The Social Medicine Portal

Single Payer Universal Health Care Bill Clears Senate in California

For Immediate Release:  1/28/10
January 28, 2010

Leno’s Single Payer Health Insurance Legislation
Wins Senate Vote 22 to 14

California OneCare Campaign
Reveals Massive Netroots, Grassroots Campaign

By a vote of 22 to 14, the California Senate today passed historic reform legislation, SB 810, that calls for sweeping changes in the financing of health care.

Under the bill, authored by Senator Mark Leno (SF), all residents would be covered by a true universal health care system, which would pay for all needed health services utilizing a “single payer” insurance system. Most residents would be required to pay into the system and all would be covered, with no additional co-pays, deductibles or exclusions for pre-existing conditions.

Comprehensive reform. Under SB 810, private insurance companies would be replaced by one non-profit health insurance fund. All services, including prescription medications and equipment would be paid by the single fund – hence the term “single payer”.  All California residents will be covered with comprehensive, universal coverage for all necessary health care including doctors, hospital, medications, mental health, medical equipment, dental, eye care and more. Under the SB 810 legislation, hospitals anddoctors would continue to operate privately, while insurance would be financed publicly..

SB 810 is expected to be revenue neutral to the state and cost most businesses and residents less for the most comprehensive health care reform plan ever offered Americans.

A strategic Plan to WIN. Sponsors of the bill applauded the Senators who supported this victory and outlined coalition plans for a massive multimedia grassroots educational campaign to pass the bill through the Assembly later this year.

One key component of the campaign will be an historic multimedia advertising campaign that will feature a new 30-second TV spot every day for a year starring celebrities, political leaders, health care activists and victims. Some 60 spots have already been produced, featuring Lily Tomlin, Paula Poundstone, Elliot Gould, Ed Begley, Valerie Harper, Connie Stevens, Tracy Newman, Ken Howard, Ed Asner, Sheila Kuehl and more. Supporters will be invited to submit their own versions.

Massive Grassroots Education. Kicking off on March 1, the 365-day ad and grass roots organizing campaign will gain momentum during the most tumultuous political period in decades, including a key state primary and the November election for Governor, Senate and Assembly seats. The goal of the campaign is to achieve passage and approval of the legislation by a two-thirds super majority of legislators in order to pass the financing legislation to implement the legislation. Similar single payer bills were passed twice by a 62% majority of the California legislature only to be vetoed by Governor Schwarzenegger.

Californians will be invited to get active on line or join neighborhood events to educate others about the benefits of this major reform of our health care system. Leaders expect that California’s success with a single payer system will lead other states to adopt it as well.

California OneCare and the 365 Ad Campaign are a project of Health Care for All-California and supported by single payer advocacy groups nationwide.

DONATE TO GET SINGLE PAYER, UNIVERSAL HEALTH CARE IN CALIFORNIA. Please support the California OneCare 365 Ad Campaign. Help us produce a new thirty-second ad supporting single-payer health care on websites and television throughout California every day for one year. Click here to donate.

For more information, contact:

Andrew McGuire, Executive Director,
Health Care forAllCalifornia and the California OneCare Campaign
Phone: 415.215.8980

Ali Bay (California Senate)

916 651-4003

What the New York Times won’t tell you: Huge rally in Sacramento in support of single payer universal health care

From California OneCareNow, Campaign for single payer bill SB810

The campaign for single payer health care reform in California got a “shot in the arm” in Sacramento Monday and a report about it became the top recommended blog on Daily Kos. Busloads of California Health Professional Student Alliance members–medical, nursing, public health and allied health students–marched to the Capitol steps  and joined a crowd of about a thousand supporters for a raucous rally for single payer. Blogger “Shockwave” attended the rally and posted his report about it on Daily Kos yesterday morning. It quickly become the #1 recommended blog on the influential progressive website. Read his report on Daily Kos, “Shockwave” is a Health Care for All-California member and a California OneCare supporter.

The video featured in the blog was created by California OneCare Campaign Co-Chair, Don Schroeder. The video is available on YouTube.

Featured speaker at the rally was Senator Mark Leno, principle author of SB 810, the California Universal Health Care Act that will begin its way through the legislature later this month. The bill, dubbed California OneCare, has passed twice before, only to be vetoed by Governor Schwarzenegger. It is expected to pass again by late summer. One goal of the California OneCare Campaign is to make sure the governor signs it this time. If he doesn’t, the goal is to override a veto with a two-thirds “healthy majority” in the legislature next year.

The event organizer and MC was JB Fenix, California Physicians’ Alliance Fellow, who was joined at the podium by Chris Scannell from the USC Medical School, and Lea Rosemurgy from the UCSF School of Nursing. Additional speakers at the rally included Deborah Burger, RN, Co-President of the California Nurses Association/National Nurses Organizing Committee, James Kahn, MD, President of the California Physicians’ Alliance, Allan Clark, Alliance President of the California School Employees Association, Nan Brasmer, President, California Alliance of Retired Americans, and Andrew McGuire, Executive Director of Health Care for All-Calfifornia and the California OneCare Campaign.

