A word about SCHIP

Andrew D. Coates, MD

The recent proposal, vetoed by President Bush, to expand the State Children's Health Insurance Program represents an important effort to defend working families with uninsured children from the grim cruelty of paying out of pocket for the care of a sick child, which can too easily lead to financial ruin for the entire family and impediments, at least, to medical care for the child.

In a recent discussion one person characterized SCHIP as a step toward universal health insurance. Another said that it was a move in the right direction that helps lay the groundwork for a publicly-financed single-payer national health program.

What does SCHIP offer people who are serious about health care reform?

Significantly the call to expand SCHIP offers us some claim to our own humanity as the crisis in American health care deepens, a yawning chasm before us.

Each of us must have wondered how much longer will we find ourselves putting coins and dollars into humble jars and coffee cans at diner counters, supermarket bake sales and church fundraisers to try to raise money for the treatments for an uninsured child with a malignancy. (Money for the broke parents of a child who never did anything to anyone and who, even from the most conservative, fundamentalist, neo-liberal or Malthusian viewpoint, could never be said to deserve his illness.)

Will we find ourselves among those parents, as we spend the quiet hour after putting our child to bed, racked by worries that she might need to see a doctor or a dentist -- but where can we find the money and the time off work? And what if the doctor said there are more tests are needed, or a specialist, or a hospital?

What kind of society do we live in that provides, so readily, such personal desperation and such collective horror when a child is sick?

The SCHIP program not only promises to address this appalling situation by reducing the number of uninsured children but should cost society relatively little since children in America are by and large healthy and require, compared to older people, fewer expensive treatments, hospitalizations and interventions. So (like the 84% in the NY Times poll earlier this year) we can all agree that SCHIP should be expanded to include ALL of the more than 9 million children in America who have had no health insurance.

But what can we ask of SCHIP?

Launched in 1998 SCHIP did help to reduce the number of uninsured children until 2004. (The program gives a block grant to states to fund programs to either augment Medicaid benefits to children or a establish a separate subsidized health insurance for children, or some combination of these two.)

However the number of children losing private employer-based coverage progressively outstripped enrollment in SCHIP. Since 2004 the number of uninsured children has not risen incrementally, but radically, by more than 1 million children, through 2006.

Yet the Democratic Party SCHIP expansion proposal, introduced by Congressman Rangel (HR 976), did not aim to cover all children. It hoped to provide funds to cover 3.2 to 4.2 million children by 2012 -- less than half of those children lacking health insurance now.

Thus as private health insurance fails and ever more children lose coverage under private plans, this SCHIP expansion (as proposed and even if enacted) would struggle mightily to meet the needs. So one step forward, one step back.

Even worse, with the costs of health care progressively skyrocketing, and SCHIP a capped grant given out state by state, funding for those children now covered by SCHIP has become a crisis in many states. More, its delivery would remain widely variable, depending on the state. More realistically then, one step forward, two steps back.

For these reasons the SCHIP expansion proposal should not be called a step toward universal health insurance.

Instead it should be championed as a measure to defend children and families from the vicissitudes of the American health care debacle -- cruelties unleashed because our system is dominated by private employer-based health insurance. We should explain that SCHIP, a laudable social reform that has protected many families from ruin, does nothing -- absolutely nothing -- about the cause of the burgeoning number of uninsured children.

Reforms that rely on private health insurance, including those that set up publicly-financed insurance alongside the existing system (as SCHIP does), will simply not work.

They will be brought down by the harsh realities of health care bought and sold as a modern corporate commodity: soaring costs at every level, widening disparities in access and outcomes, deteriorating quality, lack of choice of provider or clinic or hospital and private health insurance that doesn't provide health security and is increasingly not affordable, even for those who have it.

Proposals for health reform that avoid this fundamental issue may slow or may accelerate the inhumanities of our health care system, but they will not get us across the chasm.

We have all felt the inhumanity of the American health care abyss, a chasm split open under the wedge of corporate health care, led by private health insurance. Standing up for SCHIP is one way to stand up against the social cruelties of our health system.

By advocating in favor of SCHIP but explaining what it can and can't do as well as why it is needed, the effort can indeed help us lay the groundwork for the reform that offers a true step forward, - the proposal for a publicly-financed single-payer national health program like the House Bill HR 676.

