Health and Medicine Policy Research Group

Board and Staff in the News

January 2007 "Suburban doctor makes Hispanic 'influential 100' list" by Esther J. Cepeda in The Chicago Sun-Times.

August 2005 "Aida Giachello: The Health Crusader" by Wendy Cole in Time Magazine's The 25 Most Influential Hispanics in America.

July 2005 "Modern Physician's first annual 50 Most Powerful Physician Executives" by Jay Greene

May 2005 "A National Plan" by Quentin D. Young, MD

January 2005 "Busted" by Lee Scheier

January 2004 "Black-White Health Gap Grows" by Judith Graham

January 2004 "Health care racial gap widens here" by Jim Ritter

October 2003 "Group fights West Suburban merger" by Cheri Bentrup

July 2003 "Girls often fall through cracks in justice system" by Dawn Turner Rice

July 2002 "Point Counterpoint: The Role of Federal Government in Healthcare Reform" by Quentin Young, MD and Grace Marie Turner

February 17, 2002 "President puts military funds..." by Quentin Young, MD
February 5, 2002 "Mothers who commit murder" by Michelle Oberman

Saturday, Aug. 13, 2005
Aida Giachello
The Health Crusader
By WENDY COLE

Latinos are three times as likely as non-Hispanic whites to suffer from potentially life-threatening diabetes. They are far more likely to be plagued by asthma and hypertension too. While politicians may pay lip service to the injustice and dangers of such disparities, Aida Giachello, 59, has rolled up her sleeves to take these scourges head on. She founded the Midwest Latino Health Research, Training and Policy Center at the University of Illinois at Chicago 12 years ago. The center has since become a national model for engaging community leaders, rather than outside "experts," in collecting data, assessing medical needs and developing plans for combating health problems that disproportionately affect Latinos.

Among its programs are three diabetes-focused self-care centers in struggling Chicago neighborhoods, each serving roughly a thousand residents a month, many of them undocumented and uninsured. Giachello, a University of Chicago educated sociologist and former social worker, has made the training of researchers, physicians and nurses a priority. "There are cultural elements to providing care that even top non-Hispanic students don't understand," she says. For example, she explains, many clinicians are ignorant about the widespread use of faith healers, herbal concoctions and other home remedies among Hispanics and so don't always know the relevant questions to ask during medical assessments. "A lot of what we do comes down to building trust," says Giachello, who grew up in Puerto Rico. "We have a lot of work to do."

Click here to see the article in Time Magazine

COVER STORY

On top of their game

Modern Physician's first annual 50 Most Powerful Physician Executives ranking

By Jay Greene / July 1, 2005

View the ranking.

Ron Anderson's 22-year career at Parkland Health & Hospital System in Dallas almost ended in December 2004 when several hospital directors made it clear they wanted him out as president and chief executive officer, partly because the 735-bed public hospital was facing a $76 million deficit.

Anderson, an M.D. who completed his internal medicine residency at Parkland in 1976, not only survived the dispute but three board members who crusaded against him resigned after what some observers say was a groundswell of popular support for the CEO. Several months after new board members were appointed by the Dallas County Commission, Anderson signed a two-year contract for a base pay of $495,315.

"I was pushing for a new ($1.2 billion) hospital during a period of austerity in Texas," says Anderson, 58. "I (also) was not in favor of cutting the tax rates and spoke out about it. That is why the three board members wanted to fire me . . . but they wanted to do it under the guise of mismanagement."

In 2000, when Parkland lost $47 million from cutbacks stemming from the Balanced Budget Act of 1997, county commissioners increased property taxes. Afterward, however, commissioners decided to roll back property taxes. The tax cutbacks, just as Anderson had predicted, forced the hospital's board of managers to order huge budget cuts at Parkland in 2004 during an economic downturn.

"When you are a leader, you have to speak out for things you believe in. One board member said I was arrogant; I felt I was principled," he says.

During the yearlong dispute, support for Anderson came from former board members, employees, physicians and fellow CEOs in the Dallas hospital community. "Our charity care dropped to 47% from 55%" of total market share, he says. "The CEOs in the area wanted me to resolve this quickly. They were on my side."

And so were the readers of Modern Physician, who voted Anderson to the No. 1 spot on the magazine's first annual ranking of the 50 Most Powerful Physician Executives.

"After being CEO for 25 years, part of it may be that I lasted for so long. It may be a sympathy vote," says Anderson with a chuckle. "It is a validation that things you stand for mean something to people. You sometimes wonder: You work at a public hospital, and you don't get pats on the back from politicians you work with. It is the community accolades that are very important, particularly from peers, which is why being on this list matters a lot. I realize, however, that we are on this list because the people who work for us make it possible."

Of the top 20 physician-executives on the list, six are hospital or system CEOs, four are in government, one is a U.S. senator, six represent consumer, medical school or professional organizations and three hold top leadership positions with HMOs. The other 30 executives include 17 from consumer or physician organizations, six from hospitals, three from HMOs, three from medical groups and a U.S. senator.

"This is a wonderful example of the complexity of the healthcare networks and systems we work in," says Julie Gerberding, M.D., director of the U.S. Centers for Disease Control and Prevention, ranked No. 5. "I am taken aback," says James Mongan, M.D., president and CEO of Partners HealthCare System, Boston, ranked No. 2. "I don't feel a great sense of power on a daily basis; I take it as a compliment for the organization."

More than 10 physicians on the list also made Modern Healthcare's 2004 list of the 100 Most Powerful People in Healthcare. They include U.S. Sen. Bill Frist, M.D., (R-Tenn.), No. 3 on Modern Physician's list; Mark McClellan, M.D., CMS administrator, No. 4; Gerberding, No. 5; Molly Coye, M.D., CEO of the Health Technology Center, No. 13; and William Jessee, M.D., CEO of the Medical Group Management Association, No. 29.

Rounding out the top 10 on Modern Physician's list are William McGuire, M.D., chairman and CEO of UnitedHealth Group, No. 6; Elias Zerhouni, M.D., director, National Institutes of Health, No. 7; Sidney Wolfe, M.D., director, Public Citizen's Health Research Group, No. 8; Quentin Young, M.D., national coordinator, Physicians for a National Health Program, No. 9; and Samuel Nussbaum, M.D., chief medical officer, WellPoint, No 10.

Interestingly, Dennis O'Leary, M.D., president and CEO of the Joint Commission on the Accreditation of Healthcare Organizations, who ranked No. 13 on Modern Healthcare's list, was ranked No. 49 by his physician peers. On the other hand, Michael Maves, M.D., CEO of the American Medical Association was not on Modern Healthcare's list but made No. 19 on Modern Physician's list.

"Power is very difficult to define, and it is in the eye of the beholder," Jessee says. "Physician power often comes from being CEO of an organization whose members are increasingly recognized as a powerful group of people. Your power comes more from your ability to influence external groups like payers, government or community organizations."

