Honest health care debate must include single payer
Chris Lowe
Many BlueOregon readers probably received the same e-mail letter on Friday May 8 that I got from Trent Lutz, the executive director of the Democratic Party of Oregon, concerning recently revealed activities of a GOP p.r. flack named Frank Luntz on Republican rhetorical and political strategies toward health care reform.
As Trent L.'s DPO letter points out a bit more politely, in a memo (warning, pdf link) made public by Politico.com Luntz goes into detail about how Republicans can and should whitewash anti-reform obstructionism with huge loads of rhetorical guano.
Trent was following up on commentary by Senator Jeff Merkley drawing attention to Luntz's memo on dailyKos, for which the senator deserves kudos. More detailed critical analysis has been provided by Dr. Don McCanne of Physicians for a National Health Program in his "Quote of the Day" feature. PNHP advocates single payer health system reform.
Trent Lutz's DPO letter went on to ask for financial contributions to the DPO because "President Obama and Democratic Leaders in Washington are tirelessly working together to reform our healthcare system." At this I balked.
Since "Democratic Leaders" in Washington are engaged in their own efforts to prevent full and honest debate over health care reform, I wrote back to Mr. Lutz objecting to this appeal, cc'd to a number of DPO and Multnomah County DP officials as well as some friends. Here is what I wrote:
From: Chris Lowe PCP Multnomah County Democratic Party [phone number left out here] member, Portland Jobs with Justice Healthcare Committee (speaking only for myself)
Dear Trent Lutz (or staff),I completely agree that Frank Luntz's disgusting dishonest memo is aimed at obstruction of health care reform pure and simple, built on lies and misrepresentations and falsely implying that the Republicans are against insurance company abuses when in fact what they stand for is the status quo.
If the message you were asking me to support was that the Rs are lying that they don't support the insurance companies, I would gladly contribute what little I could afford.
But you ask that I support the efforts of President Obama and "Democratic Leaders in Washington." The plain fact is that I don't support those efforts, with the exception of John Conyers, Bernie Sanders, and the hearty brave souls who back them.
Unfortunately most of the "Democratic Leaders in Washington" are also playing anti-democratic games, reflected in the exclusion by Senators Baucus, Kennedy, Schumer, Wyden and others of advocates a slngle payer reform approach from testimony and serious consideration. Yet that approach is supported by a majority of public opinion in repeated polls.
I am unwilling to support the Democratic Party leaders' current confused approach, which appears all too likely to produce a result favored by Big Insurance at great cost to the public purse but with poor effectiveness in achieving full, equitable, quality health care for all.
The main reason given by many who say they support single payer in principle but won't work for it in practice is that it is "politically unrealistic." Congressman Blumenauer made that statement at a public forum I attended in Portland on April 16, though it's not quite clear if he supports single payer even in principle, as Senator Merkley and President Obama have said they do.
Yet to a very large extent this argument about "political realism" is a short-circuit, a self-fulfilling prophecy which evades the substance of the healthcare crisis. If everyone who said they supported single payer in principle actually stood up for it in practice, it would entirely change the terms of the debate.
Imagine such a debate. We might or might not get single payer, immediately. But at minimum we'd be much more likely to get at least the strongest kind of public option, the strongest regulation of private insurance abuses, and not be negotiating against ourselves.
And we might actually get single payer. The reason why is that it is the only approach which can improve both cost-efficiency, lowering our massively bloated costs that derive from byzantine private insurance bureaucracy and billing practices plus their demand for huge profits, while increasing health-efficiency by including people who are excluded, denied, priced and deductibled out of needed care.
Only full, equal inclusion in care, not "coverage," can improve our health outcomes, which are shamefully worse than any other industrial countries on average, and even worse when we expose class and ethnicity-based health disparities hidden by average figures.
Instead, even public option advocates among Democratic officials are negotiating against themselves, and engaging in ridiculous debates with insurance lobbyists. Per the Oregonian: The insurance lobby will "accept" not discriminating against women in individual insurance in exchange for something else? Huh!? How insulting, and how revolting that Democrats treat this seriously. And this is only one such example of unethical pursuits of profit to which the insurers are admitting.
Yet the Democratic leadership and power-brokers are looking to approaches that will massively increase costs by increasing public subsidies for the private inefficiencies and profits of these same companies. Many proposals include forcing insurance on families whose own judgment is that they can't afford the prices charged for the lemon benefits offered, something President Obama opposed in his campaign but inexplicably seems to be contemplating now.
Will I support Democratic leaders and power-brokers in taking such a ridiculous, craven, self-defeating and immoral approach? No. As a grassroots Democrat, I demand that the party leadership actually lead and help pull together the political will to do what actually needs to be done.
When the Democratic party stands up for full, open, honest debate on healthcare in which the single payer option is fully explained to the public, given the respect it deserves, and various options are honestly compared in their capacity to cut costs and deliver quality effective care equally, with the "politically possible" question put off until after the alternatives are fully and honestly aired, then I will support the DP in promoting such debate and public education.
But support the current, half-assed, negotiate against ourselves, suppress discussion of the most substantively promising approach tack of the DP leadership and power-brokers? No way in hell.
yours for cost- and health-effective equal health care for all,
(aka single payer)Chris Lowe
The dishonesty of Democratic Leaders' approach to health care reform debate was of course on full display in Washington D.C. last week, with the arrests of the Single Payer Eight for "disruption of Congress" when they stood to protest the exclusion of even a single advocate of a single payer approach from testimony to the second of three "round-tables" on health care reform held by the Subcommittee on Healthcare of the Committee on Finance of the Senate, chaired by Senator Max Baucus (D Montana).
Over the weekend, Senator Charles Schumer of New York asked that at least one single payer advocate be included in the final round-table, to be held Tuesday May 12. Senator Baucus told Schumer that if he could get another committee member to join the request, it would be granted. Pro-single payer groups have been mobilizing calls to relevant senators.
There is an Oregon connection here, since Senator Ron Wyden serves both on the Finance Committee and its Healthcare Subcommittee. On Monday afternoon when I called, the phones as Senator Wyden's D.C. office were so busy that callers had to be put on hold, possibly because of efforts by advocates of full, honest and open debate to ask him to support Senator Schumer's request.
Notice that the issue here is not policy per se, but simply that the debate be full and open. It will be interesting to see what Tuesday's news says about whether Ron Wyden stood up for honest policy making, or will continue to support undemocratic suppression and exclusion of single payer arguments and ideas from official debates.
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May 11, '09
Well written Chris. I am not certain if I support single payer or not. I AM certian that the system is broken and wholesale reform is needed. some additional thoughts concerning the "talking points" from the GOP: 1. Single payer will result in healthcare rationing. It is fait acompli. What the folks in support of single payer need to develop is a credible line of response regarding HOW rationing will work and how it will not affect overall health for the general population. 2. Current healthcare is not "patient oriented". It is rather "disease oriented" or "third party payer (insurance) oriented". Figure out a way to engage the discussion from what is really occuring now and the argument is won. 3. single payer will have to come up with a great plan regarding how the general population is brought into the equation regarding individual responsibility in the care scenario. Currently we in the US abuse ourselves to the point of breaking down and then show up in the specialists' offices demanding 100% cure. Any other outcome is anethma. 4. Figure out how the trial lawyers will be kept at bay in single payer. The wolves preying on people via late night TV commercials and unsolicited e-mails need to be shut down if any healthcare reform is going to be effective.
I'm sure that there are other talking point rejoinders, but that is what comes to mind now. The ultimate goal is a workable and affordable healthcare system for the US and its people. It is not certain that single payer is that ultimate answer, but it should be included in the discussions.
May 11, '09
We might or might not get single payer, immediately. But at minimum we'd be much more likely to get at least the strongest kind of public option, the strongest regulation of private insurance abuses, and not be negotiating against ourselves.
On target. Instant transition to single-payer may not be easy, but Democratic leaders are weakening their bargaining power by shutting single-payer out of the discussion.
Loyal Dem am I, but I will not roll over on this issue any more than I will accept occupation of Iraq or bombing of civilians in Afghanistan as copacetic just because the overheated rhetoric of the Bush-Cheney era has been tempered.
Note to DPO, DNC, Democratic Congressional caucuses and Obama administration: Republicans may be ditto-heads, but Democrats are not sheep.
May 11, '09
Kurt,
Health care is already rationed. We don't throw unlimited resources at it (even if it seems like it sometimes :-) and we never will. If you don't have insurance or can't otherwise afford to pay you usually don't get much health care until it's an emergency. Even if you have insurance you may have to fight with with them to get coverage.
If you have a universal coverage single payer system then there are no future medical expenses to fight over. Doctors and other health care providers are human and make mistakes just like the rest of us. I think some kind of no fault process for honest mistakes and mandated remedial training for the one(s) who made the mistake would reduce the costs.
May 12, '09
Single-payer would be a step forward, but would not be sufficient to solve the looming Medicare crisis-with an unfunded mandate of some $65 trillion as the baby-boomers reach 65. Solving this problem will require a total reorganization of how we provide and pay for health care.
The only credible solution to this crisis of which I'm aware is John Kitzhaber's Archimedes project. In short, the project envisions capping expenditures for health care at their present levels while totally reorganizing how we use taxpayer funds to pay for health care. Such funds would be used to provide a basic level of health care for all Americans. Individuals wishing to obtain items not covered by the basic plan could purchase supplemental insurance from private carriers. Items to be covered by the basic plan would be prioritized by a public board including representatives from stakeholders such as physicians, hospitals, nurses and patients. The Archimedes project includes many more detailed suggestions on how we might increase the efficiency of health care.
May 12, '09
The website of the Archimedes project is: http://www.wecandobetter.org
2:29 a.m.
May 12, '09
Hmmm...
Senator Schumer is pushing for more single-payer advocacy?
I wonder how that resonates with the "Schumer is a Corporate Whore!!1!!1!!" crowd that was so active around here a year ago?
As for me, I think it's perfectly reasonable to include some discussion of single-payer in the debate. But it's mostly a waste of time, since single-payer advocates (of which I am one) can't even demonstrate the support of a half-dozen Senators - much less something approaching the 51 or 60 required for passage.
The policy-making process should be focused on making policy. That is, the bulk of the time should be spent on attempting to craft solutions that might ultimately lead to passage.
May 12, '09
So, your own politcos also don't think there any real diffs between the Parties!
Good party faithful follow Kari's lead. Put your visions aside, realize your hacks won't do shit...but parlay the debate into a $1.6 million web site!
I'm going out to buy a firearm. QED, right here, folks. Talking=absolutely useless. To you, that is. $$$, for them. Pols are getting me copper one way only! QED, this website is as effective as clicking on a sidebar ad. that says, "Obama is a socialist. Vote."
To sum, fraud, fraud, fraud, fraud, fraud, fraud, fucking christians, fraud, fraud, fraud, fraud, fraud, fraud and CYNICAL FUCKING FRAUD.
May 12, '09
Ditto, thx Dems. Who's going to define "honest" to them? How dare they utter the word!!!
So, I can't see anything stopping the "Blue Oregon Recalls Sam" effort getting setup as a non-profit and starting activity immediately at blueoregonrecall.com. You want to ride the backs of morons, we'll let those morons process that. Of course, they'll bother to look up the ownership and realize that "Carrie Jisom" is no relation... Now to enquire what the rent is...oh, look, BO has hidden its registration. I have an old copy, though. Interesting. So we don't KNOW that this is still Mandate Media. I mean, it could be the official, official blog of the Blue Republicrats in Oregon.
Heads up SFB. Are you more likely to sue or be sued? If it's the former, what the hell good does it do to hide your registration? You gonna serve my new site anonymously?
That's politics. Pimping anyone that gives a damn. Free country America. There's your fundamental choice. Do you not give a damn, or do you want it up the butt? Thanks for it, indeed!
Thanks, JK
May 12, '09
We'll take that assignment!
Tired of the Dem jackass kicking progressives in the teeth, mainly here? Get out yer wallets. It's time for payback.
May 12, '09
...which is to agree with Chris' thesis, BTW.
May 12, '09
I believe that the health care "reform" process is effectively over. The industry's brilliant counter-move to voluntarily offer "2 trillion dollars in savings" (ha ha ha ha ha ha ha ha) has effectively killed the public option component in Obama's new plan, and now all that remains is two months of partisan BS prior to adoption of a meaningless and ineffective reform package. The lipstick on the health care reform pig may be one of several shades, but I have lost all hope of any meaningful change. The good news is that the US system will collapse, perhaps under the weight of unfunded Medicare and Medicaid. After the collapse, I expect that adoption of single payer won't be all that difficult.
