Jamie Chang

Since 2006, I haven't bought almost nothing that is Made in China or another nation without strict, decently fair labor laws. Simply put, I don't buy the completely idiotic argument that trade with these countries is one day going to improve the economic and social circumstances of the working class there. While the United States, Canada and some Asian and European countries do not have perfect labor and production laws, they are at least supporting populations that have some modicum of support of the basic human rights of the common working, producing woman and man. Until this is the case for China, Bangladesh, Vietnam, Mexico, India, etc., I can't buy products made in those countries. Labor practices in places like these are often at worst slavery and at best exploitation.

And what bugs me even further is that the exploitation doesn't stop there. Not only are workers cheated of their humanity, consumers of these products are often cheated as well. Think about these designer labels I found while strolling in a popular department store in downtown San Francisco:

And of course, my favorite - "We the Free", this label says ...

Free to what?

Well, here's what I think. How much do you think Mr. Marc or Vince paid to have their sweaters Made in China? How much are they asking you, the consumer, to give them for their product? When you give Ms. Malandrino $400 for a shirt Made in China, you are giving your money for her to be wealthy. So little of that $400.00 goes to the individuals who actually made the product, so you're not paying for craftmanship. You're free to pay for designer and designer's people and reps to get rich - in a filthy way. One thing that drives me nuts is when such gross behavior is veiled under eco/labor conscious boutique labeling and/or "green" marketing (ex. organic Levi's made in Mauritius or Turkmenistan)

All of this is, of course, in addition to the massive environmental impact of such production. Humans are not the only ones who are stunted in this process.

Sure this stuff is cute and you might feel good wearing it for a few weeks. But after that, it's just a shirt Made in China. One that some old lady probably bent over sewing. That some corporate designer profited thousands selling. One that you're $300.00 short because of.

Still no response from LAMade. I'm going to call them tomorrow like a complete pain in the ass.

On September 3rd, 2008:
Dear LA Made,
I was a HUGE fan. For the last two years, I've purchased a dozen LAMade products (mostly dresses), and told a bunch of friends about how soft and cute your clothes are. I was such a big fan most importantly because I am a real supporter of cute, well-priced clothing that is made in the UNITED STATES. I've been pretty bummed to see, though, that nearly your entire new line is made in China. What's up with that? Thanks, Jamie

and then on September 6th, 2008:
Hello,
I am resending this because I haven't gotten a response yet and would really like to hear from you.
Thanks!
Jamie

I've been thinking about single-payer. At school, this is the system that most of my professors really care about and would like to see implemented. I understand single-payer as a health care system where there is, literally, a single payer. In this universal health care system, the government is the payer, and they get the money to pay for the health care through taxes. The point in having just one payer is that it eliminates the wastefulness and poor care that is the result of a profit-driven health care system. There is less waste because there is more regulation, and the cost of services are drugs are curbed because the single payer can negotiate reasonable rates without competition.

I found this little clip that describes single payer, in pretty simple terms from the American Journal of Public Health January 2003, Vol 93, No.1. In blue, I wrote my own thoughts on the points, either supporting them, or wondering how the hell this would be implemented as actual policy. A lot of what I wrote is based on a series of articles by Thomas Bodenheimer, a UCSF doctor who published "High and Rising Health Care Costs" in Annals of Internal Medicine a few years back.

I really like single-payer, and I respect and support it. But I have a lot to learn and often struggle with how this would fit within the American context. I really want something like this to work, and I believe it's really important. Anyway, here goes - I hope it's interesting.

Universal, Comprehensive Coverage
Only such coverage ensures access, avoids a two-class system, and minimizes expense
How does providing care for everybody cut costs? The answer is two-fold: first is recognizing that the need for health care is an inevitability for all of us. Sooner or later, we're all going to get hurt, get sick, have babies, die. All of these things cost money. We will ALL be a burden on our health care system, where or not we're insured.
The thing is that, when people are insured, their health care services cost less. One of the major reasons for this is that health insurance means access to preventitive care. When people have access to preventitive health care services, they're less likely to have a NEED for far more expensive measures of care, like the ER. In other words, people are better able to take care of themselves before things get totally ape. Example: a few years ago, I found a lump on one of my lymph nodes. I went to my primary care physician, who said it was likely to be just a cyst. This probably cost a total of $200 or so for this 20 minute visit. If I didn't have health insurance, I wouldn't have gone for this 'preventitive' checkup. If this were something worse than a cyst, I would have likely never known until it actually hurt or started growing, at which point, the costs for treatment would likely have been thousands of dollars. For people without health insurance, the latter scenario is a lifestyle. Not only is this reality disproportionately hazardous to the poor, minority, and immigrant groups, but one that costs them, and our system, billions of dollars a year and thousands of lives. Universal health care is a NECESSITY - it is less expensive, it improves lives, and it makes health care a right, not a privilege.

