Why California Should Avoid A Canadian-Style Single Payer System

The California state legislature has recently reintroduced a bill to eliminate all private health insurance in the state and replace it with a government-run "single-payer" socialized health care, like in Canada. Governor Arnold Schwarzenegger vetoed a similar bill last year.

On May 29, 2007, the Fraser Institute, a Canadian think tank, warned that California should not adopt a Canadian-style system. Brett Skinner (director of health policy research) noted the following important points:

Health care only appears to cost less in Canada than the U.S. because Canadian public health insurance does not cover many advanced medical treatments and technologies commonly available in the U.S.

Canadian patients do not get the same quality or quantity of care as American patients.

On a comparable basis, Canadians have fewer doctors, less high-tech equipment, older hospitals, and receive fewer advanced medicines than Americans.

Canadians currently wait an average of almost 18 weeks between the time they see their family physician and the time they receive treatment from a specialist.

11 per cent waited longer than three months to see a specialist

17 per cent waited longer than three months to get necessary non-emergency surgery

12 per cent waited longer than three months to get necessary diagnostic tests.

According to Skinner, "Canadian doctors say patients wait almost twice as long for treatment than is clinically reasonable". (Emphasis mine.)

And to add insult to the injury, "while Canadians are forced to wait for treatment, the system legally prevents them from seeking treatment elsewhere and paying for it out of their own pocket unless they choose to leave the country."

In other words, the Canadian government deliberately uses force to prevent their citizens from spending their own money to seek what's best for themselves and their loved ones.

Further details are available in their full article, "California Dreaming: The Fantasy of a Canadian-Style Health Insurance Monopoly in the United States".

Hsieh LTE in Pueblo Chieftain

One of my LTE's recently appeared in the Pueblo Chieftain on May 27, 2007 (halfway down the page):

Socialized medicine

The "single-payer" system that Dr. Anne Courtright (Chieftain, May 6) advocates is nothing more than socialized medicine, her claims to the contrary notwithstanding.

If the government foots the bill for everyone's health care, then inevitably it will demand to control how the money is spent. This will mean that crucial health care decisions will be made by politicians and bureaucrats, rather than patients and doctors.

Forcing everyone into an expanded version of Medicare because the current system has problems would be just as wrong as forcing everyone into government-run public housing because some people are homeless. This would be a gross violation of individual choice and individual rights.

Paul S. Hsieh, MD
Sedalia, CO

Opinion Piece: "Socialized Medicine Is Wrong For Colorado"

[This is a copy of my latest op-ed, which I have just submitted to as a non-exclusive opinion piece to multiple newspapers around Colorado. Please feel free to forward this to anyone who might be interested. -- PSH]

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Socialized Medicine Is Wrong For Colorado

The Colorado Blue Ribbon Commission on Health Care Reform recently selected four proposals for health care reform for eventual consideration by the state legislature. Although they differ in their details, these differences are dwarfed by their fundamental similarity -- they all entail a massive increase in government interference in medicine in the name of "universal coverage."

All four plans inject government force into the doctor-patient relationship. They include some combination of forcing all residents into a single health program, forcing some or all individuals and/or businesses to purchase a state-approved insurance policy, requiring insurance companies to provide new additional benefits, establishing a new bureaucracy to set payments to the doctors for services they provide, and doubling the Colorado Medicaid population. These are just disguised forms of socialized medicine.

Similar programs have already been tried in other US states and other countries. They have all failed, resulting in higher costs and lower quality patient care. The TennCare disaster, Tennessee's failed attempt at "universal coverage," offers an important lesson for Colorado.

In the 1990s, the Tennessee government expanded the state Medicaid program to include people earning up to 300% of the federal poverty line, i.e., a middle-class family of four making $55,000 a year. The state also forced insurance companies to offer expensive new benefits and forced employers to either buy health insurance for their employees or else pay into a state fund for the uninsured. Many employers chose the second option, shifting their employees' health costs onto the taxpayers. Because of the new regulations, many insurance companies withdrew from Tennessee, forcing more patients into the state health plan.

The Tennessee government initially offered a generous benefits package. Predictably, costs skyrocketed because patients had no incentives to spend prudently. In response, the government attempted to control costs by slashing payments to doctors and hospitals.

Hospitals closed and doctors left the state in droves. Many doctors that remained stopped seeing TennCare patients, since they lost money on each one. Families with sick children often had to drive long distances to find a doctor who would see them. And they had no alternatives to TennCare because the state regulations had all but destroyed the insurance market. Ironically, TennCare ended up causing the most harm to the very people it was intended to help -- the working poor and rural patients.

Nor did TennCare save money. Instead, it nearly bankrupted the Tennessee state budget.

The problems of TennCare are not aberrations that can be fixed with a few minor reforms. They are inherent in any system of government medicine. Under such systems, bureaucrats and politicians decide what care individuals can receive, not doctors and patients. We can see this in Canada's "single-payer" socialized medical system, with its infamous waiting lists for critical medical tests and treatments. For the sake of my patients and myself, I don't want this to happen in Colorado.

Socialized medicine is not the cure for Colorado's health care problems. Forcing everyone into a government-run medical program because some people are uninsured would be just as wrong as forcing everyone to live in a government-run housing project because some people are homeless.

Instead, Colorado should adopt free market reforms such as the FAIR program ("Free-Markets, Affordability & Individual Rights") proposed by Brian Schwartz, PhD. Such programs are especially good at providing affordable quality care for the working poor and rural patients. They work precisely because they encourage individual responsibility and they respect the right of the individual to spend his health care dollar according to his best judgment.

Colorado has an opportunity to become a real innovator in health care reform. Instead of recycling failed government programs, we should set an example for the rest of the country by adopting free market solutions. Only the free market can provide Coloradans with the high-quality, affordable health care they need and deserve.

---

Paul S. Hsieh, MD, is a physician in practice in the south Denver metro region and he is a founding member of the Colorado group "Freedom and Individual Rights in Medicine" (<http://www.WeStandFIRM.org>).