Physician-executives gain power within an organization by being known as thoughtful, visionary leaders who are committed to quality improvement, says Donald Fisher, CEO of the American Medical Group Association.

"You have to be concerned about the bottom line, but the future is more about reducing medical errors and improving quality," says Fisher, who has led the AMGA for 25 years. "This is the area where physician-executives will most be judged."

Like hospital administrators who have faced financial losses, board or medical staff disputes, labor problems, medical malpractice lawsuits or government investigations, Anderson finds that power ebbs and flows.

"You are fooling yourself if you think you are powerful," Anderson says. "Sometimes you are a good leader because you followed your values well. Power is also fleeting. You can achieve it over a lifetime but lose it in a matter of minutes. When you have power, you have to use it wisely."

To practice, or not to practice

One of the more debatable criticisms leveled at Anderson was that he spent too much time practicing medicine at the hospital. Several board members claimed that took him away from critical administrative duties.

"I walk around the hospital seeing patients and teaching" residents, Anderson says. "It is absolutely an efficient way to find out what is going on. Your doctors and colleagues know, but patients can really tell you. It just takes more hours to do both."

Historically, most physician-administrators continued to practice medicine. Now, with the ranks of physician-executives swelling, some believe physicians should hang up their stethoscopes and put away their tongue depressors.

"In the '80s most physician-executives were part-time and there were very few CEOs," Fisher says. "Most practiced and did management. If you didn't show up at 2 a.m. in the ER, (other physicians) didn't think you were a physician anymore. You were still a white coat with management responsibilities. That has changed."

But the demands of clinical medicine have become more complex. Some experts believe it is more difficult for physicians to maintain knowledge and skills in both management and medicine.

"Many physicians in management don't have the time for direct patient care, but they still practice medicine by keeping up to date on all the advances of science, clinical pharmacy, medicine and technology," says Nussbaum, an endocrinologist.

Every year in two-week stints, Gerberding returns to her roots at San Francisco General Hospital to see patients and teach residents. "It adds value to my role at the CDC," she says. "You learn firsthand problems at the bedside. You are reminded how patients are affected by cancer, heart disease and AIDS, all high priorities for the CDC."

In the early part of the 20th century, most hospital administrators were physicians. That changed in the 1950s with the rise of the lay administrator and the Master of Hospital Administration degree.

Physicians, for the most part, went back to patient care and held leadership positions on medical staffs or in public health. A handful continued to run large medical groups and teaching hospitals.

The return of the physician-executive

In 1972, 11.5% of hospitals, or 813 of 7,061 hospitals, were headed by a physician, according to the American Hospital Association. But by 2002, after a wave of mergers and closures that dropped the numbers of hospitals to 6,044, only 3.3%, or 200, were led by physicians.

By 2005, physician-CEOs at hospitals have increased to 222, or 3.7% of 6,008 hospitals. In addition, membership in the American College of Physican Executives has grown to more than 14,000 from 5,700 in 1990.

"There has been a gradual re-emergence of the physician-CEO," Jessee says. "It is a reflection that healthcare requires an understanding of the product and the business of the industry. Physicians bring an understanding of what it takes to bring together hospitals and medical groups."

But modern healthcare management is much more complex than it was 50 years ago. Nursing shortages, union problems, managed care, public accountability and the myriad government regulations of today were mostly absent then.

"Back in the late 1970s there was recognition that physicians had a deficiency in knowledge and understanding of the management of institutions," Fisher says.

During this period, several professional organizations for physicians founded groups to promote physician management. For example, the AMGA created the American Academy of Medical Directors in 1975. The academy later changed its name to the ACPE.

A number of business schools also began to offer MBA programs for physicians. Medical schools have added business courses like managed care to their curriculums. The number of joint M.D./MBA programs at medical schools has increased to about 40 from 28 in 1997. Nearly 2,000 physicians have received master's degrees in medical management through ACPE programs.

During the next 10 years, Fisher says streamlined career paths for physician-executives will develop. "Some physicians after medical school could proceed right to the MBA, bypass clinical medicine and go straight into management. It is inevitable," he says.

Nussbaum, who teaches at the Washington University School of Medicine and the Olin School of Business at Washington University in St. Louis, says some medical students are pursuing dual degrees. "They want to be a senior executive at a health system, health plan or pharmaceutical company," he says.

But some hospital executives are not convinced that doctors have what it takes to manage people and large organizations. Larry Mathis, former CEO of the Methodist Hospital System in Houston, wrote a book in 2001 that took several shots at physician-executives.

"There's nothing in a physician's education and training that qualifies him to become a leader," wrote Mathis in his book, The Mathis Maxims: Lessons in Leadership. "And that's what executives are -- leaders, persuaders, team builders, communicators and organizers."

Mathis wrote that medical training teaches physicians to be "an outstanding individual performer. But leadership is not an individual action. It's a participatory process." Still, Mathis conceded: "Being a physician is actually an excellent background for a person who aspires to be an executive leader, but only if they've had specific leadership training."

Many roads lead to the executive suite

Nussbaum says medical schools and residency programs are training doctors to be part of a team. "Physicians understand that highly effective communication, setting lofty goals, inspiring people to do their best, is an important part of medicine," he says.

Fisher says that truly successful integrated systems "are those with physicians at the helm." Mongan says the medical model of decisionmaking works well in management. "Almost on a daily basis we have problems and I ask for the diagnosis. . . . Once we have the diagnosis, then we look for the treatment. That kind of thinking is quite applicable to management," he says.

Like many physicians in management, Nussbaum's road to clinical management took an indirect path. After graduating from Mount Sinai School of Medicine, New York, in 1973, he became deeply interested in public health and considered pursuing that course after his internal medicine residency at Massachusetts General Hospital, Boston, in 1976.

"I became chair of a very troubled health plan, Bay State Health Care (in 1991), where I worked under adverse financial conditions and learned to be decisive," Nussbaum says. "At BJC HealthCare, I was executive vice president of system integration from 1996 to 2000 and learned how large institutions can be responsive to the public."

Jessee considered becoming a medical school dean while at the University of California School of Medicine in San Diego. He pursued that career path at the University of Maryland School of Medicine, Baltimore, for several years, but he learned that he was a good manager during his first administrative job with the U.S. Public Health Service in 1973. "One thing I found out is that no two days are the same," Jessee says. "That was different than clinical. As an administrator, you need to be open to new challenges, ideas and have a willingness to look at problems in new ways."

Mongan started at Stanford University Medical School in Palo Alto, Calif., with a joint interest in medicine and politics. He later became a staff member of the U.S. Senate Finance Committee, working on Medicare and Medicaid legislation. After working in the Carter administration as associate director of domestic policy, he was offered the job as executive director of Truman Medical Center, Kansas City, Mo., in 1981. "I never ran anything before, but Truman felt my skills -- listening to people and coming up with solutions -- would serve me well," he says, adding: "I had a crash course in hospital finances."

