Is Mandated Universal Coverage the Right Way to Achieve Health Reform? ...

Is Mandated Universal Coverage the Right Way to Achieve Health Reform? The Health Reform Debate We Haven’t Had Yet, by Jeff Goldsmith

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Goldsmith_2I don’t know how many of you linked over to Lawrence Brown’s perspective piece “The Amazing,
Non-Collapsing US Health Care System” in the January 24th issue of the New England Journal of  Medicine
(buried in Mathew’s “Whisper it quietly. . .” post), but it’s the most useful piece of political analysis of the  health reform conundrum I’ve seen in a long time.   

What Brown argues, convincingly, is that we really have three healthcare systems: public and private health FINANCING systems (which operate in the lucrative fantasy land of “reimbursement”) and a public CARE system (the safety net urban hospitals, community health centers, public health clinics, the VA, etc.) that serve the rural and urban poor and uninsured. 

Other than a few isolated outposts like Kaiser, the third health system that Brown discusses is the only place in the United States where population health is actually practiced. And, most important, it is also is the mysterious resource that prevents the 47 million uninsured, including a very large number of our 12 million undocumented people, from dying in our streets, and causing a huge political crisis. It is invisible to much of the voting public, but thank God we have a safety net healthcare system.

This latter system has been a political stepchild of state and federal governments, and lurches from financial crisis to financial crisis, living off the land. But it has successfully propped up the other two, and, I think, helped prevent a revolution.  Precisely because it has succeeded in reaching its target populations and helping them, albeit “too late” in the disease process, it has drained both political urgency (and funding) from making the first two “reimbursement” systems universal.

It is also where most of the politically active health reformers,
like Lawrence Brown (and Ron Anderson and my old friend, Quentin
Young) work. They actually see and touch poor people. They go to their
own meetings. They rage appropriately against the hypocrisy, rhetoric
and waste they see in the rest of our so-called “healthcare system”.
They have their own political networks, and also a very impressive case
for continued funding. And they rarely communicate with their
prosperous colleagues in the other two systems, or the Executive Branch
and Congressional health policymakers who have their hands full feeding
the alligators through Medicare and Medicaid.

Closing the 47 million person funding gap by making the first two
systems “universal” has been the elusive Holy Grail of health reform.
What Brown is basically saying to the Holy Grail folks is, “Don’t Hold
Your Breath”. The left has historically advocated wiping out the
private side of the health financing system, (making Kaiser, Blue Cross
and United Healthcare disappear, basically) and controlling all payment
centrally (and politically). The right has historically advocated
making the public side disappear, by outsourcing it to private
insurers. I think this debate is tiresome because neither side is going
to disappear any time soon, and all the absolutist rhetoric does is
make people feel  angry and hopeless, and turns off voters.

Both sides tend to behave as if this crucial third sector never
existed, and some believe that you wouldn’t need it if “coverage” was
universal (or perhaps that it would be paid more generously). There is
an important flaw in this argument. We will continue to need that third
sector because we will never make coverage universal. If, in our
current intolerant political climate, the Democrats, historic defenders
of the downtrodden, cannot give the 12 million undocumented folks we
depend on every day drivers licenses, they sure as hell aren’t going to
give them health insurance. And we aren’t going to send them all home
either.

And, as the collapse of California’s health reform initiative
demonstrates, if you cannot make “coverage” affordable, you cannot
force people to purchase it. We’re all waiting for the Massachusetts
experiment to play out, but my prediction is that, due precisely to the
affordability problem, one third of the uninsured in Massachusetts will
still be uninsured five years from now. It is reasonable to forecast
that there are going to be a lot of clients of the “safety net” sector
into the indefinite future.   

Moreover, millions of safety net “customers” are eligible for
Medicaid/SCHIP do not enroll, for a variety of reasons related to
privacy, dignity, paranoia, language or other cultural barriers,
administrative cumbersomeness or fiscal reluctance of state sponsors.
An estimated 25%  of the uninsured are already eligible for public
programs and do not enroll.

Brown’s third sector also explains that mystery. They don’t have go
through all the humiliating hassle of enrolling in Medicaid or SCHIP
because they are getting free or nearly free care with at least some
measure of dignity from public sector providers.  Though many of the
facilities are old and overtaxed, and the caregivers overworked, their
patients and the families they belong to feel at home in that public
system. It is also accessible to them because it is located where they
live.

There are complicated issues surrounding the social efficiency of
having this third sector. They revolve around the untested belief that
if everyone had health insurance, they would be healthier because
they’d get care earlier. I am skeptical of this logic. True enough, the
uninsured have greater health risks for the same conditions than the
insured do, but how much of this is cultural and logistical, and how
much relates to the fact that they are not “insured” is an open
question. I’d like to see the data sorting out these multiple effects
on health status before concluding that the lack of insurance itself
was the cause of the large health disparities we presently see. 

