Public health insurance option

From Wikipedia, the free encyclopedia
https://en.wikipedia.org/wiki/Public_health_insurance_option

The public health insurance option, also known as the public insurance option or the public option, is a proposal to create a government-run health insurance agency that would compete with other private health insurance companies within the United States. The public option is not the same as publicly funded health care, but was proposed as an alternative health insurance plan offered by the government. The public option was initially proposed for the Patient Protection and Affordable Care Act, but was removed after independent Connecticut senator Joe Lieberman threatened a filibuster.

As a result, Congress did not include the public option in the bill passed under reconciliation. The public option was later supported by Hillary Clinton and the Democratic Party in the 2016 and 2020 elections and multiple other Democratic candidates, including the current President Joe Biden.

History

Federal

The public option was featured in three bills considered by the United States House of Representatives in 2009: the proposed Affordable Health Care for America Act (H.R. 3962), which was passed by the House in 2009, its predecessor, the proposed America's Affordable Health Choices Act (H.R. 3200), and a third bill, the Public Option Act, also referred to as the Medicare You Can Buy Into Act, (H.R. 4789). In the first two bills, the public option took the form of a Qualified Health Benefit Plan competing with similar private insurance plans in an internet-based exchange or marketplace, enabling citizens and small businesses to purchase health insurance meeting a minimum federal standard. The Public Option Act, in contrast, would have allowed all citizens and permanent residents to buy into a public option by participating in the public Medicare program. Individuals covered by other employer plans or by state insurance plans such as Medicare would not have been eligible to obtain coverage from the exchange. The federal government's health insurance plan would have been financed entirely by premiums without subsidy from the federal government, although some plans called for government seed money to get the programs started.

President Barack Obama promoted the idea of the public option while running for election in 2008. Following his election, Obama downplayed the need for a public health insurance option, including calling it a "sliver" of health care reform, but still campaigned for the option up until the health care reform was passed.

Ultimately, the public option was removed from the final bill. While the United States House of Representatives passed a public option in their version of the bill, the public option was voted down in the Senate Finance Committee and the public option was never included in the final Senate bill, instead opting for state-directed health insurance exchanges. Critics of the removal of the public option accused President Obama of making an agreement to drop the public option from the final plan, but the record showed that the agreement was based on vote counts rather than backroom deals, as substantiated by the final vote in the Senate.

In January 2013, Representative Jan Schakowsky and 44 other Democratic representatives introduced H.R. 261, the Public Option Deficit Reduction Act, which would amend the Affordable Care Act to create a public option. The bill would set up a government-run health insurance plan with premiums 5% to 7% percent lower than private insurance. The Congressional Budget Office estimated it would reduce the United States public debt by $104 billion over 10 years. Representative Schakowsky reintroduced the bill as H.R. 265 in January 2015, where it gained 35 cosponsors.

In the run-up to the 2016 Democratic National Convention, the Democratic Platform Committee approved a plank supporting the addition of a public option onto the Affordable Care Act. The decision was seen as a compromise measure between the Hillary Clinton campaign who during the 2016 presidential primaries advocated for keeping and reforming the ACA, and the Bernie Sanders campaign who advocated for repealing and replacing the ACA with a single-payer Medicare for All program. The Clinton campaign stated shortly before the plank was added that as president Clinton would "pursue efforts to give Americans in every state in the country the choice of a public-option insurance plan", while Bernie Sanders applauded the decision to "see that all Americans have the right to choose a public option in their health care exchange, which will lower the cost of healthcare". The call was echoed by President Obama, who in an article for the American Medical Association stated that Congress "should revisit a public plan to compete alongside private insurers in areas of the country where competition is limited."

In the lead-up to the 2020 presidential election, the public option, "once considered too far-reaching", had become "seen as a more moderate alternative" to proposals like Bernie Sanders' Medicare for All plan. A majority of candidates running in the Democratic primary, including Joe Biden and Pete Buttigieg, preferred a healthcare plan that included a public option over a single payer plan, and some candidates who preferred a single payer plan said they would also accept a public option as a compromise or step along the way to single payer, such as Elizabeth Warren, who initially said "there's no excuse for stopping at half-measures" regarding single payer, but would later pivot to supporting the enactment of a public option first before transitioning to a single payer system.

State legislation

Attempts to implement a public option have also been made at the state level. In May 2019, a law was passed and signed in Washington for the establishment of a public option, which is the first law for a public option to be passed at the state level, and is intended make a public option plan for purchase in 2021. The Cascade Select program which requires private insurance companies to provide alternative plans, known as Cascade Select plans, which are overseen, but not run, by the state; the alternative plans are sold on the ACA marketplace alongside ACA-compliant private insurance plans. The law caps provider payments on Cascade Select plans at 160% of Medicare payment rates. The Washington state law has been variably described as both a "public option" and a "public-private partnership". Similar legislation was passed in 2021 in both Colorado and Nevada.

New Mexico has also passed legislation establishing official studies into a state-level public option and have been pursuing further action, while Delaware, Oregon, and Massachusetts have completed similar studies looking into state-level public options but have taken no additional action, and other state legislatures have considered either outright enacting a public option or at least passing legislation to establish an official study on a potential public option plan.

Rationale

See also: Health care reform debate in the United States

The purpose behind the public option was to make more affordable health insurance for uninsured citizens who are either unable to afford the premiums of private health insurers or are rejected by private health insurers due to pre-existing condition. Supporters also argued (and proposed possible ways) that a government insurance company (public option) could put pressure on private health insurance companies to lower their premium costs and accept more reasonable profit margins, while also encouraging them to create more competitive plans with wider coverage, as well as eventually creating a more competitive, reasonably priced healthcare market across the industry by encouraging more efficient treatments and practices, and finally, eventually generating a large source of non-tax revenue for the government, which could help ease the rate of increasing budgetary deficit. Proponents proposed this would be accomplished by initially paying doctors and hospitals 4%-5% higher for claims than the average paid by private insurers but charging lower premiums than them, thus creating a more widely accepted, competitive product- making it the obvious choice and forcing private health insurers to create their own, similar reasonably priced, more full-featured insurance plans.

