That dastardly duo, Trent and Galen, have some questions about single-payer. Good for them. Keepin’ me honest.

On the 45 million uninsured statistic:
Our two camps will never, ever, agree on this number. Folks on my side see the number big, folks on the other side see it smaller. Galen has a valid critique if his numbers are correct–that some of the uninsured could potentially purchase their own health insurance. However, I’m not sure where his souce is getting his data (Googled it, couldn’t find the BCBS report): the Census itself reports (PDF) that 8% of the uninsured make $75,000 or more per year, and 12.5% make more than $50,000 but less than $75,000. Even if Galen’s argument holds water, that’s only 20% of the uninsured, not the 50% Galen would have you believe.

Galen’s right. Basic, mediocre coverage could probably be afforded by some of these families. Let’s ignore the fact that many probably locked in mortgages assuming that their employers would continue to provide health insurance, or that they would continue having a job. Let’s also ignore the fact that these plans require physicals and approval and come with pre-existing conditions: if your child has asthma, you dislocated your shoulder in a car accident 10 years ago, or anything else, these conditions will probably not be covered (I speak from experience, a classmate was trying to buy health insurance for himself and his two kids, and they were rejected for the two reasons I just gave). So if you have any sort of medical condition, how worth it does it really seem if your diabetes, Crohn’s disease, or any other illness isn’t covered?

I’m assuming Galen’s never worked in community health centers or with uninsured patients, because if he has, he’d realize that it’s no easy task to get people that qualify for government programs enrollled, and to keep them enrolled. (I’m skeptical about his claim, I’d really like to what “government programs” are that empty.) Most clinics have full-time benefits analysts that work their asses off trying to get people into any programs they qualify for–not just for good nature, but because the clinic needs someone to bill so it can keep afloat. There are numerous steps, income qualifications, and follow-ups involved; your child can go to the ER and get signed up for your state’s CHIP program, but some states have short re-enrollment periods, so that parents have to constantly be re-enrolling their kids.

Besides *all* of this, the point is, even if they *could* have health insurance, they don’t. There’s still 45 million people in the country without health insurance. And even if they could afford it and don’t buy it, we still *ALL* pay more for it. There are externalities and social costs involved. Galen and Trent can’t deny that.

On Galen’s other points (sorry guys, school starts tomorrow, and I’ve got to speak at orientation soon):

* A single-payer system is needed because it will control costs better, and will save us a ton of money, allowing us to provide health insurance to everyone.
* A government-run entity, like the NIH, for example, runs the Prom Committee.
* Health care demand will temporarily go up, as the people that are sick and need a primary care physician will (surprise!) get to see a doctor. Crazy, I know, as it seems, but I’d argue that illness and disease costs our economy billions, if not trillions, and if more people can get better, and better faster, it’s good for all of us. Once everyone has health insurance however, demand will stabilize. There’s a term for overusers of medical services: hypochondriacs, and it’s a psychological condition.
* Health care providers are not required to stay in the system, if they don’t want. In Canada, however, you’re not allowed to offer health insurance for services the government currently pays for. In other countries, it’s different. Google and read up. And if they want to stay in the system, you get your representatives to argue for a pay increase for you. Just as they did in Saskatchawan last year.
* The Prom Committee rations care based on need for medical services. Currently we ration it on ability to pay. You decide what’s better. “Over your own judgment?” On the snarky side, I didn’t realize that patients currently get the option to ration their own health care, or generally know enough about medicine to make an informed, educated economic decision about their care.

On “Savings From Reduced Paperwork”
Trent, it’s a pretty big argument when some estimates find that we could save all most $300 billion (BILLION, not million) on paperwork. And yes, I realize who my source is. So say they’re way off on their estimate. Say they doubled their estimate. That’s still $150 billion (BILLION, not million) in savings. Independent analyses by many consulting firms agree: single-payer is the only approach that both saves money AND provides universal coverage. Argue with The Lewin Group or Mathematica Consulting if you don’t agree. They’re not exactly flaming liberals.

On “A Free Lunch”
It wasn’t my intention to imply that anyone’s lunch is free. I thought I made it pretty clear in both the Prom analogy as well as in the single-payer animation that everyone pays into the system. If you didn’t take that away from it, sorry.

On “Medicare”
I’ve never gotten the sense from anyone in Medicare that it “trap(s) many elderly into poverty.” The elderly, when polled, *love* Medicare. That’s why you can’t touch it politically–the 65+ crowd you hang you out to dry. And I’d love to know how Medicare provides “substandard insurance.”

