Matthew Holt

Critical of Critical

Like legions of other wonks when I discovered that Tom Daschle was going to be Obama’s point guy on health care, I sent off for a copy of his book Critical. It’s a fast and easy read, but in its examination of the problem it doesn’t add much to superior books on what’s wrong with health care (much of the first section reads like an undergrad’s attempt to summarize Jonathan Cohn’s Sick) and there are some pretty weak logic flows and basic editing throughout (he refers to the book Uninsured in America on p155 as though it’s already been introduced before it actually gets introduced on p161). But ignoring all that, what does Daschle suggest we actually do?

First, he promotes himself as a scholar of failed attempts at health reform past, and of course a witness to the most recent attempt.

The ill-fated & exclusive White House study groups of Feburary
to May 1993 are therefore only to be repeated in set of window dressing
home study groups & Internet bulletin boards—who’s participants
will have as little actual positive impact on health reform as Ira
Magaziner did in 1993–4. Still the process now is notably open.

Then there’s the rather odd parade of things Daschle likes and wants
to see more of. Mental health parity is one, dental insurance is
another, and long-term care a third. To be fair these are three areas
crying out for a better solution, but Daschle doesn’t make it clear how
we’re going to expand the current definition of insurance to include
them. In addition these are areas for which Medicaid is the current de
facto half-assed solution. Medicaid is a program Daschle likes, while
many health policy wonks (well me anyway) think it should be abolished
and rolled into a genuine universal social insurance system, or at
least (as Paul Krugman suggests) be Federalized and thus removed from
the vagaries of state budgets.

But the actual coverage solution Daschle proposes, which is pretty
similar to the ones emanating from Clinton & Baucus are basically
to expand FEHBP and give it both a Massachusetts Connector-type role
and include in it a buy-in to Medicare, and to impose a pay or play
option onto employers. Somehow he’d also expand Medicaid and S-CHIP,
and then add to all this an individual mandate with subsidies to those
who can’t afford to buy-in to FEBHP. The whole thing is tied together,
sort-of, by a Federal Health Board.

Daschle is damn lucky that he didn’t call his board Fannie Med, but
he’s also unlucky in that he links it to the success of the Federal
Reserve at a time when that “success” is looking, shall we say, shaky.
However, the main role of the Federal Health Board would be as a
cost-effectiveness review organization with teeth—in that Medicare,
Medicaid & FEHBP would all be bound to follow its guidelines. So
essentially he’s advocating the creation of a national benefits package
based in some measure on real research and EBM, and assuming that
pay-for-performance will work in getting doctors & providers to
follow along.

Critics on the loony right (and old reliable Sally Pipes is there in the WSJ yesterday)
will call this rationing. More thinking critics on both sides will call
it the slow emanation of a messy single payer system, which is
essentially what it’ll turn out to be as the private plans toss the worse risks into the pool and employers steadily get priced out of providing health benefits. Jacob Hacker’s been pretty clear about that.
Daschle, like Obama, Gruber and the rest, would be happiest with a
UK-style single payer with a trade up option, but they dismiss that as
unrealistic for the US. They also dismiss as unrealistic the moderate
Emmanuel/Wyden attempts to decouple health care insurance from
employment and create a truer “market” based on social insurance
(closer to the Dutch model).

So the problem with this always comes back to two things.

One; most of the uninsured are working poor and their employers are
the NFIB small employer crowd who are all for health reform until they
figure out that it means they have to pay for it
. Even despite the
incredibly confused rhetoric coming out of NFIB lately, my guess is
that only a puny Massachusetts type “pay” fine ($213 or so) will be
little enough to get them to willingly back a public and compulsory
plan for their employees. And of course at that point all but the
richest of the remaining 55% or so of small employers who offer
coverage will ditch it too, meaning that the public subsidy for the
working poor to get insurance will have to be much greater than Daschle
thinks. Not to mention the continuing administrative nightmare of
figuring out whether someone should be in Medicaid, the new plan, or
covered by their family member.

Second, while it may be getting harder and harder for the Sally
Pipes of the world to get people worried about rationing when it’s
clear that we already have it here but that they don’t really have it
in Switzerland, Germany or France, the Federal Health Board will be
fought tooth and nail by the industry.

As I’ve been saying for a long time, to rationally rationalize the
health care system, we need to make cardiologists in Miami behave like
cardiologists in Minnesota with a consequent impact on the incomes of
doctors, hospitals and stent & speedboat salesman in high cost
areas (Yes, Jeff, I do mean Louisiana, New York, Los Angeles and Boston
too). If the Federal Health Board has teeth, that’s what it’ll do, and
the AMA, AHA, AdvaMed, PhRMA et al know it. Which is why the PhRMA front organizations have been railing against cost-effectiveness for so long.

So my guess is that the Federal Health Board, if it gets
established, will get defanged by lobbyists immediately. The
consequence of that is that the mish-mash of an “expand what we got
now” system will cover a few more people at a lot more cost (as has
been the Massachusetts experience). That’s OK because suddenly we’re
rich (or at least suddenly the government is pretending it is!).

But in a few years the stimulus will end and health care costs will
have kept going up. Then we’ll realize that due to more cuts in
Medicaid & subsidies for the working poor, and continued cream
skimming and bad behavior by private-sector health plans, enough people
have fallen through the cracks of the incremental expansion that we’ll
be back where we are today again.

I still think that the odds of significant reform in the next
Congress are less than 50/50, although they’re well north of where they
would have been sans financial meltdown and recession. But
Daschle’s book and the picks Obama has made to run health care in the
White House suggest that modest incrementalism is all we’re going to
get. I’ve always been a believer that only a big bang reform will be
able to solve the core problems of our system (primarily the incredible
costs lumped on some of those unlucky enough to be very sick). How this
gets done without a clear social insurance system that everyone pays
into according to ability, and in which there’s no real distinction between
choice of services due to the individual’s ability to pay, I don’t know. And I’m
afraid neither does Daschle.

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51 replies »

  1. Here’s a novel thought…how about all of you read the Constitution of the United States for once. And pay special attention to the enumerated powers granted our Federal Government. Or the “list of negative libertys” as our President “complains”.
    How about we send social security and medicare to the recycle bin and do away with these plans altogether.
    Do you really think they give a rat’s a.. about the 46 million uninsured? That’s chump change to somebody like George Soros. The lawmakers could throw 46 million on the problem right now and not blink and eye. That’s a lot less zeros than 800 billion last time I did the math. They want control…and you’re to stupid to see that.
    Do you really think these lifetime politicians plan to take part in these programs themselves? Of course not; These programs are simply another way to remove your liberty and control you and your property.
    That is why our founding fathers didn’t give them the authority to do such a thing…or bail out banks, home owners, or any other of these crazy notions these progressive socialists are now proposing.
    Wake up people…what happened to “Give me liberty, or give me death”

  2. “he promotes himself as a scholar of failed attempts at health reform past”
    Not true. Senator Daschle focuses on two issues:
    1. The politics of attempts at national healthcare reform in the recent past (mostly surrounding the Clinton Administration proposal in 1993-1994)
    2. The reasons why a Federal Health Board is needed.
    He does a good job on both in my opinion. No attempt at scholarship here at all. The writing style is journalistic, far from academic, a fact that makes the book quick and easy to read, but something that does not diminish its value.

  3. In Defense of Critical
    Well, OK, so 137 (a whopping 67%) of 206 pages are devoted to history, and if the notions of a Federal Health Board and PPOs are the president-elect’s idea of “fresh thinking” great disappointment is just around the corner.
    But this is an accessible read for non-wonks that, whether one favours a UK style system, a German-style system, or a Swedish-style system, describes a “necessary thing”: an independent evaluation and policy board. Senator Daschle points out a mostly-successful analog in our own political system, saying in effect “we have de-politicized money, we can de-politicize healthcare finance.” (I am aware that an argument may be made that money is not de-politicized and agree that improvement is possible, but compared to 150 years ago and even 75 years ago we’re better off, current difficulties notwithstanding).
    On page 134ff, the senator says
    Even though the Fed has to answer to the public, it is sufficiently insulated, so that its decision-making process hardly resembles what goes on in Congress or the White House. In Congress, every decision is political. It’s impossible to formulate policy without weighing the likely reactions of special interests, the other party, influential committee chairs, and the president. The next election is always just around the corner, so it’s hard to get lawmakers to think in the long term. The Fed, in contrast, can make decisions based on data and a thorough analysis of what’s best for the country.
    So, the good senator has identified the chief problem with democracy. I wonder, then, whether he’d support repealing the 17th Amendment, incongruously made during the same Progressive Era that produced the Fed. And whether he’d support returning any real independence to the Electoral College. Probably not.
    In any case, the book’s fine for the interested non-wonk. In some ways it ought to be required reading for any voter, but then we don’t require that voters can read, do we?

