Saturday, June 27, 2009

Dear Senator Brownback, #2

Dear Senator Brownback:

I wrote to you the other day regarding my concerns about including the preservation of for-profit insurance companies as a key piece of health reform.The testimony of Wendell Potter, former head of corporate communications at CIGNA, on June 24, before the Senate Commerce, Science and Transportation Committee which you sit on enhances this concern.

While I know that you were there, I believe that his statements are very serious and suggest a dangerous activity among insurance companies, possibly including conspiracy. He said, as you remember:

"I know from personal experience that members of Congress and the public have good reason to question the honesty and trustworthiness of the insurance industry. Insurers make promises they have no intention of keeping, they flout regulations designed to protect consumers, and they make it nearly impossible to understand - or even to obtain - information we need. As you hold hearings and discuss legislative proposals over the coming weeks, I encourage you to look very closely at the role for-profit insurance companies play in making our health care system both the most expensive and one of the most dysfunctional in the world. I hope you get a real sense of what life would be like for most of us if the kind of so-called reform the insurers are lobbying for is enacted.

"When I left my job as head of corporate communications for one of the country’s largest insurers, I did not intend to go public as a former insider. However, it recently became abundantly clear to me that the industry’s charm offensive - which is the most visible part of duplicitous and well-financed PR and lobbying campaigns - may well shape reform in a way that benefits Wall Street far more than average Americans."

In a truly competitive marketplace, companies would compete on the quality of their product and the price. In health insurance, they compete to find creative ways to insure only the healthy and avoid having to cover those who are sick. This is not only bizarre, it is intolerable and must not be allowed to continue.

I know that you care deeply about the health of our people, and are aware how damaging this is.Please, please do not let ideology block this one great opportunity for getting meaningful health reform for Kansans and other Americans. Stand against having for-profit insurance companies have a role. At LEAST support a meaningful public option; the opposition of thse companies means that they know that they have a bad product that cannot compete in an open market.

Please do not hesitate to contact me if I can help in any way.

Thank you
Joshua Freeman, MD

Wednesday, June 24, 2009

Dear Senator Brownback: A letter my Kansas Senator

Dear Senator Brownback:

Thank you for the response to my letter urging your support for health reform, and particularly health reform based upon a single-payer mechanism, such as that proposed in the House’s “Improved and Enhanced Medicare for All” bill, HR 676, or Sen. Sanders’ “American Health Security Act”, S. 703. Although you disagree with this approach, you have indicated your clear desire to have the highest-quality health care, at the lowest possible cost, available to all Americans, so I know that we agree on the end goal. Therefore, I hoped to be able to discuss some of the issues that you raise, and perhaps explain why it seems to me (as well as to many others) that a single-payer system would be the best solution. It is my hope that by keeping the end goal in mind, and looking at the issue, we can transcend partisan positions. Or, if not, clarify the core areas on which we disagree rather than using “sound bite” statements that obfuscate them. The New York Times reports today (June 24, 2009) in the article “Baucus grabs pacesetter role on health bill” (, that Sen. Baucus is perceived (or perceives himself) as being able to reach across the aisle more toward Republicans; it also suggests he may not be trusted completely by stalwarts of either party. I do not know about this, this is your area and not mine, but I know you are a leading Republican, and my senator, so I would like to address what may be in the best interests of Kansans, as well as other Americans.

As you note, prevention and wellness are areas that need more focus – and more funding. The simple fact is that most of the money spent in health care (of the part that goes to health care, and not administrative overhead and profit) is spent on treatment, and often the most complex treatment. This means that physicians who do things to people, and particularly end-stage complex things to people, are much better reimbursed than those who care for people by doing prevention, screening, chronic disease management, and providing a medical home. Our health system is far too heavily overbalanced to sub-specialists, with only about 30% primary care physicians, instead of the needed 50%+. And, with scarcely over 20% of students entering the primary care specialties of family medicine, general internal medicine, and general pediatrics, we are never going to get there. And when the income differential is not a little, but 200%, 300%, 500% -- we are not going to get students, especially with their onerous loan burdens, to enter primary care.

And while preventing disease is a good thing for peoples’ health, but may not save money. If you really wanted to save money on health care, you’d ask everyone to eat a high fat diet, smoke, not exercise, and drop dead of a heart attack at 45 before they could get to the hospital. That would save money on health care, but be a bad thing for them and their families and their communities, and ultimately cost us all a great deal. Prevention is good – when it is evidence-based – because it prevents disease, not because it saves money.

I am afraid that consumer-directed health care and health savings accounts are fatally flawed because, while at any given time they may meet the needs of a majority of people, those are not the people who need health care and cost us money. An appropriate health system or financing plan must understand that it can’t be “majority rule”, but be based on a social approach. Only a small percentage of us are sick at any given time, and a smaller percent use most of the health care dollars. Five percent of the people account for 55% of health costs, and 10% for 70% of the costs. The costs are not managing your cold, or blood pressure, or bad knee, but for people with cancer, older people with multiple chronic problems who are frequently hospitalized, babies in NICUs, and young car-accident victims with multiple trauma surgeries, etc.

You are concerned about bureaucrats becoming involved in health care and getting in between the patient and physician in making health care decisions. So am I; in fact I am all too familiar with it, as this is what happens now. Bureaucrats have great influence over what health decisions will be made, but they are insurance company, not government, bureaucrats. People often do not get to keep their doctors, because often when an employer changes insurance plans, or the insurance plan changes their physician panel, they have to change. If a person changes his or her job, or (all too frequently especially recently) loses his or her job, they probably will have to change doctors, or may not have a doctor at all. I know that it is popular to “knock” government bureaucracy, but it has nothing on insurance company bureaucracy! One of the most important differences is that the government is at least supposed to work for us; at its best it does, it listens. Indeed, you, my senator, are the government, and are willing to listen to your constituents. For-profit insurance companies report only to their shareholders and no one pretends they need to answer to us – and they sure don’t! Currently, even “non-profit” insurers, like the Blues, behave in the same way in order to compete.

