Sunday, November 30, 2008

93 cosponsors for HR 676

The number of cosponsors for this legislation has crept up in the last Congress, to 93. The list below, in alphabetical order by co-sponsor, shows the date at which the representative signed on to this important legislation:
Rep Abercrombie, Neil [HI-1] - 1/24/2007
Rep Baca, Joe [CA-43] - 9/17/2007
Rep Baldwin, Tammy [WI-2] - 1/24/2007
Rep Becerra, Xavier [CA-31] - 6/13/2007
Rep Berman, Howard L. [CA-28] - 6/15/2007
Rep Bishop, Sanford D., Jr. [GA-2] - 12/11/2007
Rep Brady, Robert A. [PA-1] - 2/27/2007
Rep Brown, Corrine [FL-3] - 4/17/2007
Rep Capuano, Michael E. [MA-8] - 11/9/2007
Rep Carson, Andre [IN-7] - 7/10/2008
Rep Carson, Julia [IN-7] - 1/24/2007
Rep Christensen, Donna M. [VI] - 1/24/2007
Rep Clarke, Yvette D. [NY-11] - 2/16/2007
Rep Clay, Wm. Lacy [MO-1] - 1/24/2007
Rep Cleaver, Emanuel [MO-5] - 4/22/2008
Rep Clyburn, James E. [SC-6] - 4/24/2008
Rep Cohen, Steve [TN-9] - 2/7/2007
Rep Cummings, Elijah E. [MD-7] - 1/24/2007
Rep Davis, Danny K. [IL-7] - 1/24/2007
Rep Delahunt, William D. [MA-10] - 2/12/2007
Rep Doyle, Michael F. [PA-14] - 3/21/2007
Rep Edwards, Donna F. [MD-4] - 9/29/2008
Rep Ellison, Keith [MN-5] - 1/24/2007
Rep Engel, Eliot L. [NY-17] - 1/24/2007
Rep Farr, Sam [CA-17] - 1/24/2007
Rep Fattah, Chaka [PA-2] - 1/24/2007
Rep Filner, Bob [CA-51] - 1/24/2007
Rep Frank, Barney [MA-4] - 3/7/2007
Rep Green, Al [TX-9] - 1/24/2007
Rep Grijalva, Raul M. [AZ-7] - 1/24/2007
Rep Gutierrez, Luis V. [IL-4] - 1/24/2007
Rep Hare, Phil [IL-17] - 4/30/2007
Rep Hastings, Alcee L. [FL-23] - 1/29/2007
Rep Hinchey, Maurice D. [NY-22] - 1/24/2007
Rep Hirono, Mazie K. [HI-2] - 7/23/2007
Rep Holt, Rush D. [NJ-12] - 9/18/2008
Rep Honda, Michael M. [CA-15] - 1/24/2007
Rep Jackson, Jesse L., Jr. [IL-2] - 1/24/2007
Rep Jackson-Lee, Sheila [TX-18] - 1/24/2007
Rep Jefferson, William J. [LA-2] - 6/26/2007
Rep Johnson, Eddie Bernice [TX-30] - 1/24/2007
Rep Johnson, Henry C. "Hank," Jr. [GA-4] - 2/13/2007
Rep Jones, Stephanie Tubbs [OH-11] - 5/23/2007
Rep Kaptur, Marcy [OH-9] - 2/12/2007
Rep Kennedy, Patrick J. [RI-1] - 9/24/2007
Rep Kildee, Dale E. [MI-5] - 4/17/2007
Rep Kilpatrick, Carolyn C. [MI-13] - 1/24/2007
Rep Kucinich, Dennis J. [OH-10] - 1/24/2007
Rep Lantos, Tom [CA-12] - 10/1/2007
Rep Lee, Barbara [CA-9] - 1/24/2007
Rep Lewis, John [GA-5] - 1/24/2007
Rep Loebsack, David [IA-2] - 1/24/2007
Rep Lynch, Stephen F. [MA-9] - 10/9/2007
Rep Maloney, Carolyn B. [NY-14] - 1/29/2007
Rep McDermott, Jim [WA-7] - 1/24/2007
Rep McGovern, James P. [MA-3] - 1/24/2007
Rep McNulty, Michael R. [NY-21] - 1/24/2007
Rep Meehan, Martin T. [MA-5] - 1/24/2007
Rep Meeks, Gregory W. [NY-6] - 9/20/2007
Rep Miller, George [CA-7] - 1/24/2007
Rep Moore, Gwen [WI-4] - 1/24/2007
Rep Moran, James P. [VA-8] - 1/22/2008
Rep Nadler, Jerrold [NY-8] - 1/29/2007
Rep Napolitano, Grace F. [CA-38] - 2/27/2007
Rep Norton, Eleanor Holmes [DC] - 3/21/2007
Rep Olver, John W. [MA-1] - 2/16/2007
Rep Pastor, Ed [AZ-4] - 1/24/2007
Rep Payne, Donald M. [NJ-10] - 1/24/2007
Rep Rangel, Charles B. [NY-15] - 1/24/2007
Rep Richardson, Laura [CA-37] - 9/20/2007
Rep Roybal-Allard, Lucille [CA-34] - 1/24/2007
Rep Rush, Bobby L. [IL-1] - 2/6/2007
Rep Ryan, Tim [OH-17] - 5/8/2007
Rep Sanchez, Linda T. [CA-39] - 4/23/2007
Rep Sanchez, Loretta [CA-47] - 9/20/2007
Rep Schakowsky, Janice D. [IL-9] - 4/17/2007
Rep Scott, David [GA-13] - 9/20/2007
Rep Scott, Robert C. "Bobby" [VA-3] - 1/24/2007
Rep Serrano, Jose E. [NY-16] - 2/7/2007
Rep Solis, Hilda L. [CA-32] - 2/12/2007
Rep Sutton, Betty [OH-13] - 3/27/2007
Rep Thompson, Bennie G. [MS-2] - 6/12/2007
Rep Tierney, John F. [MA-6] - 9/6/2007
Rep Towns, Edolphus [NY-10] - 1/24/2007
Rep Udall, Tom [NM-3] - 2/27/2007
Rep Waters, Maxine [CA-35] - 1/29/2007
Rep Watson, Diane E. [CA-33] - 1/24/2007
Rep Weiner, Anthony D. [NY-9] - 1/24/2007
Rep Welch, Peter [VT] - 5/3/2007
Rep Wexler, Robert [FL-19] - 1/24/2007
Rep Woolsey, Lynn C. [CA-6] - 1/24/2007
Rep Wynn, Albert Russell [MD-4] - 1/24/2007
Rep Yarmuth, John A. [KY-3] - 2/27/2007
Those adding their names in 2008 were James Moran (VA), Emanuel Cleaver (MO), James Clyburn (SC), Andre Carson (IN), Rush Holt (NJ), and Donna Edwards (MD). Sponsor John Conyers has a frequently-updated list of endorsements and co-sponsors on his website.

Tuesday, November 18, 2008

Call to Action Health Care Reform 2009

Another mostly misguided proposal for reforming our health care system has surfaced this month. It, “Call to Action Health Care Reform 2009,” comes from Montana Democrat Max Baucus, chairman of the Senate Finance Committee. See it at

Eighty-seven pages long, the Call to Action plan claims to be a “comprehensive but not exhaustive exploration of every health care issue that can or should be considered.” The document does present intelligent discussion of the many problems with our health care system and offers workable solutions to some of them, but the claim that it explores every health care issue that can and should be considered is totally false.

In fact, the one most important issue of all is totally ignored, the proper role of the for-profit private insurance industry in administering health care expenditures. By contrast, H.R. 676, a bill in the House sponsored by Representative John Conyers and 90 other congressmen, emphasizes the problems created by the private insurance industry and rightly seeks to get that industry out of the health care financing business altogether. That needs to be done because the private health insurance industry is merely a funds-sucking tapeworm in the gut of the American health care financing system, one that funnels off a huge portion of the funds that should be used to pay for health care.

Rather than to address this serious problem, Senator Baucas’s proposal calls for more investment in for-profit private health insurance. He wants to require that everyone be forced to buy health insurance, and that taxpayers subsidize the industry by supplementing the funds it receives from those who cannot afford to pay its high premiums. Senator Baucus is being disingenuous in ignoring the real problem here, but at least he is honest enough to admit that his plan will increase rather than decrease the cost of health care in the United States. That, we do not need.

