– Nancy Duff Campbell is a founder and co-president of the National Women’s Law Center, one of the nation’s pre-eminent women’s rights organizations. A recognized expert on women’s law and public policy issues, for over thirty-five years Ms. Campbell has participated in the development and implementation of key legislative initiatives and litigation protecting women’s rights, with a particular emphasis on issues affecting low income women and their families. The views expressed are her own. —

Insurance companies and others who profit from our broken health care system are mobilizing to defeat comprehensive reform by using misinformation and scare tactics. A prime example is the allegation that healthcare legislation – specifically the plan being considered by the House of Representatives – will hurt small businesses.

The fact is that small business owners, especially women, are already hurting under our current healthcare system. Leah Daniels, 29, is the owner of Hill’s Kitchen – a gourmet kitchenware store that opened last May not far from the U.S. Capitol. Daniels can’t afford to offer health insurance to her three employees. She purchased her own bare-bones plan on the individual market for protection “in case I get hit by a car,” but not much else. It costs her just under $200 a month and doesn’t cover such services as routine doctor’s visits or maternity care. Daniels, who often works 7 days a week, says that she is constantly worried about getting sick.

Daniels’ problems are, unfortunately, all too typical. A new report by the Council of Economic Advisers (CEA) found that small businesses pay up to 18 percent more than large firms for the same health insurance policy. These higher costs mean that small businesses are considerably less likely than larger businesses to provide health insurance to their employees, and those that do tend to have less comprehensive plans. And Census data show that women-owned businesses are generally smaller than male-owned businesses.

Small business owners and employees who don’t get coverage at work or through a spouse’s plan may shop for insurance individually. But if they are women – and small businesses that don’t offer health coverage tend to have large proportions of female workers – they are likely to face discrimination in the individual health insurance market. A study by the National Women’s Law Center found that insurance companies routinely charge women higher rates than men for individual policies and offer policies that exclude health needs specific to women, such as maternity care.

Women who own a small business know that the current health care system is failing them. At a meeting of women small business owners in May, Daniels says, “We went around the room and everyone either had health insurance through their spouse or didn’t have coverage at all. Women talked about being afraid to go to the doctor because they didn’t want to find out that they might be sick. It was really striking.”

The healthcare reform plans that have begun moving through Congress would help make it possible for small business owners to offer comprehensive, affordable health insurance. The House plan would make insurance more affordable by prohibiting insurance companies from discriminating on the basis of health status or gender and by allowing small businesses to purchase coverage through a new Health Insurance Exchange. The Exchange would reduce administrative costs and offer a choice of plans meeting minimum benefit standards. New tax credits would be available to help some small businesses pay for employee health coverage; the credit would be worth 50 percent of the cost of qualified health coverage expenses for businesses with 10 or fewer employees and average wages of $20,000 or less. It would gradually be reduced until firms reached 25 or more employees or average wages of $40,000 or more.

If some employers still can’t provide coverage, their employees could purchase insurance directly from the Exchange. Sliding scale subsidies would help make it affordable, and they couldn’t be turned down because of pre-existing conditions or charged more because of their gender or health history. Larger employers who fail to offer health care coverage would be required to pay an additional payroll tax, but under the plan being developed by the House, businesses below a certain size would be exempt. One version would exempt businesses with payrolls of $500,000 or less. Another would set the exemption at $250,000 – but even at this level, 76 percent of all firms would be exempt.

Opponents of healthcare reform have claimed that small businesses would be hurt by another provision: a graduated surcharge on the very wealthy to help finance health care reform. But the surcharge would only apply to households with adjusted gross income above $350,000 ($280,000 for an individual). As a result, only the wealthiest 1.2 percent of taxpayers – and only 4 to 5 percent of all tax payers with business income – would be subject to the surcharge. Women-owned businesses are especially unlikely to be affected by the surcharge. According to the latest Census data, 96.3 percent of women-owned businesses, compared to 88.9 percent of male-owned businesses, had total receipts below $500,000 – meaning that profits would be well below that level.