As you well know, in your role, it is easy for people to get confused when complex issues are involved. Therefore, when I say that I advocate single-payer I want to make clear two important distinctions. The first is that between being able to choose where you get your health care – who your doctor is, what hospital to go to (provided you live in an area where the choice exists), and having a choice of insurance companies. People care a lot about the first; no one (except the insurance companies, of course) cares one whit about the second. The only thing people care about with regard to their insurance is whether they are covered, what their co-payments and deductibles are, what their maximum costs are. Who that insurance company is has no relevance to them. Therefore, a single payer system that covers everyone the same, but allows people free choice of healthcare providers, meets that need.

The second distinction is between how much money is spent per capita by a health system and how it is distributed. First of all, stories about waits in other countries and lack of access to care are grossly overblown, and mostly come from the wealthy who, when you get down to it, really think that they should not have to stand in line with others. The data – rather than anecdotes – decisively demonstrate that the health of the population – not just those with insurance, but counting everyone – is better in every other industrialized country. But to the extent that there are waits in other countries, even if the outcomes are better for their population, that is a result of what they spend per capita, usually half to 2/3 of what we do. If, for example, the UK spent anywhere near what we spend per capita now but distributed it the way they do, there would be no waits and the health of the population would be even better. We spend more than we need to provide outstanding health care for all, but still have 47 million uninsured people and inadequate (and in some cases near third-world) health outcomes. Study after study, including the 2008 study done for the Kansas Health Policy Authority, show that single-payer would be the only system that would both cover everyone and save lots of money. That is a win-win. Instead, we are paying and not getting. Some of this is from the overuse of expensive tests and procedures, but much of it is insurance company profit and administrative waste.

Now, I understand that one person’s “waste” is another person’s income; I may say that insurance company profit is waste, but they like it, and they use it to lobby and make campaign contributions. However, that should not affect the legislative process. The American people care about having access to quality health care. They do not care about insurance companies. It would be grossly immoral for the Administration and Congress to pass a health plan predicated on maintaining the profits of insurance companies.

I have indicated that I favor single-payer, but I am willing to be convinced if there are other options that will cover everyone, provide for access to quality health care for everyone and save money. I will not accept that it has to save insurance companies, at least in the for-profit form. Many other countries use not-for-profit insurance companies to administer their health programs; maybe that would work. But issue number one, the sine qua non for a good health system, is the elimination of for-profit insurance companies. Only then can we work on the other areas of health care quality that need to be improved.

I encourage you, and all your colleagues in the Kansas delegation and in Congress, to pledge that only the interests of the health of the American people will affect your health reform decisions, and that you will give no consideration to maintaining the profits of the health insurance industry.

Thank you for your attention.

Joshua Freeman, MD
Kansas City, KS

Monday, June 22, 2009

Government sponsored health coverage: The Good, the Cautionary, and the Ugly

The good news:
The recent New York Times/CBS News poll (June 21, 2009, demonstrates conclusively that, as the headline reads, there is “Wide Support for Government-Run Health”.

“The poll found that most Americans would be NY Times willing to pay higher taxes so everyone could have health insurance and that they said the government could do a better job of holding down health-care costs than the private sector…72 percent of those questioned supported a government-administered insurance plan — something like Medicare for those under 65 — that would compete for customers with private insurers.”

Sound like overwhelming support for a single-payer plan, especially one like that called for in the “Improved and Expanded Medicare for All Act”, HR 676, with 100 co-sponsors in the House of Representatives (

Sixty-four percent said they thought the federal government should guarantee coverage, a figure that has stayed steady all decade. Nearly 6 in 10 said they would be willing to pay higher taxes to make sure that all were insured, with 4 in 10 willing to pay as much as $500 more a year.” Despite the fact that “…only a fifth of those with insurance said the cost of their own medical care posed a hardship….One in four said that in the last 12 months they or someone in their household had cut back on medications because of the expense, and one in five said someone had skipped a recommended test.”

My goodness! Where are the self-centered Americans we keep hearing about? “…only a fourth said that keeping health costs down was a more urgent need than providing coverage for the country’s nearly 50 million uninsured.” People understand that we are all dependent upon one another. And that, while I might be insured through my place of work today, I might not be tomorrow. And, while I may be healthy today, I may not always be. Good for us!

The cautionary news is that “While the survey results depict a nation desperate for change, it also reveals a deep wariness of the possible consequences. Half to two-thirds of respondents said they worried that if the government guaranteed health coverage, they would see declines in the quality of their own care and in their ability to choose doctors and get needed treatment…. ‘It is the responsibility of the government to guarantee insurance for all,’ said Juanita Lomaz, a 65-year-old office worker from Bakersfield, Calif. ‘But my care will get worse because they’ll have to limit care in order to cover everyone.’”. To her credit, and that of most of the other respondents to the survey, this did not keep her – and them -- from supporting health care coverage for all. But it does indicate how effective the propagandists from the insurance companies and the right have been in convincing people that there is a trade-off between excellent care for themselves and coverage for everyone. The fact is that the United States spends far more than enough money to cover everyone, and to give them access to excellent health care. Countries that spend much less per capita than we do manage to do this, and have far better health outcomes. We spend a great deal of our health care dollar on unnecessary but well reimbursed tests and procedures. We ensure that elective procedures for the well-insured (a decreasing group, certainly) take precedence over the necessary care for the less-well, or un-insured. We spend huge amounts of money on interventions and almost nothing on prevention; while prevention may not always save money, as I have previous discussed (February 13) in commenting on the JAMA article by Steven Woolf[1] and addressed in the wonderful-in-many-ways article by Abraham Verghese in the Wall St. Journal June 20, 2009, it can save and improve the quality of lives.

