Wednesday, July 7, 2004

Every school child knows these words that begin the Declaration of Independence, words that are core to our idea of what America is about, of what an American is. But what does it mean, that we have the right to pursue happiness and that our government must secure that right?

The Declaration does not call on government to guarantee happiness or success. Rather, it declares we are a nation that believes individuals, given the opportunity, can and should seek to better themselves and their communities. It is opportunity that government has a responsibility to assure.

How does government assure that people have opportunity, that they can "be all they can be"? The constitution of the state of Washington, like many state constitutions, holds some clues. Article IX says, "It is the paramount duty of the state to make ample provision for the education of all children ... " The founders of our state recognized that education is fundamental to opportunity. Today, their wisdom is seen everywhere in our communities and economy: Better education means having a better job, more chance for advancement and better health.

We do not debate whether all Americans should be educated; it's a given. There are debates, to be sure -- over public funding for private schools, charter schools and accountability. But the notion that government should assure universal education is widely held by people of all political stripes. So, education is a building block of opportunity -- but is it the only building block?

Consider these two points: According to the Kaiser Commission on Medicaid and the Uninsured, people in fair to poor health earn 15 percent to 20 percent less than people who are healthy. A study of 7,000 children found that those who were less healthy as babies had much lower IQ and school achievement scores than healthy children.

As with education, it doesn't take a genius or a federal grant to know that health is linked to opportunity.

How well does a student learn when she has the flu or suffers an asthma attack? How productive is a worker when he's depressed or in pain? As the Declaration says, "These truths are self-evident." Everything we know tells us that health is also a building block of opportunity. We now have unarguable information that having health insurance is key to being healthy in America:

Uninsured people with breast cancer, colorectal cancer, heart disease and trauma die at twice the rate of insured people. The uninsured are less likely to receive common treatments for heart attacks and normal surgery for acute trauma, putting their lives at risk. Increasing insurance coverage for low-income pregnant women reduces infant deaths by as much as 9 percent. Uninsured patients are hospitalized for preventable problems as much as 50 percent more often than insured patients, resulting in higher costs.

The connection is clear; the American dream requires that government fulfill its responsibility to assure that all Americans are insured.. "How?" is the big question. Again, let's look to the state constitution for a hint. The state's founders said education was a paramount duty of government and that "The Legislature shall provide for a general and uniform system of public schools." Why would they call for "public" schools? My guess is they believed the best way to assure universal education was for the government to do it.

Some may call such public institutions "socialism" but in fact we have many such institutions in capitalist America.. Who patrols our neighborhoods -- private militias? No, public servants called police. Who responds to a fire -- Wall Street-traded firms? No, public servants called firefighters. Who makes sure the food in our restaurants is safe, the water from our taps pure -- for-profit companies? No, public servants we call public health workers. When we want to make sure the most and least of us have something critical to our lives, we ask government to make it happen, not the market.

It's time to get past the myth that the private market can somehow make sure we all have the opportunity that health is basic to. It's time to figure out how government should assure that opportunity. Perhaps it should be a public utility like water companies. Perhaps it should be an arm of government, like school boards and districts. We have options, we can decide. Let's demand that our elected representatives make it happen.

Market Based Health Care

One of the most disgusting things that has happened in the last seventy years is the evolution of the United State’s market-based health care system. Who would have thought that it would come to this in America. This is the absurdity of the American health care system:

1. We treat health care as a commodity.
2. When health care becomes a commodity, the criterion for receiving it is the ability to pay, not medical need.
3. The pressure is to increase total-care expenditures, not reduce them.
4. If access to services is expanded, costs rise; if costs are lowered, access is cut.
5. The government pays 60 percent of the health care costs, and subsidizes employers so they can buy private coverage for their employees. Private health care HMOs and insurers in turn increase their profits by cherry picking their patients.
6. The American Health Care system has 45 million uninsured and another 50-90 million underinsured (exact figures are difficult to compute).

