Saturday, May 30, 2009

Health care by the numbers

$2.2 trillion: How much was spent on health care in the U.S. in 2007 ($7,421 per person.)

$4.27 trillion: How much the U.S. is projected to spend on health care in 2017.

$56 billion: The total amount of uncompensated care provided for the uninsured in 2008. (60 percent provided by hospitals.)

86.7 million: The number of people in the U.S. who lived without health insurance for part or all of 2007-08.

1.5 million: How many U.S. families lose their homes to foreclosure per year because of medical bills they can't afford.

14,000: The number of people in the U.S. estimated to be losing their health coverage every day due to recent turmoil in the job market.

$12,680: The average cost of family health coverage through employer-based plans in 2008.

$1,525: The cost of health care built into the price of every General Motors car.

120 percent: How much the employee's share of health coverage through company plans has risen since 2000. (Workers' average out-of-pocket medical costs have risen 115 percent since 2000.)

45: The number of U.S. states in which insurance companies are allowed to spend less than 75 cents of every dollar paid in premiums on their customers' medical care.

25 percent: How many more adults without health insurance are likely to die prematurely than those who are insured.

4.3: America spends 4.3 times more on health care than it does on national defense.

2.5: The uninsured often pay 2.5 times more for their medical care than the insured do, because they don't get the reduced rates insurance companies negotiate for their customers.

Sources: Henry J. Kaiser Family Foundation, Families USA, Illinois PIRG, U.S. Centers for Medicare and Medicaid Services, National Coalition on Health Care, Center for American Progress Action Fund.

This list of statistics were taken from a larger article regarding the rising number of uninsured in America. Read the entire article here.
California Budget Deficit Carving Into Health Care
Story from San Fancisco Chronicle

As the budget deficit widens, here's where additional health cuts are expected:

If your toddler gets into the medicine cabinet, no one will answer the phone at Poison Control (all state funding eliminated).

Maybe someone in your family has been laid off - more than 300,000 children lost health insurance in the last year and a half. In response, we're going to add another 225,000 children of working families to that burgeoning number (by cutting existing Healthy Families coverage - $54.5 million).

Maybe your mom with dementia has been beggared by medical bills - the family home sold, not a penny left. Unfortunately, your chances of finding a nursing home that will take Medi-Cal just went from slim to practically none ($750 million in proposed cuts plus an increase of $18.3 million in nursing home fees). But your mom's home assistance and adult day services (which you depend on to hold down your own job) got slashed ($326.5 million).

Or maybe you're doing OK but are downright furious at the homeless people shooting up on the corner. Unfortunately, we're gutting funding for one of the few things that works: substance-abuse treatment ($116.8 million).

Child welfare will be cut, and we're even going so far as to literally take clothes away from children in group and foster homes ($83.9 million).

Widespread reports of wives and children slaughtered by husbands will increase. We're cutting $20.4 million in domestic-violence funds for emergency shelters and restraining orders.

All these problems won't go away. They'll end up jamming emergency rooms, hospitals and possibly prisons, costing us much more in pure dollar amounts. We've even cut funding for family planning services for the poor ($36.8 million).

In contrast, only 5,000 state employees (out of 110,000) are targeted for layoffs, and there are no absolute dollar cuts for prison services (only anticipated savings).

You could argue that the governor and Legislature have spent the last months re-arranging deck chairs on the Titanic.

Now Gov. Arnold Schwarzenegger's revised budget spells out that, in California, when push comes to shove, children, women and the frail are the first to get tossed overboard. No lifeboats for them.

Monday, May 25, 2009

At Least One Doctor Pushes Back Against Insurance Companies
Story from San Francisco Chronicle

Dr. Bradley Carpentier, a pain management specialist,
founded the group Stop Practicing Medicine

Monterey physician Bradley Carpentier found himself spending so much time fighting with health insurers to get approvals for the treatments he prescribed for his patients that he decided to wage his own lobbying effort.

Carpentier formed a new political action committee - Stop Practicing Medicine - to target the long-standing practice of insurers hiring doctors to review physician decisions, even though the insurer-hired doctors had never seen or talked to the patient whose care they were scrutinizing.

Insurers defend the practice, saying such doctors often serve as a second set of eyes to ensure patients are receiving the most appropriate and effective treatments. But Carpentier, along with patients and other doctors who support his position, says insurers are denying and delaying care.

"We need to let the doctor take care of the patient," said Carpentier, who specializes in pain management. "Pretty much, doctors ultimately do what they want, but it just depends on fighting a lot to get that done. What we've found is fewer patients have access to care in general because we have limited resources. We're being kept so busy fighting and advocating for patients."

Health insurers and doctors have long battled over care decisions, with insurers serving as gatekeepers to set guidelines and control health costs and physicians bristling at being second-guessed and overruled. The tension reached fever pitch in the 1990s when managed care was at its height, prompting a consumer backlash that led to reforms and less restrictive forms of coverage.

Raising awareness

But Carpentier said he's seeing an increase in pushback from health plans, prompting him to refuse most insurers and, instead, treat his patients and submit reimbursement forms on their behalf. He formed Stop Practicing Medicine, he said, to raise awareness of insurance interference as lawmakers and the Obama administration begin efforts to overhaul the health care system. The organization began recruiting patient and physician members last month.

"The prospect of health reform in this particular time in history is what led me to speak out," he said, adding he is calling for restrictions of the practice but not the abolition of health insurers. "I think there is absolute change in the air and we want it to be for the better."

In poll results released last month of 389 California doctors, 87 percent described limits and restrictions that insurance companies place on doctors as a major problem.

The survey, conducted by a Seattle research firm for the California Medical Association, found 84 percent felt pressured to change the way they treat a patient because of a restriction from an insurance company and 86 percent admitted selecting a course of treatment they might not otherwise have chosen because of the pressure.

But insurer groups contend the interests of physicians and health plans are more closely aligned than ever, and that the two groups are working together on many issues such as rewarding physicians for quality rather than just quantity of care.

"It's in everybody's best interest to make sure the patient is getting the right health care treatment in the right place and in the right time," said Robert Zirkelbach, spokesman for America's Health Insurance Plans, a national trade group. He cited studies that have shown patients often don't receive the best care supported by scientific evidence.

Protections in place

California's independent medical review system allows a panel of physicians to resolve disputes between patients, doctors and insurers, said Charles Bacchi, interim president and chief executive officer of the California Association of Health Plans.

"We just believe the most important thing is that the patient is receiving the right care," he said. "And we think there are protections there for consumers already."

Dr. Michael Leong of Los Gatos, who works with Carpentier and at Stanford University, said pain management specialists are particularly vulnerable to insurance hurdles because pain is less quantifiable that other maladies and often requires highly individualized therapies or newer, more expensive drugs.

Leong said he recently saw a patient whose neck pain had flared up, but he was unable to give her an injection she receives several times a year. That's because the insurance company requires him to submit the same paperwork and go through the same authorization process each time, he said.

"I know it will get covered in two or three weeks, but that's another two or three weeks of pain," he said.

Noel Ortiz of Twain Harte (Tuolumne County), one of Leong's patients, said she regularly had to battle her insurer until she was able to manage her pain without drugs after undergoing treatment through a clinical trial. She said she has been on the hook for as much as $15,000 in medical costs while she fought for reimbursement.

The 50-year-old Ortiz, who suffered from lower back pain from years of teaching horseback riding and training horses, said she still doesn't rest easy. "I do keep an account for fear it will happen again," she said.

Learn more

For more information about Stop Practicing Medicine, visit

Focus On Orange County CA Caregiver Resource Center
Story from OC Register

Claudia Ellano knows more about caregiving than she would like.

She spent six years working and also caring for her husband, Moe, who died of chronic obstructive pulmonary disease.

And she is the director of the Orange Caregiver Resource Center, the only Orange County agency focusing specifically on the needs of caregivers who are coping with a loved one's chronic illness.

The Caregiver Resource Center ( is a program of St. Jude Medical Center and part of a statewide system of Caregiver Resource Centers for people 60-plus. It is financed through county, state and federal agencies.

A chat with Ellano:

Q. Let's talk about the typical help a caregiver can receive from your agency.

A. Well, we have a staff ready to assist with problem-solving resources and support. Just call (800) 543-8312 .

A care coordinator will talk to them about what the caregiver is needing the most — from the community or for themselves.

Q. How do you know what type of needs the loved one has?

A. We don't assess the patient. We are not here to solve problems for the patient. We are strictly here to help the caregiver with an action plan, including proper referrals, how to talk to the doctors, where to go to get assessments.

But they have to start with a diagnosis.

Q. This is a rhetorical question but — do caregivers need a lot of help today?

A. We've always known caregiving has an emotional and economic impact. But add the issues of today's economy, people losing their jobs for example, and the impact is huge! We want to be the entry point resource center for caregivers, and we are part of a large partnership of agencies ready to help.