There will certainly be more to do. Many of my postings have addressed the importance of having a health system built upon Primary care (December 11, April 5, April 29, May 21), and we don’t – that is why newly covered people in Massachusetts can’t find a doctor. And we are not on track to – think about it. If we need 50+% primary care doctors, and we now have 30% or so, we are not going to get there by having between 20% and 25% of medical students enter primary care as we are now. Or even 30%. Even at 50%, we’d have to wait 30 years till we replaced the whole physician population to get to 50%. And yet, as previously noted, we talk about it but are not really doing anything – read “pay a lot more money for” – to effectuate it. And we have to work to convince Americans that “more” is not always “better” – but I think that the poll seems to show they are getting it. We could do this!

But, the ugly bad news is that it looks like we are not only going to not get single-payer, or Medicare for all, but we are likely to not even get a strong public option. While the New York Times editorializes in favor of such a plan (also June 21, 2009,, and these polls are published, and the letters and faxes supporting single payer come fast and furious, the Congressional leadership has maintained their well-established posture:

The report from the Tri-Committee Health Reform draft is far from encouraging. It is precisely set up to disadvantage the public option, making it weak compared to the private plans. Quite the opposite of the campaign of disinformation put forward by the insurance companies and their flaks in Congress, the concern is not that the public plan will be “advantaged” but rather that the law will be written to “advantage” private insurance companies. This is because they are, at base, greedy profiteers who could not compete with a public plan on a level playing field. This is articulately addressed by Karen Tumulty in the Swampland blog,

Don McCanne, the brilliant analyst and author of “Quote of the Day”, addresses the core problems with the Tri-Committee proposal”

"Is this the model of the public option that is going to ensure that reform will bring affordable health care to everyone? Well, here are a few things that this reform will NOT accomplish:

* Not a single one of the Republicans or conservative Democrats who are opposed to the public option will sign on to this version. It is a government program not only in name, but in fact. Not only would it eliminate any hope of bipartisan legislation, it is quite likely that it could not even muster the vote of a simple majority.

* By requiring the public option to have the same market reforms as the private plans, it will prevent the government from using the great power of beneficent public social policies. A regulated insurance exchange within a fragmented, multi-payer, business-oriented insurance market would provide a very shaky infrastructure for delivering to the community the benefits of a social insurance program. Even with greater regulation, our private insurers have a business mission whereas the European private insurers have a social mission.

* A public plan that is required to comply with private insurer rules could never provide a back door entry to a single payer system. As Medicare Advantage demonstrates, the private insurers will always use devious means to provide them with an unfair advantage over our public program, even though they provide lower value per dollar spent.

* An insurance exchange, with or without a public option, perpetuates a fragmented system that prevents us from obtaining greater health care value by having the powerful purchasing strength of our own public monopsony - the secret of other systems that have slowed cost inflation.

* The administrative complexity of this model of reform makes it impossible to cover everyone. Initial estimates that this would cover 95 percent of the population are likely overly optimistic. Regardless, supporting a program that would leave even 15 million people on their own to fend for health care reflects a callous disregard for the needs of these individuals, and certainly belies the notion that we are a caring nation.

* Although this proposal shifts spending between individuals, employers and the government, creating the appearance of financing reform, it does very little to slow the continuing escalation in health care costs. Until that is seriously addressed, as it could be through an improved Medicare for everyone, the rest of this ‘stuff is written in smoke,’ as Karen Tumulty writes.”

The same folks who bailed out the banks instead of the people (why pay banks so that they don’t lose money foreclosing on people’s houses rather than give people the money to pay off the banks, so they keep their houses and the banks stay whole?) and now let them write the financial reform laws; who voted down caps on credit card interest rates 2:1, now are firmly set on letting the insurance industry write the health reform laws. Sorry, America. The only chance we have is if everyone who cares, every day, calls, faxes, and emails their representatives to say “single payer”; maybe then they’ll feel so pressured they’ll “compromise” on a strong public plan.

[1] Woolf SH, A Closer Look at the Economic Argument for Disease Prevention, JAMA. 2009;301(5):536-538.

Thursday, June 18, 2009

“No Single Payer”: Sebelius – making policy for the powerful


Item: The Kaiser Family Foundation survey again confirms the preference of the American people for a program that covers everyone.

Two-thirds to three-quarters of respondents support the following options:
1. Requiring employers to offer health insurance to their workers or pay money into a government fund that will pay to cover those without insurance (71%)
2. Offering tax credits to help people buy private health insurance (67%)
3. Expanding Medicare to cover people between the ages of 55 and 64 who do not have health insurance (79%)
4. Creating a government-administered public health insurance option similar to Medicare to compete with private health insurance plans (67%)
5. Expanding state government programs for low-income people, such as Medicaid and the State Children’s Health Insurance Program (77%)
6. Requiring all Americans to have health insurance, either from their employer or from another source, with financial help for those who can’t afford it (72%)
7. Creating a public health insurance option similar to Medicare to compete with private health insurance plans (67%)
They are almost evenly divided on the 8th question: “Having a national health plan in which all Americans would get their insurance from a single government plan: 49% favor, 47% oppose, reversing the 47%/53% split in the December poll, and, like the recent poll of physicians, showing a continuing increase in the support for a single-payer plan. And note that the greatest percent support is for the expansion of Medicare, which is a single government plan.

