While it’s comforting to just blame the GOP for the unhappiness with health reform threatening the president’s re-election, the truth is that Barack Obama repeatedly botched, bungled and bobbled the health reform message. There were three big mistakes:

The Passionless Play

While Candidate Obama proclaimed a passionate moral commitment to fix American health care, President Obama delved into legislative details.

When a Baptist minister at a nationally televised town hall asked in mid-2009 whether reform would cause his benefits to be taxed due to “government taking over health care,” Candidate Obama might have replied that 22,000 of the minister’s neighbors die each year because they lack any benefits at all. Instead, President Obama’s three-part reply recapped his plans for tax code fairness.

While Republicans railed about mythical “death panels,” and angry Tea Party demonstrators held signs showing Obama with a Hitler moustache, the president opted to leave emotion to his opponents. The former grassroots organizer who inspired a million people of all ages and ethnicities to flock to Washington for his inauguration never once tried to mobilize ordinary Americans to demand a basic right available in all other industrialized nations. In fact, he hasn’t even mobilized the nearly 50 million uninsured, who have no more favorable opinion about the new law than those with health insurance!

When CNN captured a sobbing middle-aged woman telling Sen. Tom Coburn (R-OK) of her husband’s brain tumor, only to get the reply, “Government is not the answer,” the president might have helped all Americans feel her pain. He did nothing of the sort. The public face of “Obamacare” was never a mother, father, spouse or child, but, just as the Republicans wished, it remained…Obama.

The Friend (or Enemy) of the People

Hard as it is to recall, a New York Times-CBS News poll in mid-2009 showed nearly three-quarters of Americans supported universal coverage through a government-administered plan like Medicare. But the survey also revealed “considerable unease about the impact of heightened government involvement on…the quality of the respondents’ own medical care.”

That unease surfaced even in the heart of liberal Chicago, at a Second City show satirizing the new president. A doctor tells a woman her diagnosis gives her only three months to live. When she pleads for help, the doctor tells her the good news is that Obama’s health reform plan means she’s scheduled for her next visit just six months from now. The parking lot was packed with “Obama ’08″ stickers, but the audience still broke out in laughter.

The comedy worked because it connected with real feelings. GOP consultant Frank Luntz soon urged Republicans to stress quality-of-care concerns. Obama and team remained tone deaf. Three years later, the same Times-CBS poll showed only one in five Americans thought the ACA would help them personally. A full third expected their quality of care to worsen, and just 17 percent expected it would get better.

In fact, though the individual mandate to buy insurance has received the most attention, the ACA is filled with provisions to improve care quality and individuals’ care. But for many middle-class voters, the answer to, “What’s in health reform for me?” was allowed to become, “Nothing good.”

The Caricatured Crusader.

When GOP leaders decided to just say no to Obamacare, they were honest about their political calculus. The polarization worked.

The number of Republicans saying reform would make their lives “worse off” started at only 22 percent in early 2009, according to the Kaiser Family Foundation (KFF) tracking poll, before jumping to 61 percent that summer. Just 11 percent of the critical independents began by thinking that health care reform would make them worse off, but that percentage more than tripled by summer to 36 percent.

In early 2010, the White House posted a list detailing which proposals by which Republicans had echoes in the ACA. That the mandate had originated in the conservative Heritage Foundation was nowhere to be found. Nor did the White House note that the GOP’s 2008 presidential platform had called for coordinated care and other changes almost identical to ACA provisions. In the event, none of this information was used to respond to the GOP attacks that helped sweep out Democratic candidates in the 2010 election tsunami.

It was only this past March that the administration, acting as if the Supreme Court’s ACA hearing was a political pep rally, sprang into action. It activated supporters, talked up the ACA’s Republican roots and rolled out press releases touting the law’s benefits for average Americans. It was too little, too late.

A 2009 report by the Institute of Medicine concluded that the consequences of a lack of access to medical care include “needless illness, suffering, and even death,” with the victims frequently being children. Yet health reform’s opponents have managed to switch the discussion from dead kids to the Constitution’s commerce clause. All the while, Barack Obama has flailed and failed to convince the American people that “Obamacare” is change they can believe in.

Michael Millenson is a Highland Park, IL-based consultant, a visiting scholar at the Kellogg School of Management and the author of “Demanding Medical Excellence: Doctors and Accountability in the Information Age. This post originally appeared in The Huffington Post.

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105 Responses for “How Obama Botched and Bungled the Health Reform Message”

  1. R Prat says:

    He totally missed the communication and engagement. Making change this big cannot be done through mandate or fiat. Sooner or later those that feel dread upon will have their day and I think that day is coming this June.

    • BobbyG says:

      “[I]f this Court invalidates the minimum individual coverage provision, 26 U.S.C. § 5000A, the court of appeals’ severability judgment should be reversed and, with respect to the minimum individual coverage mandate’s operation, this Court should sever, along with Section 5000A, ACA’s guaranteed issue, preexisting conditions, health-status discrimination, and adjusted community rating provisions.”

      - AHIP / BCBSA amicus brief

      http://www.ahipcoverage.com/wp-content/uploads/2012/01/AHIP-BCBSA-SCOTUS-Amicus-Brief.pdf

      In other words, they’re saying ‘we want all the old stuff back. Exclusions, recissions, denials, actuarial-based individual risk rating, no limits on MLR, etc.’

      In other words, set the clock back to 2008.

      • Nate Ogden says:

        2008 when we had fewer uninsured and premiums were 30% lower then today? OMG that would be terrible

        • MG says:

          As if premiums would magically drop 30% if these were reinstated or wouldn’t have greatly outpaced CPI and wage increases in the first place.

          It baffles my mind when anyone says the individual health insurance market was anything but a morass before HC reform filled with plenty of scumbag insurers and companies using all kinds of chicanery to get off the hook.

          ‘It’s a great market – as long as you don’t get sick!’

          • Nate Ogden says:

            How dare those evil greedy insurance companies protect themselves from people being dishonest. They should shut up and take the loss for the good of all right?

            Find me one person that has EVER had a policy recinded that didn’t lie or have “incorrect” information on their application.

            It’s a great market as long as you don’t wait until your sick to try and buy insurance then lie about your health to get a cheaper policy.

            Perspective…….

          • MG says:

            You are going seriously argue that their was rampant illegal practices with rescissions in the individual health insurance market prior to HC reform? Ugh.

            This is why having a discussion with you is a generally a waste of time. You bring plenty of interesting points up but border on the delusional in regards to your stance on issues.

          • Nate Ogden says:

            that is a subjective question. How much is rampant?

            If you get technical;

            “Occurring without restraint and frequently, widely, or menacingly;”

            Not even close, your over reacting or ignorant of the facts from listing to the MSM.

            https://insurance.illinois.gov/hiric/RescissionDataCall.pdf

            “The data call revealed that there were roughly 27,246 rescissions against a sampling size of about 6.7 million issued policies. This translates into a rescission rate of 3.7 rescissions for every 1,000 policies/certificates that were written over the five-year period covered by the survey (2004 to 2008). The rate of rescissions peaked in 2005 and was at its lowest in 2008.”

            Oh damn is that a factual smack down. For those not good at math;

            .37% as in less then 1%. On top of that it peaked in 2005 and was at its lowest in 2008. Double smack down. So know that we clearly know without doubt you were wrong how do you respond. Admit you were wrong or pull the typical lefty crap and just keep making stuff up and spreading lies.

            Why is it so hard to talk to people that know the facts?

          • Nate Ogden says:

            of the 27,000 rescissions I can find well under 1000 that were over turned, and that was after detailed review by the state. So that means for every questionable recission 27 people clearly lied and committed fraud. How many of those have been charged with a crime or suffered any penalty for fraud? And that is only people that had policies rescinded. How many more lied and got away with it?

            Want to know what is honestly rampant…..applicant fraud, for some reason the left is ok with that though

  2. Responsible_Development says:

    Maybe the opposition and unease grew as people first saw the sausage making process and and then learned for themselves what was in the sausage. Politicians asked for special treatment, only some of which has since been reversed. Insurance costs rose faster (you mean prevention and covering 25 year olds isn’t actually free?!), while the pharma/device/unerned income taxes are kicking in before the bulk of the benefits. The messaging may not have been great, but it is the substance of the bill that is deeply flawed.

  3. Nate Ogden says:

    “While Republicans railed about mythical “death panels,”

    Denial does not supercede reality. There is a legit concern about LCP, most liberals just aren’t educated enough to know what it is.

    “the president opted to leave emotion to his opponents.”

    Moe denial, I see a thread. The left has been throwing up sob stories for 40 years. Even you engage in it, just not smart enough to see it or honest enough to admit it.

    “Candidate Obama might have replied that 22,000 of the minister’s neighbors die each year because they lack any benefits at all.”

    Does that comment not play to emotion? Was it not Obama that said it? You contradict yourself in under 2 inches.

    “never once tried to mobilize ordinary Americans to demand a basic right available in all other industrialized nations.”

    great line, to bad its not true. According to the CIA China is industrialized, do you really want to compare our healthcare to their rural poor?

    Your line about mobilizing ordinary Americans is a lie.

    “More than a thousand pro-health care reform advocates gathered in Washington, DC Tuesday”

    “HUNTSVILLE, AL – A Huntsville group that supports health care reform is planning to “protest the protestors” this afternoon”

    You Tube has videos of what you claim doesn’t exist.

    “Protesters gather outside Marsha Blackburn’s office to voice their support for Health Care Reform”

    “On February 17, Health Care For America Now is organizing pro-health care reform protests around the U.S., ”

    “Hard as it is to recall, a New York Times-CBS News poll in mid-2009 showed nearly three-quarters of Americans supported universal coverage through a government-administered plan like Medicare.”

    Breaking news, people like free stuff, liberals offer everything you want for Free!!!! Majority of people don’t like 16 trillion dollar national debt. Even fewer like 40 trillion Medicare shortfalls.

    “the ACA is filled with provisions to improve care quality and individuals’ care. ”

    When Medicare was passed it was sustainable, your point? Bills mean nothing. Just because a liberal calls a bill the affordable care act doesn’t mean it is magically going to make care affordable. Most grown ups are smart enough to realize this.

    “The number of Republicans saying reform would make their lives “worse off” started at only 22 percent in early 2009, according to the Kaiser Family Foundation (KFF) tracking poll, before jumping to 61 percent that summer. ”

    Have to pass it to see what was in it!

  4. R Prat says:

    “mythical death panels”. Last weeks article in the Health Care Blog spoke to spending an arm and a leg for a month of life. No one knows the last month of life. Someone must therefore make a decision to stop treatment because they think it is not worth it. If that person is someone other than the patient and the doctor and that decision means ending life, then what do you call that? Death panel may be harsh words but they certainly caused a valuable discussion.

