Friday July 31, 2009
NEW YORK (Reuters) - The S&P 500 ended its best five-month streak since 1938 with a slight gain on Friday as government data showed softness in consumer spending but reinforced expectations that the economic slump is abating.
But the mood was cautious as the report on second-quarter gross domestic product showed the U.S. consumer was more frugal, which cut hurt economic demand. Even so, Dow industrials had their best July since 1989 while the S&P 500 and Nasdaq recorded their best gains for July since 1997.
Commodity prices, a barometer for economic sentiment, moved higher after the GDP data, but the price of safe-haven U.S. Treasury debt also rose in a sign of underlying caution.
Trading was volatile as investors digested mixed news from the GDP report. Consumer spending, which fell in the quarter, is a crucial driver of corporate profits and the economy..
GDP fell at a 1.0 percent annual rate in April-June after tumbling 6.4 percent in the first quarter. Economists had expected a 1.5 percent contraction in the second quarter.
"The GDP number came in better than expected but was masked by a lot of government spending and the consumer pulled back," said Jack Ablin, chief investment officer at Harris Private Bank in Chicago. "When you're fueling economic growth on government spending, clearly that is not a sustainable situation.
"But overall my take is that we still are going to enjoy a cyclical recovery and the third quarter will likely come in positive territory," he said.
The Dow Jones industrial average (DJI:^DJI - News) ended up 17.15 points, or 0.19 percent, at 9,171.61. The Standard & Poor's 500 Index (^SPX - News) was up 0.73 point, or 0.07 percent, at 987.48. The Nasdaq Composite Index (Nasdaq:^IXIC - News) was down 5.80 points, or 0.29 percent, at 1,978.50.
For the week the Dow rose 0.9 percent, the S&P 500 gained 0.8 percent and the Nasdaq added 0.6 percent. For July the Dow gained 8.6 percent, the S&P added 7.4 percent and Nasdaq rose 7.8 percent.
Another report showing that business activity in the U.S. Midwest was the strongest in July in 10 months also lifted stocks.
"What you're seeing is numbers that are an improvement, but a lackluster improvement. They're less bad, but not great," said Chad Morganlander a portfolio manager at Stifel, Nicolaus & Co in Florham Park, New Jersey.
Travelers Cos Inc (NYSE:TRV - News), one of the largest U.S. home, auto and commercial insurers, was a standout following positive broker comments, a day after it raised its forecast for the year. The stock jumped 2.7 percent to $43.07.
On the downside, Walt Disney Co (NYSE:DIS - News) shed 4.2 percent to $25.12. The media and entertainment powerhouse reported a 26 percent slide in quarterly earnings late Thursday as the recession continued to hurt advertising and consumer spending.
Even though Disney beat expectations by a hair, its shares were the Dow's top drag. JPMorgan downgraded the stock to "underweight" from "neutral" on Friday.
In other earnings news, Chevron Corp (NYSE:CVX - News) posted a 71 percent drop in profit on weaker energy prices and fuel demand due to the economic slump, but it raised estimated 2009 output and said cost cuts were on track. The shares rose 2.6 percent to $69.47.
Volume was moderate on the New York Stock Exchange, with 1.51 billion shares changing hands, compared to last year's estimated daily average of 1.49 billion, while on the Nasdaq, about 2.27 billion shares traded, below last year's daily average of 2.28 billion.
Advancing stocks outnumbered declining ones on the NYSE by a 1879 to 1137, while declining stocks beat advancers on the Nasdaq by 1356 to 1282.
(Reporting by Edward Krudy; Editing by Kenneth Barry)
Friday, July 31, 2009
Wednesday, July 29, 2009
Fed survey: Stabilization seen in some regions
By JEANNINE AVERSA, AP Economics Writer
WASHINGTON – The economy is finally showing signs of stabilizing in some regions of the country — especially in parts of the Northeast and Midwest — bolstering hopes of a broader-based recovery this year.
A Federal Reserve snapshot of economic conditions issued Wednesday found that most of the Fed's 12 regions indicated either that the recession was easing or that economic activity had "begun to stabilize, albeit at a low level."
The economy remains fragile. But the fact that some Fed regions reported signs of activity beginning to level out raises hope that the recession, which started in December 2007, is drawing to a close.
Four Fed regions — New York, Cleveland, Kansas City and San Francisco — pointed to "signs of stabilization," the survey said. Two regions — Chicago and St. Louis — reported that the pace of economic declined appeared to be "moderating."
Five other regions — Boston, Philadelphia, Richmond, Atlanta and Dallas — described activity as "slow," "subdued" or "weak." Only one region — Minneapolis — indicated that its downward slide in economic activity had worsened.
Combined, the assessments of businesses on the front lines of the economy appeared to be brighter than those they provided for the previous Fed report in mid-June.
The observations in the Fed survey are consistent with an assessment made just last week by Fed Chairman Ben Bernanke: that the economy should start growing in the second half of this year, ending the longest recession since World War II.
Many analysts predict the recession eased considerably in the April-to-June quarter. They're forecasting that the economy shrank at only a pace of 1.5 percent in the second quarter.
That would mark a big improvement from the annualized 5.5 percent drop in the first three months of this year. The government will release the second-quarter results on Friday. Many economists also believe that the U.S. could start growing as soon as the current quarter.
The survey's findings will figure into discussions when Bernanke and his colleagues meet next on Aug. 11-12. The Fed is expected to keep a key bank lending rate at a record low near zero to help nurture a recovery. Economists say the Fed is likely to hold rates at such record low levels through the rest of this year.
Separately Wednesday, the government said orders to U.S. factories for big-ticket durable goods plunged in June by the largest amount in five months, reflecting the troubles in the auto industry and a steep drop in demand for commercial jets.
Overall, orders fell 2.5 percent, much larger than the 0.6 percent decline economists had expected. Orders for commercial aircraft, dampened by the global recession, plunged 38.5 percent.
In the Fed report, manufacturing activity showed "some improvement" in the Richmond, Chicago and Kansas City regions. The regions of St. Louis and Dallas said the rate of decline in factory activity is moderating. The Philadelphia and Minneapolis regions saw manufacturing activity drop, while the rest of the regions described activity at "low levels."
In the factory sector, reports overall suggested that activity "remained subdued" but "slightly more positive" than in the previous survey.
Meanwhile, auto sales were mixed across the country, while travel and tourism was down in a majority of the regions.
Most regions reported "sluggish" retail activity, with shoppers continuing to be price-conscious.
But the Fed regions of Boston, Kansas City and San Francisco reported either "modest sales increases or less negative sales results," the Fed said. The Philadelphia, Atlanta, St. Louis, New York and Dallas regions reported "flat or mixed sales." The remaining Fed regions described them as "soft."
Residential real estate remained "soft" in most Fed regions, though "many noted some signs of improvement." By contrast, commercial real-estate activity weakened further.
Meanwhile, "competitive pressures" were restraining companies' ability to jack up prices. And the weak job market meant companies were more interested in cutting wages than in boosting them. Those observations are consistent with the Fed's prediction that inflation will stay low this year.
Copyright © 2009 Yahoo! Inc. All rights reserved
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WASHINGTON – The economy is finally showing signs of stabilizing in some regions of the country — especially in parts of the Northeast and Midwest — bolstering hopes of a broader-based recovery this year.
A Federal Reserve snapshot of economic conditions issued Wednesday found that most of the Fed's 12 regions indicated either that the recession was easing or that economic activity had "begun to stabilize, albeit at a low level."
The economy remains fragile. But the fact that some Fed regions reported signs of activity beginning to level out raises hope that the recession, which started in December 2007, is drawing to a close.
Four Fed regions — New York, Cleveland, Kansas City and San Francisco — pointed to "signs of stabilization," the survey said. Two regions — Chicago and St. Louis — reported that the pace of economic declined appeared to be "moderating."
Five other regions — Boston, Philadelphia, Richmond, Atlanta and Dallas — described activity as "slow," "subdued" or "weak." Only one region — Minneapolis — indicated that its downward slide in economic activity had worsened.
Combined, the assessments of businesses on the front lines of the economy appeared to be brighter than those they provided for the previous Fed report in mid-June.
The observations in the Fed survey are consistent with an assessment made just last week by Fed Chairman Ben Bernanke: that the economy should start growing in the second half of this year, ending the longest recession since World War II.
Many analysts predict the recession eased considerably in the April-to-June quarter. They're forecasting that the economy shrank at only a pace of 1.5 percent in the second quarter.
That would mark a big improvement from the annualized 5.5 percent drop in the first three months of this year. The government will release the second-quarter results on Friday. Many economists also believe that the U.S. could start growing as soon as the current quarter.
The survey's findings will figure into discussions when Bernanke and his colleagues meet next on Aug. 11-12. The Fed is expected to keep a key bank lending rate at a record low near zero to help nurture a recovery. Economists say the Fed is likely to hold rates at such record low levels through the rest of this year.
Separately Wednesday, the government said orders to U.S. factories for big-ticket durable goods plunged in June by the largest amount in five months, reflecting the troubles in the auto industry and a steep drop in demand for commercial jets.
Overall, orders fell 2.5 percent, much larger than the 0.6 percent decline economists had expected. Orders for commercial aircraft, dampened by the global recession, plunged 38.5 percent.
In the Fed report, manufacturing activity showed "some improvement" in the Richmond, Chicago and Kansas City regions. The regions of St. Louis and Dallas said the rate of decline in factory activity is moderating. The Philadelphia and Minneapolis regions saw manufacturing activity drop, while the rest of the regions described activity at "low levels."
In the factory sector, reports overall suggested that activity "remained subdued" but "slightly more positive" than in the previous survey.
Meanwhile, auto sales were mixed across the country, while travel and tourism was down in a majority of the regions.
Most regions reported "sluggish" retail activity, with shoppers continuing to be price-conscious.
But the Fed regions of Boston, Kansas City and San Francisco reported either "modest sales increases or less negative sales results," the Fed said. The Philadelphia, Atlanta, St. Louis, New York and Dallas regions reported "flat or mixed sales." The remaining Fed regions described them as "soft."
Residential real estate remained "soft" in most Fed regions, though "many noted some signs of improvement." By contrast, commercial real-estate activity weakened further.
Meanwhile, "competitive pressures" were restraining companies' ability to jack up prices. And the weak job market meant companies were more interested in cutting wages than in boosting them. Those observations are consistent with the Fed's prediction that inflation will stay low this year.
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http://news.yahoo.com/s/ap/20090729/ap_on_bi_ge/us_economy/print
Monday, July 27, 2009
Gov't plan can coexist with private insurance
By RICARDO ALONSO-ZALDIVAR, Associated Press Writer Ricardo Alonso-zaldivar, Associated Press Writer
WASHINGTON – A new government health insurance plan sought by President Barack Obama and congressional Democrats could coexist with private insurers without driving them out of business, an analysis by nonpartisan budget experts suggests.
The estimate by the nonpartisan Congressional Budget Office — seen as good news by Democrats — comes as leaders pushed Monday to make progress on health care overhaul before lawmakers go home for their August recess.
House Speaker Nancy Pelosi, D-Calif., says a floor vote is still possible in the next few days, and Democrats called a meeting of all their House members late Monday afternoon. In the Senate, a small group of lawmakers from both parties were resuming negotiations in search of an elusive compromise.
Obama's ambitious timetable for his top domestic priority has slipped as Democratic dissension has slowed the legislative work.
The White House and congressional Democrats were angered two weeks ago when the budget office director, Douglas Elmendorf, told Congress that the House bill lacked mechanisms to bring health care costs under control.
Now, Democrats are using the budget office's suggestion that a government-run insurance plan would not destroy private insurers to rebut one of the main charges against their proposal — that it would lead to a federal takeover of the private health insurance marketplace.
The controversy seems far from settled, given uncertainty over projections of how a revamped health care system would work.
Polls have shown that Americans support the idea of a public coverage option as part of health care overhaul. The insurance industry and employer groups say it could drive private insurers out of business, particularly if the government plan had the power to pay medical providers below-market rates.
More than 160 million workers and family members now get health insurance through an employer. A widely cited study by the Lewin Group, a private health research firm, estimated that more than 100 million people would sign up for the public plan proposed by House Democrats, making it the dominant insurer in the land.
But the budget office, in a letter Sunday to a senior Republican lawmaker, said its own estimate for the same legislation is "substantially smaller."
CBO estimates that only 11 million to 12 million people would sign up for the public plan — making it a much smaller player in the market. The government coverage would be available alongside private plans through a new kind of insurance purchasing pool called an exchange. CBO estimated about 6 million of those enrolled in the public plan would be workers and family members of employers that joined the exchange.
The reasons the estimates are so far apart have to do with different underlying assumptions.
The CBO estimated that the public plan would offer premiums about 10 percent lower than private plans; the Lewin analysis estimates the premiums would be at least 20 percent lower. The CBO estimates that only individuals and workers in companies with fewer than 50 employees would join the exchange, while Lewin estimated the exchange would eventually be open to all workers.
As if to underscore how such estimates can vary, the Urban Institute public policy center also ran calculations — and came up with different numbers. The Urban Institute estimated that about 47 million people would sign up for the public plan, if companies with fewer than 50 workers were allowed to join.
http://news.yahoo.com/s/ap/20090727/ap_on_go_co/us_health_care_overhaul/print
Copyright © 2009 Yahoo! Inc. All rights reserved
WASHINGTON – A new government health insurance plan sought by President Barack Obama and congressional Democrats could coexist with private insurers without driving them out of business, an analysis by nonpartisan budget experts suggests.
The estimate by the nonpartisan Congressional Budget Office — seen as good news by Democrats — comes as leaders pushed Monday to make progress on health care overhaul before lawmakers go home for their August recess.
House Speaker Nancy Pelosi, D-Calif., says a floor vote is still possible in the next few days, and Democrats called a meeting of all their House members late Monday afternoon. In the Senate, a small group of lawmakers from both parties were resuming negotiations in search of an elusive compromise.
Obama's ambitious timetable for his top domestic priority has slipped as Democratic dissension has slowed the legislative work.
The White House and congressional Democrats were angered two weeks ago when the budget office director, Douglas Elmendorf, told Congress that the House bill lacked mechanisms to bring health care costs under control.
Now, Democrats are using the budget office's suggestion that a government-run insurance plan would not destroy private insurers to rebut one of the main charges against their proposal — that it would lead to a federal takeover of the private health insurance marketplace.
The controversy seems far from settled, given uncertainty over projections of how a revamped health care system would work.
Polls have shown that Americans support the idea of a public coverage option as part of health care overhaul. The insurance industry and employer groups say it could drive private insurers out of business, particularly if the government plan had the power to pay medical providers below-market rates.
More than 160 million workers and family members now get health insurance through an employer. A widely cited study by the Lewin Group, a private health research firm, estimated that more than 100 million people would sign up for the public plan proposed by House Democrats, making it the dominant insurer in the land.
But the budget office, in a letter Sunday to a senior Republican lawmaker, said its own estimate for the same legislation is "substantially smaller."
CBO estimates that only 11 million to 12 million people would sign up for the public plan — making it a much smaller player in the market. The government coverage would be available alongside private plans through a new kind of insurance purchasing pool called an exchange. CBO estimated about 6 million of those enrolled in the public plan would be workers and family members of employers that joined the exchange.
The reasons the estimates are so far apart have to do with different underlying assumptions.
The CBO estimated that the public plan would offer premiums about 10 percent lower than private plans; the Lewin analysis estimates the premiums would be at least 20 percent lower. The CBO estimates that only individuals and workers in companies with fewer than 50 employees would join the exchange, while Lewin estimated the exchange would eventually be open to all workers.
As if to underscore how such estimates can vary, the Urban Institute public policy center also ran calculations — and came up with different numbers. The Urban Institute estimated that about 47 million people would sign up for the public plan, if companies with fewer than 50 workers were allowed to join.
http://news.yahoo.com/s/ap/20090727/ap_on_go_co/us_health_care_overhaul/print
Copyright © 2009 Yahoo! Inc. All rights reserved
Wednesday, July 22, 2009
A Brief History: Universal Health Care Efforts in the US
(Transcribed from a talk given by Karen S. Palmer MPH, MS in San Francisco at the Spring, 1999 PNHP meeting)
Late 1800’s to Medicare
The campaign for some form of universal government-funded health care has stretched for nearly a century in the US On several occasions, advocates believed they were on the verge of success; yet each time they faced defeat. The evolution of these efforts and the reasons for their failure make for an intriguing lesson in American history, ideology, and character.
Other developed countries have had some form of social insurance (that later evolved into national insurance) for nearly as long as the US has been trying to get it. Some European countries started with compulsory sickness insurance, one of the first systems, for workers beginning in Germany in 1871; other countries including Austria, Hungary, Norway, Britain, Russia, and the Netherlands followed all the way through 1912. Other European countries, including Sweden in 1891, Denmark in 1892, France in 1910, and Switzerland in 1912, subsidized the mutual benefit societies that workers formed among themselves. So for a very long time, other countries have had some form of universal health care or at least the beginnings of it. The primary reason for the emergence of these programs in Europe was income stabilization and protection against the wage loss of sickness rather than payment for medical expenses, which came later. Programs were not universal to start with and were originally conceived as a means of maintaining incomes and buying political allegiance of the workers.
In a seeming paradox, the British and German systems were developed by the more conservative governments in power, specifically as a defense to counter expansion of the socialist and labor parties. They used insurance against the cost of sickness as a way of “turning benevolence to power”.
US circa 1883-1912, including Reformers and the Progressive Era:
What was the US doing during this period of the late 1800’s to 1912? The government took no actions to subsidize voluntary funds or make sick insurance compulsory; essentially the federal government left matters to the states and states left them to private and voluntary programs. The US did have some voluntary funds that provided for their members in the case of sickness or death, but there were no legislative or public programs during the late 19th or early 20th century.
In the Progressive Era, which occurred in the early 20th century, reformers were working to improve social conditions for the working class. However unlike European countries, there was not powerful working class support for broad social insurance in the US The labor and socialist parties’ support for health insurance or sickness funds and benefits programs was much more fragmented than in Europe. Therefore the first proposals for health insurance in the US did not come into political debate under anti-socialist sponsorship as they had in Europe.