DONATE TO GET SINGLE PAYER, UNIVERSAL HEALTH CARE IN CALIFORNIA. Please support the California OneCare 365 ad campaign. Help us produce a new thirty-second ad supporting single-payer health care on websites and television throughout California every day for one year. Click here to donate.

It’s the financing, stupid! A second opinion on Atul Gawande’s “Cost Conundrum”.

I must confess that I was disappointed to see Dr. Gawande’s mantra that more or more expensive care is not necessarily better care go unchallenged even by the otherwise outstanding Amy Goodman’s Democracy Now! Unchallenged, that is, when this rather obvious (or at least very reasonable) observation was presented as the critical explanation for why the United States spends more in health care, per person, than any other country in the world, even as it leaves millions uninsured or underinsured, leads thousands to bankruptcy, and allows 45,000 — 15 times the number murdered in 9/11 — to die for lack of health insurance. Nor was he challenged when he presented his views on Massachusetts as a sound model for health care reform, even as he granted that the program had “failed to control costs”. In fairness to the interviewers, Dr. Steffie Woolhandler’s statement that the center of the Massachusetts program did not hold was shown briefly. Yet to the already confused listener or viewer, the showcase of “opposing expert views” must have felt like the usual “he said, she said” — not awfully enlightening and at best leading to skepticism about both positions.

So back to Dr. Gawande, it appears that he is smart enough to realize that certain forms of payments, like fee for service, lead practitioners to provide more care (which sometimes, but by no means always, may be unnecessary), whereas salaried doctors do not have that incentive (incidentally, salaried doctors are the norm in “socialized medicine” type systems). And yet, Gawande is not perspicacious enough to ask himself why is it that Canada, Taiwan, France, or Japan, where fee for service reigns supreme, still spend a fraction of even what our cheapest and best run hospitals do. While I am not arguing in favor of fee for service — quite the contrary, I, like many, agree that it is at least a very inefficient and administratively burdensome form of payment — I am just pointing out that given this rather banal observation, it is clear that fee for service cannot be the whole story of our high health care costs.

At any rate, had Gawande (or his interviewers) asked this critical question, rather than continuing in the all too American exercise of navel-gazing by comparing one (low-cost) American hospital with another (high cost) American hospital, he might have studied a well-run, or even the best run, American hospital’s costs against the costs of some hospital in other countries. And he surely would not have failed to see, as it appears he has, that even Switzerland, that comes second after the United States in health care costs (even if Swiss costs are substantially lower, by around 40%, than the U.S.’s), and has “private insurers”, bans profit making from the financing of medically necessary care. Right! It’s the financing, stupid!

The same is the case with the health care of all other industrialized economies. So even when Europeans, or the Japanese, talk about “private” insurers in health care they rarely, if ever, mean “for profit” insurers. Private insurers are essentially tightly regulated subsidiaries of government, and if they are ever caught “cherry-picking” they are forced to transfer some of their money to another insurer that covered sicker patients or, as the Swiss do, lower their premiums during subsequent months, unimaginable in the America private health insurance scenario.

Admittedly, some readers might puzzle: “Why would insurers even be in business if not to become filthy rich?” Well, at least one reason is that if they do a good job and attract many members, then they can sell for profit insurance for the “over and above” services (private hospital rooms, cosmetic surgery, etc.). And to note, when Swiss insurers, who prior to 1994 were pretty much like American insurers, failed to meet their part of the social contract (i.e. were becoming filthy rich at the expense of everybody else’s suffering), they got their lesson: price controls and mandated benefits that they had to provide at no profit if they wanted to remain in business.

And had Gawande delved into the politics of health care (and not merely the Pollyannaish version of its history), he surely would not have failed to discover that the coming into being of the National Health Services (NHS) was anything but a “historical accident” (and if it was, then anything can be, and the expression is meaningless). It is surely true that the physical structures, the public hospitals, were “already there” after WWII, a war during which hospitals had been built that provided publicly funded medical care for servicemen. Yet it is equally true, and arguably much more important, that around 1948 there was a confluence of critical political forces, not the least of which was the landslide victory of Labor over the Conservative Party.

How did this unexpected victory happen, despite the popularity won by Conservative British Prime Minister Winston Churchill as a “war leader”? It appears that as “national security” concerns subsided and hunger and unemployment began to take their toll over an impoverished population, Britons concluded that Labor, not Conservatives, would be more inclined and capable to guarantee “bread and butter” issues — what were increasingly seen as basic social rights, such as full employment, income security, public education, and health care. Popular demand for guaranteed basic rights was further strengthened by the success of socialist British Minister of Health Aneurin Bevin to secure the support of the medical establishment: in a masterful move, Bevin decided that offering well paid practitioners who agreed to join the NHS generous salaries would free them “from the necessity to drum up business from rich clients to pay for their basic income” (Glennerster 2007: 51). So if the birth of the NHS was a “historical accident”, it was certainly a very complex one.

So Gawande’s conclusion, given the glaring omission in his theory, is unsurprising: it is U.S. doctors, and their “culture”, the source of our high costs – doctors, that is, who respond to a perverse systems of incentives, which according to Gawande, is the way U.S. doctors are paid: more for doing more yet not better.

