Full Report from Dr. Elaine Fox on Health Care Discussion

A report by Dr. E. Fox of a meeting of 27 December 2008 at the Rogers Memorial Library in Southampton.

A list of 'Compelling Stories' and a Survey is appended to this report.

General Questions

There were 26 people in attendance including myself (host/note taker) and the moderator.
Summary of Responses from Discussion Questions:

The 26 answers as to the biggest problem in the health system varied around a main theme: private health insurance companies are the single biggest problem.

Private health insurance companies’ control of the health care system leads to increased costs and decreased care in order to assure their bottom line: profits. Inequality in health care is a direct result as the un- and under-insured pay more to make up the gap of low reimbursement by the profit-driven insurance companies. There is inequality according to whether insurance is employer based or not and according to geographic location with two- and three-fold cost differentials between states and even zip codes. Access to care as well as quality of care are unequal.
Hassle factors were viewed as purposeful on part of insurance companies so “consumers” are confused and do not know what they were reimbursed or how much of their deductible was met – adding up to more profits for insurance companies as patient claims are not honored in good faith. Special interest lobbying of elected officials who take money from the insurance companies is a big part of the problem as is the fact that many individuals have “portfolios” which include health insurance and drug companies from which they also profit. This leads many to a feeling of powerlessness as the insurance and drug industries have so deeply insinuated themselves into our lives beyond our own health care needs that there seems no way out. The lack of standard coverage between insurance company policies and what they cover adds even more complexity to the system at the cost of patients. Health insurance companies make medical decisions even when they reward tests and procedures rather than prevention, also to profit. The lack of mental health parity was cited by several in our group, attributable again to insurance companies’ profit-driven motives. Medicare Part D premiums have quadrupled since the law took effect, squeezing our aging population further, while the drug and insurance companies did great in the stock market; again this law was passed stealthily in the middle of the night, written for pharmaceutical industry profit at the expense of the health of the American people.
People are aware that they pay at least twice for health care – Medicare taxes and then increased Medicare premiums because of overpayment to subsidize the private Medicare plans; federal taxes that go to NIH R&D for drugs and then additional insurance premiums for Medicare Part D plans which do not even cover the inflated costs of all the drugs people need.

The question about how people choose a doctor or hospital and their information sources to do that got answered in some ways that are specific to our unique geographic region on the East End of Long Island.

The further east that one goes here, the less providers are actually available. This obviously limits choice of doctor. Answers ranged from those saying that there was no choice of MD here to those who said there was choice only if you could afford to pay “out of network”. Choice costs more. In the past, these decisions were based on the opinion of friends or other doctors, but now people can only choose according to their insurance. Some people said they relied on the “best doctors” lists in New York Magazine or Castle Connolly publications; others answered that the “best doctors”, when called, often did not take new patients or many insurance plans, so that choice, again, was moot as it is with other information sources such as asking a nurse who a good doctor is. There is no public access to information about providers that is transparent. One policy suggestion stressed that good, reliable providers were needed and their numbers could be increased by increasing the number and role of nurse practitioners.

The question about difficulty paying medical bills was broken down by the group into two parts – difficulty with paperwork hassles and coverage vs. actual financial difficulty with the bills. We took a vote by a show of hands (so some abstentions, etc.)  22 people said they needed help filing claims or an advocate because of confusion about coverage; only 2 people did not have this problem; 11 people said they had actual financial difficulty paying their bills; 9 did not.

There were 14 responses about how policy makers can address this problem. Eight out of those 14 responses were the same; i.e. 57% of our group said that we need, and policy makers should insist on, a “single payer” health care system for our country. Three other answers were stated differently but amount to the same input (“eliminate the middleman insurance companies”, “standard national health care for all”, “Medicare Part E”). That is, 11 of 14 attendees answering this question, a full 78 %, want policy makers to address the difficulty paying medical bills by setting up a single payer health care system for our country.

The group found this next question to be a faulty question. First of all, our current employer-based coverage is presented as a given, the default, suggesting that attendees must choose either that or a different private plan or a public plan like Medicare. In fact, only 6 out of 24 in our group even had employer based coverage. Secondly, the group did not feel that the insurance-exchange was a known quantity; the explanation in the Participant Guide was insufficient to understand how it would work. People like Medicare and the Participant Guide said only “a new public plan option”; it did not say it was like traditional Medicare. In fact, the change.gov website, in describing the Obama-Biden health care plan, said the new public plan would be based on FEHBP, not Medicare. This was a faulty misleading question that did not allow room for discussion of a single payer system which 78% of the group had already said they wanted!

