the plan as a boondoggle for insurance companies, because it isn’t single-payer, and will say that it gives government too little control. Others will attack it for what it does or doesn’t do about malpractice litigation, birth control, acupuncture, and so forth. The debate will become angry and murky and mind-numbingly complicated, and the temptation will be to put off reform yet again.

That’s exactly when you’ll need to remind yourself of what’s really at stake. So if, in the throes of the debate, you find yourself experiencing blurred vision, headache, and vertigo, here’s a prescription: go visit an emergency room, clotted with the uninsured, andsee what’s it like to try to get care. Or watch the movie. Either way, you’ll be outraged again.chonicle$

Deborah Burger
On Health Care Reform: Long Waits are really Sicko
San Francisco Chronicle
July 10, 2007

What country endures such long waits for medical care that even one of its top insurers has admitted that care is "not timely" and people "initially diagnosed with cancer are waiting over a month, which is intolerable?"

If you guessed Canada, guess again. The answer is the United States.

Scrambling for a response to the popular reaction to Michael Moore's "SiCKO" and a renewed groundswell for a publicly financed, guaranteed single-payer health care solution, such as SB840, the big insurers and their defenders have pounced on Canada, pulling out all of their old tales of people waiting years in soup kitchen-type lines for medical care.

But, here's the dirty little secret that they won't tell you. Waiting times in the United States are as bad as or worse than Canada. And, unlike the United States, in Canada no one is denied needed medical care, referrals or diagnostic tests due to cost, pre-existing conditions or because it wasn't pre-approved. U.S. waiting times are the elephant in the room few critics care to address.

But, listen to what the chief medical officer of Aetna had to say in March. Speaking to the Aetna Investor's Conference 2007, Troy Brennan let these pearls drop:

The U.S. "health care system is not timely." Recent statistics from the Institution of Healthcare Improvement document "that people are waiting an average of about 70 days to see a provider."

"In many circumstances, people initially diagnosed with cancer are waiting over a month, which is intolerable."

In his former stint as an administrator and head of a physicians' organization, he spent much of his time trying "to find appointments for people with doctors."

Brennan's comments went unreported in the major media. But some reports are now beginning to break through, spurred by the debate "SiCKO" has spawned.

Business Week reported (www.businessweek.com/technology/content/jun2007) that "as several surveys and numerous anecdotes show, waiting times in the United States are often as bad or worse as those in other industrialized nations -- despite the fact that the United States spends considerably more per capita on health care than any other country."

A Commonwealth Fund study of six highly industrialized countries (www.commonwealthfund.org), the United States and five nations with national health systems (Britain, Germany, Australia, New Zealand and Canada) found waiting times were worse in the United States than in all the other countries except Canada .

There's something else you probably don't hear about Canada. Substantial progress is being made.

Most of the wait-time problems derive from funding cuts by conservative national or provincial governments, or from the siphoning off of resources by private providers. But precisely because the Canadian system is publicly administered, Canadians are able to force their elected officials to fix problems, or get voted out of office.

Throughout Canada, there are multiple pilot programs that have succeeded in slashing wait times. Canada's latest statistics show that median wait times for elective surgery in Canada is now three weeks -- that's less time than Aetna's chief medical officer says Americans typically wait after being diagnosed with cancer.

Canada also has no waits for emergency surgeries. It also doesn't have 44 million people who are uninsured because everyone has a national health-care card guaranteeing health care from any doctor or hospital they choose. And it doesn't burden those with insurance with rising deductibles or co-pays. A study reported by Health Affairs, a policy journal, for example, found that out-of-pocket costs to U.S. consumers jumped 76 percent this year over last year alone.

Canada also surpasses the United States in a broad array of health barometers, including life expectancy, infant mortality rates, adult mortality rates, deaths due to HIV/AIDS, mortality rates for cardiovascular diseases and years of life lost to injuries and diseases, according to data from the World Health Organization and the Organization of Economic Co-operation and Development.

No wonder some people are so afraid we'll learn the real comparative story about Canada's system -- and our own.

Deborah Burger, R.N., is president of the California Nurses Association.

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Ken Terry
On Health Care Reform. For Employers, There's No Exit From Health Care.
San Francisco Chronicle
July 10, 2007

While most large corporations still offer health insurance to their employees, the rapid growth of health costs is reducing their profitability and their ability to compete internationally. So some big companies want out. But they fear that if the government takes over health care -- a likely outcome if employers stampede for the exits -- they'll be subjected to onerous mandates or tax increases. So they're unalterably opposed to the kind of single-payer system that one California Senate bill would create. And they're just as likely to fight the new Democratic Senate/Assembly measure that would require employers to cover their workers or pay 7.5 percent of their payrolls into an insurance fund. The California Chamber of Commerce -- which takes a dim view of Gov. Arnold Schwarzenegger's health reform plan, as well -- strongly opposed an employer mandate two years ago, and the chamber led the successful effort to repeal the law that imposed it.

