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We Must STOP Single-Payer Health Care in Delaware (or else) (Part 1)

Let me be quite honest at the outset: I come to bury single-payer health reform in Delaware not to praise it. I believe, as fervently and honestly as its adherents subscribe to its value, that adopting a Canadian or European-style health care system would be nothing short of a major disaster.

The US health care system today has severe problems, and we have millions of people not covered—but this is NOT the way to do it.

But there is currently legislation to be introduced (Senate Bill 177) that is claimed to have an initial co-sponsorship of 18 state legislators, and which will impose such a program on the First State.

The Delaware Unified Civic/Political Association is making a strong push to pass this bill, and has placed a lengthy, detailed description/justification on its website entitled Single Payer Delaware Health Security Act Information by Floyd McDowell.

Not for a moment do I doubt the sincerity of Mr. McDowell and other advocates of this plan. What I doubt is their judgment. Over the next few weeks I intend to take you through Mr. McDowell’s document to point out what I believe are the fundamental weaknesses and errors in this approach.

This will be wonkish reading, because there are a lot of assertions within this document that can only be assessed AFTER you have gotten your hands dirty with the details.

But if Mr. McDowell is correct and the bill enjoys 18 co-sponsors, you will never have done anything more important in terms of social legislation in Delaware in your life than to UNDERSTAND and OPPOSE this bill with everything you’ve got.

Today I am going to focus on just one of the national groups that the document uses as a foundation:

The best informative resource on state/national single payer and other health care reform plans and movements is the Physicians for a National Health Program. Their web site is pnhp.org. They are the fastest growing physician's organization in our nation and their only goal is to help bring single payer health care reform to our states and nation. Their leadership critiqued and praised our Act before it was completed in final form. Of special importance is to access pnhp.org and type in the search window, "How Much Will a Single Payer System Cost?". Then scroll down or download the summaries of 6 national and 13 statewide research study findings documenting the program and cost effectiveness of single payer systems. The 8th study from the top is the comprehensive study accomplished in Delaware by the nationally acclaimed, prestigious research organization Solutions for Progress. Their study and research report is entitled, "Single Payer Financing for Universal Health Care in Delaware: Costs and Savings." Their pnhp.org website very competently critiques the health care plans of our presidential candidates, and the single payer acts passed by state legislators in Maine and California.


Who is PNHP, and to what extent can one rely on their material?

This is actually an industry advocacy or lobbying group that does NOT represent the majority or even a significant minority of America’s health care professionals. The people involved are undoubtedly convinced that they are both right and on a crusade to save American health care. That doesn’t mean they are right, and it doesn’t mean—as we shall see—that all the links provided behind their assertions actually back up their position.

The most imposing part of the PNHP website is perhaps the page identified as ”Research, that includes the following introductory statement:

Over the past two decades, PNHP research has “framed” the debate and focused it on the need for fundamental health care reform. Some of these findings have become so well known that new members of PNHP (and most members of Congress) may not know that we are the source:


Multiple published research articles are then cited and linked. What I wonder is (A) how often anybody ever reads them; and (B) if the people who are reading them are sophisticated enough to know that they don’t always substantiate what PNHP claims they do.

Here are two examples”

One article can be reached through the link Half of all bankruptcies are caused by medical bills. Three-fourths of those bankrupted had health insurance at the time they got sick or injured. The article in question is actually titled:

“Illness and Injury as Contributors to Bankruptcy,” by David U. Himmelstein, Elizabeth Warren, Deborah Thorne, and Steffie Woolhandler, and published in “Health Affairs” in 2005.

This article makes some pretty specific claims, based on survey and interview data from 900+ individuals who had gone through bankruptcy out of a larger pool of 1,700+ subjects. When you look the statistics, they seem to bear out the link title:

% bankruptcies citing no medical cause: 34.5%
% bankruptcy citing major medical cause: 32.6%
% bankruptcy citing any medical cause: 32.0%


Thus, 64.6% of all bankruptcies were caused by medical bills, right?

Not so fast. In order to qualify as having a MAJOR medical cause of bankruptcy, we are not necessarily dealing with the people who “cited illness or injury as a specific reason for bankruptcy,” but are instead dealing with a study-defined definition of major medical causes of bankruptcy. The study considered medical problems to have been major (and therefore a major cause of bankruptcy) if ANY ONE of the FOUR following criteria were met:

Under the rubric “MajorMedical Bankruptcy” we included debtors who either (1) cited illness or injury as a specific reason for bankruptcy, or (2) reported uncovered medical bills exceeding $1,000 in the past years, or (3) lost at least two weeks of work-related income because of illness/injury, or (4) mortgaged a home to pay medical bills.


