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List of current editorials by title (state)
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Excerpts from several Paul Krugman Op-Eds NYT 2005-6
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Facing the Challenge, Extending Health Care Universally, JB Kotch and DB Lazof April 12, 2005
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Two Year Anniversary of Successful Public Health Campaign Based on Human Rights, by D. Lazof March 29, 2005.
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Corporate Incentives and the Right to Health Care, by D. Lazof March 10, 2005. What's good about incentives for corporate relocation?
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Gazette of Charleston, West Virginia endorses "Everybody In and Nobody Out" Dec 2004
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Government Run Programs - The Evil Empire Threatens, by D. Lazof Oct 18, 2004
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Responding to Recommendation to Banish the slogan"A Right to Health Care", by D. Lazof Aug 1 2004
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Good Health, A Shared Responsibility Which Generates Wealth , by D. Lazof July 2004
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Our Right to Health Care - it's more than a catchy slogan, by D. Lazof June 2004
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Response of Dr.
Himmelstein to Dr. Aaron's critique of the article on administrative waste
in the US health care system (about 25% of expenditures).
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An Easy Pill to Swallow - Confronting the Root Causes of
Our Medical Malpractice Crisis and Providing High Quality Universal Care at the
Same Time - a Project EINO issue brief July 2003
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Private Plans Versus
Social Insurance (CA) why reforms like Gephardt's of April 2003 won't amount
to much
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It's Time for
National Health Care (CT)
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Hospitals are
financially threatened by problem of uninsured (NC)
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EINO is accepting editorials that fall within our principles. We are not currently accepting op-eds
in opposition. Email our webmaster your
editorial (preferred as attachment as MS-word document or as a text
file).
Carol Kirschenbaum (August 2002)
A recent article in the Raleigh, NC News and Observer entitled "WakeMed persuades Cigna" stated "that a new health plan design sorts hospitals into two tiers, one with a $250 co-payment and one with a $750 co-payment". It is designed to steer members of Cigna Healthcare to those hospitals that charge the company less for hospital services cutting Cigna's expense for hospital care. The article stated that such factors such as quality, availability of services only at particular hospitals or how much charity care a facility provides are not considered. Granted, quality between hospitals is sometimes difficult to determine but there are certain quality measures that are widely considered to be valid.
The new design was compared to tiered prescription co-payment plans pointing members toward cheaper generics. This comparison omits the fact that when we as doctors council our patients and prescribe generics we take into account that most generics work the same as the name brand, with the same treatment benefits and side effects, while also being cheaper. Choosing generic drugs does not compromise care. Choosing a hospital should also not compromise the quality of care. Cigna hopes the tiered plans give members a financial incentive to choose lower-cost hospitals. If quality is not taken into account members may pay less now but face increased suffering and increased medical costs down the road should they fall seriously ill.
Health care choices should not be based on ability to pay but based on medical need. I want my patient's hospital to provide quality care, not just be the cheapest.
Deb Richter (April 2002)
The following talk was composed and has been delivered by Deb Richter, a
grassroots activist in Vermont and a member of EINO's advisory board. This talk has been delivered successfully to many local business groups around the state of Vermont It can serve as an example for UHC activists talking with people in business. We believe that the approach and basic concepts would be effective in most states, although modifications will be required, since Vermont where Deb lives can be considered a somewhat special case.
Problems of the uninsured and rising costs are the usual focus of health care discussions in cities around the country today. No doubt they are important, but they are symptoms of a much larger structural problem. That problem is that we have no true health care system. Today I will discuss how this bears on health care in the state of Vermont, what is wrong, what we can do about it.
In order to look at the problem we must understand that Vermont's population of 600,000 manifests a certain incidence of disease that requires a certain amount of medical care. Identifying the need and establishing the care has led over time to Vermont's having today a certain amount and kind of medical care, meaning medical personnel, facilities and services. In Vermont the need and the available care are roughly in alignment. This is an advantageous situation. It is not true of many other states, which have an excess of personnel, facilities and services. Medical care is based largely on fixed costs. At a typical hospital, for example, about 86 percent of its costs are fixed. This means of course that if it is to remain functional, its fixed costs must be met. It also tells us why excess in health care is disadvantageous: It drives up the total fixed costs within health care.