  4. Wow this is too much fun to resist for one last time.
    On the 30%, Nate’s “writing” is so confused that I thought he was talking about the variance in cost between what healthy people and sick people get charged. In fact he was talking about the 30% that I refferred to as the off the top cost taken by insurers in the individual market. Nate denied this was the number pointing to a report that in Minnesotta this number was only 9% but neglecting to point out that the average MLR for that year was between 25% (yes only 1 dollar in 4 going on actual care) and well over 100% (e.g. it included plans that got their underwriting wrong and surely wouldnt be there the next year). If Nate wanted to be honest he’d look at the overall MLRs of the big insurers which have ranged between 72% and 85% or so over the last few years, i.e. between 15% & 28% “off the top” and then he’ll tell me with a straight face that their average costs of the top are lower in the individual market than that.
    Then onto Medicare in which he tells us that enrollment is both voluntary and mandatory/automatic at the same time. Nate may think I’m a liar, but at least I don’t say two contradictory things at once.
    Meanwhile it’s good to know that we can “voluntarily” choose whether or not to make Social Security & Medicare payments (that’s the bit that’s meaningfully mandatory). I’ll let the IRS know and see how far I get.
    But joshing aside, unlike the Nate’s of the world who appear to want to go on a tax strike, I dont think paying tax and supporting the community and country is unAmerican. He clearly does, so he should probably do what many conservatives have told us liberals to–love it or leave it.
    OK, that’s the last, as I actually have work to do!

  5. Seriously what does this say about government ran healthcare where they force you against your will to take the program they dictate? These individuals wish to opt out and pay for their own care and the government won’t allow it.
    How more unAmerican can a system get?
    Other parties who have attempted to opt out have gotten letters from the
    SSA saying the bureaucracy was “not going to make a determination” about
    their request. An affidavit from David A. Nelson is included with the
    filed suit. When applying for Retirement Insurance Benefits at the SSA
    in Albany, Oregon, he told the clerical staff he refused to participate
    in Medicare Part A, and he redlined all language pertaining to
    enrollment in the program on the forms he signed. He maintained his
    position in two followup phone calls with the SSA. After considerable
    subsequent red tape, he was told his enrollment in Medicare was “automatic.”
    The litigants claim they are capable of paying their own medical bills.
    They do not want to be forced to participate in the Medicare entitlement
    program. They claim services provided under the program would be
    inferior to those they would otherwise receive, and are made available
    as a function of government funding. In other words, they are
    “effectively rationed.”
    Is this what liberal reform will look like? You join the plan we tell you to or we cut off all benefits even those not related to healthcare? What’s next are they going to start arresting seniors for not participating in Medicare?
    The plaintiffs charge that the Social Security Administration (SSA) and Department of Health
    and Human Services (DHH) “improperly adopted illegal and coercive policies that deny otherwise eligible retirees their rightful Social Security benefits if those retirees choose not to enroll in Medicare.”
    With its establishment under the Social Security Amendment of 1965, Medicare was supposed to be a voluntary program, available to – not mandatory for – eligible applicants.
    They sell you reform as voluntary then without any say make it mandatory, there’s some change we can believe in.

  6. Sorry couldn’t resist…
    “It’s called Medicare. Heard of it? It’s got a total mandate. Everyone over 65 is in it.”
    Um LIAR
    Persons age 65 and older who did not pay Social Security contributions, or were not “grandfathered” into the program by attaining 65 by 1967 may apply for Medicare Part A.
    Individuals choosing to enroll in Part A must also be enrolled in Part B of Medicare which also carries a monthly premium.
    notice choosing and may apply
    In general, the Part A premium increases 10 percent for each 12-month period that enrollment, (effective coverage), is delayed past the seven-month initial enrollment period. There is no cap on this penalty; (e.g., a delay of five years will result in a penalty of 50 percent).
    Don’t you find it odd they have penalities for late enrollment in a mandatory program everyone over 65 is in.
    A bill before the U.S. House of Representatives and a lawsuit in federal district court both aim to overturn a government policy preventing payment of Social Security benefits to senior citizens who do not enroll in Medicare.
    Norm Rogers of Illinois, one of the plaintiffs in the lawsuit, said the issue of forced Medicare enrollment hit home with him.
    “It was really personal,” Rogers said. “Since I saw my parents die on Medicare, I decided I didn’t want to be a member. It’s not a good medical system. I don’t want to be in this system

  7. One question Matt then I’ll accept your apology and let it rest. This is cut and paste from you;
    “what exactly is the justification for the 30% off the top that individual insurers & the distribution channel (yes that’s the scumbag brokers like you) receive?”
    Posted by: Matthew Holt | Jan 5, 2009 10:35:38 AM
    Who can’t read and type?

  8. Maybe you should move to a more conservative state like FL where they haven’t destroyed their market like CA has. CalChoice being a perfect example of poorly designed risk pools. Personally I think 200% is low and doesn’t adequtly allow for the risk variance but it has worked for them. Better then the 450% and 1000% CA tried to hit you for, whats wrong with the people running your state?
    “After the COBRA period ends, a HIPAA-eligible person is provided one of two methods for continuing coverage, depending on the type of prior coverage that was terminated. If the prior coverage was under an employer’s insured plan, the group insurer or HMO must offer an individual conversion policy to persons who lose their eligibility for the group coverage. The group
    insurer must offer at least two conversion policy options, including the standard benefit plan that Florida law requires small group carriers to offer. The premium for a conversion policy may not exceed 200 percent of the standard risk rate, a statewide average rate computed by the Department of Insurance.”
    2 minutes with yahoo search someone with a little insurance knowledge can disprove just about everything you, maggie, and those with similar beliefs claim.

  9. Nate. I understand your role. You sell health insurance. It’s an unneccesary role.
    We miss Ron Grenier around here–he too sold bullshit underwritten HSA/HDHP policies and decided that THCB was good forum to advertise them. We were all amused for a while. Thankfully he left in the end, and his schlock will hopefully soon be out of business, as will yours. Having said that, you appear very similar in your inability to make an argument or stick to the point.
    And while we’re discussing childishness, you were the one who started calling people liars. And now you say I’m using a “30%” figure that’s BS. You obviously can’t read or type. The number is the difference insurers charge high and low risk insurees in the individual market. I gave you the URL and the table number, and you still can’t find it? It’s 300% not 30% (even you said the difference is 85%) And it’s from a study written by Mark Pauly, the right wing free market professor who actually thinks that people like you add some value to the system! He’s on your side, buddy!
    And let me point you to a system where there’s community rating, with no “personal responsibility” in your trite meaning of, you’re on your own pal.
    It’s called Medicare. Heard of it? It’s got a total mandate. Everyone over 65 is in it. Of course you need a “mandate” to run a single insurance pool and the only effective one is majorly based on the tax system. Which is how Medicare does it, as does ever other country in the world.
    Of course, you’ll be damn glad Medicare exists when you retire. That is if idiots like you and your buddies in the private cream-skimming insurance industry haven’t destroyed it by then.
    On the other hand, wiser heads than yours in the private insurance business are seeing the writing on the wall, and will probably agree to put the cream-skimmers like your and your suppliers out of business. As I said, they and you don’t add any value, you’re just rearranging costs so they fall first on the others in the insurance pool and then on the taxpayer. Eventually the long term outcome will be that the taxpayer will take over everything. And your little gravy train will be over.
    But really I don’t expect you to understand that, so I’m afraid our little fun spat is now over.

