Health Care, Public Option, Drug Ads
Steve Novick
So I am going to jump into the health care debate to make the following argument: (1) that the public option isn’t the only thing that progressives should worry about, and (2) that high on the list of other things to worry about is the fact that Congressional leaders seem to have dropped Senator Stabenow’s and Jerry Nadler's proposal to limit deductibility of direct-to-consumer prescription drug ads.
First, though, I have to indulge in a tangent. I was thrilled to hear the President of the United States say these words in Grand Junction:
I ask sometimes, when I'm in audiences, what people think the amount of federal budget is devoted to foreign aid. And people will say, 25 percent; if we could just cut that out, we could eliminate the deficit. Foreign aid is 1 percent of our budget -- 1 percent. People think, well, it's all these pork projects and earmarks that everybody is getting. One percent. Almost all of our spending is Social Security, Medicare, Medicaid, interest on the national debt, defense spending -- things that are very hard to cut.
For a “where your tax dollars go” obsessive like myself, that was practically a religious experience.
Now. About health care. No, I’m not going to be happy if the public option is abandoned. I think a robust public option, competing with private insurers, is ideal. I think we should fight like hell for it.
But I gotta say, I don’t think that’s the only issue we should be concerned about. I think we could make some major progress without a public option – and that having a public option wouldn’t be a cure-all anyway. Let me explain why.
There are basically two issues: coverage and cost. We need to cover everyone, and we need to get costs under control.
First, it is possible to cover everyone without a public option. It may seem yucky to require people to buy private health insurance, like we force them to buy car insurance … but if we prohibit discrimination against people with preexisting conditions, if we regulate coverage and costs, and cover everyone, it’s still a pretty big deal.
Second, a public option is not necessarily the one key to cost control. I definitely think it would help. But it’s important to know that the existence of private insurance companies is not the major cost driver in the American health care system. According to recently released Federal economic statistics, health care represents 18.5% of GDP – and 2.5 of those 18.5 percentage points represent the amount insurance companies are paid in premiums and do not pay out in claims. That’s about 13% of your health care dollar. It’s more than it should be – but it’s not the difference between us and France. (And yes I know that there are also insurance administrative costs on the provider end, but I don’t think that’s the difference between us and France either.)
The real cost driver in the American system, as Atul Gawande demonstrated in his New Yorker article on high Medicare costs in McAllen, Texas, is overpriced overtreatment. Too many procedures, too many tests, too many drugs at too high a price, in the context of an incentive system which rewards doctors, hospitals and drug companies for doing and selling more stuff, and more expensive stuff, regardless of its effect on people’s actual health.
What Gawande showed is that this phenomenon exists even in the context of our existing public option – Medicare. Sure, Medicare pays less per procedure than private insurance, and it overhead costs are lower – but still, doctors and hospitals in McAllen run up huge Medicare bills, without getting better health outcomes than in other lower-cost places.
So we could have a public option, and still have drastically climbing costs. The flip side is that I think there’s a chance of controlling costs, even without a public option, if Obama’s billion-dollar investment in ‘comparative effectiveness’ research pays off, and if the results of that research are incorporated into regulation of private insurance.
As the New York Times reported in February, the research program will evaluate issues such as:
Is it better to treat severe neck pain with surgery or a combination of physical therapy, exercise and medications? What is the best combination of “talk
therapy” and prescription drugs to treat mild depression?
How do drugs and “watchful waiting”
compare with surgery as a treatment for leg pain that results from blockage of the arteries in the lower legs? Is it
better to treat chronic heart failure by medications alone or by drugs and home monitoring of a patient’s blood pressure and weight?
For nearly a decade, economists and
health policy experts have been debating the merits of research that directly
tackles such questions. Britain, France and other countries have bodies that
assess health technologies and compare the effectiveness, and sometimes the
cost, of different treatments.
The results of this research could be incorporated into an insurance regulation program. You could have regulations prohibiting the insurers from charging co-pays for the most effective and cost-effective drugs and treatments, but allowing the insurance companies to require significant co-pays for treatments proven to be ineffective but expensive. And hopefully, even aside from regulation, doctors (who are often snowed by marketing themselves) and insurance companies would act on the comparative effectiveness research on their own.
I suspect that the Obama folks already have something like this in mind. But so far, I don’t think they’ve done a terrific job explaining how we can control costs – leaving the other side to claim that controlling costs means pulling the plug on Grandma. In particular, I think they’ve missed a chance to talk about costs by hammering away at perhaps the most annoying feature of American ‘health care’ today: direct to consumer prescription drug ads.
I think many Americans already understand full well that the effect of all those TV ads is to convince a lot of people to run to their doctor and demand expensive drugs that they don’t really need. Certainly the doctors understand it. But they don’t want to lose patients, so quite often, they cave. It drives up costs for everyone.
And the kicker is, the cost of those ads is a tax-deductible business expense. We the taxpayers are subsidizing the drug companies’ efforts to convince us to buy stuff we don’t need.
Debbie Stabenow realized years ago that we should go after that tax deduction. Congressman Jerry Nadler has a bill right now to go after it. I stole the idea for my campaign, and it was one of my best applause lines. I think that if Obama and Pelosi and Reid picked it up, it would resonate. I think Americans would say “yeah! That’s right! They ARE trying to talk us into buying expensive stuff that we don’t need – or could replace with generic stuff! And they get a tax break? You gotta be kidding!”
According to the Times, the Stabenow / Nadler idea was kicked off the big Congressional kids’ health care table weeks ago – part of the effort to negotiate with interest groups, I guess. But I think that was a mistake. I think those drug ads are the best available example and symbol of runaway costs. And we need a symbol of cost control that will resonate with people.
So that’s my vote. Call your Congressfolk about the public option, sure. But while you’re at it, tell them to limit or eliminate the tax deduction for prescription drug ads.
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Aug 19, '09
Without tort and class action reform being on the table, there is no credible discussion about medical cost containment.
12:00 p.m.
Aug 19, '09
It's refreshing to read such a thoughtful piece on health care reform, Steve. Even though I think you exaggerate the impact of advertising on "overtreatment," I certainly agree with you that the central issues are cost and coverage.
For me, the key is to get to universal coverage; cost control will inevitably follow, whether we like it or not. To the best of my knowledge, no country that has moved to universal coverage has ever gone back.
I don't share the fear that my fellow Republicans seem to have about a public option (I happen to think SAIF is great, for example) but I agree with you that it is not a cure-all. By no means should that issue be allowed to kill health care reform this year.
Aug 19, '09
Steve,
I, too, enjoyed the Gawande article. Much of it was very informative. I was disappointed, however, in his writing off of medical malpractice law suits as a contributor to the high costs. He does so because Texas passed a cap on court awards in medical cases a few years ago. I think the lingering effect of 20 -30 years of training doctors to practice defensive medicine is still a huge cost driver. I agree with Boats that we are not serious (and we are proving the power of the Trial Lawyers) if we do not address the tort reform issue aggressively.
I also disagree with one of your two main issues, coverage. I don't believe, as you obviously do, that "We need to cover everyone," as you have stated. Last I checked, in this country, we are still free to do many things, but, with those freedoms come responsibilities. If someone is not responsible and does not plan for medical needs, is that your problem? If someone is not responsible and fails to teach his kids not to play with matches, are you responsible when his house burns down?
I truly appreciate the fact that you are not afraid to point out "So we could have a public option, and still have drastically climbing costs." Those who look at what is happening today (not the oft sited studies from the early 2000s) will see that many of Europe's wonderful health systems are having very serious cost containment problems and they are rationing services even more than before.
I want to see reform, too. It should be in the courts, first. Next it should be to bring competition, not by adding a public option, but by taking away all the controlling government mandates that are the real cost drivers. Let insurance companies write policies across state lines. Let them offer minimum or catastrophic plans. Let them write policies that don't offer mandated items like contraceptives, alcoholism treatment, dental anesthesia, self care for diabetes, diabetic supplies, etc., etc. In the 60s, there were almost no mandated health coverages required of health insurers. Today, across the country there are about 2000. This adds cost and removes choice.
I appreciate your post more than most at Blue Oregon and think we should be discussing things like direct to consumer drug ads and all the other cost drivers including tort law and government mandated coverage.
Aug 19, '09
Thanks, Steve, for another excellent post!
Tom writes: I also disagree with one of your two main issues, coverage. I don't believe, as you obviously do, that "We need to cover everyone," as you have stated. Last I checked, in this country, we are still free to do many things, but, with those freedoms come responsibilities. If someone is not responsible and does not plan for medical needs, is that your problem? If someone is not responsible and fails to teach his kids not to play with matches, are you responsible when his house burns down?
