POLITICS: Ghost in the Attack Machine

I’m up at Spot-on discussing the return of one of the more improbable and unlovable charcters in the last health reform debate, and her recurrence as a Ghost in the Attack Machine. As ever come back here to comment…

It’s almost full-on election season so I’m getting email from the Republican National Committee suggesting that there are problems with both the Sen. Hillary Clinton and Barrack Obama plans for health reform. Funny that – given my politics – but it gets better.

The RNC thoughtfully sent along a copy of a Wall Street Journal op-ed featuring an appearance by that blast from the health reform past, Betsy McCaughey who these days hangs her hat at the ultra-right wing Hudson Institute. In the 1990’s she was a brief star of the new right after writing, in early 1994, a magazine article in the then-quasi-liberal magazine The New Republic. Called No Exit, it contained a damning account of the Clinton Health Plan and got a fair amount of attention at the time. No Exit was a fair load of old tosh (you really keen health policy archaeologists can unearth the Clinton White House’s full rebuttal to see what I mean).

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  1. Hi!
    Anyone heard on what the Government is doing regarding privacy protection with the new push on electronic medical records? I understand that once data is collected and shared for research and data analysis to 3rd party, most Health care organization will de-identify the key data like Patient ID and name. However, even after removing these fields if there are only two people with HIV and black race in a Zip code – any data snooper can easily match data with another database and figure out the patient identity. I was wondering whether there are any new HIPAA regulations to prevent this problem? Thanks for your responses in advance. Luvai

  2. “Peter; Re non-citizen, are you Canadian or what? You say non-citizen and then “we” referring to Americans…..”
    Bev, when I say “we” I don’t mean I’m an American, but I am a member of this country subject to all of its advantages and disadvantages while I live here – who has to pay taxes AND who can’t vote. So I’m in this as a part of the collective, just not a citizen collective. I’m Canadian and my wife is an American citizen. I participate in my state and local government as well up to the point of not being able to vote. I do more “citizen” participation for this country than many citizens. I am also a citizen of this planet.
    Jeff, as I’ve posted many times universal single-pay government run with imposed health budgets is the only way this system is going to rein in costs and include us ALL in a solution. But too many people hate the prospect of sitting in the same waiting room with the guy who picks their vegetables and fruit, or who cleans their yard for starvation wages, either under the table or not. When was the last time anyone opposed to illegal immigration cared to ask (because of the deal they’re getting) to see the worker’s W2. Or how many “dedicated” tax payers who scream about illegals NOT paying taxes and sponging off the system then try to pay cash under the table to get a better deal?
    But I have also posted, as long as “we” have a government system based on prostitution principles you’ll not get much reform to work, not even the so-called “free-market” fixes talked about here. I don’t think there is enough health insurance/affordabilty/cost pain yet to get people off their ideology butts and look at real solutions. But it will come if we continue to get compounded 6%-10% increases each year that pain is unavoidable.
    This is also NOT JUST about the uninsured, citizens or illegals. I this were it would be an easy fix. There’s a whole lot of other pain out there we read about and disguss here all the time, but the status quo group likes to paint this as only an uninsured problem that’s really not a problem at all and if we could just send a few million people back to Mexico it would fix itself.

  3. Well, Brad, seeing as you use your full name and provide a link to your web site, I guess I can suggest that you click on my name, which will link you to my blog.

  4. Donald,
    No agenda with this question. Just curious, what state and city do you reside in?

  5. I’m amazed that Jeff thinks illegal immigrants and legal immigrants should be subsidized by American taxpayers and those of us who by private health insurance.
    That’s morality run amok. We don’t want immigrants, legal or otherwise, who come here to leach off our taxpayers and premium payers. Yes, immigration is an important part of our history, but that is history.
    We have to look forward. And in doing so, we have to realize that we don’t have the wide open spaces and economic opportunities begging for exploitation by immigrants that we had in the good old days. We have congested public facilities ranging from schools, hospitals and welfare departments to high ways and homeless centers.
    And, we may be facing rising unemployment, which the Fed is estimating will go to 5.1 or 5.2%. That’s still full employment, but up sharply from the 4.5% unemployment we’ve enjoyed during most of the Bush years. With unemployment rising, we have to take care of our less employable people, and you don’t do that by bringing in illegal or legal immigrants who take their jobs at below-market wages.
    Talk about morality. As Clinton says, “Let’s get real.”
    The most realistic numbers I’ve seen suggest there are 15 to 20 million illegals and their families in the country, depressing wages, underpaying taxes and flooding our overwhelmed public facilities.
    The government is vastly over counting the uninsured because the states who report on the uninsured have financial incentives to over report. And the government vastly under counts the illegals, because Bush, Obama, Clinton and other elite politicians collect campaign contributions and votes from the illegals, their employers and their relatives.
    It’s easy to be politically correct about the illegals and uninsured. It’s hard to be intellectually honest about them.i