No out-of-pocket payments
Co-payments and deductibles are barriers to access, administratively unwieldy, and unnecessary for cost containment
Co-payments prevent people from getting proper care. Has anybody wondered what the point of a co-payment actually is? The actual reason why co-payments exist is based on the economic theory of moral-hazard. The theory suggests that if a person has to pay, they are less likely to do something. So co-payments are implemented soley to provide a barrier to seeking health care! This is astonishing to me. The insurance company benefits not only from the co-payment itself, but how the cost of the co-payment make it less likely for a person to be able to access care.
Sometimes co-payments are low, but other times, they can be very costly and an extreme burden for the sick, the poor, and the elderly. Anybody with an HMO plan knows that co-payments change all the time. This may not effect a healthy 26 year old that goes to the doctor once a year and takes no medication. But picture a 70 year old grannie that takes seven or eight meds a day, and pays hundreds of dollars in co-payments each month and lives on a fixed income. Or a self-employed family who already pays tons of money on their own health insurance and has to pay a co-pay or deductible for care on top of that. Not only are these scenarios costly, but they also make things very confusing for people, both disincentives for adequate health care.

A single insurance plan in each region, administered by a public or quasi-public agency
A fragmentary payment system that entrusts private firms with administration ensures the waste of billions of dollars on useless paper pushing and profits. Private insurance duplicating public coverage fosters two-class care and drives up costs; such duplication should be prohibited
The purpose of having a single insurer is related to economic theory and market power. Market power is a complicated idea, but to make it simple, one can look at it as the ability to raise the price of something without losing customers. If a bar is selling beer for $4/pint and decides to raise the price of the beer to $6, it may lose customers. But if there was no competition, or the beer is JUST THAT GOOD, the bar may be able to raise the price without losing customers. In the latter scenario, the bar has market power.
The American health insurance industry is based on Blue Cross and Blue Shield, industries with relatively uncontested power that were started and controlled by hospitals and doctors. So basically, the mechanism by which hospitals and physicians were getting paid was developed by hospitals and physicians. Recipe for disaster. It is through this model that health care providers were able to gain market power, and continually increase their price without necessarily losing customers. To make matters worse, these same groups were very influential in writing the legislation for Medicare/Medicaid, so even public systems suffer from the same market power of providers.
If the payer (insurance) has the market power, economic theory suggests that the costs for services would increase much slower. If there is only one payer, as in the Medicare model (and suggested in the single-payer model), the payer has the market power, and thus curbs provider market power, eliminating their ability to demand unjustifiably high reimbursements. A single payer also has more leverage to negotiate reasonable prices from the private sector, for things like pharmaceuticals.
Regarding the public v. private insurance systems, I need to think about this one more. These days, my impression has been that public and private organizations ultimately behave in similar ways, but two important differences are in regulation and accountability. Private insurance is difficult to regulate on large scales and is clearly accountable to profits, which has really effed up our system and limited our ability to deliver the best care, as opposed to the most profit-yielding care. Ideally, a public single-payer is far more liable to public accountability and structured to seek responsible cost-management to optimize health care delivery, not profits.

Global operating budgets for hospitals, nursing homes, allowed group and staff model HMOs and other providers with separate allocation of capital funds
Billing on a per-patient basis creates unnecessary administrative complexity and expense. A budget separate from operating expenses will be allowed for capital improvements
I’m just starting to learn about global budgets. As I understand it, a global budget is basically when the budget is set in advance for a specific time frame. For example, a hospital may know in January that their global budget for a fiscal year is $10 million. It is then the hospitals responsibility to stay within this budget. A global budget only really works in a single-payer system, and it keeps the cost of health care down in two main ways: first, it reduces the time and money wasted on billing a zillion different insurance companies (this can be up to 12% of health care expenditures - administrative costs). Second, it reduces the ability for the provider to provide wasteful or exorbitant care.
This model is criticized for a number of reasons. The first reason is that it’s difficult to create an ideal and appropriate global budget for each hospital and this process can be influenced by special interests. Second, people get scared that the idea of a budget may reduce the quality of care available to them. Third, there is less room within a global budget environment for the development of new technologies. These are all totally legit criticisms, but countries that actually use the global budget system not only control costs way better than the United States, but also have way better health outcomes, including the UK and Canada.