I’d love to go on, but I’ve got an orientation session in 45 minutes and I still have yet to shower. Too much information, I know.

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So, Pfizer, let’s get this straight:

# You just stopped your discount card for the elderly, effective September 1, 2004.
# But the Medicare drug benefit that the discount card will replace doesn’t start until January, 2006. That’s 16 months away.
# You got a lot of press for claiming to start a program that will save “millions of working families without drug coverage” money on Pfizer medications.
# Will the elderly be able to use your new Pfizer Helpful Answers programs, or are they disqualified because they technically now how a prescription drug benefit?
# If yes, why do they have to re-enroll in a new program? If no, see hypocracy of numbers 1-3.

Thanks for the heads up, Public Health Press!

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It’s finally time to announce one of the top-secret projects that I’ve been working on this summer that’s kept me from posting more: What Is Single Payer? is an animation that I’ve finally completed that gives a very simple, basic understanding of single-payer health care, and why I think we need it.

If you know read this weblog very often, you’ll know that I advocate for single-payer health care reform; it’s a great passion of mine. If you’ve always just kind of skipped over the health care policy or reform posts, I’d urge you to watch. It’s gone through multiple revisions, multiple scripts, cuts, changes, and I’m finally happy with it. I’ve put a lot of time into it.

So please take a few minutes, turn up your speakers, and take a look. I’ve put it in the context of a single-payer site that’s been stewing for quite some time, but is always in that “never quite finished” state.

UPDATE: Thanks for all the feedback so far. I know it’s tacky to ask for links, but please link to the animation on your weblog or email it to friends; I’d like to spread it as far as possible.

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The Census released its latest findings on the number of uninsured in the US this year. We’ve gained (at least) another 1.4 million, making out grand total 45 million! ==USA! U! S! A!==

The Bush Administration says they’ve got a great new plan to get health care to Americans (nowhere in the press release does it actually say what their plan is, besides listing a couple ideas, none of which will make a dent in the uninsured). But let’s just go through these points (my commentary in itals. This is going to be fun):

* Community health centers – Three million more Americans have access to health care as a result of the President’s five-year plan to fund 1,200 new and expanded health center sites to serve an additional 6.1 million people by 2006. These health centers provide direct medical care, particularly for lower-income and uninsured Americans. The community health center where I work is seeing 20 new patients a day, very few of which have health insurance (no, not even Medicaid), and is already swamped. It does a great job, without a doubt, but the funding of the current community clinics is already too low. Oh, don’t forget, drug manufacturers are also overcharing our community health centers.

* Medicaid and State Children’s Health Insurance Program – HHS has helped states extend coverage to an estimated 2.6 low-income Americans by granting states waivers and approving state plan amendments to these programs. Overall, under the President’s leadership, SCHIP enrollment has hit an all-time high of 5.8 million children in 2003, up 1.2 million since 2001. And the program has the potential to cover even more children. You can take credit for “helping kids get enrolled in CHIP,” or you can look at it another way: 1.2 million more kids have enrolled in CHIP because their parents lost their jobs (1.8 million lost since Bush was President?), or never had jobs that provided health insurance in the first place. Back with George was Governor of Texas, he set Texas’s enrollment levels at 150% of poverty, which kicked 200,000 kids out of the program. Texas already had the second lowest number of kids with health insurance at the time.

* High-Risk Pools – In 2003, HHS provided states with $23 million in grants to help 18 states create these high-risk pools that provide coverage for people too sick to afford conventional insurance. What a fun one. Now, even though this money went toward creating these “risk pools that provide coverage,” you really can’t get very far with $23 million. We pay, on average, more than $4800 per person for health insurance in this country. $23 million / $4800 per person equals… wait for it… a whopping 4,791 extra people covered in 2003! You just helped .01% of the total uninsured!

* Medicare – More than 4 million seniors are saving with Medicare prescription drug cards for the first time. In 2006, more than 40 million seniors will have access to prescription drug coverage for the first time under Medicare. There’s plenty written on how terrible the new Medicare law is.

* Health Savings Accounts – The new Medicare law establishes these flexible, affordable accounts. Americans who set up Health Savings Accounts along with the purchase of a high-cost, high-premium, high-deductible health care plan can save tax-free money to pay routine medical expenses and future health care costs. President Bush has proposed allowing individuals who establish an account to also deduct the premiums they pay for their high-deductible policies. I forgot that 65% of uninsured people live on incomes below 200% of the federal poverty guideline, so they clearly have money to put away in a tax-free health savings account.