Did you spot the clinkers? Items 2, 3, and 4 are NOT necessarily proximate causes of bankruptcy. You can rest assured that, for example, uncovered medical bills of $1,000 did not cause bankruptcy—uncovered bills of $10,000 or more might do so, but not $1,000. And yet, in none of the data provided is any more useful figure provided. More to the point, according to the study’s own statistics, 73% of those declaring bankruptcy had LESS than $1,000 in uncovered medical bills.

What about losing 2 weeks of income during the 2 years prior to filing for bankruptcy for medical reasons? Again, this is an absurdly low number, and fails to take all sorts of critical variables into account. Did the person actually have sick-leave accrual or take FMLA time? Why is the threshold set so low? Because if it’s not, you won’t have anyone to put into the category. As it is, 79.7% of all these bankruptcies did not qualify under this standard.

As for mortgaging a home to pay medical bills, this is a real red herring. Of course there are people who do so out of desperation (but, according to the study, 98% of people declaring bankruptcy DID NOT do so), but there are also people who wreck themselves financially by the relentless and unrealistic pursuit of in-vitro fertilization or cosmetic surgery.

Note that NONE of the categories above required the debtor to actually identify them as a “specific reason for bankruptcy.” When they DID so report “illness or injury” as a specific reason for bankruptcy, no further details are given, and this is critical to the policy conclusions in the study. IF the illness, for example, was crippling or debilitating in nature and prevented the individual from holding a job, it may well have been the ILLNESS that caused the debt problem and NOT medical bills or lack of medical coverage. Just because I have health insurance and get my medical bills covered DOES NOT mean that if I have cancer, MS, ALS, a spinal cord injury, or any of hundreds of severe problems that I won’t end up in financial ruin.

That’s MAJOR medical reasons for bankruptcy as this study defines them. What about ANY medical reason? Just add the following: birth/addition of new family member; death in family; alcohol or drug addiction; or uncontrolled gambling. Let’s see, does anybody recognize the intellectual acrobatics happening when you include substance abuse and uncontrolled gambling as causes of bankruptcy that somehow relate to medical coverage? In other words, if I piss away my money at the track while hiding this addiction from my family, whose fault is it?

Why, it’s the fault of the American health care system, of course!!!

The authors then perform a well-known “bait and switch” in research circles, by moving away from their quantitative arguments (poor as they are) into qualitative data (answers from interviews). “Many of the insured debtors blamed high copayments and deductibles for their financial ruin.” For example, “a man insured through his employer (a large national firm) suffered a broken leg and torn knee ligaments. He incurred $13,000 in out-of-pocket costs for copayments, deductibles, and uncovered services—much of it for physical therapy.” This IS a case in which such uncovered medical debts led to bankruptcy, but notice that the single narrative they chose to use here is from a man who incurred uncovered medical debts that were THIRTEEN TIMES the standard they set earlier.

Now let’s look at their predictable conclusions:

Only broad reforms can address these problems. Even universal coverage could leave many Americans vulnerable to bankruptcy unless such coverage was much more comprehensive than many current policies. As in Canada and most of western Europe, health insurance should be divorced from employment to avoid coverage disruptions at the time of illness. Insurance policies should incorporate comprehensive stop-loss provisions, closing coverage loopholes that expose insured families to unaffordable out-of-pocket costs. Additionally, improved programs are needed to replace breadwinners’ incomes when they are disabled or must care for a loved one. The low rate of medical bankruptcy in Canada suggests that better medical and social insurance could greatly ameliorate this problem in the United States.


Again, aside from the usual prescription, there’s a devil lurking in the footnote to this paragraph. Check out the last sentence again: “The low rate of medical bankruptcy in Canada suggests that better medical and social insurance could greatly ameliorate this problem in the United States.”

Really? The citation for that statement is as follows: Between 7.1 percent and 14.3 percent of Canadian bankruptcies are attributable to “health/misfortune.” See J.S. Ziegel, “A Canadian Perspective,” Texas Law Review 79, no. 5 (2001): 241–256.

