We appear to have “bent the curve” in health care spending last year; national health spending grew at a historically unprecedented low of  3.9%. That’s including all national health expenditures — private insurance, Medicare and Medicaid, and out-of-pocket expenses.

You would think this was a good thing, right?

But according to Deloitte’s new survey, not necessarily:

• In the United States, three in four (75 percent) consumers say the recent economic slowdown has impacted their health care spending.
• Forty-one percent are more cautious about spending, 20 percent have cut back on spending, and 13 percent say they have reduced their spending considerably.
• Sixty-three percent say their monthly health care spending limits their household’s ability to purchase other essentials, such as housing, groceries, fuel, and education.
• In an effort to save money, 36 percent of prescription medication users say they asked their doctor to prescribe a generic drug instead of a brand name drug.
• One in four (25 percent) U.S. consumers skipped seeing a doctor when sick or injured.

• Consumers believe that hospital costs (68%), lifestyle

choices (62%), and fraud (62%) are major drivers of

overall health care costs. Administrative costs (57%),

prescription drugs (54%), and defensive medicine

(51%) are also commonly cited.

• Over half (51%) of all consumers believe that 50% or

more of health care spending is wasted

• Of those believing that the system is wasteful,

49% feel that money is wasted because

individuals are not taking enough responsibility

for maintaining their own health.

• Consumers also blame redundant paperwork

(55%), defensive medicine (46%), lack of

adherence to evidence-based approaches (40%),

and extreme measures taken at the end of life to

extend life for a short period of time (35%)

It’s amazing how health care reform, a burning issue six months ago, has fallen off the radar (unless you are sick). Nevertheless, Congress did enact something at the end of all that fighting, and pieces of the legislation will begin to go into effect this month. If you have a family, are self-employed, aging, already Ill, or employed by a small company, you might want to mark your calendar for the dates some of the changes take effect.

As of now: insurance companies can’t drop you if you get sick. Known as “recession,” this was probably the worst part of the old system and it should be gone by now, because all the insurance companies have agreed to stop this practice before it becomes mandatory by law do so.

Small businesses that offer health insurance can start taking a tax credit in 2010, too. This lasts until 2013.

June: Temporary access to Insurance for people with preexisting conditions: Ninety days after the enactment of the legislation, on June 21, 2010, there should be a new program that provides access to insurance for individuals with preexisting conditions who have not had insurance coverage for at least six months. This high risk pool will be available until 2014 when the exchanges come on line. Watch carefully for how much the premiums will cost, and remember that you have to had been uninsured for six months to be eligible.

Also this month businesses that carry retirees on their health insurance will receive government subsidies for 80% of the cost of those premiums, up to a cap of $15,000, So don’t listen to all the griping from corporations about the cost of retiree health insurance. Those costs are shifting to the government.

July: Health and Human Services is required to have a web site with information about what plans are available in each state for individuals and small businesses. Unfortunately, you probably won’t be able to understand this information until next March, when rules for how to present the information in a format that allows for easy comparisons will take effect.

September: the law will prohibit plans from excluding coverage for preexisting conditions for children until the age of 19. and children can stay on the family policy until they are 26. This happens September 23.

Also in September look for coverage for immunization and prevention services with no co-pays.

And here’s a big one: starting in September health insurance companies will have to report how much of your premium they spend on your care. This will be available on the internets, and must be 85% if you are in a large company plan and 80% for small companies and individuals. Behind the scenes, the lobbyists are wildly trying to help write the rules for what counts as care. This is a slimy business right now because it directly affects the insurance company’s profits.

Don’t tune out on all of this now, because the devil is in the details and although you may have gone on to worrying about the oil spill and the financial reform, you can be assured the health industry lobbyists have not. They are still hard at work trying to undermine reform even more assiduously.

At lunch yesterday, I was the guest of a group that contained several retired physicians. We listened to a talk by a board member from a large non-profit local hospital system. The speaker, knowledgeable and well-prepared, talked about the cost drivers of health care in America, which he listed as an over-reliance on technology, the practice of defensive medicine because of law suits, heroic measures at the end of life, lack of transparency as to the true cost of procedures, non-standard reimbursements, and a few others.

He pointed out that while we might have reformed health insurance, we had done little to cut costs, because we hadn’t changed the delivery system. And he went on to say that we had to move toward outcomes-based medicine, which he thought would convince doctors to prescribe fewer MRIs, mammograms, and other procedures that had proved to have little effect on patient outcomes.

During the discussion that followed, the comments from the physicians were not at all what I expected. Many were heated but not over the need for higher reimbursement, more tort reform, or loss of power to insurance companies.

No, instead they said we would never reduce costs until we taught physicians to make a diagnosis by taking a complete history and talking to the patient, rather than by opting out and scheduling tests. They said the art of diagnosis has all but vanished from medical school teaching and that students don’t know the simple principle of looking first for horses when hear hoofbeats, and not for unicorns. To these men, the race to adopt new technology hasn’t made the practice of medicine better, it has merely made it more expensive. Many of them are still reading their grandchildren’s X-rays to make diagnoses younger physicians miss. These guys saw diagnosis as an art, now a lost art. Many med students don’t even know how to listen through a stethoscope. Perhaps that is because doctors don’t get paid much for listening.

Personally, I think the introduction of DRG (diagnosis related group) codes has done as much as anything to discourage the art of diagnosis. A DRG code is generated after every patient visit, and allows the doctor to get reimbursed. More complicated codes get higher reimbursements, and some medical staff assign codes according to the profit motive, while others simply code incorrectly out of ignorance. But the standardization of patient codes turns every patient into a statistic. Might as well pick a code that approximates what the patient might have and give him/her some tests instead. The doctors also pointed out that their colleagues who are still in practice will not give up their MRIs easily, because they are in the habit of relying on them, and even tort reform won’t change that.

