November 28, 2012

Taiwan: Leader in Universal Healthcare Access

this after making the first steps toward single payer in 1995

http://www.wma.net/en/45blogs/2012_pblog12/index.html

Health care expenditures at 6.4 per cent of GDP are low compared with other OECD countries, but Taiwan shares with other countries the experience of an increase in health care expenditures (5.1 per cent) that exceeds the growth of the economy. Feeding this is medical utilization of 14.9 outpatient visits per person and hospital admissions of 14 per 100 persons per year. Currently expenditures under NHI exceed revenues.

To deal with the challenge of rapidly increasing costs the payment system has evolved since 1995 from initially fee-for-service with case payment to the addition of global budgets, pay for performance (P4P), diagnosis related groups (DRG), resource based relative value system (RBRVS) and capitation programs.

Last year the government passed the amended National Health Insurance Act. The act has as its purpose "endeavoring to better respond to the demands of the population and to better accommodate the practical requirements of the program".

Highlights of this "Second Generation NHI" include:

--Imposing supplementary premiums based on sources of income
--Establishing a mechanism linking revenues with expenditures by consolidating current decision-making bodies
--Diversifying payment schemes to providers
--Public disclosure of important information on decision making meetings, medical care quality, serious rule violators and financial data
--Healthcare systems are deeply rooted in each country's cultural ideas about society and values. Whether one model works for a particular country depends on its goals and values. In other words there is no evidence that one model is better than another, if you do not define what you want to achieve and whom you are willing to trust.

November 26, 2012

German investigative reporter infiltrates fundamentalist Christian college by posing--

--as prospective student.

http://theimmoralminority.blogspot.com/2012/11/german-investigative-reporter.html?spref=tw

Well so much for encouraging critical thinking. And don't forget THIS is an institution of higher learning. However the focus of this college is not simply to indoctrinate young adults, it is also to use them as a type of missionary and advocate for the fundamentalist Christian mindset while embedding them in various government agencies:



Okay so let that sink in a little. These young people are provided seemingly unrestricted access to some government agencies, and large businesses, where they are free to proselytize and even provide important services, ALL with a very aggressive agenda.

November 24, 2012

Health Insurance Exchanges May Be Too Small to Succeed

Comment by Don McCanne of PNHP: It is true that very large insurers within the exchanges can use their monopsony power (controlling the market as exclusive buyers) by demanding lower prices for health care services, but only for their own plans. Most health care costs will still be covered by employer-sponsored plans, Medicare, Medicaid and other programs. Thus plans offered by the exchanges cannot have much impact on our total national health expenditures.

Another difficulty with the monopsony power of private insurers is that when they are investor owned (WellPoint, UnitedHealth, Aetna, etc.), their first priority must be to use their leverage to benefit their investors. That results in insurance innovations that often are not particularly transparent, but have adverse consequences for the patients they insure. The private sector exercising power as a monopsony can be as evil as a monopoly.

In contrast, a public monopsony can be very beneficial in getting prices right--high enough to ensure adequate capacity in the delivery system, yet low enough to ensure value in health care.

The ultimate beneficent monopsony would be a single public program covering absolutely everyone ("single payer&quot . We could achieve this easily by improving Medicare and then making it universal. Health policy studies have proven that this would not only cover everyone, but it would finally bring us that elusive goal of health care reform - bending the cost curve to sustainable levels.

My comment: It has always seemed to me that "competition" in funding health care makes no more sense than having competing fire departments, for pretty much the same reason.

November 22, 2012

Employers lower health care costs by shifting them to employees

Comment by Don McCanne of PNHP: Pop the champagne corks! Businesses have held the rate of health benefit cost increases to only 4.1%! Though that is still twice the rate of inflation, it's the smallest increase in 15 years!

How did they achieve this success? By moving employees into lower cost consumer-directed health plans. By increasing deductibles for the plans. By other forms of cost shifting. By lowering actuarial values of plans to 60% - the minimum required by the Affordable Care Act. By adopting defined contribution strategies. By shifting to private insurance exchanges. By herding employees into narrower provider networks.

So have the employers finally learned how to slow the escalation of health care costs? No! They have dumped their costs onto the backs of their employees! So while they enjoy the bubbly in their executive suites, they have left too many of their employees without even any beer money.