Now, while doctors may certainly be part of the problem, and while paying more for doing more, even if it is not good and frequently not necessary, is obviously a bad thing, why Gawande chooses to ignore the critical and obvious fact that no other industrialized economy, and many industrializing ones (like Taiwan) leaves over 70% of its population (even if Gawande has only counted 50%) at the mercy of profit seekers when it comes to financing medically necessary care is anybody’s guess. (Elsewhere I have laid out, and many other excellent policy analysts, like PNHP doctor Don McCanne, have, why the only way to eliminate financial barriers to medically necessary care is treating health care as a social right and financing it collectively, through a tax-based or social insurance system, incidentally the only way to allow the choices that matter – of doctors and medical establishments, not “health plans” or “preferred providers” lists).

But maybe had Gawande acknowledged the obvious, I suspect that his New Yorker article, where he insists that whether insurance is public or private (we are not told whether the profit motive matters) is not that important after all, would not have never become “required” reading in the White House. Indeed, he even might have been kicked out of the sanctuaries where our health care future is being written (or cooked!), as was the case with many brave doctors (Dr. Margaret Flowers comes to mind), who keep on insisting that our politicians do what we pay them to do: put  ordinary people’s welfare before corporate interests and profits.

Pro-single-payer physicians call for defeat of Senate health bill

A national organization of 17,000 physicians, Physicians for a National Health Program, who favor a single-payer health care system, called on the U.S. Senate today to defeat the health care legislation presently before it and to immediately consider the adoption of an expanded and improved Medicare-for-All program.

Because of the urgency of the matter, we feel it is important to reproduce the letter in its entirety.

Click here to sign a petition demanding the Senate to drop the bill and pass real health care reform.

To the Members of the U.S. Senate:

It is with great sadness that we urge you to vote against the health care reform legislation now before you. As physicians, we are acutely aware of the unnecessary suffering that our nation’s broken health care financing system inflicts on our patients. We make no common cause with the Republicans’ obstructionist tactics or alarmist rhetoric. However, we have concluded that the Senate bill’s passage would bring more harm than good.

We are fully cognizant of the salutary provisions included in the legislation, notably an expansion of Medicaid coverage, increased funds for community clinics and regulations to curtail some of private insurers’ most egregious practices. Yet these are outweighed by its central provisions – particularly the individual mandate – that would reinforce private insurers’ stranglehold on care. Those who dislike their current employer-sponsored coverage would be forced to keep it. Those without insurance would be forced to pay private insurers’ inflated premiums, often for coverage so skimpy that serious illness would bankrupt them. And the $476 billion in new public funds for premium subsidies would all go to insurance firms, buttressing their financial and political power, and rendering future reform all the more difficult.

Some paint the Senate bill as a flawed first step to reform that will be improved over time, citing historical examples such as Social Security. But where Social Security established the nidus of a public institution that grew over time, the Senate bill proscribes any such new public institution. Instead, it channels vast new resources – including funds diverted from Medicare – into the very private insurers who caused today’s health care crisis. Social Security’s first step was not a mandate that payroll taxes which fund pensions be turned over to Goldman Sachs!

While the fortification of private insurers is the most malignant aspect of the bill, several other provisions threaten harm to vulnerable patients, including:

* The bill’s anti-abortion provisions would restrict reproductive choice, compromising the health of women and adolescent girls.

* The new 40 percent tax on high-cost health plans – deceptively labeled a “Cadillac tax” – would hit many middle-income families. The costs of group insurance are driven largely by regional health costs and the demography of the covered group. Hence, the tax targets workers in firms that employ more women (whose costs of care are higher than men’s), and older and sicker employees, particularly those in high-cost regions such as Maine and New York.

* The bill would drain $43 billion from Medicare payments to safety-net hospitals, threatening the care of the 23 million who will remain uninsured even if the bill works as planned. These threatened hospitals are also a key resource for emergency care, mental health care and other services that are unprofitable for hospitals under current payment regimes. In many communities, severely ill patients will be left with no place to go – a human rights abuse.

* The bill would leave hundreds of millions of Americans with inadequate insurance – an “actuarial value” as low as 60 percent of actual health costs. Predictably, as health costs continue to grow, more families will face co-payments and deductibles so high that they preclude adequate access to care. Such coverage is more akin to a hospital gown than to a warm winter coat.

Congress’ capitulation to insurers – along with concessions to the pharmaceutical industry – fatally undermines the economic viability of reform. The bill would inflate the already crushing burden of insurance-related paperwork that currently siphons $400 billion from care annually. According to CMS’ own projections, the bill will cause U.S. health costs to increase even more rapidly than presently, and budget neutrality is to be achieved by draining funds from Medicare and an accounting trick – front-loading the new revenues while delaying most new coverage until 2014. As homeowners seduced into balloon mortgages have learned, pushing costs off to the future is neither prudent nor sustainable.

We ask that you defeat the bill currently under debate, and immediately move to consider the single-payer approach – an expanded and improved Medicare-for-All program – which prioritizes the advancement of our nation’s health over the enhancement of private, profit-seeking interests.

Oliver Fein, M.D., President
David U. Himmelstein, M.D., Co-founder
Steffie Woolhandler, M.D., M.P.H., Co-founder
Physicians for a National Health Program

************

Physicians for a National Health Program (www.pnhp.org) is an organization of 17,000 doctors who advocate for single-payer national health insurance. To contact a physician-spokesperson near you, visit www.pnhp.org/stateactions or call (312) 782-6006.

