News

Spending 55% less for immigrants than U.S.-born residents
By Sherry Jacobson
The Dallas Morning News
07:29 AM CDT on Tuesday, July 26, 2005

A new national study suggests that immigrants in the United States receive about half as much medical care as their American counterparts.

U.S.-born residents averaged $2,564 in annual health care costs compared with per capita immigrant care that averaged $1,139, about 55 percent less, according to the study published Monday in the American Journal of Public Health.

The study concluded that the spending disparity refuted the notion that immigrants were “a substantial burden” on the U.S. health-care system.

It estimated that immigrant care accounted for $39.5 billion, or almost 8 percent of U.S. health-care spending in 1998, the year that was analyzed. Immigrants made up 10 percent of the U.S. population in 2000.

“These are the most recent numbers we had to work with,” said Dr. Olveen Carrasquillo of Columbia University and one of the study’s authors. “We have no reason to think that the expenditure for immigrant care has gone up in recent years as a percentage of the entire cost.”

However, Dallas health officials said Monday that there was another way to look at the numbers. The officials wondered whether the lower cost of health care for immigrants signaled that they were having trouble accessing medical services.

“You can explain this disparity as a lack of access due to language, financial and insurance barriers,” said Dr. Ron Anderson, president and chief executive officer of Parkland Memorial Hospital, which services a large immigrant population.

“There’s nothing to celebrate in this study,” he said.

Dr. Michele Smith, who treats immigrants at the Community Health Clinic in East Dallas, said it was not uncommon to diagnose more advanced diseases in immigrants, who waited too long to see a doctor.

“We see women with cervical and breast cancer who haven’t had Pap smears and mammograms” that could have caught the disease earlier, she said. “Our patients are from Mexico, Africa and the various Asian countries. Many of the women in their 60s have never had these basic tests.”

Dr. David Buhner, medical director of the Dallas County health department, noted that the lack of insurance probably was the main reason immigrants had such trouble getting into the U.S. system.

“The ticket to access is health insurance, and if you don’t have it, you can’t get in,” he said.

Higher ER costs

In fact, the study found that immigrants were more likely to use the emergency room for basic treatment than to go to the doctor’s office. Although immigrant children had a lower rate of ER visits than American-born children, their average ER costs were three times higher because immigrant children tended to be sicker when they arrived.

The study estimated that 25 percent of U.S. immigrants lack public or private health insurance. However, immigrants were broadly defined as anyone born outside the U.S., including people who had moved to this country decades ago.

“It included people from Scandinavia who’ve been here 20 years and are citizens now,” Dr. Buhner said. “There would probably be even a greater disparity in health-care spending if it had looked at just undocumented workers. Their barriers to care are associated with being poor and uninsured.”

The study found that Asian immigrants had health-care expenses similar to U.S.-born residents, while Hispanics and blacks suffered the largest disparities in such spending.

Dr. Anderson noted that the longer immigrants resided in the United States, the more likely they were to become insured. About 25 percent of Texans are uninsured, one of the highest rates in the nation.

“Thirty-eight percent of our patients are uninsured because of our mission to serve the indigent,” he said. “We’re going to get a higher burden of uninsured patients.”

The authors of the study also theorized that immigrants receive a smaller proportion of health care than they pay for.

The study also challenged the belief that immigrants are to blame for the rising cost of U.S. health care, said Dr. Sarita A. Mohanty of the University of Southern California and the lead author of the report.

Myth debunked

“Our study lays to rest the myth that expensive care for immigrants is responsible for our nation’s high health costs,” she said. “The truth is, immigrants get far less care than other Americans. Our data indicates that many immigrants are actually helping to subsidize care for the rest of us.”

The study’s authors presented it as the first nationwide analysis of immigrant health-care expenditures, basing it on data from the Agency for Healthcare Research and Quality. It considered data collected from 21,241 people who took part in the 1998 Medical Expenditure Panel Survey.

E-mail sjacobson@dallasnews.com

HEALTH CARE FOR U.S. IMMIGRANTS
All figures are annual per capita unless otherwise noted.

U.S.-born Immigrants
Total health-care spending
US-born: $2,546
Immigrants: $1,139

Emergency department costs
US-born: $91
Immigrants: $33

Office visit costs
US-born: $410
Immigrants: $209

Inpatient hospital care costs
US-born: $932
Immigrants: $634

Prescription drug costs
US-born: $507
Immigrants: $159

Costs for whites (non-Hispanic)
US-born: $3,117
Immigrants: $1,747

Costs for Hispanics
US-born: $1,870
Immigrants: $962

Costs for blacks (non-Hispanic)
US-born: $2,524
Immigrants: $1,030

SOURCE: American Journal of Public Health

Posted by pnhp at 04:11 PM | Permalink

PRESS RELEASE
EMBARGOED UNTIL 4:00 P.M. EDT
July 25, 2005

Contacts:
Sarita A. Mohanty, M.D. (323) 226-5579 (office)
Steffie Woolhandler, M.D. (617) 312-0970 (cell)
Olveen Carrasquillo, M.D. (917) 899-5403 (pager)
Nicholas Skala (312) 782-6006 (office)
(Additional contact info below)

Immigrants’ Health Care Costs are Low
Use Half as Much Care as Non-Immigrant Americans

Immigrants in the U.S. receive surprisingly little health care - 55% less than native-born Americans -according to a Harvard/Columbia University study that appears in the current issue of the American Journal of Public Health. Immigrant children received particularly low levels of care, 74% less overall than other children.

According to the study, immigrants accounted for 10.4% of the U.S. population, but only 7.9% of total health spending, and only 8% of government health spending. Per capita health expenditures averaged $1,139 per immigrant vs. $2,564 for non-immigrants. 30% of immigrants used no healthcare at all in the course of a year.

Most immigrants had health insurance coverage. Though uninsured immigrants used the least health care of any group - 61% less than US-born persons who were uninsured - even immigrants with coverage used 52% less health care than insured non-immigrants.

Immigrant children received far less care in doctors’ offices (71% less than non-immigrant children) and received 72% less prescription medications. Immigrant children had a significantly lower average number of emergency room visits than non-immigrant children. However, their emergency room costs - $45 per child - were nearly three times greater – suggesting that immigrant children forewent care until becoming very ill.

The study is the first nationwide analysis of immigrants’ health care expenditures. The researchers analyzed data on 21,241 people in the Agency for Healthcare Research and Quality’s 1998 Medical Expenditure Panel Survey, which collects detailed health spending data on a representative cross-section of Americans. They used statistical techniques to adjust comparisons between immigrants and non-immigrants for differences between the two groups in age, race/ ethnicity income, health status, and insurance status.

Dr. Sarita Mohanty, who led the study while she was at Harvard and is currently an Assistant Professor of Medicine at the University of Southern California, commented: “Our study lays to rest the myth that expensive care for immigrants is responsible for our nation’s high health costs. The truth is, immigrants get far less care than other Americans. Further restricting their eligibility for care would save little money and place many immigrants – particularly children – at grave risk. Already, many immigrant children fail to get regular checkups, and as a result more end up needing emergency care, or get no care at all.”

“Our data indicates that many immigrants are actually helping to subsidize care for the rest of us. Immigrant families are paying taxes – including Medicare payroll taxes - and most pay health insurance premiums, but they’re getting only half as much care as other families.” said Dr. Steffie Woolhandler, a study co-author and co-founder of Physicians for a National Health Program.

According to study co-author Dr. Olveen Carrasquillo of Columbia University’s College of Physicians and Surgeons: “Latino immigrants had the lowest health expenditures - $962 per person - half those of US-born Latinos ($1,870) and less than one third those of US-born whites ($3,117). The future economic success of the United States depends on a healthy immigrant workforce. Our findings suggest an urgent need for partnerships between health organizations and community groups to improve access to care, particularly for minority immigrants. This study shows that a national health program that includes all immigrants would cost much less than is widely assumed.”

####

Physicians for a National Health Program is an organization of 13,000 physicians advocating for non-profit national health insurance. PNHP has chapters and spokespersons across the country. For contacts, call (312) 782-6006

Additional Contact Information

Sarita A. Mohanty, M.D.
(Department of Medicine, University of Southern California)
(323) 226-5579
(818) 425-3618 (cell)

Steffie Woolhandler, M.D.
(Department of Medicine, Harvard University)
(518) 794-8109
(617) 665-1032
(617) 312-0970 (cell)

Olveen Carrasquillo, M.D.
(Division of General Medicine, Columbia University)
(212) 305-9782
(917) 899-5403 (page)
(917) 882-3770 (cell)

Background Fact Sheet
Health Care Expenditures for Immigrants in the United States

1- The U.S. immigrant population was 28.4 million in 2000, or 10.4% of the population, but immigrants account for 7.9% of U.S. health care expenditures ($39.5 billion in 1998), significantly less than their proportion of the population.

2- Immigrants utilize 55% less health care than U.S.-born residents ($1,139 vs. $2,546 per capita).

3- Immigrant children visit emergency rooms significantly less than non-immigrant children, but their individual ER costs are nearly three times higher ($45 vs. $18 per capita), suggesting that immigrant children forego needed care until experiencing an emergency.

4- Immigrant children utilize 74% less health care than U.S.-born children ($270 vs. $1,059 per capita).

5- Immigrant children utilize 71% less doctors’ care, 90% less inpatient hospital care, and 72% less prescription medications than U.S.-born residents.

6- 30% of immigrants utilize no health care in the course of a year compared to 20% of U.S.-born residents.

7- Immigrants utilize less health care per capita regardless of insurance status including those with private insurance ($1,711 vs. $1,906 for U.S.-born) and those with public insurance ($2,749 vs. $3,447).

8- Immigrants are more likely to be uninsured than U.S.-born residents (24.6% vs. 10.0%) but utilize less health care than other uninsured residents ($459 vs. $629 per capita).

9- Per capita, immigrants utilize 64% less emergency department care, 49% less doctors’ care, 31% less inpatient hospital care, and 69% less on prescription drugs than U.S.-born residents.

10- Latino immigrants utilize half as much health care as U.S.-born Latinos (49% less) and less than one third of U.S.-born whites (70% less).

11- It is estimated that immigrants will pay, on average, $80,000 more in taxes than they will use in government services over their lifetimes (The New Americans: Economic, Demographic, and Fiscal Effects of Immigration, National Academy Press, 1997).

12- For the purposes of the study, immigrant was defined as being born in a foreign country. The data contains no information about citizenship or legal status.

Health Care Expenditures for Immigrants in the United States
All figures are annual per capita unless otherwise noted

Total health care spending
U.S.-born: $2,546
Immigrants: $1,139

Emergency department costs
U.S.-born: $91
Immigrants: $33

Office visit costs
U.S.-born: $410
Immigrants: $209

Inpatient hospital care costs
U.S.-born: $932
Immigrants: $634

Prescription drug costs
U.S.-born: $507
Immigrants: $159

Costs for whites (non-Hispanic)
U.S.-born: $3,117
Immigrants: $1,747

Costs for Hispanics
U.S.-born: $1,870
Immigrants: $962

Costs blacks (non-Hispanic)
U.S.-born: $2,524
Immigrants: $1,030

Data by insurance status

Private insurance
U.S.-born: 74.9%
Immigrants: 58.1%

Public insurance
U.S.-born: 15.0%
Immigrants: 17.3%

Uninsured
U.S.-born: 10.0%
Immigrants: 24.6%

Per capita expenditures for uninsured
U.S.-born: $629
Immigrants: $459

Data on children (per capita):

Total health care spending
U.S.-born: $1,059
Immigrants: $270

Average number of emergency department visits
U.S.-born: 15 visits/100 children
Immigrants: 6 visits/100 children

Emergency department costs
U.S.-born: $18
Immigrants: $45

Average number of office visits
U.S.-born: 278 visits/1000 children
Immigrants: 108 visits/1000 children

Office visit costs
U.S.-born: $215
Immigrants: $63

Inpatient hospital care costs
U.S.-born: $167
Immigrants: $16

Prescription drug costs
U.S.-born: $86
Immigrants: $24

Data from the Agency for Healthcare Research and Quality’s 1998 Medical Expenditure Panel Survey (MEPS) and the 1996-1997 National Health Interview Survey (NHIS).

Source: Sarita A. Mohanty, Steffie Woolhandler, David U. Himmelstein, Susmita Pati, Olveen Carrasquillo, and David H. Bor. “Health Care Expenditures of Immigrants in the United States: A Nationally Representative Analysis.” American Journal of Public Health 2005; 95.

Posted by pnhp at 10:23 AM | Permalink

By Jim Lobe
Published on Wednesday, July 27, 2005 by the Inter Press Service

WASHINGTON — With the U.S. House of Representatives due to vote this week on the fate of the Central American Free Trade Agreement (CAFTA), international health activists are warning that the intellectual property provisions included in the pact could spell death for hundreds of thousands of poor people.

They blame the lobbying clout of ”Big Pharma,” the brand-name pharmaceutical companies that have successfully inserted language in the accord, which covers the Dominican Republic as well as the nations of Central America, to prevent cheaper, generic drug manufacturers from selling their products, including life-preserving anti-retroviral treatments for AIDS victims, to needy patients in the region.

”With CAFTA, the Office of the U.S. Trade Representative, operating at the behest of BIG Pharma, has imposed on Central America and the Dominican Republic a trade deal that will deny millions access to life-saving and essential medicines,” according to Robert Weissman, co-director of Essential Action, a public interest group here.

”The region’s combined economy is about the size of Columbus, Ohio, and its poor populations mostly cannot afford high-priced brand-name pharmaceuticals. But what for Big Pharma is dollars and cents is life and death for the people of Central America,” he said.

CAFTA, which was approved by the Senate last month by a 54-45 vote, could be sent to the House floor Wednesday or Thursday this week.

Most observers believe that its chances of approval — despite near-unanimous Democratic opposition and serious reservations by Republicans from sugar- and textile-producing states — are improving hour by hour as the White House peels away the dissidents by promising them unrelated benefits, such as big public-works and other pet projects, some of them worth literally billions of dollars.

In addition, the Republican leadership is arranging a vote on a harsh resolution aimed at curbing the flood of Chinese imports to the United States just before CAFTA reaches the floor, so that hesitant lawmakers can reassure their constituents that they are tough on trade and globalisation issues and still vote for the regional accord.

The outcome is expected to be very close, in any event, although the Republican leadership is unlikely to send it to the floor until it is reasonably certain it has the votes in hand.

While most of the debate here over CAFTA has focused on fears that it will result in the export of more U.S. manufacturing jobs and a flood of cheaply produced sugar imports that could threaten domestic producers, health activists say it will also result in unprecedented gains by the major drug manufacturers at the expense of poor people who cannot afford brand-name prices.

Among those groups that have spoken out against CAFTA’s intellectual-property provisions are the Global AIDS Alliance, Health GAP (Global Access Project), Oxfam International, and Doctors Without Borders (Medicins Sans Frontieres), as well as generic manufacturers and public interest groups in Central America itself.

”The text of CAFTA is a major score for Big Pharma,” noted Roman Macaya, executive director of the National Chamber of Generic Products of Costa Rica. ”In the name of ‘free trade,’ monopolies of medicines are being created or extended beyond what they would be under World Trade Organisation (WTO) rules, which are already in place. CAFTA’s new rules will cost human lives.”