  6. OK, Peter. So you have legitimate reasons to hate the health insurers. How do you propose fixing this problem?

  7. Peter;
    Hear, Hear to your last paragraph. Re non-citizen, are you Canadian or what? You say non-citizen and then “we” referring to Americans…..

  8. Ya, I’m one of those voluntary legal non-citizen uninsured with an income level above those stated above, and Donald and Jeff want to call me a free-rider not worth counting? Guess what guys I pay for my healthcare in more ways than just paying cash for treatment.
    I WAS insured, but BCBS behaved so badly for a minor claim it opened my eyes to what a corrupt and dishonest system is being sold to the American public that I walked and took my premiums with me – the classic free market choice. But if you don’t want to count me as one of the uninsured because it suits your argument or political position to make people think there’s nothing really wrong with what we got now, or it doesn’t really need fixing, then you’re just as dishonest as those politicians we all hate. I bet a lot more people could sacrifice much more just to pay those highwayman insurance companies, but ask the other industries in this economy if it’s OK to take money from them so healthcare can go on making us all poorer drip by drip because no one has the balls to either face the truth or tell it. The uninsured, all of them, are the canaries in the mine because they’re telling you the system stinks and is getting to toxic levels.
    The bottom line is we won’t fix this mess with an insurance model (rearranging the deck chairs) and there will have to be a lot of profit takers who will have to suffer to get to any system that gets the costs under control and gives everyone an equal shot at care. It’s gonna have to hurt, but Americans have been taught that nothing should hurt, not even wars where we can send the other family’s kid to die AND get our tax cuts as well, where we can spend nonexistent money through mortgage fraud and sell that risk to some other chump and when it all comes down, our “leaders” will just bail us out and give us free money.

  9. Matthew has misread my position on immigration. I think legal and illegal immigrants should be covered under any “universal” health insurance plan or we don’t have anything resembling universal coverage. Schwarzenegger’s plan covered illegals, so at least one politician was willing to bite that bullet.
    It is unpopular to say this right now, but whole industries depend on illegals (construction, hospitality, agriculture), and we need a credible method of giving those here illegally, as some have said, a path to citizenship. Our country was built by immigrants, and that fact that people go through hell to come here and build a life (and pay sales taxes, Social Security, etc.) suggests that we’ve still got something very special going on here in America that people all over the world want to be a part of. Stop hyperventilating on this one, Matthew, we’re in agreement.
    Remember that the Census Bureau is the source of the estimates on how many people are here illegally. Illegals do not come to the door and tell a government representative they are here illegally. The 10.2 million people counted in the 47 million are listed as “non-citizens”, and they are estimated by mathematical algorithms that were used for years to correct for underenumeration in inner cities.
    No-one, including me, knows how many are here illegally. I strongly suspect there are more than 10 million “noncitizens” who are here illegally and have no health insurance. The number 12 million is probably more accurate. They are, in fact, a big part of the problem.
    The best way to gauge the extent of this problem is to talk to community health center execs, as I did in Texas last fall, or to those who run the safety net public hospital systems. THey are being overrun. The states with the highest rates of uninsured are also our immigration gateways (Texas, California, Florida, Arizona, New York). Our fastest growing ethnic group, the hispanic/latino population, have almost a 40% uninsurance rate, and until we can penetrate through the multiple cultural and social issues that contribute to it, we’ve going to continue to have serious problems.
    Matthew is also aware that even legal immigrants are not eligible for public programs until FIVE YEARS after citizenship. This isn’t right either. We lock immigrants, legal and illegal out of health programs, and we need to change it, or we will have a gaping hole in our public health system, and our defense against pandemic flu and other emerging diseases. Whether the best way to do this is to make them all Wellpoint subscribers or to expand and strengthen the safety net was the subject of an earlier post.
    Matthew is dead wrong about my comfort with the status quo, and if he’d read my 47 Million Hostages post in Health Affairs last September, he’d know better. (How about posting a link?) There are a whole bunch of causes of the 47 million uninsured- the decline of employer based coverage, as Matthew cites, illegal immigration, free riders, racism, age discrimination, inconsistent coverage of the near poor under Medicaid/SCHIP, funding shortfalls, health insurer discrimination against people w/ pre-existing conditions, general social chaos.
    But the root cause of most of these problems is that American healthcare is too damned expensive, and increasing numbers of Americans and their governments, simply cannot afford it. Until the political candidates seriously address how to make care affordable, most of the proposed “solutions” contained in their plans aren’t going to make a damned bit of difference. Railing on about “socialized medicine”, greedy capitalists, etc. doesn’t get us anywhere close to the pragmatic solutions we need to this complex problem.

