Statuary Hall where lunch will be served.

By Debora Yost, January 20, 2009 — The traditional inaugural luncheon our government will host after Barack Obama is sworn in as commander-in-chief will be a gourmet extravaganza – right down to the calories and fat.

The nutritional toll per person for the three-course meal: 3,048 calories and 142 grams of fat – not including the wine and champagne that will accompany each course. That’s 42 percent of calories from fat – quite a bit higher than the 25-30 percent minimum the National Institutes of Health (NIH) recommends per day for healthy living.

It’s also a far cry from the healthy eating edict forced on conventioneers at the Democratic Convention in Denver a few months ago that banned fried foods and proclaimed meals should contain at least three of the following colors: red, green, yellow, purple/blue and white. Aside from the whipped sweet potatoes and winter vegetable side dishes, the only other color on the menu is white and it comes from lobster, cream and vanilla ice cream. There isn’t even a salad.

The luncheon will be hosted by the Joint Congressional Committee on Inaugural Ceremonies (JCCIC), which is headed by Sen. Dianne Feinstein and includes Nancy Pelosi, Harry Reid and other Democratic heavyweights.

The Menu

The menu features:
• Seafood Stew, accompanied by 2007 Duckhorn Sauvignon Blanc
• Brace of American Birds with Sour Cherry Chutney and Molasses Sweet Potatoes and Winter Vegetables, accompanied by a 2005 Goldeneye Pinot Noir
• Apple Cinnamon Sponge Cake and Vanilla Ice Cream accompanied by Korbel Natural Special Inaugural Cuvee

The menu, being prepared by Design Cuisine, a catering company in Arlington, Va. is said to have historical significance to President Abraham Lincoln, who enjoyed oysters, root vegetables and wild game. The brace of birds – duck and pheasant – will be served on a replica of Lincoln’s White House china, which is emblazoned with an American Eagle.

The first course, 631 calories and 32 grams of fat, is a seafood stew consisting of Main lobsters, sea scallops, shrimp and black cod made in a broth of dry vermouth and heavy cream and topped with puff pastry. This is where the white comes in. The heavy cream and puff pastry topping account for more than half the calories and nearly all the fat.

The main course, 1,534 calories and 77 grams of fat, features duck breast in skin with cherry chutney and herb roasted pheasant with wild rice stuffing, molasses whipped sweet potatoes and roasted winter vegetables. This could account for red, if the fowl is served rare.

The dessert course, 883 calories and 33 grams of fat, features caramelized apples in a bread crust topped with caramel sauce and vanilla ice cream. The bread crust alone accounts for more than half the calories and fat. The apples (Granny Smith) are green but there so much white stuff (sugar, bread and ice cream) and yellow (butter and caramel), it has to smoother the fruit’s antioxidants.

Granted, it is an occasion to celebrate. What’s more reason to celebrate than to welcome a new president. But that’s the way the conventioneers felt, too, only they couldn’t savor the moment in fried food. They were told to eat lean.

In a world and nation facing an obesity epidemic, you’d think the JCCIC would want to practice what the Democrats were preaching back in August and be a bit more prudent about what goes to the hips and arteries of our national leaders. In addition to the Obamas and Vice President-elect Joe Biden’s family, invited guests include the Supreme Court, Cabinet designees, and the Congressional leadership. Then it’s off to the parade where they might want to march instead of just watch – if they want to make room for dinner.


NY Nutrition Examiner
Link to the story: http://www.examiner.com/x-2368-NY-Nutrition-Examinee

Debora Yost, former editor-in-chief of Prevention Magazine Health Books, has authored, edited or contributed to more than 100 health books. Her most recent book is The Complete Guide to Natural Cures.

Mercury Poses Biggest Health Threat to New York Women

January 19, 2009
by Debora Yost, NY Nutrition Examiner

Sushi putting New York women at risk.

New York women are eating fish to the detriment of their health.

Even though fish consumption is down, New York women run the greatest risk of having blood mercury concentrations exceeding safe levels, according to a new study released over the weekend.

The study also reports that 19 percent of women living in northeast coastal areas – that’s one in five – have too much mercury in their blood as a result of eating fish. This is three-to-four times greater than women living anywhere else in the 50 states. New York women, the study says, lead the pack. Women in Hawaii came in second, followed by Floridians.

Among those affected the most: Asians and those making more than $75,000 a year.

The study, published in the journal Environmental Health Perspectives, was conducted on women of childbearing age between ages 16-49 because mercury is most dangerous to the nervous system of a fetus.

“The pattern suggests a more discerning series of choices in type of fish eaten rather than an overall reduction in fish consumption,” commented study leader Kathryn R. Mahaffey.

But What to Eat?

All finfish and shellfish contain mercury, according to the Environmental Protection Agency (EPA). Generally, the EPA and most doctors agree that the health benefits from eating fish – most notably heart-healthy Omega-3 fatty acids – far outweigh the risks. Omega-3s are most abundant in fatty fish. Unfortunately, fatty fish attract mercury more easily than others. Fish with the highest levels of mercury are:

· · Shark

· · Swordfish

· · King mackerel

· · Tilefish

Ironically, the women in this study were not eating these fish. Tuna was their fish of choice followed by shrimp and salmon. However, fresh tuna (not canned) follows king mackerel in mercury content.

To get the benefits without the risk, the Federal Drug Administration (FDA) and EPA recommend these guidelines for pregnant women and women considering getting pregnant:

· · Do not eat shark, swordfish, king mackerel or tilefish.

· · Eat a variety of other fish.

· · Limit consumption to two average servings a week. An average serving is considered 6 ounces.

Mercury in the Limelight

Mercury toxicity made big headlines recently after Emmy-winning Entourage star Jeremy Piven abruptly left his role in the smash Broadway show Speed-the-Plow. His physician, Dr. Carlan M. Colker, said Piven’s mercury blood level was six times greater than safe levels.

Piven told Good Morning America last week that fish was his only protein for the last 20 years and that he ate sushi twice a week for almost two years. He said he ate fish “because I thought it was good for you.”

Mercury poisoning carries a range of symptoms. Piven described having problems with balance and overwhelming fatigue.


The Job of Surgeon General

Sanjay Gupta, a neurosurgeon, is a correspondent on CNN and CBS. (Getty Images)

Q: Which of the following is included in the formal job description for the position of surgeon general of the United States?

· Helps to craft the administration’s public health policy.

· Serves as visible advocate for public health initiatives.

· Acts as media spokesperson promoting the administration’s health agenda.

A: None of the above.

The Washington Post, January 19, 2008 — In the current debate as to whether President-elect Barack Obama’s likely choice for the post of surgeon general, Dr. Sanjay Gupta, is qualified for that job, the only thing missing is a description of what the job actually entails.

Yes, we know from precedent that the surgeon general can take on big public health battles (see C. Everett Koop’s war on tobacco) or offer novel ideas for curing public health ills (see Jocelyn Elders and the teaching-masturbation-to-kids controversy). But for an actual job description — the commonplace kind such as you find attached to any employment ad in the classifieds — you’ll have to be satisfied with this, supplied by the White House press office:

The Surgeon General serves as America’s chief health educator by providing Americans the best scientific information available on how to improve their health and reduce the risk of illness and injury. The Surgeon General is appointed by the President of the United States with the advice and consent of the United States Senate for a 4-year term of office. In carrying out all responsibilities, the Surgeon General reports to the Assistant Secretary for Health, who is the principal advisor to the Secretary on public health and scientific issues.

White House Assistant Press Secretary Carlton Carroll adds that “this position can be changed in a new administration to take on more, fewer or entirely different responsibilities.”

The whole thing’s vague enough that just about anybody qualifies.

It seems to me that the real issue here is whether we like this Dr. Gupta — a practicing neurosurgeon and chief medical correspondent for CNN — enough to see and hear him talk a lot over the next four years. Since he’s such a big TV presence already, that should be easy for us to gauge. Any other questions — about his gravitas, whether he values medicine as much as he values the media, whether someone who’s been named one of People’s Sexiest Men Alive is an appropriate choice for the nation’s almost-top public health position (remember: According to the job description, the surgeon general reports to the assistant secretary for health — not even the actual secretary!) — are all beside the point.

Single-Payer FAQs

Is national health insurance ‘socialized medicine’?

No. Socialized medicine is a system in which doctors and hospitals work for and draw salaries from the government. Doctors in the Veterans Administration and the Armed Services are paid this way. The health systems in Great Britain and Spain are other examples. But in most European countries, Canada, Australia and Japan they have socialized health insurance, not socialized medicine. The government pays for care that is delivered in the private (mostly not-for-profit) sector. This is similar to how Medicare works in this country. Doctors are in private practice and are paid on a fee-for-service basis from government funds. The government does not own or manage medical practices or hospitals.

The term socialized medicine is often used to conjure up images of government bureaucratic interference in medical care. That does not describe what happens in countries with national health insurance where doctors and patients often have more clinical freedom than in the U.S., where bureaucrats attempt to direct care.

Won’t this result in rationing like in Canada?

The U.S. already rations care. Rationing in U.S. health care is based on income: if you can afford care, you get it; if you can’t, you don’t. A recent study by the prestigious Institute of Medicine found that 18,000 Americans die every year because they don’t have health insurance. Many more skip treatments that their insurance company refuses to cover. That’s rationing. Other countries do not ration in this way.

If there is this much rationing, why don’t we hear about it? And if other countries ration less, why do we hear about them? The answer is that their systems are publicly accountable, and ours is not. Problems with their health care systems are aired in public; ours are not. For example, in Canada, when waits for care emerged in the 1990s, Parliament hotly debated the causes and solutions. Most provinces have also established formal reporting systems on waiting lists, with wait times for each hospital posted on the Internet. This public attention has led to recent falls in waits there.

In U.S. health care, no one is ultimately accountable for how the system works. No one takes full responsibility. Rationing in our system is carried out covertly through financial pressure, forcing millions of individuals to forego care or to be shunted away by caregivers from services they can’t pay for.

