By admin | October 31, 2009
By Miles Mogulescu
posted: October 30, 2009 04:21 PM
The pygmy public option now being proposed in the House and Senate will not be a viable competitor to mandated private insurance.
• It will not put any meaningful pressure on private insurance companies to moderate their premiums.
• It will not have the market power to pay lower fees to doctors and hospitals than private insurance and will thus not be less expensive than private insurance.
• It will not even be available to most Americans.
• Since it will be unable to effectively compete with private insurance, it will end up with few, if any customers.
At this point, it really doesn’t matter whether or not a final health reform bill includes this type of public option in name only. The public option, as it’s now being proposed in the House and Senate, will have no meaningful impact. If Joe Lieberman or other corporate Democrats kill this meaningless public option, it will make no difference in the lives of most Americans. With or without a fraudulent public option, millions of Americans who will be required to buy insurance or pay a fine will see their premiums skyrocket as there will be no effective limits placed on how much private insurers can charge the customers whom the federal government will make buy their product.
The final nail in the public option’s coffin came when House Democrats (with no help from President Obama to twist Blue Dog arms) fell 10 or 12 votes short of including a requirement that the public option pay providers Medicare rates plus 5% and instead will be required to negotiate rates with each doctor and hospital in America. This all but guarantees that the public option will end up paying more to doctors, hospitals and drug companies than private insurance.
It’s like a brand new Mom and Pop store trying to compete with WalMart.
Here’s why, without a tie to Medicare rates, the public option will end up paying more to providers than private insurance: The largest private insurers in each market already have tens or hundreds of thousands of members. When they negotiate rates with providers, they get volume discounts of as much as 30%-40% off “retail rates,” just as WalMart gets volume discounts because of its market clout. (Because of its even greater bargaining power, Medicare often pays providers 15%-20% less than private insurance).
But without the ability to tie pricing to Medicare rates, the public option will have no ability to negotiate volume discounts. It will start out with no subscribers. It will then have to go to each hospital, doctor and drug company to negotiate rates. Without any subscribers at the outset, these providers will have no incentive to give volume discounts to the public option, which will end up paying more than large private insurers. This in turn will make the public option more expensive than private insurance.
As a result, it will sign up few subscribers. With few subscribers, it will be continue to be unable to negotiate volume discounts. Even if the public option were allowed to pay Medicare plus 5% rates, unless it already had a large number of subscribers in a particular market, providers would simply refuse to accept public option patients at these reduced rates, prefering to treat patients from higher-paying private insurers. So it’s a chicken and egg situation. Few subscribers will lead to higher costs. Higher costs will lead to few subscribers. This is a public option designed to fail.
As a result, when the Congressional Budget Office first evaluated the Senate negotiated-rate public option plan, the CBO concluded that it would end up with no subscribers. Perhaps with a little pressure from Congress, the CBO is now projecting that by 2019, approximately 6 million Americans would be enrolled in the negotiated-rate House public plan. The CBO also projects that “a public plan paying negotiated rates would…typically have premiums that are somewhat higher than the average premiums for private plans.”
The CBO notes that this public plan would attract a “less healthy pool of enrollees” than private plans. With a less healthy pool of enrolees who require more services than private plans, the cost of the public plan would continue to escalate beyond the cost of private insurance, further reducing the number of people who sign up, and further reducing its negotiating clout, leading to a vicious circle of increasing costs and unaffordability that would do little or nothing to put pressure on private insurers to lower their premiums.
As Kip Sullivan, a long-time fighter of universal health care, has argued articulately, the devolution of the public option from a robust proposal projected to cover over 129 million Americans and lower insurance costs to a sham public option that will at best cover 6 million Americans in 10 years and have no impact on lowering insurance costs is a case of “bait and switch”.
The “public option” was initially proposed by Yale political scientist Jacob Hacker and Campaign for America’s Future leader Roger Hickey as a more politically “pragmatic” alternative to the long-time progressive goal of establishing universal single payer health care (as though insurance companies and their paid-for Congressional allies wouldn’t fight against a robust public option as hard as they would fight against Medicare for All).
Hacker and Hickey laid out 5 criteria that, they argued, were essential to the success of the public option.
1. The PO had to be pre-populated with tens of millions of people by shifting all or most uninsured people, as well as Medicaid and SCHIP enrollees, into the PO, so like Medicare, it would represent a huge pool of enrollees on day one.
2. Only enrollees in the PO, not in private insurance, would be eligible for government subsidies.
3. The PO and its subsidies would be available to all nonelderly Americans (not just the uninsured and employees of small businesses).
4. The PO would pay Medicare reimbursement rates.
5. The insurance industry had to offer the same minimum level of benefits that the PO offered.
If these criteria were met, the Lewin Group (a subsidiary of health insurance giant United Health) projected that the public option would enroll 129 million Americans, have overhead of 3%, pay hospitals 26% less and doctors 17% less than the private insurance industry, and have premiums 23% below the private insurance industry average.
That was the “bait.” Now came the “switch.” The puny public option proposals that are still on the table in the House and Senate meet only the 5th of the 5 criteria for an effective public option and eliminate the first 4 criteria. They are not pre-populated; subsidies go to both the public option and private insurance; large employers are barred from buying into the public option; and the public option is not allowed to use Medicare rates but must instead negotiate rates on a provider-by-provider basis.
The result is that instead of enrolling 129 million Americans and decreasing insurance premiums, the sham public option being proposed in the House and Senate will enroll between 0 and 6 million Americans and will cost more than private insurance.
It’s time that organizations which supported a “robust” public option tell their supporters the truth: that the public option in the House and Senate bills bears no relationship to the public option they have been fighting for. (Instead, the Health Care for American Now blog praises the public option in the House bill as “a strong competitor to private insurance, keeping prices down and attracting customers.”) Its time that “progressives” in Congress like Anthony Weiner, Alan Grayson, Jan Schakowsky, Raul Grijalva and Lynn Woolsey admit to their constituents that, with no help from President Obama, they’ve lost the battle for a “robust” public option. Media figures like Keith Obermann and Rachel Maddow, who’ve been vocally talking up the public option, should be reporting the truth about the pitiful public option that’s left on the table.
As it stands now, the sham public option in the House and Senate bills serves only one purpose. It gives political cover to progressives and liberals in the House and Senate to vote for mandates that will use the power of the federal government to force uninsured individuals to buy inferior and over-priced private insurance or be fined by the IRS by being able to say, “Well, at least the bill contains something called a public option,” even if it’s a public option in name only.
