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The New Landscape of the Health Reform Debate

Bill KramerIn the recent publicity about President Obama’s budget and health reform initiative, an important issue 
has not received enough attention.  Most reporters, analysts, editorial writers and bloggers have focused on the proposed $634 billion reserve fund, the aim for universal coverage, the reduction in Medicare Advantage payments, the tax on families with incomes over $250,000, and other key features.   In the view of many Republicans and others opposed to this approach, the proposal looks like just another version of a “tax and spend” strategy to fix our health care system.  There is something different, however, and the health reform battle is moving into new terrain.

In the past, advocates of health reform focused on need to provide access to care for the uninsured.  This was (and is) a moral issue – “How can the richest nation on earth let millions of people go without access to decent health care?”  To provide universal access, however, required a lot more government spending.  This set up a conflict, because every reform proposal had a big price tag, and few politicians were willing to support a program that dramatically enlarged the federal deficit.   Many advocates believed that expanding coverage was worth it, but it faced very difficult obstacles due to concerns about the rising government debt load.

In the current debate, many people have been repeating the mantra that “we must expand access and contain costs”, but this often seems to be simply a convenient way to broaden the goals and make it look like they are being more fiscally responsible.  The Obama administration is taking a different path, however, and it is changing the debate in a fundamental way.  The President has stated that rising health care costs are the most important problem for future federal deficits. Peter Orszag, the OMB Director, makes a convincing case that we face an unsustainable trend in government spending for Medicare and Medicaid in the absence of health reform.   As a December 2008 CBO report stated:

"The rising costs of health care and health insurance pose a serious threat to the future fiscal condition of the United States. Under current policies, CBO projects that federal spending on Medicare and Medicaid will increase from about 4 percent of gross domestic product (GDP) in 2009 to nearly 6 percent in 2019 and 12 percent by 2050."

This means that health reform – if done right – won’t make the deficit problem worse; in fact, we need health reform in order to tame the long-term deficit.  This has transformed the debate about health reform.  It’s not just a desirable social policy; it’s a necessary tool for fiscal discipline.  Traditionally, “entitlement reform” has meant cutting benefits or shrinking eligibility for Medicare and Medicaid in order to hold down costs.   The new approach, however, looks at expanding health coverage as a key element of reducing the deficits. 

Is this really a new approach, or is it simply clever re-framing or wishful thinking?  There are three key elements that make it worthy of serious consideration.  -    First, the OMB and CBO are taking a long-term view of the federal deficit.  While expansion of coverage and investment in electronic health records and research will cost more in the short-run, comprehensive reform has the potential to “bend the cost curve” over ten years, thus putting the federal budget on a more sustainable course.  -    Second, the President’s recent budget proposal includes specific revenue sources, e.g., the tax on families with incomes over $250,000, which offset the increased expenses.  In the budget proposal, the net cost of the health reform reserve fund is zero.  -    Third, and perhaps most importantly, there is a much broader view of what is needed to contain health care costs.  Instead of relying on politically unpopular cost reductions such as moving Medicare eligibility to age 68 or slashing payments to physicians, the plan recognizes that system changes can drive lower costs.  For example, giving employees of small businesses a choice of health plans through an insurance exchange would introduce healthy competition, which should spur insurers to improve efficiency.  Similarly, prohibiting the use of medical screening to deny coverage would also create incentives for insurers to find more appropriate ways to reduce costs.

As the health reform debate heats up during the next few months, there will be some who attack health reform as “too expensive”.  In the past, this might have been sufficient to stop any plan to expand access to care.  The landscape has changed, however, and the battle will now be fought on different grounds. Politically, the new approach allows fiscal conservatives to line up with social liberals to support health reform.  Quietly but powerfully, this change has improved the prospects for health reform.

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  1. It would be very interesting to see a list of health insurance increases by companies around the county for the coming year.
    Debate by opponents has focused on the costs for a government plan and have ignored the cost increases for private insurance for the next 10 years. People should be reminded they pay, through taxes, the health costs for federal, state and local governmental workers; teachers, cops, firemen etc. The costs are high and will add more agony to budget makers. Even with the increases more will loose coverage.