A public option would be able to offer such competitive options, as they would not be operating as a traditional for-profit business, whereby the main priority is maximization of profits, as is the case of private health insurers- but instead operate much like a non-profit organization, whereby all funds acquired through premiums, minus operating expenses, could be paid out on claims (directly benefiting the policy holder, rather than a disproportionate amount of revenue generated from premiums paid to the insurer by the policy holder serving typical corporate uses, such as multimillion-dollar executive salaries and bonuses, stock dividends, and excess cash flows).

Additionally, government influence and power would be leveraged to encourage (primarily) hospitals (as well as medical groups and collectives) to switch medical workers currently paid directly by insurers on a claim-by-claim basis (i.e. for each individual procedure) to instead work as cooperatively as possible, in efficient teams, and receive income in salaries, which proponents believed would both be more efficient, and reduce the complexity associated with medical billing, simplifying both accounting and lowering overall healthcare costs. This primarily would only affect doctors, particularly specialists, such as surgeons, as most nurses and medical technicians are already paid salaried wages as well as pressuring healthcare provider groups and hospitals to research and employ the most cost effective methods and treatments, and work in more cooperative teams, which would allow for employees to be salaried, as opposed to the current system where the highest paid workers (mainly doctors and specialized teams) are paid individually for each procedure they perform/patient they treat.

Supporters of a public plan, such as columnist E. J. Dionne of The Washington Post, argue that many places in the United States have monopolies in which one company, or a small set of companies, control the local market for health insurance. Economist and The New York Times columnist Paul Krugman also wrote that local insurance monopolies exist in many of the smaller states, accusing those who oppose the idea of a public insurance plan as defenders of local monopolies. He also argued that traditional ideas of beneficial market competition do not apply to the insurance industry given that insurers mainly compete by risk selection, claiming that "[t]he most successful companies are those that do the best job of denying coverage to those who need it most."

Economist and former US Secretary of Labor Robert Reich argued that only a "big, national, public option" can force insurance companies to cooperate, share information, and reduce costs while accusing insurance and pharmaceutical companies of leading the campaign against the public option.

Many Democratic politicians were publicly in favor of the public option for a variety of reasons. President Obama continued campaigning for the public option during the debate. In a public rally in Cincinnati on September 7, 2009, President Obama said: "I continue to believe that a public option within the basket of insurance choices would help improve quality and bring down costs." The president also addressed a joint session of Congress on September 9, 2009, reiterating his call for a public insurance option, saying that he had "no interest in putting insurance companies out of business" while saying that the public option would "have to be self-sufficient" and succeed by reducing overhead costs and profit motives. Democratic representative Sheila Jackson-Lee, who represents the 18th congressional district in Houston, believed that a "vigorous public option" would be included in the final bill and would "benefit the state of Texas."

Alternative plans

See also: Single-payer healthcare § Proposals for a single-payer system in the United States, and Patient Protection and Affordable Care Act

The final bill, the Patient Protection and Affordable Care Act, included provisions to open health insurance exchanges in each state by October 1, 2013. As the Act requires Americans to purchase health insurance, the federal government will offer subsidies to Americans with income levels up to four times the federal poverty level.

An alternative proposal is to subsidize private, non-profit health insurance cooperatives to get them to become large and established enough to possibly provide cost savings Democratic politicians such as Howard Dean were critical of abandoning a public option in favor of co-ops, raising questions about the ability of the cooperatives to compete with existing private insurers. Paul Krugman also questioned the ability of cooperatives to compete.

While politically difficult, some politicians and observers have argued for a single-payer system. A bill, the Medicare for All Act, was first proposed by Representative John Conyers in 2003 and has been perennially proposed since, including during the debate on the public option and the Patient Protection and Affordable Care Act. President Obama came out against a single-payer reform, stating in the joint session of Congress that "it makes more sense to build on what works and fix what doesn't, rather than try to build an entirely new system from scratch." Obama had previously expressed that he is a proponent of a single payer universal health care program during an AFL–CIO conference in 2003.

A number of alternatives to the public option were proposed in the Senate. Instead of creating a network of statewide public plans, Senator Olympia Snowe proposed a "trigger" in which a plan would be put into place at some point in the future in states that do not have more than a certain number of private insurance competitors. Senator Tom Carper has proposed an "opt-in" system in which state governments choose for themselves whether or not to institute a public plan. Senator Chuck Schumer has proposed an "opt-out" system in which state governments would initially be part of the network but could choose to avoid offering a public plan.

Opposition and criticism

See also: Health care reform debate in the United States

Both before and after passage in the House, significant controversy surrounded the Stupak–Pitts Amendment, added to the bill to prohibit coverage of abortions – with limited exceptions – in the public option or in any of the health insurance exchange's private plans sold to customers receiving federal subsidies. In mid-November, it was reported that 40 House Democrats would not support a final bill containing the Amendment's provisions. The amendment was abandoned after a deal was struck between Representative Bart Stupak and his voting bloc would vote for the bill as written in exchange for the signing of Executive Order 13535.

Former Congressman and Republican House Minority Whip Eric Cantor has argued that a public plan would compete unfairly with private insurers and drive many of them out of business.

