Dear people,

I have been practicing Family Medicine in the Danville area for nearly 25 years. Never before have I seen so many people without health insurance or choosing to defer tests or medications due to concerns about cost. All Americans should have access to comprehensive health care, like most other people in the developed world.

A Harvard study several months ago found that fully one HALF of all US bankruptcies (2,000,000 people) were due to medical bills. Three quarters of those bankrupted by illness HAD INSURANCE when they got sick. And then, Congress overwhelmingly approved a major overhaul of bankruptcy laws that would make it more difficult to for people facing bankruptcy to get back on their feet.

Due to the cost of health care, most cars manufactured in North America are now made in Ontario, Canada rather than in Michigan. It seems that GM, Ford and Daimler-Chrysler are moving their manufacturing facilities to Canada as health care costs for manufacturers average $800 per per employee per year in Canada and $6,500 in the US, with $1,500 of that cost passed on to you when you buy an American car.

In 2003 wait times for elective surgery in Canada had fallen to just over 4 weeks (about the same as in US) and are continuing to decrease with the encouragement of the current Canadian Administration. The Canadian figures include ALL Canadian citizens while in the US wait times don’t include the un-insured and under-insured who simply choose not to have elective surgery.

Not only do 39,000,000 Americans NOT have health insurance, but of those who do, many are facing increasing co-pays and deductibles. Those who lose their jobs due to illness are often unable to pay high COBRA premiums eventually facing medical bills that are simply un-payable. Congress, unable to address the crisis of health care costs through both Democratic and Republican Administrations, has chosen to compound the issue by punishing workers who are forced into bankruptcy by illness.

The US has the most expensive health care system in the world and yet health care is in-accessible to a large number of Americans and our system is no longer the best. Americans have a lower life expectancy and higher infant mortality rate than many other developed countries. Infant mortality in America is WORSE than most European countries and equal to infant mortality in Cuba and South Korea.

One answer is National Health Insurance (NHI). The plan proposed by Physicians for A National Health Plan (available at www.physiciansproposal.org) would de-link coverage from employment, cover all medically necessary care without deductibles and co-payments, and cover ALL Americans. Decreased administrative costs would more than cover comprehensive care without an increase in overall health care costs (private insurers use 13.6% of premiums for overhead while both Medicare and the Canadian National Health Insurance program require less than 3%). Providing National Health Insurance would be good for business. Employer health care expenses would decrease, providing an opportunity for increased profit and increased employee compensation.

To consider National Health Insurance will require our elected officials to resist influence from industries that profit from health care and to be open-minded, courageous and innovative, characteristics often lacking in representatives from either party. National Health Insurance will become an idea more acceptable to Congress only when large corporate employers like GM, GE or IBM began complaining about health care costs and therefore pressuring government for relief. That time may be coming.

If you share my concerns, consider reviewing the PNHP proposal (call me if you can’t get on the internet and want a copy), and certainly let your representatives know how you feel.

Colin Raitiere

By Greg Bausch, President, Kentucky Rural Health Association
From Rural Health Update, Fall 2004

“Ranks of the Uninsured Grow in 2003,” exclaims the headline.

“Rural Uninsured Continues to Rise,” notes another.

And yet a third despairs that a “Report Examines Decline in Employment-based Health Coverage.”

According to these reports, a staggering 45 million Americans, 15.6 percent of our population, lacked health insurance during 2003, representing an increase of 1.5 million of our friends and neighbors since 2002. It is also alarming to note that rural Americans have an uninsured rate about 6 percent higher than our urban counterparts. So I ask you, “How many uninsured is too many?”

This decline is largely due to reductions in employer-sponsored coverage, which fell from 61.3 percent to 60.4 percent from 2002 to 2003. Unfortunately, the rates for employer-sponsored healthcare are 11.5 percent lower for the rural areas of our country as compared to urban areas, making this vulnerable population disproportionately affected.

We can point to countless businesses like lumber mills, agricultural operations, and Mom & Pop stores that offer no health benefits to even their fulltime employees. Why even at Wal-Mart, the largest employer in the country, only around 50 percent of employees have company-sponsored health insurance. So please tell me, how many people are too many without employer-sponsored health care coverage?

At my institution, we have seen our bad debt rate soar in the past couple of years, as have many other providers And while much of this problem is due to the growing number of uninsured, a whopping 40 percent of this increase at our system was from folks who have health insurance but were unable to pay the new higher co-pays and deductibles of their health plans.

