Archive for the 'Critiquing Corporate Health' Category

Single Payer in Seven Minutes!

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PNHP’s Dr. Robert Zarr has produced an engaging 7 minute film about the reasons for a single payer (EINO Everybody In Nobody Out) health plan for the US. The film called “CureALL” is directed by Kaylen Larson, an undergraduate student from Sioux Falls, South Dakota, who interned with him in the fall.

Selling Sickness 2013: People Before Profits: Call for Papers

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Our colleague Dr. Leonore Tiefer forwarded us a call for papers for the Selling Sickness 2013 conference which will take place from Feburary 20-22, 2013 in Washington D.C.

Selling Sickness 2013

Selling Sickness 2013 is the third conference in a series devoted to disease mongering.  Selling Sickness 2010 was held in Amsterdam from October 7-8, 2010. The Inaugural Conference on Disease-Mongering took place in Newcastle, Australia  from April 11-13, 2006. Videos of the talks from the 2010 conference are available on-line. The papers from the 2006 Conference have been published in a PLoS Medicine theme issue.  Dr. Tiefer has been featured previously in the Portal for her role in the film Orgasm, Inc.

For readers who may not be familiar with the concept of disease mongering, here is a synopsis drawn from the introduction to the PLoS theme issue:

Disease mongering is the selling of sickness that widens the boundaries of illness in order to grow markets for those who sell and deliver treatments. It is a process that turns healthy people into patients, causes iatrogenic harm, and wastes precious resources [1]. Disease mongering is the contemporary form of “medicalisation.” It is a process now driven by both corporate and professional interests, and it has become part of the global debate about health care. International consumer groups now target drug company–backed disease mongering as a wasteful threat to public health [2], while the global pharmaceutical industry has been forced to defend its promotion of “lifestyle” medicines for problems like slimming and sexual difficulties [3].

Call for Papers

Selling Sickness 2013 will create an interdisciplinary forum that encourages collaboration, networking, dialogue, and audience participation as well as personal and professional development. It is intended for academic scholars, healthcare reformers, consumer organizations and advocates, and progressive health journalists.

Possible submission topics include:

  • Misleading marketing and social media Over-treatment and health screening policies Industry and government whistleblowers
  • Ethics and standards in professional education and journalism
  • New models for drug development and testing Emerging conflict of interest areas
  • Personal and professional narratives (e.g., accounts of involvement in Big Pharma reform and the “Choose Wisely” Initiative)
  • Ramifications of disease mongering on public health
  • Possible presentation formats: workshops, oral presentations, panels/structured discussions, and poster presentations. Descriptions of presentation formats and submission requirements are available on the conference’s website. Submit ideas here.

Submissions from students and young activists are welcome.

Deadline for Submissions is OCTOBER 1, 2012.

For questions or for more information, please visit or email

Posted by Matt Anderson, MD

Cuba Leads the World in Lowest Patient per Doctor Ratio; How do they do it?


by Joanna Mae Souers

*Paraguayan 5th year student participating in primary care in Havana, Cuba. (2011,by Joanna Mae Souers)

In early 2007, I began studying medicine at the Latin American School of Medicine in Havana, Cuba.  I entered the program not knowing much about the Cuban healthcare system, other than that it was universal and free.  “Now that’s a system I want to learn from,” I thought to myself, “It’s a system we could all learn from.”  Five years later, what have I learned?

There are many subtle and not so subtle differences between the Cuban and the U.S. health care systems which have allowed the Cubans to equal the U.S. with respect to their health statistics, but at a much lower cost and with better preventative and primary care.  In this paper I analyze just one of the reasons for the differences between the two systems; Cuba produces more primary care practitioners per capita.  How do they do it? Medical education in Cuba is free, all doctors interested in specializing must first serve two years working in primary care, and graduating doctors are not driven to specialize by salary incentives.  This socialist approach towards medicine and medical education assures the human resources necessary to provide universal and preventative healthcare to all.

People marvel at how Cuba has “accomplished so much with so little.”  And they marvel with good reason.  According to the World Health Organization, Cuba spent only $503 per capita on healthcare in 2009, the U.S. spent almost 15 times that sum.  In fact we in the US spent $421 per person just on the administration of the private healthcare insurance system, almost enough to fund the Cuban system. [1] [2] Despite dramatically lower costs, Cuba has some of the best health statistics and health indicators of any country around the world.

Although people like to compare and contrast the health statistics of the U.S. and Cuba, I think this a bit preposterous.  Cuba, a small island in the Caribbean, is being compared to one of the largest countries in the Americas with a very different history.  So in the table below, I have shown some health statistics on Cuba and the U.S. as well as the Dominican Republic and Haiti.  The Dominican Republic and Haiti are Cuba’s Caribbean neighbors; similar in size, history and geographic location.

*Statistical information provided by the World Health Statistics 2011 Report by the World Health Organization.

From this table, we can see that Cuba’s health indicators are more like those of the “first world” in the U.S. than its neighbors in the “third world.”  The life expectancy of the U.S. and Cuba is almost identical.  Cuba supersedes the U.S. in the categories highlighted.  So we continue to ask, “How do they do it?”  Could it have something to do with their philosophy that people need doctors?  Hence, their solution is to offer a free medical education to develop young, quality doctors dedicated to serving those in need.