Once the current Congress has "solved" the health care problem, I can hardly wait to see what they do with global warming. Presumably the coal industry has retained the same PR group as the health care industry. If they have not, they are idiots.
May 12, '09
The public option is "on the table." The Baucus committee has included variants of the public option, Medicare type in its report. http://www.dailykos.com/story/2009/5/12/730498/-Senator-Baucus-Releases-Paper-On-Public-Option!
May 12, '09
Has this site simply become a toxic waste dump for wingnut and Naderist trolls? When people sign their posts with this: "thx Dems for the Butt Fucking!" should they be worthy of any consideration? How about cleaning this place up, Kari!
May 12, '09
Zarathustra
aka Puphead Software 1322 El Camino Real Euless TX 96040 Voice: 817-891-1222
http://www.pupheadsoftware.com/main.html
Who hired you, a resident of Euless TX (a suburb of Dallas Fort Worth) to camp this Oregon website?
Gig's up, Zarathustra!
May 12, '09
"So, your own politcos also don't think there any real diffs between the Parties!"
Oh, there's a difference between them all right. The Democrats actually have SOME decent politicians to offer, and fortunately all of Oregon's Democratic delegation (except I guess we're waiting for Schraeder to prove himself one way or another) is among them. The Democratic party between them make up a heterogenous group representing all ideologies, including that of the Republicans, and it seems to me we could eliminate the Republican delegation entirely and still have a balanced, constantly bogged down government of Democrats alone.
Those Democrats who are corporate whores tend to try and hide the fact and offer up excuses for screwing the people. "Oh, we tried to not screw the people, but it would have cost extra." "We didn't have the votes to not screw the people." "Sorry about screwing the people, but you know, the Republicans would have done it worse."
The Republicans are different. They really would have done it worse. We wouldn't be having a health care discussion at all if they were still in charge, unless it were to enact legislation to eliminate all taxes on insurance industry profits "so that the insurers will be able to lower their rates", except of course the insurers would not lower their rates at all, but increase them in spite of the tax giveaway and laugh all the way to the bank.
The difference is that the Republican politicians claim PROUDLY their intent to screw the people. Every last one of them. Used to be, some of them didn't, but those few are pretty much dead and gone to primary challenges from the fringe right.
Thus, our contested two party elections are a choice between voting to have your hand chopped off at the wrist, or to take a chance on what's behind the door and hope you get lucky. For those of us who like our hands, that pretty much means choosing what's behind the door every time. And in Oregon, at least, we tend to get lucky.
May 12, '09
The title of this post implies an honest health care debate but I don't see any effort on the part of Congress to do that. Period.
May 12, '09
Well, here they go again, the bastards have just kicked the single payer advocates out of the Senate finance committee meeting. Called Wyden's DC office and they were quite nasty to me. Called Baucus, they switched me to the finance committee staffer who said, "single payer is not politically feasible." F YOU!!! We must fight for this. Screw you Wyden and Baucus. Wyden, you made your career on the backs of people like my husband's great grandmother when you attended her 100th birthday early in your career, pretending to care about health care. GIVE HER MEMORY A SEAT AT THE TABLE, RON. WTF IS THE MATTER WITH YOU?
May 12, '09
Well, here they go again, the bastards have just kicked the single payer advocates out of the Senate finance committee meeting. Called Wyden's DC office and they were quite nasty to me. Called Baucus, they switched me to the finance committee staffer who said, "single payer is not politically feasible." F YOU!!! We must fight for this. Screw you Wyden and Baucus. Wyden, you made your career on the backs of people like my husband's great grandmother when you attended her 100th birthday early in your career, pretending to care about health care. GIVE HER MEMORY A SEAT AT THE TABLE, RON. WTF IS THE MATTER WITH YOU?
May 12, '09
No, the public option is NOT ON THE TABLE. I just called Baucus staffer who said it is NOT POLITICALLY FEASIBLE. Got that? What a bunch of crap. Staffer said that no Senator has co-signed single payer. Call Wyden's offices now.
10:37 a.m.
May 12, '09
Regarding rationing, personal responsibility & malpractice first thanks for the thoughtful comments on substance.
Rationing can take several forms. As riverrat points out, excluding people from care is a form of rationing -- that's how markets do it, some in, some out by price criteria, which is good for some purposes but not when universality is desired. A related element is rationing by time. This I think may be part of what Kurt refers to, e.g. stories from about delay in getting "elective" treatments that nonetheless seriously affect quality of life, knee replacements are popular example, because more urgent treatment of other persons gets priority. Again, these stories are told as if no one under the U.S. faces delayed treatments. Yet in fact some people are so delayed that they never get the treatment -- permanent delay. Others are delayed by approval processes and appeals of denials under private plans and disputes over what is "covered."
Something that may be less obvious is that failures of "personal responsibility" often are also a form of rationing, more specifically self-rationing within the context of lack of insurance, high deductibles & co-pays, coverage exclusions, and derogation of primary and preventive care including public and provider-based health education in favor of high tech, high fee-for-service specialized medicine. Many chronic illnesses that could be prevented or reduced or managed at lower cost with higher quality of life by changes in individual "health behavior" early in the course of illness develop to the point of becoming acute and requiring more expensive surgical or pharmaceutical treatments due to early neglect (or "bad" consumption or exercise choices from a health point of view).
U.S. culture tends to treat "personal responsibility" in excessive isolation because it emphasizes the individual side of human nature at the expense of the plain fact that we are social beings as well. In utilitarian economic terms, individual choices are constrained and given incentives by contexts. In more humanistic social-psychological terms, people do things that facilitate sociability and that gain approval or avoid disapproval from those who matter most to them.
So a question about our health system (not just "care" n.b.) & wider social system is whether and how it makes choices for good health easier or obstructs them, makes it easier or harder to take "personal responsibility." Mostly ours creates obstructions.
Some private systems, especially those that both provide insurance and care, like Kaiser, get the connection, but pure private insurance has trouble fitting prevention and genuine health maintenance into their actuarial processes and myriad pricing negotiations. A single payer system would have the capacity to shift the priority to primary, preventive and early-stage management (a positive form of rationing), which means in substance socially supporting individual responsibility.
In the 1880s there was a move in Portland to stop funding for public schooling altogether. The argument was that schooling was the individual responsibility of parents and potential students, and that simply making schools available undermined incentives to have the character to overcome obstacles to getting education. Similar specious reasoning often surrounds discussions of "individual responsibility" in health today. Of course individual choices inherently matter in health, just as they do with success in school. But that doesn't say anything about whether and what we should do to facilitate some choices or discourage others.
Interestingly, often self-professed "individualists" object to measures that would aid informed choice, such as say menu labeling about unhealthy foods (if McDonald's has a "healthy menu," what do we call the rest of that stuff?).
11:34 a.m.
May 12, '09
On Archimedes / We Can Do Better, I have argued on the Archimedes website that IMO Archimedes mistakes the relationship between funding & payment mechanisms and the wider reforms to create a health system, i.e. beyond a disease treatment system, that represent some of the best of Archimedes aspirations.
Unfortunately these links will not work unless you register with the Archimedes site & log in, but a longish discussion / debate by me with Archimedes/WCDB executive director Liz Baxter about why "how we pay" matters -- particularly "fee for service" -- in ways that single payer could address is here, and a discussion of some issues on the Archimedes approach to Medicare is here (scroll down to reply titled "Of course it's possible"). I'll try to write some independent posts on this stuff on BlueOregon relatively soon.
Short version of one key issue is that when Mike L. writes that John Kitzhaber advocates "capping [public] expenditures for health care at their present levels while totally reorganizing how we use taxpayer funds to pay for health care," there are a couple of problems.
The problem is that among the "public expenditures" Dr. Kitzhaber counts is tax breaks for corporations (and individuals?? not quite sure on that bit).
However, these tax breaks are "public expenditures" only on paper. In practice they are revenues foregone. In order to monetize them to redistribute their uses in "totally reorganizing" to create a health system, we would have to remove the tax breaks and tax the corporations at the rates they would pay if they didn't provide benefits.
The result would be a massive drop in private provision of private health benefits.
If we're going to be combining raised taxes on corporations (& possibly taxing individual benefits as income) with Medicaid and related SCHIP moneys with Medicare, each of which is derived in a different way, you're looking at a transformation that is fairly similar to what a single payer system would entail anyway -- but without related cost-saving benefits connected to reducing private insurance related bureaucracy, costs & cost-shifting associated with lack of transparency in pricing negotiations, and the fee for service payment system to providers with its wrongly-directed incentives.
Upshot as far as I can see for Medicare would be a severe reduction in benefits that would break the social contract the system represents.
12:07 p.m.
May 12, '09
On the politics ...
Kari, Schumer's action seems pretty clearly to me to be the smallest of token responses to forestall embarrassing publicity about the exclusion of single payer from the discussions and debates, exemplified by the protests last week which probably led to his action. It may even have been concocted with Baucus to show that not even one other subcommittee member would join him, tied to arm-twisting behind the scenes to prevent that, arm-twisting that could be related not only to the subcommittee and treatment of members' other health care proposals, but to the very powerful Finance Committee as a whole, in which the chair has the capacity to threaten members' goals in entirely other realms.
The latter is pure speculation and may be unfair to Schumer.
But in his own substantive proposals in the subcommittee and in the media he has been a force to move things in the direction of weaker "public option" versions or eliminating them altogether, acquiescing to insurance industry demands for individual mandates a la the failing Massachusetts system, and more generally being an industry shill contributing to the phenomenon of reformers negotiating against themselves.
The reason why an honest debate that includes the best option is not a "waste of time" has to do with the wider political dynamics of the fundamental policy questions, rather than the inside baseball on which you focus.
A key piece of this is media. The mass media report what politicians say and what goes on in public fora politicians create. Colluding in excluding single payer from official consideration justifies private & parastatal (PBS/NPR) suppression of information about single payer. I'm sorry you're doing it and sorry that you apparently are supporting elected officials who are doing it, because it makes the debate fundamentally dishonest.
Backbeat -- part of what is going on is a dance in which the Senate is going to be very weak & industry subservient & then something less wretched will take shape in the House and then there will be compromise that will be much less effective and fair than possible in terms of health efficiency while much more expensive than necessary in cost efficiency, probably directing expanded coerced private premium streams combined with subsidies into insurance company coffers. Possibly there will be a weak "public option" that will allow insurers to cherry pick who they wish to insure and dump others into a high-risk restricted public pool, raising costs and putting pressure on "public option" benefits.
Such an outcome would allow those who are pushing any public option without educating the public as to choices among them to claim a hollow "victory," while letting knee-jerk market ideologues claim the shortcomings are due to it being public, rather than being designed badly.
However, we can't let cynicism keep us from fighting for what's right, because if it doesn't come now, the crisis will grow, and education, argument, persuasion and organizing now will bear fruit later. The movement is growing.
May 12, '09
A single payer plan might work depending on who runs the plan. I know people around the world who are relatively happy with the plans available in the country that they live, but others aren't so happy. One problem with a single payer plan is that if the plan sucks then there isn't much a person can do about it. Currently people have the option of changing doctors, plans, health care providers, etc. Choice usually is a good thing and a single payer plan takes choices away which can in turn led to a real mess. I suspect that is why most politicians don't want to propose a single payer plan. They know that most monopoly systems in the USA are eventually corrupted. Medicare is a good example and so is Social Security. Both of those systems are "single payer" type of plans where the gov makes the rules and doesn't allow competition. Both of those plans have huge problems and the politicians really try to avoid getting involved. I would assume that a single payer medical plan would quickly become just as messed up as Medicare and I think most politicians assume it would also. They understand that they lack the capacity to actually run these things given their report card over the last 50 years.
May 12, '09
Why do some folks consider Medicare "messed up"? The funding needs to be adjusted (and most likely the Medicare payroll tax rate increased), but from my perspective the experiences of my parents and my in-laws was that Medicare (together with a reasonably priced Medicare Supplement Policy) worked wonderfully well. Between my parents and inlaws, they received heart valve replacements, hip replacements, diabetes care, cancer surgery, office visits, acute care, etc. etc. etc., all provided by high quality local medical professionals, and at no out of pocket cost to my parents / in-laws (other than their Medicare premium and Supplement premium). They had no extra waiting periods and the care was provided by the same local medical staff and hospitals that treat me and my kids under our very expensive Blue Cross plan. So I ask again, what is "wrong" with Medicare (other than the funding gap as noted)?