Item: The Congressional Budget Office (CBO) scores the proposed Affordable Health Choices Act, released 6/9/09 by the Senate HELP (Health, Education, Pensions and Labor) Committee, chaired by Sen. Kennedy, which basically sets up ways for insurance companies to get paid for insuring more people, as:
· Costing a lot : >$1 Trillion for the next 10 years
· Not covering everyone (leaving 37 to 39 million people, 13% of the non-elderly, uninsured

An alternative Congressional proposal, that of Sen. Baucus’ Finance Committee, was scored at $1.6 trillion.

Item: Secretary of HHS Kathleen Sebelius, interviewed on NPR’s “Morning Edition” June 16, 2009, says a single payer option is not on the table. “This is not a trick. This is not single payer. That’s not what anyone is talking about – mostly because the president feels strongly, as I do, that dismantling private health coverage for the 180 million Americans that have it, discouraging more employers from coming into the marketplace, is really the bad, you know, is a bad direction to go.”

Anyone see a contradiction here? A problem with denial? Folks in the administration and Congress still with their fingers in their ears? Secretary Sebelius seemed to run out of steam trying to explain why single payer would be a bad way to go; this is understandable given that the only reason it would be is that it would cut insurance company profits. It would also be unpopular with most Congressional Republicans, but that is true of almost any real reform. And what about those 180 million Americans who have private coverage? Or is it down to 178 million today? 175? And dropping? Clearly, the two things that are clear about this group are: 1) the number of people in this category continues to decrease as employers cut health insurance benefits, and 2) the quality of the coverage is decreasing – lower percent of employer vs. employee contribution, higher deductibles and co-pays, lower maximum benefits and fewer conditions covered. GM, anyone?

To add to the excitement, 3 former Senate Majority Leaders, Republicans Bob Dole and Howard Baker and Democrat Tom Daschle have come up with their own plan. It involves “pain for everyone” according to the NPR report – the Democrats would have to agree to tax employer contributions to employee health insurance, and Republicans would have to agree to have something actually happen (actually a public option). The positive on this one is that it says how it would pay for its $1.2 trillion price tag – by causing pain for everyone – but is completely weird in suggesting that the public option not be federal, but state by state.

Now don’t get me wrong – I am all for states piloting health reform proposals which might then be taken national. After all, it was a provincial plan, in Saskatchewan, that became the model for the Canadian health plan. And it has been because employer mandates, personal mandates, and other nonsense has been models tested in Oregon, Tennessee, Maine, Maryland, and Massachusetts (twice) that we know that any of the plans currently being proposed that include insurance companies won’t work to either cover everyone or save money.

But having 50 different state options run by each state? This is not such a good idea. The obvious problem – demonstrated by Medicaid, welfare, etc., is that some states would be more generous, others would, for ideological and financial reasons (or just plain meanness) be terrible. We can anticipate the probable quality of coverage from the public option in Mississippi or Wyoming. Promoters say “well, that’s what the state wants, local control, etc.” But each state has people with need; just because those in control, even if they represent a majority of the state’s residents, do not want to provide adequate benefits, it doesn’t mean that the people in need in that state will disappear. Although, if they have enough resources they can move from a poorly resourced state to a better one, which may benefit the less-generous states, but is not, I would hope the intention. In toto, it is a bad idea, bad idea.

A big part of the problem is, as discussed by Dr. Ferrer on this blog on May 8, 2009 (“What is wrong with the idea of "Consumer Directed Health Care"), that most health care utilization, and most of the cost associated with it, is by a small percent of the population at any one time. Therefore, a political process that tries to please most people while spending the least money will be unlikely to address the health needs of those who needs are greatest and resources are lowest, especially when (as is almost always the case) those making the decisions, even if they or their families have health care needs, are covered. Usually, by the way, by a single payer – the government that pays for their health coverage. (A good suggestion from a Vic Ulmer, of Saratoga, CA in letter to the NY Times: “A modest proposal to all our representatives in Congress: (1) Withdraw from your present “socialized” medical coverage and apply for a private insurance plan of your choice, or (2) Allow the rest of us Americans to have the same benefits you enjoy — taxpayer-financed public health care.” )

Meanwhile, a new group, Doctors for America ( has appeared on the scene, with apparently a great deal of clout, having meetings with the White House and Sen. Baucus. As far as I can tell, no one had heard of them before the letter that they had in the Times on 6/17 (same link as above for Mr. Ulmer’s, but nowhere near as good a letter!); turns out that they are Doctors for Obama reconstituted with a new name. Whether it is true that everyone who was in Doctors for Obama during the election (10,000) supports the position of the leadership of Doctors for American (basically, “We’re for whatever Obama is for!”) is a different question, and one that indicates some hubris on the part of those leaders. But the Democratic leadership, rejected by the AMA on the right and single-payer advocates on the left, desperately needs a doctor support group, so I am certain we will continue to see them promoted.

Overall, the discussion continues to focus more on the kind of coverage, the choice of insurer (??), and the benefit to providers than on the benefit to patients. This needs to change. People care about being able access good health care. If this means seeing the doctor they want, going to the hospital they want, fine. Let’s focus on that. People do not care about the insurance company they have except to the extent that it affects their access to health care (pays or doesn’t pay for it, restricts access, etc.) Let’s hear a lot more about the impact on people and less about the impact on providers and payers.

