Ralph Nader about Health Care
Jan Boeykens - 01.11.2004 00:32
The state of health care in the United States is a disgrace. For millions of Americans it is a struggle between life, health and money.
Health Care for All
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The Nader Campaign supports a single-payer health care plan that replaces for-profit, investor-owned health care and removes the private health insurance industry (full Medicare for all). This approach is supported by Physicians for a National Health Program (PNHP); the American Nurses Association; the U.S. Labor Party; the California Nurses Association; the National Association of Social Workers; the Associations of Physicians Assistants; and the National Association of Midwives, among others.
The United States spends far more on health care than any other country in the world, but ranks only 37th in the overall quality of health care it provides, according to the World Health Organization. The U.S. is the only industrialized country that does not provide universal health care. More than 44.3 million Americans have no health insurance, and tens of millions more are underinsured. Private corporations pay less than 20% of health costs. Thus, even if you have insurance, you may not be able to afford the care you need, and some treatments may not be covered at all.
For a family living on the edge financially and facing the onset of a serious illness or disabling injury, a lack of health insurance can trigger bankruptcy or even homelessness. Homelessness only leads to more health care problems—a world of inadequate hygiene, communicable diseases, exposure to the elements, violence, and emotional trauma. Studies by the National Academy of Sciences' Institute of Medicine find that the homeless are far more likely to suffer from chronic medical conditions such as diabetes, cardiovascular disease, and asthma.
The Nader Campaign favors replacing our fragmented, market-based system with a single-payer health plan - where the government finances health care, but keeps the delivery of health care to private non-profits, and allows free choice of doctors and hospitals for patients.
The U.S. health care system has many grave faults that could be remedied by a system of universal coverage, including serious gaps in coverage for: prescription drugs and medical supplies; dental, vision, and hearing care; long-term care; mental health care; preventive care for children; and treatment for substance abuse. A recent study by National Academy of Sciences' Institute of Medicine estimates that 18,000 25- to 64-year-old Americans die every year as a result of lack of coverage. That is 18,000 human beings every year, not counting younger Americans.
Shrinking Choices for the Health Consumer
Health care should be provided by a national, single-payer health insurance program—funded by the federal government and providing comprehensive benefits to all Americans throughout their lives. Under the current system, hundreds of billions of dollars a year are wasted by health-care sellers on billing, fraud and administrative expenses. Excess profits and high CEO (and other executive) salaries at large HMOs and other health-care companies add further costs. PNHP highlights the trend:
"Our pluralistic health care system is giving way to a system run by corporate oligopolies. A single-payer reform provides the only realistic alternative.
A few giant firms own or control a growing share of medical practice. The winners in the new medical marketplace are determined by financial clout, not medical quality. The result: three or four hospital chains and managed care plans will soon corner the market, leaving physicians and patients with few options. Doctors who don't fit in with corporate needs will be shut out, regardless of patient needs."1
Dr. Steffie Woolhandler of Harvard Medical School points out that "we are already spending enough to provide every American with superb medical care - $5,775 per person this year [2003]. That's 42% higher than in Switzerland, which has the world's second most expensive health care system, and 83% higher than in Canada." Indeed, 14.9 percent of our gross domestic product is spent on health care and the cost is growing rapidly. Japan spends 7.6% of its GDP, Australia 8.5%, Holland 8.6% and Canada 9.5%. By 2013, per capita health care spending in the U.S. is projected to increase to 18.4 percent of GDP.
A recent study by David U. Himmelstein, MD and Dr. Woolhandler found that our current system is wasteful and obstructively bureaucratic:
"Over 24% of every health care dollar goes to paperwork, overhead2, CEO salaries, profits, and other non-clinical costs. Because the U.S. does not have a system that serves everyone and instead has over 1,500 different insurance plans, each with their own marketing, paperwork, enrollment, premiums, rules, and regulations, our insurance system is both extremely complex and fragmented. The Medicare program operates with just 3% overhead, compared to 15% to 25% overhead at a typical HMO."