(The text of H.R. 676 is at

Friday, November 14, 2008

Dose of Reality: Health Insurance Costs in Retirement

The November issue of The Ester Republic features Neil Davis' discussion of just how pricey health care will be once you retire. The picture is not pretty.
With the trend away from defined-benefit retirement programs, increasing numbers of Americans are in defined-contribution programs. Many of these people will not have enough saved up for their health care and other costs.
This installment of Dose of Reality compares the effects of having these two types of retirement programs and how they interact with Medicare part A and part B, and with Social Security. As Davis says, "the results horrify me, as they should you."

Saturday, October 25, 2008

Dose of Reality: Do Not Resuscitate

In the October issue of The Ester Republic, Neil Davis discusses the issues brought out in Dr. John Geyman's book, Do Not Resuscitate: Why the Health Insurance Industry is Dying, And How We Must Replace It. The problem, as Geyman observes and Davis concurs, is that
[T]he industry has abandoned the basic goal of insurance, which is to spread risk over the population it serves. Instead of spreading risk, the industry has focused on the avoidance of risk for itself, coupled with a transfer of that risk to the public. In the process, it is destroying its own reason for being.
The consequences of this transfer of risk are that administrative costs go up, employers and other policyholders are charged more, and fewer people are able to afford decent coverage--and as a consequence, good health care. Yet the problem is getting worse, not better, and this is due to a fundamental problem in how we approach health care in the United States.

Wednesday, October 22, 2008

The Economics of Health Care

At the Democratic National Convention, Senator Ted Kennedy stated that health care is a human right, and in one of the presidential debates, Senator Barack Obama said the same thing. What this means, of course, is that this country needs to put in place a single-payer universal health care system.

“This is a completely understandable view and one that, I think, is utterly wrong,” wrote columnist Robert J. Samuelson in NEWSWEEK on September 15, 2008. Then he went on to say that the problem was not to improve insurance coverage, it was to contain health care costs. He said, “We need more realism on health care. The trouble with casting medical-care as a “right” is that this ignores how open-ended the “right” should be and how fulfilling it might compromise other “rights” and needs.” What he means by this is beyond me: how does saying fulfilling one right affect fulfilling other rights, whatever they may be?

Samuelson does not seem to understand that treating health care as a right—which implies instituting a program of universal health care—is the direct route to containing health care costs. Doing so has the potential to cut health care costs by 30 percent, while at the same time improving health care for Americans. Another columnist, Bernadine Healy writing in the October 13/October 20, 2008, issue of U.S. NEWS & WORLD REPORT, describes various ills of our dysfunctional multi-payer health care system and then says, “Changing our 50-50 blend of private and public spending into a single-payer system clearly is not feasible.” Why not?

Both she and Robert J. Samuelson seem to have preconceived ideas about health care, and they would do well to open their minds far enough to read and accept what another well-known economist and columnist, Paul Krugman, has to say about the economics of health are. In his January 1, 2007, column in The New York Times he said, “The truth is we can afford to cover the uninsured. What we can’t afford is to keep going without a universal health care system.
“If it were up to me, we’d have a Medicare-like system for everyone, paid for by a dedicated tax that for most people would be less than they or their employers currently pay in insurance premiums. This would, at a stroke, cover the uninsured, greatly reduce administrative costs and make it much easier to work on preventive care.”
Paul Krugman just won the Nobel prize in economics, for good reason it would seem. He is a thoughtful man who pays attention to and carefully analyzes factual information. Too bad Robert J. Samuelson and Bernadine don't do the same.

Friday, October 10, 2008

Pundits on Health Care

Right now, the crash of the financial markets is taking center stage, but the nation’s health care problems are still the subject of various press pundits’ commentaries. In the October 13, 2008 issue of NEWSWEEK, one of better known commentators, Jane Bryant Quinn, discusses John McCain’s health plan, and alludes to Barack Obama’s. These, of course, are not health care plans as such, but rather are health insurance plans, a fact that the pundits like her seem to be ignoring, or would rather not talk about. It is an easy way out, and a poor substitute for taking on the health care problem directly and discussing solutions.

Quinn notes that the McCain and Obama health insurance plans over the next decade are likely to cost the taxpayers an additional $1.3 billion and $1.6 billion, respectively. She clearly favors Obama’s plan over McCain’s, but she seems to be trapped in the philosophical box that does not allow thinking or discussion about anything but health insurance per se. She is not a dumb person, and I don’t understand why she doesn’t go outside the box and state what she surely knows is the way to reduce health care costs rather than increase them. Maybe her editors would not let her do that. If they would allow it, Quinn could have gone on to say that both the McCain and Obama plans were off the mark, and that the establishment of a single-payer health care system in this country has the only potential to reduce health care costs—not just a little bit, a lot. Instead of spending 16 percent of our gross national product on health care, we could be spending only 10 percent, while giving all Americans health care just as good as the citizens of all other modern countries get from their much cheaper and more effective universal health care systems.

Yes, Quinn and some of her fellow pundits could serve us better by talking more about health care, and less about health insurance. But at least in her column she does say that McCain’s belief in the magic of the marketplace is misplaced. She says, “Friends, there’s zero evidence that that works.”

Saturday, September 20, 2008

Davis honored for bringing science to the public

Neil Davis was one of six people recognized for their contributions to science research, education, and outreach recently by the American Association for the Advancement of Science Arctic Division and the Alaska Chapter of Sigma Xi, the Scientific Research Society. Davis was honored for his support of arctic science and excellence in bringing science to the public.

Friday, September 19, 2008

Dose of Reality: McCain's health care plan

In the September issue of the Ester Republic, Davis examines John McCain's health care plan and the deregulation he proposes in more detail than in previous issues. From the article:
The immediate consequence is obvious: Insurance companies would immediately relocate to states such as Alaska which have minimal if any regulations. They would no longer be required to insure persons in those states that currently require them to accept individuals with pre-existing conditions, and that means even more Americans would be unable to buy insurance.
The estimates on how many more people would be unable to afford insurance or get good quality coverage as a result vary, but it could be in the many millions.

Thursday, September 11, 2008

Saving Money on Medical Bills

Microsoft News Money recently carried a good article on how to save money on medical bills, an article from Kiplinger’s Personal Finance Magazine titled, “Save thousands on medical bills.” See The article contains several hints on how to save on medical bills that I have previously given in my column Dose of Reality: —and one I had not thought of to include.

That sound suggestion is to not pay any questionable hospital bills by credit card. The reason is simple: once you do that, you lose any ability to bargain. You have, in a sense, already agreed to the debt. Also, do not agree with a hospital’s suggestion to accept a line of credit with an outside lender, because now your debt is off the hospital’s books. The debt is to the lender, not the hospital, so you have no bargaining power at all.

Two other good suggestions contained in the MSN Money article are:

1—Check medical bills for double charging and wrong diagnoses that affect insurance payments or those you make directly.

2—Don’t hesitate to bargain, because hospitals typically charge about three times what they expect to get paid (It varies with the hospital, but that is the average.)

The article concludes with a suggestion that would sound ridiculous to a citizen of any other country with universal health care: hire a “claims assistance professional” to help you negotiate with your medical providers. Yes, because the system is dysfunctional, they will cut your bills, and collect 25 percent of the proceeds while doing it. Only in America are we willing to put up with this nonsense.

Wednesday, September 3, 2008

UAF: lecture by Devra Davis on cancer prevention and public health policy

Condensed from the public announcement:

UAF is hosting a talk by Devra Lee Davis, a University of Pittsburg epidemiology professor and author, on Thursday, Sept. 4, at 7 p.m. in Schaible Auditorium. Davis’ lecture, “The Secret History of the War on Cancer,” is free and open to the public, and will be webcast at the website of the Center for Alaska Native Health Research.

Devra Davis advocates for changing the way public health looks at cancer prevention by including toxin awareness.

“I believe if we had acted on what has long been known about the industrial and environmental causes of cancer when this war first began, at least a million and half lives could have been spared…” she writes in the preface to her book, The Secret History of the War on Cancer. Published in 2007, the book is used at major schools of public health, including Harvard, Emory, and Tulane universities.

Davis is the director of the University of Pittsburg Center for Environmental Oncology, the world’s first research institute dedicated to studying cancers caused by environmental pollution. She is also an epidemiology professor at the University of Pittsburgh’s Graduate School of Public Health.

The Center for Alaska Native Health Research at the UAF Institute for Arctic Biology, University Advancement, Alaska INBRE, the College of Natural Sciences and Mathematics; Alaska EPSCoR, and Tanana Chiefs Conference are sponsoring her trip.

