Geography & healthcare

Consumer Reports has published an article on the Dartmouth Atlas of Health Care - a wonderful thing. Consumer Reports is really on a tear about healthcare, and this article provides our friends and neighbors information about a big part of what's wrong with U.S. healthcare.

Because physicians are paid on a fee-for-procedure, cost-plus basis, the incentives are to do more procedures, rather than just the right procedures. Physicians and nurses are generally ethical people, but they're just human. Add the need to pay for that MRI machine to the old lady's son insisting on "Do whatever's necessary, doc," and you end up with unnecessarily aggressive treatments - something proven out by the crazy regional differences on how many procedures patients are getting some places - without better outcomes.

Geography and health care
The amount of medical care that people get for serious illnesses varies enormously from place to place. In the last two years of life, the average patient spent 11 days in the hospital in Bend, Ore., and 35 days in Manhattan. In those same two years, patients visited the doctor an average of 34 times in Ogden, Utah, and 109 times in Los Angeles.

The Dartmouth Atlas based those findings on the Medicare claims records of millions of patients who died from (in order of prevalence) congestive heart failure, chronic pulmonary (lung) disease, cancer, dementia, coronary artery disease, chronic kidney failure, peripheral vascular (circulatory) disease, diabetes with organ damage, and severe chronic liver disease. Together those ailments account for about 90 percent of deaths of people older than 65.

Over the years, Dartmouth research has yielded some startling insights:

• The local supply of doctors and hospitals has more influence on the amount and type of care that patients receive than their actual medical conditions have. The more medical resources a region has, the more aggressive the treatments are.
• In the regions that deliver the most care, patients have a slightly higher death rate than patients with the same conditions treated in areas that treat less aggressively.
• Patients treated most aggressively are no more satisfied with their care.
• The cost differences are vast. Average Medicare spending over the last two years of life for all hospitals ranged from a high of $81,143 in Manhattan to a low of $29,116 in Dubuque, Iowa.

So the Dartmouth folks are big on best practices, as are other medical systems that keep down healthcare costs - and simultaneously maintain good access. (Note in the Consumer Reports' articles that "Patients in the high-spending, aggressive-care regions waited longer in emergency rooms and doctors' offices than patients in lower-spending regions did.")

Linda Gorman, from the libertarian Independence Institute and a commissioner on Colorado's Blue Ribbon Commission for Health Care Reform, was always vehemently against "best practices." She argued that the science was too soft, that it was subjective, that by God if a patient wants bad care then it's their right to get it - or something along those lines.

These are folks who also consider the science behind global warming to be a bunch of hooey. I don't know whether they also think the moon landing was a hoax.

Part of progress - and survival - comes from measuring cause and effects and paying attention to the answers. Dartmouth has come up with some pretty good answers here - information that's important whether we get a healthcare system or remain stuck with laissez-faire, for-profit healthcare. If we had a healthcare system, we could move more quickly and surely with this information towards more efficient and humane standards. Until that day, we'll muddle through and probably get partway there. Or not.

Coloradoan single-payer - again!

Fort Collins' is the real deal. The progressive community likes to say that while other progressive places in Colorado (no names...) do a lot of talking, the progressives in Fort Collins actually get things done.

I gotta admit, I see proof of it on a daily basis. Here's yet another single-payer column in The Coloradoan, their paper -- this one by G. Richard Dunn. He writes:

The potential national savings has been confirmed recently at our own state level; the Colorado 208 Health Care Commission report is complete and confirms there could be a major savings in health-care costs for Coloradans. The stated charge to the commission was to make a recommendation of health care for all Coloradans and to reduce health-care costs. The good news is that one of the recommendations does exactly that! The bad news is several politicians have already responded that while it might save our residents money, we need to carefully study the issue because it might raise taxes.

The commission retained an independent cost expert and the expert confirmed that 100 percent of Coloradans, including the 800,000 presently uninsured, could be covered and still enjoy an annual savings of $1.4 billion. The commission has forwarded its findings to the Legislature.

If the Legislature and the governor will read carefully, they will find there was a great deal of public and professional support across the state during the hearings for the "Colorado Health Services Plan (single payer)."

True. The 208 Commission held hearings across the state, and they heard again and again from single-payer supporters. Some of the commissioners -- and Colorado pols -- thought that Health Care for All Colorado must have sabotaged the hearings, filling them with our members.

In fact, we'd never heard of most of the people who showed up. There's a groundswell of support for single-payer, not just in Colorado but across the country.

I'd say it's past time for the insurance industry to bring out their big guns, and start running ads on how horrible health care is outside the U.S. They seem to be counting on the Democratic politicians to bring about mandates for people to buy their crappy product. They may be reassessing that now that it's failed in California.

Rally at the Capitol, Thursday!

Come to the Thursday Rally!

Where's the single-payer coverage?

The Rocky Mountain News' media critic, Jasan Salzman, has a good question in his column today. He asks why reporters aren't asking Colorado politicians, in particular Governor Bill Ritter, about Health Care for All Colorado's single-payer plan for Colorado health care. Salzman writes that both the News and the Denver Post "have reported that Gov. Bill Ritter is worried about the expense of his goal of providing health care to all Coloradans, regardless of which plan is chosen.

"Reporters should challenge this notion by noting that the governor's own Blue Ribbon Commission for Health Care Reform states that a single-payer system would actually reduce total state health-care expenditures by $2 billion. But it would require, according to the commission's report, an 8 percent income tax increase. Our political leaders should be asked whether the real issue is cost or political will."

Governor Ritter answered that question when I posed it to him at the Faith in Action Conference last weekend. Answered it to my satisfaction, in fact. He said that he was in favor of universal health care, but that it shouldn't come to a vote until it can win.

In some ways, we're at the same stage in this issue as we were back in the 1960s with cigarettes. Lots of educating needs to take place.

But for that education to take place, the reporters do need to pay attention, and ask the questions.

