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Comments
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Kucinich was the only one who had a sensible plan to reform health care in the U.S.
For-profit health care is unhealthy.
dennis4president.com - A Healthy Nation
A Healthy Nation
Health care in the US is too expensive and leaves 46 million Americans without insurance and millions more underinsured. Dennis Kucinich is the only candidate for President with a plan for a Universal, Single-Payer, Not-for-Profit health care system.
America's patchwork of for-profit, private insurers waste billions of dollars on spending that has nothing to do with paying for care. Elaborate underwriting, billing, sales and marketing divert huge amounts of money away from delivering health care. Huge profits and staggering compensation for the insurance companies' top executives and CEO's.
To cope with the endless bureaucracy of private insurers, health care providers maintain huge administrative staffs. The administration of the health care system today consumes approximately 31% of the money spent for health care. The potential savings, as much as $350 billion per year, are enough to provide comprehensive coverage to every American without paying any more than we already do.
In Congress, Representative Dennis Kucinich has co-authored HR 676, legislation which would establish Medicare for All - a universal, single-payer, not-for-profit health care system that leaves no American behind.
Posted 02-24-2008 at 07:37 AM by AlbertP
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Debate on U.S. Health Care Reform
MYTHS AS BARRIERS TO HEALTH CARE REFORM
IN THE UNITED STATES
John P. Geyman
The U.S. health care system is deteriorating in terms of decreasing access,
increased costs, unacceptable quality, and poor system performance
compared with health care systems in many other industrialized Western
countries. Reform efforts to establish universal insurance coverage have been
defeated on five occasions over the last century, largely through successful
opposition by pro-market stakeholders in the status quo. Reform attempts
have repeatedly been thwarted by myths perpetuated by stakeholders without
regard for the public interest. Six myths are identified here and defused by
evidence: (1) “Everyone gets care anyhow;” (2) “We don’t ration care in the
United States”; (3) “The free market can resolve our problems in health care”;
(4) “The U.S. health care system is basically healthy, so incremental change
will address its problems;” (5) “The United States has the best health care
system in the world”; and
“National health insurance is so unfeasible for
political reasons that it should not be given serious consideration as a policy
alternative.” Incremental changes of the existing health care system have
failed to resolve its underlying problems. Pressure is building again for system
reform, which may become more feasible if a national debate can be focused
on the public interest without distortion by myths and disinformation fueled
by defending stakeholders.
As on many occasions over the last century in the United States, the issue of health
care reform is again moving toward center stage on the nation’s agenda. There is
growing recognition that the present system is sick, and many feel that structural
reform is required. If one has any doubts about how critical is this juncture in
U.S. health care, the Appendix (pp. 324–326) lists examples of some of its serious
problems with respect to access, cost, quality, and overall performance of the
current system (1–27).
International Journal of Health Services, Volume 33, Number 2, Pages 315–329, 2003
© 2003, Baywood Publishing Co., Inc.
315
There have been five well-motivated and serious attempts to enact a system of
universal coverage in the United States over the last 100 years. On each occasion,
health care stakeholders have pulled no punches in using disinformation and
obfuscation to confuse and mislead the public. Thus, the American Medical
Association (AMA) has repeatedly fought national health insurance by labeling
it “socialized medicine” (instead of socialized insurance), while the insurance
industry distorted the debate in 1994 by raising fears of decreased choice of
physicians and the role of government in health care. Since disinformation and
intentional misrepresentation of the real issues will certainly occur again as new
reforms are debated, this article briefly examines six myths concerning U.S. health
care, which are recurrently used to cloud the debate, maintain the status quo, and
defeat systemic efforts to reform our health care system.
Posted 02-24-2008 at 07:38 AM by AlbertP
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MYTHS OF U.S. HEALTH CARE
These six well-worn myths have been perpetuated over the years by stakeholders
in our present market-based system.
1. “Everyone gets care anyhow”
Purveyors of this myth assume that the uninsured and underinsured are able to
access health care within an extensive safety net of community health centers;
emergency rooms and outpatient clinics of public hospitals and not-for-profit
community hospitals; local health departments; or other public sector clinics and
hospitals, such as the Veterans Administration or National Health Service Corps.
While this belief may absolve their guilt about serious access problems within the
present system, it is a total misperception on many counts. Access to health care
is more complex than it may appear, even for the insured. Eisenberg and Power
(2
have drawn the analogy between access to health care and electrical current
passing through resistance—even for the insured, access suffers with each voltage
drop, whether their needed services are actually covered, their choice is informed
and available, or primary and specialty services are available.
How should acceptable access be measured? Access to medical and surgical
services is one measure, but how about preventive care, prescription drugs,
glasses, mental health care, and dental care? Does a visit to an overwhelmed
emergency room for a nonemergent problem, or to an urgent care clinic where the
physician “sees” 60 or more patients during a 12-hour shift without continuity
(and often without access to their medical records), compensate for the lack of
primary care?
While the plight of the uninsured is more obvious, there are many misperceptions
here as well. For example, 80 percent of the uninsured live in working
families, and still cannot qualify for or afford health insurance (29). Whether
insured, underinsured, or uninsured, people suffer serious outcomes of lack of
316 / Geyman
access to primary care. Three examples make the point. A 1997 study of lowincome
patients hospitalized for preventable or avoidable conditions found, for
example, that 60 percent reported receiving no care before admission, while only
17 percent had been seen in an emergency room (30). A 2001 study by Baker and
colleagues (31) of 7,500 adults aged 51 to 61 who lacked continuous health
insurance found that almost three times as many persons experienced a decline
in their health or functional status if continuously uninsured than if insured. In
another recent study of 1,900 Medicare beneficiaries, only 4 percent without
prescription drug coverage were receiving statins, compared with an estimated
60 percent who could benefit from their use (32).