Davis will also give public lectures in Nome and in Anchorage at the University of Alaska Anchorage. The Alaska Community Action on Toxics is the host for this part of her Alaska journey.

Friday, August 29, 2008

Dose of Reality: HR 676 and the presidential candidates' proposals

In the August Dose of Reality column, "HR 676: The Route to Affordable Health Care," Davis discusses why the proposal is "a dream bill...that does all the right things to create an affordable single-payer health care system."

In the July Dose of Reality, Davis looks at the health care plans of John McCain and Barack Obama:
I get the feeling that both the presidential candidates are happy to see the health care issue fade a bit, because neither of them has logically defensible positions on health care, nor do their proposals have any hope of reducing health care costs.
The primary problem in both candidates' proposals is the failure to address actual health care; instead they focus on health insurance. This failure or inability to distinguish between the two is one of the central problems in the national discussions about health care reform.

However, concludes Davis, "Obama's plan is far better than McCain's....Obama at least proposes moving in the right direction." Still, both senators would do well to take a leaf or two more from John Conyers' excellent House bill.

Thursday, August 28, 2008

A Good Investment

This year the Alaska legislature took a small but positive step toward helping to improve health care in the state by appropriating $3.85 million in support of the 26 federally funded Community Health Centers in the state. By taking this action Alaska has, for the first time, joined 37 other states which contribute funds to the CHC programs.

The Community Health Centers play an important role in providing comprehensive, affordable primary care and preventive services to those most in need. The centers accept Medicare, Medicaid, private insurance and also offer a sliding fee scale to those without insurance coverage. They now serve over 88,000 Alaskans, more than half of them with incomes below the Federal Poverty Level. Operating at 124 sites in Alaska, the centers provide the only source of medical care in many of the remote rural villages of the state. The centers are open to all Alaskans, and the care received there is far cheaper than from other sources.

The legislature’s action was in response to a funding request of $13 million from the Alaska Primary Care Association, the umbrella group for the CHCs which are all locally governed. Considering the effectiveness and low cost of the centers, the $3.85 million is a paltry sum. It amounts to only $40 per person for the 88,000 served, and to less than $6 per Alaskan. Compare that to the $1200 per person outlay for energy relief this year and think about the relative value of the two appropriations. The tiny one is an investment in the future, and the big one is a shotgun blast that has no lasting benefit. A significant portion of the money will go to the federal government in income taxes and to Alaskans who do not really need the money. How sad.

Nevertheless, the legislature took an important first step by appropriating funds to the Community Health Centers. The action might be the start of a new era of social responsibility, and we can hope that future legislatures will be far more generous in their appropriations for health care.

Sunday, August 24, 2008

Harry and Louise Return

Today, August 24, 2008, marks the return of the old Harry and Louise ads credited with defeating the Clinton universal health care plan of fifteen years ago. They are being put on the air on the eve of the presidential conventions for the same purpose as the last time: to try to convince Americans that single-payer universal health care is not in their best interest.

The persons portraying the fictional couple Harry and Louise are the same as before, now obviously fifteen years older, but the message is a little different this time. Aware that health care reform might be coming soon, the ads’ sponsors are trying to use the ads to warp that reform in a direction that favors the health insurance industry and its allies, but which is to the detriment of the users of health care, namely the American public.

The sponsors of the new Harry and Louise ads are promoting not only less regulation of the health insurance industry, they want the government to subsidize it by paying the premiums for the high-risk persons that the industry would otherwise either not insure or charge unbearable rates. They are trying desperately to maintain their throttlehold on health care financing. As one ad sponsor, the National Federation of Independent Business, states, “To the greatest extent possible, Americans should receive their health insurance and healthcare through the private sector. Care must be taken to minimize the extent to which government safety nets crowd out private insurance and care.”

Overall, the primary purpose of the new Harry and Louise ads we are going to see a lot of from now on is to maintain the profitability of the private health insurance industry. A proven propaganda ploy; it will be interesting to see how well it works this time.

Also jumping on the bandwagon is the American Medical Association with its own Louise ad (not the same Louise as in the other ads, but obviously borrowing on the Harry and Louise concept) touting the association’s reform proposal. This is not a health care reform proposal at all; rather it deals only with health insurance, and it basically also calls for less regulation of the insurance industry plus government subsidies to the industry to help pay the premiums for high-risk persons. Not the powerhouse it once was, the AMA’s membership has declined, and it now represents less than one-third of all U.S. physicians. Increasingly, physicians are going against AMA and are coming out in favor of establishing a single-payer universal health care system.

Tuesday, August 12, 2008

Another co-sponsor for HR 676

The ninety-first co-sponsor of HR 676 is André Carson (D-IL). The list of endorsements of this legislation is growing, including the US Conference of Mayors and numerous unions, including the Alaska AFL-CIO.

Monday, July 28, 2008

The Foraker-Rasmuson Health Insurance Plan

The July 27, 2008 issue of the Fairbanks Daily New-Miner carries an article based on an earlier one in the Anchorage Daily News describing what it calls a “bold insurance plan” being put forth by the Foraker Group and the Rasmuson Foundation aimed at lowering the number of uninsured persons in Alaska. The idea is to make it easier for the 6,000 employees of nonprofit organizations to buy health insurance for employees, thereby getting the employees off the rolls of the uninsured.

While laudable in its intent to help some Alaskans with their health care expenses, the Foraker-Rasmuson plan, like many other proposals, focuses on the wrong problem. The real problem is affordable health care, not the affordable health insurance the plan proposes. If health insurance actually paid for the full cost of health care, then having affordable health insurance would be a great idea. Unfortunately, that is not the case. Most commercial health insurance pays only a part of the bill, and the proportion it pays declines with greater need for health care. It is generally true that the more affordable a health insurance policy is, the lesser portion of the health care cost it pays. The majority of Alaskans need comparatively little health care each year, so whether or not they have health insurance, their health care costs are limited, perhaps only to what they pay in health insurance premiums if insured. If they have no health insurance, their cost is even less. Insured or not, these are the lucky Alaskans.

But woe is the Alaskan, insured or not, who needs a lot of health care. At no fault of his own perhaps, he has a serious car accident that puts him in the hospital, she has a complicated birth, or he contracts cancer or Alzheimer’s that requires extensive or long-term care. By the time this person pays for any premiums, deductibles, co-pays and all other out-of-pocket expenses associated with his or her health problem the person may face a bleak financial future that might well include bankruptcy.

The Foraker-Rasmuson plan fits right in with the current trend of shifting risk from employers and insurance companies over to individuals by means of high-deductible insurance policies and health savings accounts. While lowering the cost of health insurance, the plan places more of the cost of health care onto the individual, often at a time when the health problem also curtails family income because of inability to work.

One fault that I see with the plan is that it can lull people into thinking that, by having high-deductible insurance and health savings accounts, they are protected from high health care costs. They think they are safe right up to the time when a health crisis occurs, and then they find out just how bad it can get. The statistics are compatible with that pertaining to playing Russian Roulette with a 10-chamber revolver. If the person is commercially insured, only one chamber of the gun contains a bullet, but if he is not insured, two chambers contain bullets. Obviously it is somewhat safer to have insurance, but complete safety is an illusion. Real safety comes only with having a system of universal health care, in which case there are no bullets in the gun.

Sunday, July 20, 2008

Latest review, from Alaska Health Policy Review

Lawrence D. Weiss, Anchorage Daily News blogger of Health4all and editor of the online journal Alaska Health Policy Review, has come out with a detailed and positive review of Mired in the Health Care Morass. The review appeared in the July 16 issue and the excerpt below is reproduced by permission of Alaska Health Policy Review, Weiss has extensive experience in public health (PDF of his CV) and designed the Master of Public Health program at the University of Alaska Anchorage.
I found this book to be interesting, challenging in some of the more technical areas, extremely informative in those same areas, and especially interesting because of the Alaska focus. I recommend this book to anyone faced with large medical bills. I recommend this book to anyone who has a serious interest in the structure of health care financing in Alaska or nationally. I recommend this book to all health care and public health professionals, and I think this would be an excellent book for classroom use at the university. I commend the author for his ability and desire to turn personal tragedy into a public resource that will educate and help others.
One aspect of Weiss' review that is unique is his attention to the images of Patricia Davis' artwork that were used as chapter ornaments. Most of the figurines depicted were created during her ordeal of chemotherapy, and had significance for her that related to her health issues. The images were selected with this in mind.

