Illegal Aliens and American Medicine

Madeleine Pelner Cosman, Ph.D., Esq.

The Seen and the Unseen

The influx of illegal aliens has serious hidden medical
consequences.We judge reality primarily by what we see. But what
we do not see can be more dangerous, more expensive, and more
deadly than what is seen.

Illegal aliens. stealthy assaults on medicine now must rouse
Americans to alert and alarm. Even President Bush describes
illegal aliens only as they are seen: strong physical laborers who
work hard in undesirable jobs with low wages, who care for their
families, and who pursue theAmerican dream.

What is unseen is their free medical care that has degraded and
closed some of America.s finest emergency medical facilities, and
caused hospital bankruptcies: 84 California hospitals are closing
their doors. .Anchor babies. born to illegal aliens instantly qualify
as citizens for welfare benefits and have caused enormous rises in
Medicaid costs and stipends under Supplemental Security Income
and Disability Income.

What is seen is the illegal alien who with strong back may
cough, sweat, and bleed, but is assumed healthy even though he and
his illegal alien wife and children were never examined for
contagious diseases.

By default, we grant health passes to illegal aliens. Yet many
illegal aliens harbor fatal diseases that American medicine fought
and vanquished long ago, such as drug-resistant tuberculosis,
malaria, leprosy, plague, polio, dengue, and Chagas disease.
What is seen is the political statistic that 43 million lives are at
risk in America because of lack of medical insurance. What is
unseen is that medical insurance does not equal medical care.
Uninsured people receive medical care in hospital emergency
departments (EDs) under the coercive Emergency Medical
Treatment and Active Labor Act of 1985 (EMTALA), which
obligates hospitals to treat the uninsured but does not pay for that
care. Also unseen is the percentage of the uninsured who are illegal
aliens. No one knows how many illegal aliens reside in America. If
there are 10 million, they constitute nearly 25 percent of the
uninsured. The percentage could be even higher.

The Emergency Medical Treatment and Active Labor Act
(EMTALA) requires every ED to treat anyone who enters with an
.emergency,. including cough, headache, hangnail, cardiac arrest,
herniated lumbar disc, drug addiction, alcohol overdose, gunshot
wound, automobile trauma, human immunodeficiency virus
(HIV)-positive infection, mental problem, or personality disorder.
The definition of emergency is flexible and vague enough to
include almost any condition. Any patient coming to a hospital ED
requesting .emergency. care must be screened and treated until
ready for discharge, or stabilized for transfer.whether or not
insured, .documented,. or able to pay. A woman in labor must
remain to deliver her child.

The hospital must have specialists on call at all times for all
departments that provide medical services and specialties within
the hospital.s capabilities. EMTALA is an unfunded federal
mandate. Government imposes viciously stiff fines and penalties
on any physician and any hospital refusing to treat any patient that a
zealous prosecutor deems an emergency patient, even though the
hospital or physician screened and declared the patient.s illness or
injury non-emergency. But government pays neither hospital nor
physician for treatments. In addition to the fiscal attack on medical
facilities and personnel,EMTALAis a handy truncheon with which
to pummel politically unpopular physicians by falsely accusing
them of violatingEMTALA.

High-technology EDs have degenerated into free medical
offices. Between 1993 and 2003, 60 California hospitals closed
because half their services became unpaid. Another 24 California
hospitals verge on closure. Even ambulances from Mexico come to
American EDs with indigents because the drivers know that
EMTALA requires accepting patients who come
That geographic limit has figured in many lawsuits.
Los Angeles County Trauma Care Network, built in 1983, was
one of America.s finest emergency medical response
organizations. Consisting of 22 hospitals, state-of-the-art
equipment, superior emergency physicians, surgeons, specialists,
nurses, technicians, it offered 365-day, round-the-clock
emergency care for people suffering life-threatening car crashes,
industrial accidents, urban crime, natural disasters such as
earthquake and wildfire, or terrorism. Now most trauma hospitals
have left the network, and so havemany emergency physicians and
surgeons. EMTALA contributed to the Trauma Care Network.s
loss of focus and loss of money.

Illegal aliens perpetrate much violent crime, the results of
which arrive at EDs. .Dump and run. patients, often requiring
tracheotomy or thoracotomy for stab or gunshot wounds, are
dropped on the hospital sidewalk or at the ED as the car speeds
away. Usually such incidents are connected to drugs and gangs.
Even if the hospital is not exclusively dedicated to trauma care,
EMTALAstill governs treatment.

While most people coming to EDs throughout the United States
are not poor and have medical insurance, cities such as LosAngeles
with large illegal alien populations, high crime, and powerful
immigrant gangs are losing their hospitals to the ravages of unpaid
care under EMTALA. In Los Angeles, 95 percent of outstanding
homicide warrants are for illegal aliens, as are 66 percent of fugitive
felony warrants. The notorious 18 Street Gang has 20,000
members, of whom 60 to 80 percent are illegal aliens, according to
the California Department of Justice and the Los Angeles Police
Department, respectively. The Lil. Cycos Gang, notorious for
murder, racketeering, and drugs in Los Angeles.s MacArthur Park,
was thought to be 60 percent illegals in 2002, and the percentage is
higher now. Francisco Martinez of the Mexican mafia ran the gang
while imprisoned for felonious reentry after deportation.
Illegal aliens move freely in crime sanctuary cities. In Los
Angeles, San Diego, Stockton, NewYork, Chicago, Miami,Austin,
and Houston, no hospital, physician, city employee, or police
officer is permitted to report immigration violators to the
Department of Homeland Security.s Bureau of Immigration and
Customs Enforcement (the old INS or Immigration and
Naturalization Service). Los Angeles Police Department
, begun in 1979 by Chief Daryl Gates, prohibits police
officers from .initiating police action where the objective is to
discover the alien status of a person.

