You’ll remember that last week the “Max Baucus” health reform bill moved from a Senate subcommittee to the full Senate Finance Committee. This week, debate has continued in that committee about the many amendments that have been offered for the bill.
Yesterday saw the defeat of two amendments to add a public option to the bill, one offered by John D. Rockefeller (D, WV), and the other by Charles Schumer (D, NY). Remember that a public option would offer people who do not have employer health benefits the choice between buying private insurance or buying government operated health insurance.
Of the two amendments, the Rockefeller amendment was more “robust,” in terms of strong competition to insurance companies. It would have paid providers the same rates as Medicare, plus a bonus for those providers already seeing Medicare patients. The Schumer amendment was more of a compromise, offering a public option, but not allowing the government to set rates. Instead, rates would have to be negotiated with providers, just as private insurance companies now do. The Schumer plan would not have had as much power as the Rockefeller plan to keep insurance rates low.
Despite the 13 to 9 vote majority of Democrats on the Finance Committee, neither amendment passed. Once again, the conservative Democrats on the committee are responsible. True, every single one of the Republicans voted against the amendments, but that is to be expected in this super-partisan climate.
Baucus himself voted nay, citing his need to present a bill that would pass the whole Senate.
Just in case you’re interested, here are the Senate Finance Committee members and how they voted. Those who voted against both amendments are in colored print. Those who voted only against the Rockefeller amendment are in red. As you can see, two Democrats voted for the Schumer amendment who did not vote for the Rockefeller amendment. Some see this as a hopeful sign that perhaps there is room to move some votes. To that end, phone numbers are included below.
DEMOCRATS
1. MAX BAUCUS, MT Phone: 202-224-2651 Toll Free: 800-332-6106
2. JOHN D. ROCKEFELLER IV, WV Phone: 202-224-6472
3. KENT CONRAD, ND Phone: 202-224-2043 Toll Free: 800-223-4457
4. JEFF BINGAMAN, NM Phone: 202-224-5521 Toll Free: 800-443-8658 (NM only)
5. JOHN F. KERRY, MA Phone: 202-224-2742
6. BLANCHE L. LINCOLN, AR Phone: 202-224-4843
7. RON WYDEN, OR Phone: 202-224-5244
8. CHARLES E. SCHUMER, NY Phone: 202-224-6542
9. DEBBIE STABENOW, MI Phone: 202-224-4822
10. MARIA CANTWELL, WA Phone: 202-224-3441
11. BILL NELSON, FL Phone: 202-224-5274
12. ROBERT MENENDEZ, NJ Phone: 202-224-4744
13. THOMAS CARPER, DE Phone: 202-224-2441
REPUBLICANS
1. CHUCK GRASSLEY, IA Phone: 202-224-3744
2. ORRIN G. HATCH, UT Phone: 202-224-5251
3. OLYMPIA J. SNOWE, ME Phone: 202-224-5344 Toll Free: 800-432-1599
4. JON KYL, AZ Phone: 202-224-4521
5. JIM BUNNING, KY Phone: 202-224-4343
6. MIKE CRAPO, ID Phone: 202-224-6142
7. PAT ROBERTS, KS Phone: 202-224-4774
8. JOHN ENSIGN, NV Phone: 202-224-6244
9. MIKE ENZI, WY Phone: 202-224-3424 Toll Free: 888-250-1879
10. JOHN CORNYN, TX Phone: 202-224-2934
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Cartoon of the day
Wednesday, September 30, 2009
Friday, September 25, 2009
Pie in the Sky
Despite lengthy closed-door negotiations in a subcommittee, Max Baucus (D, Montana) released his “Baucus Bill” to the larger Senate Finance Committee last week with no Republican support from his panel. Both the Left and the Right have declared this version of health care reform a disaster. The Right doesn’t seem to want any health care reform during this administration. The Left is concerned that the bill is a giveaway to health insurance companies and that it doesn’t include a public option. Already the bill has attracted nearly 600 amendments, many aimed to slow down the progress of the bill. If votes on the amendments proceed at the pace they started, it will be months before the bill will make it to the Senate floor.
At the moment, instead of jumping into this briar patch, I’m going to sit back and approach health care reform from a different angle: what is it that I think I really want our system to look like? Sure it’s pie in the sky, but sometimes figuring out our dreams, even if they can easily be labeled unrealistic, is a good exercise. So I’ll tell you my dreams, and I’d love it if you’d tell me yours. Use the comment feature—please!
Pie in My Sky
1. Set an overall goal of the best health for each person with the greatest choice for the least cost.
2. Make health care universal since it is a basic human right. I’ve written about this on August 28 and August 27.
3. Make health care reform about much more than insurance, which is currently the focus of discussion.
4. Share the responsibility for health. More can be done to encourage people to be educated health consumers. Providers have a responsibility to be honest and respectful presenters of options.
5. Put great brains to work on how to deliver health care efficiently. Dr. Jim Yong Kim at Dartmouth says, “In my view, the rocket science in health and health care is how we deliver it.”
6. Rebuild medical education. We need enough doctors, especially primary care doctors, meaning that we somehow need to make being a primary care doctor as attractive as being a specialist. Hand in hand with this, we need to figure out how to make medical education less expensive.
7. Revamp the way doctors are paid. We need doctors who are not penalized for taking time with patients, who are encouraged to work preventatively, and who,when faced with problem cases, can think outside the box. This may mean finding alternatives to the current fee-for-service system, which often results in cramming as many patients as possible into a doctor’s day. We need providers who are rewarded for their success at keeping or making patients well, requiring more thought about the whole person instead of just malfunctioning parts.
8. Figure out a better balance between overuse of expensive hospital services on the one hand and the rights of individuals to the best possible diagnostic, preventive and treatment options. Experts on health care reform are now kicking around the term, “Supply-driven health care,” saying that when facilities have all those expensive machines and procedures available, the tendency is to use them even when they may not need to be used. Yet a patient struggling with a complex problem will want no stone left unturned. This may be the toughest health care finance problem of all to solve.
9. Maintain market incentives for research and development while enabling serious negotiation on the cost of life-saving products. At present, there are huge rewards for coming up with something that can be patented—a drug, a device, a bio-solution, a material. That’s been a driving force behind research and innovation. We don’t want to lose that capitalistic motivation. However, use of these products may be untenable if there is no way to cap costs. Also, when providers automatically turn to patented solutions rather than considering less costly alternatives such as supplements, dietary changes, or physical therapies, the cost of medical care obviously rises.
10. Sever the financial links between manufacturers of drugs and equipment and the providers who are rewarded for using these products. This would include eliminating company-sponsored continuing education hours for providers.
11. Share responsibility for costs of health care, deciding payment by income. Those who can pay more should. Those who can only pay a little should. We have tremendous inequities in wealth and earning power in the U.S., so this is the only way I can see universal care working. People who become ill or have an accident should not be penalized financially. A reformed universal care system will, I believe, still cost the average taxpayer less than is projected for our current unreformed system.
In addition, consumers should know up front how much visits and procedures will cost. In no other arena are consumers so uninformed about prices.
12. Sever the link between employment and health insurance. One of the reasons companies are in so much trouble in the U.S. right now is because of the burgeoning cost of health insurance. Companies should still bear some of the cost burden, but this could be done more equitably with taxes (Oh, dreaded word!) In the long run, under a reformed insurance system, companies would probably pay less in tax than they are presently paying in premiums. If health insurance were not tied to employment, it would also give employees more flexibility about changing jobs and could add to their job satisfaction.
As you can see, I haven’t laid out solutions so much as raised problems—problems that mostly remain unaddressed by any of the health care reform proposals in Congress.
I’m not sure that the pie in my sky could even begin to be achieved by anything other than a single-payer system like Medicare—along with a number of other reforms. For instance, isn’t there a fundamental conflict of interest between insurers, whose goal is profit, and my number one goal? The conflict is not in keeping people healthy—insurers profit if people don’t get sick. The conflict is in keeping costs down, providing choice, and making sure that people aren’t penalized when they need help the most.
That’s a nutshell version of my utopian health care dreams. What do you like and dislike about this? What’s your vision? Do you have any great ideas about how some of these problems can be solved?
==============
Cartoon of the day
At the moment, instead of jumping into this briar patch, I’m going to sit back and approach health care reform from a different angle: what is it that I think I really want our system to look like? Sure it’s pie in the sky, but sometimes figuring out our dreams, even if they can easily be labeled unrealistic, is a good exercise. So I’ll tell you my dreams, and I’d love it if you’d tell me yours. Use the comment feature—please!
Pie in My Sky
1. Set an overall goal of the best health for each person with the greatest choice for the least cost.
2. Make health care universal since it is a basic human right. I’ve written about this on August 28 and August 27.
3. Make health care reform about much more than insurance, which is currently the focus of discussion.
4. Share the responsibility for health. More can be done to encourage people to be educated health consumers. Providers have a responsibility to be honest and respectful presenters of options.
