Dallas’ American CareSource sees stock jump 120% in 2008

By Jason Roberson
The Dallas Morning News
January 2, 2009

American CareSource is the nation’s first publicly traded ancillary care network company. The company basically serves as a middleman, connecting payors, such as insurers, with the providers of such services as lab work and diagnostic imaging.

Ancillary services now represent 30 percent of health care expenditures, valued at $574 billion annually, according to U.S. Center for Medicare and Medicaid Services.

While most insurers can handle the 70 percent of health care dollars that go to hospitals and physicians, the largest insurers form networks with ancillary services. That’s where American CareSource comes in.

American CareSource targets smaller insurers, unions and employers that aren’t able on their own to purchase ancillary services in bulk.

(American CareSource) bills itself as a cost-saver to both payors and ancillary providers. It acts as the providers’ advocate by collecting hard-to-get payments from insurance claims; it serves as the insurers’ advocate by offering lower costs than they could get on their own.

“In some ways, we want to be the Wal-Mart or Target of health care,” said David Boone, CEO of American CareSource.

He maintains a small-company management style. Whenever a new client is secured, an old ship’s bell is rung in celebration. When the company hit $1 million in profit, Boone, as promised, strutted in the middle of the office and proceeded to do a “money dance,” wearing a Donald Trump wig, a comical green jacket and hat of dollar bills.

http://www.dallasnews.com/sharedcontent/dws/bus/stories/010309dnbuscaresource.38426b8.html

As long as we insist that health care continue to be financed through our dysfunctional, fragmented multi-payer system, we will continue to see more innovative middlemen organizations capturing and siphoning away dollars that should be directed to health care instead.

Now we have a for-profit, publicly-traded entity that adds an additional, expensive administrative layer between the health plans and the providers of ancillary services. American CareSource provides no health care products or services - only more administrative waste.

I don’t know about you, but I’ve grown weary listening to those who say that single payer advocates have failed to demonstrate that a single payer system would bring us more than only nominal, one-time savings in administrative costs. Go to the PNHP website (www.pnhp.org) and type in “administrative waste” in the search window at the top of the opening page, but be prepared to spend a lot of time.

Massive, middlemen administrative waste permeates our entire health care system. It is not limited to the excesses of the private insurance industry, though that industry is a major contributor, both directly in its own costs, and indirectly by the burden placed on the health care delivery system. There are a great many other innovative administrative organizations involved, often subsidiaries of the insurers.

These same individuals who discredit the potential for recovering administrative waste also fail to mention the other benefits of single payer such as true universality, equity, efficiency, improved value in health care purchasing, and humane methods of cost containment.

But I have to hand it to David Boone, CEO of American CareSource. What could be more appropriate for this entrepreneurial middleman organization than celebrating success with a ship’s bell, a Donald Trump wig, and a hat stuffed with dollar bills? How fitting!

This should inspire the insurance industry’s AHIP. When Congress passes health care reform based on private health plans, AHIP can pass out the Donald Trump wigs with the hats stuffed with money. But the bell? Shipping in that bell from Philadelphia won’t do since it has a crack in it. That’s okay. Piping in the opening bell of the NYSE would much more befit the occasion anyway.

Student Debt, Resident Hours, and Primary Care Redux

By Josh Freeman
Medicine and Social Justice (A Blog)
January 2, 2009

The December 18, 2008 issue of the New England Journal of Medicine includes Perspectives on 3 topics that have been previously addressed on this blog: Medical student debt (Dec 14), resident duty-hours (Dec 3, 9), and the future of primary care (Dec 11).

The piece on “Medical Student Debt — Is there a Limit?” by Robert Steinbrook presents data on the extraordinary rise in tuition, and debt, among medical students, most surprisingly in the public medical schools. “For the current academic year, tuition, fees, and health insurance at private medical schools range from $15,278 (for Texas residents) or $28,378 (for non-residents) at Baylor University to $51,969 at Tufts University in Massachusetts and $52,236 at Temple University (for nonresidents of Pennsylvania — state residents are charged at $43,232.” While tuition rates at private medical schools are generally higher than at public, the non-resident tuition at public schools is about the same as that of the privates, and the rate of rise (percent change) in the last 10 years at public schools has far exceeded that at private schools (100% vs 50% increase). Indebtedness ranged from an average (high is different) of $80,000 to $163,000 at public schools, and $70,000 to $182,000 at private schools. Some schools give significant tuition scholarships, but others are more challenged: Stanford’s endowment allows it to give a far larger number of scholarships relative to loans than does, say Drexel. More important, the article points out that the high debt burden may discourage lower-income students from applying to medical school, and to enter specialties with higher income potentials. “It is not surprising that a recent analysis showed a ’strong direct correlation’ between higher mean salary in a specialty, such as orthopedic surgery or radiology, and the percentage of residency positions filled by US graduates.” The piece says that there is no easy solution, and probably there is not. But most countries have very low medical school tuitions, but require national service of their graduates.

“Revisiting Duty Hour Limits — IOM Recommendations for patient safety and resident education” by John Iglehart, discusses that topic in a balanced way. It points out the acknowledgment in the IOM report that “Although some might propose further reductions in total duty hours, the report notes, ‘evidence suggests it is an indirect and inefficient approach given the moderate correlation that exists between resident duty hours and sleep time.’” Igelhart also notes that “the 2003 limits on duty hours have resulted in an increase in handoffs of patient care between physicians — transitions associated with increased risks to patient safety.” I have discussed this at length, but I did note that this article includes a table with a recommendation I had missed — that internal and external moonlight be counted against the 80-hour per week limits. I have no difficulty with that conceptually, as it makes perfect sense — what is the point of limiting work hours in the residency if residents can moonlight for extra money in an unrestricted fashion? — but I wonder about the legal ability of program directors to restrict the moonlighting activities of their residents in their off hours.

“The Future of Primary Care — the Community Responds” involves a followup to a series of opinion pieces and a roundtable discussion with Drs. Thomas Bodenheimer, Barbara Starfield, Katharine Treadway, Allan Goroll, and Thomas H. Lee that appeared in the November 13, 2008 issue. The comments, and responses from the roundtable participants, are salient and generally useful. Several writers noted the role of physician assistants, and one (Paul Lombardo) states that “Patients, and the U.S. health care system as a whole, would be better served if the content of and level of primary care education were better matched to the needs of patients. The physician assistant (PA) model of medical education, with its emphasis on physician-physician assistant teams, needs to be expanded.”

These are all thorny, and not unrelated, issues. What is the relationship between resident work hours and physician’s assistants? Well, someone has to do the work. Since residents, even with the 80-hour restriction, work twice as many hours as do physician’s assistants, for about half the salary, and have a greater scope of practice, it would be incredibly expensive for hospitals to replace resident labor with that of physician’s assistants, not to mention physicians. As hospitals complain about the “cost” of resident education, this needs to be kept in mind; they are much better at accounting the cost than the benefit. Even if a hospital closes its residencies because it assesses the costs are greater than the benefit, this usually includes the fact that the residents care for many medically indigent patients, and you can be sure that the hospitals are planning to no longer care for them at all, not to pay someone else to do it. This, of course, again decreases access for the most needy.

I have repeatedly said that the nucleus of a solution is a comprehensive national health program, which includes a single-payer and a system that is tasked with ensuring the health and access to quality health care of all Americans. With such a system, addressing issues such as resident work hours, medical student debt, and the composition of the physician (and NP and physician assistant) workforce could be feasible; without it, they all remain insoluble because they all depend upon each other.

(Joshua Freeman, M.D. is Professor and Chair of the Department of Family Medicine at the University of Kansas School of Medicine, though the comments in this blog are his own. He does understand his topic: http://www2.kumc.edu/fammed/Chairman.htm)

http://medicinesocialjustice.blogspot.com/2009/01/student-debt-resident-hours-and-primary.html

Josh Freeman’s comments were selected to start off this year of reform (hopefully) because they set the theme that reform should not be simply about tweaking private and public insurance options; reform needs to be about fundamental restructuring of our health care financing and delivery systems.

Single payer is frequently conceived of as simply an administrative system of collecting funds for health care through an equitable system that is designed to include everyone. Well, it is that, and that would be a great improvement over the dysfunctional, fragmented, inequitable, and inadequate system that we have.

But there is the other side to single payer: spending. Imagine having two and a half trillion dollars under the control of our own single, public purchaser of health care - a monopsony. Scary? Well, yes, but not when you compare it to the horrendously frightening system that we now have - a system which the policy makers in Washington unbelievably wish to expand.

Our current system bankrupts and even kills people. With our own public single payer system the funds would be used to save lives, preserve health, and prevent financial hardship in the face of medical need. Professor Freeman is right on target when he says, “the nucleus of a solution is a comprehensive national health program, which includes a single-payer and a system that is tasked with ensuring the health and access to quality health care of all Americans.” Otherwise our problems “all remain insoluble because they all depend upon each other.”

If we expect someday to have an efficient, high-performance health care system for all of us, repairing and expanding our primary care infrastructure is not an option; it’s an absolute necessity.

Health Economists’ Views of Health Policy

By Michael A. Morrisey and John Cawley
Journal of Health Politics, Policy and Law
August 2008

This article reports the views of a national survey of U.S. health economists on a series of questions ranging from mergers among health care providers to the profits of pharmaceutical manufacturers to fundamental health care reform. We find a high degree of agreement on issues of fact but considerable disagreement on issues that depend on values.

