AN INTERESTING CRITIQUE OF THE MASSACHUSETTS BRAINWAVE FROM THE LEFT

It's a stirring scene. The Governor, legislative leaders and leaders of Health Care For All standing in the State House Rotunda declaring victory in the fight for universal health coverage. Unfortunately, this week's tableau merely repeats one from 20 years ago when Governor Dukakis was celebrating passage of his universal healthcare bill. That plan imploded within two years, and today about 250,000 more people are uninsured in Massachusetts than the day it was signed. Unfortunately, Massachusetts' new health reform legislation looks set to repeat that disaster.

What's in the New Bill? The new bill includes three key provisions meant to expand coverage. First, it would modestly expand Medicaid eligibility. Second, it would offer subsidies for the purchase of private coverage to low-income individuals and families, though the size of the subsidies has yet to be determined. Finally, those making more than three times the poverty income (about $30,000 for a single person) would have to buy their own coverage or pay a fine.

To help make coverage more affordable, a new state agency will connect people with the private insurance plans that sell the coverage, and allow people to use pre-tax dollars to purchase coverage (a tax break that mostly helps affluent tax payers who are in high tax brackets). This new agency is also supposed to help design affordable plans.

Businesses that employ more than 10 people and fail to provide health insurance will be assessed a fee (not more than $295) to help subsidize care. Additionally, hospitals won a rate hike assuring them better payments from state programs, and several provisions were included that are meant to attract additional Federal funding to help pay for the Medicaid expansion.

What's Wrong With This Picture? First, the politicians assumed that only about 500,000 people in Massachusetts are uninsured. The Census Bureau says that 748,000 are uninsured. Why the difference? The 500,000 figure comes from a phone survey conducted in English and Spanish. Anyone without a phone or who speaks another language is counted as insured. The 748,000 figure comes from a door-to-door survey carried out in many languages (including Portuguese and Haitian Creole, common languages in Massachusetts). In sum, the reform plan wishes away 248,000 uninsured people who don't have phones or don't speak English or Spanish. It provides no funding or means to get them coverage.

Second, the linchpin of the plan is the false assumption that uninsured people will be able to find affordable health plans. A typical group policy in Massachusetts costs about $4500 annually for an individual and more than $11,000 for family coverage. A wealthy uninsured person could afford that - but few of the uninsured are wealthy. A 25 year old fitness instructor can find a cheaper plan. But few of the uninsured are young and healthy. According to Census Bureau figures, only 12.4% of the 748,000 uninsured in Massachusetts are both young enough to qualify for low-premium plans (under age 35) and affluent enough (incomes greater than 499% of poverty) to readily afford them. Yet even this 12.4% figure may be too high if insurers are allowed to charge higher premiums for persons with health problems; only half of uninsured persons in those age and income categories report that they are in "excellent health".

The legislation promises that the uninsured will be offered comprehensive, affordable private health plans. But that's like promising chocolate chip cookies with no fat, sugar or calories. The only way to get cheaper plans is to strip down the coverage - boost copayments, deductibles, uncovered services etc.

Hence, the requirement that most of the uninsured purchase coverage will either require them to pay money they don't have, or buy nearly worthless stripped down policies that represent coverage in name only.

Third, the legislation will do nothing to contain the skyrocketing costs of care in Massachusetts - already the highest in the world. Indeed, it gives new infusions of cash to hospitals and private insurers. Predictably, rising costs will force more and more employers to drop coverage, while state coffers will be drained by the continuing cost increases in Medicaid. Moreover, when the next recession hits, tax revenues will fall just as a flood of newly unemployed people join the Medicaid program or apply for the insurance subsidies promised in the reform legislation. The program is simply not sustainable over the long - or even medium - term.

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The solution these authors propose for the problems they identify is to bring in a single-payer health insurance system. And their grounds for arguing that? They argue that having the government take over would REDUCE bureaucracy. I kid you not: They actually do argue that having the government do something would reduce bureaucracy. What an incredible poverty of ideas they suffer from to propose something that goes against all human experience!