5. Put great brains to work on how to deliver health care efficiently. Dr. Jim Yong Kim at Dartmouth says, “In my view, the rocket science in health and health care is how we deliver it.”
6. Rebuild medical education. We need enough doctors, especially primary care doctors, meaning that we somehow need to make being a primary care doctor as attractive as being a specialist. Hand in hand with this, we need to figure out how to make medical education less expensive.
7. Revamp the way doctors are paid. We need doctors who are not penalized for taking time with patients, who are encouraged to work preventatively, and who,when faced with problem cases, can think outside the box. This may mean finding alternatives to the current fee-for-service system, which often results in cramming as many patients as possible into a doctor’s day. We need providers who are rewarded for their success at keeping or making patients well, requiring more thought about the whole person instead of just malfunctioning parts.
8. Figure out a better balance between overuse of expensive hospital services on the one hand and the rights of individuals to the best possible diagnostic, preventive and treatment options. Experts on health care reform are now kicking around the term, “Supply-driven health care,” saying that when facilities have all those expensive machines and procedures available, the tendency is to use them even when they may not need to be used. Yet a patient struggling with a complex problem will want no stone left unturned. This may be the toughest health care finance problem of all to solve.
9. Maintain market incentives for research and development while enabling serious negotiation on the cost of life-saving products. At present, there are huge rewards for coming up with something that can be patented—a drug, a device, a bio-solution, a material. That’s been a driving force behind research and innovation. We don’t want to lose that capitalistic motivation. However, use of these products may be untenable if there is no way to cap costs. Also, when providers automatically turn to patented solutions rather than considering less costly alternatives such as supplements, dietary changes, or physical therapies, the cost of medical care obviously rises.
10. Sever the financial links between manufacturers of drugs and equipment and the providers who are rewarded for using these products. This would include eliminating company-sponsored continuing education hours for providers.
11. Share responsibility for costs of health care, deciding payment by income. Those who can pay more should. Those who can only pay a little should. We have tremendous inequities in wealth and earning power in the U.S., so this is the only way I can see universal care working. People who become ill or have an accident should not be penalized financially. A reformed universal care system will, I believe, still cost the average taxpayer less than is projected for our current unreformed system.
In addition, consumers should know up front how much visits and procedures will cost. In no other arena are consumers so uninformed about prices.
12. Sever the link between employment and health insurance. One of the reasons companies are in so much trouble in the U.S. right now is because of the burgeoning cost of health insurance. Companies should still bear some of the cost burden, but this could be done more equitably with taxes (Oh, dreaded word!) In the long run, under a reformed insurance system, companies would probably pay less in tax than they are presently paying in premiums. If health insurance were not tied to employment, it would also give employees more flexibility about changing jobs and could add to their job satisfaction.
=================
As you can see, I haven’t laid out solutions so much as raised problems—problems that mostly remain unaddressed by any of the health care reform proposals in Congress.
I’m not sure that the pie in my sky could even begin to be achieved by anything other than a single-payer system like Medicare—along with a number of other reforms. For instance, isn’t there a fundamental conflict of interest between insurers, whose goal is profit, and my number one goal? The conflict is not in keeping people healthy—insurers profit if people don’t get sick. The conflict is in keeping costs down, providing choice, and making sure that people aren’t penalized when they need help the most.
That’s a nutshell version of my utopian health care dreams. What do you like and dislike about this? What’s your vision? Do you have any great ideas about how some of these problems can be solved?
==============
Cartoon of the day
Wednesday, September 16, 2009
Health Care Reform and the Word Game
In politics as in Scrabble, whoever controls the language controls the game. The most powerful words and phrases in the health care reform debate right now are coming from those opposed to reform: “rationing,” “death panels,” “kill granny,” “big government,” “government takeover,” “socialism,” “socialized medicine.”
Fear words like these are related to a common human phenomenon psychologists call “loss aversion.” Human beings tend to worry about changes. No matter how bad things may be, no matter how inadequate our present condition, there's always a chance it could be worse. Change may mean loss.
People who have health insurance, even expensive, inadequate health insurance, are worried that they might lose it or the medical care itself. This fear is most visceral with the “death panels” and “kill granny” phrases. I hope the claims behind these phrases have been thoroughly debunked in recent weeks, and I hope that people are beginning to realize that we already have rationing by insurance companies. It’s the last four terms--“big government,” “government takeover,” “socialism,” and “socialized medicine”-- that seem to have the most staying power, turning up again and again over the decades.
All four phrases reflect a divide in political philosophy in the United States about the role government should play in our lives. However, powerful as they are, none of these phrases is being applied accurately to the health care reform debate.
“Socialized medicine” is a system where the hospitals, pharmaceutical manufacture, and equipment manufacture are owned and operated by the government and where providers such as doctors are employed by the government. The U.K. has some of these features. Veteran’s health care has some of these features.
“Socialism” is a system of governance in which everything is owned and operated by the government and everyone is an employee of the government—hardly descriptive of our capitalist system.
A “government takeover” of medicine would mean that “socialized medicine” would be put in place. That is absolutely not under discussion under any plan before Congress or the President. Nor is it being considered even by the most radical liberals in Congress.
“Big government” is perhaps the phrase with the most credibility in this discussion. Yet all it means is that whoever is using the term thinks government should not be regulating or funding whatever area of our lives is under consideration. Do we ever hear the term "big government" in connection with huge farm subsidies to corporate farmers? In connection with defense spending? In connection with regulating people's private lives? Curious, isn't it? Is it only "big government" when social programs are involved?
Repeated often enough and with enough volume, these phrases can be highly effective in prompting the fear of change.
Is there anything in any of the bills that remotely resembles “socialized medicine”? The short answer is no.
Some members of Congress would like a “single payer system.” That is not socialized medicine. The government would not own the hospitals or the drug companies or employ the doctors. It would simply be the insurer, as it is now in Medicare.
“Single payer” is not on the table. A “public option” is. This would make the government one among many insurers. If you don’t like your current insurer’s offering, you could choose the government as your insurer. If you don’t have an insurer, you still have the government’s plan. That’s in no way “socialized medicine” or a “government takeover.”
Whether it’s “Big Government” to set things up so that health care costs are contained and people are able to afford the care they need is a matter of perspective.
============
Cartoon for the day
Fear words like these are related to a common human phenomenon psychologists call “loss aversion.” Human beings tend to worry about changes. No matter how bad things may be, no matter how inadequate our present condition, there's always a chance it could be worse. Change may mean loss.
People who have health insurance, even expensive, inadequate health insurance, are worried that they might lose it or the medical care itself. This fear is most visceral with the “death panels” and “kill granny” phrases. I hope the claims behind these phrases have been thoroughly debunked in recent weeks, and I hope that people are beginning to realize that we already have rationing by insurance companies. It’s the last four terms--“big government,” “government takeover,” “socialism,” and “socialized medicine”-- that seem to have the most staying power, turning up again and again over the decades.
All four phrases reflect a divide in political philosophy in the United States about the role government should play in our lives. However, powerful as they are, none of these phrases is being applied accurately to the health care reform debate.
“Socialized medicine” is a system where the hospitals, pharmaceutical manufacture, and equipment manufacture are owned and operated by the government and where providers such as doctors are employed by the government. The U.K. has some of these features. Veteran’s health care has some of these features.
“Socialism” is a system of governance in which everything is owned and operated by the government and everyone is an employee of the government—hardly descriptive of our capitalist system.
A “government takeover” of medicine would mean that “socialized medicine” would be put in place. That is absolutely not under discussion under any plan before Congress or the President. Nor is it being considered even by the most radical liberals in Congress.
“Big government” is perhaps the phrase with the most credibility in this discussion. Yet all it means is that whoever is using the term thinks government should not be regulating or funding whatever area of our lives is under consideration. Do we ever hear the term "big government" in connection with huge farm subsidies to corporate farmers? In connection with defense spending? In connection with regulating people's private lives? Curious, isn't it? Is it only "big government" when social programs are involved?
Repeated often enough and with enough volume, these phrases can be highly effective in prompting the fear of change.
Is there anything in any of the bills that remotely resembles “socialized medicine”? The short answer is no.
Some members of Congress would like a “single payer system.” That is not socialized medicine. The government would not own the hospitals or the drug companies or employ the doctors. It would simply be the insurer, as it is now in Medicare.
“Single payer” is not on the table. A “public option” is. This would make the government one among many insurers. If you don’t like your current insurer’s offering, you could choose the government as your insurer. If you don’t have an insurer, you still have the government’s plan. That’s in no way “socialized medicine” or a “government takeover.”
Whether it’s “Big Government” to set things up so that health care costs are contained and people are able to afford the care they need is a matter of perspective.
============
Cartoon for the day
Monday, September 14, 2009
Of Blue Dogs and Dying Options
With 256 Democrats (257 probable by November) and only 178 Republicans in the U.S. House, why, you might ask, don’t Democrats just get HR 3200, “America's Affordable Health Choices Act of 2009” through the House and be done with it? The bill has already gone through three of the five committees it must navigate, so what’s the deal? Even if health care reform has rougher sailing in the Senate, where the Democratic majority is not filibuster-proof, at least it will have passed the House. Right?