    • Nate Ogden says:

      Time 1974

      “Man, too, may be somewhat responsible for the cooling trend. The University of Wisconsin’s Reid A. Bryson and other climatologists suggest that dust and other particles released into the atmosphere as a result of farming and fuel burning may be blocking more and more sunlight from reaching and heating the surface of the earth.”

      Today man is responsible for warming, which actually stopped over 12 years ago.

      Death Panels are a myth until republicans pass any bill then death panels will be real and the fault of republicans.

      You can’t have inteligent conversations with these people. They are right now matter the facts and how dare we question them. They are smart, there mommies even told them so.

      • Nate Ogden says:

        cue BobbyG the typo super hero;

        intelligent
        no
        their

        • John Ballard says:

          Yo, Nate…
          Ease up on the Kool-ade, dude.
          I like you better when you’re calm, cool and collected. You have too much on the ball to let yourself show out like this. You remind me of someone I know who can’t stand to see a dust particle without grabbing the Pledge.

          • Nate Ogden says:

            I have bad OCD when it comes to people making stuff up like Michael. Facts are readily available on the internet with 10-20 seconds of searchingm why can’t people get them right?

          • John Ballard says:

            Just pretend it’s a parade — or better yet, a New Years Eve party… And all this stuff is just so much confetti.
            If a few pieces hit the floor it’s really okay. In fact, it’s part of the ambiance.

            Okay, I’m done. Carry on.

        • BobbyG says:

          When in doubt,

          http://dictionary.reference.com/

          Oh, wait — “doubt” and “Nate” are mutually exclusive concepts.
          __

          In fairness, John, he’s been doing better lately, in the aggregate.

  5. Joe says:

    At what point will PPACA supporters realize that it is not the messaging — it is the PPACA itself that makes it unpopular.

    Even far-left Dems (Barney Frank) have finally admitted the effort was misguided…

    Long term, Dems are helped (not to mention patients and the country) if SCOTUS throws out the whole thing.

  6. Peter1 says:

    I too have been extremely disappointed by a lack of any fire in the belly of Obama for these issues. It’s as if he expected reason and intellect would take over in the minds of Americans (not to mention congress) after he was elected. Americans always loose enthusiasm for programs when they see that long term problems cannot be solved without pain and cost.

    “2008 when we had fewer uninsured and premiums were 30% lower then today?”

    Unemployment bottomed out in 2007. Yes, Nate’s view from the Titanic just before the iceberg.

    “How many of those have been charged with a crime or suffered any penalty for fraud?”

    Guess it wasn’t fraud after all. Only people thinking insurance is the solution will agree that recessions are an important element in health care. Your health care history should only be an issue between you and your doctor.

    “Today man is responsible for warming, which actually stopped over 12 years ago.”

    http://www.realclimate.org/index.php/archives/2012/04/evaluating-a-1981-temperature-projection/#more-11398

    “We have all heard the hoopla regarding how many years it takes to evaluate a climate projection from the denialistas who wish to make something of a short term trend. These statistically challenged clowns also often want proof that models are useful, but they usually refer to projections from current research. So, you want a 30 plus years projection validated, behold- Hansen et al., 1981.”

    You’re an idiot Nate.

    • Nate Ogden says:

      Are arguments of logic really where you want to be?

      “Guess it wasn’t fraud after all.”

      So if no one is tried or convicted the crime isn’t real? So that means victims of unsolved murders aren’t really dead? But by that same logic the 99% of rescission that are not overturned means they were correct. If they were correct even under the new laws they would still be allowed.

      “Only people thinking insurance is the solution will agree that recessions are an important element in health care.”

      In your wisdom then Peter tell us how you handle someone that can afford insurance that doesn’t buy it, then gets sick, and lies about the illness in order to get lower rates?

      Is that not unfair to those that maintain insurance and do things right that others pocket the money then lie to get coverage? Why are you ok with that?

      We can save the global warming pseudo science for another place.

      I notice you don’t have much to say yourself, always linking to others, how much intelligence does that take?

  7. tcoyote says:

    Michael is only half right. The reality is actually worse.

    The President was bleeding copiously at the end of this project, and his overmatched political advisors made a calculation that the administration had committed enough political capital to ACA and that they needed to pivot to what the public really cared about-jobs, foreclosures, massive personal cash flow problems, etc. One of them even said, ignoring the evidence of rising public doubts about “health reform” that, the ACA would “sell itself”.

    In other words, the White House made a deliberate decision to change the conversation, instead of trying to explain what they’d done in comprehensible English. That’s why they didn’t defend the Berwick nomination, because they wanted to turn the page and move on to stuff the public really cared about. Health reform was a massive political loser for Obama, regardless of how many voiceless citizens it helped.

    As someone who’s read the bill twice, I can tell you this was a thoroughly mediocre piece of legislation, not only poorly drafted but poorly focused. It was a massive bureaucratic project, and a huge pork barrel gift to the consulting and “policy” communities. It is crammed full of commissions and boards to be staffed by experts, and laden with lots of tired ideas that haven’t worked so far, but “let’s try ‘em again”.

    The public has no patience with “experts” these days, or with massive bureaucratic projects. Their patience with government in general is at an all time low, and it required not only passion, but enormous public faith in government’s ability to make constructive improvements in our lives.

    The tragedy is that 30 million people, many of whom do not know they would have been helped, will lose coverage as a result. This was not a failure of passion, but a failure of political judgment and of policy.

    • John Ballard says:

      I agree.

      I came to terms some time ago that the main importance of the effort was the Herculean effort it took to finally get a constructive conversation underway. I’m convinced that without that abortive attempt to repair the train wreck we call health care in America, that conversation would still not be happening.

      To that end, I just read a reassuring link from an oncologist reporting on a recent meeting of professionals in his specialty.

      http://sunriserounds.com/?p=629

      Similar professional conversations are in progress all over the place. And I know that I know that without ACA those conversations would not be where they are today.

      • Nate Ogden says:

        from the insurance side it did get tens of thousands of employers engaged to do something about the cost. Unfortunetly tens of thousand of others still don’t care enough to make any effort.

        In most states I work workers comp is a meaningful expense and employers go to great lengths to avoid claims. The cost is substantially less then health but the same employer that will hold saftey meetings and spend time every month mangaing their workers comp can’t find time for quarterly meetings or to educate their employees.

        We see the same thing from individuals, many more are trying to become consumers. We get more calls in a month from members asking about cost or wanting some ideas on how to shop then we would get in years before it all started. Again this is offset by just as many who still don’t care or refuse to make the effort.

        Provider community has not been nearly as responsive. While I see a couple health systems making meaningful efforts to address cost most are continuing on just like nothing is wrong. As this is where 85%+ of the money goes I think this is still the major problem. If providers main focus is still extending life every day possible and providing as much care as possible instead of making what care we have affordable its going to be a rough few years. Lots of PR fights, lots of court cases, and lots of turmoil.

        Should be a gold mine for the politicians and news propogandist though.

        • John Ballard says:

          Your comment confirms my suspicions. That part about “Provider community has not been nearly as responsive” jumped out at me. That reflects my long held impression that providers — from small practices to big hospital systems — may know a lot about medicine but are crippled when it comes to accounting. For too long they have leaned on TPAs and the insurance people to manage their financial affairs.

          Insurance people are in the business of managing economic risks, not health care, and they have a century or more of experience that has only been improved by technology and actuarial statistics that only get better as the years go by.

          Health care professionals, on the other hand, manage disease and trauma (also getting better at that mission over the years) but outsource most financial issues to insurance, government and other third party resources.

          Businesses which do that don’t last long in the market. They will get eaten alive by competitors. Health care providers, though, don’t think in terms of competition. Once they have the patient that’s the end of the story. My guess is that it’s a rare patient who leaves one doctor for another (unless he’s a pain in the butt and the doctor is happy to get rid of him). (I’ve had customers like that in the food business. Happy to let a competitor try to serve him champagne at beer prices. But I digress.)

          Thanks for your reply.

          • Nate Ogden says:

            “My guess is that it’s a rare patient who leaves one doctor for another”

            Actually this is pretty common, in majority of cases people will change doctors for financial or plan reasons. It’s inconvient if a doctor leaves a network but not the end of the world.

            Dentist, OMFG, don’t you dare ask someone to change a dentist! We have groups that offer dental PPOs and have well under 50% utilization. Since dental usually caps at 1000 to 1500 every year I see people spend thousands out of their own pocket instead of switching to a PPO dentist.

            doctors generally do make terrible businessmen. The PHO/IPO HMO mess of the 90s where they rushed to accept capitation and lost their shirts is a great example. Even today though when it comes to money matters their is a breakdown in logic.

  8. I fear friend tcoyote (Jeff Goldsmith) is right about Obama’s communication strategy. They decided to cut bait — but then, when the GOP lawsuits became not a nuisance but a real threat to the entire bill, they decided to launch a two-week publicity blitz that has had zero effect on public opinion but was fun for both sides of the debate and good for television.

    The bill was poorly drafted, but that’s not what got it in trouble at all. Ironically, when it was up for debate, no one mentioned the constitutionality as a reason to vote against it. What does that tell you?

    Nate: None of my facts is made up, though you’re free to differ with the interpretation of the facts. You also may notice that this site, unlike many others, is pretty light on calling people names. People who say, “Liberals want everything for free” and use lots of exclamation points usually have a pretty liberal (as it were) interpretation of fact, and Nate, you are no exception.

    Speaking of which: are insurance companies good or bad? I don’t know, but the Gallup Poll of late last year noted that the public’s response to whether it trust/likes various industries (car salesmen, Congressmen, health insurers) now shows a split by political affiliation. Apparently, Obama’s attacks on health insurers have prompted Republicans to respond with love for their insurance company, rating them “excellent” much more than in the past.

    Oh, happy partisans!

    • Responsible_Development says:

      Most polling shows that people are satisifed with their own insurance company, especially if employer sponsored. The demagoguery of the industry comes from some politicians and the media.

      But I don’t understand the broader debate. North of 75% of health care spending is easily preventable by diet, exercise, not smoking/abusing other substances, etc. Most of the fight isn’t over the remaining 25% or less of costs, it’s over forcing those who make good lifestyle decisions to subsidize those who make bad ones. And obviously this applies to broader society as well, not just health care.

    • Nate Ogden says:

      While it’s comforting to just blame the GOP for the unhappiness with health reform threatening the president’s re-election,

      Baptist minister at a nationally televised town hall asked in mid-2009 whether reform would cause his benefits to be taxed due to “government taking over health care,”

      While Republicans railed about mythical “death panels,”

      angry Tea Party demonstrators held signs showing Obama with a Hitler moustache,

      sobbing middle-aged woman telling Sen. Tom Coburn (R-OK) of her husband’s brain tumor, only to get the reply, “Government is not the answer,”

      When GOP leaders decided to just say no to Obamacare, they were honest about their political calculus. The polarization worked.