* Hospital Discounts – The Bush Administration also is investing nearly $25 billion annually to help hospitals bear the cost of the poor and uninsured, while making it clear to these hospitals that they can, and should, provide discounted care to the uninsured or underinsured. I really know nothing about this one, but to say that I don’t think any other president hasn’t given money to hospitals to help keep them open.

* Lower Drug Prices – The Department introduced new regulatory processes that will help get low-cost generic alternatives to consumers more quickly. This initiative is estimated to save Americans as much as $35 billion over the next 10 years. Oh, the administration reduced the patent life on new drugs? Generics can’t be distributed until the drug’s patent runs out, which lasts for at least 20 years. So unless they’ve done something about that, generics won’t be getting there much faster at all. How misleading.

And what’s this? Economist Paul Krugman finally comes out in support for single-payer?

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Trent’s written about the hullabaloo that VA diabetes care is better than HMO care, and links to Marginal Revolution’s quotes on health care, claiming the US’s dollars are “more productive” than the UK’s or Germany’s. In effect, each dollar we spend goes further to improving our health.

This analysis can only be true if we ignore the 44 million uninsured, and the money we spend on their health “care;” I have a hard time believing the ER “health care” many uninsured get as a last resort is “productive” or a good use of our resources. I’ve got my own study from the Commonwealth Foundation, and while it’s more qualitative, it presents a very different picture. (It’s also trying to present the patient perspective, instead of an overall systemic analysis.) Bits from the summary:

Patient Safety: U.S. Ranked Last
* Highest reports of medication errors (re-ceiving the wrong medication or dose over the past two years).
* Most likely to say a medical mistake was made in their treatment.

Patient-Centered Care: U.S. Ranked Second-to-Last
* Ranked last (tied with the U.K.) on physicians spending enough time with patients.
* Last on physicians listening carefully to patients’ health concerns.

Timeliness: U.S. Ranked Third
* Best on hospital admission waiting times.
* Next to last on waiting five days or more for physician appointment when last needed medical attention.

Efficiency: U.S. Ranked Last
* Last on being sent for du-plicate tests by different health care professionals.
* Worst on not having medical records or test results reach doctor’s office in time for appointment.

Effectiveness: U.S. Tied for Last
* Last in patients not getting a recommended test, treatment, or follow-up due to cost.
* Last in patients not filling a prescription due to cost.

Equity: U.S. Ranked Last for Lower-Income Patients
* Worst on patients having problems paying medical bills.
* Worst on patients being unable to get care where they live.

We’re great at getting people in the OR for elective surgeries in this country–and that’s really excellent. Lord knows I wanted my tonsils out as soon as possible, after 3 successive throat infections 2 years ago. But, as I’ve written before, the most effective of treatments–procedures or pharmaceuticals–are rendered *completely ineffective* if patients are not able to afford them or have access to them.

From the end of the report:

bq. The U.S. had the greatest percentage-point disparities by income for each measure and, as a result, ranked a clear last on all measures of equity. Moreover, Americans with below-average incomes were much more likely than their counterparts in other countries to report not visiting a physician when sick, not getting a recommended test, treatment or follow-up care, not filling a prescription, or not seeing a dentist when needed due to costs. On all of these indicators, one-third or more of lower-income adults in the U.S. said they went without needed care due to costs in the past year. Americans with below-average incomes also were more likely to report difficulty getting care because of where they lived and more likely to say it is extremely or very difficult to get specialist care when needed. Even among the higher-income population, U.S. respondents often were more likely than their counterparts in other countries to report difficulty obtaining needed care due to costs.

Oh, and just so we’re clear: I’ve never advocated for “nationalized health care.” I advocate for national health _insurance_. Totally different things.

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So Illinois will be creating a state program to get Canadian-priced drugs to its citizens. Again, we’re willing to support another country’s single-payer system, but not one at home. Again, we’re willing to send our state tax dollars across the border, into Canadian pharmacies, instead of keeping our dollars here. (Aside: who wants to take bets on when some big drug scare occurs from a tampered medication coming from Canada? I wouldn’t put it past PhRMA to sabotage a few cases of a diabetes med to scare the public into buying American.)

