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Health Care Reform: Ideology, Self-Interest and Rhetoric

Thirty years ago, one of us asked the retiring CEO of one of the largest drug companies what was the worst mistake he had made as CEO.  Without hesitating he said, “Opposing Medicare.  We were so ideologically hostile to a big new government program that we lost sight of our own self-interest. All the major drug companies except Syntex opposed it.  Luckily we lost.  We have made billions of dollars because of Medicare.”

The White House “summit” on health care reform was a nice start but as the as the reform debate unfolds, public and congressional opinion and the positions of the powerful interests involved – pharmaceuticals, insurers, device manufacturers, physicians, large and small employers, and technology companies – will be swayed by their ideology, perceptions of self-interest and the rhetoric used in the debate.

At one level, there is a broad consensus in America that we need to reform healthcare to expand coverage, improve quality, and make healthcare affordable.  Public opinion polls show broad agreement and large majorities in favor of fundamental change.  Even among specific stakeholder groups, from employers to hospitals and doctors, there seems to be widespread agreement that healthcare needs to change. But, the combination of a deep ideological divide, self-interests that are mutually exclusive, and rhetoric that is capable of turning public opinion against change may end up creating an environment of inaction.

The ideological debate is about the roles of government and the market. Most Conservatives, Republicans and business leaders strongly oppose new government programs (especially if they involve substantial tax increases) and believe the market is the solution.  Many believe the individual insurance market, tax incentives (read targeted tax cuts), higher out-of-pocket costs (“skin in the game”) and competition can fix the system.  Most Liberals and Independents believe that only government can ensure that the healthy majority pays most of the cost of caring for the unhealthy minority and that markets cannot do this.  The left hates for-profit health care.  The right hates big government programs and mandates.  A poll by Harris Interactive and the Harvard School of Public Health shows  that two thirds of Republicans think we have the best healthcare system in the world but only one-third of Democrats do.

And what about self-interest?  Doctors and hospitals don’t want Medicare cuts or big, powerful insurers.  Pharmaceutical companies don’t want the government to negotiate their prices or to allow drug importation.  Doctors, hospitals and medical device companies would all benefit from a big expansion of coverage – if the prices are right.  Small employers hate mandates to provide health coverage to their workers. Unions hate mandates that individuals have to purchase health insurance.  Large employers hate  paying excess health insurance premiums because of the “under-payment” to providers by government programs. And so on. Policy is usually made by the sum of the self-interests, weighted by the political clout of each interest: who has the power and what do they want?
Each powerful stakeholder in healthcare has a “line in the sand” issue that they will not give on. The problem is that in a $2 trillion healthcare system there are many powerful stakeholders, there are very clear “lines in the sand”, and many of these self-interests are in conflict or are mutually exclusive.

One of the lessons from the demise of the Clintons’ proposals in 1994 is that rhetoric matters.  If people think reform means expanded coverage, better cost-containment, more value for money and increased personal security in the future, they support it.  If they believe reform means higher taxes, higher out-of-pocket costs, less choice, reduced quality, fewer jobs and rationing, they oppose it. Words and slogans have been misused and abused in health care policy for many years.  Most health maintenance organizations (HMOs) focused on cost containment, not maintaining health.  Managed care firms, it appeared, “didn’t manage and didn’t care.”  “Personal responsibility” and “empowerment” really meant “patients pay more.”  “Consumer-driven health care” was driven by insurers, employers and consultants and never by consumers.  A “preferred provider” was anybody with a white coat, a stethoscope and a pulse.  Almost any program to expand coverage was attacked as “socialized medicine” even when
the insurance and the care would be provided by the private sector.

Policies that would constrain costs were either “rationing” or would reduce “quality” or “choice.
Ideology, self-interest, and rhetoric will shape the health reform debate. A sneak preview of this process was embedded in the recent stimulus package.  $1.1 billion was added for comparative effectiveness research. Many policy wonks agree that we need better information on what works and what doesn’t in health care, but disagree on the details of what to study and how to use the information. Insurers and employers want a strong agency to study cost-effectiveness so they don’t have to pay for very expensivecare of marginal benefit. Their opponents call this rationing and were insistent that comparative effectiveness  research should not lead to any reduction in reimbursement.. Talk radio was full of assertions of “socialized medicine” and charges of “English style rationing” being sneaked in to an omnibus bill in the dead of night.
There is one other important lessons from history.  Speed is vital and a prolonged debate causes support for health reform proposals to decline as critics tear them apart.  And this debate will be about politics, not just policy.  If a major bill passes, it will increase the popularity of the president and help the Democrats in the next election.  If it goes down in flames, like the Clintons’ bill in 1994, Democrats are likely to lose many seats in 2010. If President Obama believes that the debate about health care can be conducted civilly without much partisan rancor, he is surely wrong.