Going Blind Under British Socialized Medicine

The rationing of health care under the government-run British National Health Service (NHS) has reached a new low for retired policeman Leslie Howard, who is suffering from age-related macular degeneration, a disease that can cause permanent blindness in a matter of months:

...Mr Howard, 76, has been told by health chiefs not to expect a penny of NHS treatment until he goes blind in one eye and starts losing sight in the other.

Nor is he the only one:

Retired midwife Doreen Kenworthy was last week given the devastating diagnosis that she was suffering from the eye condition age-related macular degeneration.

But her shock was compounded when doctors told her the NHS would not pay for treatment until she lost the sight in her affected eye and began to lose it in the other -- although further loss of sight could be prevented if she paid out thousands of pounds for private care.

The bureaucrats that manage the NHS should be thankful that there's no literal "eye for an eye" penalty for their policies. (Via John J. Ray.)

Hannah Krening's LTE to the Denver Post

Hannah Krening has written an excellent letter to the editor, which appeared in today's edition of the Denver Post (halfway down the page):

Proposals to reform health care in Colorado

As a Colorado taxpayer, breast cancer survivor and one whose first husband lost a long battle with cancer, I want to say that the state 208 Commission's recent choices of proposals to evaluate all add up to one thing for me: I hope I never have a life-threatening condition again in Colorado if any of these proposals become reality. And I hope that nobody I love has to be subjected to the rationing, waiting and other debilitating results of what they evidently believe are the best of intentions.

Bringing more government involvement into health care "reform" is not a solution. It is a recipe for disaster. Of the proposals considered, only one reflected my views: the "FAIR" proposal, which has been cast aside. Only by reducing government involvement in health care will we get the kind of justice that will bring about the best care for all at the best possible price. We must remember that health care is not and cannot be free: the skills of doctors, researchers and technology companies must be fairly compensated. The alternative is slavery of the few taxpayers who will foot the huge (unworkable) bills and of the providers of health care who will ultimately leave the profession in order not to be enslaved by it.

This is not regulation on some dispensable part of our lives. This concerns everyone's survival, to some degree; nobody will be untouched by the outcome of this process. We have a lot to lose.

Hannah Krening, Larkspur

A Positive Example of Customer Based Health Care

This recent article from the Wall Street Journal shows how customer-drive health care clinics provided better care for lower cost, precisely because consumers determine how best to spend their own health dollars. These small retail clinics are an especially good value for those with Health Savings Accounts or those who are uninsured:

Much like the response to Hurricane Katrina, private companies are far ahead of the government in answering Americans' needs, this time for more accessible and more affordable health care. Political leaders across the country seeking to expand government's role in health care should take note.

...The market is providing cheaper medicines, more affordable care -- and it is also helping the uninsured. A Harris Interactive poll conducted in March for The Wall Street Journal said that 22% of those visiting the clinics were uninsured. Wal-Mart says that half of its clinic visitors are uninsured.

Retail clinics are particularly attractive to 4.5 million people with Health Savings Accounts who have health insurance with higher deductibles and want an affordable option for some of their routine care.

Which poison do you want?

On Friday afternoon, after two days of focusing on their individual likes and dislikes, the 208 Commission selected 4 health care reform proposals which will be modeled for economic consequences, and then sent the legislature next January with the Commission's recommendation of the best plan. They reserved a fifth spot for creating their own proposal for modeling -- and I predict that their own proposal will be their recommendation to the legislature.

Although commissioners spoke repeatedly about choosing a wide selection of plans across a broad spectrum between "markets" and government control, in the end, they firmly rejected the only plan for reforming medicine and health insurance using capitalism and its free market. All four selected options completely and fundamentally impose increasing government control and regulation, and will act as poison to systemically and systematically kill medicine and health insurance in Colorado. Why do I say that?

Over the coming weeks, you will begin to hear about different aspects of these plans from a lot of sources and they will focus on the differences. But let's focus on a fundamental today. All of these plans look at the Colorado State government as the solution. Three of the four proposals want to force every single Colorado resident to either purchase health insurance or be a part of a new government health care program -- and the government will determine what the benefits are and what the providers are paid.

All of these plans impose severe restrictions on at least a portion of both health insurance and the medical services markets. All increase the amount of medical services purchased by government -- and it's already the biggest purchaser of services in both markets. As the largest consumer of services and health insurance, its purchases affect the pricing and the amount and kind of services offered. But, in addition, government then imposes regulatory mandates and controls on what's left of the market, so that consumers are increasingly left with fewer choices at higher prices. And the capitalist marketplace is blamed for this result -- when in fact, it is the Emergency Medical Treatment and Active Labor Act (EMTALA) that has caused many hospitals to close their emergency rooms and physicians to stop practicing at hospitals with emergency rooms because they can't afford to treat patients without payment as this law requires them to do. There are many other examples.

Health care is not a right. Medicine is not a right. Health Insurance is not a right. Health, itself, is a contextual condition. "I feel better today." "I'm sick today." "I don't feel as well as I usually do." "I feel healthier today than I did ten years ago." These are all statements that reflect the contextual nature of health. There is no one absolute health condition applicable to all that any individual can strive to meet -- no one perfect blood pressure reading, no one perfect weight, no one perfect cholesterol reading, heart rate or any other measure of health. People even have different temperature readings. Our health measures are a matter of statistics -- of averages, of ranges -- and there are disagreements among medical professionals about standards for most of those. Health is one measure of how well we are living -- and it changes daily.

So, how do these four plans intend to reform health care in Colorado? The four plans are as follows:

1. The Better Health Care for Colorado plan (Better Health)-- proposed by the Service Employees International Union and the Colorado Association of Public Employees -- is characterized by the Commission as the "no mandate" plan. It expands Medicaid and provides subsidies to fund the purchase of private insurance for those up to 300% of the federal poverty level.

2. Solutions for A Healthy Colorado (Healthy Solutions) -- sponsored by the Colorado State Association of Health Underwriters -- is characterized by the commission as an individual mandate plan. This plan wants to eliminate "free riders" of health care -- and seeks to expand Medicaid. It would force every Colorado resident to obtain health insurance, and has a minimum core benefit package.