Indeed, brand-name drugs, including anti-retrovirals for treating HIV/AIDS victims, are currently far more expensive than generic versions of the same medications. Big Pharma has argued that, without the higher prices for their drugs, the industry could not afford to invest in the research and other resources that are required to develop new, life-saving medications.

To them, generic producers are essentially free-loading copy-cats who can charge lower prices because they do not bear the huge research and development costs.

Thus, the major brand-name manufacturers have sought to maintain their patent rights over new drugs in as many nations for as long a period of time as they possibly can, and, in that respect, CAFTA’s intellectual-property provisions mark a major advance which they hope can be used as a precedent for similar free-trade accords with other countries.

As explained by the authoritative Congressional Quarterly, the treaty text provides that when a drug is approved in one of the pact countries, the data used to get approval for the drug will be protected in that country for at least five years, regardless of whether it had been approved in another country previously.

That provision means that Big Pharma companies may get twice as many years of protection as they do now under the North American Free Trade Agreement (NAFTA) under which companies get five years of exclusivity that starts when the drug is approved in any of the countries in the agreement.

In addition, CAFTA would allow for patent extensions for brand-name companies that go far beyond the protections in current U.S. law and also put in place new obstacles to governments that wish to license generic producers to manufacture specific medicines.

Because these provisions go beyond what both the WTO and even U.S. law have required, they have infuriated health advocates who see in them a betrayal of the Bush administration’s previous rhetorical and other commitments to make anti-AIDS medications, in particular, affordable to all of those who need them.

Central America has the second-highest death rate from communicable diseases in the Latin American region, and more than 165,000 people there are living with HIV/AIDS, according to Oxfam America.

”Almost four years ago, the Bush administration signed a declaration at the WTO Ministerial meeting in Doha pledging that WTO members should prioritise public health and, in particular, access to medicines for all when adopting national rules governing protection of drug-company patent rights,” noted Asia Russell, director of international policy at HealthGAP.

”The U.S. has broken that promise in CAFTA, and, in going back on its word, the White House has decided that being at Big Pharma’s beck and call is more important than ensuring Central Americans have access to medicines that can lives,” she said.

Indeed, a recent study by the Centre for Public Integrity here found that the big pharmaceutical companies spent more than 800 million dollars over from 1998 through 2004 on campaign contributions, most of which went to Republicans.

The pay-off resulted in, among other things, attaining a dominant presence on committees created by the U.S. Trade Representative to advise on U.S. trade policy. These committees, in turn, play a critical role in forging Washington’s positions on particular trade issues, such as intellectual property rights.

Normally, health advocates could press Congress to oppose or amend specific provisions of legislation that comes before it. But trade agreements that come before Congress under so-called ”fast-track” authority cannot be amended or altered on the floor in their entirety.

© 2005 Inter Press Service

Posted by pnhp at 10:09 AM | Permalink

Tuesday, July 26, 2005
By Alana Semuels
Pittsburgh Post-Gazette

Although her husband is employed, 30-year-old Pamela Ramirez still pays her health bills the same way many immigrants do — out of her savings account.

Ramirez, of the South Side, moved here from Argentina more than four years ago. She’s typical in that she costs less to the health care system than do native-born residents, according to a study published yesterday in the American Journal of Public Health.

The study found that immigrants use 55 percent less health care than non-immigrants, and that both insured and non-insured immigrants use less services than the native born.

Immigrants actually subsidize care for the rest of the population, according to the study, because they pay Medicare payroll taxes and health insurance premiums, but do not reap all the benefits of these services.

“This ought to explode the myth that health care costs are due to immigrants,” said Dr. Steffie Woolhandler, an associate professor of medicine at Harvard Medical School and one of the authors of the study.

In dollar terms, per capita health expenditures were around $1,139 per immigrant, versus $2,564 for non-immigrants.

This is the first national study of immigrants’ health care expenditures. It looked at data from 21,241 people in the Agency for Healthcare Research and Quality’s 1998 Medical Expenditure Panel Survey, counting anyone born outside the country as an immigrant. The data is the most recent available, Woolhandler said, and the problems it highlights — such as immigrants’ fear of seeking treatment — have probably been exacerbated in the post-9/11 world.

Woolhandler argues that it highlights the need for a national health insurance program, which is the goal of the organization she co-founded, Physicians for a National Health Program.

But a think tank that supports tighter controls on immigration said that the study shows only that immigrants are poorer than non-immigrants, and are thus less able to afford health care.

“To the extent there’s an immigration policy conclusion, it would be that we’re taking in too many poor immigrants,” said Mark Krikorian, executive director of the Center for Immigration Studies in Washington, D.C.

One of the most striking pieces of the study found that immigrant children receive very low levels of care. They got 71 percent less care in doctors’ offices, and 72 percent fewer prescription medications than native-born children. The cost of their emergency room visits was the only expenditure that was higher — three times greater than those of native-born children — implying that parents wait until their children are very ill before seeking care.

“There’s widespread agreement that young children need to see a doctor on a regular basis,” said Woolhandler. “There’s very strong evidence that there was under-use of services in immigrant children.”

Although many of Pittsburgh’s immigrants are better-educated than those in other cities, children and elderly immigrants who don’t qualify for services are particularly vulnerable, said Dr. Vish Nimgaonkar, a professor of psychiatry at the University of Pittsburgh School of Medicine and a member of Woolhandler’s nonprofit group.

Local doctors have tried to help immigrant children obtain health care by running a bilingual clinic every week at Children’s Hospital and a monthly clinic on the South Side for uninsured children.

Lack of insurance, language barriers, and cultural differences are three of the main reasons preventing immigrants in Pittsburgh from seeking care, said Dr. Diego Chaves-Gnecco, a pediatric resident at Pitt who founded the local clinics. Many Latinos he treats would rather use traditional remedies than try to navigate a health care system that doesn’t speak their language.

Latino immigrants were found to utilize half as much health care as U.S.-born Latinos, and 70 percent less than U.S.-born whites, according to the study.

“We’re overcoming those barriers,” he said. The clinics have now had more than 1,000 visits — a significant number for a city with a small Latino population.

Ramirez takes her Pittsburgh-born daughter to Chaves-Gnecco’s clinic. But she and her husband don’t have a similar outlet to seek care for themselves.

“The ideal situation is when you don’t have to overcome all the barriers we have mentioned,” she said. “Immigration status shouldn’t affect health care.”

Alana Semuels can be reached at asemuels@post-gazette.com or 412-263-1928.

Posted by pnhp at 09:06 AM | Permalink

July 25 (Bloomberg) — Health-care costs for U.S. immigrants were an average of $1,139 a year each, half as much as medical expenses for citizens born in the U.S., according to an analysis by Harvard and Columbia universities.

U.S.-born citizens had an average of $2,565 a year in health costs in 1998, the latest year for which data were available for analysis, according to the study in the tomorrow’s issue of the American Journal of Public Health.

Legal and illegal immigrants, and their children, may skip preventive care, according to the researchers. This may mean that immigration isn’t a factor in rising U.S. health-care costs, the researchers said. U.S. medical expenses rose an estimated 7.5 percent last year, to $1.8 trillion, according to the U.S. government.

“We constantly hear anti-immigrant extremists, elected officials and media commentators making baseless claims about how immigrants are contributing to our nation’s high health-care costs,” U.S. Representative Luis Gutierrez, chairman of the Congressional Hispanic Caucus Task Force said in an e-mailed statement. “This comprehensive new study shows just how unfounded these allegations are.”

The researchers spent three years analyzing data from a 1998 survey of 21,241 people in the Agency for Healthcare Research and Quality’s Medical Expenditure Panel Survey. The panel collects health-spending information on the U.S.

The data is usually released three years after it is collected, Sarita Mohanty of the University of Southern California, a study co-author, said.

“We had seen in the press and media that there were concerns that immigrants were burdening the health-care system,” she said.

‘Grave’ Disparity

Most of the results weren’t very surprising, though the disparity in the amount of health-care immigrant children received compared with children of U.S. descent was, according to the doctors. Total spending for immigrant children’s care was $270 a year compared with $1,059 for U.S.-born children, the study found.

“We were surprised by the grave disparity in health-care that immigrant children received,” Mohanty said. “The difference was remarkable.”

When the lower cost of health-care is combined with the average paid in taxes by legal and illegal immigrants, in effect they may help subsidize medical costs for U.S.-born citizens, the review showed.

The study cited a report from the National Research Council that concluded that immigrants add as much as $10 billion to the economy each year and that they will pay about $80,000 per capita more in taxes than they use in government services over their lifetimes.

Policy Makers

Mohanty said she would like to see more discussion among communities and policy makers as a result of the study. She said her hope is that the facts of the study will dispel the notions that immigrants burden the system.

“When you separate fact from fiction, as this study does, you see the real picture of our immigrant community,” Gutierrez said.

Calls seeking comment from Republican Senators Jon Kyl of Arizona, and John Cornyn of Texas weren’t immediately returned.

Feeling Unwelcome

Olveen Carrasquillo, of Columbia University in New York, that cultural barriers, account for some of the reasons that immigrants use the health-care system less. Carrasquillo, a co- author, practices medicine on the city’s West Side, which has a large immigrant and Hispanic population.

“A lot of places aren’t friendly to immigrants,” he said. “They have a lack of interpreters, and many times they feel unwelcome and intimidated by the system.”

These barriers can lead to immigrants seeking health-care only until illness has significantly advanced, the authors all agreed. Steffie Woolhandler, a study co-author and co-founder of Physicians for a National Health Program, said that she has seen cases where immigrants have delayed medical attention.

“They’re waiting until they’re desperately ill to go to the hospital,” she said.

To contact the reporter on this story:
Mario Parker in Washington at Mparker16@bloomberg.net

Posted by pnhp at 11:35 AM | Permalink

By Ceci Connolly
Washington Post Staff Writer
Tuesday, July 26, 2005; Page A11

Regardless of age, legal status or insurance coverage, immigrants, on average, receive about half the health care services provided to native-born Americans, according to findings released yesterday that immediately fueled the debate over tightening immigration policies.

Immigrants received an average of $1,139 worth of care, compared with $2,564 for non-immigrants, according to the analysis, published in the August issue of the American Journal of Public Health. The gap was especially pronounced among immigrant children, who received one-quarter the care given to U.S.-born youngsters.

“Our study lays to rest the myth that expensive care for immigrants is responsible for our nation’s high health costs,” said co-author Sarita Mohanty, an assistant professor of medicine at the University of Southern California. “The truth is, immigrants get far less care than other Americans.”

The report is based on government data that tabulated health spending for 21,000 people in 1998, the most recent year for which figures were available. The analysis includes legal and illegal immigrants.

“If we think our high health care costs are due to immigrants flocking to our shores, we’re wrong,” said co-author David Himmelstein of Harvard Medical School. Although immigrants accounted for 10 percent of the population, they consumed 8 percent of total health services, the study found.

Some immigration experts, however, said that tracking per capita spending ignores the larger societal costs of a growing immigrant population that is far less likely to have health insurance.

“The fact that immigrants, when uninsured, might use 27 percent less medical care doesn’t change the fact that they’re 200 percent more likely to be uninsured in the first place,” said Steven Camarota, research director at the Center for Immigration Studies, a Washington think tank that favors strict controls on immigration. “Why have a system that allows in so many people who aren’t self-sufficient?”

Immigrants account for 18 percent of the costs associated with the uninsured — expenses likely to be borne by taxpayers and charities, Camarota said.

Both sides said financial, cultural and language differences all make it hard for immigrants to afford care, understand medical advice or embrace recommendations from American doctors and nurses.

A much higher percentage of adult immigrants lack a high school education, which makes it difficult for them to navigate the health care system, said Elena Rios, president of the National Hispanic Medical Association.

“They don’t understand the lingo,” such as what a cholesterol reading signifies, she said. “Because of limited education levels, you can’t connect the dots and think about what prevention like physical exercise means in terms of the future and things like heart disease and cancer.”

Immigrants often live in low-income neighborhoods with fewer hospitals, clinics, physicians and pharmacies, she said. And many Latin Americans, coming from countries with government-run health systems, are unfamiliar with the concept of buying insurance.

In addition, many immigrants do not qualify for government health programs that are targeted at specific groups such as retirees, American Indians and veterans, Camarota said.

Over the long term, Himmelstein said, the potential ramifications for children are most alarming. The data showed immigrant children had fewer doctor visits, took less medication and made fewer trips to the emergency room. But their emergency room costs were nearly triple those for non-immigrant children, suggesting that immigrant families missed routine checkups and waited until a condition was more serious before seeking treatment, Himmelstein said.

It is far more likely, he said, that immigrant children do not receive standard vaccinations and let chronic problems such as asthma go untreated.

Even better-educated, insured immigrants — and U.S.-born minorities — received less care, probably because of racism and cultural differences, Mohanty said.

The paper’s authors, who are active in the liberal Physicians for a National Health Program, said one solution would be to provide everyone with basic health coverage. Short of that, they advocated lifting restrictions on government health programs and easing entry into employer-provided health plans.

Camarota, who agreed that legal immigrants should have greater access to care, said lawmakers need to take a more critical look at who is allowed into the United States. He said, “The solution to the problem is make them go home or not let them in in the first place.”

© 2005 The Washington Post Company

Posted by pnhp at 11:29 AM | Permalink

Spending 55% less for immigrants than U.S.-born residents
08:57 PM CDT on Monday, July 25, 2005
By Sherry Jacobson
The Dallas Morning News

A new national study suggests that immigrants in the United States receive about half as much medical care as their American counterparts.

U.S.-born residents averaged $2,564 in annual health care costs compared with per capita immigrant care that averaged $1,139, about 55 percent less, according to the study published Monday in the American Journal of Public Health.

The study concluded that the spending disparity refuted the notion that immigrants were “a substantial burden” on the U.S. health-care system.

It estimated that immigrant care accounted for $39.5 billion, or almost 8 percent of U.S. health-care spending in 1998, the year that was analyzed. Immigrants made up 10 percent of the U.S. population in 2000.

“These are the most recent numbers we had to work with,” said Dr. Olveen Carrasquillo of Columbia University and one of the study’s authors. “We have no reason to think that the expenditure for immigrant care has gone up in recent years as a percentage of the entire cost.”

However, Dallas health officials said Monday that there was another way to look at the numbers. The officials wondered whether the lower cost of health care for immigrants signaled that they were having trouble accessing medical services.

“You can explain this disparity as a lack of access due to language, financial and insurance barriers,” said Dr. Ron Anderson, president and chief executive officer of Parkland Memorial Hospital, which services a large immigrant population.

“There’s nothing to celebrate in this study,” he said.

Dr. Michele Smith, who treats immigrants at the Community Health Clinic in East Dallas, said it was not uncommon to diagnose more advanced diseases in immigrants, who waited too long to see a doctor.

“We see women with cervical and breast cancer who haven’t had Pap smears and mammograms” that could have caught the disease earlier, she said. “Our patients are from Mexico, Africa and the various Asian countries. Many of the women in their 60s have never had these basic tests.”

Dr. David Buhner, medical director of the Dallas County health department, noted that the lack of insurance probably was the main reason immigrants had such trouble getting into the U.S. system.

“The ticket to access is health insurance, and if you don’t have it, you can’t get in,” he said.

Higher ER costs

In fact, the study found that immigrants were more likely to use the emergency room for basic treatment than to go to the doctor’s office. Although immigrant children had a lower rate of ER visits than American-born children, their average ER costs were three times higher because immigrant children tended to be sicker when they arrived.

