Entries in "Health care"

December 22, 2011

Is a single payer health system on the way?

I have in the past harshly criticized president Obama and the Democratic party for the way they excluded the single payer and public options in the health care debate as a favor to the health insurance industries and foisted on us a complicated health care reform package in the Affordable Care Act that does not address in any fundamental way some of the key problems of cost and access.

Now comes along an analysis by Rick Ungar that says that buried in that health care reform act was a time bomb that went off on December 2, 2011 that will destroy the private health insurance industry as we currently have it and set in motion a series of events that will inevitably lead to single payer. The key, he says, is

the provision of the law, called the medical loss ratio, that requires health insurance companies to spend 80% of the consumers' premium dollars they collect—85% for large group insurers—on actual medical care rather than overhead, marketing expenses and profit. Failure on the part of insurers to meet this requirement will result in the insurers having to send their customers a rebate check representing the amount in which they underspend on actual medical care.

So, can private health insurance companies manage to make a profit when they actually have to spend premium receipts taking care of their customers' health needs as promised?

Not a chance - and they know it. Indeed, we are already seeing the parent companies who own these insurance operations fleeing into other types of investments. They know what we should all know – we are now on an inescapable path to a single-payer system for most Americans and thank goodness for it.

Ungar has a follow up post where he tries to address some of the objections that people have raised regarding his prediction.

Interestingly, the argument most often offered up in the effort to shoot down my conclusions was the position that most health insurers are already meeting, or very close to meeting, the medical loss requirements. As a result, these naysayers argued, the new MLR rules are really no big deal and there is no reason for me to suggest that the HHS regulations would have the dramatic impact I have predicted.

Many were also quick to add that the stock prices for these health insurers remain very healthy, indicating that shareholders in these companies clearly do not share my dire predictions—and the shareholders certainly should know.

But if that is the case then why, Ungar asks, are so many states requesting a waiver from these requirements from the department of Health and Human Services (HHS)?

The answer is clear. It is because the method the health insurance companies have been using to calculate their MLR - effectively throwing everything they can into the classification of an actual medical expense - is no longer going to fly and the health insurance companies know this is going to be a big problem for them.

While shareholders may be slow to pick up what is happening, likely the result of health insurance company efforts to downplay the impact of the medical care ratio requirements, the evidence makes it clear that the days of private health insurance are numbered.

Ungar points out that the Department of Health and Human Services refused a request by the state of Florida for a waiver that would prevent the insurance companies from having to return $89 million to their subscribers under the MLR requirement. Two days ago, a similar request for a waiver by the governor of Michigan was also turned down, making it the sixth state to be so denied. Indiana, Louisiana, Maine, Nevada, New Hampshire, Iowa, Kentucky, Delaware, North Dakota, Georgia, Kansas, North Carolina, Oklahoma, South Carolina, and Texas have also requested waivers. Rob Collier reports that Maine, Nevada, and New Hampshire have been approved while Iowa and Kentucky were given partial waivers for a limited time. North Dakota, Indiana and Louisiana were rejected. The list of states applying for waivers and the outcomes can be seen here.

But if single payer is the ultimate outcome, was this the intention all along? Or is this some unintended but welcome consequence of the complex legislation? The reason this matters is that if it is an unintended consequence, then the insurance industry, Congress, and the Obama administration will try to rewrite the legislation to prevent it. I have a hard time believing that the health industry with its massive lobbying efforts and a Congress and White House that is subservient to them, would not be careful to preserve their interests.

I wish I could be as optimistic as Ungar. But I am not going to allow my hopes to be raised too much.

May 14, 2011

Why the health care law is constitutional but may be overturned

Northwestern University professor of law Andrew Koppelman has a long article in the Yale Law Journal arguing that the constitutional objections that have been brought against the Patient Protection and Affordable Care Act (PPACA) health care reform package have little legal merit but that this does not mean that the current Supreme Court will uphold the law, given the propensity of some of the judges to create convoluted legal justifications to arrive at political conclusions.

The constitutional objections are silly. However, because constitutional law is abstract and technical and because almost no one reads Supreme Court opinions, the conservative majority on the Court may feel emboldened to adopt these silly objections in order to crush the most important progressive legislation in decades. One lesson of Bush v. Gore, which did no harm at all to the Court’s prestige in the eyes of the public, is that if there are any limits to the Justices’ power, those limits are political: absent a likelihood of public outrage, they can do anything they want. So the fate of health care reform may depend on the constitutional issues being understood at least well enough for shame to have some effect on the Court.

He then outlines the objections to the reform and why they cannot be sustained. He concludes with a nice summary.

What will the Supreme Court do? There is no nice way to say this: the silliness of the constitutional objections may not be enough to stop these Justices from relying on them to strike down the law. The Republican Party, increasingly, is the party of urban legends: that tax cuts for the rich always pay for themselves, that government spending does not create jobs, that government overregulation of banks caused the crash of 2008, that global warming is not happening. The unconstitutionality of health care reform is another of those legends, legitimated in American culture by frequent repetition.

The Republican Party, once a party of intellectuals and ideas, is now the captive of crazies driven by blind ideological prejudices in the service of the oligarchy. The Democratic Party has taken the place of the former Republican Party as the subtle agents of the oligarchy.

May 05, 2011

Preventing cheaper treatments to increase profits

Reader Norm sent me this news item which alleges that sheer greed for excessive profits is causing one drug company (Genentech) to try to block a possible cure for macular degeneration (which can cause blindness) from being tested and approved, because the cost of this drug ($50 per dose) Avastin is forty times less that the alternative treatment Lucentis ($2,000 per dose) marketed by the same company.

The Plain Dealer also ran a story on the fact that the Cleveland Clinic ran a comparison test anyway and found that Avastin worked as well as Lucentis.

March 18, 2011

Update on the status of single payer health plans

Despite the sabotaging of the single payer and the public option by president Obama and the Democratic Party during the health care reform debate, it is not yet dead.

In an interview with OpEdNews, Dr. Margaret Flowers of that excellent group PNHP (Physicians for a National Health Program) talks about the moves currently underway in the various states. Vermont seems the most promising state to be the first to implement a single payer system.

Medicare and Medicaid are not the causes of our national deficit, they are the victims of a broken health system. As our overall health care costs rise, so do the costs of Medicare and Medicaid. The most effective way to control our health care costs would be to expand and improve Medicare and put everybody in the country on Medicare instead of using hundreds of different health insurances as we do now.

The administrative savings alone of a single payer national health program would be around $400 billion. There are other ways that single payer/Medicare for All controls health care costs such as giving hospitals and other medical institutions a global budget and negotiating for the prices of pharmaceuticals, medical devices and services.

There is a lot happening at the state level when it comes to single payer. Currently, twenty states have single payer health bills in some phase of the legislative process.

As you may know, California has passed a state single payer bill twice in 2006 and 2008. I just returned from a large health professional student-led march, rally and lobby day at the state capital in Sacramento. The California single payer coalition is continuing to move forward to pass single payer and have it signed by the new Governor. California faces such a serious budget crisis that I was told the legislature will be basing their cuts on what will result in the least number of lives lost.

We are particularly enthusiastic this year about Vermont. They are poised to pass a single payer health bill this legislative session. The state hired Dr. William Hsaio from Harvard to design their health system. He has designed health systems for five countries, the most recent being the single payer system in Taiwan. The new governor of Vermont, Peter Shumlin, ran on a strong single payer platform. And, of course, Vermont has Senator Sanders, who has been a long time proponent of single payer.

Even with all of the stars seeming to be aligned, it is going to be a difficult process to get single payer passed in Vermont. The forces who oppose this, primarily the corporations who profit from the status quo, will be putting tremendous resources into that state to stop single payer. For that reason, many of the organizations that support single payer are working to assist the state single payer movement. Single payer advocates from across the nation are volunteering or helping to raise funds for Vermont.

I encourage your readers to visit to learn more about the efforts there and to support them.

Legislation will also be introduced at the national level again in both the House and Senate this year. It is important to work at both the state and national levels because we cannot predict where we will be successful first. Of course, the ultimate goal is a national single payer health program so that all people living in our country will have access to care and so that we can control our health care costs at the national level. Health care costs are a significant cause of our national debt.

Ohio's push for single payer is being driven by SPAN Ohio (Single Payer Action Network Ohio).

March 01, 2011

Justin Bieber supports single payer health care

The singer will undoubtedly raise the ire of those who devoutly believe that "America is the greatest country in the world in every single way, always has been, and always will be and anyone who doubts that is a an anti-American Islamofascisticcommie" by comparing Canada's single payer health care system favorably to the US system.

The Canadian-born Bieber never plans on becoming an American citizen. "You guys are evil," he jokes. "Canada's the best country in the world." He adds, "We go to the doctor and we don't need to worry about paying him, but here, your whole life, you're broke because of medical bills. My bodyguard's baby was premature, and now he has to pay for it. In Canada, if your baby's premature, he stays in the hospital as long as he needs to, and then you go home."

He's not the only celebrity thinking that the present health care system in the US is evil.

February 11, 2011

The rotten US health care system-part 4

In the previous post in this series, I said that in order to get a simple and obvious mistake corrected, I had to make 17 phone calls to the hospital's billing office, 15 calls to my doctor's office, 9 calls to the insurance company billing office, and 4 calls to the radiologist's billing office.

What is also noteworthy is the large number of people I spoke to during this saga. In my calls to the hospital billing office, I spoke with Jennifer, Sherry, Sharon, Linda, Megan, Michelle (twice), Heather (twice), Kim (twice), Sarah, Mia, Amy, Caroline, David, and Michael. In my calls to the insurance company I spoke with Dema, Dennis, Pam, Vicky (thrice), Linda, Lynn, and one person whose name I forgot to note. In my calls to the radiologist's billing office I spoke to Debbie, Marva, Debra, and Colette.

All these people are employed just to deal with billing issues and customers who have questions and problems with billing. When you consider all the people and time involved in this one simple case, is it any wonder that the bureaucratic costs are so large in the private health insurance system in the US?

My conversations with the people in the billing offices of the hospital and radiologist's office and the service call center of the insurance company were mostly cordial and friendly. They seemed to be genuinely trying to help me but they were all stuck within this awful system. The only exceptions were David in the hospital billing office (who seemed like a smart-alecky know-it-all who was unfriendly and seemed to be annoyed at my persistence and kept insisting that my efforts to rectify the error would fail) and the 'coder', the person in the hospital billing office responsible for putting the code numbers on the treatments that were submitted to the insurance company.

This coder in the hospital billing office was clearly a key gatekeeper to the process and is a shadowy and mysterious person. Early on I had found out that the billing code for a bone density scan for someone with osteoporosis was 733.00 and that for a routine bone density scan was 733.09 and I used this information in all my calls to try to get the code on my insurance claim changed from the former to the latter. I was told at one point that the coder felt that I had no business knowing the code numbers for the various diagnoses and anyway that changing the code number would not influence the insurance company. I responded that it was not the hospital coder's business to decide what my health insurance company would do and that she should simply put the correct code and leave it at that. I asked to speak with the coder but apparently no one speaks directly to this mysterious and august person. I was amused but also irritated at the idea that I, the patient who was responsible for paying the bills, should not be told how the diagnoses should be coded. It seems to be part of the plan to keep us in the dark as to how the system works so that we meekly accept their decisions.

One of the lessons that I hope people will take from this is that in order to deal with this bureaucracy, one needs to be really patient and persistent. Also, you have to keep your medical records and know what they say. I have also learned when dealing with the customer service departments of any business to keep notes of the date, time, the person spoken to, and the gist of each call. Since almost every time you get a different person, you cannot assume they know the history of your case even if it is on their computers and it helps to quote the results of previous conversations to them, because when you seem knowledgeable, they respond better.

I am also very polite to the people I speak to since they are not the problem, although I am sure that at times my weariness and exasperation with the system came through in my voice. The people who work in these call service centers are also stuck in this system and I am sure that they get yelled at a lot by angry people. Most of them sympathize with you and want to help but are limited in what they can do, so it is not fair to vent at them. It is the people in the higher levels of the insurance companies and hospitals, the people we do not usually encounter, who are the ones who try to find ways to deny coverage and thus increase their institutions profits, as Michael Moore's documentary Sicko so clearly demonstrates. They are the villains.

I recount my experience in such detail as an illustration of what people have to sometimes go through. The sad fact is that it is probably not unusual. In my case, I was finally successful at getting the error corrected and the bills paid by the insurance company. But many people will end up getting stuck with the bill, either because they got fed up with the runaround or were paralyzed by the Byzantine nature of the process or did not have the time to waste on all these phone calls or were overawed by the system. Even I was tempted at times to say the hell with it, pay the bill, and move on. But given my hatred for this system, I was determined to not let it defeat me, and so gritted my teeth and fought it all the way.

It is important to realize that this kind of thing would almost never happen in a single payer system of the kind found in most developed (and many developing) countries. In those systems the patient deals only with the health care provider and all these tedious bureaucratic matters are negotiated behind the scenes between the single payer entity and the health care providers out of sight of the patient. As far as the patient is concerned, you go and see a doctor and the doctor treats you according to their guidelines and that's it. You do not have to deal with any billing office unless you have some kind of supplementary private health insurance system in addition to the single payer one.

The solution to the problems that plague the US health care system is to adopt a single payer system and eliminate the private health insurance industry except as a form of supplemental insurance. The easiest way to do that would be to extend Medicare to everyone. The private profit-seeking health insurance industry is a parasite that sucks the life out of the health system by diverting huge sums to the shareholders and top executives and to pay the bloated bureaucracy needed to keep track of all the unnecessary paperwork. It has to go.

February 10, 2011

Brazil gives out free medicines

While people in the US struggle with health care costs, Brazil is giving away drugs for blood pressure and diabetes free to those who need them.

Brazil already gave AIDS drugs free. It can afford to do that since it is a single payer system that gives it the clout to negotiate with drug companies for lower prices.

The rotten US health care system-part 3

As I wrote yesterday, my latest bone density scan, when compared with two previous scan results taken years before showed that my bone density was not only above the cut off for a diagnosis for osteoporosis but also was actually increasing with time, so there really was no cause for alarm.

Thus the diagnosis of osteoporosis that had resulted in the insurance company declining to cover the costs of the scan and the radiologist's fees was obviously a mistake and you would think that it would be a simple matter to get it cleared up. All you would have to do is point out the obvious error (the doctor, the hospital, and the insurance companies had access to all my old medical records) and everything should be fine. But when I contacted the insurance company they said that in order to get the error corrected and the scan covered I had to get the hospital that did the scan to resubmit the claim to the insurance company with the correct diagnosis.

You would think that this also would be a simple thing. But when I called the hospital they said that I had to first contact my doctor and get them to submit a new form with the new diagnosis. When I called the doctor's office, they said that they had concluded that I had osteoporosis based on the results of my previous scan results. But since I had my latest and old scan records and knew how to interpret the numbers and knew the difference between osteoporosis and osteopenia, I was able to point out that they were wrong. They conceded that I was right and that the error would be corrected.

So that's that, right? You would expect that now everything would fall into place. You would be wrong. In fact, I predicted that I would still encounter problems in my efforts to correct this because of the bureaucratic nightmare that is the profit-seeking US health industry that benefits from denying care, and I was right. I still kept getting monthly bills for the scans and radiologist fees, and on checking the insurance company website and calling them found that nothing had been done by anyone. This resulted in a long round of phone calls by me to various people and finally in January of this year, eight months after the original scans and seven months after I brought the error to light, the matter was settled in my favor with the insurance company paying all the bills.

I will not bore you with all the details of what I had to do in order to correct what was an obvious mistake. In summary, I had to make 17 phone calls to the hospital's billing office, 15 calls to my doctor's office, 9 calls to the insurance company billing office, and 4 calls to the radiologist's billing office. Each of the phone calls to the insurance company and the hospital billing office involved first going through those infuriating and long menu systems that require you to choose between options and provide all manner of information before you get to talk to a real person. The worst ones (especially for people like me who have non-native accents) are those that use voice recognition, though I must admit the software seems to have improved somewhat and I am not misunderstood nearly as much as in the early days of this technology. In addition, I had to visit the insurance company's website numerous times to check on the status of my claim.

The sad fact is that I am sure my experience is not unusual. This kind of runaround is what many people experience in the US system and people in other countries would be horrified that we meekly put up with it. This kind of thing should not happen in a well-designed health care system like one has in single-payer programs and we should not put up with it! In my case, the experience was merely exasperating and time consuming. In the worst-case scenario I could afford to walk away from the aggravation by paying the two bills. Also my condition was not life-threatening. But for people who are dealing with serious health issues and also cannot afford to pay, the thought of being stuck with a large bill that they did not anticipate could be very stressful.

Note that I am also fortunate enough that I have the knowledge and access to information to understand the implications of the scan and lab results, to learn about what numerical codes should be assigned to various diagnoses, and also have the time and the ability (and persistence) to navigate through the complex system. Most people are not so lucky and they likely give up and pay the bill because they either get fed up or are overwhelmed and intimidated.

Next: Lessons to be learned in dealing with the system

February 09, 2011

The rotten US health care system-part 2

I have written before of the absurd levels of bureaucratic waste that runs through the US health care system. Here I would like to continue a report on one personal experience that illustrates this. I do this not because my medical history is interesting (it isn't in the slightest) but to document the appalling inefficiency of the system.

In part 1 of this series I wrote about my experience with a routine visit in May 2010 to a doctor for my regular check-up. As part of that process I had to get blood tests done and, as is common for people who have reached my age, a bone density scan. The blood test had to be done by a laboratory and the bone density scan by a hospital. All these things are supposed to be fully covered by my insurance. Since I know that the profit-seeking health industry has all manner of rules that can trip up the unwary, I made sure before I did anything that my doctor was part of the approved network, the laboratory was also approved, that routine bone density scans were covered, and that the hospital that did the scans was also approved.

Of course, a month after the procedures were completed I got bills for the blood test, the density scan, and for the radiologist who had read the scans, because my insurance company had turned down all of them. Only the doctor's visit had been approved. When I called the insurance company, they checked and found that the blood test had been turned down by mistake and said they would correct it but that the bone density scan and the radiologist's bill would not be paid because the hospital's billing office had coded my treatment as indicating that I had osteoporosis and thus my scan was not a routine check for that condition but part of treatment for it and thus not covered.

Let's pause for a moment to digest the absurdity of a health system in which a test to see if you may have a problem is covered but treatment for it is not. It reminds me of my previous saga involving a colonoscopy (part 1, part 2, part 3, and part 4), a procedure to see if one has colon cancer. According to the insurance company, they will pay for the colonoscopy unless, during that very same procedure, the doctor discovers any polyps. In other words, when I go for the procedure, I do not know whether it will be covered or not because that depends on the results of the very same procedure. What kind of system is that?

But the point here was that I had looked at my scan results and knew I did not have osteoporosis. Osteoporosis is a condition in which bone densities can become so low that people are at a high risk for fractures. I had at most something called 'osteopenia', which is not a medical condition that requires treatment, but merely a label for bone densities that are slightly above the cut-off for a diagnosis of osteoporosis. The story of the origins of osteopenia is a good example of how the drug industry exploits the fears of people in its drive for profits.

All adults start to slowly lose bone density after the age of 30 but it was not clear what level constitutes a danger for fracture and deserved the diagnosis of osteoporosis and thus require medical intervention of some kind. As the ability to determine bone densities more accurately improved, a group of osteoporosis experts convened by the WHO met in 1992 decided that they had to fix a numerical value of bone density below which they could assert that one had osteoporosis. The felt they had to draw a line somewhere in order to make an empirically-based diagnosis and did so. But as with all lines drawn to demarcate two regions for something that actually lies on a continuum, the question arose as to what to do with people who were just above the cut off. i.e., those who did not have osteoporosis but were near the line. The group decided to give the name 'osteopenia' for this region. So one way interpreting a diagnosis of 'osteopenia' is that it means you do not have osteoporosis.

For people of advancing years, osteopenia is common and not something to be unduly alarmed about. But when you pin a medical label on something, you immediately create the impression that it constitutes a problem. The ominous sounding label osteopenia can be used to frighten the unwary ("You will get osteoporosis unless you treat it!") and drug companies like Merck seized on this opportunity to frighten people and boost the sales of drugs that purport to treat this condition. They heavily pushed the sale of portable bone density measuring devices on doctors, lobbied the government to get Medicare to pay for bone density tests, and heavily marketed their drugs that allegedly increase bone density. As a result, large numbers of people suddenly started being told that they have osteopenia and to fear that it was a precursor to getting osteoporosis unless they took drugs to combat it.

In my particular case, since my bone density numbers were above the cut-off values for osteoporosis, what had happened was clearly a case of a mistake having occurred either in diagnosis or in communication and something that should be easily correctable. But I knew that nothing is simple in the rotten US health care system and predicted back in June of last year that fixing this would be complicated and that "I fully expect that there will be more glitches and more bills requiring more phone calls from me."

And I was right. But even cynical me underestimated the amount of effort it would take to correct a simple mistake.

Next: What happened in my case.

January 22, 2011

Single payer health insurance system in India

There is a common misunderstanding that the single payer system of health insurance means that the government provides all the health services. That is not true. There are many systems of single payer in which doctors and hospitals are private. It is just that the multiplicity of for-profit health insurance firms that do not add anything of value but simply introduce a vast and expensive bureaucratic layer between doctor and patient would be eliminated.

This story from the public radio program Marketplace shows how even in the rural farming sector in India, introducing a single payer system called Yeshavini has resulted in a vast improvement in health care at very low cost.

[W]hile Congress, and the rest of the country, continue to argue over who's helped and who's hurt by health care reform, the world's cheapest health insurance program can be found in India. It covers at least 4 million of that country's poorest farmers with a fairly simple philosophy: More patients means lower costs.

About a third of all of the patients at [Dr. Devi] Shetty's hospital are farmers from rural villages. They're here because they have something called Yeshaswini insurance. It doesn't cover routine doctors visits for, say, a cough or a cold, but the insurance does cover all surgical procedures. The farmer pays approximately three cents a month; the government puts in one and a half cents and farmers cooperatives operate the program.

That volume actually allows them to negotiate really good deals, lower costs of medical equipment and drugs. And the success rate for surgery at Shetty's hospital is as good as hospitals in the U.S. at a fraction of the cost.

Typically, farmers have to sell their land, take out crippling loans or just not have surgery. That's why Yeshaswini insurance is immensely popular. Farmers can choose from any one of 350 hospitals in the region.

Dr. Julius Punnen is a cardiac surgeon who helped set up the program. He says every day the hospital battles with private insurance companies to get reimbursed. But Yeshaswini is different. It was designed to provide treatment.

The private for-profit health insurance companies are a cancer on the health care system that must be eliminated.

June 29, 2010

The rotten US health care system

Just last month I went for a routine physical examination followed up by routine blood tests and a bone density scan. According to my health insurance plan, all these were supposed to be fully covered. Of course, being a veteran of the bureaucratic health care system in the US, I know that nothing is 'routine' here and so before I did any of these things I had to spend some time making sure that I was going to a doctor covered by my insurance plan and that the blood-testing laboratory and the bone-density measuring facility were also covered procedures done by approved facilities.

