Who are the Uninsured?

[kitkat24]

Who are the Uninsured? October 16, 2003

Numbers Point to Problem Created When Legislation Driven by Headlines

By Chris Patterson

Another horrifying announcement from our newspapers a few weeks ago - millions of Americans are uninsured. It's so often repeated, we no longer have to ask what people are going without. This is about health insurance.

Most articles began with alarming statistics, as the Austin American-Statesman did: "The number of Americans who lack health insurance climbed by nearly 6 percent in 2002, to 43.6 million, the largest single increase in a decade, according to figures to be released today by the Census Bureau."

Such stories, and agitated editorials that followed, are geared to evoke cries of outrage for the victims. We are led to believe that this "crisis" is "growing" and, like random urban violence, not one of us may be spared.

Editorial pages have been calling on legislators - state and federal - to do something, and do it quickly. They call for more laws, more spending, more taxes, more government.

We need to breath deeply, calm down and look at the facts.

The National Center for Policy Analysis, based in Dallas, recently examined the numbers of "uninsured."

Almost three-fourths of the newly "uninsured" are people who are making over $50,000, according to the NCPA report, and simply choose not to purchase health insurance. While this decision says many things about the cost of medicine, it does not mean that people without health insurance are poor and desperate for help.

Since 1993 the number of uninsured in households with annual incomes above $75,000 increased 114 percent, according to the NCPA. On the other side of the economic divide, the study finds the number of uninsured with annual incomes below $25,000 fell by 17 percent.

The NCPA uncovered some facts that don't make it to the newspapers. For example, young adults are less likely than other age groups to have health insurance, while those over 65 are almost all insured. Americans between the ages of 18 and 34 make up some 41 percent of the "uninsured." This makes sense. We all remember the invincible years of the twenties - that is a healthy age and most young people are making the economic decision not to waste their money for insurance they do not need at the time.

Most interesting of NCPA's findings is the length of time people remain uninsured: just under a year in 75 percent of the cases.

The shrillness of many press releases and news stories disguise the fact that many without health insurance are making a rational choice. Trumping feelings over fact, the uninsured are portrayed as hapless victims of hard employers and greedy insurers.

While passing legislation to create more programs that spend more money might make for good politics, they do no good in the long run and often deflect resources from the truly needy.

Perhaps the only accurate conclusion we can draw from headlines is that a great many Americans are opting to take care of themselves in ways not reflected in insurance headcounts. Instead of creating more programs, lawmakers should search for ways to make it easier for us all to plan and pay for our individual health care needs. Rather than raising taxes to slay an illusionary dragon, legislators could reduce the mandates making health care - and health insurance - so expensive for every one.

Chris Patterson is director of research for the Texas Public Policy Foundation, a non-profit, non-partisan research institution.

TexasPolicy.com

[fergus51]

Originally posted by roxannekkb

My goodness, Fergus, what ever gave you that strange idea. :eek:

Don't you know that public health automatically equals care by quacks, felons, misfits, and any other who couldn't get into a legitimate school of medicine or nursing?

Especially in Australia, seeing as they are all felons sent there from Englad right? Only kidding, I have never met an Australian I didn't like:)

[kitkat24]

'I would not trust my dog, let alone my mother, to many nurses'

(Filed: 29/11/2003)

Millions of pounds are being pumped into our hospitals - so why are they in such chaos? For the past 11 months, Harriet Sergeant has been free to talk to management in six NHS hospitals.

A patient in an NHS hospital exists in a power vacuum. Who is in charge of my health? Who is responsible and accountable for what? These are the questions that many patients are asking with increasing panic.

It is a revelation to anyone spending time in a hospital to discover how little of hospital activity is actually managed. The closer you get to the patient, the less management there is. No single person appears to have the authority to oversee all the elements of a patient's care, pull them together and take responsibility for that person's wellbeing.

Whether you enjoy attentive nurses, a proper diet and clean wards is simply pot luck. Nor can this arbitrary standard of care be blamed wholly on staff shortages; rather, it is a catastrophic failure of management, combined with substandard training, that has brought about a crisis in the wards.

A nurse consultant who prepares hospitals for audits gave me an example of a scene that she comes across every day in the NHS. She had walked into a ward where a second-year nurse was taking care of six patients, unsupervised by a senior nurse. An old man wearing an oxygen mask was sitting in bed, staring disconsolately at a wash bowl. Next to the wash bowl lay his breakfast, uneaten, and beside that, an overflowing sputum pot. A full bottle of urine dangled beneath the bed.

The nurse had left him with the wash bowl "to do what he could". No one had taught the nurse that she should clear everything away first, remove the urine bottle and then present the bowl of water. No one had taught her the purpose of nursing: to do for the sick what they cannot do for themselves.

The training of nurses has promoted them further and further away from the interests of their patients. In the late 1980s, nursing turned itself into an academic profession. Nurses desiring increased status and greater parity with doctors sought to transform their training into a graduate profession. The result is "a frigging mess", according to a member of the King's Fund, a charitable foundation concerned with health.

One senior staff nurse at a hospital in the West Country, who teaches at the local university, pointed out - logically enough - that the academic status of the qualification means "there has to be a lot of theory". But there is too much theory, too much emphasis on social policy and communication skills - and not enough practical work.

At a London A&E department, a staff nurse who had recently qualified complained to me that her training had not prepared her at all. In 18 months of study, she had spent only one and a half hours learning how to take blood pressure and a patient's temperature. On the other hand, a whole afternoon had been devoted to poverty in Russia.

"They don't prepare you for the things that matter," said the nurse. Instead, she had learnt how to approach a patient and what mannerisms to adopt. She shrugged. "If you don't know that already, then why are you becoming a nurse?" she asked rhetorically. Or, as an Irish sister of 17 years' experience put it: "No, I have never felt the lack of studying sociology. Kindness and common sense go a long way.''

The staff nurse had been astonished to discover how little anatomy or physiology her course contained. Anxious that her grasp of these essential subjects was "not as good as it could be", she approached her tutors. But they took a relaxed view.

Soon, she discovered that her ignorance did not matter. Her first exam, tackled after 18 months, was multiple-choice; her final exam, at the end of two and a half years, allowed her to answer three out of six questions, and so avoid revealing her ignorance.