The study estimated that 25 percent of U.S. immigrants lack public or private health insurance. However, immigrants were broadly defined as anyone born outside the U.S., including people who had moved to this country decades ago.

“It included people from Scandinavia who’ve been here 20 years and are citizens now,” Dr. Buhner said. “There would probably be even a greater disparity in health-care spending if it had looked at just undocumented workers. Their barriers to care are associated with being poor and uninsured.”

The study found that Asian immigrants had health-care expenses similar to U.S.-born residents, while Hispanics and blacks suffered the largest disparities in such spending.

Dr. Anderson noted that the longer immigrants resided in the United States, the more likely they were to become insured. About 25 percent of Texans are uninsured, one of the highest rates in the nation.

“Thirty-eight percent of our patients are uninsured because of our mission to serve the indigent,” he said. “We’re going to get a higher burden of uninsured patients.”

The authors of the study also theorized that immigrants receive a smaller proportion of health care than they pay for.

The study also challenged the belief that immigrants are to blame for the rising cost of U.S. health care, said Dr. Sarita A. Mohanty of the University of Southern California and the lead author of the report.

Myth debunked

“Our study lays to rest the myth that expensive care for immigrants is responsible for our nation’s high health costs,” she said. “The truth is, immigrants get far less care than other Americans. Our data indicates that many immigrants are actually helping to subsidize care for the rest of us.”

The study’s authors presented it as the first nationwide analysis of immigrant health-care expenditures, basing it on data from the Agency for Healthcare Research and Quality. It considered data collected from 21,241 people who took part in the 1998 Medical Expenditure Panel Survey.

E-mail sjacobson@dallasnews.com

Posted by pnhp at 11:26 AM | Permalink

Mon Jul 25, 2005 5:16 PM ET

WASHINGTON (Reuters) - Immigrants are not swamping the U.S. health care system and use it far less than native-born Americans, according to a study released on Monday.

The study, published in the American Journal of Public Health, found that immigrants accounted for 10.4 percent of the U.S. population but only 7.9 percent of total health spending and 8 percent of government health spending.

Health spending by the government, insurers and patients themselves averaged $1,139 per immigrant compared to $2,564 for non-immigrants. Thirty percent of immigrants used no health care at all in the course of the year.

Immigrant children spent or cost $270 that year, compared to $1,059 for native-born children.

“Our study lays to rest the myth that expensive care for immigrants is responsible for our nation’s high health costs. The truth is, immigrants get far less care than other Americans,” Dr. Sarita Mohanty, who led the study while she was at Harvard University and who is now at the University of Southern California, said in a statement.

“Further restricting their eligibility for care would save little money and place many immigrants — particularly children — at grave risk. Already, many immigrant children fail to get regular checkups and as a result more end up needing emergency care, or get no care at all.”

The researchers used U.S. government data taken in a 1998 survey from U.S. residents, including natural-born citizens, immigrants who had become citizens, temporary residents and illegal aliens.

“The only case in which immigrants’ costs for health care were higher than U.S.-born children was in emergency department visits ($45 vs. $18 per capita),” the researchers said in a statement.

Most immigrants had health insurance, the survey found. It said 58 percent of immigrants had private insurance, compared to 74.9 percent of native-born U.S. citizens, and 17.3 percent of immigrants had some sort of public insurance such as Medicare or Medicaid, compared to 15 percent of natives.

“Our data indicates that many immigrants are actually helping to subsidize care for the rest of us,” Dr. Steffie Woolhandler, a founder of Physicians for a National Health Program and one of the authors of the study, said in a statement.

“Immigrant families are paying taxes — including Medicare payroll taxes — and most pay health insurance premiums, but they’re getting only half as much care as other families.”

“We constantly hear anti-immigrant extremists, elected officials and media commentators making baseless claims about how immigrants are contributing to our nation’s high health care costs,” Rep. Luis Gutierrez, an Illinois Democrat and chair of the Congressional Hispanic Caucus Immigration Task Force, said in a statement.

“This comprehensive new study shows just how unfounded these allegations are and I hope it will permanently put to rest these misinformed and misguided myths.”

In 2000, there were 28.4 million immigrants in the United States, including legal and non-legal residents.

Posted by pnhp at 11:23 AM | Permalink

Existing health services are being deliberately destabilised to pave the way for an ideologically driven privatisation programme
By John Lister
Wednesday July 20 2005
The Guardian

How is it that with spending on the NHS now running at double the level of 1997, the service is running into an autumn crisis, with debts totalling at least 750m pounds, bed closures, theatres closed, services cut and estimates of 8,000 or more redundancies?

The answer lies in the breakneck process of “modernisation”, under which existing services are being deliberately destabilised to establish a competitive market system incorporating for-profit private providers, in place of a planned system of public healthcare.

Under John Major the NHS was buying less than 200m pounds worth of treatment from private hospitals a year. This will have increased 10-fold by 2007. Up to 15% of elective surgery will be hived off to private hospitals, leaving NHS trusts to cover the remainder.

Hospital buildings have also been privatised: private finance initiative schemes worth more than 5bn pounds have been completed since 1997 or are being built, and another 12bn pounds of projects are under negotiation - all of them locking trusts into costly, long-term leasehold deals.

But while New Labour ministers press relentlessly on, opposition is starting to coalesce. Last week in London a group of consultants, academics, MPs and trade-union officials met to plan a “save our NHS” coalition against these “stealth reforms”, which have little public support - a recent poll showed 89% against private provision of NHS care - and are little reported or discussed.

That is likely to change in the autumn as huge, unprecedented budget deficits - and cuts in services - begin to take shape alongside the new competitive health market.

Soon all patients must be allowed to “choose and book” elective treatment from a list including both NHS and private providers. Millions will be siphoned out of trust budgets into private-sector treatment centres: Brighton and Sussex University Hospitals NHS Trust stands to lose 85% of its elective orthopaedic work, worth 15m pounds.

The attempt by the health secretary, Patricia Hewitt, to claim the mantle of Nye Bevan in her defence of New Labour’s NHS reforms earlier this month - arguing that even Bevan “saw a role for the private sector” - should have drawn a gasp.

When Bevan nationalised the flagging network of voluntary and municipal hospitals in 1948 he made compromises that left some relics of the pre-NHS private sector intact - pay beds and private practice for consultants, and allowing GPs to remain as “independent contractors”.

But what for Bevan were concessions, to ensure the passage of ground-breaking changes, have for Hewitt become a point of principle. Billions are now diverted from NHS budgets to create a new, expanding private sector, which will now be free to poach staff from NHS hospitals. Hewitt’s first announcement in her new job was that another 3bn pounds was to be spent on services exclusively from private providers - with NHS hospitals forbidden to bid. Two modern NHS treatment centres are to be privatised, reversing Bevan’s modernisation. This is neither expanding capacity nor supporting patient choice, since existing high-quality NHS services will no longer be available in these areas.

Hewitt is also creating a new private sector in primary-care services, while GPs are encouraged to act more like businesses, and allowed to retain unspent surpluses from “practice-based commissioning”.

A survey of more than 40 countries shows that for 15 years England has gone furthest and fastest down the road of market-style reforms; but there is no evidence that these reforms improve efficiency or cut costs.

Thatcher’s 1990s marketising reforms, by fragmenting the NHS into purchasers (health authorities and GP fundholders) and providers (trusts), massively increased administrative costs and boosted the number of senior managers.

Throughout Europe and around the world, insurance-based systems with separate purchasers and providers cost more to administer than the NHS: admin costs in France and Germany are over 20% of health spending, while in the US almost a third of the $1.4 trillion spent on health goes on administration.

New Labour came to office pledging to scrap the costly internal-market system, and began to do so - only to turn rapidly back towards the current policy, creating a market in which the NHS competes on unequal terms with a private sector free to cherry-pick the most profitable specialities and treatments.

NHS productivity has been hampered by soaring costs of goods and services from the private sector. For every £1 spent on NHS staff in 1995, according to the Office for National Statistics, 71p was spent on procurement of goods and services from the private sector; by 2003 the figure was 1.15 pounds for every 1 pound on staff.

Hewitt’s plans to spend billions on buying in treatment from private hospitals and treatment centres will therefore increase costs - just as private-sector care, especially for-profit care, costs more in almost every country where it is purchased alongside public provision.

New Labour’s ideologically driven modernisation reinvents failed policies and ignores the evidence. Competition, which brought fragmentation, dislocation and widened inequalities under the Tories, is coming back as “payment by results” from next April; it is already destabilising local NHS hospitals, and will bring more closures. Foundation Trusts ape failed experiments that were dropped in Spain, brought soaring debts in New Zealand, and led to outright privatisation in Stockholm.

In Britain, what is called modernisation has already increased costs and overheads, demoralised and alienated staff, undermined planning - and done nothing to ensure equal access to local care. It cannot continue to go unchallenged.

John Lister is the information director of London Health Emergency, and lectures in health policy and journalism at Coventry University; his book Health Policy Reform - Driving the Wrong Way? is published this month.

Copyright Guardian Newspapers Limited

Posted by pnhp at 11:20 AM | Permalink

Health Care Expenditures of Immigrants in the United States: A Nationally Representative Analysis
By Sarita A. Mohanty, MD, MPH, Steffie Woolhandler, MD, MPH, David U. Himmelstein, MD, Susmita Pati, MD, MPH, Olveen Carrasquillo, MD, MPH and David H. Bor, MD
American Journal of Public Health
August 2005

Conclusions. Health care expenditures are substantially lower for immigrants than for US-born persons. Our study refutes the assumption that immigrants represent a disproportionate financial burden on the US health care system.

>From the discussion:

Our findings show that widely held assumptions that immigrants are consuming large amounts of scarce health care resources are invalid; these findings support calls to repeal legislation proposed on the basis of such assumptions. The low expenditures of publicly insured immigrants also suggest that policy efforts to terminate immigrants’ coverage would result in little savings. In addition, lower health care expenditures by immigrants suggest important disparities in health care use, especially for children. Immigrant children will grow up to become a major segment of the US workforce in the coming years. Ensuring access to health services needed for proper growth and development should be a national priority.

Policies that may improve immigrants’ access to care include providing interpreter services, ending restrictions on Medicaid and State Children’s Health Insurance Program eligibility, improving employer-provided coverage for immigrant workers, and implementing universal national health insurance. Our study lends support to these and other initiatives aimed at reducing and ultimately eliminating disparities in access to and use of health services.

http://www.ajph.org/cgi/content/abstract/95/8/1431

Comment: A comment from the PNHP press release places the issue in proper perspective:

“Our data indicates that many immigrants are actually helping to subsidize care for the rest of us. Immigrant families are paying taxes – including Medicare payroll taxes - and most pay health insurance premiums, but they’re getting only half as much care as other families.” said Dr. Steffie Woolhandler, a study co-author and co-founder of Physicians for a National Health Program.

Posted by pnhp at 09:48 AM | Permalink

JULY 21, 2005 — Legislation that would make it easier for small businesses to band together to purchase insurance and bypass state mandates is “a license to steal,” says a study released Thursday.

“The consequences are predictable: bankruptcy, delayed or forgone medical care, and loss of coverage for America’s businesses and workers,” said report author Mila Kofman, an assistant research professor at Georgetown University’s Health Policy Institute.

The report is referring to a bill (HR 525)—expected to pass the House next week—that would allow association health plans (AHPs) to bypass state regulation in areas such as mandating insurance coverage for specific treatments and procedures. Exempting AHPs from state laws, advocates say, would make it easier for small businesses to join forces and cut better deals with insurers when purchasing health care coverage for employees.

But Kofman said that the lack of state regulation of AHPs creates an easy opportunity for scam artists to come in, get their money and go out of business. “In law enforcement circles, these are called ‘cash cows,’” she said at a press conference.

The legislation would prohibit state regulators from shutting down fraudulent AHPs and would stop states from making it illegal to sell phony insurance to federal AHPs, Kofman said.

The bill would require the Department of Labor to monitor AHPs, a responsibility the agency cannot handle, Kofman said. And the bill would rely too heavily on self-reporting and self-regulation by the plans. “Crooks won’t be notifying the feds of lying, cheating, and stealing,” she said.

Between 2000 and 2002, fraudulent AHP-like plans affected more than 200,000 policyholders and left businesses and workers responsible for $252 million in medical bills, Kofman said. While the states shut down 41 illegal operations selling coverage through phony and real associations, the U.S. Labor Department shut down just three, Kofman found.

Rep. Sam Johnson, R-Texas, the leading sponsor of the House AHP bill, said such plans “protect people and increase the insured. The last time I checked, the Department of Labor has done a tremendous job monitoring the health plans of big business. I’d like to see small business have that same advantage—and their employees insured,” he said in a statement.

Groups such as the U.S. Chamber of Commerce, the National Federation of Independent Business, and the National Association of Manufacturers are pressuring Congress to pass the AHP legislation. They say such plans would help reduce the number of uninsured Americans by giving smaller employers the same market clout that larger businesses now enjoy when they purchase health coverage for their workers.

While the legislation has passed the House several times and is expected to do so again, it faces more opposition in the Senate, where Sen. Olympia J. Snowe, R-Maine, has introduced a similar bill (S 406).

Kate Sullivan Hare, executive director of health care policy for the U.S. Chamber of Commerce, said the AHP measure includes a number of licensing and solvency requirements to help prevent fraudulent companies from offering coverage. Hare also said the Department of Labor would add staff to help monitor the AHPs if the legislation became law.

“There’s nothing any of us can do about the scam operators—it’s buyer beware,” Hare said. “They’re out there now.”

Jill and Brent Burgess, who attended the press conference with Kofman, were the victims of one of those fraudulent operators. The couple, which operated their own business, lost their health care coverage for themselves and their three children when the company they bought insurance from was shut down for operating illegally, Jill Burgess said. Saddled with $30,000 in unpaid medical bills, her family had to file bankruptcy. “There was no other way out of this nightmare,” she said.

Kansas Commissioner of Insurance Sandy Praeger said there will be more victims like the Burgess family if Congress approves the AHP bill. “Simply put, allowing federal AHPs to operate outside the authority of state regulators will expose consumers to more fraud and insurance scams,” she said.

CQ HealthBeat is a daily e-mail newsletter distributed by Congressional Quarterly, Inc.

Posted by pnhp at 12:55 PM | Permalink

By Paul Krugman
The New York Times
July 25, 2005

Modern American politics is dominated by the doctrine that government is the problem, not the solution. In practice, this doctrine translates into policies that make low taxes on the rich the highest priority, even if lack of revenue undermines basic public services. You don’t have to be a liberal to realize that this is wrong-headed. Corporate leaders understand quite well that good public services are also good for business. But the political environment is so polarized these days that top executives are often afraid to speak up against conservative dogma.

Instead, they vote with their feet. Which brings us to the story of Toyota’s choice.

There has been fierce competition among states hoping to attract a new Toyota assembly plant. Several Southern states reportedly offered financial incentives worth hundreds of millions of dollars.

But last month Toyota decided to put the new plant, which will produce RAV4 mini-S.U.V.’s, in Ontario. Explaining why it passed up financial incentives to choose a U.S. location, the company cited the quality of Ontario’s work force.

What made Toyota so sensitive to labor quality issues? Maybe we should discount remarks from the president of the Toronto-based Automotive Parts Manufacturers’ Association, who claimed that the educational level in the Southern United States was so low that trainers for Japanese plants in Alabama had to use “pictorials” to teach some illiterate workers how to use high-tech equipment.