  2. One of the major problems with the health care system is that the Health insurance companies are mostly for profit organisations. I’m from Australia and here most of the health insurance companies are membership based not for profit organisations who spend all their contributions to payhealth benefits to members after they maintain their reserves and business related costs.Such companies could compete with the existing for profit companies and eventually establish themselves as the best value for consumers and give doctors the discretion to decide the best health care for their patients.

  3. Thanks to all of you who commented on my original post. In the spirit of the one who said, “Keep the conversation going”, I’d like to respond to some of the comments.
    Rick Lippman said that we need to get basic coverage for every U.S. citizen immediately. I agree – health reform doesn’t mean much if millions of people are left out. He also lists many key elements of system change and sustainability, including strengthening primary care and improving chronic disease management. To his list, I would add provider payment reform – this is a key important lever to get the needed improvements in the way health care is delivered.
    John Ballard makes a great point about unnecessary procedures and medicines as drivers of health inflation. The expanded use of evidence-based best practices — supported by provider payment reform — would help to reduce unnecessary services. And there may be ways to redesign insurance benefits so that patients are more sensitive to the costs of optional services. The key is for everyone to recognize that more does not necessarily mean better. We’re accustomed to thinking that way for most consumer goods, but we’ve gone way past the point of diminishing returns in many areas of health care. A good example (there are many): unnecessary surgery for chronic back pain is widespread – it often doesn’t relieve the pain, it costs too much, and it exposes patients to risks of infection and complications. If we redesign the system correctly, we can dampen the current cost trends and improve quality.
    “MD as Hell” speaks for many of us in his frustration with the current system. (I recently attended a large health reform summit, which opened with a video clip from “Network” – the famous “I’m mad as hell, and I’m not going to take it any more” segment.) He’s also pessimistic of the potential benefit of reform proposals such as chronic disease management, prevention, and public health measures. “Peter” offered a pithy response, so I won’t repeat his points. Personally, I think it’s OK to be skeptical, but I do believe that some of these reform elements could make things better. We shouldn’t naively rush to embrace the latest fad, but some of these ideas have been piloted and shown positive results. I hope we don’t let our understandable frustration get in the way of pursuing pragmatic approaches to improving our broken health care system.
    In a similar vein, “e-doc” is pessimistic about promises of cost containment, and he notes that Doug Elmendorf (CBO Director) testified that the chances of seeing cost savings is unlikely 10 years post reformation. I attended Doug Elmendorf’s presentation to the Senate Finance Committee on Feb. 25, but I heard something a little different. One of his main points was that much of health care spending contributes little to health, but it is “difficult” [not impossible] to get savings. He also stated that many experts agree on ways to get savings, e.g., reforming provider payments by moving away from traditional fee-for-service, but that many recommended steps will not generate savings within 10 years, for a variety of reasons. Bottom line: I agree that we should be skeptical about claims of cost containment, but it shouldn’t hold us back from pushing ahead with reforms that make sense. There is waste in the system, and we should do everything we can to reduce it. We should also be careful about unintended consequences, but I don’t think that means we should be immobilized and accept the current broken health care system – we can do better.
    “Healthcare Guru” expresses frustration at the idea of putting more money into an already expensive and wasteful health care system. I agree 100%, but there’s a timing issue. It will cost more in the short-run to provide coverage to everyone, but it will take many years for the savings from cost containment initiatives to kick in. That’s why it’s essential to look at this over a 10-year period; this is the approach taken by the President’s budget and the proposed Congressional budget resolutions. “Botetourt” makes some of these same points in her/his response to the “Guru”. On this same subject, “Rbar” also makes some excellent suggestions about use of guidelines and reducing inappropriate practice variation.
    I have to take exception with the criticisms that Nate makes. First, he doesn’t believe that insurance exchanges would help to lower costs for small businesses and individuals, based on the experiences of the Massachusetts Connector and California Choice. The Connector has been in existence only a few years, and it would be unfair to expect it to immediately bend the cost curve in Massachusetts, which is dominated by expensive academic medical centers and a few large health plans. California Choice (which is a broker-sponsored exchange, by the way, not a government program) suffers from being a voluntary program, which makes it vulnerable to adverse selection. These cases do not demonstrate that a well-designed exchange would not help to bring down costs. Second, Nate states that the “vast majority of the uninsured choose to not take insurance”. I don’t know where he gets his information; this is simply untrue. The vast majority of the uninsured are not able to afford it. Maybe some people consider that to be “voluntary”, but most of these people are forced to make a painful choice between spending on food, housing, clothing and health insurance. The market won’t fix this problem; government support is required. Finally, Nate seems to think that Medicare and Medicaid are the source of the financial crisis and that they should be eliminated. He neglects that fact that removing them would throw millions of poor and elderly people into a private health insurance system that they can’t afford. Do we really want to go back to a time when we didn’t have any public support at all for the poor and elderly?
    Dr. Jeff Luther states that a “key element of national health care reform must be universal access to a primary care medical home for all our patients”. I agree 100%, although I think additional reforms (especially provider payment reform) are needed to achieve all that we want. Dr. Luther is among a growing number of leaders in primary care who deserve our support.
    A number of commentators debated whether a single payer plan would work. I won’t dive into all the pros and cons here, but I think it’s prudent to be skeptical of claims that any one approach (single payer or market-based) will fix everything.
    Finally, I agree with most of what “Kaiserdoc” says about the importance of primary care and team-based medicine – and not just because I used to work for Kaiser Permanente. George Halvorson’s books – “Strong Medicine”, “Epidemic of Care”, and – most recently – “Health Care Reform Now!” are right on the mark regarding the problems with our current system and possible solutions.
    Thanks again for all of your comments; it’s through this kind of engagement and dialogue that we can move toward solutions that work for all of us.