Michael F. Cannon, a senior fellow of the libertarian CATO Institute, has argued that the federal government can hide inefficiencies in its administration and draw away consumers from private insurance even if the government offers an inferior product. A study by the Congressional Budget Office found that profits accounted for only about 3 percent of private health insurance premiums, and Cannon argued that the lack of a profit motive reduces incentives to eliminate wasteful administrative costs.

Robert E. Moffit of The Heritage Foundation argued that a public plan in competition in private plans would likely be used as a "dumping ground" for families and individuals with higher than average health risks. This, in his view, would lead to costs that business should pay being passed onto the taxpayer.

Marcia Angell, M. D., Senior Lecturer in the Department of Social Medicine at Harvard Medical School and former Editor-in-Chief of the New England Journal of Medicine, believes that the result of a public option would be more "under-55's" opting to pay the fine rather than purchase insurance under a public option scenario, instead advocating lowering the Medicare age to 55.

The chief executive of Aetna, Ron Williams, argued against the public option based on issues of fairness. On the News Hour with Jim Lehrer, Williams noted that a public option creates a situation where "you have in essence a player in the industry who is a participant in the market, but also is a regulator and a referee in the game". He said, "we think that those two roles really don't work well."

Public opinion

Further information: Public opinion on health care reform in the United States

Public polling has shown mixed support for a public option. A Rasmussen Reports poll taken on August 17–18 stated that 57% of Americans did not support the current health care bill being considered by Congress that did not include a public option, a change from their findings in July 2009. An NBC News/Wall Street Journal poll, conducted August 15–17, found that 47% of Americans opposed the idea of a public option and 43% expressed support. A July 2009 survey by the Quinnipiac University Polling Institute found that 28% of Americans would like to purchase a public plan while 53% would prefer to have a private plan. It also stated that 69% would support its creation in the first place. Survey USA estimated that the majority of Americans (77%) feel that it is either "quite important" or "extremely important" to "give people a choice of both a public plan administered by the federal government and a private plan for their health insurance" in August 2009. A Pew Research Center report published on October 8, 2009, stated that 55% of Americans favor a government health insurance plan to compete with private plans. The results were very similar to their polling from July, which found 52% support. An October 2009 Washington Post/ABC poll showed 57% support, a USA Today/Gallup survey described by a USA Today article on October 27 found that 50% of Americans supported a government plan proposal, and a poll from November 10 and 11 by Angus Reid Public Opinion found that 52% of Americans supported a public plan. On October 27, journalist Ray Suarez of The News Hour with Jim Lehrer noted that "public opinion researchers say the tide has been shifting over the last several weeks, and now is not spectacularly, but solidly in favor of a public option."

Between October 28 and November 13, 2009, Democratic senator Dick Durbin's campaign organization polled Americans to rank their support for various forms of the "public option" currently under consideration by Congress for inclusion in the final health care reform bill. The 83,954 respondents assigned rankings of 0 to 10. A full national option had the most support, with an 8.56 average, while no public option was least favored, with a 1.10 average.

Polls during 2019 have shown a majority support for a public option, including a Marist poll which found that 70% of Americans supported a public option while 25% opposed it, a Kaiser Family Foundation poll which found that 69% of Americans supported a public option while 29% opposed it, and Quinnipiac poll found that 58% of Americans supported a public option while 27% opposed it.

Physician reaction

In 2009, a survey designed and conducted by doctors Salomeh Keyhani and Alex Federman of Mount Sinai School of Medicine found that 73% of doctors supported a public option. A survey reported by the New England Journal of Medicine in September, based on a random sample of 6,000 physicians from the American Medical Association, stated that "it seems clear that the majority of U.S. physicians support using both public and private insurance options to expand coverage."

Conversely, a 2009 IBD/TIPP poll of 1,376 physicians showed that 45% of doctors "would consider leaving or taking early retirement" if Congress passes the health care plan wanted by the White House and Democrats. This poll also found that 65% of physicians oppose the White House and Democratic version of health reform. Statistician and polling expert Nate Silver has criticized that IBD/TIPP poll for what he calls its unusual methodology and bias and for the fact that it was incomplete when published as responses were still coming in.

In 2019, the American College of Physicians, the second largest physicians group in the United States, endorsed both single payer and a public option for US healthcare reform.

Sicko

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Sicko

 

Sicko
Theatrical release poster
Directed by	Michael Moore
Written by	Michael Moore
Produced by	Michael Moore Megan O'Hara
Starring	Michael Moore
Narrated by	Michael Moore
Cinematography	Jayme Roy Andrew Black
Edited by	Geoffrey Richman Christopher Seward Dan Swietlik
Music by	Erin O'Hara
Production company	Dog Eat Dog Films
Distributed by	Lionsgate The Weinstein Company
Release dates	May 19, 2007 (Cannes) June 22, 2007 (United States)
Running time	123 minutes
Country	United States
Language	English
Budget	$9 million
Box office	$36 million

Sicko is a 2007 American political documentary film by filmmaker Michael Moore. Investigating health care in the United States, the film focuses on the country's health insurance and the pharmaceutical industry. Moore compares the for-profit non-universal U.S. system with the non-profit universal health care systems of Canada, the United Kingdom, France and Cuba.

Produced on a roughly $9 million budget, Sicko grossed $25 million theatrically in North America. This exceeded the official expectation of The Weinstein Company, which had hoped to be in line with Bowling for Columbine's $22 million U.S. box office gross.

Synopsis

Sicko begins by noting that almost 50 million Americans were uninsured in 2007 while the remainder, who are covered, are often victims of insurance company fraud and red tape. Sicko mentions that the World Health Organization ranks U.S. health in general as 37 out of 191 countries and ranks some U.S. health measures, such as infant mortality and life expectancy, as equal to countries with much less economic wealth. Interviews are conducted with people who thought they had adequate coverage but were denied care. Former employees of insurance companies describe cost-cutting initiatives that give bonuses to insurance company physicians and others to find reasons for the company to avoid meeting the cost of medically necessary treatments for policy holders, and thus increase company profitability.