Gerberding had dreamed of being a small-town doctor since age 4. During her residency and fellowship at San Francisco General from 1981 to 1988, in the early years of the AIDS crisis, she says she developed a strong desire to work in the infectious disease and prevention area. That led her eventually to clinical administration.

"I became committed to the concept that prevention is primary and not just at the bedside because there prevention has failed," she says. "I developed (the California Primate Research Center at the University of California at Davis, from 1989 to 1993) and was successful in getting grant support and hiring people. . . . That led to an interest in the science and art of management."

Anderson also says he didn't plan to become a hospital administrator. After his residency, Anderson learned administration at Parkland in 1980 by running ambulatory care and the emergency department. In 1982, Charles Mullins, M.D., the hospital's physician-CEO, left to become vice chancellor of the University of Texas. "I didn't apply for the job," Anderson says. "They had 102 applications and I was asked to screen them." But he was offered the job and took it after receiving assurances he could teach and practice medicine.

While he was fighting hard to keep his job in 2004, Anderson says he never considered giving up. "I might have considered (taking another job) somewhere else," he says. "But the care of the community and the patient population is of paramount importance. People can fire you, but they can't take away your values, and I stayed for our employees and the community."

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A NATIONAL PLAN

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Health costs making big business ill

By Quentin Young, a Chicago physician and coordinator of Physicians for a National Health Program

May 15, 2005

On April 19, General Motors Corp. blamed its dismal first-quarter results (a $1.1 billion loss) on its $5.6 billion annual health-care tab. On top of that, the company carries $63 billion in unfunded health-benefit costs. The future certainly looks bleak.

Clearly a disaster is looming not only for GM and its workforce, but also for the entire American economy. America's other largest corporations also face skyrocketing health-care costs; General Electric Co., Boeing Co., Lucent Technologies Inc., IBM Corp., Verizon Communications Inc., SBC Communications Inc. and Ford Motor Co. have a combined $150 billion in future health-benefit obligations. Their future looks bleak too.

Ominously, non-competitive American products are sending our jobs abroad.

From candy to autos, Canadians can produce goods more cheaply because of their markedly lower health-benefits costs. For example, in Canada a Ford costs $1,400 less to make than it does to produce in Michigan. Lifesavers shaved $4 per hour off its labor costs by boarding up its hometown factory in Holland, Mich., and heading for Canada.

Alert pundits are, at long last, calling U.S. business to account.

They are pointing out what has been obvious to all industrialized democratic nations around the world for some time now: Employer-based health-care benefits are a bottomless pit. Seventeen American steel manufacturers have declared bankruptcy and terminated their retirees' health benefits.

Our nation recently learned that half of all personal bankruptcies are due to unpaid medical bills and illness, affecting 2 million people each year. Corporate bankruptcy of huge proportion looms due to our failure to deal rationally with health-care financing.

There goes America's vaunted economic advantage.

The obvious remedy, single-payer national health insurance, would end the link between employment and health insurance, while recovering much of the one third of health spending now squandered on "administrative cost," at least $400 billion in 2004.

These funds would enable our nation to cover everyone with no increase in health spending. National health insurance can cut waste and prudently control soaring costs, something business has learned it cannot do on its own.

Paradoxically, it is America's traditionally conservative physicians who are learning that the future fortunes of the medical profession, like the success of American business, hinge on reform of health-care finances.

Hence physicians, in increasing numbers, endorse single-payer national health insurance. Single-payer would address seriously the major deficiencies in our system: 45 million people without insurance, prohibitively priced pharmaceuticals, miserable mental-health benefits and the absence of a long-term care strategy for our aging population.

Single-payer would give business a level playing field with international competitors in the global economy by relieving them once and for all of the burden of crushing health benefit costs.

This healthy prescription can cure our chaotic health-care system and, in the process, foster a strong economy.

Busted!

Whether you're uninsured or underinsured, a serious illness can destroy you financially

By Lee Scheier

January 2, 2005

Barbara Eisenstein, 42, owns a small yellow townhome in the gently rolling hills of Lake Villa.

At first glance, her life seems fine. But looks can be deceiving. The reality is that she has been pushed to the edge financially and emotionally as a consequence of getting sick.

Eisenstein had no health insurance when she suffered a life-threatening condition requiring major heart surgery. In her tortuous journey through the health-care system, she says she has been treated like a pariah and often flatly refused medical care. Those physicians willing to see her have, at times, declined to perform the appropriate tests and treatment, she says, telling her they cost too much.

"I have felt like a nobody," she says, "like I was garbage."

Eisenstein is one of 45 million Americans with no medical insurance. Henry Brandt, of Chicago, belongs to a different group-those who thought they had good health coverage but who also have seen their finances destroyed by illness. They are among another 70 million who are considered underinsured, leaving them seriously exposed to catastrophic medical bills.

Together these 115 million people-roughly a third of the U.S. population-account for a preponderance of the nation's bankruptcies. A startling 1 million of the 1.9 million Americans who declare personal bankruptcy each year do so because of medical debts, according to Dr. Steffi Woolhandler, of Harvard Medical School.

Eisenstein's story is remarkable, not because her experience is so unusual-it is not-but because it was so easy for her to slip into penury.

A native of Morton Grove, she was hired in 1993 as a $25,000-a-year hostess at Jimmy's Charhouse, a family-owned business in Libertyville. Jimmy's does not offer health insurance to employees. The manager, Spiro Kokkinos, says the restaurant has sounded out employees about insurance but has never been able to get enough of them interested to make it viable.

Liability is a problem for most small enterprises, according to the National Federation for Independent Businesses. About 25 million of America's 45 million uninsured either work for a small business, own one, or are dependents of those who do. And only 48 percent of the 600,000 small businesses the NFIB counts as members offer health insurance because premiums are so high. For these businesses, which average between 3 and 9 employees, "the average employer's cost is $402 a month per employee for single coverage and $732 a month for family coverage," says Amanda Austin, NFIB manager of legislative affairs. "If the costs keep rising as they have, sooner or later there will be a breaking point, and many of those 48 percent who offer insurance will have to stop."

The high cost of health insurance is devastating to small businessesmen like Skip Trotter. A spokesperson for NFIB, he also owns Trotter Manufacturing in Rockford, which makes hydraulic valve spools. In October 2003, he had 53 employees and monthly premiums were $11,422. In December of 2004, he had 64 employees and paid $20,753 in monthly premiums, a 50 percent increase per employee.

"We employers have the same nightmare with health insurance costs that our employees have," he says.

Without an employer to pick up part of the tab, employees seeking insurance on the open market face annual premiums in the many thousands of dollars.

"This is precisely the group that is most uninsured, working people who earn more than minimum wage but not much more," says Dr. Ida Hellander, executive director of Physicians for National Health Insurance. "There is no way they can afford to buy health insurance on their own."