“Reimbursing” hospitals and doctors through private or public health
insurance to provide them care assumes not only that caregivers will do
the right thing, rather than the lucrative thing, and that families
will co-operate with them. To work, it also assumes that there is a
care system to pay near where the poor and uninsured live.  It further
assumes that there are not important non-financial (e.g. cultural)
barriers to families getting care “earlier” even if people have
coverage.   

Practicing population health, as the safety net system attempts to
do, does not assume away those cultural barriers. I think we get way
more health improvement mileage out of our community health centers
than we do out of just about any other social investment. Do we fund
them more effectively by “insuring” their patients, or simply through
more generous grants or local government salary lines?

To simply assume that extending coverage to the 47 million uninsured
somehow assures access and, therefore, better health, requires multiple
leaps of faith. There are many physical, cultural and economic barriers
separating “coverage” from “access”. Rather than focusing on
unaffordable mandates and massive tax-based subsidies, extending
coverage should focus on affordability (vitally important for the more
than ten million younger uninsured) and ease of access to multiple
insurance options, including earlier access to Medicare for the ten
million uninsured boomers. If we could lower the number of uninsured by
twenty-five or thirty million, it would be a huge victory. 

This is why any health reform legislation will contain one or more
titles increasing funding for safety net care providers. More generous
direct health funding for the safety net, with matching grants to
states and localities encouraging them to ramp up their efforts, rather
than continuing the elaborate system of largely hidden subsidies buried
in the Medicare program, is a vitally important adjunct to health
reform. Pragmatic health reform will incorporate reforming and
strengthening our healthcare safety net, and extending population
health initiatives that address the root causes of illness. 

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17 Comments on "Is Mandated Universal Coverage the Right Way to Achieve Health Reform? The Health Reform Debate We Haven’t Had Yet, by Jeff Goldsmith"


