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Volume 63, No. 8 August 2007
It's "more than a movie; it's a movement," writes columnist
Amy Goodman. Its release is being coordinated with "an
unprecedented, sophisticated grass-roots action campaign."
The California Nurses Association is leading an effort to get
1 million nurses to view the film (Az Daily Star
6/20/07). In Sicko, Michael Moore is basically calling
for Revolution.
It's not about the uninsured such as the man shown
stitching up his own laceration with a sewing needle. It's about
the 250 million Americans who have insurance, he says.
Moore does get some things right: We already have socialism
in the United States as in the fire department, government
schools, and the post office. (He seems to have forgotten
Medicare and Medicaid.) Managed care was started by Richard
Nixon. Rapacious companies are making enormous profits by denying
care. And hospital bills are often outrageous.
Moore's demons include George Bush, who created Medicare
Part D for the benefit of drug companies; Ed Annis, who derailed
an earlier effort to socialize medicine; and wicked Republicans
who torpedoed the Clintons' valiant efforts. Democratic
presidential aspirants are keeping their distance; Moore notes
that Hillary Clinton has taken money from the chief Devil the
insurance industry which Moore believes should be totally
destroyed.
But anybody who'd demonize socialism, or Communism, has been
brainwashed by grainy war-time propaganda films.
Utopia Is There and Now
Moore's masterpiece of agitprop displays his genius at
capturing the common man. Most Americans tend to look common
indeed: fat, sloppy, lugubrious, and victimized. In contrast, the
Canadians and Europeans and even the Cubans are slimmer,
sophisticated, confident, and patronizing. They live much longer
too presumably thanks to stress-free access to the best of
necessary medical care, provided by dedicated and caring
practitioners undistracted by profit motives.
Moore pretends to take on all the possible detractors.
Impoverished doctors in Britain? The one he interviewed lives in
a $1 million house and drives a loaded new Audi. The NHS has a
new program that pays him more if he gets his patients to stop
smoking and lower their blood pressure (audience applauds). Now,
if he had to have a $3 million house and three or four luxury
cars, he might consider coming to the U.S.
Burdensome taxes? Hardly. In France, workers enjoy 35-hour
work weeks, 5 weeks paid vacation, and 3 months on the Riviera to
recover from surgery. Mothers don't even have to do laundry the
government-supplied nanny does it cheerfully. The thousands shown
demonstrating in the streets are there because they, unlike
Americans, don't fear their government.
Canadians in a crowded emergency room in Ontario have only
been waiting about half an hour, they tell him; it's busy, but
extremely efficient. And totally free! They can't bear the
thought of being separated from their wonderful system. They
wouldn't dare spend an afternoon in Detroit without first buying
special insurance.
These people are all so nice. If someone is sick, they all
want to pitch in and help. From each according to his means, and
to each according to his needs; it's only right. And it's
perfectly understandable if an American tries to take advantage
of them by pretending to be the common-law wife of a Canadian,
hopping from clinic to clinic to evade police.
But some heroic volunteers of 9/11, abandoned by the sleazy
politicians Moore would make us all dependent on for medical
care, have to head south to get help.
Cuba is not hell, Moore says. It simply overthrew a dictator
we (and Texaco) liked, and replaced him with someone we didn't.
Now it has a WHO health ranking of 39, just below America's 37,
and better infant mortality.
As anticipated, Guantanamo declined to provide the heroes
with the equivalent of the excellent care to which al-Qaeda
detainees have a right. But they got a warm welcome and first-
rate service at a Cuban hospital. Just as the Cubans do?
What Moore Leaves Out
Who'd ever guess from Moore's film that highly educated
ethno-Europeans are fleeing socialism. "The only truly loyal
towards France and Germany are those who are living off the
welfare system," writes Gunnar Heinsohn of the University of
Bremen. Young, hardworking Germans, Frenchmen, Swedes, Dutch, and
Brits are packing their bags (Wash Times 6/5/07).
