This week, the Cato Institute released a 52-page report on health care reform titled: Bad Medicine: A Guide to the Real Costs and Consequences of the New Health Care Law.
The tract was written by Michael Tanner, a senior fellow at the Institute, and it rests on the thesis that the Patient Protection and Affordable Care Act (ACA) is both Unaffordable and Unfair. Inevitably, Tanner’s claims about affordability are shaky; in truth no one can project how much reform will cost over ten years—and how much it will save. There are too many variables involved. Nevertheless, Tanner seems sure: the legislation will add to the deficit, he asserts, and force insurance premiums higher. Moreover, he stamps the legislation “unjust”: it would turn private insurance companies into regulated “public utilities,” forcing them to insure sick people, while “redistributing income” from families earning “over $348,000” to families earning “$18,000 to $55,000.” Ultimately, he argues, reform represents yet another step toward turning the U.S. into a “Nanny State.”
Why a 52-page report on health care reform now? Tanner makes his purpose clear in the Introduction where he suggests that conservatives will make the new health care legislation the “centerpiece of Republican campaigns this fall,” as they lobby for repealing the Affordable Care Act, or at the very least, replacing it. Bad Medicine is meant to serve as a playbook for those who hope to kill reform.
With that in mind, The Century Foundation decided that the document deserves scrutiny. In the weeks ahead, I will be analyzing and rebutting the report’s many arguments against individual and employer mandates, insurance regulation, subsidies, reductions in Medicare spending, and the CLASS Act, a much-needed national long-term care program.
Cherry-Picking the Polls
To buttress the argument for repeal, the report begins by declaring that the reform “legislation remains deeply unpopular. Recent polls show substantial majorities support repealing it. For example, as a Rasmussen poll in late May showed that 63 percent of likely voters supported repeal, with 46 percent ‘strongly’ supporting repeal. Just 32 percent wanted to keep the law.”
To illustrate the point, page 2 of Bad Medicine features this chart:
Rasmussen Poll –May 22-23
Source: Rasmussen Reports, poll of 1,000 likely voters, May 22–23, 2010, margin of error +/- 3 percentage points, with a 95% level of confidence.
Some might object that Cato is offering a Rasmussen poll as its only evidence. Many liberals claim that Rasmussen tilts to the right. Last year, even TIME magazine called Rasmussen a “conservative-leaning polling group.” The Center for Public Integrity points out that Scott Rasmussen, the president of the organization was a paid consultant for the 2004 George Bush campaign.
Nevertheless, for the moment let’s accept Cato’s use of a Rasmussen survey. The group’s work is generally recognized as “reliable,” even if, as blogger Nate Silver notes, its “issue-based polling” tends to “elicit responses that are more conservative than those found on other national polls.”
What bothers me is not so much the pollster, but the fact Tanner has reached back to May to find a poll that supports his thesis. Keep in mind that Rasmussen has been asking the question about repealing the healthcare legislation every week since the bill passed in March. Bad Medicine was released July 12. Why didn’t Tanner include June numbers? Instead, he hand-picked the one poll, over a seventeen week span, that shows support for repeal running as high as 63%.
In May, Rasmussen commented on the spike: “Support for repeal of the new national health care plan has jumped to its highest level ever. Prior to today, weekly polling had shown support for repeal ranging from 54% to 58%. . . . this marks the first time that support for repeal has climbed into the 60s. It will be interesting to see whether this marks a brief bounce or indicates a trend of growing opposition.”
Indeed, the May 22 poll turned out to be a “bounce”—merely a blip on the screen. Over the next five weeks, support for repeal consistently dropped, while opposition to killing the bill rose.
Rasmussen Polls on Repeal of Health Care Reform: March –July
By late June, as the table above reveals, just 52% of voters favored repeal—down from 63% in that one May poll– while 40% were opposed. The most recent Rasmussen numbers, released Monday, July 15, confirms where public opinion is heading. As the pollster notes, “This is the second lowest level of support for repeal in 17 weeks of surveying since the health care bill was passed by Congress. It marks what appears to be a continuing downward trend in support for repeal since June.”
The More Americans Learn About the ACA, the Better They Like It
A survey taken at any particular point in time is not terribly meaningful. Trends, on the other hand, tell us where minds are moving. As I have argued in the past, ever since the reform legislation passed Congress on that Sunday evening in March, multiple polls have tracked growing support for the legislation.
Recent polls that go beyond the “favor/oppose’” formula to ask more probing question also have discovered that the public is keeping an open mind. For example, in June, a Kaiser Foundation poll discovered that 60% of Americans either support the ACA or prefer that it “be given a chance to work with Congress making revisions as needed.’” Just 27% favored repeal.
A June NBC/Wall Street Journal poll confirmed the wait-and- see attitude. When pollsters asked: “Would you be more likely to vote for a Democratic candidate for Congress who says we should give the new health care law a chance to work and then make changes to it as needed, or a Republican candidate for Congress who says we should repeal the new health care law entirely and then start over?’” 51% of respondents picked the Democrat, 44% picked the Republican. And as The New Republic’s Jonathan Chait notes, “this was in a poll showing a plurality (45-43) preferring a Republican-controlled Congress.” Chait adds: “One of the political benefits to Democrats of passing the Affordable Care Act . . . is that it shifted the debate to favorable terrain. Now Democrats are favoring the status quo, and Republicans are trying to pass a radical change.”
Finally, Gallup polling both affirms that the number of Americans who favor the ACA has been climbing over time, and suggests that opposition is now largely confined to the one group that already has universal coverage– seniors.