That illustrates for me a significant rise in the underinsured and the financial stress that is being placed on our providers in caring for them. So I ask you again, “How many underinsured is too many?”

We cannot allow ourselves to get caught up in a numbers game about these issues. They are just too important for that. Access to quality health care for all Americans regardless of their location, ethnicity, or ability to pay should be a right, not a privilege for a select few.

Unfortunately, it appears that only a select few will be able to afford these services in the very near future without some drastic change to the health care system.

In my view, only a system of government-sponsored universal health coverage, funded largely with the premiums we’re already paying, can hope to correct the looming crisis. The efficiencies of a single-payer, non-profit system could make the difference.

So, how many is too many? My answer is this: “One is too many.”

Oh, and while we’re at it, since William W. McGuire, chief executive officer for UnitedHealth Group Inc., personally earned $94,177,531 (including exercised stock options) in 2003, we may also want to ask how much is too much?

Greg Bausch, Pharm.D., is president of the Kentucky Rural Health Association, a member organization that educates providers and consumers on rural health issues and advocates actions by private and public leaders to assure equitable access to health care for rural Kentuckians. He also is vice president for regional services at St. Claire Regional Medical Center in Morehead. (www.kyrha.org)

On Introducing THE NATIONAL HEALTH INSURANCE BILL, HR 676,
Sponsored by Rep. John Conyers, Jr.

Marcia Angell, M. D.
Senior Lecturer, Department of Social Medicine, Harvard Medical School
Former Editor-in-Chief, New England Journal of Medicine
February 4, 2003, Washington D.C.

We are here today to introduce a national health insurance program. Such a program is no longer optional; it’s necessary.

Americans have the most expensive health care system in the world. We spend about twice as much per person as other developed nations, and that gap is growing. That’s not because we are sicker or more demanding (Canadians, for example, see their doctors more often and spend more time in the hospital). And it’s not because we get better results. By the usual measures of health (life expectancy, infant mortality, immunization rates), we do worse than most other developed countries.

Furthermore, we are the only developed nation that does not provide comprehensive health care to all its citizens. Some 42 million Americans are uninsured – disproportionately the sick, the poor, and minorities — and most of the rest of us are underinsured.

In sum, our health care system is outrageously expensive, yet inadequate. Why? The only plausible explanation is that there’s something about our system – about the way we finance and deliver health care – that’s enormously inefficient. The failures of the system were partly masked during the economic boom of the 90’s, but now they stand starkly exposed. There is no question that with the deepening recession and rising unemployment, in the words of John Breaux, “The system is collapsing around us.”

The underlying problem is that we treat health care like a market commodity instead of a social service. Health care is targeted not to medical need, but to the ability to pay. Markets are good for many things, but they are not a good way to distribute health care. To understand what’s happening, let’s look at how the health care market works.

Most Americans receive tax-free health benefits from their employers, who pay insurers a portion of the premiums for health coverage. But not all employers offer benefits, and when they do, the benefits may not be comprehensive. It’s entirely voluntary. When employers are competing for workers, they offer good benefits; when unemployment rises, they drop them.

The insurers with whom employers do business are mostly investor-owned, for-profit managed care businesses. They try to keep premiums down and profits up by stinting on medical services. In fact, the best way for insurers to compete is by not insuring high-risk patients at all; limiting the coverage of those they do insure (for example, by excluding expensive services, such as heart transplantation); and by passing costs back to patients by denying claims or as deductibles and co-payments.

We are the only nation in the world with a health care system based on dodging sick people. These practices add greatly to overhead costs because they require a mountain of paperwork. They also require creative marketing to attract the affluent and healthy and avoid the poor and sick. Not surprisingly, the U. S. has by far the highest overhead costs in the world.

It’s instructive to follow the health care dollar as it wends its way from employers toward the doctors and nurses and hospitals that actually provide medical services. First, private insurers regularly skim off the top a substantial fraction of the premiums – anywhere from 10 to 25 percent – for their administrative costs, marketing, and profits. The remainder is then passed along a veritable gauntlet of satellite businesses that feed on the health care industry, including brokers to cut deals, disease-management and utilization review companies, drug-management companies, legal services, marketing consultants, billing agencies, information management firms, and so on and so on. Their function is often to limit services in one way or another. They, too, take a cut, including enough for their own administrative costs, marketing, and profits.