Seems to me that Medicare for all is the solution that Congress should be looking at, with funding to be provided by a combination of federal budget dollars, payroll taxes, and direct participant premiums for those that are not yet retired.
May 12, '09
PUBLIC SERVICE ANNOUNCEMENT
If you or anyone you know is nearing Medicare age, make sure you have a GP in place. It is becoming nearly impossible to find ANY doctor who will take on NEW patients w/ Medicare. This is impacting my family and many others.
END OF PSA (thank you for your indulgence)
May 12, '09
Greg, the problem with Medicare is that we can't afford it. Asking what wrong with Medicare is like asking why we can't all drive new cars and live in $1M houses. Umm, because there isn't that much money to go around.
Doctors are bailing out of Medicare as fast as possible because it doesn't cover their costs. At the same time, Medicare is going broke because as a society we just can't afford to dump that much money into it. If we spend all of our resources on Medicare we won't have much left over to improve the quality of life in other areas.
I'm sure your parents and in-laws are all great folks and it is great that the taxpayers footed the bill for all of their medical expenses but maybe that money could've been better spent on education or light rail or building a new sports arena for major league soccer. There is only so much to go around and it isn't clear why old folks should grab so much of the money for themselves.
5:10 p.m.
May 12, '09
So, I can't see anything stopping the "Blue Oregon Recalls Sam" effort getting setup as a non-profit and starting activity immediately at blueoregonrecall.com. You want to ride the backs of morons, we'll let those morons process that. Of course, they'll bother to look up the ownership and realize that "Carrie Jisom" is no relation... Now to enquire what the rent is...oh, look, BO has hidden its registration. I have an old copy, though. Interesting. So we don't KNOW that this is still Mandate Media. I mean, it could be the official, official blog of the Blue Republicrats in Oregon.
I haven't got the foggiest idea what the heck this all means, but we've always been very transparent about the management of BlueOregon. It's all right there in the cute little sidebar on the left. Even with a link to my company's site, where you can see who all of our clients are! (Though, as always, I speak only for myself.)
May 12, '09
That's a really ugly website. Is that really the Prince of Prolixity, Zara's site? And you need to tell how you found it before you say that's him, since I actually don't see a Zara reference.... but the site is not impressive.
ehh.
6:30 p.m.
May 12, '09
Andy, I'm guessing you're fairly young & thus have both no memory of the time before Medicare when older people suffered miserable poverty in great disproportion, in part due to health care costs, and likewise suffered physical miseries. Similarly I'm guessing that your parents are not so old yet. Or maybe you're just a morally bankrupt person who's content to let old people suffer and eat cat food?
The "taxpayers" in question are the now elderly, who have paid a regressive payroll tax throughout their working lives in a social contract that said they'd be able to get good health care in old age at cost ("premiums") reasonable relative to the usually reduced and fixed incomes of older people. Medicare in no way is comparable to "everyone living in million dollar houses and driving new cars."
Medicare's funding problems, such as they are, result from the interaction of two demographic phenomena with rapid rise in health care costs. One of the demographic phenomena is that Medicare works. Average life expectancy at say age 50 is much longer than it was in 1965. This is partly due to the changing nature of work & things like declining prevalence of smoking, but partly due to increasing effectiveness of medical treatments, which are not rationed out of reach for part of the population as under a market-based system.
This increase in life-span is multiplied by the size of the baby-boom generation relative to its predecessors -- these are the same dynamics that affect Social Security. As with Social Security these dimensions of the problems are often exaggerated and could be met relatively easily by say raising or eliminating the cap on income subject to the respective payroll taxes.
The reason Medicare faces more severe problems is that medical prices, including drugs, are rising much faster than overall inflation. Drugs matter because so many of the life-extending treatments for older folks are pharmaceutical. A pro-corporate Congress & administration have forbidden Social Security to use its potential negotiating power based on scale to get the best price for drugs. Often research costs and risks are cited to justify this, but the drug companies are extremely opaque as to how much of their budgets goes to advertising as opposed to research & in addition there are excessive profit expectations and demands from shareholders, including self-dealing upper management (not restricted to CEOs).
This should be handled by reforming the structure of medical & pharmaceutical research & related intellectual property law, with much greater public funding and corresponding restriction of public costs for the products of research. Restoring a greater degree of restriction for pharmaceutical advertising and regulating easily corruptible relationships among medical researchers, drug companies and marketing to prescribing doctors would also be in order.
Another element in rapid rise of health care costs is increasingly expensive technologies. This is particularly intense in relation to extreme end-of-life care and there is a complex cultural ethical deliberation that we need to make in that respect. However, at present the technology issue is also exacerbated by the fact that providers are remunerated on a fee for service basis, and that prices are severely detached from actual costs due to differential negotiations with different payers as well as cost-shifting for care for the uninsured, treated as overhead & inflated by inappropriate & late treatment.
When you say "doctors are bailing out of Medicare" what you mean mainly is primary care doctors, who benefit least from the fee-for-service method of remuneration, which also inflates costs for employers and workers paying premiums to insurance companies and leads to our overemphasis on illness treatment rather than prevention and health promotion (primary care functions).
But at the end of the day the fundamental problem of Medicare is that it isolates the highest risk and cost part of the population. One of the major reasons for creating a single payer system would be to create a nationally universal risk pool, which would mitigate segregation of the elderly. At any given time about 20% of the population needs medical treatment and about 80% doesn't. Everyone is going to be in that 20% at some point in their lives, whether due to old age or accident or infectious or chronic disease (affected by "health behavior" and the interaction of genetics with environments). Use of currently paid Medicare taxes paid by active workers to pay Medicare costs of the elderly is a half-assed way to partially approximate a universal risk pool.
6:48 p.m.
May 12, '09
Oh, one more thing: When the Taiwanese government looked for a way to reform and make universal health care provision, they settled on the U.S. Medicare system as their model, expect applied to the whole population.
Regarding conservative rhetoric, Taiwan of course is not particularly known for its attachment to socialism or aversion to markets. Likewise if the model were inherently unsustainable economically, they could be expected to have seen that and made a different choice.
May 12, '09
THanks for that analysis Chris. I'm too fatigued to try to reason or engage these idiots with no social sciences training. Nor, it seems, social justice feeling.
May 12, '09
Kari, you need to delete your own comment as "not on topic."
May 12, '09
Why should doctors take on new Medicare patients?
Medicare doesn't pay full price, it dictates it's own prices to medical providers and there's nothing they can do about it.
If you had a store with wrenches on the shelf tagged at $7 and the government representative walked in each day and bought half of your inventory but only paid $5 each, what would you do?
May 12, '09
Joe: take a laxative. By mouth, please. I think they still sell the chocolate kind. And after you've cleaned the crap out of your mind, let's try again.
You are so FULL of uneducated shit lacking in any kind of insight. Who ARE you?
It feels like forever since I was married to this kind of redneck.
Honestly Joe - are you for real? I"m asking this genuinely. Are you just baiting for fun or do you believe what you are saying?
My god! It's painful, really painful to read this stuff.
May 12, '09
What is it that you don't believe, rw?
That the government purchases 1/2 of the health care services in the country?
Or that Medicare doesn't pay full price?
May 12, '09
jacksmith:
America is the only country in the developed world that has a GREED DRIVEN! PROFIT DRIVEN! IMMORAL! UNETHICAL! PRIVATE FOR PROFIT! healthcare delivery system.
Bob T:
That also describes the system that gets food into our mouths--and there's quite a lot of it. How many things in your home were provided by someone who didn't create it with some profit in mind? Just wondering.
As for health care and insurance, I'd prefer to reform what we have before going to a government-controlled system, and I mean doing things like repealing laws that mandate numerous things to be covered by health insurance policies instead of allowing individuals to pick and choose items based on their own evaluations of their own risks. I'm not particularly impressed with the system we havem but I'm not dumb enough to call it a free enterprise health care system.
Bob Tiernan Portland
May 13, '09
rw, While Joe's style may be able to put you off, the fact is that Medicare Reimburses less than 100% of the cost of services to medical providers. Until/unless that changes it would seem the model is a race to the bottom.
Would you agree?
10:16 a.m.
May 13, '09
There definitely some problems with levels of Medicare reimbursement for some docs in some areas but the recent comments here appear to be gross overgeneralizations.
There is a difference between price and cost. Private insurers don't pay "full price" either in many instances. Doctors bill a price, and if they can get that from the insurer & patient co-pay, they do, but often to be part of preferred provider networks or HMO plans they agree to take less. This shows up in bills from them as written off and in paperwork from insurers as disallowed, in my experience. One reason why a doctor may not be available in a given plan is that they won't agree to the terms of the plan. The extent to which the current system provides access to patient-preferred physicians is somewhat exaggerated, since employees are constrained by the plans employers offer. Once I had to change a doctor because my employer changed the management company it used to handle the enormous inefficient private bureaucracy (while still needing people in the personnel office to deal with them) and the management company negotiated different deals (the insurance company involved may have changed too) and my doctor no longer was in a network available to me, because he wouldn't/ couldn't accept their terms.
Anyway, there is a real problem with cost & not just price related reimbursement particularly for primary care docs in some places, in part because of Bush administration policies on the matter that are being worked on in Congress now.
That said, the AARP did physician access study (leads to pdf link; Google html version here that compared Medicare patients to privately insured patients ages 50-64. The study found no difference in reports of no problem getting a doctor (91% in both populations), reported equal levels of "satisfied" or "very satisfied," and higher levels of "very satisfied" for Medicare patients. The survey was conducted in 2006 and published in 2007 & given news stories it is possible or likely that the situation has deteriorated since then somewhat -- but the flat universal generalizations by Joe & now Kurt still are much overstated I believe. (Kurt are you using a shorthand? This usually is a kind thing you try to be careful about in my experience.)
Joe, if we took every Medicare patient and put them in private insurance, the proportion of medical services purchased for them would still be half -- it's because old people are more sick and get more treatments and more expensive treatments.
Actually, if they all were in private insurance, costs would go up dramatically because Medicare spends 3% on administration compared to 15-20% for private insurers, to which add the insurers profits.
But then a big chunk of them wouldn't be able to afford the private insurance, even if they were in groups, because they wouldn't have the employer contributions that make employer-based benefits even marginally affordable for a lot of currently insured people -- unless you had government subsidies, as in the inefficient drug plan Bush created for Medicare.
And, since a lot of them would be uninsured, they would expand the population of people getting treatment at later more expensive stages through inappropriate routes like hospital emergency departments, which would add some more expense. On the other hand, more of them would die earlier, which would probably save some money. Maybe enough would die earlier to make the other stuff a wash. Probably not, but maybe ... wouldn't that be great!
At least it wouldn't be government expenditure. So, Joe, is adhering to anti-government ideology such an important value that it justifies increasing human misery on a large scale?
May 13, '09
Single-payer shows 66% support in national polling, yet only one US senator (Sanders) is on record supporting it.
Polling on T.A.R.P. was 87% against, nationally. Yet it received a majority in both houses of Congress (most opposed were a faction of House GOP). (And, BTW, what was all that T.A.R.P. money used for, i.e., was the public right on that-yes!).
"Government of, by, and for the people"(?)
May 13, '09
You know, it would be easier to discuss these important issues rationally... if your Party wasn't constantly stabbing us in the back!!!
May 13, '09
Advocates of single-payer universal healthcare, the system favored by most Americans, continue to protest their exclusion from discussions on healthcare reform. On Tuesday, five doctors, nurses and single-payer advocates were arrested at a Senate Finance Committee hearing, bringing the total number of arrests in less than a week to thirteen. We speak with two of those arrested: Single Payer Action founder Russell Mokhiber and Dr. Margaret Flowers of Physicians for a National Health Program.
Listen/Watch/Read
"Not politically feasible" has a clear and simple meaning: powerful economic interests that make substantial campaign finance contributions and have the money to run slick PR campaigns are more powerful in our "democracy" than is the will of the people.
Healthcare, the banking system, sustainable energy - name the issue and watch corporate power stymie meaningful change that supports the interests of the people.
May 13, '09
Senator Jay Bullworth: Yo, everybody gonna get sick someday / But nobody knows how they gonna pay / Health care, managed care, HMOs / Ain't gonna work, no sir, not those / 'Cause the thing that's the same in every one of these / Is these motherfuckers there, the insurance companies!