Here’s the problem: we have absolutely NO reason to believe, and some good ones NOT to believe, that J. S. Ziegel’s definition of “health/misfortune” as a reason for Canadian bankruptcy IS EVEN CLOSE to that used in this study. The Ziegal article is a law review article, for one thing, and for another WAS NOT CITED in the current article in the section wherein they discussed the development of their own terminology and qualifications. What that means is that the authors literally cherry-picked this statistic as being useful to their case, and in the process compared not apples to oranges, but apples to spaghetti.

Now go back to the Research web page and look at what the blurb promises you this article will do: According to PNHP the article will prove that “Half of all bankruptcies are caused by medical bills. Three-fourths of those bankrupted had health insurance at the time they got sick or injured.”

The article itself—bad as it is—DOES NOT EVER CLAIM TO PROVE WHAT PNHP SAYS IT DOES. Even if you were to write off my entire analysis as bogus, the article simply never asserts what the blurb claims.

And I suspect that this may be true of many of the other articles on the website. I will give you one other example, just so that you know I did not myself cherry pick a single bad apple.

The site also argues that two articles prove that “immigrants and emergency room visits by the uninsured are not the cause of high and rising health care costs.” The article with reference to immigrants is Mohanty et al. “Health Care Expenditures of Immigrants in the United States: A Nationally Representative Analysis,” American Journal of Public Health; Vol 95, No. 8, August 2005.

Let’s take a look at this one. Everything about the blurb and the study implies (without ever quite stating) that it has been conducted to rebut the contention that illegal immigration is causing a drain on our health care system. In fact, here’s the conclusion, reduced to two sentences and quoted from the abstract:

Health care expenditures are substantially lower for immigrants than for US-born persons. Our study refutes the assumption that immigrants represent a disproportionate financial burden on the US health care system.


Notice the careful absence of the qualifier “illegal” before immigrants. When have you last heard ANYONE argue that legal immigration places a disproportionate burden on the health care system?

Here’s their definition of immigrants:

An individual was defined as US born if he or she was born in one of the 50 states or the District of Columbia. All others were classified as foreign born. Foreignborn persons included naturalized citizens, permanent residents, visa holders, refugees, and undocumented immigrants. However, data on specific resident categories were not provided in the NHIS. For the purposes of this study, the terms “foreign born” and “immigrant” were considered to be synonymous…. We could not specifically identify undocumented persons…


In other words, this article actually rebuts a claim that no one—not even Pat Buchanan or Tom Tancredo—has ever made. But it is written and presented by PNHP in such a fashion as to make you think it does.

That’s some intellectual honesty, huh?

How about this? Under the blurb, PNHP Community, we find the following:

PNHP has grown into an outstanding community of more than 14,000 physicians, medical students and other health professionals. We have members in every state and specialty, and active chapters around the country.


Sounds impressive until you toodle around the website a little, to discover that YOU CAN’T FIND ANYBODY’S NAME!

Oh, you can find the names of the authors of the cited articles, but there is absolutely no assertion that any of these folks belong to PNHP. You can find a section on PNHP Chapters nationwide. While I haven’t tried them all, I clicked on seven AND DID NOT FIND A SINGLE NAME of a physician or other health care professional willing to associate publicly with this organization. You can’t figure out who the president of the organization is or who funds it. Hell, you have to sign up and pay dues just to get a glimpse of the newsletter (and while I love you, dear readers, I was not going that far).

One last note, that 14,000 membership number sounds pretty good, until you realize that the American College of Physicians (which is only the nation’s SECOND largest professional medical group) has 124,000 members, and will proudly tell you that its President is Dr. David Dale of the University of Washington Department of Medicine (and so on down the line to include a Member’s Directory).

Here’s the unavoidable conclusion about PNHP: it is a small, anonymous industry lobbying group that makes big claims that even a relatively mild examination can determine are misleading at best.

If PNHP is both “The best informative resource on state/national single payer and other health care reform plans and movements,” and “Their leadership critiqued and praised our Act before it was completed in final form,” you should NOT consider this a positive endorsement of a proposed Delaware single-payer health reform bill.

Comments

Delaware Watch said…
This is actually an industry advocacy or lobbying group that does NOT represent the majority or even a significant minority of America’s health care professionals.

How do you know they don't represent the majority of health care professionals? You just made a bald assertion.
Delaware Watch said…
"Multiple published research articles are then cited and linked. What I wonder is (A) how often anybody ever reads them"

Your point here is what? Their studies lack validity because it's unclear how many people read them? Do you apply this question to the websites of every posted study you read? Are you using the the "sound of suspicion" only to create a red herring?

