by Jeff Jacoby

The Boston Globe
June 16, 2010

http://www.jeffjacoby.com/7618/in-love-with-socialized-medicine

PRESIDENT BARACK OBAMA was adamant: His health-care overhaul would not put Americans on the road to British-style, government-run medicine. Speaking to the American Medical Association last June, the president dismissed as “scare tactics and fear-mongering” all talk of “socialized medicine and government takeovers; long lines and rationed care; decisions made by bureaucrats and not doctors.” A few weeks later he reiterated the message: “I don’t believe that government can or should run health care.”

“I am romantic about the (British) National Health Service. I love it.” — Dr. Donald Berwick, President Obama’s choice for director of the Center of Medicare and Medicaid Services.

But if Obama is as firmly opposed to a government-ruled health sector as he claims, why has he nominated as administrator of Medicare and Medicaid — far and away the nation’s largest health-insurance programs, covering one out of every three Americans at a cost of nearly $1 trillion — a man who openly adores Britain’s socialized health care?

“I am romantic about the National Health Service,” Dr. Donald Berwick, the president’s pick for director of the Center for Medicare and Medicaid Services, told a British audience in 2008. “I love it.” Not only does he love the NHS, he extols it as “an example for the whole world — an example … that the United States needs now.”

From all accounts, Berwick, a pediatrician, is respected by his peers. He is the founder of the Cambridge-based Institute for Healthcare Improvement, and an expert on making patient care safer and more efficient. Among his supporters are Bill Frist, a physician and former US Senate majority leader, and several previous directors of the Center for Medicare and Medicaid Services.

But if Berwick’s credentials cannot be doubted, neither can his ideological commitment to centralized state power over health care, or his disdain for the ability of markets and competition to improve the quality and lower the cost of medical services.

He has publicly saluted Britain’s socialized National Health Service for rejecting the “immoral” American system and “the darkness of private enterprise.” He declares that “the Holy Grail of universal coverage” cannot be achieved with consumer-centered health care, but only through “collective action overriding some individual self-interest.”

And he embraces health-care rationing. “The decision is not whether or not we will ration care,” he said in a 2009 interview, “the decision is whether we will ration with our eyes open.” This is a view Berwick has held for a long time; more than 10 years ago he wrote that “limited resources require decisions about who will have access to care and the extent of their coverage.” Accordingly, he praises the NHS for “making tough choices” about the care it administers — unlike the American system, in which the supply of medical care is not artificially restricted. “Here, you choose a harder path,” he said in Britain two years ago. “You plan the supply; you aim a bit low; you prefer slightly too little of a technology or a service to too much; then you search for care bottlenecks and try to relieve them.”

But those who have to live with the NHS and its “bottlenecks” don’t always find them quite so admirable. For months, the British press has been reporting horror stories about the realities of government-run health care. Some recent headlines give a sense of the coverage:

“Overstretched maternity units mean mothers face a 100-mile journey to have baby.”

“Hundreds of patients died needlessly at NHS hospital due to appalling care.”

“Cash-strapped NHS trust introduces rationing for common children’s conditions.”

“Standard of care in some wards ‘would shame a third world country.’”

“Stafford Hospital caused ‘unimaginable suffering.’”

No one would deny that America’s health care system is flawed in many ways. But when it comes to the standard that matters most — the quality of health care provided — our haphazard, expensive, insurance-based system towers above the NHS.

“In Britain 36 per cent of patients have to wait more than four months for non-emergency surgery,” wrote journalist James Bartholomew in The Spectator. “In the US, a mere 5 per cent do.” By one metric after another — cancer survival rates, performance of diagnostic tests, availability of CT and MRI scanners, consultation with specialists — US health care is superior. “British state-run healthcare,” Bartholomew concluded, “is so amazingly, achingly, miserably, and mortally incompetent.”

That’s the system that leaves Berwick feeling “romantic” — the system he proclaims an “example” for the United States. And Obama wants him to run Medicare and Medicaid? Let us hope at least 51 senators say no.

(Jeff Jacoby is a columnist for The Boston Globe).

by Jeff Jacoby

The Boston Globe – link tp original article
November 1, 2009

First of two parts (Next: More competition, less government)

TWO THINGS supporters of a government-run “public option” for health insurance know for sure. One is that private health insurers are raking in obscenely high profits. The other is that only a government rival can force them to compete on price.

In a clever new commercial featuring Heather Graham as an agile sprinter named “Public Option,” the left-wing pressure group MoveOn combines both themes, describing insurance companies as “lazy” and “bloated from the profits of raising our health care costs sky-high.” Why, it asks, should anyone resist the competition a public option would generate? After all, “competition is as American as apple pie.” In a less amusing print ad a few weeks ago, MoveOn charged that “insurance companies are willing to let the bodies pile up, as long as their profits are safe.”

President Obama also attacks health insurers as avaricious profiteers.

“The insurance industry is making this last-ditch effort to stop reform,” he declared on Oct. 16, “even as costs continue to rise and our health-care dollars continue to be poured into their profits (and) bonuses.” When he addressed Congress in September, Obama insisted that only a public option will “keep insurance companies honest.” On the White House Blog, ObamaCare opponents are accused of “fighting to protect insurance industry profits.”

Indeed, there is no shortage of voices characterizing health insurers as greedy villains. Earlier this year, House Speaker Nancy Pelosi praised her party for highlighting “the immoral profits being made by the insurance industry.” On CNN last week, Ohio Senator Sherrod Brown demanded a public option “so the insurance industry can’t continue to game the system and discriminate” against women and the disabled — tactics insurers have used to “quadruple their profits in the last five years.” If quadrupled profits don’t seem rapacious enough, the union-backed Health Care for American Now! ups the ante, claiming, according to the AFL-CIO’s news blog, that “during the past five years, health insurance company profits have soared by 1,000 percent.”

Outbidding them all is Senate Majority Leader Harry Reid. Health insurance companies “are so anti-competitive,” he said last month, “because they make more money than any other business in America today.”

To such overheated agitprop, the only useful response is a cold shower of facts, and the Associated Press supplied a timely one last week. For all the impassioned talk about obscene profits and bodies piling up, AP’s Calvin Woodward reported, “health insurance profit margins typically run about 6 percent” of revenues, a return “that’s anemic compared with other forms of insurance and a broad array of industries.”

On the Fortune 500 list of top industries, health insurance companies ranked 35^th in profitability in 2008; their overall profit margin was a mere 2.2 percent. They lagged far behind such industries as pharmaceuticals (which showed a profit margin of 19.3 percent), railroads (12.6 percent), and mining (11.5 percent). Among health insurers, the best performer last year was HealthSpring, which had a profit of 5.4 percent. “That’s a less profitable margin,” AP noted, “that was achieved by the makers of Tupperware, Clorox bleach, and Molson and Coors beers.”

For the most recent quarter of 2009, health-insurance plans earned profits of only 3.3 percent, ranking them 86^th on the expanded Yahoo! Finance list of US industries. The application-software industry, by contrast, is pulling in profits of nearly 22 percent. Why aren’t MoveOn and the Democrats demanding a “public option” to compete with Microsoft and Adobe and drive down their “immoral” profits?

There are certainly industries doing worse than health insurance — airlines and newspapers, for example — but the notion that health insurers “make more money than any other business in America today” is preposterous. Advocates of a public option may find it tactically expedient to paint insurers as insatiable predators, swollen with ill-gotten profits. The reality is otherwise.

Still, the critics do have one thing right: More competition would bring down health-care premiums. But the way to increase competition is not by adding a government-run health plan to the 1,300 private firms already providing Americans with health insurance. After all, there’s no public option for auto insurance and life insurance, yet they’re sold in a highly competitive national market. There is no reason health insurance can’t be sold the same way.

Next: More competition, less government

(Jeff Jacoby is a columnist for The Boston Globe.)

The Health Insurers Have Already Won – link to original article

COVER STORY August 6, 2009, 5:00PM EST

How UnitedHealth and rival carriers, maneuvering behind the scenes in Washington, shaped health-care reform for their own benefit

By Chad Terhune and Keith Epstein

BusinessWeek

As the health reform fight shifts this month from a vacationing Washington to congressional districts and local airwaves around the country, much more of the battle than most people realize is already over. The likely victors are insurance giants such as UnitedHealth Group (UNH), Aetna (AET), and WellPoint (WLP). The carriers have succeeded in redefining the terms of the reform debate to such a degree that no matter what specifics emerge in the voluminous bill Congress may send to President Obama this fall, the insurance industry will emerge more profitable. Health reform could come with a $1 trillion price tag over the next decade, and it may complicate matters for some large employers. But insurance CEOs ought to be smiling.

Executives from UnitedHealth certainly showed no signs of worry on the mid-July day that Senate Democrats proposed to help pay for reform with a new tax on the insurance industry. Instead, UnitedHealth parked a shiny 18-wheeler outfitted with high-tech medical gear near the Capitol and invited members of Congress aboard. Inside the mobile diagnostic center, which enables doctors to examine distant patients via satellite television, Representative Jim Matheson didn’t disguise his wonderment. “Fascinating, fascinating,” said the Democrat from Utah. “Amazing.”