The polls show that health reform is a very divisive issue with the pubic, and this polarization is even stronger in Congress.  The debate will get very nasty.  Let the battle begin.

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55 replies »

  1. The status quot in the health care industry is imperative to the congressional members who depend on the large campaign contributions from this segment. The status quot is imperative to the health care industry because sweeping reform would mean billions in lost revenues. Neither group gives a damn what the citizens of this country really want. We hear these politicians say over and over that the people don’t want this reform ,the people don’t want a public option, the people don’t want competition in this market. Why not ask the people what they really want. Put it on the national ballot this fall and let us vote on this measure. I would be willing to stake my life on the fact that the majority of the citizens want to see this change. And while we are at it, let’s let the citizens vote whether or not we want to see term limitations on congress? I believe that both congress and the health care industry would be afraid to see the results. How about it? Let the people have their say!!

  2. The American health care “system” is a national disgrace an an international embarrassment. The Limbaugh, Hannity & Fox News induced nonsense that the world is frothing at the mouth to come to America for health care is simply not true. America has long ago decided that capitalism and health care are not mutually exclusive. No where else in the civilized world do they hold this opinion.
    There is enough blame to go around. Borderline criminal organizations that now front as hospitals, insurance companies that should have had their right to be in business yanked long ago, and doctors that have allowed both to control their practices.
    If the American system is so good, then why do we rank way down the list next to third world countries in infant mortality, cost per patient, life expectancy, and a host of other statistics.

  3. “If this was the case why has it never worked for Medicare?”
    Because Medicare operates within an overall broken system of healthcare where costs are just passed along -hence your contention of “cost shifting”.

  4. “2. Make all hospitals truly non-profit and community owned. That way they have a stake in meeting the needs of the community not their own ivory tower expectations.”
    Peter I hope you get your wish and enjoy a life of quiality care at King Drew or any similar fine facilities.
    1. They are already regualted the hell out of. Your just ranting so I’ll leave the many factual errors on this one alone. Darn those insurance companies for ordering so many test!
    3. or it leads to waiting list months long until funding opens up to pay for the service you need. Or to drastic cuts in reimbursment per service which doesn’t do anything to stop the unneeded services. Between the 2 items I mention and yours 2 are true and happening today, want to guess which one is a pipe dream?
    9. Why would you tax at two points to pay for one state plan? THis is one part of progressive taxation I never understood, NY is famous for it. If you want state managed plans then tax solely at the state level. Beyound that a large portion of your society, those that don’t pay taxes, are going to get 100% free coverage. Why would they not utilize the heck out of it, no matter how much they spend it never comes out of their pocket. no skin in the game has already proven to be a problem.
    1,3,8,9,10 all look exaclty like Medicare, the most expensive and inefficient plan in the country. Do you not see any potential problems in modeling yur solution after the biggest failure in Healthcare?

  5. Mohammad SHAIKHJI,
    Why are you not on Medicare? THe resaon they most likely denied your COBRA coverage was your Medicare eligibility. Eligibility under another healthplan eliminates your COBRA rights. If for some reason you are not entitled to Medicare then you need to explain to them why and do so in writing within 60 days of receiving your COBRA notice.

  6. LOL Peter,
    “Everyone in healthcare would have to operate under that budget and hence have to find ways to cut costs, not raise charges, as those would be set(negotiated).”
    If this was the case why has it never worked for Medicare? If you have a magic wand that makes all these failed dreams come to relaity pass it around. Just becuase you want something to work a certain way you can’t ignore 40 years of history proving it doesn’t.

  7. Dear Sir,
    I am 71 years old and was laid off last Oct 008.
    Medicaid did not approve my application as I am on unemployment allowance. My previous health insurer refused to give me Cobra(which I am eligible under Economy Stimulus Package)saying that because of your age you are not eligible for Cobra cover, go for Medicaid..
    Where should I go?
    To Whom I complain?
    Will you please guide.
    Sincerely.
    Mohammad Shaikhji

  8. Deron, with government paying the health bills (taxes) it would put the government in charge of setting expenditures – like corporations control their expenditures. Everyone in healthcare would have to operate under that budget and hence have to find ways to cut costs, not raise charges, as those would be set(negotiated). This will not work if we adopt a two tier health care industry – one for the “rich”, one for the rest. There would be no room for “chartered” healthcare here. The rich could set up their own offshore “concierge” clinics/care centers but that would not matter since they have already paid their tax contribution to healthcare here – more beds for the rest of us. Hospitals and physician practices would save paperwork, staff, time and expense getting paid from one source – the government, with one set of rules and a payment system that pays promptly for all their services to all their patients. There would be no need to cut charges to those who can’t afford treatment or charge them less.