Issues of Fundamental Disagreement

Arguably the most divisive statement in our entire survey was, “The United States should adopt a Canadian-style system of universal and compulsory health insurance.” Of U.S. health economists, 47 percent agreed that the United States should adopt such a system. What makes the responses to this question so divided is the fact that the entire range of answers is used; 22 percent strongly agreed, 25 percent agreed, 21 percent disagreed, and 22 percent strongly disagreed. The nearly uniform spread of answers is unique; for all other issues reported, answers tend to be concentrated around the middle (agree or disagree) with few responses in the extreme tails (strongly agree, strongly disagree). Moreover, only 10 percent responded that they didn’t know, which is among the smallest response in that category to any question.

http://jhppl.dukejournals.org/cgi/content/abstract/33/4/707

Almost all of us want 2009 to be the Year of Health Care Reform. Almost all of us agree on the facts. We agree not only on what the deficiencies are in our health care financing and delivery systems, but we also largely agree on what the impact would be of various public policies that might be enacted during the reform process.

But the debate isn’t about facts; it’s about values! Just think about the strongly held values on the two sides of the debate over whether or not “the United States should adopt a Canadian-style system of universal and compulsory health insurance.”

Many of us can speak to one side of that debate. We want a health care system that can provide high-quality care for everyone at a cost that we can afford, both individually and collectively. An improved Canadian-style single payer system would do that. Those strongly opposed to single payer have not provided us with any model that would come close to all of those goals.

If the other side doesn’t share our specific goals, then what values do they support? Perhaps it’s unfair to try to describe their values since there is such an intense disagreement, but we can parrot some of their published statements on their values.

Many support the concept of individual responsibility. Each individual should be responsible for acquiring the means to obtain whatever products or services they desire, including health care. For those who are truly incapable, minimal basic services can be provided by private charity or by public safety-net welfare programs. For average-income individuals who can no longer afford health care, it is their responsibility to make choices - either a choice to advance themselves so they can afford care, or a choice to reduce other spending such as on rent, transportation, education or other less essential products or services, or simply to do without health care.

Many oppose wealth transfer, especially in the form of progressive taxes. They believe that those who have achieved great wealth should be allowed to keep it, and those who haven’t should simply make do. Wealth should not be confiscated by the government simply because tens of millions of individuals are not capable of paying for health care that they might need. In their view it is morally just that society be stratified, richly rewarding the producers.

Many passionately support the concept of freedom, meaning “free exercise of the natural right of sole dominion over their own lives, liberty and property,” relegating government to a minimal, custodial role. They specifically reject the United Nations Universal Declaration of Human Rights, which states, “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services.”

They value greatly the entrepreneurial spirit of the private marketplace that brings us wealth-creating insurance company middlemen, and an abundance of expensive technologies that shift the profit/benefit ratios ever upward. To them, private business success has a priority over public social policies.

Freedom, entrepreneurialism, and individual responsibility are values that are not the exclusive domain of the opponents of single payer, for we all share them. The disagreement is in how we value public policies that make these concepts work for all of us. We need freedom - freedom to chose our health care professionals - a freedom that the insurers have taken away from us. We need entrepreneurialism to provide us with better technology - but technology that meets the test of value. We need to exercise our individual responsibility to take care of ourselves - but along with our responsibility to support public policies that will enhance the health of all of us.

Princeton health economist Uwe Reinhardt has said that we can do this. The facts are easy. You tell us your values and then we can design a health care system that matches them. The question is, whose values will Congress and the Obama administration honor?

At House Party on Health Care, the Diagnosis Is It’s Broken

By Robert Pear
The New York Times
December 22, 2008

When a dozen consumers gathered over the weekend to discuss health care at the behest of President-elect Barack Obama, they quickly agreed on one point: they despise health insurance companies.

http://www.nytimes.com/2008/12/23/health/23health.html?_r=1&hp

And for reform, our nation’s political leaders are going to bring us… even more of the same?

Key Issues in Analyzing Major Health Insurance Proposals

The Congress of the United States
Congressional Budget Office (CBO)
December 2008

Chapter 4 - Proposals Affecting the Choice of an Insurance Plan

Medicare-for-All

Many of the considerations that arise in designing a new option for individuals to enroll in Medicare would also affect the analysis of proposals to establish a single-payer system based on Medicare through which all U.S. residents could obtain their health insurance. In particular, the federal costs of such a proposal would depend primarily on the benefits that the system provided; the rates it used to pay doctors, hospitals, and other providers of health care; and the extent of any premium subsidies it offered to enrollees—all of which could differ from Medicare’s current design. The rules and processes used to determine eligibility for the program and to enroll individuals who are eligible would also have significant implications.

Even under a single-payer system, individuals could have a choice of insurance plans or benefit designs, but the extent and nature of those options would also depend on the features of the proposal. If enrollees were allowed to choose a private health plan paid through Medicare or could purchase supplemental private insurance (as many Medicare enrollees currently do), the rules governing those choices and the possibility of adverse selection would remain important considerations. If, instead, the Medicare plan was the only option offered and all residents were required to enroll in it, then adverse selection would not occur. That approach could reduce the administrative costs that doctors and hospitals currently incur when dealing with multiple insurers. Some enrollees might prefer a different design, however, and the lack of competition from private health plans could take away a benchmark that is commonly used to assess the adequacy of Medicare’s payments and the efficiency of its performance. More generally, that approach would raise important questions about the role of the government in managing the delivery of health care.

CBO Study (196 pages):
http://www.cbo.gov/ftpdocs/99xx/doc9924/12-18-KeyIssues.pdf

Everyone who is participating in the efforts to reform health care financing in the United Sates should have a copy of this CBO report. It describes in considerable detail the various policy decisions that must be made as we approach the goal of affordable health care for everyone, but only those policies that would apply to a multi-payer system of private and public programs.

What is clear is that each policy decision under this scenario increases the administrative complexities of the financing system, and that the inevitable tradeoffs that must be made can only result in compromises that cause us to fall short on our goals of universality, equity, efficiency, quality, access, and affordability. Once the decision is made that we must build on our current system, there is no possible way to avoid spending more money for reform that would fall so short of a high-performance system.

There is a very serious deficiency in this study. In the 167 pages constituting the main body of this report, there are only two paragraphs (above) on a model that would be far less expensive and would come as close as possible to achieving our goals. To say that single payer received short shrift in this important policy document is not simply an understatement; it is a glaring example of the extent to which Congress has gone to glibly dismiss single payer as not being a feasible option. They are going to make policy decisions impacting not only one-sixth of our entire economy, but also the physical and financial well being of each of us.

All of us throughout the nation need to rise up and express our outrage! We need to contact our members of Congress immediately and demand the urgent preparation of a CBO report that describes the policy options, and the impact that they would have, under a single payer national health program. We, the people, deserve the same detailed analysis as was given the multi-payer model catering to the special interests.

Living on the Edge: Health Care Expenses Strain Family Budgets

By Peter J. Cunningham, Carolyn Miller, and Alwyn Cassil
Center for Studying Health System Change
December 2008

Affordability of medical care is a central focus of health care reform efforts. As health care costs continue to increase and the economy declines sharply, there is very little cushion in family budgets for health care costs, even for families with insurance coverage. Financial pressures on families from medical bills increase sharply when out-of-pocket spending for health care services exceeds 2.5 percent of family income, according to a new national study by the Center for Studying Health System Change (HSC). Low-income families and people in poor health experience financial pressures at even lower levels of spending, largely because they have already accumulated large medical debts they are unable to pay off.

There is little consensus among policy makers on how to set affordability standards in medical care, in part because there is little empirical evidence to guide these decisions. In addition, most of the policy focus has been on identifying affordability standards for insurance premiums, such as in the Massachusetts health reform, with much less attention on affordability standards for out-of-pocket spending on medical services. Some analysts propose setting affordability standards based on the current distribution of out-of-pocket spending for services, such as typical spending levels for a privately insured, middle-income population.

However, a limitation with this approach is that unlike spending for premiums, mortgages, rents, and other household necessities, out-of-pocket spending on medical care is much less predictable, often unexpected and not entirely discretionary. While families may be able to budget for preventive and routine health care needs, high out-of-pocket medical spending by families is more often associated with urgent or serious health conditions, as well as provider recommendations for treatment, rather than discretionary patient choices. Thus, what people actually spend out of pocket on medical care reflects–at least in part–what they need or are prescribed, not necessarily what they can afford.

http://www.hschange.org/CONTENT/1034/

Everyone is concerned about health care costs, and there is now a consensus that we must do something about it.

The leading proposals for health care reform are designed primarily to make health insurance affordable, when what we really need to do is make health care affordable. These proposals use insurance product design and tax policies to try to balance the health benefits provided with the ability of the individual to contribute to the premium. In an effort to keep the premium affordable, patient cost sharing is included as an incentive to reduce utilization of both beneficial and marginal health care services and products.

This study demonstrates a major flaw with this approach. Although the family may be able to budget for a modest component of an insurance premium that remains the same each month, family budgets are now so tight that a mere 2.5 percent of family income that might be required for out-of-pocket cost sharing can be a family budget buster. This study shows that cost sharing can impair both family finances and family health care access.

Financing of our health care system should be totally separated from health care access. Even modest financial barriers to access should be removed from the delivery side of health care. Cost sharing has only a negligible impact on our total national health expenditures yet it can have a serious impact on the finances and health of individuals and their families.

On the financing side, attempting to establish insurance premiums that would be affordable based on family income requires an administratively complex system of matching premiums with benefits and using tax policies to establish equitable contributions by families. This is because we have been fixated on the concept that each family must have a specific, designated private health plan and the financing must fit that plan.