Impressing fiscally conservative Democrats like Matheson, a leader of the House of Representatives’ Blue Dog Coalition, is at the heart of UnitedHealth’s strategy. It boils down to ensuring that whatever overhaul Congress passes this year will help rather than hurt huge insurance companies.

Some Republicans have threatened to make health reform Obama’s “Waterloo,” as Senator Jim DeMint of South Carolina has put it. The President has fired back at what he considers GOP obstructionism. Meanwhile, big insurance companies have quietly focused on what they see as their central challenge: shaping the views of moderate Democrats.

The industry has already accomplished its main goal of at least curbing, and maybe blocking altogether, any new publicly administered insurance program that could grab market share from the corporations that dominate the business. UnitedHealth has distinguished itself by more deftly and aggressively feeding sophisticated pricing and actuarial data to information-starved congressional staff members. With its rivals, the carrier has also achieved a secondary aim of constraining the new benefits that will become available to tens of millions of people who are currently uninsured. That will make the new customers more lucrative to the industry.

Matheson, whose Blue Dogs command 52 votes in the House, can’t offer enough praise for UnitedHealth, the largest company of its kind. “The tried and true message of their advocacy,” he says, “is making sure the information they provide is accurate and considered.”

Representative Mike Ross, an Arkansas Democrat who leads the Blue Dogs’ negotiations on health reform, also welcomes input from UnitedHealth. “If United has something to offer on cutting costs, we should consider it,” says Ross, a former small-town pharmacy owner. “We need more examples that work, and everything should be on the table.”

DEMOCRATIC WELCOME

Fifteen years after the insurance industry helped kill then-President Bill Clinton’s health-reform initiative, Ross is frustrating the Obama White House by opposing proposals for a government-run insurance concern that would compete with private-sector companies. The President argues that without a public plan, premiums and medical bills will remain prohibitively high. Ross and Matheson have given strong voice to the industry’s contention that such a public insurer would actually reduce competition by undercutting private plans on price and driving them out of business. “We have concerns about a public option if it’s not done on a level playing field,” Ross says.

Obama launched his Administration vowing to extend coverage to all Americans and help pay for it by reining in insurance costs. Seven months later, insurers and pharmaceutical manufacturers that appeared vulnerable to a regulatory crackdown have been welcomed to the negotiating table by the President’s own party.

The several competing bills pending in Congress would guarantee all Americans access to health coverage, addressing the plight of the 47 million who are now uninsured. Congress plans to achieve that by expanding Medicaid, the government program for the poor and disabled; requiring insurers to accept all applicants regardless of their health; and mandating that everyone purchase coverage. Government subsidies would make the obligatory coverage more affordable. The legislation would do little, however, to slow spending by Medicare, the public program for senior citizens, or cut overall medical costs. Congress is considering taxes on the wealthy and on benefits now provided to many white-collar workers.

During the UnitedHealth road show in July, Democrat after Democrat clambered into the company’s promotional vehicle beneath a sign declaring: “Connecting You to a World of Care.” Judah C. Sommer, who heads the company’s Washington office, looked on with satisfaction. “This puts a halo on us,” he explained. “It humanizes us.”

And that Democratic proposal to tax insurance companies? It seems to be fading after the industry said it would raise rates for workers and their families.

UnitedHealth’s relationship with Democratic Senator Mark R. Warner of Virginia illustrates the industry’s subtle role. Elected last fall, Warner, a former governor of his state and a wealthy ex-businessman, received a choice assignment as the Senate Democrats’ liaison to business. The rookie senator landed in the center of a high-visibility political drama—and in a position to earn the gratitude of a health insurance industry that has donated more than $19 million to federal candidates since 2007, 56% of which has gone to Democrats.

UnitedHealth has periodically served as a valuable extension of Warner’s office, providing research and analysis to support his initiatives. Corporations and trade groups play this role in all kinds of contexts, but few do it with the effectiveness of the insurers. In June, Warner introduced legislation expanding government-backed Medicare and Medicaid coverage for hospice stays for the terminally ill and other treatment in life’s final stages. The issue isn’t a top UnitedHealth priority. But the corporation wanted to help Warner with his argument that in the long run, better hospice coverage would save money. UnitedHealth prepared a report for lawmakers finding that 27% of Medicare’s budget is now spent during the last year of older patients’ lives, often on questionable hospital tests and procedures. Expanded hospice coverage and other services could save $18 billion over 10 years, UnitedHealth asserted.

When Warner went to the Senate floor on June 15 to offer his bill, he cited those exact figures. He thanked the company for its support and put a letter from UnitedHealth applauding him in the Congressional Record.

Warner acknowledges in an interview that he worked on the hospice-care legislation with UnitedHealth executives. But he stresses that he has long experience with health issues and has formed his own views. The senator echoes UnitedHealth’s contention that a so-called public option could be a “Trojan horse for a single-payer system,” meaning government-run medical care. Warner has heard from some of UnitedHealth’s largest employer clients, such as Delta Air Lines (SWY). Delta CEO Richard H. Anderson, a former UnitedHealth executive, has told Warner and other lawmakers that big companies don’t want government to limit their flexibility in crafting employee health benefits.

ACTUARIAL ASSUMPTION

Obama’s promise to boost competition and lower costs by having the government play a much broader role in health coverage has been steadily compromised because of the resistance of such Democrats as Warner. “There are different ways to skin this and get competition” in the insurance market, Warner says.

Warner and other opponents of a public plan have relied on an estimate by John Sheils, an actuary who says that 88 million people, or 56% of those with employer-provided coverage, would desert private insurance for a government-run program. That would destabilize the marketplace and potentially kill the private insurance industry, according to Sheils, who works for the Lewin Group, a corporate consulting firm in Falls Church, Va.

UnitedHealth lobbyists routinely cite Lewin’s work, as do Senator Orrin G. Hatch (R-Utah), the second-ranking Republican on the Senate Finance Committee, and Eric Cantor (R-Va.), the House Republican Whip. Left out of these testimonials or buried in the fine print is that a UnitedHealth unit owns the Lewin Group and thus is ultimately responsible for Sheils’ paycheck. In an interview, Sheils says UnitedHealth gives him and the Lewin firm complete independence: “We call it like we see it,” he adds.

Some Democrats differ. Says Representative Pete Stark, the liberal California Democrat who chairs the House Ways & Means health subcommittee: “The Lewin Group’s so-called analysis is suspect.” The nonpartisan Congressional Budget Office has stated that the Sheils-Lewin figure is far too high.

UnitedHealth brings a mixed record to its role helping to guide health reform. The company has repeatedly hit smaller employers and consumers with double-digit rate hikes in recent years, far greater than the overall rate of inflation. An investigation last year by New York’s Attorney General will force the company to stop running two huge databases used widely within the insurance industry. By allegedly setting medical reimbursements too low—that is, skewing statistics in favor of insurers by understating “usual and customary” physician fees—the databases had resulted in the overcharging of consumers by billions of dollars nationwide. In January, UnitedHealth agreed to resolve the situation by paying $400 million in a pair of agreements with the New York Attorney General and the American Medical Assn., although it didn’t admit any wrongdoing.

In a separate case last year, UnitedHealth was forced to stop selling “limited benefit” plans with capped payouts under the imprimatur of the senior citizen group AARP. It turned out that the policies provided very modest coverage, catching many customers off guard, according to Senator Charles E. Grassley (R-Iowa), who helped bring the practice to light. Grassley pointed out that UnitedHealth paid as little as $5,000 toward surgery costing several times as much.

Despite such episodes, UnitedHealth is generally well received in legislative circles in Washington. In late May its in-house point man on reform, Simon Stevens, hand-delivered a report to key senators detailing ways to save an estimated $540 billion in federal spending over 10 years. A week later, on June 4, Stevens accompanied UnitedHealth’s chief executive, Stephen J. Hemsley, to a meeting with Senator Kent Conrad (D-N.D.), an influential moderate member of the Senate Finance Committee. Conrad has since led an effort to create nonprofit medical cooperatives that would operate much like utility co-ops as a substitute for a federally run plan. With less heft than a proposed national plan, the state medical cooperatives would pose a far weaker competitive threat to private insurers.

Conrad says in an interview that the co-op idea evolved independently of any industry input. Skirmishing over the public plan could jeopardize efforts at reform, he warns. Co-ops, he argues, are “the only alternative that’s got much of a shot” to gain sufficient votes in the Senate.

BRITISH EXPERIENCE

UnitedHealth followed up on June 30 with another report for lawmakers pinpointing $332 billion in savings through better use of technology and administrative simplification. If enacted, those changes would potentially benefit UnitedHealth’s Ingenix data-crunching unit. Ingenix, with annual revenue of $1.6 billion, is poised to establish a national digital clearinghouse to ensure the accuracy of medical payments and provide a centralized service for checking the credentials of physicians.