In Vermont the medical profession adheres to a strong medical ethic: everyone gets medical care whether they can pay or not. This has to be qualified however: Those who don't pay or underpay don't always get care in a timely fashion, which almost always means when they get it it is more expensive and they generally do not get prescription drugs. The fact they get care at all creates a problem. If enough people show up who cannot pay or underpay or an insurer refuses to pay for, a deficit is created. A large enough deficit is in direct competition with a facility's fixed costs. Financing grows unstable. The facility is jeopardized.
In Vermont, therefore, we have very good medical care, we have roughly the right amount for Vermont's population, we have a strong medical ethic among health professionals, eveiyone receives medical care. Our problem in Vermont is how we pay for it. Financing of health care in Vermont is unstable. Deficits threaten the medical care that we depend on. Confronted with deficits facilities can:
1) Close
2) Cut staff' (which impairs quality), or
3) Shift costs to those who can pay
In Vermont, we mostly shift the costs, and this registers in the form of higher taxes at all levels and higher insurance premiums. Because virtually everyone gets some medical care whether they can pay or not and because the amount and kind of medical care we have in Vermont depends on everyone's medical needs, what we have is a public entity. Vermont health care is responsive to the public as a whole. In all but name it walks and talks and otherwise behaves like a public entity. With one important exception. That exception is that there is no public commitment to pay for medical care in full for everyone. The problems that beset Vermont health care begin here. Nearly everyone, including the medical profession, assumes in some fashion that health care is a public good. How to pay for this public good is our stumbling block..
Medical care itself is public because it is a shared service. It's there because the population as a whole at any time needs a certain amount and kind of care. It's defined by those people who were sick before you. The medical services as a whole are there because of the population as a whole. Individual choice of service depends directly on collective medical needs. Medical care is a shared service, a pubic good. Our mistake is to fail to accept the public responsibility of paying for that shared service as a public good.
The first two features of a true health care system are just these: Everyone must be accounted for in terms of delivery of medical care and everyone's medical care must be paid for. If these two features are met, in other words, if the population as a whole is taken into account, then of necessity meeting the costs of providing medical care is a public responsibility.
A useful analogy are roads and highways. These are publicly funded, publicly maintained, publicly regulated. No one decides he wants a major highway for himself. Roads and highways come about based on the needs of everyone, the public. We accept the fact that we all may use it at one time or another and therefore should share in financing them publicly. Already there is a lot of public money in Vermont health care. Taxes already finance more than half. Still, there is no consistency. The mix of public and private financing carries no responsibility or commitment to pay for every Vermonter's medical care. This leads back to deficits at medical facilities and thus to unstable financing.
It's important to recognize that if Vermont wants the medical facilities and care it now has, it must find a way to meet the fixed costs. There is no avoiding this. One way or another the bill has to be paid. Currently, deficits that occur are showing up as higher insurance premiums, affecting businesses, individuals, municipalities, and in increased taxes.
Stability can only come through a health care system. A true health care system possesses at least five main features:
Everyone must be included.
It is publicly financed because this is the only way to guarantee payment for everyone's medical care.
[EINO doubts whether 100% public financing or single-payer is the only way to guarantee that everyone will be included].
It has a global budget because this is the only way to influence costs and contain spending over the entire medical care realm.
It has public stewardship because a program affecting the entire public requires it.
It has public accountability because anything affecting all the public requires it.
A health care system is a system of governance set up for two specific purposes: to see that everyone gets needed medical care and to see to it that that medical care is paid for. Nothing requires it to involves itself in the delivery of medical care. The influence the system has over medicine is mostly monetary rather than administrative. Stewardship, accountability and global budgeting assure the public that the medical care facilities needed to meet the medical care needs of a population Vermont's size will be there now and in the future, and that the medical services will be paid for. These two goals are inseparable.
