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The toughest job in America

Today, the loneliest job in American isn’t being the Maytag repair man. And the hardest job in America isn’t necessarily the Presidency. It’s being a state governor.

Take Pennsylvania (the state I call my home). Governor Ed Rendell sought the position with an explicit goal of expanding health insurance to uninsured Pennsylvanians. After two years in the job, Rendell is facing declining tax revenues, increasing costs. Rendell is already facing a $281 million deficit in this fiscal year, which could increase to over $1 billion. A detailed analysis of this story was published by PR Newswire, "Pennsylvania’s Loss of Employer Health Coverage Outstripping National Average."

The Kaiser Commission on Medicaid and the Uninsured has been studying other state initiatives targeting covering the uninsured. The Commission has found that in California, Illinois and New Mexico, for example, have been unable to broaden health insurance access to citizens without it.

That’s because, as Diane Rowland, the Executive Director of the Commission said, "Health reform … is easier when economic times are good and more difficult to accomplish and more difficult to sustain when the economy goes down."

Jane’s Hot Points: The U.S. Census Bureau found that the level of uninsured in the U.S. actually fell by 1.5 million between 2006 and 2007. Where did most of those uninsured people find insurance? Through growth in public programs funded by public (read: taxpayer) sources: Medicaid and Medicare, and in military programs including the VA and TRICARE.

The Kaiser Commission on Medicaid and the Uninsured issued a paper on The Decline in the Uninsured in 2007: Why Did It Happen? which speaks to this statistic in great detail.

The point is that the economic growth enjoyed in 2006-7 will not occur in 2008-9, and based on what macroeconomic forecasts are saying, into 2010.

Growing unemployment and the decline in the U.S. economy will inevitably result in an increase in the number of uninsured Americans.

The Commission expects this number of uninsured Americans will be no fewer than two million in 2008, and more if unemployment exceeds 6.1%.

Will these uninsured citizens, living throughout the 50 states, find a health insurance haven through public programs? Probably not. That’s because Governor Rendell and his colleagues in the National Governors Association will have less money to spend on Medicaid and children’s health (S-CHIP) programs compared to 2006-7.

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14 replies »

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  2. Yes America is different, and the so called “low income”
    make up a larger portion of our population. More people will put themselves in this category if it means getting something for “free”, this could lead to the collapse of our health care system – like with our low income housing loans.
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  3. Deron, I’m from Canada and there it’s the doctors that make the medical decisions with their patients, not some government board. The government controls the money though because they pay for the system through taxes, so everyone operates under a strict health budget. The doctors negotiate their reimbursments and prices are controlled. There are some downsides, if you want to call it that, they don’t have an MRI on every street corner so access is controlled that way, but there is very little over utilization. There have been waiting periods for some surgeries but in an emergency there is no waiting. In Ontario the government put a lot of extra cash into cataracts and hip surgery because the wait times were getting way too long. But everyone gets care. They are under the same pressures as we are with a growing aging population. But I would say that the government there is far more responsive in dealing with problems than it is here because the health system is such a big issue for taxpayers. There has also been some privatization, but Canadians don’t want the U.S. system – except the rich, but they can fly anywhere they want anyway. Under single-pay your job does not determine if you have healthcare coverage, and there are NO pre-existing conditions or retroactive insurance cancellations. Some doctor shortages are also in rural areas as they are here. It’s not a perfect system but far better than here and less costly for the country.

  4. Peter – As always, you make some good points and good analogies. I’m just concerned about the “new reality” you mentioned. I’m having visions of a Big Brother scenario where someone is closely watching over patients, physicians, and everyone else in the system with a ruler in their hand. I’m definitely not against some additional oversight because we’ve allowed the players in the system (not just health insurers) to develop a selfish attitiude and they’ve lost any sense of a system level focus. Single-payer goes well beyond that. Is that where we’re headed? Are we going to continue screwing up everything in this country and then expect the government to step in? Social Security, Medicare, the financial system, and now the entire healthcare sysytem? Food prices are pretty high right now. Let’s let the gov’t take over the farms and grocery stores because they are gouging the poor American people. Wait, farmers ARE American people, just like physicians, patients, stock brokers, insurance company CEOs, bankers, AND POLITICIANS. Pretty soon we’ll all be working for the government. Do you want to work for the government? I don’t.
    When do American citizens learn both personal and social responsibility? If we all had more of that, we wouldn’t be talking about this right now. Maybe freedom was too good to be true…

  5. Deron, we shouldn’t let the costs to unwind the insurance industry be a hurdle to fixing the system with single-pay. The longer the present system is allowed to stand the harder it will be. Surely we haven’t let the unwind costs of gutting our manufacturing sector and shipping jobs overseas stand in our way of lower prices at Walmart. It seems appropriate that when another industry (health insurance) becomes obsolete and unable to adapt, it too should suffer the same fate. There will be employee “dislocations” and some people will have to find new careers, but there will be experienced people needed to administer the new system. But I’m not too worried about lobby firms loosing their source of income since they have never been concerned about getting politicans to make sure patients lost their income to the companies they lobby for. As to whether there should or should not be a buy-out of health companies and shareholders, I’ll leave that Treasury Secretary Paulson who is getting a lot of experience sending taxpayer money to private companies in an affort to make them whole again. The offset savings in healthcare when you look at reducing health costs to a potential of 50% is also huge. But there will be initial additional costs. We wouldn’t have to train employees or build new buildings as the present insurance system has all that, we’ll just need less of it.
    As far as single-pay working in our culture, I think once it is instituted the culture will change pretty fast to realize the new reality, just as we are having to face the new reality that an unregulated and under oversighted free market just does not work. If you’ve noticed all the present “fixes”, such as in Massachusetts involve the government. That’s because we are still fixated on thinking that an insurance model is the solution, when it is really the problem. Attempts to keep the insurance industry in profits is not going to benefit patients or providers. It will be tough medicine, but look what’s happened to our financial system because we stood by and did nothing.