Q. OK. But you and I know money becomes the big problem. Unless the person you are caring for has longterm-care insurance, families have to shoulder most of the cost of caregiving.

A. We are woefully lacking in public policy for longterm care in this country.

There is an assumption that Medicare pays for senior care, but in fact it only pays for a specific number of days after an acute episode, such as a stroke.

If someone needs longterm care in the community, it's pretty much out of their own pocket. Medi-Cal might be able to pay for some help, but we know this is where a lot of the cuts are coming.

Some senior HMOs have respite dollars built in, but these are short term and intermittent kinds of funding.

Adult day healthcare, other forms of relief, are almost all private pay.

It's a challenge that isn't going to get easier.

Q. Most people think of nursing homes when they think of caregiving costs.

A. Those costs are high but only impact about 5 percent of those needing care. People want to keep their loved ones at home.

Q. What kind of calls do caregivers make to you?

A. Here's a common one: I only make $12 an hour, but the agency wants $18 to $20 an hour to provide care for my mom.

Now, even if you haven't been laid off, there's a dilemma balancing that cost of care.

Q. Not everyone is equipped mentally to do caregiving.

A. No. It can be a beautiful spiritual journey.

We can help you stay healthy and make sure you have done the legal and financial planning necessary, made your home safe for your loved one, have meals delivered, and so on.

But not everyone wants to go on this journey. Everyone has different stress levels.

Q. How's your budget this year?

A. We slipped by without being targeted. We can still provide services.

There are several networks and agencies ready to help caregivers. Here are a few sites to check out:

• – local resources such as transportation, meal delivery, respite care.

• - should answer all your questions about Medicare services available.

• – local resources and options in senior housing, including nursing homes, assisted living, senior living or retirement communities.

• – caregivers can sign up for friends, family, neighbors and other volunteer help.

• – support groups and social networking.

• – Evercare Solutions for Caregivers – an insurance program – will provide an assessment and care plan for non-members for $580. Care management after the initial assessment to help coordinate ongoing help and support is $115 per hour.

Americans Spend Millions On Caregiving
Many are forced out of their jobs and homes because of the strain to provide for their loved ones

Story from OC Register

Jodee Kalmen drew the caregiving card four years ago.

She was 50 when her husband, Peter, then 57, was diagnosed with frontal lobe dementia. His ever-worsening symptoms had already cost him his job.

She was a stay-at-home mom with two sons but became a school bus driver. They lived off her small salary, his Social Security Disability, the equity in their home.

Today, she is one of 44 million Americans responsible for caregiving a spouse or parent. The backbone of the nation's long-term care system, they represent $375 billion annual value in the care they provide.

But in these hard economic times, a new survey shows caregivers are facing escalating financial and emotional hardships that are rarely, if ever, addressed in national debates about funding health care.

There are statistics, data and websites offering help, but the truth is caregiving is where childcare was years ago, says Sherri Snelling, senior director of Cypress-based Evercare.

Few employers offer benefits. Many adult children are losing their jobs, forcing them to move in or move home parents who were in care institutions. Most caregivers are not prepared for the expense and the emotional drain.

In the next two weeks, we'll look at the data and the solutions, the questions and the few answers.

The Kalmens thought their future was secure.

"My husband and I did everything we were told to do; buy a home, save money for retirement and open college funds for our boys," Jodee Kalmen says. "What they did not tell us was that dementia was going to enter our lives and devour our financial future.

"Besides watching my husband slowly die, I have had to live on pins and needles riding the uncertainty of the economy."

After 21 years in her home, Kalman says she is down to her last financial resource — her husband's IRA, which has been decimated by the declining stock market. She's already refinanced the home three times.

She has no health insurance because she lost her job.

"I am scared," she says.

She's not alone.

A survey conducted by Evercare by UnitedHealthcare and the National Alliance for Caregiving concludes 43 percent of caregivers have taken a pay cut or have been forced to work fewer hours as a result of the recession.

Some have taken on additional job or are able to work more hours, but almost 50 percent told surveyors they have exhausted their savings and 43 percent have had to borrow money to continue caregiving.

"These people are a significant part of our society, yet their economic impact is often unmeasured and, frankly, they are discounted in the view of the public," says Dr. Alan Sokolow, chief medical officer for United Health Care.

The concern is a potential cutback in individual caregiving, he says. Many have said they are cutting back or might be forced to cut back hours spent caregiving because of employment-related demands.

"There needs to be continuing awareness of the importance of providing assistance for caregivers," Sokolow says.

But the facts are these:

•With 30 years added to the average lifespan in the 20th century, most boomers can expect to spend some years as a caregiver for parent or spouse.

•The increasing number of childless women and others without family ties brings new challenges to financing caregiving.

•Caregiving only recently became an employee benefit for some workers; few caregivers are able to access these benefits today.

•64 percent of caregivers are struggling to pay their own bills.

•63 percent have stopped saving for their own retirement or future caregiving.

•36 percent say they have found that government agencies or nonprofit groups are less able to provide services or outside help.

Next: Where caregivers can look for help today, and in the future.

Transcript: Health Care Issues Discussed By Panel
Story from the Dallas Morning News

At The Dallas Morning News' invitation, 11 health care experts from the Dallas-Fort Worth area and Texas recently shared their views via e-mail on how to make health care more affordable and accessible.

Options for reforming health care coverage range from a single-payer system like those in Great Britain or Canada to a mostly non-group market where people would shop for their own private coverage, helped by federal tax credits. Which is preferable? Or is there a better middle ground?

DR. RON ANDERSON: I've long been an advocate of the concept of a single-payer system. It's more cost-effective, and its administrative overhead is low. However, I don't think this country is ready for anything that would take away competition. If competition for patient loyalty is possible and if there is still an adequate emphasis on quality, safety and access, I would support it. America uniquely likes competition; we like choices. If the choice of doctor and hospital is made possible, that would be attractive. I think the U.S. will end up being somewhere in the middle of the road. We need to differentiate between socialized insurance and socialized medicine. The former doesn't have to travel with the latter. But to do that we have to change our delivery models to be much more cost-effective than we currently are. But I do think there is a middle ground.

ROSSIA AVERY: As a registered nurse, I have watched insurance companies distort and undermine the delivery of health care in this nation. Patients skip needed medical treatment or appointments or cut pills in half because they can't afford the high cost, even if they are insured. Our physicians are forced to follow protocols that are based as much on insurance profits as on medical standards. And our patients are forced to deal with bill collectors and insurance claims adjustors just as they should be focused on getting better. The insurance companies waste 30 percent of their care dollars on "overhead," although they have never cured a patient and, frankly, deserve no role in the delivery of medicine. The good news is we know how to fix our health care system. Nearly every other industrialized democracy provides quality, universal health coverage from a national nonprofit fund.Think of it as if we expanded and improved Medicare to cover everyone. Under this single-payer system, health coverage and access to care are based on patient need, not your ability to pay. Everyone would be covered for all needed care. You'd be guaranteed your choice of doctor and hospital, and there are meaningful controls on costs. Best of all, medical decisions are in the hands of patients, their families and their doctors and nurses, not private insurance companies. We deserve no less.There are two single-payer bills in Congress, HR 676 and S 703, and Texas is one of many states with statewide bills before the Legislature.

U.S. REP. MICHAEL BURGESS: The guide for reform should be improving what works and fixing what does not. President Barack Obama said on the campaign trail – and this is clearly something that resonated with Americans – that if you like what you have, you should be able to keep it. I take that to mean that whatever reform we undertake in Washington shouldn't force an individual back in Texas to go to a different doctor against their wishes or force anyone to buy insurance they don't want or need. I also believe we need to take a look at the tax code. It's fundamentally unfair that small businesses, the self-employed and individuals do not enjoy the same tax benefit as larger companies when purchasing health insurance. This is a key step in making health care more affordable and giving Americans more choices. We need to ensure that whatever we do doesn't adversely affect the quality and affordability of American health care, and there are some really troubling proposals out there that would do just that.