2. “We don’t ration care in the United States”
This is a common notion, often used as a put-down for those countries with
national health systems without full coverage for every conceivable health care
service (e.g., chronic renal dialysis for elderly patients, cosmetic surgery). This
myth flourishes while the prevailing public attitude (fueled by powerful stakeholders
in the present system) is outright denial that rationing is common, necessary,
or moral. Consider these examples of ways in which health care services
are rationed in everyday practice:
• Either by self-referral or through a gatekeeper, sick HMO patients have
about twice as much difficulty in seeking needed care as do healthy patients
in HMOs, PPOs (preferred provider organizations), or point-of-service
programs (33).
• Many managed mental health programs have overly restrictive admission
policies for detoxification, such as requiring delirium tremens to occur before
hospital admission is approved (34).
• Comparative rates of preventable hospitalization between those in affluent
and poor zip codes are much higher in U.S. cities than in Canadian cities
(e.g., more than twice as prevalent in San Francisco and New York than in
Ottawa or Toronto) (35).
• Use of essential drugs decreased by 9 percent in elderly persons and by
14 percent in welfare recipients after cost-sharing was introduced, resulting
in a doubling of the rates of serious adverse reactions in both groups (36).
It is an often overlooked given that our market-based health care economy
implicitly denies services to those who can’t pay for them. Another type of
rationing—denial of services to those who can pay for them—also is common
(and highly contentious). Thus, there is a growing field of litigation challenging
the prerogatives of HMOs to deny services. Some may be inappropriate denials,
while others (e.g., coverage of autologous bone marrow transplants for women
with metastatic breast cancer) may be well grounded in evidence-based clinical
Barriers to U.S. Health Care Reform / 317
science (37). What is typically missing in public attitudes in the United States,
however, is a societal (vs. individual) perspective on what services can be made
available to those who can pay without compromising basic health services
for those who cannot.
Posted 02-24-2008 at 07:38 AM by AlbertP
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3. “The free market can resolve our problems in health care”
This myth continues to underpin pro-market health care policies of both major
political parties, with the belief that the marketplace can effectively resolve
access, cost, and quality problems in delivery of health care services. Touted
as the “American way,” this view reflects the belief that a private, competitive
market exists in health care. Yet there is incontrovertible evidence that health
care markets do not behave in a freely competitive way. Robert Evans (3,
health care economist at the University of British Columbia, has pointed out
how market mechanisms in health care yield distributional advantages for
particular groups, including providers, suppliers, insurers, and more affluent and
healthier people. He calls attention to the natural alliance between providers,
suppliers, and higher-income citizens in support of private financing of health
care, leaving the burden of financing care for the sick and uninsured to the public
sector. As a result, the farther such privatization goes, the more difficult it is to
finance basic health care services for sick and lower-income people through a
smaller risk pool.
It is well documented that the public interest is not well served by an unfettered
private health care market, as reflected by these examples:
• An overriding goal of for-profit health care corporations is to maximize
return on investment to shareholders; thus, even during our current recession,
some for-profit hospital chains have reported profits of 45 percent or more
(16).
• The extent of for-profit ownership of health care organizations is higher than
many realize, including (in 199 85 percent of dialysis centers, 70 percent
of nursing homes and home care agencies, and 64 percent of HMOs (39).
• Investor-owned health care organizations provide lower quality care than
do nonprofit organizations (e.g., investor-owned HMOs scored worse in a
1999 study on all 14 quality indicators reported to the National Committee
for Quality Assurance, such as 27 percent lower rate of eye examinations for
patients with diabetes) (26).
• The overhead of investor-owned HMOs is 25 to 33 percent higher for some
of the largest HMOs than for nonprofit HMOs (40).
• Market-oriented HMOs commonly use many strategies designed more
to manage costs than to manage care (e.g., “deselection” (firing) of highutilizing
physicians, attempts to enroll healthier enrollees rather than sicker
ones) (41).
318 / Geyman
4. “The U.S. health care system is basically healthy,
so incremental change will address its problems”
Incrementalism has been the prevailing approach to health care reform for at
least 30 years in the United States, and is still the most politically popular.
Strongly supported by influential stakeholders in the present system, incremental
changes are periodically put in place, which fail to address the more
fundamental problems of the system. Examples include the attempt to contain
rising hospital costs by the DRG (diagnosis related groups) prospective
payment system (costs soared again 11 years later) (42) and the State Children’s
Health Insurance Program (SCHIP) enacted in 1997 (but by 2000 up to
21 million American children were still estimated to have significant access
problems) (43).
Incrementalism best serves advocates of privatizing health care, reflecting
values often diametrically opposed to the public interest. If incrementalism as
the dominant health policy instrument over the last 30 years was effective, a
1998 RAND analysis of many studies would not give the following findings:
50 percent of people receive recommended preventive care; 60 percent receive
recommended chronic care; 70 percent receive recommended acute care;
30 percent receive contraindicated acute care; and 20 percent receive contraindicated
chronic care (44). Under the banner of incrementalism and increased
consumer choice, there is now a vigorous effort by pro-market interests, supported
by government, to shift more and more costs of health care to consumers, thereby
discriminating against lower-income people and the sick.
The “invisible hand” deserves special comment, for much of the lobbying by
the stakeholders in the pro-market system is almost transparent behind the
scenes. Consider these examples:
• Insurance companies and their allies spent $60 million (an average of
$112,000 per lawmaker) in lobbying against a Patients’ Bill of Rights during
the first six months of 1998 (45).
• The pharmaceutical industry spent $80 million during the 2000 election
campaign supporting candidates opposed to a Medicare prescription drug
benefit (46); of the 22 candidates backed by the drug industry, 18 were elected
to Congress (47).
• A revolving door exists between stakeholder corporations and the government,
as well illustrated by this recent exchange: two former Health Care
Financing Administration (HCFA) administrators have joined the board of
the for-profit dialysis company Da Vita (which receives 60 percent of its
revenue from Medicare and Medicaid), while a former board member at
Da Vita became the new chair of the HCFA (now the Centers for Medicare
and Medicaid Services) (4.