Free Choice of Providers
Patients should be free to seek care from any licensed health care provider, without financial incentives or penalties
The motivations for this point are pretty self evident.

Public Accountability, Not Corporate Dictates
The public has an absolute right to democratically set overall health policies and priorities, but medical decisions must be made by patients and providers rather than dictated from afar. Market mechanisms principally empower employers and insurance bureaucrats pursuing narrow financial interests
I think the subtext does a good job of describing this point. This point is specifically written in to curb the fears people have that a completely government run health care system will result in a bureaucratic sterility, that health care will be dictated by rules and suits, instead of individuals, families, doctors. The fact is that this situation that we fear already exists today for too many people. That procedure you need may or may not be covered by your insurance, depending on whether the for-profit insurance company thinks it’s worth their money. This is a situation that we need to make a priority to avoid, and that is why this point is necessary to consider in the development of any single payer system. I’m not sure how this point would actually play out in daily interactions, but it is critical to take notice of its importance.

Protection of the rights of health care and insurance workers
A single-payer national health program would eliminate the jobs of hundreds of thousands of people who currently perform billing, advertising, eligibility determination, and other superfluous tasks. These workers must be guaranteed retraining and placement in meaningful jobs.
If we need to cut the cost of health care, we inevitably need to cut jobs. There is a legitimate fear that the loss of this many jobs may curb costs, but at the cost of an economic depression due to unemployment. I’m not sure how politicians intend to address this concern, although it seems to be at the tip of everyone’s tongues. I’ll look into this more and update this blog post.

April 17, 2007
Revolving Door for Addicts Adds to Medicaid Cost
By RICHARD PÉREZ-PEÑA

With grim humor, some doctors in New York call them “frequent fliers” — addicts who check into hospital detoxification units so often that dozens of them spend more than 100 nights a year in those wards.

Through its Medicaid program, New York spends far more than other states on drug and alcohol treatment, including more than $300 million a year paid to hospitals for more than 30,000 detox patients. One reason for the high cost is that $50 million is spent just on the 500 most expensive patients, at a cost of about $100,000 a person. These patients check in and out of detox wards, on average, more than a dozen times a year — a practice that experts say would not be tolerated in most states.

In the state’s 2004 fiscal year, one patient was admitted to such units 26 times at 17 different hospitals around New York City, spending a total of 204 nights, Medicaid records show. In fiscal year 2005, there was one patient who spent 279 nights in detox wards, at a cost of about $300,000.

New York State spends more than enough money to provide all the needed treatment, but “the dollars are being spent in the wrong settings,” said Deborah S. Bachrach, the state’s Medicaid director. In Gov. Eliot Spitzer’s campaign to overhaul Medicaid, she said, “this is very high on our agenda.”

George Epps, 59, was a heavy user of alcohol, cocaine and heroin and says he went through detox programs around New York City 20 to 25 times over several years. “I would come out of detox and rent a room, squander my money on drugs and women, be homeless again for a while, and check back into detox,” said Mr. Epps, who added that he had been clean for more than six years.

He was far from being one of the most extreme examples, but he says he understands the thinking of the repeat patient.

“I would tell myself I was just a brother who needed a rest, not somebody who had a problem,” he said. “I could mimic what they said with such grace and conviction, they would swear I was cured.”

Among state officials, doctors who treat addiction, service groups dedicated to helping the homeless and mentally ill, even the addicts themselves, there is remarkable agreement on why the treatment system in New York is overpriced and inefficient.

In other states, most addicts who go through detox programs do so on an outpatient basis, while in New York the vast majority are inpatients. Medicaid rules in New York also encourage hospitals to provide the most expensive kind of inpatient detoxification, though it is often not medically necessary, while many other states favor a less expensive form of inpatient treatment.

And in New York, when patients are discharged — typically after about five days — the needed transition to an outpatient treatment program often never occurs. That is one reason many patients do not fully recover from their addictions and return to detox wards, experts say.

The system suits the most frequent patients — most of them homeless, mentally ill, or both — who see the programs as a source of shelter and food. And the most expensive treatment, which usually involves some sedation, can reduce the discomfort of withdrawal better than other methods.

Some drug users, especially those on opiates, also set out to clean their systems so they can reduce the dose needed to get high, according to addicts and those who treat them. For a homeless addict, the cost of each dose is a major concern.

