Free Clinics fill medical void.

This is from USA Today.

Obviously the free and community system is being stressed by increased demand and reduced funding. This is more evidence that the US system needs something akin to the European universal health care plans. However, with the US system tied to a web of powerful insurers and private corporations such reforms have so far proved impossible. Any reform is still likely to leave the US one of the most expensive systems in the world but still not providing adequate treatment for those on the lower end of the income scale.



Free clinics fill medical void
By Marisol Bello, USA TODAY
WEST CHESTER, Pa. — By his analysis, Edward Boyer should be dead.
Boyer, who lost his health insurance with his factory job last May, is an insulin-dependent diabetic who says he can't afford his medicine. He has a new job, working part-time in the kitchen of a chain-store restaurant, but can't afford insurance, he says.
POLL: 21% of Americans scrambling to pay medical, drug bills
SKIPPED: Many forgoing routine dental care, too
A month ago, things looked grim. He had enough insulin to last a few days and didn't have $200 for a refill.
That's when a friend, also diabetic, told him about Community Volunteers in Medicine, a clinic in this suburb 36 miles west of Philadelphia.
The clinic provides free medical and dental services and medicine for the working poor — people who have no insurance but earn too much to qualify for federal or state programs.
"They kept me alive," says Boyer, 28, of Coatesville.
More Americans losing their jobs and health insurance are turning to volunteer-run free clinics and government-funded community health centers for free or low-cost medical care. The safety net is being strained as demand grows and budgets shrink.
For every 1 percentage point rise in unemployment, the number of uninsured people increases by 1.1 million, according to Families USA, a health-reform advocacy group. The U.S. unemployment rate is 8.5%.
"That's placing a major-league burden on health centers," says Tom Van Coverden, CEO of the National Association of Community Health Centers.
Community health centers are funded by states and the federal government and provide services to the poor, regardless of insurance. Patients receive free services or pay on a sliding scale based on their income.
In 2008, the country's 1,200 community health centers treated 7 million uninsured patients, up 3% from 6.8 million in 2007.
Van Coverden says the recession is likely to drive the number of uninsured up by 30%.
Free clinics are charity organizations that provide services to people who can't afford insurance or don't qualify for government health programs. They rely on donations and volunteer medical staff to care for 4 million patients a year, says Nicole Lamoureux, executive director of the National Association of Free Clinics.
Community health centers and free clinics treat a small portion of the estimated 46 million Americans the U.S. Census estimates have no insurance.
Among the challenges clinics and health centers face:
•In West Chester, Community Volunteers in Medicine treated 332 patients in February, up 26% from February 2008. The cost of care was up 21%. At the same time, the clinic was about $100,000 behind in fundraising for its $1.8 million annual budget.
•Ohio's 40 free clinics treated 56,000 uninsured patients in 2008, up from 43,000 in 2007. Marjorie Frazier, executive director of the Ohio Association of Free Clinics, expects the number to increase in 2009. In January, one clinic in Cleveland closed because it lacked funding. Ohio, one of the few states that helps pay for free clinics' operations, is cutting funding. Its two-year allocation for 2008 and 2009 was $2.1 million; for 2010 and 2011, proposed funding is $1.5 million.
•California's 800 community health centers saw increases of up to 20% in uninsured patients in the past six months. The state, facing a $42 billion budget shortfall, is eliminating payments for some services for poor adults, including dental care. As a result, the centers will lay off 1,000 dentists and other staff, leaving as many as 400,000 people without dental care, says Chris Patterson, spokesman for the California Primary Care Association.
Community health centers are getting a lifeline, though. They will receive $2 billion in federal stimulus funding for staffing, equipment and construction of new centers.
In Carrboro, N.C., Piedmont Health Services will receive $686,000 in stimulus money that will keep the center from laying off 19 of its 235 medical, dental and pharmacy workers, says CEO Brian Toomey.
Free clinics, which won't get any of that money, are stepping up fundraising. They are appealing to donors who want to contribute to charities that provide care for those who need it most in the troubled economy, says Maureen Tomoschuk, CEO of Community Volunteers in Medicine.
Anthony Hicklen hopes the donations keep coming. The owner of a janitorial business, Hicklen says he can't afford private insurance and has been going to the clinic since 2003.
This year, the clinic's volunteer doctors diagnosed him with prostate cancer. The clinic helped him join a state program for the poor that will pay for his surgery this month.
"The clinic is the only answer for a lot of people," Hicklen says. "This is a lifesaver for me. I'm 55 years old and I would like to see a few more years."