  6. Peter – I appreciate the fact that you were willing to elaborate and I think a little constructive debate is a good thing.
    I might be be sold on single-payer if someone could provide proof beyond a shadow of a doubt that single-payer is the #1 reason other countries spend less on healthcare than we do. What if other countries are more socially responsible than we are? Less greedy? Healthier? I guess what I’m saying is, we have some serious societal issues needing addressed if we’re going to have an optimally functioning healthcare system. How do you stop 14 year olds from having children? How do you stop people from shooting each other? How do you stop people from eating foods that are horrible for their health? Etc. These are all areas where we fall way behind the rest of the world.
    In terms of single-payer implementation costs, I was referring to the cost to unwind the current system and move to the new system. No other country had giants like United Healthcare, Aetna, Cigna, etc. with millions of employees, shareholders, IT systems, provider contracts, etc. The cost to unwind all of that would be substantial. That must be taken into consideration before we move forward with a plan like that.
    One final thought: I think we both share the same view of our government and political system, it stinks! Do we want them administering our healthcare system? Medicare is in serious financial jeopardy, and that program pays for far less preventive care than other payers. What would Medicare for All look like?
    I apologize to everyone for all of the back and forth between Peter and I, but I think these discussions need to happen. The next step is to find common ground and develop comprehensive solutions. That’s one challenge I’m prepared to take on, and I hope some of you are as well. I haven’t figured out what the best medium for that is, other than another blog devoted solely to healthcare reform…

  7. Deron, how much it will cost who? The providers or the patients? For the country probably about half of what the present system costs us now, if other single-pay countries are any indication. How long will it take, how can I answer that? How about 5 years, is that an ok target? You can do some research on Taiwan and their health system. They looked at every other system in the world, including ours, and chose single-pay. “Simplistc” really? as if you think I expect us to wave the magic single-pay wand. You’re new to this blog so you don’t have much background to my posts and the extend to which this topic has been discussed. But as a way to reduce over utilization and force innovation in cost cutting, single-pay is the only system that will work AND cover everyone. In Japan as an example, where charges are government controlled, they cut the reimbursement for MRIs, the result was, new MRIs were developed that cost a fraction of the old ones. Those MRIs are now being exported. I wonder if our hospitals were to buy them if our MRI charges would go down? Somehow I think not in this for profit system. As for “increasing prevalence of chronic conditions”, do you think that I think that single-pay would solve that? Single-pay is NOT just getting the government to pay for everything. We need reform to all parts of the healthcare system, but at least while we work toward a reduction in chronic conditions the people who have them will get healthcare and the system will cost less. As to the complexity of the problem, I do recognize that the only real complexity is changing a failed ideology and stopping healthcare industry lobbyists from getting our political “leaders” to game the system in their favor. Have you looked at the amount of health industry lobby money spent in Washington? As I’ve said before, we’ll need to fix the politcal system before we can fix healthcare – or the many other problems this country is facing.

  8. Peter – No offense, but your approach is simplistic and it appears that you do not fully appreciate the complexity of the problem we face. There are major cost drivers, such as an increasing prevalence of chronic conditions, that you never seem to mention. Single-payer is a shallow fix that will not produce sustainable results on it’s own. In fact, it will be a distraction that will delay our addressing those more serious health issues and cost drivers. Do you have any idea how much it will cost, and how long it will take to implement single-payer?

  9. Deron, that won’t happen from inside the healthcare industry. It will come from a single-pay system imposing health budgets that force the health industry to cut costs. That will mean getting higher efficiency and less utilization, but it will also mean income cuts to providers. Waiting for the industry to make the first move while just reducing or eliminating access to people lossing their jobs is not even a path to solving this. Do you think just trying to cover present programs with increasing patient loads is increasing access?

  10. Jane – As a fellow PA resident, I see where you’re coming from. However, the struggling economy is yet another reason why we should attack the uninsured issue by addressing the high costs that lead many of them to become uninsured, as opposed to incurring greater deficits by increasing access to a struggling system.

  11. I guess we’re seeing that a national policy of low wages, lost manufacturing, large pools of poor people, widening income disparities, a culture of unhealthy lifestyles and an overall economy based on debt is catching up with us. My state of NC is also bracing for higher deficits and lower tax receipts. Here the political scapegoat so far in local and state elections is our population of illegal immigrants that Republicans have found a convenient group to attack, but forgetting that it’s their own ideology that got us here. It’s like the person who sets fire to your house from the back door, then runs around out front and yells, “FIRE, FIRE” to look like the hero.

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