The past record of private health insurance corporations has disqualified them from continuing as the central force managing American health care. If we lack mainstream politicians with the courage to say so -- we should also see with confidence that these politicians are out of step with the American people, who recognize that private insurance has got to go.

While the question of what reform is politically possible today from mainstream Democratic Party politicians is important, the question of what reform will actually work should be more important.

We need ideas for reform that have some evidence behind them. Like the SCHIP expansion proposal, we should support a reform not because it might be enacted today, but because it can truly help people.

Single-payer national health insurance offers a clear idea for evidence-based reform that is comprehensive, workable and just. Its time is now.

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Like the experimental frog

This excellent article is short on solutions yet offers a useful sketch of the consequences of "cost-shifting" for working people -- health care "creep" indeed. We hope everyone looks to Don McCanne's Quote of the Day for regular news and policy updates.


A quiet drain on workers' wallets
Creeping cost of health care siphons pay bit by bit.
Patrick Flanigan
Staff writer
Rochester Democrat and Chronicle (where web posts gravitate to a debate over single payer)
published November 4, 2007

Call it health-care creep.

Many American workers and their families see how their share of health-care costs continues to rise each year — but not at a pace so alarming that they point to it as a single cause of economic pain.

The headlines and the national debate over health care focus on the more than 40 million Americans with no health insurance. But, year after year, added to increasing costs for gasoline and food, health-care costs for consumers are an increasing part of the equation.

Like the experimental frog who doesn't respond to the rising temperature of the water around him, many workers with employer-subsidized insurance tacitly accept the incremental growth of their health-care expenses.

"It's one of those things that comes right out of your paycheck, so you don't pay a lot of attention to it throughout the year," said Brad Rye of Webster, who works for Eric Mowers and Associates advertising and public relations. "But we always look at it very closely (when it's time to re-enroll for health insurance). We want to know what our best options are."

According to a national human-resources company, employees' contribution to health insurance premiums have risen on average by $3.31 a week since 2001, when the average employee share was $659 a year.

That weekly increase works out to about the price of a small latte at Starbucks. But tell the same worker that his or her family's annual premium contribution jumped to $1,690 — more than $1,000 from where it was seven years ago — and it quickly starts to look like a hefty expense.

What's more, according to the study conducted by Hewitt Associates, employees' deductibles, co-payments, co-insurance payments and other out-of-pocket expenses are also rising.

Hewitt estimates that in 2008, the average employee will spend a total of $3,597 for health care — up from $1,320 in 2001.

That's an additional $2,277 a year, or $43.78 a week.

Spreading the burden

Employers have been asking their workers to take on a growing share of the company's health-care expenses for about 25 years, said Gerry Wedig, a health-care economist at the University of Rochester. "They're just trying to find ways to get these costs under control," Wedig said. "Employers are reluctant to actually reduce wages, so it's one way to keep compensation in line without raising a lot of objection from employees."

Health care is one of the fastest growing segments of the American economy, accounting for about $2 trillion in annual spending or 16 percent of the nation's gross domestic product. According to a report by the Kaiser Family Foundation, health-care spending will continue to rise and could account for almost 20 percent of the GDP by 2016.

"Health care spending has exceeded economic growth in every recent decade," the authors wrote. "The persistence of this trend suggests systematic differences between health care and other economic sectors."

Experts cite a number of reasons behind the meteoric growth. These include advances in technology that have turned once-terminal illnesses into chronic conditions treated with expensive medications or procedures; the aging U.S. population; and increases in such diseases as obesity-related diabetes.

Even healthy behavior can drive the cost of health care, said Dr. David Wandtke, the vice chairman of imaging science at Strong Memorial Hospital.

"People are living longer, healthier lives," he said. "They're going to require and demand more medical treatment."

Radiology exams like CT scans and MRIs are among the most expensive procedures in health care and insurance providers are asking doctors to be more judicious about ordering the tests. But Wandtke, who agrees the providers have a legitimate concern, said that's easier said than done.

He offered the example of a 60-year-old patient who injured her back while exercising. Years ago, her doctor might prescribe two weeks of rest and order an MRI if the pain hasn't gone away.

"Now she wants to get back on the treadmill as soon as possible," he said. "She doesn't want to spend two weeks on the couch."