After everything was over, I received bills charging me the full amount for both the blood tests and the bone density scans. This meant that I had to call the insurance company to find out what had gone wrong. After fighting my way through the thicket of the voice mail jungle to get a real live person, they said that one of the bills was due to an error by their processing office and the other was due to a wrong process code entered by the laboratory. (It fascinates me that these errors always seem to favor the insurance companies, never the patient.) So then I had to call the laboratory and tell them to re-submit the bill using the correct code.

Of course, I was not surprised this happened because I have had enough experience with the absurdly bureaucratic US system to know that this kind of hassle that patients go through is the norm. In fact, I fully expect that there will be more glitches and more bills requiring more phone calls from me. All this for relatively trivial and 'routine' processes. For other people, things are a lot worse. The wife of a friend of mine died after a long illness. In addition to dealing with his grief, he now has to deal with the enormously complicated details of who should be paying for what aspects of her care. Dealing with all the paperwork and bureaucracy is practically a full-time job.

Let's not mince words. The US has one of the lousiest health care systems in the developed world. (For my previous posts on this topic see here.) This is not just my opinion. It is supported by numerous studies, the latest of which finds that the US ranks at or near the bottom on most measures when compared to six other countries (Australia, Canada, Germany, the Netherlands, New Zealand and the United Kingdom) in the quality of the health care its people receive. This will, of course, come as no surprise to those people who have paid close attention to this question and seen through the propaganda of the lucrative health industry and their bogus arguments about hip replacements and wait times and the like. (The organization Physicians for A National Health Program gives a lot of great information.)

A Business Week news report on the new study says:

Despite having the costliest health care system in the world, the United States is last or next-to-last in quality, efficiency, access to care, equity and the ability of its citizens to lead long, healthy, productive lives, according to a new report from the Commonwealth Fund, a Washington, D.C.-based private foundation focused on improving health care.

According to 2007 data included in the report, the U.S. spends the most on health care, at $7,290 per capita per year. That's almost twice the amount spent in Canada and nearly three times the rate of New Zealand, which spends the least.

The Netherlands, which has the highest-ranked health care system on the Commonwealth Fund list, spends only $3,837 per capita.

The report also debunks the most common sound-bite made by supporters of the US system, that supporters of single-payer don't really know how awful other systems are. The converse is true. People who have experienced health care in any of those other countries (like I have) are the ones who are amazed at how awful the US system is, because only they realize how much better it can be, and is elsewhere.

Dr. David Katz, director of the Prevention Research Center at Yale University School of Medicine, commented that "as a physician and public health practitioner, I have routinely spoken out in favor of health care reform in the U.S. The responses evoked have not always been kind. Prominent among the counterarguments has been: 'You should see what health care is like in other countries.'"

"This report utterly belies the notion that the former status quo for health care delivery in the U.S. was as good as it gets. Others have been doing better and we can, and should, too," he said.

In fact, the UK with its (gasp!) 'socialized medicine' turns out to be at or near the top.

U.S. patients with chronic conditions were the most likely to say they got the wrong drug or had to wait to learn of abnormal test results.

Overall Britain, whose nationalized healthcare system was widely derided by opponents of U.S. healthcare reform, ranks first, the Commonwealth team found.

An American physician now working in Canada gave the commencement address to newly minted doctors at the University of California at Irvine and he made some interesting comparisons with his experience working in the US.

It was interesting for me, as an American physician practicing in Canada, to see the recent negative depictions of the Canadian system in TV ads and lay media, depictions that bore absolutely no resemblance to the actual environment in which I practice daily. My reality is very different. I can see any patient and any patient can see me – total freedom of practice. My patients' parents have peace of mind regarding their children's health. If they change jobs or lose their job altogether in a bad economy, their children will still get the same care and see the same physicians. Micromanagement of daily practice has become a thing of the past for me. There are no contracts, authorizations, denials, appeals, reviews, forms to complete, IPA's, HMO's, or PPO's. Our Division's billing overhead is 1 %. My relationship with the hospital administration is defined by professional, not financial, standards. I have no allegiance to any corporate or government entity, nor does one ever get in between me and the patient. This environment, which some denigrate as the ever so scary system of "socialized medicine" allows for more patient autonomy and choice than was available to most of my patients in California. (my emphasis)

That is not at all to say that I practice in a medical utopia. There is no perfect health care system. The Canadian system has its own set of difficulties, challenges, and shortcomings, and Canadians are also looking to significantly reform their system. But as physicians, we have to enter the debate and we have to enter it objectively, salvaging it from the bias, misrepresentation, and demagoguery that has characterized it. Health care should not be a liberal or conservative issue, for disease, disability, and death do not recognize political affiliations.

As a socially conservative Christian myself, my belief that health care is a fundamental human right, and my efforts on behalf of single payer universal health coverage stem from my faith, and not despite it. My faith calls for personal morality, but also for societal morality – how do we treat the sick amongst us, the weak amongst us, the least amongst us?

Some form of single payer health care system (whether socialized or not) is what the US needs. Now.

POST SCRIPT: This is the best the US can do?

It amazes me that the corrupt, wasteful, and greedy health insurance industry in the US is what some people want to preserve.

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April 27, 2010

The health care scam

(My latest book God vs. Darwin: The War Between Evolution and Creationism in the Classroom has just been released and is now available through the usual outlets. You can order it from Amazon, Barnes and Noble, the publishers Rowman & Littlefield, and also through your local bookstores. For more on the book, see here. You can also listen to the podcast of the interview on WCPN 90.3 about the book.)

So after much drama, the health care bill finally became law. If anything demonstrated the fecklessness of Obama and the Democratic Party and their willingness to sell out of their supporters in order to appease their corporate overlords, it is the way that the health care bill was constructed and passed.

There is no question, as Robert Weissman writes, and which I have repeatedly pointed out, that a single payer system, the system of choice for almost every other country in the industrialized world, is more humane and more efficient than what the US currently has. (See here for all my previous posts on health care.) Even candidate Obama conceded as much during his presidential campaign. T. R. Reid's new book The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care also debunks the myths of the alleged superiority of America's health care system. Even Sarah Palin admits that when she was a child, her parents took advantage of Canada's system, saying, "we used to hustle on over the border for health care", adding "I think isn't that ironic now." Yes it is, Sarah, yes it is.

The pressure for health care reform comes largely from the fact that the private, profit-seeking entities that dominate the system (insurance and drug companies and hospitals and specialist doctors) are driving up the costs and employers want to shed themselves of this burden. (Also see another comparison of costs.)

The logical thing would have been to go to a government-run single-payer system that would be cheaper because it would spread the costs over the entire population, have the power to negotiate lower prices, reduce bureaucratic duplication, and eliminate the profit element that plagues the current system and results in such horrors as the rescission of coverage after one receives a diagnosis of a disease. The despicable insurance companies also find sleazy ways to drop coverage for people who discover they have breast cancer:

They had no idea that WellPoint was using a computer algorithm that automatically targeted them and every other policyholder recently diagnosed with breast cancer. The software triggered an immediate fraud investigation, as the company searched for some pretext to drop their policies, according to government regulators and investigators.

Once the women were singled out, they say, the insurer then canceled their policies based on either erroneous or flimsy information.

Of course, Congress and the Obama administration will not do anything to harm the interests of these companies since these very organizations that profit greatly from sick people are major contributors to their coffers. And so what we finally ended up with was a mere tweaking of the existing system.

It is not that there are no good features at all in the bill. There are, such as expanding coverage and restricting some of the worst industry abuses. But these were the bones that were tossed to the Democratic Party supporters to mask the fact that the resulting plan has internal contradictions that will eventually wreck it. The Democratic party deliberately sabotaged the one big chance the country had to enact the kind of reforms that are necessary to prevent the looming catastrophe that will occur because the basic causes of cost increases have not been addressed. As Marcia Angell, former editor of the New England Journal of Medicine, says:

What this bill does is not only permit the commercial insurance industry to remain in place, but it actually expands and cements their position as the lynchpin of health care reform. And these companies they profit by denying health care, not providing health care. And they will be able to charge whatever they like. So if they're regulated in some way and it cuts into their profits, all they have to do is just raise their premiums. And they'll do that.

Not only does it keep them in place, but it pours about 500 billion dollars of public money into these companies over 10 years. And it mandates that people buy these companies' products for whatever they charge. Now that's a recipe for the growth in health care costs, not only to continue, but to skyrocket, to grow even faster.

Glenn Greenwald quotes a Kaiser Health News report that "details the massive benefits each industry [Doctors, Hospitals, Insurers, Pharma] receives (compared to their mild costs), the success they had in killing any real competition and reform in the bill (i.e., the public option, Medicare expansion, drug-reimportation, bulk price negotiations, and an end to the insurers' anti-trust exemption)" and that the bill was enacted by "invoking and strengthening precisely the same corrupt, sleazy practices that have long driven Washington."

There have been many analyses detailing how the Democrats sold out on health care, calling the Obama strategy essentially a scam on the American people. Angell says of Obama that, "He gave away the store at the very beginning by compromising. Not just compromising, but caving in to the commercial insurance industry and the pharmaceutical industry." Glenn Greenwald and Norman Solomon lay out in detail exactly how the scam by Obama and the Democratic Party was executed. It was the shocking loss of Ted Kennedy's Senate seat in Massachusetts to Republican Scott Brown that exposed the scam for all the world to see, while paradoxically hastening the passage of the final bill.

While the Democrats still had sixty votes in the Senate, they could play out this charade that they really and truly wanted real reform as represented by a single-payer system or Medicare for all (or at least expanded) or a public option, but that they had to overcome this darned filibuster threat by the Republicans, which meant that they had to appease the most reactionary elements in their own party in order to hold on to every one of their sixty party members and thus were forced to give up on the more ambitious plans. Oh, but they were so sad that they had to compromise their ideals like this.

But as Greenwald says,

[A]dvocates of the public option kept arguing that the public option could be accomplished by reconciliation -- where only 50 votes, not 60, would be required -- but Obama loyalists scorned that reconciliation proposal, insisting (at least before the Senate passed a bill with 60 votes) that using reconciliation was Unserious, naive, procedurally impossible, and politically disastrous.

But the win by Scott Brown meant that they could not overcome the filibuster after all because of the unanimous opposition of the 41 Republicans. Faced with the possibility that they might not get any health reform bill at all through the Congress, which would have meant political disaster for them, they suddenly decided that they would use the reconciliation path to passage after all. So given how much they had said about their desire for more sweeping reform plans, you would think that now they would bring back all those elements they so ardently desired and spoke so passionately about. But no. They went with the health-insurance industry friendly bill, thus exposing that this was the bill they had really wanted all along and that everything they had said suggesting otherwise were nothing but lies. If one needed any more proof, along the way it was revealed that Obama had made a secret deal early on with the pharmaceutical industry to kill the public option, thus confirming the existence of the scam.

It should have been clear to the dimmest bulb that the health care bill that Obama and the Democrats finally passed was what would have been considered in the old days a Republican plan, one whose main goal was to leave untouched (and even enhance) the interests of big business and the wealthy. It is no coincidence that it is similar in philosophy and structure to the plan introduced in Massachusetts by Mitt Romney when he was governor. He now has the unenviable task of disowning his own plan in order to appease the crazies who now running the Republican party.

What has happened in American politics is that the Democratic party has become the Republican party and the Republican Party has gone nuts.

POST SCRIPT: The ignorance of health care opponents

The party groups that demonstrated on April 15 to denounce the health care bill, among other things, as part of some socialistic takeover of America's economy are remarkably ignorant of the reality of American politics but are driven by some inchoate sense of frustration and impotence that makes them succumb to paranoia. They pose a real danger to the Republican party, risking making it into a fringe and nutty cabal.

Cartoonist Tom Tomorrow describes how detached from reality health reform opponents really are.

September 11, 2009

My colonoscopy saga-4: Some final thoughts

(See part 1, part 2, and part 3.)

What is interesting about my experience is that even physicians whom I know personally and to whom I have told this story are surprised that whether I am charged for a colonoscopy depends on whether any polyps are found.

I also spoke about my experience at a health care panel a couple of years ago. Another panelist, a professor at another university, said that he thought that it was perfectly reasonable for us to treat health care like any other commodity and that consumers should shop around for the best deal. I responded that this was absurd. Health care is not a commodity to be compared like buying detergent. People often confront the health system in situations where they are deeply troubled or their plight is urgent or where they have few choices.

There is absolutely no justification for profit making entities like health insurance companies to be part of the system. No one has ever been able to tell me what value they add to the system. In fact they are parasites, a drain, and a hindrance to the smooth working of health care delivery. Health care services should be as universal and as profit and bureaucracy-free as your police or fire or library services.

Imagine applying the same health care logic to those other things. Suppose you had the same system for police protection. There would be separate police stations and you would have to pick a plan every year that specified your police station and the police officers who would serve you, and the services would be charged depending on what your policy said and your needs. So having a policy that would have police officers only come to investigate minor burglaries would cost less than to have them come to investigate an assault or a missing person. Such a system would be considered insane.

It used to be the case that fire protection actually was private and you would have to buy insurance in order to get firemen to come to your house to put out a fire. The system changed to a universal, single-payer public system because the unchecked fires of people who did not have insurance would spread to the houses of those who had, and people realized that fire-fighting was best dealt with as a communal responsibility. There are some things that the community should be collectively responsible for, and police, fire, and health should be among them.

The current health system in the US is run primarily for the benefit of the insurance and drug companies and also for the benefit of specialist doctors. All those groups make a lot of money within the current system at the expense of people who are sick. The US is the only country in the developed world that does not have either a socialized system like England or a single-payer system like France or Canada, both of which could be easily adopted in the US, by expanding and improving Medicare.

Even many developing countries like Sri Lanka have government-run single-payer systems as a foundation, with private health insurance supplements for those who want extras, such as private rooms in hospitals.

Some years ago, my mother in Sri Lanka was diagnosed with colon cancer. When her doctors found this out, they recommended surgery and her surgeon said that the best place for it would be in the government hospital. So she went into hospital, had the operation, and followed up with chemotherapy and radiation, all of which extended her life for some years. All the costs of her surgery and hospitalization (including intensive care) and post-operative out-patient care were free. All decisions about what treatment she should receive were made exclusively by her and her physicians, with no insurance or hospital bureaucrats involved. No conversations were required with anyone other than the doctors and nurses who treated her. No paperwork, no claim forms, no deductibles, none of maddening bureaucracy that people in the US are routinely subjected to by their private, profit-seeking health insurance companies, however sick they are.

The added value to her quality of life and to her family from not having to deal with all these hassles: immeasurable.

If Sri Lanka can do this, with a per capita health expenditure of $163 vs. $6,096 in the US, i.e. one-fortieth, why not the US?

The answer: The US can easily do it. The US spending per capita on health care is about twice that of other countries like France and Canada which have far better health care delivery systems based on the single payer model. If the money it currently spends on health care were used to fund a single-payer system, the US could easily have the best health care system in the world. Instead it has one of the worst in the developed world, entirely due to the fact that the parasitic profit-seeking entities that dominate the system, and the politicians they buy and control, seek to benefit at the expense of the sick.

It is as simple as that.

POST SCRIPT: Incredible bike riding

(Thanks to Norm.)

September 10, 2009

My colonoscopy saga-3: More discussions on the word 'routine'

(See part 1 and part 2.)

By now I am fed up with all this back and forth and decide that I will schedule the colonoscopy anyway and deal with being charged afterwards. I call the doctor's billing office again to get the final ok and learn something new. They say that the colonoscopy is considered 'routine' and thus free not only if there were no prior indications of cancer but also only if the doctor finds absolutely nothing. If the doctor finds even a single benign polyp (which is not uncommon), then it ceases to be routine (and free) and I have to pay the full amount, which is about $1,500. The insurance company had not told me this piece of interesting news nor is it spelled out in their policy. So whether I pay nothing or whether I pay about $1,500 depends not on the procedure itself but on what they find during the procedure! In other words, I have no idea going in what it is going to cost me coming out.

How crazy is this? I call the insurance company and argue that this is manifestly absurd but even after talking to the supervisor, I am told that this is what the policy is, and that's that. However, the supervisor said that if it will put my mind at rest, she can give me an upper limit to what they will charge me, whatever the outcome. Again, like the 2-3 days rule, this seems to be one that she was making up on the spot, and I was dubious as to whether it would be honored later. It looked like the kind of answer given to pesky people just to make them go away.

I am finally fed up with the whole business, all the phone calls to the doctor's office, the doctor's billing office, and the insurance company. And I still haven't spoken to an actual health care professional. This is of course the insurance company strategy all along, to wear people down so that they either go away or are willing to pay whatever is asked just to get the damn thing over and done with. Since I can afford to pay the full cost if need be, I go ahead and make the preparations and get the test.

Fortunately for me, not a single polyp is found so the colonoscopy does end up being free. But not entirely. Initially I am charged for the preliminary doctor's office visit after all. So it is back to making repeated calls to the doctor's billing office and the insurance company. I eventually find out that if the doctor bills me for the office visit under a difference code number from the one they originally used, the doctor's visit is also paid for as part of the colonoscopy. So the doctor resubmits the bill with the new number and that ends that, and my particular story had a happy ending, despite all the time wasting frustrations.

But let's take a moment to savor the absurdity of my experience. First of all, we had about six people (in the doctor's office, the doctor's billing office, several insurance company people, and their supervisors) involved in arcane discussions about rules for several weeks all before I even saw an actual health professional like a nurse or doctor. All the people I was dealing with were friendly and cordial and all the conversations were amicable, but we were all trapped in a maze of rules that made us go around with little progress, like hamsters on a wheel.

Furthermore, I am very fortunate. I have the time and knowledge and patience and access to the internet and phone to call people during the day, check the websites, and to do all preliminary work that I had to do to get all the information. But even with all that knowledge and after all my work, in the end, I still had to go in for my colonoscopy with no assurance of what it would ultimately cost me.

It so happens that I could afford to pay if necessary. But what if someone had taken the policy's assurance of 'free' colonoscopies at face value, and the doctor had found a polyp or the insurance company had dug up one of the infamous 'pre-existing conditions', and then the patient had been unexpectedly hit with a large bill that he or she could not afford. This could be a serious problem for many people who live from paycheck to paycheck and do not have the savings to deal with sudden large expenses. It is this kind of thing that starts people on the slide to ruinous debt.

Or what if someone does figure all this out like I did but for whom $1,500 is unaffordable. Or what if they had some symptom that might prevent the 'routine' classification? There will be a strong temptation to skip the procedure, take the chance that they do not have cancerous polyps, and thus not detect the cancer until it is too late.

POST SCRIPT: Real reform or the final act of the Kabuki play?

Obama gave a strong speech last night where he said a lot of good things about what his health care plan would deliver, even though it falls short of what I would like to see. He vowed to end some of the worst abuses of the health insurance industry, such as the practice of rescissions, denying coverage due to pre-existing conditions, and putting caps on the costs of treatment, but he clearly wants to keep the fatally flawed current system in place.

He promised to vigorously fight those who oppose reform and to call out those who are blatantly lying about the proposed plans, which pretty much includes all the Republicans and many Democrats in Congress plus assorted wingnuts like Rush Limbaugh and Sarah Palin.

The eternal optimist in me hopes that he really means it and that he will not return to negotiating away even these limited improvements in order to please the business interests and its lackeys, which has been his practice so far.

The cynic in me fears that this might have been the penultimate act of the Kabuki play I described earlier and that Matt Taibbi fleshed out more fully in an excellent article, where Obama gives a pretty speech to satisfy his supporters but then acts against their interests.

What is needed now is to pay close attention to the details of the legislation that finally emerges. Real policy is not made on the floor of Congress or in public speeches but in the back rooms behind closed doors where the lobbyists exert their influence in secret.

September 09, 2009

My colonoscopy saga-2: When 'routine' does not mean what you think it means

In my first post in this four-part series, I pointed out that the choice of doctors and hospitals is very limited in the US. But as I continue to look further into my 'free' colonoscopy I discover more pitfalls.

I know that insurance companies try to find ways to avoid paying so I analyze my policy carefully and call the insurance company and ask what the word 'routine' means, since only those kinds of colonoscopies are free. I am told that the colonoscopy is considered routine if it is done as part of a regular check-up and not because of any symptoms that might suggest that I may actually have colon cancer.

This strikes me as bizarre, that the procedure is free only if there are no indications at all that I have any problem. The slightest hint of a symptom and bang, I am on the hook for well over a thousand dollars, the cost of the procedure.

This is of course consistent with the profit-seeking model of the private health insurance industry in the US, which seeks to only insure healthy people so as not to pay for treatment. Think for a moment of the consequences of such a policy. It means that people who suspect that they may have colon cancer but cannot afford to pay for the exam may not seek early diagnosis and treatment (and early treatment is key to a successful cure for colon cancer) but instead gamble that there is nothing there. It also means that if the insurance company can find anything at all in my past history that could be considered an indicator of colon cancer, they can deny payment. In fact they have huge staffs whose sole task is to try and find such 'pre-existing conditions'.

But in my case, I had no symptoms so I called my primary care physician to get a referral to a gastro-intestinal specialist who does colonoscopies. He gave me a few names of people he thought were on my plan and thus should be covered. Of course, I have learned never to trust this kind of hearsay information because my primary care physician has to deal with dozens of insurance company plans and the bureaucratic maze that is the insurance industry, so I go to the insurance company website to check for myself.

The website is a nightmare to navigate. You have to select from a bewildering menu of insurance policies and within them, subclasses of policies. As Uwe Reinhart, a professor of political economy at Princeton University, said, insurance companies offer a range of policies under various names and in the employer-based health insurance system that exists in the US, each company negotiates its own benefits package. So you have to find the specific plan offered by the specific policy you signed up for from those offered by your specific company. But I am determined and plow on, having to call the insurance company a couple of times to clarify that I was on the right track.

And success! One of the recommended doctors is on the approved list. I also found that the office he works in is on the approved list of facilities. So I call the doctor's office and speak to a receptionist there to make an appointment. Of course the first thing she asked from me was my insurance information because nothing gets done in the US unless you can prove you can pay, not on how sick you are, which is another bizarre aspect of US health care that people have become persuaded is 'normal'. Once my ability to pay was settled, she said that before they could schedule the actual colonoscopy, I first needed an office visit to meet with the doctor for him to evaluate me.

This seemed perfectly reasonable, but it set off an alarm bell in my wary head. Was the office visit also covered by my insurance? I called the insurance company again just to be sure everything was ok. They said that the office visit was not covered. I argued with them that if the doctor required an office visit as part of the colonoscopy procedure, then it should be considered part of the cost of the colonoscopy and should be covered. After some back and forth, the person I spoke to put me on to her supervisor who, after some more back and forth, finally said that if the colonoscopy was done within 2-3 days of the office visit, it would be considered part of the colonoscopy. Otherwise it would count as a regular office visit and I would be charged in full for it.

This seemed absurd to me. She seemed to be making this rule up (the vagueness of the '2-3 days' seemed suspicious). So I called the doctor's office again. They had never heard of this 2-3 day rule. They transferred me to their billing office. The billing office manager was also baffled by this rule and she called the insurance company to find out what was going on. Of course, the billing office manager got a different insurance company person from the one I spoke to, and the new person said that she has never heard of this 2-3 day rule either and that the office visit is fully covered as part of the colonoscopy, irrespective of how many days separate the two.