For assignments, her tutors had set her work on social issues and ethics - including patient rights. That patients might have a right to a person qualified in how to look after them did not seem to have occurred to her teachers. She said: "Theoretically, you could go through the whole three years without anyone asking you about bed sores." She managed to qualify with only a vague knowledge of the bodies soon to be in her charge.

After graduation, she recalled vividly putting on her uniform for the first time and pinning on her badge. She had looked at herself in the mirror with a sense of disbelief. "You are expected to cope with situations that you know you just can't. There is no one to ask - or they are too busy or they don't know because they are agency nurses."

Another nurse recalled the shock of her own first days on the ward, with phone calls coming in from everywhere and acutely unwell patients. In one 10-minute period, she had to arrange transportation for a patient, give morphine to a man screaming for pain relief and see to another in a side room, who was dangerously short of breath.

"I was on my own. I did not know which way to run, which was the most important. I remember thinking, 'Shit, I just want to get out of here'.'' She added: "I learnt more in the first three months on the job than in three years at college.''

The Irish sister had scant respect for new nurses: "They picture themselves at a computer or with a doctor on his rounds. They are horrified to discover that 90 per cent of their time is doing things for the patient.

"I see nurses walk past a patient, ignoring his distress. I will not have on my ward a patient apologising because he needs to ask for care. We are dealing here with sick and vulnerable people, many of whom are dying. I aim to see them die in dignity and comfort, and for their relatives to have good memories of their last few weeks.''

The Irish sister's training had been very different - learning practical skills side-by-side with what she was studying in the classroom. She had practised washing a patient and making beds. Every three months, she had taken a three-hour exam in the morning, followed by a two-hour exam in the afternoon. "If you failed, you had one chance to repeat it - then out. You also had to go through every task observed by a nurse until you were ticked off on it."

A former matron recalled being watched and criticised - "and woe betide if you got anything wrong" - while learning to wash a patient, feed him, put on a dressing and make him comfortable. "No one learns how to make a patient comfortable any more," she said sadly. Rather like the concept of hot milky drinks - which she used to offer to patients every night at eight o'clock - the idea of comfort got jettisoned in favour of social policies.

Once on the ward, "a nurse took you under her wing to show you the ropes", recalled the Irish sister. Nowadays, the overseeing and training of newly qualified nurses can be overlooked. One staff nurse said that the atmosphere on her ward is so unfriendly that when "you screw up your courage to ask someone to show you a procedure, they give you a withering look''.

A sister explained to me that, when a nurse asks for help, "you have to set aside half an hour to show her how to do it. If you don't give her the time, she will make a mistake. But we don't have the time.''

Thirty years ago, the newly qualified nurse knew exactly what was expected of her. In one morning, she might be asked to polish all the bed pans, or give each of the 17 patients on the ward an "up" bath. Then, when she became a senior nurse, she dressed all wounds on the ward.

In the mid-1970s, task-centred care changed to client-centred care. Each nurse was allocated a group of patients for whom she did everything. "All that did was create a mountain of paperwork," said the sister. Nurses had to assess their patients, then plan their care - and all this had to be written down. It was fine if there was enough staff. But if a nurse had to cover for a colleague, she suddenly had 10 patients about whom she knew nothing.

The former matron said she had heard a woman asking a nurse for a bedpan for her mother. "She's not my patient," said the nurse.

The irony is that nurses thought that making their qualifications more academic would gain them the respect of consultants. This does not seem to have happened. Nearly every consultant I interviewed complained that the standards of nursing were, as one put it, "dangerously low". He added: "It's very frustrating to see our patients treated to such poor standards of care.''

A consultant anaesthetist at a London teaching hospital complained of patients arriving for operations with bed sores. On ward rounds, he frequently found himself helping patients to eat.

"The catering staff slam the food down. No one bothers. Spooning food into a patient is just too demeaning for professional nurses, it seems. I always thought nurses were meant to care for patients. I might be wrong. I may have missed the plot somewhere.''

Another described the difficulty of trying to find a particular patient on a ward. Every patient is supposed to have his name above the bed. But, in some hospitals, they refuse to display the name "in case it infringes your autonomy". So the consultant found himself wandering around, trying to find his patient. "There never seems to be anyone in charge who knows anything," he said.

He would try to find the patient's nurse. Then the patient's notes. "I don't often strike lucky with all three." Finally, he had to translate the nurses' diagnoses. "They refuse to use hierarchical, male-dominated medical terms, so they will not say the patient is unconscious. No, the patient has to have 'an altered state of awareness'.''

The voluntary service co-ordinator of one hospital told me a shocking story. As he was passing a room, he heard an elderly lady call urgently: "Please take me to the toilet. I have been pushing and pushing the button, but no one will come." He pointed out that only a nurse could take her and went to find one.

Three were clustered about the nurses' station, listening to Radio 1 and dipping into a box of chocolates. The co-ordinator told them about the patient, adding: "Can't you hear her calling?"

"Oh, she's always calling,'' they said, without moving. When he went back, he found the old lady face-down on the floor. He returned to the nurses. "You had better come now," he said. "I think she's dead." The voluntary service co-ordinator added: "That has happened more than once.''

Many of the patients I met had stories of neglect. One woman suffering from a placenta praevia found herself abandoned in a side room. No one came. No one checked her blood pressure or temperature. Her catheter was left in for three days. The toilets were all blocked up.

Finally, her cousin - a qualified gynaecologist - came to visit and was so appalled that she had a showdown with the nursing staff. "I would have had better treatment in the Third World," remarked the patient.

Many also told of unexpected kindness and good nursing. One woman said: "The older ones are better. The younger ones are quick to tell you: 'That's not my job' or 'That's not my patient'.''

An older nurse had taken her down to the theatre for her operation and kissed her. "It was so comforting and sweet - it made a big difference to me." But whether patients received a kiss or a reproof for "whingeing" - as one man did after a traumatic road accident - seemed entirely a matter of chance.

The attitude of the nurses is of enormous importance to a patient who is helpless and totally dependent. It is bad enough being ill and in pain. To be abandoned or treated unkindly is almost insupportable.