  4. Primary care needs to step up and reform from within. We need to actualize several well-established principles that have coalesced from throughout the world regarding primary care, and TAKE ACTION rather than continue to talk: 1) A large percentage of day-to-day minor medical problems (“the sniffles”, musculoskeletal complaints) do not need MD input to assist the patient; in the U.K. and Sweden, RNs and other trained health coaches do the bulk of this work, shifting it away from the MDs. We need to do that here in the U.S. This means, that when someone calls for an appt with the MD for either of the above issues, we set up a system in each office to have that handled by RNs, MAs, and physical therapists, NOT an appt with the MD. This will take some public and staff reeducation, but is very doable. 2) We need to stop overdoing “preventative care” — we have an “Epidemic of care” (George Halvorson’s book), and we need to educate folks about guidelines, timelines, when screening is necessary and so forth. No need for annual physicals any longer, no need for annual screening cholesterol but rather every 3-5 years, and so forth. 3) We need to handle how we do hospital and ER follow-up differently, with more phone work and less knee-jerk office visit follow-ups as half are not needed. 4) We need to designate time for proactive outreach to those who need care, via email and phone, with many team members involved and not just the MD.
    Some ideas to start us down the road. Problem? The financing. Only a few organizations can do this (Kaiser, VA, county health depts) that are not fee-for-service. We need to return to a capitation system, removing the bad parts that happened in the 80’s/90’s, with addl payment for quality performance, and NOT pay by the office visit.

  5. What’s most fearful is how much our current system costs individuals and hurts economic security. The US is fatter than any other nation because people don’t have relationships with general doctors, rather they use the expensive specialty care system to ameliorate symptoms.
    The foundation of any reform needs to emphasize prevention and primary care and convey the benefit of doing so, both in terms of cost savings and productivity. The ‘culture’ of medicine will change only if, like in the financial markets, incentives are aligned properly.
    Will healthcare finances be the next expose` on cable news shows like we have seen regarding AIG, Wall Street and Bernie Madoff?

  6. Peter if Private HC is so bad why is Obama trying to force them to pick up the tab to treat wounded soliders? Obama has hit bottom as a president trying to make american soliders, injured protecting this nation, pay for their own care or make their private insurance pay for it. If single payor and public plans are so efficient why are they always shifting cost to private insurance? The only way private HC collapses is if the morally bankrupt disgrace of a president we have now dumps all of the public responsibilities on them to drive them out of business. America can’t afford for private insurance to disappear becuase public insurance can’t pay it’s bills now.

  7. We just need to wait until private run healthcare collapses, then pay pennies on the dollar to shareholders, or even better, wait until the companies disappear into bankruptcy. The system is not sustainable, and that will work in favor of single-pay.

