Sam Stein
stein@huffingtonpost.com | HuffPost Reporting

Former Alaska Gov. Sarah Palin — who has gone to great lengths to hype the supposed dangers of a big government takeover of American health care — admitted over the weekend that she used to get her treatment in Canada’s single-payer system.

“We used to hustle over the border for health care we received in Canada,” Palin said in her first Canadian appearance since stepping down as governor of Alaska. “And I think now, isn’t that ironic?”

The irony, one guesses, is that Palin now views Canada’s health care system as revolting: with its government-run administration and ‘death-panel’-like rationing. Clearly, however, she and her family once found it more alluring than, at the very least, the coverage available in rural Alaska. Up to the age of six, Palin lived in a remote town near the closest Canadian city, Whitehorse.

Palin Crossed Border For Canadian Health Care

Imagine that same professional talent is without work, whether through illness or simply lack of work, and yet does not have to worry about paying for health insurance.

Sound like a health reformers ideal.  Provide employers the flexibility to hire talent as needed.  Provide health care for workers even when they have no income.

This model exists now

This is the model of the multi-employer health & welfare plan.

Multi-employer plans are common in those unionized industries with seasonal or irregular employment: transportation, needle trades, construction trades, and theater trades, for example.  They are governed by a board with equal numbers of employers and union representatives.  Employers pay a negotiated rate per hour worked into the Fund and the Fund provides benefits through periods of employment and transitional unemployment.  Some funds are fiscally sound enough to provide benefits through retirement.

But this is not a competitive model.  Not when your competitors provide few, if any health benefits.  The unions with benefit funds are more sensitive to the cost of health care than many of the industrial and public sector unions.  They negotiate a total wage package and see more clearly the trade-off between wages and benefits.

During the last decades they have seen medical inflation eat into their real income.  It is no wonder that Unions for Single Payer includes many unions more who traditionally have not been at the leading edge of past union struggles for health care reform.

The multi-employer fund as model

As employers increasingly abandon employer sponsored health plans in their never-ending race to the bottom, the multi-employer plan stands as a model for all of America.

Employers pay for health care only while workers are working.  They pay enough to cover workers when they are not working.  As a national model, employers would pay a percentage of all compensation, including part time wages, compensation to free lancers, bonuses, commissions and any other form of compensation.

Workers would give up a portion of their wages only while they are working.

Employers would gain unprecedented flexibility in hiring.  Decisions about part time work, part year work, job sharing, work hardening, phased retirement would not be encumbered with the fixed cost of health care.  Because workers would have equal access to health care; employers not offering health insurance now would have access to a larger labor pool.

Workers would be free to choose job opportunities or a career path or even an entrepreneurial enterprise without regard to an employer’s health plan offering.

How does this multi-employer model match up to the single payer model?   Pretty well.  They both would enjoy a near monopsony – a single buyer purchasing from a multiplicity of sellers.  Governance would be different.  The multi-employer plans would be regional private funds with local employer-employee governance.

Government would still play a significant regulatory role.  Several large regional plans would create a national system that encourages delivery system reforms and payment system reforms tailored to the unique requirements of the local economy.

It’s a model that has worked well for some Americans in the past and can be a model for all Americans in the future.

Fit for the Scrap Heap

Employer sponsored health insurance is not a system that works.  I say that as a 25 year employee benefits professional.

Despite what its proponents say in its support, their actions tell a different story.

Employers want out.

And the numbers over the last 15 years show they are getting out.

They are dropping their health care plans.  Fewer employers offer plans and those plans cover fewer employees.

From 2000 until 2007, the percentage of the population covered by employer-sponsored health insurance declined from 68.3% to 62.9%, a decline of 5.4% of a growing population, according to a study by the Economic Policy Institute.

Workforce numbers reveal an even more startling trend.  In 2007, 71% of all workers were covered by health insurance offered by their employer, down from 74.8% in 2000.

Pay attention to the words “offered by their employer”.  It does not include employees who have health care coverage through their spouse’s employer or through their parent’s employer.

Still 71% of all workers.  But only 55.4% of all private sector workers.  For all the ballyhoo about maintaining private plans, only 55.4% of private sector employees are covered by their employer.  I wonder just how many of them are covered by their spouse’s tax supported employer plan.  We rely on tax supported health care plans for government employees to provide health care for a significant percentage of the workforce.