But there are other reports, some coming from state officials, that confirm his basic point: Japanese auto companies opening plants in the Southern U.S. have been unfavorably surprised by the work force’s poor level of training.

There’s some bitter irony here for Alabama’s governor. Just two years ago voters overwhelmingly rejected his plea for an increase in the state’s rock-bottom taxes on the affluent, so that he could afford to improve the state’s low-quality education system. Opponents of the tax hike convinced voters that it would cost the state jobs.

But education is only one reason Toyota chose Ontario. Canada’s other big selling point is its national health insurance system, which saves auto manufacturers large sums in benefit payments compared with their costs in the United States.

You might be tempted to say that Canadian taxpayers are, in effect, subsidizing Toyota’s move by paying for health coverage. But that’s not right, even aside from the fact that Canada’s health care system has far lower costs per person than the American system, with its huge administrative expenses. In fact, U.S. taxpayers, not Canadians, will be hurt by the northward movement of auto jobs.

To see why, bear in mind that in the long run decisions like Toyota’s probably won’t affect the overall number of jobs in either the United States or Canada. But the result of international competition will be to give Canada more jobs in industries like autos, which pay health benefits to their U.S. workers, and fewer jobs in industries that don’t provide those benefits. In the U.S. the effect will be just the reverse: fewer jobs with benefits, more jobs without.

So what’s the impact on taxpayers? In Canada, there’s no impact at all: since all Canadians get government-provided health insurance in any case, the additional auto jobs won’t increase government spending.

But U.S. taxpayers will suffer, because the general public ends up picking up much of the cost of health care for workers who don’t get insurance through their jobs. Some uninsured workers and their families end up on Medicaid. Others end up depending on emergency rooms, which are heavily subsidized by taxpayers.

Funny, isn’t it? Pundits tell us that the welfare state is doomed by globalization, that programs like national health insurance have become unsustainable. But Canada’s universal health insurance system is handling international competition just fine. It’s our own system, which penalizes companies that treat their workers well, that’s in trouble.

I’m sure that some readers will respond to everything I’ve just said by asking why, if the Canadians are so smart, they aren’t richer. But I’ll have to leave the issue of America’s comparative economic performance for another day.

For now, let me just point out that treating people decently is sometimes a competitive advantage. In America, basic health insurance is a privilege; in Canada, it’s a right. And in the auto industry, at least, the good jobs are heading north.

E-mail: krugman@nytimes.com

Posted by pnhp at 09:58 AM | Permalink

Dear Colleague:

This summer marks the 40th year since the enactment of Medicare, the landmark health care program for the nation’s most vulnerable—the elderly, frail, and disabled. For the past decade, the Fund’s Program on Medicare’s Future has focused on the experience of beneficiaries, evaluating how new policies or emerging trends affect their coverage and access to care. In conjunction with the program’s anniversary, we are pleased to offer a new Medicare Resources page, a collection of selected Fund research on some of the program’s current challenges, including implementation of the new drug benefit, a restructured managed care program, and growing pressure to improve the quality of care while controlling costs.

Check this page again next week for a link to a webcast of a July 26th event at the Henry J. Kaiser Family Foundation conference center in Washington, D.C., noting the 40th anniversary of enactment of the laws establishing both Medicare and Medicaid, the jointly funded federal-state program that helps states provide medical assistance to low-income individuals and families. This historic event will include remarks from a half-dozen former Health Care Financing Administration (HCFA)/Centers for Medicare and Medicaid Services (CMS) administrators, former Health, Education, and Welfare Secretary Joseph A. Califano, Jr., and other health policy experts, including Kaiser President Drew Altman and Fund President Karen Davis. Also on the 26th, Health Affairs, in collaboration with the event’s co-sponsors, will publish several perspective articles by former HCFA/CMS administrators.

Posted by pnhp at 09:25 AM | Permalink

By Liz Kowalczyk
Boston Globe
July 20, 2005

Two Boston University professors plan today to release a report critical of Governor Mitt Romney’s health-care plan, arguing that it does not address the state’s soaring medical costs and that it does not provide full insurance coverage to everyone.

Professors Alan Sager and Deborah Socolar, directors of the university’s Health Reform Program, will testify at a legislative hearing focused on alternatives to the governor’s plan, which would require most uninsured Massachusetts residents to buy health insurance.

The hearing is scheduled for 10 a.m., and will be chaired by Representative Patricia Walrath, cochairwoman of the Joint Committee on Health Care Financing and Democrat from Stow. Discussions will focus on two bills that propose a single-payer health care system, also called universal health care, and a third that would redirect money from the cigarette excise tax and the national settlement with tobacco companies into health education and cancer prevention programs.

In a single-payer system, all residents would be covered under one umbrella, run by the government or some other entity. Essentially, Romney wants instead to expand the system of public and private coverage to provide insurance to about 500,000 Massachusetts residents who do not have it.

Romney has said he wants to make coverage less expensive by permitting insurers to offer low-cost policies with scaled-back benefits. People making too little to afford those plans and making too much to qualify for Medicaid would be eligible for state subsidies to help them buy insurance. Medicaid would remain in place for the poorest state residents unable to afford private insurance.

Residents who do not get health insurance would face tax penalties, and the garnishing of their wages, to cover care.

Today, Romney plans to announce more details of another component of his plan, called Safety Net Care, and to file legislation. The proposal would take the more than $1 billion a year that the state, health plans, and hospitals contribute to the so-called ”free care pool,” which pays for medical care for some uninsured residents, and to use it to help buy insurance for the residents.

Another approach being pushed by a coalition, including the nonprofit organization Health Care for All, would force most employers to cover workers.

Sager said that Massachusetts residents and insurers spent $2,176 per person in 2003 on hospital care alone, 41 percent higher than the national average.

”We don’t think [Romney’s] plan seriously attacks any of the causes of high health costs,” Sager said in an interview. ”We don’t think a single-payer is a cure-all. But it cuts a lot of administrative waste quickly by reducing complexity and provides the right foundation for squeezing out clinical waste.”

© Copyright 2005 The New York Times Company

http://www.boston.com/news/local/articles/2005/07/20/
two_bu_scholars_to_criticize_romney_health_plan/

Posted by pnhp at 08:55 AM | Permalink

By Gina Kolata
July 21, 2005

There is no one in medicine who does not consider it both crucial and long overdue to have electronic records in doctor’s offices and hospitals.

With electronic files, patient records are not stuck on pieces of paper in endless files, but are on a screen at the touch of a key. The computers alert doctors to do medical tests and avert errors by warning when they write a prescription for the wrong drug or the wrong dose. Patients can often see their own files and even make their own appointments, online, from their homes.

But most doctors have balked. The systems cost tens of thousands of dollars, and doctors worry that the companies selling them and providing support will go out of business. Many use computers to file health insurance claims, but only 20 percent to 25 percent of the nation’s 650,000 licensed doctors outside the military and the Department of Veterans Affairs are using electronic patient records.

Now, however, Medicare, which says the lack of electronic records is one of the biggest impediments to improving health care, has decided to step in. In an unprecedented move, it said it planned to announce that it would give doctors - free of charge - software to computerize their medical practices. An office with five doctors could save more than $100,000 by choosing the Medicare software rather than buying software from a private company, officials say.

The program begins next month, and the software is a version of a well-proven electronic health record system, called Vista, that has been used for two decades by hospitals, doctors and clinics with the Department of Veterans Affairs. Medicare will also provide a list of companies that have been trained to install and maintain the system.

Given Medicare’s heft, the software giveaway could transform American medicine, said Dr. John Wasson, a Dartmouth Medical School health care researcher.

But, Dr. Wasson added, it may take a while. “If you look at it from a five-year point of view, it will make a huge difference,” he said.

At first, he predicted, many doctors will bide their time, to see just how good Vista is.

Dr. Alan Garber, a Stanford University economist and internist, said of the Medicare plan: “It’s a good idea. It’s not foolproof.”

But, Dr. Garber added, Medicare’s investment and the program’s many appealing features “are all signals that it might be around for a long time and a doctor in a small office would not be taking an enormous risk.”

Medicare has not estimated what its software giveaway is worth. But Duncan Pringle, chief Vista technologist at Perot Systems, said that each doctor in a practice paid about $20,000 to $25,000 to get started with a commercial system, including costs of software, a license fee charged to each doctor, installation and servicing.

Installing Vista would cost $10,000 to $12,000 for an entire medical practice. That means that a practice of five doctors might pay $100,000 to computerize, but if the doctors used the Medicare system they might pay only $10,000 for the whole office.

The problem is that Vista has a reputation for being extremely difficult to install. Medicare says it modified and simplified it for doctors’ offices, but it remains to be seen whether doctors will want it.

Doctors are well aware that even with free software, no system is really free.

“Vista is a good system and it all sounds great,” said Dr. Thomas Jevon, a family physician in Wakefield, Mass. But, he added, “anyone who uses a computer can get frustrated and waste time trying to make it work.”

And for doctors, whose time is typically valued at $250 an hour, that time adds up.

“If a program takes 10 minutes away from your hour each day, that is costing you tens of thousands of dollars a year,” Dr. Jevon said. “That’s what’s bugging doctors.”

There is little doubt that computerized offices can help. For instance, Dr. Kevin Toppenberg recently saw an emergency patient who had injured his leg at the beach and arrived at his office wincing in pain. The patient’s regular doctor, one of Dr. Toppenberg’s 14 colleagues, practiced in another of the group’s three offices in Greeneville, Tenn., and was taking the day off.

In a typical medical practice, the man’s records would ordinarily be in a paper file in his own doctor’s office and a colleague in another office would have no way of getting them. Dr. Toppenberg, like many other doctors, would rather send such a patient to an emergency room than see him without a medical record.

“To just be working blind is scary for doctors,” Dr. Toppenberg said.

But Dr. Toppenberg’s newly installed computer program let him see the man’s record immediately, on a computer screen. After examining the man and diagnosing a probable torn muscle, Dr. Toppenberg sent him to an orthopedist. Then Dr. Toppenberg added his findings to the man’s record so his colleague would have them instantly when he needed to consult them.

The Vista project began a few years ago when Medicare officials realized that help for small medical practices was in its own backyard. The federal government had already paid hundreds of millions of dollars to develop Vista, and now uses it in the Veterans Administration’s 1,300 inpatient and outpatient facilities, which maintain more than 10 million records and treat more than five million veterans a year. Why not give Vista to doctors?

In fact, though few knew, Vista had been available all along to anyone who submitted a Freedom of Information Act request.

Over the years, the program had accrued a passionate following and even an organization, World Vista, founded in 2002 mostly by V.A. employees to help spread it throughout the world. One reason for their enthusiasm was that no company owns Vista so anyone can modify and enhance it.

It is, said Joseph Dal Molin, director of World Vista, a survival of the fittest. “What’s good survives,” he said.

One feature, for example, was suggested by a V.A. nurse. Why not put a bar code on a prescription bottle to identify the drug and its dose, put a bar code on the patient’s wristband to identify the patient’s prescription, and then scan the drug label and the patient’s wristband before administering a drug? If there was a discrepancy, Vista could catch it before an error was made. Programmers added that feature, and V.A. drug errors plummeted by 80 percent overnight.

Still, it is one thing to use a system that someone else installed and someone else maintains. It is another to get a set of disks in the mail and do it yourself.

Giving out a version of Vista is “a great idea,” said Dr. David Kibbe, director of the center for health information technology at the American Academy of Family Physicians, a group that has been working on the project. “But at the beginning, there was a lot of wishful thinking. They said, ‘We’ll just release it.’ I said, ‘Where’s the fairy dust?’ “

Those who tried to install Vista on their own would agree.

Dr. Nancy Anthracite, a family physician in Washington, needed endless hours of help from a group of Vista enthusiasts who call themselves the Hardhats and volunteer their time. Getting started with Vista was so daunting, Dr. Anthracite said, that even when the V.A. demonstrated its program at medical meetings, almost no none of those in attendance wanted to use it on their own.

“You go to meetings and they show you things doctors can do with Vista and everyone’s going , ‘Wow, wow, wow,’ ” Dr. Anthracite said. “But no one installs it.”

So for three years, Medicare and its contractors worked to make the program easier to use.

They even gave it a new name, VistaOffice, to signify that was intended for small-office practices, not the huge V.A. system.

Some, including Dr. Toppenberg, decided not to wait for the August release of the new program. Last year, he learned that he could get the unmodified V.A. version of Vista and decided to try it.

“I started looking around,” Dr. Toppenberg said. “The newer systems tended to be about $15,000 per doctor, not counting the ongoing support fees. Then I found out that the Vista system was available. You just have to figure out how to get it to work.”

He did - but it took him six months.

Anyone who wants the new Vista, which is expected to require far fewer steps to install than the V.A.’s version, must wait until August. Some, like Dr. Meyer Cohen, an internist in Boca Raton, Fla., want to see how it works before committing time and money to it.

But a few, like Dr. Ismet B. Kursunoglu, director of the Alaska Clinic in Wasilla, Alaska, cannot wait.

“There are a lot of fantastic vendors,” Dr. Kursunoglu said, “but, realistically, we’re in a time period where reimbursement is going down and costs are rising. This is free.”

“This,” he said, “is a fantastic opportunity.”

Copyright 2005 The New York Times

Posted by pnhp at 08:51 AM | Permalink

TO NATIONAL, LEGAL AFFAIRS AND HEALTH EDITORS:

San Antonio Jury Finds Humana HMO Liable for Negligently Managing Managed Care - HMOs Now Liable for Mismanaging Managed Care

SAN ANTONIO, July 21, 2005 —- In a verdict that will have widespread long-term implications for HMOs (Health Maintenance Organizations) across the nation and the estimated 130 million HMO enrollees they serve, a local jury on July 1 awarded $7.4 million in actual damages in a wrongful death lawsuit against Humana Health Plan of Texas Inc., a physician, and his physicians group under contract to provide health care services. Jurors were to consider punitive damages in the second phase of the trial, but attorneys for Humana and the plaintiffs reached an out-of-court agreement that capped those damages at $1.6 million, bringing the total amount of damages to $9 million. Humana will be liable for 35 percent of the $7.4 million in actual damages and the entire $1.6 million in punitive damages after all appeals are exhausted.

In the lawsuit, John Smelik and his two adult children accused Humana and others of negligence in the June 1, 2001, death of Joan Smelik, John’s wife of 47 years. Brant Mittler, a practicing cardiologist and a lawyer represented the Smeliks along with lead plaintiffs’ attorney Jon Powell, and Renee F. McElhaney, appellate counsel for the case from Cox Smith Matthews Incorporated, the largest law firm in San Antonio. Testifying as an expert witness for the plaintiff in this case was Dr. Linda Peeno, the internationally recognized patients’ rights activist and former Humana Medical Reviewer. Humana was represented by Wilson, Elser, Moskowitz, Edelman & Dicker, based in New York City.

The jury decision came after nearly three days of deliberation, culminating a three-week trial presided over by 224th District Judge Rene Diaz, a conservative Republican recently appointed to the bench by Governor Rick Perry. Judge Diaz most recently comes from an insurance defense background prior to being appointed to the bench. Judge Diaz recognized the importance of the case from the beginning which was demonstrated by his choice to bring in a larger than usual jury venire panel, appointing two alternate jurors, and by allowing the jurors to be paid the legal maximum of $50.00 per day.