Cheryl and Tanya: Insurance! Insurance!
Bullworth: Yeah, yeah / You can call it single-payer or Canadian way / Only socialized medicine will ever save the day! Come on now, lemme hear that dirty word - SOCIALISM!
more Bullworth: C'mon, the guys you and I get our money from, they don't want the people to have the news. They want you to think the corporations are more efficient than government, right? You want to know why the health care industry's the most profitable business in the United States? Cause the insurance companies take twenty-four cents out of every dollar that's spent. You know what it takes the government to do the same thing for Medicare? Three cents out of every dollar. Now, what is all this crap they hand you about business being more efficient than government? These guys need to be regulated. What do you think, that these pigs are going to regulate themselves?
May 13, '09
Chris, thanks for clarifying about Medicare's reimbursements and "price" versus "costs". While some primary care physicians in some regions have refused new Medicare patients, the reality is that most doctors do a significant business in Medicare patients. As noted above, Medicare pays for a huge portion of health care nationally. Since the MEDIAN physician salary is now over $200,000 a year, it's obvious that doctor's aren't losing much by treating Medicare patients. And frankly, the AMA stands right behind the hospital associations when it comes to blocking any attempt to bring transparency to medical costs. Have you ever asked your doctor how much a particular procedure costs? They have no idea. But I guarantee they know exactly how many patients they need to see every day in order to maintain their income.
As a side note, physicians are far and away the best paid profession in America. Average salary is more than double that of lawyers, and about four times what an average family of FOUR makes. No other profession comes close on average, not investment banking, not CEOs, not even professional athletes (keeping in mind you have to fold in all professional athletes in the average, including those in the minor leagues). We as a country need to ask whether our doctors really need to be in the top 1% of income earners. If they were just in the top 10%, we could provide medical coverage to a whole lot more people.
May 13, '09
Chris Lowe, thank you for your thoughtful comments. I read this and will read your future columns with an increased level of respect.
I am old enough to know better than to have expected that the Dem majority would ignore money in favor of principles. The fact that 66% of citizens favor single payer is meaningless unless that 66% can send more cash to Congress than the health care lobby, and that won't happen.
May 13, '09
Chris, relating to your point that you really just want the debate to be full and open, where do you draw the line in terms of what Congress should spend its limited time considering? Taken to the extreme, should Congress debate a right-wing proposal to do away with Medicare and Medicaid completely and throw those people into the private insurance market? Should they debate a one-child-per-family policy that would severely limit health care inflation? Should they debate nationalizing the drug industry?
My point, of course, is that there are lots of ideas, some more radical than others. You're arguing that single payer is not that radical, that it's achievable and the best solution. I guarantee I can find a conservative who would argue that total privatization meets those criteria as well. At some point, Congress rations the debate. It seems to me that the blame isn't on Congress, it's on single-payer advocates who have failed to put together a plan that can garner support from the very people it needs to. . . Congress. Isn't that how our democracy works? I've worked with Wyden and Baucus, and it's a cop out to say they have been bought by the health care industry. They are smart, knowledgeable people who have looked at this issue and rejected single-payer. Again, that's democracy.
By the way, I completely discount the single-payer polls because they do not represent the true trade-off. Ask people if they can have something for nothing, and they'll usually say yes. I have yet to see a poll that dives into the details of what would be given up under single payer that generates those same levels of support.
May 13, '09
"If we have Senators and Congressmen there that can't protect themselves against the evil temptations of lobbyists, we don't need to change our lobbies, we need to change our representatives."
May 13, '09
Mikes wrote:
It seems to me that the blame isn't on Congress, it's on single-payer advocates who have failed to put together a plan that can garner support from the very people it needs to. . . Congress. Isn't that how our democracy works?
No, that's how our lack of democracy works.
It is not necessarily a matter of Wyden or Baucus being "bought by the health care industry", [though I cannot understand why considering this would be a "cop out". It may be that Wyden or Baucus conclude that it is not worth fighting against the power of the healthcare industry. That would make them uncourageous instead of corrupt.
May 13, '09
Or maybe, Jake, they've looked at single payer and decided there are better ideas on the table. It's always tempting when someone disagrees with you to assume something malignant is at work (lack of courage or corruption, take your pick) because it's easier than acknowleding that your idea might be flawed.
May 13, '09
Miles,
Given popular support for single-payer and it's success in other countries, dismissing it as a solution to our healthcare nightmare should be accompanied by a cogent explanation. Have you seen one?
2:52 p.m.
May 13, '09
Miles,
The point about the polls as far as I am concerned is that they show that "the American people wouldn't accept it" kind of arguments aren't true, not that they show people think it's the only solution. At the April 16 meeting with Earl Blumenauer, a PNHP doctor from Oregon, and Dr. & State Senator Alan Bates who is one of the main healthcare guys in the state leg., the audience was overwhelmingly supportive of single payer. However, judging from applause, probably half or more also supported the HCAN mixed system with public option kind of approach.
You might have a look btw at an interesting article from The Boston Globe that presents evidence that many in Congress and the administration are assuming continuity in people's satisfaction with their current insurance and its prospects with those views in the early 1990s, a key element in defeat of the Clinton effort at reform.
3:28 p.m.
May 13, '09
Miles,
Single payer advocates have reasons to blame ourselves for not being more effective to date, and self-criticisms in which we should engage as we build our growing movement. Actually some of that has been occurring. For instance the relationship to organized labor has changed dramatically. But Congress certainly is to blame too, and criticizing them for suppressing the debate is legitimate and will continue as long as they continue to do it.
A piece of the blame lies with the media as well, and the echo chamber effect of mutually reinforcing limitation of debate. As far as movement self-criticism goes, doubtless there is some to be done on our media work too.
Single payer differs from the other reductio ad absurdam examples you present in that variants of it are in place in other countries and produce better results in terms of cost-efficiency, population health outcomes and popular satisfaction with the healthcare system as measured by polls than does our current system that people are twisting themselves into pretzels to maintain. The system most like ours, and even more like Ron Wyden's purely private but highly regulated proposal, that in Germany, is also the one which has the highest proportion of GDP spent on health care after the U.S.
In other words, it's not just me and other people claiming what an untried system would do. There's a lot of evidence. Likewise it also has the backing of very large numbers of healthcare professionals, including a majority in polls of primary care physicians and a number of doctors and nurses organizations.
The health care reform debate is enormously complex. The problem involves make care universal and equitable. It includes cost control. It includes needed reforms to elements of the system that downplay prevention and health promotion and create incentives to focus on treatment of illness and to multiply such treatments. There are many subordinate parts to each of those three fundamental issues.
The "managed care" movement of the 1990s sought to get hold of the cost control piece but in a way that did not address the others and amounted often to rationing care by non-health-related criteria.
Many current efforts aim at universality in ways that do not address the cost issues.
Single payer has a substantial claim, based on evidence and experience in many other countries, to address both the cost and the universality issues -- to be able to provide universality at much less cost than any of the currently going proposals. Depending on how it is done, system reconstruction for single payer could also be used to reform the incentives structures towards prevention and health maintenance.
If the health care crisis is as bad and deepening as everyone says it is -- and it is -- excluding an idea with powerful evidence behind it of capacity to address the several dimensions of the crisis, using the self-fulfilling excuse of "politically unrealistic," which really means "I don't have the political will to make sure this idea is included in the debates" -- is grossly irresponsible and incredibly lame.
3:42 p.m.
May 13, '09
On April 16 at a healthcare forum at the First Unitarian Church, Senator Alan Bates observed that at present something like 60% of working age people have health benefits with which they are reasonably satisfied though increasingly insecure as to their future. He further observed that if current trends continue in rising costs to employers & employees and simultaneous reductions in benefits, that proportion will shrink to 50%, to 40% or less, in a decade or less, and that if something else isn't done by then, the "system" and political support for it will totally collapse and we will get single payer then.
That would be a rotten way for single payer reform to come about, but the evolution of the current debates in Washington make is seem more likely now than a couple of months ago.
From last Fall through the winter, some variant of proposals like those supported by HCAN, once but apparently perhaps no longer by Senator Baucus, by now-President Obama, a mixed system of private insurance with on or another type of public option, seemed to be on the cards. That approach looks to universality by accepting greatly increased costs.
Now it increasingly looks as if the cost issue, in the context of the economic crisis and the political fall-out of the overly bank-friendly financial bailout policies, will put paid to the universality effort, blocked by solid Republicans plus center-right Democrats backed by the massive insurance industry lobby (2500 strong -- 5 for each representative or senator) & its allies.
There certainly will be some tighter regulation of the insurance industry to cut down on certain exclusionary abuses. It is not clear that there will be anything more than that at all.
If that is the outcome, the super-inflationary medical and insurance cost crisis will continue, putting pressure on Medicare and Medicaid, leading more and more employers to drop or reduce health benefits, and more and more workers to be unable to afford the reduced benefits, raised cost shares, or to judge them not worth the price. Loss of millions of jobs in recent months probably means the number of uninsured persons is approaching 50 million.
There is a practically realistic solution to all of this -- a single payer system. It just takes the political will to take up that solution.
It is not perfect. (Why is it that only single payer is held to a standard of perfection, btw?)
But then, we are not to make the perfect the enemy of the good, right?
May 13, '09
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Chris, this is where the disagreement is, that SP is a practical, realistic option. I see your point about wanting single payer to be included in the debate, but I think the reality is that the key players don't agree. They're using "political realism" and "public support" as smokescreens to avoid saying that they just think you're wrong. You can argue that they should just be honest about that, and I would agree, but I think that's the reason SP isn't on the table.
To recap the reasons why it won't work: The only way SP controls costs is through explicit rationing of care. Is that better than the tacit rationing that goes on now? Academically, yes. But few of us are going to tolerate government telling us what care we can receive and when. Case in point: my daughter has a medical condition that requires an ultrasound every three months. Medical research shows that getting an ultrasound every six months has no impact on health outcomes from the condition, on average. Under SP, I guarantee the government only covers every 6 months. But what happens on average doesn't matter to me one bit, what happens to my daughter does. And most single-payer plans limit your ability to pay for enhanced levels of service due to the equity impact. I won't support that kind of government control, and neither will most Americans, and so you're left without the cost controls that are necessary to make the system work. Any administrative savings from SP will be sucked up for years and years dealing with the employment fallout of eliminating the insurance and medical review industry. Again, you can make the academic argument that this is better in the long run, but never in human history has a government, any government, undertaken such a radical overhaul of such a large portion of its economy. I don't think our government has the capacity to do it. * Very few national health care plans were created from scratch. Almost all grew organically out of the existing system. It's really too bad we didn't do this in the mid 20th century when everyone else did, but we didn't. SP tries to reverse the clock and go back to a simpler time, but that's impossible. Instead, we need to create universal coverage given what we already have and put incentives in the existing system to control costs.
Will that be hard? Yes. Will it succeed? Maybe, maybe not. But the chances are better and the risks lower than SP, which is why all of the congressional experts on health care -- people like Wyden and Baucus -- reject SP out of hand.
May 13, '09
Or maybe, Jake, they've looked at single payer and decided there are better ideas on the table.
Uh Miles, dumbo, in fact the debate has been characterized by a refusal to actually look at the specifics of any plan This is because Democrats in the pocket of the industry (starting with Wyden) know that when the actual costs savings of a single payer or a credible public plan are put on the table, they have been studied extensively by even the Lewin Group, they won't have any argument left. No Miles, you couldn't be more wrong about what is actually going on.
To all the Medicare critics. Medicare patients are very good business in states whose reimbursement rates are favorable because they had larger populations of over-65s decades ago when the differential rates were actually set. That's why the Mayo Clinic has branches in Pheonix, AZ, and Jacksonville, FL, for instance. Unfortunately NW politicians from that time to now have wasted their time on issues that smarter politicians from other states are all too glad to let them jerk-around over while grabbing the real money for what matters.
Now the only way rates will be adjusted is in the process of re-vamping the whole system either to a true everybody-in single-payer system, or a public plan in which everybody votes with their feet by running away from private insurance.
Most of you loudmouthed clowns obviously have never actually had a conversation with provider representatives or insurance company representatives who negotiate the actual purchasing of health care services as some of us have. It's the industry's position that costs are high and going higher because they can't pinch providers tighter than Medicare does: The government sets the Medicare rates and no provider can legally offer LOWER rates and still accept Medicare. That doesn't matter in the NW but across the rest of the country it most definitely does. What you see in the NW with rates is an anomaly because NW politicians and NWers were so stupid as to give the farm away way back when the differential rates were set and the fact NWers remain stupid enough to not inform themselves about the reality of the situation. They'd much rather have morons like Blumenauer out their wasting time arguing about bicycles and toy trolleys rather than the serious matters of life, death, and a broken economy that are at stake in the health care debate.
