Sunday, July 31, 2005


Canada spends more on health care than most European and Asian nations but has some of the longest wait times and worst access to physicians in the world, concludes a report released Thursday. The paper, released by the right-leaning Fraser Institute, compares 27 countries that all guarantee access to health care, regardless of ability to pay. The report says Sweden, Japan, France and Australia all outperform Canada in the following areas: keeping women with breast cancer alive; preventing death from disease; waiting times for health services and the number of years people can expect to live without a disability.

"Canadians continue to not get value for their money," says Nadeem Esmail, co-author of the report. "We are spending a huge amount of money and getting terrible wait times, inferior access to technology and mediocre health outcomes." Canada ranks in the bottom half of nations when it comes to patient access to mammograms, CT scanners and MRI machines -- technologies routinely used to detect cancer.

The report also said Canada has fewer physicians than other industrialized nations: It ranks 24th out of 27 nations with 2.3 doctors per 1,000 people. In 1970, by comparison, the year public insurance was first fully applied to services from physicians, Canada had the second-highest number of physicians, per capita. Iceland boasts almost twice as many physicians per capita while nations such as Italy, Germany, France and Finland all have significantly more than Canada.

The report found that of all 27 countries, only Canada outlaws a parallel private system while others with universal health care, such as Sweden, Japan and Australia, allow some mix of user fees, private insurance and private hospitals to compete for patient demand. "They allow patients the freedom to see care on their own terms if the public system is unwilling or unable to meet their needs," says Esmail, a senior health policy analyst at the Vancouver-based organization.

Canada is one of only four countries with universal care that spends more than 10 per cent of its gross domestic product on health. Only Iceland and Switzerland spend more than Canada. But Albert Schumacher, president of the Canadian Medical Association, says Canada has some good reasons for spending more than most European countries -- such as the cost of serving remote areas and the complex health needs of aboriginals, immigrants and refugees. "None of these countries has jet fuel as a major health care expenditure," says Schumacher. "If we moved the rest of the country into southern Ontario, we would have a very effective health-care system." And he suggests better health outcomes in some of the European countries could be due to increased social spending in other areas, such as lengthy maternity leave, subsidized childcare, shorter work weeks and longer vacations.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Saturday, July 30, 2005


An excellent post from the Adam Smith blog:

Britain's health system regulator, the Healthcare Commission, says that (thanks to an injection of tens of billions a year) the state-run National Health Service is now meeting lots of its targets, but is failing to treat taxpaying patients as customers. One figure I saw is that 25% of patients say they are treated 'as if they are not there'.

It is this, more than anything else, which defines the failure of state-run healthcare. Sure, when you look at the statistics, you find that some things the NHS does are actually very good, while others (like our performance on killer diseases like cancer and stroke) are pretty poor compared to other countries'. But what the statistics don't pick up is how people are treated as people.

A couple of years back I spent a good deal of time around one of Britain's 'flagship' hospitals, during the last illness of an elderly relative. Since then I've been determined never to set foot in the place again if I can help it. It was filthy, of course: one expects that. But the staff were also stressed out and frankly hadn't the time, or weren't well-managed enough, to handle their elderly patients with the dignity that any of us have a right to expect. There was no joined-up liaison with the family doctor, so my relative was not given an essential medicine, with disastrous results. She lost her wedding ring (very precious to her) but the ward had no system to deal with lost property. There was no plan to provide care for her when she went back home from the hospital. And so on. It was awful, and inhumane.

I don't believe that any amount of money will change this. Yes, it might mean that more women get breast screening or that family doctors can give you an appointment within the week. But it won't mean that patients are treated like valued customers, because in our system they are not. Only if we can devise a system in which the providers are paid solely on the basis of the patients' own choices will we ever do that.


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Friday, July 29, 2005

Threat to patient care as third of British public hospitals in red

No money is ever enough where you have hungry bureaucrats to feed

Despite rapidly increasing budgets, more than a third of hospitals and a quarter of all NHS trusts failed to break even last year. The Healthcare Commission, publishing its annual star ratings, said that the overall deficit was œ500 million, a small fraction of the NHS budget of 69.7 billion pounds.

But, with the NHS facing a tougher future, with no big increases in funding after 2008 and a new and riskier financial regime, the failure hints at future problems and should be taken seriously, Anna Walker, the chief executive of the commission, said. "Financial management is really important. Patient care will suffer if it is not put right," she added. "Quality of care is inextricably linked to good financial management. Temporary instability must not lead to a permanent problem. If it does, patients will lose out because the standards of care will suffer."

The 2004-05 star ratings - the last that will appear in this form - also show that tighter targets in accident and emergency departments have caught hospitals out. For the first nine months of the year, all trusts met the target that 90 per cent of patients should wait less than four hours. But, when the bar was raised to 98 per cent for the last three months of the year, 62 out of 159 trusts with A&E departments failed to meet the higher standard.

The star ratings will be replaced by a new system that, to the casual eye, may not look very different. The "annual health check" promised by the commission will provide, it says, a more comprehensive picture of performance, but it will end, just like the star ratings, with a four-point scale, ranging from excellent to weak. For excellent, read three stars; for weak, no stars.

The star ratings' final hurrah paints a picture of gradual improvement across the NHS, despite the financial problems. Sir Ian Kennedy, the chairman of the commission, said: "There is no doubt that star ratings have been an important step on the road to effective measurement of the performance of the NHS. "They have played a part in the improvement of care, not least in a significant reductions in waiting times. But the system has not provided a comprehensive picture. We need a richer picture, reflecting the needs of patients."

Gill Morgan, chief executive of the NHS Confederation, which represents hospital managers, relished the demise of star ratings. She said: "The scrapping of star ratings is a good day for patients who may believe that their local hospital has lost a star because its services have deteriorated over the past year. "In fact, trusts have been measured against targets that have become progressively tougher and so some NHS trusts may earn fewer stars this year despite providing a better standard of care. We believe that, in some instances, star ratings have become a perverse system that scares patients and the public unnecessarily and demoralises hard-working NHS staff. That's why we are delighted that star ratings are being abolished and replaced with a new, fairer system of assessment."

This year's figures show improvements in death rates for diseases such as heart disease and cancer and a more rapid service in hospitals, with waiting times for elective operations halved from 18 to 9 months.

While 13 more Primary Care Trusts achieved a three-star rating, only 19 per cent in all earned the top status - compared with 42 per cent of ambulance trusts. But Ms Walker said that they also had concerns about the performance of trusts in the South East, an affluent part of the country with fewer health problems than more deprived areas in the North. "There are some hospitals that are not performing so well," she said. "Whether this is really a pattern or is random we don't yet know." But Andrew Lansley, the Shadow Health Secretary, said that the star ratings did not reflect the reality of clinical standards in the NHS. "Many clinical priorities aren't recorded and some targets, like A&E and GP bookings, create more problems than they solve," he said. "However, the star ratings do reflect the reality of financial performance. NHS finances are close to meltdown. One quarter of NHS trusts failed to break even last year and more are facing deficits this year


About Those Uninsured Americans...

Over the past several years there has been much discussion in both public policy circles and the media about the plight of those Americans who lack health insurance. "Over 43 million U.S. residents, nearly one in six Americans under the age of 65, lack health coverage," says the website of the nonprofit Institute of Medicine of the National Academies. This or some similar statistic is often used as evidence that there exists a large subset of the country's population that has little or no access to healthcare and that the crisis will only grow worse if some action -- typically government-funded and/or government-mandated healthcare coverage -- is not taken immediately. The facts are somewhat different.

One problem with the 43-45 million uninsured Americans figure is the fact that the statistic is dynamic, not static. "[T]he uninsured population is fluid, with many people gaining and losing coverage," reported the Congressional Budget Office on May 12, 2003, in a brief on Americans who lack health insurance coverage. "Between half and two-thirds of the people who experienced a period of time without insurance in 1998, for example, had coverage for other portions of the year." Thus, the 40-odd million uninsured people in December of a given year are mostly a different group of people from the 40-odd million uninsured from the previous January.

Another problem with the statistic is that it tells us how many uninsured Americans there are, but not who they are. This is an important distinction. A 70 year old with multiple medical problems who lacks health insurance is obviously in a much direr situation than a healthy 20 year old who lacks health insurance. Michael F. Cannon, director of health policy studies at the Cato Institute, looked into the aforementioned report from the Congressional Budget Office to find out just who the uninsured are. He discovered that "the persistently uninsured are mostly young (39 percent are under age 25, and another 22 percent are under age 35) or healthy (86 percent report their health to be 'good,' 'very good,' or 'excellent')."

