The Social Medicine Portal

MASSACHUSETTS: Doing the same thing and expecting different results

There has been much talk about Massachusetts since the victory of Senate Republican Scott Brown. Many have suggested this victory was a referendum on the Democrat’s health care reform “overhaul” awaiting a unified bill to be signed by President Obama. The centerpiece of this plan is a mandate, i.e., a legal obligation to buy health insurance, with subsidies for eligible groups, or else face a fine.

But what is the reform law enacted as Chapter 58 of the Acts of 2006 that Mr. Brown has inherited anyways? Is it really the “universal coverage” it was promised to be?  The short answer is “no”.

The momentum for reform in Massachusetts in 2006 was spurred by the Bush Administration, who was insisting that the state reduce block funding of indigent care through the state’s free care pool or lose $385 million of Federal Medicaid funds. The state has an Uncompensated Care Pool that provides funds to hospitals and community health centers that deliver care to those without insurance coverage.  This pool is funded by assessments on hospitals, health insurance premium taxes, and federal matching funds. As the number of uninsured people rose significantly in 2006, the financing for the pool became fragile and the Bush Administration threatened their federal funds if Massachusetts failed to reduce the money spent on “free care”.

So, with 657,000 uninsured residents, or 10.4% of the population, the Massachusetts Health Care Reform Act was born.  At its center is The Connector, an independent state agency offering a “menu” of private insurance plans and assisting individuals obtain their insurance. For residents at or below 300% of the Federal Poverty Level (FPL), The Connector offers “Commonwealth Care”, where “customers” can choose a subsidized health plan based on a sliding scale.  So this should expand people’s health care choices, right? Wrong. Not if your employer offers insurance. If so, you are not eligible for these subsidized plans.  For all other residents above 300% PFL, and for small employers, The Connector offers “Commonwealth Choice”, a series of regulated, non-subsidized private plan options.  Truly American, “Commonwealth Choice” allows you to choose from the Gold, Silver, Bronze, or Young Adult plans, so-rated depending on how comprehensive they are. But the bottom line is: you get what you pay for.

By way of example, the cheapest plan available to a middle-income 56-year-old now costs $4,872 annually in premiums.  However, if the policy holder becomes sick, he or she must pay an additional $2,000 deductible before the insurance kicks in.  Thereafter, the policy holder pays 20% co-insurance, (20% of all medical bills) up to a maximum of $3,000 annually.  This totals to $9,972 dollars, if heaven forbid, the policy holder becomes ill. And we haven’t even begun to talk about “uncovered services”, that “affordable” policies Massachusetts-style are full of. For those, you are on your own, as you were before.

The plan also includes an “employer mandate”, that is, employers have some obligation to contribute to the cost of insurance, in 2008 an employer could opt out by paying $295 per employee and an individual could opt out by paying $912 yearly – as a fine. These surcharges were predicted to yield $45 million dollars annually, but totaled only $5 million in the first year of the program.   In addition, individuals can apply to be excluded from the program, for “hardship waivers”, if they can prove at a court of law that there is no affordable option available to them. In 2009, 79,000 residents applied and were “exempted” based on these grounds. Or, in plain English, 79,000 individuals remained uninsured.

The financing for this reform comes from the fines mentioned above and funds diverted from the state “free care pool”, that is, from appropriations originally invested on safety net facilities for those without insurance.

Since 2006, the outcome from the Massachusetts reform has been costly and still has yet to address the issue of access to health care. Because, it is important to remember, health insurance is not health care, but rather a means to it. And whether insurance will or will not improve access to medically necessary care depends of course on what type of coverage it offers. In Massachusetts, as explained above, coverage depends on how much you pay, from “Cadillac” plans (if you have the money) to bare-bones plans, if you belong to the so-called generation of “invincibles” (the young, often cash-strapped).