Weiss describes the book chapter by chapter, commenting that the author's "writing style is straightforward and factual" and that "[t]he book includes an excellent glossary and, unlike many books in recent years, a detailed and useful index."

Addendum: this review also appeared on Health4all in two parts (see links at right).

Wednesday, July 9, 2008

Doctor Shortages?

How many doctors does it take to adequately serve 1000 people? The number varies with country, it seems. In 1997, two countries with highly rated health care systems, France (WHO rating 1st) and Germany (WHO rating 25th), had about 3.3 doctors per 1000 population, but Japan, also highly rated by WHO at 10th, had only 2.0 doctors per 1000 population. Similarly, the United Kingdom (WHO rating 18th) and Canada (WHO rating 30th) had 2.1 doctors per thousand. The less-highly rated United States (at 37th place) had an intermediate number of 2.7 doctors per 1000.

More recent data indicate that the number of doctors in the United States has declined to about 2.38 per 1000, but, curiously enough, a report from the Organization of Economic Cooperation and Development states that the number of doctors in Canada has been stable at 2.1 per 1000 for at least 20 years. The number in Alaska is about the same, 2.05 doctors per 1000 population.

Obviously, the quality of medical care in a country does not critically depend on the number of doctors the country has. However a recent report from the Alaska Physician Supply Task Force notes that because of Alaska's size, rural nature, and extremes of weather, the state really needs more doctors than it has. It should have about 10 percent more doctors per 1000 than the United States as a whole, the report recommends. Presumably the same is true for Canada because of its similar geography.


Tuesday, June 24, 2008

The Reality of Health Care: A Huge Disparity in Need


A MAJOR MYTH, One promoted by the current administration, employers and insurance companies: the American health care problem could be solved if we could convince Americans to take more personal responsibility for maintaining healthier lifestyles and giving them a greater freedom of choice in purchasing health insurance.

BUT THE MOST IMPORTANT REALITY OF HEALTH CARE is depicted by the associated diagram. The second panel states a startling fact: it takes only 5 cents of the health care dollar to pay for the health care of the lowest-cost 50 percent of the population, and notice that the highest-cost 1 percent requires 22 cents of the health care dollar. For that 1 percent, the per-person cost now exceeds $39,000 per year.

This diagram tells us that there is no way the heaviest users of health care can pay for that health care. Therefore, in a responsible society the payment for health care must be a societal, not an individual, responsibility. The only way we can exercise that responsibility is to establish a system of single-payer universal health care. We must get the for-profit health insurance industry out of the loop, as is called for by H.R. 676, the "United States National Insurance Act."

Mayors Back Universal Health Care

Yesterday, the U.S. Conference of Mayors unaninously adopted a resolution in support of the "United States National Health Insurance Act," H.R. 676. Known also as the "Improved and Expanded Medicare for All Act," H. R. 676 is sponsored by Rep. John Conyers of Michigan and 90 members of Congress.

This is an excellent bill that, unlike the proposals of Senators Obama and McCain, actually addresses health care and guarantees everyone in the country affordable health care by forcing the highly profitable private health insurance industry out of the loop. That is a necessary action if the country is to have an effective health care system like that of all other modern countries.

The backing of HR 676 by the nation's mayors is highly significant because the mayors, far more so than most elected officials, are closer to the people and more free of pressure from the pressures of health insurance industry and pharmaceutical industry lobbying efforts that hope to maintain the staus quo. The fact that the mayors are backing HR 676 indicates that the public is increasingly in favor of universal health care. We may be closer to an effective universal health care system than many have thought possible.

Monday, May 12, 2008

New reviews of Mired

From Midwest Book Review's California Bookwatch Health and Medicine Shelf:
A shocking note Americans don't know about medical bills: They don't reflect the costs of the medicine itself. "Mired in the Health Care Morass: An Alaskan Takes On America's Dysfunctional Medical System for his Uninsured Daughter" is the tale of accomplished author and geophysicist Neil Davis's fight against the American Health care system and how it is extorting Americans when they are at their most vulnerable - when they are ill themselves or deathly concerned for the well being of their loved ones. With advice to fight these corrupt practices and get the more correct and proper hospital bill, [this book] is highly recommended for anyone who has been scorned by the American health care system and for community library social issues shelves everywhere.
And from Humane Medicine, a Canadian publication, comes this:
Davis’s book is an important contribution to the literature on the American Health Care System since it is written by a consumer rather than a professional provider of medical services. Davis structured the book around the experiences that his family endured when his adult daughter, Patricia, was diagnosed with lung cancer....

Given all of Davis’ discoveries, he concluded that there are four criteria for an effective health care system. First, an effective health care system provides comprehensive health coverage for all citizens. If not, the poorest individuals will get inadequate health care. Second, a health care system ensures that health care is distributed to citizens according to their ability to pay. Otherwise, the poorest members of that society are penalized by paying a higher proportion of their financial resources for health care. Third, each health care system should provide uniform payment for necessary health care services. Fourth, prescription drug prices must be regulated, either by fixing drug prices or regulating pharmaceutical industry profits. For this to occur, the government must assume the primary role in operating the health care system.

Thus, in conclusion, this book will be especially relevant to consumers of heath care and is an eye opener for those who may be seriously ill in the United States and are trying to understand why receiving health care creates serious financial difficulties for them.

Thursday, May 1, 2008

Another four-star review from LibraryThing

A review from April 25 on LibraryThing:
The many charts and statistics he uses to illustrate his findings can be hard to understand at times, but believe it or not they accurately illustrate his point that the complexity of the American system creates expense. He skewers some fondly held myths about the U.S. Health care system and shines light on the health care systems in other nations. He also gives his prescription for how the U.S. Health care system can be changed.

Neil Davis has experiences in being a consumer of health care that most of us never hope to have, but which will become increasingly commonplace as the health care becomes increasingly broken. His answers to the health care crises (universal, uniform payments, distributed to patients regardless of ability to pay, regulation of drug companies) are well thought out and do not come from a place of a particular political ideology but instead from his own experiences and research. His book is well researched and a convincing call to radically overhaul the American health care system from someone who has experienced the worst that the American health care system has to offer.
John Conyers reprints a list of four myths about universal health care by Dr. Marcia Angell. Davis sums up an answer to her myth #4, "Claims the government can't do anything right," in his index (look up "Mistrust in government").

Monday, April 28, 2008

HR 676 Universal Health Care

I have been looking closely at health care reform and related matters for the past two years, and it seems like I learn something new every day. It embarrasses me to admit that just this week I became aware of HR 676 (The United States National Insurance Act) introduced into the House of Representatives by Rep. John Coyers (D-MI) in January 2007. This bill contains all the right provisions for setting up a first-rate universal health care system in this country. Unlike the proposals of the leading presidential candidates that continue the role of private insurance companies, HR 676 basically calls for eliminating them altogether, and turning the health care system into one having the delivery of health care as the first priority. In essence, the proposal calls for a complete conversion to a non-profit health care system.

The proposal has several key features. One is that it provides complete coverage for all medically necessary services including long-term care, prescription drugs, dental care and eye care. Another is that it provides for all United States residents and visitors. The act totally eliminates co-pays and deductibles, and it prohibits for-profit insurers from selling insurance covering services duplicating those provided by the universal health care system. Under this act, patients would have complete freedom of choice in providers, hospitals, clinics, and practices. In recognition that all this cannot happen in one day, the bill calls for a conversion to a not-for-profit health care system to take place over a period of fifteen years.

Financing for the program would be provided by an employer payroll tax of 4.75%, and employee payroll tax of 4.75%, a 5% health tax imposed on the top 5% of income earners and a small tax on stock transactions. The end effect would be a small reduction in overall health care spending.

I don’t see anything wrong with any provision of the bill; in fact it looks to be well thought out. One pleasing thing is that the bill is gaining support in Congress and elsewhere. When first introduced, the bill had 25 co-sponsors, and by April 2008 it had 90. Eighty-nine of these are Democrats, one is an Independent, but none are Republicans. No commentary needed here.

You can read the full text of the bill at:

Tuesday, April 22, 2008

Another positive review

The fifth review from LibraryThing, giving it four stars:
Less of a personal journey than an exploration into the true costs of medical treatment in the United States today, and where the money goes. For anyone concerned with injustice, inequalities, or lack of checks within the system; or anyone who is concerned that they cannot afford the medical care they or their loved ones need, this clear and non-judgmental book written by a layman with no preconceptions or industry biases is highly recommended.