As many as 10,000 illegals cross the 1,940-mile-long border
with Mexico each day. About 33 percent are caught. Many try
again, immediately. Authorities estimate about 3,500 illegal aliens
daily become permanent U.S. residents.at least 3 million
annually. EMTALA rewards them with extensive, expensive
medical services, free of charge, if they claim an emergency need
for care. Government welcomes illegal aliens by refusal to police
our borders, by reluctance to prosecute people who violate basic
American law, and by fervor to please those who abuse our
generosity and cynically ply our compassion against us.
American hospitals welcome .anchor babies.. Illegal alien
women come to the hospital in labor and drop their little anchors,
each of whom pulls its illegal alien mother, father, and siblings into
permanent residency simply by being born within our borders.
Anchor babies are , and instantly qualify for public welfare
aid. Between 300,000 and 350,000 anchor babies annually
become citizens because of the Fourteenth Amendment to the U.S.
Constitution: .All persons born or naturalized in the United States,
and subject to the jurisdiction thereof, are citizens of the United
States and the State wherein they reside.

In 2003 in Stockton, California, 70 percent of the 2,300 babies
born in San Joaquin General Hospital.s maternity ward were
anchor babies, and 45 percent of Stockton children under age six are
Latino (up from 30 percent in 1993). In 1994, 74,987 anchor
babies in California hospital maternity units cost $215 million and
constituted 36 percent of all Medi-Cal births. Now they account for
substantially more than half.

Consider the story of one illustrative family to show how reality
is the sum of the seen and the unseen. The Silverios from Stockton,
California, are illegal aliens seen as hard-laboring fruit-pickers with
family values. Cristobal Silverio came illegally from Oxtotilan,
Mexico, in 1997 and brought his wife Felipa, plus three children
aged 19, 12, and 8. Felipa, mother of the bride Lourdes (age 19),
gave birth to a new daughter, her anchor baby, named Flor. Flor was
premature, spent three months in the neonatal incubator, and cost
San Joaquin Hospital more than $300,000. Meanwhile, Lourdes
plus her illegal alien husband produced their own anchor baby,
Esmeralda. Grandma Felipa created a second anchor baby,Cristian.
Anchor babies are valuable. A disabled anchor baby is more
valuable than a healthy one. The two Silverio anchor babies
generate $1,000 per month in public welfare funding. Flor gets
$600 per month for asthma. Healthy Cristian gets $400. Cristobal
and Felipa last year earned $18,000 picking fruit. Flor and Cristian
were paid $12,000 for being anchor babies. This illegal alien
family.s annual income tops $30,000.

Cristobal Silverio, when drunk one Saturday night, crashed his
van. Though he had no auto insurance or driver.s license, and owed
thousands of dollars, he easily bought another van. Stockton Police
say that 44 percent of all .hit and runs. are by illegal aliens. AnchorBabies
had been seriously injured, the EMTALA-associated entitlement
would provide, as it did for the four-year rehabilitation of a
quadriplegic neighbor illegal alien. Rehabilitation costs
customarily do not fall under the title .emergency care,. but
partisans clamor to keep paraplegics in America rather than deport
them to more primitive facilities south of the border.
My mechanic employs an illegal I shall call Umberto, who said
when I came for my truck, .Dr. Cosman, my children lost their
shadows! Help me!.

What does this mean? Umberto has five disabled children: two
are autistic, two have attention deficit hyperactivity disorder, and
one has oppositional defiant disorder, with additional obsessivecompulsive
disorder. All take California government-supplied
medications, including Ritalin. The autistic children had
.shadows. or personal attendants, one per child, under the federal
Individuals with Disability Education Act of 1975 (IDEA). The
program provides a shadow, plus an .individual education
program. that cost about $30,000 per year per child. Umberto and
his wife dine out alone each week, thanks to California-provided
respite-care babysitters.

Illegal aliens have translators, advocates, and middlemen
supplied by immigrants. civil rights groups or by Medicaid.
MediCal in 2003 had 760,000 illegal aliens, up from 2002 when
there were 470,000. Supplemental Security Income is a nonmeans-
tested federal grant of money and food stamps. People
qualify easily. Scams, frauds, and cheats are rampant. In one clinic,
300 people diagnosed as .mildly mentally retarded. all had the
same translator, same psychiatrist, same symptoms, and similar
stipend. Fraud is an equal-opportunity employer that flouts
America.s generosity to the feeble, the crippled, and the poor.
Illegal aliens have powerful legal facilitators who litigate and lobby
for .Open Borders. and for welfare benefits for all who cross onto
America.s soil. Open Borders proponents imperil America.s
sovereignty by obliterating distinctions between legal immigrants
and illegal aliens, and between American citizens and all other
people of the hungry world.

Among the organizations directing illegal aliens into America.s
medical systems are the Ford Foundation-funded Mexican
American Legal Defense and Education Fund; the National
Immigration Law Center; the American Immigration Lawyers
Association; the American Bar Association.s Commission on
Immigration Policy, Practice, and Pro Bono; the Immigrant Legal
Resource Center; the National Council of George Soros.s
Open Society Institute; the Migration Policy Institute; the National
Network for Immigration and Refugee Rights; and the Southern
Poverty Law Center.And there are more.

Cases of .permanent disability. have burgeoned because its
definition is vague [a 12-month problem that interferes with work:
see Disability Income, 42 U.S.C. 423(d)-(1)(A), and Supplemental
Security Income, 42 U.S.C. 1382c(a)(3)(A)]; flexible, thanks to
the case; and individualistic, thanks to government
regulations. Mental, social, behavioral, and personality
disorders are included. More than 500,000 .mentally disabled.
children on psychotropic drugs for ADHD and ODD have
incentives to bad, bizarre behavior. Children.s disability
stipends are called .crazy money,. for crazy behavior.
Drug addiction and alcoholism are classified as diseases and
disabilities. Disability CodeDA&Ahad in 1983 only 3,000 stipend
recipients, but in 1994 exploded to 101,000. In 2003, between
250,000 and 400,000 got lump-sum grants of disability money via
SSI. When Linda Torres was arrested in Bakersfield, California,
with about $8,500 in small bills in a sack, the police originally
thought it was stolen money. It was her SSI lump sum award for her
disability: heroin addiction.