In 2008 the cost of the program for the state, to pay the subsidies and administrative costs to run the program, was 1.1 billion dollars, and rose again in 2009 reaching 1.3 billion. More expensive than expected, the Connector itself adds an addition 4.5% administrative cost to each policy it brokers. To reduce the price for the state, even if not for patients, insurers have increased premiums and co-pays.  As mentioned above, last year, as premiums rose 9.4% in 2009, 79,000 people who were not eligible for the subsidized Commonwealth plans were able to prove that they could not afford any other plan.

The Massachusetts reform does not change the cost of purchasing health insurance. In addition, the funding for these new insurance policies has replaced the “free care” system that included safety net clinics where low-income residents could receive care.  Now these residents are required to pay co-pays at the clinics due to the elimination of state funding, and they simply can’t afford to do so.  Therefore, this mandate to purchase a private product doesn’t achieve universal access to health care nor does it reduce the financial burden of disease on low- or middle-income families.

Steffie Woolhander, a professor of medicine at Hardvard, calls private insurance a defective product, one that leads people to bankruptcy and at the same time doesn’t provide the health care they need.  She explains, “Once failure to buy health insurance is a federal offense, what’s next? A Ford Pinto in every garage? Lead-painted toys for every child? Melamine-laced chow for every puppy?”  The idea here she’s exaggerating is that forcing residents to buy a flawed product they can’t afford, and that doesn’t provide what’s it’s supposed to, i.e. relief the “financial burden of disease”, is not a way to provide health care. Further, this mandate to buy a faulty product is no way to deliver “universal coverage” and Massachusetts should provide ample evidence for this.

But then, one does not need the over 2000 pages of legislation produced either by Congress or the Senate to realize why this is so. A much briefer paper of only 15 pages, written back in 2003, by four prestigious Princeton economists explains it very clearly. They studied why it is that the United States spends more than any other industrialized nation on health expenditures for the same amount of care, and concluded that “It’s the prices, stupid!” We may want to add to these extraordinary prices the close to 400 billion dollars in administrative waste generated by an extraordinary system built upon the idea of avoiding to pay for the costs of health care: private insurance policies.

Isn’t it time for U.S. policymakers to stop doing the same thing and expecting different results? Yet for for some odd reason, our President and many in Congress are “urging common ground” to go exactly in the same direction. Change we can believe in? Hardly.

Attention Medical Students: CaPA Medical Student Fellowships Program is taking applications

The California Physicians Alliance (CaPA) would like to invite you to apply for the CaPA Medical Student Fellowship.  The fellowship is a phenomenal, one-year, full-time, PAID position to work on healthcare reform and advance the single-payer movement.  It is THE only fellowship of its kind in California and an incredible opportunity for those interested in health policy education, advocacy, and leadership.  For further details please see our ONLINE APPLICATION.

The DEADLINE for the application is March 15^th.

Please help us spread the word about this incredible opportunity by forwarding this email to:

1.     Friends and listservs.

2.     Deans and program directors.

3.     Local campus career services.

Please contact us at CaPA.Fellow@PNHP.org if you have any additional questions.

Thank you!

How many angels can dance on the tip of a pin? A comment on the New York Times’ Economix blogpost “Is Community Rating in Health Insurance Fair”?

With all the respect that Professor Reinhardt deserves, the question he poses in the New York Times’ Economix blogpost, “Is ‘Community Rating in Health Care Fair”?, is bogus – perfect economic nonsense, morality aside.

His own 2003 paper, “It’s the prices, stupid”, lay out why we have the highest health care costs in the world: it is, critically, because we pay the highest prices on the planet for services and goods that cost a fraction elsewhere. Additionally, as the professor surely knows, another big chunk is wasted by for-profit insurers’ pushing paper around to make sure that they can get away with paying as little for our medical needs as their campaign contributions will afford.

Not to mention the fact that because we are hopelessly divided as a nation into a gazillion pools and plans, we fail to cross-subsidize in publicly useful ways, namely, very broadly and randomly, so that the system can be financially sustainable. Even for-profit insurers cross-subsidize, but in their case they do so to make sure that they enroll the healthier (and cheaper) “customers”, so that they can bring increasingly handsome profits to shareholders. And they dump the sicker and poorer on increasingly strained public plans (and then blame Medicare or Medicaid for their “financial unsustainability”).