U.K.: Discharge NHS patients sooner and save cash, says Hewitt

Some hospitals are keeping patients up to four times longer than others for simple operations, draining resources and adding to the financial pressures on the NHS, the Health Secretary said yesterday. Patricia Hewitt called on all trusts to become more efficient at discharging patients and to reduce the substantial discrepancies in hospital stays. She spoke as two more trusts announced more than 500 job losses to try to tackle spiralling debts. A total NHS deficit of more than 800 million pounds has led organisations across England to rein in spending in recent weeks and announce more than 5,000 job cuts.

Surrey and Sussex Healthcare NHS Trust yesterday became the latest organisation to confirm that it will lose staff, with 400 jobs expected to go to help to reduce a monthly 2 million pound overspend. The trust, which manages Crawley Hospital and East Surrey Hospital, has a long history of financial problems and estimates its total debt for this financial year at 41.2 million pounds. The trust said that though 400 posts would go, permanent staff numbers would drop by only about 100. On Monday the Medway NHS Trust said that up to 160 jobs would go at the Medway Maritime Hospital in Gillingham, Kent. The trust needs to cut its spending by up to 11 million in 2006-07 and claw back a 1 million overspend from 2005.

Ms Hewitt, who has faced sustained pressure recently to explain the mounting debts on the back of six years of unprecedented NHS funding, said that money could be saved and care improved by reducing some patient stays. According to analysis by the NHS Institute for Innovation and Improvement, the best trusts treat a broken hip in less than 11 days, while the slowest performers take 45 days. Many of the longer stays targeted in the report were not offering more thorough care but, rather, were being less efficient and failing to prepare for the departure of patients from hospital.

Hip replacements varied between 7.4 days in the top 10 trusts to 29 days in the lowest-performing trusts, while stays for acute strokes ranged from 13 to 55 days. Knee replacements varied from 6.4 to 20 days. "The NHS is treating more people more quickly than ever before, but there are still parts of the system that can and should be far more efficient in speeding up the patient journey," Ms Hewitt said. "Cutting the variation between hospitals in patients' length of stay means patients can leave when they are clinically ready, freeing up capacity and time to deal with new patients coming in. This firstly improves services for patients, but will also help the NHS to save thousands of bed days a year." Ms Hewitt made her comments when visiting a number of hospitals in the North West yesterday.

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This is the sort of "care" you get from socialized medicine

Three times Pamela Dale has prepared herself for potentially hazardous brain surgery, only to have it cancelled minutes before her operation because of bed shortages. Her surgery was scheduled at the Royal Brisbane and Women's Hospital. The mother-of-three has a brain tumour which is causing her blackouts. It was first diagnosed in August 2004, and in early March she was scheduled for surgery to remove the tumour. "That was cancelled half an hour before we were due to leave home due to a lack of beds," Mrs Dale, 34, said.

"The next time I was scheduled was March 27. I was told it was cancelled because there was not enough time to complete the operation." An RBWH spokeswoman said: "Hospital staff can plan to a certain point, but cannot predict when patients requiring high-dependency or intensive care will come through the emergency department, or if patients already in wards in the hospital will deteriorate and need such care."

Medical groups have claimed that Queenslanders requiring urgent surgery are continuing to be turned away by the state's public hospital system because of a bed shortage crisis and it is unlikely to be fixed soon. Besides turning away patients requiring surgery, the bed shortage often leaves public hospital emergency departments overcrowded and patients needing to be transferred to hospital wards. In his report in September last year, State Government consultant Peter Forster estimated Queensland Health would require an additional 170 beds each year for the next 20 years just to meet future demand. A Queensland Health spokeswoman said an additional 99 beds had so far been opened this year. The Government also had identified scope to open a further 170 beds in 10 public hospitals around Queensland at a cost of $36.6 million a year, the spokeswoman said.

But Australian Medical Association Queensland president Dr Steve Hambleton said overcrowding continued to be a big problem. "I have just come back from Mackay and Cairns where they are suffering from bed block - Mount Isa is the same," Dr Hambleton said. "We need 200 beds on the Gold Coast urgently. It is going to take five years to bring enough bed numbers online."

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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?

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