The plaintiff challenged managed care not on the basis of denial of care but because Humana failed to exercise ordinary care in performing its obligations in managing care. In this respect, plaintiffs presented evidence that Humana failed to follow its own Member Handbook, Physicians’
Administration Manual, and internal guidelines, policies and procedures.
The jury found that Humana did not apply case management to Joan Smelik as a process of identifying patients with “chronic or potentially catastrophic”
diseases. Case management was also supposed to deal with patients with complex diseases. Mrs. Joan Smelik was a complex patient who according to Humana never hit the “triggers” to qualify for case management. Humana’s own computer records for Mrs. Smelik showed that Humana knew of her diseases even down to the size of each of her small kidneys, which were indicative of “chronic” kidney disease. Ms. Smelik had a documented episode of acute renal failure attributed in part to the effects on her kidneys of a combination of three drugs, specifically a NSAID agent (non-steroidal anti-inflammatory drug), a diuretic, and an ACE inhibitor in September 2000.
Then, Humana approved Vioxx, an NSAID type drug, in January 2001, and later approved the purchases of the exact same three-drug toxic cocktail of prescription drugs that had put Joan Smelik into renal failure five months earlier. Mrs. Smelik died from complications of renal failure requiring emergency dialysis in May 2001.

Ten of the 12 jurors did agree that Humana was among three of the named defendants who bore responsibility for Joan Smelik’s death. The plaintiffs alleged that Joan Smelik did not receive the health care promised by Humana’s own written policies and standards. Specifically, the plaintiffs demonstrated through testimony that Mrs. Smelik was suffering from emphysema, kidney disease, and a circulatory condition that affected the kidneys and should have been closely monitored in the months before her death.

“This jury has saved lives,” added Jon Powell. The jury forced Humana to go back and actually implement its policies and procedures that supposed to be aimed at making sure members with chronic health problems receive the health care and treatment that they need in order to survive.”

Along with Humana, the lawsuit named as defendants two doctors, Dr.
Michael W. Mann and Dr. Fred C. Campbell Jr., and the Alamo City Medical Group, P.A., which was Mann’s employer and the corporate health care provider under contract to Humana. Campbell cared for Mrs. Smelik under another health insurance provider.

Prior to the trial, which began June 13, all the defendants had agreed to out-of-court settlements with the Smelik family, except for Humana. The earlier settlements totaled $602,000. Nonetheless, jurors were required by law to attribute blame for the negligence among all the defendants.
Specifically, the jury found that Humana was 35 percent responsible, Mann was 50 percent responsible and Alamo City Medical Group was 15 percent responsible. Campbell was not assessed any blame by the jury.

“This case sends a clear message that when an HMO promises to manage care, then they have to do it. And when HMOs fail to do that, the court system will hold them responsible,” said Renee F. McElhaney.

A 2004 U.S. Supreme Court decision in Aetna vs. Davila made it more difficult for disgruntled patients to sue HMOs, such as Humana, in cases where plaintiffs who receive their health plans from employers are claiming a denial of medical care. The high court ruled those cases fall under the Federal Employee Retirement Income Security Act (ERISA), which applies to most of the millions who receive HMO care through their employers and limits the amount of damages that can be recovered in a negligence lawsuit to actual losses. Smelik v. Humana was pleaded as a mismanaged Managed Care case. The Smelik verdict potentially gives new hope to HMO enrollees who are under ERISA and believe that Aetna v. Davila pre-empts their ability to sue their HMO when HMOs demonstrate negligence, fraud, substandard care or denial of benefits.

“Joan’s case will empower people across the country to take back their right to quality affordable health care,” said John Smelik. “People should spend less time having to do battle with their HMOs and more time preventing illness. The system is sick and needs to be fixed so that enrollees who pay their premiums are able to rely on their health care providers. According to the experts who testified in this case, my wife should be alive today had Humana exercised ordinary care in performing its obligations in managing care. Instead, Humana paid for prescribed medications that caused kidney damage and failure; then they let her die claiming that she did not qualify for Case Management and kidney dialysis treatments.”

The Smeliks alleged that the care delivered by Humana and its physicians to Joan Smelik was substandard. Testimony showed that Mrs. Smelik had been under case management when Humana had outsourced that service to another health care provider. But when that contract ended and Humana began handling case management on its own, Mrs. Smelik’s case was not given the necessary extra oversight. Previously, employer based HMOs’ denial of health care benefits had been largely shielded from regulation by state legislatures with the Supreme Court decision in Aetna v. Davila. Now, the Smelik verdict empowers individuals to fight against HMOs when the HMOs are focused more on saving dollars than on saving lives.

“This jury verdict shows that people enrolled in HMOs, even those insurance plans bought through their workplaces, can still turn to state courts, and ask a jury of their neighbors, to hold HMOs accountable for mismanaged managed care,” commented Brant Mittler. “Joan Smelik should have been a managed care success story. Instead she was a managed care failure.”

SOURCE> The Powell Law Firm, San Antonio, Texas

07/21/2005

CONTACT:

Jon Powell, J.D., Lead Plaintiffs’ Attorney, +1-210-225-9300, Cell:
+1-210-336-0330, jonpowell@sbcglobal.net

Brant S. Mittler, M.D., J.D., Plaintiffs’ Attorney, +1-210-408-1189,
Cell: +1-210-827-4246, bsmitt@satx.rr.com

Renee F. McElhaney, Plaintiffs’ Attorney, Cox Smith Matthews Incorporated,
+1-210-554-5597, rmcelhaney@coxsmith.com

John Peter Smelik, Husband of Joan Smelik, +1-830-885-2462, bluejay9534@yahoo.com

Posted by pnhp at 01:14 PM | Permalink

UAW members help build movement for single payer health care

by Kim Ashby
Local 862

A grassroots movement is underway to educate people about single payer health care in Kentucky.

The goal of the movement is to educate people about the unjust treatment of patients and the profiteering of insurance companies. There are over 45 million people in the United States currently without health care, and 557,000 are in Kentucky.

More than 18,000 Americans die each year for lack of health insurance. Drug companies’ profits average four times those of other Fortune 500 companies. The United States is the only industrialized nation without national health care.

Our country pays 50 percent more of our Gross Domestic Product on health care than nations with national health care programs. Consequently, the richest country, according to the World Organization, ranks a mere 37th in the world in quality health care.

In 2003 a group of concerned individuals formed Kentuckians for Single Payer Healthcare (KSPH). Linda Peeno, a physician; David Bos, of the faith community; Kay Tillow, a nurse; Ann Walsh, activist; Garrett Adams, physician; Edgar Lopez, physician; and many others, including UAW members, are working to inform the public about the benefits of a single payer health care system.

They have formed a coalition of individuals joining with other organizations across the country working to pass universal, single payer health insurance as embodied in the plan of the Physicians for National Health Program and in HR 676, the Medicare for All legislation, sponsored by Rep. John Conyers, D-Mich.

HR 676 calls for a National Health Insurance Act, an expansion and improved version of Medicare for All. “Why is this issue important and what has it got to do with me?” is a question many people ask who have little knowledge about the subject. Often they have never given the issue a second thought because they have health care and believe they will be all right.

This is what the proposed bill would provide. The new legislation, if passed, would save billions of dollars now spent on unnecessary duplication and obscene administrative costs. It would eliminate profiteering health care.

HR 676 would allow individuals the ability to choose their own physicians. It would pay for prescriptions. It would include coverage for home health, nursing home, dental, vision, mental health, hospitals, office visits, physicians and rehabilitation. It would cover everyone and remain in place even if one lost a job or retired.

The Conyers bill would restore trust to a mean and broken health care system. It would provide that all employers pay a modest tax similar to Medicare. It would eliminate co-pays and deductibles. It would give to all Americans health coverage equal to that of each official in Congress.

By joining in coalition with other organizations and building a national movement strong enough to win the support of the elected representatives, the Kentucky Single Payer Healthcare group hopes to spread the message about single payer health care.

Another desire of the movement is to inform and educate the public about the issue. The Kentucky group is working toward a positive solution that puts an end to the anger and frustration provoked by an unjust health care system. KSPH is building toward hope and health for everyone by making what is morally right also politically possible within the state of Kentucky. If we can win a single payer health care system in Kentucky, KSPH then wants to help the single payer resolution spread to other states across the country.

Everyone can help spread the message by writing, calling or faxing your member of Congress and asking him/her to support HR 676, as introduced by Rep. John Conyers.

You can also visit the website www.cnhpnow.org and sign the petition for HR 676. Join Kentuckians for Single Payer Healthcare or start a movement in your own community or state to support single payer health care.

You can also ask a speaker from KSPH to come and talk to your group about the issue, circulate petitions, and get a resolution for HR 676 passed in your local union. There are endless possibilities of ways to get involved. Just look at the possibilities and seize the one that is most comfortable for you.

Want to join the movement to help build a better health care system that will take better care of every American? Click on www.kyhealthcare.org.

uaw.org
copyright © 2005 International Union, UAW

http://uaw.org/solidarity/rnews/05/q3/r3/r3_02.cfm

Posted by pnhp at 01:04 PM | Permalink

By Susanne L. King
Berkshire Eagle

LENOX

I WAS talking to colleagues this week about the health care reform bills currently before the state Legislature, and realized once again how complex and confusing this topic can be, even for health care professionals. All involved in health care reform are using buzzwords like “universal” to appeal to residents of our state, 650,000 of whom are uninsured, and 350,000, underinsured. We are a beleaguered population that is literally dying for change.

The Institute of Medicine has described five principles for health care reform: coverage must be universal (covering everyone), continuous (not tied to a job), affordable to individuals and families, and affordable and sustainable for society. In addition, coverage should enhance health and well-being by providing access to high quality care that is effective, efficient, safe, patient-centered and equitable.

Gov. Romney has proposed a plan with a mandate that everyone in Massachusetts must buy health insurance, with partial subsidies for individuals who earn less than $28,710. Romney’s plan would rely on the for-profit insurance industry to provide “bare bones” coverage, which would include deductibles and co-payments. His plan would control costs by tightly regulating expenditures for the poor, but would still leave patients with massive medical bills and possible bankruptcy after an expensive illness. He would enforce his mandate by taking away tax refunds or garnishing wages. This is a tax from a governor who says he’s against new taxes. And as usual, the middle income population would be hardest hit.

Both Senators Robert Travaligni and Richard Moore have also sponsored legislation for health care reform. They also use buzzwords like “health care for all” and “universal.” These words sound good, but are not indicative of what these bills would provide if they were enacted. Sen. Moore’s complex proposal would expand MassHealth and pay for health insurance subsidies for low income workers. Travaligni’s bill would provide tax deductions for health savings accounts and also expand MassHealth enrollment. Both would add more cost to the system, without providing health care for everyone.

In all three plans, choice of provider would be limited by the insurance coverage offered by an employer, or by the patient’s income. This is not equitable or patient-centered. Nor are the plans continuous, since they depend on a person having a job. Finally, they would not be affordable, because they rely on the for-profit insurance industry. Patients would still have to pay insurance premiums, co-payments, and deductibles, that make insurance policies unaffordable.

The only bill that could truly provide universal, continuous, patient-centered health care, that is affordable for both individuals and society, and is sustainable, is the Massachusetts Health Care Trust Legislation, Senate Bill 755. This is the “single payer” bill. All the buzzwords are actually true about this bill.

What single payer means is that the government would collect and dispense the health care funds. In other words, the government is the “single payer” since insurance companies are eliminated. Doctors and hospitals would still be private, and patients could choose where they would go and which providers they would see. Patients would have more choices in such a system. Doctors would have reduced administrative costs. Single payer health care would be “Medicare for everyone,” but without the limits and exclusions of the current Medicare program.

The other bills are unable to provide universal, comprehensive care at an affordable price, because the insurance companies take up to 30 percent of the health care dollar, and doctors and hospitals have additional huge administrative costs dealing with the myriad profit-making insurance companies that are reluctant to relinquish the money they have collected from patients.

Chasing the insurance dollar has become a nightmare for doctors and hospitals. And the cost of health insurance has become a nightmare for patients — one family told me their managed care insurance premium for the upcoming year has risen to $17,400.

Dr. Alan Sager, a professor at Boston University School of Public Health, reports that Massachusetts spends $52 billion per year on health care, 39 percent of which is attributed to administration and overhead costs of insurance companies, doctors, and hospitals. He has calculated that we have enough dollars in the health care system right now to cover everyone, and to provide more comprehensive benefits than are currently available now, including medical, dental, prescription drug and long term care benefits.

We do not need health care “reform” that does not provide universal coverage, is not continuous, is not affordable, is not patient-centered, and does not stem the rising costs of health care. For these reasons, we do not need the bills proposed by Romney, Travaglini or Moore, none of which meet the principles of reform elucidated by the Institute of Medicine, and all of which continue to subsidize insurance companies at the expense of patient health care.

Dr. Donald McCanne, past president of Physicians for a National Health Plan, says, “For a long time it has been clear that the single payer model of reform would provide a real solution to our health care crisis. But many voices have remained silent or muffled because of concerns about political feasibility.… It’s the politics. And more and more of us now realize that we must speak up if we ever expect to change the politics.”

The Joint Committee on Health Care Financing will hold a hearing at the Statehouse in Boston on The Massachusetts Health Care Trust Legislation (S. 755) on July 20. It is sponsored and supported by four of the five legislators from Berkshire County, although Sen. Nuciforo has recently pledged his support for Travaglini’s bill as well. He will need to decide which bill he supports, because the single payer bill and Travaglini’s bill are neither comparable nor compatible.

Please contact your legislators and let them know you support Senate Bill 755, or attend the hearing and give your testimony about your health care experiences. Demand that legislators stop tinkering with the current untenable system and go for single payer health care reform.

Susanne L. King, M.D., is a Lenox physician and frequent Eagle contributor.

http://www.berkshireeagle.com/otheropinions/ci_2862789

Posted by pnhp at 12:52 PM | Permalink

Job-sponsored health plans may be targeted for taxation
By Kevin G. Hall (Knight Ridder Newspapers)
CentreDaily.com
Jul. 13, 2005

For 60 years, American workers have received job-sponsored health-care benefits that are excluded from income and payroll taxes, but now they’re in danger of taxation.

An odd coalition of groups from both the right and left wants to tax those benefits, and a special presidential commission is weighing whether to recommend ending their tax exemption when issuing its report Sept. 30 on how to overhaul the tax system.

Left-leaning advocates call for ending the tax exclusion for job-sponsored health benefits in the name of fairness. They think the benefits are an invisible tax break for wealthier Americans that’s unavailable to poorer ones, who generally don’t get job-based health insurance.

“The tax break is regressive because people at the lower-income brackets get less benefit. It does just the opposite of what it should,” said David Kendall, a senior health-policy analyst at the Progressive Policy Institute in Washington.

Some right-leaning advocates think the tax exclusion for job-sponsored health benefits should end because it distorts the free market. The Heritage Foundation, a conservative policy-research center, says the exclusion leaves consumers in the dark about the real costs of health care, leading them to make uninformed decisions that ripple through the health-care economy, driving up costs.

Advocates on left and right agree on this: Ending the tax exclusion should be accompanied by a new national tax-credit system for health care.

“The mechanics of doing it don’t have to be revolutionary,” said Mark Pauly, an expert on health-care costs at the University of Pennsylvania’s Wharton School. “The main problem now is that the exclusion makes expensive insurance look cheap.”

http://www.centredaily.com/mld/centredaily/news/politics/12124748.htm

Comment: The deductibility of employer-sponsored health coverage represents regressive tax policy. It is blatantly unfair that taxpayers are reducing the cost of health insurance for higher-income individuals while making lower-income individuals pay much more (or accept stripped-down policies that fail to provide adequate financial protection).