Per capita Cuba graduates roughly three times the number of doctors as the U.S.   In 2005 Cuba had 70,594 doctors.  Before the revolution in 1959, there were only an estimated 6,000 doctors; somewhere around half left the country after 1959.  This means they must have graduated an average of 1,469 Cuban doctors per year, not including the some 5,000 international students who graduate each year from Cuban medical schools. [3]  When we later compare these numbers to the U.S. we see that Cuba graduates 3 times the number of doctors per capita, and the U.S. must import graduating doctors from other countries just to fill the primary care residency positions.

Critics of the “Obama Plan” say that there will not be enough doctors in the U.S. to take care of all the patients if everyone has healthcare coverage.  Obama encouraged the Association of American Medical Colleges to increase the number of graduating doctors by 30% in 2010.  Ever since 1980, U.S. Medical schools have graduated 16,000 doctors a year.  Meanwhile, the population of the U.S. has grown 50 million during the same period.[4]  A 30% increase would have meant we should have graduated 20,800 medical students in 2010, but we only graduated 16,838 according to the Kaiser Family Foundation.[5]  The number of residency programs at teaching hospitals in the U.S. has been frozen since 1997, funded by Medicare.  There were 29,890 residency slots filled in 2009,positions not filled by American graduates are filled by International Medical Graduates. [4]   This means we can estimate more than 1/3 of students in U.S. residency programs are International Medical Graduates (IMGs), students from another country or a U.S. citizen, like me, who studied in another country.

In the current scheme of things, International Medical Graduates are continuously brought in to the U.S. to meet the needs of the growing patient population.  Unfortunately nothing bridges the gap, because there just are not enough residency positions and/or funding for teaching hospitals to produce enough doctors to satisfy the entire U.S. population.  Taking International Medical Graduates to meet the needs of the U.S. population only adds to the “brain drain” of developing countries around the world.  So as we produce fewer doctors, introduce more doctors from other countries; U.S. doctors work harder for less to meet the needs in the U.S. and a lot of the world remains catastrophically underserved.

Cuba leads the world with the lowest patient to doctor ratio, 155:1, while the U.S. trails way behind at 396:1.[6]  With a surplus of Cuban doctors, Cuba is able to help ailing nations around the world.  They have medical missions in over 75 different countries lead by nearly 40,000 health professionals, almost half of them are doctors.[7]  The United States by contrast imports doctors from poorer countries, further contributing to the brain drain of professionals from poorer countries to rich ones.

In Cuba education is free.  Room and board, books and amenities are included.  Doctors are not burdened by student loans and live comfortably though not extravagantly.  Harvard Medical School states in their admissions statement that an “un-married first year medical student” will spend approximately $73,000 for the 2011-2012 academic year.  This includes tuition, room and board, books, etc.[8]  Now times that by four and you have a whopping $292,000 to shell out to become a Harvard doctor.  With interest rates, loan deferments and default charges, you might end up like Michelle Bisutti.  She graduated medical school in 2003 with a $250,000 debt, in which by 2010 had increased to $555,000.[9] This may be an extreme case, but the Association of American Medical Colleges projected in their 2007 report that in 2033, students on a 10-year repayment program will only see half of their after-taxes salaries, the rest going to loan repayment.[10]

The cost of medical education in the U.S. causes more and more medical school graduates to turn to higher paying specialties and subspecialties rather than primary care or family medicine.  Dr. Thomas Bodenheimer writing for the New England Journal of Medicine, stated that “between 1997 and 2005, the number of U.S. graduates entering family practice residencies dropped by 50 percent,” based on data from the National Resident Matching Program. [11]  In the U.S. specialists predominate at a ratio of 2:1 (the reverse of other Western countries) while half of all outpatient visits are made by primary care physicians. [12]   This deficit of primary care physicians decreases people’s access to primary care and preventative medicine, causing increases in health disparities and healthcare costs.  This is because preventative medicine benefits the patient as well as reduces the number of Emergency Department visits and hospital stays.  If there are no primary care physicians to provide preventative care to the population, we see the population suffer as costs continue to rise.

* Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates. From the American Academy of Family Physicians, based on data from the National Resident Matching Program. [11]

According to a survey in 2008 by the American Academy of Family Physicians, family medicine graduates with less than 7 years of experience earn, on average, a yearly salary of $145,000.[13]  The difference in earnings between primary care physicians and specialists differed by only 30 percent in 1980, and dramatically rose up to 300 percent for some narrowly defined specialists by 2009.  In the graph below, we show the dramatic difference between median compensation for selected specialties compared to that of primary care.[14,15]

*Median Compensation for Selected Medical Specialties.
Data are from the Medical Group Management Association Physician Compensation and Production Survey, 1998 and 2005. [15]

When working in the U.S., almost every primary care physician I talk to has the same complaint, “Too many patients, and too little time.”  They are forced to see 20 to 30 patients a day just to meet pay-incentives and “keep their doors open.”  General/Family Practice physicians spend an average of 16.1 minutes with each patient per visit. [16]   Meanwhile, 18%, or roughly 48.2 million of the U.S. population under the age of 64 is without healthcare insurance.  They have no access to most GP’s or family practice physicians. [17]

We need to follow our Cuban role model, we need to be held socially accountable and produce more primary care physicians.  This can be accomplished by providing an education at full scholarship to those interested in primary care, or by increasing the number of medical students going into primary care by closing the compensation gap between primary care and the higher paid specialties.  These measures would ensure the population better access to quality primary care and preventative medicine.  It would bring down the cost of healthcare while allowing primary care physicians to practice under less stressful conditions leading to quality affordable healthcare for all.