Now that the big “debate the bill” vote is passed, we have a week for pundits on both sides of the aisle to misinform the public about what the future of the health care reform bill is. There are two tunes, one theme, and melodies underneath both. There’s an unsung chorus or two in there, too.

The Progressive Theme: Reconciliation

Progressives are pressing ahead with petitions, blog posts, and swarms to advance the idea that health care reform — or more specifically, the public option — should pass using the arcane and somewhat unrelated escape hatch of reconciliation to force a vote which requires only a majority to pass.

Proponents argue that reconciliation does an end run around the filibuster and takes the ball to the goal. And it does, in a strange, stripped-down way. Here are some examples of reconciliation legislation in the past:

1. Bush Tax Cuts Because they were passed via the reconciliation process, they expire at the end of 2010. Not particularly helpful to health care reform to have provisional reform that is not permanent.
2. COBRA the last attempt at health care reform that was ultimately diluted to something that screwed laid-off and terminated workers more than not having insurance at all.
3. TEFRA – The Tax Reform Act of 1986 It had something for everyone, but again, no meaningful social legislation and certainly nothing that had a deeper impact than the bottom line of form 1040.

It’s been suggested to me that the purpose of putting the full court press on reconciliation is to let Reid in on the worst-kept secret of our time: The public option matters to progressives and they believe it is the magic amulet to force insurers and providers to keep costs down. More rebuttal to that in my Unsung Chorus sections.

I think pressure is good. I think engagement is good. What I don’t think is good: signalling desperation to one’s opponents. There are other, better ways to work this through the process.

The Conservative Theme: Everyone hates health care reform

This is the current media and pollster theme. Everyone hates it, it’s not popular, so Congress should drop it. I could argue with their logic or foundations for making a statement like this, but it would be a waste of time. Nevertheless, this will be what we will hear from now on — that we, the people do not want health care reform. That we really, really like being denied by insurers, excluded from coverage altogether, or losing everything we’ve worked hard to save and own, like our houses.

Think about that next time you hear the theme. The press wants you to scrap any possibility of equalizing access to health care, because a pollster (and a conservative one at that) is telling us that we really hate ourselves enough to leave the status quo.

That’s logic worthy of Sarah Palin and Glenn Beck. Oh wait! They’re probably the lead singers.

And yes, there is a nod to tort reform, which is such a comprehensive topic it should not be contained in a bill about health care reform. Still, it acknowledges that it’s been suggested as a possible cost-saver in the larger scheme of things.

The Lieberman Riff: It’s all about me

Joe Lieberman. In his quest to get whatever it is Joe wants that he doesn’t have right now, he is standing tall for…Joe. I’m guessing a few more vigils like this one won’t make a huge difference, but ultimately Joe will get what Joe thinks he wants, until Joe gets tossed out of office by constituents who overwhelmingly disagree with him.

Unsung Chorus #1: Conference Committees matter

Back in September, the President held a conference call with progressives where they composed a strategy. The song went like this:

1. Get the bills out of the committees. Check.
2. Get the bills onto the floor of the House and Senate. Check.
3. Pass the House bill. Check.
4. Pass the Senate bill, even if it means adding triggers to the public option. Half a check for opening debate. Let’s see if Snowe introduces an amendment calling for triggers. If she does, it gets a full check.
5. Pass the Senate bill with 60, where one of the 60 is Snowe or Collins. Bill has triggers for public option.
6. House/Senate bills go to conference committee for merge. In Joint Committee, trigger is stripped from public option by House progressives on the committee. Conference report goes back to House and Senate, needs 51 to pass the Senate and we’re done.

Unsung Chorus #2: The whole is greater than the sum of its parts

While progressives’ intone the chorus that without a public option, health care reform is no reform at all, the truth may be something different. What the public option clearly does (and why it’s being fought tooth and nail by moderates and conservatives) is open the door to a single payer system somewhere down the line. Otherwise, it’s another choice bundled with other choices, only a public choice as opposed to a private one. I’ve seen arguments that suggest it will be the only choice that will offer a patient-centered approach, but I really think that’s idealism. Under one administration it may be something different than it would be under another. We’ve seen that with Medicare, and there’s nothing that convinces me it wouldn’t be true with a public option.

That doesn’t mean I’m against it. It just means I want everyone to step back and look at the larger picture.

The more delicate and complex melody lurks underneath the sound and fury; namely this: the entire package makes such fundamental changes to the system that it is indeed major reform that will bring the cost of health care down, with or without a public option, with or without triggers for a public option, with or without opt-outs for a public option.

No, I did not blaspheme.

Consider the analysis done by Tim Jost over at the Health Affairs blog. His evaluation is striking in its clarity:

This year’s health reform legislation has often been criticized for being health insurance reform rather than health care reform, and for not doing enough to control the cost of health care. Those who offer these criticisms have obviously not read the bills or even tried to understand them.

Jost goes on to outline how, between the two bills, just about every viable suggestion by credible sources and/or studies has been incorporated into the bill. Outcomes-based payment systems, payment bundling, quality reporting, electronic health records, patient-centered outcomes research, etc, etc. The list goes on.

These are not provisions contained in the consumer protection section of a nine-section bill. They are part of the other facets, which when put together create a new and wonderous thing. Here are the nine facets of health care reform addressed in the Senate bill.

• Title I – Quality, Affordable Health Care for All Americans
• Title II – Role of Public Programs
• Title III – Improving the Quality and Efficiency of Health Care
• Title IV – Prevention of Chronic Disease and Improving Public Health
• Title V – Health Care Workforce
• Title VI – Transparency and Program Integrity
• Title VII – Improving Access to Innovative Medical Therapies
• Title VIII – CLASS Act
• Title IX – Revenue Provisions

There are some comprehensive and major paradigm shifts in this bill. That list of nine facets adds up to something greater than the presence or absence of a public option. This is what is being lost in the public debate over, and over, and over again. The finer cuts in each of those facets are the best ideas — regardless of the party who introduced them — for reforming the entire system.