Rally at the Capitol, 31 January

HCAC questions report

The Northern Colorado Business Report ran this article on the 208 Commission, which is meeting today to go over their final report to the Colorado Legislature:

DENVER -- A group of health-care professionals who offered one of four proposals selected for review by the Colorado Blue Ribbon Commission for Health Care Reform released a statement Jan. 7 that said it has "deep concerns" about the draft recommendations that appear headed to the state Legislature later this month.

Board members of the Health Care for All Colorado Coalition, which submitted the Colorado Health Services Program proposal to the commission -- sometimes called the 208 Commission -- said the recommendations that are making their way to the Legislature on Jan. 31 won't cover all Coloradans or cut the administrative costs continually increasing health-care premiums.

Board member Michele Swenson said the 208 Commission recommendations fail to address the rising cost of health insurance premiums and would provide taxpayer subsidies to private insurance companies by requiring the purchase of a "minimum-benefit plan."

"They're moving people into minimum-benefit plans and they don't protect families adequately against health and financial risk," Swenson said. "The bottom line is, do we want to increase the bottom line of the insurance industry or increase health-care coverage for all?"

The Health Care for All Colorado proposal was the only single-payer proposal that automatically covered everyone in the state. A financial analysis showed the plan could save about $1.4 billion annually in state health-care spending but would also be the most expensive to implement, costing about $15 billion in new spending to set up.

208 Commission analysis at PNHP

HCAC board member Michele Swenson has an analysis of what's missing from the 208 Commission's final report at the Physicians for a National Health Program website. Michele writes:

The 208 Commission Recommendations fail to address:

• Rising cost of health insurance premiums (82% increase in 6 years in Colorado), as well as copays, deductibles and prescriptions
  
• The U.S. fragmented commercial health insurance system that siphons more than 20 percent of health care dollars to profits, exorbitant CEO salaries, etc. and duplicative layers of administrative waste.
  
• A greater than doubling of median family income spent on health insurance: 7.7% in 1987 to 19% in 2005
  
• As premium costs continue to increase, coverage has decreased: “Insurance does not equal health care.”

This is an excellent analysis, really recommended for Colorado bloggers and journalists who want to understand the issue.

208 Commission's Fifth Proposal

Colorado’s 208 Commission met Thursday to hear from a harried John Shiels of The Lewin Group on the results of the modeling of their own, fifth proposal for comprehensive healthcare reform in Colorado.

Their proposal is a mosaic of plans designed to shore up the leaks in covering Coloradans. Admirably, the plan attempts to offer “single-payer” to those of us who do not believe in the private insurance market and would like to buy into something like Medicare.

It would be similar to programs that allow you to buy “green” energy, in a way — with this rather large difference. You would be at the mercy of politicians wanting to gut it for ideological reasons, and you would not have the protection that British or Canadian citizens have. There, when they vote for a politican or party that promises to “cut the fat” from public expenditures, voters know they may be personally hurt when it's healthcare on the chopping block. That’s the reason behind keeping Social Security for the wealthy. When a program benefits everyone, it’s more bullet-proof.

A single-payer program only for those of us crazy enough to pay for green energy (we are mostly the same people, aren’t we?) is pretty vulnerable to attack.
Witness the slimmed down benefits that the fifth proposal gives people wanting to buy into Medicaid for all — the rational being that if you made the benefits too rich, everyone would want in. But isn’t that the point?

Shiels also presented a couple of charts showing how little the single-payer portion of the fifth proposal saves in comparison with the Colorado Health Services Plan. Because, Shiels pointed out, the benefits from single-payer come because it is, in fact, a single-payer. If it’s just one more payer, that doesn’t really help much.

The fifth proposal as it now stands would cost $1.4 billion more, according to the Denver Post. Health Care for All Colorado's single-payer plan, the Colorado Health Services Plan, would save $1.4 billion.

The commissioners decided to call the plans by numbers, instead of their crazy appellations, i.e., Healthy Colorado, Better Health for Colorado, Healthy Solutions for Colorado….

The commissioners also heard the final reports from the four advisory task forces: rural, vulnerable populations, providers, and business.

Kelly Esselman of the Mountain States Employers Council in Denver said that the business people in her task force had not really understood single-payer, and that once they found out more they were supportive of paying 4 percent or 6 percent payroll tax to cover their employees. However, they thought it would be better done at a national level than state level.

We can live with that!

BJ Scott, president of Peak Vista Community Health Centers in Colorado Springs, gave a less inspiring report from the providers task force. I’d heard that the providers were overwhelmingly positive towards single-payer. Their analysis of the various proposals seems to show that. It was difficult to say what the providers thought from the overview. I guess it was realism, the providers telling the commissioners what they’d like to see within the bounds of what is feasible.

Or not.

Scott emphasized that the group was concerned about the ongoing process of reform going in one direction. They didn’t want reform "to end up in Michigan when they thought they were going to Texas." So they wanted to see the action steps, and to see a strong plan for reform.

That’s feasible but single-payer isn’t?

She said that providers said it’s not so much how much they get paid, but rather how they get paid, with the implication being that providers are sick of fighting private insurance companies.

Commissioner Linda Gorman, from the Independence Institute, evidently picked up on troubling communitarian attitudes from the providers — what sounded like generalities to me evidently sounded alarming to her. She said that the task force’s report indicates a lot of agreement on things “I know are highly contentious.”

Gorman wanted to know just how much disagreement there had been on those broadly held do-good notions.

Complete consensus, said Scott.

A doctor in the audience who had served on the task force spoke up to agree — and also to say that while the proposals focused on financing, the providers were concerned about the delivery mechanisms. If the infrastructure of care isn’t fundamentally reorganized, he asked, how will you flatten the negative trends now occurring?