The NHS is mired in debt, with the largest deficit being
posted by Hammersmith Hospital, the one filmed by Moore
(J Laksin, FrontPageMagazine.com
6/26/07).
Ontario is being sued by Lindsay McCreith for the right to
opt out of its government-run medical care, which wanted to keep
him waiting a year for diagnosis and treatment of a malignant
brain tumor (D Gratzer, Wall St J 6/28/07). New
Democratic Party leader Jack Layton and three former Canadian
prime ministers received private treatment.
Movie-goers got a glimpse of the Gitmo prison, but not of
Castro's dungeons. For that, one must read Against All
Hope by Armando Valladares, imprisoned there for 22 years.
Dr. Linda Peeno confessed that she denied coverage of needed
medical services, to further her career as a managed-care
executive. She is immortalized by Moore. Dr. Dessy Mendoza Rivero
called attention to an epidemic of dengue. He was sentenced to 8
years in prison by Castro for "serving enemy propaganda" and the
CIA (M Faria, Cuba in Revolution).
Footage revealing Moore's route to Cuba was purportedly
censored by the Dept. of Homeland Security. Was that possibly to
keep Cubans from following it to Miami?
In his 2002 book Cuba in Revolution: Escape from a Lost
Paradise, Miguel A. Faria, Jr., M.D., editor emeritus of the
AAPS journal, wrote in detail about "The Mythic Cuban Health Care
System." In 1958, just before the Revolution, Cuba had an
excellent system, and three times as many doctors as all of
Central America combined. By 1988, 87.6% of Cubans secretly
polled had unfavorable comments about the "free" medical
system despite its vaunted low infant mortality. Even if
government statistics are true, central planners can, to achieve
certain outcomes useful for propaganda purposes, starve the rest
of the system. Notably, the mortality rate in children aged 1 to
4 years was 34% higher than that in the U.S., and maternal
mortality was almost four times higher.
In the 1990s Castro resorted to allowing American physicians
to investigate an epidemic of optic neuropathy that had been
raging for more than a year. Nearly 26,000 were blinded or
suffered severe visual loss until thiamine and other vitamins
from free-world pharmaceutical companies were distributed. Cubans
were subsisting on a diet inferior to that allotted to slaves in
1842, although they had produced an overabundance of dairy
products, beef, and poultry before the advent of central planning
in 1959.
As Moore shows, Cuba does send its physicians on
humanitarian missions but he does not show the strict security
required to prevent their defection.
For foreigners with hard cash, Cuba really does have some
world-class medical facilities and a flourishing medical tourism
industry. But ordinary Cubans live under what the Cuban American
National Foundation calls "medical apartheid."
Surely noteworthy is that Castro himself, when gravely ill
last year, had a specialist flown in from Spain (K Loder, MTV
Movie News 6/29/07).
A study that examined more than 5,800 Swedish patients on a
waiting list for heart surgery found that the long wait a median
of 55 days had consequences worse than pain, anxiety, and
financial cost: 77 patients died while waiting. Another study
published in the Swedish medical journal Lakartidningen
found that reducing the wait reduced heart surgery mortality from
7% to just under 3%.
Under global budgeting, the wait time for an angiogram was
up to 11 months in 1988, and the wait for surgery could have been
an additional 8 months. Market-oriented reforms led to
significant improvement as well as diminished costs. But when
reforms' effects were impeded, costs and waiting times again
increased (D Hogberg, Natl Policy Analysis, May 2007).
The new National Health Service contract pays dentists for
"units of dental activity" (UDAs). About 60% are expected to miss
the targets for which they have already been paid, though turning
their practices into "UDA factories." One dentist, while saying
that dentists shouldn't be paid for work they hadn't done, agrees
that the UDA system is defective. "If a patient comes in and
needs more than two crowns, it costs me more to do the work than
I get paid.... There is a huge potential for supervised neglect."
Still more dentists are expected to leave the NHS (Times
4/30/07).
