Hospitals & Asylums
Summary of the National Health Insurance Report:
Compromise to Immediately Achieve Single Payer Universal Coverage and Progressively Realize National Health Insurance that is Free for All
By Tony Sanders
Proposed April 28, 2008
100 Page Manuscript www.title24uscode.org/nhi.doc
Background: The United States is the only industrialized nation that does not have universal coverage. Over the past twenty years employer sponsored health insurance coverage has become more expensive, offers less coverage, fewer companies and families are purchasing it and the number of uninsured people has risen.
Objective: Provide all Americans with affordable universal health insurance coverage as proposed by the American Association of Health Insurance Plans (AHIP) to improve health care and health outcomes and reduce disparities, if possible free of charge.
Method: Policy making is a process which yields sub-optimization, whereby the need to compromise among competing interests gives a solution that is acceptable but not optimal (Johnson 1995: 209). Therefore the federal government shall expand Medicaid to cover the uninsured and subsidize private health insurers and medical billing on the condition that they accede to a single payer system before being nationalized at some date in the future.
Backers: The movement for National Health Insurance is well organized by the Physicians’ Working Group for Single Payer National Health Care System (PNHP) in support of Rep. John Conyers’ bill the National Health Insurance Act H.R. 676. There is widespread popular support and the date of the release of this report Cincinnati Children's Hospital hosted a National Health Care Debate.
The Goal of Universal Health Insurance
The United States is the only industrialized country in the world without a universal health insurance system. Almost 20% of the non-elderly population lacks health insurance at any given time (Vladeck 2002). In 2007 15%, 45 million people, including 9 million children, were considered uninsured in the United States. They did not pay any health insurance premiums beyond the 2.9% federal Medicare tax, if they earned a taxable income at all. 54%, 162 million were insured through their employers. 5%, 15 million were insured individually. 13%, 39 million were insured through Medicaid. 12%, 36 million were insured through Medicare. 1%, 3 million are insured through other public insurance. 80% of the uninsured were employed. They either were not offered benefits from their employer or could not afford to purchase it. The remaining 20% were either unemployed or self-employed and not willing to pay high individual and family rates. In its Concluding Observations of 2001, the Committee on the Elimination of Racial Discrimination recommended that the U.S. take appropriate measures to ensure that the right to access health care is non-discriminatorily afforded to all. The most practical method of achieving universal coverage, that would least impact the existing statutory regime, is clearly to expand state Medicaid coverage to the uninsured on the basis of income.
America’s Health Insurance Plans (AHIP), an organization that represent more than 1,300 health insurance companies, advocates for universal coverage through subsidies to existing private insurers. Their plan is that the federal government would provide subsidies for the purchase of private coverage to individuals and families with incomes under 400 percent of the FPL. Individuals with incomes under 300 percent of the FPL should receive proportionally greater assistance. People at 100 percent of the FPL should be eligible for Medicaid. Insurers would become more reliant upon taxes but would continue to collect premiums from individuals and employers (AHIP 2006). Combined with a single payer health insurance this plan is a good way for Congress to work with the existing system to immediately realize universal coverage, improve bio-security by prohibiting medical billing, increase leverage in medical price negotiations and have the standing to nationalize the health insurance industry when the time is ripe.
Growth in health care expenditure has consistently outpaced growth in Gross Domestic Product (GDP) for three decades. The portion of the US gross domestic product (GDP) that is devoted to health care more than doubled, from 7.1 percent in 1970 to 15.3 percent in 2003. Although the US regularly spends more money on health care per person and as a percentage of its GDP than other Western industrialized nation, Americans have the lowest life expectancy and highest infant mortality rates, as well as the highest proportion of uninsured citizens (Coombs 2005: xiii). For instance the infant mortality rate for the U.S. is now higher than for many other industrial countries. A baby born in El Salvador has a better chance of surviving than a baby in Detroit. The infant mortality rate in Detroit is 15.5, compared to El Salvador's rate of 9.7. Canadians live three years longer on average. Cubans have both a lower infant mortality rate than the United States and longer average lifespan (Rowland & Hoffman 2005). Older Americans are significantly less healthy than their British counterparts - more diabetes, heart attacks, strokes, lung disease and cancer. Even the poorest Brits can expect to live longer than the richest Americans (Banks, Marmot, Oldfield, & Smith 2006).