ANNE DUNKELBERG: Settling on the precise form for an American system to guarantee every one of us access to a decent standard of health care no matter what our job, income or health status is not the most difficult step in reaching health reform or the most important one. The crucial and weighty step needed is the decision as a country to ensure access to health care as a public good, just as we do education, roads, military, fire and police protection. Every taxpayer knows that these public structures on which our civilization relies (and which all but the most diehard anarchists support) are not free, and affordable health care for every American will be just that: affordable but not free. Every American will have to contribute to the health care system no matter what model we pick to deliver and finance care – just as every American has to support schools, roads and the military. The critical change will be the guarantee that Americans will not have to spend more than a predictable upper-limit percentage of their income on health care. This change will eliminate health care bills as the No. 1 cause of U.S. bankruptcies, along with the profound fear American families live with today of not being able to pay for or receive the health care their loved ones need. What Americans desperately need today is a system that will provide every person the same access to a decent standard of care at a price that they can afford and which cannot be taken away if they lose a job or become sick or injured. Once the decision to create such a system is reached, there are many models to choose from, since every other industrialized nation already has such a system. A system that provides the health care security described above could be delivered under a single-payer system like Canada's, under our current system, which includes a major role for the health insurance industry alongside large public insurers (Medicare and Medicaid), or under an infinite number of variations in between the two. In fact, no country has a perfect system, and our U.S. system will not be perfect, either. For health reform to work here in the U.S. with a continued private insurance industry, however, some of the basic ground rules for the industry will have to change.

MARIANNE FAZEN: Most employers prefer a private health care insurance system over a government-run single-payer system. We believe that a private insurance system fosters innovation, competitive pricing, accountability among providers and patients, provider payments that reward superior performance and good patient outcomes, personal responsibility for healthy lifestyles and behaviors, and a wide range of coverage choices for consumers. We've seen just the opposite in government-run programs like Medicare and Medicaid. Although there are few examples where all of these desirable characteristics are in place and working well together, employers believe that the chances of this happening are far greater in a private, tax-favored health insurance system than a government-run single-payer system. However, in order to make the private insurance affordable, everyone who is not covered by Medicare or Medicaid should be required to purchase coverage in order to spread the risks across the sick and the healthy to keep costs down. Government can help by offering tax incentives for individuals and small businesses.

DR. ROBERT FINE: An American version of single payer is the best option not only for achieving universal health insurance coverage but also for improving quality and controlling costs – both of which are necessary to achieve and maintain health care for all. Traditional market-based solutions such as individuals "shopping" for private health insurance cannot accomplish any of these tasks because medical care is not an ordinary commodity and the health care sector is not an ordinary market. The "consumer" (patient) can never be adequately educated or informed about the product, and the provider can never escape the moral obligations intrinsic to medicine – obligations that don't exist in other markets. For the past 30 years since graduating from medical school, I have watched market-based solutions fail to improve access quality or, most important, cost, which has increased from 7 percent to 17 percent of gross domestic product. And why should this matter? Because we can't compete in the global marketplace when so much of our business investment is tied up in an inefficient health care system! The necessities of competition force insurance companies to keep anywhere from 15 percent to 25 percent of every premium dollar for screening out unwanted patients, marketing and sales, private-sector executive salaries and profit. A dollar spent on insurance sales is a dollar not spent on health care services. A dollar spent denying health insurance to a patient betrays the very purpose of health insurance. On the other hand, for every tax dollar devoted to health care, over 95 cents is disbursed for health care services. The middle ground thus is not between a single-payer system and shopping for private coverage but within a single-payer system fostering cooperation rather than competition between providers. Only a single-payer system offers the efficiency of a universal premium collection system, a single risk pool and a universal payment system coupled with the freedom for patients to choose their own doctor and hospital – something they don't have under market-based proposals.

LARRY JAMES: Whether there is a better option for U.S. citizens only time will tell. I do believe that given the fact that so many Americans already enjoy publicly administered health care coverage (Medicare, Medicaid, veterans' health and SCHIP) and given the market realities and preferences of consumers here, it is most likely that our first steps into the world of universal coverage will be a blend of options. It is worth noting here that the public solutions we have already embraced are administered at a fraction of the cost of private coverage and that these groups have been able to negotiate rates that keep health costs lower than would be the case if they didn't exist at such a scale and if they weren't public plans.

STEPHEN MANSFIELD: While I believe free-markets and the associated innovation and competitiveness derived from those markets are hallmarks that have allowed America to accomplish greatness by most any historical metric of societal greatness, I also believe market forces work less effectively in cases where a society deems a good or service to be a right. Studies indicate that the overwhelming majority of Americans view access to basic health care as a right. I am among that group and hence among the group who believe our best option for reforming and improving our overall health care economy is through fiscal policy which ensures health coverage and access for all paid for by all.

J. DARREN RODGERS: Blue Cross Blue Shield of Texas supports changes that will lower the cost of health care, improve the quality and safety of care and ensure that all Americans have health insurance. Today, the federal government and states struggle to maintain programs like Medicare and Medicaid, so it's hard for me to understand how a government-run, single-payer system would improve the cost, quality and safety of health care for Americans covered by private insurance. A government-run, single-payer system would be an unnecessary new bureaucracy that would only create a huge diversion from the true goals of health care reform. A number of alternative reforms are being debated. Guaranteeing access to coverage for everyone is one example. That would have no cost to taxpayers and should be instituted before we disrupt the current system, which works well for many people. Some of the more radical options could have unintended consequences that negatively impact the quality and safety of care.

As more Americans lose their jobs and employer-based health care coverage, they're turning to individual insurance. But they're finding that policies are unaffordable and, if they have certain medical conditions, unavailable. How can we guarantee that these individuals get affordable coverage?

ANDERSON: Currently, there are ways to get individual plans, but many times what you get is a bare-bones plan with a very high co-insurance and deductible. This prevents some unnecessary utilization, but it also prevents necessary utilization. You need a system that's going to be protective of the patients and focus on quality, safety and access, not just cost. It's important to remember that insurance is not the same thing as providership. We can't meet the needs of health reform without expanding capacity to take care of more people. Our focus needs to be broader than just payment reform.

AVERY: We can't, under the current system. Insurance companies only want to cover the healthy and the young, not because they are evil but because their primary goal is not providing care but generating profit for their shareholders. They make that profit by limiting who they will cover and denying claims, even for care recommended by physicians. Thus, tens of millions of people are simply denied the ability to buy insurance if they have ever been sick, are older or considered likely to incur medical costs, and women are charged more primarily because we can have children. Could this system be any more immoral? The best way to guarantee that everyone is able to get coverage is by having one system, such as Medicare, that treats everyone fairly and has one very large risk pool that can share the risk and that also has the strength in numbers to negotiate bulk pricing from the drug companies, medical suppliers and other parties in the health care system to control costs.

BURGESS: I think our goal in reform should be to say, "If you want health insurance, you should be able to purchase it." I think with greater individual control and more equity in the tax treatment of health insurance, more Americans will be able to afford coverage on their own that isn't tied to an employer. There are a number of innovative models for making health care affordable – even outside of traditional insurance – and I think we need to be very careful not to stifle these innovations. I'm also open to some form of premium support for those who cannot afford coverage. I'm willing to consider proposals that will make health insurers reconsider their decision to use pre-existing conditions as a means of denying coverage. This is clearly bad corporate citizenship. I think the best remedy is to provide patients with more choice and control, and then you will see insurance companies actually compete for all patients regardless of health status.

DUNKELBERG: Fundamental reforms of our private insurance market will be needed to create a sustainable health care system. Texas Department of Insurance data reveal that the average cost of a family employer group premium is around $12,000 a year. But under current law our lax regulation of health insurance allows insurers to legally charge as much as $62,000 per person to a small employer group. In practice, the state insurance department data show real-world maximum annual per-person premiums being charged small Texas employers as high as $29,000. In the individual market, there is no legal upper limit on the premium at all, and of course you can simply be turned down for coverage altogether.

The key reforms needed for the private market would end most of the differences between individual and group insurance by establishing the following ground rules for every insurer:

•No person or group can be turned down for coverage ("guaranteed issue" in insurance-speak).

•The difference between the lowest and highest premium charged for the same coverage is limited. For example, the highest premium can't be more than twice the lowest.

•The differences in premiums cannot be based on your health history or status. Rate variations would only be allowed for age, gender and geography – and the final premium would still have to be no more than twice the lowest premium.

•These rules would apply to both group and individual insurance, so that individuals purchasing a policy directly could benefit from the same kinds of shared risk that those of us who work for large employers have.

Of course, regulation of the insurance market is only one key needed change. Many working Texas families earn too little to afford the full cost of coverage, even if they were guaranteed to get that $12,000-a-year average premium. Half of Texas families earn less than $56,000 a year before taxes. The family grossing $36,000 cannot afford to spend more than a third of their income on insurance premiums – not to mention the other health costs those premiums do not cover. And the newly unemployed Texan in our question above probably cannot afford to pay the full cost of coverage with their unemployment insurance benefits. For this reason, a system making coverage affordable for all will also have to set an upper limit, such as 10 percent of income, on what families are expected to pay for health care (not just insurance premiums but all expenses). It will also require intense attention to the many ways in which the costs of health care could be better controlled.