I frankly can't imagine any significance that can be assigned to your question.
Delaware Watch said…
"Did you spot the clinkers? Items 2, 3, and 4 are NOT necessarily proximate causes of bankruptcy. You can rest assured that, for example, uncovered medical bills of $1,000 did not cause bankruptcy—uncovered bills of $10,000 or more might do so, but not $1,000."

A lot of arguments seem to proceed on the "You can rest assured that..." basis. It's as if it is somehow intuitively obvious that your understanding is correct and the, as in this case, empirical claims must be wrong. As matter of fact, my first reaction to your statement that medical bills of $1,000 or more couldn't have been a proximate cause of bankruptcy made me think, "This guy has little acquaintance w/ poverty." $1,000 of bills might be a pittance to you, but "you can rest assured" it is a crushing debt to many people who have to pay rent, utilities, groceries, day care for their children while they go to their low paying jobs. Besides, all the study needs to do (and all that it purports to do) is cite unpaid medical bills as part of the claim, ACCEPTED BY THE COURT, as serving as the basis for the successful bankruptcy filing. You see, bankruptcy is a LEGAL concept and part of what constitutes either wholly or partially the proximate causes of bankruptcy is what a Court agrees to include as the basis for its finding of bankruptcy. So you happen to wrong on this matter as a matter of legal fact.

Now you might not like the fact that Courts accept unpaid medical bills of a little more than $1,000, but you don't get to make the rules in this matter. The rules have been made by the frequency of unpaid medical bills as accepted by Courts as proximate causes for bankruptcy.

You are barking up the wrong tree on this point.
Delaware Watch said…
"What about losing 2 weeks of income during the 2 years prior to filing for bankruptcy for medical reasons? Again, this is an absurdly low number,"

You actually think losing 1/2 of a month's pay isn't a problem for people living in the US? You actually think that poor people w/ children, who live from paycheck to paycheck, find it a small matter to lose 2 weeks pay? You don't think it could cause them to get behind on their bills and never catch up? That it might culminate in things like eviction? Wow.

"and fails to take all sorts of critical variables into account. Did the person actually have sick-leave accrual"

What is it that you don't understand about the phrase "losing 2 weeks of income?" If you have paid sick leave, then, hello, you get paid and don't lose income. Do you think Courts accept people who were out for 2 weeks and paid for it as losing 2 weeks of income? Is that what you believe?

Moreover, do you really believe that people working minimum wage jobs who are paid by the hour even get PAID sick leave? Tell me you are joking about all this.

"or take FMLA time?"

LOL!!! What relevance does that have? Do you even know about FMLA...e.g. you don't get paid for the time you have off unless you work a job that offers paid sick leave that you can accumulate and have accumulated enough of it to get paid while out on FMLA. But if you don't get paid sick leave or don't have enough paid sick leave, then you are out of luck. You get nada. Then FMLA only says that you can't get fired for the time off. And, amazingly, some scumbag businesspersons still object to that.

That's all FMLA offers. If you had known that, then you wouldn't have even bothered to mention it.

"Why is the threshold set so low? Because if it’s not, you won’t have anyone to put into the category."

Actually, it has nothing to do w/ the category. It has to do w/ the fact that it was a COURT APPROVED part of the bankruptcy filing. But as for why you don't get it, one can only guess. Perhaps making a career in the military w/ all the paid leave opportunities made available to you by the taxpayers or the wonderful socialized VA hospitals and medical care have left you a bit out of the loop on how much of America lives w/o the benefit of the tax-payer funded benefits you enjoyed and I enjoyed as a state employee.
Dana,
Thanks for posting. Exactly what I am trying to do here is stimulate a real debate.
Delaware Watch said…
"but there are also people who wreck themselves financially by the relentless and unrealistic pursuit of in-vitro fertilization or cosmetic surgery."

Yea, how many people does that constitute? Sure there are "people" who do so. That's not true. It's a truism. But your truism is insignificant as a refutation until you offer some evidence beyond your bald assertion.
Delaware Watch said…
"Note that NONE of the categories above required the debtor to actually identify them as a “specific reason for bankruptcy.” When they DID so report “illness or injury” as a specific reason for bankruptcy, no further details are given, and this is critical to the policy conclusions in the study. IF the illness, for example, was crippling or debilitating in nature and prevented the individual from holding a job, it may well have been the ILLNESS that caused the debt problem and NOT medical bills or lack of medical coverage. Just because I have health insurance and get my medical bills covered DOES NOT mean that if I have cancer, MS, ALS, a spinal cord injury, or any of hundreds of severe problems that I won’t end up in financial ruin."