    Average Individual policy loss ratio 91%. Matt please explain how these carriers pay “30% off the top that individual insurers & the distribution channel (yes that’s the scumbag brokers like you” while at the same time returning 91% of premium in claim payments? That would be 121% on average. Is the State lieing to everyone when they publish these reports or have you just been caught once again making facts up to support your lies?

  11. Matt,
    I’m so disappointed you retreated to such childish arguments. It betrays your intentions of reform when you make such arguments. It’s interesting you would eliminate my role yet you don’t even know what it is. What’s that say about you?
    Ironically I totally agree with Deron. That is exactly what I advocate and the best solution to the problem. Never in my career have I said or thought that someone who played by the rules shouldn’t have coverage. Unlike yourself I know how to define the word insurance, waiting till your sick to buy it isn’t insurance. The problem is everyone wants to bash insurance companies yet never discuss mandates or personal responsibility. You can’t have community rating without personal responsibility.
    Please give even one example of a dishonest example…exactly
    My role, I always get a laugh out of people like you that attack my role without even knowing what it is. When employers get sick of paying insurance companies high premiums they come to me. Usually they wait till they get to the point they can’t afford to offer insurance and need to make drastic changes. If they would come earlier it would make things easier but it’s the life I have chosen. So employer comes to me with a 40% rate increase in hand they can’t afford. We review their risk and potential liability and if the numbers work out self fund part of their risk. They do this by purchasing a high deductible plan like a 5K HSA plan. Before idiots like you complian about employees having a 5K deductible that is just the plan the employer buys. The employees keep the same lower deductible benefit plan they had before. The provider bills the insurance company who applies it to the discount then we get the bill and pay the amount between the lower employee deductible and the higher deductible the employer bought. Our clients usually save 30-60% of their premium by buying the high deductible plan and spend 20-40% paying the claims. THey see a net savings of 10-40%.
    Yes Matt I am the evil bastard that helps employers cut their cost 10-40% so they can continue to offer insurance to their employees. The world would be so much better without me wouldn’t it? On the side I do sell individual policies, if someone calls asking to buy no reason not to.
    Now that we are all clear how much of an idiot you are and how weak your arguments and knowledge of healthcare anything else you would like to say about my role?
    FYI your 30% figure is BS not supported by any study or facts, caught you lieing again there buddy.
    So the rate sheet from the insurance carrier is less relaible then a peer review study of said rate sheet….that’s interesting

  12. Maggie,
    Great response– I agree with most of what you said, except the top. There are several important reforms to the practice of medicine, that physicians, as a whole have not embraced:
    — greater adherence to EBM. Physicians’ n=7 patient experience does not outweigh the evidence from well-designed studies. Medicine is an art, but it needs a lot more science. That requires doctors to do a little less creative thinking, doing a better job following directions, i.e. cookbook medicine. EBM-based medicine is not as glorious as our romantic ideals of what physicians think of ourselves. Its a significant change in practice and mindset. One that potentially allows NPs to work alongside MDs in a primary care setting.
    — transparency on process and outcomes quality metrics. Physicians should be tracked, graded and paid based on quality metrics. Unaccountable physicians paid for service and not results, needs to be a thing of the past.
    — Cuts in salary. We speak of cuts in specialists salaries today, but an EBM-based system could allow NPs to work as PCPs and potentially lower compensation in primary care as well. At a system level, the latter could lead to more than $10 billion in annual savings, the former even more.
    Perhaps you run in a circle of enlightened docs that have already agreed to those points. But as a physician, that has interacted with many over the years, I don’t know many who embrace these important reform elements.
    I’ve been a Wennberg fan for years, so didn’t mean to give the impression that I don’t appreciate his work. My point on Berwick is that he’s a little more direct in stating what tends to be more indirectly implied by Wennberg– physicians too often aren’t doing the right thing and that needs to be fixed. Waste and distorted incentives are a critical part of it, but its founded on a practice of medicine that does not place enough importance on data and studies.
    Finally– I’ll the say the same for your work– its excellent, important, and I look forward to more. You’ve taken Wennberg’s key points and made them digestable for all and raised awareness of these issues at the same time. If my prior comments read as overly critical, that wasn’t the intent. I just strongly disagree with the point that physicians are allies in health care reform. Many of the very tough issues are ones that the medical profession isn’t ready yet to admit as a whole, and will require greater awareness by the public before meaningful changes to the practice of health care can be accomplished.

  13. Deron. This ain’t no tie. Your solution is one I agree with completely. In fact I’d have one pool with one community rating system and everyone forced to buy in, mostly via taxation. That would get rid of all the problems I talk about and Nate somewhat dishonestly descibes.
    It would also get rid of Nate’s parasitic role in the system. Something I’m comfortable with, and he probably isn’t.

  14. Matthew and Nate – I’m going to rule this one a tie because I’ve witnessed scenarios similar to what both of you described. I have seen corruption on the part of both insurance companies and individuals. The conversation you are having is a great example of why reform has not made much progress. Stakeholder groups viciously protect their turf without attempting to understand the other side.
    The truth is, we cannot do away with pre-existing condition clauses without developing some sort of community rating and/or coverage mandates. Otherwise, there would be widespread abuse similar to what Nate described. If we did that, we could do away with many of the ridiculous underwriting issues that Matthew described.

  15. wisewon–
    I know a great many doctors who are anxious for the structural reforms that we need. They are calling for an end to fee-for-service payments (I hope to publish an open letter from an oncologist on this subject on HealthBeat–he also calls for guidelines for chemo).
    In my experience only very old-fashioned doctors refer to evidence-based medicine as “cookbook medicine.” Many doctors are at the forefront of calling for comparative effectiveness research.
    As for group practice vs. solo practice–solo practice is becoming economically unaffordable. MOre and more younger doctors recognize this, and would prefer to work in a very large group, on salary. The
    Dartmouth reserach also confirms that the most efficient outcomes (high quality at a lower price) come in multi-specialty centers where docs are on salary.
    I’m not sure where you got the impression that I focus mainly on drugs and medical devices. Read my book– they devote just one chapter to them. Also see the pie charts that I frequently run on healthbeat:
    healthcare providers (hospitals and doctors) account for
    the largest share of the pie. I talk about how we can cut spending and avoid “hazardous waste” in both cases.
    As I’ve explained many times, the problem is not just over-priced, sometimes unproven drugs and devices.
    The problem is “unnecessary hospitalizatoins, ineffective, sometimes unproven tests and treatments . . .” And fee-for-service payments that create a perverse incentive to over-treat.
    I’ve written at length about how there is no proof that PSA tests and treatment for early-stage prostate cancer saves lives or in any way “alter the course of the disease.” (quoting NCI)
    And I’ve written about how the fee schedule for doctors needs to be revised, paying more for cognitive medicine and less for certain expensive, marginally effective services provided by some specialists.
    Finally, it’s not a question of Berwick vs. Wennberg.
    I know both of them, and Berwick calls the WEnnberg/Fisher reserach showing that roughly $1 out of $3 healthcare dollars is wasted, and that outcomes are no bettere-and often worse–when treatment is more aggressive “the most important medical research of the century.” If you’ve read Berwick’s collection of essays, Escape Fire, you’ll see how much he talks about waste–particularly in the chapter about his wife’s illness
    HIs effort to improve hospital systems is not just about making sure that doctors do the right things–it’s also about wringing the waste out of the system.
    Much research suggests that too often doctors don’t do the things they should do (giving the aspirin to the heart attack patient) because they are so busy doing the many hi-tech things that, insome cases, don’t need to be done.
    Don Berwick calls the Wennberg/Fisher reserach showing that probably 1/3 of health care dollars are wasted–and outcomes are no better, often worse where spending is highest– “the most important healthcare research of this century.”
    Berwick appears in a documentary that Alex Gibney has just made of Money-Driven Medicine, and he is fabulous in talking about the waste in the system.