The rationing that takes place in U.S. health care is unnecessary. A number of studies (notably a General Accounting Office report in 1991 and a Congressional Budget Office report in 1993) show that there is more than enough money in our health care system to serve everyone if it were spent wisely. Administrative costs are at 31% of U.S. health spending, far higher than in other countries’ systems. These inflated costs are due to our failure to have a publicly financed, universal health care system. We spend about twice as much per person as Canada or most European nations, and still deny health care to many in need. A national health program could save enough on administration to assure access to care for all Americans, without rationing.

Who will run the health care system?

There is a myth that with national health insurance the government will make the medical decisions. But in a publicly financed, universal health care system, medical decisions are left to the patient and doctor, as they should be. This is true even in the countries like the U.K. and Spain (or in U.S. systems like the VA) that have socialized medicine.

In a public system, the public has a say in how it’s run. Cost containment measures are publicly managed at the state level by elected and appointed agencies that represent the public. This agency decides on the benefit package and negotiates doctor fees and hospital budgets. It also is responsible for health planning and the distribution of expensive technology. Thus, the total budget for health care is set through a public, democratic process. But clinical decisions remain a private matter between doctor and patient.

What about medical research?

Much current medical research is publicly financed through the National Institutes of Health. Under a universal health care system this would continue. For example, a great deal of basic drug research, for example, is funded by the government. Drug companies are invited in for the later stages of “product development,” the formulation and marketing of new drugs. AZT for HIV patients is one example. The early, expensive research was conducted with government money. After the drug was found to be effective, marketing rights went to the drug company.

Medical research does not disappear under universal health care system. Many famous discoveries have been made in countries with national health care systems. Laparoscopic gallbladder removal was pioneered in Canada. The CT scan was invented in England. The treatment for juvenile diabetes by transplanting pancreatic cells was developed in Canada.

It is also important to note that studies show that, in the U.S., the number of clinical research grants declines in areas of high HMO penetration. This suggests that managed care increasingly threatens clinical research. Another study surveyed medical school faculty and found that it was more difficult to do research in areas where high HMO penetration has enforced a more business-oriented approach to health care.

Finally, it appears that the increasing commercialization of research is beginning to slow innovation. Drug firms’ increasing reliance on contract research organizations (and for-profit ethical-review boards) has coincided with a sharp drop in innovative new drugs and a spate of “me-too” drugs – minor variations on old drugs that offer little benefit other than extended patent life.

Won’t this just be another bureaucracy?

The United States has the most bureaucratic health care system in the world. Over 31% of every health care dollar goes to paperwork, overhead, CEO salaries, profits, etc. Because the U.S. does not have a unified system that serves everyone, and instead has thousands of different insurance plans, each with its own marketing, paperwork, enrollment, premiums, and rules and regulations, our insurance system is both extremely complex and fragmented.

The Medicare program operates with just 3% overhead, compared to 15% to 25% overhead at a typical HMO. Provincial single-payer plans in Canada have an overhead of about 1%.

It is not necessary to have a huge bureaucracy to decide who gets care and who doesn’t when everyone is covered and has the same comprehensive benefits. With a universal health care system we would be able to cut our bureaucratic burden in half and save over $300 billion annually.

How will we keep costs down if everyone has access to comprehensive health care?

People will seek care earlier when chronic diseases such as hypertension and diabetes are more treatable. We know that both the uninsured and many of those with skimpy private coverage delay care because they are afraid of health care bills. This will be eliminated under such a system. Undoubtedly the costs of taking care of the medical needs of people who are currently skimping on care will cost more money in the short run. However, all of these new costs to cover the uninsured and improve coverage for the insured will be fully offset by administrative savings.

In the long run, the best way to control costs is to improve health planning to assure appropriate investments in expensive, high-tech care, to negotiate fees and budgets with doctors, hospital and drug companies, and to set and enforce a generous but finite overall budget.

How will we keep doctors from doing too many procedures?

This is a problem in any system that reimburses physicians on a fee-for-service basis. In today’s health system, another problem is physicians doing too little for patients. So the real question is, “How do we discourage both overcare and undercare?”

One approach is to carefully control new capital expenditures. Once a hospital or imaging center purchases a multimillion-dollar CT scanner, it will try to generate enough scans to pay off the fixed cost. Explicit health planning should be done to assure that expensive machines and facilities are sited where they are needed and not where they are redundant and likely to generate overuse.

Another approach is to compare physicians’ use of tests and procedures to their peers with similar patients. A physician who is “off the curve” will stand out. A related approach is to set spending targets for each specialty. This encourages doctors to be prudent stewards and to make sure their colleagues are as well, because any doctor doing unnecessary procedures will be taking money away from colleagues.

In addition, expert guidelines by groups like the American College of Physicians, etc., can help shape professional standards – which will certainly change over time as treatments change. This really gets to the heart of “how do you improve the quality of health care,” which is a longer topic. Suffice it to say that single-payer, universal coverage provides a framework for achieving thoughtful quality improvement.

What will happen to physician incomes?

On the basis of the Canadian experience under national health insurance, we expect that average physician incomes should change little. However, the income disparity between specialties is likely to shrink.

The increase in patient visits when financial barriers fall under a single-payer system will be offset by resources freed up by a drastic reduction in administrative overhead and physicians’ paperwork. Billing would involve imprinting the patient’s national health program card on a charge slip, checking a box to indicate the complexity of the procedure or service, and sending the slip (or a computer record) to the physician-payment board.

How will we keep drug prices under control?

When all patients are under one system, the payer wields a lot of clout. The VA gets a 40% discount on drugs because of its buying power. This “monopsony” buying power is the main reason why other countries’ drug prices are lower than ours. This also explains the drug industry’s staunch opposition to single-payer national health insurance.

Why shouldn’t we let people buy better health care if they can afford it?

Whenever we allow the wealthy to buy better care or jump the queue, health care for the rest of us suffers. If the wealthy are forced to rely on the same health system as the poor, they will use their political power to assure that the health system is well funded. Conversely, programs for the poor become poor programs. For instance, because Medicaid doesn’t serve the wealthy, the payment rates are low and many physicians refuse to see Medicaid patients. Calls to improve Medicaid fall on deaf ears because the beneficiaries are not considered politically important. Moreover, when the wealthy jump the queue, it results in longer waits for others. Studies in New Zealand and Canada show that the growth of private care in parallel to the public system results in lengthening waits. Additionally, allowing the development of a parallel, private system for the wealthy means the creation of a permanent lobby for underfunding public care. Such underfunding increases the demand for private care.

What will be covered?

All medically necessary care would be funded through the single payer, including doctor visits, hospital care, prescriptions, mental health services, nursing home care, rehab, home care, eye care and dental care. We also advocate a sharp increase in public health funding.

What about alternative care, will it be covered?

Alternative care that is proven in clinical trials to be effective will be covered. For example, spinal manipulation for some lower back conditions would be covered, but not chiropractic care of the neck (which is unproven and possibly dangerous). Antioxidant vitamins would be covered for people with macular degeneration, but not for the general population (where they appear to be harmful). In general, coverage decisions will be made by the health care planning board or another public body. New kinds of treatments will be added to the benefits package over time as they are shown to be effective, including “alternative” treatments. Similarly, ineffective or harmful care can be removed from the benefits package, such as high dose epo for cancer.

Can a business keep private insurance if they choose?

Yes and no. Everyone has to be included in the new system for it to be able to control costs, reduce bureaucracy, and cover everyone. In Canada, businesses can purchase additional private insurance that covers things not covered by the national plan (e.g. private rooms, orthodontia, etc.). However, we support a comprehensive benefit package for the single-payer program that would eliminate the need (and most demand) for supplemental coverage.

Insurance companies would not be allowed to offer the same benefits as the universal health care system, a restriction contained in the traditional Medicare program. Allowing such duplication of coverage weakens and eventually destabilizes the health care system. It undermines the principle of pooling the risk. Health care systems act as universal insurers. At any one time the healthy help pay for those who are ill. If private insurers are allowed to cherry-pick the healthy, leaving the public health care system with the very sick, the system will fail.

This, in fact, is what we see happening to Medicare through the Medicare Advantage program. The government pays Medicare HMOs 13% more than it pays traditional Medicare, yet the HMOs care for a healthier mix of seniors. This is leading to privatization of Medicare and funding shortfalls for the traditional Medicare program.

What will happen to all of the people who work for insurance companies?

The new system will still need some people to administer claims. Administration will shrink, however, eliminating the need for many insurance workers, as well as administrative staff in hospitals, clinics and nursing homes. More health care providers, especially in the fields of long-term care, home health care, and public health, will be needed, and many insurance clerks can be retrained to enter these fields. Many people now working in the insurance industry are, in fact, already health professionals (e.g. nurses) who will be able to find work in the health care field again. But many insurance and health administrative workers will need a job retraining and placement program. We anticipate that such a program would cost about $20 billion, a small fraction of the administrative savings from the transition to national health insurance.

PNHP has worked with labor unions and others to develop plans for a jobs conversion program with would protect the incomes of displaced clerical workers until they were retrained and transitioned to other jobs.

How will we contain costs with the population aging?

Studies show that aging of the population accounts for only a small fraction of the increases in health costs. Japan and Europe are already facing the problem of an aging population head-on and are doing fine. They have a much higher percentage of elderly than we do, and still spend far less on health care.

The best way to approach this is to regard it as a societal problem, one that needs a solution with everyone in mind. Germany and Japan recently adopted single-payer long-term care systems to cover the long-term care needs of the elderly at home and in specialized housing. Germany is pioneering a program that pays family members to care for the elderly at home.

What about ERISA? Doesn’t it stand in the way of states implementing universal health care plans?

No. ERISA (the Employees Retirement Income Security Act) prevents a state from requiring that a self-insured employer provide certain benefits to their employees. However, a single-payer plan would not mandate the composition of employer benefit plans – it would replace them with a new system that would essentially be “Medicare for all.” The state would require employers to pay a payroll tax into the health care trust fund, which is clearly legal.

How will the Health Planning Board operate?

