It solves the problem of the 45 million Americans who are without health insurance. This group of predominantly working individuals and their families has increased dramatically since 1990 and is associated with both poorer health care and higher health care costs than the insured segment of our population. Publicly funded, universal health care insurance would provide the uninsured comprehensive health insurance, which would improve their health and lower health care costs.

It solves the problem of the underinsured, the 25% of those insured who would be bankrupted by a major medical illness, the number one cause of bankruptcy in the United States. Publicly financed, universal health insurance would protect them from medical bankruptcy.

It solves the problem of the 35% of moderate-income workers who are locked in unwanted jobs because they would lose their health care benefits if they were to leave their job. Publicly financed, universal health insurance would allow these workers the freedom to choose their work without losing their health care benefits.

It solves the problems of Medicare recipients who, on average, spend 20% of their disposable income on health care. Publicly financed, universal health insurance would decrease out-of-pocket expenses for Medicare recipients.

It solves the problem of quality health care for the poor who receive substandard medical care through Title 19 because the low reimbursement rates of Title 19 keeps the best health care givers from participating in it. By providing the same quality medical care to all individuals, regardless of income, the quality of medical care for people currently insured through Title 19 would be greatly improved.

It solves the problems of small businesses that struggle to provide health insurance benefits for their employees. Publicly financed, universal health insurance makes health care affordable for small businesses.

In addition is would assist the problems of all businesses in paying for workman’s compensation. Publicly financed, universal health care insurance would decrease workman’s compensation expenses because it alleviates the need to adjudicate conflicts over whether a medical problem is job related or not, thereby saving time and money.

Most importantly, it resolves the problems of managed care: the breach of patient confidentiality that comes from subjecting physician’s treatment recommendations to insurance company pre-approval; the compromise of patient care that results from health care recommendations being micro-managed to minimize costs; the disruption of the doctor-patient relationship that results from insurance companies having limited provider networks; and the frustration that many patients and health care givers experience in accessing and providing health care through the managed care system. Publicly financed, universal health insurance provides free choice of care giver, ensures the right of care giver and patients to determine the most appropriate health care for them, ensures the continuity and confidentiality of care, and facilitates access to health care.

All studies on single payer, universal health care predict savings. No studies predict increased costs. For example, the State of Connecticut Office Of Health Care Access studied the impact of publicly financed, universal health insurance on Connecticut in 1992 and predicted this system would save over 1 billion dollars in total health care expenses in 1999 despite providing comprehensive health care benefits to the entire population. This finding was re-confirmed in both the 1995 report of the Connecticut Office of Health Care Access, and by the 1999 study of the Massachusetts Medical Society, which showed savings of 1.7 to 2.7 billion dollars per year if this system were enacted in Massachusetts. Studies (1990) of the Act’s proposed health insurance system at the Federal level, conducted by the General Accounting Office and the Congressional Budget Office, both predicted savings of 100 billion to 200 billion dollars if this system were to be enacted throughout the United States.

The savings anticipated in these prospective studies are also supported by data from other industrialized countries that have enacted single payer universal health insurance systems. Each of these countries spends at least 50% less than the US per capita while providing comparable health care outcomes for acute illnesses, and superior outcomes for population health data such as infant mortality, and longevity.

These studies are based on decreased administrative expenses (around 50%) and decreased costs of purchasing medications and durable medical equipment in bulk (30-50%). Depending on how much of these savings are off set by increased demand, savings from 0% to 10% are predicted.

In addition, there are many other savings under such a publicly-funded, single payer system that were not considered by these studies. First, because a single payer system would emphasize preventive health and encourage the early treatment of disease, health care costs would decline in the long run because illness would be prevented and treated early, when it is cheaper and more effective to treat. Second, health care givers would work with the insuring agency to find pragmatic ways of lowering costs while assuring quality, thereby cutting ineffective testing and treatments. Third, a single payer system would reduce health care costs by coordinating and consolidating medical services and medical equipment. Fourth, non-health insurance plans which have medical benefits attached to them, such as workman’s compensation insurance, malpractice insurance and car insurance, would cost substantially less under a single payer system because conflicts over the cause of medical injury would no longer have to be adjudicated by legal proceedings. Finally, a single-payer universal health insurance plan could control costs by controlling the rate of reimbursement for medical services. Although, it is not the intention of publicly financed, universal health insurance to reduce overall income to health care givers, it is expected that health care givers will experience a substantial (28%) reduction in administrative costs, experience a reduction in malpractice insurance, save time by no longer having to have care pre-approved, and experience an increased demand for their services. All of these factors would allow reimbursement for health care procedures to be decreased while maintaining income.