Interesting examples you provide, Tom. Like it or not, you, me and everyone pays for those people who does not plan for medical needs (whether through personal negligence, the inability to afford coverage, or outright exclusion by private insurers). These are the people for whom the emergency room is the only option. No preventative care, no annual checkups, just catastrophic reaction mode care. We all pay for that in increased hospital and insurance bills. Also, with the high percentage of bankruptcies in the US due to mounting medical bills, creditors bear cost which gets spread out to us all.
You may not like being your brothers and sisters keepers and deny it you may, but follow the money.
In the case of the house burning down, we may not all share in the cost of the loss, but we do support our socialized fire departments for fighting fires. We all pay for that service and I'm not hearing a lot of arguments to turn those into for-profit ventures.
Aug 19, '09
Jack, I was astounded thre years ago when our broker showed me the top ten prescription drugs advertised and then our group's and then the state's top ten prescription drugs dispensed. the tracking was almost across the board. Steve hits it on the head here.
However, without tort reform and instating "Loser Pays" to the equation of wild class action lawsuits the system will not reform effectively.
Aug 19, '09
". If someone is not responsible and does not plan for medical needs, is that your problem?"
People lucky to have low paying jobs (at least they are employed" are not "responsible" if they put food and shelter ahead of insurance in their budget?
One aspect of a healthy person is adequate nutrition. Are you really saying everyone should buy insurance whether they can afford it or not?
1:40 p.m.
Aug 19, '09
Steve --
I think you're basically right here. I support a public option as well (heck, single-payer, if there was a whelk's chance in a supernova of it passing...)
But, I think it's critically important to recognize that if we're talking about a universal private insurance system, we're not talking about the same health insurance we have today.
We should enact strict regulations on the health insurance industry - regulations so tough that they'll scream about it being "punitive". The idea, of course, is not to punish the health insurance industry (though they deserve it), but rather to 1) curb abuses and 2) put incentives in place that improve health.
In particular, we should forbid the use of "pre-existing conditions" to either deny coverage upfront, do after-the-fact recission of coverage, cancel policies, or to charge different people different rates. In fact, I believe that everyone should be charged the same amount - whether a 60-year-old cancer survivor with diabetes or a 20-year-old Olympic athlete.
Doing those two things will force the insurance companies to make money the old-fashioned way: keep people healthy; focus on prevention.
Another thing: I think that most progressives - most Americans - haven't fully grasped the concept of the Health Exchanges that are being proposed. I know I haven't. One of my tasks this week is to really dig in and understand 'em. But as I understand 'em so far, basically what we're talking about is that if you're self-employed, unemployed, part of a very small business, etc. then you'd go into the Health Exchange. There, it'd be like being employed at a HUGE employer - where risk is shared by hundreds of thousands of people (even millions) and you'd have many choices for health insurance.
Right now, if you're a company with 10 employees, and one gets cancer, your rates go through the roof. But if you're in the Exchange with a million other people, we know almost exactly how many people in that pool will get every kind of disease next year. The rates can be set accordingly, and things get much more stable.
Aug 19, '09
http://www.katu.com/news/medicalalert/3866872.html
and
http://www.katu.com/news/7158206.html
because after all, doctors and hospitals never make mistakes, and tort reform would solve all problems?
I appreciate what Steve and Jack have written. They are the example of how intelligent discussion goes foreward.
Aug 19, '09
Steve - You write that it is still 'possible to cover everyone without a public health care option' OK let's see - what about: 1. Homeless people? 2. Unemployed people? 3. Indigent people? (You may argue that this is the above two catagories combined - but there are others that may be in this situation (like aged or unemployed give ups) without being classified in the first two catagories.
The only way these people are going to get medical care is to have an active disease like TB, Swine Flu or Smallpox (many of them already may be suffering from the former two and God help us if there is an outbreak of the latter) and be declared as a medical quarantine hazard.
If they are not, they are going to go to an emergency room, get the mininum treatment possible (a shot of something "there you're OK goodbye") and (dis)placed back out on the street. You saw that video of the old woman dumped from Harborview Hospital in Los Angeles didn't you??? She was literally dumped on the street in skid row. There is a gigantic building backlog of uninsured who just can't make the choice of buying insurance and then not having a roof or meal.
2:07 p.m.
Aug 19, '09
Steve and Jack - thanks for good posts. Jack's point about SAIF is particularly on point -- and our delegation in DC ought to be told that.
2:53 p.m.
Aug 19, '09
Last I checked, in this country, we are still free to do many things, but, with those freedoms come responsibilities. If someone is not responsible and does not plan for medical needs, is that your problem?
Yes it is because they go to the emergency room and can't foot the bill, resulting in your insurance premiums going up to cover the cost.
2:57 p.m.
Aug 19, '09
The problem with allowing people to voluntarily choose to forego health insurance is not just that in the event of serious illness or injury, the cost falls on the rest of us anyway. It also makes it virtually impossible to eliminate discrimination for pre-existing health conditions, which is critical to maintaining a system of affordable, accessible health insurance for everyone who can afford it.
Why? Because otherwise someone who has never bothered with health insurance who is suddenly diagnosed with cancer can immediately leave his or her doctor's office and sign up for health insurance. And that would be a problem for a public health insurance provider the same as for a private insurer.
In this case, the health insurance companies are right to insist that the trade-off for removing previous health conditions has to be mandatory coverage. That is the point both Hillary Clinton and John Edwards were trying to make during the Democratic primaries last year, when Obama was still insisting you didn't need a mandate.
3:07 p.m.
Aug 19, '09
I saw Obama addressing this issue the other day - he gets it now - made the point that Jack just made.
Aug 19, '09
Kari, a very insightful post. Thank you! To your issues I would add another:
Nothing could be worse than being in hospital and finding out you are no longer covered because your lifetime cap in coverage (as small as $1MM, but generally about $5MM to $6MM; unlimited on Kaiser and Group Health) has been exceeded.
Aug 19, '09
@Kari
Just curious about your statement:In fact, I believe that everyone should be charged the same amount - whether a 60-year-old cancer survivor with diabetes or a 20-year-old Olympic athlete.
Do you think that should apply to all forms of insurance or just health insurance. Does the owner of a $125,000 house pay the same as the owner of a $750,000 house? Does the driver with 4 accidents and 8 moving violations pay the same as the driver with a clean record?
Doing those two things will force the insurance companies to make money the old-fashioned way: keep people healthy; focus on prevention.
There was a story on tv the other day in re: this issue. They stated that the avg person only stays with a policy for 24-36 months b/f moving to another insurer. Given that, the insurer has no incentive to improve their health as they don't see the benefits of it. For this to work, we have to keep people with the same insurer for a long period of time.
Aug 19, '09
Wow, my respect for Steve Novick just went up about 100% based upon this thoughtful post.
As for Tom's comment about the "choice" not to have insurance, if Tom and others (representing a majority of the populace) are truly willing to be hard-hearted enough to turn someone away from even the emergency room if they could otherwise have afforded health insurance and refused to get it, then by all means don't mandate health insurance. But I don't think that's going to happen.
As for the homeless/poor/unemployed/indigent, that's where medicaid has to come in. I am going to assume that any health bill without a public option will have a program such as medicaid to help those who truly can't afford any health insurance.
Aug 19, '09
Now if Mr. Novick will disavow DeFazioism on trade issues, he's got my vote!
Aug 19, '09
No one has said that tort reform is a total solution. Including in the mix of "fixes" is a marker for one's seriousness on revamping the system though.
Who is going to extend their medical services to the underserved and/or riskier patients if malpractice premiums remain the same, compensation is lower, and patient loads are greater and the risk of a ruinous lawsuit is all the same?
One must think that health care providers are not rational actors to believe that tort reform isn't a key issue for the providers.
The reformers should try cleaning up their own act first. However, trial lawyers are sacred cows to the powers that be in this moment, so they won't.
Aug 19, '09
I guess I'm just curious how this works. If everyone has coverage (as they do now, though inefficiently using emergency rooms) and it is with no lifetime cap, and it is all paid for through our taxes, and the only people who will see taxes raised are the wealthiest 1% of the population, and we won't increase our national debt to finance this, where is the magic that makes this happen? I think this is nothing but dreaming of utopia, but, the dreams are paid for with other people's money - the evil rich. What happens when there are huge shortfalls in revenues and costs skyrockets (read the case at the NIH in the U.K. at http://markdowe.wordpress.com/2009/08/12/nhs-the-fundamental-problem/)? Do we then increase taxes on the not-so-rich? It is easy to demonize 1% of the population. I honestly think the debate comes down to this: With properly written legislation, there could be a government solution that would accomplish much of what Mr. Obama wants done. The alternative is to get government out of the way and let competition bring the costs down and the service levels up.