Immigrants on SSI, including legal aliens, refugees, and illegals
with fraudulent Social Security cards, numbered a mere 127,900
aliens (3.3 percent of recipients) in 1982. By 1992 the numbers
expanded to 601,430 entitled (10.9 percent of recipients). In 2003,
this figure was several million (about 25 percent of recipients).
The National Immigration Law Center (NILC) proudly
announced that it garnered for immigrants expensive cancer
treatments, prenatal care, and critical health services by means of its
litigation. Sometimes NILC worked in collaboration with lawyers
from the American Civil Liberties Union and the Mexican
American Legal Defense and Education Fund. Though the 1996
Welfare Reform Legislation reduced all welfare payments to all
recipients nationwide, NILC cleverly managed to restore to its
constituency of legal and illegal immigrants: $12 billion in
Supplemental Security Income, and more than $800 million in food
stamps. For many illegal aliens, America is land of the victim
and home of the entitled.

When my grandfather came to America, he first kissed the
ground of New York.s Ellis Island, then he stripped naked and
coughed hard. Every legal immigrant before 1924 was examined
for infectious diseases upon arrival and tested for tuberculosis.
Anyone infected was shipped back to the old country. That was
powerful incentive for each newcomer to make heroic efforts to
appear healthy.Today, immigrants must demonstrate that they
are free of communicable diseases and drug addiction to qualify for
lawful permanent residency green cards. Illegal aliens simply cross
our borders medically unexamined, hiding in their bodies any
number of communicable diseases.

Many illegals who cross our borders have tuberculosis. That disease
had largely disappeared from America, thanks to excellent hygiene
and powerful modern drugs such as isoniazid and rifampin.
TB.s swift, deadly return now is lethal for about 60 percent of those
infected because of new Multi-Drug Resistant Tuberculosis (MDRTB).
Until recently MDR-TB was endemic to Mexico. This
M is resistant to at least two major
antitubercular drugs. OrdinaryTB usually is cured in six months with
four drugs that cost about $2,000. MDR-TB takes 24 months with
many expensive drugs that cost around $250,000,with toxic side
effects. Each illegal with MDR-TB coughs and infects 10 to 30
people, who will not show symptoms immediately. Latent disease
explodes later.

TB was virtually absent inVirginia until in 2002, when it spiked
a 17 percent increase, but Prince William County, just south of
Washington, D.C., had a much larger rise of 188 percent. Public
health officials blamed immigrants. In 2001 the Indiana School of
Medicine studied an outbreak of MDR-TB, and traced it to
Mexican illegal aliens. The Queens, New York, health department
attributed 81 percent of new TB cases in 2001 to immigrants. The
Centers for Disease Control and Prevention ascribed 42 percent of
all new TB cases to .foreign born. people who have up to eight
times higher incidence. Apparently, 66 percent of all TB cases
coming to America originate in Mexico, the Philippines, and
Vietnam. Virulent TB outbreaks afflicted schoolteachers and
children in Michigan, adults and children in Texas, and
policemen in Minnesota. Recently TB erupted in Portland, Maine,
and Del Rey Beach, Florida.

Chagas disease, also called American trypanosomiasis or
.kissing bug disease is transmitted by the reduviid bug, which
prefers to bite the lips and face. The protozoan parasite that it
carries, , infects 18 million people annually in
Latin America and causes 50,000 deaths. This disease also
infiltrates America.s blood supply. Chagas affects blood
transfusions and transplanted organs. No cure exists. Hundreds of
blood recipients may be silently infected. After 10 to 20 years, up
to 30 percent will die when their hearts or intestines, enlarged and
weakened by Chagas, burst. Three people in 2001 received
Chagas-infected organ transplants.Two died.

Leprosy, a scourge in Biblical days and in medieval Europe, so
horribly destroys flesh and faces it was called the .disease of the
soul.. Lepers quarantined in leprosaria sounded noisemakers when
they ventured out to warn people to stay far away. Leprosy, Hansen.s
disease, was so rare inAmerica that in 40 years only 900 people were
afflicted. Suddenly, in the past three years America has more than
7,000 cases of leprosy. Leprosy now is endemic to northeastern
states because illegal aliens and other immigrants brought leprosy
from India, Brazil, the Caribbean, and Mexico.
Dengue fever is exceptionally rare in America, though
common in Ecuador, Peru, Vietnam, Thailand, Bangladesh,
Malaysia, and Mexico. Recently there was a virulent outbreak
of dengue fever inWebb County, Texas, which borders Mexico.
Though dengue is usually not a fatal disease, dengue hemorrhagic
fever routinely kills.

Polio was eradicated fromAmerica, but now reappears in illegal
immigrants, as do intestinal parasites. Malaria was obliterated,
but now is re-emerging inTexas. About 4,000 children under age
five annually in America develop fever, red eyes, .strawberry
tongue,. and acute inflammation of their coronary arteries and
other blood vessels because of the infectious malady called
Kawasaki disease. Many suffer heart attacks and sudden death.
Hepatitis A, B, and C, are resurging. Asians number 4
percent of Americans, but account for more than half of Hepatitis B
cases. Why inoculate American newborns for Hepatitis B when
most infected persons areAsians?

Tough medicine could end the cataclysm in American
medicine. I suggest the acronym CRAG for four critical actions to
reclaim America.s EDs; to restore medicine.s proud scientific
excellence and profitability; and to protect Americans against
bacterial, viral, parasitic, and fungal infectious diseases that illegal
aliens carry across our borders.

Prevent illegal entry with fences,
high-tech security devices, and troops re-deployed from Germany
and South Korea. Deport illegal aliens. Homeland Security.s
Immigration and Customs Enforcement has a division of Detention
and Removal dedicated to deportation. It is hobbled by the
powerful Executive Office for Immigration Review (EOIR), the
Department of Justice court system that consists of the U.S.
Immigration Court (USIC) plus an appellate court, the Board of
Immigration Appeals (BIA). The equation EOIR = USIC + BIA
usually provides amnesty for the illegal alien, plus another level of
appeal against deportation in federal circuit court.
Internment and deportation are politically incorrect. But
America.s inadequate federal border enforcement permits massive
daily border penetrations that violate the integrity of our medicine
and our national security.

