The Concept is called Cape Care

CAPE CARE The Cape Care model

How do you spell relief?

For visionary Province-town physician Brian O’Malley, the letters spell Cape Care.

This proposed “single-payer” health insurance program, endorsed by 10 town meeting votes, could bring relief from worry for thousands of Cape Codders without year-round health insurance. It could also relieve doctors, dentists and clinics of the paperwork that consumes up to a third of every health-care dollar. Most important, it could relieve the whole system of the pressure of ever-rising costs.

The Cape Care working group is comprised of medical professionals and citizens, including Chamber of Commerce executive Wendy Northcross and Barnstable County Human Services chief Len Stewart, whose constituents struggle every year with health-care costs. They believe there must be a better way.

A simpler way.

The problem has been that, to many Americans, “single payer” sounds a little too close to “socialized medicine.” That’s why the state’s ambitious new plan to try to get all state residents under some form of medical insurance, starting Jan. 1, fell back on the old model: many different insurance products and managed-care companies assigned a piece of the pie, with employers still responsible for insuring the bulk of workers, and traditional payments for the poor through state social-service conduits.

It’s complicated. And much more expensive than it need be.

One example from the Cape Care talking points jumps out: Under a single-payer system, insurance company systems would still be needed to process much-simplified claims. The difference would be their profit motive and their cost. According to O’Malley, when the “Blues” process Medicare claims under contract to the government, they work on a 4 percent margin. On their own commercial policies, it’s 25 percent.

This patchwork of handlers is one reason America spends so much more for health care, yet doesn’t assure humane universal coverage. According to the journal Health Affairs, U.S. citizens paid $5,267 per person for health care in 2002, 53 percent more than any other industrialized country.

Cape Care doesn’t promise that a county-wide, single-payer setup would halve the cost. Its financial model assumes that the same money we and our employers pay now in insurance premiums, out-of-pocket costs, deductibles, etc. would fund the new plan. What Cape Care does promise is universal coverage.

O’Malley isn’t shy about calling it “a social insurance system.” We already have examples of these in our towns: public schools and the fire department.

We’re not at the point of fully endorsing the Cape Care model until we see more details about how it would work and how the costs would be distributed, but we commend the grassroots effort and the working group’s desire to build consensus.

Health returns as hot issue in '08 race

Candidates shift focus to preventive care

By Susan Milligan, Globe Staff | February 20, 2007

MANCHESTER, N.H. -- Healthcare, a major theme in the 1992 presidential campaign, has returned as a critical issue in the 2008 contest. But this time, contenders in both parties are placing new focus on preventive care as a way of improving public health and ultimately reducing the skyrocketing cost of medical care.

One presidential candidate wants to give earned days off to federal workers who exercise regularly and do not smoke, while another would press schools to ban junk food. Another candidate plans to reward people who undergo regular physicals and engage in healthy lifestyles with discounts in their health insurance premiums.

Mike Huckabee, former Republican governor from Arkansas, has led the charge for giving financial incentives -- including tax breaks and paid days off -- as rewards for healthy behavior.

Democrats Bill Richardson, governor of New Mexico, and John Edwards, former US senator from North Carolina, are proposing similar ideas. Other presidential contenders have raised the issue on the campaign trail in New Hampshire.

While specialists say spending money on preventive care -- such as lowering childhood obesity rates through healthy school lunches and offering incentives to quit smoking -- may not make much of a dent in overall healthcare costs, the candidates say that preventative efforts can reduce painful, expensive-to-treat illnesses such as lung cancer and diabetes.

"Everything about the whole system is upside down," Huckabee said in a recent interview. "Doctors are rewarded for treating sick people, not keeping them well."

Candidates say they are committed to tackling the biggest health crisis: finding coverage for the 47 million Americans who do not have health insurance, a widening gap that the candidates say increases health costs for everyone.

Edwards, the only major party candidate so far to offer a detailed healthcare plan, wants to make health insurance mandatory nationwide, as Massachusetts has done for its residents.

