Minnesota Health Reform Caucus

There are currently 47,000,000 people living without health insurance in the United States of these, about 440,000 live in our state (440,000 is roughly the number of people living in Minneapolis and St. Cloud, combined).  How one chooses to interpret these numbers depends on their political beliefs.  Some believe that the high number of uninsured can be attributed to government interference with the health care industry.  They believe that the whole health care industry (and presumably our health) would benefit if the entire health care system acted more like a business.  Of course, this isn’t the first time these arguments have been used.  In 1970 we were introduced to HMO’s, the prescribed solution to our health care needs.  HMO’s were the free market solution.  A system derived to make doctors and hospitals more efficient.  30 years after the conception of HMO’s we are once again in a “health care crisis”.  The fact the HMO’s haven’t solved our problem is proof of their failure.  If you don’t believe it look at the numbers at the top.  We live in the strongest, richest and most democratic nation on this planet, and we cannot provide adequate care for one sixth of our citizens. 

Now, some people will tell you that the uninsured have no one to blame but themselves.  If they were just accountable and harder working they would be fine…  In fact the Minnesota Chamber of Commerce endorses this belief with their statement “Health care is a benefit employers offer to attract and retain good employees, not a requirement.”  Read that carefully,  “good employees”.   They don’t mention the 11,000,000 uninsured children.

            Being a “good employee” is something that should be valued in our society.  I, as well as the chamber of commerce, believe that personal accountability should be promoted.  However, if were going to believe that health insurance is entirely dependant on one’s work ethic, then we should ensure that our system reflects that belief.  So, the people who lack health insurance should guilty of something (in the words of the Chamber of Commerce, not a “good employee”) thus justifying their lack of insurance.  Their children are apparently guilty of being born into a less privileged family.  It’s unwise to settle for this type of rhetorical explanation to the “health care crisis”.  Luckily, the U.S. Census Bureau did a report in 2006 called Income, Poverty and Health Insurance in the United States.  The purpose of this report was to determine the economic condition, family size, age and racial background of these 47,000,000 people in question.  The report helps to debunk the conservative perception of the uninsured.

22,010,000 (about half of the uninsured) worked forty hours a week throughout the year.

10,000,000 (about one-fifth of the uninsured) claimed themselves as the head of household

-23,778,000 (about half of the uninsured) earned between $25,000 and $75,000 annually

-29,500,000 (more than half of the uninsured) were between the ages of 24-64

To me there seems to be something fundamentally wrong in these statistics.  The uninsured live above the poverty line but are not extremely rich.  Many work forty hours a week.  They are middle aged.  Many have families.  You see, in our country the extremely poor and the dependant are placed onto some type of state insurance program.  In Minnesota, it’s called Minnesota CARE.  So they do not make up a significant percentage of the uninsured.  On the other hand, the rich have little problem paying their premiums.  No, these 47,000,000 did not come from the extremely poor or the extremely rich. 

I know some of these uninsured people.  Many are struggling for their chance at the “American Dream”.  They work a full time job, they rarely call in sick and they don’t get fired.  These people are the “good employee’s” that the Chamber of Commerce would love to hire.  The sad part is these same people choose between diabetic testing strips or rent.  They let tooth infections become so severe that the Emergency Room cannot turn them back (which by the way, taxpayers pay for).  I am in school with a friend who is unable to afford health insurance, because he had a brain tumor, and he is too “high risk”.  Furthermore, I dare anyone to go to my friend and tell him that he somehow deserves not to be insured.  That if he just worked a little harder, he would no longer have to fear economic ruin from a medical emergency.  Tell them there is a legitimate reason their children cannot afford their prescriptions.  That them their situation is somehow a reflection of justice.  I wouldn’t dare say something that offensive, but the Chamber of Commerce would.  Remember? “Health care is a benefit employers offer to attract and retain good employees, not a requirement.”