But at its core, experts say, the overuse of costly inpatient programs is connected to the lack of housing for homeless people. People are less likely to admit themselves to hospitals, and more likely to adhere to treatment programs, when they are not living on the streets. For more than a decade, the city and state have invested in such housing, including some that accept residents who are not yet drug-free, but demand for housing still far exceeds supply.

“For this small group of what are basically professional inpatient detoxification users, it’s really a whole series of linked problems, and none of the parts of the system work very well,” said Dr. Richard N. Rosenthal, an addiction specialist and chairman of psychiatry at St. Luke’s-Roosevelt Hospital Center in Manhattan. “There’s been some progress on each element, but not enough.”

The most intensive form of treatment, “medically managed” withdrawal takes place in a hospital, usually involves some sedation, and requires a great deal of care by doctors and nurses. The next level, “medically supervised withdrawal,” can be done in a hospital, or sometimes on an outpatient basis, and requires less medical intervention and less staff.

In New York, Medicaid pays an average of more than $100 a day for outpatient medically supervised withdrawal, and close to $400 a day for the inpatient version.

But it pays more than $1,300 a day for medically managed detox — and state officials estimate that more than 40 percent of that is profit for the hospitals. Hospital executives say the margin is not that high, but they concede that the most expensive form of detoxification is a significant money-maker.

As a result, many hospitals offer that program, but not the cheaper ones. By law, hospitals cannot turn away emergency patients, and drug or alcohol withdrawal is considered an emergency. So about 80 percent of the detox patients handled by hospitals in New York are treated at the most expensive level — often because it is the only one available.

Federal officials say they do not keep state-by-state Medicaid records, but experts and state officials say it is clear that New York spends far more on drug treatment than any other state, because other states mostly provide outpatient treatment. Figures compiled by the Department of Health and Human Services support that claim, showing that New York has more hospital admissions for drug or alcohol abuse — whether paid by Medicaid or someone else — than California, Texas and Florida combined.

Of the patients in medically managed detox in New York, “about 80 percent of them are uncomplicated and could be provided with a lower service,” said Karen M. Carpenter-Palumbo, commissioner of the state’s Office of Alcohol and Substance Abuse Services.

Spitzer administration officials say the state needs to pay less for the top level of care, and possibly pay more for the others, to spur the development of those services. That fits with the governor’s plan to review what Medicaid pays for all services, with an eye to encouraging less expensive forms of care.

But those officials also know that when George E. Pataki tried twice as governor to change the detox payment system, the hospital industry, which has been losing money over all, persuaded the Legislature to protect one of its few sources of profit.

Everyone in the field agrees that drug treatment would be more effective and less expensive if a patient consistently went to the same hospital and the same set of doctors.

But in New York, a hospital has no way of checking a patient’s history at other hospitals. The state has talked for years of making that information available right away, and requiring that patients be transferred to their “home” hospitals, but to no avail.

Beyond medically managed and medically supervised detox, there is the least intensive form, called medically monitored withdrawal, which is often done in a residential treatment center, to remove addicts from the influences that contribute to their drug use. The cost per day is comparable to outpatient detox, but patients can stay for weeks.

But under rules laid down decades ago by the federal government, which pays half of New York’s Medicaid bills, Medicaid will not pay for drug treatment in a residential center, as opposed to a hospital. The state pays for a limited amount, using non-Medicaid funds.

In interviews, several current and recovering addicts who have also been homeless said they would happily accept less expensive forms of treatment, as long as they were given shelter. Sam Tsemberis, executive director of Pathways to Housing, a nonprofit group based in Manhattan, works with many such people.

“People use it instead of the shelter system,” he said. “It’s safer, you get three hots and a cot, the meals are better than a shelter, the beds are better, you get a clean change of clothes.”

When patients are discharged from hospital detox wards, the hospitals are supposed to refer them to follow-up treatment, usually through other organizations.

“The handoff doesn’t happen,” said Shari Noonan, who was the acting commissioner of the state substance abuse office last year. “There are no incentives for the hospital to make sure it happens.”

Medicaid records show that in New York State, 80 percent of patients do not have any form of outpatient treatment soon after leaving hospital detox. For almost half of them, the next drug treatment they get is another detox admission.

Ms. Carpenter-Palumbo said the state is looking into ways to correct those failings, providing incentives to hospitals to follow up, and assigning case managers to track patients. But again, such steps might require getting stable housing first.