The history of the American health care debate serves as a backdrop. Opponents of universal health care are set in the context of 1950s-style anti-communist propaganda. A 1950s record distributed by the American Medical Association, narrated by corporate spokesmodel Ronald Reagan, warns that universal health care could lead to lost freedoms and socialism. In response, Moore shows that socialized public services like police, fire service, the United States Postal Service, public education and community libraries have not led to communism in the United States.

Canada

In Canada, a citizen describes the case of Tommy Douglas, who was voted the greatest Canadian in 2004 for his contributions to the Canadian health system. Moore also interviews a microsurgeon and people waiting in the emergency room of a Canadian public hospital.

HMO origin in the 1970s

The origins of the Health Maintenance Organization Act of 1973 are presented using a taped conversation between John Ehrlichman and President Richard Nixon on February 17, 1971; Ehrlichman is heard telling Nixon that "the less care they give them, the more money they make", a plan that Nixon remarked was "fine" and "not bad". This led to the expansion of the modern health maintenance organization-based health care system. Connections are highlighted between Pharmaceutical Research and Manufacturers of America (PhRMA), the lobbying arm of the largest drug companies in the United States, lobbying groups in Washington, D.C., and the Congress. Hillary Clinton, a champion of the Clinton health care plan, is shown as a crusader for change, appointed to reform the health care system in the United States by her husband, newly elected President Bill Clinton. Her efforts are met with heavy-handed criticisms by Republicans on Capitol Hill, and right-wing media throughout the country, who characterize her plan as the harbinger of socialism. When she is defeated, her punishment is to "never speak of it again while in the White House." Seven years later, her silence is rewarded, as she becomes a Senator via healthcare industry contributions, the second largest recipient in the Senate.

United Kingdom

In the United Kingdom, a country whose National Health Service is a comprehensive publicly funded health care system, Moore interviews patients and inquires about in-hospital expenses incurred by patients, only to be told that there are no out-of-pocket payments. Moore visits a typical UK pharmacy, where pharmaceuticals are free of charge for all persons in Northern Ireland, Scotland and Wales and under 16, 16–17 in full-time education, disabled, unemployed, or over 60 in England, and subsidized in most cases for everyone else (in England); only a fixed amount of £6.65 (about $10) per item on a prescription was charged, irrespective of cost to the NHS. Further, NHS hospitals employ a cashier, part of whose job is to reimburse low-income patients for their out-of-pocket travel costs to the hospital. Interviews include an NHS general practitioner, an American woman residing in London, and British politician Tony Benn, who compares a hypothetical dismantling of the NHS to ending women's suffrage and says it would lead to a revolution.

France

In France, Moore visits a hospital and interviews the head of obstetrics and gynaecology and a group of American expatriates. Moore rides with the "SOS Médecins", a 24-hour French medical service that provides house calls by physicians. Moore discovers that the French government provides many social services and rights in addition to health care, such as daycare for $1 an hour, free college education, a minimum five weeks paid vacation by law, vacation, and neonatal support that includes cooking, cleaning, and laundry services for new mothers.

Return to US

Returning to the United States, interviews disclose that 9/11 rescue workers who volunteered after the September 11, 2001 attacks were denied government funds to care for physical and psychological illnesses they subsequently developed, including respiratory disease and PTSD-induced bruxism. Unable to receive and afford medical care in the United States, the 9/11 rescue workers, as well as all of Moore's friends in the film needing medical attention, set sail from Miami to Cuba on three speedboats in order to obtain free medical care provided for the detainees at the U.S. Guantanamo Bay detainment camp.

Cuba

The group arrives at the entrance channel to "Gitmo" and Moore uses a megaphone to request access, pleading for the 9/11 victims to receive treatment that is on par with the medical attention the detainees are receiving. The attempt ceases when a siren is blown from the base, and the group moves on to Havana, where they purchase inexpensive medicine and receive free medical treatment at the elite Hermanos Ameijeiras Hospital. Providing only their names and birth dates, the rescue workers are hospitalized and receive medical attention. Before they leave, the 9/11 rescue workers are honored by a local Havana fire station.

Finally, Moore addresses the audience, emphasizing that people should be "taking care of each other, no matter the differences." To demonstrate his personal commitment to this theme, Moore decides to help one of his biggest critics, Jim Kenefick. According to a blog posting, Kenefick feared he would have to shut down his anti-Moore website because he needed US$12,000 to cover the costs of medical treatment for his sick wife. Not wanting the U.S. health care system to limit Kenefick's ability to express his opinion, Moore sends Kenefick the money himself.

This film ends with Moore walking towards the United States Capitol with a basket full of his clothes, sarcastically saying he will get the government to do his laundry until a better day comes for the sick and hopeless who are unable to receive health care.

Cast

• Billy Tauzin as himself
• Jacques Milliez as himself
• Linda Peeno as herself

Laws discussed

• Medicare Prescription Drug, Improvement, and Modernization Act of 2003

Release

Sicko premiered on May 19, 2007, at the 2007 Cannes Film Festival, receiving a 17-minute standing ovation from 2,000 people at the Grand Theatre Lumiere. The North American première of Sicko was held in London, Ontario (where some scenes from the movie were filmed), at the Silver City movie theatre at Masonville Place on June 8, 2007, with Moore in attendance. It also had an early première in Washington, D.C., on June 20, two days before its U.S. release, with Moore appearing at a Capitol Hill press conference to promote the film.