Not all of the 6 people with employer-based coverage knew what their employer paid for health insurance. As to the employer’s role in a reformed health care system, there were 2 themes. The first was to take the employers out of it altogether; employers should have no role in paying for health insurance as it is a disincentive to business and a detriment to America’s competitiveness in the world market. The US auto industry was held up as an example. In the past, health insurance was used as a lure for employees to good companies; now the system is abused by employers like Wal-Mart. The second theme about the role of employers was that they should be responsible to support well care practices and even to incentivize preventive medicine.

The last two questions were taken as one and, again, were not felt to be good questions. 15 responded that they had gotten flu shots; 4 had not. But most of those who got the shot said they only did so because Medicare paid for it. As for mammograms and cholesterol screening, the group felt that people were aware of these recommended services but often did not receive them because of lack of access, especially due to cost – which brings up the question again of how we finance health care. In a single payer system, recommended preventive services would be covered for all Americans and that is the major public policy question. The group objected to the fact that dental care, basic oral health, was not mentioned with preventive services and was rarely covered by insurance. Similarly, screening for basic mental health problems was felt to be worthy of mention, especially substance abuse problems which are even considered separate from mental health by insurance companies. Other than assuring access and affordability, public policy can best address preventive services by public education starting in grammar school and by adequately addressing cultural resistance to certain services (culturally competent providers). As for promoting healthier lifestyles, public policy must address the obesity epidemic.

Our group added another question to discuss. “How important is it to you that private health insurance companies continue to play a central role in health care and be part of the new health care system?” Most people said it was not important to them, 4 people said to eliminate them entirely, 2 said they should have only minor roles, one said they were a “political reality” an implied they could not be challenged, and one said they provided competition for the public program that would be offered in the new system and that everyone would go to that public program. I pointed out that currently just the opposite was happening and that the private insurance companies were leaving the sick and costly patients to the public programs which were rapidly becoming underfunded. That will be a given in any competition between public programs and for-profit private health insurance because health care is not a true market. Public and private health insurance programs do not share the same goal; the first aims to assure health care, and the latter exists to make a profit. Every other industrialized country has some form of universal health care. None uses profitmaking, investor-owned insurance companies like ours to provide health care for all their people. We have an American system that works - Medicare. It’s not perfect, but Americans with Medicare are far happier than those with private insurance. Doctors face fewer hassles in getting paid, and Medicare has been a leader in keeping costs down. All the while, Medicare insures people with the greatest health care needs: people over 65 and the disabled. We should improve and expand Medicare to cover everyone. I discussed the single-payer “Medicare for All” system that is embodied in H.R. 676, the U.S. National Health Insurance Act, introduced by Congressman John Conyers and co-sponsored by 93 other members of Congress. H.R. 676 has more co-sponsors than any other health reform bill currently in Congress. State and local governments, civic/community organizations, political organizations, medical and faith organizations, and labor organizations – including 39 state AFL-CIO’s and over 400 local union organizations – have passed resolutions endorsing H.R. 676.

A list of these organizations can be found at http://www.pnhp.org/action/organizations_and_government_bodies_endorsing_hr_676_single_payer.php"

Recent polls and surveys show that 59% of physicians and 62% of Americans support Medicare for All. I am in that group of physicians and of Americans, and I made it clear to those in our Health Care Community Discussion that I, for one, was disturbed that the Participant Guidelines left no real room to discuss the Medicare for All option. How can it be “off the table” for discussion if a majority of Americans favor this solution to the health care crisis in our country? How can we believe in “change” if you won’t even discuss real meaningful change in how we finance health care in our country?

Case Histories

Compelling Story #1: Missy Croke founded the Southampton Village Volunteer Ambulance and was a vital part of our health care community. About 8 years ago, she had to give up her own health insurance - as a single mother she couldn’t afford it. Shortly thereafter she was diagnosed with a brain tumor, and the bills for the diagnostic tests cost Missy her home. She had to move in with her parents, sleeping on the living room sofa so her 14 y.o. daughter could have her own bed. Because we have no local neurosurgeon, Missy took her MRI’s into NY City to the “best” neurosurgeon who saw her in consultation initially even though she was uninsured. He told her she needed surgery but not to come back unless she brought $30,000 in cash with her. When she said she had no money, he replied, “You can eat at The Rainbow Room or you can eat at MacDonald’s.” So, Missy did not have surgery – she “opted” for alternative therapies. Last year, after an event that affected her level of consciousness, Missy finally underwent an urgent craniotomy at the closest tertiary care hospital 60 miles away. Post-operatively, before she was even walking, the hospital billing people came into her room telling her that she had to fill out papers for Medicaid and demanding documents she was not able to access. This continues now, 8 months after her surgery, adding huge stress for her and her family, making her own recovery much more difficult and causing her mother to have high blood pressure. Every month, she has to endure the stress of paperwork and documentation (now much more difficult because of memory problems after surgery) all over again. This very ill woman, herself having contributed so much to the health of our entire community, is being tormented, shamed, and impoverished by the health care system in our country.