Sandy Parker, president of the Rochester Business Alliance, said such trends leave employers little choice.

"If a company wants to reinvest in its own business, they're not going to be able to absorb these (health care) costs," she said. "It's just too much of a burden."

John Hayes, co-owner of GLC Business Services of Rochester, said his facilities-management company has contracted several different insurance providers in recent years to find the most cost-effective benefits package. Still, the company has cut its subsidy of single employees' health insurance to 70 percent from 75 percent.

"It's one cost we really don't have any control over," he said. "The benefit can't be bottomless. You want to be a good steward of labor, but you have to remain competitive."

Certainly, individual workers bear that burden differently.

Paul Failing of Irondequoit said he's noticed his health-care premium rise each year when it's time to re-enroll for his insurance policy. But the ESL Federal Credit Union employee said he hasn't paid much more attention to it than that.

"I recently traded in my Ford Expedition for a Honda CRV to adjust for higher fuel prices," he said. "I haven't had to do anything like that for health care. I'm blessed with good health."

Webster resident Robert Herloski, though, has found himself becoming an increasingly savvy consumer of health care because of a recent change in his insurance plan.

Herloski's employer, the Xerox Corp., offered a plan a few years ago that combines a high deductible with a pre-tax savings account — so he and his wife must pay all their health expenses until they reach that threshold.

He uses receipts from previous doctor's appointments to stock the account for the next year's health care expenses. But he's often stymied because the medical procedures are listed in a code and he can't easily figure out the actual cost.

"A lot of organizations are trying to control their costs and one of the ways they're doing that is to ask employees to be more cognizant of their expenses," Herloski said. "To be honest, I think it's good that more people are realizing what their medical costs really are."

Nancy Adams, executive director of the Monroe County Medical Society, said increased awareness of costs creates a double-edged sword.

"People should be more cost-conscious. One of the great disservices of the (health maintenance organization) system is it created the impression that health care costs $5 a visit," she said. But with the high deductible plans "unfortunately, some people are delaying care to lower their costs."

Adams cited a 2005 study by the Commonwealth Fund, a foundation working toward improved health care, that found about one-third of consumers in high-deductible plans said they delayed or avoided care. By comparison, 17 percent of consumers in comprehensive plans reported such delays.

"This has a lot of repercussions that concern us," she said.

For some workers, health-care benefits are as crucial as their pay.

Devery Reid-Holmes, a patient-care technician at Strong Memorial Hospital, doesn't pay any health-care premium under the contract she helped negotiate as an officer with the Service Employees International Union. So while her 3 percent raise adds just $16 week to her pay, she doesn't have to subtract any health-care expenses from that total.

"If I didn't have free health care, my paycheck would go to my car note, rent and health care," said Reid-Holmes, who is saving for a house. "We don't make a lot in wages, but at least we know we're guaranteed free health care for the next three years. That means a lot.

Controversial solutions

The rising cost of health care, with its subsidiary trends of high prescription-drug costs for the elderly, global competition with countries that provide socialized medicine, and a growing number of Americans living without health insurance, is driving a policy debate that's now decades old.

Leading presidential candidates have proposed health-care reform packages. And a bill to expand the number of children covered by the government-run health-care plan was recently vetoed by President Bush.

Wedig predicted health care will ultimately be rationed, with someone given the authority to determine when particular treatments are worth their cost to keep individual patients alive or well. Regardless of who's paying for it or how much it costs, consumers will always demand a product that keeps them alive.

"Everybody wants more time with their family members," he said.

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To Save Counties

Why a Single-payer Health Care System Would Be Good for Counties — Part One

by Paul Clay Sorum, MD
Professor of Medicine and Pediatrics
Albany Medical College, Albany, New York
and
Chair, New York Capital District Chapter of
Physicians for a National Health Program

published in NACA: The Journal of County Administration, October 2007

What can save counties from impending heath insurance-driven financial disaster? A single-payer health care system!

“The problem for counties is the soaring health care responsibilities and costs that already consume much of their budgets. County governments have a responsibility for the health of all their residents, especially for those at the margins. Many expend substantial taxpayer dollars on Medicaid, county hospitals, nursing homes, health departments, and other health costs. They provide health insurance for their current employees and retirees. All these costs are rising faster than people’s incomes and property values. County governments desperately need, therefore, a means of fulfilling their responsibilities without causing serious financial problems for county taxpayers.

