University Times

Universal health care coverage for Americans may be inching its way toward reality, a group of local health professional experts agreed. But they were far from agreeing on when it might happen nationally, what such a system might look like and how effective any plan would be in fixing other parts of a severely broken down structure.

Four speakers and three commentators made their recommendations at a panel discussion Jan. 16 titled “Approaches to Achieving Universal Health Coverage in America.” The speakers covered a wide range of topics, including what kinds of plans are under consideration, such as a single-payer system, extending Medicare to all citizens or a voucher system; how to ensure that health coverage becomes a citizen’s right; how to share the costs of universal health care, and the legislative actions already in play at the state and federal levels.

The three commentators’ responses represented the perspectives of organized medicine, health policy and current medical students.

General points of agreement among the panel participants included:

• Universal health insurance is gathering steam as it becomes a higher priority in the national consciousness and as a number of states have established programs for their citizens.

• An acknowledgement that the current system is broken, with Americans paying more and getting less quality in return.

• Embarrassment and dismay at America’s status as the least insured country in the developed world.

• Frustration that the American public is ambivalent about reforming health care.

Points of contention included:

• Whether a single-payer system is the best option, and whether such a system would add costs.

• Whether universal health care would result in rampant inefficient governmental controls.

• Whether universal health care would decrease the quality of health care for many.

Following are brief summaries of the speakers’ points.

David Blandino

Chair of the Department of Family and Community Medicine at UPMC Shadyside Hospital,

clinical associate professor of family medicine at the School of Medicine

Blandino spoke on “Universal Health Care Without a Single-payer: Oxymoron or Best Hope?” He prefaced his remarks by disclosing that he serves on the board of directors for Highmark. But he insisted his talk was based solely on his opinion and was not on behalf of any health-related organization.

“I would like there to be socially just access to basic health care services of high quality,” Blandino said. “But I believe that expansion of health services coverage to folks that are currently uninsured or underinsured is a necessary but not sufficient condition for reaching that goal. A single-payer system is not necessarily the best way to get there under the current state of affairs and it certainly is not the way to get there in the United States anytime soon.”

Blandino outlined the principal features of four health system reform proposals:

• Incremental changes in the current system, which might include miscellaneous tax exemptions and cash subsidies; expansion of Medicaid by raising income eligibility, and of Medicare by lowering age limits for eligibility; pay for performance, and improved medical records systems.

• Individual mandates with subsidies, which would require everyone to have some form of health insurance, would feature income-related subsidies and would require some tax-covered subsidies.

• Universal health care vouchers, which would: provide choice of health plans; add the ability to purchase additional services; be financed by earmarked value-added taxes; spell the end of tax subsidies for employer-based insurance; eliminate Medicaid and phase out Medicare (as people turn 65 they would continue on the voucher system), and be administered by federal and regional health boards.

• A single-payer system, which would: provide a single comprehensive benefit plan covering all Americans; eliminate private insurance except for non-covered items; limit or eliminate deductibles and co-payments; provide a national formulary for drugs with negotiated pricing, and be financed by a variety of taxes.

“I’m not going to talk about the politics of getting a single-payer system in place, which is complicated enough,” Blandino said. “My goals are to raise awareness and stimulate discussion, and to increase the number of questions that must be faced.”

He said the current state of the U.S. health care system is characterized by major non-financial barriers to access based on race, gender, age, location, mal-distribution of providers, an inappropriate balance between primary care and specialty providers, antiquated infrastructure and systems and terrible communication.

“Even if we had unlimited financing for health care services the health of many in our society would still be very poor,” Blandino maintained. “A standardized payer mechanism that is rigorously developed might become a foundation someday, but only if we work to fix many of the other problems.”

He added that universal health care proponents underestimate how difficult a transition to any universal plan would be.

A single-payer system, which is favored by many, is not necessarily the best way to go, Blandino said. “It doesn’t address the aspects of health care, such as huge regional differences in access, and disparities in care for African Americans and other groups,” he said. “The number of primary care physicians per capita is more important to the quality of health delivery and is a key aspect to lowering costs. My concern is that if you roll out a single-payer system without dealing with these other problems, you’ll have these same things, only magnified. Whatever system we come down to, we’ve got to solve the problem of getting comparative value for costs.”

Barry Tepperman

Attending radiation oncologist at Allegheny General Hospital

Tepperman spoke on “Single-payer: Guaranteeing the Fundamental Right to Health Care in America.”

“If you take away nothing else from my views take away this: Without health or the ability to restore it, life is short and of poor quality, liberty is meaningless and happiness is not achievable” — all of which are the inalienable rights spelled out in the Declaration of Independence, Tepperman said. “Therefore, access to health care is a fundamental right of all citizens.”

