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Issue No. 47 (September 2003) -- Mark Satin, Editor

Universal, preventive, and cost-effective health care is within our grasp!

Over 1,000 bills addressing health care issues were introduced during the last session of Congress, but don’t let that fool you.

Our health care system is spiraling out of control, and none of the usual suspects knows what to do.


-- We now spend TWICE AS MUCH per capita on health care as the major European nations. And none of them has 40 million uninsured. . . .

-- Health insurance premiums rose an average of 11% last year, and are expected to rise 13-15% this year (source: Alliance for Health Reform).

-- The amount employees paid on health plan deductibles rose more than 30% last year (source: Kaiser Foundation).

In response to these well-known facts, Congress has done nothing major -- which may be a blessing:

-- In July 2002, it failed to pass any of three rival plans to provide prescription drugs to the elderly (psst: most old people can already afford their drugs);

-- In August 2002, it failed to agree on a “patient’s bill of rights” (psst: would have crippled the cost-containment efforts of even the most conscientious HMOs).

And Congress isn’t our only “weakest link.” Most experts are also spinning their wheels. Check out Robin Toner and Sheryl Stolberg’s courageous article on the looming health care crisis in the New York Times, in which they conclude -- with devastating effect -- that the experts have no idea what to do (11 Aug. 2002).

Radicals are spinning their wheels. I particularly enjoyed watching radical economist Robert Kuttner throw up his hands and say, “Maybe we have contained health care costs too much” (American Prospect, 14 Feb. 2000).

Activists are spinning their wheels. A “single-payer” plan prepared by the Physicians’ Working Group on Single-Payer National Health Insurance, and supported by many activists and activist groups, is kicking around Capitol Hill. It fails to sufficiently answer any of the fundamental objections to single-payer: the government would take over another 15% of the economy (the same government that’s handling homeland security so efficiently and trustworthily); tax bills would soar; R&D would stagnate; alternative care would become the medical equivalent of private or parochial school.

The AMA has issued a rival “Proposal for Reform” that’s just as tired (but of course, better written).

Where can a good person turn?

When the politicians, the experts, and the activists are all coming up empty, it’s often a sign that ordinary Americans aren’t being listened to.

And that’s SO true here. Americans have expressed themselves loud and clear on the health care issue, and this is where we’re at:

(1) According to the nonpartisan Center on Policy Attitudes, most of us “seem to believe that health care is a right, like public education, that should be guaranteed by the government.” At the same time, though, most of us are against “significant tax increases” toward that end, and most of us are against government-run health insurance plans like single-payer (“Americans on Health Care Policy,” 30 Aug. 2000).

(2) There’s a “preventive care” explosion going on. With little prompting from Washington or Hollywood, we’re exercising, running, flossing, using condoms, adopting vegetarian or quasi-vegetarian diets, forswearing tobacco, etc., as never before.

(3) We’re voting with our feet for “alternative” health care -- chiropractic, Oriental medicine, homeopathy, etc. About 40% of us claim to have tried an alternative treatment (U.S. News, 22 July 2002), and the Institute for Alternative Futures projects that at least two-thirds of us will be using one or more alternative treatments by 2010.

The time is right to devise a national health insurance plan (and national health care system) drawing not on the tired nostrums of the left and right, but on our actually existing attitudes and behaviors.

It would have to be universal but not government-run; preventive; “integrative” (i.e., integrating conventional and alternative medicine); public health oriented; and, last but not least, less costly than what we have now.

Sounds daunting -- but look around. Hundreds of health care scholars and practitioners (many of them near the top of The System, and eager to change it) are working on bits and pieces of what could become such a plan. Over the last 10 years, they’ve published extraordinary books, articles, reports.

If you haven’t heard much about that material, it’s because it can’t be pigeonholed as “left” or “right.” David Kendall, senior health care policy analyst at the Progressive Policy Institute, captures the tone when he says, “We need to . . . find a Third Way that combines the progressive policy goal of full coverage with the efficiency of the private marketplace.”

And Dr. Kenneth Pelletier, director of the Complementary and Alternative Medical Program at Stanford Medical School, strikes another common key when he observes that “both advocates and critics of alternative medicine may decry [my] attempt to hold to a middle ground, and to sort fact from fiction.”

We don’t decry what Kendall and Pelletier and those like them are doing. We’ve welded their work together and come up with a radical middle national health care system. . . .

Make it universal

A radical middle health care system would guarantee universal access to health care -- while avoiding government-run health care -- in three ways:

-- by making it a requirement for every individual to purchase private health insurance, which Dr. Stephen Ayers deftly calls an “individual mandate” (in his book Health Care in the U.S., 1996);

-- by subsidizing those who can’t afford insurance; and

-- by crafting a “basic minimum package” of health benefits that every insurer would be required to offer at fixed cost.