April 19, 2007
Senate Bars Medicare Talks for Lower Drug Prices
By ROBERT PEAR

WASHINGTON, April 18 — A pillar of the Democrats’ program tumbled on Wednesday when the Senate blocked a proposal to let Medicare negotiate lower drug prices for millions of older Americans, a practice now forbidden by law.

Democrats could not muster the 60 votes needed to take up the measure in the face of staunch opposition from Republicans. The opponents said private insurers and their agents, known as pharmacy benefit managers, were already negotiating large discounts for Medicare beneficiaries.

Fifty-five senators, including six Republicans, supported a Democratic motion to limit debate and proceed to consideration of the bill; 42 senators voted against it. The Senate had a brief debate on the merits of the bill, which is a priority for the new Democratic majority in Congress.

Republicans framed the issue as a choice between government-run health care and a benefit managed by the private sector. The benefit is delivered and administered by private insurers under Medicare contracts.

Senator John Cornyn, Republican of Texas, denounced the bill as “a step down the road to a single-payer government-run health care system.”

Democrats said they were merely trying to untie the hands of the secretary of health and human services so he could negotiate on behalf of 43 million Medicare beneficiaries.

“The Department of Veterans Affairs is able to negotiate for lower-priced drugs,” said the Senate majority leader, Harry Reid, Democrat of Nevada. “H.M.O.’s can negotiate. Wal-Mart can negotiate. Why in the world shouldn’t Medicare be able to do that?”

A 2003 law prohibits Medicare from negotiating or setting drug prices or establishing a uniform list of covered drugs, or formulary.

Mr. Reid said Democrats fell short because of “the power of the insurance industry and the pharmaceutical industry,” which spent hundreds of thousands of dollars on lobbying and advertisements against the bill.

The vote also reflected ineffectual advocacy by Democrats, who were slow in responding to the vehement arguments of well-prepared Republican senators like Charles E. Grassley of Iowa.

“Private competition works,” said Mr. Grassley, a principal author of the 2003 law. “The Department of Health and Human Services has had very little experience and a dismal track record” figuring out what to pay for drugs.

Big companies that offer the Medicare drug benefit, like Caremark and Medco Health Solutions, “have more market power than Medicare” because they negotiate for tens of millions of people in private plans, as well as for Medicare recipients, Mr. Grassley said.

Senator Ron Wyden, Democrat of Oregon, said he did not want the government to supplant private plans. But, Mr. Wyden said, Medicare could negotiate better bargains on selected drugs that have no therapeutic equivalents or competition.

The House passed a bill requiring the secretary of health and human services to negotiate drug prices by a vote of 255 to 170 on Jan. 12, eight days after Congress convened. The Senate bill permits but does not require negotiations.

President Bush had threatened to veto both versions. AARP, the lobby for older Americans, supported both.

The Republican senators who joined Democrats in voting to take up the bill on negotiating prices were Norm Coleman of Minnesota, Susan Collins of Maine, Chuck Hagel of Nebraska, Gordon H. Smith of Oregon, Olympia J. Snowe of Maine and Arlen Specter of Pennsylvania.

Two candidates for the Republican presidential nomination, Senators Sam Brownback of Kansas and John McCain of Arizona, were not present.

An aide to Mr. McCain said he was campaigning in South Carolina and would have voted with the Democrats. An aide to Mr. Brownback said he would have sided with most Republican senators.

In creating the benefit in 2003, Congress made a radical departure from traditional Medicare, which has uniform benefits defined by law. Medicare recipients in every state have a choice of prescription drugs plans with different benefits, premiums, co-payments and deductibles. The 2003 law prohibited the government from interfering in negotiations between drug manufacturers and companies that provide the benefit. The House and Senate bills would repeal that ban.

Employers and health plans typically obtain discounts on particular drugs in return for encouraging patients to use those medicines, rather than competing products.

The Congressional Budget Office said that the Senate bill, like the House measure, “would have a negligible effect on federal spending.”

“Without the authority to establish a formulary or other tools to reduce drug prices, we believe that the secretary would not obtain significant discounts from drug manufacturers across a broad range of drugs,” the budget office said.

Some Republicans prepared to filibuster the Senate bill, but that proved unnecessary. Their whip, Senator Trent Lott of Mississippi, said Republicans had blocked consideration of the bill because they did not want to dicker with Democrats over amendments on unrelated topics, “with no happy end in sight.”

Mr. Wyden predicted that the Senate would vote again on the issue, perhaps as an amendment to a spending bill or other measure. “The fight will go on,” he said.