Copyright 2008 USA TODAY, a division of Gannett Co. Inc.

US health reform by Himmelstein and Woolhandler

New York Times - December 15, 2007
The attempts by US states to attempt to find some alternative to a truly universal system has not had very positive results and has still left many uninsured.
The stranglehold that private insurers have on the system prevents any radical reforms.

I Am Not a Health Reform
By DAVID U. HIMMELSTEIN and STEFFIE WOOLHANDLER

Cambridge, Mass.

IN 1971, President Nixon sought to forestall single-payer national
health insurance by proposing an alternative. He wanted to combine a
mandate, which would require that employers cover their workers, with
a Medicaid-like program for poor families, which all Americans would
be able to join by paying sliding-scale premiums based on their income.

Nixon's plan, though never passed, refuses to stay dead. Now Hillary
Clinton, John Edwards and Barack Obama all propose Nixon-like
reforms. Their plans resemble measures that were passed and then
failed in several states over the past two decades.

In 1988, Massachusetts became the first state to pass a version of
Nixon's employer mandate — and it added an individual mandate for
students and the self-employed, much as Mrs. Clinton and Mr. Edwards
(but not Mr. Obama) would do today. Michael Dukakis, then the state's
governor, announced that "Massachusetts will be the first state in
the country to enact universal health insurance." But the mandate was
never fully put into effect. In 1988, 494,000 people were uninsured
in Massachusetts. The number had increased to 657,000 by 2006.

Oregon, in 1989, combined an employer mandate with an expansion of
Medicaid and the rationing of expensive care. When the federal
government granted the waivers needed to carry out the program, Gov.
Barbara Roberts said, "Today our dreams of providing effective and
affordable health care to all Oregonians have come true." The number
of uninsured Oregonians did not budge.

In 1992 and '93, similar bills passed in Minnesota, Tennessee and
Vermont. Minnesota's plan called for universal coverage by July 1,
1997. Instead, by then the number of uninsured people in the state
had increased by 88,000.

Tennessee's Democratic governor, Ned McWherter, declared that
"Tennessee will cover at least 95 percent of its citizens." Yet the
number of uninsured Tennesseans dipped for only two years before
rising higher than ever.

Vermont's plan, passed under Gov. Howard Dean, called for universal
health care by 1995. But the number of uninsured people in the state
has grown modestly since then.

The State of Washington's 1993 law included the major planks of
recent Nixon-like plans: an employer mandate, an individual mandate
for the self-employed and expanded public coverage for the poor. Over
the next six years, the number of uninsured people in the state rose
about 35 percent, from 661,000 to 898,000.

As governor, Mitt Romney tweaked the Nixon formula in 2006 when he
helped devise a second round of Massachusetts health care reform:
employers in the state that do not offer health coverage face only
paltry fines, but fines on uninsured individuals will escalate to
about $2,000 in 2008. On signing the bill, Mr. Romney declared,
"Every uninsured citizen in Massachusetts will soon have affordable
health insurance." Yet even under threat of fines, only 7 percent of
the 244,000 uninsured people in the state who are required to buy
unsubsidized coverage had signed up by Dec. 1. Few can afford the sky-
high premiums.

Each of these reform efforts promised cost savings, but none included
real cost controls. As the cost of health care soared, legislators
backed off from enforcing the mandates or from financing new coverage
for the poor. Just last month, Massachusetts projected that its costs
for subsidized coverage may run $147 million over budget.

The "mandate model" for reform rests on impeccable political logic:
avoid challenging insurance firms' stranglehold on health care. But
it is economic nonsense. The reliance on private insurers makes
universal coverage unaffordable.

With the exception of Dennis Kucinich, the Democratic presidential
hopefuls sidestep an inconvenient truth: only a single-payer system
of national health care can save what we estimate is the $350 billion
wasted annually on medical bureaucracy and redirect those funds to
expanded coverage. Mrs. Clinton, Mr. Edwards and Mr. Obama tout cost
savings through computerization and improved care management, but
Congressional Budget Office studies have found no evidence for these
claims.