      You were saying what about people that make sweeping generalizations about GOP, Republicans, Tea party….oh that’s right you weren’t. Those rules and standards only apply to those you attack, you live by a loser set of rules.

      “None of my facts is made up”

      Mythical Death Panels is 100% madfe up. If you care to discuss how Americans can be certain The Liverpool Care pathways or something similar could never happen in the US I would love to educate on the matter, maybe then you will stop denying it was a real concern.

      Saying supporters of the bill were not mobolized is also false as the links I gave you prove.

      Gallop pool on populatory of industries has as much value as the person willing to pay to advertise next to it. Not even worth discussing.

  9. Nate, you’re not even well-enough informed to be close to factual. For instance, if you were referring to comparative effectiveness research leading to “death panels,” you might be excused hyperbole. (Or not excused.) But the death panel reference was in reference to end-of-life counseling in a provision proposed by a Republican from Georgia. It was demagogued by others.

    Gallup poll on industries, of course, is not paid for by any one industry — perhaps the nurses are paying all these years to be rated higher than used car salesmen? Etc., etc., etc.

    And Responsible_Development leaves out the voluminous literature on health problems’ link to socioeconomic status and environmental hazards.

    Gosh, I remember back when the left wing had the simple answer to everything. Now it’s the right wing. Maybe Sarah Palin and Ron Paul can meet up in Heaven with Abbie Hoffman and the far-left ideologues. It will be Heaven for all of them, right?

    • Nate Ogden says:

      So what your saying Michael is you have no idea what LCP is and how educated people aware of how LCP came to pass see the same potential in the proposals put forth for end of life counseling.

      What’s humorous for intelligent people is how you argue an end of life plan in the UK is not at all comparable to an end of life plan proposed here. What in the world would an end of life plan have to do with an end of life plan right?

      If your done deflecting why don’t you answer the simple question? Let me ask it again;

      What assurances were there that the end of life panel would not adopt the LCP or something very similar? LCP is a very real and functioning death panel, unless your clueless on what the word mythical means you can’t call them that. LCP is a death panel you were wrong.

    • Nate Ogden says:

      To further educate Michael

      LCP was created by non elected “experts” not accountable to the public. All of the proposals put forth by the government so far are the same set up. Non accountable bodies that have the potential to subject the public to policies they don’t agree with.

      Look at the uproar when similar bodies suggested less frequent breast exams. That was preventive testing, now imagine if this panel suggested prostate cancer not be treated for anyone over 70. Over stage 4 breast cancer not be treated.

      The reason the left rushes to label these mythical and mock those that ask the question is they are afraid to have the conversation. That and most lack the education and intelligence.

      If only death panels where as mythical as Obama’s recovery and Liberals attempts at affordable healthcare we wouldn’t be worried.

  10. Nate Ogden says:

    Michael’s MYTHICAL death panels; makes you wonder why people like him are so insistant on lieing to us….

    ‘Death Panel’ Concerns in the UK with the Liverpool Care Pathway

    A letter from a group of concerned doctors, including Dr. Peter Hargraeevs, a London-based palliative medicine physician, to the British Telegraph newspaper is raising concerns over the UK’s National Health Service (NHS) implementation of a protocol called the Liverpool Care Pathway. The letter asserts:

    “If you tick all the right boxes in the Liverpool Care Pathway, the inevitable outcome of the consequent treatment is death. As a result, a nationwide wave of discontent is building up, as family and friends witness the denial of fluids and food to patients. Syringe drivers are being used to give continuous terminal sedation, without regard to the fact that the diagnosis could be wrong. It is disturbing that in the year 2007-2008, 16.5 per cent of deaths came about after terminal sedation. Experienced doctors know that sometimes, when all but essential drugs are stopped, “dying” patients get better.”

  11. Michael Millenson says:

    Nate, I think you’re arguing past me. What panel? How does making end-of-life counseling a covered benefit involve a panel? That’s the narrow issue here. Not the UK or anything else in the US. It’s how a bipartisan bland Medicare benefit with no panel, no experts, no nothing but a benefit that would cover your local doctor became something else. So: rant away, but first, show me a real panel involved in what was really proposed. Other maybes don’t count.

    • John Ballard says:

      I think Nate’s referring to the Liverpool Care Pathway, a standardized interdisciplinary protocol for managing palliative and other medical decisions after a patient is determined to be irreversibly on the way to death. I don’t know much about it other than what can be found on the Internet, but I’m not as alarmed as he and others seem to be inasmuch as well-established measures are in place in this country guarding against euthanasia.

      A few years ago those constraints were so strong that doctors were fearful of NOT doing “everything possible” to prolong life, even in someone who was brain-dead. The cases of Nancy Cruzon and Terri Schiavo underscore the radioactive nature of the issue.

      http://www.sptimes.com/2005/02/27/Tampabay/A_fate_unclear__a_leg.shtml

      Discussions of advance directives have been characterized by many as a slippery slope leading to “death panels” the LCP reference is shorthand for that threat.

      In my post-retirement work as a non-medical care-giver for the last eight years I have seen the end of life up close and personal, sometimes for younger people with terminal conditions, but mainly with the aged. It has made me something of an evangelist for advance directives, but this comment thread is not the place for that discussion.

      Hope this helps.

      • Nate Ogden says:

        John I would ask you read about the healthy people misdiagnosed then starved and dehydrated to death. The problem is not with the dying people its with all the healthy people its murdering.

        • Nate Ogden says:

          the biggest complaint people had is the way it was created and applied. Originally family was not told and was kept in the dark. There was never a public debate or discussion about it.

          That is why arguments like Michaels are so ignorant and annoying, they keep demanding to know what bill ever proposed created death panels, that is the whole point, there never is a bill debated and passed. Its done without the public’s knowledge and input.

          They want to mock and redicule those that want debate becuase they lack the knowledge.

          • Auth says:

            A down economy ALWAYS afeftcs sales. Generally, most sales jobs are largely commission based until you start getting further up the ranks, such as territory or regional manager. I once found a financial advisor position (mutual fund jockey) that paid 18k base to start with comissions, but you lost the base after 2 years, and you had to maintain a quota to keep the base. Sales is tough, but sales and marketing are pretty much the only people top management respects, so go figure.

      • Nate Ogden says:

        “A report into palliative care in the NHS found that in one, unnamed hospital trust, half of families were not told that their loved one had been placed on the LCP and in a quarter of trusts, one in three families were not informed.”

        “Tens of thousands of patients with terminal illnesses are being placed on a “death pathway”, almost double the number just two years ago, the Royal College of Physicians has found.

        Health service guidance states that doctors should discuss with relations whether or not their loved one is placed on the scheme which allows medical staff to withdraw fluid and drugs in a patient’s final days. In many cases this is not happening, an audit has found.”

        “In addition to the withdrawal of fluid and medication, patients can be placed on sedation until they pass away. This can mean they are not fed and provided with water and has led to accusations that it hastens death.”

        “he Liverpool Care Pathway was intended for use in hospices but was given approval by the Department of Health in 2006 leading to widespread use in hospitals. Concerns about the pathway were raised first in The Daily Telegraph in 2009 when experts warned that in some cases patients have been put on the pathway only to recover when their families intervened, leading to questions over how people are judged to be in their “last hours and days”.”

        A clear example of how an unelected panel came up with an idea intended for specific uses but then spread across the entire system without any public discussion or debate.

    • Nate Ogden says:

      Where did LCP come from? They never passed a law to form a panel to kill old people.

      Where did the questionable language in the VA handbook come from?

      Where did the proposed child farm labor rules come from?

      The point of the entire argument is the government is suddenly going to pay doctors to discuss end of life care. At the same time they are also proposing other regulations to ration care. Discussions to move everyone under government healthcare. Massive expansion of government regulation over existing plans.

      If doctors are going to consult over end of life care who prepared the guidelines? What were they discussing and recommending and who created and approved it?

      Congress has gotten in a bad habit of passing vague laws then allowing unelected bureaucrats to basically make up the laws. i.e. now apparently as a TPA I am suppose to pay for birth control for my religious clients. What bill was ever proposed or passed that even hinted I might have to buy birth control for people that don’t even work for me?

      You want to argue there was never a clear cut proposal to create death panels, this is naive and ignorant argument, we are saddled with all sorts of “regulations” that were never clearly proposed , voted on, or passed. Every month HHS comes out with new regulations that disprove your argument.

      I’m not talking pass you; I’m talking at a higher level you either refuse to acknowledge or are sadly unaware of. As is anyone calling death panels mythical.

      http://www.webmd.com/breast-cancer/news/20091116/panel-breast-screening-should-start-50

      A government appointed expert panel is calling for huge changes in breast cancer screening in the United States, but a leading cancer group is highly critical of the move.

      In newly revised guidelines, the U.S. Preventive Services Task Force (USPSTF) now recommends against routine mammography screening for average-risk women in their 40s.

      HHS determines what plans cover, and also can’t cover. They could easily say screenings under 50 are not covered.

      They could decree treatment over 70 is not covered just as easily, now that they have been empowered to determine what is and is not covered without public say they can make such significant changes.

      Arguments like yours denying death panels as a legitimate concern just show how little you know about healthcare and our current systems. No grasp on how they work and things got to be the way they are.

      • John Ballard says:

        Sorry. I guess I pushed the wrong button.

        My recollection of the Terri Schiavo affair is that before the dust settled on what should have been a private matter involving no one but family members and their doctors became instead a national case resulting in the US Congress being convened for a special session to address the matter. (Oddly, many of the same people who scream about individual and states rights are often the first to invoke federal authority when they want to impose blanket federal rules for issues better left private. Abortion, in vitro fertilization and assisted suicide come to mind.)

        I’m not without fears of Big Brother, but those fears have more to do with privacy and economics than health care. As far as I can see, health care professionals are at the leading edge of real improvements and panic about death panels is simply that — panic. I realize that trolling for new patients is important for commerce, but I’m not convinced it is important for effective medicine.

        This link to an oncologist’s blog summarizes how that group of specialists are working to standardize a specialty-wide protocol for treatment options. (Catch at word — options not mandates.)

        http://sunriserounds.com/?p=629

        That kind of professional leadership is finally getting started. Better late than never, I suppose. But it’s not being dictated by government bureaucrats or technocrats. It’s happening in the field, led by card-carrying successful professionals who earn a living in the healing arts.

        I can’t resist leaving a link her to the Advance Directive forms for my state. I’m sure there are others, but I think Georgia has a really good one.
        Twelve pages of instructions and 14 pages of the form. (pdf)

        http://www.tiftregional.com/documents/Advance%20Directive/advance%20directive.pdf

        And nothing there refers to the Liverpool protocols.