  16. Excellent. Nate all your “facts” come from your “files”. Mine naively come from peer reviewed articles in Health Affairs. But if you really think that the difference between the premiums for good risks and poor risks is less than 80% you must have somehow missed the free market guru Mark Pauly’s article — where he said that the difference was much lower than people of my “ideology” claim — he said it was a difference of only 300% (exhibit 2 if you care to look). Incidentally “from my files”, I have twice I applied to Blue Shield–having had continuous coverage (and yes I do understand HIPAA and COBRA)–first time they asked me for 450% of the “good risk rate”, the second time they wouldn’t offer it at all and pointed me to the CA MRMIB high risk pool which was about 1000% of the cost of the regular rate (and I think was full at the time). Seems pretty clear that in both cases Blue Shield wasn’t very interested in my business. Oh, and what was my my pre-existing condition? Gout, controlled by $50 a years worth of medication–unlucky I didn’t have you as a wonderful broker to make my case for me the way you must have dont to get your asthma patient insurance.
    And in the end Nate your solution, oh free market wizard, is for the individual insurance market to dump all its bad risks onto the taxpayer.
    Yes that’s where the “pregnant woman trying to buy insurance” and “breast cancer patient in every state” end up.
    So if the insurance market isn’t capable of shielding society from the risk, what exactly is the justification for the 30% off the top that individual insurers & the distribution channel (yes that’s the scumbag brokers like you) receive? In fact what is the justification for your business at all? You’re just a parasite who presumably couldn’t get a job selling CDOs at Bear Stearns. But luckily your day will come too.

  17. Matt,
    Unfortunately the issue is a little more complex then that, I would need more details to give you exact answers but generally speaking the following would assist them;
    Medicaid, which by the way test FAMILY income not household. If your renting a room from someone they don’t include your landlords income in determining your eligibility.
    Almost every state has open enrollment periods for HMOs. This is an annual event where as part of the HMOs license they must accept anyone that applies.
    Further if the asthma is controlled and the rest of her app is OK she would qualify for a regular policy, I know because I have such clients.
    Unfortunate for you breast cancer was the aliment you picked, just about every state has special Medicaid eligibility for women with breast cancer.
    States like Vermont have Vermont Health Access Plan for those over 18 that don’t qualify for Medicaid or Medicare.
    This is what is really sad, there is no shortage of options. The problem is people read crap like yours and other propagandist that have no clue of the facts and THINK they don’t have options. Instead of calling someone that can help them they give up after listening to you and thus miss out. I think it is more then fair to say you do more harm to the uninsured with your misinformation then the insurance companies do with their rules to make sure the system function.
    To make 100% certain you have no creditability about anything healthcare related and thus harm no more people do you mean in 5 years of THCB and 20 years of research not one person knew about;
    “Health Maintenance Organizations (HMOs) offer an alternative to traditional insurance. It is a system in which you receive your basic health care from specific doctors and hospitals. HMOs accept individuals during their Open Enrollment Period regardless of any pre-existing health conditions.”
    Healthy NY, which FYI specifically says only count you spouse and children in household no one else.
    Today, individuals — regardless of their age or health status — are guaranteed renewable health coverage under standard individual plans designed by the Individual Health Coverage Program Board as well as under the Basic and Essential Plans sold by carriers. This Guide provides only a summary of the New Jersey Individual Health Coverage Program
    I could do this for just about every state but I think the point is clear, THCB doesn’t know what they are talking about and the 20 years of research you know is worthless. Thanks for playing it was fun.

  18. Matt,
    Happy to answer the question for you, I just hope you have enough of a math education to grasp it. Oh, I really got a kick out of you naively wrapping this in a moral debate. It’s so charming watching people with no clue what they are talking about make such baseless claims.
    Who are the 12%, first you need to know that HIPAA is a federal law that guarantees anyone that had continues coverage with a gap less then 63 days the right to buy coverage. So this 12% are people that had gaps in coverage of a minimum of 2 months.
    The next point to keep in mind is I work in insurance every day where as you have no idea what you’re talking about. So I can look at my files and give you specific examples of who the 12% are;
    Hi Nate, I just found out I am 3 months pregnant and need to buy insurance. Why didn’t you buy it before? I was healthy and didn’t need it. OK, so what are you looking for now? I just need insurance to cover the baby then I’ll drop it after the baby is born.
    HI Nate, I need to get insurance, I use to have it at my old job but when I left to take a higher paying job they didn’t offer it and COBRA was to expensive with my 2 SUV payments and large mortgage. Doctor thinks I might have X so I need to buy something quick.
    Almost every individual policy I quote that is declined is a scenario similar to this. The person CHOSE to not have insurance until they needed it then the unfair system wouldn’t let them have it.
    It’s common sense but apparently you need me to point out the economic rationale for you;
    Insurance can’t sustain itself if you allow people to only pay premium when they have claims greater then what the premium would be. It’s a law of economics, there is no getting around it.
    Now for the moral, where as you appear to think it is immoral to deny coverage to someone trying to game the system and collect benefits they didn’t contribute to I believe it is immoral to make honest people who pay their premium in case something happens pay for the expenses of those looking for a free ride. I have my morals you have your lack thereof.
    “and the rest were offered coverage at “higher rates” in other words rates so high that they were designed to preclude acceptance,”
    What information do you have to make this claim? Why is I people with your ideology feel free to make baseless claims on subjects you have no knowledge or information on at all? I have in front of me the rate sheets for 3 carriers for a couple different metro areas. In addition to that I have clients that purchased and pay for these policies that you claim are unacceptable. What do you know or have access to that these rate sheets and the actual customers don’t? Lets see United Health HMO Option 4 individual plan, 30-34 male standard rate $107. Maximum rate if they have considerable health issues is $187.25…OMG almost $200 a month for someone that is unhealthy to buy insurance! What a cruel society we live in. That covers their drugs at 10/35/60 and has a low office visit co-pay, how do we look at ourselves in the mirror. Your right Matt those rates do preclude acceptance. Normally I wouldn’t think it polite to mock someone on a blog and make fun of them like this but there is a lesson to be learned. If in the interest of pushing your political beliefs your going to run around telling lies about subject matter you have no business discussing you deserve to be publicly mocked and made the fool.
    Get some facts before you go making crap up.

  19. Oh, and Nate if you want to find a more tainted source of information than AHIP, you’ll be looking a long time. But to take an example from the very AHIP article you sent me towards
    “Approximately 88 percent of applicants were offered coverage. Offer rates varied from a high of 95 percent for applicants under age 18 to 70 percent for applicants aged 60-64. Seventy-seven percent of offers in the survey were at standard rates; 22 percent were at higher rates, and 1 percent included a coverage exception for a specified condition.”
    So fewer than 70% were offered standard coverage, and the rest were offered coverage at “higher rates” in other words rates so high that they were designed to preclude acceptance, and 12% weren’t offered coverage at all–and we know why
    Please explain why you think that a system that excludes the 12% of people in the individual market who are sickest from obtaining health insurance coverage has any justifiable moral or economic rationale. I’d love to hear your answer.

  20. Nate. OK, I accept your offer. Take my hypothetical three roommates making 20K a year each. Assume that they’re female, one is in her 20s, another in her 30s, a third in her 40s, and that one in her 30s has asthma, and the one in her 40s a history of something a little more serious, say breast cancer and depression.
    Then explain to me how and where they would get coverage in any state (with the possible exception of MA) in the individual market, that’s affordable given their income. Because there’s 5 years worth of postings on THCB and 20 years of research showing that they can’t. But please go ahead and prove me wrong. Take as long as you like.

  21. I can’t speak to the composition of the uninsured population, but I can tell you that there would be less of them if we all resolved to take better care of ourselves and educate ourselves about health maintenance. I think we would all be surprised at what a drop in demand for services would do to the costs of our system. Of course, the drop I’m referring to is a drop as a result of a healthier, more value-conscious, population, not a drop as a result of people forgoing care for economic reasons.