A health planning board would be a public body with representatives of patients and medical experts. The representatives would decide on what treatments, medications and services should be covered, based on community needs and medical science, and allocate capital for major new investments based on assessments of where need is greatest.

Since we could finance a fairly good system, like the Norwegian, Danish or Swedish system, with the public money we are already spending (60% of health costs), why do we need to raise the additional 40% (from employers and individuals)?

There are three reasons why the U.S. health care system costs more than other systems throughout the world. One, we spend two to three times as much as they do on administration. Two, we have much more excess capacity of expensive technology than they do (more CT scanners, MRI scanners, and surgery suites). Three, we pay higher prices for services than they do.

There is no doubt that we do not need to spend more than we currently spend to cover comprehensive care for everyone. But the initial transition to a universal system would be very disruptive if we spent less. That is because we have a tremendous medical infrastructure, some of which would likely retain its excess capacity during the transition phase. Secondly, we would likely retain salaries for health professionals at their current levels. Thirdly, we would cover much more than most other countries do by including dental care, eye care, and prescriptions. And for these reasons we would need the extra 40% that we are already spending – but NOT more. We could cover all the uninsured and improve coverage for those who have skimpy coverage for the same amount we are currently spending!

How much of the health care dollar is publicly financed?

Over sixty percent (60.5 percent) of health spending in the U.S. is funded by government. Official figures for 2005 peg government’s share of total health expenditure at 45.4 percent, but this excludes two items:

1. Tax subsidies for private insurance, which cost the federal treasury $188.6 billion in 2004. These predominantly benefit wealthy taxpayers.

2. Government purchases of private health insurance for public employees such as police officers and teachers. Government paid private insurers $120.2 billion for such coverage in 2005: 24.7 percent of the total spending by U.S. employers for private insurance.

So, government’s true share amounted to 9.7 percent of gross domestic product in 2005, 60.5 percent of total health spending, or $4,048 per capita (out of total expenditure of $6,697).

By contrast, government health spending in Canada and the U.K. was 6.9 percent and 7.2 percent of gross domestic product respectively (or $2,337 and $2,371 per capita). Government health spending per capita in the U.S. exceeds total (public plus private) per capita health spending in every country except Norway, Switzerland and Luxembourg.

(Source: Himmelstein and Woolhandler, “Competition in a publicly funded healthcare system” BMJ 2007; 335:1126-1129 [1 December] and Woolhandler and Himmelstein, Health Affairs, 2002, 21(4), 88, “Paying for National Health Insurance – And Not Getting It.”)

Why not MSAs/HSAs?

Medical savings accounts (MSAs) and similar options such as health savings accounts (HSAs) are individual accounts from which medical expenses are paid. Once the account is depleted and a deductible is met, medical expenses are covered by a catastrophic plan, usually a managed care plan.

Individuals with significant health care needs would rapidly deplete their accounts and then be exposed to large out-of-pocket expenses; hence they would tend to select plans with more comprehensive coverage. Since only healthy individuals would be attracted to the MSAs/HSAs, higher-cost individuals would be concentrated in the more comprehensive plans, driving up premiums and threatening affordability. By placing everyone in the same pool, the cost of high-risk individuals is diluted by the larger sector of relatively healthy individuals, keeping health insurance costs affordable for everyone.

Currently, HSAs offer substantial tax savings to people in high-income brackets, but little to families with average incomes, and thus serve as a covert tax cut for the wealthy.

Moreover, MSA/HSA plans discourage preventive care, which generally would be paid out-of-pocket, and do nothing to restrain spending for catastrophic care, which accounts for most health costs. Finally, HSAs/MSAs discriminate against women, whose care costs, on average, $1,000 more than men’s annually. Hence, on the MSA/HAS plan, the average woman pays $1,000 more out-of-pocket than her male counterpart.

Why not use tax subsidies to help the uninsured buy health insurance?

The major flaw of tax subsidies is that they would be used to help purchase plans in our current fragmented system. The administrative inefficiencies and inequities that characterize our system would be left in place, and we would continue to waste valuable resources that should be going to patient care instead. Moreover, even with tax subsidies, moderate- and lower-income individuals would be unable to afford good coverage, leaving them with modest benefits and high cost-sharing that would often make health care unaffordable. Instead of perpetuating our current inequities, tax policies should be used to create equity in contributions to a system in which everyone is assured access to comprehensive beneficial services.

If the tax subsidies are granted to individuals, employers would be motivated to drop their coverage, and most individuals covered would have merely rotated from employer coverage to individual coverage. The net reduction in the numbers of uninsured would be small. If the tax subsidies are granted to employers, a major shift in funding passes from employers to taxpayers without significant improvements efficiency or fairness. We can use the tax system to create equity in the way we fund health care, but we should also expect equity and efficiency in allocation of our health care resources. Distributing health resources according to human needs is possible only if we eliminate the private health plans and establish a publicly administered system.

What is PNHP’s response to libertarian proposals for health savings accounts and deregulated insurance plans?

In response to the libertarian view: 1) We are already spending more than enough to provide all necessary health care services to everyone, and 2) The majority of Americans believe that everyone should be able to obtain necessary health care without having to face financial hardship.

The goal then is not only to have everyone covered with insurance, but also to make sure that insurance is effective in preventing the consequences of medical debt. We have a rapidly expanding epidemic of underinsurance, and the proposals of libertarians would expose the majority of us to the potential of excessive medical debt were we to develop significant medical problems. Policies with affordable premiums work for those who remain healthy, but most of health care spending is for those with major acute and chronic problems. The deregulated insurance plans and HSAs proposed by libertarians cannot ever effectively address the problem of how we are going to pay for most of the health care in this nation.

The most efficient and effective system would be to establish a single risk pool covering everyone, and fund it equitably. The libertarians do have a problem with “equitable.” That would require a transfer from the healthy to those with greater health care needs. But the United States has an additional unique problem. Since we spend twice as much per capita as the average industrialized nation, each person’s share (national health expenditures divided by the U.S. population) is no longer affordable. For a family of four, that would be over $30,000 when median household income is about $50,000. So an equitably financed system in the United States would also require a transfer from wealthier individuals to the majority of us. Libertarians and egalitarians will never agree on the appropriate course. All other nations tend toward an egalitarian approach.

The World Health Report 2008, published by the World Health Organization, singles out the United States for its exceptionalism – a system with “singularly high additional private expenditure” that persistently underperforms “across domains of health outcomes, quality, access, efficiency and equity.” Everyone should read this report. Very brief excerpts and a link to the full report can be found at:

Won’t competition be impeded by a universal health care system?

Advocates of the “free market” approach to health care claim that competition will streamline the costs of health care and make it more efficient. What is overlooked is that past competitive activities in health care under a free market system have been wasteful and expensive, and are the major cause of rising costs.

There are two main areas where competition exists in health care: among the providers and among the payers. When, for example, hospitals compete they often duplicate expensive equipment in order to corner more of the market for lucrative procedure-oriented care. This drives up overall medical costs to pay for the equipment and encourages overtreatment. They also waste money on advertising and marketing. The preferred scenario has hospitals coordinating services and cooperating to meet the needs of their communities.

Competition among insurers (the payers) is not effective in containing costs either. Rather, it results in competitive practices such as avoiding the sick, cherry-picking, denial of payment for expensive procedures, etc. An insurance firm that engages in these practices may reduce its own outlays, but at the expense of other payers and patients.

Why not make people who are higher risk pay higher premiums?

Experience-rated insurance requires higher risk people to pay higher premiums. This approach says that people who have had cancer in the past, or who have chronic conditions like diabetes and hypertension, or who have had dangerous exposures to substances like asbestos, must pay more because they are at higher risk of using health services. Experience rating allows insurance companies to cherry-pick the healthiest people and either refuse to insure the sickest or, what amounts to the same thing, charge prohibitively high rates. This approach makes no sense. The whole point of insurance is to spread the risk so that everyone is covered. If you raise premiums – and thereby exclude from coverage – those people unfortunate enough to be sick, you defeat the point of both insurance and the health care system. Genetic conditions, childhood diseases, accidents, injuries and income distribution (or how much equality there is in a society) play a much bigger role in people’s health than “individual lifestyle” factors. And we know that even for motivated patients, alcohol and tobacco cessation are difficult, and medical weight loss nearly impossible. We need public health, primary care and education programs to try to prevent disease, but punishing patients once they are ill is inhumane and counterproductive.

Community-rated health insurance is the socially fair approach. It spreads the risks evenly among all the insured. It removes the punitive element. It does not discriminate against the very sick, nor against those of us who are at higher risk because of our age (say, over 50) or our gender (reproductive-age females have higher health expenses than men, for obvious reasons).

Health care should be organized as a public service, like a fire department. A health system organized as a business is discriminatory and accountable to no one. At some point in our lives all of us will predictably need health care. Hence health insurance is unlike any other form of insurance; we all are involved.

Won’t this raise my taxes?

Currently, about 60% of our health care system is financed by public money: federal and state taxes, property taxes and tax subsidies. These funds pay for Medicare, Medicaid, the VA, coverage for public employees (including police and teachers), elected officials, military personnel, etc. There are also hefty tax subsidies to employers to help pay for their employees’ health insurance. About 20% of health care is financed by all of us individually through out-of-pocket payments, such as co-pays, deductibles, the uninsured paying directly for care, people paying privately for premiums, etc. Private employers only pay 21% of health care costs. In all, it is a very “regressive” way to finance health care, in that the poor pay a much higher percentage of their income for health care than higher income individuals do.

A universal public system would be financed in the following way: The public funds already funneled to Medicare and Medicaid would be retained. The difference, or the gap between current public funding and what we would need for a universal health care system, would be financed by a payroll tax on employers (about 7%) and an income tax on individuals (about 2%). The payroll tax would replace all other employer expenses for employees’ health care, which would be eliminated. The income tax would take the place of all current insurance premiums, co-pays, deductibles, and other out-of-pocket payments. For the vast majority of people, a 2% income tax is less than what they now pay for insurance premiums and out-of-pocket payments such as co-pays and deductibles, particularly if a family member has a serious illness. It is also a fair and sustainable contribution.