Market-based health care has no rationale for being, no justification in a democratic country, or in a democratic republic. A health care system that neglects to include preventive medicine is a failure. Why is the United States so different from the other advanced nations of the world? The short answer is that we alone treat health care as a commodity distributed according to the ability to pay, rather than as a social service to be distributed according to medical need. In our market-driven system, investor-owned firms compete not so much by increasing quality or lowering costs, but by avoiding unprofitable patients and shifting costs back to patients or to other payers (like the U.S. government).

 This creates the paradox of a health care system based on avoiding the sick. It generates huge administrative costs, which along with profits divert resources from clinical care to the demands of business, such as consulting firms and marketing companies that consume an increasing fraction of the health care dollar.

Look what happens to the health-care dollar as it wends its way from employers to the doctors and hospitals that provide medical services. Private insurers regularly skim off the top 20 to 30 percent of premiums for administrative costs, marketing and profits. The remainder is passed along a gauntlet of satellite businesses – insurance brokers, disease-management and utilization-review companies, lawyers, consultants, billing agencies, information management firms and so on. Their function is often to limit services in one way or another. They, too, take a cut, including enough for their own administrative costs, marketing and profits. As much as half the for-profit health-care dollar never reaches doctors and hospitals – who themselves face high overhead costs in dealing with multiple insurers. The pressure is to increase total health-care expenditures, not reduce them.

Presumably, as a nation we want to constrain the growth of health costs. But that’s simply not what health-care businesses do. Like all businesses, they want more, not fewer, customers-but only if they can pay. Private insurers and providers compete with one another to avoid getting stuck with high-cost patients, so they can keep more of their revenues. But this game of hot potato takes a lot of oversight and paperwork. In fact, the hallmark of the system is the extent to which health funds are diverted to overhead and profits.

"The system is collapsing around us." That is not hyperbole. Private health insurance premiums are rising at an unsustainable average of about 14 percent per year – and as much as 25 percent in some areas of the country. Coverage is shrinking, as more employers decide to cap their contributions to health insurance plans and workers find they cannot pay their expanding share. The Census Bureau reported that nearly 1.5 million Americans lost their insurance in 2001. The fatal flaw is that we treat health care as a commodity.

In contrast to all this is "Medicare", a government-financed single-payer system embedded within our private, market-based system. It’s by far the most efficient part of our health-care system, with overhead costs of less than 3 percent, and it covers virtually everyone over the age of 65. Medicare could be even better as "Medicare for all" by including full dental care, eye care, prescription drug coverage and preventive medicine.

I personally seek a national health care plan that serves and is sensitive to the diversity of all people. A plan that has an equitable and efficient financing system, drawn from the broadest possible resource base. A national health-care plan that provides services based on equity, efficiency and quality. I seek a national health-care plan that is sensitive to the needs of persons working in the various components of the health care system and gives special attention to providing not only for affirmative action in the recruitment, training, and employment of workers, but also for just compensation for all workers at all levels and for retraining and placement of those displaced by changes in the health care system. If you still feel that there is nothing wrong with our health care system remember that "Health Generates Wealth". Sickness cost everybody money.

The Market Driven Dance

Market–driven decisions are frequently concerned more with money than patients. Refuse to authorize or refuse to pay. Shift the cost to some other or shift the costs to the tax-payers. Sure looks like a way to avoid payment. "The way to make money in the insurance business is to limit risk as much as possible." For-profit HMOs and private insurance companies are intervening and undermining physician’s decisions. The Federal, State, and Local governments are now paying 60% of the tab, and for-profits and private insurance companies are using some of our health care dollars for profits and high administrative costs. It’s disturbing to me to see people buying expensive long-term health insurance, will they ever be able to use it, will the insurance companies be able to pay for it.