So if rather than insisting on “uniquely American solutions”, such as leaving to for-profit insurance the task of financing health care for the majority of Americans, we did what every industrialized nation in the world has done, namely, ban profit from the financing of medically necessary services (yes, even the Swiss, as of 1996, have concluded that “it’s the profit, stupid”), and move to a social insurance system, the scenario, indeed the prices, painted by professor Reinhardt would never occur, so the question would be moot: both group A and B members in his thought experiment would be very happy, I suspect, cross-subsidizing whoever happens to be sick at any given moment, at dirt prices (compared to what we Americans pay), and both groups would likely feel this is fairer than subsidizing health insurance shareholders and CEO’s fat paychecks. No less importantly, they would know that we (or our children) can follow the jobs of our dreams (or even start a business!), rather than limit ourselves to those that include “health benefits” (whose numbers are decreasing as we speak).

Put another way, everybody would benefit from substantially lower health care prices, none of us would see our health care money go to financing wasteful paper-pushing, and cross-subsidization would occur for the benefit of the overall public good, in the same way that it does for any number of other things, such as Fire Departments, public schools, or National Defense. And what is more, we would finally enjoy the freedom to choose what really matters: our doctors or medical establishments, rather than from within those euphemistic lists of “preferred providers”.

Everybody would benefit, that is, except from those who make a living either at the expense of Americans’ health or by sponsoring Orwellian health care debates tantamount to those in the Middle Ages attempting to establish the number of angels that can dance on the tip of a pin.

And do not believe those who tell you that it is your fault because of your unhealthy lifestyles: Britons spend a fraction of what we do — 95% of them never see a medical bill in their lives – yet there isn’t a shred of evidence that they go more often to the gym or eat more broccoli than we do (however recommendable broccoli and exercise might otherwise be).  And neither can “technology” or “aging population” be the whole story: if not, ask the Japanese, who use far more technology than we do, visit doctors substantially more often, and are substantially older than we are, yet pay 50% of what we pay.

Finally, don’t believe in those who tell you that social insurance is “politically unfeasible” either: when Otto von Bismarck started social insurance in Germany back in 1883, he did not do so because he was a socialist, but rather to defeat socialism, because he believed that “the social insecurity of the workers makes them a peril to the state”.

We can’t expect meaningful change from politicians or experts:

It’s really up to us.

The Case for Reform? Which Reform?

In closing 2009, the editors at the New York Times make a “case for (health care) reform”. They build their case on the well documented fact that millions in America are uninsured, that the for profit insurance sector is getting richer as more and more Americans go bankrupt because they cannot pay their medical bills, and that the “political timing is right” because the Democrats have the House, the Senate and the White House.

But the question remains, will “reform” Democrats-style save the day? And how exactly will it do it, and on the back of whom?

The best rebuttal of the New York Times position (which in this case reflects the position of the Democrat majority and the White House) that I could find was written by Dr. Don McCanne, senior policy analyst at Physicians for a National Health Program. Dr. McCanne argues compellingly that “the Times doesn’t get it”. It is well worth reading in its entirety.

The only point I can add to this otherwise brilliant analysis of the bill is that it is important to not lump “opponents of reform” in the same bag. And one should be weary of those who talk about “enemies of reform”, using emotionally loaded terms to substitute for good arguments and relevant evidence.

After all, there could be disagreements about whether administering aspirin to a patient is the right thing to do or not, but one person may argue that aspirin is the wrong thing to do because aspirin is never useful, and they would be wrong – it is very useful for some things — while another may argue that aspirin is useless because the patient has cancer, and they would be right – aspirin is useless in the treatment of cancer.

So while Radical conservatives argue that reform Obama/Congress style is bad because it would get “big government” between patients and doctors, the Medicare for All, single payer community argues that the House and Senate bills are bad because they will lock us in the grip of for-profit health insurers for years to come, by making it a federal crime not to buy their products (and even subsidizing with taxpayer money the buying of their products), while failing to control costs, and leaving millions uninsured or underinsured.