Theodore Roosevelt 1901 — 1909
During the Progressive Era, President Theodore Roosevelt was in power and although he supported health insurance because he believed that no country could be strong whose people were sick and poor, most of the initiative for reform took place outside of government. Roosevelt’s successors were mostly conservative leaders, who postponed for about twenty years the kind of presidential leadership that might have involved the national government more extensively in the management of social welfare. (For instance, a key plank in Theodore Roosevelt's losing Presidential campaign of 1912 was national health insurance)
While Roosevelt was campaigning in Milwaukee, Wisconsin, on October 14, 1912, a saloonkeeper named John Schrank shot him, but the bullet lodged in his chest only after penetrating both his steel eyeglass case and passing through a thick (50 pages) single-folded copy of the speech he was carrying in his jacket.[78] Roosevelt, as an experienced hunter and anatomist, correctly concluded that since he wasn't coughing blood the bullet had not completely penetrated the chest wall to his lung, and so declined suggestions he go to the hospital immediately. Instead, he delivered his scheduled speech with blood seeping into his shirt.[79] He spoke for ninety minutes. His opening comments to the gathered crowd were, "Ladies and gentlemen, I don't know whether you fully understand that I have just been shot; but it takes more than that to kill a Bull Moose."[80] Afterwards, probes and X-ray showed that the bullet had traversed three inches (76 mm) of tissue and lodged in Roosevelt's chest muscle but did not penetrate the pleura, and it would be more dangerous to attempt to remove the bullet than to leave it in place. Roosevelt carried it with him for the rest of his life.
Due to the bullet wound, Roosevelt was taken off the campaign trail in the final weeks of the race (which ended election day, November 5). Though the other two campaigners stopped their own campaigns in the week Roosevelt was in the hospital, they resumed it once he was released. The overall effect of the shooting was uncertain. Roosevelt for many reasons failed to move enough Republicans in his direction. He did win 4.1 million votes (27%), compared to Taft's 3.5 million (23%). However, Wilson's 6.3 million votes (42%) were enough to garner 435 electoral votes. Roosevelt had 88 electoral votes to Taft's 8 electoral votes. (This meant that Taft became the only incumbent President in history to actually come in third place in an attempt to be re-elected.)
AALL Bill 1915
In 1906, the American Association of Labor Legislation (AALL) finally led the campaign for health insurance. They were a typical progressive group whose mandate was not to abolish capitalism but rather to reform it. In 1912, they created a committee on social welfare which held its first national conference in 1913. Despite its broad mandate, the committee decided to concentrate on health insurance, drafting a model bill in 1915. In a nutshell, the bill limited coverage to the working class and all others that earned less than $1200 a year, including dependents. The services of physicians, nurses, and hospitals were included, as was sick pay, maternity benefits, and a death benefit of fifty dollars to pay for funeral expenses. This death benefit becomes significant later on. Costs were to be shared between workers, employers, and the state.
AMA supported AALL Proposal
In 1914, reformers sought to involve physicians in formulating this bill and the American Medical Association (AMA) actually supported the AALL proposal. They found prominent physicians who were not only sympathetic, but who also wanted to support and actively help in securing legislation. In fact, some physicians who were leaders in the AMA wrote to the AALL secretary: “Your plans are so entirely in line with our own that we want to be of every possible assistance.” By 1916, the AMA board approved a committee to work with AALL, and at this point the AMA and AALL formed a united front on behalf of health insurance. Times have definitely changed along the way.
In 1917, the AMA House of Delegates favored compulsory health insurance as proposed by the AALL, but many state medical societies opposed it. There was disagreement on the method of paying physicians and it was not long before the AMA leadership denied it had ever favored the measure.
AFL opposed AALL Proposal
Meanwhile the president of the American Federation of Labor repeatedly denounced compulsory health insurance as an unnecessary paternalistic reform that would create a system of state supervision over people’s health. They apparently worried that a government-based insurance system would weaken unions by usurping their role in providing social benefits. Their central concern was maintaining union strength, which was understandable in a period before collective bargaining was legally sanctioned.
Private insurance industry opposed AALL Proposal
The commercial insurance industry also opposed the reformers’ efforts in the early 20th century. There was great fear among the working class of what they called a “pauper’s burial,” so the backbone of insurance business was policies for working class families that paid death benefits and covered funeral expenses. But because the reformer health insurance plans also covered funeral expenses, there was a big conflict. Reformers felt that by covering death benefits, they could finance much of the health insurance costs from the money wasted by commercial insurance policies who had to have an army of insurance agents to market and collect on these policies. But since this would have pulled the rug out from under the multi-million dollar commercial life insurance industry, they opposed the national health insurance proposal.
WWI and anti-German fever
In 1917, the US entered WWI and anti-German fever rose. The government-commissioned articles denouncing “German socialist insurance” and opponents of health insurance assailed it as a “Prussian menace” inconsistent with American values. Other efforts during this time in California, namely the California Social Insurance Commission, recommended health insurance, proposed enabling legislation in 1917, and then held a referendum. New York, Ohio, Pennsylvania, and Illinois also had some efforts aimed at health insurance. But in the Red Scare, immediately after the war, when the government attempted to root out the last vestiges of radicalism, opponents of compulsory health insurance associated it with Bolshevism and buried it in an avalanche of anti-Communist rhetoric. This marked the end of the compulsory national health debate until the 1930’s.
Why did the Progressives fail?
Opposition from doctors, labor, insurance companies, and business contributed to the failure of Progressives to achieve compulsory national health insurance. In addition, the inclusion of the funeral benefit was a tactical error since it threatened the gigantic structure of the commercial life insurance industry. Political naivete on the part of the reformers in failing to deal with the interest group opposition, ideology, historical experience, and the overall political context all played a key role in shaping how these groups identified and expressed their interests.
The 1920’s
There was some activity in the 1920’s that changed the nature of the debate when it awoke again in the 1930’s. In the 1930’s, the focus shifted from stabilizing income to financing and expanding access to medical care. By now, medical costs for workers were regarded as a more serious problem than wage loss from sickness. For a number of reasons, health care costs also began to rise during the 1920’s, mostly because the middle class began to use hospital services and hospital costs started to increase. Medical, and especially hospital, care was now a bigger item in family budgets than wage losses.
The CCMC
Next came the Committee on the Cost of Medical Care (CCMC). Concerns over the cost and distribution of medical care led to the formation of this self-created, privately funded group. The committee was funded by 8 philanthropic organizations including the Rockefeller, Millbank, and Rosenwald foundations. They first met in 1926 and ceased meeting in 1932. The CCMC was comprised of fifty economists, physicians, public health specialists, and major interest groups. Their research determined that there was a need for more medical care for everyone, and they published these findings in 26 research volumes and 15 smaller reports over a 5-year period. The CCMC recommended that more national resources go to medical care and saw voluntary, not compulsory, health insurance as a means to covering these costs. Most CCMC members opposed compulsory health insurance, but there was no consensus on this point within the committee. The AMA treated their report as a radical document advocating socialized medicine, and the acerbic and conservative editor of JAMA called it “an incitement to revolution.”
FDR’s first attempt — failure to include in the Social Security Bill of 1935
Next came Franklin D. Roosevelt (FDR), whose tenure (1933-1945) can be characterized by WWI, the Great Depression, and the New Deal, including the Social Security Bill. We might have thought the Great Depression would create the perfect conditions for passing compulsory health insurance in the US, but with millions out of work, unemployment insurance took priority followed by old age benefits. FDR’s Committee on Economic Security, the CES, feared that inclusion of health insurance in its bill, which was opposed by the AMA, would threaten the passage of the entire Social Security legislation. It was therefore excluded.
FDR’s second attempt— Wagner Bill, National Health Act of 1939
But there was one more push for national health insurance during FDR’s administration: The Wagner National Health Act of 1939. Though it never received FDR’s full support, the proposal grew out of his Tactical Committee on Medical Care, established in 1937. The essential elements of the technical committee’s reports were incorporated into Senator Wagner’s bill, the National Health Act of 1939, which gave general support for a national health program to be funded by federal grants to states and administered by states and localities. However, the 1938 election brought a conservative resurgence and any further innovations in social policy were extremely difficult. Most of the social policy legislation precedes 1938. Just as the AALL campaign ran into the declining forces of progressivism and then WWI, the movement for national health insurance in the 1930’s ran into the declining fortunes of the New Deal and then WWII.Henry Sigerist
About this time, Henry Sigerist was in the US He was a very influential medical historian at Johns Hopkins University who played a major role in medical politics during the 1930’s and 1940’s. He passionately believed in a national health program and compulsory health insurance. Several of Sigerist’s most devoted students went on to become key figures in the fields of public health, community and preventative medicine, and health care organization. Many of them, including Milton Romer and Milton Terris, were instrumental in forming the medical care section of the American Public Health Association, which then served as a national meeting ground for those committed to health care reform.
Wagner-Murray-Dingell Bills: 1943 and onward through the decade
The Wagner Bill evolved and shifted from a proposal for federal grants-in- aid to a proposal for national health insurance. First introduced in 1943, it became the very famous Wagner-Murray- Dingell Bill. The bill called for compulsory national health insurance and a payroll tax. In 1944, the Committee for the Nation’s Health, (which grew out of the earlier Social Security Charter Committee), was a group of representatives of organized labor, progressive farmers, and liberal physicians who were the foremost lobbying group for the Wagner-Murray-Dingell Bill. Prominent members of the committee included Senators Murray and Dingell, the head of the Physician’s Forum, and Henry Sigerist. Opposition to this bill was enormous and the antagonists launched a scathing red baiting attack on the committee saying that one of its key policy analysts, I.S. Falk, was a conduit between the International Labor Organization (ILO) in Switzerland and the United States government. The ILO was red-baited as “an awesome political machine bent on world domination.” They even went so far was to suggest that the United States Social Security board functioned as an ILO subsidiary. Although the Wagner-Murray-Dingell Bill generated extensive national debates, with the intensified opposition, the bill never passed by Congress despite its reintroduction every session for 14 years! Had it passed, the Act would have established compulsory national health insurance funded by payroll taxes.
Truman’s Support
After FDR died, Truman became president (1945-1953), and his tenure is characterized by the Cold War and Communism. The health care issue finally moved into the center arena of national politics and received the unreserved support of an American president. Though he served during some of the most virulent anti-Communist attacks and the early years of the Cold War, Truman fully supported national health insurance. But the opposition had acquired new strength. Compulsory health insurance became entangled in the Cold War and its opponents were able to make “socialized medicine” a symbolic issue in the growing crusade against Communist influence in America.
Truman’s plan for national health insurance in 1945 was different than FDR’s plan in 1938 because Truman was strongly committed to a single universal comprehensive health insurance plan. Whereas FDR’s 1938 program had a separate proposal for medical care of the needy, it was Truman who proposed a single egalitarian system that included all classes of society, not just the working class. He emphasized that this was not “socialized medicine.” He also dropped the funeral benefit that contributed to the defeat of national insurance in the Progressive Era. Congress had mixed reactions to Truman’s proposal. The chairman of the House Committee was an anti-union conservative and refused to hold hearings. Senior Republican Senator Taft declared, “I consider it socialism. It is to my mind the most socialistic measure this Congress has ever had before it.” Taft suggested that compulsory health insurance, like the Full Unemployment Act, came right out of the Soviet constitution and walked out of the hearings. The AMA, the American Hospital Association, the American Bar Association, and most of then nation’s press had no mixed feelings; they hated the plan. The AMA claimed it would make doctors slaves, even though Truman emphasized that doctors would be able to choose their method of payment.
In 1946, the Republicans took control of Congress and had no interest in enacting national health insurance. They charged that it was part of a large socialist scheme. Truman responded by focusing even more attention on a national health bill in the 1948 election. After Truman’s surprise victory in 1948, the AMA thought Armageddon had come. They assessed their members an extra $25 each to resist national health insurance, and in 1945 they spent $1.5 million on lobbying efforts which at the time was the most expensive lobbying effort in American history. They had one pamphlet that said, “Would socialized medicine lead to socialization of other phases of life? Lenin thought so. He declared socialized medicine is the keystone to the arch of the socialist state.” The AMA and its supporters were again very successful in linking socialism with national health insurance, and as anti-Communist sentiment rose in the late 1940’s and the Korean War began, national health insurance became vanishingly improbable. Truman’s plan died in a congressional committee. Compromises were proposed but none were successful. Instead of a single health insurance system for the entire population, America would have a system of private insurance for those who could afford it and public welfare services for the poor. Discouraged by yet another defeat, the advocates of health insurance now turned toward a more modest proposal they hoped the country would adopt: hospital insurance for the aged and the beginnings of Medicare.
After WWII, other private insurance systems expanded and provided enough protection for groups that held influence in American to prevent any great agitation for national health insurance in the 1950’s and early 1960’s. Union-negotiated health care benefits also served to cushion workers from the impact of health care costs and undermined the movement for a government program.
Why did these efforts for universal national health insurance fail again?
For may of the same reasons they failed before: interest group influence (code words for class), ideological differences, anti-communism, anti-socialism, fragmentation of public policy, the entrepreneurial character of American medicine, a tradition of American voluntarism, removing the middle class from the coalition of advocates for change through the alternative of Blue Cross private insurance plans, and the association of public programs with charity, dependence, personal failure and the almshouses of years gone by.
For the next several years, not much happened in terms of national health insurance initiatives. The nation focussed more on unions as a vehicle for health insurance, the Hill-Burton Act of 1946 related to hospital expansion, medical research and vaccines, the creation of national institutes of health, and advances in psychiatry.
Johnson and Medicare/caid
Finally, Rhode Island congressman Aime Forand introduced a new proposal in 1958 to cover hospital costs for the aged on social security. Predictably, the AMA undertook a massive campaign to portray a government insurance plan as a threat to the patient-doctor relationship. But by concentrating on the aged, the terms of the debate began to change for the first time. There was major grass roots support from seniors and the pressures assumed the proportions of a crusade. In the entire history of the national health insurance campaign, this was the first time that a ground swell of grass roots support forced an issue onto the national agenda. The AMA countered by introducing an “eldercare plan,” which was voluntary insurance with broader benefits and physician services. In response, the government expanded its proposed legislation to cover physician services, and what came of it were Medicare and Medicaid. The necessary political compromises and private concessions to the doctors (reimbursements of their customary, reasonable, and prevailing fees), to the hospitals (cost plus reimbursement), and to the Republicans created a 3-part plan, including the Democratic proposal for comprehensive health insurance (“Part A”), the revised Republican program of government subsidized voluntary physician insurance (“Part B”), and Medicaid. Finally, in 1965, Johnson signed it into law as part of his Great Society Legislation, capping 20 years of congressional debate.
What does history teach us? What is the movement reacting to?
1.Henry Sigerist reflected in his own diary in 1943 that he “wanted to use history to solve the problems of modern medicine.” I think this is, perhaps, a most important lesson. Damning her own naivete, Hillary Clinton acknowledged in 1994 that “I did not appreciate how sophisticated the opposition would be in conveying messages that were effectively political even though substantively wrong.” Maybe Hillary should have had this history lesson first.
2.The institutional representatives of society do not always represent those that they claim to represent, just as the AMA does not represent all doctors. This lack of representation presents an opportunity for attracting more people to the cause. The AMA has always played an oppositional role and it would be prudent to build an alternative to the AMA for the 60% of physicians who are not members.
3.Just because President Bill Clinton failed doesn’t mean it’s over. There have been periods of acquiescence in this debate before. Those who oppose it can not kill this movement. Openings will occur again. We all need to be on the lookout for those openings and also need to create openings where we see opportunities. For example, the focus on health care costs of the 1980’s presented a division in the ruling class and the debate moved into the center again. As hockey great Wayne Gretzky said, “Success is not a matter of skating to where the puck is, it is a matter of skating to where the puck will be.”
4.Whether we like it or not, we are going to have to deal with the persistence of the narrow vision of middle class politics. Vincente Navarro says that the majority opinion of national health insurance has everything to do with repression and coercion by the capitalist corporate dominant class. He argues that the conflict and struggles that continuously take place around the issue of health care unfold within the parameters of class and that coercion and repression are forces that determine policy. I think when we talk about interest groups in this country, it is really a code for class.
5.Red-baiting is a red herring and has been used throughout history to evoke fear and may continue to be used in these post Cold War times by those who wish to inflame this debate.
6.Grass roots initiatives contributed in part to the passage of Medicare, and they can work again. Ted Marmor says that “pressure groups that can prevail in quiet politics are far weaker in contexts of mass attention — as the AMA regretfully learned during the Medicare battle.” Marmor offers these lessons from the past: “Compulsory health insurance, whatever the details, is an ideological controversial matter that involves enormous financial and professional stakes. Such legislation does not emerge quietly or with broad partisan support. Legislative success requires active presidential leadership, the commitment of an Administration’s political capital, and the exercise of all manner of persuasion and arm-twisting.”
7.One Canadian lesson — the movement toward universal health care in Canada started in 1916 (depending on when you start counting), and took until 1962 for passage of both hospital and doctor care in a single province. It took another decade for the rest of the country to catch on. That is about 50 years all together. It wasn’t like we sat down over afternoon tea and crumpets and said please pass the health care bill so we can sign it and get on with the day. We fought, we threatened, the doctors went on strike, refused patients, people held rallies and signed petitions for and against it, burned effigies of government leaders, hissed, jeered, and booed at the doctors or the Premier depending on whose side they were on. In a nutshell, we weren’t the sterotypical nice polite Canadians. Although there was plenty of resistance, now you could more easily take away Christmas than health care, despite the rhetoric that you may hear to the contrary.
8.Finally there is always hope for flexibility and change. In researching this talk, I went through a number of historical documents and one of my favorite quotes that speaks to hope and change come from a 1939 issue of Times Magazine with Henry Sigerist on the cover. The article said about Sigerist: “Students enjoy his lively classes, for Sigerist does not mind expounding his dynamic conception of medical history in hand-to-hand argument. A student once took issue with him and when Dr. Sigerist asked him to quote his authority, the student shouted, “You yourself said so!” “When?” asked Dr. Sigerist. “Three years ago,” answered the student. “Ah,” said Dr. Sigerist, “three years is a long time. I’ve changed my mind since then.” I guess for me this speaks to the changing tides of opinion and that everything is in flux and open to renegotiation.