FAZEN: A combination of tax reforms and tax incentives seems like the best way to help individuals obtain affordable insurance. Individuals and small businesses should be able to deduct their health insurance premiums the same as large employers are allowed to do. Individuals could also receive a tax incentive, either as a credit or a deduction, to help offset the cost of insurance that they purchase for themselves. As for guaranteed coverage regardless of health status, the only way this can be affordable is to mandate that everyone purchase health insurance, whether individually or through one's employer, in order to spread the risks broadly across a large population of both the sick and the healthy. That's what insurance is all about.

FINE: We can only guarantee affordable coverage by creating a single risk pool that accepts all patients – and this means creating a single-payer system. The private health insurance market "works" by stratifying risk and excluding any patient who is not profitable for the insurer to cover. Such patients typically won't receive treatment until they are seriously ill, at which point they will come to an emergency room where treatment is much more expensive. The insurance company has denied the patient coverage, but the patient will still be treated – by law, by the inclinations of the healing professions and by ethical concepts embedded in our traditions, such as the admonition to "not stand idly by" the blood of our neighbors and treating "the least of these" brothers (and sisters) among us. The costs of this emergency treatment are then passed on to those still insured, driving up their costs and causing more people to lose insurance coverage. If we believe it is ethical to deny health insurance coverage because of a prior condition – for example, coronary artery disease – then we should believe it is ethical to deny the patient treatment in our emergency rooms and simply watch them die when they come to us uninsured with a heart attack!

RALPH HOLMES: Unfortunately, there are no guarantees that individuals, with or without health conditions, will be able to get coverage that they can afford. We realize that with rising unemployment rates, there are people who are making tough decisions such as putting food on the table or going to the doctor. From Aetna's standpoint, we offer a wide range of plan alternatives, from plans that are comparable to what individuals received from employer-based plans to lower-cost plans that provide coverage for preventative care as well as protection against catastrophic medical expenses. With different options, consumers can choose what would best fit their health and financial situations. For those who have lost their job since Sept. 1, 2008, they should look at taking advantage of the American Recovery and Reinvestment Act that was passed in February. The law provides a substantial subsidy to COBRA, which allows people to retain their health insurance benefits after a job loss. The government will subsidize up to 65 percent of their old employer's insurance premium for up to nine months. For those people who may have pre-existing conditions and are having trouble finding individual plans, this might be a good alternative. However, there might be some consumers who cannot purchase COBRA or individual plans for a variety of reasons. That is why one of Aetna's main goals is to educate people on all of the different options available to them, so that they can make informed decisions. To that end, Aetna and the Financial Planners Association developed Plan for Your Health (, which is a free, public-education Web site designed to inform consumers about all aspects of health insurance. The comprehensive site includes such things as the basics of individual health insurance, recent changes to the COBRA program as a result of the stimulus package and tips on what consumers should think about when they are purchasing plans. Other alternatives for coverage to be considered are the Medicaid or the State Children's Health Insurance programs. For the 47 million uninsured in this country, approximately 11 million people are eligible for these types of programs but do not enroll.

JAMES: Only strong public policy decisions will be able to adequately address this hard reality. Health care should not be seen as a publicly traded commodity but more as a human right or at least a "public utility." Only clear, strong regulatory policy that forces restrictions on the private marketplace will solve this problem. Ironically, it likely will be this growing problem that forces us into a new strategy altogether.

MANSFIELD: Health insurance coverage has been in what some refer to as a doom spiral for several years, as more people are uninsured and unable or unwilling to pay for their health care, and the costs for charity and bad debt are passed along to those with insurance in the form of higher premiums. That means that employer-sponsored and individual insurance policies cost more than they should because they include a surcharge for the uninsured. The resulting effect is premiums increasing to substantially more than general inflation. This prices more and more employers and individuals out of the insurance market, contributing to the downward spiral in the number of employers and individuals able to afford insurance. I think the problem must be fixed at its source, providing basic coverage for all. Doing so would reduce insurance premiums and allow more individuals and employers to afford to purchase health insurance and would change the direction of the spiral in a positive direction.

RODGERS: Health insurance is expensive because health care is expensive, so there must be reforms that impact the cost of health care. Of course, these reforms will need to extend far beyond insurance. Blue Cross Blue Shield of Texas believes everyone should have health insurance. To make individual coverage more affordable and available, Blue Cross Blue Shield of Texas supports requiring health insurers to take all applicants regardless of health status as long as there is an effective individual obligation to maintain health insurance, possibly combined with federal subsidies or tax credits for certain individuals. With everyone having health insurance, the insurance will work as it should – spreading risk across a broad population and avoiding the risk of only those who need insurance actually purchasing it. Allowing individuals to waive in or out of the insurance only when they feel they need it would only increase the cost for those who try to maintain the insurance, resulting in more uninsured.

Our health care payment system seems to reward the volume of services provided, not necessarily the quality of the outcome. How do we change reimbursements so that they reward performance?

ANDERSON: Service providers need to be rewarded for practicing prevention and achieving better outcomes. Achieving this means we need to become as evidenced-based as we can, creating incentives for both doctors and hospitals to practice prevention. We need to find a strategy that will create a win-win situation for health care providers, insurers and patients.

AVERY: The current system rewards services that generate the most profit. That's why we have inflated charges and an explosion in boutique services, while far too many of our patients go without appropriate and timely care. We need a system that is based on patient need and prevention. The most cost-effective approach is to ensure that people are encouraged and not financially penalized for getting regular medical, dental and vision checkups and other preventive health care screenings and services. This will lower overall health care costs and reduce long-term pain and suffering, and it will ensure that patients get the care they need when and where they need it.

BURGESS: The payment system is actually one of the reasons I decided to run for Congress. As a physician, I saw the way that Medicare, for example, wasn't paying nearly what it costs to treat a patient. Of course, when you're losing money on every patient you see, you can never make up for the losses with volume. And the problem is even worse in Medicaid. Fundamentally, doctors are focused on using their knowledge and skills to treat their patients in the best ways possible with the latest technology. I think new tools like comparative effectiveness research and best-practice guides are important steps in improving outcomes, but these should never interfere with the patient-physician relationship.While improving quality and efficiency are noble goals, the treatment should always be a decision between doctor and patient. Addressing medical justice reform is a key part of improving the ballooning volume of services. Too many doctors are forced to practice defensive medicine to insulate themselves from lawsuits by trial attorneys. I also like some demonstrations that have enabled doctors to recoup a portion of the savings they've returned to the government as an incentive for participating in quality improvement.

DUNKELBERG: Health economists have been thinking for several decades about how to correct the financial incentive to provide more care in order to make more money. Managed care and HMOs were the first large-scale attempt in the U.S. to change the rewards. Of course, we quickly came to realize that the incentive to deny needed care in order to make profits was just as objectionable. There are no perfect systems, here or abroad, for rewarding "performance," partly because even with the very best lifestyle choices and health care, people will still get injured and sick and eventually die. It is not easy to set goals for performance for health care providers that do not hold them responsible for the failure of individuals to follow medical advice and take care of their own health through diet and exercise. Despite these caveats, our country will be in a far better position to reward performance instead of sheer volume when no American is excluded from care due to financial barriers. One key will be making long-term connections to our health professionals and insurers. When health plans know that they will be with us for the long haul, they will have a far greater incentive to keep us healthy. Information is also key. Currently, no one is tracking the effectiveness of the vast majority of health care being delivered in the U.S. Our knowledge about what works is limited to special studies, and many of those are paid for by someone with a profit motive, which can distort whether and how the findings get shared. A health system that serves everyone will have a far greater ability to collect information about what works and what doesn't. And, without expecting doctors to make us immortal, the new world of information systems can also make sure that best practices, basic standards of care and the latest updates are communicated systematically to all doctors. One of the first steps we are already taking in the U.S. is refusing to pay for medical errors (no pay for poor performance) in Medicare.

FAZEN: There's no question that our current reimbursement system, which rewards providers for the number of services performed regardless of patient outcomes, is topsy-turvy. "Pay for performance" is a relatively new concept that is gaining traction with health plans and employers. This makes sense intuitively, but defining and measuring quality are tricky, publicly reporting providers' performance is rare, and determining a fair payment structure is extremely difficult. Only recently has national consensus been achieved by leading health care experts on how to define and measure performance for selected medical conditions, which may explain the slow start that pay for performance has had. However, health plans are now beginning to segregate providers into tiers with different reimbursement schedules, based on how well they adhere to evidence-based medical practices for certain illnesses, like diabetes and cardiovascular disease, and how well their patients fared under their care. Also, some employers are paying bonuses to physicians for delivering high-quality care and good outcomes. Medicare has a demonstration project in progress that pays bonuses to physicians who demonstrate good performance and good patient outcomes. However, I think there is a lot of concern among physicians and hospitals about "cut-and-dried" performance measurements, which tend to view health care as "pure science" without also considering the "art of medicine." They also are concerned about transparency, or public reporting of performance scores, fearing punitive action by the health plans or, worse, loss of confidence among their patients. Dallas-Fort Worth Business Group on Health members think it's very important for providers to be directly involved in determining how performance is defined, how it will be measured and how and by whom the results will be used. Our communitywide health care improvement collaborative has both hospital representatives and practicing physicians literally at the table with our employers and health plan executives making joint decisions about performance metrics for diabetes care that we will use in the Dallas-Fort Worth area, as well as reporting rules and appropriate use of the information by each stakeholder. I think we need to get the performance measurement issues worked out first before we change the reimbursement structure. But I also think a reimbursement model that rewards good performance and good patient outcomes will soon become the norm.