Having a global budget is a way of keeping close track of the total of medical care expenses. It acknowledges that fixed costs must be met and that the only fair way to keep increases in check is to look at the whole, how increases affect the whole. By now it ought to be clear that encouraging more fixed cost facilities - more hospitals, more high-tech facilities, beyond what are deemed necessary - inflates the overall costs of health care. The goal in health care is to have the supply equal the demand, or need. Increasing the supply does not necessarily drive costs down. Competition, ii is true, can weed out excess. Beyond that however the standard of purchase is not price but quality. Medical care does not respond to the retail store model. There are other reasons why the simple notion of competiton won't work in health care, but this is the main one.
A system is the most effective way of persuading the public of better health habits, thus lowering medical care needs. Any such program can only promise long-term benefits. A system is administrative1y less expensive. If everyone gets the same benefits and they are paid for and there is uniform reimbursement, administratively expenses can be at least 10 percent less.
And profit? Should we allow it? It helps to think of the total medical care expense. Is there extra money there for profit? Do we want to make room for profit, that is, use more of the money for profit than for reducing the public's financial support of the system? In a system, this like all such decisions becomes a public matter. To do all of this requires some sort of public entity, a public agency to take responsibility for the public financing, health planning, negotiation of hospital budgets and reimbursement fees for doctors. As before, the agency does not deliver the care. In most systems, delivery of medical care is private.
To work, the agency must to accountable to the public, must have broad representation within the public, must be immune as far as possible from party politics. To insure fair decision-making, everyone must have the same opportunities for medical care, the same benefits. In effect, this means those in a position to make decisions know whatever they decide directly affects their own medical care. How could we implement a system in Vermont? A study was done in 2001. It concluded, as have all past studies of this kind, that a universal system in Vermont could pay for everyone's medical care and save money.
[Similar state-comissioned studies have been completed in other states including (at least) NC, CA and MD. All with similar results.]
The study examined a single payer system. A single-payer system is on description of funding and then paying out for medical care. There are others.
The study concluded everyone in Vermont could have the same benefit package, free choice of doctor or hospital, and it could be paid for through a 5.8 percent payroll tax and a 2.9 percent personal income tax if lump sum payments from Medicare and Medicaid were figured in, as they can be. Delivery of medical care would remain private. Please, remember, this is only one possibility. Progressive taxes are fairer than flat taxes on payrolls. Another formula may possibly be more politically attractive. The presence of businesses in health care is an accident of history anyway. A public question of great political importance is how to structure the oversight agency, the steward, so that the public is honestly represented. Should it be appointed? Elected? Should it be broken up into districts, regions, counties?
Almost certainly the public accepts that things cannot go on in this way, that something must be done. Far less certain is the political will to achieve this. The fact remains that we all count on medical care, we all expect medical care services to be there when we need them. The next step is to accept the fact that we must find a fair, honest and efficient way to pay for the services for us all.
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The following Op-Ed has been widely circulated in Vermont. It is a
position paper of "Vermont Healthcare for All"
Whenever Vermont health care is mentioned, what is really referred to is an arrangement that does not rise to the level of a system. This arrangement is ineffective at controlling costs and incapable of seeing to it that the expenses of medical care are paid for, or of seeing to it that all Vermonters obtain needed medical care in a timely fashion. It therefore falls far short of anything that can be reasonably described as a health care system. At the same time it is widely acknowledged that Vermont's medical facilities and medical care are of high quality.
There are troubling signs, however. One is cost shifting. Cost shifting is a way of unburdening financial strain in one part of health care, say a hospital, by shifting it to another, say a private insurance company. Costs, once shifted, do not disappear. Ultimately, they reappear as higher private insurance premiums and higher public assessment, taxes and the like.
Virtually all of us, including the Vermont medical community, regard health care as a public good. This is especially true when we ourselves are in need of medical attention.
Most of us would say that what we want from health care, other than our free choice of doctor, are high quality medical facilities (hospitals, physicians practices, nursing homes, allied health facilities, etc.), some assurance that those services will be there when we need them, and affordable medical care. For a number of years, rising costs have diverted our attention from these reasonable expectations. So much so that our discussions of health care have obscured the idea of it as a public good. Our predominant focus has been on ways to ease costs or get around them somehow. This can lead to our losing sight of important factors in the whole picture of health care in Vermont.