According to CMS National Health Expenditure Accounts that date back to 1960 U.S. health care spending growth accelerated slightly in 2006, increasing 6.7% compared to 6.5% in 2005. Total health expenditures reached $2.1 trillion, which translates to $7,026 per person or 16% of the nation's Gross Domestic Product. The health spending share of GDP remained relatively stable in 2006, up by only 0.1 percentage point from 2005. As a share of the economy, health care has risen from 7.2% of GDP in 1965, to 8.8% of GDP in 1980, to 11.8% in 1991, to 13.4% in 2000, to over 16% of GDP today, and it is projected to be 20% of GDP just 10 years from now, unless cost containment methods are effective. Despite the high cost, the U.S. does not appear to provide greater health resources to its citizens or achieve substantially better health benchmarks compared to other developed countries.
Fig. 3 National Health Expenditures and Growth by Source of Funds 1970-2007
After 3 years of declining costs the 2006 growth rate of 6.9% was the lowest since 1999. Health spending share of gross domestic product (GDP) in 2005 was 16.0%, slightly higher than the 15.9% share in 2004. Health expenditure tends to be counter-cyclical and in times of recession health spending, particularly Medicaid, tends to increase. In 2005, governments financed 40%, $902.7 billion, of all health services and supplies while private sources financed the remaining 60 percent ($1,085 billion). Private health insurance premium growth also slowed in 2005, increasing 6.6% to $694.4 billion, compared with 7.9% in 2004. This was the third straight year that premium growth decelerated and the slowest rate of growth since 1997. The employer share of private health insurance was 74.4% in 2005, with employees paying the remaining 25.6%. Out-of-pocket spending for health care reached $249.4 billion in 2005 (Catlin, Cowan, Heffler & Washington 2007).
Over 150 million individuals received health insurance through an employer in 2005, making employer-sponsored coverage the most popular form of health insurance coverage for the non-elderly in the United States. However, in recent years, there has been concern about erosion in the availability of employer-based health benefits for workers, and especially low-income workers. From 1998 to 2005, the offer rate fell across the board, with an overall drop of 3 percentage points from 80% to 77% (DiJulio & Jacobs 2007). The percentage of workers with health insurance coverage is estimated to have slipped from 66 percent in 1979 to 54 percent in 1998. When sorted by hourly wage, 80% of workers in the highest brackets had health benefits in 1998, whereas only 26% of the lowest wage earners were so fortunate. Relatively few self employed individuals purchase policies because of the price. As income increases, the coverage rate increases, though even at four times the poverty level, only about a quarter of individuals purchased coverage. And among those with incomes at least 10 times the poverty level, only about half purchased coverage in the non-group market (Jacobs & Claxton 2008).
Together Medicare and Medicaid serve 87 million people at a combined cost of $602 billion. States served 52 million Medicaid beneficiaries at a cost of $305 billion in 2006. The Medicare program served 42 million people at a cost of $295 billion. One in five dollars used to purchase health services in 2006 came through the Medicare program, which finances about one-third of all hospital stays nationally. Since its inception, spending on Medicare has grown steadily, both in absolute dollars and as a share of the federal budget. By fiscal year 2007, Medicare’s $440 billion in total expenditures represented 16% of all federal outlays, exceeded only by Social Security benefits at $577 billion (21 percent) and military spending at $530 billion (19 percent). The Medicare Prescription Drug, Improvement, and Modernization Act of 2003 makes the most dramatic and innovative changes to the Medicare program since it began in 1965. The $37.4 billion Medicare prescription drug plan began its first year in 2006, after one year the plan costs less than expected (Hoadley, Hargrave, Cubanski & Neuman 2008). Enrollment in Medicare Advantage plans increased 63% 2005-2006, reaching 8.8 million beneficiaries in January 2008. Total Medicaid spending growth hit a record low of just 1.3% for FY 2006 as the result of defections to the Medicare Prescription drug plan in FY 2007 it rose to a higher but still relatively slow pace of 2.9%. More typical of expectations regarding Medicaid is during the economic downturn in 2002 when Medicaid spending growth hit a high of 12.7% at the same time state revenues plummeted hitting a low of -10.6 percent (Smith et al 2007). Workers' compensation programs in the 50 states and the District of Columbia and federal programs together paid $56.0 billion in medical and cash benefits in 2004, $26.1 billion was for medical care and $29.9 billion was for cash benefits (Sengupta & Reno 2007).