If you didn't read yesterday's message that included the work of Thomas Piketty and Emmanuel Saez, you should. You will see that the solution is quite simple. Tax the crap out of the plutocrats and spend the proceeds on a public insurance program for all of us - an Improved Medicare for All. (I would use less inflammatory language except that wealthy employers who have such a low regard for their own employees do not deserve elegant language.)

Please note that this message does not apply to the multitude of small businesses which are struggling to maintain a modicum of success. These businesses are also victims of the burdensome health insurance costs. They too would benefit from an equitable public insurance program, if only they would make an effort to understand what it would mean for them. It's our job to try to educate them.

November 22, 2012

Voter Bill of Rights

http://nomorestolenelections.org/voter-bill-rights

1. Pass a Constitutional Amendment Confirming the Right to Vote

Most Americans believe that the "legal right to vote" in our democracy is explicit, not just implicit, in our federal Constitution. In fact, the federal Constitution recognizes each state’s guarantee of voting rights, and furthermore, guarantees equal protection of those rights. Additionally, the federal Constitution provides for elections for the U.S. House and Senate, and repeated amendments to the Constitution have affirmed that the right to vote belongs to all citizens regardless of race (15th Amendment) or sex (19th Amendment), and to all citizens over the age of eighteen (26th).

Despite two centuries in which the right to vote has been affirmed and expanded as a constitutional right, the U.S. system of elections still does not adequately protect voting rights. Indeed, Justice Scalia in Bush v. Gore claimed that, "the individual citizen has no federal constitutional right to vote for electors for the President of the United States." (Bush v. Gore, 531 U.S. 98, 104 (2000)). Because the Supreme Court, election administrators, and elected officials have, for the most part, proven themselves unable or unwilling to implement the reforms required to protect American voting rights, we must work to adopt a federal constitutional amendment confirming every citizen's right to vote.

2. Guarantee a Voter-Marked Paper Ballot for All Voting

Every voting system in the United States must be equipped to facilitate a permanent, visible record of every vote cast, and to honor the right of the voter to mark their own ballot themselves. The public is the only realistic check on vote counts, because elections determine the composition of government itself; those in power cannot be trusted to count or process -- unsupervised -- the very ballots by which they came to office. The acid test for a free people is the guaranteed right to remove incumbents at will, especially criminal incumbents, from office. Any system that allows secret and therefore unaccountable vote counting is unacceptable because it denies the right to vote and to “kick the bums out” at precisely the moment when that right is needed the most.

3. Replace Partisan Oversight with Non-Partisan Election Commissions

It is time to overhaul our federal, state, and local election agencies to guarantee fair elections. We must replace the current system of partisan election administration, in which partisan secretaries of state, county clerks, election commissioners, and other partisan officials are able to issue rulings that favor their own political parties and themselves, with a non-partisan, independent system of running elections. We must end the practice of contracting out fundamental election functions, such as the maintenance of voter lists, to private corporations. We must also insure that independent international and domestic election observers are given full access to monitor our elections.

4. Celebrate Democracy: Make Election Day a National Holiday

Working people should not be forced to choose between exercising their right to vote and getting to work on time. While the laws of 30 states guarantee the right to take time off from work to vote, many workers and employers are unaware of these laws. Holding national elections on a national holiday will greatly increase the number of available poll workers and polling places and increase overall turnout, while making it much easier for working Americans to go to the polls. Election Day is already a holiday in Puerto Rico in presidential election years, and many Puerto Ricans celebrate and make Election Day a fun and festive party with a purpose. It's time for the United States to follow Puerto Rico's lead.

5. Make it Easier to Vote

Many citizens are discouraged from voting by unnecessary bureaucratic hurdles and restrictions. We must simplify and rationalize voter registration so that no one is again disenfranchised for failing to check a superfluous box, as occurred this year in Florida, or for not using heavy enough paper, as nearly occurred in Ohio. We must require voter registrars to sign affidavits promising to submit any registrations in their possession in a timely manner. We must eliminate police intimidation, language, physical disability, extra-legal requirements of personal identification, and other barriers to voting. To ensure that all qualified voters are able to vote, we must follow the lead of states like Minnesota and Wisconsin by replacing restrictive voter residency requirements with same-day voter registration, allowing qualified voters to register at the polls on Election Day itself.