Tepperman made the case for adopting a single-payer model of national health insurance, such as the Canadian model.

“As compared to Canada, we do not do as well. Let’s talk about the urban legends — indeed the lies — that come from people who oppose universal health care,” he said.

The big three myths, he said, were that national health insurance leads to less quality; national health insurance would cost more money, and Americans don’t want national health insurance.

“In an ideal world when we pay more, we get more service. Not!” Tepperman said. “We certainly pay more here than in every other developed country, all of which have government-assured health insurance, except Germany which does not provide insurance for its very highest paid citizens. But what do we get compared to every other country?”

The answer, he said: lower life expectancy; higher infant mortality rate; lower mammography screening rates; lower continuity-of-care rates, and fewer inpatient days per capita, among other indicators of poor quality.

Who are the uninsured? Half of the 45 million uninsured U.S. citizens are employed; a quarter are children, and only a quarter are out of the labor force, he said.

“Uninsured people are less likely to get primary care, they die sooner, they receive less prenatal care, they have poorer birth outcomes and they suffer annual health loss costs of $1,600-$3,300,” Tepperman said.

Opponents of universal health care in this country often cite problems they perceive with the Canadian system, which are myths, he said.

“The truth about Canada’s national health insurance system is it’s not socialized medicine, it’s fee-for-service, with the fee schedule set by the health plan. Patients are free to choose their own doctors and hospitals, facilities and practices are privately run, but publicly financed — in other words, it’s like Medicare, only everybody’s covered,” Tepperman said.

How does national health insurance work? “Everyone gets coverage — no co-pays or deductibles. It’s comprehensive care. It’s a much simpler system with one plan, one payer, and it’s accountable, since it’s transparent and public,” he said.

To implement national health insurance in the United States would cost about $550 billion, Tepperman maintained. “For starters, we could recover $150-$200 billion saving on overhead costs. We could repeal the Bush tax cuts for those making more than $200,000 a year and recover another $150 billion.”

National health insurance would require some new taxes, he acknowledged. “A 3.5 percent payroll tax would net $230 billion. But this would replace employer insurance premiums, with the average large employer now paying about 8.5 percent in insurance benefits, meaning a savings for employers,” Tepperman said. “Even being taxed, you have a net gain of money.”

A national health insurance system would offer other savings by eliminating premiums, co-pays, deductibles and out-of-pocket expenses for covered services, he added. “How do we know this will work? Because every other industrialized country in the world has some form of [national health insurance].”

To re-cap, national health insurance leads to better outcomes, would cost no more money and American public opinion is moving toward wanting it, he said.

Judith R. Lave

Professor and chair, Health Policy and Management at the Graduate School of Public Health (GSPH)

“No one would design the health care system we have today, but to paraphrase a certain former high ranking government official, ‘You have to go into health care reform with the system you have,’” said Lave, who spoke on “Universal Health Care: How Shall We Share the Costs?” “We don’t have the luxury of starting from scratch. But there are many different models to look at.”

Some models would change the role of government, some would affect patients’ choices and some would have more administrative complexity than others, she said. Different plans would lead to different goals, including universal coverage, simplification of the overall health care system, and new systems to compensate for the loss of employer-sponsored health insurance, she said.

“I disagree with Barry [Tepperman] about costs,” Lave said. “Universal access to health care would lead initially to an increase in the percentage of costs in the gross domestic product,” she said, which currently runs at 16 percent.

Regardless of plan choice, there will be an increase in taxes, Lave said. “Any health plan that expands coverage will lead to a large redistribution of health care payments between individuals, states, employers and the federal government,” she maintained. “Improving coverage to include the under-insured will increase overall utilization and therefore health care expenditures. Despite the rhetoric, giving people access to care before they get seriously ill will not decrease overall costs.”

On the other hand, administrative costs, currently estimated at 7.2 percent of overall health care expenditures including the costs of running public and private insurance organizations, could decrease under several of the plans. Premiums for basic services will be eliminated under some plans. And depending on the plan choice’s effect on Medicaid, state taxes could decrease, she noted.

“Among the plans, the single-payer promises [to yield] the largest decrease in administrative costs,” Lave said. “There would be no costs incurred in determining who gets tax support, for example. A single-payer system also would preclude the need for health plans by having one set of rules governing payment. And administrative costs at the provider level will decrease with a decrease in the number of plans.”

But costs likely are to be higher for plans that rely on an income-based tax credit subsidy, she noted. “A publicly paid voucher system or a Medicare-type system would lead to a larger increase in taxes.”

The problem with implementing any new system is that alone will not increase efficiency, she said. Nor will it decrease medical errors or increase the use of evidence-based medical practice.