So is there another way to think about reform? Of course there is. It is called social insurance and it has been adopted beginning in the late 19^th century by every other industrialized economy with the glaring exception of us (yes, U.S.!).

The time to demand real change and to increase the cost on our representatives of not listening to ordinary Americans has come, and it is now.

Health care students in California can still join single payer advocates in Lobby Day, on Monday January 11. For more information and to sign-up for the two-day event click here.

Gold, Pacific Rim and “The Salvador Option” in El Dorado, Cabanas, El Salvador

Gold, Pacific Rim and “The Salvador Option” in El Dorado, Cabanas, El Salvador

A few years back, when the US was worrying about opposition groups in Iraq operating out of Syria, the proposal was made to attempt “The Salvador Option” (Newsweek, 1/10/05, see also The New Statesman at http://www.newstatesman.com/200501310012). Ah, what was that? Why, just as the USA did in El Salvador (and Honduras, under John Negroponte’s watch), a plan to create rogue death squads in Iraq with a license to kill. What was done from that suggestion, I don’t know, but the fact that it was even considered and that it was called “The Salvador Option” says so much about US foreign policy (during its proposal, John Negroponte was US Ambassador to Iraq) that we must highlight that plan and keep its consideration fresh to prevent such atrocities.

Tragically, the (El) Salvador Option has, for community environment activists, returned to the site of its name, this time with the unhappy association of a transnational mining company based in Canada and the United States by the name of Pacific Rim. For an interview covering the tragedies, please see Democracy Now (http://www.democracynow.org/2009/12/29/ ).

The summary is that on 26 December a 32 year old, 8 month pregnant environmental activist named Dora Alicia Sorto Recinos was shot while carrying another of her children (also shot, but who survived), making her death the second within one week of an environmental activist opposed to Pacific Rim reopening the currently closed mine of El Dorado, and the third this year. See www.cispes.org for details of Ms. Sorto Recinos’ death and that of Ramiro Rivera, vice-president of the local Environmental Committee, who was killed on 20 December in front of his daughter, despite the police escort with him since he was shot 8 times last August. A 52 year old woman riding with him was also killed.

The first environmental and community activist killed was Marcelo Rivera (no relation to Ramiro Rivera), a teacher and cultural center director who was abducted 18 June 2009 and found dead a few weeks later in a well, his body showing signs of torture. See “The Mysterious Death of Marcelo Rivera” on Youtube, http://www.youtube.com/watch?v=yvXm52BhSHQ .

Pacific Rim, with golden tongue, has denied having anything to do with the death of Marcelo (see its official statement at http://pica-blog.blogspot.com/2009/09/pacific-rim-responds-to-report-about.html  and its official plan of exploitation of El Dorado at http://www.pacrim-mining.com/s/Eldorado.asp ).

Pacific Rim, which was denied its permit to extract gold in El Salvador in April 2009, largely due to the efforts of Marcelo Rivera, has since applied for arbitration under the US-Central America Free Trade Agreement (CAFTA) to obtain millions of dollars in compensation for the closing of the mine. You can read the report that drew the Pacific Rim denial, published on13 August 2009 by Real News, available at http://therealnews.com/t/index.php?option=com_content&task=view&id=31&Itemid=74&jumival=411 For deeper exploration of corporate greed and how trade trumps health and the environment in international treaties, see NOW with Bill Moyers on “Trading Democracy” at http://www.pbs.org/now/transcript/transcript_tdfull.html

“The Salvador Option” is an unhealthy one for all concerned, including for environmental and community activists in Cabanas, El Salvador, which is contiguous with Honduras. Authorities from El Salvador, Canada and the USA must work to get to the bottom of who is killing environmentalists in Cabanas, and stop the killing. If this is happening in El Salvador, it is happening to all of us, everywhere.

Southwest Trip by US students studying medicine in Cuba

Readers of the Portal may be interested in the blog set up by US students studying medicine at the Latin  American Medical School (ELAM) in Havana.