The essential problem underlying the dislocations in
American medicine is administrative pricing, dictated directly or
indirectly by Medicare. Like Goskomtsen, the agency that set
Soviet prices, Medicare determines prices based on imperfect
estimates and fudge factors (RA Swerlick, Wall St J
6/5/07). The failures described by Soviet economists Nikolia
Shmelev and Vladimir Popov in The Turning Point are
disturbingly similar to the Medicare challenges recounted by Paul
Ginsburg (Health Affairs, August 2005). Mismatches of
supply and demand cannot be corrected without accurate price
signals on which people are free to act.
Left-wing reformers including Michael Moore are blind to
this problem, writes John Goodman. They believe that people at
the top can formulate a plan that will be successfully and
altruistically carried out by people at the bottom, even when it
is manifestly not in their self interest to do so.
They believe that incentives do not and should not matter;
i.e., they reject economics. "For Michael Moore, the real tip-off
is the trip to Cuba," Goodman writes. "No rational proponent of
national health insurance would ever bring up Cuba." Perhaps
Moore thinks that if he re-creates the Cuban health system on
film, his fantasy will become reality.
Almost everybody else in the world knows, however, that if
Moore lived in Cuba, he'd be in prison within weeks.
An antidote to Sicko is Stuart Browning's website
www.freemarketcure.com,
featuring economic commentary as well as short reality-based
video clips: The Lemon, Two Women, Brain
Surgery, and Uninsured in America. Also view a
less-than-glowing review from over there: "What [Moore] hasn't
done is lie in a corridor all night at the Royal Free watching
his severed toe disintegrate in a plastic cup of melted ice. I
have," wrote the reviewer for The Times.
Within the past year, at least 41 physicians have closed
their offices in Calgary, Alberta, as costs were rising far
faster than their fees. This loss compounds an ongoing doctor
shortage that has left some 250,000 patients without a regular
family physician (Calgary Herald 5/18/07). While
Europeans have the right to receive care anywhere in the EU and
have it covered, Canadians are stuck with whatever provincial
governments choose to provide. The firmly closed Canadian system
is a "bureaucrat's dream and a patient's plight," write BL
Crowley and J Hjertqvist (National Post 3/1/04).
Sep 5,6. Arizona chapter, F. Edward Yazbak, M.D.
On June 7, the Government Accountability Office (GAO)
released another in a long line of reports finding that HHS and
other government agencies fail to protect sensitive data in
electronic information systems: "Personally identifiable
information about millions of Americans has been lost, stolen, or
improperly disclosed, thereby exposing those individuals to loss
of privacy, identity theft, and financial crimes" (GAO-07-935%).
In fiscal year 2006, 21 of 24 agencies indicated that deficient
information security controls were either a reportable condition
or material weakness.
Nevertheless, the draft Wired for Health Care Quality Act
fails to include patient privacy protections. See AAPS action
alert,
www.aapsonline.org/alerts/06-26-07.php.
Although electronic health records (EHRs) are touted as
central to improving patient safety, their adoption is accom-
panied by risk of liability for data loss, inaccurate data entry,
inappropriate corrections, and unauthorized access. As the EHR
makes voluminous records readily available, what will be the
physician's legal duty to review all of them?
Electronic alerts that require manual override of clinical
guidelines will create documentary evidence that could serve
either as a sword or a shield in the event of malpractice
litigation or peer-review actions. Might software vendors become
co-defendants or witnesses in negligence actions?
More extensive discovery requests or the need for expert
testimony in health informatics could raise the cost of
litigation (JB Korin, MS Quattrone, NJ Law J 6/19/07,
www.law.com).
Last year, 71 physicians were arrested for alleged crimes
related to drug "diversion," and 735 investigations of doctors
were opened, writes Tina Rosenberg (NY Times Magazine
6/17/07). Her article focuses on Ronald McIver, D.O., age 63, now
serving 30 years. He prescribed high-dose opioids and kept sloppy
records. Some of his patients abused or sold their drugs, and
one, whose medications for intense back pain enabled him to go
back to work in an auto body shop, died with opioids in his
blood and a 90% occluded coronary artery along with advanced
congestive heart failure and an old myocardial infarction. Jurors
were instructed that bad doctoring does not prove intent but
could be considered in weighing intent.