Better that Joe Lieberman’s filibuster threat forces Congress to drop this sham public option from the bill. At least, then, progressives and liberals will have to squarely face up to the implications of their vote and decide if this type of “health care reform” is really in the interests of the American people, or indeed, in the interests of the Democratic Party.
As the final bill takes shape, it’s going to be a close call whether this type of mandated “health insurance reform” with no price controls on premiums is better than no reform at all.
Read more at: http://www.huffingtonpost.com/miles-mogulescu/the-public-option-in-cong_b_340501.html
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By admin | October 31, 2009
Why Obama Needed Single Payer on the Table
Obama’s Mistakes in Health Care Reform
By VICENTE NAVARRO
Let me start by saying that I have never been a fan of Barack Obama. Early on, I warned many on the left that his slogan, “Yes, we can,” could not be read as a commitment to the major change this country needs (see “Yes, We Can. Can We? The Next Failure of Health Reform”). Still, I actively supported him against John McCain and was very pleased when he became president – for many reasons, encompassing a broad range of feelings. One reason was that Obama is African-American, and the country needed to have a black president. Another was that his election seemed to signal the end of the Bush era.
But, the most important reason was that I saw him as a decent man, surrounded by some good people who could promote change from the center and open up some possibilities for progress, giving the left a chance to influence the administration’s policies. Well, after just over seven months of the Obama White House, I have no reason to doubt that he is a decent man, but I am dismayed by the bad judgment he has shown in the choice of some of his staff and advisors. I really doubt that he is going to be able to make the changes we need. As I said, I never had great expectations about him and his policies, but even the lowest of my expectations have not been met.
Some among the many skeptics on the left might add, “What did you expect?” Well, at least I expected Obama to show the same degree of astuteness that he and his team had shown during the campaign. He seemed to be a brilliant strategist, and his election proves this. But my greatest disappointment is the strategies he is now following in his proposals for health care reform – they could not be worse. I am really concerned that the fiasco of this reform may make Obama a one-term president.
Error number One
One of the two major objectives for health care reform, as emphasized by Obama, is the need to reduce medical care costs. The notion that “the economy cannot afford a medical care system so costly, with the annual increases of medical care running wild” has been repeated over and over – only the tone varies, depending on the audience. An element of this argument is Obama’s emphasis on eliminating the federal deficit. He stresses that most of the government deficit is due to the outrageous growth in costs in federal health programs. Thus, a crucial part of the message he is transmitting is the health care reform objective of reducing costs.
This message, as it reaches the average citizen, seems like a threat to achieve cost reductions by cutting existing benefits. This perception is particularly accentuated among elderly people – which is not unreasonable, given that the president indicates that the funds needed to provide health benefits coverage to the 48 million currently uncovered will come partially from existing programs, such as Medicare, with savings supposedly achieved by increasing efficiency.
To the average citizen (who has developed an enormous skepticism about the political process), this call for savings by increasing efficiency sounds like a code for cutting benefits. Not surprisingly, then, one sector of the population most skeptical about health care reform is seniors – the beneficiaries of Medicare. The comment that “government should keep its hands off my Medicare,” as heard at some of the town hall meetings, is not as paradoxical or ridiculous as the liberal media paint it. It makes a lot of sense. An increasing number of elderly people feel that the uninsured are going to be insured at the expense of seniors’ benefits.
Error Number Two
The second major objective of health care reform as presented by Obama is to provide health benefits coverage for the uncovered: the 48 million people who don’t have any form of health benefits coverage. This is an important and urgently needed intervention. The U.S. cannot claim to be a civilized nation and a defender of human rights around the world unless this major human and moral problem at home is resolved once and for all. But, however important, this is not the largest problem we have in the health care sector. The most widespread problem is not being uninsured but underinsured: the majority of people in the U.S. – 168 million, to be precise – are underinsured. And many (32 per cent) are not even aware of this until they need their health insurance coverage.
This undercoverage is an enormous human, social, and economic problem. Among people who are terminally ill, 42 per cent worry about how they or their family will pay for medical care. And most of these people are insured – but their insurance does not cover all of their conditions and necessary interventions. Co-payments, deductibles, and other extra expenses – besides the insurance premiums – can amount to 10 per cent or even higher proportion of disposable income.
During the presidential campaign, both Obama and Hillary Clinton, in discussing the need for health care reform, made frequent reference to heart-breaking stories – cases in which families and individuals suffer under our current system of medical care. But none of the proposals that the Obama administration is ready to support would address most of these cases. It will be an embarrassing and uncomfortable moment during the 2012 presidential campaign if someone asks candidate Obama about what has happened to some of the people whose stories he told in the 2008 campaign.
Error Number Three
Obama plans to cover the uninsured by increasing taxes on the rich (a very popular measure, as shown in all polls) and by transferring funds saved through increased efficiencies in existing programs, including Medicare (an unpopular measure, for the reasons I’ve mentioned). We see here the same problems we’ve seen with other programs targeted to specific, small sectors of the population, such as the poor. Programs that are not universal (i.e., do not benefit everyone) are intrinsically unpopular.
This is why antipoverty programs are unpopular. People feel that they are paying, through taxation, for programs that do not benefit them. Compassion is not, and never has been, a successful motivation for public policy. Solidarity is. You support others with the understanding that they will support you when you need it most. The long history of social policy, in the U.S. and elsewhere, shows that universality is a better way to get popular support for a program than means-testing for programs targeted to specific vulnerable groups. The limited popularity of the welfare state in the U.S. is precisely due to the fact that most programs are not universal but means-tested.
The history of social policy shows that the best way to resolve poverty is not by developing antipoverty programs, but by developing universal programs to which all people are entitled – for example, job and incomes programs. In the same way, the problem of noncoverage by health insurance will not be resolved without resolving the problem of undercoverage, because both result from the same failing: the absence of government power to ensure universal rights. There is no health care system in the world (including the fashionable Swiss model) that provides universal health benefits coverage without the government intervening, using its muscle to control prices and practices.
The various proposals being put forward by the Obama administration are simply tinkering with, not resolving, the problem. You can call this government role “single-payer” or whatever, but our experience in the U.S. has already shown (what other countries have known and practiced for decades) that without government intervention, all the measures now being proposed by this administration will be handsome bailouts for the medical-insurance-pharmaceutical complex.