It’s easy to fixate on one cut of one facet and think you’ve heard the whole mix, but it’s a little like pointing to “Yellow Submarine” as the seminal Beatles work of their career while ignoring masterpieces like the White Album. President Obama is a man of long strategies, not short-term end runs.

Let’s sing this song, loudly. If we don’t, it won’t matter what passes. It will all play out as some sort of loss for President Obama and the Democrats when in fact, it will be a huge win for each and every person who lives in these United States.

(cross-posted from odd time signatures)

What you really want to know, and are too polite to ask, is how sick am I and what’s ahead? Yesterday I got some answers and am happy to share them with you.

I’ve been on Gleevec for one month, and yesterday’s test results show that it’s WORKING. It wasn’t a given that it would, so this is a real relief. Whew!

I’m still very sick, and the Gleevec is working on my bone marrow to kill the cancer cells. Our goal is to get rid of every one of those demons and replace all the bad cells with good ones. The doctors say the situation is “being managed” and all signs show we’re going to get the cancer cells to zero and then work on keeping them there. At that point, I will be in remission.

Remission is the state of absence of disease activity in patients with known chronic illness that cannot be cured. It is commonly used to refer to absence of active cancer when this disease is expected to manifest again in the future.

Will I be cured? – NO. Leukemia comes in two forms, acute and chronic. I will be in a chronic phase and my body will accllimate to the Gleevec and will need continual monitoring. At some point I will have to “dose up” on Gleevec and adjust to the higher dosage. I’m at risk for changing to an acute stage of the illness if the drug therapy doesn’t work or if I stop taking the drug. Yes, going to an acute stage could kill me.

I mentioned before they don’t know what causes this. Well, they also don’t know why it sometimes goes from a chronic state to an acute state, so that’s another reason why it has to be constantly monitored and I’m in for a lifetime of blood tests.

Yes, this is a life-changing situation. I have worked since I was eight years old and was paid to baby sit. I have advanced in my career, and continued my education, resulting in an income, and income taxes, that have always been higher than average norms. Up until seven weeks ago I was a productive, active member of the community. I’m someone who’s been priced out of the individual health insurance market due to a pre-existing condition. My last employer, a major health insurance company, hired people through a staffing firm or 1099 contracting and did not provide benefits. This type of staffing is common in Arizona and has grown across the country during the recession.

Today I’m fighting cancer, have been bankrupted by the illness and have been placed on Arizona’s version of the Medicaid system so that I can live. You can call me your neighbor in need and be grateful for the support, or you could choose to disparage me and call me one of those “welfare people. ”

Yesterday, the topic of healthcare reform came up while the nurse practitioner was “treating” me. She said that her solution for the problem was to “make” those “welfare people” go get a job, “at McDonald’s if they have to.”

Some days the ignorance and attitudes of people get to me and make me sicker than the cancer. Yesterday was one of them. Today some friends are participating in a protest event related to healthcare reform. They know that what happened to me could happen to any of us. I truly appreciate their support, and I may call on you for some bail bond money if any of them get arrested.

I spent the day at Health 2.0 conference in the Bay Area. This is the third year of the conference, and it has grown from a fringe group of early adopters and application developers to a bona fide e-patient movement, probably spurred by the broken health care system.

Health plans already know that whatever versions of Obama’s reform plan are passed, they will be dealing more with consumers and less with employers in the future. They are are investing in the tools to do a more subtle form of medical management than they did in the ’80s, when the HMO movement became known for the dreaded “gatekeeper” concept of denying care. During the heyday of this concept, health care costs escalated about 25% over a decade.

However, consumers became so angry that in 1999, one of the largest payers, UnitedHealth Group, said it would do no more medical management. All other plans had to follow suit, and with no effective medical management, health plan costs exploded 60% between 2000 and 2007. 20% of all commercial plan enrollees have been priced out of coverage, and now health plans have decided to be proactive again and turn back to management. But this time, they are trying to shift the paradigm and get the patient to be the manager.

Health Innovation’s Jerry Reeves, the medical director for union plans across the country, says hospitalizations are no longer the key drivers of rising costs. Costs are now being driven by ambulatory settings like ERs, outpatient settings, imaging centers, and the outsourcing of diagnostic activities outside the physicians office. A doctor visit would be the low cost solution, but people are not getting access to physicians’ offices, and wind up in the ER, which costs 13x as much to deliver the same services. In addition, Reeves said people are not getting lifesaving treatments and things they really need, because the system is so broken. He is trying to move to value-based health care.

Mohan Nair is a serial entrepreneur now with Regence BCBS, a four-state plan that has been working for last 6 years to help the system change. Regence is trying to invoke a vision of health care as everyone’s community asset: the consumer has to recognize that it’s his money and his future. Although there’s plenty of blame to go around in the health care industry, rather than trying to find someone to blame, Nair says, insurers have to change, and change quickly, altering their centers of gravity to the consumer and helping the consumer make better decisions, balancing medical management with consumer engagement. Of Regence BC/BS’s 3 million members, 30% are already actively engaged in online communities.

Over the past two years, CIgna’s 8.5 million domestic” lives” have already seen a transformation from their old school insurance company to a customer-centric universe Focused on what people actually want from this system, Cigna participates in Facebook, Twitter, Second Life, Eliza, and Intuit (Quicken Health). Cigna patients can download all their claims information in Quicken Health and see what’s been paid, what hasn’t been paid, and what their responsibility is. The application both tells people how much is actually being covered by their insurance, and explains why things are not covered — in plain English. Cigna patients have seen their information made transparent and delivered to them through many interactive channels. However, merely making information available does not necessarily encourage people to change their behavior. You need to have a motivated patient that’s willing to act on the information.

But at least the new system invites the patient in, which the current health system does not do.