The European première was held in Great Britain on October 24, 2007, at the Odeon Leicester Square as part of the 51st London Film Festival. Moore was to introduce the film, but remained in the United States due to a 'family issue', sending a lengthy letter to be read in his absence. Part of the letter gave thanks to the Rt Hon. Tony Benn, featured in the film, who delivered a short speech before the showing.

Box office

Made on a budget of $9 million, Sicko earned $4.5 million on its opening weekend. In 441 theaters, it took in an average of $10,204 per theater, the second-highest average gross of the weekend. As of February 24, 2008, Sicko has grossed $25 million in the United States and $11 million in foreign markets. Overall, the movie has made over $36 million. The film was also a huge success in DVD sales, in which it accumulated over $60 million in sales.

Critical reaction

Michael Moore at the 2007 Cannes Film Festival receiving a standing ovation for Sicko

According to the review aggregator Rotten Tomatoes, the film boasts a 92% positive rating, based on 218 reviews, with an average rating of 7.71/10. The website's critical consensus reads, "Driven by Michael Moore's sincere humanism, Sicko is a devastating, convincing, and very entertaining documentary about the state of America's health care." Metacritic reported the film had an average score of 74 out of 100, based on 39 reviews, indicating "generally favorable reviews". After its Cannes release, Variety described Sicko as "an affecting and entertaining dissection of the American health care industry".

In an early review a week before the premiere, Richard Roeper and Michael Phillips gave the film two thumbs up. Roger Friedman of Fox News called the film a "brilliant and uplifting new film" and praised Moore for the way in which he lets "very articulate average Americans tell their personal horror stories at the hands of insurance companies" and "criticizes both Democrats and Republicans for their inaction and in some cases their willingness to be bribed by pharmaceutical companies and insurance carriers."

British film magazine Empire praised Moore's filmmaking and personal artistic vision, exclaiming "Sicko is the film that truly reveals Moore as an auteur."

David Denby of the New Yorker called the film "feeble, even inane", but film critic Stephen Schaefer of The Boston Globe described Sicko as "a very strong and very honest film about a health system that's totally corrupt and that is without any care for its patients".

The film was listed as the 4th best film of 2007 by Carina Chocano of Los Angeles Times, as well as 8th best by Marjorie Baumgarten of The Austin Chronicle.

Awards

Sicko was nominated for an Academy Award for Best Documentary Feature and Moore was nominated for the Writers Guild of America Award for Best Documentary Screenplay. It was also commended in the Australian Film Critics Association 2007 Film Award for Best Documentary.

Response

News media

Journalist and free market advocate John Stossel wrote an article in the Wall Street Journal that claimed Julie Pierce's husband, Tracy, featured in Sicko, would not have been saved by the bone marrow transplant denied by his insurer.^{[citation needed]} Stossel also questioned whether this treatment would have been given in a universal health care system, citing rationing and long waiting lists in Canada and Britain. Julie Pierce claimed Stossel never contacted her or her husband's doctors, and that the insurer denied other treatments as well and questioned Stossel's assertion that Tracy would not have received this in a socialized system, arguing that they are performed more frequently in Canada than in the U.S.

Moore insisted in the movie as well as in an interview with Stossel that the treatment provided in the Hermanos Ameijeiras Hospital was just like that given to any Cuban; but Stossel's investigations led Stossel to conclude that the hospital provided service only for the Cuban elite and that this care was not available to the average Cuban. In response to criticism that only well-to-do Cuban citizens receive a decent standard of health care, Michael Moore adduced on his website the result of an independent Gallup Poll in which "a near unanimous 96 percent of respondents say that health care in Cuba is accessible to everyone". An article in the Miami Herald interviewing some Cuban exiles in the United States criticized Sicko for painting a rosy picture of the Cuban healthcare system.

In an article published in both The New Yorker and Reason magazine, Michael C. Moynihan called the film "touching, naïve and maddeningly mendacious, a clumsy piece of agitprop that will likely have little lasting effect on the health care debate". Surgeon and Associate Director of Brigham and Women's Hospital's Center for Surgery and Public Health Atul Gawande commented, "Sicko is a revelation. And what makes this especially odd to say is that the movie brings to light nothing that the media haven’t covered extensively for years."

Kurt Loder criticized the film as presenting cherry-picked facts, manipulative interviews, and unsubstantiated assertions. While admitting that the U.S. health care system needs reform, Loder criticized Moore's advocacy of government control, arguing that many services controlled by the government are not considered efficient by the American public. Loder points to a 2005 film, Dead Meat, by Stuart Browning and Blaine Greenberg, which documents long waiting lists for care in Canada. Loder points to calls for reform in Britain and France due to the same rationing.

USA Today's Richard Wolf said, "Sicko uses omission, exaggeration and cinematic sleight of hand to make its points."

WBAI Radio, part of the Pacifica Radio Network, reported that Sicko was revitalizing the debate for universal health care within the United States, calling the film "adrenaline for healthcare activists."

Healthcare industry

In a letter responding to a Wall Street Journal op-ed by David Gratzer that was critical of the film, Robert S. Bell, M.D., President and CEO of University Health Network, Toronto, said that while Moore "exaggerated the performance of the Canadian health system", it provides universal coverage of a similar quality to that enjoyed by only some Americans. Michael Moore posted a leaked memo from a Capital Blue Cross employee about the likely consequences of the film. The memo expresses concern that the movie turns people against Capital Blue Cross by linking it to abuses by for-profit HMOs.

A July 9, 2007 broadcast of CNN's The Situation Room aired a "fact check" segment by CNN's senior health correspondent Dr. Sanjay Gupta on Sicko. Immediately following the segment, Moore was interviewed live on CNN by Wolf Blitzer. Moore stated that Gupta's report was inaccurate and biased. Moore posted a point-by-point response on his website. After a debate with Moore on Larry King Live, Gupta posted a message about his position on Sicko and CNN's coverage.