Senator Amy Klobuchar, a freshman Democrat from Minnesota, said the vote showed that “the power of big pharma,” the pharmaceutical industry, “is still a presence in the halls of Congress.”

April 17, 2007
AARP Says It Will Become Major Medicare Insurer While Remaining a Consumer Lobby
By ROBERT PEAR

WASHINGTON, April 16 — AARP, the lobby for older Americans, announced Monday that it would become a major participant in the nation’s health insurance market, offering a health maintenance organization to Medicare recipients and several other products to people 50 to 64 years old.

The products for people under 65 include a managed care plan, known as a preferred provider organization, and a high-deductible insurance policy that could be used with a health savings account.

When the new coverage becomes available next year, AARP will be the largest provider of private insurance to Medicare recipients. In addition to the new H.M.O., AARP will continue providing prescription drug coverage and policies to supplement Medicare, known as Medigap coverage.

William D. Novelli, the chief executive of AARP, said, “In launching these initiatives, we are driven by our mission to create a healthier America.”

The group also said it would use its leverage to reshape the health insurance market. The organization has 38 million members, and Mr. Novelli said it hoped to have 50 million by 2011.

The new Medicare product will be marketed with UnitedHealth Group. Policies for people under 65 will carry the AARP name and will be marketed with Aetna.

Revenues and royalties from the sale of goods and services have, for many years, accounted for a substantial part of AARP’s income. AARP officials insisted that its financial interests do not affect the positions it takes on Medicare, Medicaid, Social Security and dozens of other issues on which it lobbies and litigates.

Representative Pete Stark, Democrat of California and chairman of the House Ways and Means subcommittee on health, welcomed AARP executives to the Medicare managed care market. “If they provide quality care at a fair price,” Mr. Stark said in an interview, “they could be a wonderful addition.”

But Judith A. Stein, director of the Center for Medicare Advocacy, a nonprofit group that counsels people on Medicare, said, “The new arrangements with insurance companies create a tremendous number of potential conflicts for AARP, which is a powerhouse, perceived as the most important voice for older people.”

The role of private insurers in Medicare is one of the most hotly debated issues in American health policy. In general, Republicans want to expand the role of private insurers like UnitedHealth and Aetna, while Democrats want to limit the role of private entities.

Ms. Stein and her organization work closely with AARP.

“AARP will not be perceived as a truly independent advocate on Medicare if it’s making hefty profits by selling insurance products that provide Medicare coverage,” Ms. Stein said. “AARP’s role in this market could give a big boost to the privatization of Medicare.”

AARP has opposed efforts to privatize Medicare or Social Security.

Dawn M. Sweeney, president of AARP Services Inc., the tax-paying business unit of AARP, said, "We will use our collective market power to negotiate” competitive prices for the new health insurance products.

AARP also said it would use $500 million of insurance sales revenue over the next decade to help people navigate the health care system, with a new counseling service.

Payments to UnitedHealth and Aetna will be linked to their performance in improving the health of subscribers, including members of minorities, Mr. Novelli said. The new plans will coordinate care for people with chronic conditions and will develop special programs to treat people with depression. AARP will measure how frequently the companies deliver recommended treatments to people with diabetes, hip fractures and other conditions.

Insurers typically sign one-year contracts with Medicare. Ms. Sweeney said AARP’s H.M.O. was guaranteed to be in the Medicare marketplace for two years,” though premiums and co-payments could change after the first year.

People ages 50 to 64 often find that health insurance is unavailable or unaffordable when they try to buy it on their own. AARP said its underwriting practices would be less stringent than those of many commercial insurers, but it reserved the right to deny coverage to some sick people ages 50 to 64.

"To guarantee issuance of a policy to every applicant in that age group is just not economically feasible,” Ms. Sweeney said.

About seven million people currently have health insurance of various types, mainly drug coverage or Medigap policies, carrying the AARP brand name. With the new products, Ms. Sweeney estimated, the number will double to 14 million by 2014.

March 25, 2007
Candidates Outline Ideas for Universal Health Care
By ROBERT PEAR

LAS VEGAS, March 24 — Seven Democratic candidates for president promised Saturday to guarantee health insurance for all, but they disagreed over how to pay for it and how fast it could be achieved.

Senator Hillary Rodham Clinton of New York assailed the health insurance industry and said she would prohibit insurers from denying coverage or charging much higher premiums to people with medical problems.

John Edwards, the former senator from North Carolina, offered the most detailed plan for universal coverage, saying he would raise taxes to help pay the cost, which he estimated at $90 billion to $120 billion a year.

