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Medicaid's Inadequacy To the Editor NYT

The New York Times
February 28, 2001
Letters

Re "Governors Offer 'Radical' Revision of Medicaid Plan" (front page, Feb. 26):
As it now stands, the vast majority of the nation's physicians do not accept Medicaid clientele because the fee structure does not begin to cover office overhead. When about $50 per visit is needed to allow just for rising malpractice insurance premiums and about $12 is issued by Medicaid per visit, the arithmetic is revealing. Thus, the Medicaid recipients end up, if anywhere, in public hospitals or so- called Medicaid mills with lesser facilities and substandard care.

The United States remains the world's only industrial power without a universal health care plan. Manipulating the same inadequate Medicaid budget to cover more people with lesser reimbursements is pointless. The answer is making health care a right instead of a privilege.

DON SLOAN, M.D.

New York, Feb. 26, 2001

The Medicare Modernization and Solvency Act of 2001

In the current political climate comprehensive reform will not be on the agenda. Instead, attempts will be made to reduce support of existing programs, especially Medicare. We need to protect Medicare and improve the benefits offered.

Today, the Ways and Means Health Subcommittee held a hearing on Medicare reform. To provide an alternative to proposals that would threaten Medicare, Congressman Stark has introduced The Medicare Modernization and Solvency Act of 2001. It would expand benefits, control out-of-pocket expenses, and assure solvency of the program. It is not perfect, but it is vastly superior to other current proposals.

A summary of the bill:
http://www.house.gov/stark/documents/107th/medreformsumm.html#Anchor-47857

Judith Feder, Ph.D., Professor and Dean of Policy Studies, Georgetown University, in testimony before the committee today, presented an approach to protecting and improving Medicare based on sound policy.

Her testimony should be downloaded and saved, and should be used as an educational resource to provide guidance on rational Medicare reform.
It is available at:
http://waysandmeans.house.gov/health/107cong/2-28-01/2-28fede.htm

A Conference Sponsored by The Annenberg Public Policy Center of the University of Pennsylvania and The Atlantic Monthly
February 27, 2001
"Bipartisan Paths to Expanded Health Coverage: Prospects for 2001 and Beyond"

Hon. Jim McCrery (R-LA):

Regarding explaining health care reform to audiences:
"The easiest one to explain would be a single payer system. It makes a lot of sense."

Regarding covering the uninsured:
"The single payer system solves that problem. It covers everyone."

Regarding employer health plan costs:
"It solves that problem because you don't have to pay for it anymore, as an employer. The government pays for it."

Comment: This conference was to introduce the McDermott-McCrery concept of tax credits as a possible bipartisan solution to covering the uninsured. It was clear that major problems with this proposal have not been resolved, and probably will not be. Remarkable to me was the fact that Jim McCrery, a conservative Republican, repeatedly made references to the great strengths of the single payer proposal. He seemed to be convinced that, if we do not take some other urgent action, then we will end up with "more government control with a single payer system." So it is the perfect system except that the government is in charge. Can someone explain to him that publicly administered systems, such as Medicare, are vastly more efficient than are the middleman, marketplace health plans? Doesn't that mean that single payer is as close to perfect as is possible?

The two hour conference included Jim McDermott, Jim McCrery, Matt Miller, Uwe Reinhardt, Judy Feder, and Gail Wilensky. It can be viewed at your convenience at:
http://www.kaisernetwork.org/healthcast/annenberg/feb01

Don McCanne
mccanne1@home.com

Uwe Reinhardt:

If anyone would like to take me on in a debate "RESOLVED: THAT U.S. HEALTH CARE OF THE 1980s WAS BETTER THAN US HEALTH CARE OF THE 1990s," I'll gladly take the negative of the debate, because I love to win debates, and this one I would win hands down. My opponents would not even have a fighting chance. Any takers? Try me and make my day!

Response of Bob LeBow, Past-President of PNHP:

What Uwe is saying reminds me very much of the feeling I have when I deal with issues at the Idaho State Legislature (and behind the scenes with the lobbyists). The Good Old Boys know they have the decisions sewn up. They talk a good line sometimes, but the deals have been made (or bought or traded) off the record. There's a certain smugness, a mutual backscratching fraternity of the moneyed interests, a shaking of the head when the people doing the nodding really know that there is another, already decided (and likely paid-for) agenda. Yet it has been possible to get some change into the system...some issues cry out for change. Unfortunately, health care reform is so complex and easily thwarted by a few million dollars spent to create doubt. I think many of us, "dreamers that we are," feel its our mission to do the best we can, and fight on, to get the best deal we can get for our patients, especially those most excluded from our health care system in the larger sense. There's no doubt campaign reform would help, may even be a sine qua non of meaningful reform. I will continue to dream on, despite --maybe in spite of -- Uwe's gloomy prediction.

As for Uwe's challenge on the 80s vs. the 90s, I would respond that it's a mixed bag. It depends on from whose viewpoint you're looking. From the viewpoint of people with "regular" insurance, it has to be worse in the 90s.The 90s had higher deductibles and co-pays, less choice of physician, worse continuity of care, more fragmented care, more feeling of being rushed in the doctor's office. On the other hand, in the 90s we had improved technology, better drugs, shorter hospital stays (sometimes worse, but usually not), probably an improvement in the scientific basis of care (the good side of managed care), and (likely) fewer unnecessary procedures. For the uninsured, I have seen continuing gloom and chaos --generally toward the negative side as there was less room for cost shifting to charity care. I have a much more difficult time now getting managed-cost squeezed specialists to see my uninsured patients. Our Community Health Center funding stayed static despite the demand to see growing numbers of uninsured patients. Of course, the number of uninsured grew in the 90s. And our low-income elderly patients with Medicare have seen a double-edge sword effect in the transition from the 80s to the 90s: they have much greater out-of-pocket costs for drugs and insurance premiums (and are poorer in that sense) but (the other side) the technological advances have made their lives much more enjoyable -- when they can afford these wonders. I see many more "injustices" of the system now than I did 10 years ago -- perhaps because of the increasing complexity of the system...especially for patients. From the physician's viewpoint, the 80s had to be better than the 90s, but for me, at least, I'm trying to look primarily from the vantage point of the patient. So I guess I would answer Uwe's challenge by expressing (as outlined above) my feeling that there are pluses and minuses comparing the 80s to the
90s, but on my balance, the minuses of the 90s outweigh the pluses. It would be great to see Uwe's arguments on why American health care is better in the 90s than the 80s. Maybe he can convince me, but I'd be willing to wager one meal at a for-profit hospital of the winner's choice...

Joanne Landy, Executive Director Physicians for a National Health Program-NYC
Responding to Reinhardt and LeBow - Health care better in 80s or 90s?

Whether the healthcare system was better in the 80s or the 90s--this is not really the issue. Both decades were unacceptable, though, as Bob LeBow outlines, unacceptable in different ways, and in both decades with occasional rays of light peeking through the clouds. What we need is a decent universal health care system for the 00's that's publicly and fairly financed; what we don't need is a sterile debate devoted to choosing between evils.

Jeannie Brewer, board member of California Physicians Alliance responds:

My 2 cents:

Well, for the uninsured and the uninsurable, both decades (80s and 90s) were bad and so are the 2000's.

Jeannie Brewer, M.D.
among the ranks of the uninsurable

Don's comment: You know we have a very sick health care system when a young physician, fellow CaPA board member Jeannie Brewer, is uninsurable because of a serious medical disorder.