Traditionally, sister attended the ward round with the consultant. She saw her job as taking the patient's side and putting the patient's point of view. She had, after all, taken care of the patient over the past 24 hours. The loss of sister's authority means the loss not just of patient care, but also of a patient's advocate.

Nursing is mainly done by young women, and there is a constant turnover and shortage of nurses - particularly at the lower grades. Until recently, the only way to gain promotion or an increase in salary was to move into management. This takes nurses and auxiliary nurses away from the patient and the practical care at which they should excel.

Sir Stanley Kalms, an entrepreneur who became chairman of an NHS trust for three years, remarked: "People say nurses are angels. Well, nurses are employees who do nursing." And, like every other employee, they need managing. The "modern matron" - a new post that puts a senior nurse in charge of three or four wards - lacks the tools to manage her nurses. One former matron, now a nurse consultant in audit work, pointed out how difficult it was, for example, to discipline a nurse for incompetence.

First, the busy matron or sister (who looks after one ward) has to notice what is going on - and most are too occupied to do so. Then, even if she does, discipline in the no-blame culture of the NHS is a "long-winded process".

The emphasis is on being "nice" and making sure no one is blamed. She continued: "You can't bawl them out or they'll sue you for harassment." Instead, "in a nice soft voice, you have to ask if that was the way she was taught. Does she consider it appropriate care?"

Modern management is meant to "nurture" its employees. So, the errant nurse is offered training, supervision and, of course, she is given another chance. This can go on for a year. "In the meantime," said the former matron, "patients are going through her hands and suffering.''

Most matrons or ward managers take the easier option and promote the incompetent "to get them out of your hair", she said.

Even if the nurse is disciplined, the modern matron faces a further difficulty. Who will replace the nurse? A bad one is better than none. Trusts around the country are struggling to find the staff they need for present workloads, let alone take forward government plans. Hence, the shortage of nurses insulates the profession from the normal disciplines of working life.

Nurses enter the profession to care for people. Yet their training, combined with the lack of supervision on the wards, robs them of the means to show their compassion. Those who do manage to give good care succeed despite the system, not because of it.

A male modern matron with 15 years' experience in the NHS summed up a view I heard from nearly every medical person I interviewed, including many nurses themselves: "I would not trust my dog, let alone my mother, to many of them.''

The failure of management around the patient is evident in other areas. Many patients, for example, complained about the food: it was inappropriate for their age or illness (elderly people are flummoxed by pizza), it was plain bad, or it simply didn't arrive. "My family bring me sandwiches," one old lady told me. Another commented: "I just took one look at [the meal] and I said no.''

One woman had not eaten for 48 hours. "They did offer me a tea cake which had been in the fridge for months. I had to throw it away." Her nurses seemed indifferent or helpless.

The NHS Magazine states that 40 per cent of adults are suffering from malnutrition on hospital wards. Many elderly patients are already malnourished on arrival, but studies show that their condition deteriorates in hospital.

Malnutrition results in "substantial" morbidity and mortality, complicates illness and delays recovery as well as reducing wound-healing and increasing the risk of infection. The King's Fund estimates that this costs the NHS £226 million a year. The fact that so many elderly people are actually going hungry on our wards, unnoticed, is an appalling indictment of the NHS and the management of the wards.

Essence of Care, a book distributed by the Department of Health, describes best and worst practice for patient care - from bed sores to feeding, from patient notes to incontinence. The book also categorises levels of care, beginning with "deliberately negative and offensive behaviour and attitude".

These basics are what nurses 30 years ago learnt as a matter of course. These basics were nursing. Now, the Department of Health has to regulate something as fundamental to the sick person as privacy and dignity. As a member of the King's Fund said: "What state must nursing be in that the NHS should have to put this around? "

The foreword by Sarah Mullally, Chief Nursing Officer, makes grim reading. Essence of Care, she writes, focuses on those "core and essential aspects of care" that matter to patients "quite rightly", yet that rarely attract the attention they should during the "quality improvement process''.

You cannot help but wonder at a "quality improvement process" that fails to notice bed sores or malnutrition. Ms Mullally suggests throwing a weekly tea party at which carers and patients can "express concerns". Here, then, is our modern culture of caring. Bed sores and malnutrition alongside tea parties, and a happy experience for all concerned.

There can be no doubt that the lack of management around the patient is due to matron's loss of power and the shift from the practical to the academic in nurse training.

Yet this has not been recognised, let alone tackled. If the Government was serious about improving patient care, it would give hospitals the power to pay nurses a proper wage and modern matrons the power to hire, fire and reward staff.

I met many dedicated sisters and nurses. But, in this situation, dedication is not enough. There is only so much difference an individual can make in a system that fails to support her. The focus of caring for the patient has been lost - and the effect on the patient is devastating.

This article is an edited extract from Managing not to Manage, to be published on Tuesday by the Centre for Policy Studies. To order the full pamphlet please send a cheque for £10 to Centre for Policy Studies, 57 Tufton Street, London SW1P 3QL

[gwenith, BSN, RN]

Originally posted by fergus51

Especially in Australia, seeing as they are all felons sent there from Englad right? Only kidding, I have never met an Australian I didn't like:)

:rotfl::rotfl::rotfl:

I wish I had the figures to show you but the other day I attended an "M&M" meeting - Morbidity and Mortality meeting where we look at outcomes. The Consultant who was presenting the findings was discussing patient outcomes as measured by the APACHE 2 scoring system. We are not only doing better than predicted with survival rates - we are doing MUCH better than predicted.

[fergus51]

OK, off topic but, you think that US nursing students are well prepared for life on the unit? Or that they are much more caring and less uppity than their british counterparts? You can search through this bb or any other and you will see that is seldom the opinion of those of us already working.... Unfortunately too many nurses graduate without the skills or the knowledge they need and a multiple choice NCLEX does not measure that ability....