Nathan Moracco, St of Mn Management and Budget supports the employer group for the state of Minnesota, and has devised for the state a tiered product with care systems ranked on a cost and quality basis, layered on top of incentives for members to seek the right care at the right time. The state is doing quality management around diabetes and depression care right now, because veryone knows that 5 chronic diseases account for 70% of the health care spend.

Chris Ohman of Kaiser (8.5 million members, ten states,) says they are putting finishing touches on installing their health IT system throughout the enterprise with an emphasis first on clinical care management, and second on the customer experience. Kaiser, too, knowing the numbers, is making big steps forward in chronic disease management, delivering what they feel are better benefits at lower costs.Engagement of consumers is related to this and Kaiser patients are filling prescriptions, making appointments, getting test results on the web, and then engaging with the physician.

Here’s what happens when a healthy, young, employed person with health insurance tries to use it.Reposted from my friend Howard Lindzon’s Facebook notes

I was hanging with my buddy Ian over the weekend who was recounting the horror stories of cancer and the seemingly equally difficult fight for his already paid health insurance. I asked him to write an article about it. Hopefully we can raise some awareness.

The Health Insurance Trap
Ian Sigalow

At the center of the healthcare debate is a belief among many Americans that our private health insurance system isn’t working. If you had asked me a year ago, I would have said that the government shouldn’t intervene in health insurance. Fast forward to today, after a cancer diagnosis and 4 months of chemotherapy, and I have a very different opinion on private health care. This is my story.

I was diagnosed with Seminoma in August of 2008 at the age of 29. Seminoma is a type of testicular cancer that affects one percent of all men, and it is the most common type of cancer among men aged 20 to 35. It is often cured by surgery alone, but advanced disease requires either radiation therapy or chemotherapy in addition. I was unfortunate. By the time I was diagnosed, the cancer had spread to my lymph nodes, so I had to undergo chemotherapy.

My insurance provider was Oxford Healthcare, a subsidiary of UnitedHealth, the largest private health insurer in the United States. When it comes to testicular cancer, the Centers of Excellence are Indiana University, which treated Lance Armstrong, and Memorial Sloan Kettering Cancer Center (MSK) in New York. Not only is MSK a great hospital, but it is also three blocks from my apartment. Chemotherapy patients have suppressed immune systems, so the usual ways of getting around New York, such as riding the subway, are not recommended. Like most New Yorkers I also don’t have a car. It was comforting to know that I could get to the hospital without an ambulance in case of emergency, which actually happened twice during treatment. Unfortunately MSK was out of network with my health plan.

I was rushed into chemotherapy because of my staging, so I had ten days to find a way to get MSK in network, either by upgrading plans or switching coverage. After a week I realized that neither option would work. There wasn’t enough time to switch plans because the paperwork takes weeks. I also couldn’t upgrade my plan because I work for a small business, and Oxford’s better plans are reserved for large employers. I was willing to pay any amount to get in-network access but there were no options. However, I learned that Oxford offers an “in-network exception”, where in-network privileges are granted to out-of-network hospitals based on doctor referral. I was told that if three Oxford oncologists referred me to Memorial Sloan Kettering, an in-network exception would be granted.

Oxford supplied me with a list of 300 doctors to call. Many of the doctors on Oxford’s list were no longer practicing, or had specialties outside of oncology. I found two databases online (one of which, Vitals.com, my firm later invested in) and spent the next few days researching and calling doctors with the help of a health advocate. After a lot of work I reached ten oncologists. On consultation all ten told me that I should go to Memorial Sloan Kettering based on the advanced state of my disease.

When I relayed my findings to Oxford they reneged on the offer they initially gave me and the health advocate. In addition to my calls, Oxford was going to call another set of doctors to see if they could find someone in-network to treat me. I asked the woman from Oxford why I was told to make the calls if Oxford was planning on doing it themselves. Her response was, “We were hoping you wouldn’t bother.”

A few days later Oxford called with their feedback. I saved the voicemail at home – partially because I was so infuriated and partially because the timing was so prescient. Oxford waited until late Friday August 22 to call, knowing that I was scheduled for chemotherapy at MSK the following Monday morning. Oxford was very careful with their explanation, “We cannot tell you not to go to Memorial Sloan Kettering, and we cannot tell you to delay treatment. However, we found three doctors in New York who agreed to meet with you. It will require a new consultation…” In order to get Oxford’s full coverage I had to delay treatment. I made the decision to go out-of-network.

I tried to quantify in advance the costs of out-of-network versus in-network, but it was impossible. I had all the procedure and drug codes, and I had the re-imbursement rates from Oxford based on my out-of-network benefits. The best estimate of my out-of-pocket expenses at MSK was somewhere between $5,000 and $7,000.

The final bill for treatment came to $68,000. My share of this bill, after Oxford paid their usual and customary, was $35,000. I later called the three doctors that Oxford had recommended, and based on more complete information they said that I made the right decision to go to MSK. I also found out from a former Oxford executive that patients with out-of-network benefits are almost never granted an in-network exception, so that battle was lost before it began.

What surprises many people is that the largest part of the bill was not doctor’s fees – those were only $3,000. The big piece was the medicine. Because I was out-of-network, Oxford’s negotiated rates on medicine with the hospital didn’t apply. This means that Memorial Sloan Kettering can charge whatever they want and a patient has no recourse. One example of how this adds up: I was prescribed three shots of Neulasta, which is a white blood cell booster. At drugstore.com, a single shot of Neulasta costs $3,500. At Memorial Sloan Kettering, it was $5,600. Oxford’s usual and customary reimbursement was $2,600. I didn’t have a choice, I was left with $9,000 out of pocket for three shots. It is remarkable that three shots can cost as much as a down payment on a house.

As I sit here a year later and write this I can’t help but think I am one of the lucky ones. I survived cancer, which 30 years ago would have been a death sentence. I also had health insurance, which means I am better off than 40 million Americans. However, I was astounded at how little health insurance actually covers when you get sick. And one final addendum to this story: As of June 30, 2009, Oxford added Memorial Sloan Kettering to their network, although they refuse to make it retroactive for my treatment nine months earlier. I am still fighting with both the insurance company and the hospital, and may never find a way out of the health insurance trap.