Those who want the government controlled solution either want the power it will bring to them or they have no fear of government inefficiencies or abuses. Those who want the private solution want the freedom to choose and don't trust government as much as they do the private sector. As you can imagine, I want the private solution and have suggested what I think that is, at my blog - http://ttoes.wordpress.com/2009/08/13/ideas-to-improve-healthcare-in-america/
3:39 p.m.
Aug 19, '09
What about this reported deal with the pharmaceutical industry:
http://www.nytimes.com/2009/08/18/opinion/18herbert.html?bl&ex=1250740800&en=7d0939d85b32733a&ei=5087%0A
"A couple of months ago the Obama administration made a secret and extremely troubling deal with the drug industry’s lobbying arm, the Pharmaceutical Research and Manufacturers of America. The lobby agreed to contribute $80 billion in savings over 10 years and to sponsor a multimillion-dollar ad campaign in support of health care reform.
The White House, for its part, agreed not to seek additional savings from the drug companies over those 10 years. This resulted in big grins and high fives at the drug lobby. The White House was rolled. The deal meant that the government’s ability to use its enormous purchasing power to negotiate lower drug prices was off the table. "
Aug 19, '09
Health care will never be affordable as long as doctors are allowed to charge $1825.00 to remove a skin tag. Not as long as the consumer is prevented from comparison shopping.
How can anyone claim that health care is dispensed in a free market system when I don't know how much my bill was for 3 months? I can go online and google any consumer item and see what price it is available for in seconds at various merchants. Why can't I do the same for basic healthcare? Why can't I google "physical" and see the prices that doctors are charging here in Salem so I can make an informed decision. Why can't I?
Aug 19, '09
Do we really need TV ads with a couple sitting in a bathtub out in the middle of nowhere - Do you know anybody that actually does this? I would understand a couple in the same hot tub, but I digress. One of the arguments for big pharma is they need these profits in order to do their research but:
Aug 19, '09
It takes 5 people to pay into Social Security for every 1 beneficiary - and that system is about bankrupt. I don't see how we can afford to create the new largest social program in history -Obamacare, when we can't pay for the social programs we have.
4:46 p.m.
Aug 19, '09
Tom Vail asked... If everyone has coverage (as they do now, though inefficiently using emergency rooms) and it is with no lifetime cap, and it is all paid for through our taxes, and the only people who will see taxes raised are the wealthiest 1% of the population, and we won't increase our national debt to finance this, where is the magic that makes this happen?
Uh, no. Your assumptions are wrong.
No one is saying that "it is all paid for through our taxes".
Whether you're talking about private insurance or the public insurance option, the cost will be paid through premiums. Sorry, but you still have to pay for insurance - even if you get and choose the public option.
That said, most of the proposals that include an individual mandate include sliding-scale subsidies for the poor and middle-income Americans. It's those subsidies that will be funded partly by taxes on the wealthiest Americans and partly through savings -- but the bulk of the cost will be borne directly by the individual consumer.
Aug 19, '09
Someone tell me why I'm getting phone calls from the DNC trying to hit me up for donations and claiming they're "being outspent" by opponents of health-care reform. Jesus K Reist, the DEMOCRATIC PARTY ITSELF, or at least the Congressional component thereof, contains all sorts of <s>whores for the insurance companies</s> "thoughtful" opponents of reform. And Mr. Obama and his advisers are acting like a bunch of spineless fools.
Get ready for 2010 and the new, improved version of the Contract with America, folks.
Aug 19, '09
Kari,
If everyone has to pay, how do we have universal coverage? How do those 10 Million to 47 Million "uninsured" get covered? They are going to pay for it?
My assumption is that some number of millions more people (than are covered today) will be covered by insurance of their choosing (?) and it will be paid for with tax dollars.
Is that not the case? It seems that was what the CBO thought when they said Mr. Obama's "Universal Healthcare Plan" would require over a Trillion dollars not now budgetted over the next ten years.
5:12 p.m.
Aug 19, '09
I'm with Kari on the regulation. If we do not have a strong public option or single payer we need to treat the medical insurance industry like a utiity and regulate their pricing and profits.
They have clearly abused their rights. We had trouble getting insurance for our healthy 23 year old. The policy we eventually got provides the insurance company the right to terminate the policy at any time.... so where is the insurance? The whole concept of insurance is that you have someone else who shares the risk of your medical cost. If they have a right to terminate then there is no insurance. I bet if eveyone actually read the fine print in their policies they would be shocked and say,'this ought to be illegal'. Well it should be.
I talked to a physician this week who has four children who are in their 20's and all four have been denied coverage for trivial reasons (childhood asthma, false reading on a diagnostic test, etc.). He says that the industry has changed significantly in the past five years in how they treat their customers and prospective customers in order to maximize profits. While they have always done that to some extent, it has racheted up significantly in recent years.
In most states only 1 or two companies dominate the market so the concept of free market competition is a fantasy.
Aug 19, '09
Everyone is currently covered, in the loosest sense of the term. It's just that we, the insured, pay for the uninsured when they go to the emergency room -- which is the most expensive time with the least chance of a good outcome.
The opponents of health care payment reform need to understand that we have universal coverage already; it's just the least effective and least efficient form of universal coverage.
Aug 19, '09
"... with Kari on the regulation. If we do not have a strong public option or single payer we need to treat the medical insurance industry like a utiity and regulate their pricing and profits. "
I have thought for some time that what may be needed is the sort of regulation which makes insurance companies WISH there were a public option might be the way to go if the votes aren't there otherwise.
I heard Pres. Clinton on CSPAN speaking to the Netroots convention. Sounded to me like he was saying there were things they could not accomplish in the early 1990s but at least they started---and now they are beginning to happen.
(Kind of like, back in the dark ages, when Oregon legislators put off requiring Kindergarten in public schools. People who had earlier proposed adding Kindergarten over a period of 5 years saying "That was more than 5 years ago--if we would have done it then, every school would have Kindergarten by now".)
Just heard on TV that Sen. Snowe has proposed a trigger--insurance companies get a set number of years to prove they can be competitive, but if the proof is not there at the end of that period, they get hit with what one commentator called "public option on steroids".
The thing is, what is the goal? Public option does not guarantee electronic medical records, or ending "pre-existing condition" discrimination, or asking whether fee for service is the best delivery model.
Which is why I so admired Steve's paragraph,
"But I gotta say, I don’t think that’s the only issue we should be concerned about. I think we could make some major progress without a public option – and that having a public option wouldn’t be a cure-all anyway. Let me explain why. "
I've heard Dr. Kitzhaber and Dr. Bates discuss this issue in Oregon. I heard Dr. Dean debate Dr. Frist on Charlie Rose.
Everyone who wants all elected officials to stand in a line and chant "we must have public option" (as if every slogan 6 words or less solves problems) should remember that Republicans short circuited debate over Iraq with slogans like "support the troops" (until Iraq vet Rep. Boquist gave a speech saying that should mean more than a bumper sticker slogan) and "the surge worked".
This is a complex subject. Obama told an interviewer from Newsweek some time ago that he believes Americans are looking for "explanation and complexity".
Short snappy slogans don't fill the desire for intelligent, complex debate. And if you think the town hall protesters are going to change policy in their favor, I suggest history shows the opposite is more often true.
Aug 19, '09
Unfortunately Steve, while you seem to mean well enough, your argument displays a fundamental misunderstanding of the single payer movement, as well as lack of understanding of the distinction between health coverage (insurance) market reform and health care reform. That leads you to a completely incorrect conclusion about what can be accomplished through regulatory reform of the insurance industry. (Kari is so completely uninformed that he provides little more than campaign propaganda for the people who pay him.)
First, you do not give due respect to the truth that the 20-year plus old single payer movement is based on a very thorough and sophisticated understanding of the health insurance market and the health care market (including providers, hospitals, and pharma) and the relationship between them. For that very knowledgeable community his is about market reform, not health care reform. Most definitely, it is NOT about the other agendas from prevention to electronic medical records to simplistic notions of the role for evidence-based medicine that others have tried to heap on to it. It is well understood that even the advocates of those agendas were correct in their beliefs of the small savings their pet goal would bring to our health care system, it would not "bend the curve" in the cost inflation destroying our health care system. And the same is true about tort reform.