Publicly financed, universal health insurance would be paid for through existing state and federal programs, excise fees on activities detrimental to health, employer payroll premiums, and family health premiums.

The state and federal governments would transfer funds that are currently being utilized to pay for Medicare, Medicaid, and CHIPS programs into the system. Unlike the current system in which many eligible individuals are not enrolled, the health care trust would make sure that every eligible person is enrolled, thus maximizing the state and federal funding to the universal health insurance program.

Second, excise fees would be paid on activities detrimental to health to the extent that these activities can be shown to increase health care costs. For example, tobacco products would have an additional sales tax placed on them up to the extent that the funds generated from this sales tax equal the health care costs that can be reasonably shown to be attributable to their use. Similarly, polluting industries would be taxed to the extent that their pollution can be reasonably shown to contribute to health care costs.

Third, employers would pay for health care benefits on a sliding scale basis, depending on the number of their employees. Companies with the fewest employees would pay the lowest percentage of payroll. Companies with the largest number of employees would pay the highest percentage of payroll. However, the payroll premium paid by the largest companies will not exceed the average rate that they are spending in the year in which this legislation is passed. This will make American industries more competitive in the world.

Fourth, families would pay a health insurance premium less than the average amount they would currently pay for the comprehensive health insurance being proposed. There would be no costs for families whose income is less than 185% of the federal poverty guidelines.

Because publicly financed, universal health insurance is anticipated to reduce the total costs for health care, these savings can be spread out among employers and workers.

4. It is often stated that the United States has the best health care system in the world. Wouldn’t quality of health care decrease in the US as a result of a publicly financed, universal health care insurance program?

No. The best health care in the world is available in the United States if you can pay for it. However, the United States does not have the best health care system in the world. To evaluate the health care system of the United States, the health care statistics of American citizens must be compared with the health care statistics of the citizens of other industrialized countries that utilize a different health care system. The United States is the only industrialized country that does not insure access to health care as a right of citizenship. All industrialized countries, except Germany, utilize a single payer system, as I propose. Germany utilizes a multipayer system, somewhat similar to the health care system proposed by President Clinton in 1992.

Among the 29 industrialized nations, the United States ranks 20^th and 21^st in life expectancy among males and females respectively, 23^rd in infant mortality, and last with regard to most immunizations. These statistics are accounted for by the universal availability of health insurance in other industrialized countries. It is well known that health insurance increases longevity by encouraging individuals to seek medical attention early in the course of a disease when it is easier to treat and less costly. Furthermore, many individuals without health insurance, or because of limited financial means, avoid health care visits and treatments, shortening their survival.

When quality of care comparisons are made between the United States and Canada-- the country whose population and culture is most similar to the United States--in terms of survival from cancer, coronary artery disease, kidney failure and a wide variety of other illnesses, Canada is equal to or superior to the United States although spending less than half of what the United States does per capita.

Publicly financed, universal health insurance would improve the quality of care, not just for the poor and uninsured, but for the general population, by replacing the for-profit, managed care portion of our health care delivery system with private, fee-for-service medicine in which health care decisions are made by the health care provider in conjunction with the patient. For-profit, managed health care has been shown to provide poorer quality care, and to be less satisfying to the public as per a comprehensive July, 1999 review in the Journal of the America Medical Association by Himmelstein, Woolhandler, Hellander and Wolfe.

To summarize, it is expected that publicly financed, universal health insurance will increase the quality of care not only by minimizing the negative impact of for-profit, managed care, but also by increasing the health and longevity of the population as a result of providing universal health insurance coverage that encourages preventive health care and early intervention in medical illness.

No. Canada is a poorer country than the United States. As a result Canada has a much less developed medical infrastructure than the United States. Canada has a limited supply of expensive medical diagnostic equipment such as CT Scanners. The United States has an oversupply of health care givers, hospital beds and medical equipment. For example, the United States is estimated to have two to three times as many mammography machines as is needed to provide all the necessary mammograms for the United States population (Ann Int Med 1990; 113:547). Demand for medical care in the United States could be increased by up to 40% from the current levels before demand would equal the capacity of American medical infrastructure. It is estimated that single payer, universal health care would increase demand up to 15%. Thus, this demand could be easily met by our current infrastructure without lines. Put the other way around, Canada would have no waiting lines if its health care system were to be funded at the levels of American per capita spending.