"Prosecutors are in essence pressing jurors to decide
whether an extra 40 mg every four hours or a failure to X-ray is
enough to send a doctor to prison for the rest of his life."
The DEA, Rosenberg says, refuses to draw a line on what
constitutes excessive prescribing, saying that would intrude into
professional practice. But if doctors step over the line, the DEA
is happy to put them in jail.
In November 2006, ENT surgeon Mark Capener was acquitted by
a jury on all counts of health care fraud and mail fraud that had
not already been dismissed (U.S.A. v. Mark Capener, U.S.
District Court, District of Nevada, 3:05-CR-0114-RCJ-RAM). The
defendant then sought attorney's fees under the Hyde Amendment,
arguing that the Government based its case on deliberately false
testimony and concealed the deficiencies in its case by
suppressing evidence.
The Government's fraud theory that the defendant had not
performed procedures for which he had billed was based on the
purported absence of bone fragments in the pathologic specimens.
It did not disclose this to the Defendant, suggesting to the
Court that the Government had reason to believe its theory lacked
support. In fact bone fragments were present on all the slides.
However, the Court was not persuaded that the Government and its
expert conspired to knowingly present false testimony. And since
the record showed that the Government believed the Defendant was
trying to obtain medical records in violation of HIPAA, its
suppression of the records was not determined to be vexatious.
The Court awarded Defendant about $175,000 in expert witness
fees and $104,000 in attorney's fees, only for refuting the lack-
of-bone pillar of the case, limited to a $125/hour cap.
Because he was refused hip-resurfacing surgery in Alberta,
on the basis of being older than 55, William Lloyd Murray
incurred more than $15,000 in travel costs and $5,000 in surgical
costs to have the procedure done in Montreal. He has filed a
class action lawsuit on behalf of all who are denied access to
public health care, while also prevented, through statutory and
other prohibitions, from obtaining access to other reasonable
treatment alternatives outside the public monopoly. Filed in
August 2006, the case awaits action.
In 2004, Wisconsin Right to Life (WRTL) proposed to run
three broadcast ads encouraging Wisconsin residents to prevent
anticipated filibusters of judicial nominees by calling Senators
Feingold and Kohl. The Federal Election Commission (FEC) banned
them in the weeks running up to the election, in which Feingold
was a candidate. WRTL sued, and lower courts held that the ads
did not violate campaign finance laws because they were intended
to influence public policy, not election results.
The WRTL suit raised the broader issue of whether the
government has "a compelling enough interest in regulating money
to limit 1st Amendment rights" (Medill News Service).
In an amicus filed on behalf of Citizens United and others,
attorney Herb Titus argues: "The First Amendment does not secure
the freedoms of speech, press, assembly, and petition against
`complete bans,' or `substantial impairments,' or `undue
burdens,'...." There is no "balancing." Rather, it "prohibits
`Congress from making any law abridging' those freedoms."
In a 5-4 decision, the Court found that the Bipartisan
Campaign Reform Act (BRCA) unreasonably limits speech.
"This decision allows us to communicate freely on critical
legislative issues, regardless of when during an election cycle
they occur," said Stephen J. Law, general counsel for the U.S.
Chamber of Commerce. League of Women Voters president Mary G.
Wilson derided the decision as a "win for big money."
Justices Scalia, Thomas, and Kennedy concurred in the
judgment for WRTL but thought the opinion did not go far enough,
leaving to courts the "unsavory task of distinguishing issue-
speech from election-speech with no clear criterion."
Ironically, they note, BRCA has effectively concentrated still
more power in the hands of the wealthiest, while muzzling small,
grassroots organizations such as WRTL.
One-way Phones. I wanted to find out about Medicare
MSAs, as Medicare advertises their availability in 50 states and
provides a brochure with telephone numbers on the CMS website.