  1. World Health Organization (WHO 2011); Countries. []
  2.  “Healthcare Marketplace Project, Trends and Indicators in the Changing Marketplace (Exhibit 6.11: Private Health Insurance Admin Cost per Person Covered, 1986-2003),” Kaiser Family Foundation, Publication Number: 7031.  []
  3.  “Cuba and the Global Health Workforce: Training Human Resources.” Salud! (Source Vice Ministery for Medical Education and Research, Ministry of Public Health) []
  4. Sullivan, Paul.  “Discomfort at U.S. Medical Schools.” The New York Times; April 29, 2009.
  5.  “Total Number of Medical School Graduates, 2010.”  The Kaiser Family Foundation.  []
  6.  “World Health Statistics 2011,” World Health Organization; WHO Press, Switzerland.
  7. Brouwer, Steve.  “The Cuban Revolutionary Doctor: The Ultimate Weapon of Solidarity,” Monthly Review, 2009, vol 60, issue 8 (January).
  8. Harvard Medical School Admissions, “Costs (Updated: 7/21/2011).”  []
  9. Pilon, Mary.  “The $555,000 Student Loan Burden,” The Wall Street Journal, February 13, 2010.
  10. Fuchs, Elissa.  “With Debt on the Rise, Students Face an Uphill Battle.” The Association of American Medical Colleges, January 2008.
  11. Bodenheimer, Dr. Thomas,“Primary Care – Will it Survive?” New England Journal of Medicine, vol 355;9. Pg 861-862.
  12. Alper, Philip R. “Primary Care’s Dim Prognosis,” Hoover Institution, Stanford University, Policy Review No. 158 (December 1, 2009).
  13. American Academy of Family Physicians, Income (2011).      []
  14. Alper, Philip R. “The Decline of the Family Doctor,” Hoover Institution, Stanford University, Policy Review No. 124 (April 1, 2004).
  15. Woo, Dr. Beverly.  “Primary Care – The Best Job in Medicine?” New England Journal of Medicine, vol 355;9. Pgs 864-866.
  16.  “Healthcare Marketplace Project , Trends and Indicators in Changing Healthcare Marketplace (Exhibit 6.5: Mean Time Spent with Physicians (in Minutes), 1989 – 2002),”  Kaiser Family Foundation, Publication Number: 7031, Information Updated: 4/11/05.      []
  17.  “2010 National Health Interview Survey (Tables 1.1A-B, 1.2 B)”, Center for Disease Control.  []


CDC reports only 1% of US hospitals are fully “baby-friendly”: What can be done?

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On August 5th, investigators from the CDC reported the results of two surveys on how well US hospitals and birthcenters supported breast feeding in 2007 and 2009.  They assessed the degree to which hospitals implemented the 10 WHO baby-friendly policies. These are:

  • Have a written breastfeeding policy that is routinely communicated to all health care staff.
  • Train all health care staff in skills necessary to implement this policy.
  • Inform all pregnant women about the benefits and management of breastfeeding.
  • Help mothers initiate breastfeeding within 1 hour of birth.
  • Show mothers how to breastfeed and how to maintain lactation, even if they are separated from their infants.
  • Give newborn infants no food or drink other than breast milk, unless medically indicated.
  • Practice “rooming in”— allow mothers and infants to remain together 24 hours a day.
  • Encourage breastfeeding on demand.
  • Give no pacifiers or artificial nipples to breastfeeding infants.
  • Foster the establishment of breastfeeding support groups and refer mothers to them on discharge from the hospital or clinic.
The results of the survey were not particularly encouraging. Only 1% of hospitals implemented all 10 recommendations in either year; this is required to be certified as baby-friendly.  3.5% implemented nine practices in 2009.  The majority (61% in 2007; 54% in 2009) were implementing only three to five of the recommendations.  A complete breakdown of these result is available on the CDC website, here is summary in tabular form:

A slightly more optimistic report comes from the CDC breast-feeding report card (which uses a different methodology). The report card found that the number of children born in baby-friendly hospitals is now 4.5%.

You can find a map of baby-friendly hospitals (there are currently 114 in the US) at the Baby Friendly USA website. There are two here in New York City: Harlem Hospital and NYU.

Why is this an important issue?

The CDC report focuses on the benefits of breast-feeding in terms of reducing childhood obesity. Quoting a 2010 Pediatrics study, the report notes that “[s]uboptimal breastfeeding in the United States annually results in an estimated $2.2 billion in additional direct medical costs.”  For interested readers, the benefits of breast-feeding are more fully discussed in a American Academy of Pediatrics Policy Statement which is summarized on their website and can also be downloaded in full.  To quote from that page:

Unquestionably, breast milk is far superior to any formula designed for babies, and even more critical for the health of the premature baby. The challenge lies in making breastfeeding, or providing a mother’s own milk for her baby, a comfortable, enjoyable, and manageable part of the new mother’s life.

Are the advocates for breastfeeding getting bought off by the makers of formula?


The AAP, however, is not being entirely honest in their position.  As we have previously pointed out on this website, the AAP partners with corporations that produce and advertise baby milk substitutes.  These include Abbot Nutrition (which sponsors AAP CME activities), Nestle, and Baby’s R Us (see the AAP-endorsed Becoming Us pamphlet).  This partnership may account for the AAP’s failure to advocate for the adoption of the WHO’s International Code of Marketing of Breast Milk Substitutes.