A response to Paul Krugman’s “message to progressives”: “Mr. Krugman, please let the Senate (and House) bill die”

So experts like Paul Krugman recommend that “we” progressives “take a deep breath”, set our ideological quibbles aside, and “pass the health care bill” (“Pass the Bill”, December 17, 2009, A. 35).

Not that Krugman thinks that the bill is good. Far from that, he grants that it is “way short of ideal” — that, indeed, the senators who crafted it may be motivated “largely by a desire to protect the interests of insurance companies” or, in the case of Senator Lieberman, by “sheer spite”.  He further grants that in some cases, such as in financial matters, there is little to lose by letting die a bill that waters down financial reform to the point of meaninglessness. And yet,  he fails to see that health care is in this respect no different from finance.

Remarkably, and his Nobel Prize in Economics notwithstanding, Krugman reasons fallaciously. He tells us that the case of the Senate (or House) bill is comparable to Social Security, a social insurance system that, while born “imperfect”, has become the bedrock of retirement stability for Americans.

But the healthcare bills are not social insurance – and Krugman should know this much. Social insurance systems are cooperative systems of savings, whose primary goal is to meet a basic need, and where profit plays no role. This is for instance the case of single payer health care, a Medicare for All type system that pools risk widely and is financed through a fixed and predictably affordable proportion of everybody’s income, and whose goal is to eliminate financial barriers to medically necessary care.

In contrast, both the Senate and House bills are blatant sellouts to corporate interests that, as Rep. Eric Massa compellingly argued, will “enshrine in law the monopolistic powers of the private health insurance industry” by making it a federal crime, for the first time in American history, to not buy their products.

Maybe it is Krugman who should learn from history. If he did, he would learn that Otto von Bismarck, first chancellor of the German Empire, implemented the first government-sponsored social insurance system (back in 1883) not because he cared about the welfare of workers (at least not necessarily) but rather because he considered their social insecurity to be “a peril to the state”. Bismarck had learned that much from the (failed) 1848 Revolutions and the Paris Commune, which showed him that distressed workers meant business.

History would also teach Krugman that the British government implemented “socialized medicine”  heeding the advice of a lord and in the aftermath of WWII, with an economy in shambles and confronted with  the danger of great social unrest. Or he might learn that more recently Taiwan passed single payer health care (from scratch, basically) because the party with a Parliamentary majority would have otherwise been voted out of office by an opposition that supported single payer.

Were Mr. Krugman able to learn from history he would learn that no major progressive legislation tending to greater social justice and equity passed without a fight, elsewhere or in the United States. He would also learn that what makes legislation politically feasible is not what politicians are willing to do – it never has been – but rather the cost of their not doing what their constituents demand.

Yes, I suspect that if Krugman learned from history his “message to progressives” would be quite different.

People’s Health Movement and US Health care Reform: Letter in Lancet

This week’s edition of the Lancet (12/5/2009) features a letter to the editor about US health care reform written on behalf of the US People’s Health Movement.  We were very pleased that the Lancet chose to feature a quote from the letter on their cover:

“The health-care reform process exposes how corporate influence renders the US government incapable of making policy on the basis of evidence and the public interest.”

The text of the letter can be read at this link.

American exceptionalism?

One of the many curious things about the current health care reform debate in Washington is the extent to which the US is considered to be  outside of the community of nations.  We are judged by our own standards and can learn only from our own experiences.  This phrase is neatly captured in the desire for a “uniquely American solution” to health care. (See our prior posting about “misleading messaging” and the failure of health care reform).

But what are we to say about a health care “solution” that will deny women abortions, deny care to undocumented workers and their families, not provide universal health care, and not recognize a right to health?  What are we to say about a health care system delivered up to the insurance companies and big Pharma?  Isn’t this really just a “uniquely corporate solution” to health care?

In the letter we suggest something different:

There is no excuse for the USA not to adopt a system like any of those in many other countries that cover everyone and control costs—systems that better integrate public health and individual medical care. Without such a system, comprehensive primary health care will not be implemented, nor will the social determinants of health be effectively addressed.

The belief in US exceptionalism must be laid to rest. People living in the USA are as entitled to the right to health as others, and the USA should be accountable to the same standards as any other country.

The People’s Health Movement (PHM) was established in December of 2000 in Bangalore to keep alive the goal of “Health Care for All.”  It is an organization of activists, academics, and grass roots organizations from around the world.  The website of the US circle of the PHM is at http://www.phm-usa.org/

posted by Matt Anderson, MD (a co-signator)

Public Health & Social Justice Website

The work of Dr. Martin Donohue is no stranger to the portal.  (See our previous postings on GE, NY-Presbyterian Hospital & the Hudson River Clean-up and Alternative Valentine’s Day: No gold, No diamonds, No flowers?)  He wrote to us recently that he has updated most of the presentations on his website Public Health & Social Justice.  He noted that: “as always, the powerpoints are open-access, and I am always looking for submissions from health professionals at all stages.”