But unlike in previous campaigns when candidates have focused almost entirely on the uninsured, the early presidential candidates are talking about promoting wellness as a way to avoid the high costs of treating cancers, heart disease, and other ailments.

"I think you're going to see a prevention component of virtually every candidate's healthcare reform" plan, said Drew Altman , president of the Kaiser Family Foundation, a healthcare advocacy group. But he said the idea could not take the place of expanding health insurance coverage and controlling costs on a large scale.

"Nobody can pretend we can cover 47 million uninsured people without a huge outlay of money to do it," Altman said.

Among Democrats, Senator Barack Obama of Illinois and Senator Hillary Rodham Clinton of New York, who tried and failed to pass a universal healthcare plan when she was first lady in the 1990s, have discussed preventive care in their early campaign appearances in New Hampshire. Neither has issued a detailed plan, although Obama said he would unveil his in the coming weeks.

The issue is personal to Huckabee, who as Arkansas governor dramatically changed his eating habits and began exercising after a doctor diagnosed him with Type 2 diabetes in 2003.

Huckabee shed 110 pounds, competed four marathons, and instituted a Healthy Arkansas Initiative to encourage state residents to stop smoking, lose weight, and exercise more. Arkansas state employees now receive discounts on their health insurance premiums in exchange for practicing good health habits.

Richardson, who recently announced his candidacy for the Democratic presidential nomination, has already banned junk food in New Mexico schools, installed school-based clinics that provide mental health services as well as medical tests, and reinstituted physical fitness classes in schools where it had been eliminated.

As president, Richardson said in an interview, he would give tax breaks to businesses that grant company time and on-site gym equipment to employees who want to exercise, and he would reward schools that eliminated foods such as chips, soda, and candy from their cafeterias.

"I believe we've got to focus more on preventive care, especially with kids," Richardson said. "In the long range, you get better health for all Americans."

While no lawmaker can force someone to lose weight or stop smoking, Huckabee said, governments can provide incentives that lead to behavioral changes. If elected president , Huckabee said, he would also give tax incentives to businesses that promote healthy habits, and he would allow federal workers to earn time off for good health behavior, the positive alternative to sick days.

Although elementary and secondary schools are largely under local control, Richardson asserts that the federal government has some control over school nutrition guidelines and funds some of it, giving the government leverage when it comes to school menus .

Edwards's healthcare plan is meant to cover all Americans by 2012 either through their employers or through a series of new "health markets," nonprofit plans run by states or groups of states. The health markets, offered to individuals and businesses that do not provide their own health coverage plans, would include lower health insurance premiums to individuals who take advantage of free checkups and enroll in "healthy living programs," an Edwards campaign spokeswoman said.

Healthcare specialists welcomed the candidates' ideas on preventive care but said the concept would not help slow the escalating cost of overall healthcare.

"I think they all feel the need to say something about [healthcare] costs. And who can argue against the logic of prevention?" said John McDonough , executive director of the Massachusetts-based Health Care for All. "The problem is, how do you do it in a way that makes a difference?"

Conducting numerous medical tests, for example, may catch some ailments early, he said, but on a mass scale the price of the tests may drive healthcare costs even higher.

Alan Sager , a Boston University health policy and management professor, said he worried the candidates "are talking about costs in ways that are politically safe and largely irrelevant financially."

Fast-growing healthcare costs will not be contained, he said, until lawmakers grapple with the more politically difficult issues of hospital payments, drug prices, and doctors' fees.

Huckabee said wellness programs would not only lower medical costs, but also increase Americans' productivity at work.

"This isn't just a feel-better" plan," Huckabee said. "It has real economic advantages. And it's something I've not only talked about; I've lived it."

Cape & Islands Health Insurance for All Becoming More Than Wishful Thinking
To Your Good Health - An Independent Health Care Newsletter
Vol. 13, No. 1, Page 3, Winter 2005
An essay by Brian O'Malley, MD

Can you imagine how secure we each would feel, living in a place where we had affordable, comprehensive health insurance, with full freedom of choice of our health care providers? That this insurance covered all acute and chronic care, both inpatient and outpatient, rehabilitation, preventive services, medications, supplies, and even long-term care. And that your family, and all your neighbors, were also covered.