Those who claim that healthcare reform will hurt small businesses should re-examine their facts – and the rest of us should examine who they’re really speaking for. We can’t afford to wait any longer for meaningful reform that will bring a guarantee of quality, affordable comprehensive health care for us all.

– Dr. Steffie Woolhandler and Dr. David Himmelstein are both associate professors of medicine at Harvard Medical School and primary care doctors at Cambridge Hospital. They co-founded Physicians for a National Health Program. –

Once they’re finished mandating that we all buy private health insurance, Congress can move on to requiring Americans to purchase other defective products. A Ford Pinto in every garage? Lead-painted toys for every child? Melamine-laced chow for every puppy?

Private health insurance doesn’t work. Even middle class families with supposedly good coverage are just one serious illness away from financial ruin. In a study carried out with colleagues from Harvard Law School and Ohio University we found that medical bills and illness contributed to 62 percent of all personal bankruptcies in 2007 – a 50 percent increase since 2001. Strikingly, three quarters of the medically bankrupt had insurance – at least when they first got sick.

In case after case, the insurance families bought in good faith failed them when they needed it most. Some were bankrupted by co-payments, deductibles, and loopholes that allowed their insurer to deny coverage. Others got too sick to work, leaving them unemployed and uninsured.

Now Congress seems poised to fulfill insurance executives’ prayers; make failure to buy their faulty product a federal offense. We’ve seen this brave new world in Massachusetts. Here, beating your wife, communicating a terrorist threat and being uninsured all carry $1000 fines. Our law has halved the state’s already low uninsurance rate – mostly by expanding Medicaid and similar programs at great public expense.

But reform hasn’t made care affordable for middle class families, or for the public treasury. A middle income uninsured 56 year old is now forced to lay out at least $4,800 for a policy with a $2,000 deductible before it pays for any care, and 20 percent co-payments after that. Skimpy, overpriced coverage like this left one in six Massachusetts residents unable to pay their medical bills last year.

Even among the insured, 18 percent skipped care because they couldn’t afford it. Meanwhile, as costs rise for subsidized coverage our state Senate plans to drop 28,000 people from the insurance rolls, and public hospitals and clinics have suffered draconian cuts as funds were diverted to shore up the reform.

Such shrunken coverage for the middle class and the evisceration of institutions that care for the poor prefigure the ugly reality of the president’s plan. Searching for the $150 billion extra he’d need each year just to cover the uninsured, Obama threatens to tax health benefits for those who are currently insured, effectively increasing its price. And he’d drain Medicare and Medicaid funds from safety net hospitals, anticipating a sharp drop in those unable to pay for care – a drop which has largely failed to materialize in Massachusetts.

The President’s other proposed funding streams aren’t objectionable, just illusory: unenforceable pledges from hospitals, insurers and the AMA to slow health inflation – a repeat of the empty promises made when Presidents Nixon and Carter threatened cost controls; and the assumption of windfall savings from computerization and care management, assumptions that the Congressional Budget Office has dismissed as wishful thinking.

A single payer reform could realize about $400 billion in savings annually on health care bureaucracy – enough to cover the uninsured and to provide first dollar coverage for all Americans. But the vast majority of these savings aren’t available unless we go all the way to single payer.

Adding a public insurance plan option – as the president proposes – won’t fix the flaws in Massachusetts-style reform. A public plan might cut private insurers’ profits, which is why the insurers hate it. But insurers’ roughly $10 billion in annual profits is only a sliver of the money squandered on bureaucracy.

The complexity and fragmentation of an insurance system with multiple competing payers breeds this massive waste. In addition to their profits, insurers spend vast amounts on overhead for marketing (to attract healthy, profitable members); demarketing (to avoid the sick); keeping track of their ever-shifting roster of enrollees and collecting their premiums monthly; fighting with hospitals and doctors over bills; and lobbying politicians. And doctors and hospitals spend tens of billions more keeping track of who got every band-aid and aspirin tablet, and fighting with insurers to collect payment.