Here are some of our favorite selections from the dozens of slideshows, articles, and syllabi available on the site:

• The syllabus from Dr. Donohue’s  Public Health and Social Justice Course. How can one fail to be intrigued by a public health course that starts with a reading of Michael Parenti’s How Wealth Creates Poverty in the World?  A listing of slideshows and papers from this course can be found at this link.
• A slideshow on the the links between Luxury Care & Academic Medicine.  This includes a discussion of strategies adopted by cash-strapped academic medical centers such as paying to provide care to sport teams in return for publicity, recruiting high-income foreign clients, and creating boutique clinics (such as travel clinics for travel to exotic locations).
• An article, by contrast, from the Journal of Health Care for the Poor and Underserved on the health problems of migrant and seasonal work.
• A slideshow on Scans and Scams discussing “direct-to-consumer marketing of unnecessary (and potentially harmful) screening tests; also covers CT scan controversies and health care fraud.”
• An entire page of articles devoted to the “adverse health, environmental, and human rights consequences of flowers, gold, and diamonds.”  It is important to note that Dr. Donohue offers alternative ways of offering tokens of love.
• An article on The history of hysteria from which we learn: “Egyptian papyri from 1900 B.C. (the Kahun Papyrus) recount curious behavioral disturbances in women (chronic fatigue, difficulty seeing, diffuse myalgias) thought to be caused by a wandering uterus. Symptoms were thought to result from the crowding of other organs when the uterus ascended into the abdomen. The belief that the uterus behaved as an autonomous, maverick organism within a woman led to treatments based upon that, such as fumigating the vulva with precious and sweet-smelling substances to entice the uterus back into the pelvis, while repelling it from the upper abdomen by ingesting foul-tasting foods or inhaling putrid smelling substances.“

posted by Matt Anderson, MD

Herndon Alliance’s misleading messaging leads to failure of health care reform

Over the past several years, in almost every meeting I’ve attended about health care reform, someone has suggested using “messaging” strategies to communicate more effectively. They often mention the Herndon Alliance as a resource. Herndon has been described as “the most influential group in the health arena that the public has never heard of … the messaging arm of a vast center-left infrastructure pushing health care reform.” But I’ve concluded that over reliance upon messaging strategies in general, and on message recommendations from the Herndon Alliance in particular, is a main reason real health care reform will fail this year.

“Messaging” uses techniques from public relations and cognitive science that tap into people’s values and beliefs in order to create an emotional reaction that leads to opinion or behavior change. Sophisticated messaging relies upon in-depth research through surveys, focus groups and other methods to discover clusters of values and beliefs that groups of people share. Any individual tends to fall into one of these clusters. Communications can then be tailored to reach particular groups. There is no doubt that these techniques can be effective in changing minds because they are the same techniques that sell us new cars and shoes every year. They can be used to promote anything without regard for the truth or evidence. For people working for social justice this kind of strategy can never be effective.

One of the tenets of the messaging strategy is that most people don’t reach opinions based on evidence or facts. Herndon’s specific messaging strategies discourage any mention of facts. Since it is always easier to sow doubt than confidence about any change, messages with no connection to fact or reality give an advantage to the status quo. People’s beliefs are often not based upon learning but on misperceptions acquired through individual experience, the grapevine and the media. Catering to these beliefs and values means reinforcing them, even if they are untrue or against the general welfare.

Progressives are angry about the tales of “death panels” spread by the right wing. However, the messages Herndon promotes are also misleading. Not in the outrageous way that right wing messaging is, but untrue just the same. A current statement recommended by Herndon is, “Reform will give us the freedom of secure choices—to keep our plan and doctors, to choose another private plan, or the choice of a robust public health insurance option.” As it looks now, this statement is false. It is likely that only people without insurance from their employer will have the option of choosing the public plan – if there even is a public plan. If you get insurance through your employer, your employer chooses your plan options, and can switch them at any time.

Trudy Lieberman, in Columbia Journalism Review, noted another misleading Herndon frame.

(Herndon) advises: “Don’t just say ‘bring costs down,’ … It is better to say ‘health care reform will make health care AFFORDABLE—it will cost less and you will get more.” Hey guys, that’s not likely to happen if the current nostrums for reducing medical costs remain the only ones on the table. As for getting more? The current trend in health insurance—shifting costs from insurers and employers to policyholders—means thousands are getting fewer benefits, not more.

The Herndon messaging suggestions are worded this way because their goal is to get people to accept whatever ends up emerging from the legislative meat grinder as “health care reform”. Rather than messaging about specific demands, they use words with highly positive associations to state what health care WILL do: “You will have the choice of a QUALITY affordable public health insurance plan.” This phrase doesn’t explain what characteristics a QUALITY public plan should have so that people can demand those characteristics from the congress.

There is no guarantee that the health care system we get after the legislation passes will be anything like the Herndon Alliance says. Even if people agree with the messages, they also hear the claims made by Republicans. They (rightfully) don’t trust the congress to deliver what is best for ordinary people. The health care reform debate becomes a competition between which set of misrepresentations you want to believe in. And with a third of Americans illiterate or barely literate, and most getting their news from television, they don’t have any rational basis on which to decide.