Acknowledgements:
Special thanks to medical historians and PNHP colleagues Corinne Sutter-Brown and Ted Brown for background information, critical analysis, and editing.References:
Much of this talk was paraphrased/annotated directly from the sources below, in particular the work of Paul Starr:
1.Bauman, Harold, “Verging on National Health Insurance since 1910” in Changing to National Health Care: Ethical and Policy Issues (Vol. 4, Ethics in a Changing World) edited by Heufner, Robert P. and Margaret # P. Battin, University of Utah Press, 1992.
2.“Boost President’s Plan”, Washington Post, p. A23, February 7, 1992.
Brown, Ted. “Isaac Max Rubinow”, (a biographical sketch), American Journal of Public Health, Vol. 87, No. 11, pp. 1863-1864, 1997
3.Danielson, David A., and Arthur Mazer. “The Massachusetts Referendum for a National Health Program”, Journal of Public Health Policy, Summer 1986.
4.Derickson, Alan. “The House of Falk: The Paranoid Style in American House Politics”, American Journal of Public Health”, Vol. 87, No. 11, pp. 1836 – 1843, 1997.
5.Falk, I.S. “Proposals for National Health Insurance in the USA: Origins and Evolution and Some Perspectives for the Future’, Milbank Memorial Fund Quarterly, Health and Society, pp. 161-191, Spring 1977.
6.Gordon, Colin. “Why No National Health Insurance in the US? The Limits of Social Provision in War and Peace, 1941-1948”, Journal of Policy History, Vol. 9, No. 3, pp. 277-310, 1997.
7.“History in a Tea Wagon”, Time Magazine, No. 5, pp. 51-53, January 30, 1939.
8.Marmor, Ted. “The History of Health Care Reform”, Roll Call, pp. 21,40, July 19, 1993.
9.Navarro, Vicente. “Medical History as a Justification Rather than Explanation: Critique of Starr’s The Social Transformation of American Medicine” International Journal of Health Services, Vol. 14, No. 4, pp. 511-528, 1984.
10.Navarro, Vicente. “Why Some Countries Have National Health Insurance, Others Have National Health Service, and the United States has Neither”, International Journal of Health Services, Vol. 19, No. 3, pp. 383-404, 1989.
11.Rothman, David J. “A Century of Failure: Health Care Reform in America”, Journal of Health Politics, Policy and Law”, Vol. 18, No. 2, Summer 1993.
12.Rubinow, Isaac Max. “Labor Insurance”, American Journal of Public Health, Vol. 87, No. 11, pp. 1862 – 1863, 1997 (Originally published in Journal of Political Economy, Vol. 12, pp. 362-281, 1904).
13.Starr, Paul. The Social Transformation of American Medicine: The rise of a sovereign profession and the making of a vast industry. Basic Books, 1982.
14.Starr, Paul. “Transformation in Defeat: The Changing Objectives of National Health Insurance, 1915-1980”, American Journal of Public Health, Vol. 72, No. 1, pp. 78-88, 1982.
15.Terris, Milton. “Crisis and Change in America’s Health System”, American Journal of Public Health, Vol. 63, No. 4, April 1973.
16.“Toward a National Medical Care System: II. The Historical Background”, Editorial, Journal of Public Health Policy, Autumn 1986.
17.Trafford, Abigail, and Christine Russel, “Opening Night for Clinton’s Plan”, Washington Post Health Magazine, pp. 12, 13, 15, September 21, 1993.
Physicians for a National Health Program
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Late 1800’s to Medicare
The campaign for some form of universal government-funded health care has stretched for nearly a century in the US On several occasions, advocates believed they were on the verge of success; yet each time they faced defeat. The evolution of these efforts and the reasons for their failure make for an intriguing lesson in American history, ideology, and character.
Other developed countries have had some form of social insurance (that later evolved into national insurance) for nearly as long as the US has been trying to get it. Some European countries started with compulsory sickness insurance, one of the first systems, for workers beginning in Germany in 1871; other countries including Austria, Hungary, Norway, Britain, Russia, and the Netherlands followed all the way through 1912. Other European countries, including Sweden in 1891, Denmark in 1892, France in 1910, and Switzerland in 1912, subsidized the mutual benefit societies that workers formed among themselves. So for a very long time, other countries have had some form of universal health care or at least the beginnings of it. The primary reason for the emergence of these programs in Europe was income stabilization and protection against the wage loss of sickness rather than payment for medical expenses, which came later. Programs were not universal to start with and were originally conceived as a means of maintaining incomes and buying political allegiance of the workers.
In a seeming paradox, the British and German systems were developed by the more conservative governments in power, specifically as a defense to counter expansion of the socialist and labor parties. They used insurance against the cost of sickness as a way of “turning benevolence to power”.
US circa 1883-1912, including Reformers and the Progressive Era:
What was the US doing during this period of the late 1800’s to 1912? The government took no actions to subsidize voluntary funds or make sick insurance compulsory; essentially the federal government left matters to the states and states left them to private and voluntary programs. The US did have some voluntary funds that provided for their members in the case of sickness or death, but there were no legislative or public programs during the late 19th or early 20th century.
In the Progressive Era, which occurred in the early 20th century, reformers were working to improve social conditions for the working class. However unlike European countries, there was not powerful working class support for broad social insurance in the US The labor and socialist parties’ support for health insurance or sickness funds and benefits programs was much more fragmented than in Europe. Therefore the first proposals for health insurance in the US did not come into political debate under anti-socialist sponsorship as they had in Europe.
Theodore Roosevelt 1901 — 1909
During the Progressive Era, President Theodore Roosevelt was in power and although he supported health insurance because he believed that no country could be strong whose people were sick and poor, most of the initiative for reform took place outside of government. Roosevelt’s successors were mostly conservative leaders, who postponed for about twenty years the kind of presidential leadership that might have involved the national government more extensively in the management of social welfare. (For instance, a key plank in Theodore Roosevelt's losing Presidential campaign of 1912 was national health insurance)
While Roosevelt was campaigning in Milwaukee, Wisconsin, on October 14, 1912, a saloonkeeper named John Schrank shot him, but the bullet lodged in his chest only after penetrating both his steel eyeglass case and passing through a thick (50 pages) single-folded copy of the speech he was carrying in his jacket.[78] Roosevelt, as an experienced hunter and anatomist, correctly concluded that since he wasn't coughing blood the bullet had not completely penetrated the chest wall to his lung, and so declined suggestions he go to the hospital immediately. Instead, he delivered his scheduled speech with blood seeping into his shirt.[79] He spoke for ninety minutes. His opening comments to the gathered crowd were, "Ladies and gentlemen, I don't know whether you fully understand that I have just been shot; but it takes more than that to kill a Bull Moose."[80] Afterwards, probes and X-ray showed that the bullet had traversed three inches (76 mm) of tissue and lodged in Roosevelt's chest muscle but did not penetrate the pleura, and it would be more dangerous to attempt to remove the bullet than to leave it in place. Roosevelt carried it with him for the rest of his life.
Due to the bullet wound, Roosevelt was taken off the campaign trail in the final weeks of the race (which ended election day, November 5). Though the other two campaigners stopped their own campaigns in the week Roosevelt was in the hospital, they resumed it once he was released. The overall effect of the shooting was uncertain. Roosevelt for many reasons failed to move enough Republicans in his direction. He did win 4.1 million votes (27%), compared to Taft's 3.5 million (23%). However, Wilson's 6.3 million votes (42%) were enough to garner 435 electoral votes. Roosevelt had 88 electoral votes to Taft's 8 electoral votes. (This meant that Taft became the only incumbent President in history to actually come in third place in an attempt to be re-elected.)
AALL Bill 1915
In 1906, the American Association of Labor Legislation (AALL) finally led the campaign for health insurance. They were a typical progressive group whose mandate was not to abolish capitalism but rather to reform it. In 1912, they created a committee on social welfare which held its first national conference in 1913. Despite its broad mandate, the committee decided to concentrate on health insurance, drafting a model bill in 1915. In a nutshell, the bill limited coverage to the working class and all others that earned less than $1200 a year, including dependents. The services of physicians, nurses, and hospitals were included, as was sick pay, maternity benefits, and a death benefit of fifty dollars to pay for funeral expenses. This death benefit becomes significant later on. Costs were to be shared between workers, employers, and the state.
AMA supported AALL Proposal
In 1914, reformers sought to involve physicians in formulating this bill and the American Medical Association (AMA) actually supported the AALL proposal. They found prominent physicians who were not only sympathetic, but who also wanted to support and actively help in securing legislation. In fact, some physicians who were leaders in the AMA wrote to the AALL secretary: “Your plans are so entirely in line with our own that we want to be of every possible assistance.” By 1916, the AMA board approved a committee to work with AALL, and at this point the AMA and AALL formed a united front on behalf of health insurance. Times have definitely changed along the way.
In 1917, the AMA House of Delegates favored compulsory health insurance as proposed by the AALL, but many state medical societies opposed it. There was disagreement on the method of paying physicians and it was not long before the AMA leadership denied it had ever favored the measure.
AFL opposed AALL Proposal
Meanwhile the president of the American Federation of Labor repeatedly denounced compulsory health insurance as an unnecessary paternalistic reform that would create a system of state supervision over people’s health. They apparently worried that a government-based insurance system would weaken unions by usurping their role in providing social benefits. Their central concern was maintaining union strength, which was understandable in a period before collective bargaining was legally sanctioned.
Private insurance industry opposed AALL Proposal
The commercial insurance industry also opposed the reformers’ efforts in the early 20th century. There was great fear among the working class of what they called a “pauper’s burial,” so the backbone of insurance business was policies for working class families that paid death benefits and covered funeral expenses. But because the reformer health insurance plans also covered funeral expenses, there was a big conflict. Reformers felt that by covering death benefits, they could finance much of the health insurance costs from the money wasted by commercial insurance policies who had to have an army of insurance agents to market and collect on these policies. But since this would have pulled the rug out from under the multi-million dollar commercial life insurance industry, they opposed the national health insurance proposal.
WWI and anti-German fever
In 1917, the US entered WWI and anti-German fever rose. The government-commissioned articles denouncing “German socialist insurance” and opponents of health insurance assailed it as a “Prussian menace” inconsistent with American values. Other efforts during this time in California, namely the California Social Insurance Commission, recommended health insurance, proposed enabling legislation in 1917, and then held a referendum. New York, Ohio, Pennsylvania, and Illinois also had some efforts aimed at health insurance. But in the Red Scare, immediately after the war, when the government attempted to root out the last vestiges of radicalism, opponents of compulsory health insurance associated it with Bolshevism and buried it in an avalanche of anti-Communist rhetoric. This marked the end of the compulsory national health debate until the 1930’s.
Why did the Progressives fail?
Opposition from doctors, labor, insurance companies, and business contributed to the failure of Progressives to achieve compulsory national health insurance. In addition, the inclusion of the funeral benefit was a tactical error since it threatened the gigantic structure of the commercial life insurance industry. Political naivete on the part of the reformers in failing to deal with the interest group opposition, ideology, historical experience, and the overall political context all played a key role in shaping how these groups identified and expressed their interests.
The 1920’s
There was some activity in the 1920’s that changed the nature of the debate when it awoke again in the 1930’s. In the 1930’s, the focus shifted from stabilizing income to financing and expanding access to medical care. By now, medical costs for workers were regarded as a more serious problem than wage loss from sickness. For a number of reasons, health care costs also began to rise during the 1920’s, mostly because the middle class began to use hospital services and hospital costs started to increase. Medical, and especially hospital, care was now a bigger item in family budgets than wage losses.
The CCMC
Next came the Committee on the Cost of Medical Care (CCMC). Concerns over the cost and distribution of medical care led to the formation of this self-created, privately funded group. The committee was funded by 8 philanthropic organizations including the Rockefeller, Millbank, and Rosenwald foundations. They first met in 1926 and ceased meeting in 1932. The CCMC was comprised of fifty economists, physicians, public health specialists, and major interest groups. Their research determined that there was a need for more medical care for everyone, and they published these findings in 26 research volumes and 15 smaller reports over a 5-year period. The CCMC recommended that more national resources go to medical care and saw voluntary, not compulsory, health insurance as a means to covering these costs. Most CCMC members opposed compulsory health insurance, but there was no consensus on this point within the committee. The AMA treated their report as a radical document advocating socialized medicine, and the acerbic and conservative editor of JAMA called it “an incitement to revolution.”
FDR’s first attempt — failure to include in the Social Security Bill of 1935
Next came Franklin D. Roosevelt (FDR), whose tenure (1933-1945) can be characterized by WWI, the Great Depression, and the New Deal, including the Social Security Bill. We might have thought the Great Depression would create the perfect conditions for passing compulsory health insurance in the US, but with millions out of work, unemployment insurance took priority followed by old age benefits. FDR’s Committee on Economic Security, the CES, feared that inclusion of health insurance in its bill, which was opposed by the AMA, would threaten the passage of the entire Social Security legislation. It was therefore excluded.
FDR’s second attempt— Wagner Bill, National Health Act of 1939
But there was one more push for national health insurance during FDR’s administration: The Wagner National Health Act of 1939. Though it never received FDR’s full support, the proposal grew out of his Tactical Committee on Medical Care, established in 1937. The essential elements of the technical committee’s reports were incorporated into Senator Wagner’s bill, the National Health Act of 1939, which gave general support for a national health program to be funded by federal grants to states and administered by states and localities. However, the 1938 election brought a conservative resurgence and any further innovations in social policy were extremely difficult. Most of the social policy legislation precedes 1938. Just as the AALL campaign ran into the declining forces of progressivism and then WWI, the movement for national health insurance in the 1930’s ran into the declining fortunes of the New Deal and then WWII.Henry Sigerist
About this time, Henry Sigerist was in the US He was a very influential medical historian at Johns Hopkins University who played a major role in medical politics during the 1930’s and 1940’s. He passionately believed in a national health program and compulsory health insurance. Several of Sigerist’s most devoted students went on to become key figures in the fields of public health, community and preventative medicine, and health care organization. Many of them, including Milton Romer and Milton Terris, were instrumental in forming the medical care section of the American Public Health Association, which then served as a national meeting ground for those committed to health care reform.
Wagner-Murray-Dingell Bills: 1943 and onward through the decade
The Wagner Bill evolved and shifted from a proposal for federal grants-in- aid to a proposal for national health insurance. First introduced in 1943, it became the very famous Wagner-Murray- Dingell Bill. The bill called for compulsory national health insurance and a payroll tax. In 1944, the Committee for the Nation’s Health, (which grew out of the earlier Social Security Charter Committee), was a group of representatives of organized labor, progressive farmers, and liberal physicians who were the foremost lobbying group for the Wagner-Murray-Dingell Bill. Prominent members of the committee included Senators Murray and Dingell, the head of the Physician’s Forum, and Henry Sigerist. Opposition to this bill was enormous and the antagonists launched a scathing red baiting attack on the committee saying that one of its key policy analysts, I.S. Falk, was a conduit between the International Labor Organization (ILO) in Switzerland and the United States government. The ILO was red-baited as “an awesome political machine bent on world domination.” They even went so far was to suggest that the United States Social Security board functioned as an ILO subsidiary. Although the Wagner-Murray-Dingell Bill generated extensive national debates, with the intensified opposition, the bill never passed by Congress despite its reintroduction every session for 14 years! Had it passed, the Act would have established compulsory national health insurance funded by payroll taxes.
Truman’s Support
After FDR died, Truman became president (1945-1953), and his tenure is characterized by the Cold War and Communism. The health care issue finally moved into the center arena of national politics and received the unreserved support of an American president. Though he served during some of the most virulent anti-Communist attacks and the early years of the Cold War, Truman fully supported national health insurance. But the opposition had acquired new strength. Compulsory health insurance became entangled in the Cold War and its opponents were able to make “socialized medicine” a symbolic issue in the growing crusade against Communist influence in America.
Truman’s plan for national health insurance in 1945 was different than FDR’s plan in 1938 because Truman was strongly committed to a single universal comprehensive health insurance plan. Whereas FDR’s 1938 program had a separate proposal for medical care of the needy, it was Truman who proposed a single egalitarian system that included all classes of society, not just the working class. He emphasized that this was not “socialized medicine.” He also dropped the funeral benefit that contributed to the defeat of national insurance in the Progressive Era. Congress had mixed reactions to Truman’s proposal. The chairman of the House Committee was an anti-union conservative and refused to hold hearings. Senior Republican Senator Taft declared, “I consider it socialism. It is to my mind the most socialistic measure this Congress has ever had before it.” Taft suggested that compulsory health insurance, like the Full Unemployment Act, came right out of the Soviet constitution and walked out of the hearings. The AMA, the American Hospital Association, the American Bar Association, and most of then nation’s press had no mixed feelings; they hated the plan. The AMA claimed it would make doctors slaves, even though Truman emphasized that doctors would be able to choose their method of payment.
In 1946, the Republicans took control of Congress and had no interest in enacting national health insurance. They charged that it was part of a large socialist scheme. Truman responded by focusing even more attention on a national health bill in the 1948 election. After Truman’s surprise victory in 1948, the AMA thought Armageddon had come. They assessed their members an extra $25 each to resist national health insurance, and in 1945 they spent $1.5 million on lobbying efforts which at the time was the most expensive lobbying effort in American history. They had one pamphlet that said, “Would socialized medicine lead to socialization of other phases of life? Lenin thought so. He declared socialized medicine is the keystone to the arch of the socialist state.” The AMA and its supporters were again very successful in linking socialism with national health insurance, and as anti-Communist sentiment rose in the late 1940’s and the Korean War began, national health insurance became vanishingly improbable. Truman’s plan died in a congressional committee. Compromises were proposed but none were successful. Instead of a single health insurance system for the entire population, America would have a system of private insurance for those who could afford it and public welfare services for the poor. Discouraged by yet another defeat, the advocates of health insurance now turned toward a more modest proposal they hoped the country would adopt: hospital insurance for the aged and the beginnings of Medicare.
After WWII, other private insurance systems expanded and provided enough protection for groups that held influence in American to prevent any great agitation for national health insurance in the 1950’s and early 1960’s. Union-negotiated health care benefits also served to cushion workers from the impact of health care costs and undermined the movement for a government program.
Why did these efforts for universal national health insurance fail again?