In 1971, New Brunswick became the last Canadian province to institute
that nation's single-payer plan. Back then, the relative merits of
single-payer versus Nixon's mandate were debatable. Almost four
decades later, the debate should be over. How sad that the leading
Democrats are still kicking around Nixon's discredited ideas for
health reform.

David U. Himmelstein and Steffie Woolhandler are professors of
medicine at Harvard and the co-founders of Physicians for a National
Health Program.


___________________________________

Critique of US health care system

This is a powerful critique of the US health system. The vested interests are so powerful in the US it is almost certain that any reform will leave some of the most costly aspects of the system still in place. Massachussets is supposed to be a shining beacon of reform I gather but as this article shows it has many failings. Of course a single payer scheme is regarded in the US as socialist but it or some variant of it is characteristic of almost every advanced capitalist state. The US has managed to develop a costly and inefficient public system alongside an even more costly and inefficient private system. However the single payer systems are also having their own problems often resulting in two tier systems or waiting times. Off loading of costs onto individuals is now common in almost all systems.

Boston Globe - September 17, 2007

Health reform failure
By Steffie Woolhandler and David U. Himmelstein

IN 1966 - just before Medicare and Medicaid were launched - 47
million Americans were uninsured. By 1975, the United States had
reached an all time low of 21 million without coverage. Now,
according to the Census Bureau's latest figures, we're back where we
started, with 47 million uninsured in 2006 - up 2.2 million since
2005. But this time, most of the uninsured are neither poor nor
elderly.

The middle class is being priced out of healthcare. Virtually all of
this year's increase was among families with incomes above $50,000;
in fact, two-thirds of the newly uncovered were in the above-$75,000
group. And full-time workers accounted for 56 percent of the
increase, with their children making up much of the rest.

The new Census numbers are particularly disheartening for anyone
hoping for a Massachusetts miracle. In the Commonwealth, 651,000
residents are uninsured, 65 percent more than the figure used by
state leaders in planning for health reform. Their numbers came from
a telephone survey done in English and Spanish. But that misses
people who lack a land-line phone - 43.9 percent of phoneless adults
are uninsured, according to other studies.

It also skips over the 523,000 non-English speakers in Massachusetts
whose native language isn't Spanish (e.g. Portuguese, Chinese, or
Haitian-Creole), another group with a high uninsurance rate. In
contrast, the Census Bureau goes door-to-door for its survey and has
translators for almost every language. It gets a more complete picture.

In sum, Massachusetts health reform planners have been wishing away a
quarter of a million uninsured people. Recent Patrick administration
claims that health reform is succeeding are based on cooked books.
According to the state's figures, almost half of the previously
uninsured gained coverage under the health reform bill by July 1. But
according to the Census Bureau, the new sign-ups amount to less than
one-quarter of the uninsured. Moreover, it's likely that much of that
gain has already been wiped out by shrinking job-based coverage - a
longstanding and nationwide trend.

Why has progress been so meager? Because most of the promised new
coverage is of the "buy it yourself" variety, with scant help offered
to the struggling middle class. According to the Census Bureau, only
28 percent of Massachusetts uninsured have incomes low enough to
qualify for free coverage. Thirty-four percent more can get partial
subsidies - but the premiums and co-payments remain a barrier for
many in this near-poor group.

And 244,000 of Massachusetts uninsured get zero assistance - just a
stiff fine if they don't buy coverage. A couple in their late 50s
faces a minimum premium of $8,638 annually, for a policy with no drug
coverage at all and a $2,000 deductible per person before insurance
even kicks in. Such skimpy yet costly coverage is, in many cases,
worse than no coverage at all. Illness will still bring crippling
medical bills - but the $8,638 annual premium will empty their bank
accounts even before the bills start arriving. Little wonder that
barely 2 percent of those required to buy such coverage have thus far
signed up.