The individual mandate. Single-payer would eliminate private insurance companies and make government the insurer. Managed competition (aka “Hil- larycare”) would enforce an employer mandate -- i.e., make employers do the insuring.

But increasing numbers of innovative thinkers -- such as Dr. Ayers, New America Foundation policy analysts Ted Halstead and Michael Lind (in The Radical Center, 2001), former AMA Journal editor Dr. George Lundberg (in Severed Trust, 2000), NYU Medical School professor Dr. Michael Makover (in Mismanaged Care, 1998), and Wharton School economists Mark Pauly and Patricia Damon (in Health Affairs Journal, Spring 1991) -- favor an individual mandate instead.

“[M]edian job tenure for all American workers 25 and older [is] down to five years,” say Halstead and Lind. “The model of lifetime employment with a single firm has given way to a model of serial employment with many firms. . . . Given these trends, maintaining our current employer-based health care . . . system [is] a bad proposition for all parties involved.

“It leaves employees inherently insecure because the risk of losing their jobs becomes immediately compounded by the added distress of changing health care [plans. And employers need to be freed] from the burden of serving as miniature welfare states, giving them the added flexibility they need in the new economy.”

Far better to oblige employers to “make up in salary what you lose in benefits” (Makover), and oblige every American to sign up for private insurance, “just as everyone has to be licensed to drive” (Lundberg).

It’s only fair to make everyone sign up. Going without health insurance “imposes . . . costs on others, because we as a society provide care to the uninsured” (Pauly & Damon).

Enforcement wouldn’t be a problem. You could impose tax penalties on those who failed to sign up (Al From, Blueprint Magazine, 1 April 2000). Or, more constructively, you could enroll slackers “by default” into a private insurance plan, billing or subsidizing them according to their incomes as revealed on their tax returns (Halstead & Lind).

The subsidy. It’s not enough for the government to “mandate” that we buy private health insurance. We’ve got to be able to afford it.

Dr. Makover would make any new health care system “as simple as possible,” and a radical middle health care system would solve the affordability problem simply -- with a government subsidy.

There are subsidies and subsidies. Pauly and Damon would provide tax credits and, “if the credit exceeded an individual’s tax liability, the excess would be refunded to the individual.”

Stuart Butler of the Heritage Foundation would provide a more streamlined subsidy: Make the tax credit “available ‘up front’ so that a family does not have to wait until the end of the year,” and allow the family to “assign” it to a health plan (Heritage Backgrounder #1528, 20 Mar. 2002).

Halstead and Lind would provide an admirably equitable subsidy: “Americans might be required to devote a certain percentage of their incomes to purchasing their own [basic] insurance plans, with the government picking up the rest.”

The basic benefits package. Nearly all the thinkers above would allow us to purchase as much private health insurance as our hearts desired.

What we’d be required to purchase, though -- and what the subsidy might cover or help cover -- is a basic minimum benefits package.

A package covering what Pauly and Damon call “specified health services.”

Obviously, hospital and catastrophic care should be covered. But should preventive care be covered? Alternative care? Should funds be devoted to public health measures?

A radical middle national health care system would cover all those things -- to the extent they’re what Dr. Pelletier calls “evidence-based.”

Make it preventive

Quietly but decisively over the last 10 years, physicians and research scientists have proved beyond a shadow of a doubt that many preventive health care measures are effective.

I’m not talking about dissident physicians in marginal settings. I’m talking about people -- often idealistic Baby Boomers -- who worked their way into the heart of the medical profession in order to change it for the better.

Three national bodies have taken the lead here, the first being the U.S. Preventive Services Task Force (“USPSTF”), an independent panel of experts created by the U.S. Department of Health and Human Services.

By the early 1990s it had critically assessed the clinical effectiveness of 169 preventive services. By 1996 it had zeroed in on approx. 80 health conditions -- from “abdominal aortic aneurysm” to “visual impairment” -- and recommended preventive interventions (screening tests, counseling, immunizations, etc.) for 30 of them.

Some examples: Vaccinate children against six childhood diseases, provide tobacco cessation counseling, screen adults over 65 for vision impairment, assess dental health practices.

These days the USPSTF is busily updating its findings. This spring it announced it “now finds sufficient evidence to encourage primary care clinicians to screen their adult patients for depression.”

Hard on the heels of the USPSTF came certain efforts by the Centers for Disease Control and Prevention (of the Department of Health and Human Services), “CDC” for short.