Chris - kudos for you for being one of the few truly informed and actually intelligent people commenting here. You're writing in the spirit of a true educator (some of us know what that is about) but here you are seeing why the DPO is such a failed institution --- The DPO membership doesn't even care to hold to account elected leaders when they fail to uphold Democratic Party principles they pledged to uphold. Where is Wyden as the single-payer advocates were ridiculed and arrested for having the temerity to exercise their right to petition Congress for redress? Nowhere to be found, and the DPO as a collective body has been nowhere to be found in calling Wyden to account for that failure.
May 13, '09
Wrong again, Miles. The actual market reason SP will work is because it shifts the market power for health care services to a single large purchasing entity (we the people) and it removes the severe waste of health care dollars into the private pockets of insurance companies who deliver neither health care nor market efficiency.
In fact, the dirty little secret is that no one dares actually study is the fact the actual dollars saved by removing insurance companies from the picture, leveling out disparities in payments, and shifting the balance of market power from the large corporate providers, will actually allow greater reimbursement rates to individual providers and provider groups, thereby encouraging diversity. There are good arguments and hints in the existing evidence that this will be the case. But you have people like Miles spouting unfounded talking points from the private insurance and private hospital industry.
People opposed to SP or a strong public plan need to get off their butts and do some research into where most of the health care dollars are actually spent today. You'll find that if we can shift the market power away from corporate providers who reap huge returns providing a high level of costly life-saving and end-of-life services to a small minority of the population to a single powerful health care purchasing consumer (us), then not only could we provide much more preventative and curative health care to all, but also still provide that high level of life-saving and end-of-life care at a lower cost. It's all in the balance of market power and that is what a lot of Democrats who owe their election to interests that hold that market power are trying to stop from happening. There are a lot of doctors who would be all too happy to just practice medicine at the reimbursement rate that would be possible under an SP or strong public plan and that most definitely would allows them to earn a reasonable living. Doctors who work as employees of major corporate providers don't make quite the income you might think and they have to put up with more than they should ever have to.
I know, I've talked to many doctors in that situation and they all support a single payer plan or public plan. They can see these plans would allow them to either open a private practice or be an employee of a corporate provider and no longer have to put up with the business games between the corporate front office and insurance companies they have to put with today.
And no, I'm not going to provide more info to convince those of arguing against SP or a public plan using arguments that demonstrate you don't have a clue. Convincing you is irrelevant. Like the one person said in Sicko: The way to get the health care we deserve is to make sure the politicians are scared. Those of us who are actively informed have come to perceive that politicians you support are easily scared by pointing out how little you actually know and how easily you'll abandon them personally as the truth comes out in the debate. That's why Wyden has turned into a surly jerk at public meetings and his office people are surly jerks when you call. That's what has a lot of Democrats in DC and Salem running scared right now in this debate and arresting doctors and nurses rather than listening to them.
May 13, '09
* Very few national health care plans were created from scratch. Almost all grew organically out of the existing system.
Wrong yet again Miles. Athough you might have a whacked concept of what it means to grow "organically".
Virtually all of the plans in Europe were created out of whole cloth after WWII. The Netherlands has actually tried at least three different plans since WWII and put their current system in place in 2006. The Taiwan single payer system is less than 20 years old and was built from scratch. In fact, the most important thing that can be said about the sensible health care policy of the rest of the developed world and some of the developing world is that their plans were built in an environment that was not controlled by politicians in the pocket of the American private health insurance industry and the American corporate health care providers, and that has nothing to do with some false argument about how they grew "organically" out of existing systems.
May 13, '09
Chris Lowe:
It is not perfect. (Why is it that only single payer is held to a standard of perfection, btw?)
Bob T:
Because there'll be no other options. Unless you're wealthy like Oprah and can go to another country, but then when the US has this system there'll be no place to go. And no place for Canadians to go. Or will you accept the prospect of back-alley operations, or back-alley care?
Bob Tiernan Portland
May 13, '09
Chris, if the BO proprietors would let you, would you consider running a blog thread in which you add comments and post informed statements about what is really happening from the huge advocacy community for a SP and/or a credible public plan pption? Getting the facts out to the grassroots is the best way to get them heard and make the change we need since clearly Congress is going to do it's level best to prevent the facts from being heard. I'd sure promise to never comment personally just for the chance to forward relevant items from responsible advocates that come my way several times a day (I'd bet you already see most of them given your interest in the issue.)
May 13, '09
Of course this red herring argument is utter c**p.
First, we are talking here about a national health INSURANCE system, and not an nationalized health CARE system. The only SP and public plan anyone is advocating presumes the entire current system of private health care providers remains in place and in fact will grow and diversify and become more patient-focused as the dollars now skimmed off by greedy private insurance companies are instead made available for health care.
Second, the benefits will be at least as good as the best of the Federal Employees Health Benefit Plan and Medicare, and because everybody is in there is no basis for arguing there will be anything less than a national commitment to keep improving the medical services even the poorest citizens will have available to them.
Third, the rich can continue to spend their money to buy whatever benefits above the baseline level they want. A baseline level of medical care, by the way, which will exceed what something like 80% or more of the American public would ever have a chance in their wildest dreams of having under any plan based on private insurance.
Hang in there Chris. You're a nice a guy and you have the polish it takes to deal with the misanthropic freaks, far too many who think they are "blue". Some of us have just see too many family and friends be immorally victimized by our system when they are most vulnerable, either because they have no insurance or because the real job of private insurance companies will always be to deny medical care rather than provide it, to even care to be nice about it anymore.
The health care battle is the pivotal moral issue of a generation. Particularly given the health care catastrophe we face with broken troops coming home from two wrong-headed wars. This is a battle that will either mark the ascendancy of a whole new power block that stands for the interests of working people in the political landscape, or which will show a large part of the Democratic Party is as morally bankrupt as the Republican Party.
May 13, '09
"They are smart, knowledgeable people who have looked at this issue and rejected single-payer. Again, that's democracy." And here I thought that representatives in a democracy actually represent the will of the People. Silly me.
May 13, '09
Iris, if our representatives simply represented the will of the people, we could elect robots who just read the polls and vote accordingly. Tyranny of the majority is not the system I want to live under.
He. Ca, I have no desire to respond to your puerile, name-calling rants. I've been involved in health care financing issues at both the national and state levels for 10 years, including working with Congress on overall reform. You are wrong about SP rationing, you are wrong about the administrative savings under SP, and you are wrong about the Democrats willingness to "study" SP. The good news is that with advocates like you, SP will continue to be completely unattainable.
Please excuse me, the health care industrial complex is knocking on my door. They have my check ready.
12:45 a.m.
May 14, '09
Miles,
You write: They're using "political realism" and "public support" as smokescreens to avoid saying that they just think you're wrong. You can argue that they should just be honest about that, and I would agree, but I think that's the reason SP isn't on the table.
I do argue that they should be honest about it, and moreover that they should debate the issues. Serious debate would be to the benefit of improving single payer proposals insofar as their criticisms have substance. For instance your argument about "organic" development probably has a bearing on the questions posed to single payer advocates by the divergence between the HR 676 & McDermott/Sanders state-oriented approach, as well as other potentially "intermediate" changes like Pete Stark's bill that Earl Blumenauer is co-sponsoring -- I haven't really got hold of it yet, but superficially it appears to be a robust "public option" that is not quite to the point of opening Medicare to persons under 65. (Btw, despite the rhetorical bad blood between you and He. Ca., he or she seems to have a more positive view of at least some mixed system with "public option" reforms than many single payer advocates.)
Conversely public cognizance of the arguable advantages of single payer would provide standards for evaluating the gains of other proposed reforms -- or their lack -- and, I suppose from opposing points of view, the disadvantages of single payer would highlight advantages of other types of reform. In other words, there is intellectual and policy and political merit to full debate.
Meanwhile dishonestly incomplete debate is apt to lead to poorer policy, as well as already causing poisonous politics in a number of senses, some of which are reflected in exchanges here. Representatives inherently cannot be simple reflections of popular will since popular will is not a simple or constant thing, but if they aren't open and honest about why they do what they do, it breeds distrust that undermines their standing to claim to act on their own best judgment, taking constituent desires into account, which generally is what they claim.
I need to to bed so I won't engage more with your other substantive arguments except to say that I would much prefer whatever rationing any approach (and all must have some sort) has to be transparent and equitable, over the opaque and grossly inequitable rationing of our current non-system. Also that from my point of view one of the highly objectionable features of the enormous waste of current insurance & billing bureaucracies is that it distorts debates over costs (& thus rationing). In principle it may not be bad or unreasonable for a wealthy country in a period with a disproportionately old population to decide to spend as much or even more of GDP on actual health care as we do, or to create room to deal more with individual or sub-group variations than aggregate average outcomes measures of effectiveness of treatments do. But it is hard to have that kind of discussion when so much of the cost goes to inefficient and wasteful administration.
1:09 a.m.
May 14, '09
He. Ca.,
I'm not sure I exactly understand what you're asking, but I intend to write regularly about health care reform & its debates and discontents and politics, as well as other health issues and public health aspects of other issues (and other stuff too). That will go some way toward what you're asking think.
Actually I have intended that for a while & my not having written more already has been purely due to personal circumstance.
There is no "prior restraint" exercised by any of the editors or Kari C. as owner of the site on what I or any other regular contributor writes. When I was invited to be a contributor, by Kari, but I believe following consultation among the editors, it was on the basis of a general understanding that writers should try to be interesting and informative, and that when writing about national level issues, when possible it's be desirable to look at Oregon implications or look at them from Oregon/PNW based angles. Judging from other contributors' writing, that includes personal angles as an Oregonian and doesn't mean giving up perspective as a citizen of the nation. Another guideline is to avoid posts that are little more than event announcements, which is just a facet of the injunction to try to be interesting I suppose.
Those understandings don't seem to me unreasonable or unduly restrictive. Shortcomings in what is written or not written should be laid at the feet of the potential writers & is not due in my experience to any interference from the editors/owners. Presumably their choices about whom to invite have an indirect effect on overall content of columns.
May 14, '09
If you would like to help pressure Congress to pass single payer health care please join our voting bloc: http://www.votingbloc.org/Health_Bloc.php
May 14, '09
"Given popular support for single-payer and it's success in other countries,"
Also, health care in "single payer" western nations costs 2-7 times less on a per capita basis. Opinion polls also show that firm majorities in Britain and Canada support the current single payer systems.
Based on my experiences working for a major provider, the corruption on wall street pales in comparison to the incompetence and graft in our health care industry. In fact, the same rentier mentality found in brokers and analysts is pervasive among MDs.
May 14, '09
Miles, you don't rebut because you know you can't. So we will continue to show you aren't quite what you claim.
He. Ca, I have no desire to respond to your puerile, name-calling rants. I've been involved in health care financing issues at both the national and state levels for 10 years, including working with Congress on overall reform.
Significant heealth care REFORM along the dimensions we are now talking about because the system is on the verge of collapse haven't been on the agenda since 1995. If you were actually working with Congress, you almost certainly were working on efforts dedicated first and foremost to shoring up the current broken system as Wyden has been doing because that is pretty much the only agenda of Democrats and Republicans since the mid-90s and certainly during 2000-2008. Even if you worked with somebody like Wyden, he has said from the get-go his objective was to make sure he preserved the primacy of the private health insurance industry (and force people to bail them out by forcing them to buy private insurance.) Conyer's bill has languished for nearly a decade now because the industry-oriented power center of House and Senate Democrats have refused to take the matter up.
You are wrong about SP rationing
Just saying it when you can prove it doesn't make it true, you pompous blowhard. You know if you actually discussed the details of wealth-based rationing in our current exploitative system based on selfish business decisions compared to how decisions on how we provide care would actually become public policy debate, those with your views would be rejected by the people and the numbers in support of single-payer or a public-plan would go up even higher than they are now. You're absolutely desperate to make sure people aren't allowed to actually examine the rationing issue in all it's facets because you know it will instantly become a powerful argument against private insurance.
you are wrong about the administrative savings under SP
Sorry, even the Lewin Group disagrees with you. Of course the industry spouts a bogus argument on administrative costs that goes something like this: There are certain costs (like marketing, markup on claims processing, etc.) that a single payer plan like Medicare doesn't have, so those shouldn't be counted as "administrative costs" of private insurance either. That's right, this corrupt industry actually argues that because the business costs they incur as a part of their money-making for-profit business (to other for-profits they engage with and sometimes onw) don't arise in a single-payer plan, they shouldn't have to include those costs in their "administrative costs". Talk about outrageous.
and you are wrong about the Democrats willingness to "study" SP.