That said, I have never worked with an incompetent or uncaring nurse from the UK. In my experience (and I have some) they are excellent nurses and patient advocates, though I can't comment on their training. I have worked with some great new grads and some bad ones, but I can say the same for nurses who have been out 30 years

[kitkat24]

Australia's Public Health Care System

The following 'typical' patient case descriptions attempt to illustrate how Australia's healthcare system is beginning to fail the average Australian in not providing adequately accessible and affordable medical and hospital services. Despite Medibank's original objective in 1974 to avoid creating a two-tiered system, Australia's healthcare system has effectively created two classes of service based upon the patient's ability to pay and placing financial burdens on the average Australian income earner and the longer waits for care from public hospitals.

John's knee

John is a fit and healthy sports-minded twenty-three year old who recently graduated from University, and joined a government department as a full-time casual employee. He is invited to join a departmental touch football team to play after work. He joins, pays the club membership fee (which includes basic medical insurance) and unfortunately, in his first game receives torn knee ligaments from a playing accident. Almost unable to walk the next day, he visits his doctor and is referred to an orthopaedic specialist who, after x-rays, advises arthroscopic surgery to clean up torn cartilage and fully assess possible reconstructive surgery of the knee ligaments.

John is advised that he can wait for a public hospital which is likely to take several months, or pay around $2,500 for the assessment to be carried out within four week in a private hospital. He would be eligible to claim back the scheduled Medicare fees for doctors, surgeon and operational assistants from the government. With seemingly little choice, John borrows the money and undergoes the operation.

Following the operation John is advised he will need a further operation for a ligament reconstruction with knee function likely to deteriorate the longer the operation is delayed. Public hospital availability would be at least 12 months but again, for around $3,500, a private hospital could be booked and the knee done within the month.

John, faced with further financial debt, decides to evaluate his options. He reviewed his costs and benefits to-date to discover that the total cost of the injury (GPs, specialists, surgeons, hospital and health services) amounted to $2,600 with the Medicare benefit ($620) and insurance refund ($875 for 75% of hospital cost less a $75 deductible) totalling $1,500. The residual $1,100 is John's out-of pocket expense - representing 43% of the total cost and resulting from residual Medicare schedule fee balance("the gap"), extra billing and residual hospital costs.

Joan's throat

Joan, a nineteen year old young adult is suffering from a sore throat and after a number of days of discomfort and aspirins discover she cannot swallow and goes to the Emergency department of a public hospital for treatment. She is admitted for two days and treated with antibiotics for swollen tonsils and suspected Quinsy as a public patient at no resulting cost to her. Before being released she is seen by the hospital specialist who warns that if her tonsils again become swollen or infected again she will need to have them removed.

Several weeks later while visiting another city, Joan's tonsils again become swollen and so visits a medical clinic where the general practitioner (GP) prescribes a course of antibiotics to control the infection until she can visit her own local GP. The GP refers Joan to an Ear Nose and Throat (ENT) specialist who prescribes another course of antibiotics. After the course of antibiotics her tonsils become inflamed again causing the specialist to recommend surgical removal of the tonsils while classifying the patient as Non-Urgent (category 3).

Wait times for category 3 public patient awaiting tonsil removal in a public hospital was estimated between 12 and 24 months. Alternatively, Joan has the option of paying around $2000 to have the specialist remove the tonsils in a private hospital within the next four weeks.

Joan began to evaluate her options of risking any side effects of drugs and antibiotics treatment for over a year, or borrowing money for an early operation knowing the private hospital cost and extra billing and balance of the Medicare benefits amounted to an patient out-of-pocket expense (the gap) would amount to approximately $1000.

[fergus51]

Ok, now I am really confused kitkat.... I thought you WANT a private system where the patient is the customer.... So why is it a bad thing that they have it in Australia AND those who can't pay can still get care in a public hospital? Isn't that better than having a private system without any public backup for those who can't pay? Seems like the best of both worlds. I know I would rather wait and get treatment in a public hospital than not get it at all, or have to mortgage my home to get treatment, but that's just me.

[kitkat24]

Michael Cannon is a senior fellow with the National Center for Policy Analysis in Dallas.

Executive Summary

No. 509 February 5, 2004

In 1992 Gov. Bill Clinton of Arkansas unseated

incumbent President George H. W. Bush in part by

tapping voter dissatisfaction with the rising cost of

health insurance and the growing number of

Americans without health insurance. Despite a

massive legislative campaign directed by then-first

lady Hillary Rodham Clinton, the Clinton administration's

sweeping proposal to increase federal

control over the health care sector languished and

eventually died in Congress. Today, with health

insurance costs once again rising at double-digit

rates and the number of uninsured Americans at a

new high, the Democratic candidates for president

have lined up their own health insurance reform

proposals. The major candidates are Army Gen.

Wesley Clark (ret.), former governor of Vermont

Howard Dean, Sen. John Edwards (NC), Sen. John

Kerry (MA), Rep. Dennis Kucinich (OH), Sen. Joe

Lieberman (CT), and Rev. Al Sharpton. Before leaving

the race, Rep. Richard Gephardt (MO) also put

forward a major health care proposal.

Unfortunately, the candidates' health plans

reflect the same misconceptions as and rely on

approaches similar to those of the failed Clinton

health plan. Like the Clinton health plan, they

misdiagnose what ails the health care sector;

would attempt to direct the provision of health

care from Washington, DC, through increased

taxes, government spending, and bureaucratic

control; and would magnify the perverse incentives

created by past government interventions.

Like that of the Clinton health plan, their

response to the use of unconstitutional government

power in the health care sector is to wield

even more unconstitutional power.

The five major candidates (Clark, Dean,

Edwards, Kerry, and Lieberman) would take incremental

steps toward a government-run health

care system. The two long-shot candidates in the

race (Kucinich and Sharpton) take a more aggressive

approach, calling for an immediate government

takeover. Although Sen. Hillary Rodham

Clinton (D-NY) disappointed many Democratic

Party faithful by forgoing a race for president this

year, judging by the health care proposals of the

current field, her influence is being clearly felt.

Mrs. Clinton Has Entered the Race

The 2004 Democratic Presidential Candidates'

Proposals to Reform Health Insurance

by Michael F. Cannon

Introduction

Americans endure rising health care costs,

diminished access to health care, and high

levels of frustration as a direct result of

health insurance being among the most government-

dominated sectors of the U.S. economy.