What U.S. corporations really want to do, as shown by a recent proposal from the ERISA Industry Committee (ERIC), a lobbying group for big, self-insured companies, is to limit their health care liabilities without dropping their benefits (www.eric.org). ERIC would replace the current health insurance system, in which large employers pay medical bills themselves, with one in which competing regional "benefit administrators" would assume insurance risk for all individuals not covered by Medicare, Medicaid, other government programs, or non-participating firms. Every individual would be required to buy insurance from one of the local benefit administrators, which could be insurance companies, investment firms, banks, or other parties. Each benefit administrator would offer several health plans. An employer could pay the benefit administrators whatever it wanted to help cover its workers, or give each employee a voucher for that amount, and the employee would have to pay the rest. Thus, the company would have a fixed insurance premium and would no longer be responsible for health care costs.

Another example of this "defined-contribution" approach is the contract that Goodyear Tire & Rubber Co. signed with the United Steelworkers Union last December after a two-month strike. Under the terms of the pact, Goodyear will transfer all union retiree health-care obligations to a trust fund under USW management. In effect, the union agreed to take on $1.2 billion (and perhaps more) in future health-care costs in return for $1 billion in cash and stock from Goodyear. GM, Ford and Chrysler's new owner, the Cerberus private equity firm, reportedly want to buy out their retiree health care commitments by making similar deals with the United Auto Workers.

In less unionized fields, big employers are taking a different tack: They're passing on more costs to employees and rolling out "consumer-driven plans." Critics have assailed these plans as tax shelters for the healthy and affluent; they've also pointed out that the incentives they give consumers to spend less on health care often result in the avoidance of necessary care. What's less often noted is that, like the Goodyear deal and the ERIC proposal, consumer-driven plans are designed to help employers curb their health costs. Companies contribute a set amount to health savings accounts, and there's no requirement for them to raise their contributions over time. So even if the deductible in the associated high-deductible policy keeps getting larger, it's the worker, not the company, who will be on the hook for the difference between the deductible and what's in his or her HSA.

There are many drawbacks to the employer-based system. As economists Alain Enthoven and Victor Fuchs note in a 2006 paper, it creates high administrative costs, limits wage increases, leaves many people without insurance and leads to "job lock." The ERISA Industry Committee seeks to alleviate some of these problems: for example, its approach would make insurance portable, reduce administrative costs and help self-employed people get coverage. On the other hand, many employees might discover they could no longer afford coverage comparable to what they have now.

Wherever our health care system is heading, Americans should demand that employers pay their fair share for health care. The government-run and -managed health systems of Europe, Canada and Japan require employers to ante up; and if the United States decides to switch to a single-payer system, in which the government pays all of the bills, the same will be true here. Employers, as well as individuals, must make health-care contributions in proportion to their means. Only by sharing the pain can we start to build a better health care system.

Ken Terry, a senior editor at Medical Economics Magazine, is the author of "Rx For Health Care Reform," which will be published in September by Vanderbilt University Press.

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Victorial Colliver
We Spend Far More, But Our Health Care is Falling Behind. Australia, Canada, Germany, New Zealand, UlK. spend less and do better job, studies say.
San Francisco Chronicle
July 10, 2007

Filmmaker Michael Moore might be onto something in his new documentary, "Sicko." These days, fewer Americans are buying the claim that the United States has the best medical system in the world.

With polls showing that health care is Americans' top domestic concern, politicians are scrambling to propose reforms. Consumers are buying lower-cost online drugs from foreign sources, and some even become "medical tourists" to obtain affordable treatment in other countries.

Studies show Americans aren't healthier, nor are they living longer than people in industrialized nations that spend half per capita of what we do on care.

For example, a 2007 Commonwealth Fund study that compared the United States with five other nations -- Australia, Canada, Germany, New Zealand and the United Kingdom -- ranked the U.S. health system last. The study looked at access to health care, efficiency, equity and healthy living, among other measures.

And a 2000 report by the World Health Organization, the most recent available from the U.N. organization, put the United States 37th out of 190 nations in health care services -- between Costa Rica and Slovenia. France was rated No. 1, the United Kingdom in the 18th spot, Canada at No. 30 and Cuba a couple of notches behind the United States in the 39th spot.