In discussions about the uninsured, there appears to be a tendency -- in some cases unintentional, in others almost certainly deliberate -- to regard "health insurance" and "access to healthcare" as synonymous. Not having health insurance obviously curtails one's ability to obtain certain medications, office visits, and procedures for fractions of their actual cost since the cost is not defrayed by the premiums contributed by thousands of other policy-holders. But it is inaccurate and misleading to equate health insurance with access to nominal or even emergency medical services.

At my own practice, we frequently see uninsured or "private pay" patients. Some of these patients are working people whose employer does not offer health insurance coverage. A fair number of these patients are small business owners. If asked, most of these people would say that they cannot afford health insurance, but this is simply another way of saying that it makes no financial sense for them to pay an insurance company hundreds of dollars per month in premiums so that the charge for a $55.00 office visit can be reduced to a $25.00 co-pay. While the private pay approach to healthcare carries the obvious risk of great personal financial hardship due to medical expenses in the event of developing a serious medical condition or sustaining a major injury, the unlikelihood of this happening must be weighed against the absolute certainty of having to repeatedly pay out insurance premiums to cover likelier and less costly medical services whose monthly or annual totals will most probably exceed the cost of paying out of pocket for the same services.

A lack of healthcare insurance does not preclude access to emergency medical services; indeed, such access is guaranteed by the Emergency Medical Treatment and Labor Act of 1986 at any hospital taking part in Medicare. While even a brief trip to the emergency room can be tremendously expensive for the private paying patient, relatively few such trips are made.

Reuters health and science correspondent Maggie Fox filed a story in October 2004 citing a study that debunks the idea that the poor and uninsured fill America's emergency departments. "Contrary to popular perception, individuals who do not have a usual source of care are actually less likely to have visited an emergency department than those who have such care," said Dr. Ellen Weber, a professor in the division of emergency medicine at the University of California San Francisco, who led the study which was published in the journal Annals of Emergency Medicine. According to the study, 85 percent of patients who visit the country's emergency departments have medical insurance and 79 percent have incomes above the poverty level. Said Dr. Weber, "The mistaken belief that emergency departments are overcrowded by a small, disenfranchised portion of the U.S. population can lead to misguided policy decisions."

None of this should be construed to mean that there is no problem with the delivery of healthcare in America. There are undeniable flaws in our healthcare system that prevent a significant subset of patients from getting the healthcare they require. But such flaws cannot be properly addressed if the problems are defined by statistics that are inflated or considered out of context. Just as an inaccurate set of vital signs or laboratory tests can result in a patient being given an incorrect diagnosis and improper treatment, false assumptions about the extent and character of the problem of uninsured Americans can likewise lead us to spurious remedies.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Thursday, July 28, 2005

Cheaper Health Insurance

A little competition can go a long way

Republicans haven't been getting much credit on the health policy front, despite their misguided 2003 drug entitlement masquerading as Medicare "reform." That could change soon. Last week the House Energy and Commerce Committee approved a bill that could dramatically reduce the ranks of the uninsured and spur general economic growth--all without costing a dime to the Treasury.

The idea behind the legislation, sponsored by GOP Representative John Shadegg of Arizona, is disarmingly simple: Allow Americans to buy health insurance from vendors in any one of the 50 states.

Right now Americans who aren't lucky enough to get insurance from large employers or poor enough to qualify for Medicaid find themselves at the mercy of the legislators and insurance commissioners of the state in which they happen to live. This can be OK in states that exercise this regulatory function judiciously. But in others, the young and working poor find themselves effectively priced out of the market by special-interest regulations dressed up as consumer protections.

New York requires every insurance policy sold there to cover podiatry. Acupuncture coverage is mandated in 11 states, massage therapy in four, osteopathy in 24, and chiropractors in 47. There are an estimated 1,800 or so such insurance "mandates" across the country, and the costs add up. "It is always the providers asking for the mandate; it is never the consumer," says health policy guru John Goodman, who has testified before legislatures considering such rules.

What's more, states like New Jersey and New York add two more ultra-expensive requirements: "Guaranteed issue" allows people to wait till they are sick and then buy insurance; "community rating" prevents insurers from charging different prices to people of different ages and health status. These may sound like compassionate ideas, until you realize they make insurance so expensive that millions of people are exposed to financial ruin because they aren't allowed to buy basic policies focused on catastrophic costs.

How expensive? A 2004 study by found that a typical insurance policy ($2,000 deductible, 20% co-insurance) for a family of four could be had for as little in as $172 per month in a reasonably regulated locality like Kansas City, Missouri. But in New York that family's only option--managed care--would run $840 per month, and in New Jersey family policies run a whopping $1,200-plus. We bet Democratic Representative Frank Pallone's constituents in New Jersey would be interested in his view that insurance in his state is only "slightly" more expensive than elsewhere.

As for the arguments against the bill, let's dismiss the phony federalism objection first. The Founders wrote a Commerce Clause into the Constitution precisely so Congress could act against internal restraints on trade of the sort represented by today's 50-state health-insurance market. The system has never made much sense; it is even more of an anachronism in the age of Amazon and eBay.

Critics also allege that freeing up interstate commerce will result in a "race to the bottom" in which fly-by-night insurers operating in poorly regulated states would be able to take advantage of consumers. But we've yet to hear which poorly regulated states they're talking about. The best analogy for what to expect here is probably our experience with interstate banking, which has indeed resulted in operators moving to friendly climes like Delaware and South Dakota but which has also proven nothing but a boon to consumers. A national market has allowed the growth of big, financially stable institutions that have earned consumer trust.

Nor, contrary to the self-interested arguments being put forth by the BlueCross BlueShield Association--which has effectively monopolized many highly regulated markets and fears the competition--would free commerce jeopardize the "risk pool" (i.e. the overall pool of money that makes insurance possible by allowing the healthy to subsidize the sick). In high-cost, guaranteed-issue states the young and healthy don't participate in the individual insurance market anyway; a larger national market can only improve matters.

As a major side benefit, interstate commerce in health insurance would remove a huge barrier to the efficient allocation of human resources in our economy. Right now untold numbers of Americans fear moving, switching jobs or starting their own businesses for fear of losing their health insurance. That would change if they were able to shop nationwide for policies that would follow them wherever they go.

But the most important issue here is justice. It is simply immoral that millions should be exposed to the possibility of financial ruin because of the all-or-nothing choice offered by the insurance regulations of states like New York and New Jersey. Amazingly, we hear the entire GOP delegations from both states are leaning against the bill, which may come before the full House in September. Their names belong on a dishonor roll should they end up letting the special-interest lobbies mentioned above determine their vote. We hope President Bush--who supports the Shadegg bill--is prepared to twist arms as he did on the Medicare vote. It's no exaggeration to say this could turn out to be the most humane and consequential domestic achievement of the Bush years.



The British government goes private

Patients facing long waits for tests at their local hospital will be offered treatment at a private clinic, it was revealed yesterday. Health Secretary Patricia Hewitt announced the move in a bid to cut the sick lists. About 80,000 patients waiting for non-urgent diagnostic tests such as MRI and CT scans will be given the option to have treatment more quickly at another NHS or private hospital. The new policy for patients waiting for more than 20 weeks comes into force in November.

Mrs Hewitt said: "We know many patients are caught in a bottleneck of waiting for a scan or other diagnostic service before they are referred for an operation. "This can be a worrying and uncertain time for patients. This scheme will help to tackle this hidden waiting list." She claimed by 2008 no one will wait longer than 18 weeks from GP referral to hospital treatment. GPs already fast-track more serious cases - such as when they suspect a patient has cancer - for hospital diagnostic tests.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Wednesday, July 27, 2005


The nation's largest kidney-care provider has closed five dialysis centers in the greater Washington area, which has one of the highest rates of kidney disease in the country. In addition, the dialysis provider -- Fresenius Medical Care North America -- says more closures can be expected because of a lack of reliable government funding. "When the patients are on Medicare and Medicaid, we can't survive," company Vice President Robert Ward said. "We're losing money every treatment."

Fresenius Medical, based in Lexington, Mass., has closed one dialysis center in Prince George's County, two in the District and two in the Baltimore area. The closures affect about 5,000 local patients who have end-stage renal disease and rely on dialysis to survive. Of the nearly 20 million kidney patients nationwide, more than 375,000 live between Baltimore and Fredericksburg, Va., according to the National Kidney Foundation of the National Capital Area. "Based on our population, we're right at the top," said Dr. Andy Howard, a former kidney foundation chairman.