The doctor's billing office calls me back with this information. I am still a bit suspicious and call the doctor's office to see if the office visit can be scheduled within 2-3 days of the colonoscopy, just in case. The answer is no. Why? Because the office visits takes place in one facility on one set of days and the actual colonoscopies are done in another facility on another set of days. But the fact that I have just learned that the colonoscopy is done at a different location from my doctor's office sets off another alarm bell. Is that also an approved facility in my highly restricted list of choices? Once before I had experience of having some tests done at a non-approved facility that was used by my (approved) doctor and having to pay the full cost, so I am a little suspicious. I go back to the nightmare of the insurance company website and after much searching and another call to the insurance company, I find that it is, which is a relief.

So, am I all set for my 'free' colonoscopy? Don't be silly. You think the insurance companies give up that easily?

Next: More problems with the word 'routine'.

POST SCRIPT: The US has the best health care system in the world?

Opponents of health care reform like to boast that the US has the best system in the world. What such statements tell me is that these people have no idea what people in other countries have.

In yesterday's Fresh Air, Terry Gross had a poignant interview with two young women who were diagnosed with cancer while still in their twenties. Like many young people, they were either uninsured or underinsured.

One of them was originally from the Czech Republic and she found it cheaper and less of a hassle to regularly fly back to that country for the free and bureaucracy-less treatment she received from the socialized health system in that country than deal with the system here. Think about that for a minute. The doctor who had initially diagnosed her and whom she trusted had since been removed from her plan which meant that she had to pay a huge amount just to see the doctor of her choice, which also makes a mockery of the claims that patients have choices in the current system.

The other woman was fortunate enough to marry a man who had health insurance coverage under his employer-based group plan that did not deny people with pre-existing conditions. So she is now covered though she still has to deal with the hassles that are routine here.

Both of them spoke about the nightmare of having to deal with the hassles and bills and the bureaucracy of the US health insurance system while they were still reeling from being told that they had cancer.

And these are the lucky ones who had at least some options. They are surviving. But for every young woman like this, there are many who have no options other than to go bankrupt or die young or, as is more likely, first go bankrupt and then die young.

As they say, only in America.

September 08, 2009

My colonoscopy saga-1: So where is this freedom of choice I hear so much about?

(For previous posts on the issue of health care, see here.)

In anticipation of Obama's speech on health care this week and as a coda to my long series on health care, in a four-part series I am going to write about a recent experience I had with the bureaucracy of the health care system in the US, not for any serious illness, but to get a 'routine' colonoscopy.

I recount my story in detail not because it is tragic (it isn't) but to show how even seemingly simple things are made enormously complicated because of the private profit-seeking system that we have. The absurdity of it is that what I went through is so common in the US that people think that it is the only way to do things, unaware that in other developed countries, people do not have to go through this nonsense.

But rest assured. Unlike Katie Couric, I am not going to show images of my colon or other details. The saga is entirely about my dealings with the bureaucracy that one has to go through with private health insurance companies. Almost anyone who has had any experience with the health industry in the US has been given the run-around, with mind-numbing paperwork and endless struggles with the health insurance bureaucracy. Why people are not outraged amazes me. Perhaps it is because that most people have no idea that this is not normal, that when people in other countries need health care, they simply go to a doctor, get treated, and are done with it.

A colonoscopy is used to detect and remove 'polyps', which are small growths on the colon that can become cancerous. All colon cancers begin as polyps though not all polyps become cancerous, so early detection and removal is advisable. It is recommended that people over the age of 50 get a colonoscopy exam every ten years to detect and remove such polyps. I had dilly-dallied over this for many years but my mother's diagnosis of colon cancer finally pushed me to actually get one. I then came face-to-face with the Kafkaesque absurdity of the US system that Uwe Reinhardt, a professor of political economy at Princeton University describes:

Well, I once did a dumb thing: I asked an insurance executive "What do you pay in New Jersey for a colonoscopy?"

And he just laughed at me and said, "What a silly question. There is no price for a colonoscopy. We have a different price for every hospital. And for the same hospital, we might have six prices depending on the insurance product, is it an HMO, etc."

So I said, "This is mad. How many could there be?"

He says, "There could be 30, 40 for us, but then with Aetna, they could have another 30, and everyone has a different contract, so a hospital might receive 60, 80,100 different prices for a colonoscopy, depending on which insurance company and what contract it is. So when you say 'What are the private market prices?' there is no price."

That was exactly my experience. The system was so complex and confusing that even for a routine colonoscopy, even the insurance people did not know what the rules and costs were. Is it any wonder that doctors' offices have entire teams of people simply to do the accounting and try and figure out who should pay how much for what? And that even then they have to often guess? And that patients and doctor's offices have to fight with insurance companies?

First of all, let me say that I am one of the supposedly 'lucky' ones in the US when it comes to health insurance. Both my wife and I are employed and have allegedly 'good' health insurance offered through our respective employers. We chose to be covered by one of my wife's company plans, which seemed the best suited for our needs. At the end of every year we have to go through the dreary exercise of comparing all the plans offered (since the benefits and prices and lists of approved doctors and hospitals of each can and do change each year) to make our choice for the following year.

So when I decided to have a colonoscopy, I checked the plan we had that year to see if it was covered. It was and said it was free. Terrific news! Of course, aware as I am of the tricks of the private, profit-seeking health insurance industry to try and squeeze extra profits by exploiting loopholes, I know that nothing is ever that simple and so started looking into all the fine print that is buried in the policies. My policy says that a routine colonoscopy is free but only if it is done by doctors who are on my plan at only the authorized facilities on the plan.

Americans will not be surprised at this because this is what they have grown up with but it alone immediately puts the lie to those who claim that the current US system gives you more choices in doctors and hospitals than single payer systems in other countries. In reality, the choices you have here are severely restricted to the ones given to you by the insurance company, whereas in single payer countries there is no such restriction. If I were in France or Canada, I could go to almost any doctor who was willing to take me on as a patient.

Next: When routine does not mean what you think it means.

POST SCRIPT: Matt Taibbi on health care

Some time ago, I referred to a Matt Taibbi article in Rolling Stone on the horrendous state of health care in the US and Obama and the Democrats' sordid role in preserving the system. The article was not available online then but it is now and reader Heidi has kindly sent me the link.

It begins:

Let's start with the obvious: America has not only the worst but the dumbest health care system in the developed world. It's become a black leprosy eating away at the American experiment — a bureaucracy so insipid and mean and illogical that even our darkest criminal minds wouldn't be equal to dreaming it up on purpose.

The system doesn't work for anyone. It cheats patients and leaves them to die, denies insurance to 47 million Americans, forces hospitals to spend billions haggling over claims, and systematically bleeds and harasses doctors with the specter of catastrophic litigation.

The cost of all of this to society, in illness and death and lost productivity and a soaring federal deficit and plain old anxiety and anger, is incalculable — and that's the good news. The bad news is our failed health care system won't get fixed, because it exists entirely within the confines of yet another failed system: the political entity known as the United States of America.

Just as we have a medical system that is not really designed to care for the sick, we have a government that is not equipped to fix actual crises. What our government is good at is something else entirely: effecting the appearance of action, while leaving the actual reform behind in a diabolical labyrinth of ingenious legislative maneuvers.

He also looks at the role-playing by the Democrats to hide the fact that they too are in the pockets of the health industry sharks.

In many ways, the lily-livered method that Obama chose to push health care into being is a crystal-clear example of how the Democratic Party likes to act — showering a real problem with a blizzard of ineffectual decisions and verbose nonsense, then stepping aside at the last minute to reveal the true plan that all along was being forged off-camera in the furnace of moneyed interests and insider inertia.

It is a terrific article. You should read the whole thing to see how the government really works and who it really works for. But be warned: it is not pretty.

August 31, 2009

The health care debate-17: Obama's choice

(For previous posts on the issue of health care, see here.)

In this last post in this series, I want to look at the way the health care 'debate' has progressed because it provides a classic example of how Congress and the president, supposedly meant to represent the 'will of the people' who elected them, maneuver to actually do the will of the business interests.

Polls have repeatedly shown that people are highly dissatisfied with the current system of employer-based health care in this country in which the private, profit-seeking insurance companies exert such a stranglehold. As Paul Street writes in the September 2009 issue of Z Magazine (not online), 73 percent feel that health care is either in a "state of crisis" or has "major problems" (Gallup, November 2007), and 71 percent feel that we need "fundamental changes" or have the US health system "completely re-built," compared to just 24 percent who wish only for "minor changes" (Pew Research Center, 2009).

Real reform would consist of introducing a single payer system along the lines of France or Canada or a socialized system along the lines of England. And Street points out that polls consistently show that a majority of people would support changes along those lines.

  • 64 percent would pay higher taxes to guarantee health care for all US citizens (CNN Opinion Research Poll, May 2009)
  • 69 percent think it is the responsibility of the federal government to provide health coverage to all US citizens (Gallup Poll, 2006)
  • 67 percent "think it is a good idea [for government] to guarantee health care for all US citizens, as Canada and Britain do, with just 27 percent dissenting" (Business Week, 2005)
  • 59 percent support a single-payer health insurance system (CBS/New York Times poll, January 2009)
  • 59 percent of doctors back a single-payer system (Annals of Internal Medicine, April 2008)

But of course the business lobby has enough clout to ensure that those options are not even discussed, let alone considered seriously. So the fight has been reduced to whether even a watered-down so called 'public option' should be introduced.

Political scientist and health policy analyst Jacob Hacker is the person who originally formulated the public option plan that Obama once acted as if he embraced but now seems to be trying to distance himself from. In a recent paper Hacker describes why a public option is essential for any meaningful reform, and the futility of the health-industry friendly alternatives like the health cooperatives that are being floated. He concludes:

That the two bills under consideration in the House and Senate contain a public health insurance option is considerable cause for celebration. Yet it is no cause for complacency, because the Senate Finance Committee appears unlikely to produce a bill that contains a true public plan. If, as expected, the Committee endorses federally promoted health cooperatives, they should be understood for what they are: an effort to kill the public plan and, with it, the prospect of an effective competitor to consolidated insurance companies that have too often failed to provide affordable health security.

What is interesting is that despite the concerted propaganda campaign against reform this year by the crazed 'deathers' supported by the health industry and backed by the Republicans and conservative Democrats and tacitly encouraged by the Obama administration, support for the public option remains strong. A new SurveyUSA poll released last week puts support for the public option at 77%, one point higher than it was in June. Another poll finds that 79% still support measures that constitute what is effectively the public option. The success of the propaganda campaign has been solely in confusing people as to what the phrase 'public option' implies, with only 37% being able to identify correctly what it means and 26% incorrectly thinking it refers to a British socialized system.

So Obama and conservative Democrats still have some way to go in implementing their sell-out plan to satisfy their corporate overlords while persuading the public they are true reformists. In the process they run a huge risk. Economist Paul Krugman warns Obama that the progressives who were so crucial to his electoral success are turning on him because of his subservience to the health industry.

A backlash in the progressive base — which pushed President Obama over the top in the Democratic primary and played a major role in his general election victory — has been building for months. The fight over the public option involves real policy substance, but it's also a proxy for broader questions about the president's priorities and overall approach.

And let's be clear: the supposed alternative, nonprofit co-ops, is a sham. That’s not just my opinion; it's what the market says: stocks of health insurance companies soared on news that the Gang of Six senators trying to negotiate a bipartisan approach to health reform were dropping the public plan. Clearly, investors believe that co-ops would offer little real competition to private insurers. (emphasis added)

Obama has a choice. He can go down in history as a footnote, the answer to a future trivia question as to who was the first person of color to become president of the US and as someone whose main accomplishment was to show that a president of color can be as subservient to the interests of the pro-war/pro-business one party ruling class as his white predecessors. Or he can decide to use his considerable clout and rhetorical skill to push for real health care reform and be remembered in history as one of the greatest US presidents of all time, the way that Tommy Douglas, the socialist politician identified as the originator of the state-financed health care system in that country, was chosen as the greatest Canadian of all time.

I fear that Obama's ambition does not match his soaring rhetoric. I hope I am wrong.

POST SCRIPT: Health reform information

Our local paper The Plain Dealer ran an informative series on the health care debate and provided some links to the major documents. The media has been focusing on the one that is still in the Senate Finance Committee led by reform opponent Democrat Max Baucus because that committee is the Obama Administration's best chance of avoiding real reform, which is why they have given that committee and its so-called "Gang of Six" reform opponents an effective veto over health reform legislation.

But there are other versions of health care legislation emanating from the various committees.

The 1,000 page House Bill HR 3200 can be seen here. The Congressional Budget Office (CBO) analysis of the bill can be seen here and a summary of the bill's provisions can be seen here. This site gives a detailed breakdown on what the bill would imply for each congressional district.

The Senate’s Health, Education, Labor and Pensions (HELP) Committee's proposal can be seen here. The CBO analysis of the HELP plan can be seen here.

We should also not overlook the important step that the House Committee on Education and Labor that is chaired by Dennis Kucinich took when, by a vote of 25-19, it "approved an amendment to the House's health-care reform bill allowing states to create single-payer health care systems if they so choose." After all, the Canadian single payer system began at the provincial level, and only later spread nationwide.

You can also view a side-by-side comparison of the various health reform proposals and a timeline of health reform.

Sam Smith has a good article on health care reform that asks some important questions.

August 28, 2009

The health care debate-16: Health reform Kabuki theater

(For previous posts on the issue of health care, see here.)

In this post in this series, I want to look at the political gamesmanship that is going on in health care.

As I have said repeatedly, the US is a pro-war/pro-business one party state with two factions that differ on some social issues. However, people would revolt if they realized the extent to which so many of their elected representatives of both parties are the servants of corporate interests. In order to disguise this fact, whenever an issue that involves corporate interests arises, one sees an elaborate Kabuki theater performance in which the elected officials play assigned roles, one of which involves pretending to have a major fight over some peripheral issue, while the final outcome is never in doubt.

The massive bailout to Wall Street interests was a case in point. Remember the big fuss over bonuses? Regulations? Corporate jets and other perks? That was pure Kabuki theater, the equivalent of the circuses that Roman emperors put on to amuse the people and appease their blood lust. Once a few executives had been excoriated in public and made their public penance, once the media spotlight shifted to other things, the looting of the public resumed. The big Wall Street banking interests were ultimately left alone to make huge profits and hand out big bonuses, which is exactly what is happening right now.

It is the same with health industry reform. Matt Taibbi of Rolling Stone argues persuasively that Obama was, from the beginning, in the tank with the health insurance/drug/physician/hospital industries and was never serious about making the kinds of far-ranging changes that would improve health care, if those measures went against the interests of those industries. Jonathan Cohn already had pointed out that Obama cut a deal with the drug industry not to seek lower prices. But he did want to create an image of himself as a serious reformer and use fixing the health care system, which is obviously broken, as a vote getter. So he played his Kabuki role.

Obama started out on the campaign trail talking about the virtues of the single-payer system and then falsely asserting, without any argument, that because the employer-based system was already in place, single payer cannot be implemented now in the US, despite evidence to the contrary. This enables him to rule out, right at the beginning, single payer systems as one among the mix of options to be discussed in his health care reform panels.

Then later he says that what is most important to him is not getting good health care reform passed but that it must be bipartisan. Why on earth should bipartisan acceptance be more important than good policy? That statement was the confirmation of my suspicions that Obama was not serious, because that appeal to bipartisanship immediately put him at the mercy of the Republican Party and those in his own party who were never interested in any reform, who then went on to play their Kabuki roles of objecting to any meaningful reform proposals. Obama of course had to know that they would do this. He is not stupid. This predictable opposition enables him to act as if he is being forced to compromise more than he wants to, thus preserving his reformist credentials while abjectly serving the interests of the health industry. As Glenn Greenwald says, "There is one principal reason that Blue Dogs and "centrists" exert such dominance within the Party: because the Party leadership, led by the Obama White House, wants it that way and works hard to ensure it continues."

Then Obama starts signaling that he is willing to abandon even the limited public option. All this is to lead up to the final scene of the Kabuki theater in which he finally agrees to a system that the health industry would love, such as mandating that everyone buy insurance from the private, profit-seeking health insurance industry with the government paying the premiums of those who can't afford it, while the insurance companies are given the freedom to continue the treatment-denying policies that is at the heart of their business model.

Greenwald continues:

White House threats that "you'll never hear from us again" are issued to defiant progressives only. Not only are such threats never issued to "centrists" and Blue Dogs who are supposedly impeding the President's health care agenda, but the White House does everything it can to protect those ostensible obstructionists and further entrench them in power. Isn't all of this fairly strong evidence that the White House knew, accepted and likely even desired from the start that -- despite the President's public assurances to progressives -- the "public option," understandably despised by the insurance industry, would be dropped from bill?

The very idea that Obama is valiantly struggling to cleanse the party of its corporate and centrist dominance, yet is just haplessly and helplessly unable to do so, is ludicrous beyond words.

Former insurance industry insider Wendell Potter also sees quite clearly how Obama playing his role in this Kabuki play.

Not only is Obama clearly ready to throw the public option overboard, he is embracing the requirement that we all be forced to buy insurance from private insurers. That means your tax dollars and mine will be used to pay subsidies to the big insurers to provide coverage to people who can't afford to buy their policies, because the big insurers charge far more than they should because Wall Street investors demand that they do.

During his speech in Montana, Obama talked a lot of trash about the insurance industry. Don't be fooled by that tough talk. It's all part of a strategy to try get us to believe we'll get the reform he promised during the campaign. Industry leaders are in fact delighted he's denouncing their behavior, because they believe most of his supporters -- who were hopeful the stars might finally have aligned for real reform -- will be fooled into thinking the reform bill that reaches his desk will benefit them more than the special interests with their armies of lobbyists.

That final scene hasn't been arrived at yet because there is one group that is not playing its designated role and is thus threatening to disrupt the performance. These are the progressives in Congress whose role is to be cheerleaders for Obama because he is allegedly one of them. There are hopeful signs that the progressive members of the public and Congress are seeing through this charade. They are getting angry at this sell-out on a fundamental campaign issue and they are warning Obama that they will revolt if he abandons meaningful reform.

I hope they are successful in pushing back against Obama's sell-out.

POST SCRIPT: The Onion on health reform deadlock

As usual, it is the comedians and parodists, not the news media, that sees through the Kabuki façade.

After months of committee meetings and hundreds of hours of heated debate, the United States Congress remained deadlocked this week over the best possible way to deny Americans health care.

"Both parties understand that the current system is broken," House Speaker Nancy Pelosi told reporters Monday. "But what we can't seem to agree upon is how to best keep it broken, while still ensuring that no elected official takes any political risk whatsoever. It’s a very complicated issue."

"Ultimately, though, it's our responsibility as lawmakers to put these differences aside and focus on refusing Americans the health care they deserve," Pelosi added.

The legislative stalemate largely stems from competing ideologies deeply rooted along party lines. Democrats want to create a government-run system for not providing health care, while Republicans say coverage is best denied by allowing private insurers to make it unaffordable for as many citizens as possible.

That is about as succinct a presentation of how the pro-business one party state in the US works as you will find anywhere.

August 26, 2009

The health care debate-15: The ruthless science of health industry profits

(For previous posts on the issue of health care, see here.)

Some of the supporters of the current health system have a somewhat naïve view of capitalism. They seem to have bought into the myth that the 'invisible hand' of the market will always result in good quality goods and services being provided at lower costs. That model works in some situations when there is competition among many suppliers and when the consumer has the option of not buying a product at all if they are not satisfied with the price or quality of the offerings, say as with the purchase of specific foods or a new car or a washing machine.

But it ceases to be true when people are in dire need and their options are limited. This is why one finds price gouging in essential supplies like water, food, blankets, and power generators in the immediate aftermath of a disaster like a hurricane or earthquake, when callous merchants take advantage of the misery of people to rake in huge profits. It would be insane for the government not to intervene and provide people with necessary supplies and services at those times. Look at how George Bush got hammered for the government's slow response to Hurricane Katrina.

Since health care is one of those situations in which people do not have the option of not obtaining services, and usually have to seek it in emergency situations, it is closer to the hurricane situation than that of buying a new car, which is why a strong government role is essential.

But the private, profit-seeking health insurance industry wants to go in the opposite direction. As Wendell Potter, who used to be the head of corporate communications of CIGNA, the highest public relations position of one of the largest health insurance companies, says in an interview with Bill Moyers, "The industry doesn't want to have any competitor. In fact, over the course of the last few years, has been shrinking the number of competitors through a lot of acquisitions and mergers. So first of all, they don't want any more competition period. They certainly don't want it from a government plan that might be operating more efficiently than they are, that they operate. The Medicare program that we have here is a government-run program that has administrative expenses that are like three percent or so", compared to the health insurance industry's 20%.

Potter explains to Moyers the brutal calculations that go into increasing profits by denying treatment.

WENDELL POTTER: …[T]here's a measure of profitability that investors look to, and it's called a medical loss ratio. And it's unique to the health insurance industry. And by medical loss ratio, I mean that it's a measure that tells investors or anyone else how much of a premium dollar is used by the insurance company to actually pay medical claims. And that has been shrinking, over the years, since the industry's been dominated by, or become dominated by for-profit insurance companies. Back in the early '90s, or back during the time that the Clinton plan was being debated, 95 cents out of every dollar was sent, you know, on average was used by the insurance companies to pay claims. Last year, it was down to just slightly above 80 percent.

So, investors want that to keep shrinking. And if they see that an insurance company has not done what they think meets their expectations with the medical loss ratio, they'll punish them. Investors will start leaving in droves.

I've seen a company stock price fall 20 percent in a single day, when it did not meet Wall Street's expectations with this medical loss ratio.

For example, if one company's medical loss ratio was 77.9 percent, for example, in one quarter, and the next quarter, it was 78.2 percent. It seems like a small movement. But investors will think that's ridiculous. And it's horrible.

BILL MOYERS: That they're spending more money for medical claims.


BILL MOYERS: And less money on profits?

WENDELL POTTER: Exactly. And they think that this company has not done a good job of managing medical expenses. It has not denied enough claims. It has not kicked enough people off the rolls. And that's what-- that is what happens, what these companies do, to make sure that they satisfy Wall Street's expectations with the medical loss ratio.

BILL MOYERS: And they do what to make sure that they keep diminishing the medical loss ratio?

WENDELL POTTER: Rescission is one thing. Denying claims is another. Being, you know, really careful as they review claims, particularly for things like liver transplants, to make sure, from their point of view, that it really is medically necessary and not experimental. That's one thing. And that was that issue in the Nataline Sarkisyan case.

Many of the people who oppose single-payer and other comprehensive attempts at health care reform may be doing so out of a sense of smug complacency. They may think they are healthy and have good coverage from their current employer and so life is good. Why mess with something what seems to be working so well for them? In fact, one of the most disgusting arguments that I have heard recently from opponents of health reform is that by adding the 40 million or so currently uninsured to the rolls, there would necessarily be increased waiting times to obtain medical services. In other words, in order to save a little time for them, they would like to see others have no access to health care.

The fact that so many other people suffer from either inadequate coverage or no coverage at all may not be sufficient to move those who think they have good coverage now to embrace reform. What they do not realize is that their seemingly comfortable situation could change practically overnight through no fault of their own. All it would take is for one or two of their fellow employees to get a serious illness for them to lose their own coverage. Potter explains how this happens as a result of deliberate policy by the health insurance companies:

But another way is to purge employer accounts, that-- if a small business has an employee, for example, who suddenly has [to] have a lot of treatment, or is in an accident. And medical bills are piling up, and this employee is filing claims with the insurance company. That'll be noticed by the insurance company.