For may of the same reasons they failed before: interest group influence (code words for class), ideological differences, anti-communism, anti-socialism, fragmentation of public policy, the entrepreneurial character of American medicine, a tradition of American voluntarism, removing the middle class from the coalition of advocates for change through the alternative of Blue Cross private insurance plans, and the association of public programs with charity, dependence, personal failure and the almshouses of years gone by.
For the next several years, not much happened in terms of national health insurance initiatives. The nation focussed more on unions as a vehicle for health insurance, the Hill-Burton Act of 1946 related to hospital expansion, medical research and vaccines, the creation of national institutes of health, and advances in psychiatry.
Johnson and Medicare/caid
Finally, Rhode Island congressman Aime Forand introduced a new proposal in 1958 to cover hospital costs for the aged on social security. Predictably, the AMA undertook a massive campaign to portray a government insurance plan as a threat to the patient-doctor relationship. But by concentrating on the aged, the terms of the debate began to change for the first time. There was major grass roots support from seniors and the pressures assumed the proportions of a crusade. In the entire history of the national health insurance campaign, this was the first time that a ground swell of grass roots support forced an issue onto the national agenda. The AMA countered by introducing an “eldercare plan,” which was voluntary insurance with broader benefits and physician services. In response, the government expanded its proposed legislation to cover physician services, and what came of it were Medicare and Medicaid. The necessary political compromises and private concessions to the doctors (reimbursements of their customary, reasonable, and prevailing fees), to the hospitals (cost plus reimbursement), and to the Republicans created a 3-part plan, including the Democratic proposal for comprehensive health insurance (“Part A”), the revised Republican program of government subsidized voluntary physician insurance (“Part B”), and Medicaid. Finally, in 1965, Johnson signed it into law as part of his Great Society Legislation, capping 20 years of congressional debate.
What does history teach us? What is the movement reacting to?
1.Henry Sigerist reflected in his own diary in 1943 that he “wanted to use history to solve the problems of modern medicine.” I think this is, perhaps, a most important lesson. Damning her own naivete, Hillary Clinton acknowledged in 1994 that “I did not appreciate how sophisticated the opposition would be in conveying messages that were effectively political even though substantively wrong.” Maybe Hillary should have had this history lesson first.
2.The institutional representatives of society do not always represent those that they claim to represent, just as the AMA does not represent all doctors. This lack of representation presents an opportunity for attracting more people to the cause. The AMA has always played an oppositional role and it would be prudent to build an alternative to the AMA for the 60% of physicians who are not members.
3.Just because President Bill Clinton failed doesn’t mean it’s over. There have been periods of acquiescence in this debate before. Those who oppose it can not kill this movement. Openings will occur again. We all need to be on the lookout for those openings and also need to create openings where we see opportunities. For example, the focus on health care costs of the 1980’s presented a division in the ruling class and the debate moved into the center again. As hockey great Wayne Gretzky said, “Success is not a matter of skating to where the puck is, it is a matter of skating to where the puck will be.”
4.Whether we like it or not, we are going to have to deal with the persistence of the narrow vision of middle class politics. Vincente Navarro says that the majority opinion of national health insurance has everything to do with repression and coercion by the capitalist corporate dominant class. He argues that the conflict and struggles that continuously take place around the issue of health care unfold within the parameters of class and that coercion and repression are forces that determine policy. I think when we talk about interest groups in this country, it is really a code for class.
5.Red-baiting is a red herring and has been used throughout history to evoke fear and may continue to be used in these post Cold War times by those who wish to inflame this debate.
6.Grass roots initiatives contributed in part to the passage of Medicare, and they can work again. Ted Marmor says that “pressure groups that can prevail in quiet politics are far weaker in contexts of mass attention — as the AMA regretfully learned during the Medicare battle.” Marmor offers these lessons from the past: “Compulsory health insurance, whatever the details, is an ideological controversial matter that involves enormous financial and professional stakes. Such legislation does not emerge quietly or with broad partisan support. Legislative success requires active presidential leadership, the commitment of an Administration’s political capital, and the exercise of all manner of persuasion and arm-twisting.”
7.One Canadian lesson — the movement toward universal health care in Canada started in 1916 (depending on when you start counting), and took until 1962 for passage of both hospital and doctor care in a single province. It took another decade for the rest of the country to catch on. That is about 50 years all together. It wasn’t like we sat down over afternoon tea and crumpets and said please pass the health care bill so we can sign it and get on with the day. We fought, we threatened, the doctors went on strike, refused patients, people held rallies and signed petitions for and against it, burned effigies of government leaders, hissed, jeered, and booed at the doctors or the Premier depending on whose side they were on. In a nutshell, we weren’t the sterotypical nice polite Canadians. Although there was plenty of resistance, now you could more easily take away Christmas than health care, despite the rhetoric that you may hear to the contrary.
8.Finally there is always hope for flexibility and change. In researching this talk, I went through a number of historical documents and one of my favorite quotes that speaks to hope and change come from a 1939 issue of Times Magazine with Henry Sigerist on the cover. The article said about Sigerist: “Students enjoy his lively classes, for Sigerist does not mind expounding his dynamic conception of medical history in hand-to-hand argument. A student once took issue with him and when Dr. Sigerist asked him to quote his authority, the student shouted, “You yourself said so!” “When?” asked Dr. Sigerist. “Three years ago,” answered the student. “Ah,” said Dr. Sigerist, “three years is a long time. I’ve changed my mind since then.” I guess for me this speaks to the changing tides of opinion and that everything is in flux and open to renegotiation.
Acknowledgements:
Special thanks to medical historians and PNHP colleagues Corinne Sutter-Brown and Ted Brown for background information, critical analysis, and editing.References:
Much of this talk was paraphrased/annotated directly from the sources below, in particular the work of Paul Starr:
1.Bauman, Harold, “Verging on National Health Insurance since 1910” in Changing to National Health Care: Ethical and Policy Issues (Vol. 4, Ethics in a Changing World) edited by Heufner, Robert P. and Margaret # P. Battin, University of Utah Press, 1992.
2.“Boost President’s Plan”, Washington Post, p. A23, February 7, 1992.
Brown, Ted. “Isaac Max Rubinow”, (a biographical sketch), American Journal of Public Health, Vol. 87, No. 11, pp. 1863-1864, 1997
3.Danielson, David A., and Arthur Mazer. “The Massachusetts Referendum for a National Health Program”, Journal of Public Health Policy, Summer 1986.
4.Derickson, Alan. “The House of Falk: The Paranoid Style in American House Politics”, American Journal of Public Health”, Vol. 87, No. 11, pp. 1836 – 1843, 1997.
5.Falk, I.S. “Proposals for National Health Insurance in the USA: Origins and Evolution and Some Perspectives for the Future’, Milbank Memorial Fund Quarterly, Health and Society, pp. 161-191, Spring 1977.
6.Gordon, Colin. “Why No National Health Insurance in the US? The Limits of Social Provision in War and Peace, 1941-1948”, Journal of Policy History, Vol. 9, No. 3, pp. 277-310, 1997.
7.“History in a Tea Wagon”, Time Magazine, No. 5, pp. 51-53, January 30, 1939.
8.Marmor, Ted. “The History of Health Care Reform”, Roll Call, pp. 21,40, July 19, 1993.
9.Navarro, Vicente. “Medical History as a Justification Rather than Explanation: Critique of Starr’s The Social Transformation of American Medicine” International Journal of Health Services, Vol. 14, No. 4, pp. 511-528, 1984.
10.Navarro, Vicente. “Why Some Countries Have National Health Insurance, Others Have National Health Service, and the United States has Neither”, International Journal of Health Services, Vol. 19, No. 3, pp. 383-404, 1989.
11.Rothman, David J. “A Century of Failure: Health Care Reform in America”, Journal of Health Politics, Policy and Law”, Vol. 18, No. 2, Summer 1993.
12.Rubinow, Isaac Max. “Labor Insurance”, American Journal of Public Health, Vol. 87, No. 11, pp. 1862 – 1863, 1997 (Originally published in Journal of Political Economy, Vol. 12, pp. 362-281, 1904).
13.Starr, Paul. The Social Transformation of American Medicine: The rise of a sovereign profession and the making of a vast industry. Basic Books, 1982.
14.Starr, Paul. “Transformation in Defeat: The Changing Objectives of National Health Insurance, 1915-1980”, American Journal of Public Health, Vol. 72, No. 1, pp. 78-88, 1982.
15.Terris, Milton. “Crisis and Change in America’s Health System”, American Journal of Public Health, Vol. 63, No. 4, April 1973.
16.“Toward a National Medical Care System: II. The Historical Background”, Editorial, Journal of Public Health Policy, Autumn 1986.
17.Trafford, Abigail, and Christine Russel, “Opening Night for Clinton’s Plan”, Washington Post Health Magazine, pp. 12, 13, 15, September 21, 1993.
Physicians for a National Health Program
29 E Madison Suite 602, Chicago, IL 60602
Phone (312) 782-6006 | Fax: (312) 782-6007 | email: info@pnhp.org
© PNHP 2009
http://www.pnhp.org/facts/a_brief_history_universal_health_care_efforts_in_the_us.php?page=all
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Let's Use the Mayo Clinic as a Guideline
Case Study Demonstrates the Value of
a Self-Care Strategy in Better Managing Disease and Health Care Costs
Since the mid-1990s, an enormous push toward personal empowerment and informed decision making has taken center stage as a means to change behavior and encourage people to better manage disease and subsequent health care costs. In recent years, a tremendous emphasis on self-care has enabled individuals to make well-informed decisions about when to seek care versus when to self-treat, and even how to self-treat, based on proven clinical recommendations.
A published case study of one of Mayo Clinic Health Solutions' clients, Springs Global, confirms the positive impact of a strategic self-care strategy.
Springs Global (formerly Springs Industries) is one of the largest textile companies in the United States. Like many organizations, Springs Global was faced with mushrooming health care costs and recognized that the key to managing costs was to invest in the health of their more than 10,000 employees. To reduce the bottom-line costs of health care, Springs Global recognized the need for a reliable source of self-care information upon which treatment decisions can be made.
Springs Global distributed the Mayo Clinic EmbodyHealth Guide to Self-Care, and trained employees on its use and value. The initiative yielded some outstanding results as evidenced by a survey that showed 49 percent of respondents reported that the Mayo Clinic EmbodyHealth Guide to Self-Care helped them avoid at least one unnecessary trip to the emergency room, with 9 percent of this group avoiding five or more unnecessary trips to the ER. With the average cost of an ER visit in the U.S. at $360, Springs Global potential cost savings is significant.
According to Frieda Price, occupational nurse manager at Springs Global, “The value of this initiative is clear to all parties involved, and simply makes good business sense.” For more information on Spring Global's self-care program success, request the case study in its entirety
http://www.mayoclinichealthsolutions.com/products/EmbodyHealth-Guide-To-Self-Care-Special-Report.cfm
---------------------------------------------------------------------
Decrease Drug Costs — Go Generic
ROCHESTER, Minn. — Today, more than ever, consumers can opt for generic equivalents of brand-name medications at substantial cost savings. According to the December issue of Mayo Clinic Health Letter, generic versions of brand-name prescription drugs can cost 30 percent to 90 percent less.
Last year, the Food and Drug Administration (FDA) approved a record number of generic drug applications, up more than 30 percent from 2006.
Generics might look different from the brand-name drug because they can have different fillers or coloring agents. But the active ingredients are closely regulated by the FDA and must be within a small percentage of the brand-name medication.
For a brand-name drug to become available as a generic can take decades. An initial patent life is 20 years, and patents can be extended for variations on the medication. When the patent expires, the FDA frequently grants one company six months of exclusive rights to produce the generic drug. Usually, the price drops slightly. But if the generic is widely used, other companies will manufacture the drug, and usually the price drops substantially.
Here are some brand-name drugs available as generic since 2006:
Altace (ramipril) for blood pressure and heart failure
Ambien (zolpidem), a sleep aid
Depakote (divalproex) for seizures, migraines and bipolar disorder
Fosamax (alendronate) for osteoporosis
Requip (ropinirole) for restless legs syndrome
Toprol-XL (metoprolol succinate) for blood pressure, heart failure and angina
Zyrtec-D (cetirizine/pseudoephedrine) for allergies. Now available over-the-counter.
Many more brand-name medications are expected to be available in generic forms in the next two years. Among those to watch are the migraine medication Imitrex (sumatriptan), the glaucoma drug Cosopt (timolol/dorzolamide), the anti-seizure drug Topamax (topiramate), and the herpes anti-viral drug Valtrex (valacyclovir).
Ask your doctor or pharmacist about less-expensive medication options. Not all brand-name medications have generic equivalents, but always inquire.
Mayo Clinic Health Letter is an eight-page monthly newsletter of reliable, accurate and practical information on today's health and medical news. To subscribe, please call 800-333-9037 (toll-free), extension 9771, or visit the Mayo Clinic Health Letter Web site.
About Mayo Clinic
Mayo Clinic is the first and largest integrated, not-for-profit group practice in the world. Doctors from every medical specialty work together to care for patients, joined by common systems and a philosophy of "the needs of the patient come first." More than 3,300 physicians, scientists and researchers and 46,000 allied health staff work at Mayo Clinic, which has sites in Rochester, Minn., Jacksonville, Fla., and Scottsdale/Phoenix, Ariz. Collectively, the three locations treat more than half a million people each year. To obtain the latest news releases from Mayo Clinic, go to www.mayoclinic.org/news. For information about research and education visit www.mayo.edu. MayoClinic.com is available as a resource for your health stories.Contact Information
For more information, contact:
Ginger Plumbo
507-284-5005 (days)
507-284-2511 (evenings)
newsbureau@mayo.edu
Terms of Use and Information Applicable to this Site
Copyright ©2001-2009 Mayo Foundation for Medical Education and Research
http://www.mayoclinic.org/news2008-mchi/5116.html?rss-feedid=4
--------------------------------------------------------------
APA/Mayo Partnership to Demonstrate Cost and Health Benefits of Psychological Interventions
--------------------------------------------------------------------------------
by Chris Barrett
Practitioner Focus, August 1997
Public Relations and Communications
Practice Directorate
For more information: E-mail
--------------------------------------------------------------------------------
The APA Practice Directorate recently signed an agreement with the Mayo Clinic of Rochester, Minn., to produce an actuarial model that will show the cost savings and improved health outcomes a health care system can realize if it incorporates psychological services into the treatment of coronary patients. APA and its technical consultant, Coopers and Lybrand, LLP, will use Mayo Clinic data to aid the effort. Once the actuarial model is completed, the directorate intends to pursue a full-scale demonstration project with a health system that is able and willing to test the model's predictions.
Though the concept of 'medical cost offset' has been around for some 30 years, third party payers and policy makers have not been persuaded by the aggregate nature of the data generated thus far, according to Russ Newman, Ph.D., J.D. 'They want to know that specific treatments for designated disorders can save 'X' dollars,' he said. This need provided the impetus for APA to collaborate with the Mayo Clinic.
In working with Coopers and Lybrand to develop its actuarial model, the Practice Directorate will use the Mayo Clinic's own research results combined with data on the clinic's entire cardiac rehabilitation population. This data will be supplemented by information from national health care data bases. By generalizing the Mayo Clinic's claims data and clinical research findings to the national patient population, Coopers and Lybrand will help APA produce a model to predict specific cost savings and improved health outcomes in various health care systems.
Distressed coronary patients at risk
The Mayo Clinic has generated data about the effect of psychological distress on patients recovering from heart attacks. A 1995 Mayo study found that ongoing psychological distress is an independent risk factor for poorer medical outcomes and increased health care costs following a heart attack. Specifically, psychologically-distressed patients were nearly 2.5 times more likely to be rehospitalized than non-distressed patients. And when rehospitalized, distressed patients cost $7,358 more than rehospitalized but non-distressed patients.
Building on their earlier data, Mayo is currently conducting research on the effectiveness of various psychological interventions for the clinic's distressed cardiac rehabilitation patients. The focus of the new research is on the degree of stress reduction in patients, and the impact of psychological services delivery on rehospitalization rates and overall health care costs.
Dr. Newman believes that once APA's actuarial model is complete, the association will be in a good position to convince a suitable health care delivery system to test the model in a large-scale demonstration project. 'If we can complete the demonstration, we should gain conclusive data that can help change the way cardiac rehabilitation services are delivered,' Newman predicted.
Anticipating the successful completion of the actuarial model, the directorate already is identifying several delivery systems that want help with restructuring their treatment and reimbursement mechanisms to accommodate the integration of mental and physical health services. One of these systems is a likely candidate for the APA-sponsored demonstration project.
In recent years, many health care systems have 'carved out' mental health benefits in an effort to control costs and therefore are unable to easily integrate psychological services with medical/surgical treatment. The model APA is developing will require both information management and reimbursement systems that allow for such integration. 'We hope that demonstration projects such as ours will provide a catalyst for health care systems to integrate service delivery by carving back in their mental health services,' Newman said. The upshot, he said, will be improved quality of care at reduced cost.
The Mayo project is part of the directorate's ongoing strategic initiative to help demonstrate psychology's value in the treatment of physical illness and to enhance practice opportunities for psychologists. The directorate is involved in several current and potential demonstration projects intended to provide the kind of specific data on costs and health outcomes that health care payors and policy makers seek.
APA is engaged in a collaborative demonstration project with Blue Cross/Blue Shield of Massachusetts, Inc. and the Linda Pollin Institute Research Program of Harvard Medical School. This project is evaluating the psychological, behavioral and health benefits of providing 16 weeks of group psychotherapy as an integral part of treating women with breast cancer.
http://www.apa.org/practice/pf/aug97/mayo.html
© 2009 American Psychological Association
Practice Directorate
750 First Street, NE • Washington, DC • 20002-4242
Phone: 202-336-5800 • TDD/TTY: 202-336-6123
Fax: 202-336-5797 • Email
a Self-Care Strategy in Better Managing Disease and Health Care Costs
Since the mid-1990s, an enormous push toward personal empowerment and informed decision making has taken center stage as a means to change behavior and encourage people to better manage disease and subsequent health care costs. In recent years, a tremendous emphasis on self-care has enabled individuals to make well-informed decisions about when to seek care versus when to self-treat, and even how to self-treat, based on proven clinical recommendations.
