Charles Krauthammer’s columns in the Washington Post are like the Wall Street Journal editorial page, must-reading for anyone who wants to keep up with the illogical fulminations and small-minded cruelties of what passes for intellectual discourse on the right. The intellectual bankruptcy of today’s offering shows not only why health care reform should pass, but why it will.
After scolding President Obama for continuing to push for reform despite “electoral rebukes” in Massachusetts, New Jersey and Virginia, he complains that the cost-savings in the bill are “ridiculously insignificant.” Dismissing the popular support of the insurance industry reforms that would protect most Americans from the worst predations of the health care insurance marketplace, he goes on to describe the 30 million Americans who would get health coverage as unworthy recipients of taxpayer largesse. The half trillion dollars in Medicare “cuts,” he writes, are “not to keep Medicare solvent but to pay for the ice cream, steak and flowers.”
He concludes by citing Warren Buffett as calling on the president to “start over and get it right” with a bill that focuses exclusively on cutting health care costs.
The man who ran as a post-partisan is determined to remake a sixth of the U.S. economy despite the absence of support from a single Republican in either house.”
Actually, one Louisiana Republican did vote for the bill. But that little untruth isn’t the real problem with his formulation. How can a bill whose cost-cutting is insigificant “remake a sixth of the U.S. economy”?
It can’t, and it doesn’t. Whether the bill will actually bend the upward trajectory of health care costs by a trillion dollars in its second decade, as administration officials Peter Orszag and Nancy-Ann DeParle argue in a separate op-ed in today’s Post, will be determined in large part by the success of the payment reforms that are contained in the legislation. There is a serious likelihood that the bundled payments and accountable care organizations cited by Orszag and DeParle will fail because of the monopolistic powers that hospitals and physicians have in the health care economy, and the powerful hold they have as special interests over majorities in both political parties on Capitol Hill to keep it that way (for more on that, see “Unchecked Provider Clout in California Foreshadows Challenges to Health Care Reform” by Robert Berenson of the Urban Institute and Paul Ginsburg and Nicole Kemper of the Center for Studying Health System Change on the Health Affairs website).
But challenging “Obamacare” on those serious concerns — a worthy exercise — is something that Krauthammer can’t be bothered with. That would require knowing something about or at least thinking logically about the nation’s complex health care system and how its powerful special interests interact. Instead, what we get from the troglodytes on the right are ad nominem attacks mixed with slapdash cruelty for the less fortunate (health insurance as steak and ice cream, indeed).
The Post op-ed page is badly in need of a house-cleaning.
Margalit and Peter,
My suggested approach to treating those who refused to buy insurance is essentially the same way we deal with the uninsured now. If you show up at an ER, under EMTALA, they have to treat you until you’re stabilized even if you can’t pay. They don’t have to renew drug prescriptions, provide kidney dialysis or a course of cancer treatment. If providers are willing to treat those conditions without getting paid, that is, of course, their prerogative but they don’t have to and usually won’t.
Under Margalit’s view, we would, in effect, say that while we would have preferred that you bought insurance, we will treat you for free or for whatever modest amount you can pay no matter how irresponsible you were or how foolishly you spent your money that could have been used to buy health insurance which you could have afforded with your income. All those honest and responsible people who bought insurance will now bear an additional burden to cover the cost of your stupidity and irresponsibility. Alternatively, you’re suggesting that we shouldn’t impose pre-existing condition restrictions and you can just wait until you get sick to sign up for insurance. We know that won’t work. We’re not going to have a taxpayer funded system, single payer or otherwise, anytime soon. At best, we will build on the employer based system we have and try to fix the dysfunctional individual market. That’s the reality like it or not and is probably the best we can do.
“All those honest and responsible people who bought insurance..”
You mean all those people lucky enough to have their employer buy it for them, or the ones lucky enough to have the government pay for treatment through Medicaid, Medicare and the VA?
Barry;
Unfortunately the impact is entirely lost when not reading the entire articles. These articles are often on subjects of public interest and concern and it irritates the dickens out of me that they remain subscription only (there is no abstract even). I just wrote a nasty letter to the NEJM.
I will concentrate on the second one, “Failing to Thrive” – briefly, it concerns two cases reviewed by a medical resident – one, her own grandmother who was demented and seemed to be having a stroke; the family (most of whom were physicians) debated whether to take her to an ER or not. They finally did, nothing specific was found, and after a few days she returned to baseline and was discharged, still alive and demented a year later. The second case was a 90 year old admitted from a nursing home for failure to thrive (in the resident’s words, defined as “half-dead without evidence of something objectively treatable”). The attending agreed that there was no acute disease they could treat at the time, but they couldn’t send him back because “We haven’t done anything to fix him.”
After choking on his applesauce and nearly dying from the subsequent pneumonia and various side effects from his antibiotics, a dilemma arose over whether to insert a feeding tube due to his chronic aspiration (choking).
Again I quote, “among patients who are dying of chronic disease and hence have stopped eating, feeding tubes neither prolong life nor prevent aspiration.” However, a feeding tube was offered to the family, inserted, and immediately malfunctioned. Several more days were required to get the patient back to his original state, except now with a feeding tube. “Mr. T’s hospitalization…found him half-dead at the beginning, half-dead at the end, and much sicker in the middle….”
“We see the same patients repeatedly, back and forth from their nursing homes, infested with bedsores, colonized by resistant organisms….we torture them with our needles and catheters, and they scream.”
I wish you could have read the entire articles, but you get the general idea. Wonder why costs are so high?