Commissioner Arnold Salazar said that the rural task force had only finished their report a couple minutes earlier, and that it would be emailed to commissioners soon. Basically he said that the rural folks were uneasy with workforce issues. They don’t like employer mandates, and the employer mandates’ possible effect on already fragile rural economies. He also noted that many rural areas have access to urban amenities, but truly frontier areas are isolated.

They had a lot of discussion around the need to have access to care if there are mandates. The safety net in many rural communities is the primary source of health care. Public health systems are also very important. Salazar also said that it’s difficult to establish providers in rural areas over the long term. “The moment they’re done with loan repayment they move back to urban areas,” he said.

The rural folks agreed that there needed to be more focus on oral health, behavioral health, and substance abuse.

Colorado’s laws against “co-location,” where different kinds of providers aren’t allowed to practice out of the same facility, don’t necessarily make sense in rural areas. Salazar also said that telemedicine isn’t the answer. First of all, it’s not a substitute for care, but also the infrastructure is in cities and not available in rural areas.

In rural Colorado, public health systems are very important.

The rural task force also felt leery of geographic ratings, which they felt could negatively impact rural communities.

The task force evidently advised using public health systems and protecting the work they’re able to do.

Sounds like single-payer to me.

The vulnerable populations task force issued the most complete report, pages of information that I’m going to give short shrift to here. Hope to do better tomorrow...

Arthur Powers of Thrive, a support group for people living with HIV and AIDS, spoke about their group’s work.

Rocky Mntn News reports: single-payer the one

This is a nice change: The Rocky Mountain News has published an article fairly positive about single-payer. In "Panel: Only 1 health plan would cut costs: Single-payer cited but 5th proposal still being studied," reporter David Montero writes that,

A proposal to put health care in the hands of the government is the only one of five being studied that would save money, a group working on reforming health care in Colorado told lawmakers Wednesday.

That plan, known as the single- payer system, would cut about $1.4 billion of costs from the current $30.1 billion being spent in Colorado on health care.

And of the original four plans - one submitted by insurance underwriters, one by the public employees union, another by health care providers and the single-payer - only the last was shown to cover all of Colorado's legal residents.

Montero doesn't have it quite right — the plan wouldn't put healthcare in the hands of the government, it would put healthcare financing into a non-profit single pool administered by a governing board — but he did get it right that the single-payer plan is the only one that would save money. He also reported that State Sen. Ken Gordon "said single-payer was the best plan that offered the state savings as well as broader coverage for everyone."

Kaiser disinformation about Colorado proposals

Kaiser's "daily reports" gives absolute misinformation, the opposite of the truth, on the Colorado health care reform proposals. If they weren't expert on this, I'd say it was a misunderstanding. But these guys know what they're doing. This therefore seems malicious.

They write, "The most expensive option would be the government-run single-payer plan, which would cost an estimated $26.6 billion annually."

That's in contrast with the $30 billion we now pay for health care in Colorado.

I wrote Kaiser:

Your daily report is inaccurate. Read the Lewin Group's report on the Colorado reform proposals. The single-payer option is the least expensive, not the most, as you state. One proposal would cost $595 million more; one $1.3 billion more; one $271 million more; and the single-payer program SAVES $1.4 billion.

SAVES! That's the opposite of what you wrote. Please correct this immediately.

This is from the Lewin report:

The Lewin Group Technical Assessment of Four Health Care Reform Proposals (Proof Report)
August 20, 2007 Prepared for: The Colorado Blue Ribbon Commission for Health Care Reform
BETTER HEALTH CARE FOR COLORADO - Provides care through a public program expansion and access to private insurance coverage with low-income subsidies through a Health Insurance Exchange. Individuals who purchase private coverage would have access to a limited core set of benefits, with premiums copays.
467,200 - number remaining uninsured $595 million - increase in health spending

SOLUTIONS FOR A HEALTHY COLORADO - Provides coverage to Colorado residents under a Core Limited Benefit Plan in the private sector and expands coverage under Medicaid and Child Health Plus (CHP+). Low-income people who are not be eligible for the government programs would receive a premium subsidy.
133,400 - number remaining uninsured $271 million - increase in health spending

A PLAN FOR COVERING COLORADO - Provides coverage to Coloradans through a public program expansion and a mandatory private pool for all residents not eligible for the public program. It provides a minimum benefits package in a private pool and premium assistance based on income for those who cannot afford insurance. All plans would provide a comprehensive minimum benefits package, and differ mainly on cost-sharing amounts.
106,500 - number remaining uninsured $1.3 billion - increase in health spending

COLORADO HEALTH SERVICES SINGLE PAYER PROGRAM - A single payer plan that would provide coverage to all residents of the state, including state and local workers, and residents currently covered under Medicare, Tricare, Veteran’s Health, Indian Health Services and Federal Health Benefits programs. Provides comprehensive health care benefits for all - benefits of the Colorado Medicaid benefits package plus
preventive dental. Consumers would have their choice of providers and hospitals within the state.
0 - number remaining uninsured $1.4 billion - decrease in health spending

How is that the most expensive program?

Write them too.

The Science of Change

How do people change?

After a rough day yesterday, I was ready to say that they don't.

Former Governor Dick Lamm autographed his latest book for me, writing that single-payer advocates should keep up the good work: "History is on your side," he wrote.

I wasn't sure at all yesterday that was true. I'd just met with a progressive Denver group about a vigil to be held on 28 September for the victims of our health care system: 18,000 a year, 50 a day — including my brother. The spokesperson for the group wasn't as interested when I said that no, Michael Moore wouldn't be at the vigil.

Beyond that, the group's leader said they'd be happy with any reform proposal for Colorado that comes out of the 208 Commission — or actually, they'd be supportive of any progressive proposal.

I said there was only one progressive proposal that the commission was considering: the single-payer proposal from Health Care for All Colorado.

The person shrugged and said the group has members supporting all of the proposals. No doubt true — all but the underwriters' proposal, anyway.