3. A Plan for Covering all Colorado (Plan for All) - submitted by the Committee for Colorado Health Care Solutions -- is characterized by the Commission as having individual mandates; employer mandates (or pay assessment); expands subsidies and Medicaid; provides minimum benefits of medical, dental, vision, substance abuse, mental health, and prescription drugs; and has a "purchasing pool" to negotiate insurance rates.

4. The Colorado Health Services Program (Single-Payer) - is a single-payer plan administered like a public utility with benefits to consumers and payment schedules to providers to be determined yearly. It would be independent of the legislature. It includes everyone and no one can opt out.

Three of these programs ("Health Solutions", "Plan for All" and "Single-Payer") explicitly state that health care is a right --- and the "Single-Payer" plan is the most forthright about this. It describes it as a right where a new government agency will annually decide what benefits to provide to the consumer -- and how much the doctors get paid. But, in fact, rights aren't benefits awarded by the government. Properly identified, rights are a moral principle that define and sanction a person's freedom of action in a social context, i.e. in society. Rights are freedoms to act and enforced by a proper government. These limited benefits forced on the residents of Colorado by the power of government are not rights.

The "Plan for All" and the "Single-Payer" plan seek to provide every kind of benefit -- vision, dental, mental health, substance abuse, wellness, medical, drugs, medical equipment, audiology, PT, home health and hospice care, as well as full long-term care. They would both have regulatory bodies with no or minimal legislative or court oversight and whose members would serve for 10 to 12 years. They both determine payment to the doctors using egalitarian principles (with some sort of incentive plan based on a standardized quality program), regardless of overhead, location, quality or any other factor that affects pricing in the marketplace. All providers -- including now dentists, opticians, nurses, and doctors are treated as widgets -- as another good -- and not as individuals who have the right to set their own practice guidelines and payment schedules. The single-payer plan seeks to fund this through "sin" taxes -- alcohol taxes to treat alcoholism, gasoline taxes to treat automobile related injuries, taxes on weapons and ammunition to treat firearm related injuries, as well as an income tax. The "Plan for All" would impose taxes on products with health-adverse impacts, e.g., tobacco and alcohol, or "luxury" products or services, a premium tax on health insurance and a tax on providers.

In particular, the "Single-Payer" and the "Plan for All", which both would create administrative bodies to determine consumer benefits and provider payments, put all residents of Colorado in the position of a beggar asking for a handout from the legislature or an administrative body -- how much do I get from the government this year? Each consumer and each doctor is restricted, hampered, and loses the ability to be a free and independent trader -- one who trades value for value -- based on each individual's rational assessment of the value of a particular service or good to her.

The "Better Health" plan, while not having employer or individual mandates, has, as its goal, universal care. It does impose many restrictions on the population it seeks to cover -- which is expand Medicaid to another 560,000 Colorado residents -- which would more than double the current Medicaid population. It would do this by including those up to 300% of the federal poverty level -- or a family of four of up to with an income of about $55,000. It calls these people low-income. It also creates a pool to fund subsidies for the low-income to purchase insurance and creates a Health Insurance Exchange. For these persons, it would provide limited options for coverage and emphasize managed care. These subsidized plans would be required to identify at least four lifestyle behaviors that clients would be responsible to actively follow to reach a health goal. It could include an initial assessment, follow-up in 90 days, compliance with a treatment plan, financial incentives to reward healthy behavior, and employer mandated support. This plan would treat these one-half million people as if they were small children.

But, the plan would ultimately affect all Colorado residents because someone has to pay for this program. There were 396,000 Medicaid participants in December 2005 according to the Colorado Medicaid Physician News at a cost of $1.5 billion (Another 1.5 billion was provided by the feds). The total state budget was around $15 billion then. More than doubling the Medicaid budget will affect all of Colorado. What new taxes do we see? And when this is not affordable and we have almost twenty percent of Colorado's population on Medicaid, where do we go then? The only solution that the legislature will suggest will be mandatory, universal care.

Finally, the "Healthy Solutions" plan mandates that all individual residents in Colorado purchase health insurance -- and that all insurers participate in the plan. They propose to fund this program with a 2 to 5% sales tax on all foods that have little or no nutritional value, such as fountain sodas and walk-up coffee, chips, candy and other "junk foods." They recommend that lawmakers encourage employers to push individuals to healthier lifestyles. It recommends that Medicaid start reimbursing providers at the same rate as the Colorado State Employees Health Benefit Plan. It seeks a Core Benefit Plan for Medicaid with a maximum annual benefit of $50,000, and premium subsidies for those up to 200% of Federal Poverty Level (or an income of $40,000 per year for a family of four). They also consider an employer-mandated contribution -- but only as a last resort.

So, pick your poison. A slower but, nevertheless, certain incremental death of medicine and health insurance through the "Better Health" plan. Or a quicker, faster death from one of the other three. The Commission was caught as a deer in headlights and blinded by the legislative mandate to any true reform -- to reducing government regulation and government control of medicine and health insurance. We don't have to be blind. We can reject the Commission's selection and the legislative supposition and premise that the only solution is more government. One thing is absolutely certain. More government control and regulation of medicine and health insurance means fewer quality doctors, fewer quality medicines, rationing and limiting of medical services available, as well as fewer innovations in medical treatment and care. The death of medicine is the death of us all.

We have to start talking about this now. Next year will be too late.

Letters to the 208 Commission

Today is the last day for public comment to Colorado's "208 Commission on Health Care Reform." If you're already written, thank you! If you live in Colorado but haven't yet written, please please please do so. You can make a difference! Even just a quick paragraph advocating free market reforms would be fantastic. If you have more than a spare moment to craft a letter, you should look at Lin Zinser's We Stand FIRM blog post about writing the commission. Below, I've included the letters from Lin Zinser, Paul Hsieh, and myself.

From Lin Zinser:

Americans can freely choose where to live and what kind of housing we can afford. We can choose whether to buy a car and, if so, what kind, size and price we want to spend. We can choose what kind of food to eat and whether we want it ready-made, as in restaurants or fast food joints, or whether we want it partially made, or from fresh ingredients -- where we do the preparation. We can choose what kinds of entertainment we seek, including movies, CDs, books, or whether to attend live events like wrestling matches, theater, concerts or the opera. We can choose what kind of work we do, our place of employment, and some can choose what hours to work, and whether to work from home, an office or outdoors. These are among thousands of other choices Americans make in our lives -- and because we live in America we have more choices than most other people in the rest of the world.