In fact, according to Steffie Woohandler and David Himmelstein, when you included tax supported health care for government employees, the United States already pays more in taxes for health care than any other country on the planet.

That’s not all

Employers show their true disdain for the business of health care in other ways.

They are making their employees pay more.  Over the past year employer payments for premiums have increased at an average of 9% a year. While that increase is consistent with the overall increase to employers, it does not include the additional costs of higher out of pocket expenses resulting from higher deductibles, higher co-payments and co-insurances.

They are offering their employees more restrictive health care networks and more restrictive pharmacy formularies.

They are designing plans that are deliberately intended to encourage less utilization of medical services.  The result is that U.S. citizens go to the hospital less often, stay for shorter periods, visit the doctor less.  They do pay more, though.  Did someone say they were afraid of rationing?

These changes were not greeted eagerly.  Anyone remotely connected with collective bargaining over the last 15-20 years knows that health care benefits have been and continue to be the most contentious bargaining issue between labor and management.

Employers can still do more than write the checks

Employers can and do provide a constructive role in health care.  Employers have been a prime mover in creating pressure to improve the “value” of the money spent on health care.  They have  undertaken a wide range of initiatives to promote and improve workplace wellness.

But they do not need to sponsor their own health plans to continue those roles.  Many employers in countries with national health plans have developed wellness programs and the motivation for creating a healthy workforce extends far beyond decreasing claims costs.

So what keeps employers tied to this outmoded model.  For companies that can afford it, it is an attractive retention tool.  But smaller companies that are disadvantaged in the marketplace for talent should view things differently.  Are they so blinded by anti-government ideology that they can’t recognize a better more pragmatic solution?

Not all employers are willing to step outside the ideological box and ask the question posed by Jonathan Weber, the founder, publisher, and CEO of New West, a media company covering life and business in the Rocky Mountain West.

Why Should I Have To Pay for My Employees’ Health Care?

Let’s decouple health costs from paychecks.

But in today’s economy, the concept of the paternalistic employer is obviously outdated. We are all encouraged not to count on the company, to stay mobile and flexible, to start our own businesses, to be our own brands. So why the vestigial legacy of employee-provided health care, which severely inhibits the flexibility and mobility of the work force?

Good Question.  Ask the American Benefits Council.

Next week – An existing model that could be an example for the future.

If you are among the hundreds of millions of Americans who already have health insurance through your job, … nothing in this plan will require you or your employer to change the coverage or the doctor you have.  (Applause.)  Let me repeat this:  Nothing in our plan requires you to change what you have.

Someone will need to explain to me why this is a good thing.

The door may blocked

As the President was speaking these words, the 70 workers at SK Hand Tool Corp in Chicago, IL were without health insurance because their employer had made that decision for them.  It had unilaterally stopped paying for health insurance for its employees.

An inviting portal

As the President was reassuring Americans that they could keep their health insurance, the employees of SK Hand Tools, represented by Teamsters Local 743, were starting the third week of a strike to keep their health insurance.

That strike would eventually last for ten weeks.

There is an overwhelming body of health policy research that supports the necessity of continuity of care to improve population health outcomes.  Yet for most Americans, employment is not a continuous engagement.

Why do we build a system that relies on continuity on another system that flourishes on discontinuity?

The door needs a key

Human resource professionals will argue that good employment practices encourage employee retention.  But the same HR professionals spend a significant amount of time and psychic energy on issues related to discontinuity – turnover, hiring, firing, growth and “downsizing”.

Turnover is a fact of employment life. It should not be a part of our health care life. Last week, I argued that an improved patient delivery system is a necessary pre-condition for an improved health care delivery system. To enter into the health care delivery system we must pass through a portal that screens us based on criteria such as age, income, dependent status, military status, ethnic status, and employment.

But employment status is not a reliable portal

• “Working age” describes only that portion of our lives that begins after we end the first phase of our education until we become too old or infirm to continue working
• Only 60% of firms offer health insurance
• 30% of the work force are people who primarily work as free lancers or part time employees, people not typically eligible for health care benefits

The doors open to different spaces

If we continue the image of a portal into the health care system, changing employers means changing portals.  But pass through a new portal and you enter a new space within the health care delivery system.  In health care jargon this is called a network.