All of that misses the point entirely and commits the same error you've made so far that I have already described. All of the medical matters included in the study formed part of the basis for their successful filing of bankruptcy.

The fact that you believe the only illnesses that should be considered are those that leave a person unable to work shows an even more fundamental misapprehension of the matter under study. The question wasn't about what effect did debilitating illnesses have on the capacity of bankrupt people to work. You've gone way off on a tangent there.

The question is what effect did the lack of adequate health care coverage have on the ability of people to pay their medical bills and other bills in cases of bankruptcy filings. Different matter.
Delaware Watch said…
"Let’s see, does anybody recognize the intellectual acrobatics happening when you include substance abuse and uncontrolled gambling as causes of bankruptcy that somehow relate to medical coverage? In other words, if I piss away my money at the track while hiding this addiction from my family, whose fault is it?

Why, it’s the fault of the American health care system, of course!!!"

You clearly don't have a view of addiction (yes, even gambling) that most of the medical profession has. It's a medical problem and addictions are most often treated by psychiatrists who are, after all, physicians. And if you lack medical insurance or adequate insurance, then addicted persons often do go untreated and are subject to uncontrollable compulsions.

Now those are facts. I thought nearly everyone except fundamentalists excepted the medical model of addictions by now. I guess I have been out to lunch on what people are thinking on this matter.

(I think I'll pick more of this tomorrow)
"But as for why you don't get it, one can only guess. Perhaps making a career in the military w/ all the paid leave opportunities made available to you by the taxpayers or the wonderful socialized VA hospitals and medical care have left you a bit out of the loop on how much of America lives w/o the benefit of the tax-payer funded benefits you enjoyed and I enjoyed as a state employee."

Careful, please, with your assertions about my past.

Newtonian Histrionic (is that a singular form?):

Contrary to your assumption, Dana, the overwhelming majority (17 0f 21 years) of my military service was in reserve components. For that you receive (A) no paid leave; (B) no access to the military health care system except when on active duty (which is about 30 days a year) and then can only use it for injuries or illnesses that occurred while on active duty or acute emergency care. Nor do you have, as a reservist retiree, access to VA system prior to age 62 unless your medical condition is a direct result of illness or injury on active duty.

Through 13 of the 17 years i spent as a reservist I was one of those millions of Americans who had no health insurance, and for at least half that time I lived below the poverty line.

Your arguments may be better than mine; I leave that to readers to judge. But please do not base your analysis of my supposed intellectual shortcomings on "facts" about my life that are not true.

Having said that (without RAD-baiting, I hope), we can now go back to the argument.

For all the effort both of us are putting into this, I really hope someone else is reading, don't you?
Delaware Watch said…
I knew I had an article about this somewhere. Note the average expenses for those cited in the study. They are far higher than the $1,000 group you discussed in your post.

"Half of Bankruptcy Due to Medical Bills -- U.S. Study
Wed Feb 2, 4:29 AM ET
By Maggie Fox, Health and Science Correspondent

WASHINGTON (Reuters) - Half of all U.S. bankruptcies are caused by soaring medical bills and most people sent into debt by illness are middle-class workers with health insurance, researchers said on Wednesday.

The study, published in the journal Health Affairs, estimated that medical bankruptcies affect about 2 million Americans every year, if both debtors and their dependents, including about 700,000 children, are counted.

"Our study is frightening. Unless you're Bill Gates (news - web sites) you're just one serious illness away from bankruptcy," said Dr. David Himmelstein, an associate professor of medicine at Harvard Medical School (news - web sites) who led the study.

"Most of the medically bankrupt were average Americans who happened to get sick. Health insurance offered little protection."

The researchers got the permission of bankruptcy judges in California, Illinois, Pennsylvania, Tennessee and Texas to survey 931 people who filed for bankruptcy.

"About half cited medical causes, which indicates that 1.9 to 2.2 million Americans (filers plus dependents) experienced medical bankruptcy," they wrote.

"Among those whose illnesses led to bankruptcy, out-of-pocket costs averaged $11,854 since the start of illness; 75.7 percent had insurance at the onset of illness."