.We must overturn the
misinterpretation of the Fourteenth Amendment to the U.S.
Constitution. The Constitution grants citizenship to all persons
born or naturalized in the United States and .
.. An illegal alien mother is subject to the
jurisdiction of her country. The baby of an illegal alien mother
also is subject to that home country.s jurisdiction.
When the Fourteenth Amendment was ratified, its purpose was
to assure rights of freedom and citizenship to newly emancipated
Negro citizens. American Indians, however, were excluded from
American citizenship because of their tribal jurisdiction. Also not
subject to American jurisdiction were foreign visitors,
ambassadors, consuls, and their babies born here. For citizenship,
the person was required to submit to complete, exclusive American
jurisdiction, owing allegiance to no other nation.
Long ago the Supreme Court correctly confirmed this restricted
interpretation of citizenship in the so-called .Slaughter-House
cases. [83 US 36 (1873)] and in [112 US 94 (1884)].
In , the phrase .subject to its jurisdiction.
excluded from its operation .children of ministers, consuls, and
citizens of foreign states born within the United States.. In , the
American Indian claimant was born in America, but considered not
anAmerican citizen because the law required him to be .not merely
subject in some respect or degree to the jurisdiction of the United
States, but completely subject to their political jurisdiction and
owing them direct and immediate allegiance.. To obtain
citizenship, an American Indian had to separate from his tribe and
be accepted by the United States as a citizen. A special act of
Congress was needed to grant full citizenship to American Indians.
The CitizensAct of 1924, codified in 8USCS§1401, provides that:
The following shall be nationals and citizens of the United
States at birth:
(a) a person born in the United States and subject to
the jurisdiction thereof;
(b) a person born in the United States to a member of
an Indian, Eskimo, Aleutian, or other aboriginal
tribe..

Congress by legislation has the right to create uniform rules on
naturalization, and to create dual citizenship and similar variations
upon .jurisdiction.. We must be vigilant against congressmen
voting to extend the list of those born here to include illegal aliens
or other lawbreakers, conferring American citizenship and its
generous social and medical benefits on babies born to criminals. It
is irrelevant that some lawbreakers are hard-working women
willing to do hard jobs for low pay, or that they are wives,
daughters, cousins, lovers, or concubines of men willing to do
America.s hard work. Gravid wombs should not guarantee free
medical care and instant infant citizenship in America. We must
reestablish the original limits on citizenship, and remove incentives
for indigent Mexicans and others to break America.s immigration
law. Proud legal immigrants applaud order, reason, and law.
. Punish it. This will
anger devotees of illegal aliens who believe that the Constitution
guarantees them civil rights that trump American administrative,
civil, and criminal laws.
. We must choose either to surrender
medicine to illegal aliens, or to fight illegal aliens. Surrender to
illegal aliens is surrender to collectivist America: land of moral
ambiguity and home of pacifist appeasement.

(editors note: one must look at all sides of an issue and get good data to make good decisions). The following is from http://www.pbs.org/newshour/indepth_coverage/health/uninsured/whoaretheuninsured.html
Click on to read the article. The last two paragraphs are telling:

Hoffman said that the idea that the growth of the uninsured rate is being fueled by immigrants is myth. "The numbers just don't support that," she said. "The large majority of the uninsured are U.S. citizens. While immigrants and the undocumented are less likely to have health insurance, there just aren't enough of them to make a difference in the overall rate."
But Fronstin disagreed. He said that his research found that immigration accounted for about 85 percent of the increase in uninsured rates between 1998 and 2003.

FAQ REGARDING NATIONAL HEALTH INSURANCE IN THE UNITED STATES

The following is important information from a physicians group (Physicians for A National Health Program) regarding national or universal health care in the U.S.......It is provided to allow us as "future thinkers" to look at the big picture, compare data, and then provide leadership.


Is national health insurance ‘socialized medicine’?
No. Socialized medicine is a system in which doctors and hospitals work for and draw salaries from the government. Doctors in the Veterans Administration and the Armed Services are paid this way. The health systems in Great Britain and Spain are other examples. But in most European countries, Canada, Australia and Japan they have socialized health insurance, not socialized medicine. The government pays for care that is delivered in the private (mostly not-for-profit) sector. This is similar to how Medicare works in this country. Doctors are in private practice and are paid on a fee-for-service basis from government funds. The government does not own or manage medical practices or hospitals.
The term socialized medicine is often used to conjure up images of government bureaucratic interference in medical care. That does not describe what happens in countries with national health insurance where doctors and patients often have more clinical freedom than in the U.S., where bureaucrats attempt to direct care.

Won’t this raise my taxes?
Currently, about 60% of our health care system is financed by public money: federal and state taxes, property taxes and tax subsidies. These funds pay for Medicare, Medicaid, the VA, coverage for public employees (including police and teachers), elected officials, military personnel, etc. There are also hefty tax subsidies to employers to help pay for their employees’ health insurance. About 20% of health care is financed by all of us individually through out-of-pocket payments, such as co-pays, deductibles, the uninsured paying directly for care, people paying privately for premiums, etc. Private employers only pay 21% of health care costs. In all, it is a very “regressive” way to finance health care, in that the poor pay a much higher percentage of their income for health care than higher income individuals do.
A universal public system would be financed in the following way: The public funds already funneled to Medicare and Medicaid would be retained. The difference, or the gap between current public funding and what we would need for a universal health care system, would be financed by a payroll tax on employers (about 7%) and an income tax on individuals (about 2%). The payroll tax would replace all other employer expenses for employees’ health care, which would be eliminated. The income tax would take the place of all current insurance premiums, co-pays, deductibles, and other out-of-pocket payments. For the vast majority of people, a 2% income tax is less than what they now pay for insurance premiums and out-of-pocket payments such as co-pays and deductibles, particularly if a family member has a serious illness. It is also a fair and sustainable contribution.
Currently, 47 million people have no insurance and hundreds of thousands of people with insurance are bankrupted when they have an accident or illness. Employers who currently offer no health insurance would pay more, but those who currently offer coverage would, on average, pay less. For most large employers, a payroll tax in the 7% range would mean they would pay slightly less than they currently do (about 8.5%). No employer, moreover, would gain a competitive advantage because he had scrimped on employee health benefits. And health insurance would disappear from the bargaining table between employers and employees.Of course, the biggest change would be that everyone would have the same comprehensive health coverage, including all medical, hospital, eye care, dental care, long-term care, and mental health services. Currently, many people and businesses are paying huge premiums for insurance so full of gaps like co-payments, deductibles and uncovered services that it would be almost worthless if they were to have a serious illness.