Monday, June 15, 2009

Health Reform and the "Public Option"


The debate on health care reform, at least in the inner circles of Washington and the punditocracy, has shifted to whether there will be a “public option” as President Obama has asked for. (e.g., “Obama to forge a greater role on health care”, New York Times, June 7, 2009 and “Obama urges doctors to back his health plan” NYT June 15, 2009 The discussion is about whether a public option would be “unfair”; actual human beings who wish you to believe that they are both caring and balanced, such as NY Times columnist David Brooks (on NPR, June 12, 2009) say that the danger is that public option will be subsidized, and thus “unfair” to the private insurers. This is, of course, obvious and bald nonsense. What does “subsidized” mean? If it is a public option, it is being funded with public funds, and thus could be described as “subsidized”. Opposition to “subsidy” means simple opposition to a public option. Why on earth should a program be fair to private insurance companies seeking to make a profit? I suspect that the real fear is that any public option would soon become so much more desirable than the offerings of private companies, which exist solely to make money and thus have to either raise premiums or cut benefits, that very few people – primarily the very wealthy who want boutique services – would choose the private options.

In the New England Journal of Medicine June 4, 2009, John Iglehart notes the speakers against a public-plan option They included representatives of the Heritage Foundation, the Business Roundtable, the National Federation of Independent Business, the US Chamber of Commerce, and the Blue Cross/Blue Shield Association. I think that the business group opposition may be ideological, but the insurers are another story:

Karen Ignagni, chief executive officer of America's Health Insurance Plans, also expressed strong opposition to a public insurance plan, arguing that a better approach would be a "fundamental" overhaul of government regulation of the insurance marketplace and correction of other shortcomings of private coverage — reforms that are acceptable to her organization as long as all people are required to have coverage.” That is, pay the insurance companies money to maintain their profit.

This is not to say that the national debate has devolved to that level; single payer, a universal health care system, remains, as this blog has described, the only proposal with a mass movement of actual people behind it, including consumer groups, labor unions, and church groups. They have not been silent; they have inundated members of Congress with letters, faxes, emails, and phone calls. So far these have fallen upon deaf ears. We have previously discussed the assiduous effort of Senator Baucus to ignore these voices. The most recent federal official to be caught with fingers firmly in his ears is Representative Charles Rangel, Chairman of the House Ways and Means Committee. Rangel, a Manhattan Democrat representing Harlem and the Upper West Side, has long been a progressive voice in Congress, and it is quite reasonable for single-payer advocates to have expected a more positive reception from his office than they received from that of the senator from Montana. Yet a recent fax campaign from the single-payer advocate organization Health Justice (, not associated with this blog, Medicine and Social Justice) was met, incredibly, with an incredibly hostile reception from his office, at least that in NYC. Phone calls were often not answered, not returned, and amazingly, faxes, in an indescribably juvenile response, were faxed back to the senders! This is all the more amazing in that many of those faxing were Rep. Rangel’s own constituents. Apparently, after a conversation with Rep. John Conyers of Michigan, like Rangel a senior member of the Congressional Black Caucus as well as the primary sponsor of HR 676, the main single-payer bill in Congress today, Rangel’s office (at least his DC office) became more responsive; at least the phones are being answered and the faxes are not being returned. In a dramatic style difference, Rep. Conyers himself was available to talk on the phone at length with leaders of Health Justice.

What is it with them? Why are such moderate (like Senator Baucus) and even liberal (like Representative Rangel, Senator Kennedy, and Senator Dodd) so dead set on ignoring a huge public constituency? For some, it is the direct influence of the insurance lobby, and the huge amount of money that the industry has to influence lawmakers (and the public; remember Harry and Louise) and stands to lose if single payer passes. For others, it is simply groupthink; they believe that so many others are convinced by the power of the insurance companies that single-payer could not pass. But who knows what would happen if they all stood together?

One issue raised by opponents of both single payer and a public plan is the cost of covering everyone. (NYT editorial, “Paying for Universal Health Coverage”, June 7, 2009, This is, of course, the actual opposite of what would happen with a single payer system. This emperor has no clothes. The most costly plan would be to cover everyone by mandating insurance and paying the insurance companies their going rates; of course, this, the most expensive possible option, is what the insurance industry is asking for. Funding for a single payer system starts with Medicare, which already covers our highest-cost citizens, the elderly and disabled, and folds in state and federal funds for Medicaid, the amount employers and employees pay for health insurance, and the tax dollars currently being lost through the tax exemption for health insurance contributions. The value of these dollars is enhanced through elimination of the profit being made by insurance companies. It is amazing to me that insurance companies can successfully raise the specter of government bureaucracy as an objection to a public plan – has anyone tried to get service from their insurance company recently? Is there a more cold, unrelenting, and obstructive bureaucracy?

Let me reiterate that last: ELIMINATION OF THE PROFIT NOW BEING MADE BY INSURANCE COMPANIES. ELIMINATION OF THE PROFIT NOW BEING MADE BY INSURANCE COMPANIES! Say it loud and say it proud; there is no reason the American people need to support a plan that continues, indeed builds in as its cornerstone, the profit of insurance companies. Say it often, say it to your Congressmen. We do not care about the insurance companies. Ignore them; work for the American people. The insurance industry saying “we should not dismantle the system we have” is nonsense; they are saying “let’s try to keep us making as much money as possible. To the extent that their plans call for health care dollars to go not to providing health care but providing profit, they are the enemies of the American people.
If insurance companies wanted to participate in a productive way, they should become non-profit, as they are in many other countries, and compete on the basis of quality and service. As Paul Krugman noted on June 5, 2009 in his column, (
“Let me offer Congress two pieces of advice:
1. Don’t trust the insurance industry.
2. Don’t trust the insurance industry.”