  22. Nate
    You are nitpicking with your stats. 45 vs 47 million, I mean really. I often dont agree with Matthew, but not to take notice of the number of both under and uninsured is to be blind of what is going on out there. I live with these folks every day and it is tragic (50K, 60K, etc–it does not matter, they cant afford). Believe me, they dont have ipods and SUVs either.
    As far as depth of coverage, mental health is a neglected area that has finally found parity. Coverage yes, but what you cite is gaming of codes. Different animals, and that problem needs solving. Dental care. Wow, the more I learn about oral hygiene and its impact on achievement, nutrition, advancement in the workplace, etc., the more I realize that it is also vital. OOP demands will only lead to neglect and a greater vicious cycle. There is a growing and solid body of evidence in this area.
    How much a basic plan should cover? Your guess is as good as mine, but a lot of CAM is non-essential. IVF. Maybe. But mental health services, dental, preventative services, maternity care are all first tier elements. Evidence is solid, and it is also plain decent and humane…at least in the society I want to live in. I am willing to pay more for it as well in a rational system. You can and will disagree.
    The purpose of insurance is a debate, sure–and I enjoy reading the blogs to hear peoples takes. But it is weighing the upside (from a non moral hazard perspective), ie, covering “necessary” services and its lead to greater compliance vs first dollar coverage and neglect. I do have a bias as a provider for decent and poor hard working folks, and I can say most just need information, access, and yes, we both agree on this–a rational system the helps and not harms. Again, you and I will disagree on what that should look like.

  23. “But how exactly they can afford to buy insurance in the current individual market is something I’d like you to explain.”
    How long of an explanation would you like? In summary I hate selling individual policies but still do, instead of explaining how it’s done I think the simple fact that 16.5+ million people have them proves it can be done. I would suggest reading the following for truths of the individual market, it’s not nearly the nightmare you claim.
    There are not currently 47 M uninsured. According to US Census Bureau 45,657,000 are uninsured.
    CPS data on the uninsured should be interpreted with several methodological limitations in mind:
    • Research has shown that the number of uninsured reported from the CPS is probably closer to a count of those uninsured around the time of the interview (point-in-time estimate) rather than uninsured for the entire previous year, most likely because of recall problems or respondent confusion.
    • The CPS is a “snapshot” and does not measure insurance dynamics, that is, changes over time.
    • Coverage is consistently underreported, especially for Medicaid.
    “But you are neglecting the fact that over 85m people are uninsured for at least 3 months in a 2 yr period. Any one of those who has a pre-existing condition, gets in an accident or falls ill faces the consequence of having their and their families wealth wiped out.”
    You apparently have never heard of COBRA and HIPAA. No one who has had continues coverage is in any fear of having their family wealth wiped out unless the CHOOSE to not purchase insurance. Those people choose to go without insurance, most because they are healthy and don’t feel they need it. Those that are sick and at risk purchase COBRA, 2% response rate by the way, or take a HIPAA plan. No I don’t need to worry because I took the time to learn the law and my options if such a scenario where to happen. It’s nice to know all the advisements we are required by law go unread, have you never had group insurance? And if you have had group insurance why did you not read your notice of COBRA rights and thus not make such a foolish statement?
    “And I’m sure you don’t believe that they work even though most do”
    Do you often beat straw men? I believe most illegal aliens work, being the reason they snuck into the country and all it would be sorta counter productive to not work, not to mention hard to send the remittance if your not working.
    I’ll keep an eye out for any more lies and be sure to correct them for you.

  24. OK Nate, but before you start calling people liars you should be a little careful. To wit, 50% of the uninsured do NOT make 50K a year, a quick perusal of page 2 of the latest KFF study shows that 65% of the uninsured are in households earning less than $42K.
    But it’s worse than that. Lisa Dubay, John Holahan and Allison Cook showed in Health Affairs in 2006 that the vast majority of the uninsured needed would need supplemental help to purchase insurance. And of course the $42K number is HOUSEHOLD income, and of course households do NOT just include Ozzie & Harriet nuclear families. 3 roommates earning $20K each meet your definition of “voluntarily” uninsured earning $60K a year. But how exactly they can afford to buy insurance in the current individual market is something I’d like you to explain. In addition, of course those with pre-existing conditions–those who actually do need insurance, are the least able to afford it.
    Meanwhile the 47 m ish number is the CURRENTLY uninsured. You can go on all you like about the number uninsured for a year or more which is about 50% of that. (Yes we do know the numbers) But you are neglecting the fact that over 85m people are uninsured for at least 3 months in a 2 yr period. Any one of those who has a pre-existing condition, gets in an accident or falls ill faces the consequence of having their and their families wealth wiped out. Something I’m sure that you don’t have to worry about. After all I’m sure you’re not one of “those Americans without a high-school education, from 19 to 34 years old and unemployed or working occasionally (less then 600 hours per year”. And if their lives are screwed up–well it’s not your problem is it.
    And I’m sure you hate those dastardly illegal aliens, especially with you being forced to pay for their care. And I’m sure you don’t believe that they work even though most do and pay taxes, as well many are badly mistreated by their employers. Or did you miss this little NY Times story
    But luckily since you are so wealthy and so self made, you wont have to worry about the FHB rationing your care. You can just pay cash for any care you like.
    Oh, I’m sorry, did you mean you wanted the rest of us to pay for it? That’s the spending the FHB would regulate.
    But feel free to come back here and correct all the lies you find…

  25. “but Daschle doesn’t make it clear how we’re going to expand the current definition of insurance to include them.”
    What is your current definition of insurance? From reading this post and most post from those advocating reform none of you seem to know what the term means. Further you have no understanding how to efficiently use it.
    Why would you insure dental cleanings and x-rays when you know your going to have them? Are you not aware that regardless of the insurance plan, public, private, single payor, the mere act of insuring against something adds increased cost? Are you trying to design a more inefficient system and drive up cost?
    I would expect any healthcare wonk, even a self proclaimed one, to first address the explosion in mental health diagnosis codes since the last parity legislation before advocating for more. When you have a subset of providers that are allowed to create new conditions to treat at will then require employers and payors to reimburse for them your going to have rampant fraud.
    i.e. take this paragraph from a providers practice management site;
    “When payers do reimburse you for psychiatric services, careful code selection can help you to maximize your revenue. For example, say you spent 20 minutes counseling an established patient with depression. If you code that visit as a 99213 (based on time), the current Medicare-allowed amount (without geographic adjustment) would be $52.65. However, if you spent that same 20- minute visit providing psychotherapy as described by 90804, the allowed amount would be $64.97. That’s a 23-percent increase in reimbursement for the same amount of physician time. (For other psychiatry and E/M services codes, see “Reimbursement rates.”
    “Critics on the loony right (and old reliable Sally Pipes is there in the WSJ yesterday) will call this rationing”
    How is a NHS like FHB telling me what treatments I can and can not get not rationing? You can make up any claim you like but that doesn’t change the fact some government agency will stand at the top and say regardless of your ability and willingness to purchase treatment you think would be beneficial you can’t have it.
    “One; most of the uninsured are working poor”
    This is a complete lie. In the CBO survey more then half make over 50K per year. Over one half of the uninsured are re-employed and re-insured within a four month period. You apparently don’t even know what the 45-47 million number represents. At anyone time there is no where near that many uninsured. That number is of people without insurance AT SOME POINT IN TIME during a four month period. Most uninsured are temporally so, to claim most are working poor is being completely ignorant of the facts.
    “The most recent U.S. Census survey (2007) notes that 75.1 percent of households with incomes less than $25,000 have insurance, and that 91.5 percent of families with incomes of $75,000 or more are insured.”
    Most uninsured are so by choice or illegal aliens.
    “When examining the survey data in depth, it is easy to decipher how the numbers speak to the heart of the uninsured problem. The largest populations of the uninsured are those Americans without a high-school education, from 19 to 34 years old and unemployed or working occasionally (less then 600 hours per year). Therefore, people are most likely to be uninsured when they are typically the healthiest.

  26. Since I am a patient, quite far from a “wonk,” I would like to see this site come up with some simple (and charismatically presented 🙂 ) education points for the public to help turn things in the direction that Matthew suggests. Find some middle ground.