But what would happen if the tax deductibility were eliminated in the absence of comprehensive reform? Employers are already looking for a way out of the health insurance quagmire. Even though insurance is part of the employee benefit package, losing deductibility would increase the employers net cost, assuming that employees would demand increased compensation to offset the loss of this tax benefit. Turning the rheostat up on the business community’s call for a “national solution” would be deafening.

So we can’t end the deductibility of employer-sponsored coverage until we are ready to enact comprehensive reform, but should that reform be tax credits? Tax credits would be a gift to the insurance industry. As premiums become less and less affordable for employers and for individuals, tax credits could be used to support the insurers’ market. If the tax credits are adequate to be certain that premiums are affordable and benefits are adequate, then the cost to the tax system would be far greater than the current tax loss through deductibility of premiums.

It is very unlikely that this is what conservatives have in mind. President Bush’s $1000/$3000 proposal would be grossly inadequate for moderate- and low-income individuals and would make health care unaffordable for the majority of Americans. Conservatives have suggested means-tested tax credits, but if these were large enough to be effective, then again the cost to the tax system would be inordinately high. Furthermore, it would increase the administrative complexity of our very wasteful system without providing any improvement in the functioning of our fragmented system of funding care.

What the conservatives do have in mind is a tax credit system that is affordable to the taxpayers. Small tax credits will buy small plans. Small plans will empower health care consumers to be prudent shoppers. They will be empowered to spend the money that they don’t have on whatever care nothing will buy. We must admit, that would certainly be effective in reducing health care spending.

We can get rid of the inequitable, regressive tax policies of employer-sponsored coverage, but not by compounding our problems through a system of tax credits. If we really want an equitable system that would ensure affordable access to comprehensive services for everyone, then we need to enact a program would work: a single payer system of national health insurance.

Posted by pnhp at 01:49 PM | Permalink

Carol Kirschenbaum’s vision lives on
By Bob Geary
altweeklies.com
June 22, 2005

The best thing about writing for the Indy is the chance, on a pretty regular basis, to talk to people who are generous of spirit and engaged in the hard work of trying to make the world a better place for the rest of us, not just for themselves. Even so, Dr. Carol Kirschenbaum stands out in my recollection. I met her five years ago, when she first went to the General Assembly with a simple idea—that “appropriate health care on a regular basis” should be everyone’s right in North Carolina. Carol was a fighter with a gentle soul. She was ahead of her time—we trust that’s the case, anyway—in seeing medicine as a gift to share, not something to be put up for bid. She knew her own time might be limited, and the goal beyond her own reach. But she kept on, with determination and a smile.

When I learned that Carol died last week at age 55, ending her eight-year battle with ovarian cancer, I re-read my story about her, called “Dr. K’s Cure.” We could run it again today, if we just changed a few numbers. North Carolina had almost 1 million people with no health insurance five years ago. Now we have 1.4 million. For those with insurance, premiums were increasing by almost 10 percent a year then. Now it’s double-digit increases, or else big co-pays and deductibles.

Carol’s legislation, which sought a referendum to amend the state constitution, was House Bill 1396 then. Now it’s HB 1358. The amendment, modeled after a similar provision about public education, would read: Health care is an essential safeguard of human life and dignity, and there is an obligation for the State to ensure that every resident is able to realize this fundamental right. Not later than July 1, 2007, the General Assembly shall provide by law a plan to ensure that by July 1, 2011, every resident of North Carolina has access to appropriate health care on a regular basis.

The politics of health care being how they are, Carol’s amendment is going nowhere in the legislature of 2005, just as it went nowhere in 2000. This country, alone among the so-called advanced nations of the world, still sells health care in the marketplace while treating the poor—belatedly, inadequately—out the back door. It was immoral then, as she said. It’s immoral now.

Carol Kirschenbaum wasn’t your typical doctor. For one thing, she worked as a special education teacher and then a physician’s assistant at UNC Hospitals before going to medical school at UNC-CH in her 30s. As her husband and partner, Dennis Lazof, wrote in an eloquent obituary (you can read it at www.ncdefendhealthcare.org/obit.htm ), she stood out to her mentors from the start for her dedication to patient comfort and well-being. She never lost that. Though her cancer eventually limited her ability to practice, she continued for as long as she could to care for a number of “unprofitable” and time-consuming patients who suffered from a disease called lymphedema that other doctors steer clear of.

As the founder of the N.C. Committee to Defend Health Care, Carol stepped into the debate over reforming medicine in the wake of the Clinton reform-lite disaster of 1993-94, when Democrats tried to get this country’s insurance companies to act a little more like healers and less like heels. She was convinced that only a single-payer system—a public system, that is, paid for by you and me—could rationalize the piecemeal services, and lack of services, that the health-care industry has created for us. But that would be step two, she thought. And maybe somebody else could think of a better idea. Step one was embracing health care as something we’re all equally entitled to have, regardless of income or place of employment. That’s what the amendment’s about.

Dennis was sitting shiva with family and friends Monday night at their home in Durham. He, too, is a gentle soul, and the talk was about good times and how they fell in love. When shiva ended, I asked him if Carol had been discouraged by the lack of progress toward reform. Not at all, he said. She was optimistic. Dennis, too, who was Carol’s partner in everything including NC-CDHC and a broader, national initiative of his own devising that you can read about on the Web site, thinks a breakthrough is coming.

Why? First, more and more people see that the current system doesn’t work. Huge sums of money are wasted as “providers” try to avoid the sickest, poorest patients. So support for change is growing “at a grassroots level.” Second, businesses recognize that skyrocketing insurance costs, and the uncertainty of coverage for their employees, is making them unstable. If you doubt that, ask any small business owner. For that matter, ask General Motors.

It won’t be long, Dennis believes, before business starts to call for universal public health care in the same way that, a century ago, it called for universal public education. “That started with a call in one state too, and then it spread to other states,” he said. “That’s how reform happens.”

Carol was very sick the last year, and he was her primary caregiver, so their work for the NC-CDHC lately was “weak,” he said. But the good news is, others have stepped forward to provide leadership and raise money. The committee has much more support now than ever, and is on the verge of being staffed full-time, he said, from an office that is not in their house.

It’s Dennis’s hope that Carol’s life, and death, will inspire a renewed push for reform. Donations to NC-CDHC will be split between work at the state level and the national project. Checks should be marked “Honoring Dr. K” and mailed to NC-CDHC, 1815 MLK Parkway #2, PMB #142, Durham, NC 27707.

Posted by pnhp at 01:44 PM | Permalink

Dr. Carol B. Kirschenbaum passed away peacefully in her home comforted by her husband Dennis and sister Susan early Thursday morning. Her passing concluded a courageous eight-year struggle with cancer, which was only the last in a long list of battles Carol fought and led. Born in Brooklyn, graduated from Bayside High and from Queens college, Carol came to Durham NC to train as a Physician Assistant (PA) in 1979 at age 29, following a brief career as a Special Education instructor. Carol actively cultivated and enjoyed close relationships with dear friends and family providing strength, support, love and many good times. She is survived by her mother, Pearl and brother Howard as well as her husband, sister and six nieces.

Carol practiced medicine first as a PA within UNC hospitals working in the Radiation Oncology unit. She was encouraged to continue her medical training towards an MD after her mentors witnessed her dedication to patient comfort and well-being. She trained at UNC-CH in medical school and also for her residency in Internal Medicine. During these years, Carol was actively involved in political and cultural events in the Triangle, founding Progressive Jewish Network, working on various Middle East and Central American Peace Committees, traveling to Nicaragua, working on medical relief to both Nicaragua and Palestine and as a board member of NC-Occupational Safety and Health Project along with other causes for social and racial justice.

Carol and Dennis met in late 1990. They married within the year having quickly recognized their soulmates in commitment to community, the outdoors and celebrations with friends and family. They enjoyed backpacking, swimming, camping and kayaking. They shared a special love for cross-country skiing, enjoying one pilgrimage north every year to enjoy the serene beauty of the quiet snow-covered woods. Most of these activities were continued and appreciated even more after Carol’s diagnosis of ovarian cancer.

As a physician Carol’s dedication to her patients was unparalleled. She was the only physician in our state who was trained in treating patients with lymphedema. Indeed, Dr. Kirschenbaum frequently saw patients who had not found care in neighboring states. Several of her patients for whom she was the primary physician had complex medical conditions, some severely obese. Many of these patients were “unprofitable, time-consuming patients” and had previously had little success in finding quality care. Carol advocated for the needs of patients with lymphedema and served for many years on the subcommittee for Lymphedema with the NC Cancer Care Commission.

During the most recent decade of her life Carol had been a leading proponent of universal health care in our state, as an organizer, first, for the NC chapter of Physicians for a National Health Program (PNHP) and then as a founding member and President of the North Carolina Committee to Defend Health Care (NC-CDHC). She saw NC-CDHC grow gradually into a vital statewide organization. Dr. Kirschenbaum was on the National Board of PNHP for several years, where she lobbied for recognition of the work being done at the state level and to establish a Right to Health Care, similar to the Right to Education (primary and secondary). Carol’s life continues to inspire those who witnessed her dedication to society’s least fortunate and underprivileged. Find out more about NC-CDHC at www.NCdefendhealthcare.org

Together with her husband a new national project was initiated to support and improve communication between all the organizations working for universal health care at the state level in 21 states. That project, Project EINO, based at www.EverybodyInNobodyOut.org has also become a major proponent nationally for the Right to Health Care at www.RightToHealthCare.org .

MEMORIAL FUND:

It is Carol’s wish that donations be made in her honor to “NC-CDHC” to be split between the state work and the national project. Please mark the check “Honoring Dr. K”. Such donations should be mailed to NC-CDHC/ 1815 MLK Pkwy #2, PMB #142 / Durham, NC 27707.

FUNERAL:

The funeral will be held at 10a.m. on Sunday at the Howerton-Bryan funeral home 1005 W. Main Street, Durham, NC. Following the funeral service a procession will take place to Markham Memorial Gardens.

SHIVA (BRIEF VISITS WITH FRIENDS AND FAMILY):

Family will be present at 306 Monticello Ave, Durham for Shiva. During the “shiva” friends and the entire community of Carol and Dennis’ contacts are invited to drop by and visit (no permissions, or scheduling is performed, in fact enter premises without knocking, or find your way around to back of house if weather is nice).

Shiva will be Sun, Mon, Tues 2-8 and Weds 12-4 (June 19 - June 23). If you wish, you can bring some fresh fruit, or salad to share.

306 Monticello is 3 blks from the corner of University Dr. and Cornwallis Ave in Durham. Proceed one short block SE on Cornwallis past the signal light that is Univ Dr, taking first right on small side street (Stuart), go 1/2 block to first street on left (Monticello Ave), go down almost two blocks to 306 - on left and only house on Street with a split rail fence in front yard.

Posted by pnhp at 01:41 PM | Permalink

Let’s let employers get out of the medical care business
By Jack E. Lohman
Milwaukee Journal Sentinel online
Posted: July 3, 2005

After spending 35 years in the health care industry, I never thought I’d be supporting more government involvement in medicine. But, clearly, our private system is broken.

Double-digit increases in health care costs are driving manufacturing jobs out of the country. That will continue if the system is not fixed.

Today, more Big Three autos are being made in Ontario than in Detroit. General Motors’ planned cuts of 25,000 jobs expose a trend that has been in progress for years:

GM spends $6,500 per year per employee in the United States for health care. But as it builds more of its cars in Canada, its costs will decrease to an $800 per employee per year tax to help cover that country’s single-payer system.

The sticker price on every GM vehicle includes $1,500 for health care, compared with $186 for Toyota.

What else can we reasonably expect but exodus?

It is by historical accident that employers provide medical coverage, and 40% of business leaders now want out of it. Canada’s single-payer system makes the most sense, although we can eliminate their wait times.

Even with its legendary wait times - which are short to non-existent when urgent procedures are required - Canada’s life expectancy is two years longer than ours, its infant mortality 35% lower, and all with 40% less in costs.

Turning health care administration over to one payer, as Medicare did, would keep the independence of physicians and hospitals and still allow patients full physician selection. It’s just a different way of paying the bill.

It would reduce administrative costs from a typical 30% to Canada’s 8%. Medicare’s is less than 4%. Using Medicare’s rules and fee schedule would ensure fair reimbursement, although increasing its rates slightly would make it fairer and still be less costly than what we have today.

Excessive and unnecessary testing easily adds 25% to our exorbitant health care costs, and that misuse must be curtailed.

One for-profit HMO pays its CEO $7.2 million annually, and he holds $720 million in company stock. That is patient money that is not being used for patient care. Independent physicians and hospitals are not totally free of extravagances, which also drives costs up.

Who would pay for a single-payer system? The same people who are paying for it today: Taxpayers.

We all pay for the present health care system, which costs some $1.6 trillion each year. And 100% of this money comes from we the people, through taxes, premiums, co-pays, deductibles, purchases, employer tax breaks and the other methods we use for collecting money.

When we buy a product, that company adds its health care costs to the price, and we pay at the cash register. What we are really talking about changing is how we collect and use the same money.

At the federal level, the health care, insurance and pharmaceutical industries are doing everything in their power to block progress toward an efficient system. While getting rid of our moneyed political system would fix this and many other societal problems, that isn’t going to happen soon. Politicians like the flow of campaign cash just as it is.

In the meantime, the states can act to keep jobs at home.

We can establish our own single-payer system by contracting with the same company that administers the Medicare system. With the savings, we could replace BadgerCare and Medicaid and cover all Wisconsin families.

It all makes sense for the public, but that may be its downfall.

Jack E. Lohman of Colgate is a former CEO of an independent diagnostic testing facility in Milwaukee and is executive director of www.WiCleanElections.org .

Posted by pnhp at 01:20 PM | Permalink

By Matt Leingang
Associated Press
July 10, 2005
In San Jose Mercury News

COLUMBUS, Ohio - A push for universal health coverage is being rekindled in some states by soaring health care costs and a lack of political support in Washington for federal changes.

Advocates of a single-payer system - where the government would collect taxes and cover everyone, similar to programs in Canada and across Europe - have introduced bills in at least 18 legislatures. Some are symbolic gestures, but heated debate is taking place in California and Vermont.

Opponents in California, where 7 million people are uninsured, argue that it would lead to prohibitively high taxes and bureaucratic nightmares. The bill’s author, Sen. Sheila Kuehl, says pooling the state’s money is the most efficient and inexpensive way of paying for health care.

“The level of misery with private insurers is rising, and that’s why we’re seeing this increased activity,” said Larry Levitt, vice president with the California-based Kaiser Family Foundation, which analyzes health care issues. “But whether one state can succeed, I don’t know.”

In Ohio, a group of doctors, union officials and religious leaders are gathering signatures to get a single-payer health system placed on a ballot next year.

Not since Oregon in 2002 has a state voted on a single-payer health system. Voters there soundly rejected it, as did Californians in 1994. Both times, the proposals came under fierce assault from the medical, insurance and pharmaceutical industries, which launched a battery of television commercials to oppose the movements.

Those defeats led many advocates to conclude that the single-payer movement was dead, given the lobbying power of drug companies and the health insurance industry.