Another “advocacy group” that also seems to have been influenced by corporate support is Corporate Voices for Working Families, a DC-based not-for-profit set up to provide “solutions to legislators and business on issues important to America’s children and families including: Workforce Readiness, Family Economic Stability, Workplace Flexibility, and Mature Workers.”  The Massachusetts Breastfeeding Coalition has provided a critique of the Corporate Voices worksite lactation toolkit.   It turns out that this toolkit was produced ” in consultation with a select group of corporate partners and healthcare professionals” among which were Abbott Laboratories (makers of Similac).  Abbott also provided “generous support” to the Toolkit and Abbott is listed in the resource guide.  Readers can find the full critique at the MBC coalition website.

Interestingly enough the President of Corporate Voices for Working Families,  Stephen M. King, wrote about the new toolkit on the Huffington Post describing it as “free, high-quality and up-to-date…”  He did not mention Abbott.   Perhaps it just wasn’t germane. Or perhaps Corporate Voices is just another example of astro-turfing: ” artificially created grassroots coalitions, which lobby elected officials on behalf of corporate friendly legislation, and the creation of corporate front groups with eco-friendly names like the National Wilderness Institute and the Foundation for Clean Air Progress.” (from Martin Donohoe’s article on Combating Corporate Control of Public Health.

These two examples illustrate the way corporate voices have managed to insinuate themselves into groups which nominally serve the public health.   Readers who are interested in a fuller discussion of this topic can consult Sleeping with the Enemy.

What can we do?

The CDC has provided a set of recommendations for hospitals to become baby-friendly. These are pretty common-sense and straightforward. We know what we need to do. Why aren’t we doing it?

posted by Matt Anderson, MD


From the Middle East to the Midwest, let's stand up for the rights of women and workers.


OpEd News, March 2011

As the world celebrates Women’s History Month, the U.S. House of Representatives has just launched the most devastating assault on women’s health in the history of our nation – a real case of state terrorism, or use of violence on a civilian population to achieve political goals.

If the House-passed bill is approved by the Senate and is signed into law by President Obama, Title X will be eliminated.

Title X provides basic health services, including Pap smears, testing for sexually transmitted diseases, and cancer screenings to more than 5 million low-income people, disproportionately women, at a cost that is a fraction of the cost of waging at least two wars of aggression and funding over 700 overseas military bases and at least 6,000 such bases in the United States and its territories.

This bill would also cut $210 million from Maternal and Child Health Block Grants, that also serve poor women and children; the Centers for Disease Control and Prevention would see a major cut in its funding, of $755 million, that would undermine a host of public health efforts, such as confronting HIV/AIDS; and Community Health Centers would see a $1.3 billion dollar cut that would brutally curtail services in a network of health centers in cities and rural areas providing essential primary care — so much for the Patient Protection and Affordable Care Act (PPACA) expansion of funds for community clinics.

And it gets worse, and does not stop at our nation’s shores. The same legislation would also eliminate funding for the United Nations Population Fund (UNPF), the agency providing family planning, maternity care, and sexually transmitted diseases prevention services, among many other services essential to women’s wellbeing, in some 150 countries.

This onslaught against women joins the one against working people generally, as calls to “save” Social Security and Medicare by slashing these programs multiply, and an increasing number of state legislators attempt to gut the collective bargaining rights of unions with the spurious argument that public sector employees just “earn too much” and receive “too generous benefits”.

While the subtleties of the discourse differ, not only the right but also sectors of the “liberal left”, convey the same message: workers with “generous benefits” must give them up, because it is those “benefits” that caused “the deficit”.

But just what are these “generous benefits”?

The benefits of Wall Street we know well, even if they figure nowhere in these arguments. As President Obama noted (with a straight face) in this year’s State of the Union address, “the stock market has come roaring back and corporate profits are up.”

Yet the “benefits” of the US welfare state are paltry compared to those enjoyed by millions of individuals in similarly wealthy nations – in terms of public pensions, paid vacations, and maternity leave, to mention a few. And the United States stands alone in that it lacks guaranteed access to health care. The new federal law barely gave us an obligation to purchase an insurance policy from commercial insurers, under penalty of a fine, and would leave at least 23 million individuals (5% of the US population) with no coverage whatsoever ten years out of passing this law.

It would also leave a yet-to-be-estimated number of individuals burdened by medical bills that they cannot pay, as new “consumer–driven insurance products”, with actuarial values as low as 60%, huge co-pays, and deductibles, multiply.

As to the much trumpeted deficit, as Dean Baker at the Center for Economic and Policy Institute reminds us, before the latest economic downturn the federal budget deficit was relatively modest – just over 1% of GDP in 2007, even with the cost of fighting two wars and Bush’s tax cuts (that anti-deficit crusaders remain blissfully silent about). The size of the deficit then certainly posed no danger to the economy.

But then everything collapsed, as an $8 trillion housing bubble burst, a bubble caused by the policies endorsed or even legislated by the same individuals that the Obama Administration has now asked for advice on how to “save” the economy – Pete Peterson, Alan Simpson, Erskin Bowles, among many others. So where were these anti-deficit crusaders between 2002 and 2006? They were, of course, crying wolf against…the deficit caused by the “generous benefits” of US workers.

And now, with 25 million people unemployed or underemployed, ten million underwater in their mortgages, over 50 million uninsured, and 45,000 dying every year for lack of access to basic medical care, these same economic geniuses are warning us against the “impending catastrophe” wrought by the “generous” salaries of public employees, the “Cadillac services” of minimally decent health insurance policies, programs providing basic health care to poor women, men, children and the elderly, Social Security, or Medicare.