Stevens, an Oxford-educated executive vice-president at UnitedHealth, once served as an adviser to former British Prime Minister Tony Blair. In that capacity, Stevens tried to fine-tune the U.K.’s nationally run health system. Today he tells lawmakers that the U.S. need not follow Britain’s example. Concessions already offered by the U.S. insurance industry—such as accepting all applicants, regardless of age or medical history—make a government-run competitor unnecessary, he argues. “We don’t think reform should come crashing down because of [resistance to] a public plan,” Stevens says. Many congressional Democrats have come to the same conclusion.

UnitedHealth has traveled an unlikely path to becoming a Washington powerhouse. Its last chairman and chief executive, William W. McGuire, cultivated a corporate profile as an industry insurgent little concerned with goings-on in the capital. From its Minnetonka (Minn.) headquarters, the company grew swiftly by acquisition. McGuire absorbed both rival carriers and companies that analyze data and write software. Diversification turned UnitedHealth into the largest U.S. health insurer in terms of revenue. In 2008 it reported operating profit of $5.3 billion on revenue of $81.2 billion. It employs more than 75,000 people.

In 2006, McGuire lost his job after getting caught up in the manipulation, or “backdating,” of company stock options. UnitedHealth was forced to restate earnings over a 12-year period to reflect the extra compensation it had granted McGuire and other executives. McGuire’s chief lieutenant, Stephen Hemsley, took over as CEO in December 2006. Two independent inquiries concluded that Hemsley wasn’t involved with the backdating. Nevertheless he forfeited $190 million in past stock compensation and unrealized gains to resolve the matter.

Hemsley, a former chief financial officer of the now-defunct Arthur Andersen accounting firm, generally shuns the spotlight. But when health reform became a central issue in the runup to the last Presidential election, company executives say they realized UnitedHealth needed to go on the offensive. Hemsley met with White House officials on May 15 and May 22 to promote his company’s prescription for cutting federal health spending.

In August 2007, the company hired Sommer, who previously headed global lobbying for Goldman Sachs (GS). He quickly built a new Washington team of former congressional aides and other K Street operatives. One key acquisition: Cory Alexander, former chief of staff for House Majority Leader Steny Hoyer (D-Md.), an influential moderate Democrat. Alexander had been lobbying for the huge mortgage financier Fannie Mae (FNM). Today, Sommer directs a team of nearly 50 people from UnitedHealth’s spacious Washington office on Pennsylvania Avenue, equidistant between the Capitol and White House. The company spent more than $3.4 million on in-house and outside lobbying in the first half of 2009.

Sommer has retained such influential outsiders as Tom Daschle, the former Democratic Senate Leader who now works for the large law and lobbying firm Alston & Bird. Daschle, a liberal from South Dakota, dropped out of the running to be Obama’s Secretary of Health & Human Services after disclosures that he failed to pay taxes on perks given to him by a private client. He advised UnitedHealth in 2007 and 2008 and resumed that role this year. Daschle personally advocates a government-run competitor to private insurers. But he sells his expertise to UnitedHealth, which opposes any such public insurance plan. Among the services Daschle offers are tips on the personalities and policy proclivities of members of Congress he has known for decades.

Conceding that he doesn’t always agree with his client, Daschle says: “They just want a description of the lay of the land, an assessment of circumstances as they appear to be as health reform unfolds.” He says he leaves direct contacts with members of Congress to others at his firm.

What people in Washington tend not to discuss, at least on the record, is the open secret that insurers are minimizing their forecasts of the eventual windfall they will enjoy from expanded coverage for Americans. UnitedHealth has given certain key members of Congress details about its finances and tax liability—both historical numbers and figures projected under various cost-sharing scenarios. But some on Capitol Hill are skeptical. “The bottom line,” says an aide to the Senate Finance Committee, “is that health reform would lead to increased revenues and profits [for the insurance industry]. … There will be [added] costs [to the companies], but we’re not sure the revenues and profits will be as low as they say.”

A fundamental question about the health overhaul is what minimum standards will apply to the coverage all Americans will be required to have. UnitedHealth has been exchanging a high volume of information on the topic with members of the Senate Finance Committee and their staff. Stevens, the former British health aide, regularly scans PowerPoint presentations generated by the committee staff that attempt to calculate the actuarial value of proposed benefit packages. Senators stung by the projected $1 trillion price tag are winnowing down the required coverage levels to cut costs.

This is good news for UnitedHealth, which benefits when patients pick up more of the tab. In late spring, the Finance Committee was assuming a 76% reimbursement rate on average, meaning consumers would be responsible for paying the remaining 24% of their medical bills, in addition to their insurance premiums. Stevens and his UnitedHealth colleagues urged a more industry-friendly ratio. Subsequently the committee reduced the reimbursement figure to 65%, suggesting a 35% contribution by consumers—more in line with what the big insurer wants. The final figures are still being debated.

Stevens says UnitedHealth and its corporate clients want to steer Congress toward benefit levels and cost sharing that can help control overall health spending: “We are providing another resource of actual modeling and advice on how proposals in the committees are structured and some potential unintended consequences of going down certain routes.”

Perhaps more than any other insurer, UnitedHealth is poised to profit from health reform. Its decade-long series of acquisitions has made the company a coast-to-coast Leviathan enmeshed in the lives of 70 million Americans.

United’s AmeriChoice unit is the largest government contractor administering state Medicaid programs for the poor and federally sponsored plans for children. AmeriChoice’s revenue rose 34% last year, to $6 billion, and it has 2.7 million people enrolled. Those numbers should continue rising under reform since congressional Democrats are proposing an expansion of Medicaid to help achieve universal coverage. More of the working poor would qualify for Medicaid, and AmeriChoice can sell itself to states as the leading service provider.

HEALTH COACH AT THE OFFICE

Another of the big beneficiaries among UnitedHealth’s stable of subsidiaries is OptumHealth. It’s the company’s one-stop shop for managing the chronically ill, offering wellness programs and guiding consumers on treatment options. Even before the reform debate, these services were growing in demand as big employers, state and local governments, and others tried to curb health-care spending by supervising patients more aggressively.

OptumHealth provides a broad range of services, from a 24-hour hotline where nurses can suggest the best hospital for a transplant to “health coaches” who dole out meal plans, to-do lists, and motivational messages. Some OptumHealth clients bring coaches into the office or onto the factory floor to teach about diet and exercise. Many of the cost-containment strategies Democrats are pushing call for more of the preventive care that OptumHealth sells.

“We are extremely well positioned for a much broader adoption,” says Dawn Owens, OptumHealth’s chief executive. Her division, based in Golden Valley, Minn., already boasts $5.2 billion in annual revenue.

Stevens argues that while UnitedHealth will likely benefit financially from health reform, the company will also aid the cause of reducing costs. He cites what he says is its record of “bending the cost curve” for major employers.

During a media presentation in May in Washington, Stevens said medical costs incurred by UnitedHealth’s corporate clients were rising only 4% annually, less than the industry average of 6% to 8%. But that claim seemed to conflict with statements company executives made just a month earlier during a conference call with investors. On that quarterly earnings call, UnitedHealth CEO Hemsley conceded that medical costs on commercial plans would increase 8% this year.

Asked about the discrepancy, Stevens says the lower figure he is using in Washington represents the experience of a subset of employer clients who fully deployed UnitedHealth’s cost-saving techniques, including oversight of the chronically ill. “These employers stuck at it for several years,” he says. “We are putting forward positive ideas based on our experience of what works.”

Terhune is a senior writer for BusinessWeek based in Florida. Epstein is a correspondent in BusinessWeek’s Washington bureau.

Healthcare: Do we need the Lexus? – link to original article

By Jeff Jacoby

Boston Globe Globe Columnist  |  July 29, 2009

IMAGINE the sort of car you’d drive if government regulations made it illegal to sell any automobile that didn’t feature 380-horsepower direct-injection V6 engines, computer-controlled electric power steering, eight-speed automatic transmission, four-wheel-drive, automatic climate control, “smart key’’ technology, touch-screen navigation, backup cameras, LED headlights, acoustic glass, surround-sound stereo, and leather seat stitching.

If those were the minimum requirements every car had to meet before it could be sold, would you commute to and from work every day in a Lexus LS 460 or some other luxury vehicle? Well, you might, if the steep price wasn’t an obstacle. But it’s more likely you wouldn’t be driving at all. If the government barred you from buying anything but a high-end car, you’d probably have no choice but to rely on the bus or subway, or to find a job closer to home.

What is true of transportation is true of everything else: Increase the number of amenities that a product or service must include, and more consumers will be unable to pay for that product or service.

That is why one of the simplest strategies for making health insurance more affordable is to reduce the minimum number of benefits that insurers are required to cover.