Dear Senator Kerry,

Your reported call for “lies” about health care reform to be refuted is essential and requires an urgent response. To that end, may we – British health professionals and patients – respectfully expose those “lies” which are about our National Health Service, a service which our experience shows to work successfully for the benefit of all in this country.

Continue reading to see the full letter.

PATIENT CHOICE: There is NO “death panel” in the UK NHS or anywhere else in the UK health care sector.
-Termination of a pregnancy is a personal decision if approved by two doctors. NO board or organization of any kind makes any decision about termination for fetal abnormality. Such decisions are personally made by those seeking such procedures after counselling by medical and other health professionals.
-Elderly people can get counselling and advice to help them determine their requirements for their future care, but only if they wish it. It is a service that provides information about issues such as living wills. This is similar to the US proposed Section 1233, which provides counselling and assistance to those wishing voluntarily to make their own arrangements for their future, medically and physically.
-Patients are normally registered with a family doctor practice of their choice. A patient is able to see a doctor immediately for urgent care in general practice although seeing his or her own family doctor for non-urgent care may require waiting a few days. If the patient requires referral for specialist opinion or treatment, they can choose whichever hospital they prefer.
CARE FOR THOSE WITH PRE-EXISTING CONDITIONS: In the US, people with pre-existing health problems are rarely covered by private insurance companies for those problems. Many do not change jobs for fear of losing cover for such conditions from their new insurers. The NHS is literally a life saver for those with pre-existing health problems – they are not denied care. It is vitally important that the NHS, and any government financed health plan anywhere, undertakes the care of such people.
CARE FOR THE ELDERLY: There is NO cut-off age for health care in the NHS. Senator Kennedy, like anyone else of that age, or older, and with health problems such as his, would have been treated by the NHS with the same high levels of care as someone younger. Care for the elderly includes free flu vaccinations, free medication, free operations as needed, nursing care visits, and help and adaptions for the home. Many hospitals now offer “hospital to home” programs for palliative and end of life care to enable very ill people to remain at home.

CARE FOR THE DISABLED: Professor Stephen Hawking of Cambridge University, recently awarded the Presidential Medal of Freedom by President Obama, is disabled and has always been under the care of the NHS. Professor Hawking is an outspoken admirer of NHS care. Like thousands of others who are disabled, he is entitled to free medical care and medicine, and he can get adaptions, equipment and home care to allow him to live at home.

FREE MEDICATION: NO ONE is denied medicine if they need it. All children up to the age of 16, pregnant women and adults over the age of 60, unemployed people, patients with cancer and many with chronic conditions, don’t pay for their medication from the NHS. 88% of medicines are dispensed without charge. For the minority who pay there is a standard charge of $11 dollars per prescription, regardless of the real cost of the drug. Some parts of the UK have abolished prescription charges altogether.

INSURANCE: Like the Healthy San Francisco medical plan, those in the UK can also take out private insurance, if they can afford it, although less than 1 in 8 currently do so. The co-existence of public and private coverage ensures complete freedom of choice.
THE COST: The NHS is funded by taxes and provides universal coverage while costing 8% of UK GDP. The US system currently costs 16% of GDP but leaves 45 million without insurance and a further 25 million underinsured.

BACKGROUND: The NHS was created in 1948. Its goal was to provide comprehensive medical care through taxation, universal coverage for the population which is free of charge at the point of care. It still does that despite the huge, and increasing, demands on its financial and practical resources.
The NHS is available free of charge to all regardless of ability to pay, and does not discriminate against those with pre-existing conditions. Importantly it gives freedom from fear of the financial consequences of illness.
Survey after survey shows that British patients express a high degree of satisfaction with the care they personally receive from the NHS. On average, British users of the NHS live longer and have a lower infant mortality rate than the US.
The NHS has shown itself to be open to – and often the source of – innovation. How the US manages its own health care reform will doubtless provide us with new ideas about how to improve some aspects of our own NHS service. In the same spirit, we respectfully draw to your attention what evidently works well here

Yours sincerely,

Sir George Alberti MD, PhD, PRCP
Past President of the Royal College of Physicians
Dean of Newcastle School of Medicine

Professor Alan Maryon-Davis FFPH FRCP
President, UK Faculty of Public Health

Professor Anthony Costello FRCP FRCPCH
Professor of International Child Health
Director of Institute of Child Health, UCL

Professor Andrew JM Boulton, MD, FRCP
Professor of Medicine, University of Manchester, UK
Consultant Physician, Manchester Royal Infirmary

Professor Mark B Gabbay MD FRCGP
Professor of General Practice
Head of Division of Primary Care
University of Liverpool

Professor Rodney Grahame CBE MD FRCP FACP
Consultant Rheumatologist, UCH
Honorary Professor at UCL, Department of Medicine

Professor Ian Banks
President of the Men’s Health Forum and member BMA Council

Professor Eileen O’Keefe
Professor of Public Health
London Metropolitan University

Professor Gill Walt
Professor of International Health Policy
Health Policy Unit,
Dept Public Health & Policy,
LSHTM, Keppel Street,

Professor Rosalind Raine

Reprinted from Gary Schwitzer’s blog (one of the pre-eminent health journalists and teachers)

All summer long I’ve been turning myself into an expert on health care reform. I always knew more about health care in the USA than most, because I did the public relations for the first HMO in Arizona and then went on to make health care a big segment of my company”s client roster. So I’ve been hearing about cost controls, socialized medicine, and denying treatment for twenty-five years. I also ran my husband’s medical office.

Then my friend Karoli got laid off last December, and found out she couldn’t afford her COBRA coverage and had to learn how that system worked. Some of the old NewsGang folks started talking about the power of microcommunities to bring about change. So we started USHealthCrisis.com (thanks Maxine Appleby for donating the domain name) as a place we could impart information about the state of health care amidst a financial meltdown.