  9. I agree 100% with 2,4,5, and 6. I also agree with 8 and 10, but I think we need both together and cannot have one without the other.
    I see definite advantages with #7. I think we just need to make sure we don’t add administrative costs by converting a lot of large group contracts to individual contracts.
    I agree with a lot of what you say in #1 because I deal with them on a daily basis representing my docs from both the provider and employer perspectives. However, I wholeheartedly disagree that they are the root of all problems. Patients, physicians, hospitals, and the government have played parts in the mess as well. I’m not against getting rid of insurance companies, I am just extremely uneasy with the government running the show. I guess that means I’m looking for a compromise such as forcing a change in business model of the insurers, through regulation and public competition (as long as the public plan is not allowed to run deficits made up by taxes).
    Regarding #9, I’d rather see individuals pay premiums with government subsidies based on income.
    #3 I don’t know enough about universal budgets yet, but I’m trying to find info on how they are developed. A budget is only as good as the developer(s) and the data used to develop it. I think we all need clarity and consensus on that.
    I appreciate your elaboration on your ideas. We agree on more points than you realize. My Olbermann comment was not meant as an attack. It was just a reaction to some of your responses to my points (ex. personal responsiblility = keep the wealth) Guys like Keith-O on the left and Bill-O on the right tend to take shots like that.

  10. Deron, an interesting comment following my response to Nate (“I’ll resist the urge to call you an idiot” – not resisting at all)and one earlier by you that called Oberman a schumck. You forget Nate is the one who routinely calls commenters idiots.
    As a devote Conservative I doubt you’d like my ideas but here goes. They will seem radical, but I think that they are necessary if we are to really solve healthcare – not make it perfect, but get us out of the destructive path we are sure to end up on. We are kidding ourselves if we think we can nip this problem around the edges.
    1. Get rid of private healthcare insurance companies (or at least regulate the hell out of them to reduce them to paperwork shufflers). They are the root of all our healthcare problems. Doctors don’t like negotiating with them or dealing with the massive paperwork they require, patients don’t like navigating them or fighting with them when they are submitting claims. We won’t be able to control healthcare costs without freeing us from the grip of the insurance industry – our solution does not lie in an insurance model. They can provide travel insurance and face lift insurance, just not basic health insurance.
    2. Make all hospitals truly non-profit and community owned. That way they have a stake in meeting the needs of the community not their own ivory tower expectations.
    3. Establish universal budgets that force cost controls. This will lead to self fulfilling comparative effectivness. It will also mean price controls for procedures, devices and drugs.
    4. Re-align our payment system to better support and reward primary care docs. That will mean shifting pay from specialists to primary care.
    5. Tax fast food (fat food) as a health hazard (like we do tobacco and alcohol) and dedicate that money to local healthcare. Collected locally – used locally.
    6. Remove the subsidy for corn production and shift it to fresh fruits and vegetables with a premium for organic.
    7. Remove the employer from the duty to provide health coverage. That would enable all workers the ability to change jobs anywhere in the country without fear of lossing coverage. It would also allow laid off and displaced workers to continue to be covered. It would also allow welfare recipients the opportunity to get work without sacrificing health coverage.
    8. Mandate health coverage for every resident. Mandating makes sense if costs can be reduced and held.
    9. Pay for healthcare with a dedicated federal income tax (the lions share) and a dedicated state income tax. the states would administer the plan and be accountable to their own state voters. States could adopt minor changes to an overall federal plan to account for regional differences, but if you moved to another state you would not see large changes in coverage or costs – unless that state did a better job reducing the need for healthcare and then the state health tax would be lower.
    10. Everyone would be covered, no pre-existing or appliction forms to fill out. No policy cancellations, no extra charges for being sick. Everyone would have a secure healthcare smart card.
    There, that should get you started.