  8. “Maybe the same entity now trying to save the financial asses of shareholders of these companies:”
    Ok, well I hope you’re ok with that “entity” spending another few hundred billion. That’s what your beloved single-payer option will require.

  9. Our country needs healthcare coverage for everyone, now, not later. By taxes paid in by everyone.
    This is the only fair way that EVERYONE can receive medical services, reducing the overall cost with inherent efficiencies, while raising the quality of service, and with everyone paying their fair share. Employers should not be involved in an individual’s private medical information in any way.

  10. “Opt for single payer which can be simply implemeted and will require NO NEW MONEY!”
    Every single payor type plan in the US has double digit fraud and abuse rates. Without question moving to a single payor would substantially increase claims cost as they have no utilization or spending control. Any perceived savings from simplified administration is spent 2 to 3 times over on waste and fraud.
    The biggest failure in US Healthcare is Medicare and that is your proposed solution.

  11. Harriet – Single payer will most definitely require new money. Who’s going to buy out the shareholders of United Healthcare, Aetna, etc. They aren’t just going to go away. If you have a 401k, you probably own shares via a mutual fund. I’m not going to donate my retirement plan money to Uncle Sam, knowing that he’s going to tax the hell out of me later. Buying out the shareholders of these corporations will cost in the $100s of billions alone. That doesn’t even take into account the transition costs.
    The transition to single payer will cost a lot of money and take a lot of time. We’re going to need a more compelling argument for that solution than we’ve gotten to date.

  12. If the Blue Dog Dems want a cost-neutral plan, and everyone want a fiscally reponsible plan, and the complicated mandate plans in MA and San Francisco aren’t working to the benefit of small business, if the MA plan can’t control costs, if the private insurers don’t want to “compete” with the public option–what’s a reformer to do?
    Here’s the solution–Opt for single payer which can be simply implemeted and will require NO NEW MONEY!
    Once again, we need to ask CBO to “score” HR 676–the single payer bill. See the text at http://www.thomas.loc.gov

  13. I agree that “we need health reform in order to tame the long-term deficit.” Pursuing health care reform during this economic downturn is essential as more people lose their jobs and cannot afford, or even find, insurance. A key element of national health care reform must be universal access to a primary care medical home for all our patients.
    President Obama signaled his support for putting primary care at the center of health care reform by inviting the President of the American Academy of Family Physicians, Ted Epperly, MD, to the Health Care Reform Summit held at the White House last Thursday. The national presidents of other primary care medical groups were invited as well.
    It was heartening to hear the President of the United States say we must address the primary care physician shortage as part of health care reform. As we all know, numerous studies show that evidence-based primary and preventive care and ongoing chronic illness care improve patients’ health and save the health care system money.
    What are we waiting for?
    Jeffrey Luther , MD
    President, California Academy of Family Physicians
    http://www.familydocs.org/blogs/fp-forum

  14. So, massively increasing federal spending is going to reduce the federal deficit. Of course that can only happen with an even more massive increase in federal revenue. Raising taxes on the over 250 crowd alone will not pay for it. Confiscating all the healthcare premiums now paid by everyone will not pay for it. The feds will have to require all persons not now covered to buy into the system. These are the very same people who are not covered now. They will be forced (taxed) into the system. Presumable they either cannot afford to buy healthcare or they have chosen to self insure. So if the revenue is growing faster than the expenditures, then the deficit will be smaller. Of course there is the Social Security Trust fund problem, too. We can fill that back up with the extra funds left over from healthcare. Did I hear that the payroll tax will now apply to a person’s entire income, removing the present cap? The self-employed are really going to love the next midterm and presidential elections.
    Please define “healthcare”. Will it include dental care? Chiropractic care? Accupuncture? Lasik? Lap bands? Nursing homes? Home health? Physical therapy? Orthodontics? Oral surgery? Botox? Camp physicals? DOT physicals? College physicals? Birth control pills? Abortions? Infertility? Clinical psychology? School nursing? Occupaational medicine? Worker’s comp? Disability determination? Vehicular trauma? Detox? STD screening? Grief counseling? Marriage counseling? Financial counseling? Oops. We will all need financial counseling. At least all the money will be in one place. That way there can be no waste, fraud or abuse. Just put in a lockbox.
    The public should emember the golden rule… the man with the gold makes the rules. I should think each of us should guard the gold. We might need it to help us keep and bear arms.