Maybe. But maybe not in its current form. That’s because the Democrats are far from united. Though the President spoke last week of his preference for the public option, the way he did it signaled that he will be open to compromise—a compromise that will be pushed not only by Republicans but by a number of Democrats.
First, a bit of background. The House has more than 250 Congressional Member Organizations—caucuses or coalitions formed to discuss and strategize about member causes. Most of them are specialized issue groups like the Hydropower Caucus or the Composites Caucus. There are also identity CMOs like the Black Caucus, the Hispanic Caucus, the Native American Caucus, the Caucus for Women’s Issues. Most important, there are the major Democrat and Republican caucuses.
But most relevant to the Health Care Reform debate are those CMOs that divide up the two major parties by where the members place themselves on the political spectrum. Republicans have their Republican Study Committee (right-wing) and their Republican Liberty Caucus (libertarian). Democrats have three sizeable groups: the Progressive Caucus, the New Democratic Coalition, and the Blue Dogs.
The Progressive Caucus is made up of 83 House Democrats most in favor of strong health care reform, including a public option. The NDC is the group of 63 moderate Democrats. The 52-member Blue Dogs are conservatives, especially when it comes to fiscal matters.
Republicans aside, the Blue Dogs are the House members most reluctant to vote for HR 3200. The public option—a budget insurance plan managed by the government, like Medicare—is a major sticking point for the Blue Dogs. While Progressives say that the public option is a very important feature that will help keep insurance and hospital prices down, Blue Dogs claim that such a plan would cost too much and would be unfair competition for insurance companies. The opposition of the Blue Dogs, coupled with that of some of the moderates, managed to postpone the vote on HR 3200 until after the August recess.
Interestingly, Blue Dogs are the biggest recipients these days of fundraising largesse from the health care industry. That’s not to say that members of the other Democratic caucuses aren’t also getting money from the industry; you can bet that whoever is currently in a power position, like House Speaker Nancy Pelosi—a Progressive—is going to be pulling down big contributions even from unlikely sources. Money doesn’t buy votes exactly; it’s not as simple as that. What it buys is a chance to rub shoulders with the powerbrokers. Nevertheless, the health care industry apparently figures its bucks are best spent with the Blue Dogs.
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For instance, click the Congress tab under Politicians & Elections. In the second gray box on the right, put in the name of a Congressperson and then check out who their big contributors were during what year.
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So in the end, what will the Blue Dogs do about HR 3200? That depends on the deals that can be made across party lines and across caucus lines. Will the public option survive the pressure from the Blue Dogs and their allies? Even now the Progressive Caucus is lobbying Democrats to find out who will declare the public option a must. If the count is not high enough, the public option will die in the House. Even if the public option gets through the House, and Democrats for a moment appear to be speaking with one voice, the Blue Dogs may yet prevail when the Senate and House have to work out a compromise bill. Whether there is anything in the final bill that will actually provide the competition and cost containment we need remains to be seen.
=============
Cartoon for the day
Maybe. But maybe not in its current form. That’s because the Democrats are far from united. Though the President spoke last week of his preference for the public option, the way he did it signaled that he will be open to compromise—a compromise that will be pushed not only by Republicans but by a number of Democrats.
First, a bit of background. The House has more than 250 Congressional Member Organizations—caucuses or coalitions formed to discuss and strategize about member causes. Most of them are specialized issue groups like the Hydropower Caucus or the Composites Caucus. There are also identity CMOs like the Black Caucus, the Hispanic Caucus, the Native American Caucus, the Caucus for Women’s Issues. Most important, there are the major Democrat and Republican caucuses.
But most relevant to the Health Care Reform debate are those CMOs that divide up the two major parties by where the members place themselves on the political spectrum. Republicans have their Republican Study Committee (right-wing) and their Republican Liberty Caucus (libertarian). Democrats have three sizeable groups: the Progressive Caucus, the New Democratic Coalition, and the Blue Dogs.
The Progressive Caucus is made up of 83 House Democrats most in favor of strong health care reform, including a public option. The NDC is the group of 63 moderate Democrats. The 52-member Blue Dogs are conservatives, especially when it comes to fiscal matters.
Republicans aside, the Blue Dogs are the House members most reluctant to vote for HR 3200. The public option—a budget insurance plan managed by the government, like Medicare—is a major sticking point for the Blue Dogs. While Progressives say that the public option is a very important feature that will help keep insurance and hospital prices down, Blue Dogs claim that such a plan would cost too much and would be unfair competition for insurance companies. The opposition of the Blue Dogs, coupled with that of some of the moderates, managed to postpone the vote on HR 3200 until after the August recess.
Interestingly, Blue Dogs are the biggest recipients these days of fundraising largesse from the health care industry. That’s not to say that members of the other Democratic caucuses aren’t also getting money from the industry; you can bet that whoever is currently in a power position, like House Speaker Nancy Pelosi—a Progressive—is going to be pulling down big contributions even from unlikely sources. Money doesn’t buy votes exactly; it’s not as simple as that. What it buys is a chance to rub shoulders with the powerbrokers. Nevertheless, the health care industry apparently figures its bucks are best spent with the Blue Dogs.
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Who Gets Whose $$$
If you ever have a free hour to spend investigating what lawmakers get what money from what sources, take a look at Open Secrets, a website that tracks contributions and even allows you to plug in individual lawmakers to see what they are getting from whom. For instance, click the Congress tab under Politicians & Elections. In the second gray box on the right, put in the name of a Congressperson and then check out who their big contributors were during what year.
=========================================================
So in the end, what will the Blue Dogs do about HR 3200? That depends on the deals that can be made across party lines and across caucus lines. Will the public option survive the pressure from the Blue Dogs and their allies? Even now the Progressive Caucus is lobbying Democrats to find out who will declare the public option a must. If the count is not high enough, the public option will die in the House. Even if the public option gets through the House, and Democrats for a moment appear to be speaking with one voice, the Blue Dogs may yet prevail when the Senate and House have to work out a compromise bill. Whether there is anything in the final bill that will actually provide the competition and cost containment we need remains to be seen.
=============
Cartoon for the day
Thursday, September 10, 2009
Was the President’s Speech to Congress a Game Changer?
Immediately after last night’s presidential address to Congress (Sept. 9), pundits were calling the speech a game changer in the health care reform debate. Immediate polling by CNN showed a significant bump in popularity for health care reform plans. This morning the editorials were more sober, as is always the case for post-speech analysis. We will have to wait a bit to learn what the big national polls show and longer to see how politicians will vote.
One thing is sure. If anyone hoped that distortions about the reform plans were put to rest last night, the sad news is that deliberate misinformation is not going to go away. It has been far too effective in shaping opinion to hope that propagandists will drop their efforts and instead engage in informed debate about real issues. All we have to do is surf the TV/radio talk shows today to see that the landscape has changed very little.
What the President’s speech did was to signal that reform efforts are not dead, that the President himself is ready to take a tougher, more visible role in the fight, and that we can expect that no bill is going to pass without significant changes—for good or ill.
For a couple of morning-after analyses, check this New Yorker piece or this piece by Alan Katz.
The White House plan is merely a couple of pages, while the Congressional plans are huge—over a thousand pages for HR 3200. Why the difference?
HR 3200 is written as an actual law, with all the legal language and specificity necessary to rule out loopholes and prepare for the law’s execution. The President’s plan is a succinct list of what he will and will not support. He does not need to present all the legal language, because the bill that will ultimately reach his desk will be written in Congress.
Comic strip for the day
One thing is sure. If anyone hoped that distortions about the reform plans were put to rest last night, the sad news is that deliberate misinformation is not going to go away. It has been far too effective in shaping opinion to hope that propagandists will drop their efforts and instead engage in informed debate about real issues. All we have to do is surf the TV/radio talk shows today to see that the landscape has changed very little.
What the President’s speech did was to signal that reform efforts are not dead, that the President himself is ready to take a tougher, more visible role in the fight, and that we can expect that no bill is going to pass without significant changes—for good or ill.
For a couple of morning-after analyses, check this New Yorker piece or this piece by Alan Katz.
==========================
Why is the White House plan so much shorter than the Congressional Plans?
The White House plan is merely a couple of pages, while the Congressional plans are huge—over a thousand pages for HR 3200. Why the difference?
HR 3200 is written as an actual law, with all the legal language and specificity necessary to rule out loopholes and prepare for the law’s execution. The President’s plan is a succinct list of what he will and will not support. He does not need to present all the legal language, because the bill that will ultimately reach his desk will be written in Congress.
==========================
Comic strip for the day
Tuesday, September 8, 2009
Time to Contact Your Lawmakers
Let your voice be heard. If you don't know who to contact, try Project VoteSmart for names and contact information. All you need is your zipcode. Be sure to contact at least your two U.S. senators and your U.S. representative to Congress.