“One issue is that policies to improve coverage for the uninsured will shift public resources to the insured,” Lave said. “One model would provide refundable tax credits to purchase health insurance. However, most people who would be eligible for tax subsidy already have insurance. Should they or their employers by penalized?”

Current trends in state-level political activity make her pessimistic about the future, Lave said. “With respect to Medicare, these plans are becoming more complicated and more targeted, and many states are decreasing income limits for eligibility while benefits are being cut back. Also, Medicaid is paying for some expansions by cutting back services to current recipients or providers.

“But, in the word of today’s teenagers, the status quo ‘sucks,’” she said. “We have to do something.”

Scott Tyson

CEO of Pediatrics South & member of the medical executive committee at Children’s Hospital of Pittsburgh

Tyson spoke on “Universal Health Care: Legislative Solutions.”

“Every other developed nation has universal health care coverage in one form or another and spends less. This is fundamentally un-American, and what I want you to take out of this discussion is that you need to stand up and be heard about this,” Tyson said. “I can tell you that legislative initiatives at the state level are spreading.”

He outlined some of the features of five separate kinds of legislative initiatives currently designed to provide universal health care, including some that build on existing plans.

• The market-based model. “This is a insurance-based platform. You would have multiple insurers,” Tyson said. “The insurers would by definition create an affordable high-quality product. Everyone would be required by law to have an insurance policy. Funding would be private or public or both. And it would be publicly and privately administrated. The Massachusetts model is the best example of this, and California has a somewhat similar model.”

• Tax credits. “At present, only businesses can get tax credits for insurance purchases,” Tyson pointed out. That could be extended to all insurance products, regardless of purchaser.

Funding would be public and private, though actual funding would be through lost dollars rather than actual outlays, privately administered, he said.

“There is no real precedent for this on a state level, but HSAs (health savings accounts) and MSAs (medical savings accounts) are a model of this,” Tyson said.

• Expanding eligibility for public programs. “There are requirements for eligibility for most public programs,” Tyson said. Those could be extended to a larger population.

Public programs also could provide increased coverage for certain products, such as preventative care. Funding would be primarily publicly funded to expand availability and access, and be both publicly and privately administered.

“Illinois is the closest to this, certainly on a pediatric level,” he said.

• Vouchers. As an extension of the market-based model, people would be given a voucher to purchase an insurance product. “This could come from the employer, government, payroll or a combination of these,” Tyson said. “All people would receive a voucher to go and purchase an insurance product with the market determining price, availability, etc. Funding would be public and private, and the model would be privately administered.”

• Single-payer. Under this model, all funds would be pooled. All fees would be paid from a single fund. The private market would be limited to uncovered services or services that were at least comparable. It would be publicly funded and privately administered, Tyson said.

“In all of these models, except the single-payer system, the premise is the market should be allowed to set prices, compete to help contain costs and provide the products,” Tyson said.

Features of the models include that each uses varying ways of increasing the number of covered people; each is a universal health care model, if allowed to expand fully, and each would involve the private sector to varying degrees in administering, funding and dispensing the products.

Following are brief summaries of the commentators’ remarks.

Terence Starz

President of the Allegheny County Medical Society,

clinical professor of medicine at the School of Medicine

Starz spoke on “The Organized Medicine Perspective.”

“My message is that to get this challenging problem I ask myself three questions,” Starz said. “Do I believe there is a problem? Yes. How do we go about solving this problem? How can I have my voice heard?”

The various medical professional societies in this country, including the Allegheny County Medical Society, can form a powerful voice, he said.

“There are over 800,000 doctors in the United States,” Starz said. “In Pennsylvania there are about 22,000. Organized medicine can be a forum to address these issues. But we’re doctors, and as doctors, we take care of individuals. We’re not trained in business; we’re not good at it. Nonetheless, we need to come together to get our voices heard. We want to be the healthiest country in the world.”

Organized medicine should focus on three goals, he said: promoting healthy living; promoting diversity in the profession, and mentoring colleagues. “If you look at this country between 1975 and today, we’ve increased our calorie intake on average by 150-240 calories per day. We’re the fattest country in the world. So blaming all our problems on health care costs is not right.”

Julie Donohue

Assistant professor of health policy and management at GSPH, secondary appointment in the Department of Psychiatry, core faculty member of the Center for Research on Health Care

Recent health policy data show a certain amount of ambivalence among Americans regarding the health care system, said Donohue, who spoke on “The Health Policy Perspective.”

“Eighty-five percent of the public supports the government’s role in universal health insurance,” she said, “but health care ranks low on the public’s agenda, with only 8 percent saying it is one of the two most important issues in deciding their vote in the recent election.”