Barriers to U.S. Health Care Reform / 319
5. “The United States has the best health care system in the world”
How can one look at the list in the Appendix and still believe that we have the
best health care system in the world? Yet this remains a widespread view, which
again is nurtured by the stakeholders in the present system. That such a view is
not only untenable but also arrogant toward countries with better-performing
health care systems is demonstrated by these examples:
• The average ranking for the United States on 16 health indicators in a 1998
comparative study of 13 countries by Starfield (24) was twelfth, second from
the bottom. The top five, in decreasing order, were Japan, Sweden, Canada,
France, and Australia.
• In another study by Starfield (27, 49) of 11 Western countries, the United
States was ranked last with respect to its primary care base and its per
capita health care expenditures (the highest), while ranking poorly on public
satisfaction, health indicators, and use of medication.
• A 2000 study by the World Health Organization based on various indicators
(including disability-adjusted life expectancy, child survival to five years
of age, social disparities in care, experiences with the health care system, and
out-of-pocket health care expenditures) found the average ranking of the
United States to be fifteenth out of 25 countries (50).
• A 1998 meta-analysis of 39 prospective studies in U.S. hospitals estimated
that more than 2.2 million patients had serious adverse drug reactions in
1994, resulting in 106,000 deaths (51).
• A 2000 report on the epidemiology of medical error estimated that about
1 million preventable injuries occur to U.S. patients each year (52); these
include transfusion errors, adverse drug events, surgery on the wrong side,
and mistaken identity (53).
6. “National health insurance is so unfeasible for political reasons that
it should not be given serious consideration as a policy alternative”
Since national health insurance (NHI) would require fundamental restructuring of
the health care system, it poses a threat to the stakeholders in the present system.
For many reasons, when NHI is raised as a policy alternative, it therefore becomes
a target of opportunity for interests vested in the status quo. Each time this
occurs it obscures a national debate on the real issues, which should focus on
which of the policy alternatives best serves the public interest.
NHI proposals in the United States have been attacked by their critics in past
years on many counts, including alleged lack of affordability, overly intrusive
roles of government, questions of quality, threat to the physician-patient relationship,
and lack of political acceptance. The closer that NHI comes to serious
320 / Geyman
consideration, the harder its opponents battle to denigrate such a proposal or
distort the issues.
Despite the constant pressure by stakeholders in the pro-market status quo to
keep single-payer NHI off the table of policy alternatives for health care reform,
the myth of its alleged lack of feasibility can be well countered by the facts. In
California, for example, where 22 percent of the population is uninsured, nine
alternative reform proposals have been carefully studied under the California
Health Care Options Project (HCOP). These include public program expansions,
individual and employer tax credits, employer and individual mandates, singlepayer
models, and combination approaches. These options were analyzed and
compared using a micro-simulation model developed by the Lewin Group. Most
of the options are incremental proposals, all of which would increase health care
costs without providing universal coverage. Only the single-payer proposals
would provide comprehensive care for the state’s entire population while reducing
costs by $8 billion (54). In terms of affordability of NHI at the national level, the
$1.4 trillion now being spent on health care (about $5,000 for every adult and
child in the United States) could easily fund universal coverage of comprehensive
care, if the wasteful for-profit insurance industry were replaced by a single,
publicly administered insurance program.
DISCUSSION
The United States is alone among developed Western industrialized nations in
still not having some form of national health insurance. Some have suggested that
this is because the American public has not wanted it (55, 56). Vicente Navarro
makes a convincing case for another explanation—that the power and influence of
the labor movement is the single most important factor in establishing national
health insurance in any country. With a low rate of unionization (only about
13 percent of the workforce today; 57) and without a strong and cohesive political
party representing labor, the capitalist and management class in the United States
has so far effectively thwarted any populist movement toward NHI (5. A recent
position paper developed for the Wisconsin State AFL-CIO further contends that
a class-based struggle has been fought by the right against labor since the 1930s,
with the right persistently promoting its own economic interests and unlimited
corporate power as an overall anti-worker agenda (59).
Although opponents of NHI have discounted the level of popular support for
NHI on many occasions over the years, there is good evidence that a majority or
plurality of Americans have expressed support for it, as early as the 1940s and
even at a cost of higher taxes (60). Growing evidence in recent years indicates
that the public is increasingly dissatisfied with the health care system and more
supportive of an expanded role of government in assuring access to care. There
is now widespread support, even in the conservative South, for government
regulation of HMOs (61). The most recent national poll by Harris Interactive
Barriers to U.S. Health Care Reform / 321
(August 2002) found that one-half of respondents (physicians, employers, hospital
managers, health plan managers, and public citizens) now favor radical reform,
not incremental change. Only 19 percent of physicians and smaller percentages
of the other four groups felt that “on the whole the health care system works
pretty well and only minor changes are necessary” (62).
As editor of the New England Journal of Medicine, Relman (63) warned
in 1980 of the corrosive effects of the medical-industrial complex in medicine
and health care. The ensuing years have fully demonstrated these effects. In
1990, Coddington and colleagues (64), in their book The Crisis in Health Care:
Costs, Choices, and Strategies, predicted these outcomes under our market-based
system:
• More than 40 million uninsured
• Continued gaps in safety net coverage
• Double-digit health plan rate increases
• Smaller employers cutting coverage or even dropping health plans
• Increased copayments and deductibles for employees
• Large rate increases for private insurers in shrinking markets
• Numerous failures of HMOs and withdrawal from the market by larger
insurance companies
• Continued cost shifting in an increasingly fragmented market
• Continued inflation of health care costs
Twelve years later, every one of these outcomes has taken place, precisely as
predicted.
In the early 1990s, Mark Peterson (65), well-known policy analyst and scholar
in government affairs, noted that the “iron triangle” of closely allied stakeholders
in the pro-market health care system (business, the insurance industry, and the
medical profession) was starting to break down into competition among themselves.
That even more disunity among stakeholders has occurred since then
is shown by these examples:
• Business is now supporting state regulation over health insurance premiums,
as is already the case for automobile and commercial insurance (66).