Wednesday, April 2, 2008

More reviews from LibraryThing

Two more LibraryThing reviewers have written about Mired. The first one gave a mixed review, but had this to say:
Most patients have no idea how health care billing works until they are faced with a financial crisis. A book like Mr. [sic] Davis' would be very helpful in leading them through the process, especially if they live in Alaska.
The second reviewer said this:
A myriad of books have been written on this topic; however, Mr. Davis' strength lies in the fact that he writes it from the perspective of a consumer. It could be argued that he is not qualified to write a book about the health care industry as merely a consumer. Certainly, economists may be more capable of addressing the macro issues of national healthcare, and pundits the political ramifications; however, that really isn't the purpose of Mr. Davis' book. Rather, it reads like a good summary (with a clearly liberal bent) on the state of the health care industry.

And, unlike economic and political pundits, Mr. [sic] Davis doesn't shy away from actually providing a solution. As he says, "What is needed is single-payer universal healthcare ... the most economical form is a fully socialistic system like the United Kingdom's (and the VA system as well) in which the government owns and operates the hospitals and hires healthcare providers."
(Davis recommends a single-payer arrangement like France's system or Canada's, rather than socialized medicine.)

Wednesday, March 19, 2008

Prognosis for the Future of "Mired in the Health Care Morass"

After last evening's superb event at the Blue Loon, I predict that Neil has no idea how important this book could become. It has every important element crucial to the major review and total overhaul of our horrific health insurance debacle in the USA. Because it is so personal and detailed, it is a natural ally to Michael Moore's film "SICKO". This is why the interviews with Marcia Angell and Elizabeth Warren were so fitting for the opening of the signing party. The first thing we need to do is send Moore a copy with a free pass to read this blog. Some clever legislator may seize it too, but right now that's unlikely as they are submerged in the middle of the session.

Neil has done us all a huge service. Now please everyone, READ THE BOOK!! You won't be sorry!

Your local Solarhero

Another review from LibraryThing

A second LibraryThing reviewer has posted comments about Mired in the Health Care Morass:
An excellent book that focuses on the state of health care costs for the uninsured. The under-insured and the insured have much to gain from the exhaustive statistical details in this book.… The book is not a sentimental one but a refreshing look at a father's attempt to understand how the health care system in the US charges for each procedure, medication, in and outpatient visit and makes a compelling argument and a very strong case for reform in the health insurance "industry" along with an accurate look at how we as consumers can and should take charge of our health care. Otherwise, we may end up paying for mistakes (documented in the book) of the various personnel in making coding errors or charging according to outdated schedules. Anyone facing a chronic disease--anyone who uses their health insurance at all, this book is an easy read with documentation.
This reviewer found the book's citations of websites to be a drawback, expressing a preference for more peer-reviewed print sources, but wrote, "however, these may be difficult to obtain considering the subject matter."

Wednesday, March 12, 2008

Public discussion of health care March 18

With Fairbanks Community Hospital Foundation trustee Richard Seifert acting as master of ceremonies, author Neil Davis and Mike Powers, CEO of the Fairbanks Memorial Hospital, will give a short presentation on the healthcare situation in America and Alaska today, followed by an informal Q&A and discussion. This will also be a book release party in the convivial atmosphere of the Blue Loon theatre, club, and bar, where the attendees can eat dinner while they participate and celebrate the publication of a much-needed guide through the byzantine billing methods of our current healthcare system.

Where: the Blue Loon, 2999 Parks Highway

When: 5:30 to 7:30 pm, March 18, Tuesday evening

Please come and bring your perspective and experiences to the discussion!

Friday, February 29, 2008

Clinton and Obama on Health Care

Listening to the debate of February 27, 2008, between Democratic presidential contenders Hillary Clinton and Barack Obama, I was pleased that they both paid much attention to the issue of health care. Up to this point, the Republican candidates have not said much about the health care issue, obviously wishing to ignore it. The Democrats, on the other hand, have made it clear that they want to push forward toward changing our dysfunctional health care system into something more sensible.

However, it was distressing to see both Clinton and Obama start by saying how important it was for everyone to have affordable health care and then switch the discussion over to health insurance. Perhaps intentionally, they were both failing to distinguish the difference between health care and health insurance. They each seemed to be trying to claim that having affordable health insurance was equivalent to having affordable health care.

If all health insurance was like Medicaid insurance—which pays the full costs of health care for its beneficiaries—then affordable health insurance would be equivalent to affordable health care. But we all know that most insurance policies pay only a portion of health care costs, and in extreme cases, not even a major part. It is getting worse by the day, too. Private insurers and the employers that buy insurance from them are increasingly trying to dump more of the cost of paying for health care off onto individuals. Furthermore, the insurance companies are doing their best to refuse insurance coverage to those persons needing the most health care. These are the persons who are getting hit the hardest by our current system.

It would be nice if our presidential candidates felt they could be forthright in admitting that the only way to bring affordable health care to all Americans is to establish a government-operated program of universal health care and to get the private insurance industry out of the picture altogether.

So we can only hope that once he or she gets elected, the winner of the presidential race will get down to business and push for real progress by establishing a universal health care program rather than continuing to promote a program of universal health insurance in which the insurance industry plays the major role. This industry’s high administrative costs and shareholder profits absorb a substantial share of the health care dollar. This is money that should be going to pay for health care directly, and if that money did go there, the overall cost of health care would go down.

It won’t be easy of course, because even if Clinton and Obama do, a large segment of the American public does not recognize the difference between health insurance and health care, and many are leery of increasing the government’s role in health care or any other arena. Many Americans have a hard time realizing that the best tool we have available for fixing the health care system is our federal government.

Tuesday, February 26, 2008

Second review of the book, from LibraryThing

From Kevin Bondelli, political activist and participant on LibraryThing, comes another praise-filled review of Mired in the Health Care Morass:
Davis' research is extensive, and his ability to dissect the unreasonably complex health care process is unrivaled. Due to the complexity of the process his book has a great number of charts and diagrams that do wonders to help the reader make sense of it all.

Sunday, February 24, 2008

Book news: upcoming events, first review

Two book signing events are scheduled in Fairbanks within the next week:

February 28, 6 to 8 pm at Gulliver's Books, College Road

Alaska Library Association Conference
Saturday, March 1, 2:30 to 4, Princess Hotel

Dermot Cole of the Fairbanks Daily News-Miner writes, "I look forward to reading the latest book from Fairbanks scientist and writer Neil Davis, a thoughtful researcher who has spent more time than anyone I know studying the health care system."

And David A. James, also of the Fairbanks Daily News-Miner, has written the first published review of Mired in the Health Care Morass, titled "Mired offers eloquent indictment of America's health care system", calling Davis' writing "eloquent," "persuasive," "commendable," and "illuminating."

Monday, February 18, 2008

Senate Bill 160

The current draft of Senate Bill 160 contains improvements over the original draft proposed by the sponsors, but it still fails to address the real problem of high costs of health care for the heaviest users of health care in Alaska: the total cost of health care of which insurance premiums are just a part. The bill seeks only to provide affordable health insurance, not affordable health care. For those Alaskans needing the most health care, the cost of insurance premiums is often only a fraction of the total cost of health care. They also have to pay for insurance deductibles, co-payments, and additional out-of-pocket expenses.

By mandating the purchase of insurance from private industry, the bill can only drive up overall health care costs for Alaskans. Private insurance companies have much higher administrative costs than government insurance programs such as Medicare and Medicaid, and they rake off additional money for shareholder profit. Roughly 20 to 30 percent of the health care dollars funneled through private insurers are lost in administrative costs and shareholder profits. This is money that should be spent directly for health care.

Because the effect of the bill will be to increase total health care costs, its passage by the legislature will be a backward step toward more affordable health care. The legislature would do better to expand Alaska’s highly efficient Medicaid program, making it available to more low-income Alaskans.

Sunday, February 17, 2008

Legislative public hearing on SB 160

As pointed out on Health4all, there is a public hearing on SB 160 on Monday. SB 160 is the mandatory health insurance bill introduced by Hollis French, about which Neil Davis wrote in his December 2007 Dose of Reality column.

The hearing is at 1:30 pm. Testimony is described as by invitation only.