And when that business is up for renewal, and it typically is up, once a year, up for renewal, the underwriters will look at that. And they'll say, "We need to jack up the rates here, because the experience was," when I say experience, the claim experience, the number of claims filed was more than we anticipated. So we need to jack up the price. Jack up the premiums. Often they'll do this, knowing that the employer will have no alternative but to leave. And that happens all the time.

They'll resort to things like the rescissions that we saw earlier. Or dumping, actually dumping employer groups from the rolls. So the more of my premium that goes to my health claims, pays for my medical coverage, the less money the company makes. (emphasis added)

Potter warns people who resist reform attempts that the very things they say they fear about single payer or socialized systems or even the public option are actually more likely to occur under the present employer-based system.

And another thing is that the advocates of reform or the opponents of reform are those who are saying that we need to be careful about what we do here, because we don't want the government to take away your choice of a health plan. It's more likely that your employer and your insurer is going to switch you from a plan that you're in now to one that you don't want. You might be in the plan you like now. But chances are, pretty soon, you're going to be enrolled in one of these high deductible plans in which you're going to find that much more of the cost is being shifted to you than you ever imagined. (my emphasis)

The private, profit-seeking health industry is a cold-blooded and ruthless business in which meeting the needs of sick people is at the very bottom of their list of priorities, while making profits for their shareholders and paying for their executives' luxurious lifestyles is right at the top. Why anybody would want to preserve that system can only be explained either by their ignorance of how it actually works or because the politicians have been bribed by the industry.

POST SCRIPT: Billionaires for Wealthcare speak out

"If god loved the poor people, he wouldn't let them get sick." So true.

August 24, 2009

The health care debate-14: The 'death panels' of the insurance companies

(For previous posts on the issue of health care, see here.)

Wendell Potter used to be the head of corporate communications of CIGNA, the highest public relations position of one of the largest health insurance companies. That position gave him a special insight into how the health insurance industry actually works and the very different way they present themselves to the public. At some point the contradictions became unbearable for him. He could not take it anymore and left his position and since then he has been spilling the beans about how the insurance companies really operate, how they put profits before any other consideration, and make money from the misery of sick people by denying them care in their time of need.

Potter spoke to Amy Goodman of Democracy Now! about two cases. One was a California teenager, Nataline Sarkisyan, who in 2007 was denied coverage for a liver transplant, even though her doctors' recommended it and they had insurance and had done everything that was expected of them. The family was able to get media attention and force CIGNA to reverse itself, but the reversal decision came just two hours before she died. No doubt CIGNA views this outcome as a great success since they did not have to pay for the liver transplant after all, hence their costs went down and their profits went up. Their shareholders must have been pleased.

Then there was the case of Thomas Concannon, who in 2002 was suffering from multiple myeloma, a rare form of cancer. As Goodman reports "His doctors planned to perform a bone marrow transplant, but as Concannon lay on the operating table, his insurance company, CIGNA, announced it would not cover the operation." (my emphasis)

Potter remembered both those tragic cases because he had to try and mitigate the public relations damage. In a recent interview with Bill Moyers, Potter describes how he came to his epiphany about how rotten the current system is and his own sordid role in it. It occurred when he visited a 'health expedition' run by volunteer doctors at the Wise County fairground near his hometown when he was visiting his family. Such events are sprouting up all over the country and the huge crowds that turn up are a testimony to how many people lack access to basic primary medical care. Potter describes what he saw.

I took my camera. I took some pictures. It was a very cloudy, misty day, it was raining that day, and I walked through the fairground gates. And I didn't know what to expect. I just assumed that it would be, you know, like a health-- booths set up and people just getting their blood pressure checked and things like that.

But what I saw were doctors who were set up to provide care in animal stalls. Or they'd erected tents, to care for people. I mean, there was no privacy. In some cases-- and I've got some pictures of people being treated on gurneys, on rain-soaked pavement.

And I saw people lined up, standing in line or sitting in these long, long lines, waiting to get care. People drove from South Carolina and Georgia and Kentucky, Tennessee-- all over the region, because they knew that this was being done. A lot of them heard about it from word of mouth.

There could have been people and probably were people that I had grown up with. They could have been people who grew up at the house down the road, in the house down the road from me. And that made it real to me.

Potter says that the widely contrasting world that the insurance industry executives live in carefully insulates them from the harsh realities that most people face, so that the people they deny coverage to are never seen as real people but are merely statistics.

I had a great job. And I had a terrific office in a high-rise building in Philadelphia. I was insulated. I didn't really see what was going on. I saw the data. I knew that 47 million people were uninsured, but I didn't put faces with that number.

Just a few weeks later though, I was back in Philadelphia and I would often fly on a corporate aircraft to go to meetings.

And I just thought that was a great way to travel. It is a great way to travel. You're sitting in a luxurious corporate jet, leather seats, very spacious. And I was served my lunch by a flight attendant who brought my lunch on a gold-rimmed plate. And she handed me gold-plated silverware to eat it with. And then I remembered the people that I had seen in Wise County. Undoubtedly, they had no idea that this went on, at the corporate levels of health insurance companies.

In the same interview, Moyers reveals the strategy of the opponents of health care reform, who are trying to scuttle it while saying they want it.

BILL MOYERS: I have a memo, from Frank Luntz. I have a memo written by Frank Luntz. He's the Republican strategist who we discovered, in the spring, has written the script for opponents of health care reform. "First," he says, "you have to pretend to support it. Then use phrases like, "government takeover," "delayed care is denied care," "consequences of rationing," "bureaucrats, not doctors prescribing medicine."

This came as no surprise to Potter: "They don't want a public plan. They want all the uninsured to have to be enrolled in a private insurance plan. They want-- they see those 50 million people as potentially 50 million new customers. So they're in favor of that."

It is a fascinating interview, giving a disturbing insider's look at the really evil practices of the health insurance industry. Moyers describes another case.

The day before she was scheduled to undergo a double mastectomy for invasive breast cancer, Robin Beaton's health insurance company informed her that she was "red flagged" and they wouldn't pay for her surgery. The hospital wanted a $30,000 deposit before they would move forward. Beaton had no choice but to forgo the life-saving surgery.

Southern Beale writes about her own experience:

You have no idea what it's like to be called into a sterile conference room with a hospital administrator you've never met before and be told that your mother's insurance policy will only pay for 30 days in ICU. You can't imagine what it's like to be advised that you need to "make some decisions," like whether your mother should be released "HTD" which is hospital parlance for "home to die," or if you want to pay out of pocket to keep her in the ICU another week. And when you ask how much that would cost you are given a number so impossibly large that you realize there really are no decisions to make. The decision has been made for you. "Living will" or no, it doesn't matter. The bank account and the insurance policy have trumped any legal document.

Such stories expose that the falsity of the fear mongering that in a single payer or socialized system, bureaucrats will come between doctor and patient and make life or death decisions. Such things only happen with the private, profit-seeking health insurance companies. So the closest things to the bureaucratic 'death panels' that emerged from the fevered imaginations of the deathers are actually run by the private, profit-seeking health insurance industries who, in conjunction with hospital administrators, callously consign people to death purely because of their desire for profits.

POST SCRIPT: Capitalism – A Love Story

Here is the trailer for Michael Moore's upcoming film which, like his others, should be well worth watching. His Sicko that dealt directly with the health system was great, and if you did not see it, you should rent it. But the problem with the health system is that is embedded in the capitalist mindset that values profit above all other things, and so this new film should give the bigger picture.

People will try and dismiss Moore as a 'mere' comedian in order to discredit his message. This is what the health industry and its shills in the media (I am looking at you Sanjay Gupta) tried to do with Sicko. In his interview with Moyers, Wendell Potter describes the industry's strategy of which he was a part.

Don't be fooled. His films are funny but Moore is smart and researches his material well. Try as they might, his detractors could not fault him on the facts.

August 21, 2009

The health care debate-13: The US falling further behind

(For previous posts on the issue of health care, see here.)

I have pointed out repeatedly that the US lags badly behind other developed countries in the quality and cost of the health care it provides its people. And all indications are that the US is going to fall further and further behind as other countries adopt universal health coverage based on the single-payer model.

President Obama keeps saying that if we were starting from scratch, a single payer system would be the best option, but that given the existing situation of an employer-based private health insurance system, it would be too disruptive. This is just an excuse for protecting the interests of the drug and insurance industries. After all, Medicare was introduced in 1965 and within one year, by July 1, 1966 19 million seniors were enrolled in it, almost all of the nearly 20 million people over the age of 65 at that time (see table 2-1, page 9), and there were no major problems in that transition.

Furthermore, as this article in the journal Health Affairs points out, other countries such as Taiwan made the transition from a US-style system to a single payer one quite easily. (Thanks to Heidi Nemeth for the link.)

Taiwan established a compulsory national health insurance program that provided universal coverage and a comprehensive benefit package to all of its residents. Besides providing more equal access to health care and financial risk protection, the single-payer NHI also provides tools to manage health spending increases. Our data show that Taiwan was able to adopt the NHI without using measurably more resources than what it would have spent without the program. It seems that the additional resources that had to be spent to cover the uninsured were largely offset by the savings resulting from reduced overcharges, duplication and overuse of health services and tests, transaction costs, and other costs. The total increase in national health spending between 1995 and 2000 was not more than the amount that Taiwan would have spent, based on historical trends.

Additionally, Taiwan did not experience any reported increase in queues or waiting time under the NHI. Meanwhile, the government has taken regular public opinion polls every three months to gauge the public’s satisfaction with the NHI. It continuously enjoys a public satisfaction rate of around 70 percent, one of the highest for Taiwanese public programs. (emphasis added)

As Scott Hanley says:

In 1995, Taiwan began providing government-run health insurance for everyone; by the end of the year, almost everyone in the country had enrolled and abandoned their US-style system of mixed private and public hospitals and free market insurance. What happened to health care costs? In the first seven years they ... stayed about the same.

That's right. They went from 57% insured to 97% insured without increasing overall spending on health care. People liked it, used it, remained healthy, and it was just as affordable as the private system that had insured not much more than half the population.

A recent report says that China has decided to have universal health care by 2011, and will "take measures within three years to provide basic medical security to all Chinese in urban and rural areas, improve the quality of medical services and make medical services more accessible and affordable for ordinary people."

Obama and the Democrats seem to start their negotiating process with what they think that the most reactionary elements in congress will accept, instead of the one that the country needs, let alone a really good one like a single-payer system. Cartoonist Tom Tomorrow explains the futility of this strategy.

Veteran journalist Russell Mokhiber lists the top 10 enemies of the single payer system, in alphabetical order. One or two of the names on the list may surprise you and you need to read the article for Mokhiber's reasons.

American Association of Retired Persons (AARP)
America's Health Insurance Plans (AHIP)
American Medical Association
Barack Obama
Business Roundtable
Families USA
Health Care for America Now
Kaiser Family Foundation
The Lewin Group
Pharmaceutical Research and Manufacturers Association of America (PHRMA)

However far Obama goes to appease the reactionary elements, they will still oppose reform because they want to kill it altogether. They do not want to give the Democrats a signature victory on a major issue, and they are aided in their efforts by those Democrats in Congress who are in the pockets of the health industry.

POST SCRIPT: Nutters gone wild

We have seen many examples of nutter behavior recently and it is hard to determine who is the craziest. A strong contender must be this woman who shouts "Heil Hitler!" at a Jew who is originally from Israel who was speaking in favor of health reform and for the creation of a national health care system like they have in Israel. Not surprisingly, he goes ballistic. Also watch her behavior at the end when he tells her that he had to pay $8,000 for a two-hour visit to a US emergency room. Priceless.

David Waldman notes that, to add to the irony, she is wearing an IDF T-shirt, which she presumably thinks gives her the license to freely use Nazi allusions.

August 19, 2009

The health care debate-12: Money talks

(For previous posts on the issue of health care, see here.)

Despite all the manifest advantages of the single-payer system, why is it not even discussed seriously in the decision-making bodies of government? To pose the question is to answer it. It is because the current US system is so bad that its supporters must prevent public discussion of obviously better rivals if it is to survive. The current system is the emperor that has no clothes.

Rich and powerful people either benefit directly from money that they get from the private, profit-seeking health industry (like those who work in the industry or the politicians who get big contributions from them) or have the money to get good treatment. It is these same people who protect the interests of the drug and insurance companies by refusing to even consider a single-payer system. These people use fear to keep others in line, raising downright dishonest fears of shortages, queues, rationing, lack of choice, etc if any reform should occur. They have even started upping the ante on their craziness, saying that with health reform we will start killing all old and sick people.

Uwe Reinhardt, a professor of political economy at Princeton University explains who is behind the propaganda:

Most Americans, first of all, are bombarded with propaganda. You don't know how many think tanks are paid by certain industry — insurance, drug, organized medicine — to feed out negative stories about the Canadian health system. They do of course have mishaps, as do we, but there is a whole industry collecting them and beaming them out here. That is one.

Secondly, people are always more comfortable culturally with whatever they have than with some other system.

Third, people imagine having the worst illness, and if you are really very sick in the U.S., you generally do have more hope than in any other country if you are very sick, particularly if you are well insured. But if you sort of live the average life of Americans and have a Canadian system, they have better primary care, easier access to it. They would never go bankrupt over health care, because they don't do that up there. They would realize what they are missing here.

Bloomberg reports that there are 3,300 health care lobbyists who have spent $263.4 million on lobbying during the first six months of 2009, getting their data from the Center for Responsive Politics which is monitoring the spending.

Uber-statistician Nate Silver, who did such an incredible job during the last election of analyzing the polling data, has done a statistical analysis of where politicians stand with respect to the public option and how that correlates with the amount of support they get from the health industry. He finds (surprise!) that the more they get funded by those special interests, the less supportive they are of the public option.


Take Democratic Senator Max Baucus from Montana, chair of the Senate Finance Committee and one who has fought strenuously to keep single-payer out of the debate and scuttle any genuine effort at reform. As NPR reports:

Paul Blumenthal, a writer for the nonpartisan watchdog the Sunlight Foundation, mapped Baucus' network of influence. (You can see the "Baucus influence map" at left).

"We have Max Baucus, who represents a single node, as the chairman of the Senate Finance Committee," Blumenthal explains. On his computer screen, lines radiate from Baucus to five of his former Senate staffers. Two of them served as chief of staff to Baucus, the top job in his Senate office.

All five now lobby Congress for various interests. Among their clients: drugmakers Wyeth, Merck, Amgen and AstraZeneca, plus the third-largest corporation in the world, Wal-Mart.
When Baucus ran for his sixth term last year, his campaign raised $11.6 million, according to the Center for Responsive Politics. Nearly half of the funds came from out-of-state donors, including millions from health care and other industries overseen by Finance and Baucus' other committees.

Just 5 percent of Baucus' re-election funds came from Montana donors."

Baucus courts these inside-the-Beltway donors by inviting them to Montana for weekend getaways — skis and snowmobiles in February, fly fishing and golf in June, and coming up on July 31, "Camp Baucus," which is billed as "a trip for the whole family."

Tickets start at $2,500.

So as Baucus and other lawmakers attempt to craft a bill that can smash through a virtual gridlock of interests, the awkward question lingers: To whom are they more attentive — their voting constituencies back home or the dollar constituencies who are at the Capitol every day?

That's an easy question to answer, isn't it? It appears that Baucus's Senate Finance Committee may not include a public option. See also this report.

Former Senate Democratic leader Tom Daschle's nomination to be Obama's secretary of Health and Human Services was scuttled by some tax and ethics questions. While I felt that his ethics problems were nowhere as severe as (say) Tim Geithner's who was approved because he was favored by Wall Street interests, I was glad that he did not get the position because I knew that he was totally in the pockets of the health industry lobby. Sure enough, he later came out against the public option.

Of all the presidential candidates in the Democratic and Republican primaries in the last election, only Dennis Kucinich supports single payer. The House Committee on Education and Labor that he chairs, by a vote of 25-19, has "approved an amendment to the House's health-care reform bill allowing states to create single-payer health care systems if they so choose." He is also one of the 86 co-sponsors of John Conyers' House Resolution 676 that seeks to expand Medicare coverage for all, and is a worthy step towards an eventual single-payer system. The summary of the legislation can be read here.

POST SCRIPT: Hypocrisy on health care

It is becoming increasingly clear that opponents of health care reform are willing to say anything at all, even if it means directly contradicting themselves.

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August 17, 2009

The health care debate-11: The Brits fight back

(For previous posts on the issue of health care, see here.)

I have written before of my direct personal experience with the British National Health Service (NHS) and can report that it was wonderful, helping me tremendously when I was seriously ill, entirely free of charge.

As people should know, the NHS is a truly socialized medical system in which people are treated free, doctors are government employees, and hospitals are directly run by the government, although there is a private system overlaid on top of it. It is like the VA hospital system in the US. But even though I think that the socialized model of the NHS is admirable, I think it would not be a suitable model for the US and that the single payer systems of France or Canada would be better.

Part of the strategy of the health care reform opponents has been to lie shamelessly about the systems in other countries in order to make the current terrible system in the US look good in comparison. They are helped in this effort by the fact that most people in the US have no idea what people in other countries have and so believe the distortions. In addition, the people in those countries are not bothered to combat this propaganda, even if they have heard of it. After all, what does is matter to them if foreigners malign their health care? Their attitude seems to be that they are quite happy with what they have and if Americans want to continue to wallow in ignorance, let them.

But once in a while, things get taken too far and the attacks o insultingly unfair that the people in those countries get riled up and rise to defend their system. This seems to be happening with the recent attacks on the British NHS.

One of the triggers was a recent editorial in the Investor Business Daily that tried to give support to the hallucinations of the deathers by suggesting that in the NHS people are ranked according to their usefulness when getting treatments. The editorial said:

The U.K.'s National Institute for Health and Clinical Excellence (NICE) basically figures out who deserves treatment by using a cost-utility analysis based on the "quality adjusted life year."

One year in perfect health gets you one point. Deductions are taken for blindness, for being in a wheelchair and so on.

The more points you have, the more your life is considered worth saving, and the likelier you are to get care.

In order to drive their point home, the editorial then went on to give what it clearly thought was a killer example of the ghastly results that ensue from such a system.

People such as scientist Stephen Hawking wouldn't have a chance in the U.K., where the National Health Service would say the life of this brilliant man, because of his physical handicaps, is essentially worthless.

It was clear that the writers were under the impression that Hawking, easily the most famous living scientist and the victim of a degenerative motor neurone disease that has steadily eroded his abilities until now he can only move a finger or two, was American and was able to survive and even flourish as a productive scientist because he was being treated in America.

The truth of course is that Hawking is British, was born there, lives there, and has been treated by the NHS all his life so that even now at the age of 67 he continues to work. As Hawking himself responded, "I wouldn't be here today if it were not for the NHS. I have received a large amount of high-quality treatment without which I would not have survived."

The ignorance of the editorial writers was greeted with hoots of derision both here and abroad and in response they have removed the offending sentence about Hawking claiming it was only a factual error about citizenship, without acknowledging that what was considered by them to be an example in their favor is actually a counterexample that destroys their case that the NHS is a soulless, uncaring, bean counting system.

Faced with this embarrassment, perhaps the deathers will take a cue from the birthers and challenge Hawking's British citizenship. After all, has anyone actually seen his original birth certificate? And shouldn't he also produce documentation that he lives in the UK and was treated by the NHS? The latter might be difficult since that system doesn't drown sick people with mountains of bills and other paperwork like the private, profit-seeking health insurance industry in the US.

As a result of the Hawking fiasco, more stories about the virtues of the NHS are emerging from people fed up with the lies. Read about how the NHS helped an American living in the UK with his tragic experience when his child was born with serious problems. And here's another story from someone recounting the way his father's kidney disease was treated was treated:

The National Health Service paid for the installation of a dialysis machine plus all the necessary plumbing and renovation of a room in his home so that he could use the machine three times a week rather than travel to the hospital in London. The cost was enormous and there is no way my parents could have afforded it. His quality of life for his last years was improved beyond recognition. I don't recall any bureaucracy or fuss: the entire decision was the doctor's. After he passed away the NHS paid for the disassembly and removal of everything too. (my emphasis)

And here's yet another another story about an American woman who was treated first in the US (where her case was dismissed as being purely psychosomatic) and then, since she later became a student in the UK, was correctly diagnosed and treated by the NHS for what turned out to be a serious illness that required chest surgery plus post-operative care. Her father continues:

Recently, we flew back to New York to consult with perhaps the world expert on Myasthenia. After reviewing her symptoms and treatment he declared that the doctors in Scotland were doing all the right things. He then asked how much this cost. He had a bit of a hard time understanding that the cost was exactly zero. By the way, I spent about two months paying various bills associated with that one visit to his office. Quite a contrast I'd say. (my emphasis)

Defenders of the NHS have also taken to Twitter to spread their message.

The British government has been hesitant to vigorously correct the falsehoods that are being spread here:

As myths and half-truths circulate, British diplomats in the US are treading a delicate line in correcting falsehoods while trying to stay out of a vicious domestic dogfight over the future of American health policy.

But others are stepping up:

The degree of misinformation is causing dismay in NHS circles. Andrew Dillon, chief executive of the National Institute for Health and Clinical Excellence (Nice), pointed out that it was utterly false that [Senator Edward] Kennedy would be left untreated in Britain: "It is neither true nor is it anything you could extrapolate from anything we've ever recommended to the NHS."

Defenders of Britain's system point out that the UK spends less per head on healthcare but has a higher life expectancy than the US. The World Health Organisation ranks Britain's healthcare as 18th in the world, while the US is in 37th place. The British Medical Association said a majority of Britain's doctors have consistently supported public provision of healthcare. A spokeswoman said the association's 140,000 members were sceptical about the US approach to medicine: "Doctors and the public here are appalled that there are so many people on the US who don't have proper access to healthcare. It's something we would find very, very shocking."

Again, it should be emphasized that the British NHS is far from perfect. But its shortcomings and the complaints about it stem not from the nature of the system itself but the fact that the British government does not put enough money into it. Many people do not realize that the per capita public health expenditure in the UK is less than the US public (not total) health expenditure alone (i.e., what the US government spends just on Medicare, Medicaid, and the VA).

POST SCRIPT: Stephen Colbert and Howard Dean discuss health care

Howard Dean is a good spokesperson for single payer systems and the public option.

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August 11, 2009

The health care debate-10: More comparisons with Canada

(For previous posts on the issue of health care, see here.)

The Canadian system is a single-payer system in which the federal government sets certain baseline services that have to be provided and then the provinces have some flexibility in what they provide over and above that. This means that there can be variability from province to province in the quality of health services with currently Ontario seeming to have the most complaints. Thom Hartmann talks to Sarah Robinson, who explains how it works.

But as to the question as to whether Canadians would prefer the US system to what they have there, this is an easy one: No. When the Canadian Broadcasting System held a poll to select the greatest Canadian of all time, the winner was Tommy Douglas, the socialist politician identified as the originator of the state-financed health care system in that country.

Let's look at the comparisons.

This report quotes a multi-nation study that found that:

One-third of Americans told pollsters that the U.S. health care system should be completely rebuilt, far more than residents of Australia, Canada, New Zealand, or the U.K. Just 16 percent of Americans said that the U.S. health care system needs only minor changes, the lowest number expressing approval among the countries surveyed.