Guest
Nov 18, 2008

Mandated Health Care is the right way to go provided you take advantage of economy of scale….
9 Steps to Comprehensive Quality Health Care in America
1) Shut down the private health insurance corporations.
2) Enroll all Americans (including Veterans) and the 40 million uninsured citizens into the Medicare Health Insurance Corporation. Since the current functioning Medicare Insurance Company is already accepted by almost all physicians, Hospitals and clinics in the Country, hardly any infrastructure investments on the health care delivery end will be necessary. Have all private businesses pay a Medicare premium for their employees instead of private health insurance premiums. Let employees as well as businesses contribute a fixed premium amount based on their age up until 65 for their Medicare services and drugs. Freeze current premiums for all Americans over 65 and adjust in the future according to the cost of living index. These premiums paid by businesses to Medicare for their employees should be less than that paid to current private insurance companies because of the lower overhead costs of the Medicare Corporation and improved risk distribution.
3) Hire the now unemployed former private health insurance corporate bureaucrats to actually deliver and not inhibit health care by working in hospitals, doctors’ offices, clinics and nursing homes around our Country. Demographically, the percentage of elderly Americans is rapidly increasing. With every American now insured through Universal Medicare Insurance, real health care workers will be in desperate need. For the first time in the brief but bloody history of managed care, these former private insurance corporation employees will actually touch and improve care for patients by working in physical therapy, nursing, home health care and other ancillary patient care capacities.
4) Obtain by eminent domain (for the public good) the best of the intellectual property protected computer codes which the closed private insurance businesses previously used to monitor patient care and doctors utilization and performance. Private health insurance companies have used these computer programs exclusively for the purpose of strong-arming their contracted health care providers into doing less for their patients and increasing the premium costs for sicker patients in order to achieve higher corporate profits. Medicare on the other hand can use these same computer programs for the common good; to monitor, collect data and eventually improve the efficacy of diagnoses and the treatment of diseases and medical outcomes every time a doctor submits a bill. For example, wouldn’t it be nice to know as a medical consumer (patient) which oncology groups in Boston, New York or Houston have the highest cure rates for stage III breast cancer or Stage II prostate cancer? All those numbers currently exist in cancer registries nation wide and just need to be collected and honestly disseminated. Currently, instead of solid medical data which delineates morbidity and mortality and performance, the medical consumer when choosing an oncologist must rely on word of mouth, physician referrals or advertisements in the local papers which show photographs of smiling doctors in white coats who claim to be the ‘best’ doctors in town. In addition to garnering invaluable instantaneous epidemiologic data on diagnoses and treatment of diseases based on severity and other variables, a strong Medicare based utilization review computer code would also allow Medicare to monitor doctors and hospitals who abuse a fee-for-service billing system. Any physician, institution or service found to abuse the Medicare fee for service billing system after proper review and appeal should be dealt with severely through stiff penalties and loss of their Universal Medicare provider contract.
5) Freeze Medicare physician, hospital and ancillary services reimbursements at current 2007-2008 levels. Adjust reimbursements for future services yearly by Cost of Living increases, or in the event of a deflationary economy a decreases in doctor and hospital payments. Ask any physician and they’ll tell you they would accept current reimbursement rates with COLA over the current mysterious illogical fee adjustment system of Medicare, or the physician population density reimbursement formula used by most private insurance corporations. Two tiered medical systems separating the “haves and have not’s” of society have and will always exist. Therefore, we must allow physicians to practice medicine without enrolling in or accepting the Universal Medicare reimbursement. With private medical insurance no longer available, and no performance based evidence for improved morbidity and mortality among their private for-pay patients, these extraordinarily expensive private ‘VIP’ practices will be limited.
6) Allow Medicare, much like the current Veterans Administration System and every private health insurance company and government health care system around the world, to bid on medications from pharmaceutical corporations for its Medicare drug formulary. Every physician recognizes that we don’t need a choice of a dozen redundant drugs in each pharmaceutical category. For example, we need only 2-3 statins for cholesterol, a handful of antibiotics for infections, 2 beta blockers for hypertension, and a few pain killers. Once the Government bids on pharmaceuticals for the Medicare Corporation formulary, macro economics will force prices to massively decrease to levels identical to that which all the other people of the world outside of America are paying for the same medicines. Since it has not effectively decreased morbidity or mortality in this Country, and only wastes money, we should also prohibit pharmaceutical companies and their workers from contributing to political campaigns or buying commercials on the public airways. We need to also prohibit the current practice whereby your local pharmacy and pharmacist sells your private medical diagnoses and your doctors private prescribing drug information to pharmaceutical companies so the pharmaceutical companies in-turn can directly pressure-market physicians. Prohibit pharmaceutical companies from contributing to organized medicine societies, colleges or associations because the doctors can’t rely on soft bribes or free lunches to prescribe what’s best for their patients. Prevent pharmaceutical representatives from visiting doctors’ offices or hospital pharmacies directly. Allow delivery of Medicare formulary approved sample medications for patients to physicians’ offices via post office mail only. Allow pharmaceutical companies to market products to physicians only via peer reviewed publications delivered by email or snail mail.
7) With the savings incurred from closing the private insurance corporations and paying less for drugs, have the American government fully fund the National Institutes of Health (NIH) and the National Cancer Institute (NCI) and Small Business Innovative Research (SBIR) programs. Emphasis should be placed on basic bench research carried out at not-for-profit American Institutions which employ or utilize a majority of American Citizens in their laboratories and clinics. Too often American Universities rely on free overseas labor to conduct bench research. Clinical trials should emphasize new drugs and devices which have promise to significantly decrease morbidity and mortality for any disease, including orphan diseases. Since a large percentage of private funding for drug and device studies will originate in the expanding financial liquidity and innovations and patients of the emerging developing world, we should allow the FDA to utilize research data obtained by reproduced laboratory and clinical studies performed overseas as well as in this Country.
Corruption of honest academics should be curtailed. Force all investigators to release reproduced publicly funded scientific data for all scientists to review on the internet via the Freedom of Information act (The Senator Shelby Amendment). Prohibit rights of first refusal on scientific data for private companies performing research in non-for profit institutions which receive public funding. Any rights to profits obtained from intellectual property and patents invented with combined funding from government and private sources should be split fairly among the contributing government institutions and any other private corporations funding the research, as well as with the individual inventor. Prevent organized medicine societies, associations or colleges from contributing to political campaigns since campaign donations have no relevance for physician performance or patient morbidity or mortality.
8) Offer physicians the same legal protection from malpractice lawsuits which have been established for commercial health insurance corporations during the last 3 decades.
9) The quality of current medical records software lags two decades behind business software. Therefore, we need to fund and challenge America’s best software corporations to finally develop standardized electronic medical records software for use in doctors’ offices and hospitals in order to increase the efficiency and productivity of physician charting, billing and prescribing. We should use the integrated medical records system to instantaneously and confidentially gather important epidemiologic data on physicians’ performance, patient diseases, and treatments. With new potent viruses and unsophisticated biomedical and nuclear warfare on the horizon, this system will be absolutely necessary for rapid National Security responses. Protect patient confidentiality at all costs to prevent the commercialization and abuse of patient data like that which the pharmacies trade today.
Lastly, some argue that Universal Government run health care in America will result in delays in diagnosis and treatment similar to those experienced in Britain and Canada. One can not simply compare the massive extremely functional Medicare insurance corporation based infrastructure which seamlessly delivers health care to tens of millions of people yearly in the USA to the government run westernized health care systems of Canada and Britain, France, Switzerland, Netherlands, Scandinavia, and Israel. America, for the last 40 years, thanks to the government run health insurance corporation-Medicare, has built an incredibly dense and fluid public insurance system involving almost all doctors’ offices, hospitals, clinics and ancillary services. The Medicare system dwarfs in breadth and actual practitioners and efficacy the lesser insurance systems established in all other countries. The billing and reimbursement bureaucracy for health care providers contracted with Medicare Insurance is already relatively streamlined and efficiently centralized in America thanks to 40 years of physician, hospitals and government cooperation.
We all know that the medically bankrupt private health insurance corporations and medical malpractice lawsuit threats have caused many disheartened physicians to quit practicing or downsize their practices in America. A continuation and technological upgrading of our most fair Universal Medicare based health insurance Corporation based on the concepts outlined above would undoubtedly motivate those disenfranchised physicians to return to the profession and bright younger physicians to invigorate the field. If patients, physicians and the Medicare Corporation continue to work together, without the deleterious interference of private for-profit health insurance corporations, malpractice threats and overt pharmaceutical marketing, the future for American health care will be healthy indeed.. A continuation of the status-quo mixture of a government subsidized private health maintenance insurance industry operating parallel to and within Medicare is wasteful, and will continue to provide no potential future health improvements for America.