  15. How does reality get so thoroughly removed from this debate?
    “For example, giving employees of small businesses a choice of health plans through an insurance exchange would introduce healthy competition, which should spur insurers to improve efficiency.”
    Lets look at two cases of this actually being done;
    1st up we have MA, home of the most expensive insurance in the world. An unsustainable system only a couple years away from complete collapse.
    2nd up we have CalChoice, also one of the most expensive places for small employers to buy insurance and a complete failure at controlling cost or controlling the rise in uninsured.
    NOTHING legislated by politicians has lowered cost, it is their endless regualtion that has made it unaffordable yet reformist hold up models of failure as the way to go, completly ignoring their failures.
    “How can the richest nation on earth let millions of people go without access to decent health care?”
    Honest answer it doesn’t. The vast majority of the uninsured CHOOSE to not take insurance. WHich if worded correctly shows the true intent of reformers, “How can the richest nation on earth not force millions of people to buy insurance”
    “This means that health reform – if done right – won’t make the deficit problem worse; in fact, we need health reform in order to tame the long-term deficit.”
    SMOKE & MIRRORS! Medicare & Medicaid are the financial crisis. Remove them and private insurance is sustainable in all but a handful of liberal states. Between cost sifting from public to private plans and excessive regualtion private insurance is becomming unaffordable, remove those and problem solved and with it most of your uninsured issues.
    Look at Ted Kennedys comment in 1975 after passage of his HMO Act of 1973 and see how much of a complete failure government intervention has always been.

  16. WHO’S LOOKING AT THE COMPENSATION OF THE HEALTHCARE INSURANCE EXECUTIVES?
    The health insurance companies have played a major role in our current healthcare crisis. They make huge profits and their CEOs make millions, while the rest of us are denied care.
    ANNUAL COMPENSATION OF HEALTH INSURANCE COMPANY EXECUTIVES (2006 and 2007 figures):
    • Ronald A. Williams, Chair/ CEO, Aetna Inc., $23,045,834
    • H. Edward Hanway, Chair/ CEO, Cigna Corp, $30.16 million
    • David B. Snow, Jr, Chair/ CEO, Medco Health, $21.76 million
    • Michael B. MCallister, CEO, Humana Inc, $20.06 million
    • Stephen J. Hemsley, CEO, UnitedHealth Group, $13,164,529
    • Angela F. Braly, President/ CEO, Wellpoint, $9,094,771
    • Dale B. Wolf, CEO, Coventry Health Care, $20.86 million
    • Jay M. Gellert, President/ CEO, Health Net, $16.65 million
    • William C. Van Faasen, Chairman, Blue Cross Blue Shield of Massachusetts, $3 million plus $16.4 million in retirement benefits
    • Charlie Baker, President/ CEO, Harvard Pilgrim Health Care, $1.5 million
    • James Roosevelt, Jr., CEO, Tufts Associated Health Plans, $1.3 million
    • Cleve L. Killingsworth, President/CEO Blue Cross Blue Shield of Massachusetts, $3.6 million
    • Raymond McCaskey, CEO, Health Care Service Corp (Blue Cross Blue Shield), $10.3 million
    • Daniel P. McCartney, CEO, Healthcare Services Group, Inc, $ 1,061,513
    • Daniel Loepp, CEO, Blue Cross Blue Shield of Michigan, $1,657,555
    • Todd S. Farha, CEO, WellCare Health Plans, $5,270,825
    • Michael F. Neidorff, CEO, Centene Corp, $8,750,751
    • Daniel Loepp, CEO, Blue Cross Blue Shield of Michigan, $1,657,555
    • Todd S. Farha, CEO, WellCare Health Plans, $5,270,825
    • Michael F. Neidorff, CEO, Centene Corp, $8,750,751
    This executive compensation could be used to provide quality healthcare for millions of Americans! THE HEALTH INSURANCE INDUSTRY MUST BE TIGHTLY REGULATED. In fact, there is a better solution: HR 676, The United States National Health Insurance Act, would ensure that every American, regardless of income, employment status, or race, has access to quality, affordable health care services.
    The United States National Health Insurance Act, H.R. 676. You can read about it here: http://www.healthcare-now.org/hr-676/
    If you want to learn more, go to:
    http://www.insurancecompanyrules.org/learn_more/the_roster/