Currently, 47 million people have no insurance and hundreds of thousands of people with insurance are bankrupted when they have an accident or illness. Employers who currently offer no health insurance would pay more, but those who currently offer coverage would, on average, pay less. For most large employers, a payroll tax in the 7% range would mean they would pay slightly less than they currently do (about 8.5%). No employer, moreover, would gain a competitive advantage because he had scrimped on employee health benefits. And health insurance would disappear from the bargaining table between employers and employees.

Of course, the biggest change would be that everyone would have the same comprehensive health coverage, including all medical, hospital, eye care, dental care, long-term care, and mental health services. Currently, many people and businesses are paying huge premiums for insurance so full of gaps like co-payments, deductibles and uncovered services that it would be almost worthless if they were to have a serious illness.

Isn’t a payroll tax unfair to small businesses?

The payroll tax means a cost increase for businesses that are not currently insuring their workers. However, it is much less than they would pay at present for adequate coverage for themselves and their workers. For most small (and large) businesses already providing coverage, the payroll tax will mean substantial savings.

Walter Reed Army Medical Center has been in the news lately for poor care and treatment of returning soldiers from Iraq. Won’t national health insurance have similar problems?

As we consider what we can learn from the Walter Reed Army Medical Center debacle with regard to government-run efforts, some clarifications should be made:

1. Walter Reed Army Medical Center is an Army hospital and is run by the Department of Defense. The VA hospitals are run by the Veterans Administration (Veterans Health Administration), a separate organization. The news media has clouded this fact and has led the public to presume that all government-run health efforts fail. The VA health system continues to receive the best quality scores of any segment of the U.S. health system, with the most satisfied patients. It beats the best HMOs in quality ratings, has a model information system, and focuses on primary care. It has led in addressing medical errors and in its application of AHRQ quality guidelines to both inpatients and outpatients. In 2004 it won the Baldridge Prize for quality and patient-safety improvements.

2. There is a lot we can learn from the Walter Reed disgrace. Its operation was outsourced to a Halliburton-connected company in 2002, over the objections of some Army medical personnel and leadership, with a subsequent drastic reduction in staff and loss of government employees with institutional experience. There was also some hanky-panky with the contracting process; when the government employees’ bid for the operations contract came in lower than the Halliburton company’s bid, the bids were “recalculated” to make the private company the lowest bidder.
(This section was contributed by Dr. Anne Carroll.)

What about incremental reform of the health system?

As a matter of policy, PNHP expressly opposes many so-called gradual steps towards single-payer. Many well-meaning supporters often push these bills as “feasible steps” to move us towards single-payer, but the history of these kinds of health reform efforts – Hawaii in 1974, Massachusetts in 1988, Oregon in 1989, Tennessee in 1992, Minnesota in 1992, Maine in 2003, etc. – shows that despite their claims of pragmatism, incremental reforms have consistently failed for more than three decades. Incremental reforms cannot garner administrative savings and redirect them to care. Hence they always founder on the shoals of cost. In addition, these reforms distract attention from the economically realistic, if politically challenging, option of single-payer reform.

What happens to investor-owned hospitals under national health insurance (NHI)?

“The NHI program would compensate owners of investor-owned hospitals, group/staff model HMOs, nursing homes and clinics for the loss of their clinical facilities, as well as any computers and administrative facilities needed to manage NHI. They would not be reimbursed for loss of business opportunities or for administrative capacity not used by NHI. Investor-owned providers would be converted to nonprofit status. The NHI would issue long-term bonds to amortize the one-time costs of compensating investors for the appraised value of their facilities. These conversion costs would be offset by reductions in payments for capital that are currently folded into Medicare and other reimbursements.” (Physicians’ Proposal, JAMA, August 13, 2003.)

What proportion of health spending is for undocumented immigrants?

Very little. All foreign-born people, including immigrant workers who have legal status and who have lived in the U.S. for years, account for somewhat less than one-quarter of the uninsured, according to the Census Bureau. We do know that foreign-born people in the U.S. are, on average, healthier and utilize little health care – about half of the health care (per capita) of U.S.-born persons. Surprisingly this is true whether or not they have insurance. Immigrant children receive very little care, 74 percent less overall than other children. So, if the foreign born are less than one-quarter of the uninsured, only one-eighth of health spending on the uninsured is going to the foreign born, which translates into a tiny fraction of all U.S. health spending. In fact, most immigrants have health insurance coverage, and 30% of immigrants use no health care at all in the course of a year. Undocumented immigrants are politically unpopular and hence a convenient target, but they are not the cause of rising health care costs.

The insurance industry says that PNHP’s figures on administrative costs are outdated. Is this true?

PNHP has published a series of peer-reviewed studies over the past 20 years showing a steady increase in health administrative costs. While some aspects of administrative cost estimation (e.g. physicians’ billing costs) require special studies, others, such as insurance overhead, can be easily tracked from publicly available data. These figures show no evidence of a fall in administrative costs since our most recent (2003) comprehensive estimate that administration consumes at least 31% of U.S. health care spending.

Recently, right-wing “think tanks” have released studies claiming that Medicare’s administrative costs are far higher than the official 3% estimate. These estimates add to Medicare’s costs a share of the salaries of the President and members of Congress, the cost of running the Internal Revenue Service, etc. But none of these added costs would go away if Medicare were abolished, or up if Medicare were expanded to cover everyone. Most economists agree that such expenses should not be included in calculating Medicare’s overhead.

How much could the states save on administrative waste by adopting a statewide single-payer program?

Data on total health expenditures by state (excluding administrative spending) is available at: http://www.cms.hhs.gov/NationalHealthExpendData/05_NationalHealthAccountsStateHealthAccounts.asp

Estimates of state administrative costs (a few years old, but the best available) are in an article by Drs. David Himmelstein and Steffie Woolhandler from 2003.

What will happen to malpractice costs under national health insurance?

They will fall dramatically, for several reasons. First, about half of all malpractice awards go to pay present and future medical costs (e.g. for infants born with serious disabilities). Single payer national health insurance will eliminate the need for these awards. Second, many claims arise from a lack of communication between doctor and patient (e.g. in the Emergency Department). Miscommunication/mistakes are heightened under the present system because physicians don’t have continuity with their patients (to know their prior medical history, establish therapeutic trust, etc) and patients aren’t allowed to choose and keep the doctors and other caregivers they know and trust (due to insurance arrangements). Single payer improves quality in many ways, but in particular by facilitating long-term, continuous relationships with caregivers. For details on how single payer can improve the quality of health care, see “A Better Quality Alternative: Single Payer National Health Insurance.” For these and other reasons, malpractice costs in three nations with single payer are much lower than in the United States, and we would expect them to fall dramatically here. For details, see “Medical Liability in Three Single-Payer Countries” paper by Clara Felice and Litsa Lambkros.

Universal healthcare is okay for a small country or organization like Switzerland, Canada, or the Veterans Administration, but it wouldn’t work when scaled up to meet the needs of a large country like the US

Medicare is a national program that works reasonably well. There isno reason whatsoever that would make it hard to scale up. Indeed, Medicare was initiated (and administered for tens of millions of enrollees) before computers became available – scaling it up 7 or 8 fold should not prove difficult.

In Canada, health care is administered at the provincial level. The Ontario Health Insurance Program, which includes the city of Toronto as well as rural areas, is a good example. Since much of the program we envision would be regionalized, with regions similar in size to Ontario, that program seems a sound indication that scale should not be problematic.

Recent Attacks on Single Payer Health Reform: Ideology Masquerading as Scholarship

By David U. Himmelstein, M.D. and Steffie Woolhandler, M.D., M.P.H.

Some conservative opponents of single payer health reform have been claiming that new research proves that Canada’s single payer national health insurance program has performed poorly, and that projected savings on administration are illusory. In the commentaries below we analyze the two most prominent examples of this new research a paper by June and Dave O’Neill (“Health Status, Health Care and Inequality: Canada Vs. the U.S.”) and a report by Bejamin Zycher (“Comparing Public and Private Health Insurance: Would a Single Payer System Save Enough to Cover the Uninsured?”).

The O’Neill’s “Health Status, Health Care and Inequality: Canada vs. the U.S.“

A recent paper by June and Dave O’Neill contests previous research findings that health outcomes are better in Canada than in the U.S. The O’Neills also claim that income-based health disparities are larger in Canada than in the U.S., that access to care is better in the U.S. and that cancer screening and survival are worse in Canada.

The O’Neills collected no new data. Their analysis rests on idiosyncratic, highly selective and overtly biased reinterpretations of previously published data — mostly from the Joint Canada/U.S. Survey of Health (JCUSH), a population-based survey conducted jointly by the U.S. and Canadian government statistical agencies. While they extensively cite the few pieces of published data that supports their grim view of Canada’s health system, they ignore a large body of research and statistics that conflicts with their portrayal.

We will briefly discuss the main assertions in the O’Neill paper.

1-Canada’s lower mortality rates are not a result of better health care

The O’Neills assert that Canada’s longer life expectancy (2 years longer) and lower infant mortality rate (5.3 deaths/1000 live births vs. 6.8 in the U.S.) have nothing to do with health care. Rather, they claim that non-medical factors such as substance abuse, obesity, low education and “cultural factors” explain the U.S.’ poor performance.

They argue that high infant mortality in the U.S. simply reflects the high frequency of preterm births and low birth weight, and especially the very poor outcomes among African-Americans. American’s short life expectancy, they say, comes from high rates of obesity, as well as homicides and accidents.

But the U.S.’ high rate of prematurity and low birth weight is, largely, a result of poor care — inadequately treated infections and chronic illnesses among pregnant women, and the shockingly frequent failure to deliver adequate prenatal care. 16% of pregnant women in the U.S. receive no care at all in the first trimester of pregnancy, far higher than in Canada.