Yet Social Security poses no major problem – it is projected to be fully solvent for almost 30 years with no changes whatsoever. Whichever problems it may have could be easily fixed by simply raising the cap on taxable income, a move that would affect only the wealthy. Medicare and other publicly financed healthcare programs pose a problem only because the US health care system, pre and post PPACA, is built upon a losing proposition: for-profit health insurance for medically necessary services.

It needn’t be this way. From the Middle East to the US Midwest ordinary people are demanding greater political participation and a share in the national wealth that they and only they overwhelmingly produce. As we commemorate those 15,000 brave women who back in 1908 marched through New York City demanding shorter hours, better pay and voting rights, American women and working Americans generally must demand no less.

Claudia Chaufan, M.D., Ph.D., is assistant professor at the Institute for Health and Aging at the University of California, San Francisco. She teaches sociology of health and medicine, sociology of power, comparative health care systems and sociological theory. Dr. Chaufan is also vice president of Physicians for a National Health Program-California (

The health law at one year: Should we celebrate?

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Physicians for a National Health Program Blog, March 23, 2011, March 23, 2011

On March 23, a year after President Obama signed into law the Patient Protection and Affordable Care Act (PPACA), “the most expansive social legislation enacted in decades,” according to the New York Times, it’s worth taking a look at Massachusetts.

After all, PPACA was inspired in the Massachusetts health plan, which sought universal coverage through Medicaid expansions for individuals living under 150 percent of the federal poverty level (FPL), partial subsidies for those between 151 and 300 percent of the FPL, a state-based exchange to act as a one-stop-shopping place of private insurance plans, and a mandate to purchase one of those plans under penalty of a fine.

And yet, four years after implementation, health reform Massachusetts-style has failed a critical test. As a recent study in the American Journal of Medicine showed, the percentage of personal bankruptcies linked to medical bills and illness, at 52.9 percent, has not decreased significantly, and the absolute number of medical bankruptcies has increased, from 7,504 in 2007 to 10,093 in 2009. How so?

Well, it’s not hard to understand why. Health insurance is a means to an end. The end is health care. And skimpy policies with significant, and increasing, out-of-pocket costs are useless when people need care.

And in Massachusetts, skimpy policies are not even cheap. For example, as study authors pointed out, the least expensive individual coverage available to a 56-year-old Bostonian carries a premium of $5,616 and a deductible of $2,000, and covers only 80 percent of the next $15,000 in costs of covered services (uncovered services fall 100 percent on you).

This is not small change if your annual income is around $32,000, or 300 percent of the FPL, so you’re not entitled to subsidies (which, mind you, come from taxpayers’ pockets).

But what about at least slowing the increase in health care costs? Fail again. Double-digit increases in premiums have become routine in Massachusetts, and insurers have warned this will continue next year, even as “consumer-driven” policies that shift more costs to individuals multiply.

But won’t PPACA, a federal program, control costs in U.S. health care? No, at least if you go by its effect on California, where, maybe to celebrate PPACA’s first year anniversary, Blue Shield recently announced its third premium hike since October 2010. An outside consultant found, unsurprisingly, that the planned hike was “reasonable.” (PPACA does not forbid insurers to raise their prices; it only demands that they show that increases are deemed “reasonable” by authorities that have little power to enforce their standards of reasonableness anyway.)

And what about the promise that kids with “pre-existing conditions” would not be charged more than other kids? Good luck with that one. This past October HHS Secretary Kathleen Sebelius already backed down on that promise, allowing insurers to charge more to cover sick kids to, according to the New York Times, “persuade companies to offer child-only policies.”

And Medicaid expansions, which would enroll at least 16 million individuals? Not a chance, especially after governors throughout the nation begin to implement the creative ideas offered by Sebelius explaining how, as state budgets collapse and nobody bails them out, Medicaid costs can be reduced “by cutting benefits,” as noted in California Healthlines.

Wait a minute, you might say. Whatever problems it may have, the law offers (near) universal coverage, no? Out of luck again. The law will leave around 23 million uninsured close to 10 years out from its implementation (and over 50 million annually over the next three years). Many of these will be undocumented immigrants, whom the law forbids to buy coverage from the insurance exchanges, even with their own money.

On the bright side, as the failure of the attempt to further strengthen the worst of the U.S. health care system — for-profit insurance for medically necessary care, and trading uninsurance for underinsurance — becomes increasingly apparent, a space will open up for Americans to demand real health care reform: a publicly financed, privately delivered health care system that provides comprehensive and equitable health care to everybody in the United States: an expanded and improved Medicare for All.

Claudia Chaufan, M.D., Ph.D., is assistant professor at the Institute for Health and Aging at the University of California, San Francisco. She teaches sociology of health and medicine, sociology of power, public health, comparative health care comparative health care systems and sociological theory. Dr. Chaufan is also vice president of Physicians for a National Health Program-California (

Public insurance (and NOT public "option") the best model for India

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‘The US model of private health insurers is inefficient, expensive’

Nov 26, 2010, 12.00am IST Joseph Stiglitz, the Nobel prize-winning economist has written several articles on the inequity in access to health and the flaws in the drug discovery process of pharmaceutical companies. On a recent visit to Delhi, Stiglitz spoke to Rema Nagarajan about the negative role of patents in drug discovery and the pitfalls of private insurance in health:

Why have you been pitching for a single payer system for health insurance rather than a system where several private companies compete?