Messaging works most effectively on an uninformed disempowered population and serves only to further disempower them. The Herndon Alliance disconnects people from real potential solutions to the US health crisis with messages like, ‘Health care reform will be a uniquely American solution.” This reinforces the already deeply ingrained and harmful belief in American exceptionalism, preventing people from learning from the experiences of other countries where there are better health systems.

Even health care reform activists seem to get confused by these messages. They begin to think of messaging recommendations as true statements about the actual legislation or as policy recommendations. Because of the language about “keeping your plan if you like it” some activists, are losing sight of the fact that what people really want is to be able to keep or choose their medical providers. Beyond that, “progressive” activists shouldn’t be promoting the idea of keeping your private insurance as characteristic of good reform when the private insurance system is the problem in the first place.

I am not arguing that opinion and values research isn’t useful to help activists understand what the general population or subgroups are thinking. But activists shouldn’t be so naïve as to accept the analysis and recommendations of one group without considering that group’s political goals. All opinion research is biased by the questions that are asked and the way they are asked. (I won’t critique Herndon’s research because it has been done elsewhere: HERE and HERE). Although it claims to be non-partisan, Herndon has very close ties to the Democratic Party. Democrats are the recipients of huge amount of money from the insurance, health care and pharmaceutical industries. Most analysts agree that failing to pass some kind of health care reform legislation will be a huge blow to the party. They have to pass something and Herndon has its own ideas about what it wants. What they specifically don’t want is national health insurance (single payer) and all of their messages are designed to keep people from considering that idea on its merits and convince activists that Americans don’t support it.

Like the founding and board organizations of Herndon Alliance, Families USA, Health Care for America Now (HCAN), AARP, and SEIU, most of the approximately 200 Herndon Alliance partners are groups that either have never supported a social insurance or single payer model, or are so convinced it is not politically feasible (some sincerely and some not) they will support almost any other reform when faced with a choice. Many have actively undermined campaigns for single payer that would have had a chance for success – if all “progressives” stuck together. The same scenario we are going through nationally has happened repeatedly on the state level with the same groups. Although their goal is “high-quality, affordable health care for all Americans,” the specific policies they push are those that increase access by increasing the flow of money from individuals and the government to the private insurance and pharmaceutical companies. Families USA, SEIU, and AARP are part of the PR front groups Healthy Economy Now and Americans for Stable Quality Care that also include Pharmaceutical Research and Manufacturers of America (PhRMA), the American Medical Association, the Business Roundtable, and the Federation of American Hospitals. These coalitions have presented millions of dollars of TV commercials promoting health care reform using the same warm and fuzzy misleading language as Herndon.

The climate for health reform this year is different for one reason: the rate of profit that insurance and pharmaceutical companies are making has reached its limit in the US. They need more customers to keep growing. The current health care reform increases profits by 1) requiring people to buy insurance products 2) providing government subsidies so they can actually afford the products. Even the so-called public option, since it is completely undefined (and has functioned as a marketing slogan, a bargaining chip, and a red herring for opposition), can easily be structured to channel public funds into private profits. For example, it could be modeled after some state employees’ health plans, where the government subsidizes private health plan coverage, while assuming the financial risks involved

The question remains why so many self-identified progressives are buying the Herndon Alliance strategy and message. Some just haven’t taken off the glasses and are themselves manipulated by Herndon rhetoric. Some are looking for a way to change opinion without doing the hard work of political education and consciousness raising. For the rest, Helen Redmond had a good explanation in Counterpunch.

For the Democrats, with the exception of John Conyers and a few others, they simply don’t want to abolish the private insurance industry. They are capitalists and believe in the capitalist system that makes health care a commodity to be bought and sold. For them, health care is not a human right. And importantly, they don’t want to take on President Obama who is opposed to single-payer. Like the  true cowards they are, they will not oppose Obama on health care reform even though they disagree with him.

HCAN thinks it’s impossible to get rid of the insurance companies, they’re too powerful, and they have too much money and influence. They don’t believe a large social movement can be built to take on and win against the insurers and the government. The leadership of HCAN are the ones who would have said under slavery, “We can’t win abolition, so let’s settle for a few reforms that make the lives of slaves more bearable.”

Public relations strategies are the antithesis of a human rights based or social justice approach. Social justice requires meaningful participation by people affected by a problem. Meaningful participation means that people must have the capacity to engage in advocacy for themselves. They need to participate in identifying the problem and its causes, and be supported with the tools and resources to understand it. Then they must be engaged in making demands on their representatives, government or other duty bearers. These citizens will be resistant to PR manipulation by any party. With our government seemingly incapable of making policy based upon evidence and the general, rather than corporate, welfare, there are no shortcuts to social justice.

Is CVS price gouging cancer patients?

Among the most popular posts on the portal have been those in our series on Free and Low Cost Health Care.  In this post I  would like to emphasize the importance of comparison shopping for medications.  Prices for the same medication can vary dramatically from pharmacy to pharmacy.  I would like to illustrate this by sharing the story of one of my patients.

An unpleasant experience at CVS

The patient was an 80 year old woman who had just undergone her first round of chemotherapy for cancer. Her physician prescribed Ondansetron, the generic version of Zofran, an anti-nausea drug used primarily in cancer treatment.  Ondansetron is generally taken twice a day and the physician prescribed sixty 8 milligram pills in anticipation that the patient would undergo multiple rounds of chemotherapy.