The Washington Post’s Ezra Klein comments on the divide: “Health-care reform, as you can see in the table, is comfortably popular with every demographic except for seniors. And seniors, of course, aren’t opposed to government-run health care. They love their Medicare, and insofar as they have a policy concern here, it’s that the Affordable Care Act will interfere with the single-payer system they rely on. The ACA does include some Medicare cuts, and the GOP was extremely effective at messaging on them . . . But insofar as there’s a policy message here, it’s comforting for health-care reformers. The Affordable Care Act is popular among the people it will actually affect, and unpopular among the people who are worried it will harm the much-more statist health-care system they depend on.”
In the end, whatever polls you look at—Rasmussen’s, Kaiser’s, Gallup’s–and however you slice and dice the numbers, it is very difficult to find evidence for the Cato’s initial claim, on the second page of its report that the “legislation remains deeply unpopular.”
Four months ago, few Americans knew what was in the 2,500 page bill, or what impact it would have on their lives. Uncertainty fueled anxiety. But with each passing week, the public learns more about health care reform. For instance, this week, the administration announced which preventive services insurers will be required to cover, free of charge. The rules will eliminate co-payments, deductibles and other charges for blood pressure, diabetes and cholesterol tests; many cancer screenings including mammograms for women over 40; routine vaccinations; prenatal care; and vision and hearing tests for children. The more Americans learns about the details of the legislation, and how reform will help them and their families, the better they will like it.
Thus Tanner has his work cut out for him if he hopes to persuade voters that the Patient Protection and Accountable Care Act represents “bad medicine.” In part 2 of this post, I’ll turn to his contention that individual mandates “violate individual liberties” and will “fall far short of the goal” of bringing “young and healthy individuals into the insurance pool.”
Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.
Blah, blah, blah. Repeal? No need.
Everyone knows you don’t repeal free money once it starts going out the door. And everyone knows the people who get the free money like the program that gives it to them.
Conservatives (the real ones, the ones who oppose free money) know this, and liberals (the real ones, those whose religion is getting free money for more people) know this.
So OF COURSE the new health bureaucracy is popular with Democratic voters, because it will give them more free money than they have to pay. And of course it will grow more popular over time.
You NEVER repeal the welfare state. All this talk of repealing is just something to keep the people in Republican think tanks employed, just like dreaming up new ways to give away free money keeps the Maggie’s of the world employed.
You kill or injure the welfare state by doing two things, and only two things: 1. cutting taxes. 2. Create pathways out of the resultant deficit-ridden programs. (In that order.)
You don’t accept the burden of “figuring out how to pay for it”: you just cut taxes. (Nobody who creates welfare programs actually ever figures out how to pay for them. They are quite certain that “the rich” will pay for them, someday.)
You don’t apologize for “the deficit”: you cut taxes.
Because there is one fundamental, unchanging feature of human nature you can count on: statistically, the soul is shaped like a Ponzi molecule. It wants to get more than it gives. The successes of the “progressive” movement exploit this fundamental flaw by creating programs that give more than they take in. (There is no other way to gain their political constituency.) — but the conservative who looks back over history, and out upon the trend of Western democracies, understands
that the equal and opposite charge on that molecule is the desire to not pay. This desire is the basis for the hope for avoiding the hell-hole of progressive welfare states. And it is a pretty solid hope.
All of this is to say: there will be progressive “victories”, periodically. Don’t worry about them. Stop talking about them as soon they happen. You can always count on the pendulum to swing back as people see the bill. Because, in the end, it’s just a contest to either feed or starve the fundamental human corruption — “give me your money” — over decades and centuries. Look back at Rome, watch Western Europe.
So, conservatives: you get power by talking about tax cuts, you cut taxes when you get that power, you let the wonks duel with their graphs and charts, and — did I mention? — you cut taxes.
You don’t try to figure out all the shifts in the polls, or even one election versus another. The truth is, the same people will vote for contradictory things, in sequence: they’ll vote YES on free money, and then they’ll turn right around and vote YES for a tax cut.
Endure the first, maximize the second. The rest is just talk.
Everyone: The Cato Institute’s Michael Cannon has replied to my post on the Cato Insitute’s website here http://www.cato-at-liberty.org/2010/07/19/obamacare-is-unpopular-a-response-to-maggie-mahar/
It’s an extremely civil,even gracious reply.
Unfortunately, their website doesn’t have a space for comments, so I’m responding to their reply on http://www.healthbeatblog.org– my response will be up later this afternoon.
Will be back to reply to comments here later.
Barry, are you suggesting in #3 that Congress or the states should pass legislation regarding medical protocols in end of life, or perceived end of life, situations? Or am I misunderstanding?
Margalit,
I think what’s needed is for a new societal consensus to evolve with respect to what constitutes good, sound medical practice in end of life situations in the absence of a living will, advance directive or surrogate empowered to make healthcare decisions on the patient’s behalf if the patient is unable to make his/her own decisions. Since a large percentage of end of life situations involve patients with Alzheimer’s, dementia, cancer or congestive heart failure, the medical specialty societies whose members treat those diseases should have a key voice. The role for state or federal legislators would be to enact legislation that protects doctors, hospitals and other providers from lawsuits if they follow such new guidelines that provide for anything less than “do everything.” As I’ve said many times, resources are finite and we can’t afford to give patients and their families anything and everything they might want no matter how futile or expensive. Moreover, as I suggested in my prior comment, people who specifically want heroic measures employed should pay more for their health insurance.