The first step of a solution is to recognize the need to provide adequate health coverage to all residents of all counties. Almost all health reformers, interest groups, and politicians agree that everyone should have health insurance. If people do not have health insurance, they do not get preventive care, they do not get preventive care, they delay seeking treatment for illnesses, they use the emergency rooms more frequently than those with insurance, and counties end up paying in different ways for the unpaid and higher bills.(1) The cost of the health forgone because of uninsurance has been estimated at $65 to $130 billion.(2)

Not everyone is willing, however, to provide coverage sufficient for people’s health needs. The number of “underinsured” is rising as employers offer reduced coverage. The barebones basic packages envisioned by the Massachusetts reforms, the donut hole in Medicare part D, the high deductible policies increasingly offered to employees — all these leave millions of people underinsured, unable to pay all the co-payments on their medications, at risk of allowing their illnesses get worse, and of going bankrupt if they get seriously injured or sick. Consumer Reports reported that in May 2007 that ,“29 percent of people who had health insurance were ‘underinsured,’ with coverage so meager they often postponed medical care because of costs.”(3) Even the Reader’s Digest is alarmed: in its recent poll, “two-thirds of adults 21 and older said they feel they ‘can’t afford to be sick.’”(4)

The second step of a solution is to decide how to go about providing this adequate coverage. Reform plans fall into two categories, proposing either to utilize the private insurance companies — through tax credits or vouchers, individual mandates, employer mandates, and/or expansions of public programs for the poor — or to set up a “single-payer” system. In this issue, I will explain why private insurance companies cannot provide the solution and a single-payer system can. In the next issue, I will explain how a single-payer system would work and how it can be instituted.

Private insurers add enormous costs to our already skyrocketing medical expenditures. These include both insurers’ administrative costs — the salaries of their highly-paid executives and armies of employees, their marketing expenses, and (in the case of for-profit insurers) their profits — and the billing-related costs imposed on providers. In California, billing and insurance-related functions for insurers and providers represent 20-22 percent of privately insured spending in California acute care settings.(5) In the US, we spent in 2001 $351 per capita on administrative costs, while the Canadians spent only $54 and the French only $48.(6)

The health premiums charged by private insurers are soaring, owing in part to their administrative waste and profits. Premiums have increased 78 percent since 2001, while wages increased 19 percent and inflation was 17 percent. For employment-based insurance, they averaged $12,106 for a family of four in 2007 and $4,479 for a single person.(7) As a consequence, employers, especially small employers, are dropping health insurance benefits — 60 percent of companies offered them in 2007 versus 69 percent in 2000, and only 45 percent of companies with 3-9 employees in 2007 versus 57 percent in 2000 — and individuals have difficulty in paying on the open market for adequate insurance (especially since premiums are higher for non-employment-based insurance). Thus, in spite of the widespread conviction that people need health insurance, not only has the number of uninsured risen to nearly 47 million (15.8 percent of the population)(8), but the number who are inadequately insured is rising even faster.(9) So the counties’ health burdens are increasing. Even if counties self-insure for their own employees, they may buy health administrative services and pay for health care in markets inflated by the unneeded expenses of the private insurance companies that dominate these markets.

Private health insurers must, according to the logic of the free market, contribute to uninsurance and underinsurance. As long as health insurance is a market commodity, private insurers must promise prospective enrollees as much as possible, but also reduce costs as much as possible, i.e., must spend as little as possible of their premiums on actual health care. Even if individual medical directors and other employees are virtuous and well-meaning, they must avoid sick patients and deny care if their companies are to survive in the market.

Furthermore, private insurers cannot, unlike county governments, make the health of the population a top priority. They must, like other businesses, focus on short-term results, not on the long-term health of their enrollees (especially since these people are likely to change insurers and eventually switch to Medicare). In addition, in marketing their products to select groups, they fragment the population and undermine our already-fragile sense of social solidarity: they reinforce people’s short-sighted inclination to refuse to pay for those with more health needs, and fewer means, than themselves. They encourage healthy people to forget that they might one day suffer major illness and injury and that they, and the county as a whole, benefit if all county residents are as healthy as possible.