In its report “An Ounce of Prevention -- What Are the Returns?” (rev. 1999, orig. 1993), the CDC identified 19 strategies that “prevent disease and injury,” “promote healthy lifestyles,” and make “good economic sense.”

Nine involve screening (e.g., screen women aged 50-69 for breast cancer every 1-2 years), five involve counseling, three involve immunizations.

The American Academy of Pediatrics is the third crucial player in defining basic preventive services.

In March 2000, it released its “Recommendations for Preventive Pediatric Health Care” -- a menu of 22 measures to be carried out by health care professionals on (or on behalf of) children from the prenatal stage through age 21.

The measures range from annual physical exams, to a lead screening exam (at 24 mo.), to nutrition counseling and sleep positioning counseling.

Stop for a minute. Think how much healthier and happier many of us would be if we’d received the care called for above.

A radical middle national health insurance plan should incorporate into its basic benefits package all the preventive services recommended by all three entities above.

Make it integrative

If you’re of a certain age, chances are good you associate “alternative medicine” with the Sixties counter-culture, and books that use the word “healing” a lot while brimming with venomous quarter-truths about “Western” science and the medical profession (and all other professions!).

So you might be surprised to learn that a new breed of alternative health practitioner has come to the fore.

Many of them eschew the term “alternative” for “integrative,” with its connotations of openness towards all effective conventional and alternative therapies. More importantly, many of them want alternative therapies to be tested now -- by “Western” scientific methods -- as rigorously as other therapies.

The National Center for Complementary and Alternative Medicine (“NCCAM”) has taken the lead here. Established in 1992 as a mere “Office of Alternative Medicine” (at the National Institutes of Health), and converted into a “National Center” in 1998, its extraordinary team of physician-scientists quickly identified over 600 “complementary and alternative” therapies, and has been testing the most promising of them ever since.

Five-year clinical trials are currently underway on, among other things, hypericum (for depression), shark cartilage (for lung cancer), and ginkgo balboa (for dementia).

If you want to see where NCCAM is heading, read Part II of Dr. Kenneth Pelletier’s The Best Alternative Medicine (2000), the gold standard for books of its type. Drawing on credible scientific research from around the world, it recommends alternative therapies for 76 conditions, from acne to vertigo.

It is the alternative medicine version of the lists of preventive therapies above. And it calls out to you just as much.

The integrative wing of the alternative medicine movement got a big boost in March 2000, when the White House and Congress created the White House Commission on Complementary and Alternative Medicine Policy.

Its 18 members included genuine pioneers like Thomas Chappell (Tom’s of Maine, Inc.), Dr. Effie Chow (East West Academy of Healing Arts), and Dr. Dean Ornish (Dr. Dean Ornish’s Program for Reversing Heart Disease, orig. 1990).

In its “Final Report” (March 2002) it not only concluded that “conventional and [alternative] systems of health and healing should be held to the same rigorous standards of good science.” It also and much more bravely concluded that “[a]ny medical or health care intervention that has undergone scientific investigation and has been shown to improve health . . . should be considered for inclusion in health plan coverage.”

Even when alternative therapies aren’t covered by the basic benefits package, the Commission helpfully added, they can be offered as a special “rider” or “supplement.”

A radical middle national health insurance plan should incorporate into its basic benefits package all the alternative therapies recommended by NCCAM, and some of those recommended by Dr. Pelletier. Many of the others recommended by Dr. Pelletier should be made available in a special “rider” or “supplement” for a nominal fee.

Make it public health oriented

Epidemiologists -- people who study the health of whole populations -- will tell you that it’s not enough for a national health care system to be universal, preventive, and integrative.

It also has to address the social and behavioral causes of our poor health.

According to health policy analysts Michael McGinniss and Pamela Williams-Russo, 40% of U.S. deaths are caused by behavior patterns that could be modified by public health interventions -- taxes on tobacco, grants to encourage communities to develop great areas for walking and bicycling, etc.

Nevertheless, 95% of the money we spend as a nation on health each year goes to direct medical care services. Only 5% goes to “population-wide approaches to health improvement,” i.e. public health (Health Affairs, Mar.-Apr. 2002).

Three burgeoning organizations want to change that.

You can’t avoid the Partnership for Prevention if you care about health policy and you’re in D.C. It’s one of the hottest public policy groups in town, and one of the broadest-based, with corporations, non-profits, and state health departments all aboard as members.

