Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. Links to past Gray Matters columns can be found here. Saul's Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, also appears at Time Goes By twice each month.
While we await the hoped for improvements in the health care reforms, the latest news about the irrational, fragmented and profit-driven American health care system is not good.
In a report released last month by the respected Commonwealth Fund, the United States, which spends twice as much money on health care than other advanced nations, ranks lower than all of them on the quality, efficiency and the cost of care for their citizens.
Most important, the care given and available in these countries is more equitable than in the U.S. The disparity in the care available here for more affluent whites, compared to the poor, blacks and Hispanics is too obvious. There are no uninsured in the countries cited.
The report ranked the United States last when compared to six other nations – Britain, Canada, Germany, Netherlands, Australia and New Zealand - all of which have some form of universal, nationalized or socialized health care.
The report uses data from patient and physician surveys in the seven nations in 2007, 2008 and 2009. In 2007, the U.S. spent $7,290 per person on health care. The per person spending in the six other countries ranged from $2,454 for New Zealand to $2,992 in Britain to $3,895 in Canada. Overall, the survey found that Britain’s National Health Service ranked first in patient and physician satisfaction.
“The findings demonstrate the need to quickly implement provisions in the new health reform law,” said the report. “The new legislation should begin to improve the affordability of health insurance and access to care when fully implemented in 2014.”
The other piece of sorry news is that despite meetings with the president to implement the reforms and warnings from the White House and Health and Human Services Secretary Kathleen Sebelius, insurance companies have raised the premiums on 14 million private policies and Medicare Advantage by an average of 20 percent.
That survey by the Kaiser Family Foundation [pdf] which found that double digit premium increases were not unusual, was released on June 21. The president ignored that when he met on June 22 with insurance company CEOs and spoke glowingly about the reforms and the hope that the insurance industry would cooperate.
He had warned earlier that “health insurance companies should not use the new health care reform laws as an opportunity to enact unjustifiable rate increases.” But they did and chances are that conduct will continue.
One reason is the trend reported by Wall Street analysts and Bloomberg that U.S. health insurers are “moving towards an oligopoly” in which only a few companies will dominate so much of the market that they will have the power to thwart the already weak regulations. Don McCanne, of Physicians for a National Health Plan, said,
“The insurers will keep 15 to 20 percent of the (increasing) premiums to sell us plans that cover only 60 to 70 percent of our care and they won’t really have to compete with each other.”
Many policyholders have fled to cheaper insurance but their deductibles, now averaging more than $5,000, will go even higher while their coverage will decline. One in five policyholders complain that they or a family member did not get the care they paid for. And four in ten policy holders (38 percent) reported having a problem getting their insurer to pay a bill.
Under the reforms, the insurers must spend 85 percent of their premiums on patient care. But who is to closely enforce that? The answer may be found in why the insurance industry, conservatives who oppose regulations of all kinds and most public health programs and Republicans in the Congress who seek to privatize Medicare have joined in opposition to the President’s choice to run the Centers for Medicare and Medicaid Services (CMS).
For the last eight years the leadership of CMS has been benign at best, going along with every Republican effort to weaken Medicare. Medicare was shut out of the Part D prescription drug program which is wholly private and increasingly expensive. The Republican administration increased by billions of dollars the slush fund that finances privatized Medicare Advantage to the financial disadvantage of original Medicare.
Expectations that the weakening of Medicare will cease rest with the president’s CMS nominee, Dr. Donald Berwick, a pediatrician, Harvard Medical School professor and head of the Institute for Health Care Improvement in Boston. And judging from his background, there is little doubt he’d be a strong advocate for Medicare which often influences the conduct and standards for private insurance.
I expect Berwick to be a the strongest defender of Medicare since Bruce Vladeck, who ran what was then the Health Care Financing Administration under President Clinton. That was killed by the Republican Congress and then-Speaker Newt Gingrich.
Vladeck’s successor, Nancy De Parle, now chief adviser on health reform in the White House, agreed to allow HMOs to sell Medicare policies which began the slow privatization of Medicare. (De Parle became an executive for health care firms, earning $3.5 million in 2006-2007).
Berwick would be an advocate for a stronger Medicare, which would weaken the power of the health insurance lobby. That, I believe, is a major reason Senate Republicans have vowed to kill his nomination which had languished since April in Senator Max Baucus’ Senate Finance Committee. He has yet to schedule hearings or give a reason for the delay.
Tired of Republican stalling, the president gave Dr. Berwick a recess appointment this past week to run CMS. He will still have to be confirmed when the Congress returns, but that should be easier. And in the meantime, CMS will have the strong leadership It's been lacking for too long.
Praise for Berwick has been universal among the academic health community including Harvard, Yale, Princeton and Dartmouth. He has won praise from AARP executive vice president John Rother who said Berwick’s Institute has “saved lives and money” and that his “appointment is welcome news to Medicare beneficiaries.” The American Hospital Association praised Berwick for leading a movement to make hospitals safer. And Kaiser Health News called Berwick an “inspirational leader.”
So why are Republicans calling him a “radical?” One of his sins was to give limited praise for the British National Health Service although, as Linda Bergthold pointed out in Huffington Post on June 1, Berwick has criticized its faults and is not seeking a government takeover of U.S. health care.
Republicans and Fox News commentators have also jumped on part of a 2008 speech, in which he said,
“Any health care funding plan that is just equitable, civilized and humane must – must – redistribute wealth from the richer among us to the poorer and less fortunate. Excellent health care is by definition, redistributional.”
Berwick was charged with wanting to “spread the wealth around” as if that’s a bad idea.
Berwick was also accused of supporting health care rationing because he spoke truth when he said,
“the decision is not whether or not we will ration care – the decision is whether we will ration with our eyes open. And right now we are doing it blindly...”
That is, allowing insurance companies to decide who and what they will cover.
One cannot write about Berwick without recalling his personal encounter with the dangers in American health care, when his wife almost died from a medical error when she was receiving powerful chemotherapy. He was at her bedside to save her from what might have been a fatal overdose of the medicine. Reducing medical errors in hospitals, said Bergthold, has become Berwick's life’s work.
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