But some advocates are counting on frustration with the current system to eventually turn the tide in at least one state by the end of the decade. Oregon supporters are aiming for another ballot measure in 2008.

Nationally, the number of uninsured Americans is 45 million and rising, and 16 million lack enough insurance to cover all their medical bills. Meanwhile, health care costs keep rising.

Premiums for employer-sponsored health plans rose an average of 11.2 percent in 2004, the fourth consecutive year of double-digit growth, according to the Kaiser Family Foundation. Companies across the country are raising employee fees for health care, increasing co-payments and decreasing benefits.

General Motors Corp. said in June that the crushing burden of providing employee health benefits is part of the reason it will cut 25,000 jobs over the next three years.

Dr. Ida Hellander, executive director of the Chicago-based Physicians for a National Health Program, said state campaigns show that people aren’t buying the Bush administration proposals, such as tax credits and private accounts to help more people buy private plans.

“When it comes to serious health care reform, there’s a lack of leadership among both Republicans and Democrats,” Hellander said. “People are fed up, and it’s reaching everyone, even people who thought they had good insurance.”

Mohit Ghose, spokesman for America’s Health Insurance Plans, the lobbying arm of the managed care industry, wouldn’t say if his organization is taking new single-payer movements seriously.

A publicly financed health system in any state would virtually wipe out the private health insurance industry there.

“We believe that a government-run system isn’t the solution,” Ghose said. “That said, we’re willing to work with all groups on improving access to health coverage.”

Mainstream medical groups, including the American Medical Association, oppose single-payer systems. The AMA fears they would stifle the development of new medical technology and create longer waits for patient care should government budg-ets become strapped for money, as many states currently are.

Advocates dismiss those arguments as scare tactics.

“There’s no other solution out there,” said David Pavlick, a member of the United Auto Workers in Cleveland, which has endorsed the Ohio campaign. “The system we have now is immoral, it’s foundering and it’s on its last legs.”

Pavlick said a single-payer system would be financed through a mix of payroll tax increases and new taxes on personal income. The new taxes would take the place of insurance premiums that many people currently pay for health coverage, and there would be no out-of-pocket expenses.

States would use their leverage to negotiate lower prices for prescription drugs and other health services, Pavlick said. Hospitals and doctors’ offices would be relieved of the hassles and expense of dealing with multiple health insurers.

Those claims have merit, said John Sheils, vice president of the Lewin Group, a Virginia consulting firm that conducted a study last year of how a single-payer system would work in California.

The study showed that the state would save $343.6 billion in health care costs over the next 10 years, mainly by cutting administration and using bulk purchases of drugs and medical equipment.

But Sheils said a single-payer system isn’t a panacea. States could be hard pressed to keep funding levels adequate during recessions, when tax revenues typically decline. That could lead to delays in patient services.

“There are positives and negatives with all types of health systems,” Sheils said. “The question that has to be asked is what are we getting out of our existing multipayer system that is worth all the money we are spending on it?”

Analysts say that despite flaws in the U.S. health care system, voters are still leery of making wholesale changes.

A Kaiser Foundation poll released earlier this year showed that 55 percent of Americans opposed a single-payer health system. Thirty-seven percent favored it.

Knowing that, some states are taking incremental approaches.

Maine started enrolling people this year in a state-private program that offers affordable health coverage to small businesses and families. The goal is to bring coverage to the 130,000 Mainers who lack it by 2009.

“It’s really going to the states to push health care reform along,” said Janne Hellgren, coordinator for a universal health care movement in Massachusetts. “Washington just isn’t willing to change the status quo.”

Posted by pnhp at 01:15 PM | Permalink

The Uninsured in California: Single-Payer Health Care
Project California
July 13, 2005

Serious ailments afflict California’s health care system. The “single-payer” model is seen by many as one possible cure. Advocates say such a system would provide universal coverage at less cost. But while single-payer has been much debated in California, it never has been enacted. Why? What are the obstacles it has failed to overcome?

E. Richard Brown, Ph.D., director of the UCLA Center for Health Policy Research, and Gerald Kominski, Ph.D., associate director of the UCLA Center for Health Policy Research, met with Project California to discuss the political and ideological obstacles confronting establishment of a single-payer system in California.

http://www.projectcalifornia.org/site/pp.asp?c=nmL9KgNYLyH&b=880703

Comment: This article was selected for today’s message because it provides a clear, highly credible, objective explanation of the single payer model of reform, and some of the obstacles to reform. You may find this article useful in your efforts to educate others about single payer.

Posted by pnhp at 12:27 PM | Permalink

Health Spending In The United States And The Rest Of The Industrialized World
By Gerard F. Anderson, Peter S. Hussey, Bianca K. Frogner and Hugh R. Waters
Health Affairs
July/August 2005

Do Americans have access to a greater supply of health care resources?

Surprisingly, Americans have access to fewer health care resources than people in most other OECD countries, measured in three major categories:
hospital beds per capita, physicians and nurses per capita, and magnetic resonance imaging (MRI) and computed tomography (CT) scanners per capita.

How much savings are possible through waiting lists?

Waiting lists could explain part of the difference in health spending between the United States and other OECD countries. However, there are several reasons to believe that they explain little of the difference.

First, not every OECD country experiences waiting lists, although every country spends much less than the United States on health care. The OECD Waiting Times project identified twelve OECD countries that considered waiting times for elective surgery to be a high priority but also identified seven countries besides the United States that did not perceive that they had a problem with waiting times. Health spending in the twelve countries with waiting lists averaged $2,366 per capita, while in the seven countries without waiting lists, it averaged $2,696-both much less than U.S. spending of $5,267 per capita.

A second reason is that the procedures for which waiting lists exist in some countries represent a small part of total health spending. Using U.S. survey data, we calculated the amount of U.S. health spending accounted for by the fifteen procedures that account for most of the waiting lists in Australia, Canada, and the United Kingdom. Total spending for these procedures in 2001 was $21.9 billion, or only 3 percent of U.S. health spending in that year.

From the Discussion:

Although malpractice litigation is a growing problem in the United States as well as in Australia, Canada, and the United Kingdom, there is limited evidence that it is responsible for much of the difference in health spending levels between the United States and these countries. In all four countries, malpractice litigation costs for claims against physicians are small compared with total health spending.

Another piece of conventional wisdom about why U.S. health care costs are so much higher than other countries’ is also probably overstated. It is common for people to wait for nonemergency medical procedures in some OECD countries, but these procedures do not contribute much to health spending.

In the United States, the procedures that necessitate waiting lists in other countries would account for only 3 percent of health spending.

The finding that litigation and waiting lists do not explain most of the higher U.S. health spending is perhaps not surprising considering previous research showing that the prices of care, not the amount of care delivered, are the primary difference between the United States and other countries.

These higher prices are increasingly making health care unaffordable for many Americans. Equally troubling, the more-costly U.S. health care has not resulted in demonstrably better technical quality of care or better patient satisfaction with care. Future U.S. policies should focus on the prices paid for health services and on improving the quality of those services.

http://content.healthaffairs.org/cgi/content/abstract/24/4/903

And…

Outcomes and Cost of Coronary Artery Bypass Graft Surgery in the United States and Canada
By Mark J. Eisenberg, MD, MPH; Kristian B. Filion, BSc; Arik Azoulay, BComm, MSc; Anya C. Brox, BSc; Seema Haider, MSc; Louise Pilote, MD, MPH, PhD
Archives of Internal Medicine
July 11, 2005

Coronary artery bypass graft surgery (CABG) requires substantial resources in Canada and the United States. However, patients undergoing CABG at US hospitals incur approximately twice as much cost compared with those at Canadian hospitals, with little difference in clinical outcome and despite shorter average LOS (length of stay). The difference in total in-hospital costs is almost equally attributable to differences in direct and overhead costs between the Canadian and US hospitals. This cost differential primarily reflects higher resource prices for products and labor and higher overhead costs in the United States resulting from a nonsocialized medical system.

http://archinte.ama-assn.org/cgi/content/abstract/165/13/1506

Comment: So why are health care costs so much higher in the United States than in other industrialized nations? Clearly, prices are higher.

Why are prices higher? Often the reason given is that we offer more high tech care than do other nations. But these studies suggest that we don’t, and, even if we did, we are not purchasing any improvement in quality outcomes. Although the costs of malpractice litigation and defensive medicine are frequently cited as a major contributor, these account for an almost negligible amount of the higher prices in the United States. Neither does the aging of the population account for a significant portion of the international variations in spending.

The authors tend to dismiss the administrative waste inherent in our system as being only a minor contributor to increased U.S. health spending. But numerous other studies confirm that the administrative burden is excessive and can be reduced with significant savings. Another potential source for savings by which all nations could benefit would be to identify and adjust supply side excesses (over-utilization) which fail to improve outcomes.

One other important factor that partially explains our high prices is that they are correlated with higher U.S. incomes and higher cost of living.

While we can be thankful about our nation’s wealth, most of us are quite upset about our excessive health care prices, especially when we can do something about it. We can begin by instituting administrative simplification and negotiated pricing through a single, universal health insurance program.

Posted by pnhp at 01:23 PM | Permalink

When it comes to providing broad-based social-insurance programs, it’s the government that’s rational and the market that’s dumb
By Jacob S. Hacker
The American Prospect
Issue Date: 05.06.05

Remember those bumper stickers during the early-1990s fight over the Clinton health plan? “National Health Care? The Compassion of the IRS! The Efficiency of the Post Office! All at Pentagon Prices!” In American policy debates, it’s a fixed article of faith that the federal government is woefully bumbling and expensive in comparison with the well-oiled efficiency of the private sector. Former Congressman Dick Armey even elevated this skepticism into a pithy maxim: “The market is rational; government is dumb.”

But when it comes to providing broad-based insurance — health care, retirement pensions, disability coverage — Armey’s maxim has it pretty much backward. The federal government isn’t less efficient than the private sector. In fact, in these critical areas, it’s almost certainly much more efficient.

To grasp this surprising point, it helps to understand how economists think about efficiency. Although politicians throw the word around as if it were a blanket label for everything good and right, economists mean something more specific. Or rather, they usually mean one of two specific things: allocational (or Pareto) efficiency, a distribution that cannot be changed without making somebody worse off; or technical efficiency, the most productive use of available resources. (There’s a third possibility, dynamic efficiency, but we’ll take that up in a moment.)

When the issue is health insurance or retirement security, allocational efficiency is really not what’s under discussion. Nearly everyone agrees that the private market won’t distribute vital social goods of this sort in a way that citizens need. Before we had Social Security, a large percentage of the elderly were destitute. Before we had Medicare, millions of the aged (usually the sickest and the poorest) lacked insurance. If we didn’t subsidize medical care — through tax breaks, public insurance, and support for charity care — some people would literally die for lack of treatment. Market mechanisms alone simply can’t solve this problem, because private income is inadequate to pay for social needs. This is one of the chief reasons why government intervenes so dramatically in these areas by organizing social insurance to pay for basic retirement and disability, medical, and unemployment coverage, and by extensively subsidizing the cost of these benefits, especially for the most vulnerable.

What’s usually at issue, instead, is technical efficiency: Are we getting the best bang for our necessarily limited bucks in these areas? The notion that the private market is, by definition, better at delivering such bang for the buck is the main rationale offered for increasing the already extensive role of the private sector in U.S. social policy. Thus, Medicare vouchers or partly privatized Social Security would supposedly engage the discipline of competition and lead to more efficient use of resources.

Liberals usually retort that social policies have other goals besides efficiency, most notably distributive justice. That’s true enough, and it’s another major reason why we should be profoundly skeptical of unqualified paeans to the private sector. In theory, it might be possible to design social-insurance programs that rely on the private sector but do everything that current programs do. In practice, however, privatized approaches almost invariably change the distribution of who gets the benefits, because they tend to erode common pools and subsidies (indeed, that’s what their advocates often want). Yet there’s no reason for advocates of social programs to cede the ground on efficiency while raising broader concerns of this sort, because in health and social policy, what is most just is also, in a great many cases, most efficient as well.

Broad-based insurance, after all, is not like widgets. In the fiercely competitive market of economics textbooks, multiple sellers appeal to multiple buyers who have good information about the comparative merits of relatively similar products. Competition squeezes out inefficiencies and yields optimal outcomes. But “markets” for social insurance don’t work like this. In particular, information in these markets is both scarce and unequally distributed. This leads, in turn, to all sorts of familiar distortions on both sides of the transaction. Consumers, for example, can saddle private insurers with “adverse selection,” which occurs when only high-risk folks buy insurance. The “moral hazard” problem crops up when people are insured against costs that are partially under their control, and then engage in risky behavior. On the producer side, health-insurance companies can take steps to avoid costly patients, and purveyors of retirement products can gull unwary retirees in order to enrich insiders. All of this is why insurance aimed at achieving broad and necessarily social objectives has never worked well, or indeed at all, without some government support and regulation. And it’s also why it often makes sense for that support to take the form of public insurance.

Notice I say “insurance.” The real issue in the big-ticket areas of U.S. social policy isn’t public versus private services. It’s public versus private insurance. Medicare buys essentially all its services from the private sector, and no one wants that to change. What some want to change is the degree to which Medicare is in the insurance business, and it’s here that all the efficiency advantages of the public sector become clear.

Perhaps the most obvious is the advantage that neither side wants to talk about: compulsion. In the realms of public policy under discussion, however, compulsion is often necessary to make the market work. Think about what would happen if younger and healthier senior citizens were allowed to opt out of Medicare for private coverage: The broad risk-pool of the program would collapse.

Broad programs also have another big advantage: They are ridiculously inexpensive to administer. The typical private health insurer spends about 10 percent of its outlays on administrative costs, including lavish salaries, extensive marketing budgets, and the expense of weeding out sick people. Medicare spends about 2 percent to 3 percent. And Social Security spends just 1 percent. Even low-cost mutual funds have operating costs greater than that.

Here is where critics of social insurance usually pull out their trump card — the claim that social insurance is not just inefficient but unaffordable. Maybe social insurance is, in some sense, efficient; but, these critics argue, its inexorable growth will lead the United States to financial ruin. And it is true that the growth of social insurance isn’t slowed by the usual market brake of consumer willingness to pay. (If it were, as just emphasized, it wouldn’t work.) But that doesn’t mean that there are no brakes at all. If it did, the federal government would now be a leviathan, rather than — as is the case — about as large as it was in the early 1970s. Americans don’t decide individually how much of their income to devote to social insurance. But, through their elected representatives, they do decide — in a rough way, of course — how much of the nation’s income to devote. Spending has trade-offs, in the form of higher taxes and forgone priorities, and those trade-offs are visible in people’s tax bills and everyday lives, and in public debate. Anyone who has followed recent political fights knows that politicians are not evading the rising costs of social programs.

What’s more, the government has another advantage when it comes to holding down costs: It is a powerful negotiator. Medicare pays doctors and hospitals less per service than does the private sector, and its costs have grown more slowly than private health plans over the last 30 years, despite huge technological advances in care for the aged. Medicaid is even more austere (some might say too austere): Its payments are well below private levels, and it negotiates bargain-basement prices on prescription drugs — something Medicare has been barred from doing. The main reason that Medicaid’s costs are rising so rapidly is not that it pays exorbitantly for services but that it covers a lot more children and families than it used to, a good thing in an era in which private coverage has plummeted. Lest government’s use of its countervailing power to hold down prices seems illegitimate, it’s worth remembering that this is exactly what HMOs and other big health plans were supposed to do — but Medicare and Medicaid do it better.