Hellander points out that her own health insurance coverage at the physicians group-a small organization that insures only two employees-costs $542 a month from Blue Cross Blue Shield. "I am a healthy single person," she says. "Blue Cross told me that if I had a family and everybody in it was healthy, the coverage would be $17,000 a year."

When Eisenstein investigated insurance costs, she found that she couldn't afford it on her salary after paying taxes, a $1,200 monthly mortgage and other basic expenses. "There were cheaper policies," she says, "but they don't cover much, so what good are they?"

Working 60 hours a week, she eventually became manager at Jimmy's and her salary rose to $35,000 a year-still not enough, in her view, to afford the insurance premiums that she had been quoted. So, still in her 30s and healthy, she decided to do without health insurance and hope for the best.

For eight years, Eisenstein's luck held. But in December 2001, she began experiencing pain, tingling and numbness in her hands and legs. She had trouble walking.

She tried a number of physicians. "The first question they ask is, 'Do you have insurance?' " she says. "I would say 'no' and their tone would change. They'd say, 'Well, it seems the doctor doesn't have an appointment available for three months. Do you want it?' But I couldn't wait three months; I was in terrible pain."

Eisenstein says she continued trying more doctors' offices, getting the runaround from most of them. When a physician did agree to see her, she says, restrictions were imposed. "They'd tell me certain tests cost too much so they weren't going to do them. I 'd say, 'Do I need this test?' They would answer, 'Yes, but you can't afford it.' "

Paying her own way, she was sent to Condell Hospital in Libertyville for $5,000 worth of CAT scans, MRIs, EMGs, mammograms, bloodwork and other tests. One physician said she had multiple sclerosis; another said it was lupus; a third said it was a disc that was acting up; a fourth said she had kidney problems and should be on dialysis.

She was put on nine medications, including an anti-depressant that cost her $180 a month-"and I wasn't even depressed." She was soon out of money.

Things seemed to be looking up, though, when she turned to Evanston Hospital. "They made a deal with me that I'd get 94 percent off the bill if I went through their clinic," says Eisenstein.

But the clinic had her see a different doctor each time, she says, so there was no continuity of treatment. "They kept asking me the same questions about my history over and over."

Then she started getting bills for the complete amount. "Collection agencies started phoning me. I'd call Evanston Hospital and tell them that charging me 100 percent of the bill wasn't in our agreement. I called over and over, spending hours on the phone trying to correct mistakes. Collection agencies would call me at work and harass me, screaming profanities and threatening me. I was on the verge of a breakdown."

The hospital says it can't discuss the case. "I can't speak to the particulars of this person's situation," says Mary Anne Lando, a spokesperson for Evanston Northwestern Healthcare. "We have a very generous charity-care policy and it is our interest to always provide the best care possible. I'm sorry if there were bureaucratic problems involved."

In the fall of 2002, a new symptom appeared: Eisenstein's heart began beating very rapidly, with spells of up to 250 beats per minute. A physician diagnosed it as supraventricular tachycardia-a form of accelerated heartbeat-and put her on Beta-pace, a drug designed to keep her cardiac rhythms under control. But after three more episodes-the last one with a heart rate of 250 beats per minute for more than two hours ("I thought I was dying," says Eisenstein)-surgery was ordered.

The operation, called an ablation, was performed at Condell Hospital and succeeded in correcting the heart rhythm. Eisenstein's bill came to $90,000.

She says Condell told her it would forgive half the bill if she could come up with $45,000. She couldn't. So the bill remained at $90,000, but she was put on $100-a-month payment plan. The surgeon, meanwhile, took 50 percent off his bill of $13,000, and put her on a payment plan of $100 a month plus interest. There was a third bill of $75 a month for the cardiologist.

Cindy Cordell, director of marketing and public relations at Condell, says treatment there is never based on whether someone has insurance or not. "Ms. Eisenstein qualified for a 12 percent charity write-off based on federally published guidelines," says Cordell. "She is currently paying a nominal monthly fee for her bill."

Cordell says the hospital has seen a sharp increase in its charity costs. In 2002 Condell offered $14.6 million in charity write-offs to the uninsured while in 2003 the figure rose to $22.7 million.

Meanwhile, Eisenstein's bills are piling up. Her savings have been drained, and there seems to be no end in sight. She has stopped taking Beta-pace, her heart drug, because it costs too much. "I figure I just have to take my chances," she says.

"If I get sick again, no matter what, I'm not going to seek care. I can't face the cruelty of this system again. I'll treat myself the best I can. If I die, I die."

Henry Brandt, who lives in a lakefront high-rise, had what he thought was excellent insurance. When he became seriously ill, he received superb medical care. But his treatment wiped out his entire life savings.

A 1969 graduate of Columbia College Chicago, Brandt began running the family business in wholesale hardware and building materials after his father died in the early 1970s. He earned good money, even after competition from hardware chains and giants like Menard's and Home Depot began eating into his earnings in the 1980s.

In 1990, at the age of 44, he took out health insurance at a premium of $160 a month, but never needed to use it until the day in 1997 when he walked into a Northwestern Memorial Hospital outpatient facility with shortness of breath.

"When the doctor put the stethoscope on my heart, I could see the alarm on her face," Brandt recalls.

He was taken immediately by ambulance to Northwestern, where it was determined that he had congestive heart failure brought on by two silent heart attacks. The percentage of blood being pushed in and out of his heart was 4.5, compared to the normal 55 percent. Under 10 percent usually causes death.

"They told me that mine was the lowest percentage they'd ever seen for someone who survived," he says.

Dr. David Fullerton, chief of cardiac surgery, operated on Brandt for 10 hours. Over the next six years, Brandt would undergo four more heart surgeries, twice having defibrillators sewn into his chest. The cost of these surgeries came to $250,000. Two years ago, an unidentified virus sent him into a coma that lasted 14 days. His hospital bill for that one episode totaled $200,000. His 20 percent share in the cost of prescriptions, required by his insurance company, was $15,000 a year.

Brandt says he had no choice but to dig into his $150,000 life savings to cover his medical costs as well as living expenses. With his health deteriorating and his savings vanishing, he became depressed and, seeking escape in food, saw his weight balloon to 360 pounds. His internist told him he would die if he didn't seek help. The result was costly stomach-stapling surgery in 2003.

In an effort to bring down his drug costs, Brandt applied for the insurance of last-resort: the Illinois Comprehensive Insurance Health Plan. The yearly premium is $10,200, but the drug costs are only $1,700 a year. Nevertheless, Brandt has all but exhausted his savings.

"I have had the best medical treatment the world has to offer," he says. "I estimate that my treatment since 1997 has cost over $1 million, and I would not be alive today if not for the incredible care I have received. But if I had been in a different health system, like the European or Canadian systems, I would not have suffered so much financially. It is sad that an illness and a health-care system can combine to completely decimate a lifetime's assets."