Friday, February 8, 2008

Legislative public hearing on the CON

The legislature is holding public hearings on the issue of revoking the Certificate of Need requirement. The first one is:

Saturday, February 9, 9 am
at the Legislative Affairs Office in the Alaska USA building
at 1292 Sadler Way, Suite 308, Fairbanks

Below is a list of observations on the value of the Certificate of Need requirement, forwarded to me and in direct counterpoint to many of the points raised in the insert in last Sunday's News-Miner (be forewarned, it's long):
1. The absence of market competition does not cause increasing healthcare costs. Rising costs are caused by a combination of many other factors. Three major drivers of rising health care costs are:

a. Medical advances and improved technologies account for one-half to two-thirds of the increase in health care spending in excess of general inflation.(1)

b. Neither the patient who uses healthcare nor the physician who orders it are the direct payer for most healthcare costs. Insurance lowers the effective price of healthcare, which increases demand and leads to overuse. Few people realize that the magnetic resonance image (MRI) for which they paid a $10 co-payment could actually cost $250 or more.

c. Aging and lifestyle choices, such as smoking and inactivity, contribute to a wide variety of health problems. The average age of Fairbanks is rising, one in four Alaskans smoke, and 63% are overweight.(2)

2. Adding providers often raises costs
Since “for much of U.S. health care, supply drives demand. In other words, higher-than-average utilization of a particular procedure may occur in an area where the technology or specialists performing the procedure are in abundance.”(3)

3. Other states that have abolished CON have had a variety of unintended consequences.
The Virginia General Assembly removed all medical equipment CON requirements in 1989. The result was rapid proliferation of for-profit providers. Average volumes fell and prices rose. So, in 1992, the Virginia legislature reinstated CON regulation of medical equipment. Alaska shouldn’t repeat Virginia’s mistake.

4. CON review doesn’t prevent any needed projects from going forward. It does help to ensure that they are based on a sound business plan and respond to a genuine community need.

5. Experience in the auto industry shows that medical costs are lower in states that have CON legislation.
Studies undertaken by General Motors, Ford and DaimlerChrysler demonstrate that health care expenditures per employee are significantly lower in states with CON legislation, such as Michigan and New York, than in states without it, such as Indiana, Ohio and Wisconsin.”(4) In fact, their MRI costs per covered person were up to 20% higher in states without CON.(5)

6. “Competition” doesn’t lower prices.
In Fairbanks, when AOIC opened, they charged more per scan than FMHDC. There is no evidence of lower costs or charges in states where physician-owned ambulatory surgery centers and freestanding diagnostic imaging centers are widespread.

7. Healthcare is an unusual business.
It’s possible to keep prices high even when there are alternatives because of a host of inherent structural quirks of the healthcare marketplace. Much of healthcare is supply-sensitive, where the use rate is driven primarily by the available supply of resources.(6) That is why Alaska requires a demonstration of community need before permitting additional services. Now some are seeking to repeal CON rather than play by the rules required of all service providers.

8. The state plays a necessary role in realms that markets cannot value properly.
Regulation is required to solve problems that the market cannot fix, such as education, health, public infrastructure, and clean air and water.

9. CON makes sure that good planning has been done that meets a real community need.
In Alaska, and in other states with CON programs, health care facilities are required to “play by the rules” and meet specified planning requirements. That’s it, that’s what it does.

10. Repeal of CON will NOT lead to competition, and competition will not lower costs.
As Yale professor Ted Marmor said recently, “choice and competition have no proven record of cost control in medical care either in the United States or elsewhere.”(7)

11. The notion of competition is a Trojan horse.
It may look great on the outside, but a complex set of conditions and devices lurk inside. Conditions that increase overall healthcare costs, decrease the ability of the local hospital to invest in new services and support those that can’t pay for themselves, and favor the wealthy and well-insured at the expense of the poor and the sick. Don’t be fooled by the skin-deep attraction of the competition argument.

12. Research shows “competition” has negative consequences in health care.
The Center for Studying Health System Change 2005 survey is the fifth conducted by the Center. Recent survey results reinforce and amplify earlier observations. Key findings include:

• Socially nonproductive competition between and among hospitals, freestanding service centers, and physicians appears to be having significant system distorting effects.

• It contributes to:
-- decreased average service volumes,
-- reduced system efficiency,
-- increased withdrawal of operating returns as profit,
-- promotes undesirable joint ventures, and
-- provides economic incentives for the provision of unnecessary services and of care of little benefit to patients.

• With the possibility of shifting their practices, or selected patients, to outpatient services in which they may have a financial interest, larger numbers of physicians are shunning hospital and related professional community service.
-- Many hospitals are being forced to hire physicians to provide on-call emergency, trauma and specialty care. Concern about access to specialty care – inpatient psychiatric services for example – for some patients is growing.

• With the shift of profitable services to physician owned facilities, and the increased focus on profitable services at some hospitals, “safety net” community hospitals are under increasing pressure to provide needed, but unprofitable, services. The revenue stream needed to support these services is drying up.

• This wouldn’t be good news, but if CON is repealed, we’ll be seeing it here.

13. Financial incentives can distort clinical decisions made by physician-owners.
Specialty facilities erode cross-subsidization by “cherry picking” relatively well-insured and healthy patients (where profit margins are higher) and by limiting or denying care outright to underinsured, indigent, and less healthy patients.(8)

Because physicians may refer patients to specialty facilities in which they have an ownership interest, financial self-interest may overwhelm clinical judgment and lead to unnecessary referrals, threatening both cost and quality.(9)

“Medical profiteering steers care away from what's best for the patient in favor of what's best for the doctor. That greed undermines the entire process: It compromises quality, increases cost, and erodes the patient-physician relationship.” (10)

Saying that physician self-referral arrangements are “creating incentives for overutilization and corrupting medical decision-making,” CMS’s proposed Physician Fee Schedule (PFS) rule for calendar year 2008 signals the agency’s intent to clamp down on the practice and has led some providers to temporarily put such deals on hold. (11)

According to a recent study by McKinsey, “physicians have been making profits estimated at $8 billion annually through the practice for self-referral.”(12)

“Like all of us, physicians are susceptible to the financial conflicts that are inevitable in an entrepreneurial society. Clearly, professional self-regulation isn't working. Nor is the system yet transparent enough to discourage these behaviors and protect patients. So additional safeguards are required.”(13)

Barring a legislative prohibition on physician investment in health care facilities, CON is the best safeguard Alaskans have against the problem of financially conflicted care.

14. State support for Certificate of Need (CON) is not ideological.
CON laws require that entities proposing to build new facilities demonstrate that they are meeting an unmet health care need.(14) The American Health Planning Association recently summarized the breadth of state regulation, and the pattern of distribution is not clearly related to the overall political leaning of the state. Thirty-six states today retain some sort of CON oversight.

15. Specialty providers avoid patients who are uninsured or underinsured.
Specialty facilities focus exclusively on profitable procedures. Since no financial incentive exists for the care of Medicaid patients, it is not surprising that specialty hospitals treat proportionately fewer Medicaid inpatients.(15)

16. Specialty providers are not more efficient.
The recently published MedPAC report found that physician-owned specialty hospitals do not have lower costs for Medicare patients than community hospitals, despite shorter lengths-of-stay. (16)

17. Specialty providers are not higher quality.
A recently published study by Peter Cram and colleagues found no difference in Medicare mortality rates between specialized hospitals and community hospitals, but did find that specialized facilities are more likely to treat healthier patients.(17)

There is an extensive literature demonstrating that institutions that perform a high volume of a given procedure provide higher-quality care.(18) Eliminating CON from Alaska’s largest communities, as HB287 sought to do, would only serve to dilute an already small number of procedures across a greater base of providers—with a strong potential for compromising the quality of care we can provide in-state.

18. Specialty providers treat less complex, more profitable cases.
The treatment of patients of lower acuity (“cherry picking”) by ASCs and specialty facilities appears to be taking place.(19) In strong support for this hypothesis, Ariel Winter found that Medicare patients treated in ASCs had lower risk scores (a reflection of a patient’s expected costliness based on age, sex, and diagnoses) than patients treated in hospital outpatient departments for all ten procedure categories that accounted for the highest share of Medicare payments to ASCs in 1999. (20)

Similarly, a recent GAO report found that specialty hospitals treated a lower proportion of severely ill patients in the same diagnostic categories treated at general hospitals.(21) The recent MedPAC and CMS reports also confirm these results.(22) Since no financial incentive exists for the care of Medicaid patients, it is not surprising that specialty hospitals treat proportionately fewer Medicaid inpatients.(23)

Cross-subsidies have always been a key part of the health care financing system, with hospitals using profitable services and patients covered by profitable payers to offset their losses from less profitable services and patients.(24) The strong financial incentives to select more-profitable cases and patients, combined with niche providers’ greater inclination and ability to act on those incentives, makes community hospitals financially vulnerable.