We can choose to live simply, without electricity -- as a friend's 93 year old grandmother chooses to do because she thinks simple is better, or with as much technology and space as Bill Gates can buy. We can choose to buy clothes at second hand shops -- as many of my financially well-off girl-friends do, or we can choose to spend hundreds of dollars on a haircut as Presidential Candidate John Edwards does. We can shop for groceries at Walmart, 24 hours a day, or at Whole Foods, where we pay more for organic foods. Our economic choices are not forced on us by our political status or our government.

These are the kinds of choices that people from around the world come to America to experience -- for a lifetime. People from around the world also come to America to get the latest medical technology, the newest life-saving drug, and some of the most radical treatments available, even if incompletely tested or proven -- in order to save their lives.

Think about one astonishing fact -- the people in countries with universal, mandatory health coverage -- including the Europe, Great Britain and Canada -- even if taken together, have not created the wonderful, magnificent changes that we have seen over the past 40 years in medicine in America even though their population is more than 3 times the American population. In most of these countries, such wonderful life saving treatments, even if adopted from America, are restricted or rationed.

Why has America led all of these countries in medical advancements that have enhanced the quality of life of all, including premature infants, people with failing organs, cancer victims and aging Americans? Why is there no rationing in America? Why do people come to this country for advanced treatment s for cancer and other diseases? The answer is Capitalism -- the social, economic and political system which allows men and women to use their minds in freedom, thus providing creators and producers the financial incentive -- the profit motive -- to investigate new (hence unproved and untried) technologies and new science, even at the risk of failure.

Government controlled health insurance and medicine do not foster change and innovation. They foster the status quo. One reason is that any government program, looking at unproved and untried methods or strategies, cannot spend taxpayer dollars on them for political reasons -- the risk is too great. Additionally, Government tends to enforce one standard of doing things -- one way of treatment -- whether it's the post office or health care. It took Fed Ex and UPS to provide choice in how fast a package could be delivered. There is one Medicare part A for all Americans 65 or older. Medicaid participants don't have choices -- they have limited options. But, how many choices do Americans make with regard to food, clothing, housing, transportation and entertainment every day of our lives.

The only reasonable principle for health insurance and medicine is the principle uniquely forged by the founding fathers. It is the principle enshrined by the Declaration of Independence and the US Constitution -- that all are created equal with the inalienable rights to life, liberty and the pursuit of happiness. Those inalienable rights require a social-economic-political system that promotes freedom of action -- the freedom that allows Americans to make all of the choices I mentioned -- and more. In Colorado, we need American health insurance and American medicine with its innovation and enhancement of the quality of life -- not another European government program of the status quo.

Lin Zinser
Executive Director
Ideas Matter!, Inc.
www.WeStandFIRM.org

From Paul Hsieh:

Dear 208 Commission:

Here are my responses to the two questions on which you have requested public input, regarding the health care proposals under consideration:

"(1) What are the one or two most important features that you feel must be included in any Colorado health care reform?"

The most important feature would be reduction or elimination of mandates on individuals, insurance companies, and employers. This will allow patients, doctors, and payers to negotiate the best agreements for themselves without being constrained by government force. Mandates on employers and insurance companies (such as mandatory benefit packages, guaranteed issue and/or community ratings) drive up costs without providing better care. Mandates on individuals violate the freedom of contract between patients and their doctors and force one set of patients to subsidize the health care of another set of patients. Individuals can and should be allowed to decide for themselves how to most wisely spend their health care dollars.

"(2) What is the most important principle that should be considered in any reform effort?"

The most important principle is that only free market capitalism can guarantee good quality health care at the lowest prices for patients. Countries and US states in which allocation of health care resources are left to the government inevitably spend more money for poorer-quality care. Plus the decision making become irreversibly politicized, which harms patients who don't have powerful political friends. The free market is the only way to protect the individual rights of patients and doctors. Hence, we must avoid more government mandates, or mandates disguised as limited "choices" within a set of government-selected options.

Patients, providers, and payers working within a free market will come up with innovative and cost-effective solutions that would never occur to central government planners. To deprive patients of that opportunity violates their basic rights and will cause them harm.

Reference: The Cure: How Capitalism Can Save American Health Care, book by Dr. David Gratzer, a physician who has practiced in both the US and Canada. Among other points, he shows how the government-run medical system results in higher mortality rates for treatable conditions in countries like Canada vs. the USA. Any government-run system of health care will result in more deaths of Colorado patients from to treatable diseases such as breast cancer, prostate cancer, heart disease, stroke, etc.

Thank you very much,
--------------------
Paul Hsieh, MD
Sedalia, CO
paulhsiehmd@gmail.com

From Diana Hsieh:

Dear 208 Commissioners,

I am writing to encourage you to uphold free market principles in your deliberations about health care reform proposals. A free market in health care -- as opposed to the current system of massive regulations, mandates, and entitlements -- is the only moral and practical option. All the problems from which medicine currently suffers (such as high prices for medical care, non-portable insurance, and the over-use of emergency rooms) stem from government interference in the free market.

Only free markets permit doctors, nurses, and other medical providers to act for the best interests of their patients. Only free markets allow patients to choose how to best spend their hard-earned money to secure and promote their own health. Any other system -- meaning any system with regulations, mandates, and entitlements -- injects bureaucrats into what ought to be wholly private decisions. Patients are told that they must wait months for critical care -- or they are simply denied care altogether. That kind of government meddling is inevitable. When government pays for medical care, neither doctors nor patients have any incentive to use the available medical services judiciously. Then, to prevent total financial ruin from runaway costs (and fraud), the government must step in to limit the use of medical services, whether by rationing care or denying care. Unless the system is scrapped, people will suffer and people will die. That's what the supposedly noble ideal of "universal coverage" means in practice.

The 208 Commission has a wonderful opportunity to help repeal the mandates, regulations, and entitlements that currently burden medical care for the doctors and patients of Colorado. If you do that, you can make Colorado a genuine leader in health care reform!