Mr. Ward said the number of kidney patients in the region has more than doubled since 1990 and is expected to rise further. Health care providers said dialysis centers are closing because Medicare reimbursements have not kept pace with the increase in kidney patients and treatment costs over the past two decades. "The funding [for dialysis] comes straight out of Medicare," said Nancy J. Sharp, a registered nurse with the American College of Nurse Practitioners. "Medicare pays approximately $130 [per treatment]. It hasn't raised from that since about 1983. The rest of the world keeps getting more money from inflation, but the dialysis rate has just kept the same." ....

Kathleen Smith, a vice president of government affairs for Fresenius Medical, said most kidney-dialysis centers are independent and not represented by such groups as the Centers for Medicare and Medicaid Services. "We don't have that, so we have to go to Congress on our own every year," she said. "We're trying to close centers in D.C. where the impact won't be as severe. We used to never think about that. We've started down a road we never expected to be on."

More here


The more the British goverrnment spends on its NHS, the worse it gets. But there is plenty of money for more and more bureaucrats

A woman aged 75, just discharged from hospital after hip surgery, was dumped on her doorstep by welfare workers with a bag containing some tea bags and margarine. The shocking case of Maureen Hayes sums up what charities say is serious neglect over care for the elderly. Old folk released from hospital are being given little or no support at home, campaigners claim. And many others are forced into residential care because of lack of help with washing and cooking. The number receiving home help has fallen by 21 per cent since Labour came to power eight years ago, says a report by a coalition of charities including Age Concern and Help the Aged.

Mrs Hayes, from Bournemouth, told of her struggle for help after her hospital stay. She could not wash because of her sore hip and back, was unable to get help to bathe, and developed a serious infection. Mrs Hayes said: "I have had to fight tooth and nail for the little help I have got from social services. I've needed to involve my MP. "What on earth do people do if they are less feisty and less eloquent than I am? I will fight this bureaucracy all the way, but it shouldn't have to be like that. Social services have a very patronising attitude and treat elderly people like children."

Another dissatisfied pensioner, Margaret Cracknell, 72, from Norfolk, said: "I have been told that it's down to the money. There's not enough to go round so they keep you waiting in the system, hoping you'll go away."

The charity report says that, while the Government has increased funding for social care, the sums have been outpaced by rising costs. It points out that old people make up 62 per cent of social services "clients", but receive just four per cent of funding. A consultation process on the Government's Green Paper on Adult Social Care ends this week - and campaigners warn that any new legislation is doomed to failure unless extra funding is guaranteed. Charities' spokeswoman Annie Stevenson said: "Older people everywhere are paying for inadequate social care funding with their own mental health, physical health and dignity. "Rationing social care funding for older people is making later life a misery for thousands." Aid with washing, housework, transport and mobility would increase independence and save the taxpayer millions, the charities argue.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Tuesday, July 26, 2005


In a remarkable series last week, The New York Times cited some mind-boggling numbers: As much as $18 billion a year is vanishing, thanks to Medicaid fraud, waste and abuse. How could this happen? No one's minding the till, says the Times. The number of fraud investigators nose-dived, even as the program ballooned. And it's tragic, because tough enforcement can pay for itself.

But here's what the Times forgets: Policing might cost less than corruption and waste — but it still costs something. This is not an argument against enforcement. But it's a reminder that this kind of cash drain, and the need to plug it, is unavoidable in subsidy programs — i.e., anytime someone receives services and someone else (like taxpayers) pays the tab. Why is that?

Take Medicaid: Party A, the health-care provider, delivers services to Party B, the Medicaid patient. But it is Party C — you, the taxpayer — who gets the bill. If public officials don't check that doctors and nursing homes and speech therapists really are delivering services they're billing for, that patients truly need the services, that services are delivered efficiently, taxpayers will get taken. Count on it.

But this is a tall task for a bureaucracy. And expensive. The best way to make sure services are delivered efficiently — and to only those who truly need them? Have patients pay their own way. After all, they are the ones who can best decide if the "product" is worth the price. Plus, folks who are ripped off can be counted on to ID crooks — instead of relying on elaborate computer systems, "referrals" by Department of Health bureaucrats and armies of investigators in prosecutors' Medicaid-fraud units.

Meanwhile, the $18 billion the Times cites may barely scratch the surface. After all, who's to say what counts as fraud and waste? (Some might consider all $45 billion spent on Medicaid in New York a "waste.")

Surely, a dentist who bills for 991 procedures in one day, as Dr. Dolly Rosen allegedly did, is a crook. But what about the doctor, or patient, who orders up questionable tests or treatments just because they're "free"? What about elderly folks who legally hide savings and bill taxpayers for long-term care? Or hospitals that are kept open, though they never fill up their beds? How about folks who choose not to exercise or cut down on fatty foods, but gladly accept coverage for heart disease?

Of course, few Americans might deem some of these practices "fraud" or even "waste." But surely costs would be a lot lower if patients had to write out the checks themselves. This is true of Medicaid as well as regular health insurance: When someone else ponies up, patients are sure to consume more. And why not have every little ache or pain checked — if it's on someone else's dime? Why not order the most elaborate tests, the priciest therapies?

I once twisted my ankle playing basketball. No big deal, I knew from a lifetime of twisted ankles. Still, the doctor prescribed an MRI, just to be sure; insurance would pay. I couldn't do it. I couldn't bring myself to waste that kind of cash, even if it wasn't mine. But many folks could — even as they'd surely call the doctor nuts if he ordered the $1,000 test at their expense.

No, the fact that waste and fraud are unavoidable doesn't mean Medicaid should be scrapped. America takes care of its truly sick when they can't take care of themselves. But it's a strong argument for keeping the program narrowly confined to those who truly need it and to services that are absolutely critical. In Gotham, one of every three residents is on Medicaid. Fraud? Waste? You decide.



'Value to the system' determined healthcare for communist East Germany's elderly

Under the communist regime in East Germany, elderly patients' healthcare depended on whether they could contribute to the workforce, says a letter in this week's BMJ. While those working and therefore judged "valuable to the system" could access medical treatment when needed, retired patients were considered a "drain on the public purse" says Dr Herbert Nehrlich, an East German doctor now living in Australia. X-rays and other diagnostic tests were denied people of a certain age, and retired East Germans were not hindered from travelling to the West, or staying there, he adds.

Conversely East German workers benefited from programmes to maintain and improve fitness including subsidies for sports, and breaks during the working day for sporting activities. Health inequalities between East and West Germany should be ironed out over time, says Dr Nehrlich, although higher drinking levels in the East were "not discouraged under the communist regime" and remain a problem for those living there now.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Monday, July 25, 2005

Health Insurance at Less Than $2 Per Day

A 30-year-old nonsmoker can buy health insurance for $54 dollars per month, on average, in Long Beach, CA, on the individual-plan market. The price is $56 in Sacramento, and $58.77 in Tucson. For residents of these cities, that’s less than two dollars per day. At the other end of the spectrum are New York City and Boston, where individual plans cost, on average, $334.09 and $267.57, respectively. Yes, that’s right: an individual plan in New York costs over 6 times more than in Long Beach, CA.

These numbers come from a new survey from health insurance clearinghouse eHealthInsurance, “The Most Affordable Cities for Individuals to Buy Health Insurance” (PDF link). The survey looks at the cost of high-deductible (but still less than $1,000) plans available on the individual market in the country’s largest 50 cities. Long Beach, Sacramento, and Tucson are all in the top ten for affordability. New York and Boston are at the very bottom of the list.

The survey’s most interesting finding concerns affordability: in 33 of the 50 cities, individual policies can be had for premiums of less than $100 per month, on average. Health insurance is much more affordable than most people realize, especially with the growing popularity of high-deductible HSA-joined plans.

How is it, though, that the prices for these plans vary so much by geographical region? Are the citizens of New York really 6 times more expensive to insure than those of Long Beach? While several factors are at play, the dominant one is regulation. Health care regulation and insurance mandates vary significantly by state; when states require that plans must include certain services (e.g., dental care, eye care, screenings, etc.), prices rise and insurance becomes less affordable. As the report points out, Boston and New York are the only cities on the list with several particularly onerous and expensive regulations on the books.