Guest
Nov 18, 2008

Mandated Health Care is the right way to go provided you take advantage of economy of scale….
9 Steps to Comprehensive Quality Health Care in America
1) Shut down the private health insurance corporations.
2) Enroll all Americans (including Veterans) and the 40 million uninsured citizens into the Medicare Health Insurance Corporation. Since the current functioning Medicare Insurance Company is already accepted by almost all physicians, Hospitals and clinics in the Country, hardly any infrastructure investments on the health care delivery end will be necessary. Have all private businesses pay a Medicare premium for their employees instead of private health insurance premiums. Let employees as well as businesses contribute a fixed premium amount based on their age up until 65 for their Medicare services and drugs. Freeze current premiums for all Americans over 65 and adjust in the future according to the cost of living index. These premiums paid by businesses to Medicare for their employees should be less than that paid to current private insurance companies because of the lower overhead costs of the Medicare Corporation and improved risk distribution.
3) Hire the now unemployed former private health insurance corporate bureaucrats to actually deliver and not inhibit health care by working in hospitals, doctors’ offices, clinics and nursing homes around our Country. Demographically, the percentage of elderly Americans is rapidly increasing. With every American now insured through Universal Medicare Insurance, real health care workers will be in desperate need. For the first time in the brief but bloody history of managed care, these former private insurance corporation employees will actually touch and improve care for patients by working in physical therapy, nursing, home health care and other ancillary patient care capacities.
4) Obtain by eminent domain (for the public good) the best of the intellectual property protected computer codes which the closed private insurance businesses previously used to monitor patient care and doctors utilization and performance. Private health insurance companies have used these computer programs exclusively for the purpose of strong-arming their contracted health care providers into doing less for their patients and increasing the premium costs for sicker patients in order to achieve higher corporate profits. Medicare on the other hand can use these same computer programs for the common good; to monitor, collect data and eventually improve the efficacy of diagnoses and the treatment of diseases and medical outcomes every time a doctor submits a bill. For example, wouldn’t it be nice to know as a medical consumer (patient) which oncology groups in Boston, New York or Houston have the highest cure rates for stage III breast cancer or Stage II prostate cancer? All those numbers currently exist in cancer registries nation wide and just need to be collected and honestly disseminated. Currently, instead of solid medical data which delineates morbidity and mortality and performance, the medical consumer when choosing an oncologist must rely on word of mouth, physician referrals or advertisements in the local papers which show photographs of smiling doctors in white coats who claim to be the ‘best’ doctors in town. In addition to garnering invaluable instantaneous epidemiologic data on diagnoses and treatment of diseases based on severity and other variables, a strong Medicare based utilization review computer code would also allow Medicare to monitor doctors and hospitals who abuse a fee-for-service billing system. Any physician, institution or service found to abuse the Medicare fee for service billing system after proper review and appeal should be dealt with severely through stiff penalties and loss of their Universal Medicare provider contract.
5) Freeze Medicare physician, hospital and ancillary services reimbursements at current 2007-2008 levels. Adjust reimbursements for future services yearly by Cost of Living increases, or in the event of a deflationary economy a decreases in doctor and hospital payments. Ask any physician and they’ll tell you they would accept current reimbursement rates with COLA over the current mysterious illogical fee adjustment system of Medicare, or the physician population density reimbursement formula used by most private insurance corporations. Two tiered medical systems separating the “haves and have not’s” of society have and will always exist. Therefore, we must allow physicians to practice medicine without enrolling in or accepting the Universal Medicare reimbursement. With private medical insurance no longer available, and no performance based evidence for improved morbidity and mortality among their private for-pay patients, these extraordinarily expensive private ‘VIP’ practices will be limited.
6) Allow Medicare, much like the current Veterans Administration System and every private health insurance company and government health care system around the world, to bid on medications from pharmaceutical corporations for its Medicare drug formulary. Every physician recognizes that we don’t need a choice of a dozen redundant drugs in each pharmaceutical category. For example, we need only 2-3 statins for cholesterol, a handful of antibiotics for infections, 2 beta blockers for hypertension, and a few pain killers. Once the Government bids on pharmaceuticals for the Medicare Corporation formulary, macro economics will force prices to massively decrease to levels identical to that which all the other people of the world outside of America are paying for the same medicines. Since it has not effectively decreased morbidity or mortality in this Country, and only wastes money, we should also prohibit pharmaceutical companies and their workers from contributing to political campaigns or buying commercials on the public airways. We need to also prohibit the current practice whereby your local pharmacy and pharmacist sells your private medical diagnoses and your doctors private prescribing drug information to pharmaceutical companies so the pharmaceutical companies in-turn can directly pressure-market physicians. Prohibit pharmaceutical companies from contributing to organized medicine societies, colleges or associations because the doctors can’t rely on soft bribes or free lunches to prescribe what’s best for their patients. Prevent pharmaceutical representatives from visiting doctors’ offices or hospital pharmacies directly. Allow delivery of Medicare formulary approved sample medications for patients to physicians’ offices via post office mail only. Allow pharmaceutical companies to market products to physicians only via peer reviewed publications delivered by email or snail mail.