Sixty percent of patients in New Zealand told researchers that they were able to get a same-day appointment with a doctor when sick, nearly double the 33 percent of Americans who got such speedy care. Only Canada scored lower, with 27 percent saying they could get same-day attention. Americans were also the most likely to have difficulty getting care on nights, weekends, or holidays without going to an emergency room.

Four in 10 U.S. adults told researchers that they had gone without needed care because of the cost, including skipping prescriptions, avoiding going to the doctor, or skipping a recommended test or treatment. (my emphasis)

Michael Rachlis, a Canadian doctor, exposes more myths in an article in the Los Angeles Times of August 3, 2009, where he does a side-by-side comparison of the Canadian and US health systems:

On coverage, all Canadians have insurance for hospital and physician services. There are no deductibles or co-pays. Most provinces also provide coverage for programs for home care, long-term care, pharmaceuticals and durable medical equipment, although there are co-pays.

On the U.S. side, 46 million people have no insurance, millions are underinsured and healthcare bills bankrupt more than 1 million Americans every year.

He then draws some lessons:

  • Lesson No. 1: A single-payer system would eliminate most U.S. coverage problems.
  • Lessons No. 2 and 3: Single-payer systems reduce duplicative administrative costs and can negotiate lower prices.
  • Lesson No. 4: Single-payer plans can deliver the goods because their funding goes to services, not overhead.
  • Lesson No. 5: Canadian healthcare delivery problems have nothing to do with our single-payer system and can be fixed by re-engineering for quality.

And what about the bureaucracy? In an interview, Uwe Reinhardt, a professor of political economy at Princeton University compares the two countries:

Edie Magnus: We were in a hospital that was affiliated with McGill University [in Canada], and it was a regional system that had six hospitals that were affiliated with one another, and they annually have some 39,000 inpatients, and they do about 34,000 surgeries and they deliver about 3,000 babies. And managing all of this is a staff of 12 people doing the billing, the administration. What would an equivalent hospital in the U.S. take to run administratively?

Uwe Reinhardt: You'd be talking 800, 900 people, just for the billing, with that many hospitals and being an academic health center. We were recently at a conference at Duke University [in the US] and the president of Duke University, Bill Brody, said they are dealing with 700 distinct managed care contracts. Now think about this. When you deal with that many insurers you have to negotiate rates with each of them. In Baltimore, they are lucky. They have rate regulations, so they don't have to do it. But take Duke University, for example, has more than 500,000 and I believe it's 900 billing clerks for their system. (my emphasis)

It is time to put the lies about Canada to rest. My colleague Ross Duffin (whom I must thank for sending me several of the links in the posts about Canada) put it best in a blog post way back in 2005:

[D]on't talk to me about inferior medical care in Canada. Its low reputation here is based solely on scare-mongering, knee-jerk anti-socialism, and just plain ignorance. A lot of people make a heck of a lot of money in the health care industry in this country, and would hate to see the system change, no matter how much it would benefit Americans to change it. And they can afford to spend a lot of money on advertising and lobbying to keep things just they way they are, thank you very much.

That seems to me to be exactly right.

POST SCRIPT: Bill Maher on health insurance reform

Bill Maher's final segment on New Rules says what I have been saying all along, that the US is essentially a pro-business/pro-war one party state with two factions, which is why some Democrats are allying themselves with Republicans to block meaningful health care reform.

August 10, 2009

The health care debate-9: Oh, Canada!

(For previous posts on the issue of health care, see here.)

One has to feel sorry for Canada. There they are, this perfectly nice country to the north of us, just minding its own business. And yet, whenever there is talk of health care reform in the US, the most blatant lies are told about their health system, treating it as this awful, low-quality, bureaucratic nightmare, when by any objective measure they provide better service for all their people, with better outcomes, with little bureaucracy, and at lower cost.

There is almost reflexive lying about Canada's health system by apologists for the US's profit-seeking health system. We are told that Canadians are dissatisfied with their system, that they would love to have what the US has, and that they come over here in droves to seek high quality treatment. If you are a Canadian and want to become a political and media darling in the US, all you have to do is complain about the way you were treated in Canada, as was the case of a Canadian woman who got a lot of tearful mileage in the media here by exaggerating the seriousness of her condition and claiming that she would have died if she had not come to the US for treatment. And don't forget to mention that old standby, the supposedly long wait times for those hip replacements.

Recently US Republican senate leader Mitch McConnell gave a speech lambasting the Canadian system, in particular the hospital at Kingston, Ontario. His lies were promptly debunked by Kingston General Hospital chief of staff and also rebutted by Hugh Segal, one of the most conservative of Canadian politicians, as reported in an article by Gloria Galloway in the June 24, 2009 issue of Toronto's The Globe and Mail (unfortunately behind a firewall).

One thing should be made clear. The Canadian system is not perfect. No system is. In any single-payer system what you get depends on how much taxpayers are willing to spend on the system. If you have enough money and don't care if the insurance companies will cover you, then you can get high quality treatment in the US with little wait times. That is what a profit-based system health is biased towards. So it should be no surprise that well-to-do people from other countries can be found coming to the US for treatment that they would have to wait for back in their home countries. But the fact that money talks in the US is hardly an argument for the superiority of the system.

But what about not so well-to-do people from Canada also coming here for treatment? Rhonda Hackett, a Canadian clinical psychologist who has lived in the US for 17 years explains that phenomenon in the June 7, 2009 Denver Post:

Most patients who come from Canada to the U.S. for health care are those whose costs are covered by the Canadian governments. If a Canadian goes outside of the country to get services that are deemed medically necessary, not experimental, and are not available at home for whatever reason (e.g., shortage or absence of high tech medical equipment; a longer wait for service than is medically prudent; or lack of physician expertise), the provincial government where you live fully funds your care. Those patients who do come to the U.S. for care and pay out of pocket are those who perceive their care to be more urgent than it likely is.

Can you imagine any US private profit-seeking health insurance company agreeing to pay to send someone to another country for treatment? In her article Hackett systematically addresses seven other common myths about Canadian health care, refuting the lies that are spread.

  • Myth: Taxes in Canada are extremely high, mostly because of national health care.
  • Myth: Canada's health care system is a cumbersome bureaucracy.
  • Myth: The Canadian system is significantly more expensive than that of the U.S.
  • Myth: Canada's government decides who gets health care and when they get it.
  • Myth: There are long waits for care, which compromise access to care.
  • Myth: Canada is a socialized health care system in which the government runs hospitals and where doctors work for the government.
  • Myth: There aren't enough doctors in Canada.

Hackett concludes:

It is not a perfect system, but it has its merits. For people like my 55-year-old Aunt Betty, who has been waiting for 14 months for knee-replacement surgery due to a long history of arthritis, it is the superior system. Her $35,000-plus surgery is finally scheduled for next month. She has been in pain, and her quality of life has been compromised. However, there is a light at the end of the tunnel. Aunt Betty — who lives on a fixed income and could never afford private health insurance, much less the cost of the surgery and requisite follow-up care — will soon sport a new, high-tech knee. Waiting 14 months for the procedure is easy when the alternative is living in pain for the rest of your life.

Read her excellent article to get a better understanding of how the Canadian health system works.

Next: More on Canada's system

POST SCRIPT: How to deal with lies about Canada

Ohio congressman Dennis Kucinich, one of the strongest champions of a single-payer system for the US, slaps down an analyst who works for the conservative Manhattan Institute who tries to peddle the usual distortions about Canada's system. As Kucinich points out, almost 100% of the people in Canada have insurance (in fact, the number of uninsured in the US is greater than the entire population of Canada) and nobody goes bankrupt in Canada because of health care costs. In addition, he destroys the myth of wait times, and points out that no one in Canada goes without treatment due to the inability to pay, compared with 25% of the US population. The Manhattan Institute witness is unable to respond so, like a child, he sulks and refuses to answer. Pathetic.

The witness David Gratzer's analyses have been excoriated elsewhere but his position is not surprising since the Manhattan Institute is supported by all the usual suspects who oppose health insurance reform.

August 07, 2009

The health care debate-8: Where the money goes in the US system

(For previous posts on the issue of health care, see here.)

The indisputable fact is that per capita costs for health care in the US is almost twice that of other developed countries, while producing worse outcomes. So where does the money go?

This study in the journal Health Affairs compares the US with those of OECD countries to identify what other factors are leading to the inflated costs in the US, while at the same time providing lower quality care.

In 2000 the United States spent considerably more on health care than any other country, whether measured per capita or as a percentage of GDP. At the same time, most measures of aggregate utilization such as physician visits per capita and hospital days per capita were below the OECD median. Since spending is a product of both the goods and services used and their prices, this implies that much higher prices are paid in the United States than in other countries. But U.S. policymakers need to reflect on what Americans are getting for their greater health spending. They could conclude: It’s the prices, stupid.

U.S. per capita health spending was $4,631 in 2000, an increase of 6.3 percent over 1999… The U.S. level was 44 percent higher than Switzerland’s, the country with the next-highest expenditure per capita; 83 percent higher than neighboring Canada; and 134 percent higher than the OECD median of $1,983… Measured in terms of share of GDP, the United States spent 13.0 percent on health care in 2000, Switzerland 10.7 percent, and Canada 9.1 percent. The OECD median was 8.0 percent.

People in the OECD countries can also purchase private insurance if they wish to supplement the single payer systems that most of them have.

The median country finances 26 percent of its health care from private sources. The range is as high as 56 percent in the United States and Korea to as low as 7 percent in Luxembourg and 9 percent in the Czech Republic. As a percentage of GDP, the OECD countries spent 0.4–7.2 percent of GDP on privately financed health care in 2000, with an OECD median of 2.0 percent. The United States was the highest at 7.2 percent. U.S. private spending per capita on health care was $2,580, more than five times the OECD median of $451.

What about the fear that people die in those other countries because of waiting for care for acute treatment (leaving aside the fact that people here also die because they do not have access to health care at all)?

The German and Swiss health systems appear particularly well endowed with physicians and acute care hospital beds compared with the United States. The two countries rank much higher than the United States does on hospital admissions per capita, average length-of-stay, and acute care beds per capita. The average cost per hospital admission and per patient day in these countries must be considerably lower than the comparable U.S. number, however, because both countries spend considerably less per capita and as a percentage of GDP on hospital care than the United States does. The average U.S. expenditure per hospital day was $1,850 in 1999—three times the OECD median.

The fact is that because of the profit-making emphasis in the US, health care services simply cost a lot more here.

First, the inputs used for providing hospital care in the United States—health care workers’ salaries, medical equipment, and pharmaceutical and other supplies—are more expensive than in other countries. Available OECD data show that health care workers’ salaries are higher in the United States than in other countries. Second, the average U.S. hospital stay could be more service-intensive than it is elsewhere. While this may be true, it should be noted that the average length-of-stay and number of admissions per capita in the United States are only slightly below the OECD median. Third, the U.S. health system could be less efficient in some ways than are those of other countries. The highly fragmented and complex U.S. payment system, for example, requires more administrative personnel in hospitals than would be needed in countries with simpler payment systems. Several comparisons of hospital care in the United States with care in other countries, most commonly Canada, have shown that all of these possibilities may be true: U.S. hospital services are more expensive, patients are treated more intensively, and hospitals may be less efficient.

The final argument that apologists give for the US system is that the US is unique in its ability to provide easy access to high-tech treatments. This is also not true.

Quite remarkable, and inviting further research, is the extraordinarily high endowment of Japan’s health system with CT and MRI scanners and its relatively high use of dialysis. These numbers are all the more remarkable because Japan’s health system is among the least expensive in the OECD.

On his show, Bill Moyers spoke about some of the other wasteful costs that occur in the form of bloated health insurance CEOs salaries:

Now meet H. Edward Hanway, the Chairman and CEO of Cigna, the country's fourth largest insurance company. At the beginning of the year, Cigna blamed hard economic times when it announced the layoff of 1,100 employees. But it reported first quarter profits of $208 million on revenues of $4 billion. Mr. Hanway has announced his retirement at the end of the year, and the living will be easy, financially at least. He made $11.4 million dollars in 2008, according to the Associated Press, and some years more than that.

That's a lot of oysters, although he lags behind Ron Williams, the CEO of Aetna Insurance, who made more than $17 million dollars last year, or John Hammergren, the head of McKesson, the biggest health care company in the world. His compensation was nearly $30 million.

As a CNN report says:

So, if Americans are paying so much and they're not getting as good or as much care, where is all the money going? "Overhead for most private health insurance plans range between 10 percent to 30 percent," says Deloitte health-care analyst Paul Keckley. Overhead includes profit and administrative costs.

"Compare that to Medicare, which only has an overhead rate of 1 percent. Medicare is an extremely efficient health-care delivery system," says Mark Meaney, a health-care ethicist for the National Institute for Patient Rights.

The entire health system in Canada has fewer workers to serve its population of 27 million than Blue Cross requires to service less than one-tenth that population in New England alone! This is the much-vaunted efficiency of the private sector.

Let's face the facts. The US has the most expensive and yet the worst health care system in the developed world. And it is largely due to the presence of profit-making drug and insurance companies and extortionist pricing that is squeezing money out of the system at the cost of people's health.

This is why we need to eliminate the profit-seeking private health insurance companies and institute a single-payer system.

POST SCRIPT: Bill Moyers, Sidney Wolfe, and David Himmelstein discuss single payer

In this must-see discussion, Wolfe and Himmelstein brutally expose the dirty truth about the current US health system and why the health industry here is violently opposed to the single payer system being even discussed, because they will come out far worse in comparison. They point out that we cannot create a health system that works if the private profit-seeking health insurance industry continues to play the main role.

August 04, 2009

The health care debate-7: Why health care is so expensive in the US

(For previous posts on the issue of health care, see here.)

The current health system in the US is a disgrace. Let us take some indisputable facts.

  • Health care costs in the US are way higher than in any other country.
  • Despite this, close to 15% of the population is uninsured, with the only option for such people being to go to expensive emergency rooms if the situation is dire, while in every other developed country everyone has access to primary care.
  • Using almost any statistical measure of health (life expectancy, infant mortality, etc.), the US ranks way below other developed countries.

These facts are so obvious that even conservative and right wing publications that are not ideological to the point of willful blindness have to concede the problem. Take for example, The Economist. It says:

NO ONE will be astonished to hear that health care costs more in Indiana than in India. However, a few might be surprised to learn that Americans spend more than twice as much per person on health care as Swedes do. And many may be shocked to be told that in Miami people pay twice as much as in Minnesota, even for far worse care.

The American health-care system, which gobbles up about 16% of the country’s economic output, is by far the most expensive in the world.

Another magazine, Forbes which calls itself a 'capitalist tool' points out that the US is unique among developed countries in that people actually go bankrupt because of health needs.

In 2007, medical problems and expenses contributed to nearly two-thirds of all bankruptcies in the United States, a jump of nearly 50 percent from 2001, new research has found

They randomly surveyed 2,314 bankruptcy filers in early 2007 and found that 77.9 percent of those bankrupted by medical problems had health insurance at the start of the bankrupting illness, including 60 percent who had private coverage.

Most of those bankrupted by medical problems were "solidly middle class" before they suffered financial disaster -- two-thirds were homeowners and three-fifths had gone to college. In many cases, these people were hit at the same time by high medical bills and loss of income as illness forced breadwinners to take time off work. It was common for illness to lead to job loss and the disappearance of work-based health insurance.

When you read about the quality of health care that you get in countries with single payer systems like in France, the pathetic state of affairs in the US become readily apparent. As BusinessWeek points out:

[T]he French system is much more generous to its entire population than the U.S. is to its seniors. Unlike with Medicare, there are no deductibles, just modest co- payments that are dismissed for the chronically ill. Additionally, almost all French buy supplemental insurance, similar to Medigap, which reduces their out-of-pocket costs and covers extra expenses such as private hospital rooms, eyeglasses, and dental care.

In France, the sicker you get, the less you pay. Chronic diseases, such as diabetes, and critical surgeries, such as a coronary bypass, are reimbursed at 100%. Cancer patients are treated free of charge. Patients suffering from colon cancer, for instance, can receive Genentech Inc.'s (DNA) Avastin without charge. In the U.S., a patient may pay $48,000 a year.

France particularly excels in prenatal and early childhood care. Since 1945 the country has built a widespread network of thousands of health-care facilities, called Protection Maternelle et Infantile (PMI), to ensure that every mother and child in the country receives basic preventive care. Children are evaluated by a team of private-practice pediatricians, nurses, midwives, psychologists, and social workers. When parents fail to bring their children in for regular checkups, social workers are dispatched to the family home. Mothers even receive a financial incentive for attending their pre- and post-natal visits. (my italics)

This must mean that the French system is really expensive right? Wrong. In France, the cost per capita of health care is about half that in the US! And this is despite the fact that in France, every single person is covered, while in the US 15% of its population is without health insurance. So health care should become much cheaper if we adopt the French model.

So why do people claim that providing that level of quality will be expensive here? Because the policy-makers and the media who are subservient to the profit-seeking, money-driven health industry start with the assumption that you have to preserve the interests (and of course the profits) of that industry, and then add the presently uninsured and underinsured on top of it. Of course that will be more expensive.

The economics of the situation are simple. The only way to get a better health system at lower cost is to drive the profit-seeking elements out of the system and institute a single-payer system.

POST SCRIPT: William Shatner on Sarah Palin's farewell speech

Sarah Palin stepped down as governor of Alaska, presumably to devote her full attention to giving us early warning if Russian planes should invade American airspace via Alaska (because they haven't figured out that the great circle route over the pole is much shorter) or if Vladimir Putin should unexpectedly raise his head.

Her farewell speech was the work of art we have come to expect of her, disjointed phrases that consist of brazen pandering to the military and Alaskans, swipes at the media, petty personal grievances gussied up as high principle, non sequiturs, sentences that don’t seem to end, all interwoven with ghastly and mangled imagery in the grand style of Thomas Friedman.

Conan O’Brien tried to make sense of her speech and, after several viewings, it finally clicked. It was meant as a poem.

If you can't believe that Palin said this and think Shatner is making stuff up, watch her speech. The passage Shatner quoted verbatim comes very early on.

August 03, 2009

The health care debate-6: The curious case of the swine flu vaccine guidelines

(For previous posts on the issue of health care, see here.)

The US is preparing for an expected outbreak of the H1N1 ('swine') flu epidemic in the fall. Scientists are in the process of developing a vaccine that is due to be available in October. A federal advisory board to the Centers for Disease Control (CDC) issued guidelines on July 29 for who should get priority in vaccinations.

The committee recommended the vaccination efforts focus on five key populations. Vaccination efforts are designed to help reduce the impact and spread of novel H1N1. The key populations include those who are at higher risk of disease or complications, those who are likely to come in contact with novel H1N1, and those who could infect young infants. When vaccine is first available, the committee recommended that programs and providers try to vaccinate:

  • pregnant women,
  • people who live with or care for children younger than 6 months of age,
  • health care and emergency services personnel,
  • persons between the ages of 6 months through 24 years of age, and
  • people from ages 25 through 64 years who are at higher risk for novel H1N1 because of chronic health disorders or compromised immune systems.

In a press release, the CDC says:

There is some possibility that initially the vaccine will be available in limited quantities. In this setting, the committee recommended that the following groups receive the vaccine before others:

  • pregnant women,
  • people who live with or care for children younger than 6 months of age,
  • health care and emergency services personnel with direct patient contact,
  • children 6 months through 4 years of age, and
  • children 5 through 18 years of age who have chronic medical conditions.

Stop for a moment and listen. Isn't there something strange? What you hear is silence. And yet look at what just happened. The very nightmare that anti-single payer and anti-socialized medicine zealots talk about the most has just come to pass: We are having "rationing of health care", with the decisions on who should get treatment and who should not being made by "government bureaucrats"!

So why is there not an uproar about the awful government making decisions about your health care? Because once you leave the rarefied air of generalizations about the glorious virtues of the free market and come down to concrete cases involving public health, this is obviously the way to make sensible decisions. After all, who would they like to see making decisions as to who should get the vaccines and who should not?

A team of health care professionals weighing the merits of the various options and coming to some consensus decisions about how to get the maximum benefit from limited resources, without the possibility of enriching themselves by their decisions?

Or profit-seeking private drug companies and insurance companies figuring out how to make the most money for themselves and their shareholders, presumably by giving the vaccines to those who can pay the most for it, decisions being made by people whose income and bonuses is related to how much they can make from the vaccines?

Would people like to see the flu vaccine being sold by the private sector to those who can pay the highest price, so that they can make the most profit? Isn't that how the glorious market forces should work?

The way the swine flu allocation decisions were made is exactly how, in a government-run single payer system, decisions about allocating medical resources will be made, by publicly accountable health care professionals weighing all the options and seeing how to obtain the maximum benefit.

Notice that in this specific swine flu situation, people over the age of 65 are told to go to the back of the line because the evidence suggests that they may have already developed an immunity to the swine flu from a variant from a long ago past flu. This is a switch from other flu vaccine situations where older people got priority. I would not be at all surprised if, as the news sinks in and the flu season approaches and promises to be serious, all the well-to-do seniors led by that greedy geezer lobbying group the American Association of Retired Persons (AARP), people who have long been pandered to at the expense of others because they vote in large numbers, will start pushing to get to the head of the line and demanding that they get the flu vaccine first, elbowing pregnant women and children aside.

Although I long ago qualified to join the AARP, I refuse to do so because it always seemed to me to have only the interests of better off older people in mind, especially when it comes to health care, at the expense of poor older people, children, and the rest of the general public. On health care reform, the AARP seems to want to protect the interests (and profits) of the health insurance industry and opposes single payer systems.

The AARP tries to scare its membership using fraudulent arguments. They know that their members love Medicare, and they suggest that single payer systems will eliminate it. Oh, the horror! The fact is that Medicare is a single payer system and what is being proposed by single payer advocates is to essentially expand Medicare to cover everyone, so that there will be no need for a separate program just for older people. But some greedy geezers have got so used to being treated better than everyone else that telling them that everyone will receive the same care as they do is enough to turn some of them away, fearing that they will not automatically be at the head of the line.

POST SCRIPT: The Daily Show on scared old people

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July 29, 2009

The health care debate-5: How other countries health systems compare to the US

(For previous posts on the issue of health care, see here.)

The advantages of single-payer systems over the current US system are becoming increasingly obvious. Another pro-business publication BusinessWeek concedes the advantages of the single payer system as is practiced in France.

In fact, the French system is similar enough to the U.S. model that reforms based on France's experience might work in America. The French can choose their doctors and see any specialist they want. Doctors in France, many of whom are self-employed, are free to prescribe any care they deem medically necessary. "The French approach suggests it is possible to solve the problem of financing universal coverage...[without] reorganizing the entire system," says Victor G. Rodwin, professor of health policy and management at New York University.

France also demonstrates that you can deliver stellar results with this mix of public and private financing. In a recent World Health Organization health-care ranking, France came in first, while the U.S. scored 37th, slightly better than Cuba and one notch above Slovenia. France's infant death rate is 3.9 per 1,000 live births, compared with 7 in the U.S., and average life expectancy is 79.4 years, two years more than in the U.S. The country has far more hospital beds and doctors per capita than America, and far lower rates of death from diabetes and heart disease. The difference in deaths from respiratory disease, an often preventable form of mortality, is particularly striking: 31.2 per 100,000 people in France, vs. 61.5 per 100,000 in the U.S. (my italics)

PBS's Frontline had a program Sick Around the World that looked at the health care systems in England, Taiwan, Germany, Switzerland, and Japan.