FINE: I am skeptical about "rewarding performance," which, although well intentioned and reasonable at first glance, is fraught with problems. There is too little agreement on what constitutes good performance, too few reliable tools with which to measure performance and too much uncertainty as to who should be rewarded for good performance. What tool reliably measures the effectiveness of physician communication, one of the essential elements of quality health care delivery? Or consider improved diabetic control. We can measure average blood sugar control, but a reliable, health literate, easily motivated patient is likely to have much better diabetic control than a health illiterate, unmotivated patient. Should one physician or one health care system receive greater rewards because they have more health literate and motivated patients? Overall, I think it probably is best that we stay away from too much emphasis on using reimbursement to "reward performance" at this time and focus on simpler methods of reducing unnecessary procedures. Single-payer systems have clearly already accomplished this. For example, elderly heart attack patients in the United States receive 5.8 times more revascularization procedures than elderly Canadian heart attack patients, but their mortality rates are the same. More is not always better, and single-payer systems are more efficient in curbing nonbeneficial treatments.

JAMES: Unknown to many, Medicare already is imposing quality-control performance metrics on hospitals around issues like readmissions. I know similar outcome performance and quality-of-care issues relate to home health care and other sectors of the health care world. Care standards indexed to patient outcomes will ensure that improvements are made. As President Obama clearly understands, the spread of electronic health record technology will make this much easier and more cost effective. The same electronic record capacity will make best-practice treatment protocols more accessible to doctors and hospitals and outcomes easier to obtain, report and improve upon.

MANSFIELD: We are starting to see some efforts to tie pay and outcomes together from a reimbursement perspective. For example, Methodist has been among a handful of hospitals across the country to receive additional Medicare reimbursement because the quality of our outcomes is in the optimal range. I think tying pay and performance can be a good thing if it is approached as a zero-sum methodology rather than as another veiled attempt to reduce reimbursement without sound scientific reasoning behind the methodology. It is equally important that the models encourage stellar performance and outcomes as it is that they discourage suboptimal outcomes.

RODGERS: Today, ineffective, redundant and inappropriate care is estimated to account for as much as 30 percent of health care spending. Blue Cross Blue Shield of Texas believes the incentives with the health care delivery system must be changed, and it is pursuing a number of initiatives to reward providers for delivering appropriate, cost-effective care. For example, we've converted about 25 percent of our physician agreements to "pay for performance" programs that reimburse physicians for providing the right care in the right place at the right time. Additionally, we've partnered with other organizations such as Bridges to Excellence to recognize and reward physicians for better management of patients with chronic illnesses.

There hasn't been a major federal push for health care reform since the Clinton administration's failed attempt in the 1990s. With the many differences of opinion that exist between all the stakeholders, will President Obama and Congress be able to stitch together a compromise and achieve reform this year? Why or why not?

ANDERSON: For over 15 years a lot of policymakers have decided to not touch health care. Meanwhile, health care costs have skyrocketed compared to wages, salaries, benefits and the gross national product. Hopefully, now we know enough to create a rational approach where we can save money and reinvest that money in reform. It would be better to have a system where care is given based on need rather than on ability to pay. I'm glad to see the Obama administration step up and try to create a reform package. It may not be perfect, but the current approach is not sustainable. We must be prepared to sacrifice "perfect" for "good and improving year by year," or we'll never get anything done.

AVERY: We will achieve genuine and fundamental reform of our system when patients, nurses, physicians and health care activists have constructed a movement that is as powerful as the insurance lobbyists. I believe we're watching that happen around us. For this year, it seems highly likely that President Obama and Congress will pass legislation, particularly if the House and Senate proceed with the same "budget reconciliation" process used by President George W. Bush in 2001 that allows bills to pass by a majority vote of 51 in the Senate. The outcome may also depend on whether congressional leaders fight off poison pills, such as provisions to tax employer-provided health care benefits and to mandate that individuals purchase products from the private health insurers, no matter the cost or quality. Both of these proposals would cause any compromise to lose support among health care activists and make the bill difficult, if not impossible, to pass.

BURGESS: I think we have a tremendous opportunity to reform health care. I am afraid that many Democrats are looking at this as an opportunity to settle old scores with the insurance industry or physicians, but if patient care is kept as the goal and if we remember that we have a responsibility to "do no harm," we'll be able to work toward a product both sides of the aisle can be proud of. Obviously, the numbers favor the president's party, and they can pass any bill they want without a single Republican vote. But the Democrats have indicated that they want to move forward in a bipartisan way, and I am hopeful they are sincere because I want to help. I also think we need to take our message to the American people because this is something that can be won by Republicans in the court of public opinion. I really think there are some important timing considerations, given the nature of our political calendar and the vast array of challenges facing President Obama. Nevertheless, I hope all good ideas are considered.

DUNKELBERG: In favor of health reform, President Obama has the benefit of considerably stronger backing for health reform in Congress, among the American people and in the business sector than was the case during the Clinton administration. The level of insecurity and concern among average Americans has increased dramatically, along with the costs of coverage and health care. From 2000 to 2007, Texans saw their health insurance premiums increase 87 percent, while their incomes increased only 15 percent. With the cost of coverage growing nearly six times faster than incomes, health insurance becomes less affordable for Texas families every year and for employers who are trying to maintain health insurance as an employee benefit. Voters today express a strong desire for change in our health care system, with over two-thirds saying we need a complete overhaul or major reform. While this support is strongest among Democratic voters, 59 percent of independent voters and 52 percent of Republican voters also support major reform. A bedrock concept of the administration's health reform vision is that Americans who are happy with the coverage they have today will be able to keep it, while new coverage choices will be created for those who are uninsured or who have inadequate coverage. The sense that the entire health care system will not be turned on its head overnight is critical. Having said that, every step we take as a nation to reduce the cost of care, eliminate waste and select the most cost-effective drugs and procedures will result in someone's profits being reduced, and we can expect that there will be resistance to specific aspects of change from every sector whose income is affected.

FAZEN: We all have high hopes for transformational change in the health care system, since the current system clearly isn't meeting the needs of many Americans. However, with so many stakeholders in this very rich, $2.4 trillion industry with different opinions and fears of losing out if they must give up something to help another group, I'm a bit pessimistic about achieving any meaningful reform this year. However, I applaud President Obama for making health care reform one of his administration's top three priorities. Although real reform may be beyond our grasp this year, at least this gives us an open forum for meaningful discussion and debate about both the positive and the negative aspects of our current health care system. From this will emerge innovative ideas and solutions, and there will be opportunities to test these ideas in smaller-scale pilot studies in communities and as statewide initiatives before we as a nation decide what type of national health care system we want.

FINE: I am an optimist by nature and believe in the growing good of the world through human endeavor, yet I don't think the type of reform I believe we need is likely this year. There are simply too many special interests and too much fear. Too many politicians – starting with the Clintons in the 1990s and followed by George W. Bush and President Obama – have been unwilling to take on the health insurance industry. In a single-payer system, even though marketing and risk selection services would disappear, other elements such as claims processing or supplements to a basic single-payer insurance package should survive. This remaining work will not likely be enough to keep insurance companies and their lobbyists satisfied. Meanwhile, many insurance company employees, fearful of losing their jobs, will work to scuttle any reform that might leave them unemployed, and who could blame them? Sadly, the "House of Medicine" is also divided by the fear that if primary-care reimbursements rise, subspecialty reimbursements will inevitably fall. Finally, fear among the broad public will help scuttle reform. Although over 15 percent of our population is uninsured and poor quality plus high costs affect rich and poor alike, there is too much fear among the 85 percent of us who are insured – a fear that health insurance reform will hurt more than help. I personally think this fear is illogical and not supported by the evidence, but I also know that fear does not always respond to logic.

JAMES: In my view, this is largely a matter of political will and available political capital. The president seems willing to involve everyone in the debate and the process. The prospect of some sort of "blended" solution that I've already suggested could make the process easier. The most important changes since the Clinton administration's failed attempt to achieve universal coverage relate to this president's popularity and to the impact rising health care costs are having on American business. It is no accident, nor is it surprising, that a growing number of leaders from business, industry and trade are now advocating for universal coverage of one kind or the other.