7) With the savings incurred from closing the private insurance corporations and paying less for drugs, have the American government fully fund the National Institutes of Health (NIH) and the National Cancer Institute (NCI) and Small Business Innovative Research (SBIR) programs. Emphasis should be placed on basic bench research carried out at not-for-profit American Institutions which employ or utilize a majority of American Citizens in their laboratories and clinics. Too often American Universities rely on free overseas labor to conduct bench research. Clinical trials should emphasize new drugs and devices which have promise to significantly decrease morbidity and mortality for any disease, including orphan diseases. Since a large percentage of private funding for drug and device studies will originate in the expanding financial liquidity and innovations and patients of the emerging developing world, we should allow the FDA to utilize research data obtained by reproduced laboratory and clinical studies performed overseas as well as in this Country.
Corruption of honest academics should be curtailed. Force all investigators to release reproduced publicly funded scientific data for all scientists to review on the internet via the Freedom of Information act (The Senator Shelby Amendment). Prohibit rights of first refusal on scientific data for private companies performing research in non-for profit institutions which receive public funding. Any rights to profits obtained from intellectual property and patents invented with combined funding from government and private sources should be split fairly among the contributing government institutions and any other private corporations funding the research, as well as with the individual inventor. Prevent organized medicine societies, associations or colleges from contributing to political campaigns since campaign donations have no relevance for physician performance or patient morbidity or mortality.
8) Offer physicians the same legal protection from malpractice lawsuits which have been established for commercial health insurance corporations during the last 3 decades.
9) The quality of current medical records software lags two decades behind business software. Therefore, we need to fund and challenge America’s best software corporations to finally develop standardized electronic medical records software for use in doctors’ offices and hospitals in order to increase the efficiency and productivity of physician charting, billing and prescribing. We should use the integrated medical records system to instantaneously and confidentially gather important epidemiologic data on physicians’ performance, patient diseases, and treatments. With new potent viruses and unsophisticated biomedical and nuclear warfare on the horizon, this system will be absolutely necessary for rapid National Security responses. Protect patient confidentiality at all costs to prevent the commercialization and abuse of patient data like that which the pharmacies trade today.
Lastly, some argue that Universal Government run health care in America will result in delays in diagnosis and treatment similar to those experienced in Britain and Canada. One can not simply compare the massive extremely functional Medicare insurance corporation based infrastructure which seamlessly delivers health care to tens of millions of people yearly in the USA to the government run westernized health care systems of Canada and Britain, France, Switzerland, Netherlands, Scandinavia, and Israel. America, for the last 40 years, thanks to the government run health insurance corporation-Medicare, has built an incredibly dense and fluid public insurance system involving almost all doctors’ offices, hospitals, clinics and ancillary services. The Medicare system dwarfs in breadth and actual practitioners and efficacy the lesser insurance systems established in all other countries. The billing and reimbursement bureaucracy for health care providers contracted with Medicare Insurance is already relatively streamlined and efficiently centralized in America thanks to 40 years of physician, hospitals and government cooperation.
We all know that the medically bankrupt private health insurance corporations and medical malpractice lawsuit threats have caused many disheartened physicians to quit practicing or downsize their practices in America. A continuation and technological upgrading of our most fair Universal Medicare based health insurance Corporation based on the concepts outlined above would undoubtedly motivate those disenfranchised physicians to return to the profession and bright younger physicians to invigorate the field. If patients, physicians and the Medicare Corporation continue to work together, without the deleterious interference of private for-profit health insurance corporations, malpractice threats and overt pharmaceutical marketing, the future for American health care will be healthy indeed.. A continuation of the status-quo mixture of a government subsidized private health maintenance insurance industry operating parallel to and within Medicare is wasteful, and will continue to provide no potential future health improvements for America.