It doesn’t have to be that way. Look at the traditional Medicare program. A single risk pool is established for all Medicare beneficiaries and that pool is financed primarily through equitable taxes. Medicare does have cost sharing, but this study shows us that Medicare would serve us even better if cost sharing were eliminated, fully funding the risk pool to cover payment for all essential services.

The most efficient and equitable method of financing health care for all of us would be to establish one single, universal risk pool and fund it with a system of progressive taxes. We can all pay our fair taxes, but, with fairly spartan family budgets now being the norm, we shouldn’t have to budget medical costs that are less predictable, often unexpected, and frequently in excess of discretionary income.

The Case For Public Plan Choice In National Health Reform

By Jacob S. Hacker, Ph.D.
Berkeley Law Center on Health, Economic, and Family Security
December 16, 2008

This brief has made three main points. First, public health insurance outperforms private insurance in controlling costs while maintaining access and benefits–even when compared with private plans that are regulated to ensure broad coverage. Second, public insurance has also made major strides in quality improvement, and a new public plan working with Medicare alongside private plans would be able to make much greater strides in the future. Third, a competing public plan is essential to set a benchmark for private plans, providing a “check and balance” that ensures private plans, as well as the public plan, uphold high standards.

Even within a reformed system, private plans will continue to have incentives to engage in activities that undermine health security, such as tailoring their benefits or provider networks to discourage less healthy people from enrolling. Moreover, acting alone, private plans have historically paid insufficient attention to obtaining greater value. This is in part because of their limited reach, inherent instability, and the frequent movement of patients in and out of their subscriber base, and in part because of their generally weak incentives to invest in broadly distributed information on quality or to share their performance data with other interested parties. Public plan choice creates an institutional “check and balance,” encouraging private plans to uphold high standards of quality, affordability, and access.

The Case For Public Plan Choice In National Health Reform (27 pages):
http://institute.ourfuture.org/files/Jacob_Hacker_Public_Plan_Choice.pdf

Key Findings (2 pages):
http://institute.ourfuture.org/files/Hacker_Keyfindings.pdf

And…

Insurers Seek Presence at Health Care Sessions

By Robert Pear
The New York Times
December 17, 2008

When supporters of President-elect Barack Obama hold house parties to discuss ways of fixing the health care system over the next two weeks, they may find some unexpected guests.

Robert Zirkelbach, a spokesman for America’s Health Insurance Plans, the main lobby for insurance companies, said the group was “mobilizing our grass-roots coalitions and encouraging industry employees” to participate in meetings for the Obama transition team.

Before Mr. Obama even takes office, insurance companies are raising questions about a central element of his plan that calls for creation of a new public insurance program to compete directly with private insurers. A public program would, they fear, have inherent unfair advantages.

http://www.nytimes.com/2008/12/17/us/politics/17health.html?_r=1&%2334;health%20insurance=&sq=+&st=nyt&%2334;=&scp=1&pagewanted=print

In this window of opportunity for health care reform, the model that has gained traction and is moving forward is reform based on a combination of employer-sponsored plans, an individual mandate to purchase regulated private plans through an insurance pool or insurance exchange, and an option to purchase a public plan based on an improved version of Medicare.

The private insurance industry knows that if it is to survive, it must be willing to accept everyone in both the employer-sponsored and individual markets, and they now have expressed a willingness to do so. They support a market of competing health plans, with one exception. They oppose the creation of a new competing public program because it would have “inherent unfair advantages.”

What are those advantages? Jacob Hacker, in “The Case For Public Plan Choice In National Health Reform,” explains the many reasons why a public plan is superior to the private plans in providing greater value through higher quality, better access, and greater effectiveness in controlling costs. He states that, by establishing a level playing field, the public plan option would set a benchmark as a standard for private plan performance.

The private plans profess to believe in market competition. Why should they object to a level playing field? Read this paper and you’ll find twenty pages of reasons on why they cannot compete with a public program.

So we’re once again back to the argument that we cannot go straight to a single payer national health program because it is not politically feasible. But what about the feasibility of a public option in a multi-payer system? The insurance industry is opposed because the government has “unfair advantages.” The Republicans say that they are cooperating on a bipartisan approach to reform, but once the doors close, they have made it very clear that a public option will never be approved. Hacker tells us why the public option is absolutely essential in the multi-payer model, but AHIP and the Republicans tell us that it will never happen (and they have the Senate votes to prevent it).

This report is well worth downloading since it explains so well why we need to change to a public insurance program. With minimal editing, such as removing comments about competing private plan innovation, we could use it as a treatise for a new and improved Medicare - a single payer national health program.

The HCAN coalition could use the unedited version to advocate for the multi-payer model, and we could use the edited version to advocate for single payer. Since neither approach is “feasible,” why don’t we just go for broke? To Medicare for All in one single leap!

Participant Guide for Health Care Community Discussions

Obama-Biden Transition Project

Policy Background and Key Questions

II. The President-elect’s Health Care Plan

Expand Coverage to all Americans:

* Build upon and strengthen employer coverage;

* Allow people to keep the coverage that they have and maintain patients’ choice of doctor;

* Establish a National Health Insurance Exchange that offers a range of private insurance options as well as a new public plan option;

* Require insurance companies to cover pre-existing conditions so all Americans regardless of their health status or history can get comprehensive benefits at fair and stable premiums;

* Expand Medicaid and SCHIP and provide sliding-scale premium assistance for low-income people.

III. QUESTIONS

1. Briefly, from your own experience, what do you perceive is the biggest problem in the health system?

2. How do you choose a doctor or hospital? What are your sources of information? How should public policy promote quality health care providers?

3. Have you or your family members ever experienced difficulty paying medical bills? What do you think policy makers can do to address this problem?

4. In addition to employer-based coverage, would you like the option to purchase a private plan through an insurance-exchange or a public plan like Medicare?

5. Do you know how much you or your employer pays for health insurance? What should an employer’s role be in a reformed health care system?

6. Below are examples of the types of preventive services Americans should receive. Have you gotten the prevention you should have? If not, how can public policy help?

7. How can public policy promote healthier lifestyles?

http://change.gov/page/-/Health%20Care%20Community%20Discussion%20Participant%20Guide.pdf

Health Care Community Discussion: Host and Moderator Guide

II. Your Role

If you are serving as the moderator, you should not strongly advocate for specific health policy positions. Instead, your role is to listen, facilitate discussion that elicits the views of all attendees, and help the participants draft a submission to the Transition Health Policy Team. In addition, please identify the most compelling personal stories that illustrate the need for health care reform in our country.

http://change.gov/page/-/Health_Care_Community_Discussion_Moderator_Guide.pdf

To sign up as a host:
http://change.gov/page/s/hcdiscussion

Throughout the nation during the next two weeks HHS Secretary-designate Tom Daschle is encouraging grassroots, community level discussions of health care reform. The purpose is to give the public a sense that they are actively involved in the reform process, avoiding a repetition of the Clinton political error of crafting reform behind closed doors.

If you look at both the moderator guide and the participant guide, it’s quite clear that this is not an effort to collect information to guide the policy makers in their decisions. The fundamental policy decisions have already been made, and they are listed above. This is strictly a process to build on the momentum for reform.

We have seen this process before. In 2006, a series of community hearings for the Citizens’ Health Care Working Group (CHCWG) were held throughout the United States:

“When given a choice of ten reform options at public hearings held by the CHCWG, participants clearly favored a national health program by a margin of at least 3 to 1. At meetings where participants were asked to rank the 10 options, national health insurance was ranked first 16 of 19 times (Billings, MT; Denver; Des Moines; Detroit; Eugene, OR; Jackson, MS; Kansas City, MO; Memphis; Miami; New York, NY; Philadelphia; Phoenix; Providence, RI; Sacramento; and Seattle). At two meetings participants were neither polled nor options ranked. Despite the clear public mandate, the CHCWG’s report makes no mention of the vast support for a national health program. Instead, the group’s official recommendations include only generic suggestions such as promoting ‘efforts to improve quality of care and efficiency,’ and finding a way to protect ‘against very high health costs.’” (http://www.pnhp.org/news/2006/october/citizens_health_ca.php)

The organizers of the CHCWG process were caught off guard by the intense support for a national health program. During the sessions the computer programs had to be modified to include serious consideration of the public insurance option. Yet the final report did not reflect the intensity of this support.

The scripted discussions for Sen. Daschle’s community meetings exclude any consideration of a single payer national health program. The closest they come is to discuss a “public plan like Medicare” that can be purchased as another option to a private plan through an insurance exchange. Yet a legislative staff member for a Democratic Senator recently stated that the “public option” proposal looked at present to be completely blocked by the Republicans - they will only discuss changes based upon the existing private insurance industry. One of the reform negotiators, Republican Senator Mike Enzi, last week wrote, “… we must focus on promoting new options and choices for patients. This means expanding competitive, free market plans – not moving toward a single payer health care system.”

Even though the process is a sham, that doesn’t mean that we shouldn’t speak up. We should do so, though in a civil but firm manner. The very first question asking what is the biggest problem in the health system can be answered by stating that our fragmented financing system based on private plans and public programs is wasting a huge amount of funds that should be used for health care for the uninsured and underinsured, and we can actually do that by replacing our dysfunctional financing system with a single payer national health program. We need to be certain that Sen. Daschle is shocked yet pleasantly surprised to see overwhelming support for single payer about which he has written is “brilliantly simple, ensures equity by providing all people with the same benefits, and saves billions of dollars by creating economies of scale and streamlining administration.”

Be sure to stay at the meetings long enough to be certain that the single payer message is included in the submission to the Transition Health Policy Team. We need to send that message. It remains to be seen whether or not the bureaucrats are going to try to bury it again. If they do, then maybe it’s time for a march on Washington.