Private health insurers do not, therefore, provide the solution to the crisis in health expenses faced by county governments. But a public single-payer system, similar to but more inclusive than Medicare, is the solution with public financing but largely private delivery of health care.(10) All legal residents would have an insurance card entitling them to basic but comprehensive care, i.e., access to the health services that would provide significant benefit to them. The structure of the single-payer system will be discussed in the next issue. The counties would continue to play a role in delivering health care, through their clinics and hospitals, but would no longer be burdened with paying for this care.

Critics will argue, however, that a single-payer system, an expanded Medicare for All, would not be desirable. These criticisms are found not only in the distorted charges of political candidates, but also in the serious and reasoned arguments of single-payer opponents in scholarly articles and in public forums, such as in Albany, NY, the series of four forums on “The Pros and Cons of Medicare for All” sponsored by public radio WAMC in spring 2006.(11) It is necessary to address the three major criticisms.

First, opponents of a single-payer system assert that it would amount to “socialized medicine,” to “government-run medicine,” with health care decisions made by government bureaucrats rather than by physicians. This set of charges distorts the reality of what is proposed.

• Medicare for All is not socialized medicine. In socialized systems, the physicians and other providers are government employees; in Medicare for All, they would remain as they are now, mostly private practitioners, paid not by salary but by fee for service.

• Physicians and patients in countries with national health insurance have greater freedom of decision making than do physicians in the U.S.; in Medicare for All, medicine would be macro-managed; in current managed care, medicine is increasingly micro-managed, as insurance companies strive to reduce their own costs (and thereby increase the psychological as well as financial costs to patients and providers).

Second, opponents of a single-payer system point to Canada and the United Kingdom and charge that it will result in underfunding and waiting lists.

• In fact, single-payer systems do not necessarily result in waiting lists; they are not a problem in, for example, France and Japan.

• Even if they are a problem in Canada and the United Kingdom, the extreme cases are not typical (just as the cases in the U.S. documented in, for example, Michael Moore’s movie, SiCKO, are atypical); the waiting lists involve noncritical care; and lists are being reduced through government efforts to increase capacity, even as the number of Americans without health insurance increases.(12)

• Not only do those of us with health insurance often face delays to getting certain services, but those without insurance or money face uncalculated waiting times.

• Even if our own capacity is strained as health coverage becomes universal, the American public, the American voters (most of whom currently have insurance) will not put up with longer waiting lists and will insist on increasing our capacity.

Third, opponents charge that national health insurance will causes taxes to rise and will bankrupt the country by increasing health care expenses.

• What should interest individuals is not how much they pay for health care in income taxes, but how much they pay in all taxes—sales, property, payroll, and income—plus over-the-counter health expenses. The question is, therefore, what happens to overall costs.

• The only way to achieve universal access to comprehensive health care without increasing costs is to adopt a single-payer system. The reduction in administrative costs of insurers and providers and the elimination of marketing costs and insurance company profits would save far more money than would be spent on providing health coverage for the currently uninsured.

On the national level, Hadley and Holahan estimated in 2001 that the cost of the additional health services that would be used if the uninsured were provided insurance would be $33.9 to $68.7 billion.(13) Woolhandler, Campbell, and Himmelstein calculated in 1999 that reducing our administrative costs to those of Canada would have saved $209 billion.(14) In his critique, Henry Aaron argued for a lower figure, $159 billion, but still far more than the estimated additional costs.(15) On a state level, the Lewin Group has made estimates of the cost of various plans for universal coverage in numerous states from California to Mississippi; consistently, the single-payer plans save money, the others cost money.(16)

We must, however, be realistic. Even if having a single-payer health care system would seem beneficial to county governments and residents across America, what would it actually look like, and would it truly be possible to institute such a system? These are the questions to be addressed in the next issue.

Endnotes

(1) Ayanian JZ et al. Unmet health needs of uninsured adults in the United States. JAMA. 2000;284:2061-9. Institute of Medicine. A Shared Destiny: Community Effects of Uninsurance. Washington: National Academies Press, 2003. Ross JS, Bradley EH, Busch SH. Use of health care services by lower-income and higher-income uninsured adults. JAMA. 2006;295:2027-36. County-level estimates of uninsured in 2000 by the US Census Bureau, available at http://www.census.gov/hhes/www/sahie/statecntyest2000.html, accessed September 24, 2007.