  10. Matthew or Jeff, please clarify:
    When the 10 million figure is broken out of the 47 million uninsured pool, are those 10 million typically considered “illegal,” or, like Matthew says, immigrants that are here legally, like he himself was at one point. This is an important distinction. The former, while paying taxes through whatever canard that got them on the books on the first place, are a different animal–socioeconomic, hiding in the shadows, fall through safety net more easily, etc.
    Please develop.

  11. What is really painful is to read the kind of dribble put out in the WSJ from someone at a second-rate conservative think thank who selectively chooses points that are out of context or don’t nearly do justice to their complexity/nuanced nature.
    It is a real shame that there are way too many people involved in the healthcare policy agenda who are solely driven by an ideological agenda. Even worse is that these people don’t understand/aware of even the most basic tenements of how US health care policy has been formed (e.g., like the RAND Health Insurance experiment and its impact on almost every major design facet of the current US healthcare system).

  12. Matthew, thanks for the welcome back.
    What I object to is not the health care insurance debate, but the promises the candidates are making that they can’t deliver on. And I object to the idea that Betsy, Jeff or I can’t pose serious questions about the candidates’ schemes. I call them schemes, because there are no real plans out there.
    If I trusted Obama, Clinton or Tom DeLay to buy my health insurance and make the rules under which I would buy that insurance, I might go for universal health insurance. But nowhere in the world have politicians been honest with their health insurance beneficiaries, because it’s human nature to take care of yourself before you take care of people you employ, much less those you don’t know.
    I’m for changing health insurance industry regulations radically to make the markets more honest and efficient as well as good for shareholders and patients. But I don’t think regulations that give politicians a license to buy votes is good for taxpayers or patients, and that’s what Clinton proposed in 1993 and what she and Obama are proposing today.
    That they are being so dishonest about the scope of the “problem” and about what they want to do with health care in this country proves they can’t be entrusted with power over our health insurance markets.

  13. Ok, Jeff I’ll take 80% of your speaking/consulting fees for the next year. After if I leave you 20% of them by your logic that’s the major part of them, eh? If not, then stop the BS about immigration being a big part of uninsurance, and stop connecting immigration with illegal immigration. They are different.
    The immigration figures and your stance on them are crap. Most immigrants are NOT illegal; they pay tax, have green cards or legal status etc etc. I was one of those for 10 years here. You think people like me shouldn’t have been included in a universal coverage system just because of their status. That’s inhumane BS and I object strongly — unless you want to pay me back all the taxes I paid while not a citizen. I believe you native Americaans had some issues with that in 1776….or perhaps your grandparents weren’t here yet?
    And I miss Don, thanks for coming back.
    As for Don’s issues about “the rich uninsured”, Jeff may not think I read the articles I cite, but you both seem to have missed the one in Health Affairs that showed that the uninsured with incomes over 50,000 were far from well off, and had mostly good reasons not to buy coverage http://content.healthaffairs.org/cgi/content/abstract/26/6/1745 usually because while their households may have been been modestly middle class by the stats, their actual situations were not. This is just another BS Hudson/Cato red herring.
    Both you guys are very very smart about health care, but both of you share with good old Betsy a serene contentment with the corruption of the status quo.
    I know Don always has felt that way, but I’m amazed that after a life time in health care Jeff seems to have become that way too.
    And I’m not going down that path with you…

  14. Betsy nailed Clinton in 1994, and the left obviously don’t want voters to focus on the key questions she is asking about the Obama and Clinton schemes, because the answers show their schemes are unworkable and unaffordable, not to mention dishonest.