  27. It sounds like too many of you are resigned to the fact that we are at the mercy of politicians to “fix” the system. At the same time, I’ll bet many of you would agree that our government/political system is probably about as flawed as the healthcare system. How do you reconcile this? The fact that lobbyists have so much power shows just how flawed our political system is.
    We need to get the right mix of elected officials, citizens, and healthcare stakeholders together to hash this out. If we allow any one of those factions to do it on their own, it will not be successful.
    jd – Two good points: 1) Every stakeholder must endure some pain. 2) Things need to be done in the right order. I would argue that anyone that feels reform will be expensive is looking to do things in the wrong order. Throwing money at an already expensive system is counter-intuitive in my mind.
    One final point on the danger of an over-reliance on government as a solution. A significant portion of our cost issues exist because we are an increasingly unhealthy population. Americans, for the most part, do not want to be told they are part of the problem. Politicians need to be careful not to anger their consituents because they will be looking for other work in that scenario. When you put all of those pieces together, you get superficial solutions that completely avoid some very deep problems.

  28. Thanks, Matthew,. for your review of Daschle’s term paper, which I was thinking about buying. I’ve just piled on my desk a bunch of books about health care reform, including “The President’s Health Security Plan,” (Hillary Care).
    Given that insurers have invited nationalization of their markets, and employers want out, I’m assuming that while socialized medicine is a bad idea, Congress will make the biggest mistake since it created Medicaid and Medicare. As we’ve learned from M/M, once Congress blows it, the damage can’t be undone, only worsened by so-called “reformers.”
    To me, Daschle will be remembered as the nasty divider who made it impossible for Bush to be the”uniter” he promised to be. I’m assuming his former Congressional colleagues on the other side of the aisle will not forget his attacks on them and on the President. Thus, Daschle may not be the facilitator you’re all expecting.
    What remains remarkable is that the socialists want to create a complex system to ensure that some 6 million uninsured citizens who aren’t covered by other programs will receive care. You’re all willing to make health care even harder for working people to obtain and for providers to deliver just to make politiicians more powerful and yourselves feel good.
    In a few years, when your middle income and upper income parents, grandparents and grand kids can’t get needed medicines and care because Fannie Med determines they’re too old or sick to receive such care, you’ll sing another tune.

  29. I think we have to face the fact that there is not a single major part of the industry that will be an ally when it comes to major system reforms…at least, not on those reforms that will reduce their revenue in real terms. While it may be true that “many” physicians see the need for EBM or a re-alignment of payments in favor of primary care over specialist and heroic care, “many” is not enough. We need “most,” or even “a large majority.”
    It may be hard to believe for those outside the health insurance industry, but there are also “many” insurance company officers and directors who see the need for many of the major system reforms we’ve been talking about, including EBM and a realignment in favor of primary care. That still doesn’t mean you get AHIP on board for the removal of for-profit companies from the insurance industry, or a national Medicare-for-all plan, or an injunction to not raise their rates for the next 3 years.
    Every part of the industry will have its oxen to gore. Now that the time for reform is again ripe, people need to think hard about the order in which you do it and how one reform can set the stage for the next, rather than undermine it or undermine the entire process of reform. I really don’t see very many people thinking strategically in these terms, in a political sense.

  30. Good post! I totally agree on where Daschle has missed it. Indeed, his “agenda” for healthcare is as lacking as his knowledge and experience in the industry, which is reflected in this book that was no doubt written by a couple of policy interns two years out of college.
    One thing that they’re (and many people) are missing is the comparison b/t the US and UK systems. Actually, the UK is undergoing an effort right now that will look to adopt a more private-based, market-driven solution to their outdated socialized model. Their NHS has realized that the current system is inadequate for providing quality and efficient care in a competitive marketplace, which is what they’re trying to adopt for their healthcare system. Lord Darzi has been the platform for this initiative and Tony Blair was critical to its establishment. Unfortunately, since their GP’s are unionized, it has faced a lot of opposition with Gordan Brown’s administration. Nevertheless, I find it interesting that as the new US regime aims to socialize American healthcare after many European models, the UK is looking to adopt a market-driven system that increases efficiency, innovation and competitiveness. After working in their system for some time, I have seen that they are actually light years ahead of the US when it comes to the NHS’ strategic direction for UK healthcare. Unfortunately, they’ve faced significant political challenges, which we’re also facing, but in totally different ways. So, if you want to know how Daschle’s (and Obama’s) “plan” will pan out years from now, just look to the UK’s efforts to rapidly shed and change their outdated model.
    See my update on the top concerns for healthcare in 2009:

  31. There are many things that must be addressed in reform but the introduction of a Federal Health Board is a bad idea. Reform needs to address issues such as cost sharing, overcrowded system, inefficient health care practices and the high cost.
    We do not need to introduce another layer of federal red tape. Government many times gets in the way of true reform and I feel the Federal Health Board, if enacted, would do just that.
    I have a blog at that will chronicle my views on health care reform from the perspective of a citizen whose family has several health issues.
    Cost, access to the best medical care available and insurance coverage should be the highest priorities of any reform. A Federal Health Board would develop into another uncontrollable government program and not truly provide any reform except another step toward socialized medicine.

  32. Maggie,
    I’m pretty surprised to read your response back to jd– who I think is mostly spot on.
    The basic message is not “more care is not necessarily better care” as that’s too narrow. Wennberg is part of the equation, but Berwick has the more comprehensive diagnosis– physicians are only doing the right thing 50% of the time. That’s not an acceptable rate, and that’s where the education is needed. The lack of accountability in the medical profession, coupled with the high degree of autonomy– that’s precisely what needs reform. Physicians are not “allies” of these reforms– they deride EBM as “cookbook medicine,” frown on comparisons based on outcomes data and any threat to their financial livelihood is met with dire threats about the health care system overall. I think you’re confusing the desires of many physician to see universal coverage become a reality– which is true– with a desire to see real reforms that will drive cost and quality improvements that are sustainable in the long-run. I’ve noted previously that you’ve too frequently focused your cost reduction efforts on cutting down profits of drug and medical device companies, this seems to be the other side of the coin– you’re underestimating the degree of change required from the medical profession itself. These are not changes that physicians will agree to willingly. Significant public pressure will be needed.

  33. Matthew,
    Very good posting, and I agree with most of your conclusions about the Daschle book. Two points, from someone close to the “action” here in Washington, DC.
    First, the economic crisis is one of the reasons the Obama Administration will push health reform. As the President-Elect said last week before he went on vacation, the problems with health care are closely associated with the economic crisis – implying the solution to health care will help with the economic crisis.
    Moreover, it is the first year or two of a new Administration when they have to push for reform if they are serious. And judging by all the Clintonites who have been hired, some of whom are filling key health reform posts and will studiously avoid the mistakes of 1993-1994, they are full speed ahead with putting together a package for Congress in 2009. See the November 17 posting on our blog,, for further discussion of why the planets are in alignment for something to happen. I am not saying it will be your cherished single payer system. Rather it will be a combination of the latest “fad” reforms including an insurance mandate, Medicare buy-in, FEHBP-like health insurance exchange, premium subsidies, Medicaid expansion, etc., etc. The Federal Health Board and all manner of other theoretical improvements will also be added (whether or not they have been shown to work).
    Will this prove to be the right solution, and cure all the ills of the system? Who knows. It is hard to imagine, however, a grand scheme at the federal government level that will have all the right answers. I mean, that was what Medicare was supposed to be in 1965 and look at where we are now?
    Second, the education campaign referred to by JD is already underway, albeit for very different reasons. Rather than educate consumers about their health system and health choices, it is attempting to lay the political foundation for reform legislation. By framing the issue through their “outreach” efforts they hope to control the debate. As Daschle himself was quoted in yesterday’s Washington post:
    “Daschle said lawmakers will be more likely to take up health reform if there is enough pressure from voters…he urged [Obama] to quickly capitalize on the good will that comes with a new administration. He said the [town meetings currently being held around the country] will add to the sense of urgency.
    “It will lead to members of Congress taking note. It will lead to governors taking note,” Daschle said in an interview. “It’s going to lead to a greater degree of commitment on the part of elected people.”
    (more at The Washington Post,
    Stay tuned, it will get very interesting in February.