      • John Ballard says:

        **Sigh**
        I left a comment but it has two hot links and is stuck in “moderation.”
        Oh, well. Sooner or later it will appear.
        Meantime, Nate, your link above it three years old. Protocols have changed since then and are continuing to change, thankfully, even as we speak.

        • Nate Ogden says:

          Which is the point, once it was brought to the publics attention and open for debate an acceptable program was created.

          That is all conservatives have been asking for, lets talk through this and make sure we do it right.

          People like Michael are insisting there is nothing to talk about, we should just shut up and go away.

      • steve says:

        I have been swarmed at work, but reading over this, you have gone off the deep end. Could paying for a consultation result in docs telling people they have to die? I guess, but with about the same probability of owning guns means we will al shoot each other and be dead in a week. Just because I can get paid does not mean I am going to practice unethically.

        The child labor on farms thing has been debunked. references if you want, from a libertarian writer.

        Steve

        • Nate Ogden says:

          “I guess, but with about the same probability of owning guns means we will al shoot each other and be dead in a week.”

          Thank you for proving my point. We have endless debate on gun laws. Some cities outlaw them. And the left is constantly raising this issue every chance they get.

          So discussing gun laws is acceptable debate but wanting to discuss end of life dictates from the funder of care who has motivation to lesson cost is just crazy talk and mythical?

          And you still missing the point of the debate, its not that doctors are going to kill people, that is not how LCP started. It would be nice for any of the liberals attacking me for this to actually read the history of LCP and have a clue of what they are talking about.

          I would explain LCP’s history but get in trouble for thread jacking. Its not hard to look it up and see what the concern is.

          Yes please debunk the child labor laws just suggested, its been going on for years, just ask a farmer.

          • steve says:

            Sigh. Your reading comprehension is better than that. We own guns. I own guns. I am an NRA member. I do not go out and shoot people. If you make guns easier to get, i will not go out and start shooting people. If you pay me for consulting about end of life issues I will not suddenly start telling people they should die.

            Yes, I know about the LCP. No one in the US seriously advocates for a NHS type system. It works in the UK where they are concerned about costs, but would not be accepted in the US.

            ” Some cities outlaw them.”

            Not the place to discuss it, but guns are really a federalism issue.

            Steve

          • Nate Ogden says:

            problem is not my reading I know exactly what your saying. So if all these responsible gun owners own guns with no problem can we dismiss the liberals that want to talk about gun control and the mythical issue of gun saftey?

            How about all the mythical disinfranhize arguments against voter id? There are no proposals to discriminate against minorites when it comes to voting yet the left is crying like crazy about it.

            How about this mythical war on women?

            How can you not see how hypocritical it is to ignore legit questions on death panels then turn around and make up the three items above. And there is 100 more examples of the left making issues out of arguments far less likely then death panels.

          • Nate Ogden says:

            “No one in the US seriously advocates for a NHS type system.”

            Nice subjective argument to go with it, and who is the judge of what leftest proposals are serious and which are not?

      • Peter1 says:

        “Arguments like yours denying death panels as a legitimate concern just show how little you know about healthcare and our current systems. No grasp on how they work and things got to be the way they are.”

        Just interested Nate on the policies your clients (employers) design (with your help) for their workers. Do they have limits or do they pay for everything/anything with no caps?

        • Nate Ogden says:

          all plans have caps and limits

          • Peter1 says:

            “In newly revised guidelines, the U.S. Preventive Services Task Force (USPSTF) now recommends against routine mammography screening for average-risk women in their 40s.”

            Is this a cap or a limit?

            “Warren Buffett’s decision to undergo prostate cancer screening reflects the reality that nearly half of American men 75 and older continue being tested despite official recommendations against doing so, researchers reported today.

            “PSA screening for more than 40 percent of men 75 or older is inappropriate,” said Dr. Scott G. Eggener, an assistant professor of surgery at University of Chicago Medical Center, whose research confirms that older men aren’t heeding 2008 guidance from the U.S. Preventive Services Task Force.”

            Would this be a cap or a limit?

          • Nate Ogden says:

            limit, it is limited to women over 40s

            Cap would be screenings are covered up to $300 per year or something like that

            Or you could have a cap on the number of visits in which case caps and limits are pretty much the same thing

            Buffet guideline would also be a limit

  12. Leslie M says:

    Here’s what I know: I am 60 years old, self-employed, and on COBRA until September. If health care reform is turned back, there is a fairly good chance I will spend some time uninsured before I qualify for Medicare, putting my financial stability at risk — to the extent that I could end up costing other tax payers thousands of dollars in Medicaid or uncompensated care. One message Obama has failed to communicate is that health care reform is not about poor people. It’s about hard working, middle class people, more and more of whom are self-employed or working for small businesses with no benefits. We have the chance to get it right now, with or without passion.

    • Nate Ogden says:

      How does PPACA prevent you from being uninsured?

      Are you counting on the subsidies to be able to afford coverage? If so you will cost tax payers tens of thousanbds.

      Are you worried about guarantee issue? You already have that with HIPAA

      How does driving up the cost of healthcare help small businesses?

      How does hundreds of billions added to the national debt on top of the 16 trillion we already have and 40 trillion of Medicare underfunding help?

      What would help individuals and small business is the flexibility to buy policies that are right for them, not one size fit all government designed plans.

      Lowering the cost 20-30% by addressing fraud and provider payments.

  13. Maggie Mahar says:

    Michael–

    I agree that Obama left “emotion to his opponents.”

    From the beginning, his way of handling opposition is to try to make a logical argument with facts–not emotion. He assumed that if his argument is logical and reasonable, people with agree. (He even seemed to assume that he could bring the most conservative Republicans around to his way of thinking just by being patient and rational.)

    Unfortuantely, most people respond to emotion, not reason. And medical care is an especially emotional topic. Thus conservative soundbites about “death panels” etc were very successful.

    Fearmongering is pretty easy–you just push a button.

    . Explaining how the ACA will improve health care is far more difficult–especially because it involves explaining that, at present, our hospitals are not as safe as they could and should be, and that over-treatment is a major problem which drives costs higher while putting patients at risk.

    The basic message is “less is more. Higher quality and lower costs go hand in hand,”

    Most Americans believe that “more is more”–especially when it comes to heatlhcare for themselves or their family. A great many Americans distrust science. Thjey are not interested in medical evidence. They believe that their own doctor knows best. (It’s too frightening to consider tthe possibility that he
    might be somewhere on the lower end of the bell curve that Atul Gawande talks about).. They believe that the hospital where their children were born is top notch. They don’t want to hear about infection rates and preventable errors.
    They want to feel that medicine makes them safe.

    So while I agree that Obama could have and should have brought more passion to the argument, he had a very tough job.

    I would point to Don Berwick as someone who is brilliant at explaining what’s wrong with our health care system with passion — but in a public debate with an articulate fear-monger who opposes reform, I’m afraid that Berwick would lose. People don’t want to hear that we don’t have the best health care system in the world.

    Certainly, Berwick wasn’t able to persuade many of the Republicans in Congress.

    Finally, the debate over heatlh care reform isn’t just emotionally charged, it’s about basic values. Do all Americans have a right to high quality, comprehensive care? Do we as a society have a responsibilty to ensure that they have access to care?. Many Americans would say “Not if that means I might get less care— and don’t talk to me about unncessary care!”

    Health Care Reform is a tough sell.

    • John Ballard says:

      Yesterday’s piece in the WaPo by two contributors (from Brookings and AEI already — not exactly Left-leaning outfits) underscores the point.

      Today, thanks to the GOP, compromise has gone out the window in Washington. In the first two years of the Obama administration, nearly every presidential initiative met with vehement, rancorous and unanimous Republican opposition in the House and the Senate, followed by efforts to delegitimize the results and repeal the policies. The filibuster, once relegated to a handful of major national issues in a given Congress, became a routine weapon of obstruction, applied even to widely supported bills or presidential nominations. And Republicans in the Senate have abused the confirmation process to block any and every nominee to posts such as the head of the Consumer Financial Protection Bureau, solely to keep laws that were legitimately enacted from being implemented.

      http://www.washingtonpost.com/opinions/lets-just-say-it-the-republicans-are-the-problem/2012/04/27/gIQAxCVUlT_print.html

  14. Peter1 says:

    Nate Ogden says:
    April 29, 2012 at 2:09 pm

    “limit, it is limited to women over 40s

    Cap would be screenings are covered up to $300 per year or something like that

    Or you could have a cap on the number of visits in which case caps and limits are pretty much the same thing

    Buffet guideline would also be a limit”

    Wouldn’t they be a death panel?

    • Nate Ogden says:

      matter of opinion.

      In my opinion when a person is free to purchase a policy that does or does not cover something they are exercising their free will.

      If on the other hand the government dictated what is and is not covered and requires you to buy that policy and some panel made the decision then yes it would be a death panel.

      • Peter1 says:

        A person may be free to purchase anything they want, if they can afford it. Would not being able to afford more coverage be a death panel?

        A person is not free to get what they want in their employer’s policy.

        If a test/procedure is not covered by Medicare is the patient not free to purchase themselves?

        • Nate Ogden says:

          not being able to purchase something is not someone else inflicting a decision on you. If you can’t afford steak and lobster most people won’t accuse society of starving them. And those that do complain people would ignore. EMTLA provides for basic care, no one will die in the street. Do 70 and 80 year olds need transplants though? If you can afford one and choose to spend your money that way then go ahead. I personally rather pass a few hundred K on then live longer at that age.

          An employer’s policy is not the end of one’s insurability. They are free to buy additional coverage just like they do know for life insurance, cancer, accident, deductible reimbursement etc. The availability of additional coverage for those that feel they need it is why we need to stop trying to make employer insurance all inclusive one size fits all.

          They are free to purchase but not from their doctor they receive the rest of their care. This is also a couple steps down the slippery slope. Under NHS if you get care not approved by your doctor they will cease treating it all together. So now you need to get and personally pay for all of your cancer treatment for example. It’s not far after that to eliminate all care and kick them off coverage.

          When systems are ran by government on large global budgets the cutting and planning are seldom discussed or reasonable. In Medicaid for example in numerous states and on numerous occasions when it got to expensive millions of people where just dropped. Wholly illegal in private insurance unless the carrier is getting out of the business and then those people are guaranteed coverage by the rest of the system. Their can be price shock but they are guaranteed coverage. When Medicaid eliminates your class your just done.

          As government consumes would of the insurance market finding providers who can walk away from that base is going to be harder to find. When 30% of the population was public plans that left you 70% to serve if you didn’t take money from the public plans. What happens when Medicaid and Medicare enrollment hits 50% or 60%? Could doctors afford to write off that much of the market?

          • Peter1 says:

            “EMTLA provides for basic care, no one will die in the street.”