Barry,
While I do understand and on a personal level agree with the general notion, I have no idea how you begin to codify end of life, and you will need to do that if you want to charge more or establish accepted protocols for various situations.
What does Alzheimer’s mean? Advanced Alzheimer’s? How advanced? Is there an age component, say 89? How about 88? What if a person with terminal cancer gets hit by a bus? How terminal? What if it’s a kid? What if there are 10% chances of remission? 5%? The number of permutations is as infinite as the resources are finite. And what does “finite resources” mean? 20% GDP? 19%? A certain national deficit? A minimum level of profit for providers and payers?
I have not the slightest idea how to do this and maintain a semblance of humanity.
Margalit,
I don’t think it’s as complicated as you suggest. While doctors cannot predict precisely when someone will die, they usually have a pretty good idea when the end is approaching. We already have established criteria for when a patient is a potential candidate for hospice care though some of them live a surprisingly long time. We know when and under what circumstances a palliative care consultation is appropriate. If we had a default protocol that called for no heroic measures for people near the end of life and no reasonable prospects for recovery, what I perceive that means is no feeding tube or ventilator and no surgical interventions. For late stage cancer patients who have not responded to one or two or three chemotherapy regimens, it means we stop treatments but we do our best to keep the patient comfortable and as pain free as possible. It would probably be useful, however, if some of the doctors weighed in on this instead of us (non-physicians) going back and forth.
Margalit, Barry, Barry & Nate, Nate
Margalit–YOu are right; the premutations are infinite.
Barry–
I’ve talked to palliative care specailist Dr. Diane Meier about this. She says that in a great many cases we just don’t know who is going to die–and who is going to walk out of the ICU and go home. And she has seen many, many more seriously ill patients that either you or I.
From what I’ve read, it’s easiest to tell when cancer patients are near death. Much harder in most other cases, including heart disease.
And palliative care is not for dying patients. It’s for patients who might or might not be dying, but are seriously ill and often in great pain. Hospice care is for dying patients.
On the feeding tube: research shows that patients who have had the feeding tube removed and yet still survived report feeling that they were starving to death.
I have a living will that calls for no feeding tube, but I admit, this does make me a little uneasy.
On directives: very often they do little or no good because they don’t fit the actual situation. Being seriously ill or dying is just much, much messier than a standard form can capture.
This is why I so strongly favor having a palliative care team talk to to patients who are seriously ill at the time, explain options so that the patient can decide as the situation evolves. This is the sort of thing that is best decided on a case-by-case basis, by the patient if at all possible, or, if he/she isn’t capable of making the decision, by a designated relative or close friend.
If patients have a chance to talk to a palliative care doctor and psychologist specially trained to talk to patients about dying, I think you would be suprised to find how many would accept death–and would reject further pain and suffering with very little hope of recovery.
As for having people who want “everything possible” pay more for health insurance, this means that the wealthy would have that option, while middle-class people would not.
As I’ve discussed in the past, in some religions, hanging for as long as possible is terribly important. Human beings are not supposed to make decisions about when we die. How do you tell a very religious lower-middle-class person (or her son) that they don’t have the option of “everyhing possible” to the very end simply because they didn’t have enough money to pay a higher premium?
Nate & Barry–
I agree no. 2 on Barry’s list makes a great deal of sense.
Nate–
On my credibility, you might want to check out Michael Cannon’s responoe to my reply to Cato on the Cato website. I actually have quite a bit of credibility among knowledgable people who disagree with me.
Long before we had health IT, we had medical research and medical evidence.
That medical evidence told us that certain treatments were very risky and not effective.
Yet, as I pointed out in the post, for-profit insurers continued to cover them because they feared losing market share. Vioxx is the classic case: Kaisier, the Mayo Clinic and the VA all took Vioxx out of their formularly a year before the manufacturer was forced to pull it from the market. The information about risk was out there, in peer-reviewed medical journals. For-profit insurers ignored it.
The same is true of bone-marrow transplants for breast cancer patients. . .
Nate:
In response to your July 20, 8:29 a.m. comment
As you well know, cherry-picking is and has continued to be be a problem in the individual market, not in the large group employer-based market where so many employers self-insure.
I was going to respond to the rest of your comment, but when I read it to the end, I discovered that, once again, you resort to personal attack.
Maggie,
As I think you know, I’m all for both palliative care consults and hospice care where appropriate. As a general statement, I think a less aggressive approach to end of life care, along with the relatively low amounts of litigation and fraud in the system, are all areas where I would like to see the U.S. be more like Europe and Canada.
I’ll offer one comment about religion. When I think about religious freedom, respect for religion, and the separation of church and state, I think of the following: We have the freedom to worship as we choose in our own church, synagogue, mosque, temple, shrine, etc. We have the freedom to send our children to religious schools while we are still obligated to pay property and other taxes to support public schools. We have the right to not be discriminated against when seeking employment, housing, etc. What all of these have in common is that they don’t place demands of any consequence on taxpayer resources. If we practiced end of life care less aggressively like they do in other developed countries, I don’t think it is reasonable to expect access to taxpayer resources to pay for expensive, futile care based on a religious conviction if and when it is generally not made available to most of the population unless they can self-pay.
We might also simply consider studying how good, sound medical practice as it relates to the big four end of life conditions (Alzheimer’s, dementia, cancer and CHF) is defined and applied in Germany, France, the Scandinavian countries, the UK and Canada. In the case of the first two conditions, patients are most likely to die in nursing homes while in the other two, they are more likely to die in a hospital. It would be interesting to see to what extent, if any, their protocols differ from ours. I suspect we might learn something useful though I also think we would probably need some changes in our litigation system if we wanted to embrace some of their presumably less aggressive / more conservative approaches.