The real concern is not that there will be a public option that will be subsidized, but rather that there will be a private “option” that will be subsidized either by having no public option to compete with it or by being protected from meaningful competition by a public option through the latter being hamstrung with all sorts of restrictions.
If the insurance companies or their supporters really thought that the product that they offer or could offer was better, cheaper, higher quality, more efficient or more effective, they would welcome the competition. The fact that they are so adamantly opposing it means that they know that they would be completely swamped by a well-designed public program.

Thursday, June 11, 2009

Medicare Costs: "All Politics are Local"

Former House Speaker Tip O’Neill famously said “All politics is local”, and so it seems to be in the discussions of Medicare costs.

The enormous disparities in Medicare spending between states and regions, on a per-beneficiary basis, even controlled for severity of illness and other variables, has been well documented by good scholarship primarily from the researchers at the Dartmouth Atlas of Health Care ( ). It has been an issue that Peter Orszag, President Obama’s Director of the Office of Management and Budget (OMB), has focused on, and that has gained increased traction since the publication of Atul Gawande’s article, “The Cost Conundrum” in The New Yorker June 1, 2009 ( The New York Times’ Robert Pear (“Spending disparities stir a fight in effort to overhaul health care”, June 9, 2009,, reports that the President has made this article required reading for his health reform team.

Gawande’s article focuses on the border town of McAllen, TX, where, incredibly, Medicare spends more per patient than anywhere in the country, about $15,000 per enrollee per year. This is more than twice what Medicare spends in the comparable border city of El Paso, and even more incredibly about $3,000 more than the average annual per capita income of this Rio Grande Valley town. He goes on to interview doctors and hospital administrators in McAllen who, alternately, express shock and disbelief at this statistic or assert that it because they give better care than other areas. Gawande takes several telling diversions from his discussion of McAllen to look at the research documenting wide disparities of spending in other, larger cities and metropolitan areas, and to try to figure out why this is so. He notes the work of Baicker and Chandra from Dartmouth, cited more than once on this blog, that documents an inverse relationship, on a state basis, between the amount spent by Medicare and the quality of care delivered ( ) He notes that some of the lowest costs are in Seattle, WA, Rochester, MN (home of the Mayo Clinic), Durham, NC (home of Duke); some of the highest are in Boston, New York, and Los Angeles. San Francisco, with outstanding health institutions and a high cost of living, is about the national average. He cites the 2003 study by Elliott Fisher, also from Dartmouth, who
“…examined the treatment received by a a million elderly Americans diagnosed with colon or rectal cancer, a hip fracture, or a heart attack. They found that patients in higher-spending regions received sixty per cent more care than elsewhere. They got more frequent tests and procedures, more visits with specialists, and more frequent admission to hospitals. Yet they did no better than other patients, whether this was measured in terms of survival, their ability to function, or satisfaction with the care they received. If anything, they seemed to do worse…To make matters worse, Fisher found that patients in high-cost areas were actually less likely to receive low-cost preventive services, such as flu and pneumonia vaccines, faced longer waits at doctor and emergency-room visits, and were less likely to have a primary-care physician. They got more of the stuff that cost more, but not more of what they needed.” [1]

This data has just been updated, with new analysis, by Fisher and colleagues in the New England Journal of Medicine[2] ( showing that, as described in the summary press release from the Robert Wood Johnson Foundation (which funded the research) ( costs are rising “…more than twice as fast in Dallas as in San Diego, and Medicare now spends nearly three times more to care for its enrollees in Miami than it does in Honolulu” , and that:

Where Medicare spending per enrollee grew at an annual rate of 5 percent in Miami, the rate was less than half, at 2.4 percent, in San Francisco. Medicare spent $16,351 per enrollee in Miami in 2006, almost twice the spending of $8,331 in San Francisco. The contrasting history of spending in San Francisco and East Long Island shows how even a slight difference in growth rates can make a large difference over time. Both regions had nearly identical spending per enrollee in 1992. But where San Francisco grew at 2.4 percent for the next 14 years, spending in East Long Island exploded at 4 percent. So, by 2006 spending in East Long Island was $2,300 more per enrollee than in San Francisco—about $1 billion in additional annual Medicare spending in a single region.”

Gawande quotes Peter Orszag as saying “Nearly 30% of Medicare’s costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level of low-cost areas.” This is pretty compelling stuff. Even more compelling is looking at and “playing with” the interactive map at the Dartmouth Atlas website yourself It is quite remarkable, and even fun. While the map in the NY Times article shows spending by state, the Dartmouth site provides it by “Hospital Referral Region”, that takes into account that there are many practice regions that cross state lines, as well as large differences in practice and Medicare costs in different regions of the same state. You can move your cursor over the map and bring up detail on each of these different regions. (e.g., the Kansas City region had a 2008 cost per beneficiary of $7,604, a 2.86% increase from 1992, while Wichita’s 2008 cost of $7,655 was a 4.17% increase).