Since then, we’ve been tweeting, blogging, and using every form of social media we can get our hands on to make the case for meaningful reform. Not “health insurance reform,” not just a bill that Obama can sign and declare victory, but meaningful reform that will give Americans rights to a certain basic level of primary and preventive care.

Today, with the news out of Washington that the Gang of Six is imploding and the Republicans have decided the only way to win the mid-term elections is to sabotage reform, I find my patience with politics sorely tried.

There are a couple of major issues that should be discussed with regard to reform: how are we going to pay for it and how are we going to provide enough primary care doctors in the short term to provide it.Let’s call those the “patient-facing issues.” Behind those issues lie bigger questions of incentives and outcomes: let’s call those the “political issues.”

The patient-facing issues are the ones you and I content with. Can we (or the government) afford our own health care, and can we even get an appointment with a doctor?

But these have been overwhelmed by the concerns of:
1)Pharmaceutical companies who are afraid they will make less money under a new system in which some of their products will not be paid for
2) Insurance companies who will have to cover the sick
3)Hospitals who will have to face the fact that they’ve overbuilt beds and now REQUIRE people to be sick to fill them
4)Politicans (both sides) who are afraid to make a move out of fear they won’t get those large contributions they need for their next races

And sheer whackos who think no one should have anything but them and they should have everything.

It’s enough to make me ashamed of Washington, the news media, and us — the people who sat back and allowed ourselves to oursource our health to a for-profit system that does not, in any way, really care.

OK. I’m officially freaked out by what is happening around health care reform after watching Bill Moyers’ Journal.

Single payer, which was implemented successfully by every other developed country in the world, has been dismissed as “too disruptive.” Instead, we are going to get some hodge-podge combo that will neither lower costs nor decrease paperwork in medical offices, but WILL preserve the insurance industry.

It you don’t like to click on video links (above), here’s the transcript from the first twenty minutes of the show, where a representative of the California Nurses Association, who was insured and had Aflack and a Health Savings Account, tells how she was bankrupted anyway by the illnesses of her family.

This doesn’t even include the testimony in the other half of the show from a representative of 16,000 physicians who are also in favor of a single payer plan, although the last time around it was the AMA that fought what it thought was “socialized medicine.” Now the doctors realize that the alternative is…NO medicine

BILL MOYERS: Welcome to the JOURNAL. Health care reform. It’s the talk of the town – if the town is Washington, D.C. But some possible reforms aren’t being talked about at all. Not officially, that is.

The White House and Congress have kept the lid on one of the most controversial but popular options, known as single-payer. It’s a story the mainstream press has largely ignored and that’s why we are covering it in this broadcast.

You don’t expect to see these people demonstrating in our nation’s capitol. You’ll most likely encounter them in the examining room, the operating theater, the clinic or the laboratory.

They’re doctors, nurses, and other health care professionals, unaccustomed to making themselves heard in the streets.

GERI JENKINS: People are fed up with seeing the process hijacked by the insurance industry. So, we have to keep the heat on. We have to keep putting the pressure on them to have the voice of the people heard and what people in this country really want is, which is a single-payer system, publicly funded, privately administered. And we’re going to keep pushing to make sure that message gets out there.

PROTESTERS: Single-payer! Single-payer! Single-payer!

BILL MOYERS: That’s exactly what brought them here. They want the White House and Congress to know they can’t do their job taking care of us under the health care system the way it is today.

DR. MARGARET FLOWERS:I wanted to take care of patients. And to have insurance companies and administrators that don’t know anything about medicine, telling us what we can and can’t do, was really ridiculous to me. You know, I couldn’t understand it.

DAN HENDERSON: Are we going to let insurance giants decide what’s best for Americans?

PROTESTERS: No!

BILL MOYERS:They’ve come here to tell policy makers how the life-and-death choices they make in caregiving are affected by decisions made in corporate board rooms and behind closed doors in Washington.

DR. PAT SALOMON:There were all these arbitrary decisions, which were not about people’s health care. They were about profits. How can I get away with the least amount of care offered to this person, so that their premium is going to give me the most profit? That’s not the way health care decisions should be made. It’s wrong. It’s wrong for us as a nation.

GERI JENKINS:We’re there around the clock. So we feel a real sense of obligation to advocate for the best interests of our patients and the public. You know, you can talk about policy but when you’re staring at a human face, it’s a whole different story. So I think sometimes people who define policy haven’t seen the human side up close and personal like we see it every day.

BILL MOYERS: What the protestors want is single-payer health care – a non-profit system that would remove the role of the insurance companies and unify the financing of the health care system under one entity, a government run organization, like Medicare, that would collect all health care fees, and pay out all health care costs.

DEANN MCEWEN:Single-payer is really the only solution. It’s the only way we’re going to be able to equitably distribute the resources that we have. It’s the best system that it can possibly be and serve the most number of people.

PROTESTERS: Health care! Not warfare!

BILL MOYERS:A day earlier some of these nurses and doctors showed up at the Senate Finance Committee where Democratic Chairman Max Baucus was holding hearings on health care reform.

SEN. MAX BAUCUS: Today we host the third of our three roundtable discussions on health care reform.

BILL MOYERS:To protest that no advocate of single-payer had been allowed a place at the table, some stood, turned their backs to the committee, then walked out.

Five stayed. Speaking out one by one, interrupting the proceedings.

PROTESTER: We want guaranteed health care. We want to see our doctors when we need.

SEN. MAX BAUCUS: Can we have a recess until order can be restored?

PROTESTER: We want a single-payer system.

PROTESTER: Health care should be for patients, not for profits.

BILL MOYERS: They were quickly gaveled down, escorted out, and arrested.

PROTESTERS: Free Deann now! Free Deann now!

BILL MOYERS: For nurse Deann McEwen it was worth a little jail time just to be heard.