(2) Miller W, Vigdor ER, Manning WG. Covering the uninsured: what is it worth? Health Aff. 2004.

(3) Are you really covered? Why 4 in 10 Americans can’t depend on their health insurance. Consumer Reports. August 2007. Available at http://www.consumerreports.org/cro/health-fitness/health-care/health-insurance-9-07/overview/0709_health_ov.htm, accessed September 24, 2007.

(4) Howley K. “I can’t afford to get sick”: Think your insurance has you covered? Just wait till you need it most. Reader’s Digest. April 2006: 57-70. Article and poll available at www.rd.com/healthcare, accessed September 24, 2007. A lower estimate of nearly 16 million people ages 19-64 underinsured in 2003 is given by the Commonwealth Fund: Schoen C, Doty MM, Collins SR, Holmgren Al. Insured but not protected: how many adults are underinsured? Health Aff. 2005;w5-289-302.

(5) Kahn JG, Kronick R, Kreger M, Gans DN. The cost of health insurance administration in California: estimates for insurers, physicians, and hospitals. Health Aff. 2005;24:1629-39.

(6) OECD Health Data. Accessed by David Himmelstein. [see also 1999 data referenced below published in the New England Journal of Medicine in 2003.]

(7) Kaiser Family Foundation. Employer Health Benefits 2007 Survey. Available at http://www.kff.org/insurance/7672/index.cfm, accessed September 24, 2007.

(8) US Census Bureau: http://www.census.gov/hhes/www/hlthins/hlthin06.html, accessed September 24, 2007.

(9) See the references in notes (3) and (4) above.

(10) The single-payer system most commonly proposed is described, with multiple links, on the website of the Physicians for a National Health Program: www.pnhp.org.

(11) Sorum PC. The pros and cons of “Medicare for All”: a series of public forums on health reform. Health Law Journal 2007;12: 24-37. Audio [of the forums] available at www.wamcarts.org (click on “Archives”).

(12) Canadian Institute on Health Affairs. Waiting for health care in Canada: What we know and what we do not know. 2006. Available at http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=AR_1385_E&cw_topic=1385, accessed September 25, 2006. Statistics Canada. Access to health care services in Canada, January to December 2005. Ottawa: Minister of Industry, 2006. Available at http://cansim2.statcan.ca/cgi-Hadley win/cnsmcgi.pgm?Lang=E&SP_Action=Result&SP_ID=2967&SP_TYP=2&SP_Sort=-0, accessed September 24, 2007.

(13) Hadley J, Holahan J. Covering the uninsured: how much would it cost? Health
Aff. 2003;W3:250-65.

(14) Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med. 2003;349:768-75.

(15) Aaron HJ. The costs of health care administration in the United States and Canada—questionable answers to a questionable question. N Engl J Med. 2003;349:801-3.

(16) Available at http://www.lewin.com/NewsEvents/Publications/. Look in the category “uninsured & safety net.” Accessed September 16, 2007.

[lead article in the same issue of NACA: The Journal of County Administration]

Medicare: Cost Effective Capitalism
Editorial by Bob McEvoy, Managing Editor

My cardiologist gladly accepts Medicare. He is an entrepreneur, a capitalist, and you the patient, select him. Medicare, a very low cost single payer system for those 65 and older, does not tell him that he can only see you for seven minutes, like high cost for-profit HMO’s and insurance companies have done. The results of their actions are best described by the shocking statement of the 14,000 members of the Physicians for a National Health Program. The doctors said: “For physicians, the gratification of healing gave way to anger and alienation in a system which treats sick people as commodities and doctors as investors’ tools. In private practice we waste countless hours on billing and bureaucracy. For the uninsured, we avoid procedures, consultations, and costly medications. In HMO’s, we walk a tightrope between thrift and penuriousness, under the surveillance of bureaucrats who prod us to abdicate allegiance to patients, and to avoid the sickest, who may be unprofitable.”