Wendell Potter

Wendell Potter admitted that while he was working as Head of Corporate Communications at CIGNA, the health insurance industry umbrella agency America's Health Insurance Plans had developed a campaign to discredit Michael Moore and the movie. When asked what he thought about the film Potter said that "I thought that he hit the nail on the head with his movie. But the industry, from the moment that the industry learned that Michael Moore was taking on the health care industry, it was really concerned ... They were afraid that people would believe Michael Moore."

Journalist Bill Moyers reported that PBS had obtained a copy of the "game plan" that was adopted by the industry's trade association, America's Health Insurance Plans which spelled out the industry strategies to "highlight horror stories of government-run systems". Potter explained, "The industry has always tried to make Americans think that government-run systems are the worst thing that could possibly happen to them, that even if you consider that, you're heading down on the slippery slope towards socialism. So they have used scare tactics for years and years and years, to keep that from happening. If there were a broader program like our Medicare program now, it could potentially reduce the profits of these big companies. So that is their biggest concern."

Moyers reported and Potter confirmed that there were attempts to radicalize Moore in an effort to discredit the film's message. Moore would be referred to as a "Hollywood entertainer" or "Hollywood moviemaker" to associate the film as being grounded in entertainment without any basis in objective reality. "They would want you to see this as just some fantasy that a Hollywood filmmaker had come up with. That's part of the strategy." Potter said that the strategy worked and the impact of the film was "blunted" by the public relations campaign. He agreed that Sicko contained "a great truth" which he said was "that we shouldn't fear government involvement in our health care system. That there is an appropriate role for government, and it's been proven in the countries that were in that movie. You know, we have more people who are uninsured in this country than the entire population of Canada. And that if you include the people who are underinsured, more people than in the United Kingdom. We have huge numbers of people who are also just a lay-off away from joining the ranks of the uninsured, or being purged by their insurance company, and winding up there."

Think tanks

The free-market think tanks, such as the Manhattan Institute, say that Sicko misrepresented the health systems of Canada, the United Kingdom and Cuba, and criticized it for its negative portrayal of the American health insurance system compared to these countries.

The National Center for Policy Analysis, a conservative American think tank, has also been critical of Moore's claims, focusing particularly on lengthy waiting lists and unavailability of new treatments in the publicly funded health systems of the United Kingdom and Canada, an aspect of those systems which they allege Moore failed to address.

The left-of-center/liberal-leaning Urban Institute (UI) largely agreed with Moore regarding the need for a universal health care system and failure of the current system. Urban Institute economist Linda Blumberg stated that Moore correctly provides evidence that the current system fails and a universal system is needed, adding that any system will face budget constraints. Overall, Blumberg stated that "Americans as a whole have yet to buy the philosophy that health care is a right and not a privilege" and if Moore succeeded in popularizing the idea, he "will have done the country a tremendous service." Bradford Gary agrees with the main points made by Moore but criticizes the film for making various omissions and lacking attention to detail, stating that "though Moore is not interested in the details behind the outrages he has assembled, many of his fundamental points are nevertheless accurate."

Moorewatch

Regarding Moore's donation to Jim and Donna Kenefick of Moorewatch.com, while Donna Kenefick thanked Moore, saying his money "paid for our health insurance premiums and gave us the financial breathing room to both deal with our debts", Jim Kenefick disputed Moore's account of these events, saying that his insurance would have paid for his wife's needs, and that his sites were in operation again thanks to reader donations long before he ever received Moore's check. Kenefick accused Moore of presenting his words out of context in order to defame him, and both Kenefick and his onetime co-blogger, Lee, criticized Moore for claiming to make this donation anonymously, only to highlight it in his film. They accuse him of being motivated by a desire for publicity and self-aggrandizement rather than altruism.

At a Cannes press conference, after the identity of the donor was revealed, Moore said: "I had to ask myself, 'Would you write this check if this wasn't in the film?'. I decided this is what I would do, and what I should do, and this is the way I want Americans to live."

WikiLeaks cable on Cuba and Sicko

Sicko was shown in theaters throughout Cuba and on national TV.^[62] Despite this, former United States Interests Section in Havana chief Michael E. Parmly wrote a diplomatic cable on January 31, 2008, which in part read:

XXXXXXXXXXXX stated that Cuban authorities have banned Michael Moore's movie, Sicko, as being subversive. Although the film's intent is to discredit the U.S. healthcare system by highlighting the excellence of the Cuban system, he said the regime knows the film is a myth and does not want to risk a popular backlash by showing to Cubans facilities that are clearly not available to the vast majority of them.

The Guardian newspaper, which collaborated with WikiLeaks, who leaked the cable, initially reported the cable's claim as fact, then printed that Moore complained about the factual error, and finally The Guardian printed a correction, confirming the film was in fact shown in Cuba. Moore argued that US officials simply made up the story to discredit the film as it portrays the US healthcare system in a negative light.

Legal controversy

Unauthorized distribution

The film was leaked onto the Internet two weeks before its official release on June 29, 2007. Moore denied leaking the film for publicity, and an investigation was made into the source of the Internet leak. When asked about the leak, Moore said, "I'm just happy that people get to see my movies. I'm not a big supporter of the copyright laws in this country ... I don't understand bands or filmmakers ... who oppose sharing, having their work being shared by people, because it only increases your fanbase."