By the way, Project VoteSmart is a wonderful example of bipartisan, politically multi-polar effort. For a little inspiration in these times of public nastiness, read about their operation. How many organizations can you find that insist that in order to join, every member must have a political opposite?
By the way, Project VoteSmart is a wonderful example of bipartisan, politically multi-polar effort. For a little inspiration in these times of public nastiness, read about their operation. How many organizations can you find that insist that in order to join, every member must have a political opposite?
Monday, September 7, 2009
More Email Misinformation
Claim 1: We’ve missed the opportunity to put really good health reform in place.
Not at all. The bills are still being hashed out in Congress. Whether we miss our opportunity remains to be seen.
Claim 2: The current health care system works for 85% of Americans.
No, Rogers is only accounting for the completely uninsured, which some estimates put at 43 million before the recession. That’s somewhat more than 15% of the population, so that leaves the 85% Rogers is talking about. But millions more are underinsured, bringing the percentage of uninsured and underinsured to nearly 70 million. Premiums, high deductibles, and denials of coverage are rising rapidly. Without significant reform, average health premiums for families are projected to rise from $12,298 in 2008 to $23, 842 in 2020.
Claim 3: We would “abandon American principles” by punishing those who have “earned” health care to provide for those who haven’t.
Sorry, but most of those who are uninsured or underinsured are in working families. Is Representative Rogers claiming that people who are uninsured deserve to be uninsured? I hope not.
Would those with “earned” health care be punished? The answer is complex. (1) Health reform will slow the rise in costs that will be punishing everyone. Rising costs are inevitable under our system, and the problem is big enough that it will not be solved under the current plan because the underlying reasons for the costs will not be addressed. But the plan will help, especially if there is a public option to provide real choice to individuals. (2) The money for health care reform will have to come from somewhere. We will have a higher deficit for a while, but it the long run we need to invest in better health care for the health of our economy, which is sinking under the weight of these costs. (3) For some people, there may be gains in individual plans. For instance, plans will have to include preventative care, and your plan won’t be able to drop you because you get sick.
Claim 4: The government will be able to “go in and rip you off your own individual plan.” Rogers cites Section 141, on p. 41 of HR 3200. He says the administration will have the power to “disinroll individuals” or “disinroll the whole plan.”
This is a blatant distortion. Section 141 is about establishing an administrative post to oversee what the bill institutes. Since the bill is reforming the rules for health insurance, someone has to make sure that the rules are followed and run the public option, just as someone now has to run Social Security. That new official will be the Health Choices Commissioner. The duties and authority of the new official are spelled out not in Section 141 but in 142, which I’m sure Rogers meant. The job does not include kicking you off your insurance plan. What the section says is that if an insurance company doesn’t follow the rules laid down in other sections—for instance, if it doesn’t provide preventive care or maternity care or limit its premium increases to 150% of annual medical inflation—then the Commission can fine the insurance company or not let them enroll consumers until they comply. If they repeatedly fail to comply, then yes, they may be “terminated.” This is a last resort for wayward insurance companies to comply.
Claim 5: If you are a small business owner with a payroll of under $250,000, the government can disenroll your whole plan.
This claim is quite puzzling. Unfortunately, Rogers doesn’t mention what section he’s looking at. I can only assume he’s talking about the same section as in Claim 4 above, already covered. Or perhaps he is referring to the provisions made for small businesses, many of which now do not provide coverage for employees. Under this bill, such employers are either given help in the form of tax credits to provide coverage for employees, or they are required to pay a small charge to help offset the cost of providing to help provide insurance to employees in another way. (See Sections 313, 412, and 421 with 45R.) For a discussion about why it’s necessary to make special provisions for businesses, see this explanation of “Pay or Play.”
Claim 6: Canada’s system proves that we don’t want this health care reform.
Rogers lays out a comparison between cancer survival rates in the U.S. and Canada, picking numbers that seem horrific. With calculated chivalry, Rogers insists that he will not subject our women and girls to such a system.
But wait—one major problem with this claim is that a system like Canada’s single payer system is not part of any of the proposed bills. Whether or not you think it should be, it simply isn’t. Thus the scary figures that Rogers gives are comparing apples to oranges.
Another logical fallacy in this claim is that there is no reason to pick Canada as the basis for comparison. All of the major industrialized nations other than the U.S. have universal care. Among these we can find a variety of systems, not all single payer. Overall, the U.S. shows up well in some outcomes and not as well in other outcomes in comparison to these countries. A 2007 study done for Congress—before the current debate—found that reference to these other countries, “research comparing the quality of care has not found the United States to be superior overall. Nor does the U.S. population have substantially better access to health care resources, even putting aside the issue of the uninsured.” P. 1, summary. A growing body of research calls into question the popular belief that while our medicine is expensive it’s clearly the best.
If we decide to look at Canada anyway—remembering that a Canadian style system is not on the table here, is Canadian health care worse than US health care? Here we have to say, worse at what? Picking out the areas in which the U.S. has the lead makes for great sound bytes, but it doesn’t tell the whole truth. Canada could counter with their higher life expectancy and infant mortality or their lower mortality rates for asthma, cervical cancer, lung cancer, or non-Hodgkin lymphoma.
But such isolated statistics on either side are not conclusive. For an interesting comparison, take a look at this article or this one. Scare tactics similar to Rogers’ have also been used about the U.K.’s health system. Check out this FactCheck article.
Claim 7: The health care reform bill is saying “we give up.”
Hardly. American ingenuity is not based and will not be based on the kind of health system we adopt. Nothing in the bill will prevent entrepreneurs in pharmacology, equipment, genetic research, medical experimentation, and so on from pursuing new breakthroughs. What the bill is meant to do is to provide more competition and more ways for consumers to access healthcare that works for them. Whether or not a bill with teeth can make it through Congress remains to be seen.
Friday, September 4, 2009
Who Profits from Killing Civil Discourse?-- The Clue in the Maze
Civil discourse bit the dust this summer, poisoned by deceptive ads, inflammatory labels, shouting groups of alleged ordinary citizens, terabytes of chain email, and decibellows of talk show hosts. When obvious big money is being poured into reshaping opinion, I can’t help but wonder why—and who’s doing it. After all, health care reform promises were major factors in the winning presidential campaign. Thus the massive effort to defeat all or part of health care reform is worth every American’s careful attention. As a long time mystery reader, I know that “who stands to gain” is the basic question any detective worth her magnifying glass has to answer before the culprit can be revealed. Let's see if we can sort out who might be behind the murder of civil discourse.
Let’s keep in mind that there are several health care reform plans under consideration. These are really health insurance reform plans. They will not necessarily provide some kinds of change that would make the system better for our wellness. For one detailed analysis of the various plans on the table, see this Kaiser Family Foundation site. Of the plans, HR 3200 is the House bill that we’re hearing most about. I’ve tried to wade through the actual bill but found the legal language daunting. Fortunately the site above analyzes it point by point in the left column of the first PDF link you come to.
Whatever compromise bill passes both houses of Congress and is signed by the President will be different from any of these current proposals. The big question is how different. That will depend on how successful the rhetoric and rewards are on all sides.
When it comes to who stands to gain from all the noise this summer, we should not just consider money, though that is very important. Cui bono means “good for whom”? Besides money, profit—bono—can include getting elected or getting better health care or getting good feelings by doing the ethical thing. All too often, of course, the “goods” of money and power trump the altruistic goods.
The Suspects
So, who profits? I can think of several groups of key players—sometimes called “stakeholders” in the news. I’d love to hear from you about what I’ve missed.
These are our major suspects for the murder of civil discourse. Let’s take a look at the motivations of each.
Motivations
The interests of the various players are at odds in the present system. What does each need?
1. Consumers want the best possible health care for the least possible money.
2. Their insurance group managers, who bargain with insurance companies for a policy, also want the best plan for the least money. For managers, though, the cost of a policy may be a much more important consideration than its quality. Employers may need to cut corners. Even unions and cooperative groups may not make the same choices that the individual consumer would make, faced with the same numbers. For instance, some consumers might want an option to pay a little higher premium if the coverage is significantly better. A retirement fund manager might want to go just for the lowest price.
3. The next stakeholder, hospital systems with their affiliated physician practices, are in the business of maximizing income, which can mean serving as many patients in as short a time as feasible, eliminating competition from other hospitals, avoiding lawsuits, and making deals with insurers. Though they may wish to serve the community, especially if they are “non-profits,” they have no monetary incentive other than reputation to promote wellness, decrease patients’ return trips to the hospital, or minimize procedures and charges.
4. Doctors are also providers with some of the same monetary interests as hospitals, but they are in a special squeeze in this system. In the name of efficiency, hospitals want doctors to see as many patients as possible in the shortest time, and insurer limits on charges increase that pressure. Without patient quantity, doctors can’t make enough money. The pressure is increased by high malpractice premiums, burdensome record keeping, and a swollen staff to deal with it. Most doctors these days can’t make it on their own; they need phalanxes of billing clerks to keep up with the insurance. Sometimes the billing is handed over to the hospital system.