Starting at the end of July, twelve ELAM students went on a two week tour of the Southwest United States. Their intent was to publicize the school, work as volunteers and make contacts in the health community.  The blog – which contains information about the students and the school  -  is located at: http://saludswexchange.org/

posted by Matt Anderson

Morris Heights Birthing Center – a rare gem

On 8/11/09 a group of 21 physicians and medical students from Montefiore’s Social Medicine program (Family Medicine, Pediatrics and Internal Medicine) went to visit the Morris Heights Women’s Health and Birthing Center.  Located in the southwest Bronx, it is not only one of its kind, but is also turning into an extinct concept in the New York area.  It is the only current free standing birthing center in the metro area offering an alternative to hospital births for women with low-risk pregnancies.  The Morris Heights Women’s Health and Birthing Center was also the first birthing center located in an urban underserved neighborhood, opening its doors in 1989.  The history of birthing centers stems back to the 1970’s with a movement by nurse-midwives to create a place where family-centered normal birth could occur with greater personal attention and less medical intervention.  Birthing centers create a “home-like atmosphere” where the woman, with the support of her family and friends, is encouraged to move around during labor, sit in the Jacuzzi tub, eat and drink, be periodically monitored/examined by the midwife and assisted through labor and delivery.

At the Morris Heights Birthing Center, women receive all their prenatal care from midwives with an OB-GYN available for emergencies or consultations. There are strict criteria to be deemed a low-risk pregnancy to be a patient at the birthing center.  The midwives provide prenatal care, perform the deliveries and initial neonatal physical exam, and see their patients back within 3 days of delivery.  Visiting nurses go to the home to check on mom and baby every day leading up to the first follow-up visit.  There is a connection with Bronx-Lebanon Hospital in the event a woman needs to be transferred for a variety of possible complications (fever, arrest of labor, c-section, bleeding, etc.).  Women stay on average 14 hours after delivery and the hospital transfer rate is approximately 18%. Overall, the notion of birth as a normal process and not a medical condition is what’s emphasized.

As ideal a place the birthing center is for low-risk pregnant women to deliver, it continues to face an uphill battle, especially being in New York.  The historical tension between midwifery and OB-GYN still exists today, but now with a heightened medico-legal arena.  One would think that larger medical institutions would catch on to the economic savings that comes from birthing centers, especially with length of stay always on their minds.  And one would hope women would desire less intervention and more freedom to move around and have their family in the room.  But, alas, in the era of epidurals and scheduled c-sections, birthing centers have more than just the medical establishment to butt heads with – the culture shift among patients who have been socialized to believe in the dangers of birthing and a country where poor outcomes are not tolerated.  Maybe with increased data on improved outcomes from birthing centers and the desire of patients to take more ownership of their medical experiences, Morris Heights can be a model for a new outcropping of a much-needed alternative.

Posted by Arati Karnik, MD

More musings on the politics of health care reform: Why are the mass media afraid of single payer?

What’s in for me? Musings on the politics of health care reform

Lately, several people, including readers of Social Medicine, have asked “what’s in for me” in the new rendering of the “uniquely American solution” coming out of Washington D.C. Some have also expressed concern about the change that a single payer system would bring to their relatively adequate current health insurance plan.

One thing to fear is that a bad step that consolidates the power of insurers maybe worse that doing nothing. And one thing to be skeptical about is our president’s promise that any of the Washington-cooked plans will “allow you to keep your insurance if you like it”. As many readers may suspect or know, there is no guarantee that whatever we have today will be there tomorrow (quite literally), or that tomorrow, what we have today, whatever that may be, will be affordable (assuming we still have that job through which we buy our insurance). And what is true of our policies is also true of those of our friends, children, and other loved ones.

And it gets worse: as some readers may know, our current insurance, however satisfied we are with it, may be adequate so long as we do not get too sick. Indeed, three fourths of those who declared bankruptcy for medical reasons had insurance (largely private) when they declared bankruptcy.