“It would be interesting to see to what extent, if any, their protocols differ from ours.”
Barry, I have direct experience with Canada’s system as my aged mother with dimentia was in a government subsidized nursing home. The “protocol” was that family members were given a set of options as to end of life for the nursing home to follow, from send her to hospital for life saving/extending intervention, to keep her in the home and comfortable, but take no extra-ordinary efforts. From discussions with my mother I chose the “keep her comfortable” option, which did not mean that curable infections were not treated. At no time did they check her insurance coverage for any indication that she might qualify for unlimited extra efforts.
Peter – That’s helpful. Thanks. However, I wonder what they would do if the patient could no longer communicate, was no longer mentally competent to make care decisions and/or had no relative or other surrogate to make decisions on his or her behalf. What is the default protocol that is applied under these circumstances? Is it “do everything” like in the U.S., apply common sense depending on circumstances, or just keep the patient comfortable and don’t attempt any heroics? Along the same lines, would DNR and DNI orders be part of the normal standard of care in the absence of instructions to the contrary?
Barry, the default protocol is of course important and maybe even appropriate. However, if we ask folks to pay more in premiums for heroic measures, there will be two default protocols (at the very least), one for the rich and one for the rest of us, which means the insurance card would have to be consulted before any protocol is attempted. I have a problem with that.
And to the feeding tube issue, I would expect modern medicine to be capable of providing something better than death by slow starvation, if the patient so chooses. It makes a lot of people uneasy, not just Maggie. Maybe more people would have advanced directives if the specter of being silently tortured to death would be removed. If we decide to let the patient choose, then truly let the patient choose. With all due respect to doctors’ moral dilemma, this is not a call they should be entitled to make.
j.d.
On gov’t demonizing insurers . .
Barry– Here’s the difference between the U.S. and other countires: in the U.S. the belief that one should fight death is an ungrained part of the culture.
It’s all tied up with the degree to which we value the individual and invidualism (the loss of an unique indivudal is a tragedy, even though he will be replaced by children and grandchildren); a pioneer spirit (fighting to survive no matter what–Indian attacks, blizzards, near starvation–useful when settling the West); a less than philosphical attitude toward the fact that life is finite, that we’re part of nature, dust to dust . .
I’ve heard Dr. Peter Schroeder talk about this pointing to surveys that show that when Americans are told that they have a fatal disease, they go for a second opinion. They are simply not willing to accept the fact that they are going to die. There must be a cure.
When Europeans are told they are suffering from a fatal disease, they don’t go for a second opinion. He does a wonderful job of an Englishman going home to his wife and saying “Well, Martha, I guess this is it. It was a good life, wasn’t it? Now let’s sit down, have a spot of tea, and plan the funeral.”
This is what I mean by having a philosophical attitude toward death (and life.)
What all of this means is that, in Canada, if you give a relative the choices Peter was given–keep her comfortable or send her to the hospital for life-saving/extending intervention, a Canadian family is much more likely to choose “keep her comfortable.”
An American family is much more likely to say “do everyting.”
In Canada, it would cost the family nothing to say “do everything.” This isn’t about money. They just accept the fact that, at a certain point, everyone dies.
As Peter indicates, it’s not that other countries don’t offer patients
The only way to change American attitudes about death is through a very long process of education. Palliative care leaders are the people to lead that process. But it’s not going to happen in 10 years or 20. It would take one or two generations. In the U.S.you have thte added problem that minority famlies often fear that white doctors are too quick to declare them dead. (A doctor in South Carolina told me a terrible story about a young African American man who was in an auto accident, and declared dead at the scene. It was only after he was in the morgue that he sat up . . .
This, of course, is an extreme case, but we know that minority cancer patients are much more likely to die than white cancer patients–even when both are hospitalized. Minority patients who have been in an acccident are more more likely to die than white patients. This may well be because they were in poorer health in the first place. But we also have evidence about disparities in care.
All of this complicates who you can trust to make end-of-life decisions aside from the patient himself.
As Margalit says this is not a call that doctors have the moral authority to make. And this is not a call that most doctors want to make. They are trained to save lives. Palliative care specialists, and those who work in hospices are trained to face death; patients and famlies are much more likely to trust them.
It’s also worth noting that in Europe, discussions of end-of-life care rarely money or how much it will cost the state to keep a dying patient alive. And they always stress patient autonomy, and the patient’s beliefs and values. One recent European forum on heath care emphasized: “any discussion of forgoing treatment is a sensitive issue that must be tailored to the patient’s particular needs and values.”
The don’t have clear protocols on when to let patients go.
There have been quite a few studies of end-of-life care for Muslims in Europe, emphasizing that hospitals and doctors must be senstive to cultural and religious differences when treating Muslim patients.
In many European countires doctors are very reluctant to withdraw food or water. Euthanasia is allowed only in two European countires. (Denmark and the Netherlands.)
Margalit,
On the issue of charging more for insurance for those who want heroics, we would need to know just how much more than, say, standard Medicare we’re talking about. It might be a lot less than you think.
Feeding tubes, for example, might be used primarily in a nursing home setting where the payer is either Medicaid or the patient’s family. Paying extra for insurance is irrelevant here because there is no insurance premium in connection with either Medicaid or self-payment. In the hospital setting, we would need to define just what heroics are. In the end, the insurance surcharge for those who want heroics could be surprisingly affordable. We just don’t know without further study. Even if it were an obstacle, it could be dealt with by means testing.