The survey points the way to a common-sense approach to reduce the number of the uninsured. First, and obviously, states should back away from mandates and regulations that increase the cost of insurance. As well intended as they surely are, these policies put insurance out of the reach of many low-income workers and families. Second, the survey supports the use of tax credits to make health insurance even more affordable for those who are today uninsured. The President has proposed tax credits for health insurance of $1,000 for individuals and up to $3,000 for families. In even moderate-regulation states, this could drop the cost of a year’s coverage to a level that most low-income workers could afford.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Sunday, July 24, 2005


Below are three stories from the one day (Sat 23 July, 2005) -- the first two in "The Courier Mail" and the third in the "Townsville Bulletin" about a long-established government-run health system that gets worse by the day despite huge political fallout -- even though lots of Queenslanders opt out of it and go private. This sort of thing is what all advocates of "single-payer" health schemes are in effect pressing for

Finger lost after medics drive Allan 400 km away

By: Glenis Green

It takes a lot to faze a tough old bushie like Allan Benson. But when he accidentally chopped most of a finger off with a tomahawk, even he did not expect to be told he'd have to bypass the new multimillion-dollar Hervey Bay Hospital just down the road and instead drive almost 400km to Brisbane to get the appropriate medical attention.

Mr Benson, 64, said that he did not blame medical staff, but the unwieldy health system culture in Queensland. Mr Benson said when he accidentally sliced the index finger on his right hand on Monday last week it had been left hanging by a thread. With blood pouring he made it back to the house, packed it in ice and wrapped it in a towel and then drove to the Bay's nearby hospital. "I've got no qualms with the hospital staff - they were phenomenal - but it's the administrative and government part of the system that's bad," he said.

Mr Benson said a neurosurgeon was called, only to explain that he could not operate to try and save the finger because there was no head surgeon available. Instead staff began ringing around other hospitals before finally booking him into Royal Brisbane Hospital, but said they could not justify an ambulance transfer until the following day. Mr Benson's son-in-law, James Stott, ended up driving him that afternoon to his booking in Brisbane - bypassing not just the Hervey Bay Hospital but also major, closer hospitals at Maryborough, Gympie, Nambour and Caboolture.

Because of the severity of the wound the end of the finger could not be saved and it was amputated, with Mr Benson being driven back home by Mr Stott the next day. Mr Benson said doctors at Royal Brisbane were "amazed" that he had ended up travelling such a long distance for treatment.

"Yeah, I've got a crook heart," he said. "I was on the transplant list, but after they gave me some tablets I got a bit better and I took myself off it (the list). "It just seems so stupid that they send me to Brisbane (for my finger) and someone else in Brisbane has to go without. "Hervey Bay is a new, state-ofthe-art hospital and they can't even do minor operations there."

Mr Stott described what happened as "irresponsible". "The person (at Hervey Bay Hospital) who saw us was capable of doing the surgery, but because there wasn't a supervising practitioner available - a case consultant - they were not able to do it," he said. Mr Stott said the whole episode had been traumatic and costly.

A Queensland Ambulance spokesman said it appeared Mr Benson's case had not been rated by the hospital as an emergency and as the local ambulance did not do non-emergency transfers between Hervey Bay and Brisbane, it would have been a clinical decision whether or not to call in the Royal Flying Doctor Service to airlift him to Royal Brisbane.

Fraser Coast Health acting district manager Kerry Winsor said the region's orthopedic services were suspended in May this year following the withdrawal of the Australian-trained supervising orthopedic superintendent in response to the Australian Orthopaedic Association report recommendations. She said this now meant that patients requiring specialist orthopedic treatment had to be referred to an appropriate facility.

Ignored doctors threaten to strike

By: Jeff Sommerfeld

Queensland's ongoing health crisis is set to deepen with senior specialists at public hospitals threatening to take industrial action that could increase waiting times for elective surgery. Doctors yesterday blamed the worsening health crisis on Premier Peter Beattie, whom they say was trying to create conflict to deflect attention from his Government's political woes. The conflict surrounds an overdue employment agreement for part-time medical specialists in the state's public hospitals. A significant portion of elective surgery in public hospitals is performed by the specialists known as visiting medical officers or VMOs. The agreement was supposed to have been finalised in February, with Queensland Health and the VMOs at that time mainly in agreement.

Australian Medical Association past-president David Molloy yesterday said Mr Beattie had advised the AMAQ in April that he was personally handling the VMO negotiations. "He has stonewalled it at a time when the Queensland public hospital system needs as many Australian-trained doctors as it could get," Dr Molloy said. "VMOs do very little administration work - it's all patient care. The full-time doctors do most of the administration," he said.

VMO committee chairman Ross Cartmill said Mr Beattie had advised him he wanted to delay finalising any agreement with the VMOs until he received final reports from health inquiry head Tony Morris and consultant Peter Forster. "I sent a letter saying we would accept no pay rises for VMOs until the end of the inquiries," Dr Cartmill said. "That was on the proviso we reached an agreement within two months of the end of those inquiries." He said the first contact he had with the Premier's Office was yesterday, and only after Mr Beattie had sent out a media release stating his position.

Although VMOs had threatened to take action from Monday, Dr Cartmill yesterday made a further plea for the Government to negotiate a final agreement to prevent industrial action.

In his media statement, Mr Beattie said VMOs "play a crucial role in our public hospital system. The Government values the enormous contribution they make. The public hospital system could not function without them." He said he had written to Dr Cartmill advising of 7.8 per cent pay rises for VMOs pending the conclusion of the health reviews. "The decision by the Government to award the increase in the way we have, allows for further negotiations to take place if recommendations from the Bundaberg hospital inquiry and Health Systems Review impact on the employment status and conditions of VMOs," Mr Beattie said.

Probe dropped as doctor fled

He kills someone but gets off scot-free because of regulator incompetence

The Queensland Medical Board had dropped its investigation into the operating theatre death of a Charters Towers woman when the overseas-trained doctor in charge of the procedure resigned and left the country, a Townsville inquest was told. The five-day inquest, which wound up yesterday, was inquiring into the circumstances surrounding the death of Kathryn Marnie Sabadina in December, 2000, and the possible responsibility of South African-trained Dr Izak Schalt Maree. Dr Mary Cohn, chairwoman of the Medical Board of Queensland, the body which registers doctors in the State, said at the time of Dr Maree's resignation, in 2001, the board had 397 investigations to conduct.

Counsel assisting the Coroner Michael Tate said he and several expert witnesses had been surprised to hear that the investigation had been dropped. Mr Tate said this was especially so since the board itself had written to Dr Maree, telling him it had received complaints from a senior doctor about his conduct. "The board is concerned that you may prove an imminent threat to the health and well-being of the public," Mr Tate quoted from the letter. Dr Maree resigned and left shortly after receiving the letter.

Dr Cohn said, with a workload of 397 investigations, it was decided the inquiry into Dr Maree was best put on hold. But she said the inquiry would be immediately reactivated if Dr Maree returned and again sought registration. Asked if procedures had changed, Dr Cohn said they had. Today, the investigation would have continued because there were only 170 cases in train. Dr Cohn said the board simply registered Dr Maree on his references and credentials from South Africa. It had not known he was being appointed medical superintendent at Charters Towers Hospital. "That has been changed, and the board now needs to have a job description available before interviewing a doctor for registration," Dr Cohn said.

Peter Sladden, who was the Queensland Health district manager in 2000, denied Dr Maree had been hired because he was cheap. Mr Sladden said another doctor mentioned in connection with the matter was never an applicant for the medical superintendent's job, and Dr Maree was the only applicant.

Townsville Hospital director of anaesthetics Professor Vic Callanan said Ms Sabadina's death was most probably caused by a severe allergic reaction to one of the anaesthetic drugs used in the procedure. Ms Sabadina's father, Heath Sabadina, told the inquest he did not believe his daughter had died in vain. "My daughter's death was a bit of a wake-up call for Queensland Health," Mr Sabadina told State Coroner Michael Barnes. Mr Sabadina made the comment after hearing a morning of testimony about the procedures Queensland Health has put in place as a result of his daughter's death.

Dr David Farlow, the co-author of an investigation critical of Dr Maree, agreed the events in Charters Towers during Dr Maree's time there had prompted change. He said there were now programs in place for frequent peer reviews of skills. 'Privileges', or formal permission to perform specialist functions, were now checked and refreshed every three years. There was also a closer link between regional hospitals such as Townsville and the smaller ones in the region. Dr Farlow said creating a network of contacts through refresher courses at the main hospitals allowed rural and remote doctors to increase skill levels and gain quick access to advice. He said medical equipment throughout Queensland was being standardised.