Talk about just throwing out crazed lies because you can't back actually defend anything you say when confronted with the ugly truth of your position. This takes the cake and we all can see that as doctors and nurses are arrested and ridiculed while "I'm the industry's tool" committee-member Wyden stands by with nothing to say.
The good news is that with advocates like you, SP will continue to be completely unattainable.
No the good news is that we just have to let people like you show how you and the politicians you support actually speak first in defense of a broken, corrupt system, while criticizing (without any actual demonstration of your claims) those who put people first in this reform and we'll have a chance.
Unless, of course, as this suggests:
Iris, if our representatives simply represented the will of the people, we could elect robots who just read the polls and vote accordingly. Tyranny of the majority is not the system I want to live under.
you really reject the concept of REPRESENTATIVE government and instead believe the only obligation of our elected officials is to only represent the powerful, elite, moneyed interests who will keep them elected. Wyden appears to have been in D.C. too long for our own good and by all indications sure has come to believe this.
Fortunately for us, representative government is a much more sophisticated balance between the will of the people and the tempering effect of deliberation by elected officials than you mislead here. The same is the case for single payer/public plan against our corrupt, broken private health insurance system than cowardly, career-driven Democrats like Wyden misleads people.
That is what Iris clearly knows, and was giving you the courtesy of assuming you would respond in that spirit. You didn't disappoint by not holding back and showing exactly what some of us know is the truth about your side. Your side has made it a no-holds barred fight to retain their corrupt power where nothing is out of bounds. That's the hardest truth to accept for those who say we need to put people and not profits and the industry first because of the very values that inform their advocacy. Some honorable doctors and nurses understood this and demonstrated the reality to us in the most civil way, twice, and we saw how aggressively and mean-spiritedly Baucus, Wyden and the rest responded.
May 14, '09
Miles, you don't rebut because you know you can't. So we will continue to show you aren't quite what you claim.
He. Ca, I have no desire to respond to your puerile, name-calling rants. I've been involved in health care financing issues at both the national and state levels for 10 years, including working with Congress on overall reform.
Significant heealth care REFORM along the dimensions we are now talking about because the system is on the verge of collapse haven't been on the agenda since 1995. If you were actually working with Congress, you almost certainly were working on efforts dedicated first and foremost to shoring up the current broken system as Wyden has been doing because that is pretty much the only agenda of Democrats and Republicans since the mid-90s and certainly during 2000-2008. Even if you worked with somebody like Wyden, he has said from the get-go his objective was to make sure he preserved the primacy of the private health insurance industry (and force people to bail them out by forcing them to buy private insurance.) Conyer's bill has languished for nearly a decade now because the industry-oriented power center of House and Senate Democrats have refused to take the matter up.
You are wrong about SP rationing
Just saying it when you can prove it doesn't make it true, you pompous blowhard. You know if you actually discussed the details of wealth-based rationing in our current exploitative system based on selfish business decisions compared to how decisions on how we provide care would actually become public policy debate, those with your views would be rejected by the people and the numbers in support of single-payer or a public-plan would go up even higher than they are now. You're absolutely desperate to make sure people aren't allowed to actually examine the rationing issue in all it's facets because you know it will instantly become a powerful argument against private insurance.
you are wrong about the administrative savings under SP
Sorry, even the Lewin Group disagrees with you. Of course the industry spouts a bogus argument on administrative costs that goes something like this: There are certain costs (like marketing, markup on claims processing, etc.) that a single payer plan like Medicare doesn't have, so those shouldn't be counted as "administrative costs" of private insurance either. That's right, this corrupt industry actually argues that because the business costs they incur as a part of their money-making for-profit business (to other for-profits they engage with and sometimes onw) don't arise in a single-payer plan, they shouldn't have to include those costs in their "administrative costs". Talk about outrageous.
and you are wrong about the Democrats willingness to "study" SP.
Talk about just throwing out crazed lies because you can't back actually defend anything you say when confronted with the ugly truth of your position. This takes the cake and we all can see that as doctors and nurses are arrested and ridiculed while "I'm the industry's tool" committee-member Wyden stands by with nothing to say.
The good news is that with advocates like you, SP will continue to be completely unattainable.
No the good news is that we just have to let people like you show how you and the politicians you support actually speak first in defense of a broken, corrupt system, while criticizing (without any actual demonstration of your claims) those who put people first in this reform and we'll have a chance.
Unless, of course, as this suggests:
Iris, if our representatives simply represented the will of the people, we could elect robots who just read the polls and vote accordingly. Tyranny of the majority is not the system I want to live under.
you really reject the concept of REPRESENTATIVE government and instead believe the only obligation of our elected officials is to only represent the powerful, elite, moneyed interests who will keep them elected. Wyden appears to have been in D.C. too long for our own good and by all indications sure has come to believe this.
Fortunately for us, representative government is a much more sophisticated balance between the will of the people and the tempering effect of deliberation by elected officials than you mislead here. The same is the case for single payer/public plan against our corrupt, broken private health insurance system than cowardly, career-driven Democrats like Wyden misleads people.
That is what Iris clearly knows, and was giving you the courtesy of assuming you would respond in that spirit. You didn't disappoint by not holding back and showing exactly what some of us know is the truth about your side. Your side has made it a no-holds barred fight to retain their corrupt power where nothing is out of bounds. That's the hardest truth to accept for those who say we need to put people and not profits and the industry first because of the very values that inform their advocacy. Some honorable doctors and nurses understood this and demonstrated the reality to us in the most civil way, twice, and we saw how aggressively and mean-spiritedly Baucus, Wyden and the rest responded.
May 14, '09
So we will continue to show you aren't quite what you claim.
Significant health care REFORM along the dimensions we are now talking about because the system is on the verge of collapse haven't been on the agenda since 1995.
He. Ca, you are an unpleasant person and thus I'm not going to respond to your points, with the exception of this one that relates directly to me. Significant reform discussions have been under way since the collapse of Clinton's health reform. If you're unaware of them, it means you must be unaware of anything that isn't written about by Robert Pear in the NY Times. If you're arguing that Wyden's health reform efforts don't count because they aren't as radical as what you want, that's a semantics game that is a waste of everyone's time.
May 14, '09
Another of Miles' mistaken ideas:
but never in human history has a government, any government, undertaken such a radical overhaul of such a large portion of its economy. I don't think our government has the capacity to do it.
The US economy was essentially commandeered by government during WWII. The changes were quick, profound, and concerned many sectors of the economy. We won, and an economic boom ensued.
May 14, '09
Serious debate would be to the benefit of improving single payer proposals insofar as their criticisms have substance.
Chris, maybe we need to go back to first principles on this. Why do you think that Congress, and specifically Wyden and Baucus, haven't seriously considered single payer? Is it solely because they aren't holding hearings on it now, or is it based on an historical review? Single payer was debated in committees in the early 90s and generally rejected, even by most Democrats. Since then, it has obviously been a major discussion point with many liberal interest groups, and has gained some traction with certain industry groups, like family physicians and general practitioners. It is constantly in the background of health reform conversations, and I've never been involved in a health reform conversation where it didn't come up.
Ron Wyden is arguably the most knowledgable member of Congress on health care. He has decided that single payer is unworkable. His thinking may have changed since the late 90s, but if I remember correctly at that point he believed that even if the politics of single payer could be overcome, the pure size and scope of its implementation made it highly likely to fail. And America's experience with managed care in the late 80s and 90s made it clear that Americans did not want to be told by anyone which doctors they could see and what procedures they could have done, certainly not by the government.
I understand your frustration, but to what end does holding a hearing on a reform that is not going to pass move the debate forward? Do you really think that Wyden and Baucus, who together have enaged in thousands of hours of debate and research over health care reform, are going to sit in the SP hearing and suddenly say, "Oh, you're right, that's the best system!"
It's easy to demonize those who disagree with you on policy as "captured by special interests" and "in the pocket of the health care industry." It's much harder to admit that your arguments haven't been persuasive. That doesn't necessarily mean your arguments are wrong -- although I tend to think that most SP arguments are overly simplistic and fail to acknowledge the catch 22, that the sheer complexity of our health care system is exactly what makes SP implementation impossible -- it just means that you haven't won over the people you need to win over. Isn't that the basis of our democracy?
May 14, '09
The US economy was essentially commandeered by government during WWII.
There is a big difference between commandeering an existing production process and turning it towards military rather than civilian use and taking one-sixth of the entire economy and completely restructuring how it works. Plus, the manufacturing sector of the 1940s looks like child's play compared to the byzantine national health care industry of the 2000s.
May 14, '09
Miles wrote:
...the manufacturing sector of the 1940s looks like child's play compared to the byzantine national health care industry of the 50's.
Which is why profound restructuring guided by the public interest is essential.
By the way, governmental intervention in the WWII era US economy extended far beyond manufacturing. Basic goods were rationed at the consumer end. The overall influence on the economy was huge.
Don't trust me. Read the history.
Miles wrote:
Do you really think that Wyden and Baucus, who together have engaged in thousands of hours of debate and research over health care reform, are going to sit in the SP hearing and suddenly say, "Oh, you're right, that's the best system!"
You assume that the research and debate engaged in by Wyden and Baucus have led to enlightenment, while the research and debate of single-payer supporters has been bogus. You seem to engage in hero-worship, or possibly deference to the strong-father leadership style so endearing to Republicans. Neither is well received in these environs.
10:29 a.m.
May 14, '09
Jake,
I'm not sure the entirety of World War II is where I'd want to go with this argument. The mobilization was based on intense, highly propagandized nationalistic mobilization for total war & associated with such phenomena as massive rationing of food & fuel (& attendant black markets), wage & price controls with wages better controlled than prices, cost-plus contracting for war industries, no-strike pledges that arguably laid groundwork for corporatist (political science sense) negotiating attitudes in post-war industrial unions, aided by Red Scare elements of Taft-Hartley whose groundwork was laid in WWII Smith Act prosecutions for violating no-strike pledges.
There just isn't anything comparable on the motivational side in terms of unity of purpose at any level (health services, insurance or drug industries, elected officials, appointed health officials, popular desires).
Also, in many respects the aspects of current partial reforms to which many single payer advocates object resemble the pro-business corporatism of wartime military contracting and profiteering. E.g. the coercive "Massachusetts Model" that tells people they must buy inferior "products" (plans) whether they think they can afford them or not -- a feature of Ron Wyden's plan too -- in ways that increase insurers markets & profits and are open to insurance company abuses in profit-seeking. The emphasis on seeking corporate cooperation and means of doing so in World War II could easily be advanced to support or defend a lot of what conservative and centrist (relative to the spectrum of Congress) Democrats are doing and others are doing to appease them in the "public option" debates.
It might be somewhat interesting to think about the double production conversions -- say of autos to bombers at River Rouge in Michigan and related elsewhere, and then the converse reconversion to civilian consumer durables production after the war. However those to a large extent (with the partial exception of reorganizations required by the advent & full enforcement of union organizing rights between Norris-LaGuardia in 1932 and the peak of union density at about 1/3 of all workers in the mid-1950s) those conversions involved substitutions of the content of production and the demographics of the work force, and not a fundamental reorganization of the structures, agents and terms of management such as HR 676 contemplates.
He. Ca. is right to look at comparisons in the formations of national health systems, the British case probably being the most dramatic -- in a post-war Britain completely slammed by the war, but maybe our current overall economic woes will have relevance there.
Other comparable scale kinds of comparisons might involve nationalizations and reorganizations of various industries at various places at various times.
A final example which may seem a little weird is Prohibition. I have been thinking about this a little bit in terms of trying to understand how a single payer conversion would deal with the legal claims and arguments about "property takings" to which an HR 676 approach would almost certainly give rise, as one of the few cases I can think of in which an industry was made illegal, which more or less is what HR 676 does to private health insurance. (Illegalizing the importation of slave was built into the Constitution). It seems that the legal foundation there was built on long precedent of courts upholding earlier restrictions on alcohol on the basis of the state's inherent police powers. Not clear how easily that case could be made for ending private insurance, although the intersection of such powers with public health powers might fit better.