Economic Survey of the United States, 2008

OECD (Organization for Economic Cooperation and Development)
Policy Brief
December 2008

The US economy is going through an exceptionally difficult period after having been hit by converging adverse developments, some in reaction to previous excesses during the upswing, others more exogenous. A sharp downturn in the housing market, a financial crisis and temporarily high commodity prices have caused activity to slow sharply during 2008. This happened at a time when the external position was persistently weak and the fiscal stance had become unsustainable in the long term — making for a difficult challenge to steer policy between competing objectives. Policymakers have taken actions to support growth and stabilise the financial system, while keeping a careful eye on inflation expectations. It is nonetheless likely that activity will get worse before it gets better. In addition to these short-term severe difficulties, adverse social trends need to be addressed, including incomplete access to health care, the topic of a special chapter in this Survey.

Health-care reform is needed. Despite health spending being much higher in the United States than in any other OECD country, the US population’s health status does not compare favourably on key indicators, in part because many people do not have adequate financial access to medical care. Starting from the present situation, a plan likely to be successful would replace the health insurance tax exclusion with subsidies for individual purchase of insurance and reform the insurance market as needed. There appears to be wide interest for such reform and numerous packages along these lines have been proposed.

(Omitted here are discussions of the financial crisis and the economic outlook, monetary and fiscal policies, markets for housing finance, and financial sector regulation and supervision.)

* How well does the health system perform?

Notwithstanding very high health spending (about 15% of GDP) and the use of cutting-edge technology, the health status of the US population does not appear to fare well by international comparison.

A particular source of concern is the large number of people who lack adequate health insurance.

Making progress towards health insurance coverage for all Americans should be given a high priority on the policy agenda.

* What could be done to encourage more efficient healthcare purchasing decisions?

The existing health tax exclusion should be terminated.

The tax revenues resulting from the elimination of the tax exclusion would be available to subsidise the purchase of insurance by individuals in a way that is independent of the choice of health plan.

Policy makers should consider means testing these subsidies.

* What could be done to promote health insurance coverage?

At present, the individual health insurance market is not attractive, in part because adverse selection risks have led to high premiums compared to their actuarial value, and because administrative costs are high. These problems could be addressed by increasing the size of risk pools and reforming individual and small-group insurance markets by requiring community-rated and guaranteed-issue policies, thus disconnecting the payments from individual health risks.

This approach would have a greater impact on coverage if accompanied by a requirement to be insured, as otherwise healthy people may choose to be uninsured rather than to pay community-rated premiums, which are higher than experience-rated premiums for healthy people.

Some hospitals seem prone to high-cost procedures without additional benefit to patients, while others seem able to provide lower-cost care that proves to be effective. The authorities should consider ways to enhance the dissemination of information on the effectiveness and cost of treatments and procedures. Savings could also be made by reducing payments to Medicare Advantage (MA) plans.

Currently, Medicare administrators are prohibited from harnessing competition or negotiating prices of medical equipment and supplies; instead, they must use fee schedules based on historical charges. On the basis of pilot programmes, it has been estimated that using a competitive bidding process instead of the fee schedules could reduce costs by 26% on average, based on strict criteria for product quality and security of suppliers, without significantly reducing access of beneficiaries to supplies. Generalisation of competitive bidding for medical equipment and supplies should not be delayed beyond the 18-month period stipulated in recent legislation.

Policy Brief:
http://www.oecd.org/dataoecd/60/54/41812368.pdf

Economic Survey of the United States 2008:
http://www.oecd.org/document/32/0,3343,en_2649_33733_41803296_1_1_1_1,00.html

The OECD is an important and highly credible resource for economic studies for the 30 member nations. An Economic Survey is published every 1 1/2 to 2 years for each OECD country. The newly released economic survey of the United States will be widely distributed amongst U.S. economists and policy makers.

For supporters of a single payer national health program, this report is not worth downloading. It is presented here only so that you can be aware of it in the event that someone cites it as an important contribution to our national dialogue on health care reform. It isn’t. The recommendations are the opinion of the OECD economists who have a bias toward regulated insurance markets, as opposed to government-administered public health care financing. That’s really all that you need to understand about the health care reform section of this report.

Health Highlights

The Washington Post
December 11, 2008

Jeanne Lambrew, who helped Daschle write the book about health care reform, will serve as deputy director of the new White House health policy office. Heads of health advocacy groups have described Lambrew as one of Daschle’s most trusted advisers on health issues. She will oversee planning efforts.

http://www.washingtonpost.com/wp-dyn/content/article/2008/12/11/AR2008121101979.html

And…

Hearing on Economic Recovery, Job Creation and Investment In America

Statement of Jeanne Lambrew, Ph.D., Associate Professor, LBJ School of Public Affairs, University of Texas at Austin, Senior Fellow, Center for American Progress, Action Fund, Austin, Texas
Committee on Ways and Means
October 29,2008

As I will explain, the short-run economic crisis has health policy causes and effects–and arguably the most serious long-run economic challenge is our broken health care system. I’ll conclude with suggestions on policies to address both sets of problems.

A wide range of visions and detailed plans have been developed to fix the broken health system. There is a general consensus on the need to improve quality, efficiency, and access through tools such as better managing chronic disease, promoting prevention, investing in and using comparative effectiveness research, and providing assistance to those with low-income or high-risk. There is less agreement on where, when, and how aggressively to insure more Americans, as can be seen in the presidential candidates’ plans. But rather than discussing these ideas in depth, I will end by making two points on approaches to reform.

The first is the importance of addressing the coverage and cost problems simultaneously. Coverage will continue to erode, even with expansions, if the cost of coverage continues its rapid increase.

Second, solutions should be bold but pragmatic. Important changes to the health system are needed to improve its performance. Realigning payments toward quality and coverage toward prevention, for example, will be necessary but difficult. Increasing participation in health insurance will take resources and regulation. At the same time, changes that are risky or uncertain should be avoided. Specifically, the employer-based health insurance system has its flaws, but remains the primary and trusted source of coverage for most Americans. Public programs like Medicaid and SCHIP are mainstays in the safety net that cannot be easily replaced. And Medicare should be improved but not undermined through arbitrary caps or deep cuts.

No doubt, enacting health reform in the context of economic reform will be hard. But it is not as hard as turning a blind eye while our nation’s health and economic prospects fade due to problems that may be prevented by policy.

http://waysandmeans.house.gov/hearings.asp?formmode=view&id=7466

And…

The Specter of Socialized Medicine: What Is It and Is It Invading Our Country?

By Marla Bizzle, Denise Fraga, Laurie Seremetis, Jeanne Lambrew
Center for American Progress
May 14, 2008

We’ve stood by and watched the entire industrialized world turn to varying forms of government-supported health care systems for all their citizens. But, in part because of fears about socialized medicine, similar policy changes have been blocked here. What exactly is socialized medicine, and why is it slander in the current health reform debate?

The fact is that socialized medicine in its purest form is difficult to come by in the real world. Some sort of private entity operates or is allowed to operate within almost every health system. These private-entity roles mean that many systems are better classified as single-payer and universal health care systems, which differ from socialized medicine.

http://www.americanprogress.org/issues/2008/05/socialized_medicine.html

To understand the approach to reform that will be supported by President Barack Obama and HHS Secretary Tom Daschle, you need only understand the views of Jeanne Lambrew. Those who have read Sen. Daschle’s “Critical” already have an impression of her views since she was the policy consultant for his book. It is now official that, as deputy director of the new White House health policy office, she will oversee planning efforts for the Obama/Daschle reform program.

Far too much has already been written about the Clintons’ failed attempt at reform. But Jeanne Lambrew was there, and Senators Kennedy, Daschle and Baucus were on the scene. Whatever other lessons were learned, those involved both then and now cannot be dissuaded from their belief that reform, though bold, must also be pragmatic.

One definition of pragmatic provided by the American Heritage Dictionary is “relating to or being the study of cause and effect in historical or political events with emphasis on the practical lessons to be learned from them.”

Jeanne Lambrew has learned that our nation’s health and economic problems can “be prevented by policy.” She has also learned that the specter of socialized medicine should no longer be allowed to block comprehensive reform in the United States.

If pragmatism represents the practical lessons learned, then doesn’t it seem that the pragmatic approach to health reform should represent the most effective and efficient policies, and that we should not be timid in our efforts merely because someone fears that they may hear the term, socialized medicine? Aren’t these the lessons we learned?

Yet Jeanne Lambrew insists on continuing with and expanding our current inefficient, fragmented multi-payer system that can never achieve our goals of equitable, high-quality, comprehensive care for absolutely everyone. She is a brilliant individual who is more informed than most on the policy issues. She rejects the nonsense about the socialized medicine bogeyman. So why does she and the other Washington veterans continue to begin from a position that single payer is not feasible?

The feasibility issue lies within the Senate, with Senator Chuck Grassley as the proxy. He certainly recognizes the problems. He understands the rationale of single payer. He doesn’t accept the disastrous status quo. But feasibility? Is he really going to insist that we abandon important policy choices that would actually work?

You don’t need to answer that. Just look for higher costs, more mediocrity, continued inequity, and adoption of highly flawed, wish-they-would-work policies.

Mortality in California Hospitals, 2006

State of California
Office of Statewide Health Planning and Development (OSHPD)
November 2008

In-hospital mortality refers to deaths that occur to patients during the time they are hospitalized.

The data sources for these analyses were the Office of Statewide Health Planning and Development (OSHPD) Patient Discharge Data for 2006, which includes death certificate data for 2006 and information for all patients who were hospitalized in California during that year.