MANSFIELD: I think getting it done this year is a bit optimistic, but I am of the opinion that President Obama and leaders in Congress have the will and the mandate to substantially reform our health care system. The Clintons' efforts probably failed for two primary reasons: The public mandate for change was less prevalent then than now, and special-interest groups poured lots of money into an effort to negatively influence public opinion regarding the Clinton plan. Reforming health care in a meaningful way is a tremendous public policy challenge, especially given the economic milieu. I believe this Congress and this president have the best chance anyone has had to do so, but it will be a tremendous challenge.

RODGERS: With 45 million uninsured Americans, steadily rising health care costs and unprecedented economic challenges, Blue Cross Blue Shield of Texas believes the time is right for some type of health care reform and is working with Congress to achieve this. The primary question is: Will health care reform be accomplished by addressing the underlying health care cost problem? Blue Cross Blue Shield of Texas administers health insurance for over 4 million Texans, and we've seen hospital charges go up about 50 percent in the past five years and physician charges go up about 20 percent. We can't have meaningful reform unless we find a way to deal with this reality.

What should be done about Medicare to rein in costs and improve quality?

ANDERSON: One of the best ways to improve costs is through risk reduction: to look at patients who become higher risk and make interventions to get them to lower risk. Many times this is as simple as exercise, diet, decreasing tobacco use or taking proper medications. Chronic conditions like obesity, hypertension, heart disease, diabetes and asthma can be addressed through care management and save substantial dollars while improving care. I think Parkland's network of community-based clinics is a model that can be applied other places, creating integrated health care systems where patients have a medical home. We also need to continue to invest in information technology, because the more information we have on outcomes and best practices, the more we can tweak the system to accomplish what we want.

BURGESS: I've long been a harsh critic of the way Medicare reimburses physicians and hospitals. I've also been vocal about my displeasure at the way the annual cuts are dealt with as a political football. Clearly, the low reimbursement rates in the program are affecting patients. This is something I encountered as a physician. Many of my fellow doctors wouldn't see any Medicare patients because of adverse reimbursement. Medicare is a program that gives Americans 65 and older universal coverage, but this doesn't mean they get to see the doctors they want when they want to see them. It drastically reduces their health care choices. Medicare highlights the problem with the notion that increasing funding will improve a government program. It's simply the nature of a program as expansive as Medicare that its heft becomes too difficult to control. At the end of the day, we have to recognize that millions of Americans have planned on Medicare in their retirement and that this is a promise we've made to them. Medicare should be a cautionary tale for those who want to pursue a government-based health care system. This is why I've often said we really do have an obligation to fix the health care programs the government already runs before we create new ones.

DUNKELBERG: The cost challenges for Medicare – and thus their solutions – are not really different from those facing the nation as a whole, but the population served – seniors and disabled adults – is by definition the one with the highest average costs per person. The same question asked above (how to reward health-promoting care and not high-volume care) is a challenge for Medicare just as it is for the rest of the U.S.population. Medicare's recent moves to deny payment for medical mistakes are an important step in providing financial incentives for providers to take more aggressive steps to stop avoidable errors and hospital-acquired infections. Systematic collection and sharing of what really works will help doctors provide the most effective high-quality health care based on scientific evidence, for Americans in Medicare and out. It should also be noted that Medicare already pays much lower rates to doctors and has much lower administrative costs than private insurance. Some specific cost-saving steps for Medicare should include reforming how Medicare HMOs are paid. Even though managed care was conceived of as a way to reduce health spending, Medicare HMOs are now paid about 12 percent more per person than traditional Medicare enrollees cost. Because current medical advances for seniors depend on access to medications, Medicare should take aggressive steps to monitor medications for seniors to avoid overmedication and drug interactions that can result from uncoordinated care. Fixes to the Medicare drug benefit, Part D, should address the bewildering array of options that seniors must wade through and should make sure that seniors can change plans if their Part D plan stops covering the medications they need. Finally, we sometimes confuse the serious issue of the sustainability of Medicare financing with the equally serious problem of the costs of health care services. Even if we can succeed in cutting health care costs, the system of payroll deductions and premiums must always be constructed so that the costs of running the program are fully supported. Of course, the more we control costs of care, the easier it is to keep the books in balance.

Although employer-based health care coverage remains the main source of insurance for working families, rising costs are forcing many businesses to shift more of the burden back onto families. How can we help businesses, especially smaller ones, afford health insurance for employees?

FAZEN: Tax reform should be a priority to help make private health insurance purchased by individuals and small businesses more affordable. Small businesses and individuals should be able to deduct the cost of health insurance from their income tax, just as large employers do. They also should be encouraged to purchase high-deductible health insurance plans that are eligible for tax-favored health savings accounts (so-called "consumer-directed health plans"). These plans are less expensive, give the insured more skin in the game and encourage participants to make informed decisions about where and when to obtain health care.

HOLMES: It is true that employers, mostly small businesses, bear a disproportionate share of medical expenses. A portion of the expense related to the medical care of the uninsured is allocated to private business in addition to costs related to their own employee base. In essence, we are all paying for the uninsured already. Adding this group would improve the risk profile of the entire pool (40 percent of the uninsured are between the ages of 18 and 35). An individual coverage requirement combined with subsidies for low-income people is a potential method for reducing the number of uninsured and minimizing some of the financial burden on private firms. In Texas, only 30 percent of small businesses with 50 or fewer employees offer health insurance to their employees, leaving 70 percent not supplying any type of coverage. Costs and other economics, such as trying to just stay afloat, could be the primary reasons. To lower costs, there need to be more individuals covered, which is why Aetna was the first insurer to support an individual coverage requirement, where the state or federal government would require everyone to have basic health insurance. However, in making this a requirement for those who can afford health coverage, provisions must be in place to assist those who cannot afford it or for whom access is limited. To directly help businesses, creating tax incentives for small employers to continue offering health benefits to their employees is another solution. Aetna offers a wide range of plan designs and price points for both businesses and individuals. In addition, in Texas, insurers are permitted to offer mandate-light plans to small business that exclude some of the state-mandated benefits in order to improve their affordability.

RODGERS: Blue Cross Blue Shield of Texas supports a range of options to help employers offer coverage, including targeted subsidies for small employers and individuals. There are tax credits for low-wage workers in small businesses, tax-deductible insurance premiums for those without access to employer-sponsored coverage, a refundable, advance tax credit for those whose premiums represent a disproportionate share of their income and a refundable tax credit to help those between jobs.

As the population ages and a higher percentage of the population lives with chronic conditions, long-term care will become a greater concern. Should this be addressed as part of health care reform?

AVERY: Yes. But our present, for-profit, insurance-based system is exacerbating the problem. A recent study in California, for example, found that 43 percent of people under 50 had postponed care for a chronic condition due to high out-of-pocket costs. When people delay needed care, they all too often end up in emergency rooms or with longer hospital stays, driving up costs for everyone. Under a genuine universal system not based on the profit motive, such as an expanded and upgraded Medicare system for all, people would be encouraged to seek preventive care or take medications in a timely manner, which would help manage care delivery in a more cost effective – and more humane – manner.

BURGESS: I'm not going to rule anything out. I think all good ideas need to be considered. That's what we're asking the Democrats and President Obama to do – consider our ideas. I want to put patients first. There are good ideas about long-term care out there, and I think we need to consider making long-term care insurance a more popular product. The key is to recognize this increase in life expectancy and disease management as an achievement of our advanced methods and technology in medicine instead of as a problem.

DUNKELBERG: A failure to access early care due to financial barriers leads to avoidable disability for millions of Americans. Better access to early preventive and chronic care under national health reform has the potential to reduce and delay disability and thus the need for long-term care. Again, even with the very best of care, illness and injury can and will leave Americans in need of assistance with their daily living needs. Health reform will represent a major down payment toward establishing public-private systems that allow our elders and disabled adults to live as independently as possible, but there is no question that the U.S. will need to take further steps to get to a real system of care that addresses nonmedical supports. While attacking the long-term care challenge at the same time we set up systems to create and pay for medical care access for all would be ideal, it is probably not politically feasible today.

Growing numbers of physicians are leaving the ranks of primary-care medicine, raising doubts that there will be enough to care for everyone. What can be done to recruit more young doctors to general practice?

ANDERSON: The main reason many are leaving primary care is that it's underfunded. We say it's very important, but we don't pay for it in a way that encourages young people to go into it. One thing we can do is try to decrease their debt coming out of medical school. Many students go into subspecialties that are more lucrative in order to pay for it. In addition, many doctors want a change in lifestyle. They want a healthy family life. They don't want to be burdened by the business of medicine; they just want to practice good medicine. We have to start looking at ways to entice physicians to go to rural and underserved inner-city areas. We're going to have to think outside the box to meet society's needs.