  11. What has to be done, is to get rid of the for profit Insurance companies. They add nothing to healthcare, but cost.
    Conyers HR 676 bill in Congress, is an excellant place to start. Not many even know of it’s existence.
    Administration costs, both of the Insurance Companies, and hospitals, Doctors, Drugstores etc., aproach a third of our healthcare dollar. There are hundreds of buraucracies and different coverages, Doctors, hospitals and drug merchants have to have staff to figure it all out.
    The right wing, has no answer, for them, ones benifit to society is based on the size of ones wallet. I think we are better than that.
    No bankruptcies, wouldn’t that be nice?

  12. Peter – My view on healthcare reform is that we will have to come to some sort of compromise that pulls in the best from all stakeholder groups, ideologies, etc. There are a lot of people bringing good ideas to the table on THCB. You seem to have assumed the role of the guy who lurks in the shadows and goes on the attack when someone makes a point that you don’t like. Personally, I would be interested in hearing more of your ideas. You’ve put some good ones out there in the past, but they are few and far between because you seem to spend more time in attack mode. In the interest of respectful debate, it would be great to hear you expand more on your ideas in addition to attacking others.

  13. “Examples are a small number of events or items meant to represent a larger subset, they are not all inclusive and can represent a small fraction of the total.”
    Breast reconstruction – mandated by 49 states
    Chemotherapy – mandated by 4 states
    Any of these not suitable for mandated coverage – care to “extrapolate”? This mandated issue is mostly an insurance industry issue where they want to plus profits by charging extra for a whole host of treatments and only want to compete on price by exclusion of coverage, not lowering of costs.
    “Some people are sicker then other through no fault of their own, tough that’s life,”
    That Nate, is the core of your healthcare mentality.

  14. rbar,
    this captcha has the incredible ability to identify good comments and lose them, the so so and bad ones always get through but the ones to truly be proud of always get killed somehow.
    I’m not an academic and I don’t have a study chalked full of references but in my reading and research over the years if you take the private insurance plans from the 10 lowest per capita states, adjust down for public cost shifting then back up for not covering those over 65 then compare to other industrialized nations they aren’t far apart. We have plans just as good as any other country, the problem is we have the 10 worst plans dragging us down.
    To try my hand at a metaphor I would use our school systems. As a nation we test lower then most other Industrialized countries. So walk into the top school in any state, tell them they are a miserable failure, we are scrapping their curriculum and the federal government is taking them over. People would say your nuts; these schools should be models for the rest of the schools, not thrown out with the bad.
    We have some of the best schools in the world, their achievements are drawn down by DC, Detroit, Cleveland and other complete failures. Do you think we should close those great schools because overall test scores are bad?
    Point 3 is hard to explain unless your really quick with math. Most people think HSAs are bad for those that are really sick because they have the high deductible. If you work the math out you will find they actually save the really sick money. You can’t look at a $2500 deductible plan and say it doesn’t cover someone with diabetes as well as a $500 deductible plan. You must look at the total annual out of pocket cap. On most plans the HDHP has lower total out of pocket then the $500 deductible. So a sick person sure to max out under either plan comes out further ahead with the high deductible. This is what I sell all day and have for years. Some people just don’t get it no matter how many ways you show it.
    That’s the easy part of the equation. If you’re really good with numbers take a group of 20 employees. Increase their deductible from $500 to $5000 and you save roughly 40%+ in premium. If the employer assumes the risk to continue giving employees the $500 deductible they are picking up around $3600 in risk on 50 people when you include dependents. That’s around 180K I think. Actuarial tables will show you the employer will actually only incur around 20% of that liability in claims or $36,000. The premium savings by changing plans comes out to 50-80K though so the employer sees a net savings of $14-44K roughly 10-20% for no change in benefits.
    Under no circumstances is first dollar coverage efficient to pay through insurance. It doesn’t improve care, it just increases cost. You don’t buy insurance for something you know your going to have. In any other scenario a business buying insurance for non risk is considered accounting fraud. It was a scheme Enron and others used to cook the books. Insurance companies and state tax collectors are the only ones that benefits. If your truly concerned about the cost of treatment for chronic diseases the thing to do would be to set up non profit providers to deliver the service for free. Salaried docs immune from malpractice under a charitable umbrella is the uberefficient delivery for known events. If you need dialysis go to the local county dialysis center run by ACORN or Catholic Charities West.
    People with serious conditions are already pooled in the employer market without pre-ex or rate ups. Modified guarantee issue with individual mandates for the individual market are fine just allow for a reasonable rate up for the unhealthy and no giving it away to everyone under 1000% percent of the poverty line. If you don’t penalize people some for being unhealthy they have no motivation for being unhealthy. Some people are sicker then other through no fault of their own, tough that’s life, there are people prettier then me, when there is a law forcing super models to date me I’ll pay the same insurance rate as someone born sicker then me.
    Point 1 a number of good studies on this was done by Milliman, they are a true gold standard when it comes to healthcare, not a bunch of partisan hacks like Lewin who some charlatan healthcare blogger wanks claim to be. See;
    http://energycommerce.house.gov/cmte_mtgs/110-he-hrg.091808.HealthReform.Fox.pdf
    http://www.managedcaremag.com/archives/0612/0612.costshift.html
    – Estimate of total annual premium is $13,800– Cost shift of $1,690 equals 12.2% of total
    If Public plans paid their fair share those with private insurance would see an instant discount of 12.2%.
    Not all providers can drop Medicaid and private insurers can’t drop those that don’t and thus over charge from their plans.
    Peter, if I was a smarter man I would ignore you, sadly I am not. The easy one, if you prosecute insurance fraud it lowers insurance rates which means more people can afford it and thus lowers the number of uninsured. I’ll resist the urge to call you an idiot.
    Your first….argument isn’t the word…..thought is being generous….statement, in regards to your first statement allow me you share an example to show you why your wrong. Toothpaste does a great job of preventing cavities. Preventing cavities prevents expensive trips to the dentist. Do you know any insurance carrier that covers toothpaste?
    Examples are a small number of events or items meant to represent a larger subset, they are not all inclusive and can represent a small fraction of the total. By now I hope you see where I am going with this. I gave two examples out of the 1961 mandates currently out there. If you know how to extrapolate please do so now.