The American people continue to let this happen. Do most of the Americans believe that health care coverage or health care in general is not a right for every citizen? That it must be earned. That it must be a market commodity. Do they believe that people will misuse the system if the system is funded by government insurance? People don’t want to get sick; they don’t want to end up in the hospital. In the last eight years we have been witness to a decline in our quality of care and sky-rocketing medical cost. Many doctors and nurses have been discouraged and the horror stories of what patients are going through have increased dramatically. We have taken too much of a gamble with our once honorable profession. It’s time to listen to the advocacy groups that have worked so hard for a single payer system. We can model the new system from the many single-payer systems functioning well in several other nations. Universal Health Care Action Network , Physicians for National Health Care, Everybody In Nobody Out, and many other advocacy organizations will supply you with the truth. Give them a call or email.(See the section on Organizations).

After at least ten years of looking for a solution to our health care crisis I would give this bit of advice; forget the privatization of our health care and do what is right. "Sick patients must come first in a rational and moral society." Ask the question, "What has happened to this honorable profession?"

By 1990 the stage was set for the disasters that would follow. Intelligence, common sense, courage, and compassion gave way to special interest, fear, and misconception. The AMA’s failure to provide sound leadership and keep big business from entering their area of expertise is something that must be overturned. We have paid the price and hopefully we have learned what to and not to do in leading us to better health care, not only in efficiency of our health care dollars, but coverage for all and quality of service. A chance to make a killing in our health care system is a chance that our health care system (that which we have known in the past) will die, and that chance must be eliminated. Common sense alone tells us that physicians with expertise in health care should be making the decisions on how to treat their patients, what tests to give, and how long a patient needs to stay in a hospital. Our decline can be attributed to a republican president who wanted to get elected, to a democratic president with a misguided approach toward health care reform, to the fears and misconception of the AMA, and a chance to make a killing in the health care business by our for-profit health care insurers and managed care providers. It is the responsibility of the American people to no longer turn a deaf ear to the horror stories of the uninsured and those with inadequate insurance.

35 million Americans were uninsured in 1991, and this should have alerted the people that some responsible action needed to be taken "It is no longer acceptable morally, ethically, or economically for so many of our people to be medically uninsured or seriously underinsured. We can solve this problem. "We have the resources, the skills, the time, and the moral prescience. We need only clear-cut objectives and proper organization of our resources. Have we now the national will and leadership?" (George D. Lundberg, M.D. editor of JAMA 1991). Evidently we do not, because the failure to get access to health care insurance extends far beyond the poor and the AMA and American physicians cannot come up with a plan. In 1991 President George Bush enjoyed a 90 percent approval rating. He avoided health care reform to focus on getting elected. His constituents wanted tax relief, and freedom from government regulations especially from small business and insurance companies. This attitude of the American people was one reason the door opened to for-profit health care and as we shall learn later our need for basic necessary health care does not belong in the hands of free market capitalism. Health care is too important to put to chance, it cannot be bargained for, when one gets sick they have no choice to refuse except to maybe get sicker or die. The philosophy of less government and less regulation does not apply here. The health of the American people should be a direct concern of the government of the United States. We must put the pressure on our government officials to not avoid their responsibilities and come up with and pass legislation for a National health care plan that covers all the basic necessities, and is accessible to all. Physicians will provide quality as they have done in the past. The AMA needs to clean up its act. Private insurers can sell insurance for those medical conditions beyond the necessities.

President Bush senior's answer to health care reform was to not stir the pot. He opted to give tax breaks and deductions to help the uninsured and the underinsured buy private health care insurance, but he failed to concern himself with sweeping change. A reminder here is that George W. his son and our 43^rd president is proposing these same band-aid irresponsible cures today. His state of the union message stated "our health care will not be cured by a national health care system that dictates coverage and rations care" and plainly proclaims that he has not concerned himself with research on the subject. Blind leadership will not lead us in curing our health care crisis.

It’s not hard to understand that the majority of Americans wanted health care reform and health care coverage for all. In the early 1990s Harris Wofford was elected to congress on a platform of health care reform. His quote "If convicts have healthcare coverage why can’t the working poor" helped him upset his republican candidate much to the disappointment of President Bush senior. November 1992 President Clinton wins the presidency much on his promise to give America a universal health care system.