My attitude towards Miles' arguments is that I think he's a person of good faith who's willing to debate the substance & that there are some very real issues with which the single payer movement is going to have to deal with in more depth as we get bigger and gain more power and traction, which honest debate will press us to do.
1:45 p.m.
May 14, '09
Miles,
For me first principles include that if policy-makers and politicians have reached the kinds of conclusions involved that you claim they have for the reasons you say they have, they have a responsibility to explain that. It is dishonest to say it's because of the politics if it isn't, and it's at least dishonest by omission simply to try to ignore it and force it out of consideration. Since support for single payer is growing, the responsibility to make the arguments grows concomitantly. Likewise the scale of the problems for me outweighs the "busy Congress" argument -- the amount of time and thoroughness devoted to things should bear some relationship to the significance of the issue.
Further, you are focusing on those who you say simple oppose single payer as unworkable. There is another class of politicians, arguably including President Obama and certainly including Jeff Merkley (as well as activists like Kari Chisholm here) who say "I support single payer in principle but think it's politically unrealistic." I am not sure if you are accusing them of lying in saying that, but I take them at their word & the call to include the principles is directed at them too.
You may feel fine in leaving it all in the hands of Wyden & Baucus. I don't. You ask me to parse their psychologies in ways that aren't possible. At most I can come up with several competing plausible hypotheses, among which it is not easy to apply Occam's Razor.
I know little about Max Baucus except for his recent slide on "public option" relative to last year.
With Wyden, there is not only a long commitment to the issue, but a long commitment to a particular approach originally conceived to attract Republican and more conservative Democratic support that he has had to compromise still further to get co-sponsors, now apparently stalled. It is hard to evaluate how the amount of effort he has put into that bill plus the compromises may affect how he looks at other approaches, including even mixed system with "public option" since in his plan there are only private insurers though various kinds of public subsidies and tax breaks for individuals.
Now you suggest that Baucus and Wyden (and probably others) looked at single payer in the early 1990s and rejected it. Two things here:
When I first posted it, my link to the Boston Globe article on "the lessons of '93" significantly amounting to "fighting the last war" didn't come through. I've since fixed that above, but I post it here again & commend it to your consideration.
Secondly, the situation has changed a lot since the early or mid-1990s. The cost-containment strategy advocated by economists, accountants and others who were looking at the situation in conservative economic terms and treating health care purely as a commodity, "managed care," failed. The problem of lack of universality and uninsurance has expanded. At least as saliently, the character of employer provided health benefits, descriptively and in their place in employer-worker relations has changed drastically with rising costs, with those costs increasingly shifted to employees, or limited by offering plans with very high deductibles and more exclusions, and in unionized industries, becoming a focus of demands for givebacks and a source of labor conflict. For non-union employees these changes are burdensome and the trends disquieting or frightening. For union workers and unions fighting to protect benefits, losses over benefits, and trade-offs in other aspects of collective bargaining have created much greater support for reform. The burden of even reduced or cost-shifted benefits & competition issues internally (for workers) and externally (with businesses in countries with coherent government national health systems). Meanwhile Medicaid and Medicare in the public sector face related problems that differ because of the isolation of their populations, by age on the one hand, leading to exceptionally harsh cost issues, and income on the other, leading to restriction of eligibility, now partly reverse for children, but expanded uninsurance in any case.
Predictions of the collapse of the current approach without major reform have now become routine.
Given all of those changes, that the threat of "system" collapse that would require thorough reorganization anyway, evaluations of single payer made 16 or even ten years ago do not seem to me sufficient.
The avoidance of substance and the mantra of "not politically realistic" gives the strong impression of such rejection having become just a knee-jerk background assumption if not an ideé fixe.
<hr/>As for hearings, I don't expect them to change any legislator's mind per se but that applies equally to the testimony of Karen Ignani or proponents of other overall reforms or specialists in sub-areas of reform. For them as well the main policy work, as well as political negotiation, happens outside of the hearings and largely among staff.
Rather the purpose of hearings in general is to put various matters on the public record.
More specifically with Max Baucus' "roundtables" a key expressed intent has been to bring a wide range of stakeholders into a situation and capacity to put their views and concerns on the record and lend the policy formation process transparency. The very fact of that inclusiveness makes the exclusion of single payer views and arguments more dramatic and galling to us advocates as a constituency, and falsifies the claim to transparency.
1:50 p.m.
May 14, '09
One sentence got mucked up. Should be:
The burden of even reduced or cost-shifted benefits, & competition issues internally (for workers) and externally (with businesses in countries with coherent government national health systems) has made employer perspectives much less cohesive and unsure of the status quo & the future.
May 14, '09
Dennis Kucinich: This Is A Hoax! It Is A Swindle! Wake Up America!
Kucinich slams Obama: Healthcare savings ‘unconscionable rip-off’:
"Kucinich slammed the administration’s deal, brokered with insurers, labor, healthcare providers, and other parties to save $2 trillion over the next 10 years as another bailout for a major industry.
"'This is an unconscionable rip-off of the American people. This is a bailout of the insurance industry,'" Kucinich, an advocate of a single-payer, government run system said Tuesday on National Public Radio.
"'Just like we bailed out the banks, we’re bailing out the insurance industries,' he argued. 'And so I emphatically disagree with the approach that the White House is taking. In the end, it’s going to mean more taxpayer dollars going to the insurance industry.'"
May 14, '09
Further, you are focusing on those who you say simple oppose single payer as unworkable. There is another class of politicians, arguably including President Obama and certainly including Jeff Merkley (as well as activists like Kari Chisholm here) who say "I support single payer in principle but think it's politically unrealistic."
I'm not sure those ideas are mutually exclusive. I support single payer in principle, meaning that academically it makes total sense. However, practically I think it's unworkable. And because it's unworkable, I think it's politically unrealistic. Certainly there's a chicken/egg problem here: The inability to implement SP in a way that would make it truly effective is exactly why I don't support it; and the fact that many like me don't support it makes it that much more difficult to make it workable.
For me first principles include that if policy-makers and politicians have reached the kinds of conclusions involved that you claim they have for the reasons you say they have, they have a responsibility to explain that.
I generally agree with this. And I don't want to tar the entire SP movement with the actions of a few bad characters, but my experience is that SP advocates are extremely passionate and emotionally invested in the issue. They look at SP almost as a matter of faith/religion rather than a matter of policy, and often refuse to acknowledge that there are really serious questions about SP's viability. I wonder if some of the reluctance to include SP advocates in the debate also stems from the fact that they are unlikely to agree to any compromise -- it's either SP or they'd rather have no reform at all.
For instance, I've still not heard anyone respond to the following:
May 14, '09
Chris,
I mention WWII not as a fan of the process but to rebut Miles' contention that the US government has not succeeded at large-scale economic intervention. I do not suggest that the wartime effort is a good model for healthcare reform.
The argument that single-payer is unworkable is silly. Other nations have single-payer systems. We have single-payer for senior citizens. What if the Medicare eligibility age was reduced by five years? and than by another 5 years? What if Medicare was extended to those under one year old? and then to those under five years old? At what point would it become unworkable?
Easy answer - never, because total healthcare costs would decrease with every extension of the program.
If someone argues that single-payer in infeasible because the insurance companies and for-profit providers are too politically powerful, that's not silly, just sad.
May 14, '09
He Ca wrote:
"First, we are talking here about a national health INSURANCE system, and not an nationalized health CARE system."
The health care plan attempted by the Clintons in 1993 had criminal penalties for those who went outside the system. It was not just an insurance system, it was nationalized health care.
Does anyone have any doubt that this is still the goal of the Democrats? Total control, that's the goal.
Even if it were 'only insurance' , one need only look at the government record of Social Security and Medicare, lurching from crisis to crisis every few years, to know that we do not want to entrust our future to bureaucrats and legislators in D.C. in anything resembling SP.
May 14, '09
Jake Leander:
The US economy was essentially commandeered by government during WWII.
Bob T:
It was easy to do since the precedents were set by Wilson during World War I. Read the history. Are you defending this, by the way?
Jake Leander:
The changes were quick, profound, and concerned many sectors of the economy. We won, and an economic boom ensued.
Bob T:
The boom was not because government had run the economy or micromanaged it during the war, but because people then started spending their money on new things instead of wearing out everything, and because most other producing nations didn't have that much output for some time. Others foolishly think the boom was aided by out 90% top income tax rate. Suuure.
Bob Tiernan Portland Bob T:
May 15, '09
Bob,
I mentioned history that disagreed with Miles' prediction for government involvement in th economy. As I ALREADY WROTE, I did not mention WWII economic intervention to praise its aims or methods, just to point out that it worked. Whatever the reasons for the post-war boom, it's clear that government restructuring of the economy during WWII did not lead to economic disaster.
Joe,
Your fantasies of Democratic dreams might make a fun computer game. You ought to start writing code and stop making obtuse knee-jerk comments.
Miles,
One answer to your questions on single-payer would be: see Canada. Of course, we don't need to replicate a successful existing system completely, but it's not a bad starting point.
On the matter of compulsion, Medicare allows private supplemental insurance. The Archimedes Movement suggests this as part of their model. I see no need to force people to use single-payer as long as they are contributing to its funding in relation to their ability to contribute. If Donnie Trump wants a private MD on staff, what's the problem?
As to insurance company employees: if we're going to drain resources to keep people working, I can think of many more constructive pastimes than filling out denial of service forms. Folks can work in WPA-style projects. They can do childcare. They can recover natural habitat, i.e., pull English ivy. Any of these would get them of their fat asses, improving their cardiovascular health and thus reducing the national cost of healthcare. Da da!
11:26 a.m.
May 15, '09
Jake,
Your response to a serious issue that pro-worker progressives need to deal with -- what happens to people whose jobs derive from administering unnecessary cost-multiplying procedures of the current partial health insurance system? -- is obnoxious.
It looks like it's driven by resentment of insurance denials which is understandable. Even for those people it points the blame for that at the wrong place. In any case claims adjusters & even clerical workers who merely process other people's decisions form only a small portion of spending that is sucked from care provision into administration.
There are coders and others involved in billing departments of doctors' offices and hospitals, and counterparts at the insurer end who handle the billing. There are people in personnel departments of employers who have to handle the annual & new hire complexities of insurance enrollments, the negotiating of contracts with insurers or of relationships with third party negotiating and administration organizations, dealing with employee complaints about same (at least with some employers), COBRA notices & less frequently administration after layoffs. There are people who negotiate the differential reimbursement rates for different group plans and different providers at both the insurer end and the provider end, and support staffs for both ends, people in provider organizations that set prices for "services" to include other costs not otherwise met due to uninsurance by including them in overhead, rendering actual care costs opaque, and their support staffs. There are people in insurer organizations (or joint insurer/providers like Kaiser) who set and reset policies regarding what is covered at what level (e.g. drug formularies) under which plans, make judgments about equivalence or differences among treatments, procedures and medicines. There are people who handle various tax related aspects for employees, employers, providers and ensurers. Doubtless there are others I'm missing.
I very much doubt that asses of those workers are any fatter on average than those of any other category of service or administrative worker. Lots of health care providers have fat asses or stomachs. Lots of health care reform advocates of all range of positions including single payer do.
HR 676 makes provision for dealing with the very real employment issues, because they are real. Those workers should not be ignored by single payer advocates. Still less should they be somehow demonized or falsely blamed.
Maybe you half meant it as a joke -- if so it failed.
May 15, '09
Chris,
Making joke of obesity is always dangerous ground these days, but at times I succumb. Of course insurance company employees do more than issue denials of service, of course, they are not the only obese office workers in the US, and of course, they are not responsible for the problems of our healthcare system.
Still, their pay is part of our wasted healthcare spending; they would, as a class, be healthier doing work with more physical exertion involved, and that would lower overall healthcare spending.
I'll go now as I can feel my ass expanding as I type.
1:22 p.m.
May 15, '09
Miles,
I'm not sure those ideas are mutually exclusive. I support single payer in principle, meaning that academically it makes total sense. However, practically I think it's unworkable. And because it's unworkable, I think it's politically unrealistic.
Most of the people who say "I support it in principle but don't think it's politically realistic" convey the idea they think it would be workable if you could overcome the political problems with getting it passed, and don't suggest that those political problems are due to unworkability. You suggest that many really think that but won't say so, but there's still a further distinction.