Matthew Holt points out the obvious buying power hypocrisy:

bq. IPI’s latest press-release claims that prices in Canada ought to be 82% of the US level but in fact they’re only 59%. So they think of course that Canadians should voluntarily increase their payments by some 35%. I assume the IPI also thinks that WalMart should start paying its suppliers a ton more every year, or is using your purchasing power only OK if you’re in the private sector? For that matter I don’t think WalMart lets its suppliers get away without innovating, but they certainly don’t let them raise prices to do it!

We could easily have cheaper drugs in this country, if the government was allowed to use its purchasing power, just like Wal-Mart has done. But the new Medicare legislation strictly forbids this. Even if you *want* the government to run more like a business, its own laws (written by pharma interests) prevent it from doing so.

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Tech Central Station, the free market zine funded by Republican lobbying groups and huge mega-corps has once again popped up on the medical blogs, claiming that government involvement in health care will cause the complete and total end to drug and medical device design, adding the “Soviet Russia” comparison that’s always thrown in at TCS for good measure. Galen apparently has no problem with 44 million people going without health insurance, or seniors having no prescription drug coverage, all in the name of free market innovation.

Back to the article:

bq. As government attempts to push aside the private sector, one of the freest healthcare markets in the world would become even less free.

Y’know, I don’t really see the government scrambling to sign people up for its health programs–it’s usually people that *don’t* get coverage or help from the private sector (ie: their employers) that end up having to use government programs for help. In fact, 9 million fewer people received their health insurance through employers over the past two years, and 5 million more children are insured through the government, “many because their parents lost employer-sponsored insurance.” Nice work, private sector. (Also, don’t believe for a second that the Medicare drug coverage bill isn’t just a huge stipend to the private sector–the law was written by PhRMA and won’t be able to help many of the seniors it’s supposed to.)

bq. One sure consequence would be the stifling of innovative medical breakthroughs, like new drugs and medical devices that have long been the hallmark of the U.S. healthcare system… No other country comes close to that share, because no other country fosters entrepreneurship and innovation like the U.S.

No other country also has the level of development of the US, and still denies primary care access to 44 million of its citizens, resulting in sicker people, higher costs, and for many, death.

Guess what? MRI techniques were developed, primarily, by British scientists at Oxford and other universities. Canada transplanted the first heart valves in the world, did the first successful lung transplant, developed the most successful transplant for those with diabetes, and the list goes on. If you think countries with single-payer (or even national health services) can’t innovate, you’re simply wrong. There’s still plenty of money to be made, don’t worry.

In fact, if you look at number of journal articles published per capita, the US falls somewhere in the middle–slightly more than Canada, but less than the UK, New Zealand, Switzerland, Denmark, or Norway.

And most of the drugs we develop According to the NIH, taxpayer-funded scientists conducted 55 percent of the research projects that led to the discovery and development of the top five selling drugs in 1995.

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I saw a disgusting commercial a couple weeks ago from Wal-Mart. It went on and on about how the Wal-Mart employee’s son had a heart problem, and Wal-Mart paid to send him to the Mayo Clinic for the surgery. The employee was *so* thankful that he worked at a company that would do something for his son like that.

Wal-Mart, the country’s largest private employer, only has about a third of their employees using their health care plans, due to high premiums and deductibles. It claims that 90% of their employees still *do* have some sort of health insurance, and “usually get their health-care benefits from a spouse or the state or federal government,” according to a Wal-Mart spokesperson. Talk about corporate responsibility. Wal-Mart’s so cheap because it relies on the government and other employers to keep its employees healthy. If Wal-Mart employees wanted to take advantage of Wal-Mart’s health insurance, they’d have to pay about 25% of their monthly wages to pay for it (based on what Wal-Mart pays). Even better: about 6% of Georgia’s PeachCare program, its program for uninsured kids, have a parent who works at Wal-Mart. That’s 14 times more than the next closest employer.

Hopefully Wal-Mart will catch on to Cost-Co’s strategy: pay employees more, offer health benefits, and become more profitable. By paying better, it retains good employees, and is therefore more efficient.

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Many times in the health care reform debate, we argue between reals and ideals. We say “Well, this plan might be better, but it’ll take a long time to become law, so let’s pass this other one right now, to help people in the meantime.” And generally it’s a decent proposition. Larger changes take longer to implement. But boy, in the case of this Medicare prescription drug benefit, the something is turning out to be *worse* than the nothing.

It started out with great promise: help seniors pay for their medications. Seniors have low incomes and large medication lists, so by decreasing their costs for medications, they might not have to skip a meal or two to pay for their Lipitor. What a deal!