One of its latest projects was to compile a list of 180 “Prevention Policy Ideas” that’s easily the most complete (and exciting!) such list you’re ever likely to see. On and on and on roll ideas such as these:

-- “Ban smoking in enclosed public places throughout the nation”;

-- “Enact a substantial increase in the federal excise tax on alcoholic beverages”;

-- “Increase the number of optimally fluoridated community water systems”;

-- “Create financial incentives for states to offer increased physical activity in secondary schools.”

The Institute of Medicine (of the National Academy of Sciences) has pulled together an 11-person “Committee on Capitalizing on Social Science and Behavioral Research to Improve the Public’s Health.” They’re 11 scholar-heroes, and they recently published a collection of papers that should convince even the most skeptical legislator that the “public health” approach deserves a lot more attention and money: Brian Smedley and Leonard Syme, eds., Promoting Health (2000).

Then there’s the Office of Disease Prevention and Health Promotion (of the Department of Health and Human Services), which recently brought out its third “Healthy People” document, “Heal- thy People 2010: Understanding and Improving Health” (2000).

By now, “Healthy People” is a happening as much as it is a document. Among the players are the Healthy People Consortium -- an alliance of over 350 national membership organizations and 250 state-level agencies -- and hundreds of health care practitioners and others who’ve attend national and regional meetings.

Heart and soul of the document is the part called “Leading Health Indicators,” an in-depth examination of our 10 “major public health concerns.” If you want to learn how public policy can be used to address such supposedly personal troubles as obesity, substance abuse, poor mental health, and irresponsible sexual behavior, you can’t start anyplace better than here.

A radical middle health care system cannot focus only on providing care to individuals. It must also devote substantial amounts of energy and money to the public health initiatives recommended in the three documents above.

Make it cost less

For the traditional left, it’s outrageous -- and devastating -- that most Americans aren’t willing to pay higher taxes for health care. But for the radical middle, it’s no problem. The national health insurance plan / health care system presented here could actually save us over $30 billion per year.

The following calculations make use of no accounting concepts whatsoever; all they’re meant to do is suggest light where many see darkness.

Universal. To achieve universal coverage, the total gross cost would be the number of uninsured (roughly 40 million) times the per capita cost of coverage (roughly $3,200), or approx. $128 billion per year.

Sounds formidable. But consider that the uninsured already consume on average about 60% as much health care as the insured (Pauly & Damon, cited above). Thus the net new social cost for health care for the uninsured would be approx. $51 billion per year.

Preventive. The U.S. Public Health Service estimates that adding a “core set” of clinical preventive services recommended by USPSTF to private health insurance programs would cost an average of $84 per year for women and $52 for men (Partnership for Prevention, “Policy Briefing,” 13 June 2000).

Because the radical middle national health insurance plan calls for even more preventive services, let’s estimate an average cost of $100 per human per year. That’s $28 billion per year.

On the other hand, total U.S. health care costs now exceed $1.2 trillion per year (Alliance for Health Reform). If the $28 billion per year in prevention investments manages to reduce those costs by even 5%, they’d go down by $60 billion. So we’d end up saving $32 billion per year

Integrative. It’s impossible to estimate how much our health care costs would decline if more of us substituted complementary and alternative therapies for conventional therapies. If you page through Part II of Dr. Pelletier’s book, though, and just look at the various herbal, Oriental, and physical therapies for such traditionally costly conditions as Alzheimer’s and cancer, you’d be forgiven for thinking we could knock at least 2% per year off our health care spending. That’s approx. $24 billion per year.

Public health. Total national expenditures for population-based health activities are approx. $8 billion per year (U.S. Public Health Service, For a Healthy Nation: Returns on Investment in Public Health, 1994). Since the radical middle health care system requires spending substantially more on public health, let’s multiply that figure fivefold and say we’d be spending $40 billion per year.

The U.S. Public Health Service estimates that if we make appropriate investments in six areas -- heart disease, stroke, fatal and nonfatal occupational injuries, motor-vehicle-related injuries, low birthweight, and gunshot wounds -- then within five years health care costs would plummet by 11% in those areas (For a Healthy Nation, cited above).

Let’s conservatively estimate that half of our total health care costs of $1.2 trillion per year are amenable to such savings. That means we’d eventually be saving 11% of $600 billion per year -- $66 billion per year. Subtracting $40 billion from $66 billion leaves us with net savings of $26 billion per year.

Totals. A radical middle health insurance plan and health care system could save us $31 billion per year (minus $51 billion + $32 billion + $24 billion + $26 billion = $31 billion).

Oh, and we’d be A LOT HEALTHIER too! And a lot happier and more secure.



An expanded version of this article is in my book Radical Middle: The Politics We Need Now (Westview / Perseus, 2004); see Chapter 4, "Universal, Preventive Health Care: Too Sensible?," pp. 35-46.


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