Everyone, j.d. & Nate
Everyone- My reply to Cato’s reponse is now up on http://www.healthbeatblog.org
j.d. Sorry– started to reply to you and then got lost in my reply to Barry.
To a degree, I share your concern about gov’t demonizing insurers. Or, put it this way, I think gov’t should also be taking a very hard look at drug-makers, hospitals and some specialists over-charging and selling ineffective products and treatments.
But you need to understand: the public likes to hear about gov’t squeezing insurers. It doeosn’t like to hear about gov’t pushing hospitals, device-makers etc. to offer better value. Medicare will do it, but Obama is not going to appear on TV threatening brand-name hospitals.
Of course, insurance is so expenisive in large part because U.S. healthcare is so expensive.At bottom, that’s the bigger problem.
That said, while insurers’ profit margins are relatively low, their administrative expenses are unncessarily high.
And insurers are saying that under reform, they can cut those costs (partiallly because they won’t be underwriting and cherry-picking.) Blue Cross of N.C. recently announced it plans to cut $200 million of admnistrative costs from a budget of $1 billion by 2014. That’s a 20 percent reduction.
They also said they plan to “enter into some tough negotations with hospitals.”
In Oklahoma, Health Services Corp the parent company for Blue Cross and Blue Shield by “consolidating marketing operations” in the SouthWest.
Meanwhile, in California, Aetna asked for a 19 percent rate hike for tens of thousands of customers– then, when the state began to take a close look at the numbers, Aetna admitted that it made a mistake (human error) and would have to re-do the numbers. They dont’ need a 19% hike after all, they admitted.
All of this suggests that there is room for voluntary cutting on the part of insurers. It’s good that they’re reacting to Obama’s bully pulpit; we can’t afford waste in any sector of our medical/industrial complex.
Meanwhile, some insurers are getting tough with hospitals and device-makers. For example: “CardioNet Inc. said Wednesday that UnitedHealth, one of the largest health insurers, will not cover CardioNet’s wireless heart-monitoring devices.
CardioNet said UnitedHealth Group Inc. is maintaining its view that ;outpatient cardiovascular telemetry is unproven for managing cardiac arrhythmias.’ The decision comes about a year after a Medicare administrator slashed reimbursement rates for CardioNet’s products and similar devices. That caused health insurers to lower their rates.
UnitedHealth, the largest publicly traded health insurer based on revenue, is seen as a bellwether for the industry.”
Note that UnitedHealth was following Medicare’s lead.
Cardionet was disappointed that Medicare did not include its wireless devices in Medicare’s 2010 fee schedule.
Government is going to continue to press insurers to find ways to economize and to show they are offering value for their premiums. (We can’t afford to keep the the for-profit insurance industry going if it can’t provide value .) And the public likes to hear that gov’t is pressing insurers.
But–and this is important– govt will also be pressing hospitals to lower fees , and device-makers and drug-makers to lower prices. Medicare is already cutting fees for some servcies like diagnostic testing and preventable hospital readmissions. In Rhode Island the Insurance Commissioner is capping how much insurers can pay hospitals. . .Medicare has indicated that next year, it will cut oncologists fees.
Still Washington needs to be aware that when the public hears that government cutting fees for health care providers, device-makers and drugs, this is much less popular. Americans fear that they won’t be cutting the products and servcies they want.
They are reluctant to believe that their hospitals are over-charging.
So Obama will make fewer big speeches about hospitals, drug-makers and device-makers. But quietly, Medicare will be cutting spending and insisting on better value for its dollars. And private insurers will continue to follow Medicare’s lead.
Ultimatley, over time, the public will see that health care will not suffer. Lower prices, greater efficiency and higher qualitly go hand in hand.
Nate–
About why young people don’t buy insurance:
The notion that young people forego insurance not because they don’t think they need it but because they can’t afford it comes from a Gallup poll of 30,000 young people.
I realize you talk to a lot of people about buying insurance, but Gallup is in the business of doing surveys in a scientific wa. It’s track record is pretty good.
Their surveys are more credible than anyone’s anecdotal experience. They show that young people are most likley to have insurance if they have a higher income. This doesn’t necessairly mean its cheap. It’s interesting that young people in poor health are least likely to have insurance because they can’t afford it even though they need it. Young people in good health are most likely to buy insurance, even if they aren’t in great need of having insurance (86% of those earning over $45,000 in good health.) For young people in the bottom third (earning under $24,000) subsidies will make insurance extremely affordable and for those earnign $24,000 to $45,000 it will be much more affordable. Look at tables of subsidies
“The only way to change American attitudes about death is through a very long process of education.”
Yes, but do we really want to do that? What would have happened to all the innovations and advances in medicine if people weren’t willing to fight for an extra couple of months at a time? Who is going to invest time and money in initial breakthrough therapies, if people are just fine with dying whenever? Without those initial clumsy beginnings, there is nothing to build on and there will be no major improvements. There will be no transplants today if the original organ recipients wouldn’t have been interested in clinging to dear life for a few more weeks. Same for cancer, heart disease and almost every other ailment. Maybe those folks that run the huge bills for no apparent benefit to themselves are inadvertently contributing to the well being of future generations more than us cowards who would rather go quickly. Just a thought…
“I realize you talk to a lot of people about buying insurance, but Gallup is in the business of doing surveys in a scientific wa. It’s track record is pretty good.”