In every state in the union, legislators and regulators drive up the cost of healthcare by making insurance policies more comprehensive. Rather than allow the free market to determine which medical services health plans will cover, states force consumers to pay for an array of covered benefits they may not need or want. For example, 45 states require insurance policies to include treatment for alcoholism and 34 mandate coverage of drug abuse treatment. Contraceptives are covered in 31 states, as are hairpieces in 10 states, and in-vitro fertilization in 13 states. Consumers who buy health insurance are often forced to pay for coverage of services they may consider highly dubious, such as acupuncture (benefits are mandatory in 11 states), chiropractic (46 states), osteopathy (22 states), and naturopathy (four states).

Forty years ago, there were only a handful of benefits that health policies were required by law to cover. Today, the Council for Affordable Health Insurance identifies an astonishing 1,961 mandated benefits and providers. While any one mandate may not add appreciably to the price of an insurance policy, in the aggregate their cost is huge. The Cato Institute, citing the Congressional Budget Office, estimates that state regulations increase the cost of health insurance by 15 percent. And since “each percentage-point rise in health insurance costs increases the number of uninsured by 300,000 people,’’ as scholars John Cogan, Glenn Hubbard, and Daniel Kessler point out, it is clear that the proliferation of insurance mandates is one reason why millions of Americans are uninsured.

Yet instead of pruning back this thicket of compulsory benefits, lawmakers are planting even more of them.

As Kay Lazar reported in the Boston Globe on Monday, Massachusetts legislators have filed more than 70 bills this year to increase the array of services the state’s health insurers would be required to cover. Among the benefits the pending bills would mandate are hearing aids for children, cleft palate surgery, treatment of infantile cataracts, smoking cessation products, “asthma education,’’ vitamin supplements for mitochondrial disease, post-partum depression screening – and the list goes on and on.

As it is, health insurance in Massachusetts – which already mandates coverage for more than 40 itemized benefits, providers, and patient populations – is among the nation’s most expensive. The last thing the Bay State (or any state) needs is for government to drive the cost of medical coverage higher still. It should be left to the market, not to lawmakers and lobbyists, to decide which medical services should be included in a basic-vanilla insurance policy. When lawmakers yield to special-interest pleas that this or that benefit be made compulsory, the results are less choice, higher premiums, and more individuals priced out of the market.

The key to healthcare reform is lively competition, not the dead hand of government compulsion. Legislators, take note: Enacting new mandates won’t make medical insurance more affordable. Repealing old ones just might.

Jeff Jacoby can be reached at  jacoby@globe.com .  

Eight things we can do to improve health care without adding to the deficit.

By JOHN MACKEY

The Wall Street Journal – link

“The problem with socialism is that eventually you run out of other people’s money.”

—Margaret Thatcher

With a projected $1.8 trillion deficit for 2009, several trillions more in deficits projected over the next decade, and with both Medicare and Social Security entitlement spending about to ratchet up several notches over the next 15 years as Baby Boomers become eligible for both, we are rapidly running out of other people’s money. These deficits are simply not sustainable. They are either going to result in unprecedented new taxes and inflation, or they will bankrupt us.

While we clearly need health-care reform, the last thing our country needs is a massive new health-care entitlement that will create hundreds of billions of dollars of new unfunded deficits and move us much closer to a government takeover of our health-care system. Instead, we should be trying to achieve reforms by moving in the opposite direction—toward less government control and more individual empowerment. Here are eight reforms that would greatly lower the cost of health care for everyone:

• Remove the legal obstacles that slow the creation of high-deductible health insurance plans and health savings accounts (HSAs). The combination of high-deductible health insurance and HSAs is one solution that could solve many of our health-care problems. For example, Whole Foods Market pays 100% of the premiums for all our team members who work 30 hours or more per week (about 89% of all team members) for our high-deductible health-insurance plan. We also provide up to $1,800 per year in additional health-care dollars through deposits into employees’ Personal Wellness Accounts to spend as they choose on their own health and wellness.

Money not spent in one year rolls over to the next and grows over time. Our team members therefore spend their own health-care dollars until the annual deductible is covered (about $2,500) and the insurance plan kicks in. This creates incentives to spend the first $2,500 more carefully. Our plan’s costs are much lower than typical health insurance, while providing a very high degree of worker satisfaction.

• Equalize the tax laws so that employer-provided health insurance and individually owned health insurance have the same tax benefits. Now employer health insurance benefits are fully tax deductible, but individual health insurance is not. This is unfair.

• Repeal all state laws which prevent insurance companies from competing across state lines. We should all have the legal right to purchase health insurance from any insurance company in any state and we should be able use that insurance wherever we live. Health insurance should be portable.

• Repeal government mandates regarding what insurance companies must cover. These mandates have increased the cost of health insurance by billions of dollars. What is insured and what is not insured should be determined by individual customer preferences and not through special-interest lobbying.

• Enact tort reform to end the ruinous lawsuits that force doctors to pay insurance costs of hundreds of thousands of dollars per year. These costs are passed back to us through much higher prices for health care.

• Make costs transparent so that consumers understand what health-care treatments cost. How many people know the total cost of their last doctor’s visit and how that total breaks down? What other goods or services do we buy without knowing how much they will cost us?

• Enact Medicare reform. We need to face up to the actuarial fact that Medicare is heading towards bankruptcy and enact reforms that create greater patient empowerment, choice and responsibility.

• Finally, revise tax forms to make it easier for individuals to make a voluntary, tax-deductible donation to help the millions of people who have no insurance and aren’t covered by Medicare, Medicaid or the State Children’s Health Insurance Program.

Many promoters of health-care reform believe that people have an intrinsic ethical right to health care—to equal access to doctors, medicines and hospitals. While all of us empathize with those who are sick, how can we say that all people have more of an intrinsic right to health care than they have to food or shelter?

Health care is a service that we all need, but just like food and shelter it is best provided through voluntary and mutually beneficial market exchanges. A careful reading of both the Declaration of Independence and the Constitution will not reveal any intrinsic right to health care, food or shelter. That’s because there isn’t any. This “right” has never existed in America

Even in countries like Canada and the U.K., there is no intrinsic right to health care. Rather, citizens in these countries are told by government bureaucrats what health-care treatments they are eligible to receive and when they can receive them. All countries with socialized medicine ration health care by forcing their citizens to wait in lines to receive scarce treatments.

Although Canada has a population smaller than California, 830,000 Canadians are currently waiting to be admitted to a hospital or to get treatment, according to a report last month in Investor’s Business Daily. In England, the waiting list is 1.8 million.

At Whole Foods we allow our team members to vote on what benefits they most want the company to fund. Our Canadian and British employees express their benefit preferences very clearly—they want supplemental health-care dollars that they can control and spend themselves without permission from their governments. Why would they want such additional health-care benefit dollars if they already have an “intrinsic right to health care”? The answer is clear—no such right truly exists in either Canada or the U.K.—or in any other country.

Rather than increase government spending and control, we need to address the root causes of poor health. This begins with the realization that every American adult is responsible for his or her own health.

Unfortunately many of our health-care problems are self-inflicted: two-thirds of Americans are now overweight and one-third are obese. Most of the diseases that kill us and account for about 70% of all health-care spending—heart disease, cancer, stroke, diabetes and obesity—are mostly preventable through proper diet, exercise, not smoking, minimal alcohol consumption and other healthy lifestyle choices.

Recent scientific and medical evidence shows that a diet consisting of foods that are plant-based, nutrient dense and low-fat will help prevent and often reverse most degenerative diseases that kill us and are expensive to treat. We should be able to live largely disease-free lives until we are well into our 90s and even past 100 years of age.

Health-care reform is very important. Whatever reforms are enacted it is essential that they be financially responsible, and that we have the freedom to choose doctors and the health-care services that best suit our own unique set of lifestyle choices. We are all responsible for our own lives and our own health. We should take that responsibility very seriously and use our freedom to make wise lifestyle choices that will protect our health. Doing so will enrich our lives and will help create a vibrant and sustainable American society.

Mr. Mackey is co-founder and CEO of Whole Foods Market Inc.

Americans’ Views On Health Policy: A Fifty-Year Historical Perspective – link to original article

Health Affairs – THe Policy Journal of the Health Sphere 

Robert J. Blendon and John M. Benson

   Abstract

A review of data from more than 100 public opinion surveys conducted over a fifty-year period finds that the American public has conflicting views about the nation’s health policy. They report much dissatisfaction with the health care system and with private health insurance and managed care companies, and they indicate general support of a national health plan. However, most Americans remain satisfied with their current medical arrangements, do not trust the federal government to do what is right, and do not favor a single-payer type of national health plan. The review also finds that confidence in the leaders of medicine has declined but that most Americans maintain trust in the honesty and ethical standards of individual physicians.

For decades public opinion researchers have sought to learn what Americans think of a variety of subjects, including health care. We now have more than fifty years’ worth of historical trends on Americans’ views related to health policies. Understanding these trends is important for a number of reasons. First, public opinion influences the outcome of elections and often sets the health policy agendas of those seeking public office. Second, studies have shown that public opinion influences government decision making beyond election outcomes and often affects policy decisions made by Congress, the executive branch, and the United States Supreme Court.1 Examining Americans’ views on the same issue in different time periods helps us to understand better the changing nature of the health policy environment.