FINE: Until we end the extraordinary income and lifestyle discrepancies between primary care and procedural specialties, the problem will not be solved. All physicians come into medical training on an equal basis as uniquely talented and hard-working individuals. However, the medical student who chooses a procedural specialty can easily earn two to 10 times the annual income of a nonprocedural physician. Until this disparity ceases and physicians are compensated comparably whether or not they perform a test or procedure, we will continue to see inadequate numbers of primary-care physicians.

DR. A TOMAS GARCIA III: Texas has many small towns without primary-care physicians. At the same time, there are many young physicians who are very concerned about their private lives and private time. Clearly, there will have to be some sort of financial incentive for young physicians to consider practicing in medically underserved areas. Here's where common sense comes into play. Students are graduating from medical school with hundreds of thousands of dollars of debt. Why not forgive some of these students' debts if they agree to care for Medicare or Medicaid patients in areas where doctors are in short supply? It will help the communities, and it will help the young doctors. It'll be a win-win situation.

JAMES: This is a thorny problem. One major part of any solution will be to reimburse primary-care physicians – based on clear performance and prevention benchmarks – at a rate that encourages excellence as well as entrance into this sector of health care. Again, strong public policy and investment will be required to address this clear and growing need. Plans to assist with paying medical school debt and a national campaign that rewards the decision to practice family and community medicine must be devised. Reimbursement rates for general-practice doctors should be given due attention. At the same time, we must adopt a new national "frame" for wellness and, with that, the understanding that health and wellness are less about medical professionals than we currently assume. Individuals and communities working together must be challenged to take responsibility for their own health and wellness outcomes. This does not lessen public responsibility. Rather, it creates entire communities of health and wellness advocates.

MANSFIELD: Over the past few decades, the variability between what comparably trained physicians are able to earn has expanded dramatically due to our reimbursement methodologies. This economic model is skewed very negatively against physicians in primary care. A payment system that instills more parity in this equation would help immensely. Personally, I think national health policy has allowed this situation to exist too long and has created a shortage that cannot be overcome in the near term. To meet the growing demand for primary-care services and a medical home in the face of a shortage of the physicians most skilled to provide these functions, we must make more and better use of midlevel practitioners (nonphysicians) to extend the availability of primary care. We have a crisis looming that is getting worse by the day and needs to be a major tenet of our health care reform efforts.

Would you favor a requirement that businesses either cover their employees or pay into a fund that would provide coverage?

FAZEN: The so-called "play or pay" scheme is a bad idea for employers. Employer-sponsored health insurance is and always has been considered a benefit, not a requirement, and offered voluntarily to employees, who in turn are free to accept or reject this benefit. As some states that are experimenting with a play-or-pay model are discovering, the costs associated with the generous coverage that is usually included in such plans are far higher than expected, and the fees that employers pay are usually far too low to offset these costs, so the price to pay or play keeps ratcheting upward. The alternative is to reduce benefits, but it's always much harder for government to take things away from constituents than to increase fees for the players. Businesses are not in business to lose money, so they are likely to offset the increased costs for mandated health insurance with fewer hires, lower wages and layoffs.

HOLMES: Aetna does not favor such a requirement, as it may put additional financial stress on small business, which has been the engine of growth and innovation in the U.S. Yes, we want everyone to be insured, but there are different ways to accomplish that goal, such as an individual coverage requirement.

RODGERS: In some ways, businesses that don't cover their employees pay for it in other ways, such as through increased property taxes. Whether or not businesses provide health insurance for their employees, businesses and individuals are subsidizing the care for the uninsured and underinsured and for Medicare and Medicaid members when their costs aren't fully covered. Some city governments are realizing this and are not providing economic incentives to companies that don't provide health insurance or requiring city contractors to provide health insurance. Projections are that we'll have a shortage of 1 million nurses by 2020, in part because of the limited capacity of nursing schools and the changing needs of the aging population. How can we alleviate this shortage?

Projections are that we'll have a shortage of 1 million nurses by 2020, in part because of the limited capacity of nursing schools and the changing needs of the aging population. How can we alleviate this shortage?

AVERY: The only genuine way to improve the nursing shortage is to improve safety conditions in hospitals to the point where registered nurses feel they can safely practice their profession. The result is that nearly half of all registered nurses don't work in critical-care settings – they work in offices or at home, or they just don't work. Texas hospitals demonstrate the problem. It is not uncommon to hear about a registered nurse being assigned 15 patients. That's not physically possible, and it deprives the patients of necessary nursing care while saddling the nurse with dread and worry over the patient she or he couldn't get to. I am a nurse leader in the National Nurses Organizing Committee – Texas. In recent years, registered nurses across the country have been getting organized and active around the idea of guaranteeing minimum ratios of registered nurses to patients. A model bill passed in California has resulted in safer conditions in hospitals and led to a huge increase in the state's registered nurse workforce. It has nearly ended the shortage in that state. NNOC-Texas has introduced similar legislation here (H.B. 1489 by Rep. Senfronia Thompson), and we hope all Texans will join us and support our nurses by encouraging your legislator to support this bill.

MANSFIELD: Unfortunately, we have far more bright and talented young women and men who are interested in and qualified for a nursing career than our nation's colleges and universities are equipped to train. Federal and state help is needed to support an expansion of nursing faculty and the number of nursing schools. Creative public-private partnerships, such as Methodist Health System's with El Centro College and others in the Dallas-Fort Worth area, are helping to bridge the gap, but so much more is needed. Nursing is an inspiring, worthwhile and rewarding career, but we have to do a better job of making training programs available to those wishing to pursue that career.

Both employers and government are putting new emphasis on wellness and prevention, especially regarding obesity and diabetes. What specific steps should be taken to encourage preventive care?

FINE: At least three steps come immediately to mind: changes in agricultural policy, changes in education and changes within the medical profession. Thanks to government subsidies on foods such as corn, the cheapest calories one can buy tend to be the highly processed, calorie-dense foods that promote obesity, diabetes, heart disease and other maladies. Assume an adult man needs about 2,000 calories of food daily. He can buy 2,000 calories of burgers, fries and a soda for $4 or 2,000 calories of fresh vegetables and fruits for five to 10 times as much. Yes, some people can afford the more expensive fruits and vegetables, but too many cannot. When you do the math, it becomes increasingly apparent why obesity is more a disease of poverty. Agricultural subsidies must change and be more balanced toward a diversity of healthy foods. Another specific step must occur in our education system. We should require daily physical education classes for all students at all grade levels and teach human nutrition starting in kindergarten. Finally, increasing the numbers of primary-care physicians and increasing their knowledge of human nutrition would help. However, as noted earlier, this is not likely to happen as long as physicians are paid more to dilate or bypass a clogged coronary artery than they are paid to teach a patient how to avoid the high-sugar, high-fat, pro-inflammatory diet that clogs the artery in the first place!

GARCIA: We need to reform the health care system so that it offers greater financial incentives for preventive care. It would be a winning proposition for the government, insurers and patients. Our system now often doesn't pay for preventive care. So it ends up costing everyone far more when a patient's condition worsens and must be treated. Take Medicare as one example. If Medicare routinely covered the cost of all annual physical exams, the government might identify problems early on and spare itself larger expenses later. We have a wonderful opportunity with a new administration. The older policies haven't worked. It's time to try something new.

JAMES: Any plan must face the hard challenges of pre-existing conditions among populations with little hope of reversing present physical conditions. Any real progress rests largely with the development of new strategies for young people and for those who have some reasonable chance to reverse and prevent further health deterioration by adopting lifestyle changes. Physicians must be presented with new reasons to help their patients (adults and children). At the same time, community institutions such as public-private schools, faith communities and neighborhood groups should be encouraged to emphasize daily physical activities. Our schools must restore physical education classes immediately. Community-based and relatively inexpensive approaches to health education and chronic disease control must be adopted and paid for. At Central Dallas Ministries, we have learned and documented the real cost benefit and the real health impact of community diabetes educators. One last rather radical idea: What if Americans could earn tax credits based on health improvements? Possibly every other year, a tax form could be validated by a medical professional documenting a person's health improvements, and a relative value could be assigned to this "contribution" to the public health. One thing is certain: We must begin thinking and acting in very different ways.

Dr. Ron Anderson is president and chief executive of Parkland Health and Hospital System.

Rossia Avery is a registered nurse and chairwoman of the Dallas-Fort Worth National Nurses Organizing Committee.

U.S. Rep. Michael Burgess is a Republican from Texas' 26th Congressional District and a physician.