Hellander, of Physicians for National Health Insurance, says she is not surprised to hear that someone with good coverage became indigent. "Of the million middle-class Americans with mortgages and assets who go bankrupt each year because of medical debt, 75 percent had insurance at the time illness struck," she says.

According to a Commonwealth Fund survey in 2003, 60 percent of uninsured adults and 35 percent of insured adults aged 19 to 64 had medical bill problems or were paying off medical debt. Among this group, 27 percent reported that they were unable to pay for basic necessities, including food, heat or rent because of medical bills. Forty-four percent had used all or most of their savings, while 20 percent said they had large credit card debt or had taken out loans against their homes to pay their bills.

"People in other countries view us as barbaric," says Hellander, "They can't believe that when people are most vulnerable and sick that we ruin them financially too. The consensus in the rest of the developed world is that being sick is hard enough. You shouldn't also be pushed into bankruptcy."

The problem is that even good insurance plans limit their coverage. A Commonwealth Fund study in 2002 showed that U.S. health insurers on average paid 63 percent of medical costs for people with independently obtained plans and 75 percent for those on group plans arranged through employers. However, those with cheaper insurance get very little coverage for their money. Lower priced plans cover as little as 30 percent of bills.

Dr. Quentin Young, chairman of Chicago's Health and Medicine Policy Research Group, has long believed that a national single-payer health plan is the only way to create a health-insurance system that doesn't bankrupt people like Eisenstein and Brandt.

"This is the plight looming for millions of Americans in the near future unless we adopt some type of universal health care like every other industrialized nation in the world has done," he says.

But Mohit Ghose, director of public policy for America's Health Insurance Plans, the association that represents most private health insurers, says the single-payer system is a one-size-fits-all approach that doesn't get people what they want.

"Eighty percent of the 170 million who get insurance through their employers are satisfied with their coverage, according to a Harris poll," he says. "We believe getting the 45 million uninsured access to coverage should be a concerted effort by health insurers, hospitals and government."

Ghose contends the best solution is through public-private partnerships. "We need to improve federal funding for high-risk pools," he says.

His association advocates making top-quality medicine the standard for health care. This will improve outcomes, eliminate errors and reduce costs, Ghose says. Efforts to extend access to the uninsured should build on the current employment-based system through tax incentives to the uninsured and small business owners. Also, he says, efforts need to be made to extend access to the 3 million adults and 6.5 million children who are eligible but not enrolled in Medicaid or the State Children's Health Insurance program, as well as other public-private partnerships.

Young is unconvinced. He believes that these measures will not improve the plight of the uninsured and underinsured.

"The American health system does not have a problem with funding or staffing national health care," he says. "It just has to confront the central ethical issue, that all Americans are entitled to it."

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Lee Scheier writes frequently for the Magazine on health-related topics.

SPOTLIGHT

Sharon Honaker

December 29, 2004

Get an up-to-date diagnosis on older women's health issues. "Health Care Concerns of Women as They Age," will be held noon to 1:30 p.m. Jan. 6 at Chicago Bar Association Headquarters, 321 S. Plymouth Court.

The public forum is sponsored by the CBA and the Women's Bar Association of Illinois' Joint Task Force on Issues Affecting Women as They Age. Among the panelists are State Rep. Julie Hamos (D-Evanston), Phyllis B. Mitzen of the Health & Medicine Policy Research Group, a not-for-profit research and advocacy institute, and Jonathan Lavin of the Suburban Area Agency on Aging. They will discuss long-term care, funding, and the transformation to home- and community-based care, and other issues.

The cost of the program is $10, including box lunch. Reservations are requested by Jan. 4. Call 312-554-2056.

Black-white health gap grows

Disparity rises as care improves

By Judith Graham, Tribune staff reporter

January 16, 2004

Disparities in health care for blacks and whites widened in Chicago during most of the 1990s, even as they began to narrow nationally, according to a groundbreaking new study.

More blacks than whites in Chicago were diagnosed with tuberculosis and died of cancer, heart disease, stroke and other causes, while fewer blacks received prenatal care in the first trimester of pregnancy, the report found.

Breast cancer death rates for black women in the period soared over similar rates for white women by almost 20 percent. Motor vehicle death rates for blacks topped rates for whites by nearly 70 percent.

Overall, the discrepancies translate into lower life expectancies and higher health risks for blacks, and the difference is growing.

"We would like the numbers to be moving toward equality. Instead, in Chicago, they're moving away from equality," said Steven Whitman, director of Sinai Urban Health Institute and one of the report's authors.

The study, published in the January issue of the American Journal of Public Health, is believed to be the first to examine the health of blacks and whites in a major urban center over time and put findings in the context of national trends.

It shows that an especially troubling feature of the U.S. health-care system--persistent disparities in the kind and quality of medical care received by different racial and ethnic groups--appears to be a worsening problem here.

The study looked at data from 1990 to 1998. Data for 2000, which was not included, indicate the trends remained consistent through the end of the decade.

"This is a huge issue. Unfortunately, providers are not blind to the color and economic circumstances of our patients," said Dr. Hugo Alvarez, an internist who works largely in the Pilsen neighborhood.

Why racial disparities are widening in Chicago is not clear. Growing numbers of people without health insurance, the increasingly unequal distribution of doctors and hospitals across the city, changes in the culture of medicine, and poor lifestyles could be contributing, said Dr. Quentin Young, a past president of the American Public Health Association.

Data for New York, Los Angeles, Houston and Philadelphia haven't been analyzed yet, making it impossible to determine whether Chicago's experience is characteristic of large cities or an anomaly.

There were some positive developments in Chicago. Syphilis rates and rates of low-birthweight babies declined among blacks, and the gap with rates for whites narrowed. But overall, inequality is becoming more pronounced in the city, even though improvements in health are being made.

Both nationally and in Chicago, blacks did better in 1998 on 14 important indicators of health than they had in 1990, in large part because of medical advances and interventions, according to the Centers for Disease Control. That means fewer blacks died from heart disease, stroke, cancer, motor-vehicle accidents and homicides, and rates dropped for infant mortality, low-birthweight babies, tuberculosis and syphilis.

In Chicago, however, whites showed even more substantial improvement than blacks on 11 indicators, widening the gap between the races. This is in stark contrast to national results, which showed the racial gap narrowing for 11 of 14 indicators.

"This is an enormous challenge to our public health community," said Young, who chairs Chicago's Health and Medicine Policy Research Group.

Though Hispanics are not included in the new Chicago report, other local studies and national data indicate their experience with the health-care system has many similarities to blacks'.

There are many reasons why minorities tend to fare more poorly than whites in the medical arena, according to a 2002 study published by the Institute of Medicine, an arm of the National Academies of Science.