  15. “6. Remove all state mandates and have a minimial set of federal guidelines. Maternity stays and those are good, massage therapy, acupuncture, and others are wasteful, they are services that shouldn’t even be insured let alone mandate.”
    Massage Therapy – mandated by 4 states
    acupundcture -mandated by 11 states
    Wow, those are cost drivers! If those less cost services successfully treat what would otherwise be treated by a medical doc and facility at X times the cost, what savings are you going for Nate? Or is it just past your narrow grasp to understand alternative treatments?
    “5. Prosecute insurance fraud like the crime it is.”
    = More uninsured people.

  16. Nate,
    unfortunately, my detailed comment got lost as I realize now.
    Your suggestions make sense, although I think they are unacceptable for most Americans as point 3 (“Covering routine and known expenses is wasteful. Insurance should be as it is defined, protection from unknown event or timing, it is a very poor funding mechanism.”) clearly restricts coverage – people with chronic conditions (Diabetes, COPD etc.) don’t get coverage, and I believe that they deserve the solidarity of that risk being pooled (yes, more responsiblity for such condiions as the DMII/obesity complex is warranted, but that is a separate issue).
    Re. 1), I am a physician and agree, medicaid is basically an unfunded mandate … but I am not sure how much private insurance is truly subsidizing … providers and HC system tend to simply drop medicaid, like any other plan that pays poorly.
    Re. your last post, IMHO you are creating confusion: when HC systems in any other developped country (BTW, Germany and France have different competing plans, and Germany has some private insurance as well) do better than the US hodgepodge, there is no reason to quibble about subpopulations. It’s like saying: my prototype airplane doesn’t fly, but it has the best engines in the world and thereby, my plane is superior.
    Or do you want to say: people who have good private insurance in the US are well covered, and their health ourcomes compare well to populations in other countries? Then say so.

  17. Out of curosity has any liberal/progressive ever taken the time to compare your basket of preferred industrialized nations government nirvona plans to private insurance in any of the fly over states?
    When I hear continued referall to these other nations having more efficient and better performing plans it leads me to belive you have no idea what we have here. We don’t have one plan that you can compare to a plan in another country. Comparing the aggregate results of the US to another country is intellectual laziness. We have a handful of failed and poorly performing plans. To overlook the success of the 10s of thousands of other plans shows your not interested in improvement just politics.
    Not that I personally would ever do it but anyone making such an argument, comparing aggreagte US results to other nations, should be publically ridiculed and mocked.