Patients paying for care out-of-pocket were 80% more likely to die (Odds Ratio = 1.8) and patients covered by Medi-Cal were 60% more likely to die (Odds Ratio = 1.6), compared with patients covered by private insurance. (From a table in this report, the odds ratio for Medicare was 1.1.)

http://www.oshpd.ca.gov/HID/Products/Research_Briefs/Brief1_rev.pdf

Although it is tempting to say that being uninsured causes an 80 percent higher death rate for hospitalized patients, and being on Medi-Cal (California’s Medicaid) causes a 60 percent increase in deaths, these population sectors undoubtedly varied in factors other than simply the source of payment for their hospital bills.

For this study, privately insured patients were the reference source (i.e., the base of 1.0 to determine the odds ratio for those with other payment sources). Privately insured patients in California include primarily the younger and relatively healthy workforce and their healthy families, plus those able to pass underwriting standards in the individual health insurance market. It would not be unreasonable to assume that this group would have a lower in-hospital death rate than groups that include older individuals and individuals with greater medical problems.

Medi-Cal is a welfare program for low-income people, a group with other demographic factors that could put them at greater risk of facing lethal medical conditions. The Medi-Cal program is severely underfunded, and that has reduced participation by health care providers, significantly limiting access to care for this more vulnerable population. For this reason health care reform that includes a role for Medicaid is problematic. Although eliminating Medicaid would not eliminate the other negative health factors for this group, a uniform financing system for everyone at least would reduce financial barriers to access.

Of greater concern is the very high death rate in the self-pay group (uninsured). These are people under 65, 80 percent of whom have a head of household who is employed. This is the “working America” sector, but with more modest incomes on average, and in jobs without affordable employer-sponsored health plans. This is a group in which other demographic variants are not nearly as great as this one single factor of not having health insurance. The benefits of health care reform that would include this group in a uniform financing system for everyone are obvious.

The Medicare numbers are interesting. The Medicare sector includes seniors and individuals with long-term disabilities, creating the largest high-risk insurance pool in the nation. You would expect this group to have a much higher death rate than the younger, healthier privately insured sector. Yet Medicare patients have only a 10 percent higher in-hospital death rate than do those from the healthiest sector of our population. Undoubtedly privately insured patients who are hospitalized have developed significant problems, separately them from their peer group. That likely explains why they have an in-hospital death rate approaching that of the high-risk Medicare population.

The real, non-intuitive, take-home lesson is that Medicare patients have an in-hospital death rate that is much lower than the uninsured, much lower than Medi-Cal patients, and that is close to the death rate of the younger, privately insured patients.

Medicare is a program that works. With some improvements, it would serve all of us well while eliminating the waste and inequities of our dysfunctional, fragmented, multi-payer system.

AARP collects royalties, fees from insurers it endorses

By Gary Cohn and Darrell Preston
The Boston Globe
December 5, 2008

(AARP) collects hundreds of millions of dollars annually from insurers who pay for AARP’s endorsement of their policies.

The insurance companies build the cost of these so-called royalties and fees, which amounted to $497.6 million in 2007, into the premiums they charge AARP members, according to AARP’s consolidated financial statement for that year (all insurance products, not just health).

Nowhere were AARP’s conflicting roles more evident than in its lobbying in support of a 2003 bill proposed by President Bush to expand Medicare, the federal health insurance program for people older than 65.

After the Medicare bill was signed into law by Bush in December 2003, AARP was able to expand its contract with Minnetonka, Minnesota-based UnitedHealth Group Inc., which underwrites AARP’s Medicare supplemental insurance plan.

AARP advertises that its Medicare supplemental insurance can save people thousands of dollars. While every type of supplemental policy sold by all companies must offer the same exact coverage under federal rules, AARP doesn’t sell the least expensive.

The AARP/UnitedHealth basic policy costs $582 a year more than a lower-cost competitor in New York and $428 more in Los Angeles, according to data on Medicare’s webpage.

http://www.boston.com/news/nation/articles/2008/12/05/aarp_collects_royalties_fees_from_insurers_it_endorses/?page=full

This is yet another example of the profound administrative waste that characterizes health care financing in the United States. Beyond the administrative excesses of AARP’s insurer, UnitedHealth, AARP has inserted itself as another middleman, providing yet another layer of administration, with none of those extra funds going to pay for health care.

A prime example of this excess administrative waste is found in the AARP/UnitedHealth Medigap plans. Congress recognized that the insurers were ripping off our senior citizens by selling Medigap policies that were impossible to compare. Congress then passed legislation requiring that each plan provide the exact same benefits so that it was possible to compare value based on the premium charged for each plan. The Boston Globe article demonstrates that the AARP/UnitedHealth plans have premiums that are about $500 higher, presumably because of the insertion of AARP as a superfluous middleman.

Plan F is the most common Medigap plan selected by Medicare beneficiaries, which is the plan my wife and I have. To see how much more the AARP/UnitedHealth Plan F would cost us compared to our current coverage, I went to their website to get a quote. I found out that the quote for both of us was about $500 less than we are paying! So what gives?

Looking more closely at the table of rates on the AARP/UnitedHealth website, it turns out that these are “first year early enrollment discount rates” that apply only to “new AARP Medicare Supplement Plan enrollees.” Nowhere was there any indication nor any link that would tell you what the second year rates would be. AARP/UnitedHealth has used a classic bait and switch scam to deceive our seniors and circumvent the intent of Congress to provide transparency in the purchase of Medigap plans.

Those currently crafting health care reform tell us that we need an “American solution” using the private insurance industry, and all we need to do is regulate the insurers so that their products will provide us with value. Congress has already regulated the Medigap plans, and what did we get? Even greater administrative waste, but worse, a profoundly dishonest bait and switch scam.

The private insurers have failed this test. No matter how much we regulate them, the private insurers will always find other ways to stick it to us. Their institutional investors will demand that they do so. It’s time time to dump them and adopt a publicly-administered and publicly-financed single payer system that is designed specifically to help patients instead of investors.

Lab retirees cry foul at health coverage switch

By Suzanne Bohan
San Jose Mercury News - Alameda County
December 5, 2008

One by one, Lawrence Livermore Laboratory retirees took the microphone at a forum this week, and described their confusion, anxiety and anger over dramatic changes under way with their retiree health care benefits.

The crowd of nearly 300 retired scientists, engineers, mechanics and other lab workers, along with some spouses, took to occasional taunts during a Wednesday morning presentation here by the new plan administrator and applauded at pointedly critical remarks.

This year, nearly 4,200 lab retirees and their spouses lose the group health coverage plan they have had. It was first provided by the University of California, which formerly managed Lawrence Livermore Laboratory. They then joined a group plan with virtually identical benefits offered by Lawrence Livermore National Security, or LLNS, a partnership including UC and Bechtel Corporation, which took over lab management in 2007.

And some 2,400 who took early retirement from the lab will also lose the lab’s group coverage when they turn 65 and become eligible for Medicare.

In its place, this year the lab’s Medicare-eligible retirees will join a new trend in the provision of health care benefits — called “defined contributions” — that allows employers to shift the cost of rising health care premiums onto recipients.

With defined contributions, an employer lays out a limited pot of money, typically annually, and the recipient uses it to purchase health care insurance on the open market, and to cover co-payments, deductibles and other health care expenses. Livermore lab retirees, and their spouses, will each get $2,400 annually. Any amount unused rolls over into the next year. But any costs beyond that are paid by the retiree.

Extend Health Inc., which is partly owned by America Online founder Steve Case’s Revolution Health, is now the contact point for lab retirees on Medicare. The firm acts as a health insurance broker, offering more than 170,000 plans nationwide from an array of insurers. Trained advisers work with retirees to sift though the options to find the best plan. Retirees then pay their premiums directly and are reimbursed from their $2,400 yearly allotment.

Alain Enthoven, an emeritus professor with Stanford University’s Graduate School of Business who sits on Extend Health’s advisory board, sympathized with the trauma of changing health plans but said the movement toward defined contributions is essential for controlling costs by making recipients more conscious of health care expenses, which have been rising every year since the late 1990s.

“What most people have is too good to be true,” said Enthoven, one of the early pioneers in the managed care movement.

“People are not going to go on having what they had in the past,” Enthoven continued. “It’s just not a sustainable model.”

Mark Beach, a spokesman for the AARP’s California office, agreed that health care reform requires more sharing of costs by individuals.

“Any intellectual worth their salt will say that’s a part of containing costs,” he said.

http://www.mercurynews.com/alamedacounty/ci_11151014

The current Democratic proposals for health care reform promise that you can keep the health insurance you have, if that’s what you prefer. This policy was included in the reform models to avoid losing the support of those who have been promised life-long coverage with very generous plans. Career scientists and engineers at the prestigious Lawrence Livermore Laboratory, managed by the University of California, were secure in knowing that nothing could happen to their excellent, life-long coverage offered as a perk to attract the best.

Enter Bechtel Corporation. After one year, their life-long retirement coverage is dropped, and they are given an annual defined contribution of $2400 to supplement the basic Medicare program. Just wait until the Medicare Advantage subsidies are cut back, and then see what they can purchase with that. None of them were given the option of keeping the plan they had.

Alain Enthoven says that their coverage was “too good to be true” and was “not sustainable.” So in his view what is sustainable is a shift to a defined contribution, which may make individuals better health insurance shoppers, but does so with the tradeoff of making access to actual health care less affordable. That has adverse health consequences.

Costs can be contained without creating financial barriers to care simply by adopting a single payer national health program. But according to AARP’s spokesman, apparently us intellectuals who would reduce patient cost sharing to improve access simply aren’t worth our salt. Now that really advances the health policy dialogue.