            Then where’s the “death panel”?

            “They are free to purchase but not from their doctor they receive the rest of their care.”

            ?? If a procedure is not a Medicare covered procedure then you’re saying the Medicare patient as no ability to pay for that procedure themselves?

            “They are free to buy additional coverage”

            Only if they can afford it. Are poorer people relegated to market cost “death panels” and richer ones not?

            Nate, you say government should not be involved in deciding who can get coverage but the market can – and that is different?

            “Under NHS”

            This is not England and we do not have the NHS.

            “In Medicaid for example in numerous states and on numerous occasions when it got to expensive millions of people where just dropped. Wholly illegal in private insurance”

            Yes, they are not “dropped” in private insurance but their rates are escalated to a point where people will self drop – can you tell me the difference?. But Nate, don’t you agree that government needs to cut, and if it can’t afford Medicaid then wouldn’t the “dropping” be a good budget move in line with your principles?

  15. You know, I try to treat everyone respectfully, but, Nate, you try my patience.

    If you have private insurance today, there are treatments not covered. Do you think that’s a death panel? If you have government insurance, there are treatments not covered. Is that a death panel? If so, then your assertion makes sense. Of course, the only people being forced to buy insurance — or pay a fine — are the uninsured, who have NO treatments covered — which we know does lead to death.

    Nate, you are so obdurate and so committed to not letting facts sway your opinion that you are making arguments that even Sarah Palin didn’t. Those who distorted the Affordable Care Act were talking about end-of-life counseling. Since the end-of-life counseling does not involve a panel — since, in fact, you were utterly wrong — you’re reduced to saying that IF there were a panel and it didn’t cover all care, it would be a death panel.

    Alas, no private insurer offers 100 percent coverage for everything anyone who buys a policy wants. The only other alternative is to self-insure for 100 percent of care, which only rich people can do.

    So: if the government forces a rich person to buy health insurance that doesn’t cover anything AND, at the same time, prohibits him from paying money from his own pocket for uncovered expenses, that would be a death panel. Of course, that situation doesn’t exist even in Britain, where you can pay out of pocket.

    On the other hand, if you, personally, would rather die than pay for medical care your health insurance doesn’t cover, I guess you could make that choice. But that would be a death wish, not a death panel, and a completely different discussion.

  16. Obdurate Be Thy Name says:

    Love it.

  17. Nate Ogden says:

    You said mythical death panels. You never once said Sarah Palin’s opinion or concern on death panels. Once you were challenged on the facts now the only one’s you meant to refer to are the specific argument she was making?

    I’ll correct a number of other mistakes you just made;

    “Those who distorted the Affordable Care Act were talking about end-of-life counseling.”

    You are wrong here, I and numerous other people were making the same argument I am now back when this was being debated. Maybe in your limited and partisan knowledge that is the only one you heard but there was a much broader debate going on and LPC was discussed prominently.

    Telegraph 9/3/09

    “Inch by inch, the state is taking over not only the everyday minutiae of how we live our lives, but also how long those lives should be. America has risen up against Obama’s “death panels”; it is unlikely the British have the will to exercise the same instinct of self-preservation by halting this drift towards the unthinkable.”

    The Oregonian The Oregonian 9/12/2009

    “Twelve years later, Emanuel’s Atlantic essay remains a lucid case for the existence of a slippery slope, especially under government-managed health care, to some sort of death-by-bureaucrat. Just because Ezekiel Emanuel and Sarah Palin agree that a slope exists, however, doesn’t mean that America will slip down it. In a more cost-conscious culture, there’s no question that physician-assisted suicide could lead to a particularly sinister form of rationing. The European experience offers plenty of cautionary tales — from the spread of less-than-voluntary euthanasia in the suicide-accepting Netherlands, to the recent controversy over Great Britain’s “Liverpool Care Pathway,” whose supposedly-merciful approach to dying patients may involve withdrawing care before their death is actually certain.”

    I could post an endless supply of links to 2009 specifically discussing LPC, Palin, and PPACA. Of course the liberals on here would have me kicked off for thread jacking then.

    How many articles would you need to see to admit your wrong. Search either of the quotes and they will take you to the newspaper’s site showing this discussion has been going on, your just ignorant of it. For a mythical issue it sure got a lot of mainstream discussion.

    “If you have private insurance today, there are treatments not covered. Do you think that’s a death panel? If you have government insurance, there are treatments not covered. Is that a death panel?”

    Already answered this above. If it is a voluntary purchase no, if it is a mandated purchase yes.

    “Of course, the only people being forced to buy insurance — or pay a fine — are the uninsured,”

    Not true at all, what about those with mini meds? What about those with non qualified plans? What about the tens of millions who had to buy policies with higher limits or come 2014 lower deductibles. Not very good with the facts are you?

    “if the government forces a rich person to buy health insurance that doesn’t cover anything AND, at the same time, prohibits him from paying money from his own pocket for uncovered expenses, that would be a death panel. Of course, that situation doesn’t exist even in Britain”

    Really? So when they cut off providing care if you obtain non authorized treatment under the NHS, is that what your claiming doesn’t exist?

    More local if Medicare forbids any provider who receives Medicare payments from providing care outside the guidelines where could someone go to get that care? They already do this now.

    Love how you project your inability to understand or deal with facts on me.

    • Nate Ogden says:

      October 20, 2009

      http://www.firstthings.com/blogs/secondhandsmoke/2009/10/20/obamacare-harardous-pathway-the-road-to-death-panels/

      This is precisely the paint-by-the-numbers medical approach that Obamacare threatens to bring across the pond to our shores. Indeed, former senator Tom Daschle — whom the New York Times called the most influential adviser to the president in the health-care debate — has long urged that America adopt NICE-style centralized medical planning. Indeed, according to Scott Gottlieb, writing in the Wall Street Journal, Daschle “argues that the only way to reduce spending is by allocating medical products based on ‘cost effectiveness.’ He’s also called for a ‘federal health board’ modeled on the Federal Reserve to rate medical products and create central controls on access.”

      Chillingly, current Obamacare plans call for the creation of many cost/benefit/best-practices boards, the full power of which won’t be fully known until the bureaucrats promulgate tens of thousands of pages of regulations between now and 2013, when the law would go into effect. Making matters more alarming, these boards would not only govern treatment provided in any public-option health plan, but would also be empowered to set the standards of care paid for by private insurance. Unless the final version of Obamacare is amended explicitly to prohibit such centralized health planning, don’t be surprised if an American version of the Liverpool Care Pathway comes soon to a hospital or nursing home near you.

  18. John Ballard says:

    I learned as a cafeteria manager it was hard to compete with all-you-can-eat food bars and buffets.The notion that someone dining out can pay one price then eat as much as they want is very appealing, especially for those who can afford the price at the door. But behind the thinking is the unspoken impulse to get something for nothing. Somebody else might not get their money’s worth, but I’m gonna get MY money’s worth cuz hungry or not, I’m gonna eat as much as I can hold.

    Something for nothing. Wow! That’s a very appealing idea.

    This talk of death panels tires me. Just below the surface is the curious idea that dying is somehow optional. The discussion is not very different from the idea that with the right medical care we can get something for nothing. Examined closely, that something turns out to be immortality.

    The unhappy reality is this–
    It is NOT the mission of either insurance or health care to determine IF we will die. When all the smoke blows away the mission of both is to anticipate when and how — but not IF — that final appointment with the angel of death will be made.

    The medical and insurance communities both do their best with numbers and statistics to anticipate when, where and how death will come. But nothing discovered yet can prevent anyone’s death. Jesus Himself healed many, including, according to scripture, some who were already dead. But we have no evidence that any of them are still alive. Every one of them did eventually die.

    One way to meet death is to avoid both insurance and health care altogether. It doesn’t remove the uncertainty of when and how death will come, but one can die satisfied that not one dime was wasted on either of those schemes to prevent dying. The only real cause of death is not disease or trauma — but living.

    Large numbers of people die every day not because they have been sentenced to death by any insurance or medical panel, but because they have neither. I have a term insurance policy, which means I’m betting I’m gonna die and the insurance company is betting I’m not, at least until the term is finished. After that I’m not wasting any more resources on life insurance. And I regard my medical coverage pretty much the same way. As long as I am reasonably well cared for and enjoy even limited and uncomfortable “good” health, I plan to continue. But I’m not in denial that a day will come when doctors get to the end of their resources. And no panel will avert that day.

    And from what I have seen of hospitals and long term care facilities, if either place is where I am when that day comes I can tell you already I don’t want any delays — I’ll be ready to go, and the sooner the better.

  19. For the origins of the death panel term and debate (not how it came to be used), see The New York Times: http://www.nytimes.com/2010/12/26/us/politics/26death.html?pagewanted=all

    For a nice discussion of the concept of the Angel of Death in various cultures (not including the actuarial, alas), see Wikipedia: http://en.wikipedia.org/wiki/Death_%28personification%29

    And for a commentary on the propaganda on this issue, see: http://blog.seattlepi.com/williamhare/2010/12/31/republican-right-silent-on-real-arizona-health-care-death-panel/

    • Nate Ogden says:

      NY Times, Wikipedia, Seattle PI, that is quit the echo chamber you have going there. No wonder your understanding was so limited.

      What you have is the liberal political framing of the issue, not the issue. Which raises an interesting philosophical question along the lines of a tree in the forest.

      If a discussion happens outside the liberal main stream media does it really exist? Apparently Michael thinks not.

      Thank you for the NY Times link as it actually reenforces what the argument was from the beginning;

      “When a proposal to encourage end-of-life planning touched off a political storm over “death panels,” Democrats dropped it from legislation to overhaul the health care system. But the Obama administration will achieve the same goal by regulation, starting Jan. 1.”

      So there was enough public disagreement or concern to drop a provision from a bill being voted on by the public’s representatives. Instead they backdoor implement it via regulation. But people should not be at all concerned about this because this could never lead to an LPC or anything like it, trust you it just wont?

      “A national organization of hospice care providers made the same recommendation.”

      That is where LPC came from, then it was expanded from Hospice into regular hospitals. No one paid any attention because it only applied to hospice and doctors would never do anything wrong. 5 years later it applied to most hospitals and doctors were murdering healthy people, i.e. misdiagnosed cancer then withdrawing food and water. That took all of 5 years. But that could never happen here right?

      ““Thus far, it seems that no press or blogs have discovered it, but we will be keeping a close watch and may be calling on you if we need a rapid, targeted response. The longer this goes unnoticed, the better our chances of keeping it.”

      So this is how the left wants healthcare decisions made, quietly and without anyone knowing….just like the LPC.