Treasury Department probe

In a May 2, 2007 letter, the Office of Foreign Assets Control informed Moore that he was the subject of a civil investigation stemming from the filmmaker's March trip to Cuba. In the letter to Moore, a Treasury official noted that the department had no record of Moore obtaining a license that authorized him to "engage in travel-related transactions involving Cuba", alleging that Moore violated the United States embargo against Cuba. A duplicate master copy of the film was being held in Canada should an attempt have been made by American authorities to seize the film as part of the investigation against Moore that arose from taking the American 9/11 rescue workers to Cuba for medical treatment. Moore has said that trips made for conducting journalism are usually covered under a general license, which does not require preauthorization by the State Department. Moore states that his intentions were to travel to the US Naval base in Guantánamo Bay. Upon Moore's arrival at Guantánamo Bay, a siren was sounded and Moore decided to turn around for safety.

On The Tonight Show, Moore reported that he was notified that a subpoena regarding his trip to Cuba had already been issued. According to an anonymous source reported by Reuters, Moore has not been served; rather, the government contacted his attorney, David Boies, to discuss the logistics of serving a subpoena.

Deleted scenes and extras

The DVD release includes deleted segments that Moore filmed but did not use in the theatrical release. Several scenes from the section about health care in the United Kingdom feature footage of a homeless shelter where people received acupuncture and foot massages. Discarded scenes in France include an interview with an employee from General Electric, who tells Moore they get benefits in France that GE employees do not receive in the United States. Scenes showing Moore's visit to Norway and depicting its healthcare system, social benefits, and rehabilitation-based prison system were removed from the film because the Norwegian healthcare system, which is supervised by the Norwegian Board of Health Supervision, possesses numerous benefits similar to the French system. Like the French health care system, Norwegian patients treated for illnesses such as psoriasis or rheumatism are shown eligible for two weeks' paid vacation at a spa in the Canary Islands. Norway hires a government ethicist to determine how to invest the windfall from the country's oil wealth, because they want to do it in an ethical manner. A scene where Moore visits Bastøy Prison, a Norwegian island prison, was also deleted. Here, inmates reside in small group homes and focus on rehabilitation through manual labor and farming.

Deleted American health care scenes include an uninsured woman who was offered a 50% discount for treatment of spinal cancer. She still could not afford the initial consultations, so she held a fundraiser to pay for it. After the initial visit, the 50 percent discount was revoked when the hospital discovered that she had obtained the money to pay for her treatment through fundraising, which the hospital considered to be earned income. An interview with Marcia Angell was also deleted. The former editor of The New England Journal of Medicine criticizes various practices of pharmaceutical companies and the Food and Drug Administration. Executive producer Harvey Weinstein asked Moore to remove a scene critical of Hillary Clinton, but Moore refused. Weinstein, whose company provided financing for the film, is a friend of the Clinton family.

In the DVD edition of the film, Moore added a segment called "Sicko Goes to Washington". This extra promotes the United States National Health Care Act, legislation that would create a single-payer health care system within the United States.

Health maintenance organization

From Wikipedia, the free encyclopedia

https://en.wikipedia.org/wiki/Health_maintenance_organization

 

In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded health care benefit plans, individuals, and other entities, acting as a liaison with health care providers (hospitals, doctors, etc.) on a prepaid basis. The Health Maintenance Organization Act of 1973 required employers with 25 or more employees to offer federally certified HMO options if the employer offers traditional healthcare options. Unlike traditional indemnity insurance, an HMO covers care rendered by those doctors and other professionals who have agreed by contract to treat patients in accordance with the HMO's guidelines and restrictions in exchange for a steady stream of customers. HMOs cover emergency care regardless of the health care provider's contracted status.

Operation

HMOs often require members to select a primary care physician (PCP), a doctor who acts as a gatekeeper to direct access to medical services but this is not always the case. PCPs are usually internists, pediatricians, family doctors, geriatricians, or general practitioners (GPs). Except in medical emergency situations, patients need a referral from the PCP in order to see a specialist or other doctor, and the gatekeeper cannot authorize that referral unless the HMO guidelines deem it necessary. Some HMOs pay gatekeeper PCPs set fees for each defined medical procedure they provide to insured patients (fee-for-service) and then capitate specialists (that is, pay a set fee for each insured person's care, irrespective of which medical procedures the specialists performs to achieve that care), while others use the reverse arrangement.

Open-access and point-of-service (POS) products are a combination of an HMO and traditional indemnity plan. The member(s) are not required to use a gatekeeper or obtain a referral before seeing a specialist. In that case, the traditional benefits are applicable. If the member uses a gatekeeper, the HMO benefits are applied. However, the beneficiary cost sharing (e.g., co-payment or coinsurance) may be higher for specialist care. HMOs also manage care through utilization review. That means they monitor doctors to see if they are performing more services for their patients than other doctors, or fewer. HMOs often provide preventive care for a lower copayment or for free, in order to keep members from developing a preventable condition that would require a great deal of medical services. When HMOs were coming into existence, indemnity plans often did not cover preventive services, such as immunizations, well-baby checkups, mammograms, or physicals. It is this inclusion of services intended to maintain a member's health that gave the HMO its name. Some services, such as outpatient mental health care, are limited, and more costly forms of care, diagnosis, or treatment may not be covered. Experimental treatments and elective services that are not medically necessary (such as elective plastic surgery) are almost never covered.

Other choices for managing care are case management, in which patients with catastrophic cases are identified, or disease management, in which patients with certain chronic diseases like diabetes, asthma, or some forms of cancer are identified. In either case, the HMO takes a greater level of involvement in the patient's care, assigning a case manager to the patient or a group of patients to ensure that no two providers provide overlapping care, and to ensure that the patient is receiving appropriate treatment, so that the condition does not worsen beyond what can be helped.