MPower is the NY company. Its customer service representative was
difficult to understand because she spoke such poor English. She
read a boilerplate response and said they could not answer
inquiries about MSAs, which are "under CMS compliance." I then
called the Medicare information number. The person there just
laughed at my request for an English-speaking interpreter at
MPower, and could not tell me whether MSAs had been pulled in NY
state because of questionable sales tactics. She said the
information might not be public. I asked whether she could call
CMS and find out why the plan had been pulled in NY. She said CMS
was hard to get and she could not leave a message because
information staffers have no call-back number. They can only call
out. It lets you know who's boss: Don't call us; we'll call you.
Infant Mortality. The Organisation for Economic Co-
operation and Development (OECD) finally 'fessed up, or figured
out, that the definition of live births varies from country to
country and that U.S. rates are not comparable because it defines
live births as babies with any signs of life regardless of birth
weight. In other countries, certain low birth weight babies are
considered dead and denied medical care until they are. Really
helps those statistics if you change the denominator. OECD now
puts an asterisk and a footnote on its live birth statistics,
saying they might not be comparable.
Statistics. The infant mortality rate has popped up
again: we should adopt the health system of Bolivia or Outer
Elbonia because their infant mortality or "equality" or other
statistic-du-jour is so much better than ours. So let's look at
suicide, using the WHO, which some consider the ultimate
resource. Suicides per 100,000, by sex: U.S. 17.6/4.1
male/female; UK 11.8/3.3; Japan 36.5/14.1; Canada 19.5/5.1;
France 26/9.4. Now look at Egypt 0.1/0.00; Iran 0.3/0.1; Jordan
0.0/0.0. Does this mean we should adopt the mental health systems
of the Islamic world? Or could it be they count their suicides
differently or don't count them? Maybe the WHO just takes the
data as reported. Might they count their infant mortality
differently as well? Or do you believe nobody commits suicide in
the Islamic world?
Possibly people don't want to wrap their mind around the
idea that countries keep statistics differently because it
conflicts with their goal of a single-payer system.
Sicko Review. There's a nice commentary on the
film at
www.american.com/archive/2007/june-0607/2018sicko2019-sniffles. I found it funny at times.
Surprisingly, it takes a major swipe at Hillary. It accentuates
the positive in England, France, Canada, and Cuba! It accentuates
the negative in the U.S. Moore leaves the conclusions up to the
viewer, but hopes all will rush to push for single payer.
"Comprehensive" Plans. Someone describing himself as
"the most liberal member of a liberal town council in
Connecticut" asked me for a "comprehensive" conservative health
plan because in his opinion the plans from the "liberal" side are
garbage. But this assumes there should be some top-down
prescription determined by a small elite of thinkers. That is not
how markets work. Markets bubble up from the bottom. My
"comprehensive" plan is a four-step process:
1. Put the money in the hands of the consumer.
2. Provide the consumer with reliable information.
3. Ensure a competitive supply of services.
4. Get...out of the way.
Germany. I met with three Germans who wanted to learn
more about HSAs. I learned something about their system: They do
not have a single payer, though some want to impose it on them.
They have a corporatist system. The government contributes
no money; it just enforces the rules. Participants make
income-adjusted contributions. About 200,000 400,000 persons do
not contribute; if they require care, they receive it, but must
pay the premium for that year and all preceding years when they
did not participate. It is a major challenge to figure out
"where...all that money is going." Since the funds cannot
increase charges faster than the rate of general inflation,
services often have to be cut or delayed. Stories about England
sending patients to the Continent are true, they said. They
agreed that a socialized system would be a disaster.
When Will They Ever Learn? Insurance is just one tool
that helps individuals cope with risk. It does not make people
healthier, or doctors more efficient. Anointing it with magical
powers blurs the path to other ways of financing medical care. It
took more than half a century of gulags for eastern Europeans to
discard utopias spawned by hardcore socialism. It may take
industrialized nations even longer to discover that even in
democratic societies, political wishful thinking and worn-out
Prussian social security models destroy wealth without delivering
health, and cost dearly in terms of liberty.