Our doctors and nurses are heroes and we have not heard them. I listened more closely when I was invited to join a scholarly group at the Albany Medical Center and met a Gandhi-like physician. This humble practicing physician and Professor of Medicine and Pediatrics is a well researched spokesman for providing Medicare for all, similar to what the other major industrialized nations have done. I learned that the only thing exceeding his knowledge—he holds Ph.D. and M.D. degrees—is his devotion to the sick and their healing. I am particularly honored that he is sharing his wisdom with us as you will experience.

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Extend Medicare to cover everyone

By Alan A. Pfeffer, Attorney–at-Law, and Richard Propp, MD
Capital District Alliance For Universal Care, Inc.

Who can be surprised that all three leading contenders for the Democratic presidential nominations have based their proposals for health reform on private insurance? This, after all, is what the insurance industry is paying them for.

Unfortunately these unwise proposals are so far off the mark as to be bizarre. But we believe there is good news insofar as an increasing number of citizens understand that fact.

Imagine if they were enacted as proposed. If you have insurance, stay with it, even if the premiums are increasing 8% a year, even if the actual direct and indirect overhead is 35%, even if U.S. industry is becoming progressively less competitive, good jobs are evaporating, road and bridge infrastructure are failing, and public education outcomes are falling behind the rest of the world.

If you don't have insurance, you MUST buy it from a private insurance company. If you have a family of 4 and you make $60,000, your expendable income is $48,000. Health insurance will cost $12,000. That leaves you with $3,000 per month for food, housing, automobile, maintenance, clothing, property taxes, utilities, savings, miscellaneous. You do the math.

If you can't afford it, we taxpayers will subsidize it and subsidize the PROFITS of the private insurance company. (Remember, in order to get $1 worth of healthcare, you must pay $1.35)

None of these plans discusses the delivery side of medical care, possessing major and critical faults in our present system that lead to over-utilization, unwise care, poor patient safety, and excessive deaths.

A recent example of Republican thinking on the question can be found in David Brooks' article on health care reform “The New Social Contract” (OP-ED NY Times September 7). It is filled with the false framing of the arch-conservative. Phrases like "Americans are different from Europeans" ring hollow when it comes to the necessity of healthcare. Does he really believe we are that much different from our British cousins? Reminiscent of the fallacious corporate philosophy of rejecting any improvement not invented here, this kind of thinking also appears increasingly bizarre to most Americans.

Instead of either the Republican model of doing health care reform based on individualism and private enterprise or the Democratic idea of rescuing the private health insurance industry, we would like to see health care reform based on a Judeo/Christian model of a caring community taking care of one another through a single large risk pool.

U.S. Medicare is a remarkable government success run through private physicians and mostly nonprofit hospitals. Do you hear older Americans complaining about their Medicare social insurance which has an overhead of 3%?

Most thoughtful people realize that our 35% overhead private insurance system is driving our country into economic suicide. Just ask General Motors about its healthcare costs. The role of private for profit insurance companies in health care needs to be eliminated or minimized.

We suggest extending Medicare gradually to people of ages below 65 in five year increments, similar to the proposed HR676 bill of John Conyers. At the same time the federal/state health care programs for children, SCHIP, should be expanded in both scope of coverage and the age of eligibility. When an individual reaches 45 the two programs meet and people switch from SCHIP to Medicare.

Our basic premise is that health care is not an insurable risk. It is not the same as car insurance. In the case of car insurance there is a statistical probability of an accident occurring that the car owner insures against. There is no comparable risk equation for health.

Everyone needs preventive health care and at some point we all get sick. We now know that many illnesses are genetically based. If you have the gene you are going to get the illness or at least a predisposition for it. Under the right circumstances the illness is almost certain to occur.

If you have certain illnesses like cancer, in the absence of portability, you either can't buy health insurance or the price will be exorbitant. Insurance companies are not in the business of providing health care to society but are really running an extensive gambling operation, betting on the odds of an event not occurring. Insurance companies spend an enormous amount of administrative effort and cost in denying claims and in cleverly underwriting sick people out of their plans.

Society should be providing preventive health care through non profit social insurance like Medicare to help people avoid getting sick. In a preventive model. for example, people with diabetes can get preventive care to avoid the loss of a limb or a kidney. Under current insurance models no such care is provided. So the insurance company doesn’t pay for a diabetic to get toenails properly trimmed, but insurance will pay after gangrene sets in to have the foot removed.