A single payer plan would eliminate most insurance overhead, as well as these other paperwork expenses. Hospitals could be paid like a fire department, receiving a single monthly check for their entire budget, eliminating most billing. Physicians’ billing could be similarly simplified.

While a public plan option could save on profits, it would forego most of the other $390 billion that single payer could save. Hospitals and doctors would still have to maintain their elaborate billing systems. And overhead for even the most efficient competitive public plan would be far higher than Medicare’s, which automatically enrolls seniors when they turn 65 and disenrolls them only at death, deducts premiums directly from social security checks, and does no marketing.

Moreover, a kinder, gentler public plan would quickly fail in the health care marketplace. Insurers compete by NOT paying for care: by seeking out the healthy and avoiding the sick; by denying payment and shifting costs onto patients; and by lobbying for unfair public subsidies (as under the Medicare HMO program). Competition in health insurance involves a race to the bottom, not the top.

A public plan that abstained from marketing would soon be saddled with the sickest, most expensive patients, whose high costs would drive premiums to uncompetitive levels. Similarly, failure to emulate private insurers’ schemes that shift costs to patients and other payers would be a crippling competitive disadvantage. To compete effectively, a public plan would have to copy private plans’ bad behaviors.

When addressing liberal audiences, proponents of mandated private coverage with a public plan option conflate it with single payer reform, hoping to deflect criticism from their left. Meanwhile, Republicans warn that such a plan is a back door route to socialized medicine. Both are wrong.

Eight decades of experience teach that private insurers cannot control costs or provide families with the coverage they need. A government-run clone of private insurers cannot fix these flaws. It’s bad enough that insurers are peddling damaged goods. Why make things worse by requiring Americans to buy them?

– Brian Lee Crowley is the founding president of Atlantic Institute for Market Studies (AIMS), a public policy think tank in Canada (pictured left) and Valentin Petkantchin is director of research at the Paris-and Brussels-based Institut économique Molinari. The views expressed are their own. –

President Barack Obama’s package of heathcare reforms – mandatory health insurance, public health option and increased federal government financing – is being sold as preserving independent high quality care and choice for patients while keeping down costs. Taxpayers and patients in both Canada and France know better.

Unfortunately, our experience is that once the government gets its nose in the healthcare tent, not only is spending not contained, but health care professionals lose their freedom to practice. Left with few choices, patients face shortages and waiting lists.

Washington’s proposed new public health insurance option, while not imposing Canadian-style single-payer monopolistic public health insurance immediately, will almost certainly lead to that result in the end.

One of two things will happen. If doctors prove reluctant to accept patients covered by the public option and it is thus unable to compete successfully with private insurers, the politicians will not stand idly by.

Physicians’ freedom to practice outside the public option will become increasingly hedged with restrictions, perhaps ultimately ending up, as in Canada, with doctors in the public system being prohibited from taking private patients.

Or, more plausibly, in the short term at least, private insurers will gradually withdraw from the business, incapable of winning against a government-subsidized “competitor.”

In both cases, competition in the health insurance sector will progressively vanish and the U.S. will wake up with a monopolistic-style health insurance system, à la France or Canada.

Consider yourself warned.

Our respective health care systems have proven incapable of reining in rising costs. Health spending in France, while lower than the U.S., is among the highest in the world, whatever the indicator, despite decades of mandatory, subsidized health insurance. After 1988, the public health care system has regularly been in the red, with deficits numbered in the billions of euros. The forecast deficit for 2009 alone: 9.4 billion euros (over US$13 billion).

French officials are scrambling to take more control of the system to bring these costs down, but Canada, where government controls all “medically necessary care,” shows that this is no solution at all. A growing share of Canadian provincial budgets is also swallowed by the health care system, going in 20 years (1983-2003) from 32% to 41% and on the way to 50% in a few short years. As a portion of GDP, and adjusting for population age, Canadian health care spending even ranked ahead of France’s in 2005.