Coroner Barnes said he hoped to have his findings ready to be published in about two weeks. These findings will include consideration of whether further action should be sought against Dr Maree.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Saturday, July 23, 2005

Lives put at risk as British public hospitals ignore alerts

Many hospitals are not acting on safety warnings issued when equipment and medical procedures go wrong, putting lives at risk, the Chief Medical Officer said yesterday. Sir Liam Donaldson said that the safety record of all health trusts should be made public to help to ensure that they comply with patient safety alerts promptly. A trust's record should form a major part of its yearly performance rating. In his annual report on public health, Sir Liam said that the NHS had yet to embrace the culture of patient safety, with some trusts taking years to implement alerts put out as a matter of urgency. Some trusts that were reported to be following national advice were subsequently found to be failing.

Patient safety alerts, which are issued on matters such as the use of equipment and drugs and are intended to minimise human error, are sent to all NHS organisations. About 10 per cent of patients admitted to hospital are thought to suffer some form of medical mistake. Comparing the NHS with the airline industry, where safety had been a central focus since the 1960s, the report concluded: "It is only relatively recently that attention has been focused on the safety of patient care as an issue. "Despite the relatively high level of risk associated with healthcare, systematic attempts to improve safety and the transformations in culture, attitude, leadership and working practices necessary to drive that improvement are only just beginning."

He said that, in some cases, compliance with safety alerts had started only after high- level intervention from the Department of Health, including warning letters and meetings with hospital managers.

Sir Liam highlighted several cases where patients had died as a result of an error, including a girl aged 3 who was given nitrous oxide instead of oxygen from an anaesthetic machine. Another alert was issued over intrathecal chemotherapy - injections into the spine given to treat cancer. Wayne Jowett, a teenager from Nottingham, died in 2001 after a drug was injected into his spinal fluid rather than intravenously.

Sir Liam said that after guidance on intrathecal chemotherapy was introduced later that year, NHS trusts had to complete a checklist confirming compliance with the advice by the end of December 2001. By March 2002, some 32 NHS trusts (21 per cent) remained non-compliant and it was not until the summer of 2003 that full compliance was achieved. Revised guidance was issued in October 2003, but it was not until this January that all trusts were reporting compliance, after warning letters and phone calls to chief executives. But an independent review found that not all the trusts were following the guidance. "Of the nineteen NHS trusts providing intrathecal chemotherapy services that had been reviewed by April 2005, nine were non-compliant on inspection, despite three of these having claimed compliance prior to the inspectors ' visits," Sir Liam's report said. "These trusts are now either compliant or no longer providing an intrathecal chemotherapy service. So serious were some of the breaches that services were suspended."

Sir Liam said that the slow pace at which trusts responded to the guidance -and in some cases said they had responded but were found not to have - showed that the safety culture in the NHS was not yet focused or organised enough to reduce a potentially fatal risk to patients quickly enough. "If the local NHS wants to have autonomy then their part of the bargain is that they have to meet important national standards." He added: "In some cases they need to meet them quicker than they are doing."

More here

Taxachusetts: Even the taxpayer's pocket is not bottomless: "Saying their budgets are being crippled by soaring healthcare costs, cities and towns want the Legislature to give them more flexibility in designing health insurance benefits for their employees. A report by the Massachusetts Taxpayers Foundation released yesterday cited a 'crisis in municipal health costs' and said cities and towns have seen a 63 percent increase in health insurance costs since fiscal year 2001, nearly double the rate of increase of state healthcare costs and more than four times the growth rate of local budgets. 'This is a staggering obligation that cities and towns are having to bear,' said Michael J. Widmer, president of the taxpayers foundation. 'Clearly this is unsustainable.' Municipalities say that they are hamstrung by state laws that require them to negotiate with unions on almost all aspects of health benefits."


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation. Both Australia and Sweden have large private sector health systems with government reimbursement for privately-provided services so can a purely private system with some level of government reimbursement or insurance for the poor be so hard to do?

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Friday, July 22, 2005

Who's Minding N.Y. Medicaid?

New York's Medicaid program has always had a reputation as the Cadillac of state health care programs. The 4.2 million people in the state's program have access to some of the best and most complete medical coverage in the country. The very fact that it's so generous makes it particularly critical that the public is assured that money is not being wasted. Unfortunately, the opposite seems to be true. As revealed by a year's investigation by Clifford J. Levy and Michael Luo of The Times, New York's $44.5 billion Medicaid program has become a honey pot for unscrupulous practitioners.

As one former prosecutor said, the pursuit of Medicaid fraud by Gov. George Pataki and Attorney General Eliot Spitzer is now so lax that New York State's Medicaid program "almost begs people to steal." Better management of Medicaid and expanded enforcement should pay for itself - especially since there are federal funds available if New York steps up its pursuit of those ripping off the state. Yet the number of investigators has been cut so badly that, with 400 million claims paid last year in the state, Health Department regulators uncovered only 37 cases of suspected fraud.

Albany's politicians are scrambling to blame one another for this scandal, and whipping up plans for reform. But Governor Pataki, who is now nursing presidential ambitions, is going to have to explain this one to the voters he's been courting in Iowa. Mr. Spitzer, who is running for governor, now has a big question mark on his resume as a reformer. The Legislature deserves its share of the blame as well. The State Senate, dominated by Republicans, has failed to beef up the attorney general's enforcement budget and the Assembly, controlled by Democrats, has rebuffed the Senate's ideas for Medicaid oversight.

What all state officials share is the ability to cower like Harry Potter's Dobby before the lobbyists from health unions, nursing homes, hospitals and big pharmaceutical companies. It's time for them to stop catering to this powerful shadow government. New York was once in the forefront in investigating Medicaid fraud, with charges against "Medicaid mills" a routine item on the docket. Now the state spends the most money but ranks way down the list for the number of on-site audits or cases referred for prosecution.

Every dollar stolen from Medicaid is a dollar taken from a single mother with a feverish child or an elderly person who needs a steady doctor. This is a scandal and a disgrace for the government of New York State and those who run it.


Bad Boys from Brazil: "Even residents of rich countries don't want to pay for life-saving medicines. Most industrialized states impose one or another set of price controls on drugs, blatantly free-riding on the scientific creativity of American firms. Other states make even less pretense of respecting the property rights of U.S. drugmakers. Such as Brazil. Despite its manifold economic and social woes, it has the largest economy in Latin America, ranking 11th in the world. Per capita GDP runs about $8,100 -- behind the U.S., but ten or more times that of the dozen poorest African states. Yet Brasilia believes that other nations -- or, more accurately, companies from other nations -- owe it a medical free lunch."


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Thursday, July 21, 2005


A quarter of people are not able to see their GP within two days, contrary to Government claims that the target is met in almost all cases, according to the annual review of the NHS. The State of Healthcare 2005 reveals that though many improvements have been made in health provision, a group of "Cinderella services" is being badly neglected, including dentistry, sexual health and parts of primary care.

The review, carried out by the Healthcare Commission, concludes that the NHS still has a long way to go to achieve a "patient-led" service, a key ambition of the Goverment. While praising the progress made in the treatment of conditions such as cancer and heart disease, the health inspectorate found some areas of the NHS to be severely wanting. In its analysis of primary care, the commission found that access to a GP remained a problem for many people, with around 25 per cent waiting more than 48 hours for an appointment. Ministers have claimed that the problem affects fewer than 2 per cent of surgeries. In London, demand for services is such that four out of five GPs are unable to take on new patients.

The review, which was presented to Parliament yesterday, offers further evidence of the well-documented pressures on NHS dentistry. It said that nearly 60 per cent of NHS dental practices were not taking on new patients - an increase from 40 per cent in 2001 - and in some areas no dentists are taking on new NHS patients.

Poor communication between doctors and patients was identified as another problem, with people left in the dark about the type of medications they were prescribed, their treatment options and the specifics of their conditions. The commission said it was particularly worrying that more than a third of patients were not given information on the side-effects of medicines.

One in seven patients also took issue with surgery receptionists' manner, while up to a quarter of patients in some trusts reported that the staff talked about them "as if they weren't there".

The commission also highlighted poor standards in maternity care, which were documented in its recent report into services at Northwick Park, in north London. Staff were found to be overstretched, working in cramped conditions with inadequate equipment. Poor management was identified as more at fault than lack of money.

The report also reveals the long waits for sexual health services, with 28 per cent of people needing to be seen urgently having to wait more than 48 hours, and 29 per cent of people with symptoms waiting more than two weeks.