  17. Health care guru has the right mantra. There is enough money in the system.
    Reduce diagnostic and therapeutic overkill by guideline use and more reliance on physician judgment (requires tort reform).
    Start a discussion about end of life care and practice variation and reform medicare in a year or 2.
    Start negotiating with Pharama companies to bring prices close to other industrialized nations (I agree that a lot of pressure would be needed yp get this through congress).
    Let me tell you an extreme, but typical story out of daily practice. One of my colleagues ordered a CT Angiogram of the head and neck in a 88 yo demented lady. Not only were her symptoms extremly nonspecific (occ. dizziness, confusion), but even if you identify disease, there is no specific treatment other than ASA, except for invasive procedures that are not indicated in this age group (and of either debatable value or investigational nature even in younger patients). This kind of nonsense has to stop. I very rarely see any responsibility for health care ressources (neither in docs nor in patients), and the current liability system fuels the fire.

  18. To the Guru: You are correct–there probably is enough money in the system now. The trick is the politics of money redistribution–how do you do it, over what time period, and who decides who should be disenfranchised? If it was a board game, it would be easy, and maybe a lot of different but effective solutions–kind of like world peace…that is why so many would say that the healthcare “pain” threshold is still far away from what would be required to move the mountains necessary for true reform.

  19. MD as Hell,
    Primary Care – Take it up with the RUC
    Home Care – Maybe expensive, but where would you like to live in your last years?
    Chronic Disease Managment – “Go home and just die”, is that your presciption?
    Prevention – If we can’t change habits we can at least tax bad ones.
    Public Health – I didn’t know infectious diseases were contained to the illegal population.
    Ethical and Compassionate Rationing – as opposed to rationing by price?
    “If our young people were smart, they would cut the boomers off.” – What and have a generation that’s more spoiled and shallow than boomers exist on their own?
    “The frenzy for universal healthcare coverage is a bubble that needs to pop. It is not that good a concept. Don’t break the bank buying it.”
    Universal under the present for money system will break the bank, just talk to Massachusetts. But don’t we have universal now? You said our ERs are providing comparable care with the added bonus of panicked docs ordering every test/procedure possible because all the patients were showing up with their lawyers in tow.
    I think it’s time you found a new vocation – one that gives you pleasure and peace.

  20. The landscape is changing but we are still far off. I need someone to explain to me that in a business that is overly expensive, wasteful, etc etc…..why do we need to put additional money to fix.
    There is so much money in the healthcare industry to ensure all americans, and still save some money. The key is smart managment and policy changes.
    It is silly to support the idea of more money. PURE WASTE
    rgds
    ravi
    blogs.biproinc.com/healthcare
    http://www.biproinc.com

  21. Tidbits:
    Since we’re quoting the CBO, let’s not forget that its director, Doug Elmendorf, testified before the Senate Finance Committee that the chances of seeing cost savings is unlikely 10 years post-reformation.
    I’m always amused to see predictions of health care costs in 2050.
    Presidents Clinton never dreamed that their reformation efforts would culminate into 48 million uninsured 15+ years later. The morale of the story– health care reform in any (re)form or (re)fashion is not immune to the Laws of Unintended Consequences. As H.L. Mencken said: “There is always a well-known solution to every human problem— neat, plausible, and wrong.”
    Breaking news from a famous periodical;
    ‘At hearings held by the Senate Labor and Public Welfare Committee last month, Committee Chairman Ralph Yarborough described the U.S. health-care system as a “shambles.” Edward Kennedy called it “the fastest-growing failing business in the nation.” A.F.L.-C.I.O. President George Meany urged recognition of health care as “a basic human right.
    All agreed that such a right would be guaranteed by a bill developed by the late Walter Reuther’s “Committee of 100” assorted public figures. The bill was introduced by Senator Kennedy last August and is a sweeping reorganization of the country’s health system. Essentially an expanded Social Security program, it would create a national health insurance system for all Americans. To meet an estimated price of $57 billion in its first year of operation —less than the nation’s current medical bill—the plan would derive 40% of its funds from federal revenues, 35% from an employer’s payroll tax and 25% from individual income taxes. The plan would not cut per capita health costs (now $270 a year), but it would greatly increase health coverage. Supporters claim that if the plan had been in operation last year, it would have paid 70% of all personal health expenditures, compared with 30% under existing insurance plans.’
    TIME Magazine
    Monday, October 12, 1970