You don’t need to change employers to confront a new portal.  Employers routinely place their health coverage out to bid.  A new health plan frequently means a new network forcing at least some workers to choose between continuing their relationship with their existing doctors and paying more out of pocket or choosing a new in-network doctor.

In addition, slightly more than half of employees covered by health plans work in firms that offer multiple health plans.  These employers offer annual “open enrollments” that permit employees to change health plans. The conclusion.

Employment is not an efficient portal into the health care delivery system because:

• It is not always there
• It is not there for all employees
• It does not always lead to the same health care delivery system

Next week:  Employers don’t really want to be in this business anyway.

What do I mean by a “patient delivery system”?

Understanding  patient delivery system means recognizing that people without health insurance do not receive treatment until they are in an immediate life-threatening situation.

I cannot back this up with a scientific study, only my daily experience.  But that experience contradicts an oft cited myth that no one who needs health care is turned away.  One of the most common reason that people call our office is because something happened to their health insurance that lead to a denial of treatment.

It may be as simple as the doctor calling the wrong number or it may be that the member has failed to pay their share of their health insurance premium.  But the reasons don’t make the stories any the less heart breaking.

Checkpoint Charlie for health care

To enter the health care delivery system, patients need to pass through one of the many portals that guard access to health care.

People who are employed, some people who are employed,  gain their access through employer provided health insurance.  This also permits access by their children and spouse.  Some of those may also be employed.

People over the age of 65 and certain disabled people pass through the Medicare portal.

Some people who meet certain tests for age, income, gender, and/or parental status are permitted to pass through the Medicaid portal.

Those who don’t present sufficient credentials to pass thorough one of the previously mentioned portals may be able to tap into the market for individual insurance, but only if they are healthy.

There are additional portals for members of special groups, the Veteran’s Administration or the Indian Health Service, for example.

Their common characteristic is their exclusivity; you need to pass a test to pass through the portal.  Are you working? If not, are you poor enough, or old enough, or healthy enough, or a member of an exclusive group?  And might that change next month when you have a different employer or a no employer?

The portal you pass through into the magic world of health care delivery is only the first challenge in navigating the health care maze.  That portal determines which part of the health care delivery system you have access to, how much those providers are paid, which services will be reimbursed and under what rules.

It is most unfortunate that how much providers are paid is the major factor determining which providers you will have access to.

Patient delivery and care delivery

The defining characteristic of our health care system is that patients don’t have uniform access to the health care delivery system, and that that providers don’t have consistent access to the same group of patients.

How do you coordinate care in that scenario?  Is it no surprise that millions of Americans have no primary care doctor?

There are a lot of factors contributing to the high cost of health care?  Delayed care that leads to more expensive care needs to be one of the easier causes to address.

When we deny care to millions of Americans because they have not passed through one of the approved portals and their need for treatment is not acute enough, that costs the American health care system lots of bucks.

A system that makes access to health care delivery easy can encourage primary care over expensive emergency room care.

A system that that offers the same portal into health care despite employment status or income or age permits the provider community to take a longer term view of patient care.

That is why an improved patient delivery system is a necessary pre-condition for affordable and quality health care.

Next week – why an employment based system is not an efficient patient delivery system.

By Alexandra Thomas – Bloomberg.com

Feb. 4 (Bloomberg) — Health-care spending in the U.S. will almost double in 2019 to $4.5 trillion, or more than 19 percent of the economy, as unemployment and aging baby boomers drive up government costs, economists forecast.

Spending already jumped to $2.5 trillion, or 17.3 percent of the economy, in 2009, the economists from the U.S. Centers for Medicare and Medicaid Services said in their yearly estimate, published today in the journal Health Affairs. The increase in share of gross domestic product, from 16.2 percent in 2008, was the biggest since record keeping began in 1960.

Health-Care Burden Shifts to U.S. Government as Spending Soars – Bloomberg.com

In the first corner:  “We have the best health care system in the world.  People travel to this country from all over the world to get the best health care.  the parking lots in hospitals bordering Canada are full of cars with Canadian license plates.”