19. Specialty providers raise overall healthcare costs.
On the state level, experience in the auto industry shows that medical costs are lower in states that have Certificate of Need programs because these programs reduce redundant capacity and limit the proliferation of specialty providers and unnecessary capital expansion projects. Studies undertaken by General Motors, Ford and DaimlerChrysler demonstrate that health care expenditures per employee are significantly lower in states with CON legislation, such as Michigan and New York, than in states without it, such as Indiana, Ohio and Wisconsin.(25)

The peer-reviewed literature on self-referral suggests that physician ownership of facilities leads to higher use rates. Self-referring physicians were 4 to 4.5 times more likely than radiologist-referring physicians to obtain radiological investigations, and they charged much more for tests of the same complexity.(26) Similar results have been observed for physician ownership of physical therapy and rehabilitation facilities and radiation therapy clinics.(27)

One standard hypothesis in favor of ASCs is that their main effect on hospitals is a competitive reduction in price, but on balance not a large loss of hospital outpatient surgery volume.(28) Contrary to that hypothesis, research shows a substantial loss of hospital volume.(29)

Another recent study indicates that prices do not necessarily come down, either.(30) In fact, as the economics in an imperfect market would predict, overall costs increase instead. “While purchasers are predisposed to favoring increased competition to help keep prices low, what we heard generally from health plans and employers is that specialty hospitals are contributing to higher costs without any clear quality benefits," said Paul B. Ginsburg, Ph.D., president of HSC, a nonpartisan policy research organization funded principally by The Robert Wood Johnson Foundation.

“Some purchasers believe that referring physicians, especially those with a financial interest in the specialty hospital, increase volume by inducing patient demand for elective procedures. The higher volume raises costs more than the savings achieved from lower prices from competition, leading to increased aggregate costs.”(31)

Lynk and Longley found evidence that this belief is well-founded: adding an ASC to the markets they studied caused the total volume of outpatient surgeries to rise 9% over the trend.(32) Furthermore, this volume increase is largely confined to those physician investors with a financial interest in the ASC.

There is strong evidence that ASCs—which, in Alaska, currently exist only in Anchorage—increase both overall demand and per unit costs as well, consistent with research we have cited above. The surgical use rate in Anchorage is over 50% higher than that in Fairbanks. Obviously, this leads to much higher total healthcare costs to the community as a whole—while simultaneously undercutting a community hospital’s ability to care for the most vulnerable members of the community.

20. Alaska’s CON Program
Consistent with the state’s unique geography and demography, the program has taken on a distinctive Alaskan character.
Most states that set expenditure review thresholds usually distinguish between new services, medical equipment, and health facility renovation, expansion and development. Alaska does not. Some states review all projects that establish a category service (e.g., a service for which review standards exist) regardless of their capital or annual operating costs. Others limit this to certain categories (e.g., CT scanners, MRI scanners, PET scanners, cardiac catheterization laboratories, ambulatory surgery centers, linear accelerators).

21. Eliminating or weakening CON is not a good solution to Alaska’s healthcare marketplace.
Weakening CON would make it likely that the communities in Alaska will see spiraling healthcare costs, and higher utilization—without increasing access, cost, price or quality.

Weakening CON will not result in better healthcare for rural communities or larger communities. It will only raise the overall cost of healthcare by enriching a few investors at public expense.

Alaska should consider establishing different cost thresholds for different types of projects, an approach followed by most other states. This approach recognizes that it is primarily the on-going cost of potentially excess utilization that has the greatest risk of increasing health care costs. It is also because these are the services where damaging “cherry-picking” behavior is most likely.

(1) New England Journal of Medicine, Controlling Heath Care Costs, Oct. 14, 2004.
(2) The Kaiser Family Foundation,, at
(3) General Accounting Office. Health Care: Unsustainable Trends Necessitate Comprehensive and Fundamental Reforms to Control Spending and Improve Value. Highlights of the May 2004 Health Care Forum GAO-04-793SP. Page19
(4) United Auto Workers. Health Care
(5) State of Missouri Department of Health and Senior Services. (PDF)
(7) Marmor TR and Marshaw JL. “Understanding Social Insurance: Fairness, Affordability, and the “Modernization” of Social Security and Medicare.” Health Affairs 25 (2006): w114-w134 (published online 21 March 2006; 10.1377/hlthaff.25.w114). Page w132.
(8) Sujit Choudhry, Niteesh K. Choudhry, and Troyen A. Brennan. Specialty Versus Community Hospitals: What Role For The Law? Health Affairs: Health Tracking: Marketwatch 9 August 2005.
(9) Choudhry, Choudhry, and Brennan.
(10) Brian Klepper, PhD. “When Medical Care Is Financially Conflicted.” Webcast Video Editorials. Medscape General Medicine. 2007;9(2):39. ©2007 Medscape. Posted 05/18/2007.
(11) For the proposed rule, see:
(12) Kaiser Daily Health Policy Report. “
CMS Officials Taking Steps To Reduce Physician Self-Referrals Under Medicare, Wall Street Journal Reports” Posted Sep 12, 2007.
(13) Brian Klepper, PhD. “When Medical Care Is Financially Conflicted.” Webcast Video Editorials. Medscape General Medicine. 2007;9(2):39. ©2007 Medscape. Posted 05/18/2007.
(14) Institute of Medicine, Health Planning in the United States (Washington: National Academies Press, 1981).
(15) GAO, Specialty Hospitals: Geographic Location.
(16) Medicare Payment Advisory Commission, Report to the Congress: Physician-Owned Specialty Hospitals, March 2005, (PDF)
(17) P. Cram, G.E. Rosenthal, and M.S. Vaughan-Sarrazin, “Cardiac Revascularization in Specialty and General Hospitals,” New England Journal of Medicine 352, no. 14 (2005): 1454–1462.
(18) See, for example, R. A. Dudley et al., “Selective Referral to High-Volume Hospitals: Estimating Potentially Avoidable Deaths,” Journal of the American Medical Association 283, no. 9 (2000): 1159–1166.
(19) Cram et al., “Cardiac Revascularization.”
(20) A. Winter, “Comparing the Mix of Patients in Various Outpatient Surgery Settings,” Health Affairs 22, no. 6 (2003): 68–75.
(21) U.S. Government Accountability Office, Specialty Hospitals: Information on National Market Share, Physician Ownership, and Patients Served, Pub. no. GAO-03-683R (Washington: GAO, 2003).
(22) MedPAC, Report to the Congress: Physician-Owned Specialty Hospitals; and CMS, “CMS Outlines Next Steps.”
(23) GAO, Specialty Hospitals: Geographic Location.
(24) See, for example, S. Guterman,
Putting Medicare into Context: How Does the Balanced Budget Act Affect Hospitals? 1 July 2000 (PDF accessed 10 April 2006).
United Auto Workers.
(26) B.J.Hillman et al., “Frequency and Costs of Diagnostic Imaging in Office Practice—a Comparison of Self-Referring and Radiologist-Referring Physicians,” New England Journal of Medicine 323, no. 23 (1990): 1604–1608.
(27) Mitchell and Scott, “Physician Ownership”; and J.M. Mitchell and J.H. Sunshine, “Consequences of Physicians’ Ownership of Health Care Facilities—Joint Ventures in Radiation Therapy,” New England Journal of Medicine 327, no. 21 (1992): 1497–1501.
(28) The argument is that overall volume in the outpatient surgery market rises when price in the market falls and that that increase in total market volume offsets the incremental volume that the ASC takes from the hospital.
(29) Lynk and Longley. What can happen when a hospital’s staff physicians become its business rivals. Health Affairs. 2002 Jul-Aug;21(4):215-21. Specifically, that analysis yields a coefficient estimate for the ASC effect of 0.0932 (with a statistical significance level of p=0_.0238) and an adjusted R-square of 0.8449.
(30) Robert A. Berenson, Gloria J. Bazzoli, Melanie Au.
Do Specialty Hospitals Promote Price Competition? Center for Studying Health System Change. Issue Brief No. 103. Jan. 25, 2006. (10 April 2006).
(31) Berenson, Bazzoli, and Au.
(32) Lynk and Longley.