While the middle class sinks, the health reform law has buoyed our
state's wealthiest health institutions. Hospitals like Massachusetts
General are reporting record profits and enjoying rate increases
tucked into the reform package. Blue Cross and other insurers that
lobbied hard for the law stand to gain billions from the reform,
which shrinks their contribution to the state's free care pool and
will force hundreds of thousands to purchase their defective
products. Meanwhile, new rules for the free care pool will
drastically cut funding for the hundreds of thousands who remain
uninsured, and for the safety-net hospitals and clinics that care for
them. (Disclosure - we've practiced for the past 25 years at a public
hospital that is currently undergoing massive budget cuts.)

Health reform built on private insurance isn't working and can't
work; it costs too much and delivers too little. At present,
bureaucracy consumes 31 percent of each healthcare dollar. The
Connector - the new state agency created to broker coverage under the
reform law - is adding another 4.5 percent to the already sky-high
overhead charged by private insurers. Administrative costs at Blue
Cross are nearly five times higher than Medicare's and 11 times those
in Canada's single payer system. Single payer reform could save $7.7
billion annually on paperwork and insurance profits in Massachusetts,
enough to cover all of the uninsured and to upgrade coverage for the
rest of us.

Of course, single payer reform is anathema to the health insurance
industry. But breaking their stranglehold on our health system and
our politicians is the only way for health reform to get beyond
square one.

---

Dr. Steffie Woolhandler and Dr. David Himmelstein co-founded
Physicians for a National Health Program and are primary care doctors
at Cambridge Hospital.

US poverty declining

The decline should be looked at in light of the fact that during 2000 it was 11.3 so the decline is from very high levels. At the same time as the article notes the number of people not covered by health insurance is growing.

U.S. poverty rate declines significantly

By STEPHEN OHLEMACHER, Associated Press Writer
50 minutes ago

Five years into a national economic recovery, the
share of Americans living in poverty finally dropped.

The nation's poverty rate was 12.3 percent in 2006,
down from 12.6 percent a year before, the Census
Bureau reported Tuesday. Median household income
increased slightly, to $48,200.

The numbers provided some good economic news at a time
when financial markets have been rattled by a slumping
housing market. But they were tempered by an increase
in the number of Americans without health insurance,
from 44.8 million in 2005 to 47 million last year.

Some advocates said the numbers were evidence of an
uneven economy that is leaving many Americans behind.

"Too many Americans find themselves still stuck in the
deep hole dug by economic policies favoring the
wealthy," said Rep. Charles B. Rangel, D-N.Y.,
chairman of the House Ways and Means Committee.
"Income remains lower than it was six years ago,
poverty is higher, and the number of Americans without
health insurance continues to grow."

But Douglas Besharov, a resident scholar at the
conservative American Enterprise Institute, said there
is a lot of good news in the numbers.

"We're looking at a situation where unemployment was
down, and it was down for single mothers, who make up
a substantial portion of the people in poverty,"
Besharov said. "We need a good economy. That's not all
we need, but we should not complain when it helps
lower poverty."

The last significant decline in the poverty rate came
in 2000, during the Clinton administration, when it
went from 11.9 percent to 11.3 percent.

The poverty rate increased every year for the next
four years, peaking at 12.7 percent in 2004. It was
12.6 percent in 2005, but Census officials said that
change was statistically insignificant.

The poverty level is the official measure used to
decide eligibility for federal health, housing,
nutrition and child care benefits. It differs by
family size and makeup. For a family of four with two
children, for example, the poverty level is $20,444.

The poverty rate — the percentage of people living
below poverty — helps shape the debate on the health
of the nation's economy.

Democrats on Capitol Hill said the insurance numbers
justify spending more money for a popular government
health insurance program for children.

Both chambers of Congress recently passed bills that
would dramatically increase funding for the Children's
Health Insurance Program, known as SCHIP. The Bush
administration, however, opposes both measures saying
they would result in people abandoning private
coverage for public coverage for children.

The share of Americans without health insurance hit
15.8 percent last year, the highest percentage since
1998. In 2005, 15.3 percent were without insurance.

The annual increase was fueled mainly by a decline in
the share of workers covered by employer-provided
health insurance, said David Johnson, chief of the
Census Bureau's Housing and Household Economic
Statistics Division.

Two Democrats running for president said the insurance
numbers point to weaknesses in the nation's health
care system.