The staff of the Colorado Health Reform Commission sent an
email early on a Friday evening asking for a set of questions
that any health care reform proposal should have to answer. These
were due by 5 p.m. the following Monday. With help from members
of the Health Benefits Reform Group, I formulated the following
questions. They should be applicable to any state reform
proposals.
1. Does the proposal organize the health care system to
provide maximum value to those who use its services,
with value defined from their point of view?
1.1. Pricing
1.1.1. Does the proposal further market pricing for
medical services? Does it rely on price controls of any
kind, including administrative price setting?
1.1.2. Does the proposal ensure that any physician or
health provider, and any facility, is free to treat any
patient in exchange for direct payment of a mutually
agreeable fee?
1.2. Outcomes
1.2.1. Does the proposal ensure that patients can
determine the treatments they will receive and
physicians the treatments they will provide, subject to
their own consciences?
1.2.2. Does the proposal include organizational
provisions that ensure that firms, industries,
professions, and subsidy recipients will not be able to
use the reform plan to their financial advantage?
1.3. Consumer protection
1.3.1. Does the proposal ensure that participation in
government programs is voluntary?
1.3.2. Does the proposal encourage people to accumulate
assets that may be used for future health care expenses
in lieu of third-party insurance?
1.3.3. Does the proposal allow people to modify the
amount of financial risk they are willing to bear by
choosing among different third-party insurance policies
as their circumstances change?
1.3.4. Does the proposal remain neutral with respect to
the form that third-party insurance should take as long
as insurers can meet their contractual obligations?
1.3.5. Does the proposal remain neutral with respect to
paying for health care with cash or with third-party
insurance?
1.3.6. Does the proposal subject businesses operating in
health care to the same rules as businesses operating
in other sectors of the economy with respect to anti-
trust, ownership, pricing, contracting, and reporting
requirements?
1.3.7. Does the proposal protect people from involuntary
participation in any non-governmental insurance
program?
1.3.8. Does the proposal allow the purchase of health
insurance that is not associated with an employer?
1.3.9. Does the proposal ensure that people can buy
health insurance from any insurance company approved by
a state government?
1.3.10. Does the proposal allow for the fact that people
purchase health care from a variety of sources, some of
which are both outside of Colorado and outside of the
United States?
1.3.11. Does the proposal protect consumers from arbitrary
restrictions on their ability to access medical
therapies?
1.4. Government obligations
1.4.1. Does the proposal include mechanisms to ensure
that government programs do not use government power to
compel unpaid services from providers?
1.4.2. Does the proposal have mechanisms to ensure that
government treats all providers fairly and does not
discriminate between providers via different payments
for the same service or regulatory structures that
favor some providers over others?
2. Does the proposal contain adequate structures for
reducing costs?
2.1. Does the proposal ensure that all providers and third-
party payers in the health care systems are subject to
credible competitive threats?
2.2. Does the proposal expose existing providers, including
government and quasi-government entities, to
competitive pressures?
2.3. Does the proposal ensure that all entities using or
providing health care are free to contract with others
as they see fit?
2.4. Does the proposal ensure that participation in any
health care program under the control of Colorado state
government, or any entity created by statute, is
voluntary?
2.5. Does the proposal ensure that any physician or health
provider, and any facility, is free to treat any
patient in exchange for direct payment of a mutually
agreeable fee?
2.6. Does the proposal ensure that for profit and non-profit
providers are treated equally?
3. Regulatory reform
3.1. How does the proposal plan to determine which health
care regulations produce a net benefit and which
produce a net cost?
3.2. Does the proposal embrace legal reforms that protect
participants from unreasonable torts and contradictory
regulations?
3.3. Does the proposal require that businesses operating in
health care are subject to the same rules as businesses
operating in other sectors of the economy with respect
to things like anti-trust, ownership structure,
pricing, contracting, payment, purchasing, taxation,
and reporting requirements?
3.4. Does the proposal protect consumers from unreasonable
charges?
3.5. Does the proposal contemplate legal reforms that would
encourage all participants to exercise good judgment?