Error Number Four
I can understand that Obama does not want to advocate single-payer. But he has made a huge tactical mistake in excluding it as an option for study and consideration. He needs single-payer to be among the options under discussion. And he needs single-payer to make his own proposal “respectable.” (Keep in mind how Martin Luther King became the civil rights figure promoted by the establishment because, in the background, there was a Malcolm X threatening the establishment.) This was a major mistake made by Bill Clinton in 1993.
When Clinton gave up on single-payer, his own proposal became the “left” proposal (unbelievable as that may seem) and was dead on arrival in Congress. The historical function of the left in this country has been to make the center “respectable.” If there is no left alternative, the Obama proposals will become the “left” proposal, and this will severely limit whatever reform he will finally be able to get.
But there’s another reason that Obama has erred in excluding single-payer. He has antagonized the left of his own party that supports single-payer, without which he cannot be reelected in 2012. He cannot win only with the left, of course, but he certainly cannot win without the mobilization of the left. His victory in 2008 is evidence of this. And today, the left is angry at him.
It is a surprise to me, but Obama is going to pay the same price Clinton paid in 1994. Clinton antagonized the left by putting deficit reduction (under pressure from Wall Street) at the top of his policies and supporting NAFTA against the wishes of the AFL-CIO and the majority of Democrats. The Gingrich Republican Revolution of 1994 was due to a demobilization of the left. The Republicans got the same (I repeat the same) number of votes in the 1994 congressional election that they got in 1990 (the previous non-presidential election year). Large sectors of the grassroots of the Democratic Party that voted Democratic in 1990 stayed home in 1994. Something similar could happen in 2010 and in 2012. We could see a strong mobilization of the right and a very demoralized left. We are already seeing this. Why aren’t those on the left out in force at the town hall meetings on health care reform? Because the option they want – single-payer – has already been excluded from the debate by a president they fought to get elected.
This is my concern. The alternative to Obama is Sarah Palin or someone like her. Palin has a lot of support among the people who mobilized to support John McCain. And the ridicule heaped on her by the liberal media (which is despised by large sectors of the working class of this country) helps her, or her like, enormously. I am afraid we may have, in the near future, friendly fascism. And I do not use the term lightly. I grew up under fascism, in Franco’s Spain, and if nothing else, I recognize fascism when I see it. And we are seeing a growing fascism with a working-class base in the U.S.
This is why we cannot afford to see Obama fail. But his staff and advisors are doing a remarkable job to achieve this. Ideologues such as chief-of-staff Rahm Emanuel (who, when a congressman, was the most highly funded by Wall Street) and his brother, Ezekiel Emanuel (who did indeed write that old people should have a lower priority for health care spending) are leading the country along a wrong path.
I don’t doubt that President Obama, a decent man, wants to provide universal health care to all citizens of this country. But his judgment in developing his strategy to reach that goal is profoundly flawed, and, as mentioned above, it may cost him the presidency – an outcome that would be extremely negative for the country. He should have called for a major mobilization against the medical-industrial complex, to ensure that everyone has the same benefits that their representatives in Congress have, broadening and improving Medicare for all. The emphasis of his strategy should have been on improving health benefits coverage for everyone, including those who are currently uncovered. And to achieve this goal – which the majority of the population supports – he should have stressed the need for government to ensure that this extension of benefits to everyone will occur.
That he has not chosen this strategy touches on the essence of U.S. democracy. The enormous power of the insurance and pharmaceutical industries corrupts the nature of our democracy and shapes the frontiers of what is possible in the U.S. Given this reality, it seems to me that the role of the left is to initiate a program of social political agitation and rebellion (I applaud the health professionals who disrupted the meetings of the Senate Finance Committee), following the tactics of the Civil Rights and anti-Vietnam War movements of the 1960s and 1970s. It is wrong to expect and hope that the Obama administration will change. Without pressure and agitation, not much will be done.
Vicente Navarro, M.D., Ph.D., professor of Health Policy at The Johns Hopkins University and editor-in-chief of the International Journal of Health Services. The opinions expressed here are those of the author and do not necessarily reflect the views of the institutions with which he is affiliated. Dr Navarro can be reached at vnavarro@jhsph.edu
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By admin | October 18, 2009
El Diario-La Prensa, New York
La Propuesta de Reforma de Salud beneficiará a los pacientes que no hablan inglés.
Uno de los aspectos más importantes al cuidar de pacientes es obtener una historia médica detallada. El plan de tratamiento también debe ser explicado cuidadosamente en una manera que sea comprensible para el paciente. Sin embargo, algunos grupos argumentan que estos importantes principios de cuidado médico no aplican a los pacientes que no hablan inglés. Ellos proponen que personas que no hablan inglés reciban un cuidado médico de inferior calidad para que aprendan inglés. Sin embargo, la discriminación de pacientes que no hablan inglés es ilegal en este país. Adicionalmente, organizaciones acreditadoras requieren que hospitales y aseguradoras de salud hagan esfuerzos para proveer servicios a personas que no hablan inglés. Como resultado, algunos sistemas de salud han tomado pasos para acomodar a estos pacientes. Un ejemplo es el derecho a servicios de traducción incluido en la “Declaración de Derechos” de muchos hospitales. Las reglas son flexibles y solo aplican a centros de salud donde una proporción importante de pacientes no habla inglés. Una manera de proveer estos servicios es a través de traductores profesionales, pero existen otras opciones. Por ejemplo, si más de la mitad de los pacientes hablan español, podría ser más eficiente tener proveedores de salud que hablen ese idioma. En clínicas donde se hablan múltiples idiomas, tener acceso a traductores vía telefónica a un bajo costo podría ser una alternativa.
La propuesta de reforma de salud contempla la realización de un estudio que identifique estrategias para proveer servicios lingüísticamente apropiados para pacientes ancianos que no hablan inglés. Este estudio representaría un componente critico de la reforma, pues nos permitiría comprender métodos eficientes para proveer cuidados de salud de alta calidad a poblaciones étnicamente diversas. Otro componente importante de la reforma es imponer multas a los aseguradoras de salud que no provean servicios de traducción a beneficiarios de Medicare con conocimiento limitado de inglés, de acuerdo a lo descrito en la ley. En la actualidad, las leyes no establecen penalizaciones para las instituciones que violan estas leyes anti-discriminatorias. Por este motivo, algunos hospitales y aseguradoras de salud todavía no ofrecen estos servicios. La imposición de multas a aseguradoras podría incentivar el cumplimiento de la ley.