Keep in mind that health care is a needed service in our society, therefore is cannot be a “benefit”.  Also keep in mind that the problem of the uninsured in this country is more complex than simple laziness.  Nearly half of the uninsured are currently employed full time, and the other fifth are their children.  That means that two-thirds of the uninsured in the country, probably cannot be blamed for the situation.  It’s time that we start objectively looking at the realities of the “health care crisis” and enact legislation that targets the root of the problem.  We should probably start with the massive Insurance and Pharmaceutical companies that made record profits of the premiums of hard working Americans.  We should at least stop exclusively blaming those without insurance.  To continue to do so is a display of ignorance.

By Chris Gray

Works Cited

Minnesota Chamber of Commerce

http://www.mnchamber.com/priorities/healthcare-regulations-2008.cfm

U.S. Census Bureau

www.censusbureau.biz/hhes/www/hlthins/hlthin05.html

Some thoughts about the irony of the health care debate…

By Chris Gray

The “health care crisis” is a topic that is currently being debated by politicians on all levels of government. While most agree that there is a problem with our health care system, there are many different opinions about the solution. A small group of Minnesota legislators are advocating the “single payer” or “single plan” system. The term “single payer” refers to a universal health care plan, where health care would be considered a civil right, not a privilege. Premiums would be taken directly out of taxes. Imagine “Medicare for all”, that’s the basic idea. Among the press and politicians this is portrayed as the radical solution to our problem. Likewise, the people who support “single payer” are perceived as radicals. The irony of this perception becomes apparent once you take a glance beyond the borders of this country.

There are many nations that we consider to have values and beliefs similar to our own. They are fundamentally similar to the United States. They hold democratic elections and support capitalism. They are the great democracies of Western Europe: England, France, Denmark, Norway, Sweden, Italy, Germany and Spain. Of these countries, all have adopted some form of universal health care. Other nations have followed suit. Australia, Canada and Japan have all adopted “single payer” health care. These nations constitute the bulk of what we consider the “free world”.

You see… We are the renegade country when it comes to health care. Our ideology about privatization in the field of health care is radically different than most of the free world. No other nation in the free world is seriously considering adopting our system. These countries are not debating the fundamentals of health care in their elections. These nations are not experiencing a “health care crisis”. The truth is, we stand alone in our views about health care. You could conclude that our resistance is a monument to our ingenuity, or our ignorance, depending on which side of the debate you’re on.

We should ask ourselves some fundamental questions.

Could we learn from the experiences of our ideological allies?

How can a change that aligns us with these countries, be considered a radical change?

How can the “single payer” politicians be considered radicals, when their beliefs are similar to the beliefs shared by the majority of the free world?

A change to “single payer” is not controversial. It’s not even groundbreaking. It simply requires adopting a system that has already been proven in the democracies of Western Europe. According to the CIA World Factbook, an infant born in these countries has a better chance of survival than an infant born in America. The life expectancy in these countries is higher than in the United States. So the claim that their system is failing, is ludicrous. Furthermore, according to the U.S Census Bureau, one in six American adults, and one in ten American children are uninsured, and these numbers increase each year. Every citizen in a nation that has adopted a “single payer” system has insurance. In those countries health care is considered a civil right, here we consider a visit to the doctor a privilege.

So, the next time you hear that “single payer” is too radical of a solution. Keep in mind that what we perceive as radical, other citizens of the free world perceive as ordinary. When you hear that such a change is too drastic and impossible to achieve, remember that many other nations have already accomplished that change, and I’d like to think that our nation, or state is capable of the same thing.

Works Cited:

CIA World Factbook: Rank Order- Infant Mortality Rateshttps://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.htmlCIA World Factbook: Rank Order- Life Expectancy at Birthhttps://www.cia.gov/library/publications/the-world-factbook/rankorder/2102rank.htmlIncome Poverty and Health Insurance in the United States; 2006, United States Census Bureuwww.census.gov/prod/2007pubs/p60-233.pdf

   On February 15, 2008, the US Government Accountability Office (GAO) released a report that throws more cold water on the claim that “disease management” will save money(Medicare Physician Payment: Care Coordination Programs Used in Demonstration Show Promise, but Wider Use of Payment Approach May Be Limited. GAO-08-65, February 15 http://www.gao.gov/cgi-bin/getrpt?GAO-08-65).