No. This publicly financed, universal health insurance would alter the health care payment system, it would not alter the health care delivery system. Health care practitioners would remain in fee-for-service private practice and continue to compete with one another for business. In fact the private health care system would be strengthened because health care givers would be provided with a meaningful voice in determining rates and benefits, something they are deprived of under the managed care part of our current health care system.

No. First, publicly financed, universal health care insurance would not create a government bureaucracy as I conceive it. It fact the health care payment system I envision would not be a government system. We would create a not-for-profit public trust that is under the control of a board composed of citizen health care advocates, health care givers, health care organizations, businesses, and public officials, who will be in a decided minority. Although the Trust would be accountable to government in the sense that it must obtain legislative approval for the insurance premiums which are collected through the government, its operations would not be directly controlled by government, and its employees not be government employees. Second, the system I envision would be much more efficient than the private insurance industry by law. I propose limiting the administrative costs of paying insurance claims to 3%. The 3% figure is realistic and in line with the administrative expenses of Medicare, which is the most administratively efficient health care insurance payment system in the world. The private insurance industry spends between 15 and 30% of the health care dollar on administrative expenses and profit. This is the result of micro-managing care, high executive salaries, large marketing costs, and profit. It is the administrative efficiency of the proposed health care trust relative to the for-profit health care insurance industry that would allow the Trust to expand health insurance benefits while decreasing costs.

In a sense, publicly financed, universal health insurance would create a cradle-to-grave "Medicare for All" because everyone would have health insurance, as all elderly and disabled Americans currently do. However, the analogy stops there. There is no relationship between the public health insurance program I envision and the Federal Medicare program. Medicare is a prospective payment system in which you pay into the federal health care system over your working life in order to be covered after age 65. Costs under this system have increased dramatically due to the impact of new technology and medications on life expectancy. The single payer insurance program I envision would create be paid for year to year. Any failure to balance the budget in a particular year would lead to alterations of taxes, benefits or professional fees for the next. Decisions about the health care system would be given year to year consideration in negotiations between the insurer, the public and health care givers. The system I envision would insist on a year-to-year balanced budget, something not part of Medicare’s prospective system.

This is an interesting question. Firstly, this young person equates democracy and ethics with free choice, and perceives any mandated universal program as non-democratic and unethical. From this perspective, any taxes to provide funds for needs such as national defense and fire protection would be considered undemocratic and unethical. In short, this person implies that the only good government is one that allows its citizens to do what they want, does not interfere with their acting in accord with their own perceived self- interest, and expects little or nothing in terms of responsibility to one’s fellow citizens. I disagree with this position and wish to articulate why.

The ethos of publicly funded universal health insurance assumes that democracy is not only freedom to operate in one’s own self-interest. Instead, democracy in this context refers to the right to influence and participate in the decisions that are made which affect both individual life and the life of society as a whole. Publicly funded, universal health insurance is democratic precisely because it returns the right of influence and participation to those very individuals, groups, health care givers, health care organizations, health care recipients, and businesses, which are directly affected by health care insurance. Under our current system, decisions about health care are not only made by politicians, federal and state health care administrators, and but also increasingly by executives of corporations. With no opportunity for input within our current, managed-care system, health care givers and health care recipients (i.e., virtually all of us) have become increasingly powerless. Publicly funded, universal health insurance would ensure that care givers and recipients are fairly represented and empowered to make decisions about costs and benefits, subject to legislative approval. Thus, publicly funded, universal health insurance would extend democratic control to our health care system, and would constitute an improvement even over some existing single payer systems in the industrialized world by this increased citizen participation.

Secondly, this question implies that it is unethical to pass legislation that forces citizens do something they don’t want to do, in this case pay for health care insurance they don’t think they need. The questioner makes individual freedom and choice the highest ethical value. My proposed legislation is rooted in a different set of ethics. The legislation I propose is ethical because it makes access to health care a right of citizenship regardless of income or health. Under our current health care system, access to health care is limited by ability to pay. The poor receive second class health care under the state Medicaid system, while low paid hourly workers are most likely to forgo health care access because of cost. Moreover, because of the relationship between ethnicity and class, African-Americans and Hispanic-Americans are those most likely to be without access to health care and, not surprisingly, have the poorest health care statistics. Additionally, our system either denies access to health care based on illness and/or makes it prohibitively expensive because of "preexisting conditions." We consider this kind of financially-motivated health care system be immoral, as well as inefficient. In accord with this position, a variety of church leaders, such as the Reverend Martin Luther King, Cardinal Bernadin, and the Council of Bishops have all endorsed universal health care insurance as the ethical basis for health care in the United States. Therefore, publicly financed, universal health insurance is based on the ideal that health care, like education, is a right of all citizens of our country, regardless of income. We all share the risk and benefits of this system. We all have a vested interest in making it work, and keeping one another healthy.