La mayoría de las personas que no hablan inglés en este país son trabajadores honestos que contribuyen a nuestra sociedad y economía. Algunos grupos sostienen que permitir que estas personas reciban cuidados de salud de calidad inferior o inclusive permitir que sufran o mueran rinde un servicio a los intereses nacionales. Quisiera recordarles que los principios de solidaridad y equidad de nuestros Padres Fundadores dieron origen a un país que lucho por unirse y por crear oportunidades para todos. Pensar que separarnos de estos principios nos traerá un futuro mejor es una falacia.
Olveen Carrasquillo, MD, MPH
Vice-Presidente, Latinos por un Seguro Medico Nacional
Chief, Division of General Internal Medicine
University of Miami, Miller School of Medicine
Ana Palacio, MD, MPH
Assistant Professor of Medicine
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By admin | October 18, 2009
El Diario-La Prensa, New york
Health Reform Proposal will help non-English speakers
One of the most important aspects in taking care of patients is obtaining a detailed medical history. The plan of care and treatment also need to be carefully explained in a way that is understandable by the patient. Yet some conservative groups have argued that for patients who do not speak English these important principles of medical care do not apply. They propose that persons who do not speak English get lower quality health care so that they are forced to learn English. However, discrimination of patients because they do not speak English is illegal in this country. In addition, many accrediting organizations require hospitals and large health plans to make efforts to provide language services to non-English speakers. As a result, many large health systems have taken important steps to accommodate such patients. This includes the right to translation services as part of a hospital’s “Bill of Rights”. The rules are very flexible and only apply to health care practices where a significant proportion of patients speak another language. One way to provide these services is through professional interpreters. But, there other options. For example, if over half the patients speak Spanish we think having providers who speak Spanish is a better alternative. In practices where many different languages are spoken access to low cost telephone interpretation may be a better alternative.
Now as part of health reform, the government is proposing a study to find the best approaches to providing cultural and linguistically appropriate health care services for elderly Non-English speakers. This study is a critically important component of health reform which will help us understand the most cost-efficient methods to deliver such quality health care among diverse populations in diverse settings. Another component of the health reform are imposing fines on large health plans fail to provide language services to limited English proficient Medicare beneficiaries as required under law. The problem is that current laws do not fine health providers from violating these anti-discrimination laws. Thus, some hospitals and health insurance plans still do not comply with the law. We believe that fines for health plans that act illegally maybe a way to get them to adhere to existing laws. Therefore, such fines are also another important component of health reform.
Most of the non-English speakers in this country are hard working people who make positive contributions to our society and economy. Some groups have argued that allowing patients to get inferior health care, suffer or even die because they do not speak English is in our national interests. We believe they are dead wrong.
Olveen Carrasquillo, MD, MPH
Vice President, Latinos for National Health Insurance & Chief, Division of General Internal Medicine
Ana Palacio, MD, MPH
Assistant Professor of Medicine
University of Miami, Miller School of Medicine
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By admin | October 18, 2009
South Florida Sun-Sentinel.com
Health care reform
Everyone will suffer if illegal immigrants aren’t covered in reform, some caregivers say
Florida, home to a million undocumented immigrants, pays big to take care of those who can’t get insurance, including those here illegally. If health care reform leaves out the undocumented, we’ll still be paying, caregivers warn.
By William E. Gibson
South Florida Sun Sentinel
6:15 PM EDT, September 25, 2009
WASHINGTON
Excluding undocumented immigrants from health care reform could jeopardize everyone’s health and perpetuate a costly gap in insurance coverage, medical experts warned this week.
Much of the point of health care legislation in Congress is to cover all Americans to protect the public health and ease the high cost of treating uninsured patients in emergency rooms. Some health leaders worry that leaving the undocumented out of a newly created health care system would impair attempts to prevent the spread of infectious disease, such as tuberculosis or swine flu, and continue the growing burden on public hospitals.
The gap in coverage is especially big in Florida, home to a million undocumented residents.
The warnings come while the Senate Finance Committee is drafting a bill designed to prevent illegal immigrants from tapping into new health care marketplaces, known as exchanges, where individuals and small businesses could shop for insurance.
The committee, which will resume its work next week, is expected to produce a bill that would require consumers to show proof of citizenship or legal status when joining these exchanges. The bill also would prevent the undocumented from getting tax breaks designed to make insurance affordable. And it would force newly arrived legal immigrants to wait five years before joining exchanges or getting tax breaks.
Some health leaders in Florida fear these exclusions and restrictions would undermine the advantages of reform.
“If I’m standing next to someone who has tuberculosis and who is uninsured, it doesn’t protect me if they aren’t treated,” said Fernando Trevino, dean of the School of Public Health at Florida International University. “To the degree that someone is not getting care, they are more likely to spread infectious diseases to the rest of the population.”
He and other public-health experts also say any bill that leaves a big gap in coverage would miss an opportunity to lower costs by providing preventive care to everyone.
“People forget that we already provide inefficient and expensive care to undocumented residents,” said Dr. Olveen Carrasquillo, chief of general internal medicine at the University of Miami medical school. “They come into emergency rooms with advanced stages of an illness. Often they have medical conditions that are very expensive to treat but could have been prevented with primary care.”
Restrictions on the undocumented, if approved by Congress, would apply to new benefits provided by the reform legislation. The exclusion would not block immigrants from buying insurance on the private market outside these exchanges.
Florida Sen. Bill Nelson, a Democrat on the Finance Committee, supports exclusion of the undocumented.
“Nelson’s bottom-line position is that a health care bill should not provide benefits to folks here illegally,” said spokesman Dan McLaughlin. “In fact, he supports tough verification.”
These measures stem from a determination to prevent explosive immigration issues from derailing an overhaul of the health care system. President Barack Obama tried to assure Congress in a nationally televised speech this month that “the reforms I’m proposing would not apply to those who are here illegally.”
The remark sparked an outcry from conservatives — most immediately from Rep. Joe Wilson, R-S.C., who shouted, “You lie!” during Obama’s Sept. 9 health care address to Congress. Wilson and many other Republicans say the reforms being considered would allow illegal residents to sneak into the health care system at taxpayer expense.
The undocumented have access to health care. By law, hospitals and other providers are required to treat all patients who need emergency care.
Public clinics in South Florida and elsewhere do not ask patients about their immigration status. They also give vaccinations for such things as swine flu without demanding documents.