It is in fact that muddled, rather childish focus on different agendas that has given the right wing it's opening over this recess. They have been able to present this as a battle over health care reform. They are not wrong to the extent that some terribly ignorant factions of the Democratic Party have tried to make it that. (It is absolutely no coincidence the biggest blunder to date was by Blumenauer, a PDX Democrat.) And It is also the case that some shameless Democrats like Wyden, Baucus, and Conrad who are opposed to true market reform have immorally tried to take advantage of that.
It is that failure to distinguish properly between the goal of market reform and health care reform that causes you to profoundly misread the lesson of McCallen, Texas and the relationship to so-called evidence-based medicine in this reform debate. You correctly recite the author's point that costs are out-of-control in McCallen because our current system supports and encourages business models based on doing as much testing as possible with little regard for health outcomes (The McCallen debacle has absolutely nothing to do with defensive medicine.) Cast in terms of the market reform/health care reform dichotomy, the proper role of evidence-based medicine is precisely to discourage such business models (market reform). It is absolutely not to circumscribe treatment decisions (health care reform).
I mentioned it is absolutely no coincidence the biggest blunder so far was by Blumenauer, a PDX Democrat. That is because our very own OHP is a reflection of the failure of Oregon Democrats to understand the critical difference between market reform and health care reform. That is part out of ignorance, part out of expediency, and frankly part out of some very suspect values. The OHP is exactly the kind of highly regulated private insurance system you (and Kari, but as noted, Kari is simply, truly utterly ignorant in these matters) advocate. While it is one model for market reform, and not overly successful at that since it is a system with relatively high and unsustainable costs, it most definitely is not an acceptable model for health care reform.
The bottom line reason that the argument you and Kari make about what can be accomplished through insurance regulation is utterly false is to restate the obvious: Such an approach only influences health care indirectly, and in a blunt and unpredictable, counterproductive fashion. When you regulate the insurance industry to prevent the emergence of pathological business models based around treatments and tests, those very same insurance contracts will come between patients and their doctors controlling the health care decisions they make.
What you get is last year's OHP debacle of the Barbara Wagner case. The fact it frequently will be in the best interest of the individual patient outcomes, and of us all in terms of building support for a sound national health insurance system, to pay for treatments and tests that have very low value as judged by evidence based medicine. And probably a lot of them so long as the types of such treatments and tests are diverse enough so that it is not possible for major corporate business models to grow up around them and they are in total affordable under the system.
The bottom line is that a single payer system, as the only kind of insurance system that is responsible to the people through our government process, most definitely can have the processes in place to provide the flexibility required to keep the focus on patient outcomes if that's what we want - and we should. Regulation of the private insurance industry, such as even OHP exemplifies, necessarily and unavoidably conflates achieving marketplace outcomes with patient health outcomes to the detriment of patients. In the OHP, the systemic cost control measures designed to prevent the emergence of pathological business models take concrete form as the actuarially based payment schedule in MCO and PCO contracts.
It is those guidelines which the private insurers then turn around into blanket limitations on patient care with the excuse they are just playing their role in cost control. (And I know from first hand experience that the OHP waiver system is cumbersome and, depending on your definition, compassion in the system is inversely proportional to how terminal your case is.) The right wing is absolutely right about that and I assure you a lot of single-payer advocates looking at how the Democratic Party completely confuses market reform and health care reform in this debate for less than honorable reasons share their concern. Ultimately, it is arrogance and intra-party treachery by Democrats that is going to be to blame if we fail to enact market reforms this time around.
Aug 19, '09
And by the way, people need to pay a lot more attention to finding out the good and bad reasons why Jack Roberts thinks SAIF, organized as a standalone corporation, is a good system. While I think it has some positive aspects, I'd like to ask Jack if he thinks Washington's Labor and Industries system which is much closer to a true single payer system is better, or not, since it certainly is more cost effective than SAIF for small business. (And I say that as someone who has experience in small business with both.)
Aug 19, '09
Latest on the Health Care strategy. The farce of bipartisanship is revealed and thrown under the bus. The bill is going forward in two parts, the insurance reform/regulation to be passed in one bill with 60 votes or more. The second bill, with public option, will go forward under Reconciliation with 51 votes. Makes sense. http://online.wsj.com/article/SB125072573848144647.html
Aug 19, '09
Oregon's own Nick Kristof nails it today in the NYTimes
Prisons or Health Care? http://www.nytimes.com/2009/08/20/opinion/20kristof.html?partner=rssnyt&emc=rss
Aug 19, '09
Steve Duin has a great column I just read---showing the common sense of Peter DeFazio.
"I think we've torn down the most egregious myths," DeFazio said. "It's an educational process. The only consensus I'm finding is that most people agree health insurance needs major reform. We have to plug the loopholes and get more people into the system. The major disagreements start when you talk about the level of government involvement and how you're going to pay for it."
Aug 20, '09
Another thing: I think that most progressives - most Americans - haven't fully grasped the concept of the Health Exchanges that are being proposed.
It is Kari who doesn't know what he is talking about or, very possibly, is intentionally trying to deceive people about as he pushes the agenda of politicians like Wyden that are his paying gig.
In the current debate, the Exchange concept is not intended to be nor designed to be a risk-pooling mechanism. It is instead just a managed-competition mechanism that sets coverage standards. In concrete terms it is simply a list of insurance policies for profit and maybe not-for-profit private companies offer that meet whatever list of attributes are required in whatever legislation is finally passed.
To put it another way, the Exchange concept has nothing to do with direct risk pooling as Kari completely incorrectly implies. Assuming there are no additional regulations on underwriting, which have nothing to do with the Health Exchange concept per se, risk pooling is weak and indirect: In the total fantasy of market competition that supposedly will happen despite the fact that all of the entities in the exchange are exempt from anti-trust law and therefore can wink and nod to price fix, you are supposed to be able to go to the Exchange and find someone offering a policy at a better deal that someone else.
(And be careful, on top of his attempt to claim you don't understand the Exchange concept, he may actually try to just define that as the list of available HAPI plans offered by private insurance companies that meet the constraints specified in Wyden's HAA.)
To paraphrase Fletcher (John Vernon) addressing Senator Lane (Frank Schofield) in Clint Eastwood's 1976 "The Outlaw Josey Wales"
Some of you fearful people can get mad at the messengers like me. But you cannot hide from the fact there is little that Kari argues, spins, or otherwise says about the health care reform debate that is accurate or even particularly in tune with the reality of how the market and private health insurance works. Nor can you hide from how Wyden, Baucus, Conrad, and the rest are arrogantly thumbing their noses at us and think we are too stupid enough to be misled by the spokes-tools like Kari.
And to save you the wait for Kari's cockeye'd explanation of the Exchange concept after he "digs in", here's a little something from the Huffington Post why health insurance exchanges are bound to fail.
Aug 20, '09
How can we possibly pay for this reform and the program they are suggesting. I agree that we need a radical change from the current system but this is not going to work.
Aug 20, '09
How can we possibly pay for this reform and the program they are suggesting.
The only real way to do it is through the only market reform - not health care reform - that brings all risk into a single pool: a single payer national health insurance system. That's a fact. That's it. As I said above, it is really sad that it is the arrogance and intra-party treachery of Democrats how have hijacked this argument for their pet health care campaign and to rescue private insurance companies that is going to be to blame if we fail to enact market reforms this time around.
Aug 20, '09
Del wrote:
"How can we possibly pay for this reform "
Obama keeps telling us we will SAVE money. So apparently NOTHING needs to be 'paid for'.
He will magically provide insurance for 40 million people and spend not one thin dime more than we do now.
This obviously means that the coverage you and I receive will be cut.
The health care system only spends money on sick people, not on well people.
So it is the sick that will face cuts in services that can be shifted over to cover the uninsured.
You ready for that?
Barack 'give them a pain pill, not surgery' Obama is your all-wise doctor.
He knows whose coverage to cut. Say goodbye to grandma.
Aug 20, '09
Say goodbye to grandma is akin to referencing the non-existent death panels
As stated on another thread, Canadians spend 10% of the gross domestic product for healthcare to cover everybody, whereas the US spends 16% and still leaves millions uninsured and many more underinsured. http://www.democracynow.org/2009/8/18/actor_kiefer_sutherlands_grandfather_tommy_douglas
The administrative overhead for for-profit insurance is great. Plus we get to pay for all those direct-to-consumer ads which convince us of diseases we don't have and the need to take expensive drugs.