Though doctors may mourn for the bygone relationship with the patient, few have time for lengthy problem solving. Nor is there really any monetary incentive to spend time on wellness, prevention, or low cost alternative approaches. Doctors who take such approaches tend to go broke. Medicating the symptoms is fast and is promoted by cozy relationships with pharmaceutical companies. For more, see this article and this one.
Because of doctors' financial pressures, high cost specialties are attractive to medical school graduates—hence the shortage of primary care doctors. Specialty practices are more lucrative, and the huge debt from medical school has to be paid, after all. For years, the American Medical Association actively worked to avoid a physician “glut” that might drive prices down, encouraging limits on new medical schools and hospital residencies. The AMA has changed its tune somewhat in the face of mounting evidence of specific shortages and some new medical schools are also in the works in various states.
Other provider groups such as nurses, physician assistants, medical assistants, counselors and social workers have their own issues in the health care reform debate and have faced years of cutbacks already.
5. The next suspects, the pharmaceutical, biotech, and equipment companies, as well as independent labs are all in the business of making money. They need to maximize profits for stockholders and company employees. Solving patients' health problems may be both an altruistic and monetary motivation, but keeping prices high serves company interests best. High prices may promote groundbreaking research, yes, but they also mean maintaining patents as long as possible, as well as cultivating relationships with doctors and hospitals--perhaps with special deals. Obviously, the most widespread illnesses and injuries are going to be the most financially sound targets for research. Alternative low cost treatments are not going to be in the interests of these companies unless they can be made more expensive by patenting.
6. Now we come to insurers. Again, private companies want to maximize stockholder profit, which calls not only for healthy prices for policies, but for lots of healthy policyholders and as few sick policyholders and as few pay outs as possible. How to achieve that? Refuse to insure people with pre-existing conditions (the very people who need insurance most) and figure out ways to get policyholders to pay more and more of their own bills. High deductibles are one way. Another way is limiting the number and type of procedures (Was a test covered last year? This year it may not be). Still another tactic is to impose lifetime caps and/or annual caps on pay outs. (Have you been afraid of “rationing”? Have you been afraid of “interference with doctors’ decisions”? Those nightmares already exist in our system, courtesy of these insurance tactics.)
On the good side, insurance companies are the only stakeholders besides consumers and their bargaining agents who have a real monetary interest in promoting wellness, prevention, and healthy living. Insurance companies only make money on us if we stay well or die quickly.
7. Finally, let’s consider politicians as our last suspect. Here we need to look at two issues: getting (re)elected and—for some politicians—setting up a private sector career path for the future.
Getting elected is obviously of first importance to any politician. In our system, that does not happen without huge campaign contributions from organizations—often corporations—which want something in exchange. True, the actual exchange is not legal. No politician will admit to being influenced by these gifts, but lobbyists for the same organizations are ever present in the halls of Congress. In fact, many bills are actually written by lobbyists because lobbyists have the needed expertise and incentive to get the job done. Lobbyists have become the not-so-hidden fourth branch of government—forget the traditional fourth-estate, the press. The influence of lobbyists extends to both sides of the aisle, but some companies will find one lawmaker or party more compatible and thus more likely to receive campaign help. What sort of lobbying has been done on healthcare? Try this article or this one.
Getting elected also means defeating the other candidates. A party candidate gets a boost from a strong party. If a party can sow discontent with the other party, its candidates will be more likely to win next time around. These days, we see this translated into trashing the other party at every opportunity. Good policy may take a backseat to decimating the “enemy.” We are seeing turnabouts every day in lawmakers’ stances on issues as they gauge how much damage they can do to the other party by a particular stance. Since Democrats are currently in power, Republicans are most likely to try to discredit any Democratic initiative.
The second issue to look at when considering politicians’ stake in the health care issue is the “revolving door.” Some politicians find the tight relationship with lobbyists a boon when they are voted out of office or retire. They become consultants, lobbyists, or executives for the very companies that curried their favor before. See, for instance, this story. If it’s not the lawmakers themselves going through the door, it’s their staff members.
Current law imposes a waiting period on such hiring, but stricter disincentives have—no surprise—failed to pass Congress. To demonstrate that hoards of such hires happen on both sides of the aisle, there's former Democratic U.S. Senate Majority Leader Tom Daschle, who is now “a special public policy adviser at Alston & Bird,” where he is, er, not exactly a lobbyist, but has represented clients interested in health care. Nominated to the cabinet, he was about to cross back into the government, but had to withdraw because of tax problems.
Reexamining the Suspects
With all these suspects, who had the motive and means to perpetrate the big poisoning of the summer? You detective mystery readers don’t need to be told that motive, means, and opportunity are the keys to untangling the classic mystery puzzle. We’ll need to reexamine each of the suspects.
1. Did some of the poisoning of civil discourse come from consumers genuinely afraid of what might happen to their health plans? No doubt. Many people have been scared by the hype. Some are ideologically opposed to any limitation on market forces. Some, whether Republican or Democrat, have questions about the details of the plans. But there is likely to be much more behind the disinformation campaign than unhappy individual consumers. On to the next suspect.
2. Of the negotiator-intermediaries for consumer insurance policies, the employers are the ones who have the most to gain and to lose from reform. No doubt employers would love to get out from under the burden of providing health insurance for their workers altogether. It is the single most important expense besides wages and is breaking the back of many companies. Anything that can bring the cost of policies down will benefit employers.
However, while HR 3200 will lower costs for many businesses or at least keep costs from rising as much, their costs will increase for part-time workers, who have to be covered somehow. Over the past couple of decades, the trend in many companies and institutions has been to hire part-timers exactly because the law didn’t insist they be offered health insurance.
In addition, there are all the small business owners who don’t offer health insurance to their mostly part-time staffs and will now have to ante up in the form of a tax that will help their workers buy coverage. You might think that would significantly stress the bottom line of small enterprises. What small business owners may not yet understand is that HR 3200 has built in relief for small employers so that the plan will actually be a good deal.
One big question is whether providing health coverage will in the long run increase the productivity of workers enough to offset any alleged costs. Worried employers have been some of the voices at town hall meetings, but mostly they’ve just been asking reasonable questions rather than screaming.
3. Early on, insurers looked to me like the best suspect for the perpetrators of most of the hype, especially in regard to the public option. Why wouldn’t insurance companies want to keep premiums as high as possible? Why would they want competition from a public option designed to lower those premiums by providing an alternative? Why wouldn’t they hate to be told that they can’t drop people who get sick too many times? Why would they want to be made to provide for people with pre-existing conditions? Why would they want to have to eliminate caps on coverage?
One can see why insurers are thus a highly likely suspect, and they have certainly been pouring dollars into lobbying and advertising.
4. What about doctors? Though many doctors adamantly support health care reform, some are using their doctor-patient relationship to urge against HR 3200. Still others have been drafted into the fight by fraud. The AMA has waffled on the bill. Compare this June article with this one or this anti-public-option press release. Some doctors, especially specialists, fear further limitations on their pricing structure or on their decision making, while others celebrate the possibility that they might finally get back to the ideal of helping patients to be well.
5. As for hospital systems, it is not apparent to me that they stand to gain much of anything from health care reform. HR 3200 won’t cut down much at all on the billing problems that stem from multiple insurance payers because there will still be multiple payers. What it will do that hospitals might not like is to mandate the reduction of unnecessary procedures and the reduction of the number of times a patient is released too quickly from a hospital only to have to return.
Hospitals might dislike the public option for another important reason: it will cut down on the deals they can make with insurance companies and thus cut down on a competitive edge they are getting against other hospitals—in other words, it will make it harder to monopolize a market. Here’s how it works, based on a real example from my own city.
My city is essentially a two-hospital town. Yes, there are a few others, but most of the physician practices are affiliated with one or another of the two biggies, each good hospitals across the board, but noted for research and expertise in different specialties. Recently, Hospital A forced a deal with Insurance Company C. Hospital A would give pricing breaks to the insurance company if the company would drop its coverage for patients of Hospital B. That means Hospital B’s patients now have to stop seeing all of their doctors affiliated with Hospital B, stop having their tests done at Hospital B, and stop going to Hospital B unless they want to assume out-of-network costs. Now there is no place to go for a second opinion. (Talk about rationing of care or control of doctor choice!) Why did Insurance Company C comply? The covered groups we are talking about here are quite large, composed of many public service employees. Why didn’t the groups’ negotiators find another insurer? Rising costs and corporate political pressure. I’ve learned about this deal from friends, but this instance is not the only time hospitals have employed this monopoly tactic. Certainly, it clarifies why hospitals and insurance companies don’t want a public option. It would mean that people who care about being cut off from their doctors would have a real choice.
For other views of hospital monopoly, see this and this. Look for Henry Waxman to hold hearings on the health care industry’s monopoly tactics as Congress reconvenes.