But some public-health leaders are concerned that the heated rhetoric and exclusions coming out of Washington will further discourage immigrants and some U.S. citizens. They say some residents who don’t speak English or meet the profile of a typical American — even those here legally — are reluctant to show up at public facilities for fear of harassment or deportation.
“By not covering them, we are choosing the worst for them and the worst for the rest of us in terms of financial cost,” Carrasquillo said. “We end up paying for it.”
William E. Gibson can be reached at wgibson@SunSentinel.com or 202-824-8256.
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By admin | October 18, 2009
October 4, 2009
Op-Ed Columnist
Dad’s Life or Yours? You Choose
By NICHOLAS D. KRISTOF
So what would you do if your mom or dad, or perhaps your sister or brother, needed a kidney donation and you were the one best positioned to donate?
Most of us would worry a little and then step forward. But not so fast. Because of our dysfunctional health insurance system, a disgrace that nearly half of all members of Congress seem determined to cling to, stepping up to save a loved one can ruin your own chance of ever getting health insurance.
That wrenching trade-off is another reminder of the moral bankruptcy of our existing insurance system. It’s one more reason to pass robust reform this year.
Over the last week I’ve been speaking to David Waddington, a 58-year-old wine retailer in Dallas, along with his wife and two sons. I’d love to know what the opponents of health reform think families like this should do.
Mr. Waddington has polycystic kidney disease, or PKD, a genetic disorder that leads to kidney failure. First he lost one kidney, and then the other. A year ago, he was on dialysis and desperately needed a new kidney. Doctors explained that the best match — the one least likely to be rejected — would perhaps come from Travis or Michael, his two sons, then ages 29 and 27.
Travis and Michael each had a 50 percent chance of inheriting PKD. And if pre-donation testing revealed that one of them had the disorder, that brother might never be able to get health insurance. As a result, their doctors had advised not getting tested. After all, new research suggests that lack of insurance increases a working-age person’s risk of dying in any given year by 40 percent.
“At the time David needed a transplant, the people closest to him couldn’t even offer a lifesaving donation — for insurance reasons,” said Mr. Waddington’s wife, Susan.
Travis, who is living in New York and working toward a math doctorate, is anguished at having to weigh insurance obstacles against the chance to save his dad.
“Can you put a price on your father’s life?” he asked. “My brother and I talked it over privately, and agreed that we should both go ahead and get tested anyway. It seemed like the only course of action. We presented our plan to our parents, and of course Mom immediately shot it down, with Dad firmly behind her.
“We had to respect their right to want to protect us. But it was enraging to be in that situation, and to be completely impotent to do anything to help. I told myself a number of times that we would reconsider the issue of testing if Dad’s dialysis stopped working before he got a transplant.”
David Waddington finally got that transplant when a kidney from a deceased donor became available. But our insurance system has had other excruciating consequences for the Waddingtons. Though PKD has no cure as such, there are experimental medications that may delay kidney problems. To get access to the medications, a patient must be tested — and since Travis and Michael Waddington don’t dare get tested, they don’t have access to these medications.
“The only way to do it is to lie about your name during testing, to use a fictitious name,” Susan Waddington said. “That was the advice we got from a major person in the field. We didn’t do that.”
The Genetic Information Nondiscrimination Act, passed last year, should eventually help people get access to health insurance even if they have a genetic predisposition to a disease. But insurance companies will still be free to discriminate against people who show symptoms of those diseases.
That’s what’s happening now with Michael. For years, he and Travis were afraid to mention to physicians their 50 percent chance of inheriting PKD, but recently Michael began suffering pains and went to the emergency room. After examining him and ordering tests, the doctor asked him, “Have you ever heard of PKD?”
“I felt the jig was up, and I could disclose my knowledge,” Michael said, so he told the doctor about his father.
The broader problem is this: Our broken system leads Americans to spend 16 percent of our national income on health care, twice as much as in parts of Europe, yet with maternal mortality rates and child mortality rates twice those of the best-performing countries. Lack of insurance is linked to nearly 45,000 unnecessary deaths a year, according to a peer-reviewed study to be published in the December issue of The American Journal of Public Health.
None of this seems to move members of Congress who oppose health reform. They have first-rate health care for themselves and so perhaps don’t appreciate how their posturing forces people like the Waddingtons into impossible situations. Let’s hope they find it in their hearts to overhaul an existing insurance system that is the disgrace of the industrialized world.
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By admin | October 18, 2009
October 8, 2009
Op-Ed Columnist
Let Congress Go Without Insurance
Let me offer a modest proposal: If Congress fails to pass comprehensive health reform this year, its members should surrender health insurance in proportion with the American population that is uninsured.
It may be that the lulling effect of having very fine health insurance leaves members of Congress insensitive to the dysfunction of our existing insurance system. So what better way to attune our leaders to the needs of their constituents than to put them in the same position?
About 15 percent of Americans have no health insurance, according to the Census Bureau. Another 8 percent are underinsured, according to the Commonwealth Fund, a health policy research group. So I propose that if health reform fails this year, 15 percent of members of Congress, along with their families, randomly lose all health insurance and another 8 percent receive inadequate coverage.
Congressional critics of President Obama’s efforts to achieve health reform worry that universal coverage will be expensive, while their priority is to curb social spending. So here’s their chance to save government dollars in keeping with their own priorities.
Those same critics sometimes argue that universal coverage needn’t be a top priority because anybody can get coverage at the emergency room. Let them try that with their kids.
Some members also worry that a public option (an effective way to bring competition to the insurance market) would compete unfairly with private companies and amount to a step toward socialism. If they object so passionately to “socialized health,” why don’t they block their 911 service to socialized police and fire services, disconnect themselves from socialized sewers and avoid socialized interstate highways?
I wouldn’t wish the trauma of losing health insurance on anyone, but our politicians’ failure to assure health care for all citizens is such a longstanding and grievous breach of their responsibility that they deserve it. In January 1917, Progressive Magazine wrote: “At present the United States has the unenviable distinction of being the only great industrial nation without universal health insurance.” More than 90 years later, we still have that distinction.
Theodore Roosevelt campaigned for national health insurance in 1912. Richard Nixon tried for universal coverage in 1974. Yet, even now, nearly half of Congress is vigorously opposed to such a plan.
Health care has often been debated as a technical or economic issue. That has been a mistake, I believe. At root, universal health care is not an economic or technical question but a moral one.