  34. jd-
    I definitely agree that the public needs education.
    The basic message: “More care is not necessarily better care; it may even be hazardous to your health.”
    But I do not agree that “the Obama administration will have to consciously set out to undermine the public’s faith that their providers are acting in their best interest, or even that most providers interests are very closely aligned with patient interests.”
    First of all, we do not want to t undermine trust between patient and doctor. Without trust, you don’t have a profession, simply an industry.
    Moreover, driving a wedge between doctors and patients on the issue of health reform is a terrible idea.. Many doctors are the allies of progressive reform; and they understand the problem of waste in the system as well as you or I do.
    As for cutting doctors’ fees: many doctors rexognize that we need to cut fees for less effective specialty services while raising fees for cognitive services (talking ot and listening to the patient, co-ordinating care, trying to involve the patient in chronic disease management.) Oncologists, for instance, are intersted in getting out of hte business of being highly paid to administer drugs, adn would prefer to be paid to counsel patients (laying out the pros and cons of further treatment).

  35. Thanks to those who sent private notes.
    > no chance that the public and many finger-to-the-wind
    > politicians will support reforms that require …
    > lower revenues in real terms for providers
    I’ve only begun studying the HC system this year, but this one strikes me as both a massive reality and a big challenge: by the time we get our costs under control, we’ll be spending a lot less money (duh?), and a whole lot of people are going to have to find work elsewhere.
    It’s not as bad as it might look, though, because a fair amount of the spending will go back into care for the millions of people who today are getting absolutely screwed by lack of care, going into bankruptcy, dying, and so on.
    I’m no Matthew when it comes to wonkishness but it’d be horribly inhumane if we asserted this mess is unsolvable.
    I myself have never been denied care but over the years I’ve experienced all the other economic injustices and stupidities of today’s system. It’s insane and sometimes terrifying. If you yourself haven’t, please go find one of the horror story people and talk to them.

  36. Well, heck. I hadn’t got through the book yet, hadn’t even gotten to the unveiling of Fannie Med (love that), but I’d already wondered “So what’s to keep the lobbyists from doing again what they did before?”
    What do you think it’s going to take? A really massive uprising of some sort? Some game-changing set of rule changes? Is that unlikely or even impossible?

  37. A few more thoughts after reading this very good post and discussion:
    We will know that the Obama team is serious about reforms to the health care system (and not just about incrementally expanding access to care) when they start a campaign to educate the American public about perverse incentives, how higher spending doesn’t result in better outcomes (Wennberg et al) and the other background insights on the causes of our current problem that those of us reading this blog take for granted but the general public has NO IDEA about.
    Because without a sustained education campaign there is no chance that the public and many finger-to-the-wind politicians will support reforms that require large changes in the way medicine is practiced, lower revenues in real terms for providers, and ultimately amount to a change in mindset in healthcare from entrepreneurialism to public service. Providers are the most trusted part of our current system, and so their cries that they are being forced to undergo unfair hardship, pull back on needed care and services to the needy, etc., will all be given the benefit of the doubt unless that basic trust is undermined.
    And so the Obama administration will have to consciously set out to undermine the public’s faith that their providers are acting in their best interest, or even that most providers interests are very closely aligned with patient interests. Once the public believes that their doctor or hospital is no more their friend than their insurer or government agency, then we have a chance at deep reforms. I think Matt is right here and Maggie is wrong: reforms that threaten to cut provider revenues will be eviscerated until and unless the general public has a quite different view of where the problems lie in healthcare.
    As things stand, we won’t get to that point for several years, as healthcare’s share of GDP expands from 16% to 20%, companies drop coverage and organize more effectively to lobby for cost control reforms, and more of the insured middle class directly feels the pain of high costs in the form of more cost-sharing.
    I have long argued that the surest way to accelerate public awareness of the poor value we get from our healthcare spending is to enact universal healthcare with modest reforms now. “Modest” means the most delivery system reform that providers, insurers and pharma will accept without tanking universal healthcare. At best, these lobbies will allow reforms that make universal healthcare revenue neutral, and probably not even that. But we should take such a deal to start, because with the additional taxes, paid mostly by those with incomes in the top 30%, and with the new premiums that the uninsured will be forced to pay, there will be a shock that will make more of the public look for answers to high costs. Also, conservatives will be less likely to defend the system and more likely to see it as wasteful now that government subsidies are more strongly associated with it. And liberals will no longer need to obsess about universal healthcare and can focus on making the system more affordable, and the fact of universal coverage will lessen the anger at insurers that leads to scapegoating and allow more focus on the causes of 80% or more of our poor bang for the buck that lie with the providers and suppliers of care.
    That’s not to say that we shouldn’t try to reform, say, the Medicare payment system now. It is to say that we shouldn’t tie the fate of a universal healthcare bill to it, and that when it comes time to expend limited political capital the smarter move is to spend it on getting universal healthcare first. Once that is in place, the game changes and it will be easier, not harder, to reform Medicare’s payment system and make other changes such as reducing volume-based payments and mandating evidence-based medicine.

  38. Thanks for comments all (and I wont ask what you lot are all doing indoors on a beautiful crisp winter day in the Sierras….oh, you’re not all here?)
    I will pick up on David’s point. I think that the only reason we’re at a 50/50 chance of major health reform is because of the crisis. I seriously believe that Obama wasnt too concerned about health care in the primaries–at least not for his first term–because it would cost too much and be too big fight. Instead the sudden financial crash and the recession it’s causing on main street are now making things bad enough that spending $200bn a year extra on health care seems doable in the context of spending $1 trillion to forstall a repeat of the 1930s.

  39. All good comments after a good post. Let me just add that neither Daschle’s book, nor the CBO reports, nor most of the discussions about health care reform now brewing and stewing in DC have taken place within the context of what we now understand is the most severe economic downturn in almost a century. I can’t help but believe that the reality of 10% unemployment, the demise of the auto industry, the retreat of credit broadly, and the true suffering of the public will have real impact on what the Obama White House and Congress will agree to do to change the way health care is paid for and delivered in this country. But I would suggest that we need to start factoring in the state of the economy to our prognostications. Even the CBO hasn’t done that yet! Kind regards, DCK

  40. tcoyote, I agree that the Clinton failure was partly attributable to its supposed experts, of whom most were academics and relatively few actually had practitioner experience. And of course the politics of that effort were a top-down mess. You are also correct that the ranks of the Obama team are going to be mostly eager-beaver (ideological) Dems. But that is why I’m hopeful that the hands at the helm will be more sober, experienced and strategic, like Orszag.
    I stand by my statement that the most fundamental changes we need are fairly well-known and understood: e.g., establish some level of universal coverage; payment reforms that move away from FFS to reimbursements tied to results; retool the national HC infrastructure, particularly leading to analytics/EBM/comparative pricing & performance transparency; promote meaningful consumerism. Many of us – you and me included – have long experience grappling with the structural underpinnings of the crisis, and I’d bet that, on this and related wonk communities, we could obtain remarkable consensus on the broad brush strokes of what any meaningful effort must focus on.
    That said, you are correct that knowing what changes are essential and figuring out how to start and where to spend limited political capital is highly complex, far more difficult than merely having good ideas about how to fix the system, and the real challenge of the reform process. However, the local HC meetings ask for recommendations on the changes that should be made, and not how to translate them into policy. The calculus of getting good policy made would have to figured out no matter what recommendations were on the table.