“Disease management” is a phrase popularized first by the drug industry in the early 1990s, and then by the insurance industry in the late 1990s. These industries use the term to make two false claims: 

(1) they have figured out how to reduce the severity of chronic illnesses like diabetes, asthma, heart disease, and depression; and

(2) the savings caused by the (allegedly) improved health of patients with these diseases are so large they exceed the cost of the services that led to the improved health.

“Disease management” (DM) is now part of virtually every health care “reform” proposal out there. Hillary Clinton, Barack Obama, and John McCain talk about it. DM is hailed by both of the Minnesota commissions (the Health Care Access Commission and the Transformation Task Force) that released reports early in February. As with most health policy fads promoted by the insurance industry, this one has no scientific support for it. Papers that have reviewed the scientific literature on DM conclude that, with few exceptions (DM of heart failure is one), DM does not save money and may well raise costs. The February 15 GAO report confirmed these literature reviews. But the scientific evidence hasn’t prevented the insurance industry from marketing DM programs to employers, and it hasn’t prevented policy-makers from hailing it as the next new, new thing to extract us from the health care mess.

In the year 2000, Congress passed a law requiring the Centers for Medicare and Medicaid Services (CMS) (the agency that oversees Medicare and Medicaid) to conduct several experiments to test the idea that “paying for performance” (P4P) would save money for Medicare. In other words, Congress wanted to know if paying doctors who scored well on report cards would improve health and lead to lower Medicare spending. The 2000 law also required the GAO to evaluate the experiments CMS set up. 

The first experiment CMS set up was a four-year ”demonstration” called the Physician Group Practice Demonstration which tested not only the P4P theory, but DM as well. It tested the hypothesis that if CMS paid doctors a bonus for following guidelines for the treatment of certain chronic diseases like diabetes, this incentive would cause patients to become so much healthier that Medicare’s costs for these patients would fall by at least 2 percent compared with a “control” group of Medicare patients to whom doctors gave their usual plain vanilla care (care without the DM components). CMS insisted on at least a 2-percent reduction because they believed any reduction smaller than 2 percent might not be real (it might just be due to random fluctuations that had nothing to do with the efforts of doctors to minimize the severity of chronic illness).

CMS selected ten clinics and clinic chains to participate in the PGP demonstration. Every one of the participating clinics and clinic ”systems” was huge. They all had at least 200 doctors in them (less than 1 percent of all US clinics are in systems with more than 150 doctors in them [p. 6 of the GAO report]).

The February 15 report of the GAO reported on the results of the first year of the Physician Group Practice demonstration. Here is what the GAO found:

    (1) Only two of the ten clinics or clinic chains reduced their Medicare costs by 2% or more.

    (2) This miserable performance is despite the fact that the change-in-growth-of-Medicare-expenditure figures the GAO reported are gross figures, not net figures. That is, the figures do not include the cost to the clinics of participating in the demonstration. (The GAO reported both start-up costs and year-one operating costs for all ten clinics and clinic chains. The average start-up cost was $489,000, and the average year-one operating cost was $1.3 million.) Nor do the change-in-growth figures reflect the cost to CMS of figuring out who should get bonuses. The GAO report suggests CMS spent a ton of money crunching numbers and auditing some of the clinics’ records in order to ascertain whether the DM programs saved money (see p. 29 of the the GAO report).

    (3) The GAO report states that it is very unlikely that physicians in smaller physician groups will be able to afford to pay for the people and hardware necessary to replicate the DM projects evaluated in this demonstration.

    In short, this report says

    * DM is not saving money,

    * start-up and operating costs are substantial and are not included in the “savings” estimates, and

    * most clinics won’t be able to afford to do what the ten clinics and clinic systems in this demonstration are doing. 

Kip Sullivan

Covering test strips for diabetics (Letter)

What do high premiums cover? (Letter)

I’ve posted a couple of letters I received about how our current health care system is really hurting Minnesota families. These letters put a fine point on why we must take serious steps to reform our health care system. Our little HMO experiment isn’t working! The verdict is in and letters like these are testimony to this fact.