Sorry, I meant to add that the high costs are not dollar costs alone. Families seem to want everything done and this is the result. Are we treating these people, or torturing them? (I could be snide and say ask Dick Cheney, but that’s another subject….. (:)
Bev – I’m interested in your professional medical opinion as to the extent to which the treatment patterns described in the articles happen because doctors think this is what they should be doing independent of patient and family demands and expectations and that the hospital and doctors are paid more if they do more. How significant a factor are family members’ demands and expectations to “do everything?” Also, I wonder if doctors could do a better job of explaining to families that while they are doing a lot TO the patient, they are doing little or nothing FOR the patient. Is that really what you want and do you think your loved one would want this if he or she could tell us?
“You mean all those people lucky enough to have their employer buy it for them, or the ones lucky enough to have the government pay for treatment through Medicaid, Medicare and the VA?”
Peter – Add in about 18 million people who buy insurance in the individual market including 800,000 in CA alone. Throw in millions more who pay a very significant percentage (sometimes up to 50%) of their small employer’s costs to buy in the small group market. Then add many millions of Medicare beneficiaries who spend $200 or more per month to buy a Medi-gap policy. Even in high cost Massachusetts, young people can buy a bronze level health insurance policy for less than $150 per month.
Barry, since it is immoral to just let somebody die for no reason really, and since it is unfair to ask what you call responsible people to perpetually pay for bad decisions made by others, I would suggest that the only solution is to mandate that everybody contributes to health care costs, according to their ability.
Is this being a nanny? To a certain degree, it is. I am having a hard time imagining that this seemingly more conservative country would be willing to stand by and watch people dying en masse. Therefore mandating coverage is a means of protecting the propertied from the foolishness of others. Rather conservative, I’d say.
Margalit – While I outlined the potential appeal to conservatives of Paul Starr’s suggested approach and indicated how I would deal with those who refused to buy insurance (essentially as we do now), my own preference is for a mandate to buy but offer a financial hardship exemption if the cheapest policy in the market exceeds 10% of income for middle income people and a lower percentage farther down the income distribution.
The problem with the bill as proposed is that the mandate is way too weak. It would be verified through the income tax system but many people who earn their income in the underground economy don’t file tax returns or pay income taxes. For those who do, way too many young healthy people will rationally opt to pay the penalty safe in the knowledge that if their health deteriorates, they can enter the health insurance market and buy a policy at standard rates. This is the problem in a nutshell. The insurance pools will not have enough young and healthy people which are likely to drive premiums even higher than they are now in the majority of states that currently use medical underwriting.
My alternative to Starr’s approach for people who pay the penalty rather than buy a policy while they are healthy but want health insurance when they get sick is to charge them for the premiums they would have had to pay during the time they didn’t buy up to a maximum of five years. They can pay it out over time but they will be on the hook for the money.
“according to their ability.”
This has never been accomplished before, without accomplishing this you can’t have a sustainable system. As long as people can cheat the system and get away with it they will. Dieing becuase you didn’t buy insurance when you could is the only effective way to force people to pay according to their ability.
Barry, my first choice would be to increase the penalty so there is no significant advantage to not buying coverage. I don’t know how to deal with the underground economy, or how to collect penalties from them. That’s where a VAT would be ideal, but it’s not going to happen. I would suspect though, that this is a minority that evades every other duty as well.
Yes, Nate, some people will cheat the system if they can. They do now. However imposing the death penalty for cheating on your taxes would qualify as cruel and unusual punishment in my opinion.
Barry;
I didn’t respond to your question about dr’s and resuscitation efforts because there is no one opinion and the opinions are strongly held. However, here is another one, in the Washington Post so you can read it this time, which offers another viewpoint.Would I agree with that? Hard question. My own dad died slowly of cancer but was incoherent from brain involvement so that decision was somewhat easier.
http://www.washingtonpost.com/wp-dyn/content/article/2010/03/08/AR2010030802432_2.html?hpid=sec-health
Bev – It’s an interesting article and perspective. I’ll offer the following comments.
1. How would the situation have been handled in Canada or Western Europe?
2. To what extent is our protocol driven by our litigation system and environment?
3. In this particular instance, if the patient’s information were on an easily accessible electronic registry, or a Medic Alert necklace or bracelet or on a card in the patient’s wallet, the staff would have been able to quickly learn of the DNR and DNI orders.
4. With respect to the doctor describing what he would want for himself, I wonder if he would be prepared to pay for such care out of pocket if he could afford to if that money could otherwise be used to fund his grandchild’s college education or for some other very worthwhile purpose. People are very quick to make claims on (finite) taxpayer (Medicare) resources and feel entitled to do so.
Separately, regarding treating cancer specifically, I think it is very unfortunate that oncologists and surgeons often frame the choices available to the patient in terms of fighting vs. giving up. They implicitly make the patient and family feel brave and courageous if they choose to fight but weak and cowardly if they want to give up. They are often quick to try to enroll you in a clinical trial without fully explaining what you’re signing up for in terms of risks and side effects and general quality of life. Sometimes they resist or oppose making a palliative care consultation available to the patient and family even when the hospital has a good palliative care program. They also happen to get paid more if they do more. The bias, especially at the famous cancer centers, is toward very aggressive treatment. More honesty and balance in their treatment approach would not only be helpful but would probably also be more cost-effective.
What a bunch of scummy little hypocrites, sitting there frothering at the mouth over their imagined victimization by supposed freeloaders, meaning anyone who doesn’t have health insurance. One would never suspect that these self-righteous ones are the beneficiaries of the most costly freeby in the tax code, namely the exemption from the income tax for their beloved health insurance, which costs the government over $246 billion a year in lost revenue. The “freeloaders” have to make up for this lost revenue, while paying the bills for their own health costs with income which is fully taxed. Then in regard people who have no money, their “solution” is a gigantic tax-funded subsidy, not to pay for their health care, but merely to pay an insurance company. What a bunch of geniuses!