The Canadian system has its problems. But if we could spend less and cover everyone, warts and all, I'd gladly take whatever flaws the Canadian system has over the yawning holes in coverage and we we pay so much for here in the US.
8:26 a.m.
Aug 20, '09
Joe White continues to post lies taken from the right wing playbook.
1) The health care system only spends money on sick people, not on well people.
Apparently Joe White never has a physical, has his blood pressure or cholesterol checked, has taken a child to a well baby visit. Sounds like you have a typical private policy, Joe, which discourages preventative care!
2)
He will magically provide insurance for 40 million people and spend not one thin dime more than we do now.
This obviously means that the coverage you and I receive will be cut.
Emergency room care is extremely expensive, and moving the more than 40 million uninsured Americans into an insurance plan will save billions of dollars.
From the crazy liberal, the Governor of California (http://www.fixourhealthcare.ca.gov/index.php/facts/more/6771/):
Every single person living in California has access to care—the 6.5 million uninsured simply get theirs in our emergency rooms, the single most expensive place to see a doctor. Last year, 27 hospitals in San Diego County reported losing $620 million in uncompensated care. At Scripps Mercy, the uncompensated care total was almost $50 million.
...
8:31 a.m.
Aug 20, '09
It is Kari who doesn't know what he is talking about or, very possibly, is intentionally trying to deceive people about as he pushes the agenda of politicians like Wyden that are his paying gig.
SPA -- As I said in my comment, I don't understand the Health Exchanges very well yet. I may have misunderstood the risk-pooling aspect, but it doesn't help your cause when you devote so much time to bashing me -- especially when your comments are so misinformed and silly.
Yes, Ron Wyden is a client of my firm's. So is Jeff Merkley and Earl Blumenauer. So is the Oregon AFL-CIO, which was involved in some pretty hefty criticism of Senator Wyden.
You can feel free to call me a "spokes-tool" (what a cute phrase), but I am not authorized to speak on my clients' behalf, nor would I want to. Even I did want to, I'm not sure how I'd reconcile all the disagreements among my clients. I'm pretty sure the rhetorical schizophrenia would be apparent.
When you read my comments, you're getting the real me. I don't write stuff I don't believe - and believe in.
8:34 a.m.
Aug 20, '09
Tom Vail --
Well, not everyone who is uninsured is poor. A lot of those people are middle- and upper-middle income folks who can't get coverage because of "pre-existing conditions". Others are 25-year-olds, mostly male, who think they're bulletproof.
Yes, it's going to cost something approaching $1 trillion over 10 years. That's $100 billion a year. We should do what we can to reduce the cost, sure -- but, for god's sake, that's vastly less than we've spent in Iraq - and we haven't gotten anything for that money.
The federal budget is something like $3.1 trillion. If it becomes $3.2 trillion - and we get universal health care - well, I'm OK with that.
Aug 20, '09
If the 1st goal of healthcare reform is universal coverage it is still nescessary to have some mechanism to assure that coverage is provided, to establish minimum levels of coverage and determine requirements for and administer subsidies. Also some institution must regulate the system and monitor the cost effectiveness of treatment. In other words an agency must do the things a public plan would do -except issue insurance- and do it without collecting any premiums. I don't see how you can fund the kind of oversight and co-ordination needed to contain cost and cover everyone without a primarily self funded public agency.
Aug 20, '09
Joe Hill - The 15 minutes of fame for deranged, raving, right-wing sociopaths like you is over. As of yesterday when Barney Frank led the way, and now the Democratic congressional leadership is being brought to heel to follow, you and the Republicans in Congress have been kicked out of the discussion. So as sad a spectacle as this will become, just rave on crazier and crazier as you are marginalized further and further.
A lot of you Blue Oregonians need to take a long hard look at the Joe Hills. Then take a real hard look at how Wyden, Baucus, and Conrad, have actually tried to take advantage of the turmoil the lying haters like Joe Hill have created to push their efforts on behalf of the private insurance industry, rather than get on board with Democrats to work sincerely and hard for genuine market reform that gets that corrupt industry out of the picture. And then you need to take a hard look at yourself if you are trying to carry water for that weak, scared, stupid faction as Kari continues to do.
Of course, we all know you can't argue with a dining room table. Even if it is "our" dining room tables.
8:41 a.m.
Aug 20, '09
A quick response on Oregon v. Washington worker's comp systems:
(1) Washington is one of only 5 states that have an exclusive government worker's comp provider. Oregon is among the 20 that have a public or quasi-public provider that competes with private insurers, while 25 state have only private insurers. Washington therefore is more like a single-payer system.
(2) Washington is the only state that bases its worker's comp rates on hours worked rather than as a percentage of payroll, so it is a little difficult to accurately compare rates, although arguably Washington's system may be more regressive.
(2) The Oregon Department of Consumer and Business Services issues a report that ranks all 50 states' workers comp systems based on a cost index. In 2008, Oregon was one place lower than Washington (39th vs. 38th) in cost. In 2006, Oregon was 42nd and Washington was 37th.
So this would not seem to support the anecdotal assertion that Washington's worker's comp system is more cost effective than Oregon's.
Aug 20, '09
from http://healthinsurance.about.com/od/faqs/f/preexcover.htm
Question: Will my health insurance cover my pre-existing condition? If you have a pre-existing health condition, you may be worried about what will happen if you must change health plans or buy a new insurance policy. Fortunately, in some cases, you may be able to avoid a gap in coverage.
Answer: Most health plans impose a pre-existing condition exclusion period on new enrollees. If you get your coverage through your job, this exclusion period can be no longer than 12 months.
Aug 20, '09
Why is there so much concern about a health care system being self-sustaining financially when so many branches of the federal government are not? The United States War (aka Defense) Department is not self-sustaining. To the contrary, it is among the world's most, if not THE most, wasteful entities on the planet, but there is very little opposition to funding it. Instead, we have people in Congress who want to toss the military-industrial complex tens of billions of dollars to build war armaments that the armed forces neither need or want. If we just eliminated half of the waste of which this organization and their partners in Congress are guilty, we could finance one of the best health care systems in the world.
We have recently had and will continue to have thousands of teabagger types protesting about the cost of a national health care system. It is probably a good bet that if you corralled ten thousand of these people you would be lucky to find one or two who joined the protests against the Iraq war and none who is now protesting the war in Afghanistnam.
Aug 20, '09
Bill,
Obama says he will not sign a health care bill that adds to the deficit.
Apparently you don't agree, so I'd like to know how much additional indebtedness you are willing to tolerate to obtain whatever health bill you deem acceptable.
What's your price, and how far are you NOT willing to go?
Or is there no limit with you?
Aug 20, '09
"Apparently you don't agree, so I'd like to know how much additional indebtedness you are willing to tolerate to obtain whatever health bill you deem acceptable."
Joe: Apparently you didn't get the point of my comment. That is, the hypocrisy that is involved in the debate over funding of health care. But to follow up on the point you tried to make, if we take money out of the war department's budget and give to a health care system, why would that INCREASE the deficit? You could argue that it keeps the deficit high, but it wouldn't increase it. You seem to be one of these people who don't have a problem with the national penchant for militarism that is breaking the bank, but you draw the line at spending money on humane ventures.
Aug 20, '09
Why is there so much concern about a health care system being self-sustaining financially when so many branches of the federal government are not? The United States War (aka Defense) Department is not self-sustaining. To the contrary, it is among the world's most, if not THE most, wasteful entities on the planet, but there is very little opposition to funding it.
To graphically illustrate Bill's point, check out the top of this great graphic showing the relative amounts of money spent: http://www.informationisbeautiful.net/visualizations/the-billion-dollar-gram/
Aug 20, '09
The United States War (aka Defense) Department is not self-sustaining. To the contrary, it is among the world's most, if not THE most, wasteful entities on the planet, but there is very little opposition to funding it.
To graphically illustrate Bill's point, check out this page and note the top part showing how much our Dept of "Defense" costs, and the estimated versus actual cost of the war in Iraq: http://www.informationisbeautiful.net/visualizations/the-billion-dollar-gram/
Aug 20, '09
Bill Bodden wrote:
"You seem to be one of these people who don't have a problem with the national penchant for militarism that is breaking the bank, but you draw the line at spending money on humane ventures."
So many errors here, where to start.
First of all, militarism. I prefer a much more isolationist foreign policy which earns me the wrath of many Ds and Rs alike.
