27 July 2007

Envy of the World...

Thanks to SadbutTrue of Les Enragés for the heads up on this cartoon — and he found it at Josh Marshall's video site, Veracifier.

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+;
•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.

20 July 2007

Lee reflects on that 29%

Lee Patton asks in a column on OpEd News the question that intrigues so many of us: "Who Are those 29% of Americans?"


He's done the research and has some answers. That 29% also like some other, er, odd delights — like eating crayons, sitting on hot, crispy plastic, and remember 9/11 fondly.


17 July 2007

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.”

13 July 2007

Three talking points

David Welch of Chico wrote such a good letter to the editor of the Chico Enterprise-Record that you don't really need to see the piece he's reacting to. His three points are great talking points:

Sandra Pooley's attack on Michael Moore, single-payer health care and the California Nurses Association shares a notable common feature with all right-wing attacks of single payer in that it's completely fact free.

Anyone who examines actual facts, as opposed to slogans, innuendo and rumors, has to conclude that single payer is the only solution for fixing the failed American system.

Single-payer systems around the world vary quite a lot — different financing mechanisms, different administrative structures, larger or smaller roles for the private sector. Despite that variation, they all have three things in common:

1. They cover everyone in their country. You'll never see anyone in Canada, France or Britain holding a yard sale to cover someone's medical costs.

2. They achieve population health results and specific health care outcomes comparable to the U.S. or a bit better — sometimes a lot better.

3. They do it for about half what the U.S. currently spends, or less — often a lot less.

Of course the right-wing strategy for dealing with those facts is not to confront them but to just pretend they don't exist.

Business Week magazine — a rather conservative business journal — has a new article in their July 9 issue on the French system. I would recommend it to anyone who still imagines that the U.S. has "the best health care in the world."

— David Welch, Chico

08 July 2007

Cape Care moves forward

Cape Care has hired its first employee, and hopes to bring single-payer to the 11 communities on Cape Cod that passed a non-binding resolution in support of single-payer — called Cape Care. What they haven't done is passed a tax levy to support the system.
Under a single-payer system, every resident of Barnstable County would be entitled to comprehensive health care coverage, in the same way that all residents are entitled to municipal police protection or public school education.

The county would have its own insurance product and pay for coverage by assessing residents a certain amount, the mechanics of which have yet to be worked out.

Barnstable County commissioners haven't bought into the plan yet, nor do they know much about it. "We haven't heard any details on how much it would cost or how it would work," Commissioner Bill Doherty said.
The Cape Cod folks are pointing out that while taxes would go up, overall costs would go down. This could be a silver lining for mandates like those in Massachusetts. If you're forced to buy a bad product, you might be more open to paying more taxes (but less overall) for a better product.

Those clever health insurance companies. I couldn't understand why they'd be against the Massachusetts' plan — which, after all, forced people to buy their crappy product. It turns out they were thinking ahead. I'm afraid they're smarter than the rest of us put together.

Let the backlash begin

In "Doctors wary of 'socialized medicine,'" the docs interviewed manage to parrot possibly every lie there is about single-payer.

In fact, the Gainesville Times, which probably has a reputation for intellectualism and progressive thinking equal to that of North Florida itself, has published a piece that manages to not find a single proponent of comprehensive reform — despite the fact that 57 percent of medical students and faculty are in favor of a single-payer system.

"Single-payer health care would do more harm than good. It's not going to do anything to contain costs," says one laughably ignorant doctor. In fact, every study ever done show both existing and proposed single-payer systems cost less.

"I certainly do not want a single-payer system, because customer satisfaction would go down," says another doc. "In a government-run system, there's less of a work ethic." Oddly enough, the studies also refute this guy — although you'd never know it from the enterprising reporter, who didn't bother to look into the facts on either of these statements. If her interview sources had claimed the sky was actually green in Great Britain, and tigers roamed the streets there, would she have also simply repeated it within quotation marks as though it were common knowledge?

When local experts insist that the evidence is against global warming, I bet she goes along with that as well.

Another doc has worked as a physician in Germany, Israel, and England, all of which have some form of nationalized care. "In all of those places, the political elite gets the best service. No one else gets care except on the most basic level," he said.

Which probably explains their longer lifespans, better outcomes across the board, and healthier populations. Counter-intuitive, sure...

Some more quotes:

"...the single-payer model has been "a disaster" in every country that has tried it.... "It doesn't work," he said. "It bankrupts the government, and people abuse it."

"I don't deny that there are a very large number of people without insurance. But many can afford it and choose not to buy it," he said. "I can't see changing the system for everybody just because a few people have a need."

"You would have no control over who your doctors are or what kind of care they provide," he said. "The current system may be confusing, but that's the way competition is."

"There's no consumer choice, no incentive for innovation or cost control," he said. "And individuals aren't motivated to improve their health because they're not paying the bill."

... Reynolds acknowledged that it's tough for people with pre-existing conditions to get affordable insurance. But he said that's an unavoidable fact of life in the United States, where the health care industry is big business. "Insurance plans can't accept everyone who applies," he said. "If they did, the companies would go bankrupt."

06 July 2007

Archimedes Project isn't single-payer

I met with Liz Baxter of the Archimedes Project yesterday in Portland, Ore. She's smart, savvy, and obviously well intentioned. She and former Oregon Gov. John Kitzhaber run the Archimedes Project, which I had thought was single-payer — especially since they couldn't get it through the Oregon senate.

Nope — it's just an effort to get a dialog started on what our healthcare reform should look like, with 15 priorities, some of which would make it almost impossible for health insurance companies to stay in the game.

I think its defeat may show that we might as well go straight out for single-payer, rather than dancing around it.