This discussion is divided into six sections, examining the public’s views on (1) national health insurance and the enactment of Medicare; (2) the U.S. health care system; (3) health care as a national priority; (4) confidence in health professionals and institutions; (5) satisfaction with one’s own health care; and (6) the role of government in general, as a context for health policy attitudes.

Sources of data. Despite the large number of polls conducted over the past five decades, relatively few have included questions asked with similar wordings so as to provide historical trends concerning public opinion on health policy issues. The data in this paper are restricted to those issues for which the same polling questions on a health policy issue were asked for three or more years.

The data presented here consist of specific results from more than 100 opinion surveys conducted nationwide between 1945 and 2000. We compiled these results from the POLL database at the Roper Center for Public Opinion Research in Storrs, Connecticut, from the Harris Interactive subscription service, and from published research papers containing particular historical data used in our trend series. These polls involved interviews with 500 to 2,000 randomly selected adults. In the years prior to 1985 most of the polls were conducted in person; after 1985 most were conducted by telephone.2

   National Health Care Reform

Since World War II there have been four major debates over reforming the nation’s health care system: (1) the late 1940s debate about President Harry Truman’s proposed national health insurance plan; (2) the 1961–1965 debate during the Kennedy and Johnson administrations over providing health insurance for elderly Americans (Medicare); (3) the 1971–1974 debate about President Richard Nixon’s proposed national health insurance program; and (4) the 1993–1994 debate about the Clinton administration’s health care reform proposal.

Trend data on public opinion are available for three of these four debates; only the Nixon-era debate has no trend data available. The data suggest that there were common features among these three national debates.

First, prior to the introduction of each bill, public interest in some type of national health care reform already existed. In the years leading up to the Truman proposal, 82 percent of Americans said that something should be done to make it easier for people to pay for doctor and hospital care, and 68 percent thought that it was a good idea for Social Security to cover doctor and hospital bills.3 Shortly before Medicare was enacted, 75 percent of the public said that the federal government should pass a law to provide medical care for seniors.4 During the year of Bill Clinton’s first election as president, 66 percent of Americans favored national health insurance financed by tax money—up from 46 percent in March 1980 (Exhibit 1).5

View this table in original article: EXHIBIT 1 Americans’ Attitudes About National Health Insurance, 1980–2000 

There were other similarities between the Clinton and Truman plans. After each plan was introduced and the policies were made explicit, opposing groups entered the debate and argued that the enactment of the proposal would result in a health care system worse than the existing one. In spite of the general support for a national health plan portrayed in Exhibit 1, public support for the Clinton plan declined from 59 percent in September 1993 to 40 percent in July 1994.6 Also, the public became more negative toward the Clinton plan on the issues of too much government, the cost of the plan, limits on choice of doctors, and the quality of care available.7 A similar phenomenon occurred during the debate over the Truman plan. In March 1949, 38 percent opposed the Truman plan. By October 1950, after an extensive campaign by opponents, public opposition had risen to 61 percent.8 Only in the case of Medicare did the majority of Americans continue to support the specific national reform proposal after learning more about it. Polls at the time show 61 percent and 62 percent of the public supporting the proposed Medicare legislation in the fall of 1964, and 65 percent after it was enacted in 1965.9

The Clinton and Truman examples suggest the need for caution in interpreting poll results favoring national health care reform prior to the introduction of a specific proposal. Among the confounding factors is the lack of an underlying consensus among the American public over the preferred type of national health plan. Polls that offer only one plan as a possible solution often show majority support for that proposal. But when other major alternative proposals are offered, as they were in each of these two national debates, public support splinters.

In 1946, 1963, and 1993, when the public was given the choice of more than one type of national health reform legislation, none gained majority support. Of particular interest is that when proposals are introduced involving a major private-sector role, the option of a government health plan never achieves majority support from the public (37 percent in 1946, 42 percent in 1963 for the elderly, and 28 percent in 1993).10

Recent polling presents another example of this lack of consensus. In 2000, when asked in general about national health insurance financed by taxes, 56 percent of the public (54 percent of registered voters) said that they were in favor.11 But when a clause was added specifying that all Americans would get their health insurance from a single government plan, support fell to 38 percent of registered voters (Exhibit 1).12 This illustrates the lack of public consensus on what a national health plan financed by taxes should entail.

   Views Of The Health Care System

Much of the efforts of health policymakers have been focused on improving aspects of the nation’s health care system. An important measure of public ferment for change in the health system is how satisfied Americans are with the current system and how much change they believe is needed.

One trend question assessing satisfaction with the health care system asks Americans if they think that our system works pretty well and needs only minor changes, has some good things but needs fundamental changes, or has so much wrong with it that we need to rebuild it completely (Exhibit 2).13 The first response implies satisfaction with the status quo, and the last response suggests a high level of public dissatisfaction and support for major change.

View this table in original article: EXHIBIT 2 Americans’ Overall View Of The Nation’s Health Care System, 1982–2000

 By this measure, starting in 1982, the majority of Americans have never been completely satisfied with the health care system. Americans were the most positive in 1987, when 29 percent reported that they saw the system working pretty well. In 1991, often seen as the starting point of the great health care reform debate of the early 1990s, only 6 percent held this favorable view. In that year Democrat Harris Wofford won a special Senate election in Pennsylvania on a platform calling for national health insurance. In that same year 42 percent of Americans expressed the view that the health care system should be completely rebuilt, the highest level ever reported. By 2000 only 29 percent held this view. Taken together, this trend shows that most of the public has never been completely satisfied with the system during the past eighteen years, but never has a majority supported developing an alternative system.

In a second trend, starting in 1993, a majority of Americans has expressed dissatisfaction with the availability and affordability of health care in this country. However, the proportion who reported that they were not at all satisfied has declined from 45 percent in 1993 to 26 percent in 1997 and 27 percent in 2000.14

One last specific measure of the health system concerns the adequacy of the supply of physicians. In the post–World War II period, U.S. health policymakers have gone from having great concerns about shortages of physicians to concerns about a physician surplus. Over the past two decades the proportion of Americans who think that there are too few physicians in their community has declined, from 38 percent in 1981 to 28 percent in 2000.15 However, only 10 percent perceive a physician surplus in their community, and this figure has not changed in two decades. This suggests that if a physician surplus is developing, it is not yet visible to the public.

   Health As A National Priority

Over the years a number of experts and commentators have expressed concerns about the high level of health spending in the United States. These concerns have not been shared by the general public. Since 1973 the majority of Americans has said that the United States is spending too little rather than too much on improving and protecting the nation’s health (Exhibit 3).16

View this table in original article: EXHIBIT 3 Americans’ Attitudes About Spending To Improve And Protect The Nation’s Health, 1973–1998 

The lowest levels of support for more spending occurred in 1978 and 1980, when national health care cost containment was being debated. The highest levels occurred in 1990 and 1993 during the debate over national health care reform. At no time in this quarter-century trend did more than 9 percent of the public feel that the nation was spending too much on health. The question wording is rather broad and is likely to include public support for increased spending on health care, public health, prevention, and/or medical research.

Although Americans may have continuously supported more spending on health, the priority for health spending and activity has fluctuated over time. Since 1993 Americans have been asked what they think should be the two most important issues for government to address (Exhibit 4).17 In January 1993, 31 percent of Americans selected health care (excluding Medicare) as one of these two issues. The high point in public priority for health care was in October 1993, again at the height of the health reform debate.

View this table in original article: EXHIBIT 4 Percentage Of Americans Naming Health Care Or Medicare As One Of The Two Most Important Issues For Government To Address, 1993–2000

   Public Confidence In Health Professionals And Institutions

Historically, because of their expertise and their unique role in patient care, physicians have played a dominant role in health policy. Over the past thirty years, however, public confidence in the leaders of medicine, as well as most other major American institutions, has declined (Exhibit 5). In the longest trend series, the proportion of Americans reporting a great deal of confidence in the leaders of medicine has declined from 73 percent in 1966 to 44 percent in 2000.18 The lowest level of public confidence occurred in 1993 (22 percent), during the debate over national health care reform.

View this table in original article: EXHIBIT 5 Public Confidence In The People Running Medicine And Assessment Of The Honesty And Ethical Standards Of Medical Doctors, 1966–2000

This decline in public confidence in the institutional leaders of medicine has not affected Americans’ high level of respect for practicing physicians, who have consistently been among the highest-ranked professionals. The past twenty-five years have witnessed no change in Americans’ assessment of the honesty and ethical standards of physicians.19

Unfortunately, there is no comparably long trend for health care institutions. A shorter series, starting in 1997, asks the public to rate the job various industries and institutions are doing for their consumers (Exhibit 6).20 Hospitals are the health care institution seen by the most people (72 percent) as doing a good job for its constituents; managed care companies, by the fewest (29 percent).

View this table in original article: EXHIBIT 6 The Public’s Assessment Of The Job Various Industries Are Doing Serving Their Consumers, 1997–2000

Since 1997 there has been a twenty-two-percentage-point decline in the proportion of the public saying managed care companies are doing a good job for consumers and a twenty-point decline in positive assessments of the pharmaceutical industry. Of note, both of these declines occurred during a period when there was a major national debate about the desirability of expanding government’s regulatory role in these two areas.