The average bankrupt person surveyed had spent $13,460 on co-payments, deductibles and uncovered services if they had private insurance. People with no insurance spent an average of $10,893 for such out-of-pocket expenses.

"Even middle-class insured families often fall prey to financial catastrophe when sick," the researchers wrote.

Bankruptcy specialists said the numbers seemed sound.
"From 1982 to 1989, I reviewed every bankruptcy petition filed in South Carolina, and during that period I came to the conclusion that there were two major causes of bankruptcy: medical bills and divorce," said George Cauthen, a lawyer at Columbia-based law firm Nelson Mullins Riley & Scarborough LLP.

"Each accounted, roughly, for about a third of all individual filings in South Carolina."

He said fewer than 1 percent of all bankruptcy filings were due to credit card debt. "That truly is a myth," Cauthen said in a telephone interview.

Cauthen said he was not surprised to hear that so many of the bankrupt people in the study were middle-class.

"Usually people who have something to protect file bankruptcy," he said. "The truly indigent -- people that we see on the street -- there is no relief that we can give them."

Dr. Steffie Woolhandler, a Harvard associate professor and physician who advocates for universal health coverage, said the study supported demands for health reform.

"Covering the uninsured isn't enough. We must also upgrade and guarantee continuous coverage for those who have insurance," Woolhandler said in a statement.

She said many employers and politicians were pressing for what she called "stripped-down plans so riddled with co-payments, deductibles and exclusions that serious illness leads straight to bankruptcy."

http://story.news.yahoo.com/news?tmpl=story&cid=1896&e=3&u=/nm/health_bankruptcy_dc"
Note that instead of being blanketly accepted as accurate, as your article about another study suggests, not only I find the bankruptcy studies in question to be problematic. If someone prefers the Kellog School of Management to me, here it is:

(I think all the URLs necessary are in here as well to follow the whole controversy)

My point is that the medical bankruptcy horror--to the extent that advocates of single-payer systems credit it--is NOT an undisputed fact, but an ongoing debate.

Here it is:

Medical Costs Contribute To Fewer Than One In Five Bankruptcies, Say Kellogg Management School Researchers

Dranove and Millenson Fault Analysis In Earlier Study,
But Himmelstein And Harvard Coauthors Defend One-In-Two Estimate

Bethesda, MD -- Data from a much-cited 2005 study show that medical expenses contribute to less than 20 percent of all bankruptcies, far fewer than the 50 percent estimate offered by the original study’s authors, according to an article by David Dranove of the Kellogg School of Management and Michael L. Millenson, a consultant and visiting scholar at the Kellogg School, published today as a Health Affairs Web Exclusive.

In “Medical Bankruptcy: Myth Versus Fact,” Dranove and Millenson also characterize most Americans who declare bankruptcy because of medical expenses as “marginally middle class” at best, and they say that a single-payer national health insurance system would not be an effective weapon against such bankruptcies.

In their paper, Dranove and Millenson critique “Illness and Injury as Contributors to Bankruptcy,” published 2 February 2005 as a Health Affairs Web Exclusive and written by David Himmelstein, Elizabeth Warren, Deborah Thorne, and Steffie Woolhander. Himmelstein and Woolhandler are members of the Harvard Medical School faculty; Warren teaches law at Harvard; and Thorne, formerly of Harvard, is currently an assistant professor of sociology and anthropology at Ohio University.

Two Perspectives on Dranove and Millenson’s paper also appear on the Health Affairs site. The first is Himmelstein and colleagues’ response to the Dranove and Millenson; the second is an overview offered by Robert Seifert and Mark Rukavina, the policy director and executive director of the Access Project. Dranove and Millenson also present a short response to Himmelstein and colleagues’ Perspective.

“It is insufficient to show that medical problems are associated with bankruptcy; one must determine whether, and to what extent, medical spending causes bankruptcies,” Dranove and Millenson write. To answer that question, “we must identify those people who stated that illness or injury was a cause of bankruptcy and also stated that medical bills contributed to bankruptcy.” In reanalyzing the data from Himmelstein and colleagues, Dranove and Millenson conclude that “medical expenditure bankruptcies” actually constituted only 17 percent of the bankruptcy filers those authors surveyed.