-- DMH

Diana Hsieh
Sedalia, CO

Please feel free to post your letter to the 208 Commission in the comments.

Illinois Medical Society Opposes Single-Payer Coverage

As an interesting contrast to the Colorado Medical Society, which has taken a position in favor of "mandatory" and "universal" health care reform, the Illinois State Medical Society has recently taken an explicit stand against single-payer plans or other massive government intrusions into medicine. At their April 2007 annual meeting, they adopted the following "Principles For Health System Reform".

In particular, I would like to highlight their "Guiding Principle #1":

1. Health care delivery and finance system reform should use the current public-private system as a basis and focus on incremental evolutionary change.

This principle recognizes that while the current health care system is not without shortcomings, it should be used as the basis for change and any type of government-run proposal should be rejected. Single-payer, federally-run or state-run proposals would require radical restructuring of the health care financing system and would control costs by rationing services and limiting choice. Such systems may promise universal coverage, but coverage does not equate to access to care when the end result is centralized health care rationing.

Their recognition that government-run medicine leads to rationing is crucial, and I hope that more Colorado physicians will be willing to make similar statements.

Their concept of using the current system as a basis for reform is necessarily very open-ended, but at least it leaves open the possibility of market-based reforms, such as the FAIR proposal ("Free-Markets, Affordability & Individual Rights") by Dr. Brian Schwartz.

The overall Illinois guidelines are still mixed, with some elements I support and other elements I oppose. But overall, their position is far superior to the one taken by the Colorado Medical Society.

Now is the time.....

Between now and Saturday, May 12, 2007, is the only real opportunity to voice your concerns to the 208 Commission through the public comment. After May 12, there is no opportunity for public comment before they select the 3 to 5 proposals, which they will do at public hearings on May 17 and May 18. These 3 to 5 proposals will be the ones submitted to the state legislature next January for its consideration. This means that you and your voice could be heard by the legislature through the commission.

There are currently 11 proposals being considered. I have summarized the 11 proposals briefly below -- at the end of this post.

Only one of the proposals recommends deregulation of the insurance market and of Medicaid. That proposal was submitted by Brian Schwartz, PhD, and his full proposal (worth reading) is called FAIR (Free Markets, Affordability and Individual Rights). (You must download it - it's toward the bottom of the page).

The Commission numbered each tendered proposal -- and the FAIR plan is number 21. The other plans include individual mandates, insurance company benefit mandates, insurance company guaranteed issue and community rating mandates, employer mandates, provider mandates, or some combination of the above. My summary of all eleven is provided at the end of this post.

The Commission is requesting comment on 2 issues related to these proposals:

1) What are the one or two most important features that you feel must be included in any Colorado health care reform?
2) What is the most important principle that should be considered in any reform effort?

There are two ways to provide comment to the 208 Commission. 1) You may submit a comment in writing by e-mail to 208Commission@coloradofoundation.org. It is crucial to send your comments this way. Any comment sent to this address will be posted on the Commission website and distributed to all Commissioners for review in advance of the May 17-18 meeting. But the e-mail must be received by May 12. Comments sent to individual commissioners, or received after the deadline will be ignored.

Alternatively, there are five meetings planned across the state this week -- May 10 and May 12 -- for public comment and where you have the opportunity to speak before one or more commissioners. They still want you to submit written testimony at the time of your oral presentation.

This is the last opportunity to express your opinion about the most important principle (and features) to be used to select any proposal. This is the time to speak about capitalism v. government control, the individual rights of doctors and other providers v. the needs of some patients, and freedom in medicine and health insurance v. insurance mandates and other instances of government force.

To be effective to the Commission, any written (or oral) comments must state specifically ONLY the principle and or features that are most important to health care reform, and to give specific reasons for that choice. They are not interested in your advocacy or rejection of any particular proposal.

Some examples of written comments to the 208 Commission might be

• The most important feature to include in any health care reform would be to eliminate all mandates -- whether they require individuals or employers to purchase health insurance, or whether they impose benefit packages on insurance companies, or impose mandatory guaranteed issue and/or community ratings of insurance companies; or any mandate on the care or treatment (including the cost for that care) provided by any health care provider. Mandates violate the freedom of contract between individuals, doctors and insurers. They also increase the cost of health insurance policies for the healthier citizens by subsidizing the cost of those who are not as healthy. OR,
• The most important principle to consider in any health care reform would be that only capitalism can provide the best quality of medicine and health insurance at the lowest possible price. For example, the United States leads the world in innovative, new science and technology in medicine because of its tendency towards market based solutions, not in spite of them. Government controlled medicine and insurance advocate the status quo, and are resistant to change. To continue to have better and better technology to save more premature births, to enhance the quality of the lives of diabetics, heart patients, cancer victims old age survivors, as well as countless other conditions, we must turn to capitalism and capitalism alone, for its infinite choices and solutions, made by individuals in a free market. OR,
• The most important principle to consider is that government involvement in medicine has caused the problems we face in health care today and we need to get government out of medicine. For example, the 1942 IRS ruling distorted the market to favor employer-purchased health insurance policies over individual purchased ones, thus taking the responsibility for the purchase of health insurance from the individual, eliminating portability, transparency of the costs of medical services and health insurance, and encouraging too much coverage for routine care, while discouraging catastrophic care coverage. Another example is EMT ALA, which required all hospitals with emergency rooms (and their doctors) to treat any person, regardless of ability to pay, who believed they had an emergent health issue. This caused doctors and hospitals to treat some people, while getting paid nothing. This in turn caused hospitals and doctors to charge others who could pay more, and caused some hospitals and doctors to stop providing care -- to close emergency rooms and to stop practicing at hospitals with emergency rooms. We need to eliminate provider mandates. OR,
• The most important principle of any health care reform would be respecting individual rights of doctors, insurers, employers and individuals. Doctors and hospitals must be free of mandates that require them to participate in any program (e.g., EMT ALA). Insurers must be free to contract and provide whatever benefits they deem profitable or appropriate (eliminate all mandates including mandatory guaranteed issue and community rating). Employers and individuals must be free to purchase health insurance at whatever level they deem appropriate (e.g., high deductible - HSA, basic minimum, catastrophic only, etc.). No one has a right to force others to provide him or her health care or health insurance -- even though many governments have treated both as temporary privileges -- granting benefits which it can then take away depending on cost, majority vote, or other illusory standard
  

Again, these are examples. The crucial thing is to pick the most important principle for health care reform, or one or two features that are important to consider in health care reform, and make them your own. Feel free to use any of these, expanding or narrowing them to suit your situation. There are many more specific examples for any principle or feature that could be used.