One example of a hospital ad campaign against health reform includes this gem, produced by Conservatives for Patient’s Rights. A legitimate grassroots political organization? Only if your definition of “grassroots” includes founding and backing by a multimillionaire former hospital CEO. The TV ads were put together by the same public relations company that made "Swift Boat Veterans for Truth," the ad that smeared John Kerry’s patriotism and belittled his military service.
Yes, the hospital systems are definitely in the running as suspects in the murder of civil discourse.
6. On to the next suspect, suppliers. First, let’s think about companies that supply equipment to hospitals and patients. These no doubt dislike cost-cutting provisions in the health care reform that may reduce high prices companies can charge for their products. Some products, indeed, may be deemed unnecessary and may no longer be covered. Again, a public option would make it more likely that tough negotiation through a government plan would bring prices down.
The next major group of suppliers is pharmaceutical companies. Until recently, this industry opposed the health care reform bills. They worried that instead of all the separate insurers trying to negotiate prices with them as now happens, it would be mainly the government negotiating with its far greater clout. The “doughnut hole” in Medicare Part D is also up for closure, meaning drug companies would have to give Medicare patients a discount. In addition, there was the specter of allowing import of cheaper drugs from Canada. Consequently, the drug industry was opposed to reform plans early on. More recently, President Obama has angered many supporters by backing off from these cost saving possibilities with an agreement that would give up the power of government price negotiation and import from Canada if pharmaceuticals would support health care reform and promise voluntary price drops. See also this.
For the moment, then, pharmaceuticals are not my pick for the murder of civic discourse this summer. Lately, though, there have been rumbles of discontent on both sides of the agreement, so keep an eye on further developments.
7. So what about the politicians? Motive and means abound. Now that Democrats are in power, they are definitely a target, especially the head guy who has hung a fair amount of credibility on getting reform passed. Republicans have expressed their intent to frustrate Obama and the Democrats on everything they can in order to take back Congress in 2010. As talk show host Rush Limbaugh put it bluntly, he wants Obama to fail. Republican politicians are a little more subtle, but the language isn't far different. [By the way, Senator Inhofe is picking only figures that are favorable to his viewpoint. The U.S. is actually 8th in breast cancer survival behind seven other universal care countries. For a different view on Canadian health care, see this article.]
Conflict between the two parties is big entertainment in the media. Nothing is better than a fight for garnering an audience, so why wouldn’t the party out of power, the Republicans, encourage the biggest public fights possible? Democrats are not a united front, however. Blue Dog Democrats in particular, know from whence their constituent and campaign support comes. Remember those lobbyists? They’re on both sides of the aisle.
The Accusation
Now that we’ve reexamined the suspects, can we say who killed civil discourse in the summer of ’09? I’m going to pick the big gainers if health reform goes down--especially if the public option goes down. Those would be insurers, hospitals, and suppliers, aided by Republican politicians and their pundit accomplices. The means? Enough money to spread lies and distortions across the landscape.
Let’s keep in mind that there are several health care reform plans under consideration. These are really health insurance reform plans. They will not necessarily provide some kinds of change that would make the system better for our wellness. For one detailed analysis of the various plans on the table, see this Kaiser Family Foundation site. Of the plans, HR 3200 is the House bill that we’re hearing most about. I’ve tried to wade through the actual bill but found the legal language daunting. Fortunately the site above analyzes it point by point in the left column of the first PDF link you come to.
Whatever compromise bill passes both houses of Congress and is signed by the President will be different from any of these current proposals. The big question is how different. That will depend on how successful the rhetoric and rewards are on all sides.
When it comes to who stands to gain from all the noise this summer, we should not just consider money, though that is very important. Cui bono means “good for whom”? Besides money, profit—bono—can include getting elected or getting better health care or getting good feelings by doing the ethical thing. All too often, of course, the “goods” of money and power trump the altruistic goods.
The Suspects
So, who profits? I can think of several groups of key players—sometimes called “stakeholders” in the news. I’d love to hear from you about what I’ve missed.
- Consumers
- Insurance group managers (e.g. employers, unions, retirement plans)
- Providers
- Hospitals
- Doctors and support staff
- Counselors, psychologists, and social workers
- Labs
- Suppliers (e.g. pharmaceutical companies, equipment companies)
- Insurers
- Politicians
These are our major suspects for the murder of civil discourse. Let’s take a look at the motivations of each.
Motivations
The interests of the various players are at odds in the present system. What does each need?
1. Consumers want the best possible health care for the least possible money.
2. Their insurance group managers, who bargain with insurance companies for a policy, also want the best plan for the least money. For managers, though, the cost of a policy may be a much more important consideration than its quality. Employers may need to cut corners. Even unions and cooperative groups may not make the same choices that the individual consumer would make, faced with the same numbers. For instance, some consumers might want an option to pay a little higher premium if the coverage is significantly better. A retirement fund manager might want to go just for the lowest price.
3. The next stakeholder, hospital systems with their affiliated physician practices, are in the business of maximizing income, which can mean serving as many patients in as short a time as feasible, eliminating competition from other hospitals, avoiding lawsuits, and making deals with insurers. Though they may wish to serve the community, especially if they are “non-profits,” they have no monetary incentive other than reputation to promote wellness, decrease patients’ return trips to the hospital, or minimize procedures and charges.
4. Doctors are also providers with some of the same monetary interests as hospitals, but they are in a special squeeze in this system. In the name of efficiency, hospitals want doctors to see as many patients as possible in the shortest time, and insurer limits on charges increase that pressure. Without patient quantity, doctors can’t make enough money. The pressure is increased by high malpractice premiums, burdensome record keeping, and a swollen staff to deal with it. Most doctors these days can’t make it on their own; they need phalanxes of billing clerks to keep up with the insurance. Sometimes the billing is handed over to the hospital system.
Though doctors may mourn for the bygone relationship with the patient, few have time for lengthy problem solving. Nor is there really any monetary incentive to spend time on wellness, prevention, or low cost alternative approaches. Doctors who take such approaches tend to go broke. Medicating the symptoms is fast and is promoted by cozy relationships with pharmaceutical companies. For more, see this article and this one.
Because of doctors' financial pressures, high cost specialties are attractive to medical school graduates—hence the shortage of primary care doctors. Specialty practices are more lucrative, and the huge debt from medical school has to be paid, after all. For years, the American Medical Association actively worked to avoid a physician “glut” that might drive prices down, encouraging limits on new medical schools and hospital residencies. The AMA has changed its tune somewhat in the face of mounting evidence of specific shortages and some new medical schools are also in the works in various states.
Other provider groups such as nurses, physician assistants, medical assistants, counselors and social workers have their own issues in the health care reform debate and have faced years of cutbacks already.
5. The next suspects, the pharmaceutical, biotech, and equipment companies, as well as independent labs are all in the business of making money. They need to maximize profits for stockholders and company employees. Solving patients' health problems may be both an altruistic and monetary motivation, but keeping prices high serves company interests best. High prices may promote groundbreaking research, yes, but they also mean maintaining patents as long as possible, as well as cultivating relationships with doctors and hospitals--perhaps with special deals. Obviously, the most widespread illnesses and injuries are going to be the most financially sound targets for research. Alternative low cost treatments are not going to be in the interests of these companies unless they can be made more expensive by patenting.
6. Now we come to insurers. Again, private companies want to maximize stockholder profit, which calls not only for healthy prices for policies, but for lots of healthy policyholders and as few sick policyholders and as few pay outs as possible. How to achieve that? Refuse to insure people with pre-existing conditions (the very people who need insurance most) and figure out ways to get policyholders to pay more and more of their own bills. High deductibles are one way. Another way is limiting the number and type of procedures (Was a test covered last year? This year it may not be). Still another tactic is to impose lifetime caps and/or annual caps on pay outs. (Have you been afraid of “rationing”? Have you been afraid of “interference with doctors’ decisions”? Those nightmares already exist in our system, courtesy of these insurance tactics.)
On the good side, insurance companies are the only stakeholders besides consumers and their bargaining agents who have a real monetary interest in promoting wellness, prevention, and healthy living. Insurance companies only make money on us if we stay well or die quickly.
7. Finally, let’s consider politicians as our last suspect. Here we need to look at two issues: getting (re)elected and—for some politicians—setting up a private sector career path for the future.
Getting elected is obviously of first importance to any politician. In our system, that does not happen without huge campaign contributions from organizations—often corporations—which want something in exchange. True, the actual exchange is not legal. No politician will admit to being influenced by these gifts, but lobbyists for the same organizations are ever present in the halls of Congress. In fact, many bills are actually written by lobbyists because lobbyists have the needed expertise and incentive to get the job done. Lobbyists have become the not-so-hidden fourth branch of government—forget the traditional fourth-estate, the press. The influence of lobbyists extends to both sides of the aisle, but some companies will find one lawmaker or party more compatible and thus more likely to receive campaign help. What sort of lobbying has been done on healthcare? Try this article or this one.