More here

Taxachusetts goes wild: "At a time when other states are kicking people off Medicaid to save money, Massachusetts is headed in the opposite direction. Over the past year, the state has added 50,000 people to its Medicaid program, which provides health insurance for the poor. Enrollment reached 985,000 this spring, and in the coming months, it could top 1 million, an all-time high, according to state officials. There is no single explanation for the surge, say those who follow Medicaid's fortunes, but the most critical one may be a change in the political climate. Governor Mitt Romney has promised to provide health insurance to everyone in Massachusetts, and his administration has concluded that signing more people up for Medicaid is one way to accomplish that goal. ''I'm not a giant fan of the governor's, but I will give him credit for putting his money where his mouth is,' said John E. McDonough, executive director of Health Care For All, an advocacy group based in Boston. Romney insists putting more people on Medicaid is affordable. 'When everyone is insured, care will be better and costs will be lower,' said Romney in a telephone interview."


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Wednesday, July 20, 2005

New York Medicaid Fraud May Reach Into Billions

Socialized medicine at work:

It was created 40 years ago to provide health care for the poorest New Yorkers, offering a lifeline to those who could not afford to have a baby or a heart attack. But in the decades since, New York State's Medicaid program has also become a $44.5 billion target for the unscrupulous and the opportunistic.

It has drawn dentists like Dr. Dolly Rosen, who within 12 months somehow built the state's biggest Medicaid dental practice out of a Brooklyn storefront, where she claimed to have performed as many as 991 procedures a day in 2003. After The New York Times discovered her extraordinary billings through a computer analysis and questioned the state about them, Dr. Rosen and two associates were indicted on charges of stealing more than $1 million from the program.

It has drawn van services, intended as medical transportation for patients who cannot walk unaided, that regularly picked up scores of people who walked quite easily when a reporter was watching nearby. In cooperation with medical offices that order these services, the ambulettes typically cost the taxpayers more than $50 a round trip, adding up to $200 million a year. In some cases, the rides that the state paid for may never have taken place.

School officials around the state have enrolled tens of thousands of low-income students in speech therapy without the required evaluation, garnering more than $1 billion in questionable Medicaid payments for their districts. One Buffalo school official sent 4,434 students into speech therapy in a single day without talking to them or reviewing their records, according to federal investigators.

Nursing home operators have received substantial salaries and profits from Medicaid payments, while keeping staffing levels below the national average. One operator took in $1.5 million in salary and profit in the same year he was fined for neglecting the home's residents.

Medicaid has even drawn several criminal rings that duped the program into paying for an expensive muscle-building drug intended for AIDS patients that was then diverted to bodybuilders, at a cost of tens of millions. A single doctor in Brooklyn prescribed $11.5 million worth of the drug, the vast majority of it after the state said it had tightened rules for covering the drug.

New York's Medicaid program, once a beacon of the Great Society era, has become so huge, so complex and so lightly policed that it is easily exploited. Though the program is a vital resource for 4.2 million poor people who rely on it for their health care, a yearlong investigation by The Times found that the program has been misspending billions of dollars annually because of fraud, waste and profiteering. A computer analysis of several million records obtained under the state Freedom of Information Law revealed numerous indications of fraud and abuse that the state had never looked into. "It's like a honey pot," said John M. Meekins, a former senior Medicaid fraud prosecutor in Albany who said he grew increasingly disillusioned before he retired in 2003. "It truly is. That is what they use it for."

State health officials denied in interviews that Medicaid was easily cheated, saying that they were doing an excellent job of overseeing the program. "This continues to be an area where we think that we have made substantial progress," said Dennis P. Whalen, executive deputy commissioner of the State Health Department. "But by no means are we sitting back and resting on the accomplishments that we have made."

Nonetheless, after being informed of The Times's findings, the Republican majority in the State Senate began a push recently to overhaul the system intended to protect Medicaid, which has been sharply reduced even as Gov. George E. Pataki and lawmakers have nearly doubled the program's budget over the last decade. The Democratic majority in the Assembly has remained on the sidelines. So has Mr. Pataki.

New York's Medicaid program is by far the most expensive and most generous in the nation. It spends far more - now $44.5 billion annually - than that of any other state, even California, whose Medicaid program covers about 55 percent more people. New York's Medicaid budget is larger than most states' entire budgets, and it spends nearly twice the national average - roughly $10,600, more than any other state - on each of its 4.2 million recipients, one in every five New Yorkers....

James Mehmet, who retired in 2001 as chief state investigator of Medicaid fraud and abuse in New York City, said he and his colleagues believed that at least 10 percent of state Medicaid dollars were spent on fraudulent claims, while 20 or 30 percent more were siphoned off by what they termed abuse, meaning unnecessary spending that might not be criminal. "So we're talking about 40 percent of all claims are questionable," Mr. Mehmet said - an amount that would approach $18 billion a year.

More here

Dick McDonald comments:

The true liberal bleeding heart is caught between a rock and a hard place. They want to provide for the indigent but protect their elitist sensibilities that would insure their “privacy” is protected. They presently don’t have any privacy, they just won’t admit it. The ACLU makes lots of government-paid fees protecting that which doesn’t exist. In a digital world each of us is photographed and IDed hundreds of times a day and don’t even know it. So New York loses $45 Billion a year that could be caught by a grammar schooler with datamining software. But who in NY would dare take on the Manhattan liberal elite, their MSM, the Democrat Party and all those who protect liars and thieves. Not tough New Yorkers, they are too busy chasing corporate crime and Republicans. They are wussy, cowards protecting a criminal enterprise they could stop in a New York minute. Or, they have no clue what data mining is.

NYT whines about it on the front page today: "New York Medicaid Fraud May Reach Into Billions". Data mining software discovers in microseconds the repetitive fraud this scam is based on. But data mining is so invasive in the minds of the liberals, they can’t even suggest it to catch terrorists, much less criminals. Here data miners would just chase repetitive billings. Yet who dare suggest criminals be scrutinized. Surely not your NYT leftist mob. They just like to uncover problems, they never solve them. Read the article for yourself and pretend you are Nancy Drew in the second grade with data mining software and see what I mean.


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Tuesday, July 19, 2005


Below are some excerpts (with comments) from a policy document prepared by the supporters of "single payer" health care in Vermont. Key terms have been bolded. Everything is put into the dead hands of a new bureaucracy. What people get will depend on the decisions of the bureaucrats as much as the doctors

"The VHCA document posits a cost and affordability crisis. “The majority of what we spend on health care goes to infrastructure costs (that) are largely fixed. Therefore, the single effective way to control total health care costs is to control the size of the health care infrastructure itself and not by controlling utilization. Payment for health care is a collective investment in the health care infrastructure… The important question is exactly how much we are willing to invest in our health care infrastructure. Decisions cannot be left to chance.” As the proposal makes clear, decisions will largely be left to the government.

A major problem, says the document, is oversupply of services, and “the importance of matching supply to need, not demand…Stability [in health care] comes by looking at the health infrastructure as a whole, determining its reasonable costs, and implementing an overall budget in a fiscally responsible manner.” Demand, initiated by patients who may not understand what they really need, will be replaced by government-controlled allocation of services on the basis of what patients are determined to reasonably need.

“The only efficient way, in fact the only feasible way, to modify and control long-term costs is to impose a budget across the entire infrastructure. Such a budget’s main functions would be to allocate annual hospital budgets based on available financing for the coming year, negotiate uniform reimbursement rates within specialized sectors of medical care, and engage in planning and distribution of health care services… Explicit public policy rationing should take into consideration the available money for a certain service, the benefit of the treatment, and the expense of the treatment.”

“A universal health care system pays for all necessary medical care for everyone, is largely publicly financed, employs an overall budget across the system, manages health planning, and is accountable to the public.”

Thus, some all-powerful entity must have complete control over the infrastructure (hospitals, nursing homes, physician and nursing services). This entity, and not consumer demand, must determine what “investments” are “reasonable” and what services are “necessary”. This entity must establish and enforce overall budgets, ration services to patients, fix reimbursement rates for all doctors and nurses, and be “fiscally responsible”.

That entity – a monopoly Health Maintenance Organization (HMO) - can only be the Government.

The document says that the government will not run the health care system, only coordinate it. “Medical decisions are determined by doctor and patient without bureaucratic interference.” It is hard to believe that a doctor working for a cost-conscious HMO, and subject to utilization pre-approval and an end-of-year drawback for overprescribing tests and medications, would believe this. The report says that “physicians’ worst fears about bureaucracy, interference, and erratic reimbursement rates already are here in the form of managed care.” Why the proposed single payer system, funded by taxation and required to be “fiscally responsible”, will be any sort of improvement over an HMO is not explained.