While the O’Neill’s dwell on the high obesity rates in the U.S. as an important non-medical cause of mortality differences, they ignore Canada’s significantly higher smoking rate — a graver threat to health than obesity. Moreover, they cite data from the OECD that exaggerates the obesity differences, ignoring the more reliable JCUSH data that they use for most of their other comparisons (presumably because the JCUSH found more modest differences in obesity rates).

They emphasize that accidents and homicides account for a large fraction of the U.S./Canada mortality difference among young adults, age 20-24. But deaths are rare in this age group, and accident/homicides account for virtually none of the difference in older age groups, where almost all of the deaths occur. In fact, differences in heart disease cause most of the Canadian advantage — a difference that almost certainly reflects, at least in part, better access to care in Canada.

The O’Neills also ignore the fact that the U.S. had a lower infant mortality rate than Canada’s until the passage of national health insurance (NHI) in Canada, after which Canada’s rate fell sharply. Similarly, they never mention that most of Canada’s advantage in life expectancy emerged shortly after NHI was implemented.

In many of their data tables on mortality and other health measures, the O’Neills’ separate out white from minority Americans, and indicate that Canadians’ health outcomes are similar to those of white Americans. Of course, excluding minorities in the U.S. means excluding one third of the entire population, and more than three quarters of the poor. In essence, they want to exclude the 100 million poorest and sickest Americans, and compare the remainder to a cross section of Canadians, including the sick and poor.

2-Other measures besides mortality rates are better indicators of the quality of health care in the two nations, and the U.S. comes out well on these.

The O’Neill’s simply assert that self-reported health status (the answer to the question “How would you rate your health? Excellent, good, fair or poor?”) is a better measure of the impact of the health care system than are mortality rates. Yet this measure has never been validated for cross national comparisons of the type they make, and it seems very likely to be greatly affected by cultural norms. And, as with death rate comparisons, only by eliminating minority Americans from the comparison can they conclude that the U.S. looks slightly better than Canada.

They then compare the two nations using a “health utility index” and the percent of people with pain that limits their activities. For both of these, Canadians do better than Americans, until minorities are subtracted from the population.

Finally, they compare the prevalence of chronic condition like diabetes, emphysema and arthritis in the two nations, and the proportion of people with each condition who are getting treatment. They conclude that while slightly more Americans are chronically ill, more of them are getting treatment. But millions of uninsured Americans with chronic illnesses like diabetes or high blood pressure are unaware of their diagnoses because they can’t afford the doctors visit or lab test needed to make the diagnosis. Surveys will not identify undiagnosed persons as having chronic disease. Hence, the proportion getting treatment is falsely inflated in the U.S. Moreover, even the differences they cite to favor the U.S. are not statistically significant. Hence, a more accurate depiction of the data would state that among people who know of their diagnoses, rates of care are similar in the two nations.

3-More Americans get cancer screening and the U.S. has more high tech health resources than Canada

The O’Neills cite higher screening rates in the U.S. for cervical cancer (PAP smears), breast cancer (mammography), colon cancer (colonoscopy or sigmoidoscopy) and prostate cancer (PSA testing). Only the small PAP smear difference is real.

For mammography, they include all women 40-69 in their calculation of screening rates. But neither the American College of Physicians nor the Canadian Task Force on Preventive Health Care recommend mammograms for all women 40-50. Mammograms for women in this age group leads to more breast surgery and other cancer treatments, but has not been shown to lower overall mortality. It is likely that most of the difference in breast cancer screening is due to higher screening rates among young women in the U.S., who may even be harmed by excessive mammograms.

There’s a similar problem with their analysis of colon cancer screening. They include people age 40-69. Yet standard guidelines do not recommend colon cancer screening in normal risk individuals before age 50. They’ve fudged the data to get a result they want.

Neither the U.S. Preventive Services Task Force nor its Canadian counterpart recommend routine PSA testing because its not at all clear that such testing does more good than harm — it turns up lots of false positives, including many small tumors that would never cause serious problems if left untreated. Routine screening may well lead to many unnecessary operations that leave men incontinent and impotent. Yet the O’Neill’s interpret Canada’s lower PSA screening rate as an indicator of poor quality care.

We may ultimately find that PSA screening or early mammography saves lives — or causes more harm than good. But at present, we just don’t know whether the lower use of these technologies in Canada is a good thing or a bad one.

Their analysis also trumpets the greater number of CT scanners and MRI machines in the U.S. as an indicator of better quality. Yet recent estimates suggest that in the coming years radiation from CT scans may cause as many of 2% of all cancer deaths in the U.S. — about 30,000 excess deaths annually. It is far from clear that the greater use of CT scanners in the U.S. (relative to Canada) causes more good than harm.

4-Waits for care compromise access in Canada, and these access problems are worse than those in the U.S.

The O’Neill analysis admits that fewer Canadians than Americans report an unmet health need (11.3% vs. 14.4%). In the U.S., cost is the big problem, while waits for care are more prominent in Canada. They try to obfuscate the Canadian advantage on access measures by presenting a complex sub-group analysis of pain suffered by those unable to get care. But when you cut through their obfuscation, even this measure favors Canada; about 12% more Americans who say they’re unable to get care report being in pain.

5-Cancer mortality rates are higher in Canada, indicating worse cancer care

The O’Neills claim that mortality rates for lung, breast, colon and prostate cancers are lower in the U.S. than in Canada. They calculate mortality rates by dividing cancer deaths by the number of cases of cancer.

When cancer death rates are calculated in a more standard fashion, i.e. the number of deaths per thousand people in the population, age adjusted cancer mortality is actually lower in Canada than in the U.S. for all of these cancers except colorectal cancer. But there are more cancers diagnosed in the U.S. Hence, the death rate among those who are diagnosed — the figure the O’Neills choose as the most important – is lower in the U.S.

This higher incidence of cancers diagnosed in the U.S. probably reflects more intensive screening programs, which diagnose more people with cancer. But, as stated above, its far from clear that diagnosing small prostate cancers based on PSA screening causes more good than harm. Most elderly men with prostate cancer do not die of that disease, but of heart disease or some other illness. (It is likely that some breast and lung cancers that are diagnosed through screening would also never come to light without screening.) In the U.S., these men with small, non-lethal cancers appear in the denominator of the O’Neill’s calculation of cancer mortality rates, but not the numerator. In Canada, they appear in neither the numerator nor denominator. Thus, their estimate of cancer mortality rates is biased against Canada because of the higher screening rate in the U.S.

6-Income-based health disparities are, if anything, steeper in Canada than in the U.S.

The O’Neills admit that health differences between those above and below the median income are sharper in the U.S. than in Canada. In fact, the differences between the top and bottom 10% are also bigger in the U.S., as are those between the top and bottom 25% etc.

But the O’Neills want to measure health inequities on a new scale. They observe that the rich in the U.S. are much richer than the rich in Canada, and the poor are much poorer. Rather than comparing high and low income persons, they decide to analyze how much worse health gets for each dollar decrease in income. Since the U.S. income gradient is much steeper, this analysis automatically makes the health per dollar gradient less steep. Notice that this method would find that a nation with almost no income inequality would automatically have very steep health inequalities.

Here’s an example. In Country A, the top 1% has an average income of $60,000 and a mortality rate of 100 per 1000. The bottom 1% has an average income of $30,000 and a mortality rate of 130 per 1000. Then, according to the O’Neills’ method for each $1000 increase in income, the mortality rate rises 1 per 1000.

In Country B, the top 1% has an average income of $603,000 and a mortality rate of 100 per 1000. The bottom 1% has an average income of $3,000 and a mortality rate of 300 per 1000. Then, according to the O’Neills’ method for each $1000 increase in income, the mortality rate rises only 1 per 3000.

So the O’Neills’ calculus would judge the income/health gradient less steep in Country B (where the poor have a death rate 300% higher than the wealthy) than in Country A (where the poor have a death rate 10% higher than the wealthy).

7-What’s left out?

The O’Neill’s paper cites dozens of references. But they fail to mention any of the numerous previous studies that directly address the questions they seek to answer. These include:

1-Previous analyses of the JCUSH data by the National Center for Health Statistics (http://www.cdc.gov/nchs/pressroom/04news/firstjointsurvey.htm) and by our group at Harvard (http://www.ajph.org/cgi/content/abstract/96/7/1300), which found a far different result.

2-The many published studies directly comparing the quality of medical care in the two nations for cancer patients, renal dialysis patients etc. 38 of these studies were included in a systematic review which concluded that, on average, mortality rates are 5% lower in Canada (http://www.openmedicine.ca/article/view/8/1).

3-The large body of literature showing that Canada’s health care system is far more efficient, with administrative overhead that is a small fraction of the U.S. level (http://content.nejm.org/cgi/content/short/349/8/768)

4-A recent analysis of deaths that could be prevented by good medical care ranked the U.S. worst among the 19 nations studied, well behind Canada which ranked 6th. Moreover, while Canada’s ranking improved between 1997 and 2003, the U.S. fell further behind. (http://content.healthaffairs.org/cgi/content/abstract/27/1/58)

There is much to criticize in Canada’s health care system. But the O’Neill’s analysis strays far from legitimate scientific discourse, mixing selective citation and creative accounting that is intellectually dishonest.

Bejamin Zycher’s “Comparing Public and Private Health Insurance: Would a Single Payer System Save Enough to Cover the Uninsured?”

Benjamin Zycher, an economist at the right wing Manhattan Institute, has recently issued a report disputing claims that a single payer health care reform would realize large administrative and overhead savings. We will briefly respond to the main arguments in Zycher’s paper.

1-Medicare’s administrative costs are far higher than the figure given in the National Health Accounts.

The National Health Accounts indicate that administrative costs account for only 3% of total Medicare spending (vs. 14% in private insurers). But Zycher wants to add to this a proportional share of all government spending. That is, he claims that 14% of the President’s salary, the cost of Congress, the FBI, the federal courts etc, should be attributed to Medicare, since Medicare accounts for 14% of federal spending. Based on this, he estimates “true” Medicare administrative costs at 6% of total outlays, and concludes that potential savings on insurance overhead is only 8% of premiums, not 11%.