  41. Matthew–
    Great food for thought.
    The idea that we should find it comforting
    if we envison a Federal Health Board as a
    sort of medical Federal Reserve has struck me,
    from the outset, as crazy..
    Alan Greenspan’s tenure as Fed
    chairman demonstrates that the Fed
    chairman is appointed at the pleasure
    of the president, and
    serves his political interests.
    Paul Volcker was an exception.
    It would be better to compare the Federal
    Health Baord MedPac. Appointed by the Comptroller General, they members of MedPac are well-informed, intelligent and generally apolitical. (When you read their reports it is hard to believe that it is a government body–it’s only the writing style that gives them away.)
    But I don’t see how to truly insulate a Federal Health Board from Congress adn lobbyists unless it has separate funding. (Here I come back to the dedicated VAT tax proposed by Emanuel as the sole funding for healthcare. It is Not Regressive because what the poor and middle-class get in return (free healthcare) is worth more than what they would pay in taxes. If Healthcare is funded by something like a VAT–that grows, automatically with the economy– the Board would not have to go back to Congress every year for appropriations. That’s the key–not being dependent on Congress, or the heatlh care industry–for money.
    I think that the Health Board’s evidence-based research could have teeth if Medicare used it to Raise Co-Pays and lower fees for less effective or marginally effective treatments.
    And, truth to tell, that is rationing–just a different form of ratinoing than we are practicing today. Today, we ration care according to abilitiy to pay. Tomorrow, we hope to ration care according to how effective a product or service is–using financial disincentives to steer doctors and patients away from less effective care.
    I wouldn’t use the “R” word when trying to sell reform, but I think reformers should be honest about this when talking to each other. We’re talking about saying No. We’re talking about less care, fewer treatments. What we have to explain to the public is that we are not saying No to something they need– we are trimming in areas where risks outweigh the potential benefits.
    Jeff– I agree that Medicare is “the heart of the matter”– which is why I see reforming Medicare first as an excellent demonstration project for national health reform.
    Medicare can do many things that the most recent CBO report calls for: insist on a discount from drug-makers; assume that diagnostic imaging equipment is used 75 percent of the time –as the evidence shows–(instead of 50 percent of the time), and lowering fees accordingly; beginning to track which hospitals and doctors are “outliers” in terms of efficiency (more treatments, outcomes not better, probably worse), informing them, and utlimately, if they cannot change, paying them lower fees.
    Medicare can also use evidence-based reserach and
    guidelines from the NCI and the Preventive Servcies Task Force to raise co-pays and lower fees for less effective services–or services not recommended for patients fitting a certain profile. (Mammograms for average-risk women under 50 and over 70; PSA tests, etc.)
    There is a pretty fair consensus on what Medicare needs to do among the doctors and public health experts on The Century Foundation’s Working Group on Medicare reform, and generally, we’re just following recommendations aleady made by MedPac.
    A great many people know what needs to be done. The problem is having the political will to do it. But I think Medicare’s economic crisis will create the political will–especially when the alternative is for Medicare to slash phsician’s fees, across the baord, by 20% in Januayr of 2010.
    Matthew– I agree that it’s unlikely that the Obama adminsitation will try to accomplish universal coverage next year.
    But I think they will expand Medicaid and SCHIP, cancle some or all of the windfall bonus for Medicare Advantage insurers, and back many of the Medicare reforms listed above, including insisting on discounts from drug-makers. There are also many people who agree with you that Medicaid should be folded in Medicare, or , at the very least, made a federal program. (I totally agree.)
    If they did all of that, I would hardly call it
    “incremental reform.” I would see it as paving the way for universal health reform.
    See the newest, long CBO report and its 117 optoins for increasing revenues and/or cutting costs, virtually all of which would also lift quality.
    As I wrote on HealthBeat today, I agree with Bob
    Laszewski that it will take more than one piece of legislation to make this work. It will be a process.
    But I believe that Orszag et. al. will do it thoughtfullly, and that Daschle will be, as Brian suggests, the facilitator in Congress.

  42. Brian, the Clinton team was “all wonks all the time” and look how far they got. The Obama team is going to be innundated in wonks, most of whom are Democrats, and really want to “help”. Crowd control is already a major issue. In fact,
    thoughtful well intentioned lay people with good political radar and judgment are precisely what are needed right now, not input from the “wonkery”. Agree on the Potempkin Village theatricals. Not an improvement over Hillary’s staged town meetings. . .
    I really wonder about your statement “the changes critical to making healthcare better are hardly a mystery”. The system is so vast and there are so many things wrong with it that the question of where Obama/Daschle should start and where they spend their limited political capital is actually highly complex. As Daschle correctly observed in his book, It has been political judgment and the inability to manage the “industry” pushback where past efforts have broken down.

  43. “The health economists who staff it won’t be able to find enough “evidence” to justify what are going to be, at their base, still political decisions.”
    Nice post and comments. I would disagree that these are “political” decisions. What makes them even more contentious is that they are “values” questions (I would concede that the distinction between values and politics decisions, may be semantics, but I think people are much less willing to compromise with regard to “values” as opposed to “politics”).
    For example, just setting the value of a human life is difficult. Lets be hypthetically generous and say 10 million. Who would be willing to pull the plug on the incubator for the deformed but photogenic infant at 10.2 million? Or less emotion laden, but a real money question: Who should get statins? If it costs 10 billion a year to extend the average life by a week, is it worth it? A month? A year? Add a concept like YPLL (year of potential life loss)and decide – save the baby or 100 seventy-nine year olds?
    Medical care will always be contentious because there arn’t too many people willing to say, “I ain’t worth that much, I’ll die.” The vast majority of medical interventions are of dubious value. To the extent that there have been any improvements in public health, they have been due to better water quality, decreases in smoking, and vaccines. Yet if your doctor says its a good idea to get a nuclear magnetic scan, are you really goint to say, “I can do without?” And if somebody else says, your doctor is wrong, you don’t need that, are you going to go along with it?
    I would be happy with a medical reform that gives us France’s system, but I never see contentiousness about medical coverage abating.

  44. Genuinely excellent analysis, Matthew.
    I wholeheartedly agree with your critique of Daschle’s book. It’s the fuzzy work of a thoughtful and well-intentioned lay person, rather than the targeted analysis of a wonk. Accordingly, its recommendations tend to be ideological, idealistic and conventional, rather than fresh and pragmatic.
    To me, offering up Daschle the politician in the form of Daschle as health care expert is reflected perfectly in the health care reform parties being held around the country, showing just how earnestly the Obama team – and most visibly Daschle – want to be seen to care about what regular people think about how health care change should work. Of course, to those of us who have spent much of our careers focused on the problems of national health care reform, the changes critical to making health care better are hardly a mystery. This should be especially true for someone like Daschle, who in the last several years has laid claim to being an authority on the subject. So the window-dressing of health care reform parties rings hollow as pure political theater.
    That said, leveraging Daschle’s political resources in the cause of HC reform may make good sense. He is well intentioned and committed to change, and oriented in approximately the right direction. Most important, he can potentially leverage his accumulated Congressional cachet to bring home the votes that are the keys to meaningful change, especially against the backdrop of very powerful, entrenched industry lobbying efforts. The big bet is whether Daschle is strong enough to successfully spearhead real change in this environment.
    I’m hoping that the real strategic planning octane behind the Obama health care effort will be folks like Peter Orszag, who have consistently shown a deep understanding of the cost, transparency, mis-aligned incentives and technology-as-answer-to-all-our-prayers problems, and who, as his recent CBO reports detailed, recognize that major structural changes will be required to actually impact the system.
    In other words, I’m hoping that the Obama HC effort will be an amalgam of the experiences, perspectives and skills of the various players assembled to make it happen, rather than the personal weaknesses of specific players designated to be its most visible facilitators.

  45. Thoughtful posting, Matthew.
    The problem with focusing on the uninsured is that the biggest societal risk remains Medicare, and the Democrats, because they still “own” the program, have a lot of trouble talking candidly about how to reform it. Since most private insurers shadow price against Medicare payment rates and coverage, how Medicare structures the benefit and devises a less inflationary and more thoughtful payment strategy for a program which is going to shortly begin acquiring 76 million new customers is, as Graham Greene would have said, the heart of the matter.
    What scares me about Daschle is the excessive faith in a technocratic solution to the Medicare benefits and payment conundrum. The health economists who staff it won’t be able to find enough “evidence” to justify what are going to be, at their base, still political decisions. Fannie Med, as you cleverly put it, is a deux ex machina solution to what will remain a fundamentally political problem- how to separate the strong from the weak claims on Medicare spending, and how to avoid overpaying for solutions that provide negligible societal benefit.
    Having said all this, I’m more optimistic than you that Obama will commit the political capital to a comprehensive solution and not simply kick the can down the road.

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