      Isn’t the left and PPACA trying to move us towards ACOs and global payments? So these organizations will be getting lump sums, at the same time they are now on the hook for providing the care the government is going to pay them to advise these costly members it is ok to die sooner. When HMOs where in this situation the left called them death panels non stop. Now you have taken it one step farther, your paying providers to convince patients it’s ok to die, I guess that is one way of lessening the opposition to them.

      So I see you have walked back pretty much everything you have said prior to this. It’s not that Death Panels are mythical it’s just the left rather not have this discussion. Thanks for the honesty. Facts are not determined by ideology, you would be wise to remember that. Just because you disagree doesn’t mean it doesn’t exist.

      • Peter1 says:

        “Do 70 and 80 year olds need transplants though? If you can afford one and choose to spend your money that way then go ahead.”

        But that’s not what you are arguing. Should Medicare be paying for them? I think your answer should be yes, because otherwise you will argue “death panel”.

        • Nate Ogden says:

          if the person buys and pays for a policy that covers them then yes. The problem with Medicare is people don’t contribute a fraction of what they spend. It’s a ponzi scheme built on increasing population paying the claims of earlier beneficiares. I forget the exact ratio of what people pay in plus interest and what they take out but if it was a private company they would have been shut down years ago.

          I don’t think its right seniors paid for a policy that covers X and are now getting 20 times X. At the expense of the grandkids and the future.

          • John Ballard says:

            Nate, with these two very clearly written paragraphs you have summarized the entire discussion about Medicare and Social Security. My guess is that a large number of people, maybe even a majority, would agree completely with what you have said.

            Having said that, however, I can only speak for myself when I say I disagree with that argument. I realize you will not agree with what I am about to say, and will very likely not grasp the point altogether, but I’s saying it in the simplest words I can find.

            These two programs, Medicare and Social Security, are NOT, and NEVER WERE intended to either be or work the same as insurance. They are what historians and political scientists refer to as social contracts. In other words, they represent a political consensus not unlike collective decisions to amend the Constitution, build a network of federally planned and funded Interstate Highways or even wage war. These are national agreements and commitments linking the working population with the non-working population. At any given time, the working population is taxed to fund those commitments to the non-working population, most of whom are too old or certifiably unable for other reasons to work any more. (And to the extent that they/we DO work, that additional work is also taxed for the same reason.)

            It’s time for us to agree to disagree about this simple idea. I like it and you don’t. For me it is simple humanitarian (and I might add Christian) justice. But for you it is a violation of common sense, and your sense of fair play and personal responsibility.

            Is that about the shape of how we disagree?

          • Nate Ogden says:

            There was a recent study on how people of different political persuasions grasp the concepts of the other party. Not surprising the results.

            http://www.american.com/archive/2012/april/liberals-or-conservatives-who2019s-really-close-minded

            I understand the concept of social contracts. I even agree that we need social contracts and in places they serve a purpose and belong. I also believe there are two sides to social contracts just like there are at least two side to all contracts. Contracts are based on consideration, those receiving benefits under these contracts have not fulfilled their end of the consideration.

            Merely being born into the country or moving into it, legally or none, should not create an obligation on society to provide for someone.

            While I’ll agree SS was not presented as an insurance program I would disagree on Medicare. From my readings of the congressional debates and meetings it was always presented and was sold to the public as insurance. People would like to call it a social contract to avoid the comparison to insurance, as insurance it is a complete failure on all measures, but that’s not how they got it passed. Early version of its not a tax unless we need it to be a tax.

            I would disagree on why we disagree. If Medicare covered the 13% of seniors that needed help with catastrophic claims I would be ok with it for the most part.

            I disagree with the additions made to SS, disability for example, while needed protection for those truly disabled, is a complete joke. There is no pretense of processing claims correctly the first time or policing those asking for benefits.

            Where we seem to disagree, not to assume, is our expectations of what the public provides for their end of the consideration. I don’t see where you expect anything from them, and this I have major issues with, philosophically and christian. I take issue with able bodied people being entitled to the fruit of my 12 hour work days. At the minimum I rather keep my money and hire them to do remedial work I don’t have time for because I work so much. Instead I pay taxes so they can stay home playing video games and making babies.

            Obviously there are people deserving of assistance and I have always argued those people are short changed. We don’t provide them near the assistance they deserve because we waste the majority of it on those that do not.

          • Peter1 says:

            “I don’t think its right seniors paid for a policy that covers X and are now getting 20 times X. At the expense of the grandkids and the future.”

            Isn’t that the fake fear mongering of those screaming “death panels” when they say the govmet is taking away your/my benefit (unlimited use) so that constitutes a death panel yet those same screamers (such as yourself) don’t want to pay for unlimited use and are just using it as a red herring created from invented facts.

            Tell us which way you want it Nate. Either you want to control costs or you want unlimited use.

          • Nate Ogden says:

            Unlimited benefit? I suggest you lay off the questions and go read a little. Your suffering Michael knowledge deficency. Medicare is no where close to unlimited. Medicare wouldn’t even come close to qualifying as creditable coverage under PPACA.

          • John Ballard says:

            Well, Nate, I gave it my best shot. We can’t even agree to disagree. At least I tried.

            As for the link to the AEI piece, I’m not surprised that a Conservative living in New York, encircled by Liberals, would quietly come to the conclusion that he understood both sides but those around him would never grasp where he was coming from.

            As a Liberal having grown up in the South, surrounded by Conservatives (the people around me have elected Newt Gingrich, Bob Barr, Herman Cain, the late Larry McDonald, Lester Maddox, and a laundry list of other less well known arch-Conservatives) I have developed exactly the same attitude, but with the poles reversed. Like those New York Conservatives, I have also had to walk on eggs all my adult life lest I become entirely outcast by those around me.

            I guess we all have our respective echo chambers.

            http://www.commondreams.org/view/2012/02/07-5#.TzbarIEWkJN.facebook

            http://pss.sagepub.com/content/23/2/187

            It feels crude, illiberal to point out that the other side is, on average, more stupid than our own. But this, the study suggests, is not unfounded generalization but empirical fact.

          • Nate Ogden says:

            Thought you might enjoy this read John

            http://volokh.com/2012/05/01/bleeding-heart-libertarianism-and-social-justice/

            Different perspective on social contracts/justice and how just about every ideology supports them. The question is not that conservatives are opposed as most liberals like to argue but to the degree and what the public owes to society.

          • John Ballard says:

            Thanks, Nate.
            Been there. Done that.
            Discussions like that no longer interest me.

            My career in the food business managing the working poor gave me a first-hand look at what it means to be at the bottom of the social and economic ladders. (Growing up in the South also helped shape my thoughts.) And it’s not a place where most people pecking on keyboards would want to be.

            Lincoln said the Lord must have loved the common man — He made so many of them. For all of human history the ratio of rich and poor has not changed a lot, although the spread (gap between top and bottom) has varied widely.

            I’ve been blessed to have as much as I need plus enough to share. But nothing in my experience has led me to think that those of us with both power and resources have no responsibility to care for those with neither.

            http://whatever.scalzi.com/2005/09/03/being-poor/

            For millions of our citizens having anything more than emergency health care is as distant a notion as cosmetic surgery or membership in an expensive social club. America, in my opinion, should be better than that.

          • DeterminedMD says:

            I fully agree with Nate on this. Selfishness and narcissism are the operating words these days with boomers especially, and it will doom this society a lot sooner than those in denial will come to realize.

            I am at peace that I will not see a dime from Social Security, that I paid for my parents and inlaws to get theirs and they were the supports I appreciated in their time. For boomers, and I am one of them mind you, they as a group can stick it where it don’t shine!

            See Carlin 1996 show, Back in Town, near the end, when he summarizes them perfectly, “Gimme that, it’s mine; they are cold, bloodless…”

            Amazing how a World War conflict can screw up a society post war!

  20. Peter1 says:

    “Unlimited benefit? I suggest you lay off the questions and go read a little. Your suffering Michael knowledge deficency. Medicare is no where close to unlimited. Medicare wouldn’t even come close to qualifying as creditable coverage under PPACA.”

    Then you would want Medicare to cover and pay for more coverage? You’re sending mixed signals Nate. Either Medicare needs to cut costs or it needs to cover more so that it’s not accused of using a death panel mentality.

    You haven’t answered my question Nate. Should Medicare pay for transplants on 70-80 year olds since you oppose the use of “death panels”?

  21. Munira Alhouti says:

    In my pinion Obama new health care will give his community better chance to live their life. People will be eligable for health insurance without looking for their pre-existing sickness. Most of Middle class people do not recognize the important of having health insurance in their life . Off course the health insurance will more expensive then it used to be ,but people will have coverage for their health.

  22. DeterminedMD says:

    Face it, PPACA as a whole is not about America, just a party’s self serving interests. I am sick of the posturing and lack of invested debate to redo this legislation better than round 1. And frankly, if the constituents of Pelosi’s district can’t figure out by now she is lame and useless as a representative and Party fixture, can’t wait for that earthquake to wake them up!!!

    Sorry, not wishing death and destruction, just a f—-g wake up call to literally jolt them into seeing 70% of America does not embrace their mind frames!

  23. bob hertz says:

    I missed this dialogue when it was “viral,”. but let me add a valuable poiint belatedly.

    One reason that Obama did not push harder for the PPACA is that the funding for it was sneaky in the first place.

    If the Dems had said in 2009, “We want to expand Medicaid to16 million people, and we want to subsidize 20 million others who get no employer benefits, and this will cost $150 billion a year, and we should raise income taxes by 2%………………..”

    this would have been an honest proposal.

    But their judgement was that it would never pass.

    Instead they cobbled together a bill which used 3 year federal carrots to expand Medicaid, used phony Medicare savings twice to pay for subsidies, and added an individual mandate to keep private insurers in the game, and combined a smattering of new taxes now but benefits that start four years from now…………

    It is worth noting that when Social Security passed in 1936, the Democrats controlled 80% of Congress and had Roosevelt. They could have passed a ham sandwich.

    When Medicare and Medicaid passed in 1965, we had full employment plus the new taxes required in the bills were minimal. Some of this was due to ignorance of what these programs would ultimately cost.

    In 2009 the public was less prosperous, so less generous, and there is much less ignorance about costs. Obama gambled that he could get his place in history with health reform, and paying for it would be someone else’s problem. (We had a fellow named Bush who approached Iraq in the same way, so it is not a partisan failing.)

  24. John Ballard says:

    Excellent point. The question of where the money comes from is a sticky one, indeed. As you point out, both Social Security and Medicare/Medicaid have designated payroll taxes which seem to be generating two really big revenue streams. Tweaking Social Security would be fairly straightforward but the GOP continues to salivate every time they look at all those dollars actually going to beneficiaries without first being skinned by brokers and bankers so the same old privatization schemes keep getting pushed.

    Medicare is a different story. I am of the opinion that there is enough money for health care, but not enough for the ancillary non-medical baggage that has grown on the system like an acute infestation of warts.