A published case study of one of Mayo Clinic Health Solutions' clients, Springs Global, confirms the positive impact of a strategic self-care strategy.
Springs Global (formerly Springs Industries) is one of the largest textile companies in the United States. Like many organizations, Springs Global was faced with mushrooming health care costs and recognized that the key to managing costs was to invest in the health of their more than 10,000 employees. To reduce the bottom-line costs of health care, Springs Global recognized the need for a reliable source of self-care information upon which treatment decisions can be made.
Springs Global distributed the Mayo Clinic EmbodyHealth Guide to Self-Care, and trained employees on its use and value. The initiative yielded some outstanding results as evidenced by a survey that showed 49 percent of respondents reported that the Mayo Clinic EmbodyHealth Guide to Self-Care helped them avoid at least one unnecessary trip to the emergency room, with 9 percent of this group avoiding five or more unnecessary trips to the ER. With the average cost of an ER visit in the U.S. at $360, Springs Global potential cost savings is significant.
According to Frieda Price, occupational nurse manager at Springs Global, “The value of this initiative is clear to all parties involved, and simply makes good business sense.” For more information on Spring Global's self-care program success, request the case study in its entirety
http://www.mayoclinichealthsolutions.com/products/EmbodyHealth-Guide-To-Self-Care-Special-Report.cfm
---------------------------------------------------------------------
Decrease Drug Costs — Go Generic
ROCHESTER, Minn. — Today, more than ever, consumers can opt for generic equivalents of brand-name medications at substantial cost savings. According to the December issue of Mayo Clinic Health Letter, generic versions of brand-name prescription drugs can cost 30 percent to 90 percent less.
Last year, the Food and Drug Administration (FDA) approved a record number of generic drug applications, up more than 30 percent from 2006.
Generics might look different from the brand-name drug because they can have different fillers or coloring agents. But the active ingredients are closely regulated by the FDA and must be within a small percentage of the brand-name medication.
For a brand-name drug to become available as a generic can take decades. An initial patent life is 20 years, and patents can be extended for variations on the medication. When the patent expires, the FDA frequently grants one company six months of exclusive rights to produce the generic drug. Usually, the price drops slightly. But if the generic is widely used, other companies will manufacture the drug, and usually the price drops substantially.
Here are some brand-name drugs available as generic since 2006:
Altace (ramipril) for blood pressure and heart failure
Ambien (zolpidem), a sleep aid
Depakote (divalproex) for seizures, migraines and bipolar disorder
Fosamax (alendronate) for osteoporosis
Requip (ropinirole) for restless legs syndrome
Toprol-XL (metoprolol succinate) for blood pressure, heart failure and angina
Zyrtec-D (cetirizine/pseudoephedrine) for allergies. Now available over-the-counter.
Many more brand-name medications are expected to be available in generic forms in the next two years. Among those to watch are the migraine medication Imitrex (sumatriptan), the glaucoma drug Cosopt (timolol/dorzolamide), the anti-seizure drug Topamax (topiramate), and the herpes anti-viral drug Valtrex (valacyclovir).
Ask your doctor or pharmacist about less-expensive medication options. Not all brand-name medications have generic equivalents, but always inquire.
Mayo Clinic Health Letter is an eight-page monthly newsletter of reliable, accurate and practical information on today's health and medical news. To subscribe, please call 800-333-9037 (toll-free), extension 9771, or visit the Mayo Clinic Health Letter Web site.
About Mayo Clinic
Mayo Clinic is the first and largest integrated, not-for-profit group practice in the world. Doctors from every medical specialty work together to care for patients, joined by common systems and a philosophy of "the needs of the patient come first." More than 3,300 physicians, scientists and researchers and 46,000 allied health staff work at Mayo Clinic, which has sites in Rochester, Minn., Jacksonville, Fla., and Scottsdale/Phoenix, Ariz. Collectively, the three locations treat more than half a million people each year. To obtain the latest news releases from Mayo Clinic, go to www.mayoclinic.org/news. For information about research and education visit www.mayo.edu. MayoClinic.com is available as a resource for your health stories.Contact Information
For more information, contact:
Ginger Plumbo
507-284-5005 (days)
507-284-2511 (evenings)
newsbureau@mayo.edu
Terms of Use and Information Applicable to this Site
Copyright ©2001-2009 Mayo Foundation for Medical Education and Research
http://www.mayoclinic.org/news2008-mchi/5116.html?rss-feedid=4
--------------------------------------------------------------
APA/Mayo Partnership to Demonstrate Cost and Health Benefits of Psychological Interventions
--------------------------------------------------------------------------------
by Chris Barrett
Practitioner Focus, August 1997
Public Relations and Communications
Practice Directorate
For more information: E-mail
--------------------------------------------------------------------------------
The APA Practice Directorate recently signed an agreement with the Mayo Clinic of Rochester, Minn., to produce an actuarial model that will show the cost savings and improved health outcomes a health care system can realize if it incorporates psychological services into the treatment of coronary patients. APA and its technical consultant, Coopers and Lybrand, LLP, will use Mayo Clinic data to aid the effort. Once the actuarial model is completed, the directorate intends to pursue a full-scale demonstration project with a health system that is able and willing to test the model's predictions.
Though the concept of 'medical cost offset' has been around for some 30 years, third party payers and policy makers have not been persuaded by the aggregate nature of the data generated thus far, according to Russ Newman, Ph.D., J.D. 'They want to know that specific treatments for designated disorders can save 'X' dollars,' he said. This need provided the impetus for APA to collaborate with the Mayo Clinic.
In working with Coopers and Lybrand to develop its actuarial model, the Practice Directorate will use the Mayo Clinic's own research results combined with data on the clinic's entire cardiac rehabilitation population. This data will be supplemented by information from national health care data bases. By generalizing the Mayo Clinic's claims data and clinical research findings to the national patient population, Coopers and Lybrand will help APA produce a model to predict specific cost savings and improved health outcomes in various health care systems.
Distressed coronary patients at risk
The Mayo Clinic has generated data about the effect of psychological distress on patients recovering from heart attacks. A 1995 Mayo study found that ongoing psychological distress is an independent risk factor for poorer medical outcomes and increased health care costs following a heart attack. Specifically, psychologically-distressed patients were nearly 2.5 times more likely to be rehospitalized than non-distressed patients. And when rehospitalized, distressed patients cost $7,358 more than rehospitalized but non-distressed patients.
Building on their earlier data, Mayo is currently conducting research on the effectiveness of various psychological interventions for the clinic's distressed cardiac rehabilitation patients. The focus of the new research is on the degree of stress reduction in patients, and the impact of psychological services delivery on rehospitalization rates and overall health care costs.
Dr. Newman believes that once APA's actuarial model is complete, the association will be in a good position to convince a suitable health care delivery system to test the model in a large-scale demonstration project. 'If we can complete the demonstration, we should gain conclusive data that can help change the way cardiac rehabilitation services are delivered,' Newman predicted.
Anticipating the successful completion of the actuarial model, the directorate already is identifying several delivery systems that want help with restructuring their treatment and reimbursement mechanisms to accommodate the integration of mental and physical health services. One of these systems is a likely candidate for the APA-sponsored demonstration project.
In recent years, many health care systems have 'carved out' mental health benefits in an effort to control costs and therefore are unable to easily integrate psychological services with medical/surgical treatment. The model APA is developing will require both information management and reimbursement systems that allow for such integration. 'We hope that demonstration projects such as ours will provide a catalyst for health care systems to integrate service delivery by carving back in their mental health services,' Newman said. The upshot, he said, will be improved quality of care at reduced cost.
The Mayo project is part of the directorate's ongoing strategic initiative to help demonstrate psychology's value in the treatment of physical illness and to enhance practice opportunities for psychologists. The directorate is involved in several current and potential demonstration projects intended to provide the kind of specific data on costs and health outcomes that health care payors and policy makers seek.
APA is engaged in a collaborative demonstration project with Blue Cross/Blue Shield of Massachusetts, Inc. and the Linda Pollin Institute Research Program of Harvard Medical School. This project is evaluating the psychological, behavioral and health benefits of providing 16 weeks of group psychotherapy as an integral part of treating women with breast cancer.
http://www.apa.org/practice/pf/aug97/mayo.html
© 2009 American Psychological Association
Practice Directorate
750 First Street, NE • Washington, DC • 20002-4242
Phone: 202-336-5800 • TDD/TTY: 202-336-6123
Fax: 202-336-5797 • Email
Sunday, July 19, 2009
The Case for Universal Health Care in the United States
Outline of Talk Given on June 4, 1999
By John R. Battista, M.D. and Justine McCabe, Ph.D.
Why doesn’t the United States have universal health care as a right of citizenship? The United States is the only industrialized nation that does not guarantee access to health care as a right of citizenship. 28 industrialized nations have single payer universal health care systems, while 1 (Germany) has a multipayer universal health care system like President Clinton proposed for the United States.
Myth One: The United States has the best health care system in the world.
Fact One: The United States ranks 23rd in infant mortality, down from 12th in 1960 and 21st in 1990
Fact Two: The United States ranks 20th in life expectancy for women down from 1st in 1945 and 13th in 1960
Fact Three: The United States ranks 21st in life expectancy for men down from 1st in 1945 and 17th in 1960.
Fact Four: The United States ranks between 50th and 100th in immunizations depending on the immunization. Overall US is 67th, right behind Botswana
Fact Five: Outcome studies on a variety of diseases, such as coronary artery disease, and renal failure show the United States to rank below Canada and a wide variety of industrialized nations.
Conclusion: The United States ranks poorly relative to other industrialized nations in health care despite having the best trained health care providers and the best medical infrastructure of any industrialized nation
Myth Two: Universal Health Care Would Be Too Expensive
Fact One: The United States spends at least 40% more per capita on health care than any other industrialized country with universal health care
Fact Two: Federal studies by the Congressional Budget Office and the General Accounting office show that single payer universal health care would save 100 to 200 Billion dollars per year despite covering all the uninsured and increasing health care benefits.
Fact Three: State studies by Massachusetts and Connecticut have shown that single payer universal health care would save 1 to 2 Billion dollars per year from the total medical expenses in those states despite covering all the uninsured and increasing health care benefits
Fact Four: The costs of health care in Canada as a % of GNP, which were identical to the United States when Canada changed to a single payer, universal health care system in 1971, have increased at a rate much lower than the United States, despite the US economy being much stronger than Canada’s.
Conclusion: Single payer universal health care costs would be lower than the current US system due to lower administrative costs. The United States spends 50 to 100% more on administration than single payer systems. By lowering these administrative costs the United States would have the ability to provide universal health care, without managed care, increase benefits and still save money
Myth Three: Universal Health Care Would Deprive Citizens of Needed Services
Fact One: Studies reveal that citizens in universal health care systems have more doctor visits and more hospital days than in the US
Fact Two: Around 30% of Americans have problem accessing health care due to payment problems or access to care, far more than any other industrialized country. About 17% of our population is without health insurance. About 75% of ill uninsured people have trouble accessing/paying for health care.
Fact Three: Comparisons of Difficulties Accessing Care Are Shown To Be Greater In The US Than Canada (see graph)
Fact Four: Access to health care is directly related to income and race in the United States. As a result the poor and minorities have poorer health than the wealthy and the whites.
Fact Five: There would be no lines under a universal health care system in the United States because we have about a 30% oversupply of medical equipment and surgeons, whereas demand would increase about 15%
Conclusion: The US denies access to health care based on the ability to pay. Under a universal health care system all would access care. There would be no lines as in other industrialized countries due to the oversupply in our providers and infrastructure, and the willingness/ability of the United States to spend more on health care than other industrialized nations.
Myth Four: Universal Health Care Would Result In Government Control And Intrusion Into Health Care Resulting In Loss Of Freedom Of Choice
Fact One: There would be free choice of health care providers under a single payer universal health care system, unlike our current managed care system in which people are forced to see providers on the insurer’s panel to obtain medical benefits
Fact Two: There would be no management of care under a single payer, universal health care system unlike the current managed care system which mandates insurer preapproval for services thus undercutting patient confidentiality and taking health care decisions away from the health care provider and consumer
Fact Three: Although health care providers fees would be set as they are currently in 90% of cases, providers would have a means of negotiating fees unlike the current managed care system in which they are set in corporate board rooms with profits, not patient care, in mind
Fact Four: Taxes, fees and benefits would be decided by the insurer which would be under the control of a diverse board representing consumers, providers, business and government. It would not be a government controlled system, although the government would have to approve the taxes. The system would be run by a public trust, not the government.
Conclusion: Single payer, universal health care administered by a state public health system would be much more democratic and much less intrusive than our current system. Consumers and providers would have a voice in determining benefits, rates and taxes. Problems with free choice, confidentiality and medical decision making would be resolved
Myth Five: Universal Health Care Is Socialized Medicine And Would Be Unacceptable To The Public
Fact One: Single payer universal health care is not socialized medicine. It is health care payment system, not a health care delivery system. Health care providers would be in fee for service practice, and would not be employees of the government, which would be socialized medicine. Single payer health care is not socialized medicine, any more than the public funding of education is socialized education, or the public funding of the defense industry is socialized defense.
Fact Two: Repeated national and state polls have shown that between 60 and 75% of Americans would like a universal health care system (see The Harris Poll #78, October 20, 2005)
Conclusion: Single payer, universal health care is not socialized medicine and would be preferred by the majority of the citizens of this country
Myth Six: The Problems With The US Health Care System Are Being Solved and Are Best Solved By Private Corporate Managed Care Medicine because they are the most efficient
Fact One: Private for profit corporation are the lease efficient deliverer of health care. They spend between 20 and 30% of premiums on administration and profits. The public sector is the most efficient. Medicare spends 3% on administration.
Fact Two: The same procedure in the same hospital the year after conversion from not-for profit to for-profit costs in between 20 to 35% more
Fact Three: Health care costs in the United States grew more in the United States under managed care in 1990 to 1996 than any other industrialized nation with single payer universal health care
Fact Four: The quality of health care in the US has deteriorated under managed care. Access problems have increased. The number of uninsured has dramatically increased (increase of 10 million to 43.4 million from 1989 to 1996, increase of 2.4% from 1989 to 1996- 16% in 1996 and increasing each year).
Fact Five: The level of satisfaction with the US health care system is the lowest of any industrialized nation.
Fact Six: 80% of citizens and 71% of doctors believe that managed care has caused quality of care to be compromised
Conclusion: For profit, managed care can not solve the US health care problems because health care is not a commodity that people shop for, and quality of care must always be compromised when the motivating factor for corporations is to save money through denial of care and decreasing provider costs. In addition managed care has introduced problems of patient confidentiality and disrupted the continuity of care through having limited provider networks.
Overall Answer to the questions Why doesn’t the US have single payer universal health care when single payer universal health care is the most efficient, most democratic and most equitable means to deliver health care? Why does the United States remain wedded to an inefficient, autocratic and immoral system that makes health care accessible to the wealthy and not the poor when a vast majority of citizens want it to be a right of citizenship?
Conclusion: Corporations are able to buy politicians through our campaign finance system and control the media to convince people that corporate health care is democratic, represents freedom, and is the most efficient system for delivering health care
What you can do about this through your state Green Party
Work to pass a single payer, universal health care bill or referendum in your state. State level bills and referenda will be most effective because a federal health care system might in fact be too bureaucratic, and because it is not politically realistic at this time.
Bills or referendum must be written by and supported by health care providers for the legislature to take them seriously. It is thus imperative to form an alliance with provider groups. The most effective provider group to go through is Physicians For A National Health Program which has chapters in every state (see hand out for partial listing of contact people). A number of states already have organized single payer efforts: Massachusetts, California, Washington, Oregon, New Mexico, and Maryland. Join with them.
A first step is to contact state representatives from PNHP and offer to join with them to write and support a bill bringing single payer, universal health care to your state if this has not already been done. The Connecticut and Massachusetts Bills can be used as models to make this task easier (email us at riverbnd@javanet.com and we will send you copies of the bills). A referendum is another way to go, in which case the California referendum can be used as a model.
A second step is to contact state legislators and find a group who are willing to sponsor such a bill.
A third step is to create a coalition of groups to work together to support and publicize this work, or to try to bring together existing groups to work together on this project. Labor unions, progressive democratic groups, Medicare/Senior Advocacy groups, the Labor Party, the Reform Party, UHCAN, existing health care advocacy groups, and state health care provider groups are all imporatnt to work with and get to join such a coalition. The state medical society and state hospital association are critical to work with in order to get any legislation passed. Try to get them to work with you to design a new model for health care delivery. They will be particularly concerned about who will control the system, and be very mistrustful of government. A public trust model with participation by providers, hospitals, business, the public and government is like to be much more acceptable to them than a pure government system. Emphasize doing away with managed care, and get them to try and work with you to find other ways to control costs (necessary to convince politicians) such as quality assurance standards, which will also protect them from malpractice
A fourth step is to give talks in support of your bill or referendum where ever possible. Senior groups, medical staffs, church groups, high school assemblies, and labor unions are particularly good sources. Excellent materials including slides, a chart book and videos are available through PNHP.
A fifth step is to raise money through fund raisers, contributions and benefits held by entertainers. Benefits are particularly useful in bringing out people who you can inform about single payer, universal health care and your efforts.
A sixth step is to develop media access. The creation of videos that can be shown on local cable access TV stations is very effective. Newspaper articles, letters to the editor, and articles by the press are critical. Radio interviews and radio talk shows are important.
Getting the public to write and call their state representatives in support of a proposed bill is critical, as is coordinating testimony at a public hearing.
Because the data about single payer universal health care are so revealing of the problems with corporate America, and because the US citizenry is so concerned and dissatisfied with our health care system these efforts may yield surprisingly positive results and be helpful in establishing the Green Party in the US as a party of the people, by the people and for the people.
We would be happy to help you. Contact us by email at riverbnd@javanet.com, by phone at 860-354-1822, or by mail at 88 Cherniske Road, New Milford, CT 06776
http://cthealth.server101.com/the_case_for_universal_health_care_in_the_united_states.htm
By John R. Battista, M.D. and Justine McCabe, Ph.D.
Why doesn’t the United States have universal health care as a right of citizenship? The United States is the only industrialized nation that does not guarantee access to health care as a right of citizenship. 28 industrialized nations have single payer universal health care systems, while 1 (Germany) has a multipayer universal health care system like President Clinton proposed for the United States.