Our current system forces millions of voters to wait up to ten hours to vote. This is unacceptable, and it disenfranchises those who cannot afford to wait. To increase access to the polls, all states must provide sufficient funding for enough early voting and election-day polling places to guarantee smooth and speedy voting. To ensure equal access and minimize the wait at the polls, election authorities must allocate resources based upon the number of potential voters per precinct. We must put an end to the government-backed practice of allowing partisan activists to challenge the voting rights of individual voters at the polls. Instead, the government must invest in campaigns designed to educate voters about how they can exercise and protect their right to vote.

6. Count Every Vote!

Voters must know that their vote will count and make a difference. Every recent presidential election has been marred by the discounting millions of spoiled, under-vote, over-vote, provisional and absentee ballots. This discounting of votes has disproportionately impacted people of color, especially African Americans, and is a fundamental voting rights and racial justice problem. Election officials must ensure that every voting precinct and wards is adequately staffed with sufficiently trained personnel and professional supervision; that old and unreliable voting machines are replaced; that absentee ballots are mailed with a sufficient time for delivery; that every ballot, including provisional ballots, are counted; and that provisional ballots count for statewide and federal contests regardless of where the vote is cast. Election officials should wait until after any recounts have been completed to provide final certification of election results.

7. Implement Instant Runoff Voting (IRV) and Proportional Representation (PR)

We must replace our current "first-past-the-post" system with Instant Runoff Voting (IRV). Unlike our current system, which forces voters to reject their preferred candidate in favor of a "lesser evil" who may have a better chance of defeating the candidate they most fear, IRV allows them to choose both. In this way, it eliminates the so-called "spoiler" and "wasted vote" effects and gives voters a more democratic set of choices. Under IRV, voters simply rank candidates in order of their preference (first, second, etc.). If a candidate wins a majority of first choice votes, that candidate is the winner. If no candidate gets a majority of first choices, the lowest vote-getting candidate is eliminated, and his/her votes are given to the candidates whom the supporters of the eliminated candidate chose as their second option. Counting continues until one candidate has received a majority. IRV therefore not only allows voters to voice their real preferences; it also ensures that the will of the true majority, not a mere plurality, produces the winner of each election. In addition, IRV makes it possible to conduct the runoff count without the need for a separate and expensive runoff election. Instant Runoff Voting has been used successfully around the world, including Ireland, Australia, and most recently, San Francisco.

The right of representation belongs to all citizens. Our winner-take-all elections award representation to the largest factions and leave everyone else, often the majority, unrepresented. The winner-take-call system unnecessarily restricts choice, polarizes politics and limits political discourse. We must adopt Proportional Representation (PR) for legislative elections to ensure the fair representation of all voters. Millions of Democrats in Republican areas and Republicans in Democratic areas are unrepresented in our system, and the majority of Greens, Libertarians, and other independents are unrepresented at all levels of government. Our system should provide fair representation to all voters, in proportion to their numbers.

8. Replace Big Money Control With Public Financing and Equal Air-Time

In a system where the amount of money a candidate spends is directly related to their likelihood of winning, it is not surprising that voters think politicians are more concerned with big campaign contributors than with individual voters. We must follow Maine's lead by establishing a nationwide system of full public financing for all ballot-qualified candidates. We must require the broadcasting corporations that license our public airwaves to provide airtime for debates, and free time for all ballot-qualified candidates and parties.

9. Guarantee Equal Access to the Ballot and Debates

In our current electoral system, independent parties and candidates face a host of barriers designed to limit voter choice and voice. Ballot access laws and debates specifically designed to exclude independent party candidates discourage voting and undermine the legitimacy of our elections. In most cases, the established parties have never themselves met the signature requirements they impose on independent parties. We must eliminate prohibitive ballot access requirements, and replace the partisan Commission on Presidential Debates with a non-partisan Citizens Debate Commission.

10. Abolish Electoral College, Enfranchise Ex-Offenders, Enact Statehood for the District of Columbia

It is time to end the safe state/battleground state dichotomy and make all votes equal, no matter the state of the voter. We must amend the Federal Constitution to replace election of the President by the Electoral College with direct election by the voters. At the same time, for so long as the Electoral College persists, we must amend our state laws and constitutions to allocate each state's electors to the winner of the national popular vote.

The permanent disenfranchisement of former felons, a practice that falls outside of international or even U.S. norms, is an unreasonable and dangerous penalty that weakens our democracy by creating a subclass of four million excluded American citizens. The practice has also been used to purge voter lists of hundreds of thousands of citizens never convicted of any felony. Because the criminal justice system disproportionately penalizes African American males, this disenfranchisement is racist in its impact and is constitutionally suspect. Those states that permanently disenfranchise felons must amend their laws and practices to restore full citizenship to ex-offenders.