Instead of a market where health care

providers and patients benefit each other and

society by pursuing their self-interest, government

involvement in health insurance

markets has given America a system that substitutes

waste for economy, rising prices for

affordability, and bureaucratic dictates for

consumer choice.

In a free market, consumers and producers

make voluntary exchanges that benefit

both parties. In a genuinely free market, consumers

motivated by their own self-interest

will naturally make decisions that reward the

most efficient producers, while punishing

inefficiency and high prices. As a result, producers

search for less costly ways of meeting

consumer needs. In that environment, prices

convey information. They signal to consumers

the cost to society of providing various

products at different points in time. To

producers, prices convey information about

what consumers want, helping them identify

activities useful to consumers and avoid

unwanted activities. Over time, this process

makes an ever-increasing number of products,

of ever-increasing quality, available to

an ever-larger number of consumers.

In America's health care sector, government

blocks the market process by hiding

prices from patients, thus encouraging

patients to consume more care and demand

less value. This denies patients information

on how their actions affect others, a necessary

component of controlling costs and eliminating

waste. At the same time, it denies producers

information about what consumers value

most. Rather than let producers be guided by

prices that reflect consumer preferences, government

distorts prices or sets them arbitrarily.

This encourages producers to pursue lawmakers'

preferences instead of consumers'--

and to lobby for prices that reflect their own

preferences. Denied the necessary information,

consumers and producers are less able

and willing to circumvent waste, inefficiency,

and high prices. Controlling health care costs

and improving patient satisfaction require

reforms that bring consumers' preferences to

the fore by removing government's preferences

--by deregulating health insurance and

restoring incentives for patients to demand

value.

The health plan proposed by President

Clinton in 1993 would have taken America in

the opposite direction. Government would

have encouraged patients to consume more

medical care and demand even less value,

sending more distorted signals to producers

through greater use of price controls. The

information necessary to promote health

care quality and eliminate waste would have

been even more severely restricted.

Although the details of their proposals

differ, the Democratic candidates for president

in 2004 are all basically following the

approach of the Clinton health plan. They

would expand "coverage" with vast subsidies

and mandates, encouraging Americans to

consume even more medical care. And they

would empower others--employers, insurers,

and government bureaucrats--to tell consumers

when they have had enough.

The candidates' plans reflect a consensus

among many observers that rising health

care costs must be remedied with additional

regulations and subsidies, that the problem

of millions of Americans who lack insurance

must be addressed by doing whatever

expands "coverage." That is understandable.

Many people who would like to purchase

health insurance find it priced beyond their

means, and once one is "covered" many medical

expenses are passed on to someone else.

This analysis is a misdiagnosis of the problem.

Health care costs and the number of

uninsured continue to rise, not for lack of

government, but because too much government

has crippled the normal market

processes that make health care of everimproving

quality available to an ever-larger

share of the population. The candidates' pro-

posals would add even more government to

the mix.

How much more? Between 2005 and 2013,

the candidates' proposals would cost anywhere

from $591 billion (Edwards) to $6.268

trillion (Kucinich). To put this in perspective,

consider that the prescription drug entitlement,

recently enacted as part of Medicare

reform and considered the largest new government

program since the Great Society, is estimated

to cost only $410 billion1 (Figure 1).

Financing any of the proposals would require

the next president to repeal all of the tax cuts

enacted in 2003 ($140 billion from 2005 to

2013) and a significant portion of the tax cuts

enacted in 2001 ($1 trillion from 2005 to

2011).2 The U.S. Department of the Treasury

estimates that repealing the 2001 and 2003

tax cuts would raise taxes an average of $1,544

for more than 100 million Americans and cost

a married couple with an income of $40,000

and two children $1,933 annually.3 At least

two of the proposals would require further tax

increases.

The proposals are likely to cost much

more than projected and would add to an

already growing burden on taxpayers. Cost

projections have repeatedly and famously

underestimated future spending on government

health programs and other entitlements.

4 Gail Wilensky, who administered

Medicare and Medicaid for President George

H. W. Bush, said of the new Medicare prescription

drug benefit:

If history is any guide, it will cost more

than we think. . . . Not because people

are deliberately low-balling the estimates,

but because we have never been

able to correctly estimate the cost of a

new benefit, and this one is much bigger

than most.

For example, when Medicare was enacted,

hospital costs were projected to be $9 billion

in 1990. Actual spending in 1990 was more

than $66 billion.6 There is no reason to

believe the costs of the candidates' health

insurance proposals will be lower than projected;

there is ample reason to believe they

will be higher.

Government spending on those proposals

would compound the enormous budgetary

pressures of existing federal entitlements.

The present value of the future fiscal imbalance

of Medicare and Social Security alone is Between 2005 and 2013, the candidates' proposals would cost anywhere from $591 billion

(Edwards) to $6.268 trillion (Kucinich).

estimated to be more than $43 trillion before

the new prescription drug benefit is added.7

Under current law (again before adding the

cost of the new Medicare benefit), Social

Security, Medicare, and Medicaid will consume

nearly 80 percent of federal spending

by 2040.8 In addition to placing new duties

on taxpayers, the candidates' health proposals

would make existing obligations greater

by subjecting Medicare and Medicaid to

greater medical inflation.

The cost of those proposals, however,

would go well beyond federal outlays. Each

would impose hidden costs on employers and

workers and lead to greater state government

spending. The costs include dampened economic

growth resulting from higher tax rates.

People who oppose the influence of money

in the political process will find much to dislike

about the candidates' health insurance

proposals. Each would increase government

control over the health care sector and with it

the amount of money spent to influence how

government exerts that control. By conservative

estimates, health care interests spent more

than $600 million on political contributions

and lobbying activities in the 2001-02 election

cycle.9 Health professionals make the second

highest contributions to congressional campaigns.

10 Health care groups ranked second in

terms of dollars spent on lobbying activities in

2000.11 The health care industry's interest in

government is a direct result of government's

influence over the health care sector. Under

any of the candidates' proposals, health care

regulation would increase and with it political

contributions and lobbying activities of health

care interests.

Finally, the candidates' proposals would

expand the federal government's power far

beyond what the Constitution grants.