But, as compelling as the data may be, all politics is local. The NY Times article cites immediately negative comments from the high-cost states. An aide to Sen. Bill Nelson of Florida said he was “`adamantly opposed’ to the proposed cuts in higher spending areas because the cuts did not distinguish between necessary and unnecessary care.” This is incorrect; the studies looked at comparable care. Gawande cites another Dartmouth study by Sirovich, et. al. [3]: “She and her team surveyed some eight hundred primary-care physicians from high-cost cities (such as Las Vegas and New York), low-cost cities (such as Sacramento and Boise), and others in between. The researchers asked the physicians specifically how they would handle a variety of patient cases. It turned out that differences in decision-making emerged in only some kinds of cases. In situations in which the right thing to do was well established—for example, whether to recommend a mammogram for a fifty-year-old woman (the answer is yes)—physicians in high- and low-cost cities made the same decisions. But, in cases in which the science was unclear, some physicians pursued the maximum possible amount of testing and procedures; some pursued the minimum. And which kind of doctor they were depended on where they came from.” Mayo -- in Minnesota, or Florida, or Arizona -- costs less, points out Gawande, because physicians are salaried and work in an organized integrated health system, as does the Geisinger Clinic in Pennsylvania, often identified as a leader in this area. He describes Grand Junction, CO, with an average per-beneficiary cost of $5873 and very high quality ratings, where physicians have agreed to charge the same fee to Medicare, Medicaid and private insurers.

Sen. John Kerry of Massachusetts said: “There is too much uncertainty about the Dartmouth study to use it as a basis for public policy. Researchers can’t explain why some areas of the country spend more on health care than others. There could be many reasons spending could vary: higher costs of living, sicker people or more teaching hospitals.” Nice, but wrong. There is not uncertainty; the studies consistently show the same thing. Why the costs vary is the subject of Gawande’s article, but cost of living doesn’t cut it (the cost of living in McAllen is way less than in San Francisco but Medicare spending is much higher). Teaching hospitals is another story. Clearly they do cost more. But even if we were to agree with Sen. Kerry’s statement that “States like Massachusetts are concentrated centers of medical innovation where cutting-edge treatments are tested and some of the nation’s finest doctors are trained. This work might cost a little more but it benefits the entire country,” this doesn’t explain it all. Mayo Clinic has great training and cutting-edge research; McAllen has little (there is a great family medicine residency program that operates at low cost, in contrast to the rest of the town, and provides excellent care to many poor people). It has much more to do with practice patterns and culture.

It has to do with money coming into the state, and all politics are local. Sen. Kerry and Sen. Nelson are likely to be joined by other “progressive” senators from big high-cost states such as Sen. Charles Schumer of New York (remember his impassioned support for the finance industry, based in his state), and Sens. Barbara Boxer and Dianne Feinstein of California, as well as others. Unless, of course, they can figure out that the care in Feinstein’s San Francisco (2008 cost: $8,331, 2.36% increase from 1992) is as good as in Boxer’s Los Angeles ($10,810 3.04%) and at least as good as Nelson’s Miami ($16,351, 4.99%).

What we have to hope for is that, all politics being local, the senators representing the lower cost states, Republican and Democratic, liberal and conservative, can outnumber those from the high cost areas and vote for the right thing, and do something about this to control the cost growth of Medicare; reducing high-cost areas to low cost areas would eliminate the bankruptcy threat. Because, on this one, as a result of all politics being local, Kerry and his allies are in the wrong.

[1] Fisher ES, “Medical Care – is more always better?”, N Engl J Med. 2003 Oct 23;349(17):1665-7
[2] Fisher ES, Bynum JP, Skinner JS, “Slowing the Growth of Health Care Costs — Lessons from Regional Variation” NEJM 2009 Feb 26;360(9):849-52.
[3] Sirovich B, Gallagher PM, Wennberg DE, Fisher ES, “Discretionary decision making by primary care physicians and the cost of U.S. Health care”, Health Aff (Millwood). 2008 May-Jun;27(3):813-23.

Monday, June 8, 2009

More on Dr. Tiller

The Kansas City Star ran a lengthy article on Dr. Tiller’s life, “The Complex Life of George Tiller” on June 7, 2009, . I was particularly moved by this piece:

In September 1991, after the protests ended, Tiller granted a rare interview, saying he was tired of the rumors circulating about his practice. He said that contrary to the contentions of abortion protesters, he did not perform elective abortions up to birth. He opened a desk drawer and pulled out a three-ring notebook.
`These are the things we do, ’ he said, pointing to color snapshots of aborted fetuses. `Hydrocephalus, spina bifida, fused legs, open spine, lethal chromosome abnormality. Nature makes mistakes.’
He flipped the page. `This is the brain coming out of the back of the head. This is a baby that’s allergic to itself. Look at this. There’s all water; no brain whatsoever. The skull’s just completely collapsed. This is a foot coming off the hip. You tell me that if you had one of these, you wouldn’t be devastated.’ ”

I was particularly disgusted by what followed:

“Dave Gittrich, state development director of Kansans for Life, said he had seen Tiller’s photos of abnormal fetuses.
‘They all still look like babies to me,’ he said.

If these all look like babies to Mr. Gittrich, and his colleagues – just read what the previous paragraph says – he is blinded by his prejudice.

Gittrich continued:
“‘And I think many of those children could have led healthy, productive lives if they were given a chance.’ ” I have no idea where Gittrich would get such an idea, but that he thinks so is prima facie convincing evidence that he, and his colleagues who believe similarly, should not be involved in any way in making the decision.

Actually, he – and those who believe as he does -- never should. He – and so often it is a “he” -- is not the woman who is pregnant. He is not facing the heartbreaking conflict of wanting a baby but having a fetus that cannot survive. Indeed, he is not facing any consequences whatever regarding any decision made by any woman about her abortion, and has absolutely no standing in it, and should be ashamed to voice his ignorance and arrogance. When he gets pregnant, he can make any decision he wishes. If someone who values his input gets pregnant, then they can solicit his input. Otherwise he has nothing to say that anyone else needs to listen to.