The US model of private health insurers has been proven inefficient and expensive. Rather than provide better healthcare at lower costs, insurance companies innovate at finding better ways of discrimination. They are inefficient because they are trying to figure out how to insure people who don’t need the cover and keep out people who need it. With many companies, they also need to spend on marketing and advertising. The incentives are all wrong and the transaction costs are very high and you have to give them a high profit. In health, social and private incentives are totally disparate. Competition does not work in healthcare especially in the health insurance market. Several countries like the UK, France and Sweden have a single payer system, differing only in the organisation of healthcare delivery.

Several health insurance companies are setting up business here. Should India be worried?

India would be in a terrible mess, given the size of its population, if it went down the wrong route (of private companies for health insurance). They should learn from the mess that the US has got into. Once the companies start making profits, special interests in politics will come into play and it will be difficult to get them out. In India, given the disparities in income, a single system for delivery might not work. So, it will probably need a mixture of public and private provision or maybe public healthcare for basic clinics and reimbursement for others, or the UK model where provisioning or delivery is also through public institutions.

Are you against intellectual property especially in health research into medicines?

I am not against intellectual property (IP). But the benefits of IP have been exaggerated and the costs underestimated. IP creates monopolies. And it does interfere with economic efficiency by interfering with the flow of knowledge and the use of knowledge, particularly for developing countries. The TRIPS (trade-related aspects of intellectual property rights) agreement is trying to impose the same IP framework on everybody. The question is whether IP promotes innovation. Increasingly, the evidence is that it may actually impede innovation. It is leading to infinite negotiations around patents. More money is being spent on lawyers than on research. New ideas are the most important input into research. IP is making that input difficult to get. We need some IP. But we also need to find better ways of financing and incentivising research such as government-sponsored research.

Is it viable for governments to finance drug research?

Yes, public financing of drug research is financially viable. In a system where government pays for drugs, it is in effect, the government or the public who pay for hugely expensive drugs. Drug companies greatly exaggerate the cost, especially on research. If you broke down their costs, you would see that basic research is done by the government. The applied research of a particular molecule is mostly done by small companies, often linked to universities, which is still private. But the biggest cost is testing of the drugs and that is usually blown up and often includes promotion costs.

Read more: ‘The US model of private health insurers is inefficient, expensive’ – The Times of India

From "consumer-driven" health care to "consumer-driven" fire department.


While “consumer-driven fire department” sounds decidedly weird, for some reason some have been brainwashed to believe that “consumer-driven health care” makes sense.

But it does not. It makes no more sense to let people’s house burn down because they cannot pay their fire-department fees — maybe they chose the wrong “plan”? or a plan with a deductible they cannot afford? – than to let them die because they cannot afford their health care.

Now, why the new federal law, the Patient Protection and Affordable Care Act P-PACA), will fail to keep its two key promises (protecting patients and making health care affordable), is not the topic of this posting, because I and many others have commented on it extensively elsewhere.

Rather, it is to point out that if we continue turning health care more and and more into a “consumer good” that those who have the ear (and pockets) of Congress and the White House can make a profit off of (and P-PACA reinforces the trend ), we are up to extremely unpleasant experiences.

Such as, for instance, looking at our homes burn down while the Fire Department watches. And unfortunately, this nightmare is already with us. It happened just a few days ago, in Tennessee.

Here is a video clip produced by, illustrating the story and the debate it ignited in cyberspace:

“No pay, no spray”.

Interestingly, one reporter critiques the city implementing the fee because it likens a public service, fire protection, to auto insurance (note: remember the comparison made by President Obama  between health insurance and auto insurance, once even the token gesture, the ‘public option’, towards his progressive base had been cast aside to give full way to the Well Point-crafted federal legislation?)

And here is how the episode is described in Amy Goodman’s show, Democracy Now:

Tenn. Fire Department Allows Home to Burn Down over Unpaid $75 Fee

In Tennessee, a local fire department refused to put out a house fire last week because the homeowner had forgotten to pay $75 for fire protection from a nearby town. The firefighters showed up to the scene of the fire and then watched as the home of Gene Cranick burned to the ground. Cranick’s neighbors had paid the $75 fee, so when the fire spread across the property line firefighters took action, but only to save the neighbor’s property.

The local mayor defended the actions of the firefighters. South Fulton Mayor David Crocker said, “Anybody that’s not in the city of South Fulton, it’s a service we offer. Either they accept it or they don’t.” On Monday, Gene Cranick appeared on Countdown with Keith Olbermann.

Gene Cranick: “Everything that we possessed was lost in the fire. Even three dogs and a cat that belonged to my grandchildren was lost in it. And they could have been saved if they had been—they had put water on it. But they didn’t do it, so that’s just a loss.”

Keith Olbermann: “When you all called 911, as I understand it, you told the operator you’d pay whatever was necessary to have the firefighters come put out and prevent the fire from spreading to your house. What was their response?”

Cranick: “That we wasn’t on their list.”

Are we going to watch in disbelief while our homes burn down?

As Dr. Bill Skeen, executive direction of Physicians for a National Health Program-California, wrote:

Sadly, those of us who believe healthcare is a right know that this country has never assumed the mantle of providing healthcare to all its residents. Currently we leave 50 million of our brothers and sisters uninsured; 45,000 of them die each year because of it. It is time for us to stand up and demand that our nation return to the real American values of empathy and compassion and caring about our neighbors’ wellbeing.

Last night we as a nation let a family’s house burn to the ground while those who could save it watched and did nothing. Everyday we let more than a hundred people die who have no health insurance. Are we willing to standby and do nothing to stop it?