In a New York Times/CBS poll conducted in March, health care ranked as the top domestic concern. And in "Sicko," Moore highlights Americans' disillusionment with their health care system, comparing it to systems in other countries, including France, Canada, Britain and Cuba.

Many health experts say Moore might be glorifying other systems -- particularly the once in France. Still, they accept his argument that other nations are doing a better job than the United States in providing coverage for all residents and making sure people have access to primary care and preventive services.

The United States has a private system for all but the poor and elderly. The countries lauded in "Sicko" have national systems funded primarily through the government.

"We, unlike any other country, have 46 million people who are uninsured, and that raises a whole host of health and financial issues," said Ken Thorpe, professor of health policy at Emory University.

Those issues are undermining the health of Americans, several studies have shown. While the United States may have cutting-edge medical technologies, many people lack access to such advanced care, limiting any positive health impact.

"Ours is really is a sick-care system. We have tremendous technical capabilities to deal with people with serious illness," Thorpe said. He argues, though, that it is far more cost-effective to prevent people from getting sick or at least catch illnesses early through better monitoring.

Karen Davis, president of the Commonwealth Fund, a nonprofit foundation that supports health care research, said many of the problems associated with poor primary care can be traced to the fragmented structure of our health care system. U.S. patients often have trouble seeing the same doctor on short notice, see multiple doctors who sometimes fail to communicate with one another and forgo care because they don't want to spend the money.

"We tend to have more medical errors than other countries, in part because of this highly specialized, fragmented system," she said. "More things can go wrong and do go wrong."

Moore's film has been criticized for showing the positive side of health systems in other countries while glossing over negative aspects.

"There's almost only positive attributes about the British, the French and Cuban system. Invariably, no system is perfect. I think this sort of detracts from his credibility on these comparisons," said Stephen Zuckerman, health economist with the Urban Institute in Washington, D.C.

Moore ignores the fact that private coverage still exists in most countries with nationalized health care. And he avoids showing solutions other than adoption of a government-funded system, often known as single-payer.

"He's trying to be entertaining. But if the objective here is to kick off a serious study about the British and Cuba as an alternative to the U.S. system, you need a lot more than what was presented in 'Sicko,' " Zuckerman said.

In "Sicko," Moore addresses one of the biggest criticisms of the Canadian system -- long wait times for care -- by asking patients in an Ontario emergency room how long they had to wait. All respond that they got treated quickly.

But the Commonwealth Fund report found that both U.S. and Canadian patients were more likely to wait six days or more for an appointment. Waiting times for specialists or elective surgery were shortest in the United States and Germany. U.S. patients were less likely than Canadians to have to wait more than four hours in an emergency room, the report found.

Moore also implies that care in Canada, Britain and France is virtually free. He dismisses claims that the French are overtaxed by showing the comfortable life of a French couple who even have money left over to travel.

But la vie francaise isn't entirely en rose. The country has a high unemployment rate of 9 percent along with high taxes. In France, taxes amount to more than 44 percent of gross domestic product, compared with 26 percent in the United States, according to the Organization for Economic Cooperation and Development.

Still, the United States spends a higher percentage of its gross domestic product on health than any other country -- more than 16 percent compared to France's 10.7 percent. The United States spends $6,102 per person in public and private funds compared with $3,159 per capita spending in France.

Americans living in France generally praise the French system.

Roderick Beck, a former New Yorker who moved to Paris this spring, said the profit motive that drives insurance companies as well as physicians is the central problem with the U.S. health system.

"What are those insurance companies doing at the most fundamental level? Collecting cash and paying out benefits," said Beck, 45, who works for a telecommunications firm. "Governments using taxation and a simple health care card do that more efficiently than an insurance based system."

Bruce Gain, 41, a U.S. journalist living in France since 2003, said the French system is better because the government strictly controls prices and the number of doctors per capita is much higher than the United States.

"As far as access to medial technology goes, there are more doctors here to offer the latest treatments and drugs at affordable costs," Gain said.

Davis, of the Commonwealth Fund, said the United States does not need to adopt nationalized health care to improve efficiency. For example, she said, the Netherlands has a well-developed system for after-hours primary care that would reduce emergency room visits.

"There's a lot we can learn from other countries," she said.

The World Health Organization in 2000 ranked the United States 37th out of 191 countries in health care services.

U.S. life expectancy is nearly three years shorter on average than Canadians' and about two years less than that of the French.