They add: “Even for that 17 percent, we cannot state with any degree of certainty whether medical expenses were the most important cause of bankruptcy. To move from causation to magnitude, it is necessary to perform multivariate statistical analysis,” using a control group of solvent individuals and including variables such as employment and marital status. While Himmelstein and colleagues did not perform this type of statistical analysis, other studies that did so concluded that “medical debt is like any other debt -- a cause but not the most important cause of bankruptcy,” Dranove and Millenson write.

Indeed, while Himmelstein and colleagues assert that “solidly middle-class Americans are at risk,” of being bankrupted by health care costs, Dranove and Millenson note that the median income of the debtors surveyed by Himmelstein and colleagues was only $25,000. This is a group for whom “health care spending amounting to a few thousand dollars in the two years prior to bankruptcy would represent just the tip of the iceberg threatening to sink their creditworthiness,” the two researchers say.

While Himmelstein and colleagues’ original article suggested that a Canadian-style national health insurance plan could be an effective weapon against medical expenditure bankruptcies, Dranove and Millenson cite research showing that direct medical costs are just one part of the large financial burden associated with serious illness. Any universal health insurance plan comprehensive enough to guarantee financial protection against all of those costs would have to be more comprehensive than any existing single-payer system, they write, making it so expensive that paying for it “might actually poke holes in the safety net for other vulnerable citizens.”

In their Perspective response, Himmelstein and colleagues charge that Dranove and Millenson “manipulate the data [from our original paper] far beyond legitimate reinterpretation.” The Harvard researchers defend the accuracy of their original conclusion that “medical problems contribute to about half of all bankruptcies.” They note that “Dranove and Millenson’s definition misclassifies costs for medications and home care as ‘nonmedical’” and excludes, for instance, “bankrupt families who took out second mortgages to pay medical bills [but] described their reasons for filing as ‘to save our home.’”

Himmelstein and colleagues write that debtors’ $25,000 median income “in the year prior to filing reflects the setbacks that led to bankruptcy (for example, illness that caused job loss), not socioeconomic status before the onset of disaster.” They point to the fact that most debtors had owned homes, attended college, and held good jobs, as proof of medical debtors’ middle class status. In addition, they criticize Dranove and Millenson for “misrepresent[ing] the previous literature on medical bankruptcy” -- for example, ignoring one study’s conclusion that “medical debts are often buried in credit card balances and second mortgages,” as well as a Commonwealth Fund study’s finding that “37.2 million adults annually are ‘contacted by a collection agency about owing money for medical bills.’”

The Harvard researchers also defend their view that national health insurance could prevent most medical bankruptcies, writing that “many other countries have implemented comprehensive health and disability coverage that does the job [of protecting against illness-related financial ruin] quite well.” Himmelstein and Woolhandler are co-founders of the group Physicians for a National Health Program, which advocates for single-payer national health insurance in the United States.

Himmelstein and colleagues note that “most [U.S.] medical debtors had taken the prescribed steps to protect themselves. Three-quarters had health insurance when they got sick. But for many, private coverage lapsed when they lost work because of illness. In other cases, the insurance they bought in good faith had so many holes that it left them unprotected.” Himmelstein and colleagues write that Dranove and Millenson “should take a hard look at the defective products sold by their funders in the insurance industry.”

In their Perspective overview of the controversy, Seifert and Rukavina do not address the specific incidence of medically induced bankruptcies. Whatever that number may be, they say, medical debt is “surprisingly common,” affecting the insured as well as the uninsured, the middle class as well as the poor. Seifert and Rukavina state that medical debt both undermines families’ financial security and functions as a barrier to health care. Indeed, “the care-seeking behavior of privately insured adults with medical debt is much more like that of uninsured people,” the two authors state.

Seifert and Rukavina assert that simply counting the number of uninsured people is not an accurate measure of the success of efforts to improve access to health care. “It is time to expand our policy vocabulary beyond insurance coverage and begin to examine the adequacy of that coverage in ensuring health access and improving health status and financial security,” the authors declare.

You can read the Dranove and Millenson paper at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w74,

Himmelstein and colleagues’ Perspective at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w84,

Seifert and Rukavina’s Perspective at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w89,

and Dranove and Millenson’s final response at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w93.
As a side note, a minor point that I found fascinating was the statistic about how many people get contacted each year by collection agencies regarding medical bills.

Having had several medical problems in my family over the past 5 years I have been contacted numerous times by the collection agency that works for Christiana Care. It is not because I am delinquent in my bill at all, but because CC has a terrible track record at filing with the insurance companies, and then bills you before the window with, say, BCBS, closes.