The National Health Insurance Act
In 2003 the Physicians’ Working Group for Single Payer National Health Care System proposed to eliminate all for profit hospitals and private insurance plans and the creation of a single payer national health care system that would cover every American and be financed entirely with government funds. The doctors say the efficiency of such a plan would save enough to pay for health insurance of all citizens who lacked coverage. Under their proposed system, modeled after the Medicare system, the government would pay private doctors to provide services and would cover all medically necessary services, including long-term care, mental health and dental services, and prescription drugs and supplies. Panels of medical experts and community representatives would determine what services were medically necessary and effective. By eliminating the high overhead and profits of private, investor owned insurance companies; the new system would save at least $200 billion a year. An increase in taxes to fund the new system would be fully offset by the elimination of insurance premiums and out-of-pocket costs.
H.R. 676, the “National Health Insurance Act/Expanded and Improved Medicare for All” offers to provide for comprehensive health insurance coverage for all United States residents. The bill would change the financial system by instituting a single payer health insurance system that finances hospitals and health care providers on the basis of need rather than by the procedure. The Act will reduce health disparities by race, ethnicity, income and geographic region, and to provide high quality, cost-effective, culturally appropriate care to all individuals regardless of race, ethnicity, sexual orientation, or language Representative John Conyers (MI-14) introduced the bill on January 14, 2007, at the beginning of the 110th Congress. As of April 2008 there were 89 cosponsors.
The Plan is to provide everyone with free health insurance by nationalizing private health insurers and eventually raising taxes to cover the cost of health care. The Plan will provide comprehensive universal coverage through a single-payer system of privately delivered, publicly financed healthcare - better healthcare at less cost. The Program will provide all individuals residing in the United States and in U.S. territories with free health care that includes all medically necessary care, such as primary care and prevention, inpatient care, outpatient care, prescription drugs, emergency care, long term care, dental care, chiropractic services, vision, hearing, and mental health services
Under section 101 anyone residing in the United States would be eligible after filling out a form at the office of any licensed clinician. The form would not be longer than 2 pages, and they would receive a card in the mail. Under section 102(c) there would be no cost sharing, co-payment or deductible. Institutions would be prohibited from participating in the Program unless it is a public or nonprofit institution, for profit institutions would be given 15 years government financial assistance to make the conversion under section 103(a). Nonprofit health maintenance organizations (HMOs) that actually deliver care in their own facilities would be allowed to participate in the Program under section 103(c). Patients would be given the freedom of choose from participating physicians and institutions. Private health insurers would be prohibited from selling health insurance coverage that duplicates the benefits provided under this Act with the exception of such insurers who sell benefits that are not medically necessary, such as cosmetic surgery benefits under section 104.
Under section 211 the USNHI Trust Fund would finance the Program with amounts deposited: (1) from existing sources of Government revenues for health care; (2) by increasing personal income taxes on the top 5% income earners; (3) by instituting a progressive excise tax on payroll and self-employment income; and (4) by instituting a small tax on stock and bond transactions. Under section 303 the Program gives first priority in retraining and job placement and unemployment benefits to individuals whose jobs are eliminated due to reduced administration. Under non-bureaucratic single-payer, society would save close to $300 billion a year in healthcare costs – by eliminating private insurers and their wasteful administrations, advertising, commissions, profiteering and multi-million dollar CEO salaries.
