Almost 13% of veterans – 1.8 million - lack health insurance, and many who might be eligible for care in VA facilities do not live close enough to one to utilize it. Like most Americans without health insurance, most of these vets are employed but their employer does not offer insurance and they cannot afford to purchase it privately. In addition, 3.8 million family members of these vets lack health insurance.
The crisis in veteran’s care is only getting worse, and will get much worse as mental and physical problems associated with the Iraq war continue to increase. When elected to congress I will propose a fairly straightforward solution: the creation of “Medicare Part V”. Medicare Part V would have benefits equal to those provided by VA coverage, but would reimburse any Medicare provider (physicians, hospitals, labs, physical therapy centers, imaging facilities, etc.). Any veteran who does not have health coverage could then receive coverage through Medicare Part V. Any veteran who lives far from a VA facility who would prefer to get care through local providers could “opt-out” of the VA System and select Medicare Part V instead. We should decide also if we would want to extend this to uninsured families of veterans, or at least allow them to purchase coverage through this system if they cannot get private coverage. This would lessen the pressure on the VA system and remove the backlog of vets waiting to get care.
Wednesday, August 22, 2007
Tuesday, August 21, 2007
Free Enterprise in Healthcare?
No one will argue that free enterprise doesn’t stimulate innovation and hard work. One of the biggest challenges we face in health care is how to provide health care to all Americans while maintaining a system which fosters innovation, research, and development. But when health care is out of the financial reach of many Americans (over 42 million receive Medicare, another 42 million receive Medicaid, and over 46 million have no insurance) one has to wonder where the profit is going to come from – and why their must be profit – if everyone is to be covered. Rudy Giuliani recently compared health care to plasma TV’s – saying that all we need is more people buying health insurance through the private sector to drive down the cost – “just like the cost of plasma TV’s has come down over the past few years.”
Rudy – I got news for you: American health care is NOT an example of free enterprise! There is no competition! Let’s look at some examples: About 25 years ago Tagamet came out for treating ulcers. A wonderful drug, it was quite pricy for the time at $65 per month. But people bought it because it worked – it was a wonder drug. Soon Zantac came out, which worked as well but had fewer drug interactions, so it quickly became very popular also. Over a few years Pepcid and Axid came out. When their drug reps would come into my office to chat me up about their products, they would compare them favorably to Zantac. Not better, but just as good. I would always ask – will they cost my patients any less than Zantac? I was always told that they were priced “comparably” – meaning the same! I always told the reps to tell their corporate bosses that if their product were priced competitively I would prescribe it. Pepcid and Axid never gained much market share because they never competed. Eventually Pepcid was allowed to market an OTC (over-the-counter) version which was a 10mg tablet, keeping the 40mg tablet by prescription only. The pharmacy cost for a 40mg tablet (prescription) was $2.60, or $78 per month. The pharmacy cost for a 10mg tablet (over-the-counter – with competition from Maalox, Mylanta, Tums, Rolaids, Zantac 75, etc.) was only $0.20! So there was never any price competition for the prescription drug – only for the one people paid for out of their own pockets. Regardless of this rip-off, insurance companies continued to happily pay the $78 per month for 40mg Pepcid. Likewise, many insurance companies paid $50 for a tube of “Lotrisone” cream – a patented mixture of common steroid and antifungal creams, each of which could be purchased for $2 or less. Of course the insurance companies get secret rebates from the drug companies, so we never really know what they pay for a given medication. This keeps the normal retail price high so that those without insurance get screwed. This is only legal because it is arranged through intermediary shell companies called “Pharmacy Benefit Managers”, or PBM’s.
Every service in health care costs far more to the cash-paying patients than is charged to insurance companies. A CT scan at our local hospital costs $3,000, when no insurance company pays more than about $650. A new-patient visit with a specialist may set you back $420, when Medicare pays them $160 or so. In a free-enterprise system you would think that cash would be more valuable than a future payday that requires billing and record-keeping expenses. I had a patient who needed a stress test – he called the hospital to see what it would cost him – and they could not or would not tell him! He was supposed to just wait until he received the bill to know what the cost would be! Likewise, if you are in the hospital or the office, and I or another doctor tells you that you need a CT scan or a consultation from a specialist, do you get to price-shop (or shop quality?)? THAT would be free enterprise!
Rudy thinks that with competition health care will become cheap like plasma TV’s. Well, Rudy, a LOT of old folks buy hearing aides, and the price of those is now $2-3,000 each – about the only electronic device that has gotten MORE expensive! Interestingly, the VA system, which provides hearing aides to about a million veterans per year, and which negotiates for the best price, pays about $300 a unit for hearing aides. And meanwhile Dave Weldon voted to prevent the U.S. government from negotiating lower drug prices for the Medicare Program. Our current approach to health care has failed an unacceptable number of Americans. It is time for a serious look at the system.