Zycher’s argument assumes that expanding Medicare to cover all Americans would drive up the costs of all government agencies, Congress etc. — an absurd assumption. Would we really raise the president’s salary, or a senator’s pay as part of implementing a single payer system? In fact, there is no reason to posit increases in any such costs, and the Canadian experience suggests that Medicare’s overhead could actually be reduced to about 1% by simplifying hospital and physician payment.

2-The higher taxes needed to fund national health insurance would cause massive economic losses that more than offset any administrative savings.

Zycher argues that every dollar collected in taxes by the government actually costs the economy about $1.76 because of foregone private investment. He wants to add a large portion of this cost to Medicare’s overhead, arriving at an estimate that overhead consumes 52% of total Medicare spending.

First, his estimate of the economic consequences of taxation is questionable at best. His assumption that the taxes raised for NHI would come from investment, not from existing health care expenditures, is unfounded. Its simply crazy to posit that money flowing to health care through private insurers provides strikingly more stimulus to the economy than the exact same amount flowing through a government insurance plan.

3-Private insurers’ overhead is not really wasteful.

Zycher admits that Medicare and NHI achieve large savings on underwriting, advertising etc. But he argues that these activities are good things because they “align premiums with costs”, stop the healthy from cross-subsidizing the sick, and make everybody pay the true costs of their own care. He assumes that a market-based health insurance system — which minimizes risk pooling and cross-subsidies – must be most efficient. Therefore, the costs of administering such a market are, by definition, not waste but a necessary part of efficiency.

Of course, he does not and cannot adduce any evidence that a market-based health insurance system is actually efficient. In fact, the overwhelming evidence indicates that it is far less efficient than NHI.

4-What Zycher leaves out.

Zycher’s arguments completely ignore the massive administrative waste that private insurers inflict on hospitals, doctors, nursing homes etc. In fact, insurance overhead accounts for only one-quarter of total health care administrative costs in the U.S. The complexity of our current reimbursement schemes requires providers to fight with insurers for payment for every aspirin and bandaid. This requires a huge administrative staff, billing computers etc.

In contrast, a single payer system could greatly streamline providers’ paperwork. Paying hospitals on a lump sum budget basis — e.g. as a fire department is currently paid — could cut hospital administration costs in half. Similar savings could be realized by simplifying doctors’ billing.

In sum, Zycher’s analysis falsely inflates Medicare’s overhead costs, makes outlandish assumptions about the economic costs of taxes vs. premiums, attributes unsubstantiated social benefits to advertising and insurance underwriting, and ignores the massive administrative burden borne by providers.

Physicians for a National Health Program
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Phone (312) 782-6006 | Fax: (312) 782-6007 | email: info@pnhp.org
© PNHP 2009

This page presents the fundamentals of our current healthcare system and single payer.


1. Our Current Healthcare System

2. Single Payer versus Socialized Medicine

3. Healthcare in Canada and Elsewhere

4. Arguments for Single Payer (Single Public Healthcare Insurance)

5. Motivating Others to Get Interested

1. Our Current Healthcare System

Our current healthcare system is not only broken; it is in crisis.

The problems with our current system are numerous. Recently Rand Corporation found that much of the care delivered in the United States in sub-standard. “Using 439 indicators of quality developed by multi-specialty expert panels, the analysts found that participants received only 54.9% of recommended care—a proportion that varied little across the categories of preventive, acute and chronic care.” This report included some of the best hospitals to be found in this country.

There are other major problems:

There is great inefficiency in the present healthcare system.

In California, there are hundreds of private insurance companies, hundreds of government insurance programs, and even more private health care funding sources, and thousands of different benefit plans.

With a major portion of health dollars going to “administration” costs, including large executive salaries, commissions, and stockholder dividends, fewer dollars actually go to health care.

7 million Californians are uninsured. Millions more are underinsured

Costs are rising for premiums, co-pays, and deductibles for less coverage.

People have fewer choices.

Hospitals, emergency rooms and trauma centers are closing.

Half of personal bankruptcies are caused by medical bills.

For-profit managed care maximizes profit (not our health) and rations care.

Lack of insurance is the 7th leading cause of death in the United States.

World Health Organization ranked the U.S. health care system 37th in the world in a composite ranking based on specific population-based healthcare outcomes, such as life expectancy and infant mortality; the U.S. was ranked 55th for fairness.

The United States is the only industrialized country that does not have universal health care.

2. Single Payer versus Socialized Medicine

Senate Bill 840 would create a publicly-funded, not for profit health care system. There would continue to be both public and private care providers. Providers would choose how and where they want to practice medicine just as they do today.

Cost-effective, simplified finance and administrative framework for providing universal health coverage. Framework is adapted to a state or nation’s unique needs and resources.

State or nation establishes a health insurance plan that covers all residents.

Health Fund collects and disburses all health care dollars.

Purchasing Fund implements bulk purchasing and gets discounts on pharmaceuticals and durable medical equipment.

Plan administered by a single agency. Administration uses only 1%-5% of the budget. Current administrative costs are between 27%-30%.

Billions of dollars are saved by finance, purchasing and administrative consolidation.

Savings are used for health care services and provider reimbursement.

Plan is financed by a progressive state tax and by federal dollars already spent on health care. New taxes replace health insurance premiums, co-payments and deductibles.

95%-99% of each tax dollar goes to health care services and provider reimbursement. (Today only 70%-73% of each health care dollar goes to health care).

Medical decisions are made by medical providers and patients.

Patients choose their own providers.

Quality of care is improved through equitable distribution of resources, public participation in policy making, provision of preventive care to everyone, risk adjusted budgets that pay the true costs of care, integrated statewide health care data bases used to perform comprehensive planning, public access to non-confidential information, linkage of research and innovation to health care needs, use of evidence-based medical practices and pharmaceuticals, return of decision-making to providers and patients and a system of consumer advocates with authority to resolve complaints.

3. Healthcare in Canada and Elsewhere

This is an interview with Tom Barnard, M.D., who has practiced in both the United States and Canada.

Tom Barnard, MD, talking to Esther Wanning, 3/5/05

Dr. Barnard practiced in Petaluma, CA, for one year in 1994-1995. He then returned to Canada

TB: I’m originally from the states and I was trained at Cornell and Rochester, and I finished my training in family medicine and anesthesia. …I was married to a woman whose family was from Ontario, and she and I were both interested in working in poor and underserviced places. We moved to the north of Ontario, and I ran an ambulance program in the remote part and took care of people in native reserves. I did anesthesia; I delivered babies; I was a coroner. That was really the golden age of the Canadian system, before the conservative economics in health care really took hold and prior to the time when very expensive medical technologies and increasingly expensive drugs became such an issue in terms of affordability. It was a totally marvelous experience compared to what I had seen in the US. We’d see a sick kid in a remote town and fly her out and take her to where she could get the best care. Completely without a fee. People had everything available to them.

Since then, the Canadian system – as many other health care systems around the world — has come under a lot of financial pressure, in part because of the conservative fiscal economics over the last couple of decades, and in part because medical technology and pharmaceuticals have become so horribly expensive. But one of the real advantages of each province’s having its own mandate is that they have a good ability to regulate drug costs. By and large the costs are much less here than in the states, though of course it depends on the particular drug.

EW: I read an article by Malcolm Gladwell in the New Yorker saying that the generic drugs cost as much or more in Canada as they do here.

TB: That’s crap. I live so close to the border that I see some patients who come over here. A couple of weeks ago, I saw a woman with breast cancer, who was on a five-year protocol of post-surgery tamoxifen. She was living on $6 or $800 a month, and her drug was costing her something like $150 US for a two-month supply. I wrote her a prescription and at the pharmacy in my building it cost $10. This was a generic tamoxifen, made by the same country that produced the tamoxifen she used in the United States. Metforman, which is a commonly used drug for diabetes has been available in Canada as a generic for a long time. In the States it’s still under patent, and the difference in cost is at least ten times. I have a pharmacist friend who sees patients who come over by the busload here and for the most part the drugs are at least 30% cheaper here. On an individual basis, sometimes you have a really cheap generic drug in the states.

You know you pay for the drug research through your taxes. The basic research is done by the Candace Perts of the world at the NIH, perhaps at universities. Not to say that the drug industry is all bad, but what they tout as costs of research are probably widely inflated. And I can tell you as a physician, the drug companies spend a whole lot of money on marketing. But the television ads aren’t allowed in Canada. I think the private industry can have a role in educating people, say about diabetes, etc., what the possible treatments are, but never mentioning specific drugs.

In Canada, the industry itself has created a pretty stringent set of guidelines. They don’t take you and your wife out to dinner anymore. It’s very carefully controlled. And any dinners they put on are oriented toward education rather than any particular product. The other night for instance they had Paul Richter from Harvard on a teleconference. He’s a sterling researcher. He certainly wasn’t promoting a drug.

My office is completely computerized and every exam room has a computer connected to a high-speed line. I had a lady the other day who said, well, I have this Rothman-Thompson syndrome, and I said “What’s that?” So right then, I looked it up and got a whole printout.

I’m involved in a study at the University of Toronto, where they’re taking docs in the field and teaching physicians how best in a time-efficient way to do evidence-based medicine. It’s a struggle you know, because you don’t have an infinite amount of time. I think of docs working for HMO’s in the states where there’s a certain amount of pressure to see a lot of patients. The fee for a visit to a family practitioner is not huge, and also there’s a large shortage of doctors. in Ontario alone there are probably a thousand or so family physicians lacking for this population. So our practices tend to be quite large.

While there are always downsides to any approach, I think it makes a lot of sense to have one insurance company that’s not for profit, run by the state or some non-political organization.

When I worked in Petaluma I had to give my credentials to 33 insurance companies. Here, the billing part of medical practice is such a dream. I see a patient, I write a little code onto a piece of paper, I leave it on my secretary’s desk, and she does the billing right there. At the end of the day it goes directly from the computer to the ministry of health and we get paid once a month, direct deposit in the bank . It takes like—no time.

EW: So you never have to have a conversation about whether they’ll pay for it?