    If Medicare and other medical expenses are to be lowered the answer lies not with rationing but with the reduction of the numerous non-medical expenses sucking the system for other purposes. This looks like another good place for me to paste my favorite list of non-medical expenses, all of which have but one revenue stream — medical
    bills.

    § TV ads — some of the most expensive air time for some of the most costly productions in the ad industry.

    § Mammoth executive bonuses and golden parachutes for both health care
    administrators and insurance companies

    § Facilities with manicured landscaping, marble floors, lived plants, flat-screen TVs in every room, and concierge food service

    § Elaborate accounting arrangements by which large so-called “not
    for profit” health care systems, often augmented by equally large,
    embedded insurance companies (BCBS comes to mind) launder bills mostly for the benefit of very profitable clinics, specialty practices and device manufacturers.

    § ”Free scooters” advertised for Medicare beneficiaries. Sometimes
    comes with a free recipe book or lighted magnifier “just for making the
    call!”

    § Catered meals and other treats for hungry office staffs,
    compliments of your favorite drug or other supplies sales
    representative.

    § And speaking of sales, don’t forget the sales bonuses for high
    performers. The only people in America with no limit to how much they might earn are not in medicine or other specialties, but in sales.
    (Investment bankers are in the running, of course, but they are in fact
    limited by how much capital and/or credit they have. Enterprising sales
    people have only transportation, cosmetics and a few other expenses.

    § Don’t let’s leave out some red meat for the tort reform crowd —
    legal and accounting services, and a grey area often called “defensive
    medicine.”

    With the exception of a dedicated group of community volunteers who provide a few ancillary goods and services, every dime of all that has but two sources:

    1.) Medical bills
    2.) Government grants for teaching hospitals and research by NIH. (taxes)

    What am I missing?
    *
    *
    *
    *
    *
    *
    * Yes, of course. I almost forgot — MEDICAL CARE!

    ~~~~~~~~~~~~~~~~~

    Don’t you love watching those ED ads where the whole landscape goes tumescent?
    That’s a really great special effect, huh?
    Makes you all horny just watching.

  25. bob hertz says:

    Good points, John. For over 20 years, Medicare explicitly allowed hospitals to amortize the cost of new facilities inside the reimbursements for care. In other words, the feds paid hospitals to expand.

    The result is that the fixed costs of US hospitals are about $600 billion a year.
    Even if all the waste and corruption that you cite is flushed out, and it should be, the fixed costs might be $525 billion a year.

    You are proposing some good ways to cut the fat, but I fear we might have to cut into bone as well to keep Medicare afloat.

    • John Ballard says:

      Thanks.

      One of my pet peeves after looking closely at the big picture for about eight years (I am a retired cafeteria manager, but my post-retirement life has been with senior care which as you know furnishes the biggest revenue stream for health care) is the status of what is euphemistically called “non-profits.” As far as I can tell, the operational and accounting practices of not-for-profit operations would quickly cause crash and burn results in the for-profit market. But thanks to their tax status there is no reason to be what for-profit operations call good business and ordinary people like you and I call being “thrifty and responsible.”

      As a result, non-profits in health care, mostly hospitals but also a few insurance outfits (BCBS comes to mind) are mainly money laundering operations in a very profitable FOR-profit ecosystem from individual practices to drugs to clinics to large specialty practices. Patients are managed by the medical-industrial complex in the same manner that dairy cattle or poultry are managed by agri-business. They may as will be getting milked or laying eggs. And when I come across references to “transitions of care” it really pushes my button.

      As long as we regard basic health care as a commodity these problems will not be resolved.

  26. Bill says:

    Here in NH, the state employs roughly 10,000 full-time staff who pay very little for their health. I confirmed the exact amount by submitting an inquiry to http://www.nh.gov/transparentnh/, asking how much they pay. I would tell you, but there is a strongly worded confidentiality clause in the email from the Admin Dept that says I can’t.

    So, despite the high irony of ‘confidential transparency,’ what I can tell you is this. As a self-employed person who is also self-insured in NH, I pay over 90% more per annum than they do.

    Next. As part of the same inquiry, I asked how many self-employed there are in NH. They said they don’t know. Not surprising, because what else would we expect from the state of New Hampshire (and the rest of the country)? They don’t care about the small business segment of this economy. I discovered through reaching out to a small-business non-profit that about 130,000 self-employed work in NH.)

    Pooling risk is supposed to be the centerpiece of Obamacare for bending the cost curve, but the above numbers directly contradict that. A tiny group of 10,000 pays a pittance compared to what 130,000 people would have to pay were they all to self-insure? It is insulting. We all know that several state and federal laws work in concert to explicitly prevent us from pooling risk.

    There is a need to recognize self-employed and micro-businesses as contributors to the economy.

    Allowing the self-employed to pool risk would not only do that. It would propel underemployed people back into the work force. I’m sure many people would try to work for themselves if they knew they could access fairly priced health insurance. It would dismantle the ‘cliff’ that one falls off when losing a job. But as the architects of the cliff know, if a skilled union employee saw a chance to quit the union and work for him or herself, he’d leave in a heartbeat. Union bosses know that there are many talented people who work for them. So it really pays to have a system in place where a union member pays under $2,000/year, and the self-insured pays $20,000/year.

    Problem is, a side effect of keeping union rosters full is the death of entrepreneurship.

    Come 2014, you might feel a little better if you earn below Obama’s subsidy lines. If not, as Obama-care will compel folks to buy comprehensive policies, premiums will actually grow. So the future is now for the self-employed. A grim, brutal reality of being ignored. Everything else about Obamacare is noise.

    • Peter1 says:

      “I pay over 90% more per annum than they do.”

      You would probably pay 90% more than any employed person (public or private) who gets their health insurance paid (tax free) by their employer.

      Bill, as a self employed person how much of that 90% do you deduct from your federal/state taxes on your return?

      “There is a need to recognize self-employed and micro-businesses as contributors to the economy.”

      How, by giving them more tax breaks?

  27. Bill says:

    Peter1:

    I’m used to the type of disdain you exhibit towards the self-employed and micro-businesses. We’re a legitimate work force of professionals, my friend.

    My point is that entrepreneurship should be encouraged through a level playing field vis-a-vis health insurance costs. There are a host of jobs that can be done working from home, and most would agree the side effect of fewer cars on the road would be a good thing.

    • John Ballard says:

      Save me the pity party, Bill, and quit trying to game the system. Self-employed individuals and whatever you are calling microbusinesses have been popping up in America in good times and bad since before group insurance came about, and it’s still happening. One of the forgotten objectives of the Bush administration (which never happened) was tweaking the tax codes to uncouple health care from business altogether.

      http://www.aei.org/article/society-and-culture/poverty/tax-reform-and-health-insurance/

      When auto makers pay more for health care than for steel, or Starbucks pays more for coffee than group insurance — it’s time to take a few bricks off the wagon. Your “micro-business” is gonna be a helluva lot more successful if you can devise a way to get health care off the balance sheets altogether.

      The smart self-employed people I know are using extremely high-deductible plans in conjunction with health savings accounts. That’s not disdain. It’s advice.

      • Bill says:

        Thanks for the advice, John! Know of a higher deductible plan than the $10,000 one I already have? Geez, if it weren’t for expert advice like yours, what would I do?

        No, you’re right. That’s not disdainful at all.

        Microbusinesses = companies with 10 or fewer employees

        Uncoupling health from business is exactly what I’m talking about. Pooling risk across states lines among 22 million self-employed seems a good start, and makes a lot more sense than a government takeover of the entire system.

        Or better yet, how about an actual market of 300 million Americans shopping for insurance across state lines?

        • John Ballard says:

          That “across state lines” trope is simply that — a trope.
          The reality is that insurance is crafted in the several states in accordance with each state’s very different regulations. A recent study indicates that operating in several states has the unwanted result of driving up premiums.

          http://www.insurancejournal.com/news/national/2012/05/08/246688.htm

          The study compared the regulatory compliance costs of 85 insurance companies doing business in multiple states with 147 multi-state RRGs and found that traditional insurance companies have significantly higher compliance costs because of those multiple regulations. For instance, he found that the average traditional insurance company in his sample spends $187,000 a year on licensing fees in multiple states, while the average RRG spends only $49,000 for one.

          In total, his research showed the average standard insurance company spends about $9 million a year to comply with regulations. RRGs, however, spend an average of $2.9 million to comply with regulations.

          Leverty says those costs then drive up a firm’s expenses and are passed along to policyholders in the form of higher premiums. But more than that, he writes, they also limit consumer access and market competitiveness by acting as a drag on expansion into new states. Leverty’s research showed that the average standard insurance company pays $74,500 in new expenses whenever it enters a new state to comply with regulations in the new market.

          It’s one of the favorite GOP talking points, I know. And it sounds great to me as well. But since the insurance lobby is probably second only to the defense industry, my guess is that they already knew it sounds good but is a stinking idea, or it would have long ago come about.

          (Of course I’m not sure how they might square the circle of 10th amendment vs federalism. Interstate insurance commerce would be a Constitutional invitation for even more federal intervention than is already being complained about. )

    • Peter1 says:

      “My point is that entrepreneurship should be encouraged through a level playing field vis-a-vis health insurance costs.”

      Why just a level playing field for “entrepreneurship”? Why not everybody?

      “Everything else about Obamacare is noise.”

      Even being able to deduct 100% of your self-employed health costs?

      “as Obama-care will compel folks to buy comprehensive policies, premiums will actually grow.”

      So, pooling risk across state lines will lower costs and pooling risk across the entire country will raise premiums? A mandate will bring in a large pool of the healthy and young which will spread risk – even for you.

      When people talk about buying across state lines they really mean they don’t want to pay for someone else’s risk but just buy what their risk represents in a pool system that fractures risk pooling.

      “Or better yet, how about an actual market of 300 million Americans shopping for insurance across state lines?”

      That would be government run single-pay. Other countries show that it can be done for about half of what we pay.

      • Bill says:

        “Why just a level playing field for “entrepreneurship”? Why not everybody?”

        Because the playing field is quite obviously tilted in favor of public and private unions and employees working for major corporations. For them, there is no healthcare crisis. Why would we devote energy to an area where there is no problem to begin with?

        We should take steps to facilitate access to affordable health through work, not government subsidies. We need to make it easy for anybody to start a company or work for themselves. Say what the GOP will about wealthy job creators, but the fact is that anybody can be a job creator given the chance. Government workers paying $1,500/year for health and self-employed paying $20,000 is a grossly unfair system of crony politics. So, that’s why we should start with entrepreneurs.

        (If I had to guess, you have very good health insurance. By and large, the only people I meet who are supporters of Obamacare are people who already have good coverage, and have never experienced what it’s like being outside of the government’s crony circle of favorites)

        “Even being able to deduct 100% of your self-employed health costs?”