Getting elected also means defeating the other candidates. A party candidate gets a boost from a strong party. If a party can sow discontent with the other party, its candidates will be more likely to win next time around. These days, we see this translated into trashing the other party at every opportunity. Good policy may take a backseat to decimating the “enemy.” We are seeing turnabouts every day in lawmakers’ stances on issues as they gauge how much damage they can do to the other party by a particular stance. Since Democrats are currently in power, Republicans are most likely to try to discredit any Democratic initiative.
The second issue to look at when considering politicians’ stake in the health care issue is the “revolving door.” Some politicians find the tight relationship with lobbyists a boon when they are voted out of office or retire. They become consultants, lobbyists, or executives for the very companies that curried their favor before. See, for instance, this story. If it’s not the lawmakers themselves going through the door, it’s their staff members.
Current law imposes a waiting period on such hiring, but stricter disincentives have—no surprise—failed to pass Congress. To demonstrate that hoards of such hires happen on both sides of the aisle, there's former Democratic U.S. Senate Majority Leader Tom Daschle, who is now “a special public policy adviser at Alston & Bird,” where he is, er, not exactly a lobbyist, but has represented clients interested in health care. Nominated to the cabinet, he was about to cross back into the government, but had to withdraw because of tax problems.
Reexamining the Suspects
With all these suspects, who had the motive and means to perpetrate the big poisoning of the summer? You detective mystery readers don’t need to be told that motive, means, and opportunity are the keys to untangling the classic mystery puzzle. We’ll need to reexamine each of the suspects.
1. Did some of the poisoning of civil discourse come from consumers genuinely afraid of what might happen to their health plans? No doubt. Many people have been scared by the hype. Some are ideologically opposed to any limitation on market forces. Some, whether Republican or Democrat, have questions about the details of the plans. But there is likely to be much more behind the disinformation campaign than unhappy individual consumers. On to the next suspect.
2. Of the negotiator-intermediaries for consumer insurance policies, the employers are the ones who have the most to gain and to lose from reform. No doubt employers would love to get out from under the burden of providing health insurance for their workers altogether. It is the single most important expense besides wages and is breaking the back of many companies. Anything that can bring the cost of policies down will benefit employers.
However, while HR 3200 will lower costs for many businesses or at least keep costs from rising as much, their costs will increase for part-time workers, who have to be covered somehow. Over the past couple of decades, the trend in many companies and institutions has been to hire part-timers exactly because the law didn’t insist they be offered health insurance.
In addition, there are all the small business owners who don’t offer health insurance to their mostly part-time staffs and will now have to ante up in the form of a tax that will help their workers buy coverage. You might think that would significantly stress the bottom line of small enterprises. What small business owners may not yet understand is that HR 3200 has built in relief for small employers so that the plan will actually be a good deal.
One big question is whether providing health coverage will in the long run increase the productivity of workers enough to offset any alleged costs. Worried employers have been some of the voices at town hall meetings, but mostly they’ve just been asking reasonable questions rather than screaming.
3. Early on, insurers looked to me like the best suspect for the perpetrators of most of the hype, especially in regard to the public option. Why wouldn’t insurance companies want to keep premiums as high as possible? Why would they want competition from a public option designed to lower those premiums by providing an alternative? Why wouldn’t they hate to be told that they can’t drop people who get sick too many times? Why would they want to be made to provide for people with pre-existing conditions? Why would they want to have to eliminate caps on coverage?
One can see why insurers are thus a highly likely suspect, and they have certainly been pouring dollars into lobbying and advertising.
4. What about doctors? Though many doctors adamantly support health care reform, some are using their doctor-patient relationship to urge against HR 3200. Still others have been drafted into the fight by fraud. The AMA has waffled on the bill. Compare this June article with this one or this anti-public-option press release. Some doctors, especially specialists, fear further limitations on their pricing structure or on their decision making, while others celebrate the possibility that they might finally get back to the ideal of helping patients to be well.
5. As for hospital systems, it is not apparent to me that they stand to gain much of anything from health care reform. HR 3200 won’t cut down much at all on the billing problems that stem from multiple insurance payers because there will still be multiple payers. What it will do that hospitals might not like is to mandate the reduction of unnecessary procedures and the reduction of the number of times a patient is released too quickly from a hospital only to have to return.
Hospitals might dislike the public option for another important reason: it will cut down on the deals they can make with insurance companies and thus cut down on a competitive edge they are getting against other hospitals—in other words, it will make it harder to monopolize a market. Here’s how it works, based on a real example from my own city.
My city is essentially a two-hospital town. Yes, there are a few others, but most of the physician practices are affiliated with one or another of the two biggies, each good hospitals across the board, but noted for research and expertise in different specialties. Recently, Hospital A forced a deal with Insurance Company C. Hospital A would give pricing breaks to the insurance company if the company would drop its coverage for patients of Hospital B. That means Hospital B’s patients now have to stop seeing all of their doctors affiliated with Hospital B, stop having their tests done at Hospital B, and stop going to Hospital B unless they want to assume out-of-network costs. Now there is no place to go for a second opinion. (Talk about rationing of care or control of doctor choice!) Why did Insurance Company C comply? The covered groups we are talking about here are quite large, composed of many public service employees. Why didn’t the groups’ negotiators find another insurer? Rising costs and corporate political pressure. I’ve learned about this deal from friends, but this instance is not the only time hospitals have employed this monopoly tactic. Certainly, it clarifies why hospitals and insurance companies don’t want a public option. It would mean that people who care about being cut off from their doctors would have a real choice.
For other views of hospital monopoly, see this and this. Look for Henry Waxman to hold hearings on the health care industry’s monopoly tactics as Congress reconvenes.
One example of a hospital ad campaign against health reform includes this gem, produced by Conservatives for Patient’s Rights. A legitimate grassroots political organization? Only if your definition of “grassroots” includes founding and backing by a multimillionaire former hospital CEO. The TV ads were put together by the same public relations company that made "Swift Boat Veterans for Truth," the ad that smeared John Kerry’s patriotism and belittled his military service.
Yes, the hospital systems are definitely in the running as suspects in the murder of civil discourse.
6. On to the next suspect, suppliers. First, let’s think about companies that supply equipment to hospitals and patients. These no doubt dislike cost-cutting provisions in the health care reform that may reduce high prices companies can charge for their products. Some products, indeed, may be deemed unnecessary and may no longer be covered. Again, a public option would make it more likely that tough negotiation through a government plan would bring prices down.
The next major group of suppliers is pharmaceutical companies. Until recently, this industry opposed the health care reform bills. They worried that instead of all the separate insurers trying to negotiate prices with them as now happens, it would be mainly the government negotiating with its far greater clout. The “doughnut hole” in Medicare Part D is also up for closure, meaning drug companies would have to give Medicare patients a discount. In addition, there was the specter of allowing import of cheaper drugs from Canada. Consequently, the drug industry was opposed to reform plans early on. More recently, President Obama has angered many supporters by backing off from these cost saving possibilities with an agreement that would give up the power of government price negotiation and import from Canada if pharmaceuticals would support health care reform and promise voluntary price drops. See also this.
For the moment, then, pharmaceuticals are not my pick for the murder of civic discourse this summer. Lately, though, there have been rumbles of discontent on both sides of the agreement, so keep an eye on further developments.
7. So what about the politicians? Motive and means abound. Now that Democrats are in power, they are definitely a target, especially the head guy who has hung a fair amount of credibility on getting reform passed. Republicans have expressed their intent to frustrate Obama and the Democrats on everything they can in order to take back Congress in 2010. As talk show host Rush Limbaugh put it bluntly, he wants Obama to fail. Republican politicians are a little more subtle, but the language isn't far different. [By the way, Senator Inhofe is picking only figures that are favorable to his viewpoint. The U.S. is actually 8th in breast cancer survival behind seven other universal care countries. For a different view on Canadian health care, see this article.]
Conflict between the two parties is big entertainment in the media. Nothing is better than a fight for garnering an audience, so why wouldn’t the party out of power, the Republicans, encourage the biggest public fights possible? Democrats are not a united front, however. Blue Dog Democrats in particular, know from whence their constituent and campaign support comes. Remember those lobbyists? They’re on both sides of the aisle.
The Accusation
Now that we’ve reexamined the suspects, can we say who killed civil discourse in the summer of ’09? I’m going to pick the big gainers if health reform goes down--especially if the public option goes down. Those would be insurers, hospitals, and suppliers, aided by Republican politicians and their pundit accomplices. The means? Enough money to spread lies and distortions across the landscape.
Monday, August 31, 2009
Email Disinformation
! Caution !
If you've been the recipient of an email recently making the cyberspace circuit--an email supposedly tipping us off to the faults of the Congressional health care plan, HR 3200--take note. You've been scammed, or at the very least, misinformed.
Check out the email and the actual facts at FactCheck.org, always a good stop for digging up reliable information about public issues. Here's the FactCheck page that shows the email and dissects its points.