The letter from a diabetic who describes how her HMO is forcing her to use a substandard test strips is a good example of how our broken HMO system limits our choices. This is especially ironic since the fear of losing our freedom of choice is a concern that is raised whenever a “single-administrator” system is proposed as a way to cut administrative waste and achieve universal health care. It’s actually the other way around. Universal coverage provided by private medical professionals and a single administrator will give us more choices, not less.

In the second letter my young constituent wonders why his parents have to argue with their insurance company to pay for essential medical services. He writes, “I’m confused, isn’t that why my parents pay health care premiums every month?”

I’m confused too, my friend. It’s not right. We legislators need to make it right.

Have you written to your state representative? They need to hear from you.

David Bly

Yet another poll demonstrates that a majority of Americans support universal coverage under a single-payer system. A poll conducted during the week of December 14-20, 2007 by the Associated Press and Yahoo found that 65 percent of Americans support extending Medicare to everyone, and that 54 percent are willing to identify themselves as single-payer supporters. 

Here are the questions asked by the AP-Yahoo poll:

“The United States should adopt a universal health insurance program in which everyone is covered under a program like Medicare that is run by the government and financed by taxpayers.”

“Do you consider yourself a supporter of a single-payer health care system, that is a national health plan financed by taxpayers in which all Americans would get their insurance from a single government plan, or not?”

Sixty-five percent answered yes to the first question, and 54 percent said yes to the second one. (Poll results available through link at: http://news.yahoo.com/page/election-2008-political-pulse-voter-worries. After you click on the link at this address, scroll down to page 15.)

A single-payer system and a Medicare-for-all system are synonymous. Why, then, was support higher for extending Medicare to all than for a system described as a “single-payer”? The answer, it seems obvious to me, is the level of familiarity people have with Medicare versus the concept of “single payer.” Medicare is a familiar program, while the phrase “single-payer” is not.

These data tell me that as people become more familiar with single-payer their support for it will rise. I believe the same applies to Medicare for all. As people become more familiar with what that means, and as more political leaders and other opinion-makers promote Medicare for all, support for Medicare for all will rise beyond the two-thirds level that exists today.

The 2007 AP-Yahoo poll confirms a 2003 ABC News Poll which asked a nearly identical question about universal coverage under Medicare. That poll reported that 62 percent of Americans supported extending Medicare to all in the fall of 2003. Statistically speaking, the results if the ABC News poll and the AP-Yahoo poll are identical (in other words, the 3 percent difference is within the margin of error). Between 2003 and 2007, the awful Medicare Part D drug program began (it began on January 1, 2006). Despite the justifiably bad publicity the Part D program has gotten, support for a Medicare-for-all system has not fallen. I’m not sure whether that means Americans have mixed feelings about the Part D program, or dislike it but don’t blame Medicare for it.

Kip Sullivan

On January 8, 2008, the Minneapolis Star Tribune published an op-ed I wrote criticizing report cards on doctors and other health care providers (”Report cards won’t improve health care”). I noted that both of the Minnesota health care commissions due to report in the next few weeks will recommend greatly expanding the use of medical report cards, and that such a recommendation is likely to harm some patients and do nothing to lower health care costs.  To illustrate why medical report cards can do little to solve the health care crisis, I compared them to the school report cards required by the No Child Left Behind (NCLB) Act. The NCLB report cards have not improved the quality of education for all kids, but they have driven up the cost of education and have caused some schools to rid themselves of their more troubled students.

In this post and the next several I will offer some additional arguments and evidence supporting my criticism medical report cards that I didn’t have room to offer in my op-ed.

In my op-ed I focused on a report card on the 150 or so doctors in New York who operate on patients with heart disease and the 36 hospitals where these procedures are performed. The quality measure in this report card is the rate at which patients die within 30 days of surgery. I focused on this report card because it is among the oldest medical report cards published in America, it is the most sophisticated and most studied medical report card in America, and yet it has recently been shown to harm sicker patients. If a report card as sophisticated, as highly regarded, and as expensive as the New York heart surgery report card is harming patients, then it is reasonable to conclude that the vast majority of all other report cards in use now or to be published in the future have the potential to harm patients.