Says who? I just tore apart a gallap poll last week, There is nothing scientific about what they do. They push a political agenda and try to pretend they can support it with fact. I’m in the business of selling insurance, the people I work with every day are in the business of selling insurance. The brokers I work with and myself quote and sell a multitude many times more people then gallap polls. By any scientific measure my direct results are more valid and substbatial then their telephone poll.
Further you don’t seem to grasp the difference between polling on who buys something and making the unscitific leap to claiming those that don’t buy do so becuase of affordability. It’s a subjective measure and one they don’t even ask in their poll.
You can’t produce a single study to back up anything your claiming here. Until you show me a study breaking down the personal income and expenditures of the uninsured you can’t beging to claim they can’t afford it. I’ll challenge you to even define affordability. Does someone that forgoes $80 a month insurance premium but has a $130 a month cell phone bill qualify as non affordable?
I have 10 times the information on these people that Gallop does, if anything is anecdotal it is their 5 minute survey over the phone. Did Gallop see the car they drove? Did Gallop see how they were dressed?
You can’t dismiss facts for your partisan gain.
” For young people in the bottom third (earning under $24,000) subsidies will make insurance extremely affordable”
I thought all these were going to be covered under their parents plan? In which case the only subsidy is from business.
“To a degree, I share your concern about gov’t demonizing insurers. Or, put it this way, I think gov’t should also be taking a very hard look at drug-makers, hospitals and some specialists over-charging and selling ineffective products and treatments.”
Here is a crazy idea, since government is the most inefficient and expensive plan in the entire world how about they start by demonizing themselves? Maybe after they clean up their own plan they can cast dispeersion on everyone else?
“That said, while insurers’ profit margins are relatively low, their administrative expenses are unncessarily high.”
By what measure do you make this claim? I charge $20 PEPM to administer a self funded plan. Medicare directly spends about $23.33 per member. My plans have a fraud rate under 1%, Medicare and Medicaid are around 10%. If your going to make these wild baseless claims start backing them up. You can’t produce a single measure by which Medicare is more efficient then me except wasting money.
The problem is you on the left make these wild claims and are never held responsible to back them up. You feed the distortion and blame that leads people to case blame in the wrong place and thus nothing ever gets fixed.
“Government is going to continue to press insurers to find ways to economize and to show they are offering value for their premiums.”
” (We can’t afford to keep the the for-profit insurance industry going if it can’t provide value .)”
Not true at all, we can’t afford to keep public healthplans going unless they learn to control cost and fraud like private insurance plans do. The crisis in healthcare is not in private plans, its the trillions of unfunded prmoises in public plans.
Let me fill in some missing history, this is exactly what Ted Kennedy said when he created HMOs, then when they did exactly what congress wanted them to, they turned on them. You cheer United now but 2 years when someone supposedly will die without a cardionet you will demonize them for not covering them. That is exactly what the left and trial lawyers did 10 years ago.
“As you well know, cherry-picking is and has continued to be be a problem in the individual market, ”
No I don’t know, I sell insurance and don’t beleive there is cherry picking. Based on what knowledge do you claim there is cherry picking and how do you define cherry picking? If your going to claim charging someone that is sick a higher rate them someone that is healthy then by your defining of the word there is, by normal definition there is not. It is an illegal pratice and hasn’t been around for years.
Nate, just a general question: are your practices and efficiencies representative of all private insurers, or are they just representative of your company? In other words, should I extrapolate from your $20 overhead to say that UHC’s is the same? And isn’t a TPA somewhat different than actually selling insurance?
United and Anthem can get away with charging $40 PEPM maybe a little more. For what that includes it is still a bargin compared to Medicare. When you actually do the math Medicare spends roughly $23 directly on administration, another $10-$15 indirectly through CMS and other agencies that contribute to its administration and then loses $58 PEPM to fraud. Total that is $91 compared to $40-$50 for private insurance. Private insurance includes far better customer service and websites, disease management, wellness, and many other services that medicare does not. To say that is unnecessary high is just partisian propoganda.
Private insurance could easily pay claims like Medicare, FYI want to know how much your customer service call volume drops when you just pay everything!, and eliminate all the frills and end up just like Medicare, what has that gained? Less service and higher total cost.
People that don’t know what they are talking about like to compare the $23 and $40+ and say see how much more efficient Medicare is, and just pretend the rest of the equation doesn’t matter.
I guess if Medicare was such a bad deal for insured as Nate says then they could just pay for and use private insurance. I wonder why 65s+ don’t do that?
I don’t know Peter maybe it has something to do with them taking away your social security?
Y&ou really need a 10 second rule Peter, think for 10 seconds before you make stupid responces. You will also see if you read that I never once said it was a bad deal for insured. In fact it is an incredible deal at the time you actually become an insured seeing as how you don’t pay for it. Free is always a good deal even when it is wasteful of other people’s money.
No Nate, it’s not free, it’s been paid for out of their pay checks and is also paid from their taxes. But I guess that for “free” insureds will accept some hassels dealing with Meducare. The reason they don’t use private insurance is they couldn’t afford the rates even with your assertions that private insurance is so effecient and cost effective. Even during their working life most got their paid for insurance from their employer.
careful Peter you can’t say things like that on left leaning blogs. Or financial ones either. Medicare taxes are to pay for current enrollee’s Medicare coverage. Paying your Medicare Tax in now way entitles or promises you future benefits.
I personally think it should but if it did then uncle sam would have another 100 trillion of debt on his books and be insolvant by all measures.