SEIU has a proposal that has very meager benefits with a $35,000 cap — meaning that if you're in an accident forget staying out of bankruptcy. It would leave 465,000 uninsured of Colorado's 780,000 currently uninsured, at an additional cost of about $600 million. On the plus side, they don't have mandates to buy shoddy products from for-profit companies.

A group of safety-net providers has a proposal that would have both individual and business mandates to buy inadequate insurance, further enriching insurance companies, adding to the numbers of underinsured, and expanding the safety net. It would add $1.3 billion to the current total state health spending of $30 billion, with about 100,000 still uninsured.

The underwriters have a proposal that would have individual mandates to buy insurance, but no business mandates. A $50,000 cap. It would leave about 133,000 uninsured, and cost another $271 million.

Health Care for All Colorado's single-payer proposal would SAVE $1.4 billion — lowering that total health bill in the state. It would cover everyone. Three-quarters of Colorado's households would pay less for health coverage than they do now. Colorado businesses that currently insure their employees would pay less than they do now. The benefit package is a rich one.

So which is the progressive proposal? Which is the sustainable proposal?

When I heard this group would not be backing the single-payer proposal and wouldn't co-sponsor the vigil, I couldn't stop my eyes from crying. Damn eyes.

It doesn't hurt when conservatives spread their misinformation. Today's paper had a conservative columnist saying that the great challenges of the Republican party will be to maintain troops in Iraq and keep private health insurance. Eh.

What hurts is that the people who should be behind single-payer have convinced themselves that they're smarter than that — that there has to be an interim step between injustice and justice. What would that have looked like with ending slavery? With the Civil Rights Movement? And when they say that change is impossible, it makes it impossible. We won't get to single-payer until progressive groups embrace it. We'll never convince the social Darwinists and libertarians. But these folks should be with us.

It was therefore a relief to read Susan Rosenthal's The Science of Change: How it Happens and How it Doesn't. She lays out a strategy of hope. The three parts of change are:

Social support. People need support from others to overcome feelings of powerlessness, to create strategies for change and to act on them. In the context of supportive relationships, we learn that we are neither crazy nor powerless. By pulling together, we give each other hope and strength....
Presenting problems as solvable. To change their behavior, people need to see themselves and the world differently, in ways that make change seem possible....
Michael Moore’s film, "Sicko," has made a huge impact, not only because it reveals the horrors of the American medical system, but because it shows them to be neither necessary nor inevitable.
Repetition. When the level of struggle is high, people seem to change overnight in a kind of explosive chain reaction. At all other times, the dominant ideas are those that maintain the status quo. Changing those ideas requires patient and repeated encouragement. It’s like boiling water.
You put the kettle on the stove and turn up the heat, but nothing seems to happen. Do you remove the kettle in disgust at the failure of heat to boil water? Of course not!

Forcing people to buy inadequate insurance from the industry that has created our healthcare crisis is taking the kettle off the fire. It's not progressive. It's capitulation. It's not what's "feasible." It's a dead end.

Jim Spencer reappears!

The Denver Post's fine columnist Jim Spencer was given the boot earlier this year — a matter of rationing liberal views, evidently.

We all missed him — and so I was pleased to see his byline on this column: "In the Matter of Health Care Versus Baloney" at Colorado Confidential, Colorado's preeminent progressive blog.

Spencer, as always, did his homework responding to the Rocky Mountain News's scurrilous attack on Health Care for All Colorado's proposal to the Blue Ribbon Commission for Health Care Reform. The title of that RMN piece? "Single-payer Baloney."

They got just about everything wrong. No. They got everything wrong.

Unlike the Rocky, which didn't evidently do any research, no quotes, no references, and they certainly didn't get in touch with us or the Colorado Nurses, Jim quoted Donna Smith:

But on the business side, the U.S. system “doesn’t even make economic sense,” said Donna Smith of Aurora, whose family health problems forced her and her husband to declare bankruptcy. “Single payer would lower the burden on American businesses.”

Smith and her husband, Larry, appear in Michael Moore’s documentary “SICKO,” which lambastes the U.S. health care model. Smith testified before Congress in July about the inability of many Americans to afford health care. She just started a group called American Patients for Universal Health Care.

If you’re worried that Smith isn’t objective because she has a dog in this fight, then check with Colorado’s own financial consultant on health care reform. The Lewin Group has issued a preliminary finding that cumulatively, a single payer health system will save Colorado money on health care.

The Rocky did print Fran Ricker's and my rebuttal on Saturday — which was good of them, since it's a combined circulation that day of both Rocky subscribers and Denver Post subscribers.

208 Commission writes their own proposal

Michele Swenson, a Health Care for All Colorado board member, shared these notes on the July 23 meeting of Colorado's Blue Ribbon Commission for Health Care Reform, also known as the 208 Commission. The 24 commissioners, now 27 with three additional commissioners appointed by Colorado's new governor, were charged with soliciting reform proposals, getting independent financial analysis on the top four or five proposals, and then presenting their findings to the Colorado Legislature. The commission decided early on to create their own proposal, and to only submit one reform plan to the Legislature. The Lewin Group, the independent analyst, came back mid-July with number crunching that showed the single-payer plan to be by far the plan that would cover the most people (everyone), with better coverage than virtually any of us now has, for a savings of $1.6 billion. Commissioners weren't impressed. They're still looking to create their own plan, keeping the health insurance industry at the heart of financing health care. Michele took these notes at the commission's proposal committee's first meeting.

Key Questions considered for creating a 5th proposal

•Individual mandate;
•Role of employers;
•Role of government;
•Expansion/reform of Medicaid/CHP+;
•Portability;
•Government subsidies for those on a minimum benefit;
•Minimal benefits

Much of the discussion centered on individual mandate. Commissioner Arnold Salazar said the only question for him was whether an individual mandate would cut costs and increase coverage; otherwise, he would oppose it.