Senator Barack Obama of Illinois appeared less conversant with the details of health policy and sometimes found himself on the defensive, trying to explain why he had yet to offer a detailed plan to cover all Americans.

“The most important challenge is to build a political consensus around the need to solve this problem,” Mr. Obama said.

Gov. Bill Richardson of New Mexico offered a potpourri of ideas to achieve universal coverage, including tax credits to help people buy insurance and an option to let people ages 55 to 64 buy coverage through Medicare.

To help pay for his proposals, Mr. Richardson said, he would “get out of Iraq” and redirect money from the military to health care.

The candidates spoke at a forum on health care at the University of Nevada, Las Vegas, sponsored by the Service Employees International Union and the Center for American Progress Action Fund, a liberal advocacy group. Sponsors of the forum said they had also invited Republican candidates, but none attended.

Health care is emerging as a top issue in the 2008 presidential race, as businesses join consumers in demanding action to curb costs and cover the uninsured.

Nevada has gained new prominence in the political calendar. It will provide an early test of voter sentiment in a Sunbelt state with a large Hispanic population, and the results here could help create momentum for a Democratic candidate going into New Hampshire. Nevada Democrats are scheduled to hold presidential caucuses on Jan. 19 next year, five days after the Iowa caucuses and three days before the first-in-the-nation primary in New Hampshire.

Mrs. Clinton said she hoped to make health care “the No. 1 voting issue in the 2008 election.”

Her remarks were reminiscent of a speech she gave to the service employees union in May 1993, when she attacked “price gouging, cost shifting and unconscionable profiteering” in health care and the insurance industry.

On Saturday, she said that the failure of her proposal for universal coverage in 1994 made her more determined to achieve the goal now.

“It also makes me understand what we are up against,” Mrs. Clinton said. “We have to modernize and reform the way we deliver health care. But we have to change the way we finance it. That’s going to mean taking money away from people who make out really well right now.”

Mrs. Clinton complained that “insurance companies make money by spending a lot of money, and employing a lot of people, to avoid insuring you, and then if you’re insured, they try to avoid paying for the health care you receive.”

To deal with such problems, Mrs. Clinton said, “we could require that every insurance company had to insure everybody, with no exclusion for pre-existing conditions.”

Mr. Edwards, who disclosed on Thursday that his wife’s cancer had returned in an incurable form, reaffirmed that he was “definitely in the race for the duration.”

He said that he and his wife, Elizabeth, were getting “too much credit” for their courage and determination. Millions of women have had to struggle with cancer “without what we have, without great health care coverage, without knowing they can get all the medications they need,” he said.

“One of the reasons that I want to be president of the United States,” Mr. Edwards said, “is to make sure that every woman and every person in America gets the same kind of things we have.”

Under the Edwards plan, employers would have to cover their employees or pay into a fund that would finance coverage. Senators Clinton and Obama also expressed interest in this idea.

Mr. Edwards said he would help pay for his plan by “rolling back George Bush’s tax cuts for people making more than $200,000 a year.”

Mr. Richardson said universal coverage “could be achieved in my first year as president,” if voters sent more Democrats to Congress.

As president, he said, he would duplicate the steps he has taken as governor, to “cut junk food out of schools” and to ban smoking in most workplaces, including bars, restaurants and stores.

Mr. Obama said that he would be issuing a detailed plan “over the next couple of months” to achieve universal coverage by the end of the first term of the next president, in January 2013.

When asked why he did not have such a plan, he said, “Our campaign now is a little over eight weeks old.”

While most people get coverage through employers, Mr. Obama said, he wants to foster federal and state purchasing pools. Employers would still have the option of providing coverage, he said, but after 10 or 20 years, “many people may find that they get better coverage,” or better value, outside their employers.

Mr. Obama said he did not know how much it would cost to achieve universal coverage. In response to a question, he said, “I have not foreclosed the possibility that we might need additional revenue” to reach that goal.

“We should not underestimate the amount of money that could be saved in the existing system,” Mr. Obama said. But he opposed cuts in payments to hospitals, doctors and nurses.

Another candidate, Senator Christopher J. Dodd of Connecticut, emphasized his experience, saying that as president he could immediately begin work with Senate committee chairmen to forge a consensus on legislation to cover all Americans.

Mr. Dodd said he would push for legislation making it easier for nurses to form unions, even if they performed some supervisory duties.