The important message here is that this is only one of thousands of examples where individuals who wanted to keep the insurance they had were not allowed to do so. It was not their choice. Some of the many reasons that individuals involuntarily lose their coverage were discussed in a previous Quote of the Day. Since our politicians are about to provide us with reform that allows us to keep the coverage we have, it would be of value to review that message now to see why keeping the coverage you have is only a fantasy for most of us.

http://www.pnhp.org/news/2008/july/keeping_the_insuran.php

Critical: What We Can Do About the Health-Care Crisis

By Senator Tom Daschle, with Scott S. Greenberger and Jeanne M. Lambrew
Thomas Dunne Books, February 2008

The key question for any health-care reform plan is, “How will it cover people?” Most of the world’s highest-ranking health-care systems employ some kind of “single-payer” strategy - that is, the government, directly or through insurers, is responsible for paying doctors, hospitals, and other health-care providers. Supporters say single-payer is brilliantly simple, ensures equity by providing all people with the same benefits, and saves billions of dollars by creating economies of scale and streamlining administration. But pure single-payer system is politically problematic in the United States, at least right now. Even though polls show that seniors are happier with Medicare than younger people are with their private insurance, opponents of reform have demonized government-run systems as “socialized medicine.”

I have strong views on what an “ideal” system would look like. But I’m not willing to sacrifice worthy improvements on the altar of perfection. I find it encouraging that the leading Democratic presidential contenders appear to share this attitude. The proposals that Obama, Clinton, and Edwards put forward would improve our current system rather than scrapping it, using the Massachusetts reform plan as a model.

The Federal Health Board

I believe a Federal Health Board should be charged with establishing the system’s framework and filling in most of the details. This independent board would be insulated from political pressure and, at the same time, accountable to elected officials and the American people.

First, it would set the rules for the expanded FEHBP, placing conditions on the private insurers wishing to participate.

Second, the Federal Health Board would promote “high-value” medical care by recommending coverage of those drugs and procedures backed by solid evidence.

A third function of the Federal Health Board would be to align incentives with high-quality care.

Finally, the Federal Health Board might also play a role in rationalizing our health-care infrastructure.

http://us.macmillan.com/critical

When it was announced that Tom Daschle was Barack Obama’s choice to be Secretary of Health and Human Services, it was also announced that he would not only be an administrator, but also he would lead the team that is crafting the definitive health care reform proposal for the Obama administration. That is why Sen. Daschle’s book, “Critical,” is important to us. It provides us with the views of the person who will be working with Congress to reform our health care system.

The fundamentals of his proposal are essentially the same as those proposed by Barack Obama, Max Baucus, and most of the other Democrats who have been advocating for reform. He would continue employer-sponsored coverage, expand public programs, and provide an FEHBP-type program, including a Medicare-like option. He would attempt to achieve universal coverage through an individual mandate with financial assistance for lower-income individuals.

Daschle also includes other concepts that are making the political rounds, such as information systems, community health centers, quality measurements, and “shared responsibility.”

One essential reform that seems to be missing from his proposal is the need to reinforce our primary care infrastructure, providing everyone with a medical home. Maybe that could be extrapolated from his call for rationalizing our health care infrastructure, but, if so, it is of such great importance that he should advocate for it explicitly.

What is relatively unique in Daschle’s proposal is the recommendation for a Federal Health Board, based on a model similar to the Federal Reserve System. One of the more important functions would be to provide oversight of the private insurance industry in his multi-payer system, a role that would be unnecessary in a single payer system. The other functions he describes can easily be or already are provided by existing agencies, though introduction of a single payer system would certainly be accompanied with appropriate bureaucratic reform.

Although he recommends that this board be quasi-independent, insulated from political influence, there is still risk that ideological extremists could gain control. Think of the failure of the Federal Reserve System to provide adequate oversight of our financial system, contributing to our current financial meltdown. That might not have occurred if free-market ideologues such as Alan Greenspan had not been in charge of the Federal Reserve. The Supreme Court is also insulated from political interference, yet obviously it too is controlled by ideologues, over whom we have no control. Imagine if we had a Federal Health Board composed of those individuals who, through the Medicare Modernization Act, damaged our public Medicare program. If they had been in control of such a board, we could have been much further down the road toward their goal of a totally privatized Medicare system.

Most troubling is Sen. Daschle’s conclusions on single payer. He describes it as the model used by the “world’s highest-ranking health care systems.” He acknowledges, without dispute, that supporters say that it is “brilliantly simple, ensures equity by providing all people with the same benefits, and saves billions of dollars by creating economies of scale and streamlining administration.” Yet he rejects it merely because it is “politically problematic.” He would sacrifice the “ideal” system because he is “not willing to sacrifice worthy improvements on the altar of perfection.”

It certainly is true that opportunities for enacting beneficial policies can be missed when the politics are not in alignment. But it is also true that bringing the politics into alignment can eliminate the opportunity to enact ideal policies. For success in achieving a high-performance health care system, we shouldn’t sacrifice policy; we should change the politics.

“The Doctor’s Door” by Michael Merenda. Work in progress - unfinished and not released. Performed by Mike and Ruthy.

The Doctor’s Door
by Michael Merenda

In my youth I traveled
Over land and sea
I fell in love with a farmer’s daughter
And she fell in love with me

Before long we’d married
I took her from her home
Very shortly after that
Something went terribly wrong

I’d gotten her with child
We were of course overjoyed
Until the fever took her body
And neither of us were employed

I went to the door of the doctor
Said, “Help us, Sir, if you can.”
He said he’d not see us without
Five gold pieces in our hand

“Sir, I’ve no gold pieces
But I’ll be forever in your debt
If you would only save my wife
And this unborn child I’ve never met.”

O, the night blew rainy
O, the night blew cold
And my young wife she died that night
Under the doctor’s door

Now that you’ve heard my story
Hang your head and cry
How the rich man turned his back
And let the poor woman die

In my youth I traveled
Over land and sea
I fell in love with a farmer’s daughter
And she fell in love with me

© 2008 Concert Works Music, ASCAP
Reproduced with permission of the author.

Michael Merenda, writer, composer, musician, - an amazing young artist, - is a new father. We heard him in a breathtaking performance with Ruth Ungar Merenda.
Mike and Ruthy, proud parents of infant Will, brought their son to the show. Mike mentioned that although he wrote “The Doctor’s Door” when Ruth was pregnant, he needed to wait until after the baby arrived to perform the song.

We understand! The song speaks so well to the shame and anguish we suffer, but also to our higher calling as physicians.

The members of Physicians for a National Health Program believe it is time to open the doctors’ doors. PNHP members include people like Drs. Arnold Ritterband and Benjamin Friedell. Dr. Friedell founded the Oneonta Free Clinic and Dr. Ritterband founded the Schenectady Free Health Clinic.

PNHP reflects the true calling of our profession: to serve our fellow human beings. We must not allow money interests to ruin the human relation of caregiving. Here PNHP not only reflects the ideals of our profession, but real physician values: 59% of American physicians would prefer to practice under a system of national health insurance.

We not only take to heart the higher purpose of our profession, but the higher purpose of our society. Democracy in the United States has failed when our country has more infant death and more maternal death per pregnancy than any other developed nation. Is health not the foundation of personal freedom?

Michael Merenda’s song inspires us to work harder to win the day when we will hang our heads and cry no more, when we will proudly say that in the United States no one goes without health care.

Thank you, Mike and Ruthy!

Surprise Health Bills Make People See Red

By Anna Wilde Mathews
The Wall Street Journal
December 4, 2008

Insured patients are sometimes hit with unforeseen charges after emergencies, when they are taken to the closest hospital regardless of whether the facility accepts their insurance. Consumers also may be billed after visiting in-network hospitals if they received treatment from medical providers who work there but don’t participate in the same health plans. When that happens, insurers often pay part of the doctors’ fees, and the physicians bill patients for the difference. This is the practice known as balance billing, and it can leave consumers battling both the insurer and the medical provider to get the charge reduced.

California regulators recently made it illegal for people covered by health-maintenance organizations to be balance-billed for out-of-network emergency services.

Physician groups say doctors have the right to refuse to sign up with insurers’ networks, and regulators shouldn’t bar doctors who don’t participate in health plans from billing insured patients. They say that insurers’ payments to out-of-network health providers are often unfairly small. “You can’t turn it around and say it’s the doctor’s fault,” says Nancy Nielsen, president of the American Medical Association.

Insurers counter that they shouldn’t be forced to pay whatever fee out-of-network health-care providers demand. “You have a set of specialists who won’t contract with health plans, and they want to bill whatever they choose,” says Robert Zirkelbach, a spokesman for America’s Health Insurance Plans.

http://online.wsj.com/article/SB122834911902477643.html

Balance billing is a payment required by physicians that is in excess of the benefits covered by the patient’s insurer. It is a prime example of the unfairness that permeates our system of health care financing. It can be unfair for all parties.

Balance billing is certainly unfair for patients who purchased insurance in good faith only to find that they receive large bills for services that their insurance should have covered. Denying physicians the right to bill full fees for services that the patient’s insurer should have covered, but didn’t, is unfair to the physicians who have no contract with the insurer. Physicians who hold out for exorbitant fee schedules are unfair to the insurers who are trying to put together a reasonable list of in-network physicians to serve their beneficiaries.

Let’s step back and see if we can make some sense out of this.

Let’s agree that the goal of our health care financing system should be to be sure that everyone can receive the health care that they need without exposure to financial hardship. Not only are financial barriers removed for the patient, but also enough funds are allocated for the delivery system to be sure that it will be there when needed. Obviously that means that physicians should be adequately compensated.