Commissioner Linda Gorman said that Massachusetts has just backed away from an individual mandate, which someone noted would prompt "public pushback." Gorman said that Lewin is not equipped to model individual mandate, which requires data on insurance take-up. It was noted that the mandate for motorists coverage is not working. She also said individuals are responsible to pay for their own health care; that health care is not a right, and providers do not have to provide care for all.

Commissioner Steve Erkenbrack questioned whether an individual mandate is enforceable.

Commissioner David Downs, MD, cited a RAND Corp. study demonstrating that take-up is not good, even with subsidies. He noted that Massachusetts has no defined care for which to provide access, and that their $380/month cost for coverage per individual is too high. Dr. Downs noted the high cost of fragmentation. He cited a government role of assuring adequate infrastructure - information technology, for instance. He said he thought that the Colorado Coalition for the Medically Underserved proposal [not one of the proposals modeled] had a default sign-up similar to a single payer option.

Commissioner Allen Jensen said that the Commission has not looked at the broad spectrum. He cited Medicaid and regulatory reform as two big costs. He said with or without individual mandate, uninsurance rates remain the same.

Commissioner Barbara Yondorf said that her idea of "voluntary single payer (a 2-track plan) would not work without an individual mandate. She suggested asking Lewin to model this both ways. She said that "single payer has a lot of problems." She expressed the desire of some to "fix Medicaid/CHP first."

Commissioner Mark Simon asked for a discussion of the responsibilities of insurers and providers.

Commissioner Don Kortz asked if immigrants would be covered. Commission Chair Bill Lindsay said that is a subject for later committee discussion.

Rocky presents to the 208 Commission

Bill Lindsay, chair of the Blue Ribbon Commission for Health Care Reform, couldn’t believe it.

The independent analysts had just informed the commission that Health Care for All Colorado’s single-payer reform proposal, which would bring universal health care to Colorado via a model similar to that found in other industrialized countries, would actually save money.

“Everyone in Colorado will have increased coverage — and we’re going to save $1.6 billion.” Lindsay said. “It surprises me that we’ll be able to do that.”

Those following comparative studies on health care systems would not have been surprised.

“The single-payer systems always do best,” says Dr. Elinor Christiansen, the past president of Health Care for All Colorado, a non-profit group advocating for single-payer, universal health care. “Why do you think other developed countries can care for all their people at half the cost we do — with equal or better outcomes? They use the cost efficiencies of a single risk pool, better prevention, and best practices.”

The Lewin Group, an independent firm offering actuarial analysis of four Colorado reform proposals, presented their findings to the Blue Ribbon Commission (also known as the 208 Commission) Tuesday. They work out complicated mathematical models — sometimes accurate to within a dollar of reality — that give insight into how much each of the four Colorado proposals will cost and how much good they’ll really do. It’s one thing for a reform proposal to say that doctors will continue to be well compensated and quite another to actually specify how much they’ll be paid; one thing to say that coverage will be expanded and another to say by how much. The Lewin Group’s analysts insist on detail in order to offer their educated guesses on what reforms will do.

John Shiels, a senior analyst with the group, told the skeptical commissioners that Lewin had always found savings when they modeled single-payer systems.

The four lead authors of the various proposals being modeled also had a chance to present to the commission.

Luckily, Dr. Rocky White from Alamosa, author of Health Care for All Colorado’s single-payer proposal, hadn’t been present when Lindsay had explained what the authors should discuss.

Lindsay had opened the day-long meeting by saying that the authors would talk about what modeling criteria had been problematic for them, and how they had arrived at their proposals’ assumptions. That’s pretty dry stuff compared to what Rocky offered.
The lanky 6’4” rancher physician told the commission that he’d been raised in an evangelical, Republican family in Nebraska, and carried those values with him when he moved to Alamosa to practice medicine and raise his family.

In 1986 he was one of 24 physicians to join together in a medical practice in Colorado’s rural San Luis Valley. “Only one of those 24 physicians was a Democrat,” Rocky told the commission. “We believed in the free market system.”

But they were paddling upstream with medical economics, in particular rural medical economics. “Fall of 2004, we went broke,” Rocky says. “We were working our butts off, seeing more patients than we could handle, and we still went broke.”

Part of the reason for that is because 23 percent of the San Luis Valley’s population is on Medicaid. Another 28 percent is on Medicare. Rocky’s practice loses 30 cents on the dollar with Medicaid. They break even with Medicare.

Worse, the uninsured population in the San Luis Valley is at 28 percent. “Everything that’s screwed up and wrong with our healthcare system is magnified there,” he says. “I began to study earnestly. Why were there so many uninsured? Why were we going broke? Believe me, the last thing I wanted to do was decide single-payer was the answer. But until we take away the profit motive from the financing of healthcare, we cannot fix our system.”

Rocky notes that he’s not a natural enemy of health insurance. He was, in fact, the medical director of an insurance company for four years.

But he also sees the system from the point of view of a provider, from the point of view of his patients, and from the point of view as a business owner. “I’ve seen all four sides,” he says. “I’ve seen people die because they delay their healthcare because they couldn’t get insurance. If we’re going to do this, we should do it right.”

A couple years ago, the Cortez area state legislator, Mark Larson, called Rocky and asked him to write a single-payer bill that Larson could take to the legislature — just to begin a dialogue. Rocky wrote a bill, and after Larson saw it he phoned Rocky. “Are you nuts?” he asked.

Larson didn’t want to introduce the bill after all, but he did want to establish a Colorado commission to study reform. Deanna Hanna and Anne McGihon also worked to pass that bill, Senate Bill 208 — thus the 208 Commission. “Instead of a commission to study single-payer, it became a commission to study healthcare reform,” Rocky told the commission. “I think that’s great. Between all of us we’re going to come up with a solution. The choice isn’t between right and wrong, left or right, but values. Do we value everyone having healthcare? Or are we going to continue to value Wall Street more than that? Don’t get me wrong — I value Wall Street too. But there’s something else that I see beyond my own 401k. Beyond that is the health of Colorado.”