Fidelity to the Constitution requires reducing

federal power over the health care sector.

A positive agenda for improving America's

health care system would focus, not on the

candidates' paper guarantee of "coverage," but

on restoring the market processes that make

health care of ever-improving quality available

to an ever-greater share of the population.

Remembering the Clinton

Health Security Act

In 1993 a Clinton administration task

force, directed by First Lady Hillary Clinton,

devised and proposed a sweeping reorganization

of America's health care sector. The

Clinton health plan would have increased

government controls and exacerbated trends

of rising costs and waning consumer sovereignty.

Under the Clinton Health Security Act,

the power of individuals to make countless

choices about their health care would have

been handed over to government, and the

few remaining market mechanisms that contain

costs and promote quality would have

been lost. The federal government would

have compelled all Americans to buy health

coverage, dictated what type of coverage they

would receive and where they would "purchase"

it, set prices for coverage and medical

services, and encouraged states to form their

own single-payer health care systems.

Commenting on the Clinton health plan, The

Economist wrote,

Not since Franklin Roosevelt's War

Production Board has it been suggested

that so large a part of the American

economy should suddenly be brought

under government control.12

Though it might have left some private

health insurance companies standing, the

Clinton health plan would have let government

direct the financing of medical care to

such an extent that America could no longer

have been said to have a private health care system.

Rising costs, diminishing quality, and

rationing of care would have been exacerbated

in the United States as they have been under

other socialized health systems. Notable features

of the Clinton health plan follow.

Compelled Behavior

The most draconian aspect of the Clinton

health plan was its mandates on individuals

and employers. The federal government

would have compelled Americans to purchase

health insurance whether they wanted

it or not, forced employers to pay 80 percent

of the cost, and subsidized premiums for

low-income individuals and small employers.

The option to decline health insurance coverage

would have become a right no American

could exercise, and health insurance "premiums"

a tax few could avoid. In 1993 David

Rivkin of the American Enterprise Institute

commented on the unconstitutionality of

the individual mandate:

In the new health care system, individuals

will not be forced to belong because

of their occupation, employment, or

business activities--as in the case of

Social Security. They will be dragooned

into the system for no other reason than

that they are people who are here. If the

courts uphold Congress's authority to

impose this system, they must once and

for all draw the curtain on the

Constitution of 1787 and admit that

there is nothing that Congress cannot

do under the Commerce Clause. The

polite fiction that we live under a government

of limited powers must be discarded

--Leviathan must be embraced.13

Standard Benefits Package

The federal government would have controlled

the coverage citizens received. A

National Health Board would have been vested

with the responsibility and power to make

billions of decisions that consumers would

otherwise have made for themselves. That

panel of "experts" would have dictated what

types of health insurance Americans would

purchase, how much they would pay in premiums,

and how much could be spent on

health care nationwide.

The board would have been charged with

constructing a package of health benefits

that all Americans would have had to purchase.

Creating a one-size-fits-all standard

benefits package ignores the fact that there is

no "right" package of benefits. Individuals

have different preferences when it comes to

health insurance, just as they do when it

comes to doctors, cars, and clothes. Imposing

the same coverage on everyone means many

people will be forced to purchase benefits

they do not want. For example, the Clinton

health plan would have required Americans

to buy coverage for elective abortions.14

Declining unwanted, government-mandated

benefits today can be difficult. It may involve

dropping coverage, changing jobs, or even

moving to another state. However, any of

those is easier than passing a new federal law

or leaving the country, which is what would

have been necessary under the Clinton health

plan. Insofar as a standard benefits package

forces consumers to buy benefits they otherwise

would not, it encourages them to consume

more care to obtain some value for the

money they would rather have spent elsewhere.

In addition to the National Health Board,

the Clinton plan would have impaneled a

National Quality Management Council to

develop standards of quality coverage and

care. All health plans would have been

required to comply with the council's quality

guidelines. In effect, the council would have

substituted its judgments about quality for

those of more than 250 million consumers. It

is certain that such a panel's judgments

would have delivered quality in some

instances and failed in others. Patients

adversely affected by the council's judgments,

however, would not have had the

option of avoiding them. Care could have

been delivered only according to the council's

guidelines.

Price Controls

The National Health Board would have set

prices and spending levels for the entire health

care sector. No health insurance premium

could have exceeded the average for a geographic

area by more than 20 percent. Many

observers predicted this price control would

health plan's premiums would have been the

same for everyone--young and old, healthy

and sick--within a politically determined geographic

area. Forcing people with below-average

needs to subsidize those with above-average

needs would have stimulated demand

among both groups. The former would have

wanted to get the most value for their forced

contributions, and the cost of coverage and

care for the latter would have been dramatically

lowered. The board also would have controlled

spending nationwide by drafting global

budgets that dictated how much could be

spent on medical care in a certain geographic

area. Global budgets in other nations have

invariably led to rationing of care.15

Health Alliances

Another feature of the Clinton health plan

was "managed competition": government

would bring together private insurers and consumers

in an artificial marketplace, much like

the Federal Employees' Health Benefits Plan.

The Clinton health plan would have created

state-based "regional health alliances" to serve

everyone within a geographic area, with the

exception of those working for certain large

employers. The alliances would have been

operated by state governments or quasi-governmental

agencies and would have been

responsible for enforcing the dictates of the

National Health Board and the National

Quality Management Council. Individuals

would have been automatically enrolled in

their regional health alliance and in some

instances automatically assigned to a plan.

Although consumers could have chosen

among a few health plans, those options

would have been heavily restricted by a standard

benefits package, price controls, and

other regulations. Moreover, third-party payment

and other perverse incentives would

have been intensified. The alliances would

have created a semblance of competition, but

without the economizing incentives that

come from allowing risk-based insurance pricing

or letting consumers decide how to spend

their health care dollars. Consumers would

have continued to pay a small fraction of the

cost of the medical care they consumed,

encouraging them to demand more care but

less value. Community rating would have

encouraged consumption but discouraged

healthy behavior.