Among the candidates at the forum, Representative Dennis J. Kucinich of Ohio offered the most sweeping proposal, to create “a universal, single-payer not-for-profit health care system providing Medicare for all.”

“Health care is a right, not a privilege,” Mr. Kucinich said.

Another candidate, former Senator Mike Gravel of Alaska, called for “a universal single-payer plan.” He said he would give people vouchers, which could be used to pay doctors and hospitals, and a choice of five or six health plans.

March 21, 2007 - NYTimes
Massachusetts Sets Benefits in Universal Health Care Plan
By PAM BELLUCK

BOSTON, March 20 — Massachusetts took a major step toward enacting its near-universal health care overhaul, with the board that oversees the plan voting on Tuesday to require insurers to provide certain minimum benefits, including coverage of prescription drugs.

The decision, subject to final approval in June, would make Massachusetts the first state to establish standards that apply to every resident and every health insurer.

“It’s setting the definition of what is acceptable health care coverage, which is really unique in America,” said Stuart H. Altman, a professor of health economics at Brandeis University. “What you’re doing is not only affecting what the uninsured can get. You indirectly are affecting what is considered to be acceptable coverage for everybody.”

The requirements were worked out over several months and include several compromises, balancing the interests of businesses, insurers and health care advocates.

For example, the board, called the Commonwealth Health Insurance Connector Authority, agreed to phase in some of its requirements, giving residents and employers an extra 18 months to buy health plans that meet all the new criteria. While residents will still need to have some form of insurance starting in July, they will have until January 2009 to get all the required coverage.

“This is another giant step forward,” Jon Kingsdale, the executive director of the authority, said at the meeting. Later, he said, “basically we have to be thinking about January ’09. It’s not a perfect solution, but it’s an acceptable solution.”

The goal of the health insurance law, passed in April 2006, was to make sure that most of the state’s uninsured residents, about 515,00 people, would be covered. Those who fail to get insurance would face penalties that could include the loss of a personal income tax deduction.

About 47,000 of those people fall below the federal poverty line and are eligible for Medicaid. An estimated 150,000 with incomes at 100 percent to 300 percent of the poverty line will get a state-subsidized rate but will still have to pay something, typically $18 to $170 a month.

The rest will be required to buy insurance that meets standards set by the authority, and the challenge has been to make those plans affordable while ensuring enough coverage.

Earlier this month, the authority approved plans from seven insurers with premiums ranging from $175 to $288 a month and deductibles ranging from nothing to $2,000 a year.

Among the compromises the board made Tuesday was allowing insurance plans to continue to place caps on lifetime coverage, something that advocates for universal coverage had been pushing to eliminate.

The authority also voted to set a maximum deductible for basic health plans of $2,000 per individual per year, and a maximum out-of-pocket cost of $5,000 if providers within an insurer’s network are used.

Prescription drugs generated some of the most impassioned discussion Tuesday.

Richard Lord, a member of the authority board and president of Associated Industries of Massachusetts, which represents 7,500 employers, appealed to the board not to require drug coverage.

“No other state does this,” Mr. Lord said. “To prescribe it as a requirement I just think is going beyond what the law intended.”

But Dolores Mitchell, the executive director of an agency that provides health insurance to 265,000 state employees, said that for some residents, drug coverage was “not just optional, it’s maybe life and death, to say nothing of the preventive, since those people who can’t afford it often end up in the hospital.”

Ultimately, insurers, business interests and advocates said they found something to like in the plan.

“There are people who are satisfied with insurance that covers less than these requirements, and there are advocates who believe that all insurance should cover more than these requirements,” said James Roosevelt Jr., the chief executive of the Tufts Health Plan and chairman of the Massachusetts Association of Health Plans. The authority, he said, “struck a balance.”

Brian Rosman, the research director for the advocacy group Health Care for All, said he was “disappointed that the board did not eliminate lifetime maximums,” but called the drug requirement “a terrific step.”

He said his group’s next priority was pressing the authority to delay imposing penalties on lower-income people who may struggle to afford the minimum required insurance.

That could include people like Ali Shriberg, 33, of Brookline, who is afraid she will not be able to afford a $2,000 deductible on a $40,000 salary as a freelance corporate trainer.

And Maria Alves, 39, a dental assistant from the Dorchester area of Boston, who has two children, ages 9 and 14, and a husband on disability.

“I save a lot to give my kids food to go to school and pay the rent for them to live,” Ms. Alves said. “Now they will penalize me if I don’t have insurance. I cannot afford it. I wish I can, but I can’t.”

Katie Zezima contributed reporting.