We accept that life is unfair, that some people will live in cramped apartments and others in sprawling mansions. But our existing insurance system is not simply inequitable but also lethal: a very recent, peer-reviewed article in the American Journal of Public Health finds that nearly 45,000 uninsured people die annually as a consequence of not having insurance. That’s one needless death every 12 minutes.
When nearly 3,000 people were killed on 9/11, we began wars and were willing to devote more than $1 trillion in additional expenses. Yet about the same number of Americans die from our failed insurance system every three weeks.
The obstacle isn’t so much money as priorities. America made it a priority to provide tax breaks, largely to the wealthy, in the Bush years, at a 10-year cost including interest of $2.4 trillion. Allocating less than half that much to assure equal access to health care isn’t deemed an equal priority.
The plan emerging in the Senate is no panacea. America needs to promote exercise and discourage sugary drinks to hold down the rise in obesity, diabetes and medical bills. We need more competition among insurance companies. And conservatives are right to call for tort reform to reduce the costs of malpractice insurance and defensive medicine.
But those steps are not a substitute for guaranteed health coverage for all Americans. And if health reform fails this year, then hopes for universal coverage will recede again. There was a lag of 19 years after the Nixon plan before another serious try, and a 16-year lag after the Clinton effort of 1993. Another 16-year delay would be accompanied by more than 700,000 unnecessary deaths. That’s more Americans than died in World War I, World War II, Korea, Vietnam and Iraq combined.
The collapse of health reform would be a political and policy failure, but it would also be a profound moral failure. Periodically, there are political questions that are fundamentally moral, including slavery in the 19th century and civil rights battles in the 1950s and ’60s. In the same way, allowing tens of thousands of Americans to die each year because they are uninsured is not simply unwise and unfortunate. It is also wrong — a moral blot on a great nation.
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By admin | October 18, 2009
October 16, 2009
Op-Ed Columnist
A Hatchet Job So Bad It’s Good
In the past, the insurance industry’s power has been a major barrier to health-care reform. Most notably, the industry paid for the infamous “Harry and Louise” ads that helped kill the Clinton plan. But times have changed.
Last weekend, the lobbying organization America’s Health Insurance Plans, or AHIP, released a report attacking the reform plan just passed by the Senate Finance Committee. Some news organizations gave the report prominent, uncritical coverage. But health-care experts quickly, and correctly, dismissed it as a hatchet job. And the end result of AHIP’s blunder may be a better bill than we would otherwise have had.
For 2009, it turns out, is not 1993. Once again, Republicans have tried to kill reform with smears and scare stories. But all they seem to have killed with their cries of “socialism” and warnings about “death panels” is their own credibility. Some form of health-care reform is highly likely to pass.
So it’s a different game than it was 16 years ago. And it’s a game that the insurance industry apparently doesn’t know how to play.
The motivation for the AHIP report seems to have been the decision by the Finance Committee to weaken the penalties for individuals who don’t sign up for insurance, even as it retains regulations requiring that insurers offer the same policies to everyone, regardless of medical history. The industry worries that some people will game the system, remaining uninsured as long as they’re healthy, then signing up when they get sick.
This is, believe it or not, a valid concern. Many health-care economists believe that a strong individual mandate, requiring that almost everyone sign up, will be needed to make health reform work. And the Finance Committee probably did weaken the mandate too much.
But AHIP, apparently unable to help itself, didn’t stop there. Instead, the report threw every anti-reform argument the authors could think of at the wall, hoping that something would stick.
One argument was particularly striking: the claim that attempts to limit Medicare spending would lead to higher insurance premiums. In fact, the report assumes that 100 percent of any reduction in Medicare payments to hospitals will translate into higher costs for patients with private insurance.
The only way to justify this claim is to assume that all hospitals are purely charitable institutions, charging as little as they possibly can. Now, some hospitals may fit this description. But all of them?
What’s more, this argument stands the usual logic of markets on its head: if you believe AHIP’s story, competition raises prices instead of reducing them. And it doesn’t matter where the competition comes from: anyone who gets a better deal, whether it’s Medicare or a private insurer, makes life worse for everyone else. I don’t believe that, and neither should you.
Of course, the report doesn’t mention these implications. The only bad competition it talks about is competition from the government. Specifically, it claims that a public insurance option would be a bad thing — not because it would be inefficient, but because the public plan would negotiate better prices. Isn’t that an argument for, not against, such a plan?
Which brings us to the ways in which AHIP may have done health reform a favor.
As I said, the individual mandate probably should be stronger than it is in the Finance Committee’s bill. But there’s a reason the mandate was weakened: fear that too many people would balk at the cost of insurance, even with the subsidies provided to lower-income individuals and families. So why not address that cost?
Aside from making the subsidies larger, which they should be, there are at least two changes to the legislation that would help limit costs. First, health exchanges — special, regulated markets in which individuals and small businesses can buy insurance — can be made stronger, in effect giving small buyers a better bargaining position. Second, the public option — missing from the Finance Committee’s bill — can be brought back in, giving private insurers some real competition.
The insurance industry won’t like these changes, but that matters less than it did a week ago.
There’s also another point, which House Speaker Nancy Pelosi has stressed. Part of the opposition to a strong individual mandate comes from the sense that Americans will be forced to buy policies from a greedy insurance industry. Giving people, literally, another option — the right to buy into a public plan instead — would defuse that opposition.
Even with stronger exchanges and a public option, health reform would probably increase, not reduce, insurance industry profits. But the insurers wanted it all. The good news is that by overreaching, they may have ensured that they won’t get it.
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By admin | October 18, 2009
October 18, 2009
Editorial
The Public Plan, Continued
In the debate over health care reform, no issue has produced more fury and sound bites than the question of whether to include a government-run insurance plan. It is not indispensable, and its role would be limited. Even so, we strongly support inclusion of a public option — the bigger and stronger the better. That is the best way to give consumers more choices, inject more competition into insurance markets, hold down the cost of insurance policies, and save money for the federal budget.
Here are some of the basic issues to consider, and the current legislative state of play:
WHO COULD ENROLL? While critics rail against a government takeover of health care, the reality is that the vast majority of Americans — those who have access to health insurance offered by large employers — would not be eligible to enroll in a public plan.
If Congress approves a public plan, it would be sold only on new insurance exchanges to people who now buy their policies directly from private insurers, work for small companies or are uninsured, often because they cannot afford to pay the high premiums charged for people without group coverage.
People eligible to use the exchanges could choose from a menu of private plans and, we hope, a cheaper public plan as well. Subsidies would be provided to help low- and moderate-income people pay their premiums.