In case you're wondering, FactCheck is a project of the The Annenberg Public Policy Center of the University of Pennsylvania, which is dedicated to communication issues. It's a fine idea to know the source of what you read. To that end, I'm trying to provide source information whenever I present something besides my own opinion.
Sunday, August 30, 2009
Friday, August 28, 2009
Healthcare and the Common Good
Are you among the exceedingly wealthy in this country? Can you manage never to get sick or have an accident? When your time comes, can you guarantee you'll slip peacefully into that good night with no need for costly drugs, surgery, and machines? If the answer to these questions is no, you can’t afford life-long health care on your own.
Like it or not, health care is a group project. That, of course, is what insurance is all about. Costs of care are spread around to both the temporarily healthy and the ill. In order to fund care for the ill, temporarily healthy people have to chip in so that when their own small or large disaster strikes, there will be enough there to cover that, too. Take away the healthy people, and the whole enterprise falls apart. We are all in this together—or we should be.
Truly, health care is a matter of the common good, like public schools, roads, bridges, and public transportation. I surely can’t afford to build roads, but I use them, I’m glad they’re there (most of the time), and I’m happy to contribute to their maintenance. We need everyone to be part of the pool for spreading the costs around.
That’s one good reason for putting everyone in the health care pool. It’s just practical. What happens to the uninsured now? Certainly, many uninsured are temporarily healthy. Whether they could pay for health insurance or not, they are hoping they will never get sick. When they do get sick and have to be treated in an emergency room, the costs are spread to the rest of us via higher insurance costs, but now those costs are much more expensive. And there are those who put off medical care long enough that what could have been treated easily now is more complicated, dangerous, and costly.
Practicality isn’t the only reason, or even the most compelling reason, to get everyone into the pool—but it’s an awfully fine reason. And yes, that would be universal health care.
Like it or not, health care is a group project. That, of course, is what insurance is all about. Costs of care are spread around to both the temporarily healthy and the ill. In order to fund care for the ill, temporarily healthy people have to chip in so that when their own small or large disaster strikes, there will be enough there to cover that, too. Take away the healthy people, and the whole enterprise falls apart. We are all in this together—or we should be.
Truly, health care is a matter of the common good, like public schools, roads, bridges, and public transportation. I surely can’t afford to build roads, but I use them, I’m glad they’re there (most of the time), and I’m happy to contribute to their maintenance. We need everyone to be part of the pool for spreading the costs around.
That’s one good reason for putting everyone in the health care pool. It’s just practical. What happens to the uninsured now? Certainly, many uninsured are temporarily healthy. Whether they could pay for health insurance or not, they are hoping they will never get sick. When they do get sick and have to be treated in an emergency room, the costs are spread to the rest of us via higher insurance costs, but now those costs are much more expensive. And there are those who put off medical care long enough that what could have been treated easily now is more complicated, dangerous, and costly.
Practicality isn’t the only reason, or even the most compelling reason, to get everyone into the pool—but it’s an awfully fine reason. And yes, that would be universal health care.
Coming up sometime soon: another reason for universal health care.
Thursday, August 27, 2009
Do we need to reform our health care system?
I’d like to pay more heed to facts than to opinion, but I recognize that the two are hard, perhaps impossible, to separate. After all, as William Jennings Bryan said, “Facts mean nothing unless they are rightly understood, rightly related and rightly interpreted.” And we all know how he screwed that up! Nevertheless, as I find information that seems verifiable, I’ll label it fact.
So, a few facts to begin:
1. The USA is among the richest countries of the world according to Gross Domestic Product per capita. It falls into the categories of “industrialized” and “developed.”
2. The USA is the only one of the top twenty richest countries not to have universal health care—health care available to every citizen regardless of income—except, apparently, the Cayman Islands, the British Virgin Islands, and Equatorial Guinea. I looked up health care in each of the countries. If I missed other universal provider countries, please correct me. The systems vary widely in how they are funded and no doubt in how good the care is.
3. Between 36 and 58 million US citizens are uninsured. The numbers are slippery because the last best count was Census data for 2007, data that didn’t account for the economic downturn this year. However, the Census numbers also included non-citizens. Corrected figures, then, range between the numbers listed. Here is one explanation. And here is another.
4. Many additional US citizens are underinsured, perhaps as many as 25 million. Here is one explanation. And here is another.
The trend in health insurance is higher deductibles—also known as catastrophic insurance. Instead of paying higher premiums, the insured pays a much higher deductible, a dangerous gamble.
5. Health insurance is costing families more. Premiums are rising quickly—by one estimate, the past ten years has seen an increase at four times the rate of inflation. See, for example, the situation in the state of Missouri. See also this analysis on costs.
6. More than 60% of personal bankruptcies in 2007 have been attributed to medical expenses. Most were insured at the onset of illness. Note that this was before the recession hit.
7. The USA spends much more on health care per capita than any other country, despite the fact that not everyone has access. Among the world’s countries, the USA ranks number 52 in doctors per capita and number 19 in acute care hospital beds per capita.
8. Health care outcomes in the USA are not necessarily better than in other countries. The USA is ranked number 50 in life expectancy, number 45 in infant mortality.
Comparison of health outcomes across countries is fraught with statistical challenges. The Organization for Economic Co-operation and Development has been trying to collect and compare health care data across its 30 member countries for several years. OECD has identified a number of indicators of the efficacy of a country’s health care. While comparison problems in the data are addressed in the report, it gives the best cross country comparisons I’ve located. In terms of favorable outcomes on some of these indicators, the USA ranks number 8 in breast cancer five year survival rate out of 21, number 9 in cervical cancer five year survival rate, number 6 in colorectal cancer five year survival rate, number 20 out of 25 in mortality from asthma as a primary cause, number 9 out of 23 in offering annual flu vaccine to those over age 65, and number 5 out of 12 in providing retinal exams for diabetics. Statistics for the USA were not available in such measures as heart attack and stroke.
9. The World Health Organization (WHO) has declared access to healthcare a fundamental human right. In addition, Article 25 of The Universal Declaration of Human Rights, a UN document inspired in part by Eleanor Roosevelt, declares: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.” [bold face added]
So, a few facts to begin:
1. The USA is among the richest countries of the world according to Gross Domestic Product per capita. It falls into the categories of “industrialized” and “developed.”
2. The USA is the only one of the top twenty richest countries not to have universal health care—health care available to every citizen regardless of income—except, apparently, the Cayman Islands, the British Virgin Islands, and Equatorial Guinea. I looked up health care in each of the countries. If I missed other universal provider countries, please correct me. The systems vary widely in how they are funded and no doubt in how good the care is.
3. Between 36 and 58 million US citizens are uninsured. The numbers are slippery because the last best count was Census data for 2007, data that didn’t account for the economic downturn this year. However, the Census numbers also included non-citizens. Corrected figures, then, range between the numbers listed. Here is one explanation. And here is another.
4. Many additional US citizens are underinsured, perhaps as many as 25 million. Here is one explanation. And here is another.
The trend in health insurance is higher deductibles—also known as catastrophic insurance. Instead of paying higher premiums, the insured pays a much higher deductible, a dangerous gamble.
5. Health insurance is costing families more. Premiums are rising quickly—by one estimate, the past ten years has seen an increase at four times the rate of inflation. See, for example, the situation in the state of Missouri. See also this analysis on costs.
6. More than 60% of personal bankruptcies in 2007 have been attributed to medical expenses. Most were insured at the onset of illness. Note that this was before the recession hit.
7. The USA spends much more on health care per capita than any other country, despite the fact that not everyone has access. Among the world’s countries, the USA ranks number 52 in doctors per capita and number 19 in acute care hospital beds per capita.
8. Health care outcomes in the USA are not necessarily better than in other countries. The USA is ranked number 50 in life expectancy, number 45 in infant mortality.
Comparison of health outcomes across countries is fraught with statistical challenges. The Organization for Economic Co-operation and Development has been trying to collect and compare health care data across its 30 member countries for several years. OECD has identified a number of indicators of the efficacy of a country’s health care. While comparison problems in the data are addressed in the report, it gives the best cross country comparisons I’ve located. In terms of favorable outcomes on some of these indicators, the USA ranks number 8 in breast cancer five year survival rate out of 21, number 9 in cervical cancer five year survival rate, number 6 in colorectal cancer five year survival rate, number 20 out of 25 in mortality from asthma as a primary cause, number 9 out of 23 in offering annual flu vaccine to those over age 65, and number 5 out of 12 in providing retinal exams for diabetics. Statistics for the USA were not available in such measures as heart attack and stroke.
9. The World Health Organization (WHO) has declared access to healthcare a fundamental human right. In addition, Article 25 of The Universal Declaration of Human Rights, a UN document inspired in part by Eleanor Roosevelt, declares: “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care and necessary social services, and the right to security in the event of unemployment, sickness, disability, widowhood, old age or other lack of livelihood in circumstances beyond his control.” [bold face added]
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