Guest
GR
Oct 19, 2008

Thank you, Mr. Goldsmith excellent article.
In addition health care, “fear”, can be used to implement change that has less to do with your health and more to do with control.
http://www.healthplan.9f.com/

Guest

good work

Guest
EdSmith
Feb 10, 2008

I find this terribly sad. Jeff Goldsmith has this golly-gee resume and gets paid to speak to corporations on health care. Yet, he says we can’t have universal care because it has never worked before in the U.S. And, returning to the original subject, nothing is going to get fixed as long as we have the third sector of free clinics relieving pressure.
Perhaps Jeff keeps busy by entertaining the swells with cracks like the one above about the podiatrist, chiropractic, and reiki lobbies. I can hear the yucks from the AMA/AHIP country club crowd already.
Universal coverage can be accomplished. And, a government system can work. Oregon came up with a start years ago and the facts can be read here http://www.citizenshealthcare.gov/resources/slide/kitzhaber_chcwg.pdf
Here is the quote from former governor Kitzhaber as to why the plan ultimately failed:
“The demise of the Oregon Health Plan was not simply due to the depression, the budget deficit and the lack of funding. It was also due to the larger system in which it existed – by the fact that we were trying to bring about meaningful reform within the constraints and contradictions of a fatally flawed federal structure. This is not a state problem; it is not a Medicaid problem – it is a national problem, a system problem — and it cannot be resolved at the state level without fundamental changes in the structure of the federal system in which states efforts must take place.”
So we will let Jeff Goldsmith decide if he is going to be part of the fundamental change needed or if he will help maintain the system that lets his neighbors needlessly die and live in pain and disability for years.

Guest
EdSmith
Feb 10, 2008

I find this terribly sad. Jeff Goldsmith has this golly-gee resume and gets paid to speak to corporations on health care. Yet, he says we can’t have universal care because it has never worked before in the U.S. And, returning to the original subject, nothing is going to get fixed as long as we have the third sector of free clinics relieving pressure.
Perhaps Jeff keeps busy by entertaining the swells with cracks like the one above about the podiatrist, chiropractic, and reiki lobbies. I can hear the yucks from the AMA/AHIP country club crowd already.
Universal coverage can be accomplished. And, a government system can work. Oregon came up with a start years ago and the facts can be read here http://www.citizenshealthcare.gov/resources/slide/kitzhaber_chcwg.pdf
Here is the quote from former governor Kitzhaber as to why the plan ultimately failed:
“The demise of the Oregon Health Plan was not simply due to the depression, the budget deficit and the lack of funding. It was also due to the larger system in which it existed – by the fact that we were trying to bring about meaningful reform within the constraints and contradictions of a fatally flawed federal structure. This is not a state problem; it is not a Medicaid problem – it is a national problem, a system problem — and it cannot be resolved at the state level without fundamental changes in the structure of the federal system in which states efforts must take place.”
So we will let Jeff Goldsmith decide if he is going to be part of the fundamental change needed or if he will help maintain the system that lets his neighbors needlessly die and live in pain and disability for years.

Guest
Feb 8, 2008

Interesting comments.