DEANN MCEWEN:They’re our public representatives. You know? They’re supposed to represent us. And here they are, representing the interests of the corporations.

And it’s outrageous. And it’s almost like how dare you not listen to us? You know? We’re here to tell you what we see. We’re the experts, not you. You sit in that chair and you bring the gavel down on single-payer. You’re bringing the gavel down on democracy. And you know, not in my lifetime. Not on my profession.

BILL MOYERS: The next day, with several hundred reinforcements, they marched on Congress.

DR MARGARET FLOWERS: Guess what Senator Baucus? You need the police because you’re the criminals, we are not committing a crime, you are committing the crime of not listening to our voice and not being responsible to the American people.

BILL MOYERS: Two members of Congress spoke up in support. Freshman Representative Eric Massa from upstate New York, a Democrat…

REP. ERIC MASSA: Allow us to get President Obama on the right track, cover his back, give him the political cover he needs to make the tough decisions.

PROTESTER: Thank you Senator Sanders.

BILL MOYERS: And Vermont’s Independent Senator, Bernie Sanders.

SEN. BERNIE SANDERS: All over this place, there are thousands of lobbyists representing greed and short-term profits. And it’s nice to see ordinary people coming here to Washington fighting for the rights of their patients and all of our people.

Our current health care system is disintegrating. We need a new system. And what we need is a system not based on the profits of the private health insurance. We don’t need a system mired down in bureaucracy and waste.

We don’t need a system where CEOs earn all kinds of outrageous salaries. We don’t need a system in which companies are paying out huge profits to their stockholders. What we need is a single-payer, national health care system.

BILL MOYERS: After the rally, they fanned out through the halls of Congress, to make the case for single-payer. But they’re battling the odds – against deep pockets and swarms of highly-paid lobbyists for huge corporations that reap billions from health care profits. But, they say they’re not giving up.

DONNA SMITH: The people still matter. We do matter in this process, and it’s the only thing. If we give up, then we do hand it over to the corporate interests. No human rights struggle in the history of this country’s been an easy one. This is a human rights struggle. We’re going to win it, but we’re going to have to keep fighting and struggling and speaking out. There may have to be more people arrested. There may have to be more brave nurses out there speaking out, but we’re going to win this.

BILL MOYERS:Donna Smith is with me now. She works as a community organizer and legislative advocate for the California Nurses Association, whose 85 thousand members across the country were early champions for a single-payer program. Welcome to the Journal.

DONNA SMITH: Thank you very much, Bill.

BILL MOYERS: What’s going on that you have to take to the streets?

DONNA SMITH: They’re not listening. Congress is not listening to advocates of a single-payer system. In fact, they seem to be bent on one direction and one direction only.

BILL MOYERS: What is that?

DONNA SMITH: Expanding the broken system that we have now. We have so many insurance companies involved in making health care decisions in this country, and so many Americans suffering at the hands of those insurance companies, whether it’s through higher premiums and higher co-pays and deductibles, and all the things that American citizens deal with – not to mention 14 thousand of us losing employer-based health care benefits every day. So having-

BILL MOYERS: 14 thousand-

DONNA SMITH: A day, during this economic recession.

BILL MOYERS: Regular people?

DONNA SMITH: Regular people losing their employer-based system. And yet Congress, certainly the Senate, and certainly – as evidenced through Senator Baucus’s committee – seems to be just on the bee line to make a system where we all have to purchase that private health insurance product that has not been serving us very well as patients, and certainly as nurses and doctors, in this country for many years.

BILL MOYERS: So that moves you out to the streets? That says this is the only way we’re going to be heard?

DONNA SMITH: I think it’s the only way we can. So many formal requests have gone in to the, not only to Congress, but to the administration. President Obama set out to have White House forums on health care reform. He had his first one at the White House. Single-payer advocates had to really protest and get quite active and fax and call, and doctors and nurses threatened to go to the streets to be outside the White House advocating for single-payer, to be let into that discussion. And finally two representatives were invited into that White House forum. They didn’t speak, however, they were invited in.

BILL MOYERS: Now, you must have an opinion as to why that is.

DONNA SMITH: Because they’ve already made a choice. They’ve already made a choice, I think, to stay with the moneyed interest, the people who fund the campaigns, the people who fuel the government system as we know it now. You know, certainly where Senator Baucus is concerned, he’s the third highest recipient of donations from the health insurance and health care industry in general. The third. The highest Democratic recipient. And sometimes I feel so strongly that he ought to have to disclose that at the beginning of every single hearing that he chairs.

BILL MOYERS: But he says, of course, “That doesn’t affect my judgment. This doesn’t affect my decision.”

DONNA SMITH: I don’t think I’d buy that. And I don’t think there’s very many people in this country that would buy that. If you have someone who’s giving you money to insure that your position to stay in a very powerful role in the United States Senate – that’s a prime position politically.

BILL MOYERS: What is it you would like those folks to know, those regular citizens to know about this issue, about single-payer and why it’s important to them?

DONNA SMITH: I tell people, I always ask them to tell me if they understand single-payer and what it’s all about. It’s a great idea from the left, which is public financing, combined with a great idea from the right, which is private delivery. And you put it together in one system that takes out the waste and the abuse that’s really happening, which is where all the money goes into the health insurance. Up to 30 percent of the costs have nothing to do with health care at all and everything to do with fueling the health insurance needs.

And I’ve had so many tell me, doctors and nurses who work in offices where doctors have had to spend hours of every day not in patient care but on the phone, hassling with insurance companies, trying to negotiate to get a patient a treatment. It makes it very difficult to deliver the right kind of care.

BILL MOYERS: I saw your testimony before Congress two years ago, 2007. And you were angry.

DONNA SMITH: Very angry.

DONNA SMITH AT SENATE HEARING: You left me broken and battered because you failed to act on health care reform. Just as I have come out of the shadows of economic ruin and shame, so, too, will others come forward to hold you accountable. Remember the hard-working people who elected you. Their bankruptcy shame, my bankruptcy shame due to medical crisis, really is your shame. You are the body that could have acted and has yet not done so.