When the patient went to pick up the prescription at her local CVS she was asked to pay $900. When she demurred from what seemed like an excessive price, the pharmacist offered to supply a lesser quantity of pills – 10 for $150. This was still the same price, but a lesser quantity of pills.  The patient was informed that all pricing of drugs was done centrally by CVS and that nothing could be done at the store about the price. She left the pharmacy and asked me for assistance.

I checked my Epocrates software and learned that thirty 4mg Ondansetron tablets were available on drugstore.com for about $39.99. The equivalent price for this patient’s prescription (120 4mg tablets) would be $160, not $900. To verify that this was a fair price I called a local pharmacy I use frequently in the Bronx and asked them how much they charged for sixty 8 milligram tablets.  I was told that they could sell this for $135, perhaps less if my patient did not have much money. When I mentioned the CVS price of $900 the pharmacist remarked, with a touch of irony, “that’s quite a mark-up.”

The “mark up” in this case meant that CVS charges roughly six times what other pharmacies are charging.  I would consider this to be price-gouging (“pricing much higher than is considered reasonable or fair“).  It is particularly concerning that the victim of this was a vulnerable elderly patient undergoing her first round of chemotherapy.  Fortunately, she was able to get her medicine for considerably less at a pharmacy I recommended.

CVS responds

I wrote to CVS about this case and here is the gist of their reply:

1.  CVS’s two primary drug chain competitors charge more for Ondansetron.

Learning that three of the major pharmacy chains all charge six times the going rate for Ondansetron is hardly reassuring.  And, as I never tire of repeating to my sons, “the fact that someone else gets away with doing something wrong, doesn’t mean you should do it.”

2. CVS also sells other anti-nausea medicines (notably Prochlorperazine and Promethazine) at considerably less, about $10 for a ninety day prescription.

This may well be true, but what exactly does it mean for my patient? Certainly, CVS cannot suggest that she should have exercised some type of medical judgment that Promethazine (a drug she undoubtedly never heard of) was equivalent to the medicine prescribed by her oncologist. Should she have had the oncologist paged at 6PM to request a cheaper medicine? And what if the oncologist had stated that drugs like Ondansetron  are considered among the drugs of choice for chemotherapy related vomiting? (See, for example, The Medical Letter, 12/15-29/2008)

3. Finally, CVS noted that it provided a variety of other services, such as expanded hours and online prescription ordering, that were not offered by its competitors.

Yes, but do such services justify these prices?  And will my patient be making an informed choice when she spends the extra $700 plus dollars for the CVS extras?

Let the buyer beware

The most important lesson of this story is that drug prices vary dramatically from store to store.   The chain stores are not always the cheapest. And, as many patients learn, you might have better luck bargaining with a local pharmacist.

What are the larger implications of this case?

As the debate over health care reform rages in Washington, it is important to keep in mind the fundamental question we face:  Is health care just another commodity (like bricks or toothpaste) or is it a human right?

The social argument for making health care a commodity is based on the idea that market rationality will create an efficient health care system.  Individual consumers guided by rational self-interest will make wise choices, rewarding efficient health care suppliers with their patronage and punishing inefficient health care suppliers. Of course, no actually existing health care system is run this way.  And there are many ways in which health is not like a commodity. Nonetheless, the belief that rational markets will create efficiency in health care is behind many recent reforms internationally and the current proposals to have insurance companies administer the US health care system.

But a case like that of this patient shows several of the weaknesses of this argument.  Having just received her first session of chemotherapy and without any medical expertise, this patient was particularly vulnerable and clearly  in no position to make the presumably rational choice of – for example – calling up a variety of pharmacies to ask for alternate prices.  Or of calling up her oncologist and querying her oncologist’s medical judgment.  Or of deciding that she would prefer more nausea to less money.

Indeed, can there be an economically rational choice with respect to nausea versus money?

It might be argued that the responsibility for economic rationality lies with the physician, not the patient.  But in this case the physician had prescribed a generic medication, an economically rational choice.  Is one really to expect physicians to know the prices of all the medications they prescribe at all the potential pharmacies their patients visit?

This is a dramatic case, but the issues are similar in less dramatic ones.

Wouldn’t the rational thing be for the government to assure that people get the drugs they need and negotiate real prices with the drug companies?  This solution is not without its own set of problems, but surely they are better than what happened to my patient.

A suggestion for action on this issue:

This story is old news.   In August of 2004, the (then) New York State Attorney General Elliot Spitzer released a survey of drug prices in the state and documented “Sharp Price Differences … in Common Prescription Medications.” To remediate this situation the Attorney General’s office set up a website that would allow consumers to comparison shop the 150 most common drugs: http://rx.nyhealth.gov/pdpw/.  Other States have undertaken similar initiatives.

And yet the price disparities continue to exist.  Perhaps this should be one of Project Censored’s top censored stories.  They take nominations at this link.

Disclaimers

The patient in this case graciously provided me with permission to share her story.  I have no financial interests in any pharmaceutical company or drug store chain.  I would not want readers of this column to construe this story as a specific endorsement of drugstore.com.  Buyers should beware, always.

posted by Matt Anderson, MD

A day in the life of a primary care physician: prior authorizations, denials, and delays in treatment.