And that, whether you worked for a small or large business, or ran one, or were self-employed, or retired - you would be equally covered. That both you, and your health care providers, would be freed to concentrate on maintaining your health - rather than worrying about the adequacy of your coverage.

In fact, every resident of Cape Cod and the Islands would have just this insurance, if a proposed social insurance program, currently referred to as Cape Care, were to be developed and adopted here.

It would cover all residents of the Cape and Islands with a non-profit health insurance program, governed and administered locally. The existing network of health care providers here on the Cape and Islands would maintain their existing ownership and governance. This program would simply provide a uniform insurance coverage, much like Medicare, for the great majority of their patients.

For people without health care insurance for any part of the year, it would bring the security of access to regular health care services, without barriers. For employed people, the security of coverage, independent of changes in their jobs. For those with coverage, the security of controls on the runaway costs.

And for the health care providers of the region, relief from the enormous paperwork burden - estimated to consume one-third of our income. Relief from the arbitrary coverage denials, the frustrations of the referral and prior approval processes. Relief from the multiple contracting demands of competing insurers.

The reduction in administrative expenses would fund the expanded coverage. Because we already pay in many, many ways for health care-associated costs, new money will not be required. We currently pay an extravagant price for our health care- more, in fact, than any other population on earth. Unfortunately, much of this spending doesn't actually buy any health care. Despite years of patches - futile efforts to cover all the people who remain without health care coverage - this goal remains unaffordable and unattainable.

The administrative costs of the growing tangle of programs amount to as much as 39% of the health care dollar in Massachusetts. Simplified insurance programs - including Medicare itself, and national health insurance programs - operate at 5% or lower overhead. Reduction to this level would save, literally, hundreds of millions of dollars each year for the Cape and Islands. Current health care expenditures and entitlements would be channeled, creating a health care fund that pays for all care. Simplified claims processing and a uniform set of procedures will ensure low operating costs for the system.

In addition to the administrative costs, further savings are expected. Two aspects of this proposed model address significant failings in the current market-based approach. The power of medications to effectively treat disease is becoming limited by their runaway costs.

Practicing physicians confront this dilemma daily. A rational drug formulary, developed with expert guidance and local control, would help control these costs. Instead of forcing each consumer to find and negotiate their own best 'deal', volume discounting for both covered medications and Durable Medical Equipment would give us collective strength - and substantial savings.

Finally, the most important cost saving of all, is that achieved by improvement in our collective health by reducing the burden of illness. Preventive health care and early detection services form a cornerstone in this effort. Ongoing care for chronic illness by skilled providers who know the individual patient - does reduce the long-term complications of disease. These services would be covered, and their access facilitated for all.

Information systems would link health care providers. And, taking guidance from the findings of the many in-depth community surveys conducted by the human service agencies of our three water-surrounded counties, our resources would be focused on the key needs of our people. One of the driving concepts is to use coverage as a policy tool to provide the health care services particularly needed in our community.

Groups of dedicated and knowledgeable people have been meeting for almost a year now, shaping and clarifying its vision. The Lighthouse Health Access Alliance, composed of health and human service professionals working on Cape Cod, Martha's Vineyard and Nantucket, has provided an important supporting role in this development. Over the next several years we will begin interim steps to provide health insurance coverage to those with the greatest unmet needs.

We currently envision a 501(c)3 not-for-profit organizational structure, with a Board of Directors, and professional administration. A separate Health Policy Advisory Board, of community representatives and health care providers, would be responsible for setting standards, coverage, preventive health services, etc.

In coming months, we will continue to study the many implications of such a program for the health and the economy of our region. Each and every one of us is a stakeholder in this discussion and this process. It will be up to us to shape it according to our collective vision. We have only to imagine the sense of security that could be ours with Cape Care, and believe sufficiently in our ability to succeed, to motivate our labors.