In 1993 Dr. Lundberg wrote another editorial for the JAMA and his conclusion paragraph stated: "We stand at the threshold of reform. We shall soon see whether this administration and the Congress will confront the abyss of a widely divided electorate, or spook at the potential political calamity that awaits, and rear up and retreat in disarray, allowing meltdown to loom ever closer". "Or will the political leadership grasp a vision of our future, charge firmly and steadfastly ahead to bridge the abyss with eyes wide open in the interests of patients, the public, and the nation, placing narrow political vistas and rigid ideologies behind them, and plan and act strategically in all our best interest".

President Clinton’s Plan was another foolish approach to universal health care reform. It did not include physicians and health care reformers in the planning process. It should have included physicians because it only makes sense that we would want physicians in charge of our health care decisions. It should have been open to the public and employers because they are the ones that would have to pay for it. Imagine putting pressure on employers with an employer-mandate system and excluding them from the construction of the plan. Bound to fail it opened the door for private health care companies and insurers to enter. President Clinton’s plan was to produce competition between large insurance companies to lower rates and let employer’s afford health care coverage for their employees. The plan was employer-mandated and the AMA rescinded its support for it and this removed political cover for the key element of reform. Alternative plans were available, and in May 17, 1994 JAMA printed an article rating the plans with the following criteria:

None of the plans received a very high rating. 70 percent rating went to the highest plan. Too bad none of these could fit the criteria, because we all know what happened next. What happened next would completely stress out a just person or a working person trying to stay afloat, it would make a dictator flinch, a Christian vomit, and an unscrupulous businessman rich. It would cause much suffering and heartache and lead many into bankruptcy. Unheard of in America before, and in most other industrialized counties today, is the allowing of for-profit medicine on a grand scale. Healthcare dollars going for huge profits, excessive administration costs, and unneeded costly advertisement. Other unheard of things; like not insuring people with preexisting conditions or charging them 4 to 5 times the going rate, dropping people from coverage if they get a costly medical condition, double digit inflation or inflation many times the growth of the GDP, capitation, gag rules, threatening physicians, undermining a physicians decision from a remote place without examining the patient, people put on waiting list until an insurance company can come up with a decision to pay, people going broke because they get sick. The uninsured and underinsured go without prescription drugs and fail to see a doctor when necessary. They become sicker because of untimely diagnosis and about 18,000 die annually due to being uninsured. When the uninsured get sick they end up in the emergency room or in the hospital costing us huge expense, which could have been prevented. We are not focusing on preventive care, which would keep down a lot of health problems. Right now we rank about 37^th in the worlds healthiest people, and 54^th in fairness.

The Physician’s Responsibility

The Struggle for a Comprehensive Health Care Plan in America

In 1937 a committee of 430 physicians reported that:

Unfortunately Morris Fishbein editor of the Journal of the American Medical Association from 1924-1949 set the tone for the argument against a universal, comprehensive national health care insurance program. In 1932 he called it an incitement for revolution, socialism, and communism. In 1937 he warned on the committee’s report above that it would be hazardous for government to control medical education, science, and medical practice. The proposed changes would enslave the medical profession he asserted, adding that no people could endure with "a medical profession enslaved to make a politicians holiday." In 1945 President Truman declared, "Every American had the right to adequate medical care." Morris Fishbein said the President was proposing nothing less than "Socialized Medicine," which would destroy good patient care. In 1962 President Kennedy inspired the bill for Medicare and again the AMA was against it "This bill would put government smack into your hospital, defining services, setting standards, establishing committees, calling for reports, deciding who gets in and who gets out, what they get and what they don’t, even getting into the teaching of medicine, and all the time imposing a federal administered financial budget on our houses of mercy and healing. The AMA made a strong point about the runaway costs that would result from the entitlement to care. The point was lost in the perception that the AMA was pursuing only its own self-interest. It was all about money.