  18. “I wuold like to ask you, Nate, to give me an answer how the current “system” that you seem to defend, would ever be able to address the cost explosion, while making sure that we don’t spend a quarter of our GDP on healthcare that is not outperforming other developped countries who spend a fraction.”
    1. Force all public plans to reimburse providers at a fair rate so cost is not shifted to private plans. THis will reduce private plan cost 10-20%.
    2. Elimiate all regualtion that is poorly written or only serves to drive up the cost of private insurance with minimial benefit to the public. Examples would be COBRA, leave the law in place but remove the requirement that notices be mailed with less then 2% are returned. This would also remove the almost endless election period someone has when they don’t get a notice. A small employer should not be bankrupt because HR lost or forgot to enter a change of address. Women’s health notice, HIPAA, and other annual mailings eliminated. This is common sense, if every health plan in the country is required to mail a notice to every memeber in the country wouldn’t it save a firtune to have a federal website of laws and notification? All these laws do is keep the post office in business.
    3. Remove the insurance tax deduction for non insurance premium. Covering routine and known expenses is wasteful. Insurance should be as it is defined, protection from unknown event or timing, it is a very poor funding mechanism.
    4. Equal pricing, how can a publicly funded hospital charge one tax payor more then another for the same service? This will kill the monoply some large insurers have which has always been supported by congress. Congress has steered the public into a handful of large national carriers which is not in the best interest of the public at all.
    5. Prosecute insurance fraud like the crime it is.
    6. Remove all state mandates and have a minimial set of federal guidelines. Maternity stays and those are good, massage therapy, acupuncture, and others are wasteful, they are services that shouldn’t even be insured let alone mandate.
    7. Require public funds to honor their promises. Plans like Obamas to make soliders injured at war pay for their own care with their private insurance and Medicare being secondary to private insurance need to stop. If you sell someone on a plan like Medicare or make a promise to care for our Vets you need to live up to it. If the public plan was poorly designed and can’t sustain itself then it needs fixed, not just shifting the cost to private insurance. A handful of states require employers to cover overage dependents, this is to get large claims off Medicaid, our small employers have no obligation to pay for the healthcare of non employees, these laws are what makes private insurance expensive.
    That’s a handful to start discussing, I have a few dozen more if the discussion advances that far. For people that truely know healthcare the problem is obvious, Medicare, Medicaid, MA, and other liberal health plans are unsustainable. In an effort to stay afloat they have been shifting cost to private plans for decades.
    Private plans have built in sustainability, when it gets to expensive changes have to be made to keep it going, it can’t off load cost onto tax payors. Anyone that gets past the propoganda and politics and really studies the history can see this. As we progressed from indeminity plans to PPOs to HMOs and back and every time Congress cuts reimbursements you can see the effect on the private system and how it responds.
    Our private system is a hostage of our failed public plans, free them and they will operate fine and not require trillions in tax payor money.
    Peter if your going to make my arguments don’t half ass it. I’ve educated you more then enough times that you should be able to make a deeper argument then the one you did. Sometimes I worry your not learning anything.

  19. rbar, you’ll find Nate’s solution will be to remove the government entirely from healthcare and go back to the 60’s when, as Nate says, we all paid 50% of our health costs – of course homes were about $16,000 and cars about $2500.

  20. Nate,
    you misunderstood my (and Mrgalit’s) comment about the VA. The comment was about impoverished people you can find there (not the service they receive); these are mostly aged veterans that are dirt poor, and yet they contradict your conservative stereotype of the welfare queen that you brought up earlier.
    I don’t know what to think about the VA system as a whole … some features definitely smell of government bureaucracy with poorly motivated employess. And yet, Nate, the outcome/efficiency studies of the VA I have lately heard about show that the VA is delivering efficient care at a relatively low price.
    What I see now as physician in one of the epicenters of fierce private provider competition is: absurd diagnostic and therapeutic overkill, absurd overcapacities (in terms of beds, in terms of unneeded specialty providers) and yet construction of a new oversized facility (which triggered the competitor to add on unneeded facilities as well) … the whole thing is so stupid that this writer will leave private practice here for academia (there are of course other reasons as well).
    I wuold like to ask you, Nate, to give me an answer how the current “system” that you seem to defend, would ever be able to address the cost explosion, while making sure that we don’t spend a quarter of our GDP on healthcare that is not outperforming other developped countries who spend a fraction.

  21. rbar and Margalit,
    I’ll be the first to agree VA care is substandard, my family has a long and current millitary relationship. That being said, the failure of government to deliver on the promises they made vets is all the more reason we shouldn’t trust them with any more of the healthcare system. How can you parade the poor treatment of vets out in an argument then turn around and propose we give Washington more responsibility.
    The government has failed to deliver the care they promised to the Vets, the Poor, and the over 65. Please explain to us why you think if we turn over the rest of the system they will finally do a sufficent job?
    On top of the poor service to date Obama wants to require wounded soliders and their private insurance to pay for war injuries.
    What is it about failure that attracts you so much?