To be sure, public insurance could still dampen what economists call dynamic efficiency, that is, innovation and improvements in quality. But in some areas, like sending out retirement checks, it’s not clear where the innovation will come from, while in others, like micromanaging providers, it’s not clear that the private sector’s “innovations” are really worth emulating. Many of the innovations have to do with discriminating against people at risk of getting sick, micromanaging doctors, and shifting out-of-pocket costs onto patients. Profit-motivated entrepreneurs quickly realize that the most effective way to minimize costs is to get rid of the people most likely to need care. This may be efficient from their perspective, but it’s obviously not efficient for society.

Plus, when it comes to the most basic and important form of dynamic efficiency — namely, quality control and improvement — the public sector is arguably as capable as the private sector, and probably more so. As Phillip Longman has argued in an important Washington Monthly article on veterans’ health care, the Department of Veterans Affairs (VA) has used its central power to create a model evidence-based quality-improvement program. Although the Medicare program still has a long way to go to match the VA, no one disputes that it conducts more rigorous reviews of technology and treatments than private health plans do. Indeed, private plans use Medicare’s criteria for covering treatments as their standard of medical necessity. Information about quality is a classic public good — everyone benefits from it, but few have strong incentives to supply it. A large insurer with extensive data on its patients and considerable power to reshape market practice is arguably best positioned to provide such a good.

And this is simply to focus on efficiency. As noted already, the public sector runs circles around the private sector in terms of equity, the other major rationale for social insurance. If the current functions of social insurance were just turned over to the private market, vast numbers of people simply wouldn’t be able to afford anything as good as Social Security and Medicare. Conservatives like to argue that everything provided in the Social Security package — the annuity, disability, and life-insurance coverage — could just be purchased in the private market. It could, but at far greater cost for most Americans, and many applicants would be deemed “uninsurable.” All of which suggests that the claim that social programs are “inefficient” is often just a politically correct way of saying that they don’t follow the usual market logic of giving the most to those with the greatest means.

Liberals frequently stress the equity argument but buy into the efficiency critique because they recognize, correctly, that the market is usually tremendously efficient. But they shouldn’t accept that premise when it comes to social insurance. Well-functioning markets are indeed efficient for ordinary commerce, but well-designed social insurance is almost always more efficient than its market counterparts when it comes to dealing with the basic social risks that capitalism invariably produces. It’s high time for liberals to say what logic, evidence, and the lived experience of citizens all show: The efficiency attack on social insurance, far from a self-evident truth, is usually an attack on the ideal of social insurance itself — the notion that everyone, regardless of income or likelihood of need, should be covered by a common umbrella of protection. And, ultimately, social insurance is good for the efficiency of society as a whole, not just because it provides much-needed protections at a reasonable cost, but also because it allows people to deal with what FDR once called the “hazards or vicissitudes” of modern capitalism without draconian restraints on the free play of the competitive market.

So the next time someone complains to you about the compassion of the IRS, the efficiency of the post office, all at Pentagon prices, tell them you’d be happy with the efficiency of Social Security, the compassion of Medicare, all at Medicaid prices.

Jacob S. Hacker, a political scientist at Yale and New America Foundation fellow, is the author of The Divided Welfare State, as well as of the forthcoming books The Great Risk Shift and, with Paul Pierson, Off Center: The Republican Revolution and the Erosion of American Democracy.

Posted by pnhp at 08:17 AM | Permalink

CEOs Defend Healthcare Deal
By Debora Vrana
Los Angeles Times
July 9, 2005

UnitedHealth’s William W. McGuire and PacifiCare’s Howard Phanstiel described the $8.1-billion deal (the acquisition of PacifiCare Health Systems Inc. by industry giant UnitedHealth Group Inc.)… as a step toward a more rational healthcare system.

“We’re going to bring in some new things there,” (McGuire) said. “This very much fits into our agenda to try to bring better healthcare services to different constituents and do it in a way that is unbounded by geography and other traditional restraints. I’m committed to it as I can be.”

Over the long term… an answer (to problems with the nation’s healthcare
system) will involve finding a way to ensure that everyone receives a minimum level of care, he said. But some treatments will be available only to those who can afford them.

“There is not enough money to pay for the healthcare system as it operates today. It is indiscriminate, it is non-scientifically based, it is founded on anecdote as much as it is science,” McGuire said. “We have to change course.”

Phanstiel, 56, would become an executive vice president of UnitedHealth Group and remain in Orange County. He said Friday that he would reap about $190 million from the transaction in PacifiCare stock options, restricted shares and other equity instruments (plus about $25 million in other benefits).

“I’m not doing this to get money…,” Phanstiel said.

http://www.latimes.com/business/la-fi-united9jul09,1,6408727.story

Comment: Just to be clear, this is not “to get money,” but it is to “change course” by being certain that “some treatments will be available only to those who can afford them.”

The United States stands alone in rationing health care for the uninsured based on the ability to pay. UnitedHealth/PacifiCare is joining the process of expanding this uniquely American concept into rationing health care for the insured as well, based on the ability to pay.

If insurance is no longer about the egalitarian concept of sharing risk, then what is it for? Maybe it really is “to get the money.”

Posted by pnhp at 02:42 PM | Permalink

The Nuffield Trust
The Public-Private Mix for Health
Edited by Alan Maynard

This book, written over 20 years after the publication of a similar collection of essays, examines again the complexities, frustrations and progress of healthcare systems in a leading group of rich countries. Like its predecessor, it offers few panaceas, but the insights of its authors show that the political and economic challenges of healthcare reform are now better articulated, if still largely unmet. The resilience of some of the obstacles to efficient reform articulated over 20 years ago and examined here again demonstrates the power of public and private interest groups in resisting changes that will benefit the patient. The ongoing battle between funders, providers and consumers is the business of healthcare, like many other markets. The characteristic of healthcare, however, is its resistance to change and the preservation of inefficient practices by management techniques appropriate for Dickensian times.

Despite differences in culture, history and resourcing, the nature and performance of healthcare systems worldwide are very similar. Political debates about healthcare reform are dominated by covert ideological arguments, and the policies these debates produce are generally ill-focused in terms of resolving well-evidenced common performance and incentive problems. As a consequence, the political necessity is created for the next often-irrelevant ‘redisorganisation’ of structures, epitomised nicely in the behaviour of successive Dutch and British governments, both having adopted, abandoned and readopted reforms in the past 15 years. Such changes usually fail to define the causes of inefficiencies in performance and pay scant attention to how better systems of incentives can be implemented to remedy performance problems.

http://www.radcliffe-oxford.com/books/bookdetail.asp?ISBN=1+85775+701+7

Comment: If you wish to be a serious participant in the national dialogue on health care reform, this book is an absolute must-read.

The United States has a unique position amongst the wealthier nations. We have the most expensive health care system, yet we are the least effective in ensuring affordable access to care. Everyone agrees that we need change, but we fail to move forward with reform because we are locked up in the debate as to whether the private or public sector would serve us better.

Before this book discusses the relative roles of the public and private sectors in the health systems of various nations, it discusses the pervasive role of ideology in the optimization of the public-private mix. Although the debate over the public-private mix is often framed as a linear spectrum with libertarians and authoritarians at either end, the authors instead describe the libertarian-egalitarian polarity. Much of the political process of reform is driven by these ideological positions.

The problem is that the debate over ideology is the wrong debate. Instead the dialogue should be over the best mechanisms to provide efficiency, control of expenditures, and ensuring equity in funding and access. No system will be purely public or private, so decisions should be made on changes that will improve the functioning of the system based on understanding of the impact of various well-described policies. Effective solutions would invariably have the support or opposition of ideologues, but the ideology should not control the process. Health policy science has advanced dramatically in the past couple of decades, and we have the knowledge on how to make the systems work.

Many lessons of the public-private mix can be learned from the discussions in this book of the systems of the United Kingdom, United States, Canada, France, Scandinavia, Germany, New Zealand and Australia. Single payer supporters will be particularly interested in the chapters on the United States by Uwe Reinhardt and on Canada by Robert Evans. But we should not allow our egalitarian, single payer ideology to deter us from reading the other chapters which help to clarify the advantages and the deficiencies of various government and market solutions.

As Professor Maynard states, “Political debates about healthcare reform are dominated by covert ideological arguments, and the policies these debates produce are generally ill-focused in terms of resolving well-evidenced common performance and incentive problems.”

It’s time to end our policies of “redisorganization” and move forward with rational reform. Optimizing patient care is too important of a process to worry about the response of ideologues, whether or not they’re pleased with the results.

Posted by pnhp at 08:46 AM | Permalink

Book Review by Don McCanne
The New England Journal of Medicine
July 7, 2005

Universal Coverage: The Elusive Quest for National Health Insurance

(Conversations in Medicine and Society.) By Rick Mayes. 207 pp. Ann Arbor, University of Michigan Press, 2004. $26.95. ISBN 0-472-11457-3.

Observers of the U.S. health care scene cannot help but be perplexed by the enigma of a system of funding health care that leaves so many patients financially vulnerable, in spite of per capita spending on medical care that is almost twice that of the average industrialized nation. We tend to look for relatively simplistic explanations of this phenomenon, but most theories are too narrowly focused to provide adequate enlightenment. In contrast, in this book, Rick Mayes provides a political history of the reform movement that demonstrates why it seems almost improbable that national health insurance ever could have reached the threshold of political feasibility.

Mayes begins with President Franklin Roosevelt’s decision to abandon his attempt to include national health insurance in his Social Security legislation. Roosevelt feared that the opposition of the politically influential American Medical Association would doom his entire program, a risk that he dared not take. Mayes then describes several other critical junctures at which comprehensive reform again seemed feasible but failed each time, primarily because of a lack of the requisite political alignment of influential interests. The one notable exception was the success during the Johnson administration in enacting the Medicare and Medicaid programs. Mayes ends with a description of the politically inept effort of the Clintons, which never could have produced a consensus.

Perhaps the most important contribution to understanding why the quest for universal coverage remains elusive is Mayes’s description of the various incremental measures that were effective in increasing coverage but, ironically, solidly institutionalized the reforms and thus made it more and more difficult to enact a universal system. Even Social Security, as one of the most popular government programs ever, was a factor, since Medicare was a logical expansion of the provision of security in retirement. Labor’s eventual support of employer-sponsored coverage, with the acquiescence of business interests, firmly secured the position of the insurance industry as a major player in health care funding. Medicaid nominally fulfills the commitment to provide coverage for patients in poverty, and many believe that tweaking this program would provide the final major increment of bringing in low-income people who currently do not qualify for Medicaid.

Although Mayes does fill in the blanks in confronting the complexities of health care reform, nevertheless it is clear why many observers believe that refinement of our current institutions would be adequate and that a comprehensive national health insurance program is not necessary.

Such complacency ignores the fact that many of the tens of millions of people without coverage do suffer adverse health outcomes and even death.

Also disconcerting is the fact that the newer, ubiquitous, innovative insurance products are no longer adequate to ensure either financial security or health security. But Mayes does give us hope. Although he acknowledges that critical junctures are rare, he notes that they do occur, especially in response to unmet social needs. Perhaps the deterioration in insurance coverage that has taken place may have brought us much closer to our next critical juncture than most of us realize.

Don R. McCanne, M.D.
Physicians for a National Health Program Chicago, IL 60602 don@mccanne.org

http://content.nejm.org/cgi/content/full/353/1/103-a

Copyrighted © 2005 Massachusetts Medical Society

Posted by pnhp at 08:17 AM | Permalink

By Dan Kurland
Charleston Gazette (Charleston, WV)
May 13, 2005

May 1-8 was Cover the Uninsured Week, a time to focus on the broader health-care crisis. Writer Alwin Hawkins sums up the situation fairly well: “Everything I see we can do to fix the problem is either politically, ethically or financially disastrous.” But that’s probably not what you wanted to hear.

Health care is funded in a la-la world of cost-shifting. Uncompensated care is covered by overcharging those who actually pay. Charity care is partially reimbursed by the government. Everyone thinks someone else is paying. No one realizes that whether insurance is based on individual contributions, employer contributions, or government programs, in the end individual citizens pay all health-care costs out of pocket, in higher prices and lower wages, or in taxes. And insurance companies, like casinos, never lose.

Oh, for a while there seemed to be a glimmer of hope. HMOs tried to restore fiscal restraint, and the Clintons, bless their hearts, thought by satisfying everyone they could satisfy everyone. But it just wasn’t that simple. Vested interests just don’t play nice with others. It’s against their nature and their interests.

So here we sit, watching retirees lose pension benefits, the employed endure higher premiums and co-pays, and businesses cut back benefits. Defined contributions replace defined benefits, and why shouldn’t they? Costs have skyrocketed. Why make promises you can’t keep? It’s not business’s fault that prices went up, or that workers want affordable health care.

As more people drop from the lists of the insured, states seek ways to insure the growing number of uninsured. Not by subsidizing insurance, of course. There’s no money for that. Instead they look to low-cost private insurance packages. But low cost implies low coverage. Fewer services, higher co-pays, higher deductibles and lower maximum benefits. Yet everyone benefits: The uninsured are offered coverage, the insurance industry gets a new product to sell, and providers are protected against the rising costs of uncompensated care. Without insurance companies, after all, how would people get health care? (Hint: the public education system.)

As states create new initiatives to insure the uninsured, reduced federal Medicaid funding forces those very same states to uninsure the otherwise Medicaid-insured. There’s a war going on, and tax cuts to save. We must keep our priorities straight.

And keep our values straight as well. People can make up their own minds when they buy a car, why not a heart transplant (read: consumer-directed choice)? They can save for a vacation, why not a bypass (read: health savings account)? Must government always tell us what to do? Smoking, drinking, Big Macs and Barcaloungers. Wait long enough and there’ll be a pill for obesity. We all know it. Trust me. Wait. You’ll see the ad on TV.

We have moved from physician-based health care to pill-based health care, from a needs-based (I feel sick) to a market-inspired (…may last for four hours…) health-care system. We take pills for diseases we never imagined we had, whether there is clinical evidence to support their value or not. Everything is marketing. Once physicians start owning imaging centers, they obviously need volume (patients) to amortize their investment. Economic necessity clearly cannot be denied.

Of course, in time it will all catch up with us. Skyrocketing prices and continuing unhealthy lifestyles will lead to fewer insured and more uncompensated care and increased financial strain on the health-care industry. Providers will be forced to turn away Medicaid patients because below- cost reimbursement policies are sucking them dry. Whoops! That’s already happening! Government will have to step in to save failing hospitals to assure medical care.

When people are dying on the streets — or worse, health-care companies are going south on the stock market — others might actually take to the street and demand something be done.

When providers no longer have economic and political leverage, real changes can be made. We’ll be free to replace doctors with nonphysician health-care providers for preventive procedures, to insist on doctor-pharmacist collaboration in disease management, and to reimburse home care instead of hospital care. We’ll have the will to limit each patient to a single transplant, to ban Cheetos, to forbid Game Boys, and to prohibit low-probability end-of-life care. We’ll be free to legislate that school buses drop our children a half mile from schools to assure they get their exercise, and that all school lunches have two vegetables (not counting ketchup).

At least we won’t have to make the hard decisions. They’ll have been made for us.

Kurland is health action coordinator of Covenant House and creator of the Web site www.criticalreading.com

Posted by pnhp at 11:02 AM | Permalink