Myth One: The United States has the best health care system in the world.
Fact One: The United States ranks 23rd in infant mortality, down from 12th in 1960 and 21st in 1990
Fact Two: The United States ranks 20th in life expectancy for women down from 1st in 1945 and 13th in 1960
Fact Three: The United States ranks 21st in life expectancy for men down from 1st in 1945 and 17th in 1960.
Fact Four: The United States ranks between 50th and 100th in immunizations depending on the immunization. Overall US is 67th, right behind Botswana
Fact Five: Outcome studies on a variety of diseases, such as coronary artery disease, and renal failure show the United States to rank below Canada and a wide variety of industrialized nations.
Conclusion: The United States ranks poorly relative to other industrialized nations in health care despite having the best trained health care providers and the best medical infrastructure of any industrialized nation
Myth Two: Universal Health Care Would Be Too Expensive
Fact One: The United States spends at least 40% more per capita on health care than any other industrialized country with universal health care
Fact Two: Federal studies by the Congressional Budget Office and the General Accounting office show that single payer universal health care would save 100 to 200 Billion dollars per year despite covering all the uninsured and increasing health care benefits.
Fact Three: State studies by Massachusetts and Connecticut have shown that single payer universal health care would save 1 to 2 Billion dollars per year from the total medical expenses in those states despite covering all the uninsured and increasing health care benefits
Fact Four: The costs of health care in Canada as a % of GNP, which were identical to the United States when Canada changed to a single payer, universal health care system in 1971, have increased at a rate much lower than the United States, despite the US economy being much stronger than Canada’s.
Conclusion: Single payer universal health care costs would be lower than the current US system due to lower administrative costs. The United States spends 50 to 100% more on administration than single payer systems. By lowering these administrative costs the United States would have the ability to provide universal health care, without managed care, increase benefits and still save money
Myth Three: Universal Health Care Would Deprive Citizens of Needed Services
Fact One: Studies reveal that citizens in universal health care systems have more doctor visits and more hospital days than in the US
Fact Two: Around 30% of Americans have problem accessing health care due to payment problems or access to care, far more than any other industrialized country. About 17% of our population is without health insurance. About 75% of ill uninsured people have trouble accessing/paying for health care.
Fact Three: Comparisons of Difficulties Accessing Care Are Shown To Be Greater In The US Than Canada (see graph)
Fact Four: Access to health care is directly related to income and race in the United States. As a result the poor and minorities have poorer health than the wealthy and the whites.
Fact Five: There would be no lines under a universal health care system in the United States because we have about a 30% oversupply of medical equipment and surgeons, whereas demand would increase about 15%
Conclusion: The US denies access to health care based on the ability to pay. Under a universal health care system all would access care. There would be no lines as in other industrialized countries due to the oversupply in our providers and infrastructure, and the willingness/ability of the United States to spend more on health care than other industrialized nations.
Myth Four: Universal Health Care Would Result In Government Control And Intrusion Into Health Care Resulting In Loss Of Freedom Of Choice
Fact One: There would be free choice of health care providers under a single payer universal health care system, unlike our current managed care system in which people are forced to see providers on the insurer’s panel to obtain medical benefits
Fact Two: There would be no management of care under a single payer, universal health care system unlike the current managed care system which mandates insurer preapproval for services thus undercutting patient confidentiality and taking health care decisions away from the health care provider and consumer
Fact Three: Although health care providers fees would be set as they are currently in 90% of cases, providers would have a means of negotiating fees unlike the current managed care system in which they are set in corporate board rooms with profits, not patient care, in mind
Fact Four: Taxes, fees and benefits would be decided by the insurer which would be under the control of a diverse board representing consumers, providers, business and government. It would not be a government controlled system, although the government would have to approve the taxes. The system would be run by a public trust, not the government.
Conclusion: Single payer, universal health care administered by a state public health system would be much more democratic and much less intrusive than our current system. Consumers and providers would have a voice in determining benefits, rates and taxes. Problems with free choice, confidentiality and medical decision making would be resolved
Myth Five: Universal Health Care Is Socialized Medicine And Would Be Unacceptable To The Public
Fact One: Single payer universal health care is not socialized medicine. It is health care payment system, not a health care delivery system. Health care providers would be in fee for service practice, and would not be employees of the government, which would be socialized medicine. Single payer health care is not socialized medicine, any more than the public funding of education is socialized education, or the public funding of the defense industry is socialized defense.
Fact Two: Repeated national and state polls have shown that between 60 and 75% of Americans would like a universal health care system (see The Harris Poll #78, October 20, 2005)
Conclusion: Single payer, universal health care is not socialized medicine and would be preferred by the majority of the citizens of this country
Myth Six: The Problems With The US Health Care System Are Being Solved and Are Best Solved By Private Corporate Managed Care Medicine because they are the most efficient
Fact One: Private for profit corporation are the lease efficient deliverer of health care. They spend between 20 and 30% of premiums on administration and profits. The public sector is the most efficient. Medicare spends 3% on administration.
Fact Two: The same procedure in the same hospital the year after conversion from not-for profit to for-profit costs in between 20 to 35% more
Fact Three: Health care costs in the United States grew more in the United States under managed care in 1990 to 1996 than any other industrialized nation with single payer universal health care
Fact Four: The quality of health care in the US has deteriorated under managed care. Access problems have increased. The number of uninsured has dramatically increased (increase of 10 million to 43.4 million from 1989 to 1996, increase of 2.4% from 1989 to 1996- 16% in 1996 and increasing each year).
Fact Five: The level of satisfaction with the US health care system is the lowest of any industrialized nation.
Fact Six: 80% of citizens and 71% of doctors believe that managed care has caused quality of care to be compromised
Conclusion: For profit, managed care can not solve the US health care problems because health care is not a commodity that people shop for, and quality of care must always be compromised when the motivating factor for corporations is to save money through denial of care and decreasing provider costs. In addition managed care has introduced problems of patient confidentiality and disrupted the continuity of care through having limited provider networks.
Overall Answer to the questions Why doesn’t the US have single payer universal health care when single payer universal health care is the most efficient, most democratic and most equitable means to deliver health care? Why does the United States remain wedded to an inefficient, autocratic and immoral system that makes health care accessible to the wealthy and not the poor when a vast majority of citizens want it to be a right of citizenship?
Conclusion: Corporations are able to buy politicians through our campaign finance system and control the media to convince people that corporate health care is democratic, represents freedom, and is the most efficient system for delivering health care
What you can do about this through your state Green Party
Work to pass a single payer, universal health care bill or referendum in your state. State level bills and referenda will be most effective because a federal health care system might in fact be too bureaucratic, and because it is not politically realistic at this time.
Bills or referendum must be written by and supported by health care providers for the legislature to take them seriously. It is thus imperative to form an alliance with provider groups. The most effective provider group to go through is Physicians For A National Health Program which has chapters in every state (see hand out for partial listing of contact people). A number of states already have organized single payer efforts: Massachusetts, California, Washington, Oregon, New Mexico, and Maryland. Join with them.
A first step is to contact state representatives from PNHP and offer to join with them to write and support a bill bringing single payer, universal health care to your state if this has not already been done. The Connecticut and Massachusetts Bills can be used as models to make this task easier (email us at riverbnd@javanet.com and we will send you copies of the bills). A referendum is another way to go, in which case the California referendum can be used as a model.
A second step is to contact state legislators and find a group who are willing to sponsor such a bill.
A third step is to create a coalition of groups to work together to support and publicize this work, or to try to bring together existing groups to work together on this project. Labor unions, progressive democratic groups, Medicare/Senior Advocacy groups, the Labor Party, the Reform Party, UHCAN, existing health care advocacy groups, and state health care provider groups are all imporatnt to work with and get to join such a coalition. The state medical society and state hospital association are critical to work with in order to get any legislation passed. Try to get them to work with you to design a new model for health care delivery. They will be particularly concerned about who will control the system, and be very mistrustful of government. A public trust model with participation by providers, hospitals, business, the public and government is like to be much more acceptable to them than a pure government system. Emphasize doing away with managed care, and get them to try and work with you to find other ways to control costs (necessary to convince politicians) such as quality assurance standards, which will also protect them from malpractice
A fourth step is to give talks in support of your bill or referendum where ever possible. Senior groups, medical staffs, church groups, high school assemblies, and labor unions are particularly good sources. Excellent materials including slides, a chart book and videos are available through PNHP.
A fifth step is to raise money through fund raisers, contributions and benefits held by entertainers. Benefits are particularly useful in bringing out people who you can inform about single payer, universal health care and your efforts.
A sixth step is to develop media access. The creation of videos that can be shown on local cable access TV stations is very effective. Newspaper articles, letters to the editor, and articles by the press are critical. Radio interviews and radio talk shows are important.
Getting the public to write and call their state representatives in support of a proposed bill is critical, as is coordinating testimony at a public hearing.
Because the data about single payer universal health care are so revealing of the problems with corporate America, and because the US citizenry is so concerned and dissatisfied with our health care system these efforts may yield surprisingly positive results and be helpful in establishing the Green Party in the US as a party of the people, by the people and for the people.
We would be happy to help you. Contact us by email at riverbnd@javanet.com, by phone at 860-354-1822, or by mail at 88 Cherniske Road, New Milford, CT 06776
http://cthealth.server101.com/the_case_for_universal_health_care_in_the_united_states.htm
Health care in Canada From Wikipedia
Health care in Canada is funded and delivered through a publicly-funded health care system, with most services provided by private entities.[1]
Health care spending in Canada is projected to reach $160 billion, or 10.6% of GDP, in 2007. This is slightly above the average for OECD countries. In Canada, the various levels of government pay for about 71% of Canadians' health care costs, which is slightly below the OECD average. Under the terms of the Canada Health Act, the publicly funded insurance plans are required to pay for medically necessary care, but only if it is delivered in hospitals or by physicians. There is considerable variation across the provinces/territories as to the extent to which such costs as outpatient prescription drugs, physical therapy, long-term care, home care, dental care and even ambulance services are covered.[2]
Considerable attention has been focused on two issues: wait times and health human resources. There is also a debate about the appropriate 'public-private mix' for both financing and delivering services.
Canada's healthcare spending is expected to reach $171.9 billion, or $5,170 per person, in 2008. Health expenditures are expected to be 10.7% of the gross domestic product. Hospitals account for the largest segment in spending at $48.1 billion, however, this amount is declining. According to the OECD, spending was second amongst other countries, less than United States and more than Norway, Switzerland and Luxembourg[3].
Canada has a federally sponsored, publicly funded Medicare system, with most services provided by the private sector. Each province may opt out, though none currently do. Canada's system is known as a single payer system, where basic services are provided by private doctors (since 2002 they have been allowed to incorporate), with the entire fee paid for by the government at the same rate. Most family doctors receive a fee per visit. These rates are negotiated between the provincial governments and the province's medical associations, usually on an annual basis. A physician cannot charge a fee for a service that is higher than the negotiated rate — even to patients who are not covered by the publicly funded system — unless the physican opts out of billing the publicly funded system altogether. Pharmaceutical costs are set at a global median by government price controls. Other areas of health care, such as dentistry and optometry, are wholly private.
History
[edit] 18th century
Hospitals were initially places which cared for the poor; others were cared for at home. In Quebec (formerly known as New France and then as Lower Canada), a series of charitable institutions, many set up by Catholic religious orders, provided such care.[4] As the country grew, hospitals grew with them. They tended to be not-for-profit, and were run by municipal governments, charitable organizations, and religious denominations (both Catholic and Protestant). [5] These organizations tended to be at arm's length from government; they received subsidies from provincial governments to admit and treat all patients, regardless of their ability to pay. Dr. David Parker of the Maritimes was the first to operate using anesthetic. One of the first "modern" operations, the removal of a tumour, was performed by William Fraser Tolmie in British Columbia.
[edit] 19th century
The first medical schools were established in Lower Canada in the 1820s. These include the Montreal Medical Institution, which is today the faculty of medicine at McGill University; in the mid-1870s, Sir William Osler changed the face of medical school instruction throughout the West with the introduction of the hands-on approach. The College of Physicians and Surgeons of Upper Canada was established in 1839 and in 1869 was permanently incorporated. In 1834, William Kelly, a surgeon with the Royal Navy, introduced the idea of preventing the spread of disease via sanitation measures following epidemics of cholera. In 1871, female physicians Emily Howard Stowe and Jennie Kidd Trout won the right for women to be admitted to medical schools and granted licenses from the College of Physicians and Surgeons of Ontario. In 1883, Emily Stowe led the creation of the Ontario Medical College for Women, affiliated with the University of Toronto. In 1892, Dr. William Osler wrote the landmark text The Principles and Practice of Medicine, which dominated medical instruction in the West for the next 40 years. Around this time, a movement began that called for the improved health care for the poor, focusing mainly on sanitation and hygiene. This period saw important advances including the provision of safe drinking water to most of the population, public baths and beaches, and municipal garbage services to remove waste from the city. During this period, medical care was severely lacking for the poor and minorities such as First Nations[6]
[edit] 20th century
The twentieth century saw the discovery of insulin by Frederick Banting and his colleagues, Charles Best, J.J.R. Macleod, and J.B. Collip[7] in 1922. For this, Frederick Banting and J.J.R. Macleod of the University of Toronto won the 1923 Nobel Prize in Physiology and Medicine[8]. Dr. Wilder Penfield, who discovered a successful surgical treatment for epilepsy called the "Montreal procedure," founded the Montreal Neurological Institute in 1934.
Tommy Douglas' (centre left) number one concern was the creation of Medicare. In the summer of 1962, Saskatchewan became the centre of a hard-fought struggle between the provincial government, the North American medical establishment, and the province's physicians, who brought things to a halt with a doctors' strike.The early 20th century saw the first widespread construction of government run hospitals, mainly asylums for the mentally ill and Sanatoriums for those suffering from tuberculosis. Calls for increased government involvement also became common, and the idea of a national health insurance system had considerable popularity. William Lyon Mackenzie King promised to introduce such a scheme, but while he created the Department of Health he failed to introduce a national program. During the Great Depression calls for a public health system were widespread. Doctors who had long feared such an idea reconsidered hoping a government system could provide some stability as the depression had badly affected the medical community. However, governments had little money to enact the idea. In 1935, the United Farmers of Alberta passed a bill creating a provincial insurance program, but they lost office later that year and the Social Credit Party scrapped the plan due to the financial situation in the province. The next year a health insurance bill passed in British Columbia, but its implementation was halted over objections from doctors.
[edit] The beginning of coverage
It was not until 1946 that the first Canadian province introduced near universal health coverage. Saskatchewan had long suffered a shortage of doctors, leading to the creation of municipal doctor programs in the early twentieth century in which a town would subsidize a doctor to practice there. Soon after, groups of communities joined to open union hospitals under a similar model. There had thus been a long history of government involvement in Saskatchewan health care, and a significant section of it was already controlled and paid for by the government. In 1946, Tommy Douglas' Co-operative Commonwealth Federation government in Saskatchewan passed the Saskatchewan Hospitalization Act, which guaranteed free hospital care for much of the population. Douglas had hoped to provide universal health care, but the province did not have the money.
In 1950, Alberta created a program similar to Saskatchewan's. Alberta, however, created Medical Services (Alberta) Incorporated (MS(A)I) in 1948 to provide prepaid health services. This scheme eventually provided medical coverage to over 90% of the population.[9]
In 1957, the federal government passed the Hospital Insurance and Diagnostic Services Act to fund 50% of the cost of such programs for any provincial government that adopted them. The HIDS Act outlined five conditions: public administration, comprehensiveness, universality, portability, and accessibility. These remain the pillars of the Canada Health Act.
By 1961, all ten provinces had agreed to start HIDS Act programs. In Saskatchewan, the act meant that half of their current program would now be paid for by the federal government. Premier Woodrow Lloyd decided to use this freed money to extend the health coverage to also include physicians. Despite the sharp disagreement of the Saskatchewan College of Physicians and Surgeons, Lloyd introduced the law in 1962 after defeating the Saskatchewan Doctors' Strike in July.
[edit] Medical Care Act
The Saskatchewan program proved a success and the federal government of Lester B. Pearson, pressured by the New Democratic Party (NDP) who held the balance of power, introduced the Medical Care Act in 1966 that extended the HIDS Act cost-sharing to allow each province to establish a universal health care plan. It also set up the Medicare system. In 1984, the Canada Health Act was passed, which prohibited user fees and extra billing by doctors. In 1999, the prime minister and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility."[10]
[edit] Government involvement
This section does not cite any references or sources. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (November 2007)
The various levels of government pay for about 70% of Canadians' health care, although this number has decreased somewhat in recent years. The British North America Act did not give either the federal or provincial governments responsibility for health care, as it was then a minor concern. The Act did give the provinces responsibility for regulating hospitals, and the provinces claimed that their general responsibility for local and private matters encompassed health care. The federal government felt that the health of the population fell under the Peace, Order, and Good Government part of its responsibilities. This led to several decades of debate over jurisdiction that were not resolved until the 1930s. Eventually the JCPC decided that the administration and delivery of health care was a provincial concern, but that the federal government also had the responsibility of protecting the health and well-being of the population.
By far the largest government health program is Medicare, which is actually ten provincial programs, such as OHIP in Ontario, that are required to meet the general guidelines laid out in the federal Canada Health Act. Almost all government health spending goes through Medicare, but there are several smaller programs. The federal government directly administers health to groups such as the military, and inmates of federal prisons. They also provide some care to the Royal Canadian Mounted Police and veterans, but these groups mostly use the public system. Prior to 1966, Veterans Affairs Canada had a large health care network, but this was merged into the general system with the creation of Medicare. The largest group the federal government is directly responsible for is First Nations. Native peoples are a federal responsibility and the federal government guarantees complete coverage of their health needs. For the last 20 years and despite health care being a guaranteed right for First Nations due to the many treaties the government of Canada signed for access to First Nations lands and resources, the amount of coverage provided by the Federal government has diminished drastically for optometry, dentistry, and medicines. Status First Nations individuals only qualify for a set amount of visits to the optometrist and dentist, with a limited amount of coverage for glasses, eye exams, fillings, root canals, etc. For the most part First Nations people use the normal hospitals and the federal government then fully compensates the provincial government for the expense. The federal government also covers any user fees the province charges. The federal government maintains a network of clinics and health centres on Native Reserves. At the provincial level, there are also several much smaller health programs alongside Medicare. The largest of these is the health care costs paid by the worker's compensation system. Regardless of federal efforts, healthcare for First Nations has generally not been considered effective[11][12][13].