NOW IS THE TIME to send your comments to the 208 Commission. The Commissioners need to understand what is important to you, what principles are crucial to you and how those principles are manifested in features of the various proposals.



To assist you in understanding the essential features of all eleven plans being considered for submission to the legislature, I have summarized them below. You may read the full proposals at the 208 Commmission website by downloading any or all from this page. I used the commission number for each plan. These 11 proposals are as follows:

#21 – FAIR (Free Markets, Affordability and Individual Rights) proposed by Brian Schwartz, PHD. Plan proposes to lower cost of health insurance by eliminating all insurance benefit mandates, thus allowing people to obtain less coverage for fewer dollars. Eliminates single-group of one which eliminate guaranteed issue and community rating for that market.
Seeks to encourage high deductible HSA health insurance plans.

Medicaid Reform seeks to transfer more enrollees into private insurance market. It also uses cost-sharing to eliminate over-consumption of some Medicaid services. He also advocates reduction of asset sheltering for long term care in Medicaid. He also advocates increasing access to home care and, most provocatively, to allow Medicaid to compete for funding with voluntary charities in the private market.

#16 -- The Colorado Health Services Program, proposed by Health Care for All Colorado Coalition – is a single payer, publicly financed program. It covers all primary, preventive, specialty, surgical care, automobile and work-related injuries, prescription drugs, mental health services, chiropractic, dental, basic vision, audiology, home health and hospice services, among others. It states that all providers and hospitals will be paid the same for the same level of service, thus eliminating the drive for profit in determining the quality of care. It is explicitly egalitarian and states that every resident has equal access to program benefits. There is no opt-out provision.

It calls for a statewide, fully integrated information technology network to track outcomes, utilization and expenditures. Removes profit motive from financing resulting in a truly egalitarian health care system. Would create the Colorado Health Services: a non-profit government "insurance company," administered and governed as a public utility with five districts and it would be strictly regulatory - no outside supervision or control. All of its decisions final. It would also determine malpractice, but allow its findings to be public in malpractice litigation in a court of law.

#12 – A Plan for Covering Colorado, proposed by the Committee for Colorado Health Care Solutions – requires a single insurance pool – in which all insurers would be required to participate and would be mandatory guaranteed issue and community rated. All individuals, including all state employees, and employers will be mandated to purchase insurance through the single pool. Employers would be mandated to pay a portion of the employees' health insurance or pay an assessment to the state per employee. Individuals (and employers) would be limited to opt for one of 6 to 10 standardized benefit plans. Policy mandates would include a list of essential services, but could include options of type (PPO or HMO), choice of provider panels, and amounts of co-pays or deductibles allowed. Employers required to allow workers to pay their share of premium through payroll deduction. So employers become the enforcement mechanism -- they collect the premium and forward to the state.

This single insurance pool wold be administered by new public authority – Colorado Health Insurance Purchasing Authority. It will define benefit packages, define and periodically update a standard set of benefits based on effectiveness and cost, define and certify “high-value" providers, define subsidy and premium assistance requirements to be provided to low to middle income individuals. Consumers with premium assistance can opt for only 2 plans, with one an HMO. Authority will also decide guidelines for performance of providers, and of course, determine the amounts paid to the providers.

#11 – Community of Caring proposed by a coalition of CCHN, CCC, CA and CBHC. Individuals have mandate to purchase adequate health insurance; there is also an employer mandate to contribute to employee coverage; Insurers must guarantee insurance regardless of health according to community rating. The plan will provide subsidies to low-income and small businesses and expand Medicaid to more people. Benefits will include preventive care, routine medical services, maternity, diagnostic testing, hospitalization, emergency care, outpatient surgery, mental health and substance abuse treatment, physical, occupational and speech therapies; in-home, hospice, and nursing facility care; durable medical equipment and pharmacy, plus oral health benefits.

Creates a quasi-governmental entity that is exempt from TABOR called Health Insurance Partnership. Also creates and funds the Community of Caring Collaborative Board and the Safety Net Stabilization Program. It will establish comprehensive benefits package, competitively negotiate contracts with private health plans; implement quality standards for insurers and providers; and collect taxes from individuals and employers for the program, and collect monies from state agencies and premiums from health insurers for more funding. It says it will provide a variety of products that modify cost sharing or offer enhanced benefits.

#10 – Healthy Colorado Now – proposed by the Colorado Coalition for the Medically Underserved. Employer Mandated on pay or play basis, which means that employers must pay for insurance or pay an assessment per employee to the state. Policies are guaranteed issue, community rated, standard benefits. There will be a default enrollment system with individual mandates, but the employer is ultimately responsible if the individual doesn't purchase insurance. Benefits will exclude services without proven benefits or with poor cost benefit ratios, so no experimentation or new technologies can be tested or tried. There will be spending caps per individual beneficiary. There will also be a limitation of expensive and heroic services.

Creates the Personal Responsibility Option in Colorado (PRO-CO). Governed by non-profit, non-governmental authority called the Colorado Health Authority. Adopt "medical home" standards, which mandates that every individual must choose a primary care physican who then becomes a gate keeper for specialty services. The plan supposedly creates incentives for standardized care. It will implement new information technology, define standard policy benefits, and provide quality and performance standards. Every non-ERISA insurer must offer at least the PRO-CO benefit package. Individuals do have the option to buy higher levels of coverage. Evidence based medicine.

#9 – An Individual Based Insurance System proposed by the South Denver Metro Chamber of Commerce. Individual and Insurance Company mandates. Mandatory maintenance routine care policies (up to $100,000) and mandatory preventive care (required to get annual exam). Guaranteed issue, community rating. Catastrophic care funded by 5 to 20% of maintenance policy premiums – with financial backing of the pool from a state governmental safety net similar to the role of the FDIC. Mandated benefits on maintenance policies – may limit benefits on cosmetic, self-inflicted, treatment without a reasonable scientific basis, highly experimental, infertility and repetitive injuries caused by extreme choices.