Not every American would have been

forced into a regional health alliance. Certain

large employers would have been allowed to

operate their own alliances, though they

would have been required to conform to the

same benefits, pricing, and quality standards

and would have faced other incentives to join

a regional alliance. The Clinton health plan

also would have encouraged states to launch

single-payer health care programs, under

which the state would finance medical care

for everyone within its borders. Interestingly,

federal employees, including members of

Congress and many of those who drafted the

Clinton health plan, would have been excluded

from regional alliances for four years after

the first Americans were forced to enroll. Had

the regional alliances not met the planners'

expectations, that would have granted politically

powerful federal workers enough time

to carve themselves out of the alliances permanently.

Higher Taxes

The Clinton health plan would have resulted

in a massive tax increase. The Clinton

administration initially estimated its health

plan would save taxpayers money, though few

people believed that prediction. As one observer

noted at the time:

[V]irtually all of the perverse incentives

of the current system are to be left in

place, while the Administration is

expanding coverage for the millions

who are uninsured. This amounts to a

stimulation of demand, combined

with a constriction of supply. This is

akin to turning up the heat on a pressure

cooker, while clamping down on

the lid. At some point, the lid will blow

and the costs of the system will skyrocket

in bigger deficits and even higher

taxes.

Under heavy criticism, the Clinton administration

was forced to admit the program

would cost taxpayers an additional $700 billion

over five years, and some observers maintained

it would cost significantly more in

higher tax revenue and lower economic

growth.17

An Incremental Approach

The Clinton health plan was so massive in

scope that it collapsed of its own weight.

Since its defeat, supporters of greater government

control over the health care sector have

focused on incremental rather than wholesale

measures. As President Clinton told a

group of supporters in 1997:

I'm glad I tried to do the health care

plan. . . . Now that what I tried to do

before won't work, maybe we can do it

in another way. That's what we've tried

to do, a step at a time, until eventually

we finish this.18

One of those steps already has been taken.

Internal documents from the Clinton administration's

health care task force reveal the

group considered a number of options for

phasing in "universal coverage" starting with

children. Phasing in full government control

first for children and then later for adults was

discussed with the task force by a senior aide

to Sen. Edward Kennedy (D-MA), a longtime

advocate of a single-payer system.19 In 1997,

with the help of Senator Kennedy, the

Clinton administration created the State

Children's Health Insurance Program, which

expanded government financing of health

care to cover more low-income children. The

2004 Democratic presidential candidates'

proposals would take the next several steps

down this road.

2004: The Democratic

Presidential Candidates

Many features of the Clinton health plan

have resurfaced in the health platforms of the

Democratic candidates for president in 2004:

expanding government health programs; individual

and employer mandates; a standard

benefits package; government quality standards;

price controls; health insurance subsidies;

exemption of federal workers from rules

that govern others; and higher taxes, both

explicit and hidden. One ostensible difference

is the proposal to use tax credits to expand

insurance coverage (Clark, Dean, Edwards,

Kerry, Lieberman). Although tax credits have

the potential to curb third-party payment and

improve consumer choice through a more

equitable distribution of the tax subsidy for

health insurance, the tax credits proposed by

the candidates would do little more than subsidize

greater consumption of health care. The

five leading candidates (Clark, Dean, Edwards,

Kerry, Lieberman) would expand government

control over the health care sector incrementally

and subsidize health insurance with

refundable tax credits. The two long shots

(Kucinich and Sharpton) would go well

beyond even the Clinton health plan and

establish a nationwide single-payer system.

Features Common to All Plans

Higher Taxes, Hidden Taxes. The costs of all

of the plans for which cost estimates are available

would far outstrip the cost of the recently

enacted Medicare prescription drug benefit.

The least expensive plan (Edwards) would cost

a projected 40 percent more in 2013. The most

expensive proposal (Kucinich) would cost

nearly 17 times as much.20 The cost estimates

are likely to understate actual government

outlays and do not account for additional hidden

costs.

Financing any of the candidates' proposals

would require the next president to repeal

all of the tax cuts enacted in 2003 ($140 billion

from 2005 to 2013) and a significant

portion of the tax cuts enacted in 2001 ($1

trillion from 2005 to 2011).21 All of the candidates

have endorsed repealing a significant

portion of those tax cuts. Some propose

additional tax increases. Kucinich would

impose a 7.7 percent payroll tax to finance a

single-payer system.

Expanding Government Programs. Each

candidate would expand the reach of government

health programs. Even the incremental

expansions of Medicaid and SCHIP proposed

by some candidates (e.g., Dean) rival

the cost of the new Medicare prescription

drug benefit. The expansions would increase

the "entitlement" attitude toward health care

and diminish private-sector coverage. Again,

the proposals of the five leading candidates

would crowd out private health insurance by

as much as 50 percent of the proposed expansions.

22 The proposals of Kucinich and

Sharpton would crowd out the entire private

health insurance industry.

Price Controls. Each candidate would

expand the reach of government price controls

by expanding government programs at

the expense of private-sector coverage.

Government-determined prices would be

imposed on more transactions, and the share

of prices set by private payers would shrink.

In proposals containing health alliances (see

below), premiums would be community

rated, creating a disincentive for younger and

healthier risks, attracting more expensive

risks, and putting taxpayers on the hook for

the costs of adverse selection.

Standard Benefits Packages. Each proposal

would give government greater power to dictate

the type and level of health benefits consumers

would receive. This most obviously

would occur in government programs, but

candidates who would preserve a private

health insurance market would mandate

that consumers purchase governmentordained

benefits. Some would require certain

types of coverage and measures of quality,

while others would prescribe appropriate

deductibles and copayments.

Features Common to Some Plans

Individual and Employer Mandates (Clark,

Dean, Edwards, Kucinich, Lieberman). Forcing

consumers to do what government wants is

particularly detrimental to the goal of determining

what consumers want. Several candidates

would either compel certain individuals

to obtain coverage or compel employers to

provide coverage for some or all workers. The

mandates would be enforced by various tax

penalties.

Automatic Enrollment and Government

Monitoring of Insurance Status (Clark, Dean,

Edwards, Kerry, Lieberman). Several candidates

would set up procedures to enroll individuals

automatically in government health

programs or monitor their insurance status,

or both. Status would be monitored through

schools, the Internal Revenue Service, or

other government agencies. Candidates

proposing single-payer systems (Kucinich

and Sharpton) have not specifically addressed

these issues.