Despite being a provincial responsibility, the large health costs have long been partially funded by the federal government. The cost sharing agreement created by the HIDS Act and extended by the Medical Care Act was discontinued in 1977 and replaced by Established Programs Financing. This gave a bloc transfer to the provinces, giving them more flexibility but also reducing federal influence on the health system. In 1996, when faced with a large budget shortfall, the Liberal federal government merged the health transfers with the transfers for other social programs into the Canada Health and Social Transfer, and overall funding levels were cut. This placed considerable pressure on the provinces, and combined with population aging and the generally high rate of inflation in health costs, has caused problems with the system.
[edit] Private sector
About 30% of Canadians' health care is paid for through the private sector. This mostly goes towards services not covered or only partially covered by Medicare, such as prescription drugs, dentistry and optometry. Some 65% of Canadians have some form of supplementary private health insurance; many of them receive it through their employers.[14] There are also large private entities that can buy priority access to medical services in Canada, such as WCB in BC.
The Canadian system is for the most part publicly funded, yet most of the services are provided by private enterprises. Most doctors do not receive an annual salary, but receive a fee per visit or service.[1] According to Dr. Albert Schumacher, former president of the Canadian Medical Association, an estimated 75 percent of Canadian health care services are delivered privately, but funded publicly.
"Frontline practitioners whether they're GPs or specialists by and large are not salaried. They're small hardware stores. Same thing with labs and radiology clinics ...The situation we are seeing now are more services around not being funded publicly but people having to pay for them, or their insurance companies. We have sort of a passive privatization."[1]
The Canada Health Act of 1984 "does not directly bar private delivery or private insurance for publicly insured services," but provides financial disincentives for doing so. "Although there are laws prohibiting or curtailing private health care in some provinces, they can be changed," according to a report in the New England Journal of Medicine.[15][16] In June 2005, the Supreme Court of Canada ruled in Chaoulli v. Quebec (Attorney General) that Quebec's prohibition against private health insurance for medically necessary services laws violated the Quebec Charter of Human Rights and Freedoms, potentially opening the door to much more private sector participation in the health system. Justices Beverley McLachlin, Jack Major, Michel Bastarache and Marie Deschamps found for the majority. "Access to a waiting list is not access to health care," wrote Chief Justice Beverly McLachlin.
The Quebec and federal governments asked the high court to suspend its ruling for 18 months. Less than two months after its initial ruling, the court agreed to suspend its decision for 12 months, retroactive to June 9, 2005. This means that, for the interim, there would be no change to the status quo.[17]
[edit] Physician organization
Each province regulates its medical profession through a self-governing College of Physicians and Surgeons, which is responsible for licensing physicians, setting practice standards, and investigating and disciplining its members.
The national doctors association is called the Canadian Medical Association[18]; it describes its mission as "To serve and unite the physicians of Canada and be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. "[19] Because health care is deemed to be under provincial/territorial jurisdiction, negotiations on behalf of physicians are conducted by provincial associations such as the Ontario Medical Association.[20] The views of Canadian doctors have been mixed, particularly in their support for allowing parallel private financing. The history of Canadian physicians in the development of Medicare has been described by C. David Naylor. [21] Since the passage of the 1984 Canada Health Act, the CMA itself has been a strong advocate of maintaining a strong publicly-funded system, including lobbying the federal government to increase funding, and being a founding member of (and active participant in) the Health Action Lobby (HEAL).[22]
However, there are internal disputes. In particular, some provincial medical associations have argued for permitting a larger private role. To some extent, this has been a reaction to strong cost control; CIHI estimates that 99% of physician expenditures in Canada come from public sector sources, and physicians—particularly those providing elective procedures who have been squeezed for operating room time—have accordingly looked for alternative revenue sources.
One indication of this internal dispute came when Dr. Brian Day of B.C. was elected CMA president in August 2007. Day is the owner of the largest private hospital in Canada and a vocal supporter of increasing private health care in Canada. The CMA presidency rotates among the provinces, with the provincial association electing a candidate who is customarily ratified by the CMA general meeting. Day's selection was sufficiently controversial that he was challenged—albeit unsuccessfully—by another physician. The newspaper story went on to note that "Day said he has never supported the privatization of health care in Canada, and accused his detractors of deliberately distorting his position." [23]
[edit] Criticisms
[edit] Wait times
One of the major complaints about the Canadian health care system is waiting times, whether for a specialist, major elective surgery, such as hip replacement, imaging procedures such as MRI or Cystoscopy, or specialized treatments.
A March 2, 2004, article in the Canadian Medical Association Journal stated, "Saskatchewan is under fire for having the longest waiting time in the country for a diagnostic MRI—a whopping 22 months." [25]
According to the Fraser Institute, treatment time from initial referral by a GP through consultation with a specialist to final treatment, across all specialties and all procedures (emergency, non-urgent, and elective), averaged 17.7 weeks in 2005.[30][31] However, the Fraser Institute's report is greatly at odds with the Canadian government's own 2007 report.[32]
Since 2002, the Canadian government has invested $5.5 billion to address the wait times problem.[33] In April 2007, Canadian Prime Minister Stephen Harper announced that all ten provinces and three territories would establish patient wait times guarantees by 2010. Canadians will be guaranteed timely access to health care in at least one of the following priority areas, prioritized by each province: cancer care, hip and knee replacement, cardiac care, diagnostic imaging, cataract surgeries or primary care.[34]
[edit] Medical professional shortage
Canada's shortage of medical practitioners causes problems.[35] With 2.1 doctors per thousand population in 2006, Canada is well below the OECD average of 3.1. Canada's 8.8 nurses per thousand was also below the OECD average of 9.7.[36] Suggested solutions include increasing the number of training spaces for doctors in Canada, as well as streamlining the licensing process for foreign doctors already in the country.[37]
Doctors in Canada make an average of $202,000 a year (2006, before expenses).[38] Alberta has the highest average salary of around $230,000, while Quebec has the lowest average annual salary at $165,000, creating interprovincial competition for doctors and contributing to local shortages.[38]
In 1991, the Ontario Medical Association agreed to become a province-wide closed shop, making the OMA union a monopoly. Critics argue that this measure has restricted the supply of doctors to guarantee its members' incomes.[39]
According to a 2007 article from CTV News, the Canadian medical profession is suffering from a brain drain. The article states, "One in nine trained-in-Canada doctors is practising medicine in the United States...If Canadian-educated doctors who were born in the U.S. are excluded, the number is one in 12." [40]
In September 2008, the Ontario Medical Association and the Ontarian government agreed to a new four-year contract that will see doctors receive a 12.25% pay raise. The new agreement is expected to cost Ontarians an extra $1 billion. Referring to the agreement, Ontario premier Dalton McGuinty said,"One of the things that we've got to do, of course, is ensure that we're competitive ... to attract and keep doctors here in Ontario...".[41]
In December 2008, the Society of Obstetricians and Gynaecologists of Canada reported a critical shortage of obstetricians and gynaecologists. The report stated that only 1,370 obstetricians were practicing in Canada and that number is expected to fall by at least one-third within five years. The society is asking the government to increase the number of medical school spots for obstetrics and gynecologists by 30 per cent a year for three years and also recommended rotating placements of doctors into smaller communities to encourage them to take up residence there[42].
[edit] Restrictions on privately funded health care
Main article: Canada Health Act
The Canada Health Act, which sets the conditions with which provincial/territorial health insurance plans must comply if they wish to receive their full transfer payments from the federal government, does not allow charges to insured persons for insured services (defined as medically necessary care provided in hospitals or by physicians). Most provinces have responded through various prohibitions on such payments. This does not constitute a ban on privately funded care; indeed, about 30% of Canadian health expenditures come from private sources, both insurance and out-of-pocket payments.[43] The Canada Health Act does not address delivery. Private clinics are therefore permitted, albeit subject to provincial/territorial regulations, but they cannot charge above the agreed-upon fee schedule unless they are treating non-insured persons (which may include those eligible under automobile insurance or worker's compensation, in addition to those who are not Canadian residents), or providing non-insured services. This provision has been controversial among those seeking a greater role for private funding.
In 2006, a Canadian court threatened to shut down one private clinic because it was planning to start accepting private payments from patients.[44]
Governments have responded through wait time strategies, discussed above, which attempt to ensure that patients will receive high-quality, necessary services in a timely manner. Nonetheless, the debate continues.
[edit] Cross-border health care
This section may require cleanup to meet Wikipedia's quality standards. Please improve this section if you can. (January 2008)
The border between Canada and the United States represents a boundary line for medical tourism, in which a country's residents travel elsewhere to seek health care that is more available or affordable.
[edit] Canadians visiting the U.S. to receive health care
Some residents of Canada travel to the United States because it provides the nearest facilty for their needs. Some do so on quality grounds or because of easier access.
According to a September 14, 2007, article from CTV News, Canadian Liberal MP Belinda Stronach went to the United States for breast cancer surgery in June 2007. Stronach's spokesperson Greg MacEachern was quoted in the article saying that the US was the best place to have this type of surgery done. Stronach paid for the surgery out of her own pocket.[45] Prior to this incident, Stronach had stated in an interview that she was against two-tiered health care.[46]
When Robert Bourassa, the premier of Quebec, needed cancer treatment, he went to the US to get it.[47]
In 2007, it was reported that Canada sent scores of pregnant women to the US to give birth.[48] In 2007 a woman from Calgary who was pregnant with quadruplets was sent to Great Falls, Montana to give birth. An article on this incident states, "There was no room at any other Canadian neonatal intensive care unit."[49]
Champion figure skater Audrey Williams needed a hip replacement. Even though she waited two years and suffered in pain, she still did not get the surgery, because the waiting list was so long. So she went to the US and spent her own money to get the surgery.[50]
A January 19, 2008, article in The Globe And Mail states, "More than 150 critically ill Canadians – many with life-threatening cerebral hemorrhages – have been rushed to the United States since the spring of 2006 because they could not obtain intensive-care beds here. Before patients with bleeding in or outside the brain have been whisked through U.S. operating-room doors, some have languished for as long as eight hours in Canadian emergency wards while health-care workers scrambled to locate care." [51]
While some Canadians have gone to the US to receive health care services, the numbers are few and insignificant when compared to the population as a whole. Also note that travel costs to the US as well as other expenses make this trip to the US affordable only to those that have the money to do so. Many health care lobbyists in the US are using the argument that Canadians come to the US for treatment because they want to block a public option in the US.
[edit] US citizens visiting Canada to receive health care
On the other hand, some US citizens travel to Canada for health-care related reasons:
Many US citizens purchase prescription drugs from Canada, either over the Internet or by traveling there to buy them in person, because drug prices in Canada are substantially lower than in the US; this cross-border purchasing has been estimated at $1 billion annually.[52]
At least one Canadian entrepreneur is beckoning US residents to Canada for simple surgeries, such as knee and hip replacements.[53] However, the article does not cite any actual patients who have responded to his offer.
Because medical marijuana is legal in Canada but illegal in most of the US, many US citizens suffering from cancer, AIDS, multiple sclerosis, and glaucoma have traveled to Canada for medical treatment. One of those is Steve Kubby, the Libertarian Party's 1998 candidate for governor of California, who is suffering from adrenal cancer.[54] Recent legal changes such as Proposition 215 may decrease this type of medical tourism from California only.
Rarely mentioned, is the use of Canadian medical facilities by relatives of Canadian citizens living in the USA, either US citizens or Canadian ex-pats. Many of the aforesaid will routinely use Canadian addresses to make use of Canadian hospital out-patients facilities, adding to the concern with wait-times in Canadian hospitals.
[edit] Canadian health care in comparison
The Canadian health care system is often compared to the US system. The US system spends the most in the world per capita, and was ranked 37th in the world by the World Health Organization in 2000, while Canada's health system was ranked 30th. The WHO ranking has been criticized by some for its choice of ranking criteria and statistical methods, and the WHO is currently revising its methodology and withholding new rankings until the issues are addressed.[55][56]
Canada spent approximately 10.0% of GDP on health care in 2006, more than one percentage point higher than the average of 8.9% in OECD countries.[36] According to the Canadian Institute for Health Information, spending is expected to reach $160 billion, or 10.6% of GDP, in 2007.[57] This translates to $4,867 per person.
Most health statistics in Canada are at or above the G8 average.[58] Direct comparisons of health statistics across nations is complex. The OECD collects comparative statistics, and has published brief country profiles.[59]
Country Statistics Statistics: Life expectancy,Infant mortality rate, Physicians per 1000 people, Nurses per 1000 people, Per capita expenditure on health (USD), Healthcare costs as a percent of GDP, % of government revenue spent on health, % of health costs paid by government
Australia: 81.1, 4.7, 2.8, 9.7, 2,999, 8.8, 17.7, 67.0
Canada: 80.4, 5.4, 2.1, 8.8, 3,678, 10.0, 16.7, 70.0
France: 80.9, 4.0, 3.4, 7.6, 3,449, 11.1, 14.2, 79.7
Germany: 79.8, 3.8, 3.5, 9.8, 3,371, 10.6, 17.6, 77.0
Japan: 82.4, 2.8, 2.1, 9.3, 2,474, 8.2, 16.8, 82.7
Sweden: 80.8, 2.8, 3.5, 10.7, 3,202, 9.2, 13.6, 81.7
UK: 79.1, 5.0, 2.5, 11.9, 2,760, 8.4, 15.8, 87.0
US: 77.8, 6.9, 2.4, 10.5, 6,714, 15.3, 18.5, 46.0
Health care spending in Canada is projected to reach $160 billion, or 10.6% of GDP, in 2007. This is slightly above the average for OECD countries. In Canada, the various levels of government pay for about 71% of Canadians' health care costs, which is slightly below the OECD average. Under the terms of the Canada Health Act, the publicly funded insurance plans are required to pay for medically necessary care, but only if it is delivered in hospitals or by physicians. There is considerable variation across the provinces/territories as to the extent to which such costs as outpatient prescription drugs, physical therapy, long-term care, home care, dental care and even ambulance services are covered.[2]
Considerable attention has been focused on two issues: wait times and health human resources. There is also a debate about the appropriate 'public-private mix' for both financing and delivering services.
Canada's healthcare spending is expected to reach $171.9 billion, or $5,170 per person, in 2008. Health expenditures are expected to be 10.7% of the gross domestic product. Hospitals account for the largest segment in spending at $48.1 billion, however, this amount is declining. According to the OECD, spending was second amongst other countries, less than United States and more than Norway, Switzerland and Luxembourg[3].
Canada has a federally sponsored, publicly funded Medicare system, with most services provided by the private sector. Each province may opt out, though none currently do. Canada's system is known as a single payer system, where basic services are provided by private doctors (since 2002 they have been allowed to incorporate), with the entire fee paid for by the government at the same rate. Most family doctors receive a fee per visit. These rates are negotiated between the provincial governments and the province's medical associations, usually on an annual basis. A physician cannot charge a fee for a service that is higher than the negotiated rate — even to patients who are not covered by the publicly funded system — unless the physican opts out of billing the publicly funded system altogether. Pharmaceutical costs are set at a global median by government price controls. Other areas of health care, such as dentistry and optometry, are wholly private.
History
[edit] 18th century
Hospitals were initially places which cared for the poor; others were cared for at home. In Quebec (formerly known as New France and then as Lower Canada), a series of charitable institutions, many set up by Catholic religious orders, provided such care.[4] As the country grew, hospitals grew with them. They tended to be not-for-profit, and were run by municipal governments, charitable organizations, and religious denominations (both Catholic and Protestant). [5] These organizations tended to be at arm's length from government; they received subsidies from provincial governments to admit and treat all patients, regardless of their ability to pay. Dr. David Parker of the Maritimes was the first to operate using anesthetic. One of the first "modern" operations, the removal of a tumour, was performed by William Fraser Tolmie in British Columbia.
[edit] 19th century
The first medical schools were established in Lower Canada in the 1820s. These include the Montreal Medical Institution, which is today the faculty of medicine at McGill University; in the mid-1870s, Sir William Osler changed the face of medical school instruction throughout the West with the introduction of the hands-on approach. The College of Physicians and Surgeons of Upper Canada was established in 1839 and in 1869 was permanently incorporated. In 1834, William Kelly, a surgeon with the Royal Navy, introduced the idea of preventing the spread of disease via sanitation measures following epidemics of cholera. In 1871, female physicians Emily Howard Stowe and Jennie Kidd Trout won the right for women to be admitted to medical schools and granted licenses from the College of Physicians and Surgeons of Ontario. In 1883, Emily Stowe led the creation of the Ontario Medical College for Women, affiliated with the University of Toronto. In 1892, Dr. William Osler wrote the landmark text The Principles and Practice of Medicine, which dominated medical instruction in the West for the next 40 years. Around this time, a movement began that called for the improved health care for the poor, focusing mainly on sanitation and hygiene. This period saw important advances including the provision of safe drinking water to most of the population, public baths and beaches, and municipal garbage services to remove waste from the city. During this period, medical care was severely lacking for the poor and minorities such as First Nations[6]
[edit] 20th century
The twentieth century saw the discovery of insulin by Frederick Banting and his colleagues, Charles Best, J.J.R. Macleod, and J.B. Collip[7] in 1922. For this, Frederick Banting and J.J.R. Macleod of the University of Toronto won the 1923 Nobel Prize in Physiology and Medicine[8]. Dr. Wilder Penfield, who discovered a successful surgical treatment for epilepsy called the "Montreal procedure," founded the Montreal Neurological Institute in 1934.