DOES IT MAKE INSURANCE MORE AFFORDABLE? Most experts agree that a public plan should be able to provide insurance at a lower cost because it would have no need to earn a profit and could either demand or bargain for lower prices from health care providers. That should spur private insurers, eager to attract millions of new customers on the exchanges, to find ways to hold down their premiums as well, at least on the exchanges.
That would be good news for higher-income Americans on the exchange, roughly a fifth or less of the total, who would pay all of the cost of their insurance. It would benefit few, if any, of the rest, namely the low- and moderate-income people who would receive government subsidies to help buy insurance. All versions of the legislation would require these people to spend specified percentages of their income toward the premium and a government tax credit would then pay the rest.
The real savings would accrue to the government, which would then have to spend less money to subsidize purchases of lower-cost public or private insurance.
If there is a political trade-off to be made, the only good reason for abandoning a strong public plan would be in exchange for much more generous subsidies to make insurance affordable for all those who would be required to buy coverage or pay a fine. That would benefit consumers but put a greater strain on the Treasury.
WHAT’S THE STRONGEST PUBLIC PLAN? That is apt to emerge from the House, where the Democrats need only a majority to pass legislation and are constrained only by the need to satisfy conservatives in their own party. The speaker’s office is considering three options.
In the most robust, the public plan would pay hospitals and other providers based on Medicare reimbursement rates, typically lower than private insurance rates. That would allow the public plan to charge lower premiums than private plans, and save the government substantial money in reduced subsidies — more than $100 billion over the next decade. There is a danger that the low payments might push some hospitals, especially in rural areas, into deeper financial trouble.
A middle option would have the public plan negotiate reimbursement rates with providers just as private plans do; its bargaining power would depend on how many people it enrolled. Finally, a hybrid version would start with negotiations with providers to set prices for services, but switch to a Medicare-based formulation if the plan’s premiums rose too rapidly. Our preference would be for the most robust plan possible, with care taken to mitigate adverse effects on rural areas.
WHAT ARE THE OTHER IDEAS? The Senate has been far more hostile terrain for a public option because its filibuster rules require 60 votes to ensure passage.
In an effort to win support from conservative Democrats and possibly a Republican or two, the Finance Committee approved a bill with no public option, relying on nonprofit cooperatives with too little market power to be effective.
The Senate health committee approved a public plan that would negotiate rates with providers. Now the majority leader is trying to mesh the two bills into a form that could ultimately pass.
Several other proposals have been floated in hopes of drawing conservative support. One would establish a public plan only in states where private plans failed to offer affordable choices; the danger is that the criteria for judging affordability might be too lax. Others would let the states decide whether to set up a public plan. The strongest compromise would be to accept the Senate health committee’s provision for a national public plan that would negotiate rates with providers and allow states to opt out. Our guess is that few would do so.
A PUBLIC PLAN FOR EVERYBODY? Too often insurance markets are dominated by one or two big companies. We believe that, after a break-in period, the insurance exchanges, with a public option, should be opened to virtually everyone covered by large employer-based plans.
That would give the vast majority of Americans a bigger choice of insurance options than they now have at most workplaces — and a greater stake in pushing Congress to approve a strong public plan.
•
This editorial is a part of a continuing series by The Times that is providing a comprehensive examination of the policy challenges and politics behind the debate over health care reform. You can read all of these articles at: nytimes.com/edhealthcare2009
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By admin | August 23, 2009
Friday 21 August 2009In a week of claim and counter-claim about the merits of healthcare provision in the US and UK, Ed Pilkington travelled to Quindaro, Kansas, to see how the poorest survive.
by: Ed Pilkington | Visit article original @ The Guardian UK
In the furious debate gripping America over the future of its health system, one voice has been lost amid the shouting. It is that of a distinguished gynaecologist, aged 67, called Dr Joseph Manley.
For 35 years Manley had a thriving health clinic in Kansas. He lived in the most affluent neighbourhood of Kansas City and treated himself to a new Porsche every year. But this is not a story about doctors’ remuneration and their lavish lifestyles.
In the late 1980s he began to have trouble with his own health. He had involuntary muscle movements and difficulty swallowing. Fellow doctors failed to diagnose him, some guessing wrongly that he had post-traumatic stress from having served in the airforce in Vietnam.
Eventually his lack of motor control interfered with his work to the degree that he was forced to give up his practice. He fell instantly into a catch 22 that he had earlier seen entrap many of his own patients: no work, no health insurance, no treatment.
He remained uninsured and largely untreated for his progressively severe condition for the following 11 years. Blood tests that could have diagnosed him correctly were not done because he couldn’t afford the $200. Having lost his practice, he lost his mansion on the hill and now lives in a one-bedroom apartment in the suburbs. His Porsches have made way for bangers. Many times this erstwhile pillar of the medical establishment had to go without food in order to pay for basic medicines. In 2000 Manley finally found the help he needed, at a clinic in Kansas City that acts as a rare safety net for uninsured people. He was swiftly diagnosed with Huntington’s disease, a degenerative genetic illness, and now receives regular medical attention through the clinic.
So how does he feel about the way the debate in the US has come to be dominated by Republican-inspired attacks on Britain’s NHS and other “socialised” health services which give people the treatment they need even if they cannot afford to pay for it?
”I find that repulsive and an absolutely bone-headed way to go,” he says. “When I started out practising I certainly didn’t expect this would happen. I thought the system would take care of everybody.”
Over the last month President Obama’s attempts to live up to his election promise to extend healthcare to all Americans has stalled in the face of a sustained rightwing guerrilla attack. Opponents of Obama’s reforms have succeeded in distracting attention from Manley and the 46 million other medically uninsured, swinging the focus instead on to the “evils” of publicly funded healthcare. The fear tactics were epitomised by Sarah Palin’s wholly inaccurate claim that the reforms would set up “death panels” that would force euthanasia on to older people.
Such scaremongering has dismayed and infuriated Sharon Lee, the doctor who now treats Manley in Kansas City. “I’m very angry, very angry,” she says. “Many of the people I treat have already been in front of a death panel and have lost - a death panel controlled by insurance companies. I see people dying at least monthly because we have been unable to get them what they needed.”
Lee’s clinic, Family Health Care, is a refuge of last resort. It picks up the pieces of lives left shattered by a health system that has failed them, and tries to glue them back together. It exists largely outside the parameters of formal health provision, raising funds through donations and paying all its 50 staff - Lee included - a flat rate of just $12 an hour.