That being said, the US lived up to its commitments by following thru on Iraq, something many of the rest of the UN members didn't have the courage or commitment to do.
Which is why I would withdraw us from the UN in the first place. But since we're there, we should live up to what we commit to do.
The 1991 ceasefire in Iraq was continually violated and Sadaam deceived the international community in an effort to bluff Iran.
Sadaam lied, people died.
If a madman runs into the street waving a gun and the cops shoot him, but later find the gun wasn't loaded, are the cops the bad guys? I don't think so.
Second, I am all in favor of people spending as much as they wish on humane ventures.
How much of your own money have you spent to buy health insurance for a family that can't afford it?
But it is not the job of the federal government (in our system of limited government and separation of powers) to be the world's kindest charity.
It makes no sense to send a dollar in 'charity' to Washington that is returned as a dime to 'help' someone. Usually it's a vote buying scheme anyway.
You want to be generous and help people buy health insurance? Use your own money to do so. Don't use tax money to paint yourself as a charitable person.
Aug 20, '09
We need tort reform desperatley but no one wants to take on the big lawyer's unions.
Aug 20, '09
Congress Deadlocked Over How To Not Provide Health Care:
Though there remain irreconcilable points, both parties have reached some common ground in recent weeks. Senate leaders Harry Reid (D-NV) and Mitch McConnell (R-KY) point to Congress' failure to pass legislation before a July 31 deadline as proof of just how serious lawmakers are about stringing along the American people and never actually reforming the health care industry in any meaningful way.
"People should know that every day we are working without their best interests in mind," Reid said. "But the goal here is not to push through some watered-down bill that only denies health care to a few Americans here and a few Americans there. The goal is to recognize that all Americans have a God-given right to proper medical attention and then make sure there's no chance in hell that ever happens."
"No matter what we come up with," Reid continued, "rest assured that millions of citizens will remain dangerously uninsured, and the inflated health care industry will continue to bankrupt the country for decades."
http://www.theonion.com/content/news/congress_deadlocked_over_how_to?utm_source=a-section
Aug 20, '09
Regarding Jack's comments on the WA and OR workers'compensation systems. I've managed and adjudicated claims in both systems. The L&I model is an endless paperwork nightmare. There are needless delays for treatment for the injured worker as well as administrative relief for either the worker or the company. Suggesting that a state-wide healthcare model could be born out of L&I workers' compensation, while interesting, is a fool's errand.
Aug 20, '09
tl (in sw): Thanks for the link to the chart. Very interesting.
Joe: I would respond to your comments above, but it would get us off topic. I also suspect it would be pointless.
Aug 20, '09
Concerning Kurt Chapman's comment:
Regarding Jack's comments on the WA and OR workers'compensation systems. I've managed and adjudicated claims in both systems. The L&I model is an endless paperwork nightmare. There are needless delays for treatment for the injured worker as well as administrative relief for either the worker or the company. Suggesting that a state-wide healthcare model could be born out of L&I workers' compensation, while interesting, is a fool's errand.
My experience, and those of people I know, has been exactly the opposite for comparable situated workers. One doesn't have to believe me, but perhaps one also needs to take Chapman's comment with a grain of salt based on the statement about administrative relief (there are administrative processes one must also exhaust under our system) and an earlier claim:
However, without tort reform and instating "Loser Pays" to the equation of wild class action lawsuits the system will not reform effectively.
Tort reform simply is NOT a contributor the escalating costs of our system and the "defensive" medicine argument simply has not been borne out by research. "Lazy medicine", on the other hand, and the McAllen lesson of a pathological business model based on excessive testing, are different stories with which tort reform has no connection.
Concerning Jack Roberts' comment:
Jack's comment also had a link and a revealing statistic that does not support his contention that the very facts he cites would not seem to support the anecdotal contention that Washington's worker's comp system is more cost effective than Oregon's. In the link it is noted that
Tracking the longer-term trends, the national median rate index peaked in 1994 at $4.35 and reached its lowest point in 2000 at $2.26. It decreased to $2.48 per $100 of payroll in 2006 after increasing in 2002 and 2004. For 2008 it has continued its decrease, now to $2.26, which ties the all time low
During that same period, SAIF's relative ranking increased from 42 to 38 (meaning became LESS favorable compared to the rest of the country), while L&I's decreased (meaning became MORE favorable compared to the rest of the country) from 37 to 39.
As far as the issue of percentage of hours worked versus percentage of payroll. Washington's system is actually progressive in a very interesting way: Wages and wage increases are not penalized by increased workman's comp levies so that the net wage/wage raise an employee receives is not a gross wage/wage raise the employer can afford decreased by the workman's comp contribution. The opposite is the case in Oregon: An employer must determine the gross wage or wage raise it can afford to pay and give the worker only a net wage/wage raise after the workmen's comp contribution is deducted.
Put another way, in Washington, the "workman's comp penalty" militates to keep a lid on the number of hours employees work. In Oregon it militates towards keeping a lid on employees compensation rate.
Finally, it must be noted that SAIF's history has been tumultuous at best, including a radical reorganization in the 1980s, and the current form of SAIF reflects considerable bad faith and political intrigue during that history. While L&I has had it's own ups and downs, it has existed more or less in it's current form for nearly a century (I don't know the actual date L&I was created). As a state agency, L&I is subject to the public in a way that SAIF as an independent corporation is not.
With all due respect to Jack, the argument whether Washington's workmen's comp system is more or less cost effective, or more or less favorable to working people, turns on much more sophisticated understanding of the statistics and what they mean the particular treatment he gives them.
Aug 20, '09
And to drive home the point that this about being honest to reality rather than a commitment to a particular health insurance system, I wanted to put this call to action in a separate comment.
I support single payer because the facts argue it is the best market reform and market reform is the only way we are going to bring health care costs under control.
Nonetheless, I also quite recognize the best we are going to get is some form of public option, so the only responsible thing to do is to argue for a public option that actually accomplishes market reform.
The President clearly had this same line of thinking in mind in his campaign position against mandates and for a public option. Those who watched his town hall online today as I did may have noted he did not reaffirm his opposition to a mandate but he did unequivocally reaffirm his support for a public option. (It seems the opposition to a mandate has been replaced by support for income based subsidies.) So I think we can conclude a mandate will be in the legislation, especially since House and Senate Democrats who represent the industry are for mandates.
Now I know it is also quite fashionable in Blue liberal circles to bash Blue Dogs Democrats. However, I want to quote a couple of comments by Rep. Mike Ross (D-AK) who Blue liberals have made their bete noire in what obviously is an otherwise troubling story:
"The extreme right had a two-week love affair with me," Ross said. "The extreme right, simply, they do not want healthcare reform. And so, they saw me as killing healthcare reform because I put the brakes on healthcare reform."
On the public option, Ross said he would not vote for a plan that would "force government-run healthcare on anyone. Period." But he also said that the House bill contained a public plan that is "strictly…an option."
In other words, he is opposed to a mandate to participate in a public option, but I can't find a comparable statement of opposition to a public option in any of his statements. And his office confirmed to me that he is not categorically opposed to a public option
Why does all of this matter? Because it suggest the current political situation for sure is not how the media presents it. And it also suggests the right political tactics are not what the media, and the industry wants to trick us into pursuing.
In the last 24 hours we have heard reform legislation in the Senate will be split into two parts. The first will be insurance reform and it will pass because a lot of different and devious interests will fight for their preferred version. The second piece will potentially create a public option and the political fight will be much more difficult.
So the first thing progressive activists should be doing in the next 96 hours is determine if this indeed is how it is going to go down.
The next thing progressive activists should be doing is focusing massive effort on getting everyone to tell their Senators the first part must contain three fundamental elements:
1) Insurance reforms that will absolutely prevent private insurers from "cherry picking" and therefore cause adverse selection in any plan (ie. a public plan)
2) "Play or Pay" requirements on business with due consideration
3) Explicit language in the legislation that the mandate is conditional on creation of a public plan in the second step. If the second step fails to happen, or to result in a public plan, the mandate is off.
With regard to the last objective, I think people can appreciate the power of the argument that just as the Blue Dogs and the right say people should not be forced by the government to participate in a public plan, neither should the government, and especially neither should Democrats, collude with corporate interests to force people against the people.
With those three things in place, the result will be that the Senate and House will be in a difficult position to produce a result that does anything but create conditions for a robust public option that is a right first step towards market reform.