It is also time to end the disenfranchisement of the over half million Americans who reside in the District of Columbia. D.C. residents deserve the same political rights enjoyed by citizens of our nation's fifty states, namely full voting representation in both houses of the U.S. Congress, as well as legislative, budgetary, and judicial sovereignty. Washington D.C. is the only existing majority African American federal jurisdiction, and thus, the denial of D.C. voting rights is inherently racist. Furthermore, the denial of D.C. voting rights cannot be defended on the basis of population size; the majority white State of Wyoming has a smaller population. It is time to grant statehood to the District of Columbia.

About the Voter Bill of Rights:
The Voter Bill of Rights is a product of the 2001 Democracy Summer program, a proto Liberty Tree Foundation event. It was amended for the 2004 No Stolen Elections! campaign, and amended again for the No More Stolen Elections! campaign.

November 18, 2012

Raising the Age of Medicare Eligibility: A Fresh Look Following Implementation of Health Reform

Raising the Age of Medicare Eligibility: A Fresh Look Following Implementation of Health Reform
http://www.kff.org/medicare/8169.cfm

Several major deficit-reduction and entitlement reform proposals include raising Medicare's age of eligibility from 65 to 67 as a way of improving Medicare's solvency. This Kaiser Family Foundation report estimates the expected effects on such a change on the federal budget, as well as on affected seniors' out-of-pocket costs, employers, Medicaid and others in light of the major changes in coverage enacted under the 2010 health reform law.

The study estimates that raising Medicare’s eligibility to 67 in 2014 would generate an estimated $5.7 billion in net savings to the federal government, but also result in an estimated net increase of $3.7 billion in out-of-pocket costs for 65- and 66-year-olds, and $4.5 billion in employer retiree health-care costs. In addition, the study projects that the change would raise premiums by about 3 percent both for those who remain on Medicare and for those who obtain coverage through health reform's new insurance exchanges. The study assumes both full implementation of the health reform law and the higher eligibility age in 2014 in order to estimate the full effect of both the law and the policy proposal.

In the absence of the health reform law, raising Medicare's age of eligibility would result in an increase in the uninsured, according to other studies, as many older Americans would have difficulty finding affordable coverage in the individual market in the absence of Medicare. With health reform, virtually all 65- and 66-year-olds would be expected to obtain alternative sources of coverage.

The study is authored by researchers from the Kaiser Family Foundation and the Actuarial Research Corporation and is available online. It is the first in a new series of Kaiser Family Foundation studies examining the effects of proposed Medicare changes on the program’s beneficiaries, the federal budget and other stakeholders.

NOTE: Originally released in March 2011, this report and news release were updated in July 2011 to reflect additional provisions of the 2010 health reform law. These adjustments result in lower estimates of net federal savings and aggregate out of pocket spending attributable to raising the age of eligibility.

Despite the savings to the government, overall health care costs will INCREASE due to shifting them to employers and to sick people, by $2.5 billion dollars.

November 18, 2012

Raising Medicare Age Will COST Money and It Is Bad for Health

http://theincidentaleconomist.com/wordpress/delaying-medicare-eligibility-is-bad-for-health/

By now most of the blogosphere has weighed in on Joe Lieberman’s idea of increasing Medicare eligibility from age 65 to 67 (see Frakt, Klein, Volsky, Drum, Krugman). Most of the focus has been on how the delayed eligibility will affect overall health costs. Though federal costs may go down, overall costs would not, because most would just be shifted to seniors themselves. Cost isn’t everything, though. There’s something else delay would do: harm health.

This is not guesswork on our part; there’s clear evidence in the literature. In several papers, Michael McWilliams and colleagues found that utilization, spending, and outcomes for age-eligible Medicare beneficiaries differed for those who had been uninsured prior to turning 65 vs. those who had been insured. Their work was based on survey data, sometimes merged with Medicare claims. This is a relatively strong analytic approach since it exploits a discontinuity in coverage that potentially applies to nearly all individuals: the vast majority of the population enrolls in Medicare at age 65.

The authors found that, relative to those with insurance before age 65, those without insurance prior to Medicare eligibility spent much more money on health care after they became Medicare eligible. In other words, people wait to get care until their Medicare kicks in. This is bad both for health and for the federal government’s bottom line.