Disparities in Health Insurance
The number of children who are uninsured rose from 7.9 million in 2004 to 8.3 million of 65.1 million children in 2005. Since 1998, when SCHIP began, funded by a federal excise tax on tobacco, the percentage of uninsured children has been dropping steadily, from a high of 15.4% to 10.8% in 2004. Although two-thirds of uninsured children are below 200% of the poverty level, the growing number of uninsured children in these moderate-income families reflects mounting concerns about the affordability of health insurance for middle class families (Schwartz 2008). In December 2007, Congress passed S 2499 which extended SCHIP through March 2009. The bill maintains current funding levels for the program of $5 billion per year; with an additional appropriation of $1.6 billion in FY 2008 and another $0.275 billion in FY 2009 (through March 2009) to address states that have projected shortfalls. Total SCHIP program expenditures are $2.7 billion from States and $6 billion from the federal government for a total of $8.7 billion (Burman, Kenney & Rueben 2007). The proposed increase in the tobacco tax was unfair but the idea is sound, the original program was financed with a federal tobacco tax in 1998. The Tobacco corporations are entitled to a seamless transition from the largest civil settlement in the history of the United States, $206 billion over 25 years, $8 billion a year, from the Tobacco Master Settlement Agreement of November 23, 1998 to a federal tax.
Disparities related to race, ethnicity, and socioeconomic status pervade the American health care system. Based on data from the 2006 National Health Institute Survey (NHIS), a total of 54.5 million (18.6%) persons of all ages were uninsured for at least part of the year prior to the interview Working-age adults were almost twice as likely to experience this lack of coverage (24.1%) as children under the age of 18 (13.0%). The percentage of children uninsured during at least part of the year prior to the interview decreased from 18.1% in 1997 to 12.6% in 2005. In 2006, 12.7% of poor children and 16.5% of near-poor children did not have health insurance. A significantly greater percentage of Hispanics (33.1%) were uninsured than White (10.5%), Blacks (16%), Asians (13.3%) or other, including people of multiple races (21%). In the United States the major disparity in health insurance coverage regards working age people who do not get employment sponsored insurance or qualify for a disability. In general men are more likely to lack insurance than women.
Nearly half the population, about 125 million people, live with some type of chronic condition. About half that number live with multiple chronic conditions. Of the Medicare population, 88% are estimated to be living with one or more chronic conditions and 65% with multiple chronic conditions. Recent figures commonly show 5% of the population using over 50% of health care resources and 50 % using over 95 percent. This leaves half the population using less than 5% of health care resources. Similar figures apply to the older Medicare population, with a concentration of expenditures in the last year of life and especially during the last month (Cassel 2005: 111).
Public health and medical crimes and errors such as diverting medical supplies and human resources, abuse and torture, spreading illness to profit, sponsoring domestic abuse, medical killing in the name of science, and eugenics for social goals, have been perpetrated with the complicity of health and medical professionals since the dawn of time. Uses and misuses of biomedical and public health knowledge during time of war or armed conflict are commonplace and the transition to NHI should not be attempted until the nation is officially at peace. There is an Ethical Responsibility to Study and Prevent Error and Harm. In the context of health care, an error is an unintended act or omission, or a flawed system or plan that harms or has the potential to harm a patient. In health care there is a delicate balance between neglect and abuse. The Institute of Medicine estimated that 18,000 deaths in America could be attributed to a lack of health insurance coverage in 2004, in 2006 that number had risen to 22,000 (Goldman & Rowland 2008). In 1999 the Institute of Medicine’s Committee on Quality of Health Care in America reported that medical errors cause 44,000 to 98,000 hospital deaths annually, claiming more lives than car accidents, breast cancer, or AIDS. Inadvertent deaths in other treatment venues, such as nursing homes and doctors offices add to that toll (Coombs 2005: 251). Another study puts the number of death attributed to medical error at 783,936 more than heart disease, 699,697 or cancer 553,251 (2001) (Null, Dean, Feldman, Rasio & Smith 2003).
In the time of King David, BC 1037-967, when people obeyed strict dietary and hygienic laws and alms and wisdom flowed freely, regulated by written Psalms, the bible states, “the days of our lives are 70 yrs, and by reason and strength 80, yet they boast only of labor and sorrow” (Psalm 90-10). For most of history humanity was not so wisely ruled and life expectancy was between 25-50 years. Primarily as the result of improvements in water purity and sewage treatment, but also because of technological advancements in medical treatment, pharmaceutical drugs and government regulation between 1900 and 2000, life expectancy at birth in the United States increased from 47 to 77 years. Life expectancy for people aged 65 increased more than 6 years during the twentieth century, in 2002 a 65 year old American woman could expect to live almost 20 more years and a moan additional 16.6 years.