The document claims that such a system will be affordable for taxpayers by citing the 2001 Lewin Report. This report claims that installing a single payer system in Vermont would cause an initial cost increase of $63 million, but this would be more than offset by $153 million in administrative savings (health insurers and premiums would disappear, and providers would no longer bill for services) and $30 million in drug formulary savings (all prescription drugs would be purchased at Medicaid prices.) The total projected savings of $118 million was about 5% of Vermont’s 2001 health care expenditures. To pay for the benefits, employers would pay an additional payroll tax of 5.8 percentage points, and employees an additional 2.9 points.

Whether a state health care authority could purchase prescription drugs for all patients within the state, regardless of their incomes, at Medicaid prices is legally very doubtful.

The single payer backers have not shied away from their goal: complete government control of all health care facilities and providers, explicit government rationing, and full taxpayer financing."

More here


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Monday, July 18, 2005


Unfortunately, the body politic's grasp of Medicaid lags about 20 years behind its understanding of welfare. The Left launches a fusillade at any mention of such heresies as applying the lessons of welfare reform to Medicaid. The New Republic's Jonathan Cohn calls such an approach "heartless" and says that "rolling back Medicaid means the poor and disabled will have to confront medical bills alone. The bankruptcies will pile up, emergency rooms will get even more crowded, and, yes, some people will die."

Rip van Welfare

One wonders whether Cohn and others slept through the last ten years. During the welfare-reform debate, the Left predicted that scaling back federal cash assistance to the poor would be similarly disastrous. The most hysterical predictions were that one million children would be thrown into poverty and that the poor would be starving in the streets.

Welfare reform produced exactly the opposite of what the Left expected. Caseloads plummeted and poverty decreased -- often dramatically -- for every racial category and age, including children. Poverty remains lower today than at any point prior to welfare reform, going back to 1979. Many who opposed the 1996 law have since admitted that it accomplished a large measure of good. And evidence stemming from part of that law suggests that with regard to Medicaid, the Left is again misreading the tea leaves.

Though wholesale Medicaid reform was thrown overboard in 1996, the welfare-reform law contained a little-noticed provision that eliminated Medicaid eligibility for non-citizen immigrants. One person who did notice was Harvard economist George Borjas. He discovered that the result of this "draconian" measure was exactly the opposite of what many would predict: coverage among non-citizen immigrants increased. Borjas explains, "The immigrants most likely to be adversely affected by the new restrictions significantly increased their labor supply, thereby raising their probability of being covered by employer-sponsored insurance. In fact, this increase in the probability of coverage through employer-sponsored insurance was large enough to completely offset the Medicaid cutbacks."

The robust economy of the late 1990s cannot explain these results, Borjas argues, because states that offered coverage to those cut from the Medicaid rolls saw coverage levels for this group decrease, while states that did not saw coverage levels increase. As author Jason DeParle has written, "When welfare was there for the taking, they got on the bus and took it; when it wasn't, they made other plans."

Borjas notes that immigrants responded not just to the Medicaid cuts, but to all the changes in the 1996 law. Nonetheless, a natural experiment has demonstrated that Medicaid cuts produced exactly the opposite of what opponents would predict, and that -- by at least one measure -- the cuts were more compassionate than the program's previous (supposed) generosity.

The Status Quo Prevails

With these successes pointing the way, one might think Republicans would be eager to mount an all-out assault on Medicaid's vicious cycle of inflating health-care costs and promoting dependency. Not so.

In its proposed budget for fiscal year 2006, the Bush administration backed away from its earlier reform proposals, which themselves were a watered-down version of what Republicans offered in 1995. Indeed, the budget laments that states have not done enough to expand Medicaid. It proposes additional state flexibility, but mostly in the service of such expansions. The CBO estimates the administration's proposed reductions in future spending would amount to one half of one percent of Medicaid spending over the next ten years. Projected Medicaid spending fell by as much due to technical adjustments that CBO made in March to its baseline projections. The administration's budget boasts that Medicaid "will continue to grow at a robust rate."

The picture is no less bleak at the other end of Pennsylvania Avenue. After a tough negotiating session -- with themselves -- congressional Republicans have just agreed to a budget that reduces future federal Medicaid spending by less than one percent. Lest anyone think this constitutes a cut, instead of growing 41 percent by 2010, federal Medicaid spending will now grow by 39 percent -- again, about the same as the change wrought by the CBO's technical adjustments.

Some Republican governors, notably Florida's Jeb Bush and South Carolina's Mark Sanford, have proposed restructuring Medicaid benefits with health savings accounts (HSAs). Beneficiaries would receive money in an HSA to use toward copayments and deductibles, and could keep what they don't spend. The idea is to give beneficiaries an incentive to be prudent consumers, and it builds on what seem to be successful "cash and counseling" programs in Florida, Arkansas, and New Jersey.

Yet this approach may trade one set of problems for another. Beneficiaries should be more careful shoppers if they share in the savings. However, the lure of cash benefits may lead to higher enrollment (only about half of Medicaid-eligible individuals are enrolled), longer enrollments (many beneficiaries only use Medicaid for brief periods), greater utilization of all available benefits, and greater dependency.

Real Medicaid Reform

States should experiment with HSAs and other approaches, including different rules for different types of beneficiaries. Far more important than restructuring benefits, however, is reducing the reach of Medicaid's perverse and harmful incentives.

First, Congress should stop encouraging Medicaid expansions by freezing payments to states at the 2005 amount, just as welfare reform froze payments to states at the 1995 amount. According to Congressional Budget Office figures, freezing federal Medicaid spending at 2005 levels would produce $941 billion in savings by 2015, or enough to wipe out 96 percent of the cumulative ten-year federal deficit.

Second, Congress should give states maximum flexibility to use federal funds to meet a few broad goals, as it did with AFDC's replacement, the Temporary Assistance for Needy Families (TANF) program. Those goals should include:

* targeting medical assistance to the truly needy;

* reducing dependency;

* reducing crowd-out of private effort, including charitable care; and

* promoting competitive private markets for medical care and insurance.

A necessary first step toward allowing states to focus resources on the truly needy would be eliminating the federal entitlement to Medicaid benefits, just as Congress eliminated the federal entitlement to cash assistance under TANF.

By themselves, these reforms would not alter a single state's program. Each state would have the power to keep its program running (and growing) just as it would under current law. However, states likely will experiment with ways of providing efficient care to those who truly need assistance and encouraging private charitable care, without encouraging dependency, increasing health-care costs, or imposing a crushing burden on taxpayers.

To state plainly what it means to focus resources on the truly needy, states should use this new flexibility to remove from the Medicaid rolls all those who could obtain coverage elsewhere. To do otherwise robs taxpayers and diverts assistance away from those who need it more.

Opponents will argue that those who move from Medicaid to private insurance may end up with less coverage. But as important as how much coverage people have is how they obtain it. When people work and become more productive, both they and society benefit. Offering people Medicaid in lieu of (allegedly) inferior private coverage, on the other hand, tells them that the way to get more is by doing less: work less, save less, cultivate less self-reliance. That is a recipe for dependency.

Like welfare, Medicaid must be reformed for the sake of its recipients. The likelihood that anyone will soon offer this type of assistance brings to mind a passage from Charles Murray's 1984 book Losing Ground, which is credited with sparking the welfare reform movement: "The real contest about the direction of social policy is not between people who want to cut budgets and people who want to help. When reforms finally do occur, they will happen not because stingy people have won, but because generous people have stopped kidding themselves."

Setting Medicaid reform aside might have made political sense in 1996. It makes zero sense today. The Left may be forgiven for missing or misinterpreting the lessons of welfare reform, or the effects of Medicaid. Republicans, however, have little excuse. Republicans and moderate Democrats need to take stock of this program, take stock of themselves, and finish the job of welfare reform.



For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Sunday, July 17, 2005


Yes, folks and fellow libertarians, we DO agree: Public healthcare is an abomination, and should be destroyed, and replaced by PRIVATE, VOLUNTARILY funded systems and organizations, so that nobody pays for something they neither use nor want! The problem is, we're so far down the rabbit-hole in this arena that the transition - just from statist quo to a neutral situation, to say nothing of actually moving toward free market solutions - will require either a very careful and gradual retreat from socialized medicine … or a complete sacrifice of every person who's been left with no choice but the present fiasco, or DEATH!