3.6. How does the proposal plan to determine whether current
licensing, inspection, and reporting requirements
produce net benefits?
3.7. Does the proposal contemplate legal structures that
will protect providers from arbitrary and capricious
peer reviews?
3.8. Does the proposal reduce legal barriers to entry
affecting hospitals, specialty hospitals, long-term
care providers, in-store medical practices, insurers of
all kinds, providers or professional services, drug and
device manufacturers, and suppliers of drugs and
medical equipment?
3.9. Does the proposal contemplate the legal reforms that
would be necessary to encourage people who wish to
create charity care clinics can do so without risking
their personal assets?
4. Does the proposal promote the use of economically
efficient subsidies designed to maximize the general
welfare?
4.1. Does the proposal reform Medicaid?
4.1.1. Do Medicaid subsidies accrue to individual
patients rather than to providers?
4.1.2. Can individual Medicaid patients spend the money
that they receive at the provider of their choice? Can
they purchase necessary supplies and services from the
supplier of their choice?
4.1.3. Does the proposal contemplate regulatory reform
that allows the program to develop regulations and
programs that treat different Medicaid populations
according to their needs?
4.1.4. Does the proposal contemplate Medicaid reforms
that encourage Medicaid clients to use their Medicaid
benefits wisely?
4.1.5. Does the proposal include public access to
Medicaid financial data so that amounts paid to
providers, vendors, consultants, administrators,
contractors, overseers, investigators, tax collectors,
auditors and so on, as well as the purpose of the
expenditures, can be clearly discerned?
4.1.6. Does the proposal provide ways to discriminate
between and effectively manage financial arrangements
for people in legitimate need and those who take unfair
advantage of subsidized and safety-net programs?
4.1.7. Does the proposal ensure that taxpayer-funded
services will be provided only to eligible persons?
4.1.7.1. How will the proposal ensure that taxpayer-funded
services are not provided to deceased persons,
persons with fraudulent identification,
nonresidents, persons not meeting financial
requirements, illegal aliens, and so on?
4.1.7.2. What penalties will be assessed for those who try
to defraud the system by faking evidence of
eligibility?
4.1.7.3. What mechanisms in the proposal are designed to
ensure that payment for taxpayer-funded services
is actually rendered?
4.2. How does the proposal contemplate providing medical
care for people who, by reason of incapacity or simple
cussedness, do not comply with administrative
requirements?
4.3. Will the subsidies contemplated by the proposal
encourage, or crowd out private mechanisms for
financing medical services?
4.4. Does the way subsidies are distributed in the proposal
deepen Colorado s "low-wage trap" by imposing effective
marginal tax rates on low-income people trying to work
their way out of dependency?
4.5. How does the proposal plan to distinguish between
essential and non-essential health care services?
4.6. How does the proposal contemplate ensuring that
taxpayer-funded programs provide good value for the
money spent?
4.7. Given that funds for taxpayer-funded programs are
limited, how will the proposal manage the tradeoffs
that are necessary in a resource constrained subsidy
program?
4.8. How does the proposal propose to measure the
effectiveness of taxpayer-funded subsidy programs?
4.9. How does the proposal plan to determine the type and
level of subsidies?
5. Programmatic considerations
5.1. Does the proposal have a sunset provision?
5.2. How does the proposal plan to measure success?
5.3. What trigger mechanisms automatically sunset the
proposal in the event of budget excesses, poor
performance, or other foreseeable problems?
At the next meeting, Commission staff announced the following
common threads from the questions received:
Cover everyone, if not, who (sic)?
Individual mandate?
Medicaid/CHP + expansion or reform?
Cost containment strategies
Benefit minimums
What are we going to do with private insurance?
Subsidies to make coverage affordable
Financing
The staff announced that it had also received questions from
AcademyHealth, Colorado Health Institute, Health Care for All,
The New American Foundation, Navigant Consulting, Families USA.
In general, each of these organizations believes that government
is the solution rather than the problem. Perhaps you would like
to expand the range of considerations in your state if any
opportunity is presented.
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