Disproportionately large numbers of minorities run into financial barriers to medical care because they are poor and lack insurance. Nationally, 14.2 percent of whites have no health insurance, compared with 20.2 percent of blacks and 32.4 percent of Hispanics, according to the latest Census Bureau data.

Gabrielle Union, who is African-American, lost her health insurance a year ago when she left her job as a controller for a recycling company. Since then, she has put off seeing doctors, even though migraine headaches and fibromyalgia, a muscle disorder, have caused her intense pain.

"It's not easy being sick and lacking resources. It puts a real strain on," said Union, who lives in Oakbrook Terrace.

There are fewer doctors and hospitals serving largely minority neighborhoods in Chicago than there are in largely white neighborhoods, making access to care more difficult. Substandard housing, inadequate education, language barriers, pollution, unhealthy lifestyles and crime all contribute to poorer health in these areas.

Alvarez, the Pilsen doctor, tells an altogether too-typical story of a 23-year-old Hispanic woman who came to see him after consulting six doctors. Though her periods were irregular and her skin darkening, the other physicians had dismissed the complaints.

Alvarez was the only doctor to order tests; they showed the woman had Addison's disease, a rare disorder of the adrenal glands that can be fatal under certain conditions.

Dr. Randall Maxey, a Los Angeles kidney specialist and president of the National Medical Association, which represents black physicians across the U.S., tells of a woman who had exceedingly high blood pressure.

A previous physician had told the woman she didn't need medication because "you're African-American and it's expected your blood pressure will be higher," Maxey said.

Many years ago, the doctor's own young son was told by a school nurse "all little black boys have skin rashes" when he went to her office for medical advice. "Black people's [medical] problems are discounted all the time," he said.

Health care racial gap widens here

January 16, 2004

BY JIM RITTER Health Reporter

Nationwide, the health gap between blacks and whites is narrowing, but in Chicago the gap got wider during the 1990s, a study has found.

Researchers examined 14 health measures, and in Chicago, African Americans improved in every category.

But in 11 categories, whites showed greater improvements than blacks between 1990 and 1998. These categories are heart disease, stroke, lung cancer, breast cancer, motor vehicle injuries, suicide, homicide, all causes of death, prenatal care, teen mothers and tuberculosis.

The gap narrowed in infant mortality, low birth weight and new cases of syphilis.

By contrast, the gap nationwide narrowed in 11 categories and got wider in three categories.

"Chicago is dramatically moving in the wrong direction," said study co-author Steven Whitman of Sinai Urban Health Institute. "We have to figure out what is happening and do something about it."

The study was published in the American Journal of Public Health.

Researchers found no clear-cut trends in the health disparities between whites and Hispanics.

Researchers took a preliminary look at the racial gap in 13 other cities. Of the 10 categories they examined, the racial gap narrowed in seven categories in New York, San Diego and Memphis and in six categories in Philadelphia and Detroit. In Chicago and Los Angeles, the gap narrowed in just two categories. Only Washington, D.C., where the gap narrowed in one category, did worse.

Medical sociologist Richard Warnecke of the University of Illinois at Chicago suggested one possible reason for Chicago's widening racial gap. In some states, he said, hospitals that have state health contracts must provide a certain amount of free health care to the uninsured. There is no such requirement in Illinois.

"The safety net is shrinking," Warnecke said. Cook County's Stroger Hospital and Mount Sinai Hospital provide free care, "but they're overloaded."

Many African Americans don't have health insurance. Consequently, diseases are diagnosed later, and outcomes are less favorable, Warnecke said.

Breast cancer illustrates the problem. In 1998, there were 28.6 deaths from breast cancer for every 100,000 black women in Chicago, but only 18.6 deaths among white women. "This means African American women in Chicago are 54 percent more likely to die of breast cancer than white women," said Dr. David Ansell, chairman of Sinai Health System department of medicine.

Many African American women who lack health insurance do not have a regular doctor, and this reduces the likelihood they will get prompt diagnosis and treatment. "There's no continuity of care," Ansell said. "These women get bounced around from place to place."

Darnie Holmes lost her job and her health insurance last year, right around the time she was diagnosed with breast cancer. Many women in her position delay treatment because they can't afford the medical bills. Holmes was lucky. Mount Sinai Hospital agreed to do her surgery even though she didn't have insurance. "I'm doing fine," she said.

Some black women who are heads of households are slow to get treatment, said Ethel Nettlesbey, an African-American hotline counselor for Y-ME National Breast Cancer Organization.

"We take care of everything and everyone and put ourselves last," Nettlesbey said. "We're going to put food on the table before we go to doctors."

Group fights West Suburban merger

BY CHERI BENTRUP
Staff Writer

Oak Leaves

October 15, 2003

Catholic directives that would eliminate birth-control services at West Suburban Health Care has prompted formation of a group lobbying against the proposed acquisition by Resurrection Health Care.

Dr. Debbie Stulberg, a family practice physician in her second year of residency at West Suburban, has organized West Suburban Hospital Merger Watch.

The group has an active core of eight resident doctors and one attending doctor. Many more midwives, doctors and nurses have voiced concerns about the merger and its implications, Stulberg said, but won't speak publicly for fear of losing their jobs.

West Suburban Health Care on Sept. 22 announced it had signed a letter of intent to become part of Resurrection Health Care, Chicago's largest Catholic health-care system. The next step in the process is to draft legal documents to be executed at the purchase, expected in early 2004.

"If in fact the Resurrection Health Care and West Suburban Hospital does become final, we will be following the religious directives of the Catholic Church," West Suburban spokeswoman Marlena Lagina said in response to questions about changes to women's health care. She would not comment further.

West Suburban officials in June 1999 ended a three-year affiliation with Loyola University Health System, saying among other things they wanted to "continue to serve as a non-sectarian health-care provider."

Stulberg works at the PCC Community Wellness Center at 14 Lake St., where she treats many low-income women and children, as well as some adolescents.

Stulberg said she's concerned Resurrection will prohibit services including post-delivery tubal ligation for mothers, and emergency contraception for rape victims.

"Some of the things we do in the hospital wouldn't be able to happen," Stulberg said.

"Patients who delivered babies won't get tubal ligations, which is a common procedure. There are hundreds of tubal ligations done at West Suburban each year. The hospital would have to say, 'We can't do that here,' but give them places they could go."

That means a six-week wait for new mothers, a separate surgery and two recovery periods instead of one, Stulberg said.

"The other big concern is the emergency contraception in the emergency room," Dr. Brian Smith, who also practices at the Wellness Center.

Rape victims also would have to be sent elsewhere for emergency contraception, she said.

"It's a big burden" to tell a rape victim to find another hospital, Stulberg said.

Merger Watch members include the Chicago-based Health and Medicine Policy Research Group.

"We're concerned about the residents in the Austin and Oak Park areas," said policy analyst Lee-Lin Wang of the research group, an independent policy center focused on health care for the poor and underserved.