Isn’t a payroll tax unfair to small businesses?
The payroll tax means a cost increase for businesses that are not currently insuring their workers. However, it is much less than they would pay at present for adequate coverage for themselves and their workers. For most small (and large) businesses already providing coverage, the payroll tax will mean substantial savings.

Won’t this result in rationing like in Canada?
The U.S. already rations care. Rationing in U.S. health care is based on income: if you can afford care, you get it; if you can’t, you don’t. A recent study by the prestigious Institute of Medicine found that 18,000 Americans die every year because they don’t have health insurance. Many more skip treatments that their insurance company refuses to cover. That’s rationing. Other countries do not ration in this way.
If there is this much rationing, why don’t we hear about it? And if other countries ration less, why do we hear about them? The answer is that their systems are publicly accountable, and ours is not. Problems with their health care systems are aired in public; ours are not. For example, in Canada, when waits for care emerged in the 1990s, Parliament hotly debated the causes and solutions. Most provinces have also established formal reporting systems on waiting lists, with wait times for each hospital posted on the Internet. This public attention has led to recent falls in waits there.
In U.S. health care, no one is ultimately accountable for how the system works. No one takes full responsibility. Rationing in our system is carried out covertly through financial pressure, forcing millions of individuals to forego care or to be shunted away by caregivers from services they can’t pay for.
The rationing that takes place in U.S. health care is unnecessary. A number of studies (notably a General Accounting Office report in 1991 and a Congressional Budget Office report in 1993) show that there is more than enough money in our health care system to serve everyone if it were spent wisely. Administrative costs are at 31% of U.S. health spending, far higher than in other countries’ systems. These inflated costs are due to our failure to have a publicly financed, universal health care system. We spend about twice as much per person as Canada or most European nations, and still deny health care to many in need. A national health program could save enough on administration to assure access to care for all Americans, without rationing.

Who will run the health care system?
There is a myth that with national health insurance the government will make the medical decisions. But in a publicly financed, universal health care system, medical decisions are left to the patient and doctor, as they should be. This is true even in the countries like the U.K. and Spain (or in U.S. systems like the VA) that have socialized medicine.
In a public system, the public has a say in how it’s run. Cost containment measures are publicly managed at the state level by elected and appointed agencies that represent the public. This agency decides on the benefit package and negotiates doctor fees and hospital budgets. It also is responsible for health planning and the distribution of expensive technology. Thus, the total budget for health care is set through a public, democratic process. But clinical decisions remain a private matter between doctor and patient.

What about medical research?
Much current medical research is publicly financed through the National Institutes of Health. Under a universal health care system this would continue. For example, a great deal of basic drug research, for example, is funded by the government. Drug companies are invited in for the later stages of “product development,” the formulation and marketing of new drugs. AZT for HIV patients is one example. The early, expensive research was conducted with government money. After the drug was found to be effective, marketing rights went to the drug company.
Medical research does not disappear under universal health care system. Many famous discoveries have been made in countries with national health care systems. Laparoscopic gallbladder removal was pioneered in Canada. The CT scan was invented in England. The treatment for juvenile diabetes by transplanting pancreatic cells was developed in Canada.
It is also important to note that studies show that, in the U.S., the number of clinical research grants declines in areas of high HMO penetration. This suggests that managed care increasingly threatens clinical research. Another study surveyed medical school faculty and found that it was more difficult to do research in areas where high HMO penetration has enforced a more business-oriented approach to health care.
Finally, it appears that the increasing commercialization of research is beginning to slow innovation. Drug firms’ increasing reliance on contract research organizations (and for-profit ethical-review boards) has coincided with a sharp drop in innovative new drugs and a spate of “me-too” drugs - minor variations on old drugs that offer little benefit other than extended patent life.

Won’t this just be another bureaucracy?
The United States has the most bureaucratic health care system in the world. Over 31% of every health care dollar goes to paperwork, overhead, CEO salaries, profits, etc. Because the U.S. does not have a unified system that serves everyone, and instead has thousands of different insurance plans, each with its own marketing, paperwork, enrollment, premiums, and rules and regulations, our insurance system is both extremely complex and fragmented.
The Medicare program operates with just 3% overhead, compared to 15% to 25% overhead at a typical HMO. Provincial single-payer plans in Canada have an overhead of about 1%.
It is not necessary to have a huge bureaucracy to decide who gets care and who doesn’t when everyone is covered and has the same comprehensive benefits. With a universal health care system we would be able to cut our bureaucratic burden in half and save over $300 billion annually.
How will we keep costs down if everyone has access to comprehensive health care?
People will seek care earlier when chronic diseases such as hypertension and diabetes are more treatable. We know that both the uninsured and many of those with skimpy private coverage delay care because they are afraid of health care bills. This will be eliminated under such a system. Undoubtedly the costs of taking care of the medical needs of people who are currently skimping on care will cost more money in the short run. However, all of these new costs to cover the uninsured and improve coverage for the insured will be fully offset by administrative savings.
In the long run, the best way to control costs is to improve health planning to assure appropriate investments in expensive, high-tech care, to negotiate fees and budgets with doctors, hospital and drug companies, and to set and enforce a generous but finite overall budget.