Rudy – I got news for you: American health care is NOT an example of free enterprise! There is no competition! Let’s look at some examples: About 25 years ago Tagamet came out for treating ulcers. A wonderful drug, it was quite pricy for the time at $65 per month. But people bought it because it worked – it was a wonder drug. Soon Zantac came out, which worked as well but had fewer drug interactions, so it quickly became very popular also. Over a few years Pepcid and Axid came out. When their drug reps would come into my office to chat me up about their products, they would compare them favorably to Zantac. Not better, but just as good. I would always ask – will they cost my patients any less than Zantac? I was always told that they were priced “comparably” – meaning the same! I always told the reps to tell their corporate bosses that if their product were priced competitively I would prescribe it. Pepcid and Axid never gained much market share because they never competed. Eventually Pepcid was allowed to market an OTC (over-the-counter) version which was a 10mg tablet, keeping the 40mg tablet by prescription only. The pharmacy cost for a 40mg tablet (prescription) was $2.60, or $78 per month. The pharmacy cost for a 10mg tablet (over-the-counter – with competition from Maalox, Mylanta, Tums, Rolaids, Zantac 75, etc.) was only $0.20! So there was never any price competition for the prescription drug – only for the one people paid for out of their own pockets. Regardless of this rip-off, insurance companies continued to happily pay the $78 per month for 40mg Pepcid. Likewise, many insurance companies paid $50 for a tube of “Lotrisone” cream – a patented mixture of common steroid and antifungal creams, each of which could be purchased for $2 or less. Of course the insurance companies get secret rebates from the drug companies, so we never really know what they pay for a given medication. This keeps the normal retail price high so that those without insurance get screwed. This is only legal because it is arranged through intermediary shell companies called “Pharmacy Benefit Managers”, or PBM’s.
Every service in health care costs far more to the cash-paying patients than is charged to insurance companies. A CT scan at our local hospital costs $3,000, when no insurance company pays more than about $650. A new-patient visit with a specialist may set you back $420, when Medicare pays them $160 or so. In a free-enterprise system you would think that cash would be more valuable than a future payday that requires billing and record-keeping expenses. I had a patient who needed a stress test – he called the hospital to see what it would cost him – and they could not or would not tell him! He was supposed to just wait until he received the bill to know what the cost would be! Likewise, if you are in the hospital or the office, and I or another doctor tells you that you need a CT scan or a consultation from a specialist, do you get to price-shop (or shop quality?)? THAT would be free enterprise!
Rudy thinks that with competition health care will become cheap like plasma TV’s. Well, Rudy, a LOT of old folks buy hearing aides, and the price of those is now $2-3,000 each – about the only electronic device that has gotten MORE expensive! Interestingly, the VA system, which provides hearing aides to about a million veterans per year, and which negotiates for the best price, pays about $300 a unit for hearing aides. And meanwhile Dave Weldon voted to prevent the U.S. government from negotiating lower drug prices for the Medicare Program. Our current approach to health care has failed an unacceptable number of Americans. It is time for a serious look at the system.
Bush just waiting for the poor to die?
Nine million children in this country lack health insurance. To not have health insurance means they miss well-child checks and may rely on the emergency room for care when they are ill. These aren't necessarily homeless kids - with more and more jobs in this country not offering health insurance, it should be no surprise that 70% of kids without health insurance have at least one parent who works. Kids with chronic diseases may not be able to get the medications and the care they need to stay well. In a country as rich as ours, this is intolerable. The Medicaid Program exists to help the poorest of the poor, and the Children’s Health Insurance Program (S-CHIP) was created to help those not-quite-so-poor get health care. Congress recently voted – both Republicans and Democrats - to extend eligibility for this program to families of four earning up to around $40,000 per year. This would be funded by an increase in cigarette taxes – a move which in itself will benefit public health by reducing smoking, especially among teens and young adults. The majority of Americans support government assistance to help families obtain health coverage. Our president, however, feels that this is a threat to the free enterprise system – a White House spokesman said: “This will have the effect of encouraging many to drop private coverage, to go on the government-subsidized program”. Apparently Dave Weldon agrees with Bush, since he voted against the CHIP expansion. Bush has threatened a veto, and there may be enough votes to override his veto. So now he has ordered the CMS to adopt new rules which would prohibit any state from expanding services unless they have provided services to 95% of those under the poverty level. NO state has that high a participation rate, so he again is trying to get around the desires of congress and the American people.
Also – I have news for Weldon and the president. I am self-employed, and I buy health insurance for my family of four. It is a standard plan – nothing fancy and no dental insurance included. I pay almost $12,000 per year for this. Do Dave Weldon and President Bush really think that a family earning $35,000 or even $40,000 per year can buy health insurance? It just isn’t possible. Long ago our country realized that education needed to be publicly subsidized – that there was a basic injustice in keeping education out of the reach of poor kids. (Dave Weldon would like to do away with public education also)
Kids have no control over their situation. Shouldn’t every child in this country have health care?
Also – I have news for Weldon and the president. I am self-employed, and I buy health insurance for my family of four. It is a standard plan – nothing fancy and no dental insurance included. I pay almost $12,000 per year for this. Do Dave Weldon and President Bush really think that a family earning $35,000 or even $40,000 per year can buy health insurance? It just isn’t possible. Long ago our country realized that education needed to be publicly subsidized – that there was a basic injustice in keeping education out of the reach of poor kids. (Dave Weldon would like to do away with public education also)
Kids have no control over their situation. Shouldn’t every child in this country have health care?
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