The commissioners’ first questions were centered on profit. Barbara Yondorf, senior program officer with the Rose Foundation, asked if the Health Care for All Colorado Plan — which is titled the Colorado Health Services Plan — was like traditional Medicare for all.

“Absolutely right,” said Rocky.

Steven Summer, executive director of the Colorado Hospital Association, confirmed that profit was eliminate from financing but not from delivery of healthcare.

Summer also noted that if everyone were on Medicare, we’d have a bankrupt system. Rocky agreed that was the case, but only because Medicare dollars come out of general funds and because it has to work in our current flawed system.

Steve ErkenBrack, a West Slope commissioner with a non-profit health insurance plan, went back to the question of profit. “Do you envision removing all profit, so there would not be for-profit hospitals?”

Rocky reassured him that there would still be for-profit hospitals, providing a core set of benefits for every Coloradan. Those benefits were based on Medicaid benefits — which are actually very good, albeit with very bad funding. “I would say that most of you with private insurance don’t have coverage as good as Medicaid gives.”

Elisabeth Arenales, director of the Colorado Center on Law and Policy, asked about the benefits package. “My sense was that benefits might fluctuate, depending on the budget,” she said.

Rocky agreed that might be the case, but that the Colorado Health Services Plan had to begin somewhere. “We may find that we’ve saved so much more money that we can offer more benefits,” he said. “The point is that it won’t be the legislature deciding what the benefits should be, and we’re not going to have six board members of an insurance company deciding that they’re not making enough money, and cutting benefits.”

The Colorado Health Services Plan will be administered by a publicly accountable board.

Arenales asked what the thinking was on dental and eyeglasses.

Rocky agreed that those items should be in the plan.

Lisa Esgar, senior director of Operations and Finance, Colorado Department of Health Care 
Policy & Financing, pointed out that Medicaid benefits were good for children, but not good for adults.

The back and forth was lively and continued until Lindsay, the commission’s chair, urged the Lewin representatives to present their analysis on the plan, which would answer many of the group’s questions.

That analysis and the rest of the analyses aren't yet at the commission’s website, but baseline material is.

Commissioners did ask the inevitable questions about what if the federal government wouldn’t cooperate with the program. Lewin agreed that to make the Colorado Health Services Plan work, all the government dollars going to other plans would have to be captured.

ERISA came up as well. That’s the 1974 federal law that keeps states from requiring that businesses provide benefits for their employees — so that national employers wouldn’t have to offer a different set of benefits for worker in each state,

“We’re going to make an assumption that this will go forward,” said Rocky. “We outlined and addressed the ERISA concerns in the proposal. If we’re going to have a single-risk pool, we have to have a single-risk pool. To let large companies take their young healthy employees and carve out a place for themselves defeats that. We can’t be scared of the ERISA boogeyman.”

The Lasik surgery myth

The guy in the audience stood to declare that Lasik surgery shows that if the free market were just allowed to work, it would work in healthcare just like it does everywhere else. Lasik's costs just keep going down.

This is a cherished myth on the right. Because a one-time, walk-in surgery's costs have dropped, they'd like to believe that little Thomas Wilkes' $4,000-a-day factor for hemophilia would also drop. Eventually.

Suppose it did — suppose it dropped 20 percent a year, like Lasik surgery has. By 2009, perhaps Thomas' daily costs for that medication would just be $3,000 a day. Perhaps the Wilkes could afford that. Of course, that medication is just one part of their costs — all together Thomas' treatment costs about $1 million a year.

The fact is that the cost of catastrophic illness and injury under free market conditions would be beyond reach for most of us. We'd just have to hope we didn't get sick or hurt and know that we'd die if we got cancer or were hit by a bus — leaving our children orphaned.

We can't afford to be on our own when it comes to healthcare. We have to pool the risk, and be smart about funding preventive care.

I attended the Northern Colorado Business Journal's Health Care Summit today, mostly to hear "The Great Single-Payer Debate" between Dr. Cory Carroll, a single-payer universal healthcare advocate, and Republican State Senator Shawn Mitchell.

That debate was originally to have been between a Blue Ribbon Commissioner and Dr. Carroll. Weren't the commissioners supposed to keep an open mind about possible solutions?

There were also "healthcare heroes" awards, one of which went to Dr. Glenn Pearson, who was given the award for his work supporting Physicians for a National Health Plan. It is so refreshing that a business journal would recognize Dr. Pearson's work like that. I hope they're not penalized by insurance companies pulling advertising. It was a brave move.

Dr. Carroll, a Health Care for All Colorado supporter, gave a great presentation on why business should support single-payer universal healthcare.

He made the point that as long as there's the 1986 EMTALA law — that's the Emergency Medical Treatment and Active Labor Act — which requires hospitals to care for people in dire need of treatment, that the "free market" really can't work in healthcare. Hospitals would have to be able to turn away victims of car accidents, if they could not pay. Now while that may fit in with the Independence Institute's libertarian values, it's certainly not "What would Jesus do?"

"For a true free market system to succeed, those who cannot pay do not get care," Dr. Carroll said.

This is something those against single-payer universal healthcare play both ways. On the one hand, they complain that government intervention has distorted the market, and that's why it doesn't work. On the other hand, they say that we don't need single-payer, we just need to strengthen the safety net. But not government, I guess. Although anyone from the hospital associations or from charitable organizations will tell you that there's no way that charities can afford to replace the government safety net. Single-payer universal healthcare could, however.