We don’t need to. And we mustn’t.

Let’s pick up the phone and call our U.S. Representatives today, and tell him or her to co-sponsoer HR676 when it is reintroduced next year in Congress. Tell him or her that you are outraged at what happened in Tennessee and that these two issues, fire protection and health care for all, are one and the same at their core. They demonstrate the incontrovertible need for government to protect the common good, and for we Americans to show our humanity to each other.

The Capitol Switchboard at 202-224-3121 / 202-224-3121  can connect you to the office of your Representative.

See below for a list of US Representatives that demonstrated their support this year for single payer by co-sponsoring HR 676. Please thank those legislators for their support, and urge the others to get on board!

Let us demand Medicare for All – everybody in, nobody out!

Name                                  State    District    Date signed
Rep Woolsey, Lynn C.        CA        6             01/26/09
Rep Miller, George             CA        7             03/19/09
Rep Lee, Barbara               CA        9             01/26/09
Rep Honda, Michael M.      CA      15             02/11/09
Rep Lofgren, Zoe                CA     16             05/20/09
Rep Farr, Sam                    CA      17             01/26/09
Rep Berman, Howard L.     CA     28             01/26/09
Rep Becerra, Xavier           CA     31              03/17/09
Rep Chu, Judy                   CA     32              07/31/09
Rep Watson, Diane E.        CA    33              01/26/09
Rep Roybal Allard, Lucille   CA    34             03/30/09
Rep Waters, Maxine           CA    35             03/19/09
Rep Napolitano, Grace F.   CA    38             01/26/09
Rep Baca, Joe                   CA    43              10/07/09
Rep Filner, Bob                  CA    51              02/11/09

If it smells a rat…or "why does the public distrust the new federal health insurance law"?

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This is in essence Trudy Liberman’s message:

“If it looks like a rat, walks like a rat, and smells like a rat…it is likely a rat!”

And this is the problem with those who puzzle about the response of ordinary Americans to the “Patient Protection and Affordable Care Act” (PPACA), recently signed into law. Those folks are trying to figure out the “riddle” of the “ambivalent” response of Americans to the law. “What is it with these folks (ordinary Americans) that they can’t recognize what is good for them?”, they wonder.

Yet as I, and so many others, have argued repeatedly, the law fails on its two key promises:

1) It does not seriously protect patients from the financial burden of disease — in fact, it does not even promise to, certainly not to the 23 million who, according to the Congressional Budget Office (CBO), will remain uninsured by 2019.

2) It fails to make health are affordable, both to the nation (taxpayers) and to individuals. Indeed, according to the CBO, the law will actually increase federal health care expenditures, even as it “covers” around 32 million folks with shoddy policies that can pay as little as 60% of covered services (for the uncovered services, you’re on your own, as you have always been!).

Not to mention the out of pocket costs for individuals and families, that continue, and will continue, to increase as I type and you read this posting…

And Americans are no worse than other peoples when it comes to sensing bait and switch approaches, and smelling rats, which government officials from both parties, attempt to sell as something else, as they insist on insulting our intelligence (maybe they hope that if you repeat lies or distortions enough the public will be convinced that they are “facts”).

So stop scratching your head, pollsters, and trying to figure out what in the “message” has failed to convince Americans about PPACA.

“It’s the content, stupid!”

Trudy Lieberman makes an excellent point about precisely this issue, so I am copying her analysis in its entirety.

Distrust and Health Reform, by Trudy Lieberman

A fine piece last Wednesday by Politico’s Carrie Budoff Brown dissects what political prognosticators from Bill Clinton to Obama pollster Joel Berenson had predicted about the ultimate acceptance of health reform legislation. “Rarely have so many political strategists been so wrong about something so big,” she writes. “At the six-month mark, the law remains a riddle for political analysts, lawmakers and the White House.”

Riddle? Not really. Months ago the public sensed a bait and switch, and the media weren’t helping them out. The seeds of the public schizophrenia over reform were sown during the presidential campaign, when candidates Obama and Clinton talked about universal health care, making it seem that the country was on the verge of adopting a true national health insurance system like the rest of the developed world.

That’s not what they had in mind, and universal health care morphed into universal coverage provided by private carriers. Then the pols and the press discarded that term when the rationale for reform became insurance market reform—a snoozer for sure.

The constant bashing of insurance companies by the president, his health secretary Kathleen Sebelius, and advocacy groups did not compute with the public. Many Americans have had wicked experiences with insurers—but if they are so evil, why give them twenty-five million new customers? At the gut level, that didn’t make sense, and media explanations about bringing everyone into the risk pool didn’t resonate. But probing further would bring up the nasty, controversial subject of the individual mandate—the requirement that everyone have insurance. The pols were not eager to talk about the central feature of the legislation, and the press didn’t discuss it much either.

If they did, that might have raised another better-to-ignore topic, affordability: whether middle income folks would really be able to afford a policy they will be required to buy, even with government tax credits to help pay the premium. Last week I interviewed twenty-eight-year old Michelle Zywicki in the Waupaca, Wisconsin public library. She doesn’t earn much working twenty hours a week at Dollar General, and can’t find a full time job. She has no insurance. Zywicki heard she would have to pay a fine for not buying insurance which she cannot afford.

Because her income is low, I told her, she probably would get large subsidies when the mandate took effect. “Why hasn’t anyone told me that?” she shot back angrily. “I’ve tried to read articles and they put me to sleep.” Somehow, dear colleagues, we’ve missed with her—and probably millions more in her shoes.