Tommy Douglas' (centre left) number one concern was the creation of Medicare. In the summer of 1962, Saskatchewan became the centre of a hard-fought struggle between the provincial government, the North American medical establishment, and the province's physicians, who brought things to a halt with a doctors' strike.The early 20th century saw the first widespread construction of government run hospitals, mainly asylums for the mentally ill and Sanatoriums for those suffering from tuberculosis. Calls for increased government involvement also became common, and the idea of a national health insurance system had considerable popularity. William Lyon Mackenzie King promised to introduce such a scheme, but while he created the Department of Health he failed to introduce a national program. During the Great Depression calls for a public health system were widespread. Doctors who had long feared such an idea reconsidered hoping a government system could provide some stability as the depression had badly affected the medical community. However, governments had little money to enact the idea. In 1935, the United Farmers of Alberta passed a bill creating a provincial insurance program, but they lost office later that year and the Social Credit Party scrapped the plan due to the financial situation in the province. The next year a health insurance bill passed in British Columbia, but its implementation was halted over objections from doctors.
[edit] The beginning of coverage
It was not until 1946 that the first Canadian province introduced near universal health coverage. Saskatchewan had long suffered a shortage of doctors, leading to the creation of municipal doctor programs in the early twentieth century in which a town would subsidize a doctor to practice there. Soon after, groups of communities joined to open union hospitals under a similar model. There had thus been a long history of government involvement in Saskatchewan health care, and a significant section of it was already controlled and paid for by the government. In 1946, Tommy Douglas' Co-operative Commonwealth Federation government in Saskatchewan passed the Saskatchewan Hospitalization Act, which guaranteed free hospital care for much of the population. Douglas had hoped to provide universal health care, but the province did not have the money.
In 1950, Alberta created a program similar to Saskatchewan's. Alberta, however, created Medical Services (Alberta) Incorporated (MS(A)I) in 1948 to provide prepaid health services. This scheme eventually provided medical coverage to over 90% of the population.[9]
In 1957, the federal government passed the Hospital Insurance and Diagnostic Services Act to fund 50% of the cost of such programs for any provincial government that adopted them. The HIDS Act outlined five conditions: public administration, comprehensiveness, universality, portability, and accessibility. These remain the pillars of the Canada Health Act.
By 1961, all ten provinces had agreed to start HIDS Act programs. In Saskatchewan, the act meant that half of their current program would now be paid for by the federal government. Premier Woodrow Lloyd decided to use this freed money to extend the health coverage to also include physicians. Despite the sharp disagreement of the Saskatchewan College of Physicians and Surgeons, Lloyd introduced the law in 1962 after defeating the Saskatchewan Doctors' Strike in July.
[edit] Medical Care Act
The Saskatchewan program proved a success and the federal government of Lester B. Pearson, pressured by the New Democratic Party (NDP) who held the balance of power, introduced the Medical Care Act in 1966 that extended the HIDS Act cost-sharing to allow each province to establish a universal health care plan. It also set up the Medicare system. In 1984, the Canada Health Act was passed, which prohibited user fees and extra billing by doctors. In 1999, the prime minister and most premiers reaffirmed in the Social Union Framework Agreement that they are committed to health care that has "comprehensiveness, universality, portability, public administration and accessibility."[10]
[edit] Government involvement
This section does not cite any references or sources. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (November 2007)
The various levels of government pay for about 70% of Canadians' health care, although this number has decreased somewhat in recent years. The British North America Act did not give either the federal or provincial governments responsibility for health care, as it was then a minor concern. The Act did give the provinces responsibility for regulating hospitals, and the provinces claimed that their general responsibility for local and private matters encompassed health care. The federal government felt that the health of the population fell under the Peace, Order, and Good Government part of its responsibilities. This led to several decades of debate over jurisdiction that were not resolved until the 1930s. Eventually the JCPC decided that the administration and delivery of health care was a provincial concern, but that the federal government also had the responsibility of protecting the health and well-being of the population.
By far the largest government health program is Medicare, which is actually ten provincial programs, such as OHIP in Ontario, that are required to meet the general guidelines laid out in the federal Canada Health Act. Almost all government health spending goes through Medicare, but there are several smaller programs. The federal government directly administers health to groups such as the military, and inmates of federal prisons. They also provide some care to the Royal Canadian Mounted Police and veterans, but these groups mostly use the public system. Prior to 1966, Veterans Affairs Canada had a large health care network, but this was merged into the general system with the creation of Medicare. The largest group the federal government is directly responsible for is First Nations. Native peoples are a federal responsibility and the federal government guarantees complete coverage of their health needs. For the last 20 years and despite health care being a guaranteed right for First Nations due to the many treaties the government of Canada signed for access to First Nations lands and resources, the amount of coverage provided by the Federal government has diminished drastically for optometry, dentistry, and medicines. Status First Nations individuals only qualify for a set amount of visits to the optometrist and dentist, with a limited amount of coverage for glasses, eye exams, fillings, root canals, etc. For the most part First Nations people use the normal hospitals and the federal government then fully compensates the provincial government for the expense. The federal government also covers any user fees the province charges. The federal government maintains a network of clinics and health centres on Native Reserves. At the provincial level, there are also several much smaller health programs alongside Medicare. The largest of these is the health care costs paid by the worker's compensation system. Regardless of federal efforts, healthcare for First Nations has generally not been considered effective[11][12][13].
Despite being a provincial responsibility, the large health costs have long been partially funded by the federal government. The cost sharing agreement created by the HIDS Act and extended by the Medical Care Act was discontinued in 1977 and replaced by Established Programs Financing. This gave a bloc transfer to the provinces, giving them more flexibility but also reducing federal influence on the health system. In 1996, when faced with a large budget shortfall, the Liberal federal government merged the health transfers with the transfers for other social programs into the Canada Health and Social Transfer, and overall funding levels were cut. This placed considerable pressure on the provinces, and combined with population aging and the generally high rate of inflation in health costs, has caused problems with the system.
[edit] Private sector
About 30% of Canadians' health care is paid for through the private sector. This mostly goes towards services not covered or only partially covered by Medicare, such as prescription drugs, dentistry and optometry. Some 65% of Canadians have some form of supplementary private health insurance; many of them receive it through their employers.[14] There are also large private entities that can buy priority access to medical services in Canada, such as WCB in BC.
The Canadian system is for the most part publicly funded, yet most of the services are provided by private enterprises. Most doctors do not receive an annual salary, but receive a fee per visit or service.[1] According to Dr. Albert Schumacher, former president of the Canadian Medical Association, an estimated 75 percent of Canadian health care services are delivered privately, but funded publicly.
"Frontline practitioners whether they're GPs or specialists by and large are not salaried. They're small hardware stores. Same thing with labs and radiology clinics ...The situation we are seeing now are more services around not being funded publicly but people having to pay for them, or their insurance companies. We have sort of a passive privatization."[1]
The Canada Health Act of 1984 "does not directly bar private delivery or private insurance for publicly insured services," but provides financial disincentives for doing so. "Although there are laws prohibiting or curtailing private health care in some provinces, they can be changed," according to a report in the New England Journal of Medicine.[15][16] In June 2005, the Supreme Court of Canada ruled in Chaoulli v. Quebec (Attorney General) that Quebec's prohibition against private health insurance for medically necessary services laws violated the Quebec Charter of Human Rights and Freedoms, potentially opening the door to much more private sector participation in the health system. Justices Beverley McLachlin, Jack Major, Michel Bastarache and Marie Deschamps found for the majority. "Access to a waiting list is not access to health care," wrote Chief Justice Beverly McLachlin.
The Quebec and federal governments asked the high court to suspend its ruling for 18 months. Less than two months after its initial ruling, the court agreed to suspend its decision for 12 months, retroactive to June 9, 2005. This means that, for the interim, there would be no change to the status quo.[17]
[edit] Physician organization
Each province regulates its medical profession through a self-governing College of Physicians and Surgeons, which is responsible for licensing physicians, setting practice standards, and investigating and disciplining its members.
The national doctors association is called the Canadian Medical Association[18]; it describes its mission as "To serve and unite the physicians of Canada and be the national advocate, in partnership with the people of Canada, for the highest standards of health and health care. "[19] Because health care is deemed to be under provincial/territorial jurisdiction, negotiations on behalf of physicians are conducted by provincial associations such as the Ontario Medical Association.[20] The views of Canadian doctors have been mixed, particularly in their support for allowing parallel private financing. The history of Canadian physicians in the development of Medicare has been described by C. David Naylor. [21] Since the passage of the 1984 Canada Health Act, the CMA itself has been a strong advocate of maintaining a strong publicly-funded system, including lobbying the federal government to increase funding, and being a founding member of (and active participant in) the Health Action Lobby (HEAL).[22]
However, there are internal disputes. In particular, some provincial medical associations have argued for permitting a larger private role. To some extent, this has been a reaction to strong cost control; CIHI estimates that 99% of physician expenditures in Canada come from public sector sources, and physicians—particularly those providing elective procedures who have been squeezed for operating room time—have accordingly looked for alternative revenue sources.
One indication of this internal dispute came when Dr. Brian Day of B.C. was elected CMA president in August 2007. Day is the owner of the largest private hospital in Canada and a vocal supporter of increasing private health care in Canada. The CMA presidency rotates among the provinces, with the provincial association electing a candidate who is customarily ratified by the CMA general meeting. Day's selection was sufficiently controversial that he was challenged—albeit unsuccessfully—by another physician. The newspaper story went on to note that "Day said he has never supported the privatization of health care in Canada, and accused his detractors of deliberately distorting his position." [23]
[edit] Criticisms
[edit] Wait times
One of the major complaints about the Canadian health care system is waiting times, whether for a specialist, major elective surgery, such as hip replacement, imaging procedures such as MRI or Cystoscopy, or specialized treatments.
A March 2, 2004, article in the Canadian Medical Association Journal stated, "Saskatchewan is under fire for having the longest waiting time in the country for a diagnostic MRI—a whopping 22 months." [25]
According to the Fraser Institute, treatment time from initial referral by a GP through consultation with a specialist to final treatment, across all specialties and all procedures (emergency, non-urgent, and elective), averaged 17.7 weeks in 2005.[30][31] However, the Fraser Institute's report is greatly at odds with the Canadian government's own 2007 report.[32]
Since 2002, the Canadian government has invested $5.5 billion to address the wait times problem.[33] In April 2007, Canadian Prime Minister Stephen Harper announced that all ten provinces and three territories would establish patient wait times guarantees by 2010. Canadians will be guaranteed timely access to health care in at least one of the following priority areas, prioritized by each province: cancer care, hip and knee replacement, cardiac care, diagnostic imaging, cataract surgeries or primary care.[34]
[edit] Medical professional shortage
Canada's shortage of medical practitioners causes problems.[35] With 2.1 doctors per thousand population in 2006, Canada is well below the OECD average of 3.1. Canada's 8.8 nurses per thousand was also below the OECD average of 9.7.[36] Suggested solutions include increasing the number of training spaces for doctors in Canada, as well as streamlining the licensing process for foreign doctors already in the country.[37]
Doctors in Canada make an average of $202,000 a year (2006, before expenses).[38] Alberta has the highest average salary of around $230,000, while Quebec has the lowest average annual salary at $165,000, creating interprovincial competition for doctors and contributing to local shortages.[38]
In 1991, the Ontario Medical Association agreed to become a province-wide closed shop, making the OMA union a monopoly. Critics argue that this measure has restricted the supply of doctors to guarantee its members' incomes.[39]
According to a 2007 article from CTV News, the Canadian medical profession is suffering from a brain drain. The article states, "One in nine trained-in-Canada doctors is practising medicine in the United States...If Canadian-educated doctors who were born in the U.S. are excluded, the number is one in 12." [40]
In September 2008, the Ontario Medical Association and the Ontarian government agreed to a new four-year contract that will see doctors receive a 12.25% pay raise. The new agreement is expected to cost Ontarians an extra $1 billion. Referring to the agreement, Ontario premier Dalton McGuinty said,"One of the things that we've got to do, of course, is ensure that we're competitive ... to attract and keep doctors here in Ontario...".[41]
In December 2008, the Society of Obstetricians and Gynaecologists of Canada reported a critical shortage of obstetricians and gynaecologists. The report stated that only 1,370 obstetricians were practicing in Canada and that number is expected to fall by at least one-third within five years. The society is asking the government to increase the number of medical school spots for obstetrics and gynecologists by 30 per cent a year for three years and also recommended rotating placements of doctors into smaller communities to encourage them to take up residence there[42].
[edit] Restrictions on privately funded health care
Main article: Canada Health Act
The Canada Health Act, which sets the conditions with which provincial/territorial health insurance plans must comply if they wish to receive their full transfer payments from the federal government, does not allow charges to insured persons for insured services (defined as medically necessary care provided in hospitals or by physicians). Most provinces have responded through various prohibitions on such payments. This does not constitute a ban on privately funded care; indeed, about 30% of Canadian health expenditures come from private sources, both insurance and out-of-pocket payments.[43] The Canada Health Act does not address delivery. Private clinics are therefore permitted, albeit subject to provincial/territorial regulations, but they cannot charge above the agreed-upon fee schedule unless they are treating non-insured persons (which may include those eligible under automobile insurance or worker's compensation, in addition to those who are not Canadian residents), or providing non-insured services. This provision has been controversial among those seeking a greater role for private funding.
In 2006, a Canadian court threatened to shut down one private clinic because it was planning to start accepting private payments from patients.[44]
Governments have responded through wait time strategies, discussed above, which attempt to ensure that patients will receive high-quality, necessary services in a timely manner. Nonetheless, the debate continues.
[edit] Cross-border health care
This section may require cleanup to meet Wikipedia's quality standards. Please improve this section if you can. (January 2008)
The border between Canada and the United States represents a boundary line for medical tourism, in which a country's residents travel elsewhere to seek health care that is more available or affordable.
[edit] Canadians visiting the U.S. to receive health care
Some residents of Canada travel to the United States because it provides the nearest facilty for their needs. Some do so on quality grounds or because of easier access.
According to a September 14, 2007, article from CTV News, Canadian Liberal MP Belinda Stronach went to the United States for breast cancer surgery in June 2007. Stronach's spokesperson Greg MacEachern was quoted in the article saying that the US was the best place to have this type of surgery done. Stronach paid for the surgery out of her own pocket.[45] Prior to this incident, Stronach had stated in an interview that she was against two-tiered health care.[46]
When Robert Bourassa, the premier of Quebec, needed cancer treatment, he went to the US to get it.[47]
In 2007, it was reported that Canada sent scores of pregnant women to the US to give birth.[48] In 2007 a woman from Calgary who was pregnant with quadruplets was sent to Great Falls, Montana to give birth. An article on this incident states, "There was no room at any other Canadian neonatal intensive care unit."[49]
Champion figure skater Audrey Williams needed a hip replacement. Even though she waited two years and suffered in pain, she still did not get the surgery, because the waiting list was so long. So she went to the US and spent her own money to get the surgery.[50]
A January 19, 2008, article in The Globe And Mail states, "More than 150 critically ill Canadians – many with life-threatening cerebral hemorrhages – have been rushed to the United States since the spring of 2006 because they could not obtain intensive-care beds here. Before patients with bleeding in or outside the brain have been whisked through U.S. operating-room doors, some have languished for as long as eight hours in Canadian emergency wards while health-care workers scrambled to locate care." [51]
While some Canadians have gone to the US to receive health care services, the numbers are few and insignificant when compared to the population as a whole. Also note that travel costs to the US as well as other expenses make this trip to the US affordable only to those that have the money to do so. Many health care lobbyists in the US are using the argument that Canadians come to the US for treatment because they want to block a public option in the US.
[edit] US citizens visiting Canada to receive health care
On the other hand, some US citizens travel to Canada for health-care related reasons:
Many US citizens purchase prescription drugs from Canada, either over the Internet or by traveling there to buy them in person, because drug prices in Canada are substantially lower than in the US; this cross-border purchasing has been estimated at $1 billion annually.[52]
At least one Canadian entrepreneur is beckoning US residents to Canada for simple surgeries, such as knee and hip replacements.[53] However, the article does not cite any actual patients who have responded to his offer.
Because medical marijuana is legal in Canada but illegal in most of the US, many US citizens suffering from cancer, AIDS, multiple sclerosis, and glaucoma have traveled to Canada for medical treatment. One of those is Steve Kubby, the Libertarian Party's 1998 candidate for governor of California, who is suffering from adrenal cancer.[54] Recent legal changes such as Proposition 215 may decrease this type of medical tourism from California only.
Rarely mentioned, is the use of Canadian medical facilities by relatives of Canadian citizens living in the USA, either US citizens or Canadian ex-pats. Many of the aforesaid will routinely use Canadian addresses to make use of Canadian hospital out-patients facilities, adding to the concern with wait-times in Canadian hospitals.
[edit] Canadian health care in comparison
The Canadian health care system is often compared to the US system. The US system spends the most in the world per capita, and was ranked 37th in the world by the World Health Organization in 2000, while Canada's health system was ranked 30th. The WHO ranking has been criticized by some for its choice of ranking criteria and statistical methods, and the WHO is currently revising its methodology and withholding new rankings until the issues are addressed.[55][56]
Canada spent approximately 10.0% of GDP on health care in 2006, more than one percentage point higher than the average of 8.9% in OECD countries.[36] According to the Canadian Institute for Health Information, spending is expected to reach $160 billion, or 10.6% of GDP, in 2007.[57] This translates to $4,867 per person.
Most health statistics in Canada are at or above the G8 average.[58] Direct comparisons of health statistics across nations is complex. The OECD collects comparative statistics, and has published brief country profiles.[59]
Country Statistics Statistics: Life expectancy,Infant mortality rate, Physicians per 1000 people, Nurses per 1000 people, Per capita expenditure on health (USD), Healthcare costs as a percent of GDP, % of government revenue spent on health, % of health costs paid by government
Australia: 81.1, 4.7, 2.8, 9.7, 2,999, 8.8, 17.7, 67.0
Canada: 80.4, 5.4, 2.1, 8.8, 3,678, 10.0, 16.7, 70.0
France: 80.9, 4.0, 3.4, 7.6, 3,449, 11.1, 14.2, 79.7
Germany: 79.8, 3.8, 3.5, 9.8, 3,371, 10.6, 17.6, 77.0
Japan: 82.4, 2.8, 2.1, 9.3, 2,474, 8.2, 16.8, 82.7
Sweden: 80.8, 2.8, 3.5, 10.7, 3,202, 9.2, 13.6, 81.7
UK: 79.1, 5.0, 2.5, 11.9, 2,760, 8.4, 15.8, 87.0
US: 77.8, 6.9, 2.4, 10.5, 6,714, 15.3, 18.5, 46.0
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