  22. Nate
    Margalit is right. Serious suggestion: Go to an urban VA (one was part of my training) and look at the veterans, and you will see what poverty is like.
    Margalit, with “bare bones coverage” (approx. 33 posts earlier), I mean: the medical necessary and reasonable (what some people here termed “lean medicine”). Only medical tests and treatments that are proven to be beneficial in the literature, or where is clear expert consensus. NOT the status quo, namely: MRIs for migraines and axial back pain, stress tests/coronary Agrams for healthy 20 yo with anxiety symptoms, back surgery for no good reason, extensive surgery in demented NH residents in their 80s … but of course we need tort reform for that, otherwise the physicians will be pressured to continue the present diagnostic overkill.
    Doctors should be reimbursed reasonably. And coverage just for generics probably would do.

  23. I came across at your blog and I find it very interesting. It was worth reading. Thanks for sharing this information. Keep it up!

  24. It is difficult to express oneself economically…but the benefits are many…like people will actually listen.

  25. Nate, as far as I know about one quarter of those sent to Vietnam had family incomes below poverty level and about three quarters were from lower middle/working class background. Same segment that has difficulties paying for healthcare today. Most draftees then and most enlisted people today are not college graduates, since they enlist after high school. Not sure regarding their political views.
    You also asked “What exactly do we owe the poor?”. One third of all homeless men are veterans. I think we owe them something more than an occasional blanket distributed by a charity.
    As I said before there is abuse everywhere where there are people. If you “oppose giving it away to those that take because they choose not to give”, then make sure that this includes our well heeled cousins on Wall Street, Detroit and various other big business hubs.

  26. “Peter – It sounds like you’ve been watching too much Olbermann lately!”
    Oh, you mean that “left wing schmuck”? Sorry, never watch him. I was just quoting you, “right wing folk”

  27. “but we all know who gets drafted and who gets to stay home and go to college.”
    There hasn’t been a draft in 30+ years. It’s college educated and mostly conservatives who do all the country’s fighting.
    “Most poor people, given a choice, will not elect to be impoverished.”
    I disagree, it is due to their choice that most people are impoverished in this country. Drinking and smoking alone make enough of a financial difference in ones life to doom them to a life of poverty or lift them and their family out of it. Someone doesn’t need thousands of dollars in community out reach and training to know a pack a day smoking habit is bad for you.
    “An equitable arrangement in any society is for one to contribute according to his/her abilities and receive according to his/her needs.”
    For 70 years those on the left have taxed so each recieved according to his/her needs. It has NEVER been part of the progressive platform that they contribute according to his/her abilities. Conservatives don’t oppose charity and social help, we oppose giving it away to those that take because they choose not to give. Their are millions of able bodied welfare receipiants who don’t contribute to their ability. All of those collecting unemployement are not contributing to their ability.
    That saying is nothing more then a Rovian framing like Maggie describes. The failure of socialism/liberalism is the failure to require the contribution. Thats what has always failed the ideology and it always will.

  28. “A great country isn’t defined by its government, it’s defined by its people.”
    Deron, from what you’ve been saying the “people” have defined the country as a bunch of over-eating, TV watching, healthcare abusing, children breeding, welfare sucking, responsibility shirking screw-ups.
    “Why are the core values of social responsbility (Liberals) and personal responsibility (Conservatives) becoming increasingly at odds and mutually exclusive over the years?”
    Social responsibility = Share the wealth
    Personal responsibility = Keep the wealth

  29. Margalit – I agree 100% on your point on education. I wish we could have dedicated about $5 billion from the stimulus package to health education, with a primary focus on the underpriveleged.
    I’m not claiming to have the answers. I just think we need to step back and look at some underlying trends that are really the core problems, as opposed to focusing on the symptoms of those problems. I’ll bet any “problem” with the healthcare system we discuss here can be traced back to either greed, selfishness or irresponsiblility. Medical homes, HIT and single-payer don’t address those things. We must decide as a citizenry that we want to be a great country and then we need to each figure out how we can contribute to that change. A great country isn’t defined by its government, it’s defined by its people.

  30. “There is an inverse relationship between the size of government and the level of morality, and personal and social responsibility of the citizenry.”
    Deron, how does the, “morality and personal and social responsinbility” shown by mortgage brokers, lenders, bankers and Wall Street investment houses relate to your statement of an inverse relationship? If what you say is true then the lack of regulation would have prevented our financial meltdown. Seems that government IS necessary to provide the moral compass.