The private, profit-seeking health industry knows that their system is terrible compared to what single payer or socialized systems can offer and so they have to obscure and confuse things as much as possible. What has been amusing to watch has been the logical knots that the health industry has been tying itself up in to avoid even the minimal public option that has been proposed, saying that it would drive them out of business. Of course, if their claims that the government cannot run anything properly, that the private sector is far more efficient and will provide better health care at lower cost, then they should not have anything to fear from a public option. Even president Obama, who has been trying to placate the private health insurance industry, found this argument a bit much, saying, "Why would it drive private insurers out of business? If private insurers say that the marketplace provides the best quality healthcare, if they tell us that they're offering a good deal, then why is it that the government -- which they say can't run anything -- suddenly is going to drive them out of business? That's not logical."

The fact that they are trying to prevent a public option shows that the opposite is true. What they really fear is that once you take the profits, the huge salaries and bonuses of their top executives, and their exorbitant bureaucratic costs out of the system, the public system will be cheaper and more efficient and people will flock to it. Because of this fear, they and their lobbyists will first try to prevent any discussion at all of a meaningful public option, such as single payer.


If forced to concede one, they will try to hobble it by either limiting access to it or put in a lot of restrictions and rules in order to make is as inefficient and expensive and callous as the private system. "Opponents say private insurers could not compete with a public plan that didn't have to make a profit. They argue that private health plans would end up going out of business, leaving only an entirely government-run health care system."

I sincerely hope that this is true. Profit-making entities have no business being in the position of making health care decisions.

What the industry would really like is for the government to mandate that everyone have private insurance and pay for it, and at the same time reserve the right to deny coverage so that they make more profits. Because of this, we should be aware that the public plan that finally emerges from Congress may not be that good because of the amount of money that the health industry funnels to members of Congress. They may try to fob off on us some lousy system that they label the 'public option' that is designed to fail.

We should keep pushing for a single-payer, Medicare-for-all type system. The group Physicians for a National Health Program (PNHP) has done wonderful work in pushing for single payer and has created a comparison chart of public option vs. single payer. Single Payer Action Network in Ohio (SPAN Ohio) has come up with a plan just for the state that has the following features:

  • Patients get free choice of health care providers and hospitals.
  • When you go to your own personal physician for visits, there are NO premiums, NO co-payments, NO deductibles, NO one excluded. You pay nothing.
  • When you get your prescription filled by your pharmacist, there are NO premiums, NO co-payments, NO deductibles, NO one excluded. You pay nothing.
  • If you need hospitalization, there are NO premiums, NO co-payments, NO deductibles, NO one excluded. You pay nothing.

It beats me why anyone would prefer the current bureaucratic, service denying nightmare of the private, employer-based, profit-seeking system over such a plan.

POST SCRIPT: Tom Tomorrow on health care

One of my favorite cartoonists has been on a tear recently with three strips on health care: one, two, and three.

July 27, 2009

The health care debate-4: What the public thinks

(For previous posts on the issue of health care, see here.)

The fact that the current US system is broken and needs a complete overhaul with government involvement is becoming increasingly apparent to almost anyone except for those who have some kind of visceral reaction to the government being involved in anything. It is because of the stark reality faced by ordinary people that, despite the incessant propaganda against single payer public plans by the health industry and its allies in Congress and the media, the polls are pretty clear that people favor a greater government involvement in the health care system.

There is a Quinniapiac poll that shows that 69% want a public option.

A recent New York Times poll also finds that 72% favor "the government offering everyone a government administered health insurance plan like Medicare that would compete with private health insurance plans." The poll also found that "most Americans would be willing to pay higher taxes so everyone could have health insurance and that they said the government could do a better job of holding down health-care costs than the private sector."

Meanwhile, as Bernie Horn points out, in another new poll "Eighty-three percent of Americans favor and only 14 percent oppose "creating a new public health insurance plan that anyone can purchase" according to EBRI, a conservative business research organization. This flatly contradicts conservatives' loudest attack against President Obama's plan to provide quality, affordable health care for all."

To combat the charge that this was a biased poll funded by single payer supporters, we should note the groups that fund the EBRI (Employee Benefit Research Institute): "EBRI's biggest donors include: AT&T, Bank of America, Boeing, General Dynamics, General Mills, IBM, JPMorgan Chase, Morgan Stanley, Northrop Grumman, Schering-Plough, Schwab, T. Rowe Price, UBS Financial, and Wal-Mart. EBRI also receives large contributions from the insurance industry, including: Blue Cross Blue Shield, CIGNA, Hartford, Kaiser Permanente, Massachusetts Mutual, Metropolitan Life, Union Labor Life, and UnitedHealth. And who funded this particular EBRI poll? "AARP, American Express, Blue Cross Blue Shield Association, Buck Consultants, Chevron, Deere & Company, IBM, Mercer, National Rural Electric Cooperative Association, Principal Financial Group, Schering-Plough Corp., Shell Oil Company, The Commonwealth Fund, and Towers Perrin."

As an ABC News/Washington Post poll showed in 2003, the majority of Americans support a single-payer, government-sponsored health care system, even when they hear the right-wing's alarmist arguments. David Sirota highlighted some key findings of the poll:

  • Question 48 in the poll shows that 79% of Americans say they support "providing health care coverage for all Americans, even if it means raising taxes" over "holding down taxes, even if it means some Americans do not have health care coverage."
  • Question 49 shows 62% say they support a universal health care system "run by the government and financed by taxpayers" over the current system.
  • Question 50 shows 57% say they would support this program even "if it limited your own choice of doctors" (which doesn't necessarily have to be a side-effect of a single-payer system).
  • Similarly, question 51 shows 62% say they would support this program even "if it meant there were waiting lists for some non-emergency treatments" (again, not necessarily a side-effect).

So let's stop talking about "popular opposition" to government involvement in health care. The people who are opposed are the people in the current system who benefit from the sickness of others or have a knee-jerk reaction to anything that involves the government. What they are really scared of is that the public plan will be so popular that everyone will want to join in. Currently estimates of the people who will want to get in can get as high as 119 million, a number suggested by one of the health industry's main lackeys, Sen. Charles Grassley (R-Iowa).

What the health industry wants is to get their hands on the 50 million or so who are currently uninsured as a new revenue stream. As Robert Parry points out:

The industry's hope is that the government will mandate that those Americans sign up for private insurance and offer subsidies for those who can't afford to pay the premiums.

Fifty million new customers and government largesse to help pay the bills would be a huge windfall for the insurance industry, which otherwise faces a decline in its market because Baby Boomers are reaching the age to qualify for Medicare and because rising unemployment is draining the pool of Americans who have insurance through their employers.

So watch for them to make noises about how they support everyone getting insurance, while at the same time fighting any attempt to change the way the current system works because it has proven so profitable for them.

Since they are aware that the public supports the public option, their strategy is likely to be to make the public option as unattractive as possible.

POST SCRIPT: The Chasers are back

That group of Australian pranksters target torture advocates John Yoo and Dick Cheney.

There was a time when the US was a leader in this kind of political guerilla theater, led by people like Abbie Hoffman and the Yippies. I remember being enthralled by their antics even though I was far away in Sri Lanka.

Remember when they ran the pig Pigasus for president in 1968 under the slogan "Pork Power"?

And who can forget the political theater of the trial that followed the violent Democratic convention of that year? See the documentary Chicago 10 for an excellent encapsulation of the comic drama of that tumultuous event.

And what about the time that the irrepressible Hoffman said that they were going, using meditation, to get the Pentagon to levitate and spin, and the media actually arrived to cover that attempt? Norman Mailer's Pulitzer Prize winning book Armies of the Night offered an insider's look at the 1967 anti-war March on Washington that formed the backdrop.

Has this kind of political street theater become another casualty of outsourcing to other countries?

July 24, 2009

The health care debate-3: Why profits should not be a factor in health care

(For previous posts on the issue of health care, see here.)

It is important to realize that in the single payer or socialized systems, everyone is covered and no one is denied coverage for lack of employment, pre-existing conditions and the like. Does that mean that one will be able to have any treatment that one desires whenever one desires it? Of course not. Whenever there is greater demand than resources available, there will always have to be decisions made as to how those resources are to be utilized, and invariably some treatments may be denied or delayed for some people.

The point is that this occurs even now in the private health insurance system that we have in the US. The difference, and it is a huge one, is that the private health insurance decisions about whom and what to treat are made by bean counters who are driven by the insatiable drive to make profits for their companies and who seek every means to deny treatment. There is almost nothing that ordinary people can do when they get shafted by the companies, because they are expert at giving you the run-around.


In single-payer and socialized medicine, decisions about how to allocate resources are made by collectively by physicians, other health professionals, and public policy makers who try to maximize the benefits of the system with the resources they have. There is usually some kind of board that is responsible for the workings of the system, but unlike the boards of directors of private, profit-seeking health insurance companies, they do not personally benefit financially by limiting treatment. And if we do not like how the system is run, then we have power to change things in that we can either vote to give the system more resources (the way we vote levies for schools and libraries) or we can vote for a government that will make the changes we desire. The public ultimately controls the health care system, which is as it should be.

It is also important to realize that in both single payer and socialized systems that are in existence in other countries, people still have the option to buy private health insurance if they want extra services, so those people who want premium services can still have them.

Those who think that they have good insurance now in the US from the profit-seeking private health insurance companies and resist change towards a single-payer or socialized system might be in for a nasty shock when they actually get ill because the health insurance industry has entire teams of people whose sole job is to find ingenious ways to deny coverage. The US health care system is truly wonderful as long as you do not get sick. Reporter Lisa Girion of the Los Angeles Times of June 17, 2009 reports on how the insurance companies cancel the medical coverage of sick people after they are diagnosed, a practice known as 'rescission'.

An investigation by the House Subcommittee on Oversight and Investigations showed that health insurers WellPoint Inc., UnitedHealth Group and Assurant Inc. canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period.

It also found that policyholders with breast cancer, lymphoma and more than 1,000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses.

Denial of coverage is mostly done by using the infamous 'pre-existing conditions' loophole. Insurance companies will go to great lengths to dig up something, anything, that can be used to deny claims and cancel coverage altogether. "A Texas nurse said she lost her coverage, after she was diagnosed with aggressive breast cancer, for failing to disclose a visit to a dermatologist for acne… One employee, for instance, received a perfect 5 for "exceptional performance" on an evaluation that noted the employee's role in dropping thousands of policyholders and avoiding nearly $10 million worth of medical care."

Michael Moore's film Sicko (see my review) interviewed people whose job was to do this and get rewarded for it by the insurance companies. This should be no surprise. After all, then president Richard Nixon approved of setting up the present employment based private health insurance system only after he was assured by his aide that "Edgar Kaiser is running his Permanente deal for profit… All the incentives are toward less medical care… the less care they give them, the more money they make… the incentives run the right way." The present system is running exactly as they envisaged.

In May 2008 my younger daughter graduated from college so she immediately ceased to be on our health plan. But her job started only in August 2008 so we had to go through the dreary business of shopping around to get temporary coverage for the months of June and July before she got on her new company's plan. That kind of irritation alone should be enough for people to want to ditch the present system in favor of one where coverage is decoupled from one's employment status. For most people, the biggest nightmare about losing their job, or even changing it, is how to ensure health care for them and their families.

But that's not all. When my daughter later went to the doctor for some minor treatment, the insurance company would not pay unless she could prove that it was not a 'pre-existing condition', which meant that we had to go back and get all the documentation about her two month temporary coverage. Even that was not enough and we had to get the paperwork of the coverage she had before that and submit that too. All this took a lot of time and the matter still has not been resolved. In the meantime she left that job and got a new one, so we don't know what will happen now. But if she had not taken the precaution of getting temporary coverage for the two-month period of June and July 2008 (which happens to many people between jobs), and if we had not been conscientious about keeping all the paperwork, they would have simply denied her claims and she would have been on the hook for the entire amount. And there is nothing that we could have done about it.

Suzie Madrak relates an awful story about the hassle she went through when she injured her ankle. Because the injury occurred when she fell while getting down from a truck, her health insurance and auto insurance companies kept passing the buck to each other as being the party responsible for paying for treatment. This kind of thing simply would not happen in a single-payer or socialized system.

Anyone who has had to deal with the health insurance companies knows the aggravation that occurs routinely. The funny thing is that most Americans think this is normal because they have never known anything better. People in countries that have single-payer or socialized health systems never have to deal with an profit-making insurance bureaucracy that seeks to make money by denying treatment.

It is important to always bear in mind one undeniable fact: In the current system, it is that the primary mission of the private health insurance industry is to maximize the profits of their shareholders, not to provide good service to sick people.

The fact that finding ways to deny coverage is an important part of their profit-making strategy emerged once again when during congressional hearings last month, Rep. Bart Stupak, the chairman of the House Subcommittee on Oversight and Investigations asked each of the heads of the major health insurance companies whether he would at least commit his company to immediately stop rescissions except in cases where they could show intentional fraud. All of them said "No", thus confirming that denying coverage to sick people by any means possible is a deliberate profit-seeking policy of these companies.


POST SCRIPT: Bill Maher makes a commercial for the American Medical Association

July 22, 2009

The health care debate-2: Combating the health industry propaganda

(For previous posts on the issue of health care, see here.)

In order to effectively combat the health industry propaganda that seeks to preserve the current terrible system, people need to have a clear idea of what the main issues are and get clear on what the various terms mean.

First of all, ‘universal’ coverage, by which is meant that everyone has access to some health care is not enough. It is possible to achieve this by demanding that everyone must purchase private health insurance (the way all drivers must purchase auto insurance) and then providing aid for those who cannot afford it. All this would do is put more victims in the clutches of the rapacious and inefficient private health insurance companies and increase their profits while not improving the system.

So while universal coverage is a necessary condition, it is not sufficient. What is needed is universal coverage that is in the form of either single payer or socialized medicine. But the health industry and their lackeys are so terrified about people learning the truth about those systems that they have filled the debate with distortions that need to be swept away. A good place to start is by looking at this short animation that clearly explains how single payer works and why it is the best system.

Furthermore, not only are such systems not strange, unfamiliar, and complicated, the US has already had versions of them for decades and the people served by them are largely satisfied and would protest violently if they were eliminated.

The single payer system is what we now call Medicare, in that there is a single entity (the government) to which we pay premiums (in the form of payroll taxes) and which negotiates with and reimburses health care providers for the services they provide. In this system, people have the freedom to choose their doctors and hospitals. These are the systems that exist in countries like Canada and France.

The socialized medicine system is the Veterans Administration, in that the health professionals involved (doctors, nurses, etc.) are government employees and the medical facilities are government owned and run. This is the system in countries like England.

In both these systems, everyone who is qualified using simple minimal criteria (by age for Medicare, by military service for the VA) and needs treatment gets it without having to deal with health insurance bureaucrats, without being turned away because of 'pre-existing conditions', without worrying about the fine print in complicated forms, or all the other things that make dealing with the current private health insurance system such a nightmare.

It is interesting that all those who claim that single payer and socialized medicine are awful evils carefully avoid mentioning Medicare or the VA. If they were consistent, they would call for the abolition of those two programs. But they know that would be political suicide. People on Medicare and in the VA system, while complaining that they would like to see the system work better, would nevertheless react furiously to any suggestion of eliminating those programs and putting them back at the mercy of the callous private health insurance industry.

Watch this clip of Vermont Senator Bernie Sanders at a Senate hearing explaining this point clearly and making John McCain squirm by pointing out that when he and other politicians talk about how awful socialized medicine is, they are attacking the VA. Sanders challenges his fellow senators that if they think that socialized medicine and single payer systems are so bad, then they should propose legislation to abolish the VA and Medicare.

Of course, there are no takers because that whole argument is a fraud, manufactured by the health industry and its Congressional lackeys. As Sanders points out, those systems do not deny health care because you had a 'pre-existing condition' or because you lost your job. As Sanders points out, opinion polls repeatedly show that people want the government to be in the business of health care and they want more things like VA, not less. As he says, the US Senate may be the only body in the entire country that thinks that a private health insurance system is better.

In fact, the simplest health care reform to implement would be to incrementally expand some form of Medicare to eventually cover everyone, perhaps starting with young children.

With Medicare, we already have a working model that is in place and that everyone knows how to deal with. It would be relatively easy to build on it. On does not need to design an entirely new system from scratch.

POST SCRIPT: French health care system

CBS News compares the French health system (which I think would be the best model for the US to follow) with the US system. (Thanks to RCarla)

July 20, 2009

The health care debate-1: Clarifying the issues

(For previous posts on the issue of health care, see here.)

The late Walter Cronkite said, "America's health care system is neither healthy, caring, nor a system." And he was right. It is a rotten structure that has continued purely on the basis of its ability to fool people using smoke and mirrors into thinking it is better than it is. But the structure is so bad that the façade is crumbling and the need for reform cannot be hidden anymore.

As the health care reform debate gathers steam, those who benefit greatly from the current system (drug and health insurance companies, hospitals, and doctors) by making large amounts of money while delivering less than adequate care, and the members of Congress whom they effectively bribe to protect their interests, and the mainstream media which is always obsequious in advancing the interests of the business and political elite, are going flat out to preserve as much of their interests by either lying or fear-mongering or creating confusion. As all the various plans are debated, with their details, it is important to keep clear what the issues are, and the next series of posts will try to do that.

These are the lies and distortion that are spread by the health industry:

  1. The US currently has the best health care system in the world.
  2. The private sector is better than the government at providing everything, including health care.
  3. Single payer or socialized systems are massive, complicated, expensive, bureaucratic nightmares that will not provide timely and quality health care.
  4. There is no freedom of choice under single payer or socialized medicine.
  5. The people in those countries that have single-payer health care systems (which is practically every other developed country and many developing countries) have terrible care and the people in those countries envy what we have in the US.

Expect to hear lots of frightening stories about how terrible single payer and socialized medicine is (although exactly how those plans work will be rarely explained and comparative statistics will rarely be produced) and how strange and confusing it will be for everyone. Expect to hear a lot of anecdotes about the long wait times that the people in those systems encounter. If you want to get the facts about single payer to counter this propaganda, see this FAQ page prepared by the group Physicians for A National Health Program (PNHP).

During all these discussions, the key question that will be avoided at all costs is what value the private health insurance industry adds to the health system. This is because the answer is zero. It is actually more accurate to say it is negative, because these companies are parasites, existing purely to take money out of the system in the form of high bureaucratic costs and profits. Currently the amount of money that is siphoned off by them is estimated at 30% of the total health care budget, far higher than the overhead costs in single payer systems.

All these special interests will try and avoid even mentioning the phrase 'single payer' and refuse to even consider it as one of the options. In fact it is only because advocates have loudly demanded that it be included, to the extent of even disrupting meetings and hearings and getting themselves arrested, that it has had any mention at all.

The only alternative that will be deemed to be even worth discussing is something called a 'public option'. Every effort will be made to make even this clumsy and cumbersome, so as to make the present system look good in comparison and thus preserve the profits of the health industry and confuse the public that this is how single-payer or socialized medicine works.

Last month, former Labor Secretary Robert Reich described how 'Big Pharma' (the large drug companies) is planning to kill even this limited public option, let alone single payer.

I've poked around Washington today, talking with friends on the Hill who confirm the worst: Big Pharma and Big Insurance are gaining ground in their campaign to kill the public option in the emerging health care bill.

You know why, of course. They don't want a public option that would compete with private insurers and use its bargaining power to negotiate better rates with drug companies. They argue that would be unfair. Unfair? Unfair to give more people better health care at lower cost? To Pharma and Insurance, "unfair" is anything that undermines their profits.

So they're pulling out all the stops -- pushing Democrats and a handful of so-called "moderate" Republicans who say they're in favor of a public option to support legislation that would include it in name only. One of their proposals is to break up the public option into small pieces under multiple regional third-party administrators that would have little or no bargaining leverage. A second is to give the public option to the states where Big Pharma and Big Insurance can easily buy off legislators and officials, as they've been doing for years. A third is bind the public plan to the same rules private insurers have already wangled, thereby making it impossible for the public plan to put competitive pressure on the insurers.

But Big Pharma is just one player opposing any meaningful reform. Allied with it are all the other parasites getting rich off the misery of sick people, and their allies and sycophants and enablers in Congress and the media.

Next in the series: Combating the health industry propaganda.

POST SCRIPT: Walter Cronkite

In the wake of the death last week of legendary newsman Walter Cronkite, the current media has rightly eulogized him as representing some of the best elements of journalism. In a terrific essay, Glenn Greenwald notes how the media praise people like Cronkite and David Halberstam after they die, and bask in their reflected glory, while carefully avoiding adopting the very practices that made them exceptional journalists.

The essay is too good to excerpt. You should really read the whole thing.

March 06, 2009

The need for a government-run single payer health care system

I have said before that while I voted and supported Obama against McCain, he is firmly committed to following the policies of the pro-war/pro-business elites that govern this country. No politician can get elected to high office otherwise.

Perhaps nowhere is this clearer than his attitude to single-payer health care. I have written extensively about this in the past and it is clear that a system like that of France provides the most cost effective means of providing high-quality health care to everyone without the incredibly expensive, burdensome, and bureaucratic system that we have in the US.

But although Obama talked a lot about providing access to health care to everyone, when he called a summit to be held yesterday (March 5, 2009) to discuss this serious problem and said that he wanted wide-ranging views on how to solve it, he deliberately excluded those who wanted the single payer system as part of the discussion. His key people on health care reform are those with ties to the parasitic health insurance industry. Hillary Clinton did the same thing with her earlier ill-fated efforts to reform the health care system.

Politicians and the health insurance industry like to call for 'universal' health insurance as long as all it requires is that the government mandate that everyone have private health insurance, because that would hugely increase their profits. This is why it is important for people to realize that 'universal' health care and 'government-run single payer' health care systems are not the same thing. The latter is far, far, better.

Obama initially did not want not even allow the views single payer advocates to be heard, even though one of the most senior members of his own party, Congressman John Conyers, has proposed House Bill 676 to establish just such a system. This is because almost the entire government is beholden to the health-drug-hospital lobbies and they are all fearful that when more people realize how much better a government-run single payer system is, they will demand it.

But the supporters of single-payer flooded the government with protests about this exclusion and at the very last minute, an invitation was extended to advocates of single payer. They invited Conyers and Dr. Oliver Fein, who is president of Physicians for a National Health Program, whose mission is to obtain a single payer system. As their site points out:

The U.S. spends twice as much as other industrialized nations on health care, $7,129 per capita. Yet our system performs poorly in comparison and still leaves 47 million without health coverage and millions more inadequately covered.

This is because private insurance bureaucracy and paperwork consume one-third (31 percent) of every health care dollar. Streamlining payment through a single nonprofit payer would save more than $350 billion per year, enough to provide comprehensive, high-quality coverage for all Americans.

That illustrates why, as I said before, it is extremely important that the people who voted for Obama not cut him any slack at all and keep up the pressure on him, because the lobbies that dominate the government work 24/7 to keep the pressure on the politicians they buy so that they follow their dictates. Obama is no exception, however much his most ardent supporters might think he is different.

This success in gaining entry to the summit does not mean that single-payer is going to win out soon. The for-profit health care lobbies that make fortunes out of the sickness and misery of people have too much at stake and are still too powerful to be vanquished that easily. They are vampires, preying on people's fears in order to preserve their profits, and it will take a lot to drive a stake through their hearts. What kind of mentality pays bonuses to employees if they can cancel the policies of sick people, and thus save the company money? And yet, in the for-profit health care system we have now, such a cruel policy is good business practice.