Cost containment

Although businesses pursued the HMO model for its alleged cost containment benefits, some research indicates that private HMO plans do not achieve any significant cost savings over non-HMO plans. Although out-of-pocket costs are reduced for consumers, controlling for other factors, the plans do not affect total expenditures and payments by insurers. A possible reason for this failure is that consumers might increase utilization in response to less cost sharing under HMOs. Some have asserted that HMOs (especially those run for profit) actually increase administrative costs and tend to cherry-pick healthier patients.

History

Though some forms of group "managed care" did exist prior to the 1970s, in the US they came about chiefly through the influence of President Richard Nixon and his friend Edgar Kaiser. In discussion in the White House on February 17, 1971, Nixon expressed his support for the essential philosophy of the HMO, which John Ehrlichman explained thus: "All the incentives are toward less medical care, because the less care they give them, the more money they make."

The earliest form of HMOs can be seen in a number of "prepaid health plans". In 1910, the Western Clinic in Tacoma, Washington offered lumber mill owners and their employees certain medical services from its providers for a premium of $0.50 per member per month. This is considered by some to be the first example of an HMO. However, Ross-Loos Medical Group, established in 1929, is considered to be the first HMO in the United States; it was headquartered in Los Angeles and initially provided services for Los Angeles Department of Water and Power (DWP) and Los Angeles County employees. 200 DWP employees enrolled at a cost of $1.50 each per month. Within a year, the Los Angeles Fire Department signed up, then the Los Angeles Police Department, then the Southern California Telephone Company (now AT&T Inc.), and more. By 1951, enrollment stood at 35,000 and included teachers, county and city employees. In 1982 through the merger of the Insurance Company of North America (INA) founded in 1792 and Connecticut General (CG) founded in 1865 came together to become CIGNA. Also in 1929 Dr. Michael Shadid created a health plan in Elk City, Oklahoma in which farmers bought shares for $50 to raise the money to build a hospital. The medical community did not like this arrangement and threatened to suspend Shadid's licence. The Farmer's Union took control of the hospital and the health plan in 1934. Also in 1929, Baylor Hospital provided approximately 1,500 teachers with prepaid care. This was the origin of Blue Cross. Around 1939, state medical societies created Blue Shield plans to cover physician services, as Blue Cross covered only hospital services. These prepaid plans burgeoned during the Great Depression as a method for providers to ensure constant and steady revenue.

In 1970, the number of HMOs declined to fewer than 40. Paul M. Ellwood Jr., often called the "father" of the HMO, began having discussions with what is today the U.S. Department of Health and Human Services that led to the enactment of the Health Maintenance Organization Act of 1973. This act had three main provisions:

• Grants and loans were provided to plan, start, or expand an HMO
• Certain state-imposed restrictions on HMOs were removed if the HMOs were federally certified
• Employers with 25 or more employees were required to offer federally certified HMO options alongside indemnity upon request

This last provision, called the dual choice provision, was the most important, as it gave HMOs access to the critical employer-based market that had often been blocked in the past. The federal government was slow to issue regulations and certify plans until 1977, when HMOs began to grow rapidly. The dual choice provision expired in 1995.

In 1971, Gordon K. MacLeod developed and became the director of the United States' first federal HMO program. He was recruited by Elliot Richardson, the secretary of the Department of Health, Education and Welfare.

Types

HMOs operate in a variety of forms. Most HMOs today do not fit neatly into one form; they can have multiple divisions, each operating under a different model, or blend two or more models together. In the staff model, physicians are salaried and have offices in HMO buildings. In this case, physicians are direct employees of the HMOs. This model is an example of a closed-panel HMO, meaning that contracted physicians may only see HMO patients. Previously this type of HMO was common, although currently it is nearly inactive. In the group model, the HMO does not employ the physicians directly, but contracts with a multi-specialty physician group practice. Individual physicians are employed by the group practice, rather than by the HMO. The group practice may be established by the HMO and only serve HMO members ("captive group model"). Kaiser Permanente is an example of a captive group model HMO rather than a staff model HMO, as is commonly believed. An HMO may also contract with an existing, independent group practice ("independent group model"), which will generally continue to treat non-HMO patients. Group model HMOs are also considered closed-panel, because doctors must be part of the group practice to participate in the HMO - the HMO panel is closed to other physicians in the community.

If not already part of a group medical practice, physicians may contract with an independent practice association (IPA), which in turn contracts with the HMO. This model is an example of an open-panel HMO, where a physician may maintain their own office and may see non-HMO members.

In the network model, an HMO will contract with any combination of groups, IPAs (Independent Practice Associations), and individual physicians. Since 1990, most HMOs run by managed care organizations with other lines of business (such as PPO, POS and indemnity) use the network model.

Regulation

HMOs in the United States are regulated at both the state and federal levels. They are licensed by the states, under a license that is known as a certificate of authority (COA) rather than under an insurance license. State and federal regulators also issue mandates, requirements for health maintenance organizations to provide particular products. In 1972 the National Association of Insurance Commissioners adopted the HMO Model Act, which was intended to provide a model regulatory structure for states to use in authorizing the establishment of HMOs and in monitoring their operation.

Legal responsibilities

HMOs often have a negative public image due to their restrictive appearance. HMOs have been the target of lawsuits claiming that the restrictions of the HMO prevented necessary care. Whether an HMO can be held responsible for a physician's negligence partially depends on the HMO's screening process. If an HMO only contracts with providers meeting certain quality criteria and advertises this to its members, a court may be more likely to find that the HMO is responsible, just as hospitals can be liable for negligence in selecting physicians. However, an HMO is often insulated from malpractice lawsuits. The Employee Retirement Income Security Act (ERISA) can be held to preempt negligence claims as well. In this case, the deciding factor is whether the harm results from the plan's administration or the provider's actions. ERISA does not preempt or insulate HMOs from breach of contract or state law claims asserted by an independent, third-party provider of medical services.