"These statistics show what most Americans know: tens
of millions of our fellow citizens are completely left
out of the economic progress enjoyed by the
individuals and corporations on the very top," said
Democrat John Edwards, who has made eradicating
poverty a centerpiece of his campaign. "We need truly
universal health care and a national effort to
eliminate poverty."

Sen. Hillary Rodham Clinton noted that there were a
lot fewer people without health insurance when she
first addressed the issue as first lady. In 1993,
there were 39.7 million Americans without health
insurance, according to the Census Bureau.

"It is an even deeper outrage today," she said.

The Census Bureau on Tuesday released 2006 income and
poverty figures for all the states and every city and
county with a population of 65,000 or more.

Among the findings:

_Maryland led the country with a median household
income of $65,144. It was followed by New Jersey,
Connecticut, Hawaii and Massachusetts.

_Mississippi had the lowest median income, at $34,473.
It was followed by West Virginia, Arkansas, Oklahoma
and Alabama.

_Mississippi had the highest poverty rate, at 21.1
percent. It was followed by Louisiana, New Mexico,
Arkansas and West Virginia.

_Maryland had the lowest poverty rate, at 7.8 percent.
It was followed by New Hampshire, Connecticut, New
Jersey and Hawaii.

___

Krugman on Bush's Health Care Views

In spite of the fact that almost every other advanced capitalist state has some form of universal health care the US considers it some sort of socialist plot and even most Democrats will not even say straight out they are in favor of some single payer system. The result is a health care system that is the most expensive in the world but far from the best particularly for the working poor. It is so inefficient that even without universal care the public expenditure in the US is greater than that in the UK that has a universal system--as percentage of GDP. But the US also has a huge private expenditure as well.


The New York Times
July 30, 2007

An Immoral Philosophy

By PAUL KRUGMAN

When a child is enrolled in the State Childrens Health Insurance
Program (Schip), the positive results can be dramatic. For example,
after asthmatic children are enrolled in Schip, the frequency of
their
attacks declines on average by 60 percent, and their likelihood of
being hospitalized for the condition declines more than 70 percent.

Regular care, in other words, makes a big difference. Thats why
Congressional Democrats, with support from many Republicans, are
trying
to expand Schip, which already provides essential medical care to
millions of children, to cover millions of additional children who
would otherwise lack health insurance.

But President Bush says that access to care is no problem After
all,
you just go to an emergency room and, with the support of the
Republican Congressional leadership, hes declared that hell veto
any
Schip expansion on philosophical grounds.

It must be about philosophy, because it surely isnt about cost. One
of
the plans Mr. Bush opposes, the one approved by an overwhelming
bipartisan majority in the Senate Finance Committee, would cost
less
over the next five years than well spend in Iraq in the next four
months. And it would be fully paid for by an increase in tobacco
taxes.

The House plan, which would cover more children, is more expensive,
but
it offsets Schip costs by reducing subsidies to Medicare Advantage
a
privatization scheme that pays insurance companies to provide
coverage,
and costs taxpayers 12 percent more per beneficiary than
traditional
Medicare.

Strange to say, however, the administration, although determined to
prevent any expansion of childrens health care, is also dead set
against any cut in Medicare Advantage payments.

So what kind of philosophy says that its O.K. to subsidize
insurance
companies, but not to provide health care to children?

Well, heres what Mr. Bush said after explaining that emergency
rooms
provide all the health care you need: Theyre going to increase the
number of folks eligible through Schip; some want to lower the age
for
Medicare. And then all of a sudden, you begin to see a I wouldnt
call
it a plot, just a strategy to get more people to be a part of a
federalization of health care.

Now, why should Mr. Bush fear that insuring uninsured children
would
lead to a further federalization of health care, even though
nothing
like that is actually in either the Senate plan or the House plan?
Its
not because he thinks the plans wouldnt work. Its because hes
afraid
that they would. That is, he fears that voters, having seen how the
government can help children, would ask why it cant do the same for
adults.

And there you have the core of Mr. Bushs philosophy. He wants the
public to believe that government is always the problem, never the
solution. But its hard to convince people that government is always
bad
when they see it doing good things. So his philosophy says that the
government must be prevented from solving problems, even if it can.
In
fact, the more good a proposed government program would do, the
more
fiercely it must be opposed.