Guest
Jeff Goldsmith
Feb 7, 2008

What Ed is talking about is essentially what Uwe Reinhardt proposed years ago (First Class, Business Class, Economy Class coverage) which Ann Miller RN mentioned in the first comment. In Uwe’s scheme, unlimited access to elite institutions and no waiting was financed by the wealthy out-of-pocket. If we could restrain provider political interests from lobbying to have their services included in the basic coverage package (podiatrists, chiropractors, reiki practitioners, etc.) and focus on primary care/drugs/dental care and have catastrophic type coverage for most everything else, we could have an affordable basic package and lots of people would choose to be covered voluntarily.
The Clintons never got this far, but it is what would have sunk their plan if they’d been able to get it through Congress. The subsidy costs would have eaten them alive and broken the federal budget. The benefit package is the prime fiscal/political risk in any universal coverage scheme. History shows that our political system- federal or state- is incapable of constructing an affordable basic package. Which is why I think, racism and Lou Dobbs aside, universal coverage is simply not going to happen.
Apropos of an earlier post, this is where Massachusetts broke down- an expensive teaching hospital centric care system, mandated in vitro fertilization, etc. By the time you add in all the goodies, and by the way, outlaw medical underwriting and mandate community rating and guarantee issue, you’re back to unaffordable rates that no-one will voluntarily pay without heavy subsidies. For kids and young adults, a good 40% of the uninsured, the monthly premium COULD be as little as $50-60 a month with disciplined and creative benefit design.
Right now, 25% of the uninsured who are eligible for public coverage do not enroll, and something like 8 million employed people decline employer based coverage (mainly for family members). These are the core users off the safety net/ community-based care systems. It may not seem like much of a “choice” (to use the safety net vs. enroll in Medicaid/SCHIP) if people don’t have the cash to afford private coverage, but forcing the working poor to buy private coverage they cannot afford thru mandates was what sank health reform in California, and it was the Democrats, not the satanic capitalists and free marketers, who killed it. This issue is a public policy quagmire. It is not insoluble, but it requires getting a long way past the feel-good sloganeering we’re engaged in now.

Guest
EdSmith
Feb 7, 2008

I am still trying to get all this straight. If Jeff Goldsmith is arguing for stable funding for the third sector because it works well, or good enough, then can’t we reduce the question to how many of us should use this third sector? And, that begs the question of who funds and monitors this third sector.
It seems so much of U.S. health care debate boils down to rich people, or the self-perceived rich, not wanting to run into their gardener in a waiting room. The well-to-do want assurance they get the best care, or at least better care because they have money. (Yeah, I know they don’t want to contribute anything to poor people’s doctor bills either, but too bad— sick, poor people make the U.S. worse off so we need to force rich people to be responsible by taxing them.) Just give everyone tax-funded basic care. For everyone with a lot of money who wants prestigious, celebrity care, they can pay retail or buy expensive insurance.
If all the doctors only want to be boutique doctors, cut off all the government subsidies for them (like Medicare funding of medical schools) and push the advantages of a regular paycheck and not having to hire three staffers to argue with insurance companies. I’d rather see a doctor motivated by providing medical care than by babying and misleading rich patients for money, anyway.
If everyone is not covered, there is going to be continual arguments about how many get to use the third sector. Just the homeless and jobless? Families of four making less than $60K? How about the DINKs in their twenties making $150K going without insurance so they can vacation in Mexico twice a year?
I don’t see why this needs to be treated as a revolution. Yes, it may hit the insurance exec’s salary hard, and the million dollar a year specialist MD might suffer a blow, but somehow I think they should be able to take the punch.

Guest
Peter
Feb 7, 2008

Does the third shelter system (homeless shelters) prevent revolution in housing? Does the third mental health system (jails) prevent revolution in mental health care? I guess they do if most people were forced to interact with these groups on a daily basis. But as EdSmith said very well, should that be how we justify their existence and prevent overhaul of a morally and financially bankrupt system. As costs continue to rise at unsustainable rates more and more people will find themselves depending on the third system – epecially in an economic downturn when the jobs with healthcare disappear. Maybe that’s when the revolution will occur.
jd, I don’t think we can give everyone commercial insurance without raising the income levels for subsidy dramatically. Then it will be pretty much a de facto universal system. But is that the solution, we just forget about cost control and pay the price of what the private sector has created in healthcare? Is this really about protecting the commercial insurance market? “This is an argument against trying to bring everyone into commercial insurance and Medicare, as they function now.” Yes it is, because that won’t work to control costs, it will feed costs.
If we were all in the third system think how much costs could be reduced? Do you think there is over-utilization in the third system – not likely. Over-utilization is what everyone here talks about when discussing getting control of costs. We all seem to want control of over-utilization, but will we be able to live with it?
I have learned to understand that just giving poor people access to healthcare does not improve their health,(IHS) it just improves the treatment of their condition (a bad thing?). The same for their education, teachers and schools give them access but do not improve their test scores or graduation rates. Culture, family and neighborhood, has a much higher grip on outcome. If it didn’t we’d get the same ratio of success/failure in affluent homes. But is that any justification for keeping them fighting daily for adaquate healthcare care or equal education? How many people able to easily pay for health insurance actually change THEIR lifestyle to reduce their need for care? It seems they’re the ones driving over-utilization.