Some research has found even higher levels of administrative cost in our current health care system. A December, 2002 report for the state of Massachusetts, designed to develop a statewide plan for "universal health care with consolidated financing," reported that 40 percent of every health care dollar spent in the state goes to administrative costs. Prepared by the pro-HMO consulting firm Law & Economics Consulting Group, the report studied three options; only the single-payer option met the developmental criteria.3
Studies show that savings from a single-payer system would be more than enough to provide universal coverage for the same amount that we are now paying. In 2001, a federally funded study of single-payer universal health coverage, prepared for the Office of Vermont Health Access by the Lewin Group, found the state could save more than $118 million a year over current medical insurance costs-and still cover every Vermonter. "Our analysis indicates that the single payer model would cover all Vermont residents, including the estimated 51,390 uninsured persons in the state, while actually reducing total health spending in Vermont by about $118.1 million in 2001 (i.e., five percent). Thesesavings are attributed primarily to the lower cost of administering coverage through a single government program with uniform coverage and payment rules."4
The impact of overhead on private physicians is also significant.
"Physicians in the U.S. face massive bureaucratic costs. The average office-based American doctor employs 1.5 clerical and managerial staff, spends 44% of gross income on overhead, and devotes 134 hours of his/her own time annually to billing. Canadian physicians employ 0.7 clerical/administrative staff, spend 34% of their gross income for overhead, and trivial amounts of time on billing (there's a single half page form for all patients, or a simple electronic system)."5
Fraudulent Billing
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Typical government estimates put the figure for billing fraud and abuse at 10 percent of annual spending, amounting to over $150 billion annually. PNHP urges the banning of investor-ownership health care sellers in order to dramatically reduce fraudulent billing. Single-payer will reduce fraud because all of the medical information will be in one system - not multiple systems, i.e. multiple insurance companies, employer records, hospital records. Malcolm Sparrow of Harvard University points out that about 90% of hospital bills have mistakes, with overcharges comprising two out of three of the errors, according to business surveys. Unlike the single-payer system in Canada&mdashwhere everybody has health insurance and no one sees a bill—here in the U.S. complex and fragmented bills devour huge amounts of time and resources. Single-payer would reduce both bureaucracy and the opportunity for fraud and bring to light patterns regarding outcomes or other areas needing attention.
Waste in Health Care Practices
A recent study by researchers at Dartmouth Medical School suggests that care in the U.S. could be just as good, or better, and cost a lot less - perhaps as much as 30 percent less - if conservative practice patterns were adopted. In regions with nearly identical health care needs, the Dartmouth team found that the overall quantity of services performed could vary by as much as 60 percent. The differences were due to more frequent physician visits, greater use of specialists and minor tests, and more in-patient stays. More expensive care does not necessarily result in better chances of survival or greater levels of satisfaction with that care. Indeed, by some standards, such as quality of care, access to outpatient services, and preventive care-like flu shots and Pap tests-higher-intensity regions actually fared worse than conservative regions.6 Sometimes too much medical care does harm to a patient, such as unnecesary x-rays, and even operations, having adverse side effects. The single-payer system helps to minimize this problem-physicians ordering unnecessary tests or performing needless surgeries will be spotted. This can only contribute positively to every patient's ability to do real health planning.
The Seeds of Single–Payer—Sound Proposals & Reputable Endorsements
The Nader Campaign finds persuasive a plan based on Physicians for a National Health Program's A National Health Program for the United States: A Physicians' Proposal, first published in the New England Journal of Medicine in 19897, and A National Long-term Care Program for the United States; A Caring Vision, published in the Journal of the American Medical Association in 1991 (both available at www.pnhp.org). Founded by Drs. David Himmelstein and Steffie Woolhandler of Harvard Medical School, PNHP has received endorsements for its plans from over 12,000 physicians and medical students, among them: former Surgeons General David Satcher and Julius Richmond; Marcia Angell, MD-Past Editor, New England Journal of Medicine; Quentin Young, MD-Past President, American Public Health Association; Joel Alpert, MD-Past President, American Academy of Pediatrics; Christine Cassell, MD-Past President, American College of Physicians; Elinor Christiansen, MD-Past President, American Medical Women's Association; and Gary Dennis, MD-Past President, National Medical Association (titles for affiliation only).
Under PNHP's proposed plans:
* "Everyone would be included in a single, comprehensive public plan covering all medically necessary services, including acute, rehabilitative and long-term care, mental-health services, dental care, prescription drugs and medical supplies.
* "Everyone would have access to personalized care with a local primary care physician, and free choice of doctors and hospitals at all times. In a publicly-financed, universal health care system medical decisions would be left to patients and doctors, not to insurance companies or the government.
* "Health care sellers would stay private, and the health plan would provide for different payment schemes for health-care sellers, to minimize disruption to the existing system. The payment schemes would be designed to prevent profit motives from unduly influencing physicians, so there would be no structured incentives to recommend too much or too little care.