How could this be so? Isn’t health insurance supposed to insure me against the financial burden of disease? It is, but in our case it does not. Our health insurance system is not designed primarily to pay for your medical needs, but to make a profit. We are the only industrialized, wealthy country that leaves the medically necessary care of over 70% of the population at the mercy of a for profit insurance system. We only pay collectively for the “deserving downtrodden” — the too poor, the disabled, and the elderly  (yes, the “bad customers” that private insurers do not want). And there is little reason to believe that this situation will change substantially or enough with Washington’s “health care overhaul” (for a full explanation of why this is so please click here for my KQED series on health care reform). .

So back to the “what’s in for me” question: the New York Times’ editors, in yet another classical display of corporate media news selectivity, answer this question today, with no mention of better alternatives than keeping for profit insurers in the middle of the game. But are they to blame? They are in line with, or simply following on the footsteps of, no other than the president, who has laid out the “menu” of health care reform “alternatives” including nothing that could disrupt the powers that be — maybe, he says, ”taking some of the profit motive out of health insurance will make insurers offer better products“! (yes, he said it with a straight face — one’s got to recognize the talent!).

In the same edition of the Times, reporter David Leonhardt “enlightens” us further with his economic wisdom, explaining that if we believed that the critical problem in our health care system was greedy for profit private insurers who have co-opted the political process were were mistaken all along (yes, also with a straight face!): the real problem, argues Leonhardt, are those greedy doctors who won’t accept being paid a salary and insist on fee-for-service.

(For the record, I personally think that fee for service is a poor way of paying doctors, and as a practicing physician I was on a salary most of my career, and loved it, but it is not fee for service that explains why we pay over twice as much for health care as do Canada or Taiwan, both countries that rely heavily on fee-for-service to pay doctors — it’s the administrative overhead coming from our crazy ”choice of plans”-based system, and our lack of collective purchasing power which leads to, for instance, our paying the highest prices on the planet for pharmaceuticals and other services).

And still, some a#@$%#@#$ in congress keep on screaming at the top of their lungs about the “dangers of socialized medicine”, and appealing to the politics of fear,  that has been so successful in the past, to remind us about the long lines to see a doctor in those early winter mornings in “communist countries” such as Canada, the UK, or Germany.

To the point that some folks in Canada got so mad about the malicious misrepresentations of Canadian health care that they even wrote a letter to President Obama, demanding that this misrepresentation stop. Indeed, a recent major Canadian survey showed that Canadians have excellent access to primary care and that 92% of them would even recommend their family doctor to a friend, far more than any of the “happy carriers of private insurance” in America can say, constrained as we are by in-network lists of doctors, hospitals, and the like.

Okay, back to the “what’s in for me in a single payer system” question. How can I compare its benefits to what Washington insists on selling us (or rather, ramming down our throats)?

Here’s an excellent comparison back to back between corporate supported health care reform (yes, even AARP, a major seller of for profit private insurance, congratulated Congress for the plan!) and single payer.

And if all this makes you mad, you can keep faxing your legislators demanding real reform (it’s easy and free…). Or support, or even join, MadAsHellDoctors (students in the health professions are welcome!).

It’ll take many, many of us….

“Mad as Hell” tour of doctors demands single payer and “taking back” our democracy

It is happening, folks….a brave group of doctors from Oregon, sick and tired that the political process has been coopted by corporate America, and that our democracy is as good as the money you have to buy it, is getting on the road to express their outrage.

The “Mad as Hell” tour will start in Portland, Oregon, make about 14 stops, including Philadelphia, and arrive in DC around September 29.

What should be clear is that while these doctors are indeed mad about the disastrous state of our health care system, they are especially mad about the phony health care reform coming out of Washington D.C. (including, but not limited to, the so-called “public option”).

Except for Spokane, most stops will be in middle America and the East, yet if there is enough interest (and $$$$!) other stops may be added.

Our colleagues are inviting the medical community, including all students in the health professions, to join in the effort and to follow the caravan.

You can visit their website for further information on their plan.  And yes! They need donations….