How will we keep doctors from doing too many procedures?
This is a problem in any system that reimburses physicians on a fee-for-service basis. In today’s health system, another problem is physicians doing too little for patients. So the real question is, “How do we discourage both overcare and undercare?”
One approach is to carefully control new capital expenditures. Once a hospital or imaging center purchases a multimillion-dollar CT scanner, it will try to generate enough scans to pay off the fixed cost. Explicit health planning should be done to assure that expensive machines and facilities are sited where they are needed and not where they are redundant and likely to generate overuse.
Another approach is to compare physicians’ use of tests and procedures to their peers with similar patients. A physician who is “off the curve” will stand out. A related approach is to set spending targets for each specialty. This encourages doctors to be prudent stewards and to make sure their colleagues are as well, because any doctor doing unnecessary procedures will be taking money away from colleagues.
In addition, expert guidelines by groups like the American College of Physicians, etc., can help shape professional standards - which will certainly change over time as treatments change. This really gets to the heart of “how do you improve the quality of health care,” which is a longer topic. Suffice it to say that single-payer, universal coverage provides a framework for achieving thoughtful quality improvement.

What will happen to physician incomes?
On the basis of the Canadian experience under national health insurance, we expect that average physician incomes should change little. However, the income disparity between specialties is likely to shrink.
The increase in patient visits when financial barriers fall under a single-payer system will be offset by resources freed up by a drastic reduction in administrative overhead and physicians’ paperwork. Billing would involve imprinting the patient’s national health program card on a charge slip, checking a box to indicate the complexity of the procedure or service, and sending the slip (or a computer record) to the physician-payment board.

How will we keep drug prices under control?
When all patients are under one system, the payer wields a lot of clout. The VA gets a 40% discount on drugs because of its buying power. This “monopsony” buying power is the main reason why other countries’ drug prices are lower than ours. This also explains the drug industry’s staunch opposition to single-payer national health insurance.

Why shouldn’t we let people buy better health care if they can afford it?
Whenever we allow the wealthy to buy better care or jump the queue, health care for the rest of us suffers. If the wealthy are forced to rely on the same health system as the poor, they will use their political power to assure that the health system is well funded. Conversely, programs for the poor become poor programs. For instance, because Medicaid doesn’t serve the wealthy, the payment rates are low and many physicians refuse to see Medicaid patients. Calls to improve Medicaid fall on deaf ears because the beneficiaries are not considered politically important. Moreover, when the wealthy jump the queue, it results in longer waits for others. Studies in New Zealand and Canada show that the growth of private care in parallel to the public system results in lengthening waits. Additionally, allowing the development of a parallel, private system for the wealthy means the creation of a permanent lobby for underfunding public care. Such underfunding increases the demand for private care.

What will be covered?
All medically necessary care would be funded through the single payer, including doctor visits, hospital care, prescriptions, mental health services, nursing home care, rehab, home care, eye care and dental care. We also advocate a sharp increase in public health funding.

What about alternative care, will it be covered?
Alternative care that is proven in clinical trials to be effective will be covered. For example, spinal manipulation for some lower back conditions would be covered, but not chiropractic care of the neck (which is unproven and possibly dangerous). Antioxidant vitamins would be covered for people with macular degeneration, but not for the general population (where they appear to be harmful). In general, coverage decisions will be made by the health care planning board or another public body. New kinds of treatments will be added to the benefits package over time as they are shown to be effective, including “alternative” treatments. Similarly, ineffective or harmful care can be removed from the benefits package, such as high dose epo for cancer.

Can a business keep private insurance if they choose?
Yes and no. Everyone has to be included in the new system for it to be able to control costs, reduce bureaucracy, and cover everyone. In Canada, businesses can purchase additional private insurance that covers things not covered by the national plan (e.g. private rooms, orthodontia, etc.). However, we support a comprehensive benefit package for the single-payer program that would eliminate the need (and most demand) for supplemental coverage.
Insurance companies would not be allowed to offer the same benefits as the universal health care system, a restriction contained in the traditional Medicare program. Allowing such duplication of coverage weakens and eventually destabilizes the health care system. It undermines the principle of pooling the risk. Health care systems act as universal insurers. At any one time the healthy help pay for those who are ill. If private insurers are allowed to cherry-pick the healthy, leaving the public health care system with the very sick, the system will fail.
This, in fact, is what we see happening to Medicare through the Medicare Advantage program. The government pays Medicare HMOs 13% more than it pays traditional Medicare, yet the HMOs care for a healthier mix of seniors. This is leading to privatization of Medicare and funding shortfalls for the traditional Medicare program.

What will happen to all of the people who work for insurance companies?
The new system will still need some people to administer claims. Administration will shrink, however, eliminating the need for many insurance workers, as well as administrative staff in hospitals, clinics and nursing homes. More health care providers, especially in the fields of long-term care, home health care, and public health, will be needed, and many insurance clerks can be retrained to enter these fields. Many people now working in the insurance industry are, in fact, already health professionals (e.g. nurses) who will be able to find work in the health care field again. But many insurance and health administrative workers will need a job retraining and placement program. We anticipate that such a program would cost about $20 billion, a small fraction of the administrative savings from the transition to national health insurance.
PNHP has worked with labor unions and others to develop plans for a jobs conversion program with would protect the incomes of displaced clerical workers until they were retrained and transitioned to other jobs.

How will we contain costs with the population aging?
Studies show that aging of the population accounts for only a small fraction of the increases in health costs. Japan and Europe are already facing the problem of an aging population head-on and are doing fine. They have a much higher percentage of elderly than we do, and still spend far less on health care.
The best way to approach this is to regard it as a societal problem, one that needs a solution with everyone in mind. Germany and Japan recently adopted single-payer long-term care systems to cover the long-term care needs of the elderly at home and in specialized housing. Germany is pioneering a program that pays family members to care for the elderly at home.

What about ERISA? Doesn’t it stand in the way of states implementing universal health care plans?
No. ERISA (the Employees Retirement Income Security Act) prevents a state from requiring that a self-insured employer provide certain benefits to their employees. However, a single-payer plan would not mandate the composition of employer benefit plans - it would replace them with a new system that would essentially be “Medicare for all.” The state would require employers to pay a payroll tax into the health care trust fund, which is clearly legal.