* "A transition fund would be established for insurance-company employees whose jobs would be eliminated due to the simplicity of the single-payer system.
The Nader Campaign wishes particularly to applaud the soundness of PNHP's focus on prevention as a critical part of health care. Adequate provision of prevention services not only fosters healthier lives but also proves highly cost-effective in the long run. A commitment to prevention services will require the implementation of systems ensuring the reduction of environmental factors leading to chronic illness (i.e. reducing or eliminating lead in our water, mercury contamination in our food, and asthma-inducing air pollution), especially in our urban areas. Public health policies are needed to wean our culture away from fatty fast foods and encourage healthier life styles, via sound diets, exercise regiments, and reductions in smoking and drug use. As PNHP notes8:
"Quality requires prevention. Prevention means looking beyond medical treatment of sick individuals to community-based public health efforts to prevent disease, improve functioning and well-being, and reduce health disparities. These simple goals, articulated in {the National Center for Health Statistics'} Healthy People 2000, remain elusive. Nine preventable diseases are responsible for more than half of the deaths in the United States, yet less than 3% of health care spending is directed toward prevention."
A single-payer health plan that includes a prevention focus will be integral to mitigating behaviors and environmental conditions that increase health problems. Again, in the words of PNHP:
"Health care financing should facilitate problem solving at the community level. Community-based approaches to health promotion rest on the premise that enduring changes result from community-wide changes in attitudes and behaviors as well as ensuring a healthy environment. Stores that refuse to sell tobacco to minors and promote low-fat foods, schools that teach avoidance of human immunodeficiency virus infection, and a {public}health department that can guarantee clean air and water have a more vital role in ensuring health than does private health insurance."
The views of nurses are also persuasive. As Deborah Burger, RN, President of the California Nurses Association said:
* As caregivers responsible for protecting patients 24 hours a day, seven days a week, registered nurses see clearly the failure of our current healthcare system and the crisis in access, availability, and quality of health care for everyone in this nation.
* The roots of the crisis lie in the growth of a healthcare industry concerned primarily with revenue, profits, and market share rather than quality healthcare.
* The California Nurses Association favors creation and implementation of a new system based on a single, universal standard of care for all that respects the humanity and the right of all our residents to quality healthcare. Key components should include:
* Single, universal standard of care applied to all patients
* Universal access for all; not to be tied to income, residency status or other exclusionary criteria
* Uniform benefits
* Mandated and enforced safe caregiver staffing ratios based on patient need
* Expansion of clinical and economic reporting requirements
* Giving priority to healthcare problems associated with race, gender or socio-economic status
* A shift away from private administration and financing to a model of public administration and financing
* Require hospitals provide all necessary and appropriate care to any patient needing emergency care
Prohibit healthcare providers from seeking to limit care to only the most healthy, and thus least expensive, patients
* Computer-based technologies based on patient and caregiver safety standards and skill enhancement, rather than skill displacement
* Transition employment programs for workers displaced as a result of healthcare reforms
The U.S. Labor Party's "Prescription for a Healthy America" also makes a contribution to the cause of fundamental reform. The Labor Party Plan, called Just Health Care (www.justhealthcare.org), calls for:
* Taking the profit out of health care noting that as much as 30 cents of every premium dollar is squandered on enormous CEO salaries, shareholder profits, advertising and administration.
* Providing comprehensive coverage of all appropriate care, including:
* doctor visits
* nursing home and long-term care
* hospitalization
* preventive & rehabilitative services
* access to specialists
* prescription drugs
* mental health treatment
* dental & vision services
* occupational health services
* medical supplies & equipment
* Guaranteeing access to health care {The Labor Party plan notes: "The number of Americans without health insurance continues to increase each year. Of the 44.3 million uninsured, nearly half aged 18-64 work full time. Just Health Care will extend coverage to every U.S. resident whether working full or part time, retired, laid off, in school or between jobs. By taking health care off the bargaining table, quality health care becomes a right, not a benefit."}
* Fair financing {The US Labor Party points out that the cost of health care is rapidly rising. The United States will spend $1.6 trillion on health care in 2004.}
Consumer Oversight
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Any system, even one animated by service and our non-profit structures, requires oversight by the consumers-requiring inserts in communications (paper or electronic ) from health care vendors and the single-payer agency, inviting consumers to join and voluntarily contribute minimum membership dues. The Nader Campaign proposes that a federally-chartered non-profit membership organization be created through a Congressional charter to serve as a national patient watchdog (with state chapters) to keep this large part of our economy on its toes. Patients would be able to sign up at their local doctor's office, hospital, or clinic. This organization-call it the Consumer Health Vigilance Association-would have full-time advocates overseeing relevant governmental agencies, Congress, and the private health sector. Empowered with all the rights that corporations wield-advocacy, lobbying, litigation, research, and alliance-development with other citizen groups-this modest organization would be chartered so as to ensure that public policies affecting the provision, quality, and cost of health services reflect fairly the needs and concerns of consumers and continue to be informed by their organized voices.