Dr. Carroll included a David Letterman-style top ten reasons why business should support single-payer universal health care. I missed #2, but here are the rest of his reasons:

10. The single-payer system will reduce liability insurance and workers compensation costs for businesses.
9. Single-payer will eliminate the costs and headaches of running a health benefits program — no more annual negotiations with insurance companies.
8. Single-payer will eliminate complaints from employees about the company's health plan.
7. Single-payer will reduce incentives to hire part-time workers.
6. Single-payer will curb medical bankruptcies and free up money for spending on consumer items.
5. Single-payer will reduce the overall costs of covering employees.
4. Single-payer will eliminate retiree benefit costs.
3. Single-payer will reduce absenteeism because the workforce will be healthier.
2. Dunno.
1. Single-payer will allow health care costs to be controlled and predictable, eliminating a major source of business uncertainty and a barrier to planning.

Dr. Carroll also gave the audience a brief history lesson on universal healthcare, with dates that other countries adopted universal health care — the 1800s for Germany — and failed attempts in the U.S.: 1935 for FDR; 1948 for Truman; and 1994 for Clinton.

Sen. Mitchell was smart and funny. He offered the standard criticisms of single-payer universal healthcare — that the U.S. does best for breast cancer and that you might have to wait for a hip replacement in Canada — and managed to make it sound as though the U.S. system was always best and other countries' systems wracked with problems. His foundation seemed to be that yes, primary care was good in those countries, and you were probably happy with your care as long as you didn't need a specialist, but once you needed a specialist you'd be best off flying to the U.S. for care. Which isn't true at all.

All the same, he was personable and funny — and seemed open to learning more about single-payer. He seemed to think that those other countries were moving towards the U.S.'s system, which has no bearing in reality. The Canadian Supreme Court saying that auxiliary health insurance should be legal does not in any way equate to those countries moving more towards our system. People in the rest of the industrialized world mostly assume that Americans have universal healthcare too. Doesn't everyone? Those people who do know — and more will soon, because "SiCKO" will be a hit internationally — feel sorry for us.

Conservatives everywhere are in favor of cost-effective universal healthcare, which means single-payer universal healthcare or a slight modification of it. The U.S. right is the exception that proves the rule on this. What's more, the best of them, if they only had the facts in hand, would surely join their Tory brethren.

Legislative malpractice

Two physicians, Eugene and Linda Farley (related by marriage, presumably) have a great lead in "Farley and Farley: Single-payer health care is just the right prescription" in the Madison, Wisconsin, Capital Times:

What if a doctor knowingly rejected a proven cure despite years of successful tests among diverse nations, a cost that is just half of the existing treatment and is hugely popular among patients who have experienced it?

Wouldn't that be a shameful lapse in medical ethics?

If so, how will we label those state legislators who appear afraid to seriously consider the Health Security Plan model of "an expanded and improved Medicare for all"? If legislators won't thoroughly debate a proven answer for our health crisis, wouldn't that be a cowardly case of "legislative malpractice"?

This piece could be applied word for word in Colorado, regarding the 208 Commission and Health Care for All Colorado's proposal here:

The Wisconsin [Colorado] proposal would make three key differences in our system:

1. A publicly accountable body would replace the rapacious "middleman" insurers in collecting revenues and paying benefits, thereby shrinking the enormous costs of insurance bureaucracy.

2. Citizens, not an HMO, would have the right to choose their doctor and their hospital. (Both doctors' practices and hospitals would remain in private hands.)

3. Every citizen of Wisconsin would have health care coverage.

Sadly, the first comment in response to this is incredibly ignorant. Insurance propagandists can pat themselves on the back for this one. Purplepenguin writes: "People are already using our current insurance-system to call out for bans on doughnuts & smoking. If this sort of thing is passed, that will only get worse..... Sorry...as good as it sounds, it's not worth the trade-off in freedoms."

Right. Just like smoking and pastries have been banned in all the countries now offering their citizens single-payer, universal healthcare. Right.

What's the priority?

There's a great quote about single-payer in Hartford Business. The quote is from Connecticut's new state insurance regulator, a guy that the headline says, "Comes With Close Ties To The Industry."

Now when I was writing stories (but not heads), I'd get something like that into the paper and think that surely some of our readers would get it. As Norm Jenson over at One Good Move says, "I thought these things might be clues."

This new regulator warns about the dangers of a single payer system.

“'I don’t know how that would integrate with the private market. I don’t see that happening,' he said."

"Ah-hah" moment. This may be the same problem that some of the commissioners on Colorado's 208 Commission have. They can see that a universal risk pool is most efficient; they can see that it's immoral and bad for business to leave citizens without healthcare (or with inadequate healthcare) and bankrupted when they get sick — but how the hell do you shoehorn a single-payer system into the private market?

Can't be done, they sadly conclude.

As do we who advocate for single-payer. Can't be done. Which way you go from there says a lot about your priorities. Is your priority propping up an unjust and inefficient private market, or is it getting quality healthcare to people in an efficient and just manner?

Which side are you on?

Sicko at Cannes and HCAC on KRFC

Tomorrow night's "Imagine Action" program, 6 - 7 p.m. on Fort Collin’s KRFC (88.9 FM or online here), will focus on health care reform. Guests will be Health Care for All Colorado and Physicians for a National Health Program member Dr. Cory Carroll, a local family practitioner and president of the Larimer County Medical Society; Rudy Deutschmann, president of the State Association of Health Underwriters; and HCAC board member Eliza Carney, who will discuss the 208 Commission and the political process around health care reform.

The call-in number is 970-221-5065.

In more international single-payer news, take a look at Salon’s feature article on Michael Moore’s new film Sicko. It will do your heart good.

Author Andrew O’Hehir writes that Sicko is

both a more finely calibrated film and one with more far-reaching consequences than any he's made before. Moore is trying to rouse Americans to action on an issue most of us agree about, at least superficially. You may know people who will still defend the Iraq war (although they're less and less eager to talk about it). But who do you know who will defend the current method of healthcare delivery, administered by insurance companies whose central task is to minimize cost and maximize shareholder return? Americans of many different political stripes would probably share Moore's conclusions at the press conference: ‘It's wrong and it's immoral. We have to take the profit motive out of healthcare. It's as simple as that.’