        You obviously have never worked for yourself. Please enumerate the long list of breaks that the self-employed get. Let’s see, the financial crisis begotten from ill-conceived CDO’s, bad legislation, Fannie/Freddie… and oh wait, and the self-employed?

        The self-employed have only been able to deduct health costs for the last two years. You are apparently tone deaf to that. Meanwhile, big companies have been able to deduct those costs forever. And guess what? The self-employment deduction is subject to review at year-end. This notion that self-employed have some big advantage is highly inaccurate, to say the least.

        “That would be government run single-pay.”

        No, it wouldn’t. It would be a market, which is apparently a foreign concept to you. I lived in Japan for over a decade with their single payer system, by the way. Our system is far superior, and a single payer system would be a huge step backwards. I don’t have time to list all my experiences there, will post on that later.

        • Peter1 says:

          “We need to make it easy for anybody to start a company or work for themselves.”

          I guess you’d enjoy the increased price competition then? Working for yourself is about risk. The “market” is supposed to reward risk takers.

          “We should take steps to facilitate access to affordable health through work”

          I agree, affordable health care IS the issue, but that would mean significant price reductions from providers – many of which are self employed – like you. Would you like to take income away from them for your benefit?

          “that’s why we should start with entrepreneurs”

          Please don’t confuse being self employed and no employees like yourself with being an “entrepreneur”. Usually entrepreneurs risk large amounts of their own cash to build an organization/market where they employ people, and ironically then provide company paid health care to attract good employees.

          “(If I had to guess, you have very good health insurance. By and large, the only people I meet who are supporters of Obamacare are people who already have good coverage, and have never experienced what it’s like being outside of the government’s crony circle of favorites)”

          Actually I’m uninsured, mostly by choice. I don’t really support Obamacare as it did not address costs, and mandates we contribute to the most expensive system in the world. But on principle, a mandate is what is needed for a properly functioning system with no free riders.

          I have never worked for government and have worked for myself as well as companies.

          You’ll also find most people with company paid health care do not support Obamacare as they’re afraid they’ll loose something.

          “No, it wouldn’t. It would be a market”

          You seem to want it both ways, no government control (a “market”) but government facilitating easy access to affordable care. A “market” in health care is what you and I experience every day – the individual market, where we have to negotiate what we pay and what we can afford to have access to – without benefit of subsidies (private of public).

          Why don’t you stop paying $20,000 per year to insurance companies and bank that money for your own health care? That’s what I’m doing.

          • Bill says:

            “Would you like to take income away from them for your benefit?”

            Yes, absolutely. And not for my benefit but everybody’s. They add no value to the system.

            “Please don’t confuse being self employed and no employees like yourself with being an “entrepreneur”. ”

            I respectfully disagree. A successful self-employed could just as easily start by farming work out to others as his/her business grows. At some point it would make sense to incorporate.

            You are right about risk/reward. Your instinct about significant capital outlays being a prerequisite to entrepreneurship is wrong, though. In fact, if you make that a prerequisite, no wonder the wealth gap is only growing larger. The average person who may have all the right stuff to start a business is shut out because of initial costs, while people who already have money fill the void. And when they succeed, they just get more.

            “You’ll also find most people with company paid health care do not support Obamacare as they’re afraid they’ll loose something.”

            True.

            “You seem to want it both ways”

            No. The government has legislated a thicket of rules that prevents a market from happening. By ‘facilitate,’ I mean that the government would have to slash and burn much of those rules and get out of the way.

            What you and I experience is hardly a market. There is no price transparency, no ability to shop around, no choice. There are exactly three insurance companies offering individual policies here in NH, dominated by Anthem.

            When I shop for a used car, though, that’s a market. Tons of choice. A plethora of ways to research the product and pricing that supports it.

            When I go buy groceries, same deal. In fact, let’s aliken grocery shopping to the health market. Imagine if you will… A union member going to buy a gallon of milk. His member card is processed when he checks out, and the milk costs a $1. A self-employed isn’t part of the club. When he checks out, the same milk costs $20.

            In a nut shell, that’s how the health market works. Click on the link posted by John Ballard below and watch the ABC clip. Pricing is totally random. I’d wager that the person charged $50,000 for a routine procedure in the clip is self-employed.

            You could argue in the example of the used car market, one person could negotiate a better deal than another. True. But, you would never get one person paying $15,000 for a used Tacoma with xxx miles, and another paying $75,000 for the same thing. And the reason that never happens is because of market forces.

            “Why don’t you stop paying $20,000 per year to insurance companies and bank that money for your own health care?”

            Because I am supporting my wife and two young kids. If it were just me I’d think about it.

  28. Bill says:

    It raises interesting questions. I use a payroll service that charges a very reasonable monthly rate. This initial rate stays the same for the first five employees (if I had employees), in any state in the US. The complexities of state-by-state payroll laws would appear to fall in line with the thinking of the report you cite, and yet this company is able to continue to offer their service at a low price.

    Conversely, applying this model to Amazon would surely make book and other merchandise pricing skyrocket there because of compliance costs. So, are we saying we are able as a nation to turn a blind eye to the state regulation for enjoying book reading, but that it is impossible for health insurance? Is our thinking really that limited?

    We need a paradigm shift. I don’t doubt the results of the report, but I do question the presumption that existing state rules are etched in stone.

    • John Ballard says:

      Oh I don’t think it has as much to do with regulations as the byzantine webs of contract arrangements and network configurations holding together the insurance people and the actual health care providers. I figured out a few years ago that health care billing (unlike whatever business you probably have) is not based on ordinary accounting. It’s more along the lines of “throw a bunch of sh** against the wall and see what sticks.” Unlike the Amazon inventory, healthcare isn’t something to be purchased on line and delivered by UPS. Here’s a post I put together recently about the crazy variations of health care costs.

      http://www.newshoggers.com/blog/2012/04/hcr-crazy-health-care-costs.html

      Take a look at the airlines comparison video. No need to watch it all the way through… You’ll get the idea pretty quick.

    • John Ballard says:

      I don’t think you’ll need to shop out of state to find lower health care costs. I bet you can find wide swings within a fifty mile radius. With the right PCP for advise, you and a few others might think about becoming your own health care co-op. It my be feasible to keep a concierge practice on retainer.
      http://en.wikipedia.org/wiki/Concierge_medicine

      (I’m going to bed Good night.)

  29. bob hertz says:

    Buying health insurance across state lines, at the present time, is beneficial primarily to men under age 45 in states like New York and Massachusetts.

    There is a very specific reason. Those states require individual health policies to cover pregnancy. This causes all premiums to go up. Pregnancy is the most common cause of hospitalization under age 65.

    Whereas that man can go to Idaho and buy a policy without maternity coverage. That might save him $400 a month, which is a lot.

    This is not a trivial issue, but at the same time it is not the silver bullet of health care reform that some Republicans have been implying. The insurance companies which sell cheap policies to younger men are the same ones who decline anyone with a health history………it is the core of their business model.

    • Peter1 says:

      “Whereas that man can go to Idaho and buy a policy without maternity coverage. That might save him $400 a month, which is a lot.”

      What might a policy in Idaho with pregnancy coverage cost? Surely with less risk spread it would quite expensive?

      About 75% of property taxes go to support schools. We’ve never had kids, don’t plan to as do most people over 50. I’d love to be able to opt out of paying to educate other peoples kids.

  30. bob hertz says:

    I am not sure if your last comment on education was ironic or serious, but either way you have hit on a very core issue –

    namely, what costs are the responsbility of society and what costs are the responsibility of the individual?

    Most areas of American life have pretty good clarity on this classic question.
    The public pays for the fire department with taxes, but you have to buy your own fire insurance and sprinkler systems. Taxes pay for public libraries, but if you want to own a book or get it fast you have to buy it yourself.

    Health care has much less clarity, which is partly why we have been debating it for the last thirty years.

    Pregnancy is a perfect example of our muddled-ness. Poor people on Medicaid get free childbirth, and new mothers on group insurance get childbirth with deductibles, but new mothers outside these categories have to worry about every hospital bill.

    I am on the side of those who feel that childbirth should be free for anyone.
    If we can pay $500 billion a year to keep seniors alive to age 78+, we can pay about $35 billion a year to make all 4 million annual childbirths into risk-free events.

    But instead of the clarity which I would desire, we have some states with mandates and some employers with coverage, and our usual crazy quilt of spending huge amounts of money to prove we are not socialists.

    Bob Hertz, The Health Care Crusade

  31. Peter1 says:

    “They add no value to the system.”

    Bill, doctors (self employed) add no value to the system? Hospitals add no value to the system?

    “At some point it would make sense to incorporate.”

    It usually makes sense to incorporate. Heard of an “S” corp? Millions of them, but none are what I would consider, “entrepreneurs”. They don’t create anything but for themselves – no jobs, no investment, just personal income with the protection of limited liability . Entrepreneurs usually create waves, others just ride them – as a single self employed you’re riding a wave.

    “The average person who may have all the right stuff to start a business is shut out because of initial costs, while people who already have money fill the void. And when they succeed, they just get more.”

    Age old problem. But if it were easy you’d have much more competition and the potential rewards would not be as great. Would you want the government to make it easier for you?

    “What you and I experience is hardly a market. There is no price transparency, no ability to shop around, no choice. There are exactly three insurance companies offering individual policies here in NH, dominated by Anthem.”

    You may not “experience a market” but I do. As a self pay uninsured I always attempt to get a discount and shop around with providers. It’s not easy and I agree price transparency is non-existent, but with work and a hard mental attitude it does work to a degree. If you have a high deductible plan with health savings then you need to bargain just as hard as I try. Have you ever tried to get a discount from your doctor?

    I don’t like the system and would prefer single-pay where I don’t have to negotiate price with my provider – but for now I have to.

    By the way, most retail choice and price competition is an illusion. A limited number of manufacturers dictating MSRP that inflates the price to allow “sales” discounts give the consumer a false idea that they’re in control. Auto dealers are the worst offenders. Ever wonder why Ford dealers can offer $1000s off MSRP – because MSRP is just a marketing number. And you can’t get a written quote to take from dealer to dealer – they make you sign a binding sales contract to get the “price”.

    Would you want the same system for your doctor? Would you want your doctor putting ads on TV offering sales discounts? In health care do you shop price or look for best qualified?

  32. Hope Tyberg says:

    Algo que se puede aprender de valor de cada entrada del blog y es hilo de los comentarios.

  33. 私はよく分からない理由正確な理由が、この私のために遅いサイト信じられないほど非常に極端ロードしています。 問題の問題か、ある他の誰がこのをしている問題は私の最後に? 後で後でと問題がまだ存在するかどうか私は戻ってチェックします。

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