Wednesday, February 6, 2008

Health Care for Alaskans: An "Informational" Publication

An insert with the above title (minus the weasel quotes) in the Fairbanks Daily News-Miner's Sunday edition appears, at first glance, to be a special medical issues insert created by News-Miner staff. Article bylines read "Staff Report", with the exception of an article on the last page entitled "Certificate of Need hinders health care innovation," which is written by Michael Morrisey and Michael Ciamarra.* It is on the bottom of this last page, and this page alone, that a small notice reads, "Paid for by the Alliance for Healthcare in Alaska, 1275 Sadler Way, Fairbanks, AK 99701," thus revealing that the 8-page newsy-looking insert is in fact a paid advertisement. The staff "reports" are in fact opinion pieces, and are riddled with false and misleading statements.

Articles in this advertisement include:

• "Nation faces crisis due to physician shortage," which falsely claims that physician shortages "will only be exacerbated with universal health care"; and that "It is well documented that many Canadians wait an inordinate amount of time for their much-needed medical and surgical care," and "end up coming to the United States for their treatment".

• "Alaska's healthcare system locked in textbook 'monopoly'," laughably states, "It is important to understand that the health care system in America is second to none." This is flatly false, unless one is extolling its virtues as a money-making machine for insurance and pharmaceutical companies.

• "Competition necessary for industry to flourish," is a summarization of a presentation by Mark J. Botti of the Antitrust Division of the US Department of Justice in February 2007, "Competition in Healthcare and Certificates of Need." It extolls the virtues of competition in health care and argues against the need for Certificates of Need laws.

• "Breaking down 'Certificate of Need'" (subtitled "Program designed to aid patients in health care community now contains flaws, causes more harm than good"), provides a timeline graph of the number of states with CON laws and takes the form of arguments and rebuttals on the CON issue.

• "Certificate of Need hinders health care innovation,", which describes problems in Alabama, Georgia, and North Carolina's CON laws.

Quite clearly, the sponsors of this multipage advertorial want Alaska's Certificate of Need law overturned, as requested by Governor Palin (although this action was NOT recommended by the Alaska Health Care Strategies Planning Council she created to advise her). Unfortunately, the Alliance for Healthcare in Alaska appears willing to promulgate nonsense in order to do it.

*Ciamarra is vice president of the Alabama Policy Institute, a right-wing conservative think tank, described by the U of Alabama College Republicans as "the largest and most influential Conservative think tank in the state of Alabama."

Thursday, January 31, 2008

A Note from the Publisher: Book signing at Gulliver's

The advance copies of Mired in the Health Care Morass are due from the printer today, and the main shipment should be arriving before the end of February. Please contact the publisher if you are interested in obtaining a review copy for your periodical.

Gulliver's Books, Fairbanks, Alaska's local independent bookstore, will be hosting the first book signing on February 28, Thursday evening, 6-8 pm.

Monday, January 28, 2008

More on CON Legislation

A year ago, Governor Sarah Palin, with Administrative Order No. 232 established, in the Office of the Governor the Alaska Health Care Strategies Planning Council. The purpose was to “identify short-term and long-term strategies to effectively address the issues to, and cost and quality of health care for Alaskans,” and to report it its findings “to the governor and the Legislature by January 1, 2008.” In May 2007, the governor appointed 14 voting members to the council which would be managed and operated by Karleen Jackson, Commissioner of Health and Social Services. It would also have as ex-officio non-voting members the chairs of the legislature’s Health, Education and Social Services committees, Senator Bettye Davis and Representative Peggy Wilson. The voting appointees consisted of five doctors, two nurses, one health insurance industry representative, five health association or health facilities administrators, and one town mayor. Notice that no health consumers or health consumer advocates were included in the membership.

One issue taken up by the council was the matter of Alaska’s Certificate of Need (CON) legislation, and the council established within itself a Certificate of Need Negotiated Regulations Committee. This committee issued a report stating that the current CON legislation needed changing, but it reported a very strong consensus among members that the CON process “should not be eliminated” and offered several suggestions for strengthening and clarifying the current regulations.

So what happened then? Commissioner Karleen Jackson ignored these recommendations, and concluded that the CON program does not benefit the citizens of Alaska, “given the litigious environment surrounding it.” Then awarding the council members a second kick in the teeth for their efforts, Governor Palin, as part of her Alaska Health Care Transparency Act presented to the legislature, called for the repeal of Alaska’s certificate of need legislation in entirety.

I bet those people who served on the Health Care Strategies Planning Council will think twice before again agreeing to another committee assignment from the governor. But this sort of thing happens a lot in Alaska state government. A governor has preconceived ideas about something so and appoints a committee in hopes that it will reach a conclusion that will justify the governor’s view and subsequent action.

This time it did not go well, so Governor Palin simply rejected the committee’s conclusion that the CON legislation needed to be both retained and improved upon.What will happen now is anybody’s guess, but let’s hope the legislature follows its conscience and stands up to the governor on this issue. Legislators would do well to listen to what the Alaska Health Care Strategies Planning Council had to say about how to improve the CON legislation and then take steps to do it.

Sunday, January 20, 2008

Health care an issue in upcoming Alaska elections

People running for office in Alaska are getting tough questions from their audiences on the campaign trail, apparently. Phil Munger at Progressive Alaska observed this when Ethan Berkowitz addressed the Mat-Su Democrats:
Berkowitz handled an array of questions fairly deftly until the talk turned to reform of our failing medical care structures. He's the least progressive of the three Dems on this, and struggled in his earnest efforts to answer some sweeping questions from the audience, with answers which wouldn't really provide solutions.

Berkowitz is right that medical care reform is a very complex set of problems with no easy answer for one community, let alone for the entire state or for our country. When he talked of waste, inefficiency and greed as being the major systemic flaws, though, his suggestions that we can tweak our way out of this dilemma didn't resonate at all with the audience.
David Sirota writes about alternatives being proposed in Washington state and Wisconsin: publicly controlled not-for-profit health care systems. Proposals like this could be adapted for Alaska, although we'd need to look at what is appropriate here.

Wednesday, January 16, 2008

Certificate of need law

In her State of the union address on January 16, 2008 Governor Sarah Palin expressed her desire to eliminate Alaska’s certificate of need law. With this statement the governor is demonstrating that she cares more about the needs of profit-seeking business interests than the Alaska public’s need for affordable health care. As I wrote in my Dose of Reality column published in the Ester Republic in September 2007, the elimination of the certificate of need law is guaranteed to drive Alaska health care costs up. Proliferation of unneeded for-profit health care facilities will force nonprofit hospitals to raise their overall rates to compensate for losses incurred when their existing facilities are underutilized. Not only that, health care consumers must also bear the costs of the for-profit facilities, and part of that cost is the profit raked off by the operators of these facilities. Their primary purpose is to make money, and for them the provision of health care is secondary. Counter to what Governor Palin says, it will be a disservice to the Alaska public to repeal our certificate of need law.

Thursday, January 10, 2008

Talk at the Interior Democrats' luncheon

Neil Davis on health care finance at the Interior Democrats' Luncheon
Westmark Hotel, 12 noon
813 Noble Street, #1
Fairbanks, Alaska

Wednesday, January 9, 2008

A Note from the Publisher: About the book

The marketing campaign has begun! The first batch of galleys of Neil Davis' book, Mired in the Health Care Morass, are done and will be mailed tomorrow to prospective reviewers. From the cover:
Mired in the Health Care Morass describes a predicament known to almost 47 million Americans: paying for medical bills without health insurance. Neil Davis navigated this financial black hole and discovered a hidden truth: medical bills don't reflect the costs of medicine. Davis describes the harrowing journey his family took in paying for cancer treatments, and comes to the well-informed conclusion that our health care system is broken, and doesn't have much to do with health.
John P. Geyman, MD, professor emeritus in family medicine at the University of Washington and author of the bestselling book, The Corporate Transformation of Health Care, read the manuscript and provided this explanatory prepublication review of Davis' work:
This is a well written and researched book illuminating the dark interior of health care financing, ranging across billing practices for physician services, drugs, laboratory and hospital services. A penetrating analysis from a consumer's point of view, unique in its detail, which shows how complex, fragmented, unaffordable, and unsustainable our market-based health care "system" has become. Motivated by the tragic illness of a family member, Davis carries his research to a study of our system as it compares with those of other industrialized nations, making a compelling case for a publicly financed system of single-payer national health insurance.