But the oxymoron of government cost containment is not the only problem. In the name of restraining costs – so fashionable currently in Washington – governments are adding further inefficiencies by piling on more bureaucracy.

Since 1996, there is a cap on national health care spending in France and growing pressure on health care professionals in the public system to cut costs. In 2004, patients’ choice of physician and specialist was also severely limited.

Independent private medicine – once one of the main pillars guaranteeing quality and timely care in the French system – is being slowly strangled. At the end of 2008, nurses lost their freedom to practice where they please, while a new law will do the same for physicians by imposing an annual financial penalty if they refuse to practice where the government tells them to. Specialists’ fees are increasingly regulated. The last pillars of competition among providers, and choice for French patients, are thus undermined.

Canada again is a good example of where the logic of such policies will lead the French and the Americans in the future.

North of the border, decades of total government control over health care have led to chronic doctor shortages and waiting lists. Roughly 1.7 million Canadians were unable to find a family doctor in 2007 and have to queue in impersonal clinics where they exist. Yet only a physician can order tests or get a patient in to see a specialist.

Despite continual infusions of fresh tax dollars, waiting times for hospital treatment went from an average of 7.3 weeks in 1993 to 17.3 weeks in 2008, although there was a minuscule decline last year as a result of massive political pressure. The problem is so severe that the Supreme Court of Canada acknowledged in a historical 2005 ruling that patients die as a result of waiting lists for public health care.

Finally, coverage of new drugs is delayed by a year or more for patients relying on the public system. Even with this delay, by October 2007 less than half of new drugs launched between 2004 and 2006 had been listed for payment.

Based on experience in both our countries, government health insurance and government financing inescapably lead to a crackdown on health care providers and bureaucratization of the entire health care system. Americans should look carefully at our experiences before going any further down the slippery slope of state-controlled health care.

– Peter Morici is a professor at the Smith School of Business, University of Maryland School, and the former Chief Economist at the U.S. International Trade Commission. The views expressed are his own. –

American health care is broken.

At 16 percent, the United States spends a much larger share of GDP on health care than Western European economies. Yet the United States has about 45 million uninsured, while its peers do not.

Many Americans between 50 and 65 cling to jobs they don’t want simply to keep health benefits. Their European cohorts are not so constrained.

Simply, European systems ration and control prices more effectively than do U.S. private insurers.

Americans can see a specialist quicker than patients elsewhere; however, U.S. private insurers impose endless paperwork and multiple trips to tawdry, inconvenient locations for blood work, x-rays and other tests that should be conducted simultaneously and under one roof with the specialist.

After your internist finds blood in your urine, it takes many absences from work and visits to moribund waiting rooms to locate the kidney stones, and finally schedule surgery.

In Britain, the National Health Service just makes you wait—it’s cheaper.

Instead of formal rationing, U.S. insurance companies harass patients with processes reminiscent of queuing procedures for a Black Sea vacation in the old Soviet Union. They chisel down physician fees and hospitals stays and lavish the savings on insurance executives who become wealthy in the bargain.

Prescription drugs are another issues altogether—pharmaceutical companies set prices arbitrarily and well beyond the reach of even the tough guys at insurance companies.

President Obama has some good ideas and some bad ones. He proposes a government run program that uninsured Americans may join if they can afford; however, since most of the uninsured can’t pay full price for coverage, he plans to subsidize their membership with tax dollars. In addition, he wants to pay doctors to use computers and software, and establish a national data bank on best medical practices.

Hence, he aims to fix the system by creating a massive new entitlement, subsidizing doctors to buy technologies other businesses already purchase to increase efficiency and profitability, and compile information doctors and insurance companies already collect when they prescribe and approve treatments. Those will drive costs up more than lower them.

Republicans reflexively oppose another government health agency, and this is to the detriment of genuine reform. Medicare has proven more effective at providing doctor and hospital services to the elderly than private-managed-care alternatives.