West Suburban is a key provider of health care to uninsured and Medicaid-insured patients. The MergerWatch Web site states 24 percent of the discharges from West Suburban in 1999 were Medicaid patients compared to 4.8 percent at Oak Park Hospital, 8.6 percent at Gottlieb in Melrose Park and 10.4 percent at MacNeal in Berwyn.

"We're trying to get people aware of what's going on," Wang said. "Now is the time we need to act."

West Suburban Hospital Merger Watch expects to host two forums this fall to inform the public on what changes are in store if the merger with Resurrection goes through.

Smith said Medicaid and uninsured typically seek care and admittance to the hospital through the emergency room, and law prohibits them from being turned away for inability to pay. He's more concerned about the limits on women's health care and the control a Catholic hospital would have over its residents.

"Others are disappointed that this would affect the residents," he added.

Housestaff, the organization that represents West Suburban's residents and fellows, in April issued a statement opposing any merger that would limit the scope of care they provide and training they receive.

Smith thinks West Suburban officials could solve these issues by forming a separate entity, other than Resurrection, to employ the residents before the deal is finalized.

Stulberg questions whether doctors in their own offices at West Suburban Medical Center could prescribe birth control or talk to a patient about contraceptive options and sexually transmitted diseases.

"It affects a lot of patients in many settings," she said. "What scares us as health-care providers is that we can't talk to our patients about their options."

The PCC Wellness Clinic is working to become independent of West Suburban, Smith said.

"If the clinic can become more independent of West Suburban, hopefully, we won't be strictly tied" to Catholic doctrine, Stulberg said.

But Stulberg said she would rather see the merger stopped.

"We don't feel it's the best thing for our patients, the community West Suburban serves," she said. Stulberg said the hospital's administration needs to look at other options.

"The hospital is struggling financially. To put it in medical terms, we think the treatment might be worse than the diagnosis. Is it worth losing services that are so important to the community? We think the hospital should go back to the drawing board," she said.

West Suburban reported operating losses of $19.1 million in 2001 and $13.4 million in 2002. In the fiscal year that ended in June, the hospital reported a profit of $397,000.

Girls often fall through cracks in justice system

Dawn Turner Trice
July 11, 2003

When we think of the incarcerated, young female offenders tend to slip below the radar.

That's too bad because girls ages 10 to 17 are the fastest-growing population in the juvenile detention system, according to the Office of Juvenile Justice and Delinquency Prevention in Washington.

Between 1980 and 2000, the arrest rate for girls in this age category increased 40 percent. Girls also have a 70 percent recidivism rate, despite being fewer in number and less violent than young male offenders.

Half of all incarcerated girls have some degree of mental illness. Many have been physically or sexually abused. Some have abused drugs, sold their bodies or been involved in gangs. They are poor, uneducated and disproportionately minority.

The Chicago-based Health and Medicine Policy Research Group on Wednesday held a daylong conference at the University of Illinois at Chicago titled "Healing Girls in the Juvenile Justice System: The Challenge to Our Community."

Margie Schaps is executive director of the group and the organizer of the conference, which had more than 200 attendees.

She said the purpose of the day's events was to assemble physicians, psychologists, lawyers, teachers, ex-offenders, substance-abuse experts and probation officers to figure out how to help these young offenders. The goal is to better help them develop into productive citizens and stay out of juvenile correctional facilities.

To do this, they need a greater array of follow-up services to deal with issues that may have contributed to their incarceration. That's true rehabilitation.

Schaps said that in the absence of intervention, girls are becoming more aggressive and more violent.

"In my research for the conference, anecdotally, I found that the girls blame the chaos in their lives," she said. "Their lives are in total disarray, and they are very fearful and more aggressive. Life is very different now than 25 years ago."

She said it used to be that there was at least one stable adult in their lives who could guide them. These days, many young girls headed for trouble don't have a support system.

A 17-year-old attending the conference told me that over a 21-month period, she spent time in a juvenile detention center and a group home after being convicted of drug possession. While serving time, she was in therapy and learned a lot about anger management.

Since being released, she returned to school, dropped out and is endeavoring to get back on track. "Now I'm learning to cope on my own," she said.

In a time of fiscal crisis, where does the money come from to help these young women?

Well, sometimes it's not a matter of allocating more dollars, but better directing them. You start by re-examining programs already in place, then asking how they can be retooled and improved upon.

Schaps said one challenge is that many of the programs for young offenders were created solely with boys in mind.

She said studies show that girls process trauma differently and need different approaches.

It costs $37,000 a year to lock up a young offender, Schaps said. It costs about $5,000 a year to offer intervention in which a child gets intensive family therapy for six months. It helps most if therapy is preventive, but statistics show that an ex-offender also can benefit.

If you commit a crime, you should be held accountable. But a 70 percent recidivism rate translates into too many wasted lives.

I have a childhood girlfriend who's incarcerated. That's one of the reasons the topic resonates with me. My friend wasn't a child when she committed her crime, but as I think back, I do remember the early warning signs and often wonder what could have been done to save her. I also wonder what's in store for her when she's released.

Ideally, these girls would make choices that would steer them away from juvenile detention. But some are set on paths so perilous that incarceration often becomes unavoidable.

Illinois has various task forces considering lists of items for policy overhaul. This topic deserves to be placed high up on more than one of those lists.

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Dawn Turner Trice's column appears Mondays. Mary Schmich is on vacation.

Copyright © 2003, Chicago Tribune

Point Counterpoint: The Role of Federal Government in Healthcare Reform

As a part of Blue Cross Blue Shield’s online newsletter, BCBSHealthIssues.com, Dr. Quentin Young, MD, Chairman of Health and Medicine Policy Research Group, and Gracie-Marie Turner, President of the Galen Institute were asked to participate in the Point-Counterpoint series. Below Blue Cross Blue Shield poses four questions about the role of federal government in healthcare reform, following are their responses. For more information on this report, go to http://www.bcbshealthissues.com.

Question #1:

What has been the greatest success to date of the federal government's involvement in the healthcare insurance system? What has been the greatest failure? Why?

Dr. Quentin Young MD responds:

Actually, several government "successes" should be cited which establish the achievement and fitness of its involvement in the provision of health services, in particular through healthcare insurance.

The premier program is, of course, Medicare. Flawed though it is by concessions made to its opponents in 1965, it stands as an exemplary harbinger of what we as a people can achieve through our democratic system of government. Yes, Medicare is burdened with counter-productive co-pays, deductibles and caps. The original act actually proscribed payment for preventive care and check ups, while conspicuously failing to provide for coverage of medications - changes imposed at the last minute by medical and insurance interests.

That said, Medicare protection of everyone over 64 (and, later, the fully disabled) is among the most valued social justice enactments in our history. Its universality and freedom from means-testing and marketplace limitations stand in stark contrast to the costly, chaotic, dysfunctional private health insurance system - whether employment-based, self-pay or other - that plagues our non-Medicare public.