How will the Health Planning Board operate?
A health planning board would be a public body with representatives of patients and medical experts. The representatives would decide on what treatments, medications and services should be covered, based on community needs and medical science, and allocate capital for major new investments based on assessments of where need is greatest.
Since we could finance a fairly good system, like the Norwegian, Danish or Swedish system, with the public money we are already spending (60% of health costs), why do we need to raise the additional 40% (from employers and individuals)?
There are three reasons why the U.S. health care system costs more than other systems throughout the world. One, we spend two to three times as much as they do on administration. Two, we have much more excess capacity of expensive technology than they do (more CT scanners, MRI scanners, and surgery suites). Three, we pay higher prices for services than they do.
There is no doubt that we do not need to spend more than we currently spend to cover comprehensive care for everyone. But the initial transition to a universal system would be very disruptive if we spent less. That is because we have a tremendous medical infrastructure, some of which would likely retain its excess capacity during the transition phase. Secondly, we would likely retain salaries for health professionals at their current levels. Thirdly, we would cover much more than most other countries do by including dental care, eye care, and prescriptions. And for these reasons we would need the extra 40% that we are already spending - but NOT more. We could cover all the uninsured and improve coverage for those who have skimpy coverage for the same amount we are currently spending!

How much of the health care dollar is publicly financed?
Over sixty percent (60.5 percent) of health spending in the U.S. is funded by government. Official figures for 2005 peg government’s share of total health expenditure at 45.4 percent, but this excludes two items:
1. Tax subsidies for private insurance, which cost the federal treasury $188.6 billion in 2004. These predominantly benefit wealthy taxpayers.
2. Government purchases of private health insurance for public employees such as police officers and teachers. Government paid private insurers $120.2 billion for such coverage in 2005: 24.7 percent of the total spending by U.S. employers for private insurance.
So, government’s true share amounted to 9.7 percent of gross domestic product in 2005, 60.5 percent of total health spending, or $4,048 per capita (out of total expenditure of $6,697).
By contrast, government health spending in Canada and the U.K. was 6.9 percent and 7.2 percent of gross domestic product respectively (or $2,337 and $2,371 per capita). Government health spending per capita in the U.S. exceeds total (public plus private) per capita health spending in every country except Norway, Switzerland and Luxembourg.
(Source: Himmelstein and Woolhandler, “Competition in a publicly funded healthcare system” BMJ 2007; 335:1126-1129 [1 December] and Woolhandler and Himmelstein, Health Affairs, 2002, 21(4), 88, “Paying for National Health Insurance - And Not Getting It.”)

Why not MSAs/HSAs?
Medical savings accounts (MSAs) and similar options such as health savings accounts (HSAs) are individual accounts from which medical expenses are paid. Once the account is depleted and a deductible is met, medical expenses are covered by a catastrophic plan, usually a managed care plan.
Individuals with significant health care needs would rapidly deplete their accounts and then be exposed to large out-of-pocket expenses; hence they would tend to select plans with more comprehensive coverage. Since only healthy individuals would be attracted to the MSAs/HSAs, higher-cost individuals would be concentrated in the more comprehensive plans, driving up premiums and threatening affordability. By placing everyone in the same pool, the cost of high-risk individuals is diluted by the larger sector of relatively healthy individuals, keeping health insurance costs affordable for everyone.
Currently, HSAs offer substantial tax savings to people in high-income brackets, but little to families with average incomes, and thus serve as a covert tax cut for the wealthy.
Moreover, MSA/HSA plans discourage preventive care, which generally would be paid out-of-pocket, and do nothing to restrain spending for catastrophic care, which accounts for most health costs. Finally, HSAs/MSAs discriminate against women, whose care costs, on average, $1,000 more than men’s annually. Hence, on the MSA/HAS plan, the average woman pays $1,000 more out-of-pocket than her male counterpart.

Why not use tax subsidies to help the uninsured buy health insurance?
The major flaw of tax subsidies is that they would be used to help purchase plans in our current fragmented system. The administrative inefficiencies and inequities that characterize our system would be left in place, and we would continue to waste valuable resources that should be going to patient care instead. Moreover, even with tax subsidies, moderate- and lower-income individuals would be unable to afford good coverage, leaving them with modest benefits and high cost-sharing that would often make health care unaffordable. Instead of perpetuating our current inequities, tax policies should be used to create equity in contributions to a system in which everyone is assured access to comprehensive beneficial services.
If the tax subsidies are granted to individuals, employers would be motivated to drop their coverage, and most individuals covered would have merely rotated from employer coverage to individual coverage. The net reduction in the numbers of uninsured would be small. If the tax subsidies are granted to employers, a major shift in funding passes from employers to taxpayers without significant improvements efficiency or fairness. We can use the tax system to create equity in the way we fund health care, but we should also expect equity and efficiency in allocation of our health care resources. Distributing health resources according to human needs is possible only if we eliminate the private health plans and establish a publicly administered system.

Won’t competition be impeded by a universal health care system?
Advocates of the “free market” approach to health care claim that competition will streamline the costs of health care and make it more efficient. What is overlooked is that past competitive activities in health care under a free market system have been wasteful and expensive, and are the major cause of rising costs.
There are two main areas where competition exists in health care: among the providers and among the payers. When, for example, hospitals compete they often duplicate expensive equipment in order to corner more of the market for lucrative procedure-oriented care. This drives up overall medical costs to pay for the equipment and encourages overtreatment. They also waste money on advertising and marketing. The preferred scenario has hospitals coordinating services and cooperating to meet the needs of their communities.
Competition among insurers (the payers) is not effective in containing costs either. Rather, it results in competitive practices such as avoiding the sick, cherry-picking, denial of payment for expensive procedures, etc. An insurance firm that engages in these practices may reduce its own outlays, but at the expense of other payers and patients.