Financing
Although we can easily provide universal, single-payer health insurance for the same amount that we spend and waste on health care now, public funding will be required to replace the portion now paid for by employers and individuals. Consider PNHP's model:
"A universal public system would be financed this way: The public financing already funneled to Medicare and Medicaid would be retained. The difference, or the gap between current public funding and what we would need for a universal health care system, would be financed by a payroll tax on employers (about 7%) and an income tax on individuals (about 2%). The payroll tax would replace all other employer expenses for employees' health care. The income tax would take the place of all current insurance premiums, co-pays, deductibles, and any and all other out of pocket payments.
For the vast majority of people a 2% income tax is less than what they now pay for insurance premiums and in out-of-pocket payments such as co-pays and deductibles, particularly for anyone who has had a serious illness or has a family member with a serious illness. It is also a fair and sustainable contribution.
Currently, over 44.3 million people have no insurance and thousands of people with insurance are bankrupted when they have an accident or illness. Employers who currently offer no health insurance would pay more, but they would receive health insurance for the same low rate as larger firms. Many small employers have to pay 25% or more of payroll now for health insurance - so they end up not having insurance at all.
For large employers, a payroll tax in the 7% range would mean they would pay less than they currently do (about 8.5%). No employer, moreover, would hold a competitive advantage over another because his cost of business did not include health care. And health insurance would disappear from the bargaining table between employers and employees."9
However, before assessing any income tax, the Nader Campaign would tax the corporations polluting the environment, industries manufacturing addictive products, and stock speculation-in addition to closing corporate tax loopholes. These tax law changes will be more than sufficient to make an income tax surcharge on most individuals unnecessary (for further detail, the Nader campaign will be detailing its position statement on taxes in the coming weeks).
Providing universal health care can only be accomplished through a single-payer system: no country ever achieved universal coverage with private health insurance. President Harry Truman proposed universal health care in 1948 but was rebuffed by Congress. The time to act is yesterday. Let us end our disastrous descent into the corporatization of medicine and its callous consequences.
1. 1 David U. Himmelstein, MD & Steffie Woolhandler, MD, "Why the US Needs a Single Payer Health System, June 29, 1995 See:  http://www.pnhp.org/facts/why_the_us_needs_a_single_payer_health_system.php
2. 2 Of course, every program has overhead, but the current system of health insurance-based medical service has massive, unnecessary and duplicative overhead.
3. 3 See: Physicians for a National Health Program at: http://www.pnhp.org/facts/single_payer_system_cost.php?page=2 To get the full report e-mail:  UHCEF@aol.com
4. 4 "Analysis of the Costs and Impact of a Universal Health Care Coverage Under a Single Payer Model for the State of Vermont", The Lewin Group, Inc. Full text of the study is availableon-line at: http://www.dsw.state.vt.us/districts/ovha/spgappendixf.pdf
5. 5 David U. Himmelstein, MD & Steffie Woolhandler, MD, "Why the US Needs a Single Payer Health System, June29, 1995 See: http://www.pnhp.org/facts/why_the_us_needs_a_single_payer_health_system.php
6. 6 Elliott S. Fisher, David E. Wennberg, Thérèse A. Stukel, Daniel J. Gottlieb, F. L. Lucas, and Étoile L. Pinder, "The Implications of Regional Variations in Medicare Spending. Part 1: The Content, Quality, and Accessibility of Care," Ann Intern Med, Feb. 2003; 138: 273 - 287.
7. 7 A National Health Program for the United States: A Physicians' Proposal, The New England Journal of Medicine 320:102-108 (January 12), 1989
8. 8 A Better-Quality Alternative: Single-Payer National Health System Reform," Originally published in The Journal of the American Medical Association September 14, 1994, Volume 272 Copyright 1994, American Medical Association.
9. 9 Physicians for National Health Care, http://www.pnhp.org/facts/singlepayer_faq.php
* Marijuana is a Medicine
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