Here is a quote from a highly regarded researcher on medical quality to the effect that the New York report card (published by the New York Department of Health) is widely regarded as the gold standard: “New York State’s measurement and publication of coronary artery bypass graft (CABG) surgery mortality rates has emerged as a model in the campaign for useful performance data…. The reality is that these measures of performance are … the best available, and that substantial improvements are not likely for some years.” (Stephen F. Jencks, “Clinical performance measurement — a hard sell,” Journal of the American Medical Association 2000;283:2015-2016, 2015, 2016).

Now here’s a quote from a study published in 2003 which found that the New York report card on coronary artery bypass grafts (CABGs) is harming sicker patients: “[O]ur results show that report cards [on heart surgeons] led to … marginal health benefits for healthy patients, and major adverse health consequences for sicker patients.” (p. 577). “[M]andatory reporting mechanisms inevitably give providers the incentive to decline to treat more difficult and complicated patients” (p. 581). “[M]ore severely ill … patients experienced dramatically worsened health outcomes.” (p. 583) “Report cards led to a decline in the illness severity of patients receiving CABG in New York … relative to patients in states without report cards” (p. 583). (David Dranove et al., “Is more information better? The effects of ‘report cards’ on health care providers,” Journal of Political Economy 2003;111:555-588, 583.)

Several other studies have reached the same conclusion: New York’s report card is causing heart surgeons to refuse to perform surgery on sicker patients because they believe the higher death rates of these patients will make them look bad on the evening news. (The New York TV stations lavish much attention on this report card.) Obviously, the New York Department of Health did not want this to happen. The Department in fact went to great pains to minimize the probability that doctors who performed surgery on sicker patients would be given low grades because of their sicker patients as opposed to their inferior skills. The Department sought to adjust the mortality rates of the doctors and hospitals being graded by collecting data on 72 factors outside of the surgeons’ and hospitals’ control that affect mortality rates. These factors include whether the surgery was done on an emergency basis or was scheduled in advance, whether the patient was in shock or had a normal pulse when surgery began, whether the patient was 80 years old or 50, the number of clogged coronary arteries and their degree of narrowing, the patient’s prior history of heart attacks, and on and on.

Collecting and crunching all these data is very expensive. New York’s Department of Health has five full-time employees working on this one report card, and each of the three dozen hospitals has to employ a full-time data coordinator just to funnel all the information on heart patients demanded by the report card publishers at the Department of Health. (Edward L. Hannan et al. “Public release of cardiac surgery outcomes data in New York: What do New York state cardiologists think of it?” American Heart Journal 1997;134:55-61).

Has the bad news about the New York heart surgery report card caused anything to change? Nope. The Department of Health continues to crank out the report card, and Pennsylvania and several other states have passed laws requiring agencies in their states to start publishing similar report cards. The fascination with report cards among policy-makers in the face of evidence indicating they are expensive and could be harming patients illustrates a serious problem with how health policy is established in this country.

Kip Sullivan

A favorite refrain of apologists for America’s sick health care system is that if we were so bold as to bypass the bloated insurance industry in favor of a Medicare-for-all system rationing would become common place. The alleged “evidence” for this claim is that Canada’s single-payer system causes rationing. The never articulated corollary is that rationing just doesn’t happen in the US.

But when we ignore the silly assumption that rationing doesn’t occur in the US and ask, Is rationing worse in the US than Canada, the answer turns out to be a resounding yes. The research indicates rationing is on the order of 25 to 50 percent worse in the US than in Canada.

I’m aware of three studies that have used scientific methods to compare rationing in the US with rationing in Canada. The method used in all three studies was to ask Americans and Canadians if they did not get health care services they believed they needed in the previous year.  I invite readers to post any other study they can find that has been published in a peer-reviewed journal that uses a similar or better methodology.

 Here are short descriptions of the three studies.