In the second corner: “There are 100,000 deaths per year from hospital infections and a similar number from prescription drug errors, and an equally horrific number of people who need to be re-admitted to the hospital for complications.  And what about “Never Events”, those medical errors that are described as adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and usually preventable.

And there is a voice in a third corner: “We have the most expensive health care system in the world yet the United States is not ranked among the top twenty nations in infant mortality, maternal mortality, longevity, or hospital admissions avoidable with access to health care.”

It’s a bit like arguing who won the Super Bowl (this is Super Bowl weekend, after all) by comparing rushing yardage, passing yardage, first downs, time of possession.  Unlike football, in health care there is no touchdown metric, no definitive “points on the board” that decides health care quality.

Which corner would you pick?

It might depend on what your immediate need is.  If you have a rare and complex disease, you might be sympathetic to the guy in corner one.  If you are scheduled for knee surgery, you might be paying attention to corner two.  You would certainly hope that the doctor doesn’t commit a “Never Event” by operating on the wrong knee.  If you are paying the health care bill, the logic of corner three should be compelling.

But the three points of view are only mutually exclusive in political debate.  In reality, quality includes all three perspectives, and to ignore any one of them is to ignore and important perspective.

However, it is corner three that gets short shrift, because it is the perspective that requires the broadest viewpoint.  The primary feature of our health care quagmire is its fragmentation forcing all stakeholders to see and focus only on that which they appear to have some control over.

A while back there was an article in Health Affairs that asked the question, does access to specialty care mean better quality health care.  This question touches on the perspectives of all three corners, but in particular corners one and three.

The authors used broad quality measures and to compare areas with poor access to specialty care to areas to good access to specialty care.  This generally meant comparing rural areas with urban areas.  They found that there was little difference in broad measures of healthcare quality.

Quality and specialty care

The interesting part of the study from my perspective is that they took another step.  They looked inside the areas with good access to specialty care and examined outcomes of people who were referred to specialists by primary care physicians and those who self-referred.  The concluded that self referrals generally had poorer outcomes.

The hypothesis that they offered as an explanation is that specialists are trained to interpret symptoms from the perspective of their own specialty.  Primary care physicians are better trained to make a judgment as to which specialist should treat the patient.

My conclusion is that our fragmented approach to health care blocks effort at achieving quality outcomes.  Efforts to achieve quality outcomes is focused in narrow manageable categories.  Quality managers ask the question – did this care have a good outcome?  They don’t dare ask the question – how did this person get to the point where he/she needs this care?  Could we have intervened earlier to avoid this care?

Patients without access to the health care delivery system don’t get appropriate interventions.  Most patient health care is not managed in any meaningful sense.  Managed care does not mean managing care but instead means confining patients inside a pricing network, whether or not it is to the betterment of broad quality outcomes.

Next week:

Why an improved patient delivery system is a necessary pre-condition for affordable and quality health care.

By ANNA WILDE MATHEWS

With the fate of a national health care overhaul unclear, state legislators are pushing their own bills aimed at expanding coverage, though tight budgets are likely to hinder many of these efforts.

Lawmakers in at least two states, California and Missouri, have introduced legislation for the current session to create government-backed coverage for state residents. In others, including Virginia and New Jersey, legislators are hoping to tweak existing state programs to include more people.

In 11 states, lawmakers have proposed bills for this year aimed at improving access to health care, said the National Conference of State Legislatures.

States Try to Move Health-Care Bills – WSJ.com

So I want to get a head start on the next round.

Moving ahead

Because whatever happens in this round, round 2 cannot come soon enough.  It is unrealistic to expect health care reform to be a once and done proposition.  The Model T was not invented with 4 wheel anti-lock disk brakes or fuel injection.

So over the next few weeks, I would like to take a look at some of the issues that will still remain even after health care reform legislation is passed.

But first let’s give some thought to what we want from our  health care system.

Universal access.

This has to be at the top of the list.  Universal access is important for several reasons.  To listen to the current debate, one might think that universal access is only about spreading the risk between the healthy and the sick.  If we can find a way to get more healthy people into the system it will spread the cost and make health insurance less risky for insurers.