I would estimate that no more than 50 cents of the health care dollar actually reaches the providers – who themselves face high overhead costs in dealing with multiple insurers.

What are the signs of the imminent collapse of this system? Private health insurance premiums are now rising at an unsustainable rate of about 13 percent per year – and as much as 25 percent in some areas of the country. Coverage is shrinking, as more employers decide to cap their contributions to health insurance and workers find they cannot pay their rapidly growing share. And finally, with the rise in unemployment, more people are losing what limited coverage they had.

This is not a system that can be tinkered with. It needs to change. The program we are introducing today is the very soul of simplicity and efficiency, compared with our private health care system. It is a single-payer system – that is, health care funds would be distributed by a single, public entity, so that health care could be coordinated to eliminate both gaps and overlap.

In many ways, our program would be tantamount to extending Medicare to the entire population. Medicare is, after all, a government-financed single-payer system embedded within our private, market-based system. It’s by far the most efficient part of our health-care system, with overhead costs of less than 3 percent, and it covers virtually everyone over the age of 65, not just some of them. Medicare is not perfect, but it is by far the most popular part of the U. S. health care system, and in my opinion its problems would be relatively easy to remedy – but that is another subject.

What are the usual objections to the sort of national program we are calling for today? They are mostly based on a number of myths.

Myth #1 is that we can’t afford a national health care system, and if we try it, we will have to ration care. My answer is that we can’t afford not to have a national health care system. A single-payer system would be far more efficient, since it would eliminate excess administrative costs, profits, cost-shifting and unnecessary duplication. Furthermore, it would permit the establishment of an overall budget and the fair and rational distribution of resources. We should remember that we now pay for health care in multiple ways – through our paychecks, the prices of goods and services, taxes at all levels of government, and out-of-pocket. It makes more sense to pay just once.

According to Myth #2, innovative technologies would be scarce under a single-payer system, we would have long waiting lists for operations and procedures, and in general, medical care would be threadbare and less available. This misconception is based on the fact that there are indeed waits for elective procedures in some countries with national health systems, such as the U. K. and Canada. But that’s because they spend far less on health care than we do. (The U. K. spends about a third of what we do per person.) If they were to put the same amount of money as we do into their systems, there would be no waits and all their citizens would have immediate access to all the care they need. For them, the problem is not the system; it’s the money. For us, it’s not the money; it’s the system.

Myth #3 is that a single-payer system amounts to socialized medicine, which would subject doctors and other providers to onerous, bureaucratic regulations. But in fact, although a national program would be publicly funded, providers would not work for the government. That’s currently the case with Medicare, which is publicly funded, but privately delivered. As for onerous regulations, nothing could be more onerous both to patients and providers than the multiple, intrusive regulations imposed on them by the private insurance industry. Indeed, many doctors who once opposed a single-payer system are now coming to see it as a far preferable option.

Myth #4 says that the government can’t do anything right. Some Americans like to say that, without thinking of all the ways in which government functions very well indeed, and without considering the alternatives. I would not want to see, for example, the NIH, the National Park Service, or the IRS privatized. We should remember that the government is elected by the public and we are responsible for it. An investor-owned insurance company reports to its owners, not to the public.

Some people say that a single-payer system is a good idea, but politically unrealistic. That is a self-fulfilling prophecy. In my opinion, the medical profession and the public would be enthusiastic about a single-payer system if the facts were known and the myths dispelled. Yes, there would be powerful special interests opposing it and I don’t underestimate them, but with courageous leadership, such as Representative Conyers is providing, and the support of the medical profession and public, I believe there is nothing unrealistic about a National Health Insurance Program.

I want to mention one final and very important reason for enacting a national health program. We live in a country that tolerates enormous disparities in income, material possessions, and social privilege. That may be an inevitable consequence of a free market economy. But those disparities should not extend to denying some of our citizens certain essential services because of their income or social status. One of those services is health care. Others are education, clean water and air, equal justice, and protection from crime, all of which we already acknowledge are public responsibilities. We need to acknowledge the same thing for health care. Providing these essential services to all Americans, regardless of who they are, helps ensure that we remain a cohesive and optimistic country. It says that when it comes to vital needs, we are one community, not 280 million individuals competing with one another. In seeking to ensure adequate health care for all our citizens, we have an opportunity today to reassert that we are indeed a single nation.