And if activists bring sufficient pressure to bear so that we succeed in getting those three things into the insurance reform component, you can bet the last dollar the insurance industry wants to snatch from you that Senators and House members will be looking for the easiest, fastest way to get the second component done with a public option with the 2010 elections looming. That sets up the next step for activists:
1) Bring pressure to bear that the second component simply is legislation that allows anyone, including businesses under the play-or-pay requirement, to buy into Medicare.
With sufficient restrictions on private industry to prevent adverse selection, conditions exist which militate to bringing a healthier cohort of people into the Medicare system, which changes the financial picture dramatically.
Finally note that if the dual bill approach is not what happens, the conceptual framing of splitting insurance reform and creation of a public plan is still useful and the goals for activists are still a good strategy.
Aug 20, '09
This should have said:
"and especially neither should Democrats, collude with corporate interests to force people to give their money to the private insurance industry."
Aug 20, '09
To Tom Vail and Kim who argue tort reform is an essential part of reducing health care costs:
I posted before a study that finds that medical malpractice premiums account for less than 1% of health care costs:
Medical malpractice premiums are less than one-half of one percent of overall health care costs, and medical malpractice claims are a mere one-fifth of one percent of health care costs.
http://www.centerjd.org/air/pr/090722.html
Tom questioned the study, but provides no alternative stats or studies. Can either of you provide statistics or studies which support your view that tort reform/liability is such a driver of health care costs? Can you provide examples of US states or foreign countries where tort reform has had the results you believe we could get nationwide here?
Aug 21, '09
WE need a public option.
Apparently Republicans enjoy paying 30-60% more for their crummy health care. In the immortal words of Carl Perkins: Rave on, children I'm wit chew.
Apparently they want to have end of life discussions with their insurance carrier (sorry, no coverage, drop dead) and not a government paid doctor of their choice.
So for those who are sentimental about that fairy tale called the free enterprise system, I say let them have it.
Yes to public option. No to insurance reform. If they want to make their (death) bed with anti-social(ist), free market mechanisms, I say let them have their wish.
Aug 21, '09
Bill Bodden wrote:
"Joe: I would respond to your comments above, but it would get us off topic. I also suspect it would be pointless."
I was simply responding to your dig about me 'not supporting spending on humane ventures'.
I do support humane ventures.
The question (and it's not off-topic at all, it's the main point of discussion between conservatives and socialists) is whether the government is the proper venue for humane ventures.
If you want to start a charity work that gathers donations and buys health insurance for those who truly can't afford it, you can count on me donating.
But the Constitution doesn't set up the federal government as a giant charity organization.
The founders gave us a system of separation of powers and limited government.
We can dream up lots of humane tasks, but should we assign them to the federal government?
Do we want a health care system with all the compassion of the IRS?
It's on-topic, so ahead and defend it.
Aug 21, '09
Signs of Joe White's mental problems:
1) Lack of contact with reality:
it's the main point of discussion between conservatives and socialists
He's for sure not a conservative and few if any comments here indicate anyone is a socialist.
2) Distortion of language and perception, and comments of others:
whether the government is the proper venue for humane ventures.
He plays semantic games with the term "human ventures" from how it was used in the question. His does so to use that to launch into entire fringe theory of government. From the leap he's made, he would have to be opposed to the whole notion of public health, military defense, sanitation, social security, Medicare, etc. (Another sign of his problems would be irrational distinctions between what is a "humane venture" and what isn't).
3) Disconnected assertions that are irrational because they don't logically follow and aren't supported by any argument:
But the Constitution doesn't set up the federal government as a giant charity organization.
The founders gave us a system of separation of powers and limited government.
From Bodden's thoroughly sane comments about how we the people can act collectively to make best use of our resources in service of our nobler instincts in a representative Democracy, he babbled on from incoherent theories of "humane ventures" to ravings about "giant charity". Of course there is no actual argument there, just disconnected shouts. It's almost like when one hears a disturbed person mumbling to themselves and occasionally raises the decibel level of a fragment of a statement to audible level.
4) Paranoia about the government
Do we want a health care system with all the compassion of the IRS?
Exactly what is the connection between a public health insurance system and the IRS, and specifically in their mission, other than they both would be agencies that we the people collectively have decided to establish?
Take a deep breath Joe White. You are right in your apparent belief that there are a lot of people who support reform that you see as on the other side who make assertions that are as irrational as some of those you make. Blue Oregon is thick with them and there are more than a few in the Congress.
But most the folks in the grassroots and in Congress working hard for sensible, humane, health care reform who want to make sure you have access to the health care services you choose for yourself. Unfortunately, your arguments so far show you don't actually want others to similarly have access to health services they would choose for themselves. That is all the serious reformers that you are so vehemently opposed to that it drives you to distraction are about. We would like to have honest, rational conversations with you and people who share your distorted views about health care reform, but that is not your goal.
Aug 21, '09
"If you want to start a charity work that gathers donations and buys health insurance for those who truly can't afford it, you can count on me donating."
Let me compliment you on you willingness to donate a few bucks to a worthy cause, but let me ask, "If you are willing to donate, say, 50 bucks why would you have a problem - instead - paying an extra $50 on your taxes?" To anticipate your response, there is no guarantee that giving to a charity will be more efficient than giving to the government. Unfortunately, there are many incidents reported in the press about failures and criminal activities in some charitable organizations.
I'm reminded of a TV reporter asking people on the street what they thought of health care reform when the Clintons were bungling their attempt. The reporter asked, "How about if instead of paying insurance companies premiums you paid the same amount of money in taxes?" One person said he was opposed because he didn't want his taxes raised. The reporter explained that financially it wouldn't make any difference to him if he no longer had to pay insurance premiums. The response was, "I don't care. I don't want my taxes raised." The reporter came back with a suggestion that people might pay less in taxes than premiums and/or getter better medical care. Again, the response was, "I don't care. I don't want my taxes raised."
"The question (and it's not off-topic at all, it's the main point of discussion between conservatives and socialists) is whether the government is the proper venue for humane ventures."
It seems to me perfectly proper for government to promote humane ventures. To the contrary, the government should not be engaging in inhumane and criminal ventures such as unprovoked aggression against other countries. Consider the illegal war on Iraq and Obama's misadventure in AfPak as examples.
Joe, I think you might want to check some reliable source, which excludes right-wing radio and TV pundits, to learn the real meaning of "socialists" and "socialism." When corporations own the government, as is the case here in the United States, that is not socialism.
"But the Constitution doesn't set up the federal government as a giant charity organization."
What Constitution, Joe? Presidents, politicians in Congress, pundits in the media, and the people trot out the Constitution when it suits them and ignore it when it is politically expedient.
Prior to the vote in October 2002 to authorize the illegal aggression against Iraq, Senator Byrd, the recognized authority in the senate on the Constitution, made a speech informing his fellow senators they would be violating their oaths to uphold the Constitution if they voted to transfer the authority to go to war to the president. More than 70 senators did so - for political expediency. And about 75% of the people, according to polls, agreed to these senators violating the Constitution. Is that the Constitution you have in mind, Joe?
Aug 21, '09
Bill Bodden asked:
"Let me compliment you on you willingness to donate a few bucks to a worthy cause, but let me ask, "If you are willing to donate, say, 50 bucks why would you have a problem - instead - paying an extra $50 on your taxes?"
It's an honest question, and I don't mind answering it.
I don't want the govt in charge of health care for the same reason I wouldn't want the government to be in charge of food production and distribution.
We need to beware of becoming beholden to the government for our necessities.
Our founders had a healthy distrust of government power, and I share that.
They set up a limited government with few, and enumerated powers.
It has given us, while not a perfect system, the best experience with political freedom that the world has probably ever seen.
True, a charity may be (at times) as inefficient if not more so than a government agency (usually the reverse is the case, but for the sake of argument I'll accept the premise).
The difference is that if that occurs, you have the option of immediately stopping your contribution to the inefficient bureaucracy and seeking a better way of accomplishing the desired goal.
If you give government the opportunity to establish a monopoly, you make government the 'only game in town', and then you are stuck. There is no incentive to efficiency or compassion when the field is swept of competitors.
You're gonna get a health care system with all the efficiency of the DMV and all the compassion of the IRS.
And no options.
Aug 21, '09
Joe White's response to Bill Bodden is the clearest, most concise explanation I have seen of why large numbers are showing up at Town Halls.
Gerald Ford also said it quite succinctly in 1974: "What is it, in a few words, that all Republicans believe? We believe - along with millions of Democrats and Independents - that a government big enough to give you everything you want is a government big enough to take from you everything you have."