The Clinton health care plan provided universal health insurance through a multi-payer system. This plan was complex, cumbersome, costly and inefficient, because it did not resolve the problems and costs associated with managed care and the multi-payer system. That was a completely different system from what I propose, and should have been defeated because it would have been ineffective in containing health care costs. I propose universal health care through a single payer, public health system. This system saves money despite increasing benefits and utilization. It is democratic, ethical, fiscally conservative, and would resolve the problems associated with our current multi-payer system. For those reasons it is a vast improvement over the Clinton plan and should be enacted.

Health care givers would have a choice of participating in the health care system or not. Those that participate in the system would accept the negotiated fee determined by the Health Care Trust as full payment for their services. Those that do not participate in the system would be free to charge whatever rates they would like for their services.

There is little doubt that health care givers would find this system acceptable. Health care givers are very unhappy under managed care, a system that increases their overhead and hassle, reduces their income, and takes decision making away from them. They will readily accept an unmanaged health care system with less administrative hassle as long as their overall income is not significantly reduced, which my proposal is not intended to do. In addition, health care professionals would be given a meaningful voice in determining fees, covered benefits, and quality care standards, something they are precluded from under managed care. Finally, health care professionals will have the opportunity to serve the entire population without consideration of ability to pay. A 2004 survey of physicians in Massachusetts showed the majority of them favor publicly financed, universal health insurance.

I would recommend putting aside 1% of the health care system’s assets to retrain workers displaced by it for the first three years. Many of these workers would be employed by the Health Care Trust, which would administer the health care system in each state. Many of the remaining displaced workers could be retrained as health care workers. Since the demand for health care will be increased by this system, there will be many openings for health care workers. This is a more equitable situation than the common practice in the private insurance industry whereby insurance workers lose their jobs due mergers of insurance companies, without any concern given to workers’ future well-being.

Cost containment, quality assurance and fraud issues would be handled through a Quality Assurance Division of the Health Care Trust. The Quality Assurance Division would work with a health care giver advisory board to determine pragmatic and cost-effective quality standards, which it would use to educate providers on cost containment issues. The system educates health care givers through quality of care standards, rather than micro-managing individual cases.

Quality assurance would be handled in two ways. First, by investigating complaints from patients about their health care givers or health care organizations. Second, by investigating those situations in which the pattern of utilization of a particular health care giver differs significantly from the patterns expected under the quality of care standards established by the Trust with input from health care giver and health care organizations.

Fraud would be investigated through a system similar to Medicare. Care givers whose patterns of care significantly differ from their colleagues would be investigated to determine if the basis for these discrepancies represents fraud. Furthermore, consumers would receive copies of all billing done by their caregivers and be encouraged to report discrepancies between what the trust was billed for and what services their caregiver provided.

Private, for-profit insurers spend 15% to 30% of insurance premiums on administrative costs. Medicare spends 3%. Single payer systems spend 8 to 10% on administration, but that includes educating the public about preventive health care, researching the system, and providing quality assurance functions. Private, for-profit insurers are more expensive because they must market their programs, constantly enroll and reenroll members, micro-manage care, and make a profit. All of these costs are eliminated in a single payer system.

It is true that managed care systems initially tamed the inflation in American health care by reducing caregiver fees and reducing hospital stays. However, the costs of the American health care system continue to rise, both as a percentage of American GDP and in terms of cost per capita. In the period from 1990 to 1997 the percentage of cost of health care in the United States rose from 13.2 to 14.7 %. During the same period, the cost of health care in Canada remained the same at 9.5% of GDP without micro-managing care. Furthermore, most health care experts expect health care costs in the United States to rise significantly in the years ahead. When the costs of medical care in for-profit dominated markets is compared with not-for-profit markets, for-profits cost significantly more. Single payer systems control costs better than managed care systems without the problems of the latter: breaches of patient confidentiality and continuity of care; compromise of patient care.

Thirty five years ago when Canada enacted a public health care system both Canada and the United States spent the same percentage of their GDP on health care, 7.5%. Now thirty years later Canada spends 9.7 per cent of its GDP on health care and the United States spends 15% on health care, despite "managing" care for the majority of our citizens.