Compelling Story #2: Mary Larson, who recently saw her 87 y.o. mother through end of life care, had to constantly advocate for her to make the system work. Mary’s mother had home health care insurance which she was able to use first at home, then in an assisted living facility, and finally in an Alzheimer's community. Mary literally spent days navigating phone trees with untrained claims assistants to claim her mother’s long term care insurance benefits. Mary even had to deal with the Insurance Commissioner of the State of Illinois (ins. co. headquarters) because she couldn't get them to pay her claims. Mary did this all from NY; her mother was in Minnesota. The NY Times later named this insurer, describing how many seniors just gave up trying to file for the long term care benefits due to them. The next ordeal was Medicare Part D. (The apartment manager where Mary’s mother lived said that one of her tenants actually shot himself after he finally got himself enrolled in Part D and found out he had to go through it all again for his wife who was in a nursing home.) At the end of her life, Mary’s mother’s premiums for Medicare Part B and D, and her out of pocket drug costs, were equal to her entire Social Security check. With no other source of income and no daughter to advocate for her, this elderly woman, like so many other Americans, would have died impoverished by our health care system.

Compelling Story #3: In order to get an individual policy to cover me and my family after my COBRA ran out, I had to sign a waiver agreeing that my policy would not cover me for anything having to do with a Caesarean section. This was apparently because I had a daughter who was born 5 or so years earlier by C-section, and the insurance company must have considered it a pre-existing condition. I didn’t know it then but I had joined ranks with the 5 million women of child-bearing age who have insurance policies that do not cover maternity costs. My policy was a high deductible one ($10,000), and I did not realize that, even without a C-section, it would probably cost me that much to have another baby. Two years later when it was time to have my second child, I had huge stress worrying about the added cost I would incur should I need a C-section to safely deliver my baby. My doctor did not even offer it, reasonable medical option though it was, because she knew I was not covered. Ultimately, the stress led to complications from my “normal” delivery, and the insurance company had to pay for the cost of my re-hospitalization – but this did not assuage the pain of my complications and days of being separated from my newborn and my family. No woman should have to face financial ruin while trying to deliver a healthy baby. Private insurance companies inflict (medically) unreasonable as well as unethical conditions on often unwitting patients (including doctors who are patients) desperate for coverage, all in the hopes of bigger and bigger profits. And, by selling policies that leave people underinsured, they increase the cost of health care for everyone.

Compelling Story #4: Reverend Alison Cornish said that her health insurance costs two or three times as much here as it would if she lived in a different state or zip code. She said that, as a minister, she cannot choose where she is called.

Compelling Story #5: Forced to buy individual insurance because her employer did not offer it, one person could only get coverage as follows: she had to pay $500/month for one year with no coverage and submit to a physical exam to rule out pre-exixting conditions. Insurance coverage would only begin after that one year had passed.

Compelling Story #6: Pre-approval of length of hospital stay varies widely between insurance policies and impacts tremendously on patient prognosis. The story told was about two patients in the same hospital room, one of whom had to worry about insurance renewal of his stay beyond 3 days and the other whose approval was good for a 14-day stay. The added stress on the patient who feared having to go home in 3 days because of no insurance coverage significantly decreased his rate of recovery.


Results from event at Rogers Memorial Library, Southampton, NY, 27 December 2008



a. Cost of health insurance 10

b. Cost of health care services 4

c. Difficulty finding health insurance
due to a pre-existing condition 2

d. Lack of emphasis on prevention 2

e. Quality of health care 1

f. All of the above 3


a. Community meetings like these 11
b. Traditional town hall meetings 1
c. Surveys that solicit ideas on reform 2
d. A White House Health Care Summit 4
e. Congressional hearings on C-SPAN 0
f. All of the above 5


a. More background information on problems in the health system 2
b. More information on solutions for health reform 12
c. More stories on how the system affects real people 0
d. More opportunities to discuss the issues 5
e. All of the above 2

Note: responses for each question total more than 20, because some people circled more than one answer.