Creates Colorado Health Commission to investigate quality and cost factors that "drive" cost and quality. Discounts for health lifestyle choices. Massachusetts style connector to link insurers and consumers. Vouchers for poor. State clinics for poor and uninsured – one per county.

#7 – Connecting Care and Health for Colorado proposed by CCHI. Universal coverage. Individual and employer mandates. Guaranteed Issue and Community rating. Expansion of public programs. Standardized benefits, including minimum benefit requirement. Diagnosis and treatment, preventive dental care, vision and hearing services, mental health, substance abuse, cancer screenings and other chronic disease screenings, rehab services, non-emergent medical transportation and other appropriate services.

Creates the Stakeholder Oversight Commission to supervise 3 advisory committees – health care quality, rural health and health disparities. Private insurance includes all state mandated benefits and two or three enhanced plans that include vision and dental benefits. Tax assessment on employers with tax credit for those who provide health insurance. Mandate all residents to purchase insurance.

#6 – A Phased Approach to Achieving Universal Health Coverage in Colorado proposed by Kaiser Permanente.
Expand Medicaid programs to children with premium assistance. Individual mandates such that an individual must have coverage through their employer, individually private coverage or through a public program. There will be a tax and surcharge on those who remain uninsured. Guaranteed issue, community rating. Would increase and encourage the use of HMOs. A medical home or primary physician essential. Evidence based guidelines. Statewide medical records database.

Uses voluntary HMOs and providers; but also a statewide managed indemnity plan mandated for those not in HMO. Individuals in indemnity plan must choose primary care physician – a medical home. Reimbursement rate is 100% of medicare for non-HMO providers, HMO rates are reimbursed on a capitated basis and determined at the state level. Individuals eligible for group plan must use that plan. Basic or comprehensive plan with a deductible (0, $2000 or $10,000).

#4 – Comprehensive Health Care Plan for Colorado proposed by CLUB 20. Individual mandates for tier 1 coverage – basic benefits using appropriate associated reimbursement rates using Oregon as model. Providers mandated to participate in quality improvement efforts and meet quality standards.

It would create Colorado Health Commission to coordinate and direct new overarching elements of health care reform. Also would create the Colorado Care Connector to assume role of current medical and efficiently provide Tier 1 coverage to those who can’t afford it. Promote concept of medical home with primary care provider. Can purchase Tier 2 coverage – which allows for unlimited health care options.

#2 – Better Health Care for Colorado proposed by Service Employees International Union. This plan is a bit vague but seeks to create a path for universal health coverage. It doesn't appear to have mandates, but I'm not sure how universal coverage is to be enforced without mandates.

It would create a new quasi-public entity to provide access to private insurance specifically tailored for "target" populations. The exchange would coordinate health care financing from multiple sources, and offer products to subsidized uninsured and non-subsidized small businesses. Would offer limited health plan of $25,000 to $35,000 annual benefit; pre-paid plan; more comprehensive coverage such as in the State Employee Health Insurance Plan, and other plans for indigent or high risks. Managed care approach. Would have employer-sponsored insurance with an opt-out provision.

Colorado Public Radio Wants to Hear Your Opinion on Health Care Reform

While listening to NPR/Colorado Public Radio recently, I heard their solicitation for public stories on health insurance issues from listeners. Basically, they're asking for average citizens to send them stories of their experiences and opinions on health care coverage in Colorado (both good and bad), as part of their "Public Insight" initiative. Presumably, this will be incorporated into their intermittent special series on health care reform in Colorado.

For instance, something like Ari Armstrong's recent excellent blog post on the virtues of HSA's (Health Savings Accounts) and how they are good for him and his wife would be a perfect item to submit:

<http://www.westandfirm.org/blog/2007/04/how-hsas-help-women-and-men.html>

If you have anything you'd like to submit, the relevant Colorado Public Radio webpage is:

<http://tinyurl.com/yodfmh> or
<http://www.publicradio.org/public_insight_network/forms/form_display.php?form_code=2a8d6b497db1>

Some of the other stories in their series are available at:
<http://www.kcfr.org/index.php?option=com_content&task=view&id=162&Itemid=274>

Although their stories appear slanted in favor of universal coverage, I'm hoping that they would be willing to air an alternative perspective in favor of Health Savings Accounts, free markets, and individual rights.

FYI, here is my submission to their webpage. In addition to the standard demographic information, I told them that I had adequate insurance and no insurance horror stories. In response to their last two questions, I gave the following answers:

[CPR: "Do you have experience or expertise that gives you deeper insight into this issue? If so, tell us more."]

I am a physician practicing in the south Denver metro area. I am alarmed by the moves towards a misguided system of "mandatory universal health coverage". I believe this will harm both patients and doctors in Colorado. Hence, as a physician, I am opposed to this dangerous trend. I've written an Open Letter to Colorado Physicians on this subject which is available online at:

<http://www.WeStandFIRM.org/docs/Hsieh-01.html>.

A shorter version was recently published as a Letter to the Editor in the March/April 2007 "Colorado Medicine", which is the bimonthly journal of the Colorado Medical Society. I've been told that it has aroused some lively debate amongst physicians, which was one of my goals.

[CPR: "What else about this issue deserves more attention and investigation?"]

I would like to draw attention to the fact that whenever government-mandated "universal coverage" has been implemented in other US states, it has resulted in worse patient care and rising costs - the exact opposite of the intended effects.

In Tennessee, their universal coverage scheme has been a medical and fiscal disaster. Maine is thinking of scaling back their benefits because their system is unsustainable. In Massachusetts, rising costs have forced the state government has had to choose between reducing the numbers of people they will cover (i.e., making it less "universal"), raising taxes, or cutting back benefits - they've chosen to violate the "universal" element to avoid a political backlash. The government-run approach to coverage inevitably leads to rising costs, rationing, or both. Hence, I do not want to see Colorado repeat the mistakes of other states.