The national debate on health reform has uncovered innumerable “health care horror stories” in which cancer patients worry more about their bills than their malignancy or where pregnant women are laid off and dropped from their insurance soon before their due date.  These stories are tragic, and unconscionable for the richest country in the world, however, as a physician, this is not my typical experience.  Instead, what I see every day is patients with private health insurance who cannot afford the copays for their medications, delays in treatment as I grovel for prior authorization with a non-physician utilization reviewer, and patients stuck with huge bills for routine services that they thought they were covered for.

In my practice, patients have a mix of private and public coverage.  While I work with some extremely impoverished patients who qualify for public insurance through Medicaid, it is the people with employee sponsored private insurance who are most at risk for roadblocks to care.  As a primary care physician, it is hard enough to fit all of the recommended screening, health education, and chronic disease management that complex patients need into a fifteen minute visit.  When the burden of battling with insurance companies is added to the equation, there is no way that I can succeed.  My patients, especially the ones with private insurance, are forced to deal with the high copays, denials of claims, and delays in care.

Reflecting on the past week, a bunch of cases come to mind.  While these stories may lack drama, it is nonetheless troubling to me how frequently my treatment recommendations are impeded by difficulties with health insurance.  And I am sure my patients are not alone in suffering the consequences:

Ms. D, came in Wednesday.  She has high blood pressure and very high cholesterol.  I had not seen her in over six months, but she works a demanding job, so I figured that she had just been busy.  In the office, we did not talk about her blood pressure.  We did not talk about diet and exercise.  She had not followed up for so long because at the prior visit I had sent her for an echocardiogram of the heart and she was billed $800 for the test.  Her insurance would only cover $200.  We spent the entire visit talking about how she could not afford to pay this bill.  I just don’t get it.  She has private health insurance.  She was having symptoms that had been worsening over several visits and needed further evaluation – exercise intolerance and palpitations.  Now, she is receiving daily letters from a collections agency, and she is frightened to come to the doctor because of the bills that may show up in the mail.

Mr. D, a security guard with diabetes, hurt his knee while fishing and had severe pain and swelling.  When I initially saw him a few weeks ago, there did not seem to be any major structural damage to the ligaments, so I recommended a conservative approach with rest, ice, and anti-inflammatory medications.  Now, several weeks later, the pain and swelling had not subsided, so I ordered an MRI to evaluate for more subtle damage to the knee.  After several attempts at prior authorization, the private insurance company refused to pay for the test.  Baseball players get MRIs the same day for any bump or bruise, but even going through the appropriate prior authorization process, I could not order an MRI for my patient with private health insurance.  I am not looking forward to all the phone calls that it will require to protest this denial of necessary diagnostic test.

On Thursday, Mr. F came in to have his blood checked.  He requires blood thinners to prevent recurrence of blood clots which could be fatal.  He has twice previously had clots in the blood vessels of his calves, and he once had a blood clot travel to his lungs.  He has a clotting disorder that makes any break in treatment with the blood thinners extremely dangerous.  Warfarin is an effective and inexpensive blood thinner, but it requires frequent monitoring because its activity is affected by numerous interactions with other medications and foods.  His blood test showed that the warfarin was not doing its job, so I recommended an increased dose.  It takes about three days for the dosage change to have a full effect, so I also recommended injectable blood thinners, which act more rapidly, until we could demonstrate that his warfarin had reached a therapeutic level.  However, he could not afford the copay for the injectable blood thinner, so he must hope that he does not develop another blood clot as we wait for the higher dosage of warfarin to take effect.

Yesterday, I saw Ms. E for a follow up appointment.  She is only in her 30s but has already had major back surgery for a disk problem.  She stands for six hours a day at work and has recently had worsening of her back pain.  Her spine specialist had recommended physical therapy, instead of a repeat operation, but she cannot go because her private insurance company requires a copay for every session.  She has been unable to work because of the worsening pain, so she cannot afford these copays and has not been able to follow the treatment plan.  I do not want her to become dependent on pain killers, but since the treatment recommended by her orthopedist is not a realistic possibility, we are running out of options.

I could fill many pages with stories like these of my patients whom are hard working, have private health insurance through an employer, but just cannot get the care that they need, because of unreliable coverage.  It frustrates me that executives of health insurance companies spend millions on advertising to disparage public health insurance, and Republican politicians are stone walling meaningful health care reform because they are afraid that a public health insurance option would put private health insurance companies out of business.  I do not care who provides health insurance for my patients.  Whether they have public or private insurance, I just want them to get the best care possible.  If private health insurance companies provide a high quality product, they will not be “forced” out of business by a public plan.  It makes sense that competition between a public plan and private plans would lower costs, improve quality, and guarantee an option to those who do not have employer sponsored coverage.  As a physician, I need to advocate for my patients.  Private health insurance companies have thousand of lobbyists and millions of dollars to spend.  So why do these companies need so many politicians, including Democrats, advocating for them as well?  This is not about ideology.  It’s about patients who cannot afford their medications or who face bankruptcy due to medical bills.  We need meaningful change and we need it now.

- Aaron Fox, MD