Guest
Jeff Goldsmith
Feb 6, 2008

The Indian Health Service is laboring against huge cultural odds- poverty, massive adult unemployment, rampant alcohol abuse and a burgeoning meth epidemic, domestic violence, child neglect, third world diseases. I honestly don’t think more orthopedists and ENT specialists are going to make that big a difference. We ought to be ashamed of what we have done to our native American brothers.
To repeat a point made in the post, I think there is more leverage in actually providing more generous direct funding of safety net providers, particularly at the community health center and neighborhood clinic level, than in providing heavily subsidized coverage to the same populations. Not to dismiss Ed’s personal experiences here, but there are comparable horror stories of people with excellent insurance who have slipped between the cracks in a fragmented and unaccountable private health system. It isn’t about government.
It is not encouraging that our federal government has somehow continued to subsidize wheat growers with wheat at $10 a bushel, and oil producers with oil at $90 a barrel. It doesn’t bode well for managing the cost of the massive subsidies required to make universal coverage work. I think we get a lot more mileage out of locally managed and operated care systems that actually treat high risk people. We should do what we can to grow health coverage both from the private and public ends, but we should be under no illusions that we will close enough of the gap to make the safety net unnecessary. We should be talking now about how to make it stronger and more effective.

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jd
Feb 6, 2008

My second to last sentence should have been something like:
This is an argument against trying to bring everyone into commercial insurance and Medicare, as they function now.

Guest
jd
Feb 6, 2008

I’m trying to wrap my head around this.
Is this the basic idea: of the 45+ million uninsured, we shouldn’t try to bring them all into the commercial system. We should instead aim to split this group into parts, some of which would become commercially insured, some of which would join a government-sponsored insurance program, and some of which would remain technically uninsured but have access to free or nearly free care through a loose system of community clinics and hospitals? Is that the proposal?
I understand that community clinics are one of the most efficient parts of our system (to put it in other terms, they provide good value for the money spent). I also understand that they serve as an escape valve that allows costs to go up elsewhere without breaking the system utterly and causing a revolution. But that isn’t an entirely good thing. Sometimes its better to have the revolution and get it over with so that you can start fresh.
Putting aside a complete redesign of the health care system, what I don’t understand is why we can’t have the safety net system AND give everyone insurance. We could have both, and those who get commercial coverage would largely avoid those clinics and hospitals, while those who get public coverage (or a base-line coverage) would continue to largely use the safety net health care providers, but now they would bring with them a more reliable source of funding. Isn’t that preferable to leaving some uninsured?
Or am I just getting hung up on the title? OK, maybe it’s not that you don’t want to insure everyone, by which I mean cover everyone for most of the cost of their care. It’s that in doing so you don’t want to focus on providing more funds to that part of the health care provision industry which swallows resources at an alarming rate to provide care of questionable necessity. Partly this is about relative efficiency, and partly this is about supporting those parts of the health care system that are in the lower income communities and are best-placed to serve the poor.
In other words, this isn’t an argument against mandates or insurance. This is an argument about trying to bring everyone into commercial insurance and Medicare. Have I got it right now?

Guest
Lee Gugerty
Feb 5, 2008

Good idea to point out that increasing coverage does not necessarily increase access to care. Here is an example of where people have access (through your public care system) but not enough coverage — the Indian Health Service. That is, Native American users of the IHS have relatively easy access to health care (at least if they live near an IHS clinic); but they receive less comprehensive health care (e.g., no access to orthopedists and ENT specialists unless it’s an emergency; no access to some of the newer and more effective pharmacotherapies.) Political point: the US Senate is now considering a bill Senate 1200 to rectify some of these problems of lack of comprehensive coverage.

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EdSmith
Feb 5, 2008

Reading Lawrence Brown’s piece, Jeff Goldsmith’s commentary, and a few posts make me feel like I’ve fallen down Alice’s rabbit hole. Let me in on the joke someone. These are Modest Proposals, right?
Arguing that the third sector safety net relieves the pressure to improve U.S. health care, is like arguing we can let our highway system go because poor people can always walk or bum rides and there is more money made in selling airline tickets and SUV’s to drive around the potholes than in fixing roads.
How do you define collapse? Is it when your neighbor dies because he spent an hour in an ER waiting room because all the beds were filled with safety net users? Is it when your kid loses 20 IQ points because you didn’t get his fever tended soon enough because you had a miserable experience in the ER a year ago and you still have $1200 to pay on the bill? Is it when Chrysler goes under because it can’t compete because of health insurance premiums? The first two are isolated, but approaching, lightning strikes you may have avoided. The third has already happened.
And don’t be using words like Flexnerian. They don’t scare us off anymore.
Someone needs to manage U.S. health care. Doctors, hospitals, and insurance companies have failed miserably. No other first-world county participates in this craziness. Don’t talk about American gumption and private choices. There is no free market at play until I can buy drugs at the liquor store and have the vet take out my gall bladder. Neither sounds like a good idea. Until someone comes up with something better, it is fine with me for the government to manage health care.