First of all, there is a tendency to overlook the fact that at any one time in a population of 600,000 (the size of Vermont's) a certain amount, or incidence, of disease occurs. This establishes the need for a certain amount of medical care. Health care facilities evolve in a shared relationship with the population's needs. The relationship holds reasonably closely as long as health care is not subject to the distortions of a market place that places profits first among all considerations.
Second, it is usually forgotten that it is the sick not the healthy who define the extent and kind of medical care available. This is another way of making the point above, that the health care bears a strong relationship to the incidence of disease in the population it serves. Payments made by the sick or in their behalf by third parties, are what support health care services in Vermont. This is captured in the notion that it is the sick who keep the beds warm for those who are healthy.
Third, health care facilities that have evolved in the way described become more or less fixed-cost entities. Their operating expenses are largely fixed. Whether they are working at full capacity at any one moment is subject to the normally varying need for those services at that moment. Regardless, their fixed costs remain the same. They must be met if they expect to avoid financial stress. Financial stress usually leads to cost shifting or to measures like staff cutting that invade quality of care.
Fourth, it is seldom emphasized enough that Vermont's medical community has always conducted itself under a strong ethic to provide care to those in need whether they can pay or not, and continues to do so. This clearly has financial repercussions when the care is not fully paid for or paid for at all.
Fifth, a crucially important fact must be kept in mind: that a small percentage (20 percent) of Vermonters are very sick and use 85 percent of the health care. But it would be mistaken to think of them as the same people all the time. They include accident victims and victims who suddenly become ill with life threatening diseases. The very sick should not be dismissed as too costly by the remaining 80 percent of the population who are largely healthy and use little health care. This for ethical reasons of course, but also because as stated above, they essentially define the amount and kind of medical services we have. Payments for their health care are the main financial support of the health care services that all of us expect to be available to us should we need them.
Unless these factors are taken into consideration upfront it will be difficult to remedy any perceived problems in Vermont health care. The relationships that hold among these five points are of great importance for any discussions of health care. Omitting or changing any one of them will have profound, undesirable consequences for health care. For example, if medical care were limited to only those capable of paying in full, it would require a complete reversal of the medical community's ethics.
Even if the medical community could be convinced, which is highly unlikely, limiting care to those capable of paying would affect what kind and how many medical facilities would continue in Vermont. The same problem arises if medical care is confined to the 80 percent of us who are mostly healthy. If this happened, the impact on medical facilities would be even more drastic. Without the very sick 20 percent, medical facilities would shrink dramatically because the money wouldn't be there to support them and because the patients wouldn't be there to require their services.
Changes to any of the five conditions listed above will impact negatively on Vermont health care. What may look like cost-saving proposals must be weighed against the social costs to Vermonters and the non-monetary costs to Vermont's medical care facilities? These conditions can be modified to some small extent. But finally they must be accepted by any plan to alter Vermont health care, lest we permanently damage our social fabric in Vermont and the medical care facilities we have.
It is our contention that the fundamental problem in Vermont health care is structural. It originates in how we pay for medical care not the medical care itself or who gets it. Our medical facilities are roughly adequate for the medical needs of Vermonters. Our ways of paying the largely fixed costs of these facilities, however, are not adequate to meet their financial needs.
In other words, Vermont's health care arrangement provides medical care to virtually all Vermonters. The extent and kind of its medical facilities has evolved from the incidence of disease in the entire Vermont population. Yet our ways of paying for medical care do not make provision for all Vermonters. Nor do they cover full medical costs in many instances. This strains the financial stability of our health care.
The structural problem is, there is no structure. The elements of health care are not structured into a system capable of assuring us that our medical care will continue to be good, will be there when we need it, or that it will be affordable. These are the minimum requirements a health care system is created to address.
Every other country in the industrialized world has recognized these factors. Consequently, they all have health care systems. Some are more successful than others. Some have the government delivering the health care, but most have private delivery. They differ in many aspects, but all have four common features.
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