Universal access is central to cost control.

According to a Commonwealth Fund study, the United States ranks 19^th among industrialized countries in deaths preventable by health care.  And as the number of uninsured increase our ranking slides.  Assuring all Americans that they can easily access health care is about a culture change.  Those on the margins of our health care system generally don’t have access to good primary care.

They delay treatment until their condition requires more acute intervention, and then they are more likely to go to an emergency room, the most expensive care setting.

Universal care is also about quality care.

There are those who argue that we need to focus on the delivery of care first.  Delivering quality care would lower the cost of health care, making it more affordable and consequently allowing more people into the system.  I maintain, that the most significant impediment to a high performance health care delivery system is a fractured and fragmented patient delivery system.

Affordable care

Care is not accessible if it’s not affordable. We must rethink what affordable means.  Let’s not focus on isolated groups with affordability issues.

How much can we as a society afford?  Is it 15% of our income or 5% of our income?

What is radical about this idea is that the financial exposure and risk is different.  Just as universal access permits the healthy to subsidize the cost of health care for the sick; so a revised understanding of affordable care will enable those with high incomes to support the health care costs of those with low incomes.

We do this in many ways now, and in later posts I will explore how we do that overtly and covertly.

Quality care.

Americans expect the highest quality of health care.  But do we get it?  What is quality health care?  What outcomes should we expect when we spend 16% of our economy on health care?  What does it even mean to spend 16% of our Gross Domestic Product on health care?  Is there such a thing as too much health care?

This will be the focus of my next post.

Photo:  Grassy Mounds and A Winding Path ©Peter Anderson/GettyImages

You seem to think that the reason the Dems did not do well in Massachusetts has to do with jobs. Maybe, but not quite.

It’s about how you don’t get it.  And the people in Massachusetts see that in the way you have handled health care.

Now look at the mess you created.  Your health insurance program is at risk.  The Supreme Court just handed your opponents a blank check and the likelihood of changing that court now is very much in question.

Massachusetts was a bad model for reform

ERISA ties the hands and the feet of state governments that want to solve their uninsurance problem.  The Commonwealth of Massachusetts came up with one of very few ideas left over to them.  If it works at all in Massachusetts, and people will argue that, it is because Massachusetts is a relatively high-income state with relatively few people uninsured.

To try and apply that model to states like Louisiana, Texas, or Nebraska is misguided at best.  To be blackmailed by the likes of Sen. Ben Nelson (D-NE) is insulting.  To ask the people of Massachusetts to pay for it?  Oops.

And if you can’t get something right that they understand, how can you get anything else right?

Do you think that everyone in the state of Massachusetts is as noble about health care as Senator Kennedy?  They don’t all live in Hyannis Port.

Try my job

If you want to understand health care and health insurance, I suggest you spend a day in my chair.

You can explain to the guy with a job but who can’t work, who can’t get a final decision on his workers’ compensation claim and therefore has no income, which he should pay, his rent or his health insurance for his family.

“I’m sorry, sir. Your short-term financial problems are not our problems. We play the hand we are dealt.  And that means no money, no health insurance.”  Maybe you can even explain to him how our employer –sponsored health insurance is the foundation of our health care system.

You can explain to the retiree, why she needs to enroll in Medicare.  You can say, “We can’t continue your employer sponsored supplemental retiree health insurance if our retirees don’t enroll in Medicare.  It’s too bad that your doctor doesn’t accept Medicare and that you were scheduled for surgery.  I understand you trust this doctor, and that this is a stressful time for you.  But find a doctor that not’s so greedy.  We all need to sacrifice in this economy.”  Maybe you can even explain to her why you think a single-payer system is a bad idea.

You can speak to the mother of the child who is too old to qualify to stay covered under the parent’s plan.  “Yes, ma’am, I understand that your child needs medical care to be well enough to enter the work force.  Yes, I understand that most of the jobs he would qualify for don’t offer health insurance.  But rules are rules.

“Besides, we certainly don’t want to force all employers to provide health insurance.  We want to force your son to buy health insurance or your employer to continue to cover your son.”  I’m confident, with your rhetorical skills, you can win her over.

Just like you won over the people in Massachusetts.