  15. I see Matthew’s still trying to sell a pig in a poke. Hey, guy, take a look at today’s New York Times.

    There is no consensus among health economists about how many free riders there are, or on their economic impact. But of the 47 million uninsured people in the United States, 7.3 million come from families with incomes of $75,000 or more, and an additional 6.9 million earn between $50,000 and $75,000, according to 2006 census estimates.

    And then recall the LA Times story a couple of years ago that cast doubt on the 47 million uninsured figure. There is one Census report that says there are only 36 million uninsured.
    So while Jeff is correct that there are a lot of holes in the Obama and Clinton schemes, the bigger question is, Is the uninsured “problem” big enough to justify universal health insurance, i.e., socialized medicine?
    Socialized medicine, of course, is the ultimate objective of both the Obama and Clinton schemes. The candidates aren’t being honest about their promises nor their intentions.

  16. I’m neither a Republican or involved in any way in the campaign, but the McCaughey article actually raised a lot of valid problems with the Democratic proposals. If you read the Health Affairs article, 10 million of the uninsured are non-citizens, and they accounted for 20% of the increase in the uninsured from 2000-2006. (Matthew needs to actually read the articles he cites . . .). Illegals are a huge fraction of the problem in Texas, Arizona, New Mexico and California, and they have placed huge pressure on the safety net institutions in those states, just as McCaughey says.
    The biggest contribution of non-citizens to the uninsured problems came in the 1990’s when the borders collapsed, not in the period of the Health Affairs study. To repeat from an earlier blog entry, if the Democrats cannot even give illegals drivers’ licenses, they sure as hell aren’t going to give them health insurance, which means a minimum of 10 million uninsured people and no universal coverage.
    There are also a lot of reasons why the 25% of the uninsured who are eligible for public programs do not enroll besides the fact that states don’t “market” these programs very aggressively. See my “47 million Hostages” blog in Health Affairs in September for a more complete discussion.
    She’s also right about the problem of young people being forced to subsidize their elders through mandates. Uninsured 24 year olds working in service industry jobs are subsidizing Warren Buffet’s Social Security payments right out of their paychecks. If you force them to buy “community rated”, guaranteed issue health insurance, instead of coverage that actually fits their risks, you get both huge and unaffordable subsidies from the government and/or a lot of non-compliance (and justifiably angry young people). We’re already shafting the young via Social Security and Medicare. It’s good they are voting in increased numbers because young people could really get hammered by the social engineers on this one. If coverage is actually affordable, on the other hand, a lot of parents will pay the bill for them.
    Unless we try a LOT harder than either Democratic candidate has suggested so far, the coverage will not be affordable and forcing people to buy it will be opposed by Democrats, not just the hard right; the Democrats are the people who killed California’s health reform proposal for this precise reason.
    She’s also right about Massachusetts’ unwillingness to certify high deductible health plans as qualifying for their state Connector program. Massachusetts gummed the bullet on reducing the cost of coverage, and thusfar has enrolled only 16 thousand people in their non-Medicaid coverage alternative. Lots of work to do here.
    And, sadly, she’s right about electronic health records. The Rand Study savings mostly come from eliminating duplicative diagnostic testing (lab and radiology), which if you’ve spent any time in the real world, you realize is actually driven by physicians and hospitals who make extra money on the tests, not the lack of an EHR. Until the payment incentives change, you don’t get the savings Rand forecast. She’s also right that EHR’s have thusfar been unprofitable for providers, and have not produced the efficiencies they should have. The products are very expensive, fragile, difficult to use and costly both to install and maintain. And unless there are public subsidies, a lot of primary care physicians, smaller hospitals and safety net institutions will still be using paper in a decade, mandates or no.
    The bottom line: there are a lot of holes in the Democratic health reform plans, and a lot of legitimate questions re: feasibility, cost and social justice which need to be answered by whoever the lucky Democratic nominee may be. As a moderate Democrat, I’m far from sold on either of these “plans” so far.

  17. That’s right! More profits, less health care (LOL). The United States spends twice what the average industrialized country spends on health care but we’re clearly not getting value for the money. We need a healthcare system that’s about caring for people’s health, not a healthcare economy that is trying to make a failed economic policy look strong.

  18. There’s no problem in the US health care system that has not been caused or greatly exacerbated by heavy government intervention into the market. Most free market-oriented health care commentators hold this view and advocate a market-based approach to solving our problems.
    However, rather than having an honest debate – Mr. Holt has always chosen to construct a straw horse by smearing opponents (myself included) as advocates of the “status quo” and “far-right”. (Funny that the PNHP are never described as “far-left” here).