Delaying Medicare even longer would likely make this worse. People would forego care longer, health would suffer, and Medicare would pay for the consequences later.

This shouldn’t surprise anyone. It makes sense. It’s hard to get affordable insurance as you approach age 65. If you’re lucky enough to have insurance, then you’re getting the care you need, so getting Medicare is nice, but not a huge change in your life. If you’re uninsured, though, then getting Medicare is a huge change. If you know you need care, and it’s expensive, then you will likely try and wait until the Medicare kicks in to get it. People do this all the time; the evidence above confirms it.

Raising the eligibility age will just force these people to wait longer. If this somehow saved us money, then we suppose you could have a debate about its benefits and harms. Knowing that it will likely cost Medicare more, however, means that it’s entirely possible that delaying Medicare eligibility will cost more and lead to worse outcomes. That’s the worst of both worlds.

Graphs and charts are available online.

References

[1] McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Health of previously uninsured adults after acquiring Medicare coverage. JAMA. 2007;298:2886-94.
[2] McWilliams JM, Meara E, Zaslavsky AM, Ayanian JZ. Use of health services by previously uninsured Medicare beneficiaries. N Engl J Med. 2007;357:143-53.
[3]Page 2 of this document--Kaiser Foundation study on cost shifting effects of raising the Medicare age.

November 14, 2012

Accountable Care Organizations May Have Difficulty Avoiding The Failures Of Integrated Delivery--

Comment by Don McCanne of PNHP: The Affordable Care Act includes several measures supposedly to control health care spending, but analysis of the health policy literature to date suggests that none of these will have more than a negligible impact. Most hope is held out for accountable care organizations (ACOs), but this report by Burns and Pauly suggests that these new entities include many of the flaws of previous similar efforts, primarily the failed integrated delivery networks of the 1990s.

In reading their full article you will understand better why we cannot expect dramatic results from ACOs and the mechanisms that they would use such as disease management, care coordination, realignment of financial incentives, health information technology, electronic health records, computerized physician order entry, clinical decision support systems, and especially the Medicare shared savings program.

As opposed to well established integrated health systems like Kaiser Permanente, these new systems will be formed from the existing health care community. The authors explain that there is no guidebook to develop and implement a coherent system by combing the existing professionals and institutions. Efforts will require considerable money and time. New personnel such as care coordinators and information technology staff will be required. As they state, "We have seen no model of a 'flat' accountable care organization--one requiring no increase in numbers or layers of staffing." And it will be difficult "to ensure that all changes are internally congruent."

Although most agree that there is a need for reinforcement of our primary care infrastructure, the authors provide evidence that the demands of care coordination under ACOs will cause a reduction in time spent on direct patient care. One study indicated that care coordination would require an additional 3.2 weeks per year of physician time.

The successful Kaiser and Group Health models took many decades to develop. You cannot suddenly take the existing fragmented delivery system and create competing, truly integrated systems in each community. That is what was wrong with Enthoven's managed competition model, and that is what is wrong with the incipient accountable care organization model.

The greatest risk of ACOs seems to be that Medicare will use them to help meet the political goal of "reducing entitlement spending," sacrificing the emphasis on quality because of cost considerations, and applying pressure to ratchet down spending. The latter is particularly a problem because private health systems are not very adept at identifying and ferreting out waste, rather they reduce spending primarily by impairing access. Selectively limiting Medicare spending will further compound access problems by a reduction in the numbers of willing providers, likely diminishing public support of Medicare.

In contrast, a single payer system is designed to reduce the abundance of identifiable waste, especially administrative, while improving both quality and access. It would be fine to continue with a demonstration project studying integration of health care to see if such delivery system reform could improve quality, but we don't want to allow that to displace the much needed financing and health system reforms of single payer. That's where we would have the greatest return on quality, access and costs.

November 14, 2012

The deficit busting Progressive Caucus People's Budget

http://cpc.grijalva.house.gov/index.cfm?sectionid=70

Budget of the Congressional Progressive Caucus Fiscal Year 2012

The People’s Budget eliminates the deficit in 10 years, puts Americans back to work and restores our economic competitiveness. The People’s Budget recognizes that in order to compete, our nation needs every American to be productive, and in order to be productive we need to raise our skills to meet modern needs.