Anne Dunkelberg is associate director of the Center for Public Policy Priorities in Austin.

Marianne Fazen is executive director of the Dallas-Fort Worth Business Group on Health.

Dr. Robert Fine is director of the Baylor Health Care System's Office of Clinical Ethics and Palliative Care.

Dr. A. Tomas Garcia III is a trustee of the Texas Medical Association.

Ralph Holmes is president of Aetna Inc.'s southwest region.

Larry James is president and chief executive of Central Dallas Ministries.

Stephen Mansfield is president and chief executive of Methodist Health System in Dallas.

J. Darren Rodgers is president of Blue Cross Blue Shield of Texas.

Who's Afraid Of A Public Plan?
Story from the Chattanooga Times Free Press

A new report showing that health insurance premiums in Tennessee rose five times faster than workers’ earnings from 2000 to 2007 is deeply troubling, but it certainly is not surprising. Workers still lucky enough to have access to employer-provided insurance — less than 55 percent in Tennessee still do, as compared to 60 percent nationally and 70 percent a decade ago — are well aware that their premium costs have eaten up their wage gains in recent years, even as their coverage has declined and their out-of-pocket expenses have soared.

Such depressing and clearly unsustainable trends should be fueling national demand for health care reform and the creation of an alternative public insurance plan for voluntary, tax deductible purchase.

The medical industry’s control

The dynamic of the public dialogue on this critical issue, unfortunately, is controlled by the medical industry and its lobbyists. And they are doing everything in their power to kill the concept of a public plan that would help keep insurers, hospitals, pharmaceutical companies, high-end health care providers and medical device suppliers from over-charging — and that ultimately would help reduce spending on health care.

The new insurance cost figures were compiled by a coalition of Tennessee groups that advocate health care reform and creation of a public plan. A spokesman for one advocacy group attributed the sharp increases in insurance costs to the dominance of the state’s two largest insurance providers — Blue Cross Blue Shield of Tennessee, which covers 45 percent of Tennessee’s insurance market, and UnitedHealth Group Inc., which covers 16 percent. A combination of other companies carry the 39 percent balance.

Big insurers rule

Their dominance, he asserted, allows BCBST and UnitedHealth to “set the prices, ... make the rules and call the shots.” It also enables BCBST to boast reserve funds of $1.4 billion, and executives at UnitedHealth to capture obscenely high compensation packages.

A number of other factors, to be sure, contribute to excessively high health care costs. A short list is illustrative: Too little focus on preventive and wellness care, and too much on procedures; excessive use of expensive technology; defensive diagnostic procedures to protect against malpractice claims; excessive hospital and provider costs; needless administrative costs to combat excessive insurance denials; and needless complexity of insurance claims, diagnostic codes and bundled services.

The insurance industry cites many of these factors, but it rarely addresses its own excessive costs and profit margins, and the needless complexity of its pricing rules, claims procedures and denials.

Blue Cross officials here maintain that Tennessee ’s 62 percent increase in premium costs from 2000 to 2007 (vs. the 12 percent gain, to $25,639, in the same period for median wage workers) primarily reflects the growing cost of medical services and the more intensive use of services required by the demographic shift toward a larger aging population.

While the latter may be true, the former is not reflective of medical cost margins in all other highly industrialized countries — all of which offer universal health care under different models, advanced medical services equal to those in the United States, and typically better health indices, more doctors and more hospital beds per capita.

Other advanced countries offer all this while spending between 8-to-11 percent of gross domestic product on health care. America, by contrast, spends nearly 17 percent of GDP on health care — a level expected to reach 21 percent within 10 years — and still leaves 47 million citizens uninsured, and far more citizens under-insured and subject to medical bankruptcy in the event of a medical crisis.

Pharma’s a culprit, too

Prescription drug prices for the top 50 most-used drugs, as well, are two-to-three times higher in the United States than in every other advanced country — and they are rising fast, if not faster, than other insurance and provider costs. This is largely due to Big Pharma’s anticipation of government price negotiations and their urge to set price markers higher now.

Not surprisingly, BCBST spokesperson Mary Thompson told this newspaper’s Dave Flessner that a government-organized insurance plan, available on a voluntary basis to citizens not satisfied with private market and employer-organized plans, ultimately would crowd out private companies and dampen the very competition that reform advocates seek.

Let insurers compete

That’s a disingenuous argument. Such a public plan should spur competition. The proposal is for a public option plan modeled on plans federal workers receive and administered on a Medicare-style model, like those BCBST administers for a profitable administrative service organization (ASO) fee in a number of states. If private insurers can do better than government, they should be able to offer a better product, or a lower cost.

If they can’t or won’t take that challenge, then that would expose the fallacy of relying on high-profit insurance companies to help reduce the unsustainable curve of the medical industry’s profit taking, and the medical miseries it is producing for this nation’s increasingly under-insured and uninsured population.

Given the choice, most citizens, if they had their say, would take a good public plan and peace of mind. Employers, relieved of health insurance costs, would be more competitive in the face of global competition. And workers, liberated by portable coverage that wouldn’t go away if they changed jobs or careers, would find new freedom and bargaining power in their new mobility.

Opinion From Paul Krugman: Blue Double-Cross
Story from the NY Times

That didn’t take long. Less than two weeks have passed since much of the medical-industrial complex made a big show of working with President Obama on health care reform — and the double-crossing is already well under way. Indeed, it’s now clear that even as they met with the president, pretending to be cooperative, insurers were gearing up to play the same destructive role they did the last time health reform was on the agenda.

So here’s the question: Will Mr. Obama gloss over the reality of what’s happening, and try to preserve the appearance of cooperation? Or will he honor his own pledge, made back during the campaign, to go on the offensive against special interests if they stand in the way of reform?

The story so far: on May 11 the White House called a news conference to announce that major players in health care, including the American Hospital Association and the lobbying group America’s Health Insurance Plans, had come together to support a national effort to control health care costs.

The fact sheet on the meeting, one has to say, was classic Obama in its message of post-partisanship and, um, hope. “For too long, politics and point-scoring have prevented our country from tackling this growing crisis,” it said, adding, “The American people are eager to put the old Washington ways behind them.”

But just three days later the hospital association insisted that it had not, in fact, promised what the president said it had promised — that it had made no commitment to the administration’s goal of reducing the rate at which health care costs are rising by 1.5 percentage points a year. And the head of the insurance lobby said that the idea was merely to “ramp up” savings, whatever that means.

Meanwhile, the insurance industry is busily lobbying Congress to block one crucial element of health care reform, the public option — that is, offering Americans the right to buy insurance directly from the government as well as from private insurance companies. And at least some insurers are gearing up for a major smear campaign.

On Monday, just a week after the White House photo-op, The Washington Post reported that Blue Cross Blue Shield of North Carolina was preparing to run a series of ads attacking the public option. The planning for this ad campaign must have begun quite some time ago.

The Post has the storyboards for the ads, and they read just like the infamous Harry and Louise ads that helped kill health care reform in 1993. Troubled Americans are shown being denied their choice of doctor, or forced to wait months for appointments, by faceless government bureaucrats. It’s a scary image that might make some sense if private health insurance — which these days comes primarily via HMOs — offered all of us free choice of doctors, with no wait for medical procedures. But my health plan isn’t like that. Is yours?

“We can do a lot better than a government-run health care system,” says a voice-over in one of the ads. To which the obvious response is, if that’s true, why don’t you? Why deny Americans the chance to reject government insurance if it’s really that bad?

For none of the reform proposals currently on the table would force people into a government-run insurance plan. At most they would offer Americans the choice of buying into such a plan.

And the goal of the insurers is to deny Americans that choice. They fear that many people would prefer a government plan to dealing with private insurance companies that, in the real world as opposed to the world of their ads, are more bureaucratic than any government agency, routinely deny clients their choice of doctor, and often refuse to pay for care.

Which brings us back to Mr. Obama.

Back during the Democratic primary campaign, Mr. Obama argued that the Clintons had failed in their 1993 attempt to reform health care because they had been insufficiently inclusive. He promised instead to gather all the stakeholders, including the insurance companies, around a “big table.” And that May 11 event was, of course, intended precisely to show this big-table strategy in action.

But what if interest groups showed up at the big table, then blocked reform? Back then, Mr. Obama assured voters that he would get tough: “If those insurance companies and drug companies start trying to run ads with Harry and Louise, I’ll run my own ads as president. I’ll get on television and say ‘Harry and Louise are lying.’ ”

The question now is whether he really meant it.

The medical-industrial complex has called the president’s bluff. It polished its image by showing up at the big table and promising cooperation, then promptly went back to doing all it can to block real change. The insurers and the drug companies are, in effect, betting that Mr. Obama will be afraid to call them out on their duplicity.

It’s up to Mr. Obama to prove them wrong.