TB: Oh no, that virtually never happens. If it’s a medical emergency. I may call a consultant or a cat scan radiologist or the MRI guy and say, “Hey Joe, can I get Sally in right away?” But that’s really a courtesy call.

EW: But that’s not saying who’s going to pay for it, which is the first question here.

TB: No, no question about that. Never an issue. The only issue is that publicly funded systems like this may have a problem in capacity. For example, there may be an MRI scanner on every street corner in San Francisco. In Canada, on the other hand, there are several MRI scanners in a city the size of Windsor. So when you need an immediate scan you have to push some buttons. If it’s not urgent you might not get it the same day or even the same week. A system that’s built around trying to conserve medical resources doesn’t have that redundancy in the equipment. If you need a hip replaced because you broke your hip, you can get that done today or tomorrow. If you need a hip replaced because you’ve got osteoarthritis, it may take a few months. And that’s because there are relatively fewer operating rooms, etc. There isn’t a medical arms race, where you can get the surgery done at any clinic as long as you’re willing to pay for it. But sometimes I think procedures are done in the US for reasons of remuneration rather than medical necessity.

EW: And here if you don’t have the insurance, you may not have the necessary procedure done at all.

TB: Believe me, that year in Petaluma was a real eye-opener. When I was there docs were going bankrupt. I made an okay living, but that area, we were practically poverty-stricken.

Here, I have to say honestly, it really is a pleasure to see people and not to worry about whether they can afford the care. That said, things come up. Not everybody here has coverage for medication. And some therapies are covered and some aren’t. Massage therapy, for instance, you now have to have supplemental insurance. Many of my patients work for the auto industry locally. They for the most part have supplemental plans where you get a certain amount of massage therapy or reflexology.

Some of the experiences I had that year in Petaluma were astonishing. I worked at a free clinic one night every couple of weeks, in a soup kitchen kind of place, and I was amazed at the level of pathology of the people who came into that clinic. And most of these people were workers with no insurance. They had the kinds of things that in Canada you would only see in a textbook, like thyroid disease, that had gone untreated for two years. And you’d think, “My God, what year is this?” Or I’d see some poor Hispanic grandmother who had metastatic breast cancer, and she’d known she had had this lump for a least a year, but she wouldn’t go see someone because she didn’t have insurance. God, it was really heartbreaking, and that stuff would never happen here. You see a lady with a breast lump here — and I have a huge population of migrant workers and people without financial resources — and that person here would have all the care and there would be no question about whether they could afford it.

There are many positive sides to this system. With a single insurance system there’s just a huge administrative saving. It’s not that I don’t have my frustrations. We all do. But in terms of getting care for people, this system is marvelous. Honestly, the waits are pretty rare.

Another thing. By and large, malpractice issues are not a concern for physicians here either. First of all, we have malpractice insurance from a plan run by physicans called the Canadian Medical Practice Association. It’s a fantastic thing, it’s really cheap. Maybe Canadians aren’t that litigious, but God, I’ve been in practice thirty years, and I’ve never been sued. Our costs for malpractice I think are around $2,000 a year; it’s not even on the radar screen. Here the coverage is completely seamless.

EW: I would assume that part of the reason that docs are sued so little is that people think of their physicians as their friends and their advocates, whereas here, they often think of the doc as the advocate of the insurance company. And when you feel that your physician is denying you care when he’s putting money in his pocket, the relationship suffers.

TB: That doesn’t happen here at all. Ethically, we should be the person’s advocate for care, and there’s no reason here that you would be concerned about the cost of the procedure.

EW: Tell me about something else. Here, the high-paid specialists are the least likely to go for a single-payer plan as apparently they suspect their incomes will plummet.

TB: Here, we had an earning cap for certain classes of physicians of $450,000 dollars. It was just elimininated in the current round of negotiations. It would depend on where you worked. And you might do some surgery outside the cap. But in a city like Windsor which is relatively underserved for ophthomology and where there was no cap, it could be $750,000, and this is without overhead issues. In the states you might easily have a 50% overhead. My overhead here is 25%. My secretary-receptionist does all my billing and takes care of it all in a minute.

There are a few things people pay out of pocket for, like a professional drivers’ physical.

EW: But there’s no copay for the usual services. People here worry about the idea of not having copays and envision lines of hypochondriacs filling people’s offices.

TB: I have to tell you that has not been my experience. Honestly, most people just don’t come for fun. I have a lot of people who might be hypochondriacal, but I don’t see them a lot. That objection I think is based more on somebody’s personal bias than on reality. If you really look at it, look at the Rand Corporation studies or whatever, it seems that what copayments do is to delay reasonable care, and then people get sicker. I think by and large what you want at a primary care level is accessibility and affordability. You want that level of care to be very accessible. And beyond that, ideally, what you want is to be able to access the secondary and tertiary levels of care without worry about whether the patient can afford it. And I think this system does that really well.

It’s not that I don’t complain, and say to myself, geez, I’m only getting $30 for this visit. But I earn a few hundred thousand a year, really working very reasonable hours, and most primary care physicians in the states don’t have that luxury. I think the system has been very good to me.

I really like what I do every day. Medicine’s fun, it’s great, you can really help people, and especially when you’re not worried about whether the patient can afford a chest X-ray.

EW: I don’t know why more specialists aren’t buying into the single-payer idea. They hate the system too, the phone calls, the insurance company clerks.

TB: I think it’s a question of the devil you know. The big thing with single payer that needs to be emphasized for a state like California is that it is true that you don’t want it to be a political football. You want some sort of free-of-politics person running it who is like a judge or a czar who the people feel comfortable with and who they can trust and who isn’t going to be under the hand of some political party, which will change accessibility. If the Canadian system has a problem it’s that it’s a bit of a political football. The Conservatives –who are like the Republicans– get elected and the next thing you know there is all this downsizing. Then the liberals elected and it changes. That part is a little frustrating. But despite all those little fluctuations, for the most part what people see is pretty much good access to care, unquestioningly. Your kid gets leukemia, she gets care, you don’t pay, there’s no question. There are ancillary costs, driving here and there, but the system even covers a lot of that. There may be a problem if someone needs a heart transplant and there may not be a lot of hearts available, but that’s a problem in the states too.

My brother died in NY essentially of leukemia because he didn’t have insurance and couldn’t afford a bone marrow transplant. He may not have lived anyway of course, but to not even have access to care….you can’t have a decent society like that.

EW: Is there anything you miss about practicing here?

TB: I can’t say I do. You can certainly get MRI and CT scans in a minute, but you’d have to justify any of that with the insurance carrier, and that wasn’t very pleasant. Here, I’m able to get good care for people and really advocate for them without worrying about whether they can afford it.

Again, the big thing is you don’t want to feel like a pawn of the state, an employee of a state system. While all docs understand that they have to work for the most part within some kind of insurance system, we want the least intrusive system possible and one that remains affordable and gives care to everybody.

It’s really important to support the poor and the children. We’re learning now that a society that ‘s not taking care of it’s young and its pregnant moms and babies will reap the horrible negative returns. Without adequate care in the first years, they wind up with diabetes and hypertension and cardiovascular disease later. The more we understand that, the more we realize that, by God, we have to provide decent care for them because otherwise we’re going to go bankrupt taking care of them later. In the U.S., you’re not caring for the disenfranchised people, who paradoxically you will get the most savings from.

It’s a simple math problem. George Bush is going to have to get that. If you’re so bloody conservative, add up the numbers and see where you should put some resources. It’s crazy not to be doing that, not to mention the human tragedy, but even on an economic level it makes no sense.

EW: I don’t know why that doesn’t penetrate and I don’t know why businesses won’t buy in.

TB: Businesses here are very comfortable with the idea that their employees get great health care, and they save a bundle. That’s a huge advantage for Canadians.

On a human level, this kind of system is tremendously reassuring. I think California could do a grand job of putting together a big not-for-profit plan that would take care of everybody and save a hell of a lot of money. And I think the docs come out doing better, not worse, financially.

Again, it’s math. Figure out how much you’d save by not having billing complications. And consider the anxiety of having procedures halted in the hallway because the insurance clerk decided it wasn’t going to be covered. I had that experience, and it was catastrophic. Of course, docs don’t want to feel that they are going to be poor because the system changes over. And they won’t be. The cardiologists here make a damn good living. There was recently a neurosurgeon here who moved to Michigan, but it had to do with the hospital not buying him the right equipment, and he was mad. He was making as much money here as he’s making in Michigan. That was not the issue. I think a lot of that stuff is more emotion and hype than reality. I don’t think many docs move to the US. A lot of docs have moved from Ontario to Alberta, where they have oil revenues and pay a lot.


Americans down on the U.S. health-care system

Dutch rate theirs most favorably of 10 industrialized nations

By Kristen Gerencher, MarketWatch

July 13, 2008

SAN FRANCISCO (MarketWatch) — International comparisons of health-care systems can be tricky to tease out, but the Dutch appear most satisfied with their system and Americans the least satisfied, according to a new survey of 10 industrialized countries.

The Dutch system was most popular with its citizens while adults in the U.S. were itching for national reform the most, according to Harris Interactive, which cited three separate data sets.

A third of Americans said they believe the U.S. system “has so much wrong with it that we need to completely rebuild it,” while only 9% in the Netherlands hold such a sentiment about their health-care system. Twelve percent of Spaniards favored a complete overhaul, compared with 15% in France, 17% in New Zealand, 18% in Australia and 20% in Italy.

People in the Netherlands also were most likely to say their health-care system works well and needs only minor changes, with 42% holding that view vs. 29% who said so in France. About a quarter of participants in Canada, New Zealand and Australia were fairly satisfied with their health care. The U.S. and Italy were least likely to want minimal changes, with only 12% and 11% supporting just minor tweaks, respectively.

Americans are fed up with the headaches in their system, but that’s generally not due to the quality of care they receive, said Uwe Reinhardt, professor of economic and public affairs at Princeton University. Had the survey asked participants about their most recent hospital stay, for example, the U.S. likely would’ve scored higher, he said.