Poverty Line
Lee has just opened an outpost of her clinic in the outlying neighbourhood of Quindaro, an area of boarded-up houses and deserted factories where work is hard to find and crack plentiful and a per capita income is $11,025. A third of the population is below the federally defined poverty line.
And yet the local health department has decided the only health centre in the area will be closed by the end of this year and moved 30 blocks west to a much more prosperous part of the city where income levels are five times higher. Before long, one of the poorest areas of Kansas - of America - will be left without a single doctor, with only Lee’s voluntary services to fall back on.
Even that is academic. Many of the residents of Quindaro were unable to see a doctor in any case - because they were uninsured. In Kansas, anyone who is able-bodied but unemployed is not eligible for government-backed health insurance as is anyone earning more than 39% of federal poverty levels. That leaves a huge army of jobless and low-income working families who are left in limbo. “It’s the working poor who are most at disadvantage,” Lee says.
As a result, she sees the same pattern repeating itself over and over. People with no insurance avoid seeking medical help for fear of the bills that follow, until it is too late. “When people come in they are already very, very sick. They have avoided seeing the doctor thinking that something may clear up, hoping they may be getting better.”
Beth Gabaree, who came in to see Lee for the first time this morning, has experiences that sound extreme but are in fact quite typical. She has diabetes and a heart condition. Until two years ago they were controlled through ongoing treatment paid for by her husband’s work-based health insurance. But he was in a motorbike crash that pulverised his right leg and put him out of work.
That Catch 22 again: no work, no insurance, no treatment. Except in this case it was Beth who went without treatment, in order to put her husband’s dire needs first. He receives ongoing specialist care that costs them $500 a go, leaving nothing for her. So she stopped seeing a doctor, and effectively began self-medicating. She cut down from two different insulin drugs to regulate her diabetes to one, and restricted her heart drugs. “I do what I think I need to do to keep four steps out of hospital. I know that’s not the right thing, but I can’t justify seeing the doctor when my family’s already in money trouble.”
The problem is that she hasn’t kept herself four steps out of hospital. Her health deteriorated and earlier this year she became bedridden. Even then, it took her family several days to persuade her to go to the emergency room because she didn’t want to incur the hospital costs. “It was hard enough without that,” she says.
After an initial consultation, Lee has now booked Gabaree for a new round of tests for her diabetes and is arranging for free medication. “It’s wonderful,” Gabaree says. “I’m so blessed. I didn’t know you could get this sort of help.”
That she sees basic healthcare as a blessing, not as a right, speaks volumes about attitudes among the mass of the working poor. Also revealing is the fact that Gabaree has absolutely no idea about the debate raging across America. She hasn’t even heard of Obama’s push for health reform, nor the Republican efforts to prevent it. “I don’t watch much television,” she says.
That provides Palin et al with a massive advantage: the 46 million people who would most benefit from Obama’s plans are also among the least educated and informed, and thus the least able to make political waves. All of which leaves Lee fearful about the prospects for change. She has, after all, been here before - in 1993 when Hillary Clinton’s pitch to overhaul the health system foundered. That attempt ended up doing more harm than good from Lee’s perspective. Many of her most important donors stopped funding the centre because they assumed that the White House was fixing the problems. After the Clinton reforms crashed, brought down by the same rightwing assault that Obama is now enduring, it took many months for the centre’s funds to regain their pre-1993 levels.
Recession
Lee fears history could be repeating itself. This time round there is the recession more unemployed equals more uninsured people who come knocking on the door of Family Health Care. Last year Lee and one other doctor between them dealt with 14,000 visits, and the numbers are rising daily. All of which leaves Lee part despairing, part determined to fight even harder for the bare minimum of human dignity. The frustration is that every day she must beg and plead with other health providers for simple treatments for her patients. “It drives me crazy with frustration,” she says.
She rattles off a litany of horror stories. There was the man who walked into the clinic with a brain tumour. It took Lee three months to get him an MRI scan and another two to get an appointment with a neurosurgeon. Or the patient whose nerves in his neck were pushed against his spinal cord so that he lost use of both arms; by the time Lee found a way of getting him an MRI he was so sick he had to be operated on immediately. Or the woman who had such heavy periods she would wind up in ER every three months requiring a blood transfusion. What she really needed was a hysterectomy. “It took us almost a year to beg hospitals until she finally did get a hysterectomy,” Lee says.
These are the stories, the broken lives, that have been obscured by the fury generated by the Republican rump. Unless Obama finds a way to regain the political initiative, to remind Americans that only nine months ago they voted overwhelmingly for change, then the future of millions appears bleak.
”Here’s what I’d like to ask Palin,” Lee says. “People without health insurance are dying, here in America, right now. So I’d like to ask her: how does that fit into your vision of good and evil, Sarah Palin?”
Obama’s Plan: Health of the Nation
What is Obama trying to do?
The goal is to increase access to healthcare by regulating costs. His plan would guarantee all citizens eligibility for care, but the government is not proposing a “single-payer system”, like the NHS. Instead, private health insurers would continue to operate under new rules that would lower premiums and remove loopholes that allow them to avoid paying for treatment when it is most needed. Per person, healthcare costs are higher in the US than in any other country, and have been rising faster than the level of inflation. The quality of care is less of an issue - although citizens with solid insurance may be frustrated by the paperwork and costs associated with the current system, they have fewer complaints about their doctors and hospitals.
Who’s opposing Obama’s plan?
Those who fear the government would introduce congressional “death panels” to make end-of-life decisions for the elderly. The insurance industry is worried about their bottom lines. Members of Congress and voters on the left and right are concerned about the future tax burden. Many Americans also object to any increase in government involvement in their personal lives.
How can healthcare costs get so out of hand?
Many insurance plans do not cover “pre-existing conditions”, so it can be difficult for people who have a chronic ailment to secure cover. Loopholes allow insurers to refuse reimbursement even if the policyholder did not know they had a particular condition when they took out insurance. “Lifetime caps” allow insurers to set a maximum amount of cover.
Who are the uninsured?
Up to 46 million Americans are uninsured, because they are unemployed, or their employer does not provide cover, or because they do not qualify for existing government-funded healthcare. People 65 and older can qualify for Medicare, the poor can qualify for Medicaid, veterans and members of the military can qualify for Veterans Health Administration and Tricare and children can be covered under a programme called SCHIP. Those overlooked by the system include the young just entering the workforce, the self-employed, the unemployed and people who work for small businesses.
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