Moreover, among voters who did say that health care was important, 30 percent said they meant health care costs, 21 percent said it was the problem of expanding coverage to the uninsured and 21 percent said that the biggest problem was Medicare, including the Medicare prescription drug benefit, Donohue said.

A vast majority of Americans (86 percent) also say the health care system needs either fundamental change or complete rebuilding, but 68 percent rate their own health plan as good or excellent, she pointed out.

There are powerful interests groups striving to maintain the status quo, as evidenced by the fact that three of the top 10 lobbying industries are health related, with spending by pharmaceutical/health products lobbyists leading the way, followed by the health insurance industry.

Donohue said the bottom line is that public opinion will need to act as a counterweight to the powerful interest groups opposed to reform; that health care needs to be elevated to a stronger election issue, and that while the public values universal coverage, it lacks consensus on how to get there and who needs to make the necessary financial sacrifices.

Gabriel Silverman

Pitt medical student

“Of course, I can’t claim to represent all medical students, but I can tell you the AMSA, the American Medical Student Association’s, position,” Silverman said. “They represent 68,000 members. AMSA supports a single-payer system as having the best possibility for improving quality in health care, and it supports a guarantee of health care to all Americans.”

He said that while the focus of medical students is on becoming practicing physicians, there is general awareness that the health care system is in great trouble.

“Every year we see an increasing number in uninsured and under-insured people, we see health spending is rising rapidly, and nowhere faster than in the U.S.,” he said.

U.S. health spending is more than twice as much on average as any of the other 30 Organization for Economic and Cooperative Development countries. But it’s also growing faster — two times as fast as the rest of the countries on average, he said.

“By controlling for the GDP (gross domestic product) and controlling for the age of the population, the difference, primarily, is due to the way we finance health care. All these other countries are funded by the government, and therefore they’re better able to control costs,” Silverman said.

“Of course, this is only going to get worse as the baby-boom turns into the ‘geri-boom.’ The number of people over 65 is increasing. Those in my class will graduate from their fellowships in 2015, which is right when this will take off. Medical students will be inheriting this system. Currently, we spend 16 percent of our GDP on health care. That’s projected to be 26 percent by 2030. And, in 2030 the number of people over 85 kicks up.”

During this period of rapid change in the nation’s demographics and increases in health care spending, any reform of the health care financing system will have to respond with a correspondingly large change, he maintained.

“The best method for controlling costs, for improving quality and for covering everyone seems to be single-payer system,” Silverman said.

“While some say getting such a system is politically unrealistic, to anyone practicing medicine 30 and 40 years from now it seems imperative. For us the stakes are even greater. We’re going to be around for a while.”

Rohan Ganguli, Pitt professor of psychiatry, pathology and health and community systems, moderated the Jan. 17 panel discussion.

Copies of PowerPoint presentations and other event materials are accessible at www.publichealth.pitt.edu/content.php?page=977&context=ContextNews.

*****

While a Jan. 16 panel in Scaife Hall covered the serious topic of achieving universal health coverage in the United States, the event was not without its humorous moments.

To illustrate the point that the movement toward universal health coverage in this country has proceeded at a glacial pace, David Blandino told a joke.

“A health economist dies and goes to Heaven. And he’s talking to God, and asks, ‘Do you think there’ll ever be a single-payer health system in the United States?’ And God said, ‘I think so. But not in my lifetime.’”

Barry Tepperman, a native of the United States’ northern border neighbor, joked that he was “the token Canadian exile” in the bunch.

But Judith Lave, at her turn, took issue with that, saying, “In the interest of full disclosure, I’m also Canadian. My coming to this country, however, had nothing to do with health care. I came for love.”

Medical student Gabriel Silverman made the point that the United States sticks out like a sore thumb in terms of health care coverage inadequacy by doing a dead-on impersonation of an unexpected character.

“As students, of course, we’re still learning and I decided it would be helpful to turn to old mentors,” Silverman said. “So, I turned to ‘Sesame Street.’ Cookie Monster in particular.

“I approached Cookie about these problems with health care and he showed me a graph of the percentage of population covered by publicly funded health care in each country in the Organization for Economic and Cooperative Development,” Silverman said. OECD is a group of 30 developed countries that share a commitment to a democratic government and a market economy.

“Cookie Monster said, ‘Look at the graph.’ And then he sang this song: “One of these things is not like the other things. One of these things doesn’t belong. Can you guess which thing is not like the other things before I finish this song?’

“I said, ‘Cookie, it’s obvious. There are 30 countries here and all are 100 percent covered by the government, except Turkey and Mexico, which were 66 and 50 percent covered, and then there’s coverage for the U.S. which has only 25 percent of its people covered.’”

—Peter Hart