The proportion of Americans who believe that the growth of managed care is a bad thing has increased from 28 percent in 1995 to 52 percent in 2000. In addition, Americans are more likely now than in 1995 to believe that the growth of managed care will harm the quality of medical care (59 percent in 2000, 39 percent in 1995) and not help to contain costs (53 percent in 2000, 31 percent in 1995).21

    Americans’ Views Of Their Own Health Care

Health policy differs from many other policy areas in that the public’s views on issues are shaped at least in part by their own experiences. Two historical trends—one concerning Americans’ satisfaction with their own medical care, the other with confidence in ability to pay for a major illness—measure these experiences.

In the twenty-two years the first question has been asked, more than 80 percent of Americans have reported that they are satisfied with their last visit to a physician (Exhibit 7).22 Also, confidence in ability to pay for a major illness has improved over the years.23 Despite the increase in the number of uninsured Americans nationally, the proportion reporting such confidence has risen from 50 percent in 1978 to 67 percent in 2000. This improvement in financial confidence may be related to more comprehensive insurance and increased benefit coverage for the insured population, or it may reflect the effects of increased family incomes and assets that could be drawn upon in case of large medical bills.

View this table in original article: EXHIBIT 7 Americans’ Satisfaction With Their Own Medical Care And Confidence In Their Ability To Pay For A Major Illness, 1978–2000

  The Role Of Government

For those involved in health policy today, the public opinion environment is very different from what it was a generation ago. The period from 1964 through the early 1970s saw the enactment of Medicare, Medicaid, the War on Poverty’s health care programs, and a plethora of new government regulatory measures aimed at improving the health care system. Those decisions were made in an era when there was less widespread citizen distrust of government, a greater public willingness to have government regulate the private sector, and less public concern with the level of federal taxation.

In 1964, the year before Medicare and Medicaid were enacted, only one-fourth of Americans expressed distrust in the federal government (Exhibit 8).24 When the Clinton health plan ultimately failed in Congress in 1994, distrust of the federal government had risen fifty-four percentage points. These same years have also seen a decline in public support for government regulation of the private sector. In 1964 only 43 percent of Americans agreed with the statement that the government has gone too far in regulating business and the free enterprise system.25 This figure rose to 60 percent in 2000. Americans are clearly less willing today to see expanded government regulation in general than they were during the 1960s. Similarly, in 1961 only 46 percent of Americans thought that their federal taxes were too high.26 This figure rose to 69 percent in 1969 and stood at 63 percent in 2000.

View this table in original article: EXHIBIT 8 Americans’ Attitudes About The Federal Government, 1956–2000

  Discussion

A number of key questions arise from this historical review of public opinion. First, what do we know about the stability of public opinion on health care policy over the past five decades? The picture presented here is mixed. On many of the issues we examined, public opinion has been stable over long periods of time. However, in the cases of national health care reform, the priority for government action on health care, confidence in the leaders of medicine and government, and concerns about federal taxation, public opinion has changed markedly over the years. Even more dramatic is the decline of public support for both the Clinton and Truman health plans over a short period of time.

Second, what do we learn about the consistency of public opinion over these many areas of health policy? Americans hold many beliefs that are consistent with a general view of what is right or wrong about health care in the United States. However, it is striking to see how many conflicting views the public holds on health policy issues.

On the one hand, Americans report substantial dissatisfaction with our mixed private/public health care system and with the private health insurance and managed care industries. A majority of Americans indicate general support for a national health plan financed by taxpayers, as well as increased national health spending. On the other hand, these surveys portray a public that is satisfied with their current medical arrangements, in many years does not see health care as a top priority for government action, does not trust the federal government to do what is right, sees their federal taxes as already too high, and does not favor a single-payer (government) type of national health plan. Over the years these conflicts in beliefs have been difficult to resolve in legislative debates, particularly around the issues of large-scale national health care reform. This is likely to remain the case in the years ahead.

Finally, are there any lessons for better interpreting public opinion on health policies in the future? The answer from this review is clearly yes. Because Americans do hold many conflicting values and beliefs that affect their views on health care policy, it is important to be cautious in interpreting the public mood based on single, isolated public opinion questions. To be a useful guidepost for policymakers, opinion surveys require enough depth in their question wordings so that respondents can work their way through their conflicting values and beliefs to come to judgment on the issue.

   Editor’s Notes

Bob Blendon is professor of health policy and political analysis at the Harvard School of Public Health. John Benson is managing director of the Harvard Opinion Research Program, Harvard School of Public Health.

This work was supported jointly by the Henry J.Kaiser Family Foundation and the Robert Wood Johnson Foundation. The views expressed are solely those of the authors, and no official endorsement by either sponsor is intended or should be inferred.

   NOTES

R.J. Blendon and M. Brodie, “Public Opinion and Health Policy,” in Health Politics and Policy, ed. T.J. Litman and L.S. Robins (Albany, N.Y.: Delmar Publishers, 1997).

When interpreting these findings, one should recognize that all surveys are subject to sampling error. Results may differ from what would be obtained if the whole population of adults had been interviewed. The size of the error varies with the number surveyed and the magnitude of difference in the responses to each question. Most national public opinion surveys have sample sizes of about 1,200 persons, in which the results will, with a 95 percent degree of confidence, have a statistical precision of plus or minus three percentage points of what would be obtained if the entire population had been interviewed. The sampling error for 500 respondents is plus or minus five percentage points; for 2,000 respondents, plus or minus two percentage points. Possible sources of nonsampling error include nonresponse bias, as well as question wording and ordering effects. Nonresponse produces some known biases in survey-derived estimates because participation tends to vary for different subgroups of the population. To compensate for these known biases, the sample data are typically weighted in analysis, using parameters from the most recent available census data. Other techniques, including random-digit dialing, replicate subsamples, callbacks staggered over times of day and days of the week, refusal conversions, and systematic respondent selection within households, are used in telephone surveys to ensure that the sample is representative.

S.L. Payne, “Some Opinion Research Principles Developed through Studies of Social Medicine,” Public Opinion Quarterly (Spring 1946): 93–98.

National Opinion Research Center/Anti-Defamation League of B’Nai B’Rith (Storrs, Conn.: Roper Center for Public Opinion Research, October 1964).

CBS News/New York Times polls (Roper Center, 12March 1980 and 8 July 1992). The complete trend also includes results from the following polls: CBS News/New York Times polls (Roper Center, 13 February 1980, 22 April 1981, 30 March 1990, 28 October 1990, 3 June 1991, 18 August 1991, 22 January 1992, 12 January 1993, and 28 March 1993); New York Times poll (Roper Center, 3 December 1995); and Harvard School of Public Health/International Communications Research poll (Roper Center, 16 August 2000). Question wording: “Do you favor or oppose national health insurance, which would be financed by tax money, paying for most forms of health care?”

Gallup poll (Roper Center, 24 September 1993); and Gallup/CNN/USA Today poll (Roper Center, 15 July 1994).

Gallup/CNN/USA Today polls (Roper Center, 22 September 1993 and 28October 1993); and Gallup polls (Roper Center, 24 September 1993 and 16 April 1994).

Gallup polls (Roper Center, 6March 1949 and 8 October 1950).

Gallup/Potomac Associates polls (Roper Center, September 1964 and October 1964); and Harris poll (Roper Center, April 1965).

Gallup poll (Roper Center, 12 April 1946);Opinion Research Corporation poll (Roper Center, 15 March 1963); and Henry J. Kaiser Family Foundation/Commonwealth Fund/Louis Harris and Associates poll (Roper Center, 6 August 1993).

Harvard/ICR poll, 16 August 2000.

Washington Post/Henry J. Kaiser Family Foundation/Harvard University poll (Roper Center, 5 July 2000). The complete trend for this question wording also includes results from Henry J. Kaiser Family Foundation/Harvard School of Public Health/Princeton Survey Research Associates polls (Roper Center, 4 November 1998, 8 October 1999, and 3 December 1999). Question wording: Do you favor or oppose “a national health plan, financed by taxpayers, in which all Americans would get their insurance from a single government plan”?

Question wording: “Which of the following statements comes closest to expressing your overall view of the country’s health care system? On the whole, the health care system works pretty well and only minor changes are necessary to make it work better; there are some good things in our health care system, but fundamental changes are needed to make it work better; the health care system has so much wrong with it that we need to completely rebuild it.”

Gallup/CNN/USA Today polls (Roper Center, 8 January 1993, 10 January 1997, and 7 January 2000).

American Medical Association poll (Roper Center, 24 July 1981); and Harvard/ICR poll, 16 August 2000.

Question wording: “We are faced with many problems in this country, none of which can be solved easily or inexpensively. I’m going to name some of these problems, and for each one I’d like you to tell me whether you think were spending too much money on it, too little money, or about the right amount. Are we spending too much, too little, or about the right amount on… improving and protecting the nation’s health?”