You see, I do not hold that "collateral damage" is any more appropriate a concept in welfare than in warfare. Challenge my libertarian roots if you will, but I'd even rather see a continued worsening of the welfare state than to see people dying in the streets of America - merely because nobody gives a damn enough to reach out a hand to help!

I do not refer to the "professional victim" class which has sprung up in the wake of massive public subsidization of institutionalized "public charity" … I'm talking about people really in need (temporarily or permanently) and who cannot afford - to take care of themselves - thanks mostly to the way things are mandated and managed, by government and its handmaidens and lapdogs....

When we gave up the ability to contract directly, doctor to patient and vice versa, we forfeited "market behavior" to the corporatist manipulation model. Once that paradigm took over, its partner-demons jumped in: government, bureaucracy, regulation, paperwork, permissions and penalties, "malpractice" lawsuits and insurance, etc. - only an infinitesimal slice of which had anything to do with providing better service in treating health issues! (And lest we forget, as soon as the doctors and hospitals began to allow government to help "protect" them, one of the first incursions was against "drug vending" - leading to countless doctors in jail, and countless legitimate pain-sufferers with no relief!)

Unraveling this snarl is not going to be a simple thing like "abolishing TennCare." It will take a series of actions, and (unless we really want the blood of thousands, perhaps hundreds of thousands, of lives on our hands?) it's going to take some alternative pathways, to create and provide private (or voluntary community) measures - the kind that do what is needed to make "staying healthy" a matter of minor cost and inconvenience, at least for the vast majority of us … the way it once was!

Meanwhile, we will need to focus charitable aid on those who are truly unable to do for themselves. We'll also need to become better at convincing some of the folks around us that "just letting them die" is not a reasonable option for enlightened and self-affirming human beings to take. Only then can we honestly say we are acting in a way that truly promotes liberty - for those who can, to exercise it freely, here and now; for those whose resources are (currently?) limited (by factors beyond their control?) to taste it for themselves, and then strive to do what they can to at least reach toward that personal liberation for themselves.

I don't wish to live in a "free society" where people blithely ignore what is going on around them, and spend all their time cleaning their rifles and bolstering the barricades - instead of seeking ways to connect and become a productive part of a society of free and equal individuals, who leave each other alone … but are also always willing to do what they can, to help a neighbor is in need to regain footing. I don't really think you do, either!

More here


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.


Saturday, July 16, 2005


In my lifetime, I've watched a lot of costs plummet... power tools, tires, computers, telephones, air travel, batteries, and household appliances, just to name a few, and in each case, the quality has increased dramatically over the same time. During that same time, health care quality has also increased (with a lot of exceptions), but the costs have skyrocketed. What in the hell is it about health care that makes it such an exception?

I'm going to present some powerful clues... food for thought. I said that we don't know whom to scream at concerning health care costs, and that's the germ of a clue. There is one group of people who, for many decades, have been claiming to be knowledgeable about and concerned with health care costs, and promising they will do something about it. Politicians. The problem is precisely that they have been trying... and trying... and trying. Like all other "solutions" produced by government, their results have been exactly the opposite of what they intended.

In the 2004 Minnesota legislature, 40 pieces of legislation concerning health care were considered. FORTY! If you've ever read a legislative bill, you know that's a massive amount of legal language, complex enough to drive one to distraction, filled with qualifiers and exceptions... and loopholes that will require clarification, modification, and more legislation in the future. Every bill pleases some people and displeases others who will introduce contrary legislation or try to revoke the original... and it goes on and on and on.

The seemingly simple idea of using legislation to improve something (anything) adds immense complexity to a field that is complex to begin with. Medical science is complex, unpredictable, and constantly changing. Add in political tinkering that is often misinformed, or politically biased, and very slow to change, and you've taken a complex scenario and made it damned near impossible to grasp.

One natural result has been the rise of very big corporations in health care. Only an organization with enough size to justify legal and legislative specialists can understand and respond to the complexity created by government tinkering, and that's just the beginning. An organization with that level of expert specialization can affect legislation... introduce it, lobby for and against bills, and create publicity to sway public opinion in favor of their positions... which are positions, naturally, that will further tip the playing field in their favor.

Minnesota also has a weird moratorium on hospital construction (here's your chance to read a bill). It's too complex to go into here, but in 1984, our legislature concluded that there was wasted hospital capacity... too many beds available. Most of us less well-informed folk might think that would actually be POSITIVE... but not our legislature.

Allina wanted to build a hospital in Sartell. They had to seek an exception to the moratorium. The impending presence of new competition in Sartell got the folks at St. Cloud Hospital all excited. In an explanation of why Allina should not be allowed to open a hospital in Sartell, just 6 miles from them. St. Cloud Hospital says:

The St. Cloud Medical community has grown into a regional referral center for Central Minnesota. We have created competition for the Twin Cities hospitals.

So... competing against Twin Cities hospitals is good? Well, uh, I mean... they go on to say:

Competition does not work in health care - it actually drives up costs.

Huh? I guess they mean that competition is good if you're the new kid trying to make a buck, but bad if you're already established and trying to protect your business. To be fair, I'm sure I could find similar contradictions from Allina, but they're a lot bigger, have better writers, and wouldn't be so easily detected.

As soon as politicians get involved in trying to "fix" something, complexity sets in like a never-ending plague, and it always has the effect of killing off the little guys and enabling the big ones. It always has the effect of reducing competition and raising costs. More importantly, it drags resources away from the core business and into attacking and defending through legislation. Health care isn't just health care any longer. It's an industry politically regulated and tinkered with to such an extent that the actual health treatment and care is little more than a by-product.

More here


In 1997, Quebecer George Zeliotis was told he would be waiting a year for a hip replacement. There was no private medical option in Canada. And rather than do what some Canadians who can afford the time and money do - head for the US - he filed a lawsuit with Montreal Dr. Jacques Chaoulli, a longtime advocate for private medicine. The case was twice shot down in Quebec courts before they brought it to the highest court. The Supreme Court of Canada has ruled in favor of same-sex marriage and medical marijuana - hardly a gang of right-wing killjoys. Yet Chief Justice Beverley McLachlin and Justice John Major, in their ruling, concluded that "delays in the public health care system are widespread, and ... in some serious cases, patients die as a result of waiting lists for public health care." The court also emphasized the serious psychological suffering caused by prolonged denial of care.

Our socialized health-care system is idealized in the US by the likes of Hillary Clinton, Ted Kennedy, Michael Moore, and the California senate, which recently passed a bill guaranteeing publicly funded health coverage to every resident of the state. Here at home, true believers hold the system as close to them as the flag. Any suggestion that the system is less than perfect, or that it may be beneficial for a private tier to coexist with the public, is bound to start arguments.

This, in spite of a US-Canada sponsored study on the state of healthcare that showed Canadians and uninsured Americans had quite similar levels of satisfaction when it came to healthcare. In the same report, more Americans overall (53 percent) than Canadians (44 percent) were said to be "very satisfied" with the state of their health care.

The day of the Supreme Court ruling, there was some hyperbole, with Prime Minister Paul Martin boldly asserting that "nobody" wanted two-tiers, and Saskatchewan's Premier Lorne Calvert declaring Canada was on its way to an American-style system. "American-style health care," to your average Canadian, means a system where people routinely have to sell their homes to pay for treatments. The relative truth of that assumption aside, what we appear to be headed for is European or Australian-style healthcare, in which private and public intermingle nicely.

As to the prime minister's statement, a June 2004 poll found a majority of Canadians - 51 percent - in favor of allowing a parallel private care system. Support was highest in Quebec, at 68 percent, and in Saskatchewan and Manitoba, at 57 percent.

Recently, I had orthopedic surgery. The biggest challenge for me was the desperate Yellow Pages search for a family doctor to refer me to a surgeon. When that was accomplished, it was a three-month wait to see the surgeon, followed by three months more for the surgery. I have no complaints about the care, the surgery, or the kindness showed to me by everyone from the family doctor to the hospital staff. As someone who could not afford to pay for surgery, I'm grateful a surgeon was available to me.

But I also wouldn't mind if other Canadians opted out of our system. I'd assume that ultimately good things would trickle down to me in the form of - for starters - shorter waiting times and fewer doctors leaving Canada. Americans who hold Canada's system up as a model should keep in mind that there are better models than equal access to something inadequate.

More here


For greatest efficiency, lowest cost and maximum choice, ALL hospitals and health insurance schemes should be privately owned and run -- with government-paid vouchers for the very poor and minimal regulation.

Comments? Email me here. If there are no recent posts here, the mirror site may be more up to date. My Home Page is here or here.