For completeness, other federal government programs are worthy of mention that, directly or indirectly, favorably affect healthcare insurance.

For example, the main engine of biological research in the world is our government's National Institutes of Health. With an initial appropriation in 1887 of $300 and $20.3 billion awarded in 2001, the Institutes have enjoyed enormous popular support.

Further, the Food and Drug Administration and the Agency for Healthcare Research and Quality are two other splendid examples of "government involvement" that safeguard our insurance system from purely market-driven forces.

What has been "the greatest failure" of federal involvement in health insurance? The delay in establishing a universal single-payer system - "everybody in, nobody out" - that is serving the people in all of the other industrial democratic nations.

Grace-Marie Turner responds:

One of the federal government's greatest successes in health insurance has been its hands-off attitude toward employment-based health insurance, the vehicle through which nearly 200 million Americans receive some form of health coverage.

In 1974, Congress enacted the Employee Retirement Income Security Act (ERISA). Among other things, ERISA allows employers the freedom to design health insurance plans with minimal federal or state regulation or mandates. This gives them maximum flexibility to negotiate benefits and prices and to try innovative approaches to health coverage. Health insurance is evolving to be more consumer-focused as companies experiment with new ways to empower employees to make wise decisions about their health coverage, with incentives to spend healthcare dollars wisely.

One of the biggest flaws in the federal government's role in health insurance is its failure to treat working Americans equally in providing subsidies. Workers who get their health insurance through their jobs receive a generous tax break as long as the employer writes the check for their policy. This provides a strong incentive for people to get their health insurance through the workplace and has led to a stable system that has served the majority of people well.

But it has major drawbacks.

Tax policy discriminates against those who don't or can't get health insurance at work. If people buy health insurance on their own, most have to pay the premiums with after-tax dollars, which can be quite a stiff penalty.

For those who do get health insurance at work, they have to take the policy offered by their employers, even if they don't like the coverage.

In our increasingly mobile society, people need other choices than just a system that ties health insurance to the workplace.

Question #2:

What is the most appropriate role for the federal government in the healthcare delivery system?

Dr. Quentin Young, M.D. responds:

The accumulated experience of all of the economically advanced, democratic countries of the world has established the role of national government as the most efficient mechanism for financing healthcare for its people. Therefore our federal government should expand its service as the agent for Medicare financing to the entire population.

By this act, enormous savings in administrative cost would be realized immediately. Private health insurance requires 15-30% for these services, whereas Medicare administration is less than 3%. Canada's universal system requires 0.9% on average among its provincial systems. Beyond liberating tens of billions of dollars from these non-productive functions, national health insurance that covers everyone is the most reliable way to guarantee services to all who need them in a system oriented toward equity, prudence, and quality.

This program also would restore to physicians professional prerogatives and autonomy that have been compromised by market-oriented contemporary delivery systems. These systems of course seek maximum return to the investors, an arrangement that has brought great grief to the American public by limiting or denying services.

With a single payer national health program we can turn our attention to the unfinished work of the American health system: universal coverage; prescription drug benefits to all; expanded preventive health services; and, not least, it can provide for the expanded long term care needs of our aging population.

The very good news is that we have the required financial commitment ($1.4 trillion dollars in year 2000, or $4,200 for every U.S. inhabitant), enormous physical capacity (hospitals, nursing homes, clinics, hi-tech equipment) and a superb, highly skilled health professional and technical workforce.

The missing ingredient is the national commitment to a universal system.

Grace-Marie Turner responds:

One of our national values, expressed through a mosaic of legislation, is that people in the United States should not go without needed medical care. But our system of distributing subsidies for health coverage looks like a giant Swiss cheese.

The appropriate role for government is to stop expanding public programs that micromanage the healthcare system through price controls and burdensome regulation and, instead, to equalize and rationalize subsidies to provide funding for people who need help in obtaining health insurance - ideally in the private marketplace.

A new idea has passed both houses of Congress in different forms that would begin to move us in that direction. The idea is to provide refundable tax credits to lower-income Americans and families who don't have health insurance.

President Bush proposes to provide $1,000 to individuals and $3,000 to families each year to help them purchase health coverage. A recent study by the online broker, eHealthInsurance, found that this subsidy would cover 75% of the premiums for the great majority of people who buy coverage from them.

Another study by Professor Mark Pauly of the Wharton School at the University of Pennsylvania found that the number of uninsured would drop by at least 50% if a tax credit worth half the value of a decent health policy were available to all of the uninsured.

Refundable tax credits would provide financial help to those who make too much to qualify for Medicaid and too little to receive good health insurance at work.

The system we have now is terribly inequitable. The poor, the elderly, children, the disabled, and selected others qualify for generous taxpayer-supported health benefits through public programs that collectively spent $587 billion last year. Those who receive health insurance at work receive a generous tax break worth more than $130 billion a year.

Workers with incomes of about $25,000 a year are least likely to receive any help in purchasing health insurance. A crucial role for the federal government is to amend this inequity. Refundable tax credits would be an important step in the right direction.

Question #3:

Healthcare costs are rising again, at double-digit rates. What role, if any, should the federal government play in helping to reduce the cost of healthcare?

Dr. Quentin Young responds:

The federal government can achieve spectacular cost reductions through a system of tax-based, national health insurance (NHI). Indeed, only the feds can realize these savings.

We start with healthcare expenditures in 2000 (It is more now, of course): $1.4 trillion dollars. Administrative waste, presently squandered on the 15 - 30% that the private insurance system charges us, can be sharply reduced. In sharp contrast, our single-payer federal Medicare system spends less than 3%. Extending single payer to the entire population would capture these bureaucratic billions for healthcare and, at the same time, put an end to exorbitant executive salaries, stock options, and perks. Administrative savings with NHI: $150 billion.

The fastest rising healthcare expenditures are for pharmaceutical products. NHI could effect cost reductions of 40 - 60% by bulk purchasing from the drug companies (the Veterans Administration presently does just that). Drug cost savings with NHI: $50 billion.

Further billions can be recovered with an appropriate utilization of generic (rather than costly trademarked) drugs, in accord with evidence-based practice recommendations. Similarly, through education of prescribing physicians, the NHI system could significantly reduce inappropriate prescription of antibiotics, NSAIDS and other misused medication. Savings from improved pharmaceutical practice through NHI: billions.

Covering the entire population, NHI can better implement preventive services, including immunizations, Pap smears, tobacco smoking cessation, fitness programs and reduction of blood lipids and weight. Also, NHI will obviate the well-documented increased mortality and morbidity associated with care-avoidance or care-delay in the uninsured, which regularly results in more costly care. Savings from timely care through NHI: billions.

Of course, a universal system offering comprehensive, quality se