Take Jeff Merkley, who says he'd vote for a single payer bill if it came to the floor, though he won't take any action as of now to bring that about. If you were in the Senate, you wouldn't. In principle, you oppose a single payer reform of the current system, because features of existing relationships and cultural and personal ideas, values or desires make in unworkable. You say you don't oppose the abstract idea as a type of design. IMO that is taking the idea of "in principle" to a more abstract level than what the phrase in relation to "politically impossible" usually conveys.
President Obama's recent "if I were starting from scratch I'd support single payer" probably resembles your position here.
For instance, I've still not heard anyone respond to the following:
Well, that's partly because it's a thread about opening up the debate. I'd like to have Marcia Angell and David Himmelstein & Steffie Woolhandler and others face those questions in public from senators and representatives and see their answers reported. Also interrogated, criticized, rebutted, supported, modified by them or other relative co-thinkers perhaps.
A counter-question: Why would you support a single payer system even "in principle academically" if you thought these questions inherently unanswerable? What would your academic answers to them be if you were building from scratch?
Briefly: -- Under HR 676, the Conyers (& Kucinich & 73 other co-sponsors this session) bill, "expanded and improved Medicare for all" would be mandatory -- and open -- for all, in the sense that it would be paid for by taxes. Moreover, as HR 676 is written, private insurance that covered the same costs, programs & services would be illegal.
Because it would be tax-funded, I am not sure that what you say about allowing additional supplemental insurance on a wider basis than the current bill provides destroying the universal risk pool is exactly true. It would be less true than under Wyden's bill I think because his HAPI Plans would primarily be based on premiums & employer contributions. A tax-funded system would be more comparable to public schools where people retain private schooling options/rights. That can affect the politics of funding, perhaps.
Actually I think HR 676 goes further in making the single payer system both mandatory and exclusive. Certainly in the French system there is considerable latitude for supplementary insurance. I think in Canada that may vary with province. In Germany (rooted in Bismarckian ideas of social insurance that are the source, directly or indirectly, of many of Wyden's ideas, I believe, as well as of Social Security), participation in their not-for-profit non-governmental "sickness funds" is mandatory for people in the bottom two thirds of income, with an additional 15% of the population opting in, so over 80% are in those funds, something under 20% are solely in the private insurance market, and some proportion of those in the sickness funds have additional insurance. (I forget how this relates to old-age pensions & the provision of health care for retirees).
-- On rationing, I need to go back to HR 676 to think about this in some more and remind myself of its exact provisions, but like Wyden's plan, the basic definition of coverage is related to the most generous plan available to Federal employees. This of course is partly political in both cases because it's what members of Congress get.
It may be the case in HR 676, and it certainly could be and probably should be that a single payer system would reimburse providers partly or largely on a capitation basis rather than a purely fee-for-service basis. A key aspect of our current deeply inequitable rationing system is that there are considerable medically unnecessary or ineffective treatments or services due to a combination of fee-for-service incentives and malpractice defensiveness, even while care is completely denied or extremely deferred for other persons.
I suppose political interference in potentially an issue but your certainty that it would kill any s.p. system seems unevidenced. It doesn't seem to have done down other systems, although the peculiarities of the U.S. legislative structure compared to more common parliamentary systems might make it a bigger problem here. Creation of an administrative regulatory body in the right way might help mitigate such problems. But say the Orrin Hatch legislation in '94 that removed patent medicines marketed as food supplements or under other euphemisms from FDA regulation of effectiveness, and to a lesser extent safety, illustrates potential problems.
The rationing issue is of course tied to the new technologies issue and to end of life care issues (also substantially interlinked).
I'll try to come back to this issue more extensively in another context, but as to your broad definition of the OHP approach in the general sense of "what can we afford?" (i.e. not specifically the list mechanism), one of the key reasons to seek the elimination of unneeded administrative & profit costs is to be able to get a better handle and better ability to deliberate that question as a nation.
The other aspect of that problem is the opacity as to actual costs that's introduced by the way provider billing is handled and several different kinds of costs (capital costs, facilities maintenance, personnel, medicines & materials, uncompensated care provided to uninsured) all get folded into the "fees" attributed to given "services" in different ways by different providers, and further obscured by differential price negotiations for different groups and plans among insurers, employer/employee or other groups (or individuals), and providers (including group practices, clinics & hospitals).
I'd throw that back into your court, as to how other kinds of reforms might make actual costs and their actual sources more transparent.
Finally, on rationing, however difficult it may be under single payer or any other kind of reform, it is very hard for me to imagine a worse or more inequitable form of rationing than that we currently use. Likewise we must insistently face the fact that we have rationing now. It seems to me that at minimum a single payer system provides a structure in which a better system of making choices about priorities can take place.
Do you defend the current way of rationing care? Do the proposals being included in the current debates in any substantive way address the rationing that occurs because of spending on care supplanting spending on care? Do they in any substantive way address the lack of transparency and inequities even among the insured population?
-- I agree with you that the dramatic reconstruction of administration and care delivery that would come with a single payer system would involve large scale job loss. If you were to go back through what I've written on BlueOregon about health care reform you'd find that it's not something I've ignored. HR 676 has provisions for dealing with conversion including giving priority to displaced workers in hiring related to the expansion of coverage & care, for retraining, and for financial support in the transition. They aren't terribly specific and clearly if H.R. 676 were to pass there would be need for much more detailed implementing legislation.
However, I don't think that the costs of workforce development needed to deal with the displacements should be accounted as health care costs in terms of understanding their meaning to the issue of cost control. In overall costs of health care provision to the economy, the recurrent non-care costs of administration and profit continue indefinitely as long as the "system" remains unreformed. The costs of transition to deal fairly with the workers involved would be limited in time, perhaps to a decade, and to my mind should be treated more like a kind of capital cost.
The current economic crisis would make this more of a wild card, practically and politically, if single payer were an immediate prospect. There would be arguments against it as worsening unemployment and against the costs of a fair transition.
On the other hand, if the politics of the crisis move us toward a more people-oriented and less banker & finance capital-oriented response to reconstructing the economy, the people-oriented transition policies needed to make health care better and more fully and equitably available and control future care costs provided by single payer might be encompassed in such a reconstruction.
--Technology costs I think are basically a special case of the rationing or priority-setting issue.
<hr/>After this response I'm probably not going to say more on this thread which is approaching chalupaland & I've had more than my say. But I expect to write more posts to pursue the substantive questions (this was really just about open debate), sometimes more discretely from one another. I'll read further comments with interest.
1:34 p.m.
May 15, '09
Jake,
Well, for me the issue is more stomach than ass, which according to the stats is probably worse, healthwise ("apple vs. pear shaped"). ;->
Maybe also I'm oversensitive because I'm in public health and have done some work related to obesity & overweight, from a social epidemiology perspective.
But as single payer advocates I think one of our strengths lies in addressing the class and other social inequities of the current set-up & that we need to look at workers in the administrative jobs in question as workers & that blaming them for their work would be shooting ourselves in the foot, just like blaming fast-food workers for obssity would be, or bank workers for the big-finance bailouts, & on & on.
As you allude, the bigger issues with obesity & overweight have to do with how we've constructed our food system on the one hand and divided our labor on / defined work on the other & the set of structures and incentives and constraints and pressures they put on people's choices that affect their health.
a luta continua.
1:44 p.m.
May 15, '09
Oops: two back:
"Do the proposals being included in the current debates in any substantive way address the rationing that occurs because of spending on administration and profit supplanting spending on care?"
May 16, '09
Jack Leander:
I mentioned history that disagreed with Miles' prediction for government involvement in th economy. As I ALREADY WROTE, I did not mention WWII economic intervention to praise its aims or methods, just to point out that it worked.
Bob T:
Well, that is still something to debate. While the government was micromanaging that economy (with less liberty for people, a topic we won't get into), we had plenty of rationing and had to do without a lot of things and could not replace worn out items for some years. In other words, the success was steered in a very narrow direction and was pumoed by a single major customer.
Jack Leander:
Whatever the reasons for the post-war boom, it's clear that government restructuring of the economy during WWII did not lead to economic disaster.
Bob T:
Well, sure, because the war-time micro-management came to an end eventually. It was hard for it to not work during the war considering the conditions I described above. But you wouldn't want to go on and on like that.
Bob Tiernan Portland
May 16, '09
Jack Leander:
I mentioned history that disagreed with Miles' prediction for government involvement in th economy. As I ALREADY WROTE, I did not mention WWII economic intervention to praise its aims or methods, just to point out that it worked.
Bob T:
I should also point out that it's impossible to compare the two situations. The existance of both the German and the Japanese war machines did focus everyone (for the most part), and was known to be a temporary thing (provided the Allies could prevail). In peacetime, however, such a similarly led, micro-managed economy would inevitably become political far beyond our capacity to prevent it from becoming. People who understand government and basic economics understand that, while starry-eyed romantics do not. All you have to do is examine various managed portions of the economy, such as agricultural production, from inception to what it is now (and what it became long ago, in fact). You can study the economy of the USSR, for example, to see how bureaucrats running things w/o knowing or caring about market forces, to see how that would work. American bureaucrats would be no better over time (a few weeks, perhaps).
The main reason the government as an institution wants to be in charge of health care in some variation of national health care (which would lead to it going beyond single payer if it starts with just that) is because of the power rather than any desire to do good. The idea is not to solve anything, but to be in charge of it and use it as a way to keep the same general strain of government mindset going. And contrary to popular belief, the Repubs will be the progressives' best friends -- once implemented, the Repubs will never get rid of this program even when in a majority. It'll be just one more thing that the government won't do well. The Repubs may not want the blame or credit in creating it, but they'll fight tooth and nail to "improve" it time and again just as the Dems will--to show that they are "governing" properly.
Bob Tiernan Portland
May 16, '09
Bob T.
WWII and single-payer are comparable in the large amount of economic activity to be reorganized by government. Miles said there was no successful precedent. I simply pointed one out.
Large scale economics seldom allows compete confidence in identifying cause and effect. It is clear that before WWII the US economy was still not fully recovered from the Depression, and that after WWII we experienced an economic boom. I do not think it too bold to suggest that WWII government economic issues did not cause severe economic damage, which is all I need to counter Miles' assertion.
Chris,
I'm with you on the importance of social solidarity. I do wonder at times - and this is not a topic for the present conversation - whether 'fat acceptance', which is aimed at allowing people to build healthy self-esteem, also contributes to our epidemic of obesity.
And thanks for the well thought out comments on single-payer. Too bad such comments are not allowed at Congressional hearings on healthcare, even when Democrats hold healthy majorities in both chambers and also control the White House. It makes one wonder....
May 16, '09
Jack Leander:
WWII and single-payer are comparable in the large amount of economic activity to be reorganized by government. Miles said there was no successful precedent. I simply pointed one out.
Bob T:
I understand -- but I still think that the comparison ends at pointing to each example being about reorganization of a "large amount of economic activity". It was probably very easy to make it successful in the short run and with much focus due the need to avoid being defeated, and this was not the first case of economies being put on a war footing (I forgot to mention earlier two of my "favorite" examples of Wilsonian micro-management of the WWI economy: the Price Fixing Committee, and the Commissioner of Finished Products -- the conduct of this managed wartime economy, by the way, led to such things as squashing IWW's lumber-based people in Oregon, Washington and Idaho so that their stikes did not slow the supply of wood for airplanes for the AEF).
Jack Leander:
Large scale economics seldom allows compete confidence in identifying cause and effect. It is clear that before WWII the US economy was still not fully recovered from the Depression, and that after WWII we experienced an economic boom. I do not think it too bold to suggest that WWII government economic issues did not cause severe economic damage, which is all I need to counter Miles' assertion.
Bob T:
Again, it was not given the long-term test (it was, however, in the USSR and we know how that turned out) but the overlay of the on-going war, with the government as main (and major) customer certainly skewed the multitude of lessons one could learn from this example. If it "worked", it was because in that situation the government could point a gun and make it work, at least long enough to win the war. Afterwards, some of this management remained but we also saw a rise in such micro-management at state and local levels that had previously (often) been overturned by the courts, and we'll never be able to know how much economic activity, unemployment, and underemployment has resulted ever since. In that sense, you can say that the Soviet economy worked in that they did manage it, right up until they closed shop.
Bob Tiernan Portland
May 19, '09
Nice animation explanation of single-payer here.
<h2>http://www.pnhp.org/multimedia/animation_what_is_singlepayer.php</h2>