Poverty and Uninsurance Diverge: So let’s solve the problem!

.
Wyandotte and Johnson counties form the Kansas side of the Kansas City metropolitan area. Wyandotte, mainly Kansas City, KS, where I live, is an old “rust-belt” inner city, packing-house industrial city, and is the poorest county in Kansas. Johnson, to its south, consists of older inner suburbs and newer, were-recently-farmland suburbs, and is the richest and most populous Kansas county, with more than 3 times the population of Wyandotte. In Johnson County, only 14% of the population is below 200% of the poverty level, compared to Wyandotte County’s 44%, but it actually a slightly larger absolute number (73,200 to 67,400) because of Johnson County’s larger population. More interesting is the uninsured rate; while it has fewer than 10% more people under 200% of poverty, Johnson County has 2.5 times as many uninsured people as does Wyandotte County.

This means, obviously, that there are many non-poor uninsured people, and this is a national phenomenon. For most of this century, poverty and uninsurance rates tracked together. But in the late 1990s, with poverty rates decreasing, uninsurance rates continued to rise. With the recent recession, both have climbed, but uninsurance is rising at a higher rate. (See graph).

This dissociation between poverty and uninsurance is a very troubling phenomenon; while it is bad enough for poor people to not have financial access to health care, more and more of the uninsured are not poor.

Thus the case for health reform: let’s do something about this. Let’s dissociate the “privilege” of having health insurance from being employed by an entity large enough to afford to provide it, and make sure everyone has financial access to high quality care. Unfortunately, the current plans in the Congress will not do so. The recent assurance by Senate Majority Leader Reid that the Senate bill will contain a “public option”, as will the House bill, obscures the fact that the public option it contains will be weak; in an ostensible effort to not give the public option an “unfair advantage” over private insurance plans, it has been given an unfair disadvantage – it will not be able to use its public status to set rates for provider compensation, as does Medicare, or for drug prices, as Medicare (under the bad restrictions of Part D) also does not.

This is, of course, bizarre: why should anyone, other than the insurance companies themselves, care that they can continue to make money hand over fist while providing inadequate coverage, and not be held accountable by having to compete with a public option that provides comprehensive coverage and does not have to make a profit? Oh yes, the senators and congressmen who get contributions from those insurance companies, yes, but the rest of us? Why should we care? And why should we not insist that our representatives represent our interests, and not those of the insurance companies?

Much of the opposition – not only to single payer, but to a “public option” has been based on, not to put too fine a point on it, lies spread by opponents who are mostly on the payroll of insurance companies. These lies have led people to think that they will lose the excellent medical care, and extensive freedom of choice that they have under the current system (oh, whoops, forgot, they don’t!) if we have a government program. Writing in the Oct 28, 2009 issue of JAMA, Joseph S. Ross and Allan S. Detsky look at “Health care choices and decisions in the United States and Canada”[1], choosing Canada specifically “…because the Canadian health system, with much greater government involvement, is often publicly portrayed in the United States as limiting choice.” They review the restraints on choice of insurance plans, hospitals and doctors, and diagnostic testing and treatments, and conclude, modestly that “…there is clear evidence that for Canada’s health care system, less choice in insurance coverage (although guaranteed) has not resulted in less choice of hospitals, physicians, and diagnostic testing and treatments compared with the United States. In fact, there is arguably more choice.” More than “arguably”, I’d say, based on the evidence provided in their piece.

The fewer obstacles that are placed in the way of services to people, the more efficient they are, the more they are appreciated, and the less they affront the dignity of the people receiving them. When comprehensive services are provided to everyone, there is no need to put people through rigorous screening to see if they are poor enough, or don’t have other insurance, or are deserving enough to receive them.

Ironically, or maybe not, the same legislators who decry government bureaucracy are those who demand that bureaucracy through establishing restrictions on programs that help people. This includes, of course, income and citizenship verification for those seeking help with health care; after all we wouldn’t want people to “cheat” and avail themselves of public services when they didn’t “need” them, when their incomes exceeded the 200% of poverty, or 100% of poverty, or 38% of poverty* that we require. If there were one program for everyone, a single-payer or Medicare-for-all program, then all this bureaucracy could be eliminated. We wouldn’t have to screen people, because everyone would be eligible. It would be everyone’s program.

I have written before about the enormous administrative cost involved in both insurance companies (payers) and providers having huge teams of people to try to deny payment or get paid; in one more way, a single-payer plan would eliminate administrative waste and bureaucracy. Funny that those anti-government-bureaucracy folks can’t – or won’t – see it this way.

*38% of poverty was what one's income used to have to be to get financial assistance in Kansas if you were a childless adult -- and it was $100/month. Now it is not available at all.

[1] Ross JS, Detsky AS, “Health care choices and decisions in the United States and Canada”, JAMA, Oct 28, 2009;302(16):1803-4.
.

“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. http://www.kff.org/kaiserpolls/upload/7892.pdf:

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
http://www.cbo.gov/ftpdocs/103xx/doc10310/06-15-HealthChoicesAct.pdf

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.”
http://www.npr.org/templates/story/story.php?storyId=105442888

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.” http://www.nytimes.com/2009/06/17/opinion/l17health.html )

Meanwhile, a new group, Doctors for America (www.drsforamerica.org) 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.