• The interests of small and mid-size employers are often at odds with those of
large employers, and most that offer health benefits to their employees are
looking for ways to decrease their expense and responsibility by passing along
more costs to employees.
• Some business leaders have joined the National Coalition on Health Care
in support of these principles—health insurance for all, cost containment,
improved quality of care, equitable financing, and simplified administration
(67).
322 / Geyman
• Only about 30 percent of U.S. physicians are members of the AMA, which has
lost much of its influence over health policy over the last 50 years; although
the AMA still opposes NHI (as it did Medicare and Medicaid during the
1960s), many physicians now support a system of social health insurance.
A battle is raging over the future of U.S. health care, much of it behind the
scenes. In their defense against growing pressure by stake challengers for effective
change, the corporate class will promulgate the myths described here in
well-funded campaigns of disinformation. However, a fresh proposal for fundamental
reform of the health care system could well succeed the next time around
if these six myths are seen as such and a national debate can be sharply focused
on the public interest. The middle class, not just the lower class, is affected
by the increasing unaffordability of health care. The length and depth of the
current recession will broaden the constituency adversely affected by the present
system and increase the influence of grassroots activism for reform. The aftermath
of the September 11 tragedy will stretch the nation’s resources and call into
question the value being returned on the country’s already huge investment in
health care.
Assuming that the political will for serious health care reform will increase over
the next few years and that these six myths can be exposed as such by a broad
coalition of defenders of the public interest and by responsible media coverage,
the following developments would appear to favor fundamental reform, even
to the point of a national health insurance program:
• More emphasis than in the past on campaign finance reform
• Fallout from the Enron and World Com scandals that will focus public
attention on the damage to the public interest by corporate greed
• Need for improved health care while maximizing potential cost savings
(e.g., about $150 billion could be saved each year by eliminating administrative
costs and profits of an enormous insurance industry—more than
enough to fund NHI) (6
• Recent studies in several states showing projected cost savings of singlepayer
plans—such as annual savings of $8 billion in California (54) and
$118 million in Vermont (69)
• Support of a single-payer system by 64 percent of members of the American
Medical Women’s Association (70)
• Growing activist influence of Physicians for a National Health Program
(PNHP), with over 9,500 members
• Preference for a single-payer health care system by 57 percent of respondents
in a 1999 study of more than 2,100 medical students, residents, faculty, and
deans in U.S. medical schools (80 percent response rate) (71)
• Single-payer proposals moving forward in several states, including Massachusetts,
Vermont, Maine, Florida, and Oregon
Barriers to U.S. Health Care Reform / 323
• Recent bipartisan support for passage in the U.S. Senate (by a vote of 78 to 21)
of the Greater Access to Affordable Pharmaceuticals Act against a wellfinanced
campaign by the drug industry (72)
• Growing support behind House Concurrent Resolution 99 that would require
enactment of legislation by October 2004 assuring universal health care for
all Americans meeting 14 explicit criteria (73)
Americans want, and deserve, a system assuring them of access to health
care, free choice of physician, affordable care of high quality, trust and respect.
What many now get is a disorganized, failing, and nonsustainable system with
increasingly serious problems of access, cost, quality, and equity. The most unfortunate
aspect of previous reform efforts is how successful their opponents have
been in purveying myths in order to change the subject, distort the debate, and
promote hopes that tinkering around the edges of the current system will succeed.
Neither of the two major political parties is yet prepared to address fundamental
reform, still subscribing to an incrementalism that has been a complete failure for
more than 25 years. The current experiment with consumerism conveys a cruel
illusion of “progress,” is unfair, and won’t resolve system problems.
Medicine has the opportunity to take a leadership role in promoting a broad
consensus supporting what should be unassailable principles of reform against
which reform alternatives can be assessed. These principles could well include
(a) guaranteed universal coverage; (b) free choice of physicians; (c) continuity
of primary care; (d) a comprehensive, basic set of clinically effective benefits;
(e) cost containment with affordability, and (f) commitment to continuous
quality improvement. Hopefully, the time for much needed structural reform of
the nation’s ailing health care system will soon be at hand.
APPENDIX
Problems with the U.S. Health Care System
Decreasing access to care
• More than 40 million Americans are uninsured (17% of the population
less than 65 years of age (1), more than the combined population of Texas,
Florida, and Connecticut) (2).
• The number of uninsured under age 65 has increased by almost one-third
since 1987 (3).
• Twenty percent of the uninsured cannot afford health insurance if offered
by their employers (4).
• One-quarter of all nonelderly Americans are uninsured for at least one month
per year (5).
• Of health care personnel less than 65 years of age, 12.2% were without
health insurance in 1999 for themselves and their families (up from 8.4%
in 198 .
324 / Geyman
• In 32 states, a parent working full-time at the minimum wage of $5.15 per hour
is ineligible for Medicaid and can’t afford insurance (7).
• Only 64% of U.S. workers are covered by employer-based insurance (.
• Consolidation and decreasing choice are occurring for employer-based insurance
(e.g., American Express dropped 164 HMOs nationwide in the last
two years, retaining 4 (5).
• In 2001, 37% of applicants for insurance in the individual insurance market
were turned down, even with a $500 deductible and $20 co-pay for
physicians’ visits; only 10% were approved without restrictions or higher
premiums (9).
• In the event of recession, the number of uninsured is projected to increase
to 61 million by 2009 (10).
Increasing costs of care
• Health spending is projected to increase to 16.2% of GDP by 2008, almost
doubling to $2.2 trillion (11).
• Compared with a Consumer Price Index of 1.6% for the 12 months ending
December 2001, medical care was up 4.7% (12).
• Employer-based insurance premiums increased an average of 14% in 2002
(13).
• Prescription drug costs increased 17.3% in 2000 (12).
• Average family health insurance premiums are now $7,053 (19).
• Nongroup insurance for a typical family is now estimated to cost $10,000
per year (14) (so a tax credit of $2,000 won’t help much).