“What Americans are upset about is the unbelievable hassle of having to select health insurance, maybe not getting it … losing insurance when they lose their job,” Reinhardt said. “The American citizen is massively insecure.”

Doctors and nurses routinely hear demoralizing news that U.S. medicine is inferior “when the real problem is the way we finance health care and the hassle of claiming insurance,” he said.

Americans’ feelings about the U.S. health-care system have remained stable over the last decade, with roughly twice as many saying they want a complete overhaul compared with other nations, said Karen Davis, president of the Commonwealth Fund, a private foundation in New York that has tracked the issue.

What’s more, Americans’ personal share of medical expenses is the highest in the industrialized world, Davis said. In 2007, 30% of Americans reported having out-of-pocket medical expenses of more than $1,000 in the last year compared with 19% of Australians, 12% of Canadians, 10% of Germans and New Zealanders, 5% of Dutch and 4% of Britons.

Accounting for success

The Dutch financing system has been transitioning to a new model in the last year, where residents contribute payroll taxes into a central fund, Reinhardt said. Then they receive a voucher to buy coverage from nonprofit or for-profit private insurers.

Those polled as the change went into effect may have been reluctant to add any more reforms — even though the system functions pretty much the same way as before, he said.

“The system is so tightly regulated and so many transfers are made among people to make sure everyone can afford the insurance and everyone has access to the same care that it’s really just a social insurance system in disguise,” Reinhardt said. “It’s not even vaguely close to the U.S. system.”

Dutch health care also addresses patients’ need for medical attention during nonbusiness hours, Davis said. “The Netherlands has this amazing off-hours system of care so you can always get a nurse or doctor at night or in the evening.”

It’s not just Dutch patients who seem satisfied. In 2006, only 3% of physicians in the Netherlands said they thought their system needed a complete overhaul compared with 9% of U.K. doctors and 16% of doctors in the U.S, according to the Commonwealth Fund.

In some countries that have universal coverage, a sense of pride pervaded the participants’ answers, along with a smaller dose of concern about the systems’ sustainability. In Great Britain, nearly 70% agreed that the National Health Service must be maintained because it’s “crucial” to British society, according to the Harris Interactive survey. But 24% called it a “great enterprise” that probably can’t be maintained in its current form.

Contemplating trade-offs

Majorities in France (70%) and Britain (59%) said their health systems are the envy of the world. Still, nearly as many in France as in the U.S. said fundamental changes are needed to make the system work better. Half of American adults said so compared with 47% of French adults.

Victor Rodwin, professor of health policy and management at New York University’s Wagner School of Public Service, said the French and Danish have among the highest satisfaction rates in European polls of health-system perceptions.

“The French tend to defend their system because they look across the channel and see the British system of rationing and they say that’s not for them,” he said. “They look across the Atlantic and see the U.S. number of uninsured and high prices and say that’s not for them.”

At the same time, some French physicians complain that they’re underpaid and that the system is weighed down by wasteful spending and a lack of responsiveness to consumer preferences, Rodwin said.

In France, people automatically receive a standard, generous insurance benefit that includes prescription drug coverage, he said. They have no deductibles but small copayments. The system is financed largely through taxes.

“What makes France unique is there’s such good access not only to primary care, which you also get in Britain, but also to specialty care,” Rodwin said. “And there’s a high premium on patient choice.”

To be sure, France has one of the most expensive health-care systems in Europe, with expenditures totaling about 11% of its gross domestic product. The U.S. spends 16% of its GDP on health care. Cost containment has been an issue in France for the last 20 years, but unlike the U.S., lawmakers there aren’t talking about national health reform, Godwin said.

Still, cost concerns are growing, he said. “There is an increasing realization that this cannot last forever. There’s constantly new technology and pressure to cover all this and deliver it to the entire population.”

Harris Interactive tapped three sources for its findings. The data for France, Italy, Spain and Germany come from an FT/Harris Poll conducted in June 2008 for the Financial Times. The data for the U.S. and Great Britain come from a Harris Interactive survey conducted for the International Herald Tribune and France 24 in May 2008. The data for the Netherlands, Canada, New Zealand and Australia come from a Harris Interactive survey conducted for the Commonwealth Fund between March and May 2007. End of Story

Kristen Gerencher is a reporter for MarketWatch in San Francisco.

Copyright © 2008 MarketWatch, Inc. All rights reserved.

A Chronicle report:

Two women, two cancers, two health-care systems

– Tom O’Brien

San Francisco Chronicle

Thursday, December 29, 2005

After a long time away, you see with new eyes.

I moved back to the United States with my Canadian wife and two small boys after living 15 years in Toronto and Ottawa. U.S. health care now looks both expensive and scary, leading me to conclude that we’d do better with an entirely different system.

Nowhere has this been put in sharper relief than in the story of two colleagues. Struck in March with cancer, an American colleague worried about death, insurance loss and bankruptcy. In contrast, a Canadian colleague and cancer victim had only her disease to fight.

Susan was on sick leave when I came to work at my new job in August. She was middle-aged and single with a grown family and well liked in my office. She was undergoing chemotherapy to treat breast cancer and not able to work. Our employer supported her beyond the normal period of sick days and vacation.

But the scary question for anyone but the rich hit with a catastrophic illness in the U.S. health-care system is: How long will an employer’s support go on if the battle goes far beyond the time allotted for sickness and vacation? Susan worried about the loss of health-care coverage and what ensues — second-rate care, bankruptcy, choosing between timely drug therapies and even modest necessities. She died this month before those fears were realized. But had she lived, she and her family would have confronted the excruciating battle survivors have to fight with insurance companies, employers and health-care providers over cost, length and quality of treatment.

In contrast, my former colleague Kathleen back in Canada was gripped by uterine cancer, which had spread to her intestines. While she was locked in a life-and-death battle for 18 months, she didn’t have to worry about losing her health care and choosing which bills to pay. Canadian Medicare covers everyone for everything in hospitals and doctors’ offices, including some elective procedures. This means no health care-caused bankruptcies. No fights with insurers. No insurance-driven financial worries. Kathleen could save her energy for battling her cancer instead. She did recover, and while her recovery was not necessarily the direct result of differences in care systems, there is no question that she would have suffered more with the burden of financial worries related to her health-care needs.

I hear stories here about Canadians lining up for basic medical care. But despite plenty of doctor appointments, occasionally bringing my children to the ER, and having had a heart procedure myself, I didn’t witness any delays for necessary (let alone emergency) care. In survey after survey, Canadians support public, nonprofit health care by a wide margin.

And why not? Compared to the United States, Canada has much lower infant-mortality rates and a longer life expectancy, according to data from the World Health Organization. Canadian women get just as many mammograms, for example, as do American women. This is achieved despite spending far less per person on health care — 10 percent of per capita GDP in Canada goes to health care versus 15-plus percent in the United States, according to WHO research.

After 40 years of private health care in America and 15 years of Canada’s Medicare, I’ll take the latter. But of course, I can’t; it’s not available here. I love my country but not the private health-care system that abandons many people and worries even more.

Few Americans know that every other industrial country in the world has a health-care system more or less like Canada’s. I think even fewer realize that we do, too — it’s called (U.S.) Medicare. The system that boosted the health of Americans 65 and older is similar to Canada’s system for everyone. They’re both “public, not-for-profit, single-payer” systems with low overhead costs. So why not extend Medicare to every American?

Our seniors like it. Sure, it will raise the cost of this government program by billions of dollars, according to even the most conservative estimates. But it will save money for both individuals and employers who now purchase private health insurance. After all, it’s not how much of your income you pay, it’s how much you keep. You’ll keep more under Medicare-for-all, and every child, woman and man would get the timely health care they need.

Give people the opportunity to face and fight their illnesses, not their insurance companies.

Tom O’Brien joined the California Nurses Association (www.calnurse.org) upon moving back to the United States in August.

4. Arguments for Single Payer (Single Public Healthcare Insurance)

Universal Single Payer Insurance will do the following:

It establishes a single publicly accountable trust fund.

It collects the dollars and pays the bills for comprehensive care delivered by both private and public sector providers.

Everyone will always be insured.

Only single payer financing and administration saves enough money to provide high quality, comprehensive coverage for all

Californians., according to the Healthcare Options Project(2002).

There are other important points:

Security—No one ever loses their insurance, if they remain residents of California. Californians who work out of state for a California-based firm and senior Caliifornians who retire out of state but choose to continue paying into the California system will not lose coverage.

Choice— Everyone can choose their doctors.

Comprehensive Benefits –Benefits include prescription drugs and mental health care.

High Quality—Doctors and patients decide on care; safe staffing ratios are in place in hospitals. There will be offices of the Consumer Advocate throughout the state.

Simple Administration —A single administration minimizes paper work for individuals and providers.

Cost Effective —Sound financing provides health care for all Californians without spending more. Cost control is achieved through global budgets, bulk purchases of drugs and durable medical equipment,

Good Public Policy—A sound single payer plan fosters personal responsibility and community solidarity.

5. Motivating Others to Get Interested

Perhaps getting people to look at how many areas of our lives can be improved would prompt them to be interested in, indeed get involved with, the effort to bring a better healthcare system to our state.

A universal care with single payer financing would provide reliable, quality coverage for all Californians for life. If you want or need to change jobs, you will not love your insurance. A “pre-existing” condition inhibits people’s ability to change employment.

Why not create a health-focused—not profit based—administrative system. For the first time, California will have an independent, non-profit administrative team to oversee the system, manage costs, and maintain quality. A better healthcare system would bring together all stakeholders—providers, consumers, hospitals, public health experts—to identify and help solve local service problems.

Quality of care will be greatly improved by funneling all data from providers into one place.

Fraud can be better contained by utilizing a single data collection system.

California’s business climate would be improved by contolling healthcare costs. All California employers will pay an affordable health insurance premium based on their payroll, resulting in a level playing field among competing business.

And since all employees will also contribute their fair share to premiums, labor-management strife over healthcare should end.

With no deductibles or out of pocket costs to pay, California families could save from $300 to $3,000 per year while business could save from $300 to $2,000 per employee (see Lewin Group study).