The United States spent more than $6,000 per person on health care in 2004, about double what France, Germany and Canada spent per capita.

Sources: World Health Organization, United Nations, Organization for Economic Cooperation and Development

Paul Krugman
Health Care Terror
New York Times
July 9, 2007

These days terrorism is the first refuge of scoundrels. So when British authorities announced that a ring of Muslim doctors working for the National Health Service was behind the recent failed bomb plot, we should have known what was coming.

"National healthcare: Breeding ground for terror?" read the on-screen headline, as the Fox News host Neil Cavuto and the commentator Jerry Bowyer solemnly discussed how universal health care promotes terrorism.

While this was crass even by the standards of Bush-era political discourse, Fox was following in a long tradition. For more than 60 years, the medical-industrial complex and its political allies have used scare tactics to prevent America from following its conscience and making access to health care a right for all its citizens.

I say conscience, because the health care issue is, most of all, about morality.

That’s what we learn from the overwhelming response to Michael Moore's "Sicko." Health care reformers should, by all means, address the anxieties of middle-class Americans, their growing and justified fear of finding themselves uninsured or having their insurers deny coverage when they need it most. But reformers shouldn’t focus only on self-interest. They should also appeal to Americans’ sense of decency and humanity.

What outrages people who see "Sicko" is the sheer cruelty and injustice of the American health care system sick people who can't pay their hospital bills literally dumped on the sidewalk, a child who dies because an emergency room that isn’t a participant in her mother’s health plan won’t treat her, hard-working Americans driven into humiliating poverty by medical bills.

"Sicko" is a powerful call to action but but don’t count the defenders of the status quo out. History shows that they're very good at fending off reform by finding new ways to scare us.

These scare tactics have often included over-the-top claims about the dangers of government insurance. "Sicko" plays part of a recording Ronald Reagan once made for the American Medical Association, warning that a proposed program of health insurance for the elderly the program now known as Medicare would lead to totalitarianism.

Right now, by the way, Medicare which did enormous good, without leading to a dictatorship is being undermined by privatization.

Mainly, though, the big-money interests with a stake in the present system want you to believe that universal health care would lead to a crushing tax burden and lousy medical care.

Now, every wealthy country except the United States already has some form of universal care. Citizens of these countries pay extra taxes as a result but they make up for that through savings on insurance premiums and out-of-pocket medical costs. The overall cost of health care in countries with universal coverage is much lower than it is here.

Meanwhile, every available indicator says that in terms of quality, access to needed care and health outcomes, the U.S. health care system does worse, not better, than other advanced countries even Britain, which spends only about 40 percent as much per person as we do.

Yes, Canadians wait longer than insured Americans for elective surgery. But over all, the average Canadian's access to health care is as good as that of the average insured American and much better than that of uninsured Americans, many of whom never receive needed care at all.

And the French manage to provide arguably the best health care in the world, without significant waiting lists of any kind. There's a scene in "Sicko" in which expatriate Americans in Paris praise the French system. According to the hard data they're not romanticizing. It really is that good.

All of which raises the que0stion Mr. Moore asks at the beginning of "Sicko": who are we?

"We have always known that heedless self-interest was bad morals; we know now that it is bad economics." So declared F.D.R. in 1937, in words that apply perfectly to health care today. This isn't one of those cases where we face painful tradeoffs here, doing the right thing is also cost-efficient. Universal health care would save thousands of American lives each year, while actually saving money.

So this is a test. The only things standing in the way of universal health care are the fear-mongering and influence-buying of interest groups. If we can’t overcome those forces here, there’s not much hope for America’s future.

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Susan Brink, COMMENTARY
Why 'Sicko' hits a nerve. A medical director and a think tank researcher watch and weigh in on problems exposed in Michael Moore's new documentary.
Los Angeles Times
July 2, 2007

The Los Angeles premiere of "Sicko" at the Samuel Goldwyn Theater was over, the audience on their feet and the "stars" — a.k.a. underserved, suffering patients and whistle-blowing insurance company employees — had taken their bows.

Michael Moore, wearing a suit-minus-tie and sans his signature cap, was looking at them with a paternal glow.

Then came the lone question, shouted from the audience.

"What do we do?"

For Moore, it's a no-brainer. He wants the insurance industry out of the picture. He rattled off two bills, a kind of "Medicare for All" plan (SB 840) proposed by state Sen. Sheila Kuehl (D-Santa Monica) and a similar national bill in Congress sponsored by House Judiciary Committee Chairman John Conyers Jr. (D-Mich). Both bills propose a system modeled on Medicare, funded by tax dollars, with guaranteed benefits extended to Americans of all ages.