The idea of rejecting a single payer system simply because it is financed by government is utter nonsense. Polls should be taken to see how many senior citizens have complaints against Medicare versus complaints against private insurance companies. We believe there will be far less complaints against Medicare.

If someone wants to buy private insurance for uncovered special items, they can. It will not be illegal and may be needed as a "wrap-around" for items that SCHIP and Medicare do not cover.

As to the fear of how America pays for it, we are already paying twice as much as other industrialized countries on a per capita basis.

America needs to get its priorities in order. We need a national debate on what is really important: farm subsidies to pay for crops that are not grown, insurance company profits for stockholders, space exploration, bridges to nowhere, foolish wars, or paying for health care so everyone can have a fair chance at life.

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Single solution

[The chairman of the Tompkins County (NY) Legislature explains what single-payer national health insurance would save counties.]

Single Solution:
One universal health care system answers all the questions

By TIM JOSEPH
First published: Sunday, November 4, 2007 in the Times Union

Gov. Eliot Spitzer has formed a task force to examine how to achieve universal health care access in New York. There are two fundamentally different approaches that can be taken to solve the problem.

One is to build on the current patchwork of employer-provided insurance, Medicare, Medicaid, Child Health Plus, Family Health Plus, individual pay as you go, indigent care provided by emergency rooms, etc. This approach involves making the health care system more complicated by adding patches to cover people currently left out.

The other approach is to replace the current system with a single government-managed health insurance system, sometimes called ``single payer'' or ``Medicare for all.''

As an elected county leader, I find that a tremendous amount of my time, and my county's budget, is devoted to one or another aspect of health care for some segment of our citizens. Nearly all of that time is devoted not to delivering health care, but to sorting out who will pay for it.

A big advantage of a single-payer system, compared with our current patchwork, is that it resolves this issue once and for all, and thus offers substantial savings in administrative costs.

Every estimate I've seen of those savings overlooks the myriad hidden costs associated with our current system. Here are just a few of those costs I encounter every day:

My county, like every county in the state, has an Office for the Aging. We have a 10-person staff. The largest part of their work consists of helping seniors navigate the health care system, find programs available to help them, and plan how they will manage health care costs now and in the future.

Our personnel department includes a full-time benefits manager who is mostly occupied with assisting employees in dealing with the health insurance program. Those employees lose productive work time consulting with the benefits manager and fighting insurance company denials, which can take hours from the workday.

When we negotiate with our employee unions, health care is always the biggest topic. We have a health care consultant on retainer to help us examine and cost out plan changes that we present to our unions in an attempt to control costs. At least two-thirds of the staff time devoted to collective bargaining is spent on health care issues.

We devoted hundreds of hours of staff time to developing and publicizing a discount prescription card available to all county residents to reduce drug costs for those without insurance.

We have a $400,000 state grant to form a health insurance consortium among local governments to purchase employee health care as a larger group. We will hire a consultant to help us form that consortium and find a suitable plan. Various county staff devotes substantial time to this project.

We have staff in our mental health, public health and social services departments devoted to collecting fees from private insurers to reduce the public cost of programs that deliver various health services.

We have people waiting in jail whom judges are prepared to release to drug or alcohol treatment programs as soon as we can assure payment to the treatment center. Staff in local agencies and our Department of Social Services work on getting these inmates into health care programs, mainly Medicaid, that will cover treatment. Meanwhile, we pay the cost of incarceration.

Our economic development staff encounters aspiring entrepreneurs who would like to start their own businesses, but are tied to a job by the health insurance benefits. Meanwhile, new businesses often have trouble attracting the employees they need, because they cannot yet offer a health plan.

We have staff who don't like their jobs and perform at less than the desired level, but who remain because they need the health insurance.

Nurses and other health care professionals routinely leave direct service to take jobs in insurance companies, contributing to our severe shortage of nurses and physicians.

This is just a partial list of the many ways county government and local economies spend time and money dealing with the question of who will pay for health care.

None of these costs are ever included in comparisons between single-payer and other health care systems, but every one of them would go away if there was a single, simple and consistent answer to the question, ``Who will pay?''

Only a single-payer system will accomplish that.

Tim Joseph in chairman of the Tompkins County Legislature.

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