The present system has become so appalling that now even a majority of doctors want a single payer system, because they themselves are finding the current system dehumanizing, deprofessionalizing, and a bureaucratic nightmare.

The latest sign is a poll published recently in the Annals of Internal Medicine showing that 59 percent of U.S. doctors support a "single payer" plan that essentially eliminates the central role of private insurers. Most industrial societies -- including nations as diverse as Taiwan, France, and Canada -- have adopted universal health systems that provide health care to all citizens and permit them free choice of their doctors and hospitals. These plans are typically funded by a mix of general tax revenues and payroll taxes, and essential health-care is administered by nonprofit government agencies rather than private insurers.

There will be no real improvement in the health care system until the private, for-profit health insurance industries are removed from it. But the health insurance lobby is powerful and has huge access to the halls of government and the media. It will take a huge groundswell of popular sentiment to overcome it.

POST SCRIPT: How other countries did it

The US is the only major country without a government-run single-payer health system. Supporters of the present system self-servingly argue that switching over would cause huge disruptions and chaos. This article in the New Yorker describes how the single payer system was introduced in other industrialized countries, with minimal fuss and to great satisfaction.

The French health-care system has among the highest public-satisfaction levels of any major Western country; and, compared with Americans, the French have a higher life expectancy, lower infant mortality, more physicians, and lower costs. In 2000, the World Health Organization ranked it the best health-care system in the world. (The United States was ranked thirty-seventh.)

July 26, 2007

Single payer health universal insurance coming to Ohio?

(For previous posts on the topic of health care, see here.)

Efforts are underway to try get a universal, single payer health care system in Ohio. The group behind it is the Single-Payer Action Network Ohio (SPAN Ohio), which is supporting legislation instituting such a plan. Their website provides more information about their initiatives and meetings.

The Health Care for All Ohioans Act has been introduced in the Ohio House (H. B. 186) and the Senate (S. B. 168).

The main points of the legislation can be seen here but here are the highlights:

  • Patients get free choice of health care providers and hospitals.
  • When you go to your own personal physician for visits, there are NO premiums, NO co-payments, NO deductibles, NO one excluded. You pay nothing.
  • When you get your prescription filled by your pharmacist, there are NO premiums, NO co-payments, NO deductibles, NO one excluded. You pay nothing.
  • If you need hospitalization, there are NO premiums, NO co-payments, NO deductibles, NO one excluded. You pay nothing.

In each case, the health care provider is reimbursed from the Ohio Health Care Fund.

So how does the Ohio Health Care Fund get its money? Under the proposed plan, people who earn less than the Social Security tax cap (currently $97,500 per year) pay no additional taxes. The money to fund the system comes from a variety of sources: up to 3.85% payroll tax paid by employers; up to 3% gross receipts tax paid by businesses; 6.2% tax on individual compensation in excess of the Social Security tax cap; 5% surtax on adjusted gross income over $200,000; funds from other government sources. Remember that currently employers that provide private health insurance have to pay for it. That money can now be directed to the Ohio Health Care Fund instead.

An Ohio health care agency runs the program and its governing board consists of the state director of health and fourteen other members, two from each of the seven regions that make up the state. The two members are elected for two-year terms by a regional health advisory committee, which in turn is elected by a meeting convened of the county and city health commissioners of each region.

Since there are many misconceptions (often deliberately perpetrated by the health care industry and its allies in the media) about what a single payer system involves, here is a handy document that compares the myths with the realities.

One of the big distortions that will be perpetrated by the health insurance and drug industries and politicians is to treat 'universal' and 'single-payer' as if they are synonymous terms. They are not and people should be vigilant when that sleight-of-hand is attempted. 'Universal' refers to the fact that every person should be covered, with no exceptions. 'Single payer' refers to the mechanism by which the health care system is financed and health care providers reimbursed.

It is not difficult to provide 'universal' private health insurance coverage, if that coverage is bad. All one needs to do to achieve that is to compel everyone to purchase some kind of health insurance, like the way people are compelled to buy auto insurance in order to drive, and some states have gone that route. But all that achieves is people or their employers being forced to purchase high-deductible, low-treatment coverage. Such policies will not result in better and more accessible treatment for more people or reduce the frustrating bureaucracy that we all encounter now. In fact, it will be a profit windfall for the private insurance companies as they get even more people into their nets. Such 'universal' programs would not be an improvement on the current system, though it will be touted as such by the health-care industry and their apologists.

'Single-payer' means something different, that there should be just one single entity, preferably run by the government or at the very least a non-profit publicly accountable board, that collects the money and spends it on the health care system. The single payer plan calls for the complete elimination of profit-driven private health insurance companies from the health care system, and has to be an essential component of any meaningful health care reform. As Sicko pointed out, the introduction of profit-making bodies between the patient and the doctor is the single feature that has resulted in the health care system in the US being so inferior to its peer countries.

Candidates should not be able to evade the issue by saying they support universal health-care. The question that should be asked is whether they support single-payer universal health care. Of all the presidential candidates in both parties, only Dennis Kucinich is calling for such a universal single-payer system, although many of the other Democratic candidates have signed onto the vague 'universal' health care part.

A petition has also been started by SPAN Ohio to gather signatures to put the legislation onto the statewide ballot. This petition contains the officially approved summary of what the legislation contains, as well as the full text of the bill. It is a parallel track strategy to the bills in the state legislature to get the same results.

I am collecting petition signatures so if anyone wants to sign it, or collect signatures as well, please contact me or SPAN Ohio. My petition form is limited to those who reside in Cuyahoga County.

The Cleveland branch of SPAN Ohio meets at 7:00pm on the first Monday of each month at the ACLU building, 4506 Chester Avenue. Other branch locations and meeting times can be found on their website.

POST SCRIPT: Handy guide to candidates

With so many people running for president, it is hard to compare their stands on the various issues. One enterprising website has done us all a favor by preparing a table that gives capsule summaries of their views. Of course, you will need to look elsewhere for more details and nuances.

July 24, 2007

CNN, Michael Moore, Sicko, and fact-checking as propaganda tool

(For previous posts on the topic of health care, see here.)

All Michael Moore's films deal with very serious topics in ways that are both informative and entertaining. His films have dealt with corporate greed, violence in society, the Iraq war, and now the health industry. Along with Robert Greenwald's Brave New Films, he provides a perspective and viewpoint that is almost completely absent from the mainstream media.

What is curious is the response to his films. People seem to find it hard to accept that his critiques are largely accurate and desperately seek to find something, however trivial or immaterial to his main point, that is wrong so that they can discredit his entire case. They seem to be eager to characterize Moore as not being a "serious" person.

The so-called "fact-checking" by CNN medical correspondent Sanjay Gupta, for example, has to be seen to be believed. He accused Moore of "fudging facts" but got his own facts wrong, and the only "expert" his report showed was an academic who did business with the medical industry, although this fact was not pointed out. Gupta accused Moore of cherry-picking data, when the same charge could be leveled at CNN, and the differences in any case were small and immaterial to the case Moore was making.

I am all for fact-checking statements made by public figures, and Moore should not be exempted. But the point is that while CNN enthusiastically "fact-checks" anti-establishment figures like Moore, they almost never do similar things for the statements by government and industry personnel. This is characteristic of the media propaganda model that was pointed out by Noam Chomsky and Edward Herman in the classic work Manufacturing Consent. Moore rightly chastised Blitzer for the fact that the mainstream media uncritically passed on all the outrageous statements by Iraq war advocates leading up to the 2003 invasion. They are doing a similar thing now with respect to Iran. Where is their vaunted "fact-checking" on those important issues? To find any serious fact-checking of statements by Bush or Cheney or any administration spokespersons, one needs to read blogs.

There is no question that big media outlets are completely beholden to the medical and drug industries because of the extensive advertising revenue they receive from them, and thus avoid taking a hard line against them. If Gupta or Blitzer did a really serious comparison of the US and (say) French health care systems and concluded that the French were better, the CNN top brass would get stern calls from the health-related industry and they would feel the heat. The point is not that Blitzer and Gupta are deliberately hiding the truth (though that might be the case), it is that the way the media filters operate is that only people who think like them, who are already sympathetic to the US health care industry and will bend over backwards to show them in a good light, will get to the position they currently occupy. So the fact that they effectively act as shills for the health industry should not come as a surprise. (See my previous post and here for more on how the media works.)

It seems that if you are well-dressed, articulate person from a so-called "respectable" institution like a think-tank or government or academia or the media (I am thinking of people like William Kristol, Charles Krauthammer, Mitt Romney, Alan Dershowitz, Rudy Giuliani, Joe Lieberman, and the innumerable loyal Bushies and Cheneyites), you can say the most outrageous, even borderline insane, things (such as advocate torture and indefinite detention without trial or access to lawyers, undermine the Bill or Rights, attack Iran, link Iraq to al Qaeda and 9/11, and not even rule out the use of nuclear weapons) without being challenged and fact-checked, as long as you are promoting the pro-establishment or pro-war or pro-business point of view. Running fact-checks on what these people say, especially George Bush during his public speeches and press conferences, would be very helpful but is rarely done.

But when it comes to Michael Moore, the mainstream media are eager to trot out their "fact-checking" teams to scrutinize him, because he is challenging the joint war/business establishment of which they are an integral part. The news media tends to assume that when Moore (a big fat guy in an open-neck shirt and unkempt hair stuffed under a baseball cap and looking like a trucker) comes ambling along, he must be simply shooting from the hip, as sloppy with the facts as he is with his appearance.

The reality is that Moore is a sharp guy who has a research team in place to back up the statements in his films. He is not a just-off-the-boat bumpkin that his cinematic persona projects and he knows that all the big establishment guns are just waiting for him to make a mistake so that they can pounce and use that single slip to discredit his whole thesis, a common tactic used by big corporations. It is not an accident that he can provide immediate refutations of Gupta's allegations. His research team has probably anticipated every possible challenge to his film and prepared a counter-offensive before even releasing the film. (CNN has now responded to Moore's charges against them.) See also Moore's website on the detailed documentation behind his film.

This is why CNN was reduced to desperately looking for something, anything, to support their contention that he "fudged the facts," and resorted to distortions when they couldn't find anything substantive. But people who condescend to Moore and take him lightly because he does not talk or look or act like a sophisticated intellectual are falling into a trap because they tend to underestimate him, and then are taken by surprise when he slaps them down with facts and reason, as Blitzer and Gupta experienced. When directly challenged, Gupta could not provide even a single example of how Moore "fudged the facts," and was reduced to whining about Moore using different sources for his data (even though all the sources used were authoritative) and how Moore described the health care systems of other nations as "free" when they were funded by taxes. This alone shows how far Gupta is stretching to try to discredit Moore. Does Gupta think we are so stupid that we believe that all the services we all commonly describe as "free" (libraries, parks, public schools etc.) magically appear as gifts from Santa Claus and are not funded by our taxes? The point is that "free" in those contexts is commonly understood as meaning that we can access those services at any time without having to produce cash or prove that we can pay.

And most importantly, in the other countries which have universal, single-payer health care systems, not a single person goes bankrupt or loses their home or has to forego other of life's essentials because of their health care needs. That is what "free" means, as Gupta must know but chooses to obfuscate.

In his report, Gupta also seemed to act like he had made a big journalistic scoop by 'discovering' that Cuba was at rank #39 (behind the US at rank #37) in the overall health care quality ranking. In fact, Moore's film clearly showed the two rankings. It was Gupta's CNN report that implied that Moore's film hid this fact by themselves hiding Cuba's on-screen ranking in the film behind a caption, as can be seen below where the left is from the film and the right is what was shown by CNN. This was a truly outrageous thing for a so-called journalist to do. So it was Gupta and CNN who were "fudging the facts."

sicko_facts_up_front_th.jpg cnn_covers_up_cuba_th.jpg

(Pam Martens points out that Gupta co-hosts a TV show called AccentHealth that is sponsored by drug companies likeMerck, whose products Gupta has been praising. And here is some background on Sanjay Gupta that suggests that he is a Deepak Chopra wannabe, using the same kind of medical-related, feel-good, pseudo-scientific mumbo-jumbo that seems to appeal to a lot of people.)

What I find odd is that even some people who share Moore's politics tend to try and distance themselves from him and treat him as a gadfly. One of the best analyses of the responses to Moore and his film was done by James Clay Fuller and it is well worth reading in its entirety. As Fuller says: "Apparently there is a rule in corporate journalism that every mention of Moore and his films, or Moore without his films, must contain at least two snide observations about his biases, his ever so naughty attacks on rich and powerful but somehow –- in the eyes of the corporate journalists -- defenseless people such as the chairman of General Motors, and, if you can slide it in, Moore's physical appearance." Another good analysis of the facts in Moore's film can be heard in this Fresh Air interview with Jonathan Oberlander.

You should really see Sicko if you have not already done so.

POST SCRIPT: Michael Moore with Stephen Colbert

It was a great interview. See the clip.

July 19, 2007

Oh, and about those wait times for medical treatment. . .

When all their other arguments about the advantages of the current US health care system compared to universal, single-payer systems in France, Canada, England, Germany, etc. are shown to be false, apologists for the US health care system turn to their trump card: alleging that wait times to see a doctor in those countries is longer than it is in the US. This statement by the lobbying group America's Health Insurance Plans is typical: "The American people do not support a government takeover of the entire health-care system because they know that means long waits for rationed care."

The problem with this type of allegation is that the US does not systematically collect data on wait times, whereas the other countries do collect the data and make them public. The assumption seems to be that in the US, if there is no data, then the wait times must be zero. No data, no problem!

But using the scant data that is available, BusinessWeek points out that except in a few selected, non-emergency situations, even this charge is false: "In reality, both data and anecdotes show that the American people are already waiting as long or longer than patients living with universal health-care systems."

As Paul Krugman points out in his New York Times July 16, 2007 column:

[B]y and large, opponents of universal health care paint a glowing portrait of the American system that bears as little resemblance to reality as the scare stories they tell about health care in France, Britain, and Canada.

The claim that the uninsured can get all the care they need in emergency rooms is just the beginning. Beyond that is the myth that Americans who are lucky enough to have insurance never face long waits for medical care.
. . .
[N]ot all medical delays are created equal. In Canada and Britain, delays are caused by doctors trying to devote limited medical resources to the most urgent cases. In the United States, they're often caused by insurance companies trying to save money.

This can lead to ordeals like the one recently described by Mark Kleiman, a professor at U.C.L.A., who nearly died of cancer because his insurer kept delaying approval for a necessary biopsy. ''It was only later,'' writes Mr. Kleiman on his blog, ''that I discovered why the insurance company was stalling; I had an option, which I didn't know I had, to avoid all the approvals by going to 'Tier II,' which would have meant higher co-payments.''

He adds, ''I don't know how many people my insurance company waited to death that year, but I'm certain the number wasn't zero.''

(You can read about Kleiman's plight here, which occurred despite having what he calls "fancy-dancy health insurance through my employer, which as it happens also owns one of the world's dozen best medical centers".)

And what about that favorite of US health care apologists, the waiting time for hip replacements? Krugman looked at that too:

On the other hand, it's true that Americans get hip replacements faster than Canadians. But there's a funny thing about that example, which is used constantly as an argument for the superiority of private health insurance over a government-run system: the large majority of hip replacements in the United States are paid for by, um, Medicare.

That's right: the hip-replacement gap is actually a comparison of two government health insurance systems. American Medicare has shorter waits than Canadian Medicare (yes, that's what they call their system) because it has more lavish funding -- end of story. The alleged virtues of private insurance have nothing to do with it.

Krugman's conclusion is right on target:

The bottom line is that the opponents of universal health care appear to have run out of honest arguments. All they have left are fantasies: horror fiction about health care in other countries, and fairy tales about health care here in America.


As usual, cartoonist Tom Tomorrow succinctly captures how the media is colluding with the administration in fanning the flames for war with Iran, exactly the way it did with Iraq.

July 17, 2007

Hidden costs of US health care

(For previous posts on the topic of health care, see here.)

In my previous posts following on the film Sicko (Haven't seen the film yet? It is well worth it.) I have been focusing on the tangible costs and benefits of the US health care system compared to those of other developed countries, and showing why the US system comes out badly in comparison. The chief culprit is the insertion of profit-making private health insurance companies between the patient and health care providers, creating an immediate trade-off between profit and providing care that is detrimental to the latter.

But there are several intangibles that are also important. The main one is that having one's health insurance tied to one's place of employment highly distorts the basis on which people make important life decisions. Right now, many people make decisions of what job to take and where to live based on the health care provided by employers. People with families and young children are especially caught in a bind. Some people spend their entire lives in dead-end jobs that they hate, trapped because of the fact that they cannot afford to leave and lose the health benefits. This is especially so if they or a member of their family has a health problem that becomes a non-covered 'pre-existing condition' in their new workplace, and thus denied coverage, at least for a limited time.

What is the cost of this? For one thing, it discourages entrepreneurs and freelancers. A person who wants to quit his or her job to start their own business or implement an innovative idea is strongly discouraged from doing so, especially if they have families. Not only is the cost of purchasing private insurance for themselves prohibitive, so is the cost for providing it for their employees. In 2004, the average cost of health insurance for family coverage was $9,950, which means that it is likely to be around $12,000 in 2007. This is close to the amount earned annually by a full-time minimum wage worker. How many business ideas have never seen the light of day, how many jobs never created, because potential innovators just could not bring themselves to risk the health of their families by leaving their jobs?

Health insurance tied to businesses also discourages the creative arts. Painters, writers, sculptors, poets, actors, dancers, and musicians are people who add enormously to the quality of life of a community. A community that has a vibrant arts community is one that is lively and healthy. Most artists do not go into it for the money (although they have dreams of their work becoming widely recognized someday) but because they really love what they do and are willing to suffer some hardship for it. They are willing to forego luxuries and live fairly Spartan lives with respect to housing, food, clothing and the like, just to have the opportunity to create art. Many are willing to take part-time jobs to cover life's essentials so that they have the time and freedom to devote to their passion. But the biggest single expense for such people is the cost of buying health insurance as private individuals. Many simply do not do so, gambling that they will not get very sick.

Then we have young people, straight out of high school or college who may want to experience a carefree life for at least a short time before settling down, and maybe travel around this vast country doing various jobs, seeing new things, meeting new people, and learning about the various communities they pass through. Maybe they want to work in underprivileged areas. Right now, the only way to safely do that is to do it through an organization that provides health insurance. If they go on their own, they have to buy expensive private health insurance or take the risk that they will not need health care. Even for the volunteer organizations that provide health insurance, providing it is a big headache and expense.

Then there is the problem of transitioning between jobs and between school and jobs. There are often gaps between the times when students leave college and start their first jobs. Because they have left school, they no longer are covered by their family or school health insurance policies. They have to shop around for some coverage for the transition period until they get their first job. People who have a gap when they move from one job to another can sometimes use COBRA coverage during the transition.

Even people who like their jobs and have health insurance plans to choose from (the so called 'lucky ones') face all kinds of irritations. The family may select an insurance plan and from it choose pediatricians for their children, an internist for the parents and a gynecologist for the mother, all within that one plan. The next year, they are likely to find that some of the physicians are now on different plans. So you have to repeat the process of comparing health care plans, weighing the costs and benefits, comparing physician lists, and trying to figure out who and what to keep and to jettison. This has to be done every year. And then you have to keep track of all the paperwork and receipts and co-payments. I think people have got so beaten down that they simply do not realize how much time goes into taking care of all these details. It is only when they get drawn into the bureaucratic nightmare that results when coverage is denied or some major illness strikes that they realize what a crazy system they are in.

Why have people in the US become so numb and accepting of this state of affairs? In surveying the responses to the film Sicko, James Clay Fuller makes a good point:

Not one mentions the comments by Tony Benn, a former member of Britain's Parliament. Yet Benn's statements probably are the most profound element of the film.

He notes, as other good people often do, that "if we have the money to kill (in war), we've got the money to help people."

But, more importantly, Benn tells Moore, that all of Europe and many other places have good health care systems while the United States lacks such a basic service because in Europe and elsewhere, "the politicians are afraid of the people" when the people get angry and demand some action. In the United States, he observes, "the people are afraid of those in power" because they fear losing their jobs, fear being cut off from health care or other services if they speak up and make demands.

"How do you control people?" Benn asks, and he answers: "Through fear and debt."

His point is that in the United States we have a great overabundance of both.

When are people going to get angry enough to say "We're mad as hell and we're not going to take it anymore"?

POST SCRIPT: The invertebrate Congress

On Bill Moyers' show, Conservative Bruce Fein argues why Bush should be impeached and criticizes a spineless Congress for not doing so, and John Nichols (author of the book The Genius of Impeachment) agrees.

Here is a transcript.

Another conservative Paul Craig Roberts (Assistant Secretary of the Treasury in the Reagan administration and former Associate Editor of the Wall Street Journal editorial page and Contributing Editor of National Review) has also called for the immediate impeachment of both Bush and Cheney.

The idea of impeachment was inserted into the US constitution as a vital check against the president assuming dictatorial powers akin to those of a king. It was almost tailor-made to deal with situations like that which currently exists. But the Democratic Party leadership seems unwilling to do this.

July 12, 2007

How universal single-payer systems protect us against catastrophes

(For previous posts on the topic of health care, see here.)

I think almost everyone across the political spectrum would concede the fact that the fifty million Americans currently without health insurance would definitely benefit from the adoption of a universal, government-run, single-payer health care system. The reason that it has not been adopted is that many of the remaining 250 million have been frightened into thinking that their medical coverage would decline from what they have now.

This feeling that "The present system works for me so why tinker with it?" is based on the assumption that our lives are stable and that things will continue just as they are into the foreseeable future. I am not so sanguine about this, perhaps because I am older and have repeatedly seen and experienced how the slings and arrows of outrageous fortune can strike anyone at any time and dramatically change lives. As a result I think it unwise to base our policy decisions on the rosy assumption that what is true for me now will continue to be true for me tomorrow. All it takes is a single catastrophe that causes the loss of our job, which could happen to any of us at any time, and all our comfortable assumptions about the future can end up in the trash can.

It is not uncommon for people who are incapacitated by an illness or an accident to themselves or someone in their family to lose their jobs and not be able to get another one with health benefits. As a result, such families are faced with stark choices: suffer or die for lack or treatment or have the family risk bankruptcy paying for it.

US News & World Report summarized the findings of a study that looked at a representative sample of bankruptcies across the country:

We have health insurance for several reasons, but one of the big ones is to protect us from high medical bills when we get sick. But insurance, it turns out, may not be the protection that many people think it is. Illness and medical bills are big reasons behind fully half of all personal bankruptcies, affecting about 700,000 households per year, according to a new study. And most of those households had insurance.
. . .
These were working- class or middle-class people, and 76 percent of them had health insurance when they first got sick. (Many lost this coverage because the insurance was through their jobs, so it disappeared when they couldn't work.) Half of the bankruptcies were caused, in part, by illness and medical debt. Their median debt was about $16,500, and the major part of that debt was payments to doctors and hospitals. Families initially tried to pay the debt for several months, says Elizabeth Warren, a bankruptcy expert at Harvard Law School. Sixty-one percent went without needed medical care to make payments, 30 percent had a utility shut off, and 22 percent cut back on their food.