Sicko purposefully does not focus on the 50 million or so Americans who don't have health insurance, as scandalous as that is, but on the horror stories of middle-class working folks who believed they were adequately covered. There are so many of these they begin to blur into each other: the woman in Los Angeles whose baby was denied treatment at an emergency room outside her HMO network, and died as it was being transferred hours later; the woman in Kansas City whose husband was repeatedly denied various drugs his physician prescribed for kidney cancer, and who in the last stage of life was denied a bone-marrow transplant that could have saved his life; the woman who was told her brain tumor was not a life-threatening illness, and died; the woman who was told her cancer must have been a preexisting condition, and died.

If the Salon article whetted your appetite for more reviews, here’s one from The Guardian:

His question: what has happened to the idea of universal healthcare in the United States?

In four tidy acts, Michael Moore spells out the facts. Act one: 50 million Americans have no health cover, and 250 million who think they do, through costly health insurance schemes ($2,000 per person a year), are often denied treatment when they need it….

Act two: when did it all start going wrong, asks Moore. The answer: in August 1971. President Richard Nixon and his adviser Edgar Kaiser plot to break the system. "The less care they give, the more money they make," says Nixon, caught on tape….

Meanwhile astute national publicity campaigns have demonised the concept of universal healthcare by associating it with "socialised medicine", which in American English translates as "Soviet medicine" - the kind such oppressive regimes as Canada, Britain and France have adopted for their citizens….

Act three: Moore pays these regimes a visit….

Act four, the most powerful: Moore decides to test the US administration's claim that Guantánamo Bay prisoners get the best free healthcare in the world. He takes 9/11 volunteer rescue workers, whose health problems were not covered by the state because they weren't on its payroll when they ran to help, to Guantánamo Bay in Cuba….

And lastly, the news, also in The Guardian, that the U.S. government is trying to impound Moore's film – a claim that’s hard to dismiss considering everything else in our country’s recent past. “Now, according to movie mogul Harvey Weinstein, whose Weinstein Company is behind the film, the US government is attempting to impound the negative.”

The pretext would be Cuba. Moore had applied for permission to travel there but received no reply until this month, when “the treasury department notified Moore that it was investigating him for unlicensed travel to Cuba.

Watch a trailer for Sicko and more on Moore's website.

HCAC makes the final cut!

The Health Care for All Colorado proposal to the Blue Ribbon Commission for Health Care Reform made the final cut and will go on to the evaluation firm, Lewin, for analysis. In fact, the proposal was the only proposal in yesterday’s discussion that seemed to have a clear mandate to go in – all the others were batted back and forth, some of them because they were so similar to one another that they didn’t offer clear enough differences for separate evaluation, others because of questions about their merits.

Here is a round-up of the four plans that will be evaluated, with their numbers. The plans names are similar, and although it would have been just as easy to refer to them by the submitting entity, i.e., HCAC’s plan, SEIU's plan, or the underwriters’ plan, commissioners were referring to them by number.

HCAC’s proposal (#16) the Colorado Health Services Plan, was submitted in coalition with the Colorado Nurses Association, the Older Women’s League, and the Physicians for a National Health Program. Rep. John Conyers is in favor of state efforts like ours, and we expect that he will endorse the proposal as well.

The proposal is a single payer, publicly financed program that covers all primary, preventive, specialty, surgical care, automobile and work-related injuries, prescription drugs, mental health services, chiropractic, dental, basic vision, audiology, home health, long-term care, and hospice services, among others. Under this program, all providers and hospitals would be paid the same for the same level of service, thus competing by the quality of care provided. Through it, every resident has equal access to program benefits. There is no opt-out provision.

It calls for a statewide, fully integrated information technology network to track outcomes, utilization and expenditures. Colorado Health Services would be a non-profit government “insurance company," administered and governed as a public utility with five districts.

The other proposals to be evaluated are those submitted by the Committee for Colorado Health Care Solutions, the Service Employees International Union, and the Health Insurance Underwriters.

A Plan for Covering Colorado (#12), submitted by the Committee for Colorado Health Care Solutions, requires all Coloradans to have health insurance. A fee would be assessed through income tax filing that would cover the uninsured. Employers would pay a portion of the employees' health insurance or an assessment to the state. This plan would create a single purchasing pool that could negotiate rates and plans, and which would have guaranteed issue and community rating. The plan would create the Colorado Health Insurance Purchasing Authority, which will define benefit packages. The standard set of benefits would be based on effectiveness and cost. The authority will also decide guidelines for performance of providers and determine the amounts paid to the providers.

Better Health Care for Colorado (#2), proposed by Service Employees International Union, provides premium assistance for purchasing private coverage. It would provide Medicaid-funded insurance subsidies for those under 300 percent of the Federal Poverty Level (FPL). Those subsidies would cover all of the premium’s cost for those at 100 percent of the FPL; with pro-rated subsidies for those up to 200 percent of poverty to ensure that they don’t spend more than 5 percent of their income on premiums. It would provide a basic benefit package (with annual benefits capped at $25,000 to $50,000) with no deductible through a pool. The plan would also allow individuals to use the subsidy for employer-sponsored insurance. This plan would also reform Medicaid by implementing pay-for-performance for Medicaid hospitals and Medicaid long-term care facilities and other methods.

Solutions for a Healthy Colorado (#5), submitted by the Colorado State Association of Health Underwriters, requires all Coloradans to have health insurance in a reformed market that would include guarantee issue product in the individual market. It would also require guarantee issue of a core benefit plan in the individual market that would include a “Core Limited Benefit Plan” that all carriers would be required to offer with guaranteed issue and with modified community rating. The government would subsidize purchase of the limited benefit plan for those up to 250 percent of the FPL. All provider reimbursements would be tied to one common basis, adjusted for performance on quality benchmarks.