• HMO profits were up 16% in the second quarter of 2001 (15).
• For-profit hospital chains reported huge profits in the third quarter of 2001
(e.g., HCA at 47%; Tenet, 45%) (16).
• Corporate greed burgeons while access declines and costs go up (e.g., 23 top
executives of investor-owned HMOs were paid more than $63 million in
salary in 2000, plus $109 million in stock options) (17).
• Administrative costs account for about 26% of the nation’s health care
expenditures (1.
Variable and often poor quality of care
• Many factors lead to poor quality of care, including denial of services (1,
lack of primary care and continuity (19), unnecessary procedures/surgery
(20), and neglect of psychosocial and quality-of-life issues (21).
• Documented regional variations in care cannot be justified by clinical evidence
or population differences (e.g., 20-fold differences in carotid endarterectomy
rates in 16 large communities in four states) (22).
• Ten of 28 evaluations by the Technology Evaluation Center of the national
Blue Cross and Blue Shield Association showed drugs, devices, or procedures
to be either lacking or uncertain in their effectiveness (23).
Barriers to U.S. Health Care Reform / 325
• The U.S. ranks last among 13 industrialized Western countries for low
birthweight percentage, neonatal and overall infant mortality, and years of
potential life lost (24).
Nonsustainable, overly complex, inefficient system with poor performance
• The more than 1,200 insurers have an increasing burden of paperwork and
bureaucracy (25).
• The insurance industry, largely investor-owned, is pursuing profits and
returns to shareholders while discriminating against the sick.
• The chronic problems of inadequate access, rising costs, and unacceptable
quality of care are refractory to all attempted incremental remedies.
• The market-driven private sector is often in conflict with public interest (26).
• A weak primary care base ranks the United States last among 11 industrialized
nations based on 11 criteria (27).
• There is a growing need for the increasingly fragile public safety net.
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2. Mills, R. J. Health insurance coverage 1999, U.S. Census Bureau. Curr. Popul. Rep.,
2000.
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Benefit Research Institute, Washington, D.C., 2000.
4. Swartz, K. Who owns the problems of the uninsured? Inquiry 33: 103–105, 1996.
5. New York Times, November 9, 2001.
6. Case, B. G., Himmelstein, D. U., and Woolhandler, S. No care for the caregivers:
Declining health insurance coverage for health care personnel and their children,
1988-1998. Am. J. Public Health 92(3): 404–408, 2002.
7. Families USA. Press release, November 20, 2000.
8. Who declines employer-sponsored health insurance and is uninsured? Health Aff.
(Millwood) 19(1): 253, 2000.
9. Kaiser Family Foundation. June 19, 2001.
10. Custer, W. S., and Ketsche, P. The Changing Sources of Health Insurance. Health
Insurance Association of America, Washington, D.C., 2001.
11. Wall Street Journal, September 27, 2001.
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13. 2002 Health care cost survey. Med. Benefits 19(2): 1, 2002.
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February 13, 2002.
15. Weiss Ratings Press Release, February 4, 2002.
16. Findley, S. Research brief: National Institute for Health Care Management Research
and Educational Foundation (September 2000). Med. Benefits 17(2): 5–6, 2000.
326 / Geyman
17. Data update. PNHP Newsletter (Chicago), January 2002, p. 8.
18. Schiff, G. D., Bindman, A. B., and Brennan, T. A. A better-quality alternative:
Single-payer national health system reform. JAMA 272: 803–808, 1994.
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2268–2271, 1991.
20. Leape, L. L. Unnecessary surgery. Annu. Rev. Public Health 13: 363–383, 1992.
21. Carpenter, W. T., Jr., and Buchanan, R. W. Schizophrenia. N. Engl. J. Med. 330:
681–690, 1994.
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Direct reprint requests to:
Dr. John P. Geyman
Department of Family Medicine, Box 354696
University of Washington
Seattle, WA 98195-4696
e-mail: jgeyman@u.washington.edu
Barriers to U.S. Health Care Reform / 329Posted 02-24-2008 at 07:41 AM by AlbertP
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3. “The free market can resolve our problems in health care”
This myth continues to underpin pro-market health care policies of both major
political parties, with the belief that the marketplace can effectively resolve
access, cost, and quality problems in delivery of health care services. Touted
as the “American way,” this view reflects the belief that a private, competitive
market exists in health care. Yet there is incontrovertible evidence that health
care markets do not behave in a freely competitive way. Robert Evans (3,
health care economist at the University of British Columbia, has pointed out
how market mechanisms in health care yield distributional advantages for
particular groups, including providers, suppliers, insurers, and more affluent and
healthier people. He calls attention to the natural alliance between providers,
suppliers, and higher-income citizens in support of private financing of health
care, leaving the burden of financing care for the sick and uninsured to the public
sector. As a result, the farther such privatization goes, the more difficult it is to
finance basic health care services for sick and lower-income people through a
smaller risk pool.
It is well documented that the public interest is not well served by an unfettered
private health care market, as reflected by these examples:
• An overriding goal of for-profit health care corporations is to maximize
return on investment to shareholders; thus, even during our current recession,
some for-profit hospital chains have reported profits of 45 percent or more
(16).
• The extent of for-profit ownership of health care organizations is higher than
many realize, including (in 199 85 percent of dialysis centers, 70 percent
of nursing homes and home care agencies, and 64 percent of HMOs (39).
• Investor-owned health care organizations provide lower quality care than
do nonprofit organizations (e.g., investor-owned HMOs scored worse in a
1999 study on all 14 quality indicators reported to the National Committee
for Quality Assurance, such as 27 percent lower rate of eye examinations for
patients with diabetes) (26).
• The overhead of investor-owned HMOs is 25 to 33 percent higher for some
of the largest HMOs than for nonprofit HMOs (40).
• Market-oriented HMOs commonly use many strategies designed more
to manage costs than to manage care (e.g., “deselection” (firing) of highutilizing
physicians, attempts to enroll healthier enrollees rather than sicker
ones) (41).