My plan is simple. Establish an optional plan, similar to Medicare, for Americans between 50 and 65. Let those Americans subscribe, if they choose, by transferring their employers’ payments to that system or keep their existing coverage. That would create needed competition for private insurers and drive down prices, and permit statist Democrats to prove the government can do better or fail.

Require drug companies to charge Americans no more than they charge in the regulated markets of Canada, Britain, France and Germany. Drug prices would rise abroad as those systems would no longer be able to free ride on Americans paying for drug company research, but U.S. prices would fall to a lot less than current levels.

Finally, the government already pays for about 45 percent of U.S. health care. President Obama has promised to weed out waste. Fine—cap spending at its present share of GDP, and find the money there to pay for the uninsured with the savings.

Obama believes in international competition for business—let him show that U.S. government health care can be as efficient as government systems abroad in providing universal coverage.

–Diana Furchtgott-Roth, former chief economist at the U.S. Department of Labor, is a senior fellow at the Hudson Institute. The views expressed are her own. –

Today President Obama submits his budget outline to Congress, and, with it, a $634 billion fund for health care drawn from higher individual and small business taxes and lower reimbursements to medical providers.

Reform of our health care system is long overdue.  If you’re unemployed, or work for a small business that offers no health plan, or someone in your family has an existing illness known as a “pre-existing condition,” your main concern might be how to get health insurance.

As Obama said on Tuesday night in his address to the nation, “We can no longer afford to put health care reform on hold.”  But setting up a $643 billion fund and raising taxes in the middle of a recession isn’t necessarily affordable either.

In testimony yesterday before the Senate Committee on Finance, Congressional Budget Office Director Douglas Elmendorf presented options for controlling health care costs.  He warned that “reducing or slowing spending over the long term would probably require decreasing the pace of adopting new treatments and procedures and limiting the breadth of their application.”  That’s rationing by another name, not a comfortable concept to Americans. (To read the testimony in pdf format, click here.)

Mr. Elmendorf pointed to the current employer-based health insurance system, where health insurance premiums are untaxed income to workers, as one of the main causes of price increases.  He suggested replacing the tax exclusion or restructuring it, so that patients have more incentives to control costs.  In that way the purchase of health insurance would be similar to the purchase of home insurance or auto insurance, services that consumers appear able to purchase without major problems.

President Obama has said he will consider all proposals.  During his campaign, the centerpiece of his health reform effort was to set up a new health insurance plan, similar to the Federal Employees Health Benefits Program. It would be open to all, with “affordable” premiums and co-payments.

In addition, he proposed a new National Health Insurance Exchange to set standards and regulate private insurance underwriters. Those who could not meet the standards would close.

In a third provision, some employers who offer health insurance now would have to pay higher premiums in order to raise benefits to the level of the new public plan.  Those employers who don’t offer health insurance would be required to pay into the new plan, a new tax.

One way President Obama proposes to save health care dollars would be to encourage or require doctors and hospitals to use electronic health records.  Although privacy concerns have stalled this effort, it could save billions of dollars a year in medical error.  The stimulus bill allocates $20 billion to this effort.

Yet setting up an electronic data base raises many questions.  Can people opt out of the national database?   Should the federal government or individual states mandate one type of standard that can be shared between institutions? Can private companies be allowed to compete among themselves to offer the most convenient method to the medical community?  These questions need debate.

Obama plans to fund his $634 billion fund through higher income taxes on those making over $250,000 as well as limiting itemized deductions by 20 percent. This would be a substantial increase in tax for those households, as well as for small businesses who file under the individual tax code.

Yet even these numbers might be understated.  The insurance program for federal employees is of a higher quality and more costly that typical private-sector coverage.  Expanding health insurance and providing better care costs more money, not less.

Everyone agrees that health insurance needs to be easily accessible and portable, like auto and home insurance.  The question facing us is how to get there and how to pay for it.

Diana Furchtgott-Roth can be reached at dfr@hudson.org. For previous columns, click here.