Our Budget Eliminates the Deficit and Raises a $31 Billion Surplus In Ten Years
Our budget protects Social Security, Medicare and Medicaid and responsibly eliminates the deficit by targeting its main drivers: the Bush Tax Cuts, the wars overseas, and the causes and effects of the recent recession.

Our Budget Puts America Back to Work & Restores America’s Competitiveness
• Trains teachers and restores schools; rebuilds roads and bridges and ensures that users help pay for them
• Invests in job creation, clean energy and broadband infrastructure, housing and R&D programs

Our Budget Creates a Fairer Tax System
• Ends the recently passed upper-income tax cuts and lets Bush-era tax cuts expire at the end of 2012
• Extends tax credits for the middle class, families, and students
• Creates new tax brackets that range from 45% starting at $1 million to 49% for $1 billion or more
• Implements a progressive estate tax
• Eliminates corporate welfare for oil, gas, and coal companies; closes loopholes for multinational corporations
• Enacts a financial crisis responsibility fee and a financial speculation tax on derivatives and foreign exchange

Our Budget Protects Health
• Enacts a health care public option and negotiates prescription payments with pharmaceutical companies
• Prevents any cuts to Medicare physician payments for a decade

Our Budget Safeguards Social Security for the Next 75 Years
• Eliminates the individual Social Security payroll cap to make sure upper income earners pay their fair share
• Increases benefits based on higher contributions on the employee side

Our Budget Brings Our Troops Home
• Responsibly ends our wars in Iraq and Afghanistan to leave America more secure both home and abroad
• Cuts defense spending by reducing conventional forces, procurement, and costly R&D programs

Our Budget’s Bottom Line
• Deficit reduction of $5.6 trillion
• Spending cuts of $1.7 trillion
• Revenue increase of $3.9 trillion
• Public investment $1.7 trillion


President Bill Clinton


Jeffrey Sachs


The Economist


The Washington Post


Rachel Maddow


Economic Policy Institute


The Washington Post


Forbes

November 3, 2012

American College of Emergency Physicians: It's Time for Single-Payer

http://www.acepnews.com/index.php?id=2049&type=98&tx_ttnews[tt_news]=1564&cHash=da03e20e36

Winston Churchill’s iconic remark, reportedly issued at the dawn of America’s entry into World War II, is equally applicable to the present American health care debate and the crisis that spawned it. Regardless of whether you are elated or disappointed with June’s historic Supreme Court decision upholding the constitutionality of the Affordable Care Act, it is certainly no panacea for the problems facing U.S. health care. Even with the law intact, and despite its best intentions, it will still leave some 25 million uninsured, underinsure millions more, expand the corporatization of health care, and do little to control the escalating costs of care over the long term. So it’s clear we need to do the right thing: the creation of a national, universal, publicly funded health care system, free of the corrupting power of profit-oriented health insurance, and at the same time capable of passing constitutional muster. In short, the right thing is an expanded and improved Medicare-for-All program, otherwise known as single-payer.

Don’t be so shocked. For the last 30 years, we have tried all the alternatives, and none of them have worked. We have experimented with HMOs, PPOs, high-deductible health plans, health savings accounts, pay-for-performance, capitation, and disease management. These ideas have been promoted in various iterations, often with great fanfare, by public and private payers alike, yet none of them have shown long-term success at bending the cost curve. And the promise of the latest reforms du jour, such as Accountable Care Organizations and Patient-Centered Medical Homes, is speculative at best. American health care is unique among the world’s democracies in that it was never planned in terms of enabling legislation or explicit constitutional authority. As others have stated, our employer-based insurance system, which now covers about 160 million Americans, was an accident of history. Its lineage can be traced to FDR’s wage and price control policies during World War II, where employers were permitted to offer workers health insurance in lieu of higher wages as a job inducement. This benefit has evolved piecemeal into the Rube Goldberg complexity that is contemporary employer-sponsored health insurance, with some 1,200 private plans each doing the same things – medical underwriting, coordination of benefits, claims adjudication and denial, marketing, public relations, lobbying, litigating, and paying shareholder dividends and inflated CEO salaries while forcing individuals to pay a higher share of premiums, increased deductibles, expanded copays, or a combination of all three. Taken as a whole, private insurers’ activities are duplicative, inefficient, wasteful of scarce health care resources, conducive of job lock, and completely misdirected in supporting the 21st-century health care agenda that America needs and deserves.