318 / Geyman
4. “The U.S. health care system is basically healthy,
so incremental change will address its problems”
Incrementalism has been the prevailing approach to health care reform for at
least 30 years in the United States, and is still the most politically popular.
Strongly supported by influential stakeholders in the present system, incremental
changes are periodically put in place, which fail to address the more
fundamental problems of the system. Examples include the attempt to contain
rising hospital costs by the DRG (diagnosis related groups) prospective
payment system (costs soared again 11 years later) (42) and the State Children’s
Health Insurance Program (SCHIP) enacted in 1997 (but by 2000 up to
21 million American children were still estimated to have significant access
problems) (43).
Incrementalism best serves advocates of privatizing health care, reflecting
values often diametrically opposed to the public interest. If incrementalism as
the dominant health policy instrument over the last 30 years was effective, a
1998 RAND analysis of many studies would not give the following findings:
50 percent of people receive recommended preventive care; 60 percent receive
recommended chronic care; 70 percent receive recommended acute care;
30 percent receive contraindicated acute care; and 20 percent receive contraindicated
chronic care (44). Under the banner of incrementalism and increased
consumer choice, there is now a vigorous effort by pro-market interests, supported
by government, to shift more and more costs of health care to consumers, thereby
discriminating against lower-income people and the sick.
The “invisible hand” deserves special comment, for much of the lobbying by
the stakeholders in the pro-market system is almost transparent behind the
scenes. Consider these examples:
• Insurance companies and their allies spent $60 million (an average of
$112,000 per lawmaker) in lobbying against a Patients’ Bill of Rights during
the first six months of 1998 (45).
• The pharmaceutical industry spent $80 million during the 2000 election
campaign supporting candidates opposed to a Medicare prescription drug
benefit (46); of the 22 candidates backed by the drug industry, 18 were elected
to Congress (47).
• A revolving door exists between stakeholder corporations and the government,
as well illustrated by this recent exchange: two former Health Care
Financing Administration (HCFA) administrators have joined the board of
the for-profit dialysis company Da Vita (which receives 60 percent of its
revenue from Medicare and Medicaid), while a former board member at
Da Vita became the new chair of the HCFA (now the Centers for Medicare
and Medicaid Services) (4.
Barriers to U.S. Health Care Reform / 319
5. “The United States has the best health care system in the world”
How can one look at the list in the Appendix and still believe that we have the
best health care system in the world? Yet this remains a widespread view, which
again is nurtured by the stakeholders in the present system. That such a view is
not only untenable but also arrogant toward countries with better-performing
health care systems is demonstrated by these examples:
• The average ranking for the United States on 16 health indicators in a 1998
comparative study of 13 countries by Starfield (24) was twelfth, second from
the bottom. The top five, in decreasing order, were Japan, Sweden, Canada,
France, and Australia.
• In another study by Starfield (27, 49) of 11 Western countries, the United
States was ranked last with respect to its primary care base and its per
capita health care expenditures (the highest), while ranking poorly on public
satisfaction, health indicators, and use of medication.
• A 2000 study by the World Health Organization based on various indicators
(including disability-adjusted life expectancy, child survival to five years
of age, social disparities in care, experiences with the health care system, and
out-of-pocket health care expenditures) found the average ranking of the
United States to be fifteenth out of 25 countries (50).
• A 1998 meta-analysis of 39 prospective studies in U.S. hospitals estimated
that more than 2.2 million patients had serious adverse drug reactions in
1994, resulting in 106,000 deaths (51).
• A 2000 report on the epidemiology of medical error estimated that about
1 million preventable injuries occur to U.S. patients each year (52); these
include transfusion errors, adverse drug events, surgery on the wrong side,
and mistaken identity (53).
6. “National health insurance is so unfeasible for political reasons that
it should not be given serious consideration as a policy alternative”
Since national health insurance (NHI) would require fundamental restructuring of
the health care system, it poses a threat to the stakeholders in the present system.
For many reasons, when NHI is raised as a policy alternative, it therefore becomes
a target of opportunity for interests vested in the status quo. Each time this
occurs it obscures a national debate on the real issues, which should focus on
which of the policy alternatives best serves the public interest.
NHI proposals in the United States have been attacked by their critics in past
years on many counts, including alleged lack of affordability, overly intrusive
roles of government, questions of quality, threat to the physician-patient relationship,
and lack of political acceptance. The closer that NHI comes to serious
320 / Geyman
consideration, the harder its opponents battle to denigrate such a proposal or
distort the issues.
Despite the constant pressure by stakeholders in the pro-market status quo to
keep single-payer NHI off the table of policy alternatives for health care reform,
the myth of its alleged lack of feasibility can be well countered by the facts. In
California, for example, where 22 percent of the population is uninsured, nine
alternative reform proposals have been carefully studied under the California
Health Care Options Project (HCOP). These include public program expansions,
individual and employer tax credits, employer and individual mandates, singlepayer
models, and combination approaches. These options were analyzed and
compared using a micro-simulation model developed by the Lewin Group. Most
of the options are incremental proposals, all of which would increase health care
costs without providing universal coverage. Only the single-payer proposals
would provide comprehensive care for the state’s entire population while reducing
costs by $8 billion (54). In terms of affordability of NHI at the national level, the
$1.4 trillion now being spent on health care (about $5,000 for every adult and
child in the United States) could easily fund universal coverage of comprehensive
care, if the wasteful for-profit insurance industry were replaced by a single,
publicly administered insurance program.
DISCUSSION
The United States is alone among developed Western industrialized nations in
still not having some form of national health insurance. Some have suggested that
this is because the American public has not wanted it (55, 56). Vicente Navarro
makes a convincing case for another explanation—that the power and influence of
the labor movement is the single most important factor in establishing national
health insurance in any country. With a low rate of unionization (only about
13 percent of the workforce today; 57) and without a strong and cohesive political
party representing labor, the capitalist and management class in the United States
has so far effectively thwarted any populist movement toward NHI (5. A recent
position paper developed for the Wisconsin State AFL-CIO further contends that
a class-based struggle has been fought by the right against labor since the 1930s,
with the right persistently promoting its own economic interests and unlimited
corporate power as an overall anti-worker agenda (59).