Harris polls (Roper Center, 22 January 1993, 4 March 1993, 28 April 1993, 24 June 1993, 13 August 1993, 1 October 1993, 11 November 1993, 20 December 1993, 2 February 1994, 4 April 1994, 23May 1994, 17 September 1994, 8November 1994, 9 December 1994, 8 June 1995, 26 October 1995, 9 January 1997, 5 June 1997, 20 August 1997, 15 October 1997, 14 January 1998, 18 February 1998, 27 April 1998, 17 July 1998, 12 August 1998, 9 September 1998, 11 November 1998, 7 January 1999, 11 February 1999, 8 April 1999, 14 May 1999, 10 June 1999, 12 August 1999, 17 September 1999, 22 October 1999, 2 December 1999, 6 January 2000, and 8 September 2000); for February–July 2000, Harris poll (New York: Harris Interactive, 25 July 2000). Question wording: “What do you think are the two most important issues for the government to address?”

Harris poll (New York: Harris Interactive, 26 January 2000). Question wording: “As far as people in charge of running medicine are concerned, would you say you have a great deal of confidence, only some confidence, or hardly any confidence in them?”

Gallup polls (Roper Center, 11 June 1976, 19 August 1977, 24 July 1981, 20May 1983, 12 July 1985, 23 September 1988, 8 February 1990, 16 May 1991, 26 June 1992, 19 October 1995, and 4 November 1999); and Gallup/CNN/USA Today polls (Roper Center, 19 July 1993, 23 September 1994, 9 December 1996, 6 November 1997, and 23 October 1998). Question wording: “Please tell me how you would rate the honesty and ethical standards of people in these different fields [medical doctors]—very high, high, average, low or very low.”

Question wording: “Do you think [each of these industries] generally do a good or bad job of serving their consumers?”

Harris poll (New York: Harris Interactive, 19 July 2000).

Question wordings: “Thinking about the last time you saw a medical doctor about yourself, would you say you were very, fairly, not too, or not at all satisfied with the medical care you received?” (1978–1987); and “Thinking about your most recent visit to a medical doctor, would you say you were very satisfied, somewhat satisfied, not very satisfied, or not at all satisfied with the medical care you received?” (1990–2000).

Question wording: “How confident are you that you would have enough money or health insurance to pay for a major illness? Are you very confident, somewhat confident, not very confident, or not at all confident?”

National Election Surveys, “The NES Guide to Public Opinion and Electoral Behavior,” <www.umich.edu/~nes/nesguide/toptable/tab5a_1.htm> (14 September 2000), for 1958–1994, 1996, and 1998; Washington Post/Kaiser/Harvard polls (Roper Center, 28 November 1995 and 30 June 1999); and ABC News/Washington Post poll (Roper Center, 30 March 2000). Question wordings: “How much of the time do you think you can trust the government in Washington to do what is right: just about always, most of the time, or only some of the time?” (1958–1994, 1996, 1998, 2000); and “How much of the time do you think you can trust the government in Washington to do the right thing: just about always, most of the time, or only some of the time?” (1995, 1999).

Gallup/Potomac Associates poll (September 1964); CBS News/New York Times polls (Roper Center, 8 January 1978, 7 November 1980, and 22 April 1981); Council on Excellence in Government/Hart and Teeter Research Companies poll (Roper Center, 16 March 1995); Pew Center for the People and the Press/Princeton Survey Research Associates poll (Roper Center, 25 September 1997); Washington Post/Kaiser/Harvard poll (Roper Center, 10 August 1998); and NPR/Kaiser/Kennedy School poll (26 May 2000). Question wording: (Agree/disagree) “The government has gone too far in regulating business and interfering with the free enterprise system.”

Gallup polls (Roper Center, 16 February 1956, 6 April 1957, 4 March 1959, 10 February 1961, 8 February 1962, 11 January 1963, 28 February 1964, 10 February 1966, 9 March 1967, 12March 1969, 16 February 1973, 14 May 1982, 7 June 1985, 8 March 1990, 28March 1991, 26 March 1992, 29March 1993, and 16 December 1994); and Gallup/CNN/USA Today polls (Roper Center, 9 April 1996, 24 March 1997, 17 April 1998, 6 April 1999, and 7 April 2000). Question wording: “Do you consider the amount of federal income tax you have to pay as too high, about right, or too low?”

Posted by NEJM • August 12th, 2009 • Printer-friendly

Robert J. Blendon, Sc.D., and John M. Benson, M.A.

New England Journal of Medicine – link to original article

Now that Congress has adjourned and most members are back in their own states or districts, they will be listening to what their constituents have to say about the debate over health care reform. We examined the results of 22 recent nationwide public opinion polls (see Recent Opinion Polls on Health Care Reform; polls are cited parenthetically hereafter), working with support from the Kaiser Family Foundation and the Robert Wood Johnson Foundation, to find out what our legislators might be hearing.

On issues such as health care, we believe that public support for change is shaped by the interaction of three factors: people’s perception of problems that affect the country, their assessment of their own current life situation, and their worries about their own future.1 Currently, a majority of Americans are highly critical of the health care system (HSPH June 17), believe it requires major change (CBS July 24), and are very concerned about the problems facing the uninsured (CBS June 12). At the same time, most Americans are satisfied (”very” or “somewhat”) with the quality of the health care they receive (CNN July 31) and most insured Americans are satisfied with their own health insurance coverage (ABC June 18). Even when asked about their own health care costs, more than half say they are satisfied (ABC June 18). In contrast, the uninsured report more problems than insured Americans with their care and with health care costs (HSPH June 17).

Although most Americans are satisfied with their current arrangements, a majority say they are worried (”very” or “somewhat”) about having to pay more for their health care or insurance coverage and are concerned that the quality of care they receive will get worse. Also, a majority of insured Americans say they are worried about losing their coverage (KFF July 7). In addition, nearly half of Americans believe that their federal income taxes are already too high (Gallup April 6).

The public mood today about health care is very similar to what it was at the outset of the 1993 health care reform debate. In 2009, as in 1993, health care is seen as the second-most-important issue for government action, after the economy (Harris May 11).2 More than three fourths of Americans support a major change in the health care system (CBS July 24),2 and more than half favor enactment of a national health insurance program (HSPH June 17).2 The biggest difference is that President Barack Obama has a much higher approval rating than President Bill Clinton did (58% vs. 38%) (CBS July 24 and CBS Aug. 2), which suggests that Obama has more opportunity for leadership.

For most Americans, reform in 2009 means lowering health care costs and providing coverage for the uninsured (KFF Feb. 3). To most people, costs principally mean their own and their employers’ costs, with lower priority placed on solving the country’s aggregate spending problem (KFF July 7). In addition, the public sees a possibility for improvement in the quality of care. Only 38% of Americans believe that health care in the United States is better than that in other industrialized countries, and 27% think it is worse (Pew April 28).

So far, neither the House nor the Senate has passed health care reform legislation. The current debate encompasses several elements that might be in the final legislation, and only a few of these are likely to gain public attention.

One key issue is the appropriate role for government in health care. The public believes the role of government should be expanded: 62% believe the government should exert more control over the health care system (CBS July 9), and 55% believe that the federal government should guarantee health insurance for all Americans (CBS July 24). But Americans don’t believe this increased responsibility should lead to a government-run system, which 58% would see as a negative outcome (QU June 23).

Another major issue is whether a public insurance plan should be offered as a competitor to private plans. Five of the six polls that raised this question show majority support (from 52 to 69%) for a public, or government-administered, health insurance plan (CBS July 24; ABC June 18; KFF July 7; QU June 23; Pew July 22); the sixth shows support of 46% (NBC June 24). Supporters of a public plan hold divergent views about whether the plan should be administered by a government agency (33%) or by an independent organization with government funding and oversight (66%) (ABC June 18).

Then there is the question of mandates. Some reform proposals would require all individuals to have health insurance coverage. Public support for such an individual mandate ranges from 49 to 56% if no mention is made of subsidies for people who cannot afford insurance (ABC June 18; Gallup July 10). If a mandate were to include such subsidies, support ranges from 53 to 70% (CBS July 24; ABC June 18; KFF July 7; Pew July 22). On the other hand, when people are told about penalties that people would have to pay for not having coverage, support drops to 44% (ABC June 18). Public support for an employer mandate, under which employers would be required to offer health insurance to their employees or pay a penalty into a fund, ranges from 61 to 64% (KFF July 7; Pew July 22; Gallup July 10). As for mandates for insurers, support for requiring insurers to cover all applicants, even if they have a preexisting condition, ranges from 75 to 79% (CBS July 24; ABC June 18; Pew July 22).