One of two people invited by the Los Angeles Times to view the premiere and offer their insights and expertise said she agreed with Moore. Dr. Karen Lamp, medical director of the Venice Family Clinic, which provides free care to 23,000 uninsured and underinsured people each year, says she believes in universal coverage.

"I was ashamed at watching the experiences these people had," Lamp said as we brushed past actors Larry David and John Cusack to nab a table on the theater's patio. The crowd inside clustered around Moore.

But for someone on the front lines of trying to catch those who fall through the cracks, the dramatic examples on the screen were not revelations. "I actually didn't think the stories were all that extreme," Lamp says.

Jeffrey Wasserman, the other invited viewer, was more circumspect.

"There's not just one way to do this," he said, passing up the sushi offered by a waiter. A senior policy researcher for the Santa Monica think tank Rand Corp., Wasserman is working on a project comparing just about every healthcare plan proposed by states, congressional leaders and presidential candidates.

Because the goal of the Rand project is to put forth objective measures of all proposals, he keeps his opinions to himself.

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Complex problems

As Moore's movie points out, the problems associated with America's system are economic, social and cultural. They go beyond the boundaries of the provision of medical care. We see a case of patient dumping, shown through the lens of surveillance video snippets from Union Rescue Mission in Los Angeles, in which a disoriented woman in a hospital gown is dropped off in a cab to wander aimlessly. No healthcare reform plan will solve America's homeless problem, Wasserman says: "People have nowhere to go, they have no social support."

We see uninsured Rick, who sawed off the tops of two fingers and can afford to have only one tip reattached. He chooses the less costly ring finger. Then Moore presents a contrast: a Canadian man who has had a worse saw accident, losing all five fingers, but has had all of his fingers reattached, at no charge.

There are Donna and Larry Smith, insured but left bankrupt by the co-pays and deductibles they were charged after his three heart attacks and her cancer. They lose their home and must move into their daughter's basement storage room.

And there is Frank, at 79, still mopping bathroom floors and unloading crates for an hourly wage and health insurance benefits because Medicare's drug benefit doesn't cover all the medications his wife needs.

"If there are golden years, I can't find them," Frank says in the movie.

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Drug expenses

It was after 11 when the showing ended, and the crowd was drifting away, heading down Wilshire Boulevard. Lamp comments that she knows plenty of people like Frank, who, despite the new Medicare drug plan, can't afford prescriptions. "That's been a nightmare for us," she says.

The Medicare drug plan has a coverage gap in the middle, called the "doughnut hole," ceasing payment when medication costs reach $2,400. Federal payments don't begin again until costs have reached $5,451 , but by then, Lamp says, many of her patients have given up.

Long delays in care is another tale familiar to Lamp: "Until our patients find the clinic, they've often gone a long time without care," she says. She describes a woman who came into the Venice clinic with a huge breast tumor that could have been found earlier if she had had preventive screenings.

In "Sicko," some people simply cannot get health insurance. One young man who is 6 foot 1 and weighs 135 pounds is denied coverage because he is too thin. A woman who is 5 foot 1 and 178 pounds is turned down because she is too fat.

The film, Lamp and Wasserman agreed, is a conversation starter.

"Moore presented a powerful and emotion-packed series of stories that illustrate just how broken our healthcare system is," Wasserman says. "He has a unique talent for being able to tell stories through the eyes of people."

Lamp, like Moore, endorses the single-payer system as a way out of the mess. Wasserman keeps mum on what he thinks. The Rand project — results will be released next year — will analyze a range of possible solutions including single-payer systems and one in effect in Massachusetts.

That state plan weaves together private and public agencies to cover nearly everyone. It requires employers to provide health insurance or face a fine, and that money helps finance insurance coverage for people who can't afford it.

The Rand project also will examine consumer-directed plans that require more responsibility and higher co-payments from patients. The theory is that those measures will encourage people to make wiser, less costly health decisions.

In line with that, Rand will put an objective mix of measures of cost, access and quality on a grid so the reader can interpret the economics and trade-offs of each proposed solution.

The next phase of the discussion is up to the American public, and its collective answers to that question shouted from the audience: What do we do?

Of course some of America's health problems — obesity, smoking-related disease, poor diet — are matters that individuals could take in hand for themselves. When Moore left the stage, he may have been giving a nod to the need for such personal responsibility. "Now, come and join me for a walk," he said, "to the salad bar."