A 1995 survey reported that rationing was 50 percent worse in the US. The survey determined that 12 percent of Americans and 8 percent of Canadians reported they were unable to get “needed medical care” in the previous year (Karen Donelan et al., “All payer, single payer, managed care, no payer: Patients’ perspectives in three nations,” Health Affairs 1996;15(2):254-265).

A 1998 survey reported that rationing was 40 percent worse in the US than Canada. Fourteen percent of Americans versus 10 percent of Canadians said “there was a time in the past 12 months when they needed medical care but did not get it” (Karen Donelan et al., “The cost of health system change: Public discontent in five nations,” Health Affairs 1999:18:206-216).

A survey conducted during 2002-2003 jointly by Statistics Canada and the US National Center for Health Statistics reported data indicating rationing was 27 percent worse in the US. This survey indicated that 13.7 percent of Americans and 10.7 percent of Canadians reported having “unmet health care needs” in the previous year. When other investigators adjusted these results to reflect differences between the US and Canadian respondents in age, gender, race, income and immigration status, they found that rationing was 27 percent worse in the US (Karen E. Lasser et al., “Access to care, health status, and health disparities in the United States and Canada: Results of a cross-national, population-based survey,” American Journal of Public Health 2006;96:1300-1307).

I’m aware of a fourth study that asked about rationing due to cost only. This study reported that rationing was four times worse in the US than in Canada.

It is important to remember that single-payer advocates are not calling for a reduction in US spending levels to the Canadian level (which is about 40% below the US level on a per capita basis). So rationing under an American single-payer system will not only be a lot less than under the current American system, but a lot less than under the current Canadian system.

Kip Sullivan

Henry Aaron of the Brookings Institute is not my favorite health policy expert. His solution to rising health care costs is rationing. Nevertheless, his latest article in Health Affairs is well worth reading. It makes the point that health care inflation is going to be reduced somehow in the next quarter-century, and the only question is whether it will be done sensibly or irrationally.

Aaron’s article (”Budget crisis, entitlement crisis, health care financing problem — which is it?” Health Affairs 2007;26:1622-1633) begins with the observation that annual inflation in US health care spending has exceeded annual growth in income by 2.7 percent for the last four decades. Then Aaron presents some data on what will happen over the next several decades if the gap between health care inflation and income growth persists at the 2.5 percent level. I offer here two of Aaron’s conclusions.

 First, Aaron predicts total health care spending will exceed 20% of Gross Domestic Product by 2016, and 30% by 2033 (by comparison we were at about 7% in 1970). Second, he predicts that the amount of after-tax money Americans will have to spend on non-health goods and services will grow by only 1% between now and 2019, and then flatten out between 2020 and 2045, and then decline.

Aaron predicts that the great pressure health care spending will place on all other types of spending  (education, transportation, military spending, recreation, etc.) will lead to immense political pressure to cut back on health care spending. I don’t subscribe to the notion implied by some observers that there is some magic limit to the amount of national income that can be devoted to health care. But I do agree with Aaron that as health care spending impinges ever more seriously on all non-health spending, the political pressure to do something will grow.

As has been the case for the last four decades (which is approximately when the modern health care reform debate began), we have two basic choices. We can reduce health care inflation by cutting the waste in the system (the administrative waste generated by the insurance industry, the over-purchasing of capital equipment by hospitals and clinics, the overcharging by specialists and drug companies, and fraud), or by rationing. If we want to solve the problem by cutting out waste, we need to implement a single-payer system. If we prefer rationing, then we should continue on our current course — we should leave the insurance-industry middleman in control of our health care system. There is no escaping having to make this choice.

 Kip Sullivan

Interested in learning more about single-payer, universal health care?  Here’s a great Newsweek Article by Jane Bryant Quinn:

Yes, We Can All Be Insured

Affordable, Quality, Comprehensive Universal Health Care Without the Waste and Interference of the Middleman.We are a group of Minnesota legislators and health care advocates working to build grassroots support for progressive health care reform.

We believe a single-payer system provides the best opportunity to cut costs and improve quality. We plan to identify and take steps toward such a system.