Aug 21, '09
Critical questions to anyone considering a public option should be:
Are you willing to give up tax deductibility of your health care expenses/insurance cost in order to finance a public option?
Are you willing to add a 1% - 3% employee paid payroll tax to fund a public option?
Are you in favor of an employer payroll tax of up to 8% (play or pay) for those employers not willing to provided healthcare insurance for their employees and families?
Question #3 is probably a slam dunk. If the responent is not willing to answer "YES" to either of Questions #1 or #2, then they should have no say in the debate.
I could easily answer "YES" to all three questions.
Aug 21, '09
A government agency may be (at times) as inefficient if not more so than a corporation, but if that occurs you have the option of withdrawing your support of the inefficient bureaucracy and seeking a better candidate to accomplish the desired goal. That is, of course, assuming that you actually believe in democracy...
If you give a corporation the opportunity to establish a monopoly, you make it the 'only game in town', then you are stuck. There is no incentive to efficiency or compassion when the field is swept of competitors.
Aug 21, '09
Ed Bickford wrote:
"If you give a corporation the opportunity to establish a monopoly"
Since most mid-size and large employers self insure, there are literally millions of companies to choose from.
You do understand how this works, don't you?
Aug 21, '09
I am a socialist and I support socialized medicine, systems in which the government operates health care facilities and employs health care professionals, like in Finland, Spain, Israel, Cuba, and the U.K.
Like in our own Veterans Health Administration, and like in the medical departments of the U.S. Army, Navy, and Air Force.
"Single Payer" is therefore a compromise for me.
You want "Public Option"? Then you START negotiations from the socialized medicine position and then let the Reich propose the public option as a compromise. And then you prepare for the bait-and-switch. Politics is not rocket science.
But since Democrats are either too dumb or too ideologically blind to do that, here's an alternative:
Oppose the privatized-wealth-generating sellouts now being contemplated. Join with your equally ideologically blind Republican sisters and shout down the corporatists' plans until only Single Payer remains on the table. All of you who have followed Obama like lemmings to the cliff edge can still change course and get what you say you wanted all along, even if it's not socialized medicine.
Aug 21, '09
Arguing with J. W. would be like aguing with a kitchen table. I know how monopolies work, and I know J. W. would never admit the truth of how they do.
Aug 21, '09
Ed,
Perhaps I took it for granted that you understand self insured plans. From your evasive answer, I am not sure that you do.
In a self insured plan (which most mid-size and large employers use), the employer collects the premium, the employer pays the claims.
If there is money left over after claims have been paid, it is the employer who pockets the money and makes a profit.
It is important that people understand this, but many do not. (The fault is not entirely theirs. Many employers gloss over this in order to protect health insurance as a profit center for the business.)
The employer contracts with an 'insurance company' to provide administrative services and a line of reinsurance in case the amount of claims goes overboard in any given year.
The risk is largely carried by the employer. The employer does the 'insuring', not the 'insurance company'.
The only time that the 'insurance company' is on the hook as far as risk, is in the rare instance that claims greatly exceed premiums in a given year.
Most employers make a nice profit on their self insured plans each year. If they didn't they would not continue to sponsor them.
So there are literally millions of insuring companies out there. The US is nowhere near monopoly when it comes to health insurance.
No where near.
Aug 21, '09
Joe, you have an incomplete and simplified view of Employers' Self Insurance. As one who has administered and managed such plans let me fill in the knowledge gaps:
Aug 21, '09
Knock on wood! I doubt J. W. is convinced of much by your fine exposition of the onus of self-insurance, Kurt. It was merely a dodge by him to avoid having to admit that he and his ilk do not believe in democracy at all, wishing to be granted aristocracy instead. The reality of the operant monopoly on health care stands irregardless, forcing people to put their finacial survival up as collateral for being allowed to live.
Aug 21, '09
Kurt,
Yes, I presented the concept in simplified language so that all could understand it. But everything I said is accurate.
I could (like you) go into much more technical detail and then claim 'your understanding is incomplete and simplified'
What you appear to imply by this is inaccuracy. But nothing I said is inaccurate.
Your blanket statement that self insure plans are 'revenue negative' gives a false impression however. Yes, in some years employers do not make a profit but in most years they do.
In either case (profit or loss for the employer), it is not the 'insurance company' that makes a profit by carrying the primary risk. The 'insurance company' makes it's profit from the relatively safe activity of administering the employer's plan. They also make a profit from the reinsurance.
Of course, the main point of this was that health insurance is not anywhere near a monopoly at present.
There are millions of companies insuring their employees. The 'insurance companies' that Ed is so frightened of are playing a secondary, administrative role.
Aug 21, '09
Joe, you are either deliberately obtuse or just plain nuts. Most employers who self insure DO NOT make a profit off of self insurance in most years. It just does not happen. If they did, then US Steel would still be in operation and would not be out of business; GM would not have PAID $5.3 Billion to the UAW for them to take over GM's health care trust for union members, retirees and dependents and U.S. Freightways would still be in operation out of their former Portland Hub instead of being now known as USF, Inc, and amalgamation of Reddeway, Holland and what was left of USF.
Aug 21, '09
Kurt,
Don't put words in my mouth.
I didn't say it was enough profit to make up for a bad business model.
But they take in more in premiums than they pay out in claims.
Aug 21, '09
You know Joe, you just keep digging a deeper and deeper hole with your lack of knowledge and understanding. Your otherwise plausible points are lost when you divert to areas you nkow little, or nothing about.
The three examples I gave were self insured plans that so overloaded the existing company with debt that they caused the very actions I described, not "a bad business model" as you described.
By the way, thanks for the best chuckle of the evening, I'm sure andrew Carnegie would be pleased to know that his US Steel Trust was a "bad business model".
Aug 21, '09
Joe: You make reasonable arguments in your response to my comment. The problem is that you based your comments on selective viewing. You are right in being skeptical about governments, but you ignore the fact that governments also can get it right.
In the World Health Organization Report for Year 2000 the French and Italian national health systems (government-run) were rated Number 1 and Number 2, respectively, despite France changing governments to include socialists and conservatives. If ever there was a chaotic series of governments, Italy has had it, but still it came in second on the list for overall attainment and delivery.
In case you don't know or forgot, the United States came in at 37th on that roster - just two slots ahead of Cuba despite the latter being under a punitive embargo. Given the escalating costs for health care under our corporate system, the United States might very well come in with a lower rating if there were a new survey taken.
As for Gerald Ford, he wasn't the brightest.
Aug 21, '09
Bill,
WHO is a political tool of the UN.
It's hard to get a good rating on a non-government health system when one of the requirements is having a government-run health system.
Who cares what the UN thinks? Not I, and not most Americans.
If we wanted to be like the rest of the world we would've stayed in those countries instead of starting this one.
Aug 21, '09
Kurt Chapman wrote:
"By the way, thanks for the best chuckle of the evening, I'm sure andrew Carnegie would be pleased to know that his US Steel Trust was a "bad business model"."
Step away from the straw, Kurt. Quit building strawmen.
Nowhere did you hear me blame AC (dead since 1919) for the troubles of US Steel many decades later.
Is that really the best you can do Kurt? Honestly?
Aug 21, '09
btw Kurt, when you claim:
"Most employers who self insure DO NOT make a profit off of self insurance in most years."
are you counting on people forgetting that you admitted that those who self insure usually
"have a 3-5 year history of claims paid to premiums paid of 70% or less" ?
Do you expect us to believe that this goes south as soon as they self insure? It does not.
Employers generally make a profit from their health plan.
Aug 21, '09
Joe go home; you clearly haven't a clue what you are talking about. Kiddie time is over, now let the adults carry the conversation.
Aug 21, '09
Kurt Chapman wrote:
"If the responent is not willing to answer "YES" to either of Questions #1 or #2, then they should have no say in the debate."
You know Kurt, most folks aren't afraid of debating people who disagree with them.
Your view that some should have no say in the debate is the mark of someone who isn't confident of his position.
They usually start name-calling and tossing around ad homs soon after. oh I see you did.
Aug 22, '09
Perhaps Kurt and Joe could lend more weight to their respective arguments by providing statistics or studies which back up their claims. Little or no progress is made in the discussion by simply poking holes in the other's argument, questioning one's intelligence, or saying something is so because one says it is so.
Bill provided some stats from the WHO. Rather than questioning the findings by discounting the organization, I invite Joe to provide stats or a study from an organization his believes to be unbiased and apolitical. It's always easier to poke holes in someone else's argument than it is to persuasively state and strengthen one's own.
Aug 22, '09