Medicare Part A is free to enrollees, they pay nothoing for it. Medicacre Part B is $90 or what ever current price is. C/MA is usually free, and D varies. A benefit package that if priced would cost 8K plus per year in fact goes for $1200. That is why it is such a steal.
Regarding the fallacy of your argument. If you waived Medicare you would not get your taxes returned to you. So instead of getting a subsidized plan at 1200 you would have to pay 7-8K, private insurance does deliver Medicare cheaper then medicare does so it would cost less.
You also seemed to not want to address the fact the federal government takes away your SS benefits, why was that left out?
“So instead of getting a subsidized plan at 1200 you would have to pay 7-8K, private insurance does deliver Medicare cheaper then medicare does so it would cost less.”
7-8K really, for a 65+ year old probably with pre-existing? At what deductible and co-pay? And who could afford that on a pension anyway? If I had my way we’d all be on individual plans, single-pay would happen so fast in this market insurance companies wouldn’t know what hit them. Private insurance does what Medicare can’t and that is raise rates by compounded % each year – anybody can do that and make money especially without giving anything back in return, except of course higher deductibles and co-pays. You also don’t get your public school taxes back when you use a private school – it’s part of what little social solidarity exists in this country, at least for now. How would your grandma get her Medicare paid if the wealthy could get their Medicare taxes back?
“You also seemed to not want to address the fact the federal government takes away your SS benefits, why was that left out?”
You think I defend that? In fact I don’t agree with any use-specific tax being used for general fund purposes. But since voters hate any tax and especially tax increases, legislators are forced to play hide the ball with taxes to dishonest balance budgets. If you don’t like how elected reps balance budgets talk to voters who think services should be free, at least for them. As I’ve said before, Americans really do like taxes, just other peoples.
“7-8K really, for a 65+ year old probably with pre-existing? At what deductible and co-pay?”
Peter you really are simple sometimes. What do you think the average spending per Medicare beneficiary is per year? Add admin and retention you have your insurance premium. Private insurance delivers the exact same medicare benefits, there is your second answer, slightly less then Medicare does. They also do it minus the 10% fraud rate. Thus private insurance could deliver Medicare for the same, worst case scenerio, or slightly less, maybe 5-10%.
” Private insurance does what Medicare can’t and that is raise rates by compounded % each year”
You think Medicare expenditures aren’t increasing? They just don’t publish it as a rate so simple minded people who can’t be bothered to look up facts before shoting out the mouth never know. They also cut reimbursements and shift cost to keep their increases down.
“How would your grandma get her Medicare paid if the wealthy could get their Medicare taxes back?”
Prior to liberals like you, who fail basic math, passing Medicare Grandma didn’t need ANY help paying her medical bills. 87% of seniors where able to pay 100% of their own medical expenses till death. After you passed Medicare now 19% of seniors are on Medicaid and very few can afford to pay their own medical expenses. Thank you Peter and Democrats for solving a problem that didn’t exist and creating a much bigger one in the process.
“You think I defend that?”
Peter your the one who asked why seniors don’t cancel Medicare and buy their own coverage. If you knew the answer and agree with it why did you ask?
Your original question made as much sense as asking why humans don’t get rid of cars and flap our wings. While the solution is praticle and makes sense it is not possible. For all intents and purposes Americans are forced into Medicare and don’t have the option to opt out.
Peter, Maggie, Matt any other liberals here want to argue Medicare saved seniors from dependence like it was claimed to pass Medicare?
A central rationale offered to the public for the bills that became Medicare was that they would enable people to “avoid dependence” in old age. In fact it was a bogus rationale that served as a key form of transaction-cost augmentation used to secure the bill’s passage. That this rationale was not believed by the bills’ authors in HEW is clearly indicated by Celebrezze’s acknowledgments above regarding the omission of coverage for catastrophic illness. Nonetheless, government officials’ repeated assertions that Medicare would “avoid dependence” made it more difficult for voters to understand that dependence in old age would not be forestalled by these measures, thereby diminishing resistance to the bills.
Above is why the liberal argument about the tea party being against government but taking Medicare is such dishonest BS. They paid for it alreadyt and wouldn’t get a refund to replace it and they would lose their SS they already paid for.
Senator Gordon Allott (R., Colo.) described it to the Senate as a “program of ‘Robin Hood in reverse’” that showed “complete disregard for need in disbursement” and represented a “giant step” toward making “every citizen as dependent as possible on his Government for his every need” (U.S. Cong. Rec.-Senate 8 July 1965: 15935).
When Rep. Albert Ullman (D., Ore.) cited allegations that the “public is somehow being hoodwinked” and “being misled” and asked HEW’s Wilbur Cohen about the degree to which the public misunderstood the program, Cohen stated that “we do recognize this problem and I think it has been complicated by the use of the term ‘medicare’ which is an erroneous term when applied to this program” (U.S. House Hearings 1965: 104). Although government officials sometimes expressed dismay about this public misimpression, the misinformation nonetheless fueled support for passage of a bill they strongly supported.
margalit & Peter
Thanks for your comment
We’re no longer making medical breakthroughs that extend overall life expectancy.
Relatively inexpensive medications plus lifestyle changes have made death by heart disease rarer, but that just means that you’re more likely to die of cancer–or Alzheimer’s.
We are very, very far from anything like a cure for Alzheimers. As palliative care specialist Dr. Diane Meier points out, with all of this “innovation” we are simply “saving” ourselves to die of some form of dementia.
In my boomer generatoin, and more people will find that their bodies outlive their minds. There are worse things than dying
Some see struggling for an extra few months as heroic.