Although opponents of NHI have discounted the level of popular support for
NHI on many occasions over the years, there is good evidence that a majority or
plurality of Americans have expressed support for it, as early as the 1940s and
even at a cost of higher taxes (60). Growing evidence in recent years indicates
that the public is increasingly dissatisfied with the health care system and more
supportive of an expanded role of government in assuring access to care. There
is now widespread support, even in the conservative South, for government
regulation of HMOs (61). The most recent national poll by Harris Interactive
Barriers to U.S. Health Care Reform / 321
(August 2002) found that one-half of respondents (physicians, employers, hospital
managers, health plan managers, and public citizens) now favor radical reform,
not incremental change. Only 19 percent of physicians and smaller percentages
of the other four groups felt that “on the whole the health care system works
pretty well and only minor changes are necessary” (62).
As editor of the New England Journal of Medicine, Relman (63) warned
in 1980 of the corrosive effects of the medical-industrial complex in medicine
and health care. The ensuing years have fully demonstrated these effects. In
1990, Coddington and colleagues (64), in their book The Crisis in Health Care:
Costs, Choices, and Strategies, predicted these outcomes under our market-based
system:
• More than 40 million uninsured
• Continued gaps in safety net coverage
• Double-digit health plan rate increases
• Smaller employers cutting coverage or even dropping health plans
• Increased copayments and deductibles for employees
• Large rate increases for private insurers in shrinking markets
• Numerous failures of HMOs and withdrawal from the market by larger
insurance companies
• Continued cost shifting in an increasingly fragmented market
• Continued inflation of health care costs
Twelve years later, every one of these outcomes has taken place, precisely as
predicted.
In the early 1990s, Mark Peterson (65), well-known policy analyst and scholar
in government affairs, noted that the “iron triangle” of closely allied stakeholders
in the pro-market health care system (business, the insurance industry, and the
medical profession) was starting to break down into competition among themselves.
That even more disunity among stakeholders has occurred since then
is shown by these examples:
• Business is now supporting state regulation over health insurance premiums,
as is already the case for automobile and commercial insurance (66).
• The interests of small and mid-size employers are often at odds with those of
large employers, and most that offer health benefits to their employees are
looking for ways to decrease their expense and responsibility by passing along
more costs to employees.
• Some business leaders have joined the National Coalition on Health Care
in support of these principles—health insurance for all, cost containment,
improved quality of care, equitable financing, and simplified administration
(67).
322 / Geyman
• Only about 30 percent of U.S. physicians are members of the AMA, which has
lost much of its influence over health policy over the last 50 years; although
the AMA still opposes NHI (as it did Medicare and Medicaid during the
1960s), many physicians now support a system of social health insurance.
A battle is raging over the future of U.S. health care, much of it behind the
scenes. In their defense against growing pressure by stake challengers for effective
change, the corporate class will promulgate the myths described here in
well-funded campaigns of disinformation. However, a fresh proposal for fundamental
reform of the health care system could well succeed the next time around
if these six myths are seen as such and a national debate can be sharply focused
on the public interest. The middle class, not just the lower class, is affected
by the increasing unaffordability of health care. The length and depth of the
current recession will broaden the constituency adversely affected by the present
system and increase the influence of grassroots activism for reform. The aftermath
of the September 11 tragedy will stretch the nation’s resources and call into
question the value being returned on the country’s already huge investment in
health care.
Assuming that the political will for serious health care reform will increase over
the next few years and that these six myths can be exposed as such by a broad
coalition of defenders of the public interest and by responsible media coverage,
the following developments would appear to favor fundamental reform, even
to the point of a national health insurance program:
• More emphasis than in the past on campaign finance reform
• Fallout from the Enron and World Com scandals that will focus public
attention on the damage to the public interest by corporate greed
• Need for improved health care while maximizing potential cost savings
(e.g., about $150 billion could be saved each year by eliminating administrative
costs and profits of an enormous insurance industry—more than
enough to fund NHI) (6
• Recent studies in several states showing projected cost savings of singlepayer
plans—such as annual savings of $8 billion in California (54) and
$118 million in Vermont (69)
• Support of a single-payer system by 64 percent of members of the American
Medical Women’s Association (70)
• Growing activist influence of Physicians for a National Health Program
(PNHP), with over 9,500 members
• Preference for a single-payer health care system by 57 percent of respondents
in a 1999 study of more than 2,100 medical students, residents, faculty, and
deans in U.S. medical schools (80 percent response rate) (71)
• Single-payer proposals moving forward in several states, including Massachusetts,
Vermont, Maine, Florida, and Oregon
Barriers to U.S. Health Care Reform / 323
• Recent bipartisan support for passage in the U.S. Senate (by a vote of 78 to 21)
of the Greater Access to Affordable Pharmaceuticals Act against a wellfinanced
campaign by the drug industry (72)
• Growing support behind House Concurrent Resolution 99 that would require
enactment of legislation by October 2004 assuring universal health care for
all Americans meeting 14 explicit criteria (73)
Americans want, and deserve, a system assuring them of access to health
care, free choice of physician, affordable care of high quality, trust and respect.
What many now get is a disorganized, failing, and nonsustainable system with
increasingly serious problems of access, cost, quality, and equity. The most unfortunate
aspect of previous reform efforts is how successful their opponents have
been in purveying myths in order to change the subject, distort the debate, and
promote hopes that tinkering around the edges of the current system will succeed.
Neither of the two major political parties is yet prepared to address fundamental
reform, still subscribing to an incrementalism that has been a complete failure for
more than 25 years. The current experiment with consumerism conveys a cruel
illusion of “progress,” is unfair, and won’t resolve system problems.