In 1900, one third of all deaths in the United States were attributed to three major categories of infectious disease: pneumonia and influenza, tuberculosis, and diarrheal diseases and enteritis. Many additional deaths were caused by typhoid, menningococcal meningitis, scarlet fever, whooping cough, diphtheria, dysentery, and measles. Altogether, common infectious diseases accounted for 40% of all deaths in 1900 but they accounted for only 4% of all deaths in 2000. Cardiovascular disease (CVD; heart disease and stroke) accounted for 14% of all deaths in 1900 and for 37% in 2000. Cancer accounted for only 4% of all deaths in 1900 but for 23% in 2000. In 1900, infant mortality was 162 per 1,000 live births and life expectancy at birth was only 47 years. In 1940, infant mortality was 63 per 1,000 live births and life expectancy was 55 years. In 2000, infant mortality was 7 per 1,000 and life expectancy was 77 years. As a result of these changes in mortality, and of reduced birth rates, the population of the US is aging. In 1900, only 18% of US residents were age 45 or older. In 1940, 28% were age 45 or older and in 2000, 34% were age 45 or older.
The United States is by no means the world leader in longevity however the oldest person in the world is American. For life expectancy at birth, it is ranked twenty fourth among males and twenty first among females, behind Japan and most Western European countries. In terms of life expectancy at age sixty-five the United States ranks thirteenth for males and fourteenth for females, once again trailing Japan and Western Europe (Cassel 2005: 2-3). Counting smaller countries, the United States continues to lag behind at least 40 other nations. Andorra, a tiny country in the Pyrenees mountains between France and Spain, has the longest life expectancy, at 83.5 years, according to the U.S. Census Bureau. A study of 99% of US death records note a continued differences by race and sex. Life expectancy for whites in 2005 was 78.3, the same as it was in 2004. Black life expectancy rose from 73.1 in 2004 to 73.2 in 2005, but it was still nearly five years lower than the white figure. Life expectancy for women continues to be five years longer than for men.
The age-adjusted death rate for heart disease dropped from 217 deaths per 100,000 in 2004 to about 210 in 2005, and actual deaths dropped from about 652,500 to about 649,000. The stroke rate dropped from 50 per 100,000 to about 46.5, and the number of stroke deaths dropped from about 150,000 to 143,500. But the count of cancer deaths rose from about 554,000 to about 559,000, according to the report. There was a 5 percent increases Alzheimer's disease, the No. 7 leading cause of death, and for Parkinson's disease, No. 14. There was a slight increase in the infant mortality rate, from 6.8 per 1,000 live births in 2004 to 6.9 in 2005 (Kung, Hoyert, Xu & Murphy 2007). Most of recent progress in life expectancy is attributed to the public becoming increasingly aware of the impact of smoking, excessive drinking, uncontrolled hypertension, lack of exercise and poor diet on the incidence of disease and injury (HIAA 1997: 31). More work is needed in the field of ethics.
Single payer health insurance will greatly simplify health care administration. Even without instituting NHI, the coordination of benefits (COB) under a single payer system, namely the Centers for Medicare Medicaid and SCHIP (CMS), would reduce administrative costs, simplify billing and eliminate biohazards resulting from the proliferation of medical billing. Single payer insurance would ensure that a covered person does not recover more than the actual medical expenses when more than one policy provides benefits. One insurance company is designated the primary carrier, the plans that are determined not to be the primary plan determinate responsibility for payment so that the total payments from all plans do not exceed actual medical expenses (HIAA 1997: 8).
The cost of nationalizing health insurance by prohibiting private insurance plans from collecting premiums from those above the FPL would be much higher for the government, although cheaper to society as a whole. Government health expenditures would need double to cover the benefits provided by private health insurance and out of pocket expenses but this would be theoretically offset by increased tax revenues earned from eliminating tax subsidies for the purchase of private health insurance premiums. For instance, an estimated $14.5 billion were collected in State Premium Taxes from health insurance companies (AHIP 2007). The federal government gives taxpayers 80% credit for the purchase of private employer and individual health insurance plans so that there would be roughly $750 billion more of taxable income to offset the $650 billion in benefits paid by private health insurers. Theoretically no increase in taxation would be necessary, increased tax revenues would merely need to be diverted to the Centers for Medicare, Medicaid and SCHIP (CMS), the government would nationalize private insurance trust funds, and more taxes could levied on the richest 5%.