The president’s equivocation on the public option allowed its large number of supporters to believe it was possible to create an alternative to private insurance, only to have their hopes dashed when it became clear the mighty stakeholders didn’t want it, and so the pols threw it under the bus. Nancy Pelosi herself kept telling reporters that the House bill would have a strong public option, perhaps knowing all along it wouldn’t make the final cut. To the public, Pelosi’s remarks came across as just another politician’s flimflam.

A month ago in Columbia, Missouri, holding one of my periodic town hall meetings, I talked to fifty-six-year-old Charles Paxton, who told me: “When they started it, I was for the law. By the time they got it done, I thought it was not a good idea. There were way too many compromises made to get it passed. You know it’s not going to do what it should.” What news there was of the president’s deal making with insurance companies, doctors, hospitals, and drug companies didn’t sit well with people who thought those days were over.

Republicans have exploited this distrust that is likely to intensify as more people learn about the mandate. “I don’t like the fact people will be forced to buy insurance,” said Hannah Spratt, a University of Missouri sophomore who is not spending her time watching Glenn Beck. Robert Hanna in Lincoln, Nebraska, told me he would never vote for a Democrat ever again, because the president “said he wouldn’t sign a bill that would increase the deficit and include illegal aliens which the bill does.” The GOP message had gotten through.

Shortly after Congress passed the law in March, with the polls showing deep public skepticism, David Axelrod told ABC News: “I think as the American people become familiar with what this program is and what it isn’t, they’re going to be very, very happy with it.”

Seniors with super high drug expenses were supposed to like the $250 rebate, but it is the proverbial drop in the bucket for those whose drug expenses mount in the thousands, and those who remember that the idea of allowing the government to negotiate with drug makers to bring prices down, too, was thrown under the bus. Even though young adults can now get coverage under their parents’ insurance, some are finding that’s not as easy as it sounds.

Others are learning that the law has consequences they weren’t told about. The president said many times people could keep the insurance they had if they liked it. Reform would not affect them. Lifting the lifetime cap, for example, affects only those with catastrophic expenses which most people don’t have. Instead, those whose medical expenses are low are now seeing their premiums rise to cover the additional risk the country’s for-profit insurers must now assume for lifting the cap and other new provisions the law calls for.

In late summer, at a road show cum pep rally in Philadelphia organized by Families USA, the group’s deputy director, Kathleen Stoll, told the crowd, mostly seniors, “there has been a lot of misinformation about Medicare and it’s very frustrating.” But the bait and switch continued. I don’t remember hearing the mandate mentioned, but Stoll did promise “we’ll see insurance more affordable.”

Politico’s Budoff Brown tells us that the Dems are running for cover, reporting that Senate Democrats up for reelection, like California’s Barbara Boxer and Colorado’s Michael Bennet, don’t even mention the law in the health sections of their campaign websites, and don’t take credit for its passage. Obama himself, she reported, does mention the law, “but it’s usually just a few lines wedged between the economy and the financial regulatory overhaul.” How’s that for leadership?

A few years ago, speaking at the annual meeting of the Association of Health Care Journalists, Don Barlett, of the esteemed reporting team of Barlett and Steele, told journalists that we are lying to our readers. I don’t know that we’ve lied as much as ignored parts of the story that mattered to people. My town halls show that there are large segments of the public that still don’t know about the law, and others don’t know what or who to believe.

Campaign Desk repeatedly noted that stories about how reform would affect ordinary people were MIA. “There’s a real danger reform will pass without families knowing what’s in store for them, financially speaking,” I wrote. How can we expect the results to be any different?

The Problem with Band-Aid Approaches to Critical Social Needs: Health Care in California

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Even as several states are challenging the constitutionality of the recently passed federal health care legislation, PPACA, and odd situation is emerging in those states  where those challenges are less immediate or imminent.

As reported by California Healthline, Gov. Arnold Schwarzenegger (R) signed and vetoed several health care-related bills, not to challenge the federal health reform law but rather on the (dubious) grounds that these bills would duplicate its provisions.

So a perfectly reasonable, incremental-approach type bill, AB 2540, by Assembly Member Hector De La Torre (D- South Gate), which would have made it illegal for a health plan to collect a policyholder’s premiums and then rescind coverage after the member becomes ill, was vetoed (so much for the promise of  an end to rescisions).

Similarly, AB 2042, by Assembly member Mike Feuer (D-Los Angeles), which would have prohibited health plans from raising rates more than once each calendar year, was also vetoed (so much for PPACA helping you keep your plan if you like it).

The California governor also vetoed AB 1600, by Assembly member Jim Beall (D-San Jose), which would have required most health insurers to cover the diagnosis and treatment of mental illness, and AB 113, by Assembly member Anthony Portantino (D-La Cañada Flintridge), which would have required most health insurers to cover mammograms (so much for PPACA enhancing preventive health care).

Why would the California governor so blatantly block legislation that would clearly favor ordinary citizens vis-a-vis corporate actors, however important a question, is not the topic of this posting.  Nor is the problem with health care corporations, whose first fiduciary responsibility, like that of any other corporation, is to produce profit for shareholders.

The real question is why leave a basic human need and social right to corporate America in the first place and what is the role of ordinary citizens of democratic nations in deciding upon this and similar issues.

It is high time that these questions be debated in every American household. Their answer will determine what type of country and society we will bestow on our children.