Others see it as folly and wince at the sight of a mature adult, flailing about, screaming No, No, NO, not ME!. I’ll pay anything! I have plenty of money! I was my mother’s favorite son! You don’t understand, I can’t die!!
Accepting death is a sign of growing old gracefully, accepting aging and death as part of life, part of nature is a sign of maturity, and I think, of having lived a good life. I know two people–one in his late 70s, one in his 90s, who have lived very full lives and are not afraid of dying. Each of them has had a brush with death. (Though they are concerned about what a hospital might put them through before they die.) I also know a man who was philosphical about dying when in his 70s. (He was a diabetic, had lost his eyesight, and endured amputations of his toes.) In the hospital, the doctors “brought him back.” He was very very angry. “What the F… is this!” he shouted. Luckily, his daughter stood up for him, refused to let the doctors put him on dialysis (even though the doctor shouted at her) and he managed to die a few days later.
Read the story in the NY Times magazine a few weeks ago about “What Broke My Father’s Heart.”– See the end of the story, and how the mother handled her own mortaltiy–with extraodinary grace and dignity.
Also, biological science is beginning to make it clear that in terms of life expectancy, affluent Americans are close to a natural limit. It’s not possible to push life expectancy to 120, making it the “new 100.”
Ssee the opening chapters of Nortin Hadler’s book “Worried Sick.”
Nor would we want to live that long. See Gulliver’s Travel’s and the people he meets who never die . . . .They just age, and age, and age.
Sorry to go on at such length. But this is such an important subject.
On Nate’s insurance company and how it’s different from other insurers: Nate works for an alternative insurance company in an alternative universe.
Peter– Yes, legislators are forced to play “hide the ball” with taxes. To be fair only a very few other countires have found a different way to fund public pensions and they are much, much smaller, which makes it much, much easier.
In any case, Social Security is not in trouble. With just a couple of very small fixes, it will be solvent for a very long time. And the fixes don’t have to come immediately.
“On Nate’s insurance company and how it’s different from other insurers: Nate works for an alternative insurance company in an alternative universe.”
Your most intelligent retort yet Maggie. Hey if you don’t have facts on your side I rather you try humor then just making them up like you usually do.
And FYI I don’t work for I own. There are those of us who actually get out and solve problems, myself, and those of us who stay home and write fiction, thank you for your contribution.
“Thus private insurance could deliver Medicare for the same, worst case scenerio, or slightly less, maybe 5-10%.”
Is that all!? I’d expect at least half for all your defending of private sector insurance. Thanks but I’ll take a public system that has a chance to really give us reductions. Medicare is stuck paying the going rate set by the private sector – which we know is unsustainable.
“After you passed Medicare now 19% of seniors are on Medicaid and very few can afford to pay their own medical expenses.”
If that’s true (not even close to provable), but funny, that’s not true for single-pay countries, it’s because Medicare has been a cash cow for private healthcare (other than PCPs) and a success for private healthcare lobbyists, not to mention the AARP.
“You think Medicare expenditures aren’t increasing?”
If FICA Medicare went up the 6%-10% compounded yearly increases that private health premiums are there’d be screaming demand to cut costs. But those increases are added to the deficit cause it’s easy and passed on to company plans that shield the insured – you’re all delusional. Talk to people in the individual market not privelaged enough to get an employer or government to pay their health costs – you’ll see the truth about this system’s complete failure.
1. It does not solve the problem. We never had a health care crisis,we had a health care COST crisis. There may be some things in the bill that address some cost but does not bring down cost effectively because they did not start out working on the true problem.
2. The mandate placed on individual citizens is inherently wrong. Unconstitutional or other wise,it’s unethical to Mandate the purchase especially without bringing the cost down first. see 1. The group of people who will be negatively affected by this the most are the very people tit is supposed to help POOR people,primarily working poor,poverty level wage earners will now be forced to buy inadequate insurance that won’t include dental or optical(not comprehensive as advertised),or face a tax penalty-fine. They are promised aid,but most working poor make just enough to be en-eligible for other subsidies,so this will probably be the case with this as well.
All in favor,pat your self on the back for sticking it to low poverty level income workers.
3. a more ethical approach would have been to just readjust the eligibility for medicaid. example make medicaid optional enrollment for any citizen making less than $20,000 a year. regardless of age,gender race,orientation,religion. Fix medicaid/medicare flaws,
Allow insurance companies to sell across state line,co-op policies for various groups( all the Cashiers in the country could get on a nationwide cashier plan.
4. If they want to help working poor,consult working poor instead of consulting higher income segments.
they don’t have to stop there, that would just be a place to start. I’m all for making Affordable health care AVAILABLE for everyone,but I think it can be done in a way that would not infringe on the right of persons choosing not to participate. They have social med in other countries,but they don’t fine you if you don’t utilize the system(extremely high tax rates not withstanding). They rushed to much before coming up with real solutions.
They(the fed gov.) could have done a couple things quickly to help some in drastic dire need,like some type of stop-gap emergency medical relief fund to save people from dying,then then they could have come back to working on practical long term solutions.
I really don’t like the mandate. To me the Individual Mandate is the worst part,and it is contrary to the often discussed “public option”. there is a huge difference between “optional” and “mandatory”.
The car insurance comparison is terrible,weak at best.
Many states still allow persons to be self-insured,
and owning a car is optional, it’s a choice,having a placenta isn’t. It leads one to believe it is just another federal government quagmire with allot of negative side effects that while causing a tremendous amount of social hostility and unrest.
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