Friday, June 5, 2009

Health Insurers "Balk"

In the New York Times, June 3, 2009, Reed Abelson writes “Health insurers balk at changes for small business”, The gist of the article is that small businesses, unable to self-insure or to spread risk among large numbers of employees, are facing the same adverse – and expensive – market that individuals do. This is if a small business still offers health insurance to its employees: “…fewer small businesses are offering coverage, “ he writes, “especially the very smallest employers. About half of companies with 9 or fewer workers do not provide health benefits.”. Even the changes that the health insurance companies have ostensibly agreed to (if you believe them), addressed in this blog on May 16, 2009,
Health Care Industry Pledge to Cut Costs: No News at All, are not, apparently, being considered for the small businesses that employ over 40% of US workers. The insurance companies Abelson spoke to had different points of view; Aetna and Cigna “…say they would generally support similar federal rules for both the individual and small business markets…”, while WellPoint opposes the changes and United Health Group “…declined to discuss whether it would favor the changes…”, as did the Health Care Service Corporation, “…a Blue Cross operator in big states, including Texas and Illinois,” and “The national association representing Blue Cross plans also declined to comment”.

In small companies (again, the ones that actually offer health insurance) the total premiums are not only higher, but the share employees pay is more than half, while in large companies it is less than 1/3. Moreover, the article does not address at all the fact of underinsurance, that is, “what kind of coverage are employees getting?” The concept of underinsurance has been getting some traction in national discussions, but mostly it is felt by individuals. Almost all people will be underinsured if they get sick enough. This was the message of Moore’s “Sicko!” (all the featured people had had insurance), and of a variety of commentators who note that many “insurance” policies have such high deductibles and co-payments, and often maximum limits on payments, that they are worth very little. Despite high premiums. One business owner described by Abelson found his costs go from $4600 to $6000 a month to cover his 13 employees, so he had to find another carrier. What it doesn’t say was whether the health insurance coverage was comparable – or even whether the old policy was any good.

Quality of health care is a big issue. I strongly recommend the important, if upsetting, piece by Dr. Atul Gawande in the recent New Yorker, June 1, 2009, He makes many good points, which I will address in the near future, but one is that the fact of who pays does not affect the quality or cost of health care if what we pay for doesn’t change. That said, the quality of the health insurance coverage one has makes a big difference when you get sick.

The New England Journal of Medicine recently had another triumvirate of articles on health reform in its May 28, 2009 issue. Jacob Hacker, Mark V. Pauly, and Victor R. Fuchs all weigh in with their perspective on the Obama administration’s “public plan option” ( Hacker, a political science professor at UC-Berkeley asserts that “Public health insurance emphasizes the broad sharing of risk, ensuring coverage that is affordable and of high quality for the small portion of the population that accounts for most health spending.” This sounds good, and emphasizes the point made by Bob Ferrer on this blog (May 8, 2009) that a small portion of people account for most of health spending which is why looking at a program that supplies what each person (e.g., 25 year old health aide to a congressperson) thinks they would like doesn’t do anything for costs. Hacker also says, however, that “On the other hand, private plans are generally more flexible and more capable of building integrated provider networks and they have at times moved into new areas of care management in advance of the public sector.” Boy, talk about damned with faint praise! Does this say anything really good about the private health insurance sector? Even if it were true, does it seem in any way to be comparable in importance to what he says public insurance does? I’m not sure, however, that Hacker is not entirely serious; sometimes academic experts find the oddest things to be important, stuff that would never enter into an actual regular person’s thinking.

A great example is provided to us by Dr. Pauly[1] who states, in regard to people buying insurance, that “Having insurance you prefer rather than what someone else selects for you will make you more likely to choose to be and remain insured.” Huh? When did you last hear a person for whom the choice of insurance you preferred was a big deal? People want to choose their doctor, their hospital, etc., but their insurance company? (“I’ve always been an Aetna man, myself!”) I don’t think so. Oh, he means type of insurance plan! I think I want the one that gives me the most comprehensive coverage and costs the least. Don’t you? Who doesn’t? Dr. Pauly? Some other economist? Who wants the one that has the worst coverage and pays the most? What’s that you say? He means there is a trade-off between better coverage and lower cost? Well, maybe, but actually not.

In general, the larger the organization you work for, the better and more comprehensive the coverage and the lower the cost (both to you, directly in terms of your premiums, co-payments, and deductibles, and to your employer) and the smaller the organization (hey, we got back to the original topic of this piece! Have faith!), with the smallest being the individual, the worse your coverage and the more expensive it is.

So what is the point? What is the biggest organization? Even bigger than the late General Motors with its, um, “Cadillac” insurance? Why, it’s all of us! The public! A public insurance plan (let’s say – single payer, Medicare for all) that covers all of us can get us the best deal. And you can be sure that if Dr. Pauly, and Dr. Hacker, and the president of the newly-slimmed-down GM, and your Senator all have to be in the same plan as you and your elderly ill grandmother, they will make sure it is a good plan. What an idea! All being in it together!

Of course the health insurers balk at the idea of covering small business. They balk at anything that will not cause them to have maximal profits. The question is why any of the rest of us should care, and why in heck maintaining health insurance company profits are given any consideration at all (not to mention the seat at the head of the table) in the health reform debate! We should call the balk, and if they object throw them out of the game!

You can see I’ll never be a business-school economist.

[1] Professor of health care management, business and public policy, insurance and risk management, economics, and film noir (no, not really the last; I guess I just got carried away; seems like he teaches everything else) at the Wharton School of the University of Pennsylvania).

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