Why not make people who are higher risk pay higher premiums?
Experience-rated insurance requires higher risk people to pay higher premiums. This approach says that people who have had cancer in the past, or who have chronic conditions like diabetes and hypertension, or who have had dangerous exposures to substances like asbestos, must pay more because they are at higher risk of using health services. Experience rating allows insurance companies to cherry-pick the healthiest people and either refuse to insure the sickest or, what amounts to the same thing, charge prohibitively high rates. This approach makes no sense. The whole point of insurance is to spread the risk so that everyone is covered. If you raise premiums - and thereby exclude from coverage - those people unfortunate enough to be sick, you defeat the point of both insurance and the health care system. Genetic conditions, childhood diseases, accidents, injuries and income distribution (or how much equality there is in a society) play a much bigger role in people’s health than “individual lifestyle” factors. And we know that even for motivated patients, alcohol and tobacco cessation are difficult, and medical weight loss nearly impossible. We need public health, primary care and education programs to try to prevent disease, but punishing patients once they are ill is inhumane and counterproductive.
Community-rated health insurance is the socially fair approach. It spreads the risks evenly among all the insured. It removes the punitive element. It does not discriminate against the very sick, nor against those of us who are at higher risk because of our age (say, over 50) or our gender (reproductive-age females have higher health expenses than men, for obvious reasons).
Health care should be organized as a public service, like a fire department. A health system organized as a business is discriminatory and accountable to no one. At some point in our lives all of us will predictably need health care. Hence health insurance is unlike any other form of insurance; we all are involved.
Walter Reed Army Medical Center has been in the news lately for poor care and treatment of returning soldiers from Iraq. Won’t national health insurance have similar problems?
As we consider what we can learn from the Walter Reed Army Medical Center debacle with regard to government-run efforts, some clarifications should be made:
1. Walter Reed Army Medical Center is an Army hospital and is run by the Department of Defense. The VA hospitals are run by the Veterans Administration (Veterans Health Administration), a separate organization. The news media has clouded this fact and has led the public to presume that all government-run health efforts fail. The VA health system continues to receive the best quality scores of any segment of the U.S. health system, with the most satisfied patients. It beats the best HMOs in quality ratings, has a model information system, and focuses on primary care. It has led in addressing medical errors and in its application of AHRQ quality guidelines to both inpatients and outpatients. In 2004 it won the Baldridge Prize for quality and patient-safety improvements.
2. There is a lot we can learn from the Walter Reed disgrace. Its operation was outsourced to a Halliburton-connected company in 2002, over the objections of some Army medical personnel and leadership, with a subsequent drastic reduction in staff and loss of government employees with institutional experience. There was also some hanky-panky with the contracting process; when the government employees’ bid for the operations contract came in lower than the Halliburton company’s bid, the bids were “recalculated” to make the private company the lowest bidder.(This section was contributed by Dr. Anne Carroll.)

What about incremental reform of the health system?
As a matter of policy, PNHP expressly opposes many so-called gradual steps towards single-payer. Many well-meaning supporters often push these bills as “feasible steps” to move us towards single-payer, but the history of these kinds of health reform efforts - Hawaii in 1974, Massachusetts in 1988, Oregon in 1989, Tennessee in 1992, Minnesota in 1992, Maine in 2003, etc. - shows that despite their claims of pragmatism, incremental reforms have consistently failed for more than three decades. Incremental reforms cannot garner administrative savings and redirect them to care. Hence they always founder on the shoals of cost. In addition, these reforms distract attention from the economically realistic, if politically challenging, option of single-payer reform.

What happens to investor-owned hospitals under national health insurance (NHI)?
“The NHI program would compensate owners of investor-owned hospitals, group/staff model HMOs, nursing homes and clinics for the loss of their clinical facilities, as well as any computers and administrative facilities needed to manage NHI. They would not be reimbursed for loss of business opportunities or for administrative capacity not used by NHI. Investor-owned providers would be converted to nonprofit status. The NHI would issue long-term bonds to amortize the one-time costs of compensating investors for the appraised value of their facilities. These conversion costs would be offset by reductions in payments for capital that are currently folded into Medicare and other reimbursements.” (Physicians’ Proposal, JAMA, August 13, 2003.)

What proportion of health spending is for undocumented immigrants?
Very little. All foreign-born people, including immigrant workers who have legal status and who have lived in the U.S. for years, account for somewhat less than one-quarter of the uninsured, according to the Census Bureau. We do know that foreign-born people in the U.S. are, on average, healthier and utilize little health care - about half of the health care (per capita) of U.S.-born persons. Surprisingly this is true whether or not they have insurance. Immigrant children receive very little care, 74 percent less overall than other children. So, if the foreign born are less than one-quarter of the uninsured, only one-eighth of health spending on the uninsured is going to the foreign born, which translates into a tiny fraction of all U.S. health spending. In fact, most immigrants have health insurance coverage, and 30% of immigrants use no health care at all in the course of a year. Undocumented immigrants are politically unpopular and hence a convenient target, but they are not the cause of rising health care costs.

The insurance industry says that PNHP’s figures on administrative costs are outdated. Is this true?
PNHP has published a series of peer-reviewed studies over the past 20 years showing a steady increase in health administrative costs. While some aspects of administrative cost estimation (e.g. physicians’ billing costs) require special studies, others, such as insurance overhead, can be easily tracked from publicly available data. These figures show no evidence of a fall in administrative costs since our most recent (2003) comprehensive estimate that administration consumes at least 31% of U.S. health care spending.
Recently, right-wing “think tanks” have released studies claiming that Medicare’s administrative costs are far higher than the official 3% estimate. These estimates add to Medicare’s costs a share of the salaries of the President and members of Congress, the cost of running the Internal Revenue Service, etc. But none of these added costs would go away if Medicare were abolished, or up if Medicare were expanded to cover everyone. Most economists agree that such expenses should not be included in calculating Medicare’s overhead.
How much could the states save on administrative waste by adopting a statewide single-payer program?
Data on total health expenditures by state (excluding administrative spending) is available at: http://www.cms.hhs.gov/NationalHealthExpendData/05_NationalHealthAccountsStateHealthAccounts.asp
Estimates of state administrative costs (a few years old, but the best available) are in an article by Drs. David Himmelstein and Steffie Woolhandler from 2003.
Physicians for a National Health Program