  22. Primary care: Gutted by 25 years of maneaged care and disrespecting. Nothing is beter than a doctor who has cared for you since birth, but that is not the model of primary care for the future. That will be a computer and a nurse practitioner.
    Home care: an inefficient expensive indulgence. Wildly abused and highly profitable for the agencies. You don’t really believe they are nonprofits, do you?
    Chronic disease management: Make the patient do right? Are you going to track all the hypertensive patients for compliance in controlling their blood pressure?
    Prevention: Pie in the sky. It is a concept that will exert evolutionary pressures on the species, however.
    Public health: The great scourges are tamed, except the politically protected infectious diseases from illegals and immune-suppressed.
    Ethical and compassionate rationing… This one is good; should be entertaining to see the politicians do this. Fat chance.
    I can just hear the State of the Union message from some future president: “We are addicted to healthcare.”
    One hundred years from now we will all be dead. The bill for our “healthcare” will remain unpaid.
    If our young people were smart, they would cut the boomers off. Live while you are alive. The world has no shortage of human life. What makes ours so special?
    The frenzy for universal healthcare coverage is a bubble that needs to pop. It is not that good a concept. Don’t break the bank buying it.
    There, I feel better. Good post.

  23. Dr Robert Carl Parisien says: the newest argument for reform is that its needed for fiscal and competitive reasons. I have to admit I agree with this. The health care system in the US has become an immense drag on the economy and our competitiveness.

  24. “…health reform – if done right – won’t make the deficit problem worse; in fact, we need health reform in order to tame the long-term deficit. This has transformed the debate about health reform. It’s not just a desirable social policy; it’s a necessary tool for fiscal discipline.”
    Absolutely.
    A big part of the challenge is that Americans fall into two large groups: those who don’t pay and those who imagine they do. A third, very tiny group realizes that the true cost of their health care is a helluva lot more than out of pocket expenses, thanks to company, union, government or other sources that pick up the main tab. As for the true costs, most people haven’t a clue. John Sinibaldi’s lament last week hit the nail on the head. He gets it.
    https://thehealthcareblog.com/the_health_care_blog/2009/03/a-brokers-lament-we-brought-this-on-ourselves.html#more
    As a layman whose Medicare eligibility just arrived I wouldn’t mind waiting another two or three years, but in order that that to happen the “private sector” would have to furnish realistic and portable alternatives. Anyone who reaches this age without a “preexisting condition” is an unusually fit specimen. And it is not realistic to imagine employers will support swelling numbers of employees into their aging years. Thanks to a promising new generation job security becomes shaky at fifty-plus. I had three employers in forty years, but have had five more during the last five. Portability and affordability are not optional.
    When I first began looking at this discussion I had a poisoned attitude about insurance. Shareholder profits, sales bonuses and hefty executive compensations all come from one source: premiums. And those who pay those premiums imagine they are paying for health care. Little thought is given to administrative overlays, kickbacks and/or discounts between companies and providers, etc.
    But healthcare inflation seems to be more the result of unnecessary procedures and medicines driven by a sales-driven Yankee impulse to profitable enterprises. Americans are consuming health care with the same energy that drives them to shopping malls or all-you-can-eat buffets. I may not need yet another pair of shoes, or that ice-cream topping, but hey, it’s here in my face, so why not?
    Keep the conversation going.

  25. Bill Kramer,
    You are absolutely correct about the landscape change
    We STILL have a moral issue but we have a financial sustainability issue also which if not addressed will sink us all.
    In that regard-
    We need to get some basic coverage to every US citizen immediately.
    For long term systemic changes and sustainability we need more
    – primary care
    – home care
    – chronic disease mgt
    – prevention
    – public health
    – ethical and compassionate rationing especially at the end of life
    (HIT IS JUST A TOOL FOR ABOVE)
    As far as the “health care industry” there will be clear winners and clear losers.
    But the real winners wil be all the citizens of our nation
    Dr. Rick Lippin
    Southampton, Pa

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