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Association of American Physicians and Surgeons, Inc.
A Voice for Private Physicians Since 1943
Omnia pro aegroto

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?

Health in Cuba

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).


Waiting Lists Matter

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).


NHS Dentists May Have to Repay Millions

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).


Economics v. Utopia

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.


Socialized Medicine Is Sicko

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.


Calgary Doctors Leave; Patients Stuck

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).


AAPS Calendar

Sep 5,6. Arizona chapter, F. Edward Yazbak, M.D.
Oct 10-13. 64th annual meeting, Cherry Hill, NJ.

Government Still Fails to Protect Privacy

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.


Electronic Records Raise New Liability Risks

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).


No Let-up in Pain Prosecutions

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.


Acquitted Doctor Awarded Legal Fees

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.


Class Action Filed against Calgary Health Region

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.


U.S. Supreme Court Limits McCain-Feingold

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.
Lawrence R. Huntoon, M.D., Ph.D., Lake View, NY


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.
Linda Gorman, Independence Institute, Golden, CO


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.
Russell W. Faria, D.O., Newport, OR


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.
Alieta Eck, M.D., Somerset, NJ


"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.
Greg Scandlen, Consumers for Health Care Choices


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.
Robert Hamilton, M.D., Godfrey, IL


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.
Alphonse Crespo, M.D., Vevey, Switzerland

Legislative Alert

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? 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? What penalties will be assessed for those who try to defraud the system by faking evidence of eligibility? 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


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.