The AMA blocked Medicare for three years, but in 1965 Medicare and Medicaid became a reality. The trend to rising costs began ten years before Medicare and Medicaid, and both social programs did not interfere with the practice of medicine. In 1970 President Nixon was for a national health care plan and in 1991 promise for a national health care plan helped elect President Clinton. Before 1993 the AMA was tired of being viewed as an enemy of patients in need, and this caused divisions in its members, but by the end of 1993 they mustered enough togetherness to effectively undermine support for the Clinton plan. This gave political cover to conservative members of congress on both sides of the aisle, and paved the way for Managed Care which was supposed to be the answer to cost containment. Despite the Clinton’s commitment for reform, none of the leading legislators for reform were included in the shaping of the Clinton plan. Nor were physicians, hospitals, and insurers. The employer-based employer-mandate private insurance plan was not what the country needed anyway. What followed was not the answer either. Even before the Clinton plan failed, big insurance companies like CIGNA, Aetna, Prudential, and others knew that the Clinton plan was dead in the water. They moved aggressively into the new market model of managed care. What followed was the policy, to make money in the insurance business,  to limit risk whenever possible. "Powerful economic incentives, transforming the profession of medicine into a business more then ever before." We all know what happened next. If an insured person developed an expensive illness they were dropped from coverage. If a person had a preexisting condition they couldn’t get insurance. Doctors were threatened and bullied into joining managed care companies, and were offered below market salaries. Capitation where payment was made on per capita bases which inspired a get them in and get them out policy. Then the awful and scandalous gag rules. Costs have gone up 4 or 5 times the inflation rate for the rest of the economy.

The AMA has played a prominent role in keeping a Universal, Comprehensive, health care policy accessible to all from becoming a reality. All these years and we still have an unjust system, but now it has evolved into a major problem and it cannot continue. We are at the brink! If only we had followed our Constitution on this one or listened to our earlier presidents. The American Medical Association has struck down health care reform time and time again. We would be a lot further toward a Universal, Comprehensive Health Care Plan that covers all if it wasn’t for the AMA’s misconceptions, fears, and special interest, or the lack of courage and concern from most of our political leaders. A national health care plan is not socialized medicine, its socialized payment of medicine it does not tell physicians how to practice medicine. The support of the AMA toward righting our health crisis, that they had a part in creating, will give back professionalism to physicians, and put medical decisions back where they belong. They should be on the side of a national health care plan like the rest of the industrial countries have. At the present time decisions are being made by employers, insurers, managed care companies, and government officials, it would be hard to find a country that would allow this to happen. We must look like fools to the rest of the world.

National health care reform has been called the most complicated issue to face US policy makers since the great depression, but it should be easier to make good decisions now. History has showed us our mistakes, and it should help us in planning for the future. Other countries have also shown us the way, their health care plans are not perfect but they are far better than what we have. There probably will never be a perfect health care system. We will have to ration care that’s a reality, but we don’t have to put up with the irrational and extensive rationing that we have now. Medicare has done us proud, but it needs to be extended to everybody for a more just and efficient system. Medicare has shown that we can have a universal, comprehensive plan and keep our administrative costs low. Covering prescription drugs, eye and dental would help.

The American people must put justice above all else. Health care reform has been called the second most important issue after the economy. It helped Harris Wofford a democrat with no political experience, get elected to the Senate. It got Bill Clinton elected to the presidency. President George Bush failed to have a policy except a bandaiding package. Tax credits to help the poor purchase insurance, tax deductions to the middle class to pay for insurance, and large purchasing pools to help small businessmen buy affordable insurance. This was pure politics for President Bush and not a thought for a good health care system. He took this stand because his constituents wanted tax breaks on capital gains. But he made a mistake and this cost him the election. Now President George W. is proposing the same policy of tax breaks to solve the health care problems, when what is really necessary is sweeping change. His statement in his State of the Union Speech in which he said "Our health care problems will not be solved by dictating coverage and rationing care" clearly shows his administration doesn’t understand or concern itself with compassionate and rational health care reform.

President George W. Bush has done nothing to reform these important issues at hand and he has eliminated many of the environmental programs.

             Health Care Reform

President Bush has eliminated or failed to act on many environmental issues that make us sicker.