Should physicians have the right to unilaterally dictate the fees that the third party payer must pay? When Medicare was introduced, we saw what happened. Fees skyrocketed. Medicare had to adopt payment policies that would ensure that compensation was reasonable. That has been and always will be a work in progress, but an effort continues to be made to provide a reasonable balance that would advance the public good: fair fees for physicians without an excess burden on taxpayers.

It is very rare to see balance billing for a patient enrolled in the traditional Medicare program (except maybe by error) since very few physicians totally opt out of the Medicare program. Those physicians who do not sign Medicare contracts are still required to adhere to a payment schedule unless they establish what amounts to a private contract with every Medicare patient they see.

What is the role of private insurers in setting fees? They establish a contract with patients to pay for services, but only under the terms of the contract. The only reason that private insurers still exist is that they also establish contracts with selected physicians and other providers who agree to the discounted reimbursement rates dictated by the insurer. Physicians who decline to sign contracts to become providers under these plans are free to charge any patient, whether or not covered by these plans, their usual fees. That is, until now.

California has made it illegal, in emergency situations, for physicians to bill the patient for balances not covered by the patient’s own insurance plan, even though the insurer has no contract with the physician. Think about that. The only contract is between the patient and the insurer, yet the state has given the insurer the authority to enforce upon physicians the terms of a contract that doesn’t even exist!

We’ve seen what’s unfair about balance billing, so how could we introduce fairness? If we had an improved Medicare program that covered everyone, the patient would never have to worry about being billed for balances that are not defined by the program. That’s fair. Under a universal Medicare program, reimbursement would be negotiated with physicians to be sure that rates were adequate to cover legitimate expenses and still provide reasonable profits. That’s fair.

And the private insurers who are extorting physicians with whom they have no contractual relationship, while they burn up resources on egregiously wasteful administrative excesses? With our own improved Medicare system we wouldn’t even need them, and we would show them the door. Now that’s really fair!

Now is the Time for Health Care Reform: A Proposal to Achieve Universal Coverage, Affordability, Quality Improvement and Market Reform

AHIP (America’s Health Insurance Plans)
Board of Directors’ Statement
December 2008

… the Board of Directors of America’s Health Insurance Plans (AHIP) is offering a new set of proposals aimed at moving the nation toward a restructured health care system in which no one falls through the cracks, all Americans have high quality, affordable coverage, and the efficiency and effectiveness of the system are greatly improved.

Soaring Health Care Costs Need To Be Brought Under Control

3. Streamline administrative processes to increase efficiency, make the system easier for patients and providers to navigate, and reduce costs.

Administrative processes should be streamlined across the health care system. In advancing this recommendation, we recognize the need for our industry to come to the table with proposals for how we can do our part. We have committed to develop a multi-payer online portal to give providers a uniform method to communicate with health plans and afford them access to current information on eligibility and benefits. This will ease the administrative challenges that physicians and other providers face, and will help them and their patients better understand coverage and predict out-of-pocket costs. We are also working with providers on a standard data aggregation approach with the goal of giving providers and consumers useful performance information. Administrative streamlining should be viewed through the eyes of consumers, with the goal of making the health care system easier to navigate and more consumer friendly. A key part of this effort is our focus on the reform of market rules to enhance access for consumers and provide them with clear, useable information on coverage and care options.

http://www.americanhealthsolution.org/assets/Uploads/healthcarereformproposal.pdf

As the momentum for reform builds in our nation’s capitol, the board of directors of AHIP has made the wise decision to provide a definitive statement of their concepts of reform. Very soon the future role of their industry in the financing of health care in America may well be defined by political policy makers. Obviously the industry wants policies that will ensure a robust market for their products.

Although there are many important concepts presented in their report, only the statement on administrative efficiency was selected for this message. The reason is that the private insurance industry has been a major contributor to the profound administrative waste that characterizes our dysfunctional, fragmented system of financing health care. If the private insurers are to have a legitimate role in the future of our health care system, the first requirement that we should demand of them is administrative efficiency.

Reading their proposal to “streamline administrative processes,” you have to ask yourself, what is the substance of their proposal? They are recommending a continuation of the same inefficient, fragmented structure that we now have, except that it is expanded to include everyone. Their call for a token online portal will not provide the structural reform that we need, and may actually increase the administrative burden of our financing system. The fact that they have failed to seriously address this administrative waste, largely of their own making, in and of itself should disqualify them from further participation in the reform process.

This is not to say that this report has no redeeming value. There are some worthwhile proposals. They have stressed the importance of improving our primary care infrastructure. They also have recommended an expansion of our public health infrastructure. These are much needed investments that have been neglected far too long. But the last thing that we would want to do is to superimpose private insurer administrative functions on these crucial programs. The report states “health plans are uniquely positioned to assist in this effort,” but what we need is for the insurance industry to get out of our way as we introduce these repairs to our health care delivery system.

If you still believe that the private insurers have a legitimate role in health care financing, all you need to do is read the relatively detailed section on insurance markets, public programs, and regulation. You could not possibly describe a proposal that would better serve the interests of the private insurance industry. They would create a standard of underinsurance, require all of us to purchase their products, and pretend to address affordability issues through tax credits. The private insurance industry wins the jackpot, while patients and taxpayers lose.

The AHIP board of directors must feel quite smug in having foisted off on us this con job. But wait. This is only their vision; it is not yet our reality. We can do something. We can demand reform that benefits patients and taxpayers. Do you think Washington can hear us?

UnitedHealth to Insure the Right to Insurance

By Reed Abelson
The New York Times
December 2, 2008

For these economically uncertain times, the UnitedHealth Group has a “first of its kind” product: the right to buy an individual health policy at some point in the future even if you become sick.

Called UnitedHealth Continuity, the product is not actual medical insurance, but is aimed at people who may have insurance now but are worried they may lose it — and may not be able to obtain replacement insurance on their own. They may expect to retire early, for example, before they qualify for Medicare. Or they are worried about the possibility of losing their job and their health coverage.

People who are already sick will generally not be eligible for the new product. Those who do pass a medical review, will pay 20 percent each month of the current premium on an individual policy to reserve the right to be insured under the plan at some point in the future.

http://www.nytimes.com/2008/12/03/business/03insure.html?ref=business

One of the many reasons that there is a push for comprehensive reform is that, in most states, individuals who have medical problems are denied the opportunity to purchase insurance on their own. This is one of the more serious flaws in insurance markets since this defeats the primary purpose of insurance - providing individuals with health care needs affordable access to health care.

Those crafting reform would address this problem by including guaranteed issue in their reform proposals. Insurers would be required to offer coverage to those with health care needs, but this would work only if it were coupled with an individual mandate for everyone to purchase coverage, otherwise premiums would skyrocket because of a concentration of high-cost individuals in the insurance risk pools.

There are still those who would prefer to see private sector solutions in the insurance marketplace. In this new product, UnitedHealth Continuity, the private insurance industry is demonstrating the thinking behind market solutions to our health insurance problems. A public sector approach would automatically include everyone forever, making health care a right. In a plan that only the innovative private marketplace sector could devise, the UnitedHealth Group, without providing any insurance benefit whatsoever, has created a way of selling us the the right to health care at some time in the future, but a right that you can purchase only if you are healthy and don’t need care.

Besides the most obvious flaw of selling a right that everyone should have, there is another policy flaw in this proposal. Those who purchase this right and remain healthy would have a full range of insurance options and might well choose other options that may be more appropriate. Those who develop medical problems in the interim would have no choice but to enroll in this plan, only to find that premiums would be unaffordable because of the concentration of other high-cost individuals in the program.

Even with guaranteed issue, an individual mandate, and a regulated marketplace, the private insurance industry will continue to innovate to enhance the business success of their industry. With chants of “health care is a right” in the background, the insurance industry has provided us with yet another innovation in which they can sell to us our right without providing any service or product, merely the option to purchase coverage in the future.

Would someone explain once again why momentum is building in Washington, D.C. to keep this industry in charge of our health care financing? With a single payer national health program, we would play by our rules, not theirs.

Blue Cross Blue Shield of Michigan Answers Attorney General

MarketWatch
December 1, 2008

Blue Cross Blue Shield of Michigan provided more than 300 pages of detailed financial and membership information today to Michigan Attorney General Mike Cox to answer his request for further information about Michigan’s individual health insurance market. The information confirms growth of Michigan’s individual health insurance market and escalating financial losses suffered by BCBSM, the state’s last-resort insurance carrier, in its individual line of business.

BCBSM has warned policy makers and regulators over the past 16 months that because of Michigan’s 30-year-old regulatory structure — which allows all other carriers to dump high-risk individuals into BCBSM’s insurance pool without limit or regulation — uncontrollable financial losses on individual policies will escalate and lead to BCBSM’s entire business becoming financially unstable in the near future.

“Michigan’s individual health insurance market is set up to fail financially,” said Mark Bartlett, BCBSM executive vice president and chief financial officer. “It’s a hard truth, especially if you oppose reforming the market, but it is the truth. Unless comprehensive reform is achieved this year, the financial situation will grow into a crisis that threatens health care, the economy and the health insurance safety net for millions of Michigan residents.”

http://www.marketwatch.com/news/story/Blue-Cross-Blue-Shield-Michigan/story.aspx?guid=%7B5379FA18-BBBE-4084-A40A-AB5CFFB0BDAD%7D

The individual health insurance market in the United States has presented a policy challenge to those attempting to craft a health care financing system that includes everyone.

In most states, insurers marketing individual plans have slowed the increase in their premiums by selling exclusively to healthy individuals. This is important because it takes only a modest number of individuals with health care needs to drive up premiums to ever less affordable levels.