In terms of paying for reform, 58 to 68% of Americans support raising taxes on people with higher incomes (in some polls, those earning more than $250,000 a year) (Pew July 22; Gallup July 10; KFF June 1); 30% support taxing all employer-provided health insurance benefits (QU June 23), with 25 to 43% in support of taxing only more expensive health plans (Pew July 22; Gallup July 10; KFF June 1); and 33 to 38% support using savings from Medicare to help pay for reform (Pew July 22; Gallup July 10). Support for the use of Medicare savings, however, rises to 53% when the savings come from limiting increases in payments to physicians and hospitals (KFF June 1). Only 32% support increasing the deficit to help pay for health care reform (KFF Dec. 4).

As we examine these key issues, we see that three elements — requiring insurers to cover people with preexisting conditions, increasing taxes on people with higher incomes, and an employer mandate — have widespread public support. Introduction of a public plan as a competitor is supported in most polls, but respondents vary in their beliefs about how such a plan should function. There is widespread opposition to taxing employer-provided benefits and increasing the deficit to help pay for reform. On the other three issues — an individual mandate, an increased role for government, and using Medicare savings — the public is more divided.

These mixed results do not suggest how the public will come down on the questions that will determine their support for health care reform legislation. Other, broader factors will ultimately affect support. For many Americans, three questions remain unanswered: Will reform improve the nation’s health care system? Will their own care get better? Will their own costs become less burdensome?

At this point in the debate, the public has not come to a firm judgment on these questions. About half (47%) think that access to health care in the United States will expand if health care reform passes (Gallup July 24). About 4 in 10 (41%) believe the quality of care in the United States will improve (KFF July 7). The public is divided on the question of how reform will affect health care costs nationally, with one poll showing a plurality thinking that cost growth will slow and another showing a plurality thinking that costs will increase (KFF July 7; Gallup July 24) (see table).

At a personal level, most Americans do not think the current reform legislation will improve their own health care or lower their costs (KFF July 7; Gallup July 24). In addition, more than three fourths believe that their own taxes will increase (Fox July 21). Uncertainty about the potential effect of legislation appears to be leading to volatility in the level of public support for the reform plans of President Obama (with 42 to 56% in support) (NBC July 24; CNN July 31; NPR July 22) and Congress (with 38 to 54% in support) (Pew July 22; ABC July 15).

It is clear that most of the public wants a major change in the health care system. But majority support for a specific legislative proposal will depend on Americans’ believing that they and the country will be better off if such a change is enacted.

Recent Opinion Polls on Health Care Reform*

ABC News–Washington Post polls (July 15–18, 2009; June 18–21, 2009)

CBS News polls (July 9–12, 2009; August 2–3, 1993)

CBS News–New York Times polls (July 24–28, 2009; June 12–16, 2009)

CNN–Opinion Research Corporation poll (July 31–August 3, 2009)

Fox News–Opinion Dynamics poll (July 21–22, 2009)

Gallup polls (July 24–25, 2009; April 6–9, 2009)

Gallup–USA Today poll (July 10–12, 2009)

Harris Interactive poll (May 11–18, 2009)

Harvard School of Public Health (HSPH)–Robert Wood JohnsonFoundation poll (June 17–21, 2009)

Kaiser Family Foundation (KFF) polls (July 7–14, 2009; June 1–8, 2009; February 3–12, 2009)

KFF–HSPH poll (December 4–14, 2008)

NBC News–Wall Street Journal poll (July 24–27, 2009)

National Public Radio (NPR) poll (July 22–26, 2009)

Pew Research Center for the People and the Press polls (July 22–26, 2009; April 28–May 12, 2009)

Quinnipiac University (QU) poll (June 23–29, 2009)

* The Harris Interactive poll is available from Harris Interactive, New York. All other polls are available from the Roper Center for Public Opinion Research, Storrs, CT.

The views expressed in this article are solely those of the authors, and no official endorsement by the Kaiser Family Foundation or Robert Wood Johnson Foundation is intended or should be inferred.

Dr. Blendon reports serving on the board of directors of and holding stock in Assurant, and he and Mr. Benson report receiving grant support from the Blue Cross Blue Shield of Massachusetts Foundation. No other potential conflict of interest relevant to this article was reported.

Source Information

From the Harvard School of Public Health, Boston (R.J.B., J.M.B.); and the John F. Kennedy School of Government, Cambridge, MA (R.J.B.).

This article (10.1056/NEJMp0906392) was published on August 12, 2009, at NEJM.org.

References

Blendon R, Benson J. How Americans view their lives. Challenge 2007;50:5-25.

Blendon R, Benson J. Americans’ views on health policy: a fifty-year historical perspective. Health Aff (Millwood) 2001;20:33-46. [Free Full Text]

My company ran a hospital in London. We don’t want to go the government route.

By ALAN B. MILLER

Wall Street Journal – link to original article

August 12, 2009

With Congress now in recess, the debate over health-care reform has moved to each member’s home district. The American people have rightly been asking elected officials many probing questions. While few Americans deny we need health-insurance reform (too many people lack adequate coverage), most believe we receive the best quality health care in the world and do not want to see it compromised.

Several advocacy groups and members of Congress want a single-payer insurance system, modeled after Medicare, to cover all Americans. They say Medicare works to provide health care to seniors, so government should extend the program to Americans of all ages. Others want to create a government-run plan, sometimes called a “public option,” which they say would compete with private insurance but would only be two steps away from a single-payer system.

There are more than 1,300 insurance companies competing for business without unneeded competition from a federal government plan. Backed by tax dollars, a government-run option could offer artificially low rates without regard to profitability, or even meeting operating expenses. That would push businesses to move employees to the public-option plan, ultimately putting private insurers out of business and leaving only a single-payer system run by the government.

A single-payer system may appear attractive to some. But as someone with more than 30 years of experience running a leading hospital company with international operations, I have firsthand knowledge of the hidden costs.

Medicare reimbursements to hospitals fail to cover the actual cost of providing services. The Medicare Payment Advisory Commission (MedPAC), an independent congressional advisory agency, says hospitals received only 94.1 cents for every dollar they spent treating Medicare patients in 2007. MedPAC projects that number to decline to 93.1 cents per dollar spent in 2009, for an operating shortfall of 7%. Medicare works because hospitals subsidize the care they provide with revenue received from patients who have commercial insurance. Without that revenue, hospitals could not afford to care for those covered by Medicare. In effect, everyone with insurance is subsidizing the Medicare shortfall, which is growing larger every year.

If hospitals had to rely solely on Medicare reimbursements for operating revenue, as would occur under a single-payer system, many hospitals would be forced to eliminate services, cut investments in advanced medical technology, reduce the number of nurses and other employees, and provide less care for the patients they serve. And with the government in control, Americans eventually will see rationing, the denial of high-priced drugs and sophisticated procedures, and long waits for care.

My company’s experience with health care in the United Kingdom illustrates the point. In the 1980s, we opened The London Independent Hospital to serve the private medical market in the U.K. The hospital had not been open long when representatives of a 1,000-bed government-run hospital located a short distance away approached us to borrow high-tech equipment and instruments. Because people were ill and needed procedures the government hospital could not provide, we provided that hospital with the help it needed. But that experience convinced me that under a single-payer system hospitals do not receive the money required to purchase advanced technology or provide quality care.

Advocates of a single-payer system say that hospitals would survive if they learned to operate more efficiently. While we are always looking for ways to improve efficiency, the economic conditions of the past few years have already forced most institutions to reduce expenses and increase efficiency as much as possible.

The reality is that Americans have come to expect the best health care in the world, and to provide that, hospitals must continue to invest in advanced medical technology, salaries for well-trained nurses and technicians, and state-of-the-art facilities. If hospitals were required to operate solely on revenue from a single-payer system, they could no longer afford to provide the care that Americans deserve.

Single-payer systems have proven to be wholly inadequate in Canada and the U.K. Most people in America are satisfied with the care they receive, so it is important that we take the time to fix only the parts of our system that need repair. Let’s not destroy a system that works well for most Americans. Let’s judiciously change only the areas in need.

Mr. Miller is chairman and CEO of Universal Health Services Inc.

A Short Course in Brain Surgery

By Jose A Hernandez, MD

Posted in Facebook - 8/09/09

Harvard University’s Malcolm Sparrow, specialist in health-care fraud, estimates that as much “20 percent of the federal health-care budget is consumed by fraud, which would be $85 billion a year for Medicare.” While on the Medicaid side the GAO calculates Medicaid fraud at $33 billion, and this does not include Medicaid’s nursing-home “benefits.” (1) Fraud is only one part contributing to the inability of government health-care system to control its cost, which now outpaces private insurance by approximately 1/3. (2)
In contrast Safeway, implementing market-forces which rewards personal responsibility through financial incentives, was able to keep per capita health-care costs flat while most American companies’ costs have increased 38% over the same four years. This grocery-chain calculates that if the nation had adopted their approach in 2005, the nation’s direct health-care bill would be $550 billion less than it is today. (3)

Based on this snapshot into health-care cost, what would you predict is the most effective mechanism to control the skyrocketing health-care cost, market-forces or government control?

1) Government health care is a target for massive fraud.

2) Costs of Medicare/Medicaid Have Outpaced Other Health Costs by 1/3 Since 1970

3) How Safeway Is Cutting Health-Care Costs