It ran into problems when everyone started to realize that the bill would essentially be written by the pharmaceutical industry (no one really seems to deny this). Seniors are supposed to get a discount on their drugs, and if they pay too much, the federal government steps in and helps to pay for them, too. This sounds all fine and dandy, until you realize that the pharmaceutical companies have increased the drug prices 4.3 times inflation in the last year, so that whoops, look at that, even *with* the discount the drugs are still the same price. Funny how that works.

Senator Mark Dayton (D-MN), who uses his Senate salary to pay for trips to Canada so seniors can buy cheap meds, opposed the prescription drug bill, and for good reason: it won’t help many seniors, and will actually hurt some of the most vulnerable. Ah, the law of unintended consequences. A report that Senator Dayton quotes by the Congressional Budget Office predicts that the seniors that currently have good prescription drug coverage will probably lose their coverage, as employers drop their retired employees’ drug coverage, since the government will be paying the tab. And hey, will you look at that–it came true!

bq. New government estimates suggest that employers will reduce or eliminate prescription drug benefits for 3.8 million retirees when Medicare offers such coverage in 2006.

In a “well, duh” analysis the bill, Gerald Anderson of Hopkins says that if we lowered prices, it would fix the Medicare drug plan. Holy hell, Gerry, what a brilliant plan! But he’s worried that by cutting prices, drug companies won’t make as much money, and therefore won’t invest in as much R&D. Never a more bogus claim if I’ve ever heard one. Drug companies spent twice on advertising what they do on R&D; so wouldn’t they just spend *less* on advertising? No company is going to hault their drug development process, or else their future profits would be gone, and they’d cease to exist. Patents, although ridiculously long in this country, don’t last forever.

Senator Dayton makes a number of other great points in his speech:

bq. Now, why are the prices so much lower in Canada than they are in this country? It is because the Canadian Government stands up for its citizens and negotiates prices that are lower and will not agree to prices that are exorbitant. And their citizens are the beneficiaries of these prices that are one-third, one-fourth, one-fifth of what they are in the United States–not even close approximations.

People say the Government ought to act more like a business, and they are right. What we are proposing the Government would do is exactly what large corporations which self-insure or HMOs do, which is to purchase volumes of prescription drugs at negotiated discounts of 30 percent, up to 50 percent. It is exactly what my colleague BOB GRAHAM from Florida has pointed out, that the Veterans Administration does quite successfully, with fantastic savings for veterans and for the American taxpayers who pay for part of the cost of that program.

But not under this legislation. This legislation would prohibit what they call Government interference in price setting negotiations. Why? Well, once again, the words of the bill belie the intent and the result. It says: “in order to further competition.” What deception that is. It says, let a bunch of small-competitor plans offer nickel-and-dime savings, but prohibit the Government from insisting upon and getting 5 times, 10 times that amount of savings, savings that would benefit everyone in America–seniors and everyone else. Those price reductions would be reflected in domestic market prices.

The critics call it price fixing. Well, there is price fixing now in this country. It is the drug companies that are doing the price fixing. They are given monopolies, called patents, for 15 to 20 years or more. They set the prices, they raise the prices, and we have to pay the prices. But that kind of price fixing, I guess, is all right according to some who want to prohibit the Government from doing so.

Does anybody really believe Americans are going to be upset about paying lower prices for prescription drugs? Does anybody think consumers in America are going to say: Government is acting in a way that I don’t support? In fact, it will be the opposite. People will say: Wow, my Government is doing something for me. My Government is standing up for me against these big corporate entities that I don’t have the ability to face by myself. I don’t have that purchasing power. I can’t go to a drugstore and negotiate price. Even as a pharmacist I can’t negotiate a different price. My Government is standing up for me the way the Canadian Government is standing up for their citizens. By golly, my Government is doing something right.

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You have to be a pretty sadistic, greedy, mean-spirited, vile, wretched, and corrupt industry to overcharge the elderly and the poor (not mutually exclusive). But if anyone can be sure to sink to that level, it’s big Pharma!

Let’s see. You overcharge community health centers, which are already facing budget cuts, and trying to maintain the safety net in this country, taking care of the poor and working class of this country. And then, to top that, you raise the costs of drugs so that the Medicare prescription drug card discounts just maintain your current level of revenues! Brillant!

(And then you pay doctors $10,000 to prescribe your drugs.) If that’s not an industry that cares about the health of the population, I don’t know who does. I’m guessing GreaterRX won’t be covering these stories.

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