Instead, a market-based reform, such as Dr. Brian Schwartz's FAIR proposal ("Free-Markets, Affordability & Individual Rights") would be much better for Colorado. His proposal is available on the 208 Commission website at:

<http://tinyurl.com/39o87y> or
<http://www.colorado.gov/cs/Satellite?c=Page&childpagename=BlueRibbon%2FRIBBLayout&cid=1176241324570&p=1176241324570&pagename=RIBBWrapper>

British Doctors Admit to Medical Rationing

This story about the NHS (i.e., the British National Health Service) just appeared in the British press:

"Doctors admit: NHS treatments must be rationed"

British doctors will take the historic step of admitting for the first time that many health treatments will be rationed in the future because the NHS cannot cope with spiralling demand from patients.

...James Johnson, the BMA [British Medical Association] chairman, will warn that patients face a bleak future because they will increasingly be denied treatments. He will urge the NHS to be much more explicit about what it can realistically afford to do and ask political leaders to engage in an open, honest debate about rationing.

The article also notes that rationing of health care under the NHS has been going on for a long time, but just never openly named as such.

The article also quotes Health Minister Andy Burnham as defending the NHS as "the right model for Britain's future" and it should continue to be "comprehensive and universal".

Some people don't seem to learn from failure.

"Health Care in a Free Society: Rebutting the Myths of National Health Insurance"

As the debate about "health care reform" heats up in Colorado, many of the advocates of socialized medicine attempt to point to the alleged benefits that such systems have delivered in other countries. Although it is important to keep sight of the fundamental moral arguments against socialized medicine, it can often be helpful to cite real-world facts to bolster the moral case. Hence, papers such as "Health Care in a Free Society: Rebutting the Myths of National Health Insurance" can be very informative. This article, written by John Goodman of the National Center for Policy Analysis explodes a number of commonly-cited myths, such as the following:

Myth #1. In Countries with National Health Insurance, People Have a Right to Health Care

Myth #2. Countries with National Health Insurance Deliver High-Quality Health Care

Myth #3. Countries with National Health Insurance Make Health Care Available on the Basis of Need Rather Than Ability to Pay

Myth #4. Although the United States Spends More per Capita on Health Care Than Other Countries with National Health Insurance, Americans Do Not Get Better Health Care

Myth #5. Countries with National Health Insurance Create Equal Access to Health Care

Myth #6. Countries with National Health Insurance Hold Down Costs by Operating More Efficient Health Care Systems

Myth #7. National Health Insurance Would Benefit the Elderly and Racial Minorities

Myth #8. Countries with National Health Insurance Have Been More Successful Than the United States in Controlling Health Care Costs

Myth #9. Single-Payer National Health Insurance Would Reduce the Cost of Prescription Drugs for Americans

Myth #10. Under National Health Insurance, Funds are Allocated So That They Have the Greatest Impact on Health

Myth #11. A Single-Payer National Health Care System Would Lower Health Care Costs because Preventative Health Services Would Be More Widely Available

Myth #12. The Defects of National Health Insurance Schemes in Other Countries Could be Remedied by a Few Reforms

Each myth is dissected in detail, with numerous citations to support his refutation of each one. His discussion of myth #12 is especially good, because he shows the the problems of nationalized health care are necessarily and inevitably part of a socialized medical system, when politicians and bureaucrats are put in charge of health care decisions, rather than patients and doctors. Hence, they cannot be reformed by just tweaking the government system a little bit. In essence, the problems arise because health care decisions are based on the politics of pull rather than the judgements of individual patients and doctors seeking their own best interests in a free market.

During some of the recent exchanges in the opinion sections and online comment boards of the newspapers, I've seen several of these myths asserted. Goodman's paper provides some valuable intellectual ammunition to combat these falsehoods.

(The above paper is about 26 pages long. Those who want to read an even more detailed version can go the related article by John Goodman and Devon Herrick, "20 Myths About Single Payer Insurance", which runs well over 100 pages!)

Update On The "Crazy Letter"

The Denver Post did publish my response to the Jim Spencer column in today's edition:

Jim Spencer called my April 25 letter "crazy" and accused me of violating my oath as a physician because I argued that health care is not a right.

The exact opposite is true. My moral responsibility to my patients requires that I oppose socialized medicine. When countries like Canada attempt to guarantee a "right" to health care, it inevitably leads to rationing of vital medical services. Under their "single payer" system, Canadian patients routinely wait for months before government bureaucrats allow them to get MRI scans or surgeries that are immediately available in the U.S. Doctors cannot practice good medicine when handcuffed by such a system - and many will quit medicine rather than work under those conditions. (For more information, see www.WeStandFIRM.org.)

Trying to create a universal "right" to health care turns patients into pieces of meat and turns doctors into slaves. Neither is right for Colorado.

Paul Hsieh, M.D., Sedalia

The other letter they published at the same time was also good:

Jim Spencer refers to a letter from a physician regarding the "right" to health care as the craziest he has read in some time. Plainly, Mr. Spencer has no idea what a "right" is.

A "right" refers to a freedom of action that an individual possesses. For example, "the pursuit of happiness." It does not refer to a sanctioned or legalized gain of unearned goods or services, nor does it involve the violation of others' rights. These are more properly termed "theft" or "slavery," and are obviously immoral.

A "right" to health care necessarily involves enslavement of health care workers (Canadian physicians have no right to private contracts) and confiscation and redistribution of tax monies.

If it were so easy to provide health care as a "right" by simple legislative fiat, as Mr. Spencer implies, then I cannot understand why we do not end hunger by passing a similar law forcing restaurants to provide food.

The health care problems we have now would best be addressed by reintroduction of the concept of personal responsibility, re-establishment of a free market and the rewarding of charity care. Only then will "rights" truly be respected.

(They left his name off the online version, but the print version lists him as "Michael K. Stahl, M.D., Carbondale".)

After reading the Spencer column and my reply, one of my partners also e-mailed me:

Amazing. Absolutely amazing. While reading Spencer's article, the "looters" from Atlas Shrugged kept coming to mind. Keep fighting the good fight.

I had no idea that he had any familiarity with either Atlas Shrugged or Ayn Rand, so that was a pleasant surprise!