No. This would not be a return to unregulated fee-for-service medicine in which there was a great escalation of costs. Cost for medical services would be negotiated in this system between the insurance trust, health care givers, and representatives of the general public and businesses in open discussions in which the cost of raising fees on insurance premiums would be apparent. Over 80% of medical costs are fixed under our current health care system. The only costs that are not fixed are those paid by self-insured or uninsured individuals. The state and federal governments and health maintenance organizations all establish prices for medical services. Under the proposed system, costs would be negotiated and would be utilized as one means of cost control. This would constitute an advantage both for health care givers and those insured by health care, as each would have an opportunity to engage in the negotiating process.

There is nothing in this Act that would stifle competition in health care. Health care givers and health care organizations would still compete with one another for patients. In fact the system would become more competitive because everyone in the state would be free to see any health care giver. There would be no limitations on caregiver choice as there is under the current health care system, all licensed willing caregivers would be allowed to participate in the system. However, as per our current system, there would be little or no competition among caregivers on the basis of cost. Currently, 80 to 90% of health care costs are fixed by the insurer, without input from care givers or health care organizations. Under the proposed system, these costs would be established by negotiations among caregivers, health care organizations, health care advocates, taxpayers and the insurer.

There is no good philosophical justification for employers paying a share of medical insurance premiums. Although it does represent a twentieth-century practice, it has been declining in recent years. Currently, approximately 48% of the insured obtain their insurance through their employers. However, because health insurance is a major expense, labor unions have typically sought this benefit as part of their members’ employment. To take this away would mean that employees would have to win back this compensation in the form of increased wages. Instead of taking this approach, I suggest health care insurance benefits as a mandated aspect of all employment, although taxing employers at different rates depending on the number of their employees. Passing this type of program without employer payroll taxes would mean that health care premiums for individuals and families would have to be increased and workers would have to negotiate increased wages to compensate for this lost benefit.

18. Would the development of new medications, and the profits of pharmaceutical industries be severely hampered by the kind of program you advocate?

 

No. First off, major pharmaceutical companies spend more on advertising their medications than producing them. Many medications are produced by our federal government and turned over to pharmaceutical companies at little or no cost. Second, I am not interested in destroying the profits of pharmaceutical companies. We should be aware however that pharmaceutical industries had the highest return on investment of all industries in the second half of the 20^th century. I am interested in balancing the profits of pharmaceutical industries with the needs of people. Our current system has results in tens of thousands of people dying as a result of an inability to pay for medications. This must end. The US is the only industrialized country that does not negotiate prescription drug costs. I am only suggest we bulk purchase medications to lower drug costs just like for profit, managed care companies do not. I have not advocated for mandatory price controls.

 

19. What do you think of the Medicare Prescription Drug Bill passed in 2003?

 

This was a truly horrible piece of legislation. I believe it will increase prescription costs for the average Medicare recipient rather than lower them. It is absolutely shameful that this legislation provided incentives, corporate welfare, for pharmaceutical industries while forbidding negotiating lower pharmaceutical prices from them as is currently done by the Veteran’s Administration and most state governments. This was a bald attempt to privatize Medicare and is another example of our current government seeking to subsidize the profits of corporations over the good of the public.

 

20. What do you think of incremental health care reform aimed at approaching universal health care insurance coverage?

 

Any incremental health care reform, no matter how well intentioned, will only increase health care costs. The only way to lower health care costs is through publicly financed, universal health insurance programs.

 

21. Are there any health care reforms you would support other than a publicly financed, universal health insurance program?

 

I would support the federal government mandating universal health care insurance to the states and allowing each state to find its own means to provide universal health care insurance. I believe that through that kind of experiment a single payer system will be shown to be the most effective and efficient.

 

22. What is your position on the high cost of medical malpractice insurance?

 

I believe publicly financed, universal health insurance is the best answer to our current medical malpractice insurance crisis. By providing health care insurance to all Americans the cost of medical malpractice insurance will decrease dramatically because patients will no longer have to sue to obtain the medical care they need and will have the care they received already paid for. International experience shows that universal health insurance is the best way to decrease medical malpractice insurance costs. In addition, caps on non-economic losses, pain and suffering, while maintaining the right to sue, as has been enacted in California is a reasonable and effective approach to controlling the high cost of medical malpractice because the increases in the cost of malpractice insurance appear to be directly related to the increasing levels of awards made in malpractice cases.

 

23. Would the publicly financed, universal health insurance program you advocate cover the services of alternative medicine practitioners?

The system I advocate would cover the health care services of all health care practitioners licensed by the state in which they practice.