Now that the momentum is building for truly universal coverage, the policy makers crafting reform are faced with the problem of how to cover those with greater needs largely left out of the individual market. One solution has been to establish high risk pools, but the success with such efforts has been almost negligible. Blue Cross Blue Shield of Michigan provides us with a real life experiment of how disastrous that approach can be. They have been warned that they are at risk of losing their status as a licensee of the Blue Cross and Blue Shield Association.

That brings us back to the fundamental problem that has been stated repeatedly in these messages. If everyone were to be included in the risk pools for private plans, and if the coverage were adequate to prevent financial hardship for those with health care needs, then the private insurance industry is no longer capable of providing us with health plans that have affordable premiums.

The solution? One single, universal risk pool. A single payer national health program: a new and improved Medicare for all.

The Los Angeles Times today quotes one of the founders of the Herndon Alliance:

“There is a growing understanding that you have to give people choice and you can’t take away what they have,” said Ron Pollack, head of Families USA, an influential advocacy group for healthcare consumers that is working with a diverse collection of interest groups to build consensus. “One of the big no-nos is that you must not ever threaten the coverage that people have.”

Do people really love their health insurance? What is the origin of such false wisdom? Kip Sullivan illuminates the question in the following message from the All Unions Committee For Single Payer Health Care — HR 676:

================

Why Does Celinda Lake Oppose Single Payer?

Self-described as “one of the Democratic Party’s leading political strategists,” Celinda Lake has claimed that single-payer reform lacks meaningful popular support. Lake’s research, done for the Herndon Alliance, has consistently supported reform based upon private health insurance. She and the Herndon Alliance are largely responsible for the notion that a single payer Medicare-for-all healthcare system is ‘not politically feasible.’

Lake’s findings are in sharp contradiction to numerous polls showing that single payer is enormously popular.

* In a New York Times/CBS News poll in February 2007, 64% said that the federal government should guarantee health insurance for all Americans.

* In October 2003, 62% of respondents to a Washington Post/ABC News poll said they preferred “a universal health insurance program, in which everybody is covered under a program like Medicare that’s run by the government and financed by taxpayers.”

* These findings were repeated in a 2007 Associated Press-Yahoo poll in which 65% supported a Medicare-for-all system.

Kip Sullivan, an attorney and health systems analyst, has been at work on a soon-to-be published analysis of the research methods and methodology used by Celinda Lake to conduct her work on behalf of the Herndon Alliance.

Sullivan has written over 100 articles on health policy, many of which appeared in national newspapers, magazines and journals such as American Journal of Public Health, Health Affairs, Los Angeles Times, The Nation, New England Journal of Medicine, New York Times, and Washington Monthly. He is the author of “The Health Care Mess: How We Got Into It and How We’ll Get Out of It” (AuthorHouse, 2006). He has a BA from Pomona College and JD from Harvard Law School.

Below is Sullivan’s executive summary. For a copy of the article, contact Sullivan at kiprs[at]usinternet.com.

An analysis of Celinda Lake’s slide show, “How to talk to voters about health care”
By Kip Sullivan, November 29, 2008

Executive Summary

Celinda Lake is a pollster who has developed a slide show entitled, “How to talk to voters about health care.” Based on research Lake did for the Herndon Alliance, a coalition formed in 2005, Lake offers an explanation of how “Americans” view “health care reform.” According to Lake, “Americans” have surprisingly conservative “values” about this topic. According to Lake, this means advocates for “health care reform” must not only use and avoid certain words, but they must endorse and avoid certain policies.

Examples of Lake’s findings include:

* Americans think Medicare is “frighteningly flawed” and, consequently, Americans oppose a national health insurance program based on Medicare or which resembles Medicare;
* Americans who have private health insurance not only like it, but like it so much they will resist a Medicare-for-all solution to the health care crisis because it does not leave them the option of continuing to receive coverage from a health insurance company;
* Americans don’t want to pay for health insurance for “the undeserving,” a category which includes even the parents of average Americans;
* Americans don’t like the phrase “universal coverage” or “universal health insurance,” and prefer “quality, affordable health care”;
* Similarly, activists should never say “Medicare for all,” and instead say “choice of public and private plans,” which is, of course, equivalent to saying no one should support a Medicare-for-all (or single-payer bill) and should instead only support legislation that allows the health insurance industry to continue to take in tax dollars and premium payments. (Under a Medicare-for-all system, one payer like Medicare would replace the nation’s 1,500 health insurance company as the sole payer of clinics, hospitals and other providers.)

To understand why Lake would depict Americans as Scrooges who like their health insurance company and are afraid of Medicare, it helps to understand why the Herndon Alliance was formed. The Alliance was founded by individuals who have either opposed or refused to support Medicare-for-all legislation and instead supported legislation like President Bill Clinton’s 1993 Health Security Act, a bill that would have pushed all but the wealthiest Americans into HMOs. In 2005, several individuals who would play leading roles in creating the Herndon Alliance met to discuss why they “keep losing,” that is, why none of the bills they had supported in the past were enacted or, if enacted, stayed enacted. These individuals decided that the primary problem was the “values” of the American people. According to this diagnosis of the problem, their failure to achieve universal coverage was not due primarily to the power of the insurance industry or the unattractiveness of the legislation they had supported, but rather to the “values” of the average American.

But this diagnosis conflicts with a large body of research which shows that 65 to 85 percent of Americans support universal health insurance, and 60 to 70 percent support a Medicare-for-all program. For example, a 2007 poll by AP-Yahoo asked respondents whether they agreed or disagreed with this statement: “The United States should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers.” Sixty-five percent said yes.

If the Herndon Alliance founders had said that a large majority of Americans support universal coverage and Medicare-for-all programs, and this support can be reduced by false propaganda against such programs, that would have been an accurate diagnosis. But they didn’t. Instead, they adopted the much more questionable assumption that most Americans harbor “values” that cause them not support universal coverage. It is reasonable to infer that Lake was hired by the Herndon Alliance to produce research to confirm their armchair diagnosis of the American pyche.

Lake’s research occurred in three stages: a “mapping values” stage, a focus group stage, and a polling stage. There were serious defects in all three stages.

In the first stage, as Lake put it, “[O]ur research … explor[ed] … the core values that shape … views on health care….” The result of this first stage was a report by a firm called American Environics (AE) that claimed to identify 117 “values” held by Americans that allegedly have some influence over how we think about health care reform. These “values” had names like “brand apathy,” “discount consumerism,” “more power for big business,” “meaningful moments,” and “sexual permissiveness.” The “value” known as “meaningful moments,” for example, was defined this way: “The sense of impermanence that accompanies momentary connections with others does not diminish the value of the moment.” Lake and AE refuse to explain where these “values” come from or how any of them relate to “health care reform,” much less deserve to be called “core values that shape … views on health care.”

On the basis of these “values,” AE divided Americans into eight groups or “clusters” with names as fanciful as the “values” AE says we hold. The three largest groups, in order of size, were “Proper Patriots” (34 percent), “Marginalized Middle-Agers” (17 percent), and “Mobile Materialists” (13 percent). AE describes the millions of people in these “clusters” in terms that can only be called psychobabble. Here is how AE stereotypes Mobile Materialists:

This group tries to impress others with their homes, cars, clothes and looks, scoring high on Status via Home, Buying on Impulse, Importance of Brand, Joy of Consumption, Crude Materialism and Ostentatious Consumption. … [T]he new rims for their car or yet more designer handbags are welcome escapes from everyday drudgery. They tune out after work by watching MTV Cribs (Living Virtually) and feel best when they make time for a workout at the gym or a mani-pedi (Look Good Feel Good, Concern for Appearance).

The second and third stages of Lake’s research were based on the bizarre results of the first stage. For her focus groups, Lake selected people who represented the strange “clusters” concocted by AE. Lake does not tell us how she determined that the people she selected fell into one of the “clusters,” or what questions she asked them. All we hear from Lake are her conclusions about what allegedly went on in the focus groups. It was from these focus groups that Lake allegedly learned that Americans don’t support “universal coverage,” fear Medicare, feel good about their health insurance company, and think their own parents are among “the undeserving.”

In the third stage, Lake conducted a poll designed to see how people felt about a health care reform proposal she developed during the second stage (called “guaranteed affordable choice”) compared with single-payer. She wrote the question in a way that ensured the respondents would favor “guaranteed affordable choice” (GAC) over the single-payer proposal. To offer just one example: Lake declined to tell her respondents that patients would continue to have limited choice of doctors and hospitals under the GAC plan while under the single-payer plan patients would have complete freedom to choose their doctors and other providers.

In short, Lake delivered to the Herndon Alliance the results the founders of the Alliance were looking for. She told them, in effect, that they were right all along to support legislation that leaves the insurance industry at the top of the health care food chain and not to support a Medicare-for-all or single-payer proposal. And she gave them the rationale they wanted to hear – that they were justified in abandoning single-payer and supporting a role for the health insurance industry because that’s what Americans want them to do.

But to give the Herndon Alliance the results they wanted, Lake had to rely on secretive and biased methods. Until Lake reveals her methods and offers a reasonable explanation for why her results are so different from those of other researchers, the public should treat Lake’s research as junk science.

Distributed by:

All Unions Committee For Single Payer Health Care–HR 676
c/o Nurses Professional Organization (NPO)
1169 Eastern Parkway, Suite 2218
Louisville, KY 40217
(502) 636 1551

For a complete list of the unions that have endorsed HR 676 and a sample union resolution write to Kay Tillow at nursenpo[at]aol.com.