Then, when insurance payments are still pending, CC starts billing you as if they had failed to pay. When payments do come in, CC credits them to the oldest outstanding balance rather than the service indicated by the insurer. As a result, CC gets the bills hopelessly mangled.

I am not suggesting that this is the case for everyone, but people in both industries (insurance and hospitals) tell me that hospitals tend to send items to collection far faster than other industries, and without real cause in many cases.

Point being: simply being contacted by a collection agency for medical bills is NOT necessarily a strong indicator of financial trouble on the part of the indebted party.
"This is actually an industry advocacy or lobbying group that does NOT represent the majority or even a significant minority of America’s health care professionals.

How do you know they don't represent the majority of health care professionals? You just made a bald assertion."

Hopefully you now have gotten to the last three paragraphs of this post where I documented this assertion. I agree that in writing it, I should have had my evidence a whole hell of a lot closer to the assertion. Sorry.
"Multiple published research articles are then cited and linked. What I wonder is (A) how often anybody ever reads them"

Your point here is what?

Dana,
My point is that anybody can put up a very impressive looking public policy website and claim to have wads of research to back it up. Working with casual browsers and students I have discovered a marked tendency NOT to actually read the stuff at the links, but to accept it at face value if there are official-looking citations.

You can't actually verify that this material is good unless you go to the articles.
"Multiple published research articles are then cited and linked. What I wonder is (A) how often anybody ever reads them"

Your point here is what?

Dana,
My point is that anybody can put up a very impressive looking public policy website and claim to have wads of research to back it up. Working with casual browsers and students I have discovered a marked tendency NOT to actually read the stuff at the links, but to accept it at face value if there are official-looking citations.

You can't actually verify that this material is good unless you go to the articles.
"Besides, all the study needs to do (and all that it purports to do) is cite unpaid medical bills as part of the claim, ACCEPTED BY THE COURT, as serving as the basis for the successful bankruptcy filing. You see, bankruptcy is a LEGAL concept and part of what constitutes either wholly or partially the proximate causes of bankruptcy is what a Court agrees to include as the basis for its finding of bankruptcy. So you happen to wrong on this matter."

No, not really. When you go into bankruptcy you cite ALL debts and assets whether they are what actually drove you into bankruptcy or not.

I could have $1,000 of medical bills, $1,000 of bills from the cable company, and $42,000 worth of bills from a contractor. All would be listed on my worksheet, but to suggest that in this case the medical bills drove me to bankruptcy or even contributed significantly is misleading.

I am NOT contending that medical bills sometimes do drive people into bankruptcy. I AM contending that this study doesn't prove it, and that its methodlogy is poor.

In order to make their case they need statistics that would weight the bankruptcy claims.

They don't present such facts; wouldn't they have presented them if they did?
Wow, covered a lot of ground BUT must confess I am under-whelmed. Some areas make me wonder if clarity is the goal. When SN cites the Northwestern U people it appears he is presenting two sides and then a third to settle it (against Himmelstein and Woolhandler). Yet Seifert and Rukavina seem to support the view that insured folks are at risk for financial ruin due to unexpected medical costs that are not covered.

Furthermore, the comments about collection agencies behavior (which he seems to think is often not really a threat, since it wasn't for him)illustrate another area where present concerns would be ameliorated by adoption of single payer (government paid, but privately delivered, as in traditional Medicare).

Even though I am not convinced by his counter arguments re two articles cited by pnhp.org, I still wonder how many HE read thoroughly to identify two that he thought he could effectively dispute?

I urge all readers to actually go to the pnhp.org website to evaluate it themselves. I have spent a lot of time there, and think it is quite effective and well supported by the peer reviewed articles it cites -- many of which I have reviewed. BTW, several individuals are listed, even on the pnhp.org home page. If you really care to know who is involved, you could also contact those listed. They are not bashful. Thanks for reading.

J T Garland, MD
Minneapolis MN USA
endocrinologist, retired 2005
JT,
Thanks for visiting; sorry you were under-whelmed.

Two notes just to set the record straight:

(A) you didn't actually deal with substance of my methodological concerns with the bankruptcy article or at all with the immigration/health services article; in point of fact almost any article on the PNHP website can be challenged; many of them are far closer to being op-ed pieces than actual research.

(B) most of the names on the PNHP website to which you refer are pretty recent additions; that's one of the difficulties in dealing with net-based material; it changes pretty rapidly.

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