Cato Policy Analysis No. 509 February 5, 2004

Mrs. Clinton Has Entered the Race: The 2004 Democratic Presidential Candidates' Proposals to Reform Health Insurance

by Michael F. Cannon

Michael Cannon is a senior fellow with the National Center for Policy Analysis in Dallas.

--------------------------------------------------------------------------------

Executive Summary

In 1992 Gov. Bill Clinton of Arkansas unseated incumbent President George H. W. Bush in part by tapping voter dissatisfaction with the rising cost of health insurance and the growing number of Americans without health insurance. Despite a massive legislative campaign directed by then-first lady Hillary Rodham Clinton, the Clinton administration's sweeping proposal to increase federal control over the health care sector languished and eventually died in Congress. Today, with health insurance costs once again rising at double-digit rates and the number of uninsured Americans at a new high, the Democratic candidates for president have lined up their own health insurance reform proposals. The major candidates are Army Gen. Wesley Clark (ret.), former governor of Vermont Howard Dean, Sen. John Edwards (NC), Sen. John Kerry (MA), Rep. Dennis Kucinich (OH), Sen. Joe Lieberman (CT), and Rev. Al Sharpton. Before leaving the race, Rep. Richard Gephardt (MO) also put forward a major health care proposal.

Unfortunately, the candidates' health plans reflect the same misconceptions as and rely on approaches similar to those of the failed Clinton health plan. Like the Clinton health plan, they misdiagnose what ails the health care sector; would attempt to direct the provision of health care from Washington, DC, through increased taxes, government spending, and bureaucratic control; and would magnify the perverse incentives created by past government interventions. Like that of the Clinton health plan, their response to the use of unconstitutional government power in the health care sector is to wield even more unconstitutional power.

The five major candidates (Clark, Dean, Edwards, Kerry, and Lieberman) would take incremental steps toward a government-run health care system. The two long-shot candidates in the race (Kucinich and Sharpton) take a more aggressive approach, calling for an immediate government takeover. Although Sen. Hillary Rodham Clinton (D-NY) disappointed many Democratic Party faithful by forgoing a race for president this year, judging by the health care proposals of the current field, her influence is being clearly felt.

Full Text of Policy Analysis No. 509 (PDF, 26 pgs, 163 Kb)

[gwenith, BSN, RN]

Kitkat - thank-you mate I needed the laugh!!!!

I am not laughing at you - it is just that you are presenting as "proof" that the Australian Health Care system is worse than the USA's system an excerpt from the senate committee that is looking into the current system to see how fair and equitable it is. By it's very nature that committee will look for faults and holes within the system - why??? because they want to report to the government to recommend that we fix those holes.

Now what did the senate find? - well neither of those cases cited are exactly immediately life threatening but they do point to the fact that these people might have to wait for surgery to be done in the public system OR if they had private health cover it could be done straight away.

And your point is.............................?????

[NurseHardee]

OK, kitkat, I will. The entire premise that a national health care plan is like the mother of all HMOs is nonsense. HMOs are private enterprises that limit costs in order to make profits for the owners. A national health care system is not a profit making enterprise, and will try to cut costs on an entirely different basis.

You nead to stop and ponder some of this nonsense that you find on sites (leftwatch.com) where Brian Carnell can spout such tripe often and freely. It's unconvincing, because even places like Cuba are doing better on many indices of national health than the US, let alone comparing the US system with Canada's or Britain's.

In the US, never has so much money bought so little real health care. Carnell, the author of the article, is a Right Wing idealogue who hasn't a clue to making things any better, so instead, he thrives on pretending that other health systems are even more dysfunctional than the US's. The US system is a model for other countries that can only drive their standard of care down, as it is currently doing so in the US.

We need government to start to make decisions about health care based on more than just politicians being lobbyied and bought off by corporations. That's the Big Government plan we have at present. Big Government needs to make decisions about national health and security on something more substantial than trying to create a climate good for big bizness.

Nurse Hardee

---------------------------------------------

Comment specifically about this part:

Which brings up my other pet peeve about nationalized health plans proposed for the United States. Advocates of such plans frequently blast HMOs for interfering with the doctor-patient relationship by dictating what doctors can and cannot offer their patients. But a nationalized health system would simply substitute a single entity -- the federal health agency -- for the various HMOs. Call it the mother of all HMOs.

The trend in countries that have nationalized health care is not some utopian health care system where doctors get to treat patients regardless of cost. Rather it is a system where health care is explicitly rationed by state and/or national health care agencies and health care decisions are completely subsumed to the need to control costs.

ME:

When I post something like this, everybody just has this as a reply: "I am sure that you can find many articles to 'clog' up this BB". But nobody wants to discuss the findings:

So, should we just say, oh that is some conservative finding less disregard it like Fraser and Canada, or should we ponder it, question it, digest it, and take it to heart?

Kitkat

[dudenurse]

Kit Kat Im with you!!!

How on earth in a Government paid system are you going to have free market to hire fire your doctor. How do you think he will just pay for all the test and proceedures you may require. Are we creating a bottomless bank account from which any american (and illegal alien who happens to walk through the door). That is imposible the doctors hands will be tied because Big Brother will decide we cannot cover every proceedure (look at the cutbacks in our own medicare system. My God IT IS RIGHT IN FRONT OF OUR FACES YET WE CHOOSE TO IGNORE THE FACTS.

I especially agree with the comment about who the real enemy is. Its the lawyers who have driven up costs. Without malpractice suites we could probable cut proceedure costs in half (or enrich the Doc)

Yes this is my first post because this topic so enrages me.

Equal and socialized medicine for all will never work the way we imagine it like communism didn't work as imagined. Unlimited healthcare costs unlimited dollars money which to work will require unlimited taxes that I am already tired of paying.

Ok that was a bit of a broad generalization but food for thought.

Later

[NurseHardee]

Well, the Dude has given us the conventional US wisdom once again. And things are just Jim Dandy compared to the horrors that hide in the shadows he says.

[dudenurse]

Yup!!