BILL MOYERS: You had had cancer of the uterus, and while your husband was suffering from heart disease. And you went bankrupt even though you were insured?

DONNA SMITH: Yep. That’s why I was asked to testify. I tell people that our story, my husband’s and my story’s not unique. It’s not because we’re so unique that people talk about us because we’re not unique. So many millions of Americans do what all middle-class families do. You hang on. You watch your premiums rise over time and your benefits shrink. And as long as you’re healthy, you absorb some of that cost and you deal with it and you make decisions.

But if you get sick, you find out just how inadequate that insurance may be. And I tell people not only did I have health insurance, I had Aflac disability insurance and a health care savings account on top of that. So we were like the prime example of responsible people who try and keep ourselves covered. And yet when we got sick, there was no way the deductibles and out-of-pocket maximum exposure added up so quickly that we were buried very quickly financially.

BILL MOYERS: There are people who would listen sympathetically to that story and nonetheless say that to move to single-payer now would be disruptive of the health care system. That’s the term they use, disruptive.

Do you think that moving to a single-payer plan, even if it were politically feasible, would disrupt the health care system?

DONNA SMITH: What a great question. And you used some of my favorite words in that, “political feasibility.” I often answer that real quickly in saying I hear tell a year and a half ago that a man named Barack Obama, when polled against John McCain, would have lost in every state but Hawaií and Illinois. So political feasibility is all a relative thing, isn’t it?

And I trust that if he wanted to make single-payer happen, he could make it happen. Would it be politically difficult? Absolutely. I sat in a committee meeting with some staff members of Senate Finance some time ago. And somebody gave this argument, it’s not politically feasible to do single-payer. So many people who will say, “Don’t let the perfect be the enemy of the good.”

And I think, well, that’s an interesting analogy, acknowledging that the perfect may be single-payer but that you can’t do it ’cause it’s politically not feasible. So I sat there and I let this person talk. And he said, there’s a visceral reaction to single-payer.

And I let him talk for a minute. I said, “From whom? Who’s the visceral reaction from?” The Congress, he said, because elections are reality. These people have to run for new terms every so often. The money and the power that’s exerted in Washington on them from the health insurance and health industry lobbies is very powerful. It’s hard for them to break out of that loop. It takes an awful lot of nurses and doctors in the streets and being arrested, apparently, and more than 60 percent of the American public to say to them, “We’re behind this. This is what we want you to do.”

And in terms of disrupting the system, oh, my god, talk about disruption. I just saw Max Baucus’s white paper has just been released on what he envisions or what his committee, not just him, but his committee envisions for the future of health care reform financially in this nation. Wow. You talk about complexity and difficulty with what we’ll all have to deal with.

They envision mandates going into effect January 1st of 2013. But any insurance reforms or any tightening up of what happens to insurance companies would be allowed to phase in over a ten-year period.

BILL MOYERS: So what is your strategy? The clock is ticking. The President and Congress have said we want health care reform by the 1st of August. That’s just a few months away. What will you be doing between now and then?

DONNA SMITH: We’re going to stay very active. The nurses, of course, are going to stay in the streets wherever they need to, and very much on the minds of these folks to say this has not been an intellectually honest or policy honest discussion that we’ve had so far in this country. And don’t you think we owe that to each other to at least be intellectually honest about this discussion? And let’s put it all out on the table and argue on the merits. Let’s have a debate on the merits of single-payer on the floor of the Congress and see where it goes from there.

BILL MOYERS: You’ve been saying that, though, Donna Smith. You’ve been saying that, but last week during your rally, only four members of Congress showed up.

DONNA SMITH: You get louder. You get more insistent. You do what many of our nurses are doing. We’re going to do a little more action in California next week. You know, California’s passed single-payer legislation twice now. Governor Schwarzenegger has vetoed it twice. I suspect that California will continue to pass it until they have a governor who signs it.

There are some people who believe that passing single-payer will have to come through a state level first. And that once one of the major states passes it, that it will topple over into the rest of the nation. As people see it as the most cost-effective, smartest way to do it not only for governments but for American families.

BILL MOYERS: When we did a report on the Journal 12 or 15 months ago on the California nurses and the fight out there for single-payer, we were inundated with mail saying they’re socialists and you’re a fellow traveler. What do you say to people like that, who read into what you’re doing a call for state government-run socialistic medical care?

DONNA SMITH: I laugh a little bit in light of the last six months on how much money we’ve thrown into Wall Street and how much money we’ve thrown in keeping financial markets stable in this country. In three days, we were able to come up with three quarters of a trillion dollars to throw into Wall Street. So the argument about socializing things and making things government-run seems a little bit yesterday to me, just intellectually.

But I tell people, you know, look, don’t fear this. This is not- you’re not turning into a Communist red nation. Please don’t be afraid. Even in polling data where the words “socialized medicine” is used, even in that polling data, almost 50 percent of the American public say, “Okay. Do it.” And data where we just ask about a national health insurance system, and that’s through “The New York Times” and CNN and Yahoo! and a number of polls, 60 percent of the American public say we’ve got to have a national health program. We just have to do it. It’s the only way we fix this mess. It’s spun out of control. It’s going to bury us financially. It’s going to mortgage our children, and it kills people. It just is not working.

BILL MOYERS: Donna Smith, thank you very much for being with me on The Journal.

DONNA SMITH: Thank you so much, Bill.

Raise your voice, people. I already live under socialized medicine: Medicare. It’s fabulous, but it is going broke because the rest of the system is incentivized to send the oldest, sickest people to the government. You may not be sick now, and you may think you are insured now, but let me tell you that nobody gets out of this life alive:) It’s worth raising your voice for decent health care and not being sure the government will come to some kind of compromise, abetted by insurance industry campaign donations, that will protect you.