Fig. 6 Administrative and Clerical Personnel as a Percentage of the Health Care Labor Force in the United States, 1969 through 1999
NHI would cause the loss of as many as 2.5 million jobs in private insurance companies, clerical and administration staffing, as the result of the reduced administrative burden of single payer national insurance. 2.5 million is 0.83% of the general population and 1.66% of the work force. The unemployment rate would be expected to increase by 1.5% if everyone were laid off at once. Section 303(e) of HR 676 gives these millions of displaced workers first priority in retraining and job placement in the new system. Clerical, administrative, and billing personnel in insurance companies, doctors’ offices, hospitals, nursing facilities, and other facilities whose jobs are eliminated due to reduced administration shall be eligible for two years of unemployment benefits.
The US health insurance industry in 2007 covered more than 249 million people and employed an estimated 469,172 people directly to underwrite and another 881,863 indirectly to sell, settle or adjust policies, a total of 1,3510,035 workers. The average wage of direct employees was $61,409 for a total of $25 billion. The average wage of indirect employees was $50,119 for a total of $43.5 billion (AHIP 2007). Private insurance is more than ten times more labor intensive than state plans in Canada. NHI would put as many as 1 million insurance professional out of work. Between 1968 and 1993, US medical care employment, not including private health insurance agents, grew from 3.976 to 10.308 million full-time equivalents. Administration grew from 0.719 to 2.792 million full-time equivalents, or from 18.1% to 27.1% of the total employment. If US hospitals and outpatient facilities adopted Canada's staffing patterns, 1,407,000 fewer managers and clerks would be necessary (Himmelstein, Lewontin & Woolhander 1996).
Fig. 7 Uninsured Rates Among the Non-elderly by State, 2005-2006
Insuring the uninsured in a social insurance system, that would not disrupt the insurance industry so much, would not cost the government as much. As demonstrated by their lack interest, the uninsured are in relatively good health. In 2001 uninsured Americans received about $35 billion worth of uncompensated care through a patchwork of funding from hospitals, clinics, government programs and private sources. Total government spending for the uninsured already accounted for 80 to 84% of their treatment. It is estimated that to provide needed medical coverage for the uninsured would cost $44.9 billion in public programs or $68.7 billion in private insurance plans (Coombs 2005: 264). Medicaid is the most practical program, needing the least statutory reconstruction, to extend coverage to the uninsured. Medicaid is already financed 50-70% by the federal government, so it would not unduly burden the states for the federal government to cover the uninsured.
$55 billion is a reasonable estimate for implementing the AHIP plan to achieve universal health insurance in 2009. A single payer system could be implemented at the same time for the estimated cost of $300 million to the government, for the printing of electronic health record cards for every citizen, another $1 billion to expand CMS claims processing and $250 for providers to purchase card scanners and computer software via which CMS would pay and bankrupt all health care claims. The transition to universal coverage does not need to be expensive. This amount could be levied by increasing the Medicare taxation on the richest 5%. The taxpayers would be relieved to know they were investing in national health insurance futures. They would be immediately rewarded altruistically with the knowledge their tax dollars were paying for universal coverage for the working poor. Seeing the single payer system work would assure them that bill and premium free national health insurance was in near future for them as well.
In conclusion, single payer universal coverage, is a temporary compromise that Congress should reach with NHI, that remains the long-term goal. Congress could enact single payer universal health insurance by passing the HR 676 with a clause abstaining from prohibiting the sale of private insurance in section 104 until sometime in the future. Single payer insurance is a medical necessity to stop the proliferation of bio-terrorism in medical billing and state Medicaid/Medicare contracting corporations and agencies that reduce life expectancy and consumer satisfaction. Universal coverage is also necessary to the medical establishment for two reasons. First, to overcome rising disparities in health outcomes, between the rich and the poor and between the United States and other developed nations. Second, to maintain standing in a world where the United States is the only developed nation that does not offer its people universal coverage.
Sanders, Tony J. National Health Insurance: Compromise to Immediately Achieve Single Payer Universal Coverage and Progressively Realize National Health Insurance that is Free for All. Hospitals & Asylums. 100 pgs. April 28, 2008
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