If you simply ask around, you will find many examples of people who have been forced to make drastic decisions because of their health care situation. A couple I know moved to Mexico because they could not afford to pay for their health care here.

But even if people are willing to shut out from their minds the possible of such an unfortunate turn of events happening to them personally (and human beings are very skilled at avoiding thinking about such things), surely they would like to feel that their families and children and grandchildren and great-grandchildren will not have to suffer? The odds are very high that several people in each one of our extended families will face a health-related crisis in their lives that will threaten to send them into destitution. Even if we are blasé about ill health striking total strangers, surely we cannot be so complacent about our own descendents?

David U. Himmelstein, MD and Steffie Woolhandler, MD provide a detailed case (scroll down) for "Why the US Needs a Single-Payer Health System" outlining the toll the present system in the US takes on both patients and health care professionals, and the increasing monopolization of the system by a few giant corporations. They describe the huge amounts of paperwork that doctors in the US have to do because of the complicated and cumbersome health insurance system here. They have to employ a number of clerical staff simply to process the different paperwork with all the different insurance companies and then haggle with them over payment and treatment. In addition, the health insurance companies have to negotiate contracts with different companies in different states with different laws and regulations. As a result, "Blue Cross in Massachusetts employs more people to administer coverage for about 2.5 million New Englanders than are employed in all of Canada to administer single payer coverage for 27 million Canadians."

Perhaps we should start by providing single payer health care coverage to all children. Children are not responsible for their lot in society and should not be deprived of basic needs of food or shelter or clothing or education or health care.

There was a very sad story in the film Sicko. (Although I keep talking about the sad stories in it, I should emphasize that Sicko is also a very funny film.) It was about a little girl who was taken to a hospital emergency room with very high fever. They refused to provide treatment because she was not 'entitled' to be treated there, and insisted that she be transferred to a hospital across town, the place where she was 'supposed' to go to. She died during the time that she was transferred from one hospital emergency room to another.

To be denied treatment for purely bureaucratic reasons is unconscionable. It puts the health care professionals also in an impossible situation. If the emergency room physicians and nurses at the first hospital had realized that the child had a life-threatening condition, I am certain that their natural humanity would have taken over and they would have treated the child irrespective of whether she qualified or not. But if they had treated the child and it was something that could have waited, they might have been reprimanded for providing treatment to an 'unauthorized' patient. Why should health care professionals have to be put into making such kinds of bureaucratic decisions instead of doing what they are trained to do, which is simply treating the patient in front of them as best as they can?

As Martin Luther King, Jr. said, "Of all the forms of inequality, injustice in health care is the most shocking and inhumane."

POST SCRIPT: Where's Freud when you need him?

Comedian Craig Kilborn gets a laugh out of our ability to see sex symbolism everywhere .

July 10, 2007

Time for 'socialized' medicine in the US?

(For previous posts on Sicko and the merits of a government-run, universal, single payer health care system, see here and here.)

Michael Moore's excellent film Sicko has cinematically exposed the deep flaws of the US health system. His film scarcely touches on the awful plight of the 50 million people who have no insurance at all. That would have been bad enough but instead he sought to highlight the plight of those who do have health insurance and think they are secure, but discover to their horror that their insurance companies let them down in their moments of greatest need.

He emphasizes the fact that when you introduce profit-making entities in between the patient and the health care providers, you have guaranteed that attempts will be made to deny health care as much as possible. The insurance companies actually have employees whose task is to dig deep into your past to see if they can find anything, anything at all, that would enable them to invoke the fine print in their policies and deny coverage. Hence many people receive nasty shocks that they are not covered just as they are reeling from the discovery that they have a serious illness.

And this is why in the US you have a system in which the minority who are rich and powerful and influential have access to very good health care because they are in a position to create trouble for the insurance companies, while the vast majority are vulnerable to finding out that getting ill can mean ruin.

One of the curious things about the health care debate in the US is that the opponents of a government-run, single payer, universal health care system try to portray it as this mysterious, unknown, complicated, untried, massively bureaucratic, expensive system that one should not experiment with.

This is ridiculous. It is the system in the US that is mysterious, complicated, massively bureaucratic, and expensive. Government-run, universal, single payer systems are the norm in the developed world and in many countries of the third world. There are any number of working models that have been in existence for over half a century for which cost-benefit analyses exist and the operating structures are well known. It is the US, almost in isolation, that has a bizarre, labyrinthine, bureaucratic, and expensive system.

The basic concept of how single payer health care works is very easy to understand as this wonderful little animation illustrates. What is needed is to select the model that might adapt best to the US and modify it to meet our needs. The only difficulty to doing that would be to combat the vested interests of the health insurance and drug interests who will fight tooth and nail to keep making massive profits off the sickness of people.

Even magazines like BusinessWeek concede that the French system is superior to the US:

In fact, the French system is similar enough to the U.S. model that reforms based on France's experience might work in America. The French can choose their doctors and see any specialist they want. Doctors in France, many of whom are self- employed, are free to prescribe any care they deem medically necessary. "The French approach suggests it is possible to solve the problem of financing universal coverage...[without] reorganizing the entire system," says Victor G. Rodwin, professor of health policy and management at New York University.
. . .
France also demonstrates that you can deliver stellar results with this mix of public and private financing. In a recent World Health Organization health-care ranking, France came in first, while the U.S. scored 37th, slightly better than Cuba and one notch above Slovenia. France's infant death rate is 3.9 per 1,000 live births, compared with 7 in the U.S., and average life expectancy is 79.4 years, two years more than in the U.S. The country has far more hospital beds and doctors per capita than America, and far lower rates of death from diabetes and heart disease. The difference in deaths from respiratory disease, an often preventable form of mortality, is particularly striking: 31.2 per 100,000 people in France, vs. 61.5 per 100,000 in the U.S.

There will still be some bureaucracy because it will be needed to do all the paperwork to run the health care system. But the point is that this bureaucracy is invisible to the patients. As far as the patient is concerned, you go to the doctor and you get treated. That's it. You do not have to fill in any forms. The paperwork goes on behind the scenes between the government, the drug companies, hospitals, and the health professionals. Even for the doctors the paperwork is simplified because they are now dealing with just a single payer of their services and don't have to keep track of multiple health insurance companies, each of which has different rules for what they can and cannot do. This is why the entire health system in Canada has fewer workers (scroll down) to serve its population of 27 million than Blue Cross requires to service less than one-tenth that population in New England alone.

But while the surface debate is about policy, the deeper debate is about a fundamental difference in philosophy

At one extreme, there are those who take the view that it is up to each one of us to look after our own interests and feel perfectly comfortable ignoring the needs of others. Such people take the point of view that each person is responsible for their health care. The 'free market' should operate and people should shop around for what works for them. If they do not have the means to do so, then that is their own fault or their own tough luck. They have failed to provide for themselves and cannot expect the rest of society to look after them, except for what private charities might provide.

At the other end (which is where I am) are those who feel that when it comes to basic issues like health care, it is the responsibility of every one to look after everyone else. Decent health care is not a commodity like toothpaste to be bought and sold on the market. It is a fundamental right that everyone (especially children and the elderly) is entitled to, irrespective of their ability to pay, and should be seen as a collective social obligation. Most such systems are based on spreading risk over a large number of people and because of that principle, while there are options for people to buy supplemental insurance on the private market, there cannot be an opt out provision, just as there is no opt out for police or fire systems or trash collection or libraries or parks or all the other similar collective systems that we currently have in place.

Those who oppose single payer health care systems try to frighten people with all kinds of bogeymen. The extent to which they are willing to go sometimes reaches levels of downright lunacy. In the wake of the release of Sicko, some have even said, if you can believe it, that adopting a single payer system could result in more terrorism! There are no depths of fear-mongering to which they will not sink.

But the tried and true standby to try and frighten people is the charge that single payer systems equate to 'socialized medicine', as if that is an automatic disqualifier.

It is a tribute to the success of the propaganda model that simply the word 'socialism' strikes such fear in so many people in the US. But the fact is that the word is ill-defined in this context. There are some health care systems where the hospitals are actually run by the government, and the health care professionals are government employees. This is perhaps closest to what might be meant by 'socialized medicine' and is close to what England has with its National Health Service. Then there is the French system where things are a mix of public and private, and the government mainly acts as the sole entity financing the system, collecting money in the form of taxes and using that to pay for services.

If the scaremongers want to invoke the word 'socialized' so broadly as to mean the spreading of the risk across the whole population, then that is no strange concept to the US because then socialism is already rampant in the US.

Sometimes US 'socialism' occurs a highly distorted form, where the risks are spread around to everyone but the benefits accrue to a wealthy few. Consider for example the FDIC insurance that banks carry. Every person is underwriting that insurance through our taxes, but it benefits the banks and those who have money to deposit. The past US government bailouts of the auto and airline industries when they were in trouble are examples where the costs and risks are borne by all of us, but the benefits accrued to a select few. The savings and loan debacle of the 1980s was again an instance of the risks and costs being 'socialized' (i.e., spread over the entire population), irrespective of whether people had money in the savings and loans institutions or not.

The better form of 'socialized' services is where everyone pays for services and everyone also benefits, such as is currently the case in the US with 'socialized' fire departments, 'socialized' police departments, 'socialized' parks, 'socialized' libraries, 'socialized' trash collection, 'socialized' hurricane and weather forecasting, 'socialized' air traffic control, 'socialized' roads, the list goes on endlessly. All these function on the assumption that there are certain things which are a collective good, and that we all should contribute to their maintenance so that we benefit as needed. 'Socialized' medicine should be seen as a natural addition to such existing 'socialized' public services, not some strange alien concept.

No health system is perfect. There will always be people who suffer and die because of the lack of equipment or drugs or incompetence. But no one should suffer and die because of the lack of ability to pay or because of bureaucratic hurdles erected in their path in order that some people can make a profit.

In the next post in this series on Thursday, I will look at the "But I'm ok, aren't I?" attitude that opposes change in the health care system because the speaker thinks that he or she is secure now.

POST SCRIPT: Health care industry contributions to candidates

Michael Moore is helping us keep tabs on how the health care industry is contributing money to presidential candidates of both parties.

Of course, the industry is doing this purely out of a sense of public service and for the sake of supporting democracy, and not to bribe the candidates to make sure that a government run, single payer, health care system is never seriously considered, whoever happens to win.

July 06, 2007

Discussing health care seriously

In my discussions with people on serious and controversial topics, I have some simple rules of thumb to tell me tell whether the discussion is worth pursuing or whether the other person is not serious and talking further is a waste of time.

For example, when discussing evolution, as soon as someone says something along the lines of Mel Gibson's "If we descended from monkeys, then how come there are still monkeys? How come apes aren't people yet?" then you know that you are dealing with someone who is either being willfully dishonest or is so ignorant of the basic facts of the topic under discussion that it is not worth continuing unless one is willing to spend a lot of time to bring that person up to speed. The wrongful use of the second law of thermodynamics is another example of a warning sign.

A similar situation applies to global warming when, during a cold or snowy spell someone triumphantly suggests that this has conclusively proven that global warming is a myth.

In discussing politics, the signal is when one makes a criticism of some action of the US government (such as its decision to ignore habeas corpus, or to invade Iraq, or its numerous covert destabilization actions in other countries) and the other person replies "If you don't like it, then why don't you go to Russia/France/China/Cuba/Sweden/(fill in the blank for whatever other country the speaker does not like)?"

In all these cases, the signs are clear that there has been no attempt by the other person to really engage with the issue and he or she has resorted to what he or she thinks is a clever debating point but in actuality has little or no content behind it.

In the case of the debates over the merits of a universal, government run, single-payer health care system, the signal that someone is not serious is when he or she trots out the waiting times for hip replacements in Canada as an argument about how the Canadian system is so terrible in comparison to the US. In the wake of the release of Michael Moore's film Sicko, we can expect to see this being trotted out repeatedly, as indeed it already has.

As Kevin Drum pointed out a few months ago, the hip replacement argument is a sign of egregious cherry picking of data.

When comparing huge and complex systems like the health care or education systems in different nations, making point-to-point comparisons of isolated cases is of little use. No system is going to be better at every single thing, so this kind of debate results in each side selecting just those pieces of data to suit its purposes. There are probably some elective procedures for which there are longer waiting times in other countries than for those with high quality insurance plans in the US. It would not surprise me in the least if access to tests using expensive equipment like MRI machines is easier in the US (for those who have the requisite insurance coverage, of course) than it is for people in other countries. Health care in the US is aimed at servicing the well-to-do, because it is they who are the decision and policy-makers and as long as they are kept content, they are unlikely to want to make changes that reduce the profits of the health care industry, let alone eliminate them entirely, even if the changes benefit the general public.

One needs to look at aggregate measures to better compare quality and cost across nations. For example, the World Health Organization in 2000 put out The world health report 2000 - Health systems: improving performance in which it used the following measures for the comparison for health systems, using measures of both goodness and fairness:

  1. overall good health (e.g., low infant mortality rates and high disability-adjusted life expectancy);
  2. a fair distribution of good health (e.g., low infant mortality and long life expectancy evenly distributed across population groups);
  3. a high level of overall responsiveness;
  4. a fair distribution of responsiveness across population groups; and
  5. a fair distribution of financing health care (whether the burden of health risks is fairly distributed based on ability to pay, so that everyone is equally protected from the financial risks of illness)

Based on these criteria, according to the WHO study (p. 152), the US comes in at #37 in rank internationally, compared to France (#1), England (#18), Canada (#30), and Cuba (#39).

Michael Moore's Sicko (which you should really see) points out that on measures like life expectancy at birth and infant mortality rates (i.e., the number of infants who die before reaching the age of one year for each 1,000 births), the US lags behind its developed world counterparts, even though its spends far more on health care as a fraction of its GDP (13.6% in 1998) than its nearest competitor Germany (10.6%). Per capita spending is also highest is the US ($4,178) with the next highest being Switzerland ($2,794).

The reason the US gets so much less for the money it spends on health care is because of the vast amounts siphoned off to the insurance and drug companies, partly due to profits and partly due to a huge bureaucracy to handle the complex billing and processing process involved with private health insurance. Such costs account for between 19.3 and 24.1% of health care spending in the US compared with between 8.4 and 11.1% in (say) Canada.

 image001.pngThere is a strong (negative) correlation between infant mortality and life expectancy, as can be seen from this graph, where each dot represents the data for a country, along with a linear regression line. The implication is clear that the best way to improve life expectancy is to reduce infant mortality. The reason that many developing countries have high infant mortality rates and resulting low life expectancy is that lack of access to clean water results in diarrhea and this leads to dehydration, which is often fatal for infants. (As an aside, the international conglomerate Nestle deserves widespread condemnation for its policy of marketing infant formula in the developing countries, despite the lack of easy access to clean water to prevent infection. Breastfeeding is always preferred except in exceptional cases, but because of the Nestle marketing campaign became perceived as inferior to formula.)

But when comparing the US to the rest of the developed world, access to clean water is not the main issue, so widespread access to health care emerges as the prime suspect for its low ranking. For example, infant mortality rates for non-whites in US cities are two to three times as high as the national average.

What really irks many people in the US about Moore's film is perhaps not so much the adverse comparison with Canada, England and France. People who for some reason are enamored of the system here will complacently trot out once again hip replacement waiting times to claim a spurious superiority. It is the fact that among the 221 countries listed, Cuba's infant mortality rate (6.04, rank 40) and life expectancy rates (77, rank 56) are almost identical with the US infant mortality (6.37, rank 42) and life expectancy (78, rank 45) that really rankles.

The US government's implacable animosity to Cuba, trying to strangle its economy with boycotts and embargos and repeated attempts at destabilization and even assassination of its leaders, has to be one of the cruelest policies ever implemented towards a country that is not a threat to its security. And yet despite that deliberate attempt at destroying the Cuban economy, Cuba has managed to create a public health system that is a model for third world countries, and produces results in key indices that are comparable with the US. Cuba is legendary among third world countries in its generosity, sharing its medical personnel and expertise around the world.

Kevin Drum wonders if Moore's use of Cuba in his film was a clever public relations strategy, knowing that it would trigger the almost reflexive anti-Cuba venom that exists in certain quarters in the US and that they would make a huge fuss, thus giving him free publicity. "Moore's brilliance at getting his mortal enemies to do all his publicity for him is unparalleled."

Drum may be right. In the weird media world we live in, it is not enough for Moore to accurately portray the scandal that is the US health system compared to its peer countries. That information has been out there for a long time, and ignored by the power elites. He had to create a fuss and by going to Cuba, he did so.

POST SCRIPT: This Modern World

Cartoonist Tom Tomorrow sums up the predictable responses to Sicko by the apologists for the US health care industry.

July 02, 2007

Film review: Sicko

When I was just six years old, I became gravely ill with polio. Although Sri Lanka had first-rate doctors, they felt at that time that they did not have the specialized services to provide the kind of treatment that was best for me and recommended that, if at all possible, my family take me to England. We were not wealthy, just middle class, and did not have the kind of money that would enable my parents to afford this. But by an incredible stroke of luck, my father just happened to work for the Sri Lankan state bank that just happened to have a branch in England. It was the bank's practice to rotate their officers to that branch and my father was due to go in few years but because of the urgency of my illness, his bosses quickly arranged for him to be immediately transferred to the London branch. As a result we arrived in England and simply by virtue of the fact that we now lived there, I was able to get health care through the British National Health Service.

I remember many, many visits to doctors and tests, followed by major surgery that required weeks of recovery in a city hospital followed by months of convalescence and rehabilitation in a country hospital that was more like a country retreat than a hospital. The single-story wards opened out onto rolling fields and woods. The hospital was for people having extended stays and so we had teachers who came every day to help us keep up with our school work and we also had crafts and games and social events.

Six years later the process was repeated when I required a second major operation to consolidate the results of the first.

I remember my hospital experience as a very happy one, with kindly doctors and nurses, and a caring environment. It is because of all this treatment that I have been able to lead a normal and healthy life since then.

And all this treatment was completely free. No paperwork, no deductibles, no applying for reimbursement, none of the headaches and the sheer bureaucratic drudgery that awaits anyone who gets ill in the US. The only thing that my parents had to be concerned about was my health.

All these memories came flooding back to me when I went to see Michael Moore's excellent film Sicko last Saturday. In his bemused everyman persona, Moore visited Canada, Britain, France, and Cuba and talked to doctors and patients and other people about the treatment they receive. Their experience now seemed the same as what I had long ago: When you get sick, you go to the doctor and the hospital and they treat you as best as they can, according to their best medical judgment.

That's it. It is very simple, just as it should be.

Moore compared this with the nightmare that is the health care system in the US, where your ability to pay and the quality of your insurance coverage is the determining factor in your treatment. Anyone who has had even routine treatment knows the rigmarole that one has to go to check whether the doctor is on the plan, whether the visit or treatment or test or facility is covered, what the co-pay and deductibles are, followed by all the stuff that one gets in the mail that are sometimes invoices, sometimes bills, the many phone calls that have to be made to correct errors and find out information, the haggling with insurance companies over complicated details. The list goes on.

Why this difference? Simple. It is in the US that private profit-making agencies have been inserted between the patients and the health care system. In a revealing clip using the famous Nixon tapes, Moore reveals how this came about. In 1971, Edgar Kaiser (founder of Kaiser Permanente), through Nixon's aide John Ehrlichman, presents to President Nixon the idea of having a private profit-making health care industry. Ehrlichman explains the best part of this plan: "Edgar Kaiser is running his Permanente deal for profit. . . .All the incentives are toward less medical care. . . . the less care they give them, the more money they make. . . . the incentives run the right way."

To which Nixon replies, "Not bad."

Once that private profit element is introduced, the rest follows. It now becomes in the interests of the insurance companies to deny or reduce both coverage and treatment because there is a direct trade-off between profit and treatment. The more treatment the patient gets, the less profit the insurance companies make. And the film shows how doctors working for the insurance companies were rewarded by the amount of care they denied, even if patients died as a result. Some of those people who did these things as part of their job were haunted by what they had done to people in order to increase the profits of the insurance companies.

As I watched, it struck me that the two major surgeries that I received for free in England would very likely not have been allowed by the health insurance companies here because at that time they were considered somewhat experimental. As the film shows, the charge of being 'experimental' and 'condition caused by a pre-existing condition' are two of the many, many excuses used by the health insurance companies to deny paying for treatment.

The film also shows how politicians of both parties are bought and sold by the insurance companies, and how their shills in the media fight tooth and nail the idea of universal health care. These shills for the insurance and drug companies also laughably try to make the case that the people in countries like Canada and Britain and France are dissatisfied with their systems, when in actual fact those people think it is bizarre that we have to make our own arrangements to pay for health care, rather than having it taken care of by our taxes.

Of course those systems are not perfect and people do complain about some things. But when the Canadian Broadcasting System held a poll to select the greatest Canadian of all time, the winner was Tommy Douglas, the socialist politician identified as the originator of the state-financed health care system in that country.

Needless to say, this being a Michael Moore film and one that spotlights a huge business-political alliance, there is a vigorous counteroffensive to discredit it. But CNN did a fact check on Moore's assertions and concluded:

Our team investigated some of the claims put forth in his film. We found that his numbers were mostly right, but his arguments could use a little more context. As we dug deep to uncover the numbers, we found surprisingly few inaccuracies in the film.
. . .
Moore says that the U.S. spends more of its gross domestic product on health care than any other country.

Again, that's true. The United States spends more than 15 percent of its GDP on health care -- no other nation even comes close to that number. France spends about 11 percent, and Canadians spend 10 percent.

Like Moore, we also found that more money does not equal better care. Both the French and Canadian systems rank in the Top 10 of the world's best health-care systems, according to the World Health Organization. The United States comes in at No. 37. The rankings are based on general health of the population, access, patient satisfaction and how the care's paid for.

So, if Americans are paying so much and they're not getting as good or as much care, where is all the money going? "Overhead for most private health insurance plans range between 10 percent to 30 percent," says Deloitte health-care analyst Paul Keckley. Overhead includes profit and administrative costs.

"Compare that to Medicare, which only has an overhead rate of 1 percent. Medicare is an extremely efficient health-care delivery system," says Mark Meaney, a health-care ethicist for the National Institute for Patient Rights.

I was expecting be angry by what I saw in Sicko and that did happen. Since this was a Michael Moore film, I also expected to laugh and that also happened because there are scenes that are vintage Moorisms. What I had not expected was to be so touched and moved by the human stories. At heart, ordinary people tend to care for one another. The film recounts one story after another of people reaching out across politics and nationality and class boundaries, because illness touches everyone's sensibilities. Scenes like the Cuban firefighters who wanted to honor the 9/11 rescue workers.

The difference is that in the US people tend to think in terms of helping informally, those whom they might know personally, or through charities. In countries like Canada, Britain, France, and Cuba, they realize that this does not work for something as basic as health care. The health of the people is too big and too important to be in the hands of private profit-making companies or charities. The government has to do such things, just like it does the fire departments and police, and they support it through their taxes. There is the sense in those countries that there is a shared social obligation to provide health care for everyone.

The only people who benefit from the kind of system the US currently has are the shareholders and top executives of health insurance and drug companies, and those doctors who aspire to great wealth.

What the US needs is a government-run, single payer health care system.

See Sicko and you will better understand why.

POST SCRIPT: Michael Moore on TV

See the interview with Jay Leno.

You can also see Moore respond to some questions on Larry King's show.