Medicine has the opportunity to take a leadership role in promoting a broad
consensus supporting what should be unassailable principles of reform against
which reform alternatives can be assessed. These principles could well include
(a) guaranteed universal coverage; (b) free choice of physicians; (c) continuity
of primary care; (d) a comprehensive, basic set of clinically effective benefits;
(e) cost containment with affordability, and (f) commitment to continuous
quality improvement. Hopefully, the time for much needed structural reform of
the nation’s ailing health care system will soon be at hand.
APPENDIX
Problems with the U.S. Health Care System
Decreasing access to care
• More than 40 million Americans are uninsured (17% of the population
less than 65 years of age (1), more than the combined population of Texas,
Florida, and Connecticut) (2).
• The number of uninsured under age 65 has increased by almost one-third
since 1987 (3).
• Twenty percent of the uninsured cannot afford health insurance if offered
by their employers (4).
• One-quarter of all nonelderly Americans are uninsured for at least one month
per year (5).
• Of health care personnel less than 65 years of age, 12.2% were without
health insurance in 1999 for themselves and their families (up from 8.4%
in 198 .
324 / Geyman
• In 32 states, a parent working full-time at the minimum wage of $5.15 per hour
is ineligible for Medicaid and can’t afford insurance (7).
• Only 64% of U.S. workers are covered by employer-based insurance (.
• Consolidation and decreasing choice are occurring for employer-based insurance
(e.g., American Express dropped 164 HMOs nationwide in the last
two years, retaining 4 (5).
• In 2001, 37% of applicants for insurance in the individual insurance market
were turned down, even with a $500 deductible and $20 co-pay for
physicians’ visits; only 10% were approved without restrictions or higher
premiums (9).
• In the event of recession, the number of uninsured is projected to increase
to 61 million by 2009 (10).
Increasing costs of care
• Health spending is projected to increase to 16.2% of GDP by 2008, almost
doubling to $2.2 trillion (11).
• Compared with a Consumer Price Index of 1.6% for the 12 months ending
December 2001, medical care was up 4.7% (12).
• Employer-based insurance premiums increased an average of 14% in 2002
(13).
• Prescription drug costs increased 17.3% in 2000 (12).
• Average family health insurance premiums are now $7,053 (19).
• Nongroup insurance for a typical family is now estimated to cost $10,000
per year (14) (so a tax credit of $2,000 won’t help much).
• HMO profits were up 16% in the second quarter of 2001 (15).
• For-profit hospital chains reported huge profits in the third quarter of 2001
(e.g., HCA at 47%; Tenet, 45%) (16).
• Corporate greed burgeons while access declines and costs go up (e.g., 23 top
executives of investor-owned HMOs were paid more than $63 million in
salary in 2000, plus $109 million in stock options) (17).
• Administrative costs account for about 26% of the nation’s health care
expenditures (1.
Variable and often poor quality of care
• Many factors lead to poor quality of care, including denial of services (1,
lack of primary care and continuity (19), unnecessary procedures/surgery
(20), and neglect of psychosocial and quality-of-life issues (21).
• Documented regional variations in care cannot be justified by clinical evidence
or population differences (e.g., 20-fold differences in carotid endarterectomy
rates in 16 large communities in four states) (22).
• Ten of 28 evaluations by the Technology Evaluation Center of the national
Blue Cross and Blue Shield Association showed drugs, devices, or procedures
to be either lacking or uncertain in their effectiveness (23).
Barriers to U.S. Health Care Reform / 325
• The U.S. ranks last among 13 industrialized Western countries for low
birthweight percentage, neonatal and overall infant mortality, and years of
potential life lost (24).
Nonsustainable, overly complex, inefficient system with poor performance
• The more than 1,200 insurers have an increasing burden of paperwork and
bureaucracy (25).
• The insurance industry, largely investor-owned, is pursuing profits and
returns to shareholders while discriminating against the sick.
• The chronic problems of inadequate access, rising costs, and unacceptable
quality of care are refractory to all attempted incremental remedies.
• The market-driven private sector is often in conflict with public interest (26).
• A weak primary care base ranks the United States last among 11 industrialized
nations based on 11 criteria (27).
• There is a growing need for the increasingly fragile public safety net.
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National Academy Press, Washington, D.C., 2001.
2. Mills, R. J. Health insurance coverage 1999, U.S. Census Bureau. Curr. Popul. Rep.,
2000.
3. Fronstin, P. Sources of Health Insurance and Characteristics of the Uninsured:
Analysis of the March 2000 Current Population Survey. Issue Brief No. 228. Employee
Benefit Research Institute, Washington, D.C., 2000.
4. Swartz, K. Who owns the problems of the uninsured? Inquiry 33: 103–105, 1996.
5. New York Times, November 9, 2001.
6. Case, B. G., Himmelstein, D. U., and Woolhandler, S. No care for the caregivers:
Declining health insurance coverage for health care personnel and their children,
1988-1998. Am. J. Public Health 92(3): 404–408, 2002.
7. Families USA. Press release, November 20, 2000.
8. Who declines employer-sponsored health insurance and is uninsured? Health Aff.
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9. Kaiser Family Foundation. June 19, 2001.
10. Custer, W. S., and Ketsche, P. The Changing Sources of Health Insurance. Health
Insurance Association of America, Washington, D.C., 2001.
11. Wall Street Journal, September 27, 2001.
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15. Weiss Ratings Press Release, February 4, 2002.
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17. Data update. PNHP Newsletter (Chicago), January 2002, p. 8.
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681–690, 1994.
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Health Aff. (Millwood) 3(2): 6–32, 1984.
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Chicago, 1999.
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Oxford University Press, New York, 1998.
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Direct reprint requests to:
Dr. John P. Geyman
Department of Family Medicine, Box 354696
University of Washington
Seattle, WA 98195-4696
e-mail: jgeyman@u.washington.edu
Barriers to U.S. Health Care Reform / 329Posted 02-24-2008 at 07:41 AM by AlbertP
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