This sounds like a caricature, but it isnt. The truth is that this
good-is-bad philosophy has always been at the core of Republican
opposition to health care reform. Thus back in 1994, William
Kristol
warned against passage of the Clinton health care plan in any form,
because its success would signal the rebirth of centralized
welfare-state policy at the very moment that such policy is being
perceived as a failure in other areas.

But it has taken the fight over childrens health insurance to bring
the
perversity of this philosophy fully into view.

There are arguments you can make against programs, like Social
Security, that provide a safety net for adults. I can respect those
arguments, even though I disagree. But denying basic health care to
children whose parents lack the means to pay for it, simply because
youre afraid that success in insuring children might put big
government
in a good light, is just morally wrong.

And the public understands that. According to a recent Georgetown
University poll, 9 in 10 Americans including 83 percent of
self-identified Republicans support an expansion of the childrens
health insurance program.

There is, it seems, more basic decency in the hearts of Americans
than
is dreamt of in Mr. Bushs philosophy.

Comparison of US and Canadian Health Care Outcomes

Well neither the US nor the Canadian system are very good in comparison to many European systems. The Canadian system would have probably looked even better if more non-insured US patients were included in the study. Of course for the well off the US system is probably one of the best in the world.


Canadian health system fares well in study
Apr 17, 2007 08:08 PM
Anne-Marie Tobin
Canadian press

Health outcomes for patients in Canada are as good as or better than in the United States, even though per capita spending is higher south of the border, suggest Canadian and U.S. researchers who crunched data from 38 studies.

The findings were published in the inaugural edition of Open Medicine, a new online medical journal launching Wednesday in the aftermath of a rift last year between some editors and the publisher of the Canadian Medical Association Journal.

"In looking at patients in Canada with a specific diagnosis compared to Americans with the same diagnosis, in Canada patients had at least as good an outcome as their American counterparts – and in many situations, a better health outcome," said one of the 17 authors, Dr. P.J. Devereaux, a cardiologist and clinical epidemiologist at McMaster University in Hamilton.

"And that is important because in the United States, they're currently spending a little over $7,100 per individual on health care annually, whereas in Canada we're spending a little over $2,900 per individual annually," he said in a telephone interview from Brantford, Ont.

The study covered data on patient populations in the United States and Canada from 1955 to 2003. To conduct their meta-analysis, researchers identified almost 5,000 titles and abstracts. Of these, 498 appeared potentially eligible on initial review. Eventually, 38 studies were deemed to be eligible.

Researchers began by asking the question: Are there differences in health outcomes (mortality or morbidity) in patients suffering from similar medical conditions treated in Canada versus those treated in the United States?

"Overall, Canada did better, and in fact we found a statistically significant five per cent mortality advantage to people with diagnoses in Canada compared to their counterparts in the United States," Devereaux said.

Because of the extreme variability in study-to-study results, the researchers suggested caution was appropriate in interpreting this finding.

Overall, 14 of the 38 studies showed better outcomes in Canada, while five favoured the U.S. The other 19 studies showed equivalent or mixed results in the two countries.

Canada really stood out in one area – lower risk-adjusted death rates for dialysis care.

"What it (the study) shows is that despite an enormous investment in money we do not see better health outcomes (in the U.S.)," Devereaux said.

"And importantly, where our two systems do diverge is that America has a mixture of private insurance in terms of the funding for health care whereas in Canada we have medicare system for hospital and physician services. The medicare system allows us enormous efficiencies in terms of cost saving relative to private insurance."

He said the Canadian health-care system does have issues and needs improvement, "but certainly using medicare funding and not-for-profit delivery is the best way to actually maximize health outcomes and in a cost-effective manner."

The public is barraged by people saying Canada's health-care system has problems and the solution is to move toward allowing two-tiered medicine, and for-profit health-care delivery, he said.

The researchers "wanted decisions made based on evidence, and not based on beliefs and ideologies," Devereaux added.

Few uninsured patients in the U.S., who probably suffer the worst quality care, were included in the studies examined.

Some explanations for the results include the fact that American health care has administrative inefficiencies that public funding – without multiple competing insurance companies – eliminates. And because drug prices are controlled, Canada saves on prescription drug costs.