  31. There is a difference between a well researched NY Times or New Yorker research piece, crammed with facts and pithy quotations, and rambling free association and rhetorical point scoring. Count the facts and quotations from content experts or people living through a problem, and tell me how much actual content there is in a post, as opposed to mere bloviation.
    The wonder of the Internet is that people are free to be who they are, and to express their opinions directly without the filter of an editor. However, that freedom has been abused, particularly by flaming, spamming and, as suggested above, by these e-filibusters. It is an electronic version of the Tragedy of the Commons. We’ve managed to keep the flaming to a minimum in THCB, and people are reprimanded when they are abusive. Filibustering is another form of abuse, a form of bullying. Let’s exercise some intellectual discipline, regardless of what ideological position you come form. Clear and concise is helpful to all of us.

  32. “Today, we have a new, highly articulate and intelligent president who is able to speak, thoughtfully, and at length. I hope this will set a new standard for literacy.”
    I would like to start this post by thanking Nate for inviting everyone here today.(for those that don’t know look up Obama’s St. Patty Day massacre, it’s when any pretence of his intelligence was killed in cold Guinness)
    We have a president who on a good day can read a teleprompter. He has shown ZERO ability to articulate off the cuff or sans said prompter.
    Out of respect I’ll avoid the cheap shot reference to the special olympics, unlike our president I do have some compassion.
    “They didn’t buy the election with enormous donations from a few people. They won the elections with a great many very small donations.”
    Well unless you add up all the small donations the same person made then they were large and illegal. Don’t forget all the foreigners that contributed illegally as well, don’t want to lose them for the next election.

  33. For tcoyote
    “Over the past 20 years Karl Rove conservatives have made a fetish out of “framing issues” in one or two lines– bumper-stickers that are supposed to pass for thought. In fact, they dont’ want their listeners to think.”
    HOPE CHANGE

  34. tcoyote–
    There are those that think that posts and comments on blogs should always be short.
    The problem is that if people are going to move beyond assertions and opinions–if they are going to make arguments ,in depth, with evidence–that takes time and space.
    As a former jouranlist, I’m acutely aware of the way that space limitations force most newspapers and magazines to compress stories into simplistic, watered-down versions of the truth.
    A few publications avoid this: The New Yorker stands out as a publication that still publishes long, in-depth stories.
    This isnt’ to say there isn’t a place for short posts, or short newspaper pieces– but they are better suited to less serious, less complicated topics than healthcare, or the economic melt-down.
    I agree about rambling.It would be nice if bloggers (including yours truly) and those who comment on blogs had editors, proof-readers, copy-editors, and the time to really refine our prose. But that wouldn’t mean writing shorter; it would mean writing better.
    Brevity appeals to lazy thinkers–or people who want to close off thought. Over the past 20 years Karl Rove conservatives have made a fetish out of “framing issues” in one or two lines– bumper-stickers that are supposed to pass for thought. In fact, they dont’ want their listeners to think.
    Today, we have a new, highly articulate and intelligent president who is able to speak, thoughtfully, and at length. I hope this will set a new standard for literacy.
    Deron S.–
    Sorry if I seem arrogant. But the fact is, as Obama puts it, with a grin, “I won.”
    When conservatives drew a line in the sand–and controlled both Congress and the White House, did you write about how this was “divisive” and “dangerous”??
    Now, the American people are fed up, and so they voted the Democrats into office. In 2010, many Republican senators will be up for re-election in states that Obama took. Many more Hispanics, African Americans and other minorities will come out to vote than in Congressional elections of the past. (They now know their votes count: their votes tipped the scale for Obama.)
    Assuming the president’s popularity holds until the 2010 electoin, it seems likely we will have more Democrats in Congress. This will put Democrats in a position to achieve changes comparable to the changes that we saw under LBJ: the civli rights movement; a war on poverty (that was very successful if you actually look at statistics on the delincing share of Americans who were poor from 1965-1972); woman’s rights . . .
    Some people may not think these were great achievements, but many people do– and these are the people who are in power now, because Americans voted them into power. They didn’t buy the election with enormous donations from a few people. They won the elections with a great many very small donations. And
    virtually no one has suggested that they “stole” the election with chicanery at the polls.
    (Btw the polls show that views about governmetn involveement in our lives have changed since the melt-down began. )
    Times are changing: Not only do we have an African-American President and First Lady (who, I suspect will be very influential), the Secretary of State is a woman. The president has appointed some extremely intelligent men and women to important positions–a brain trust we haven’t seen in Washington in a long time. (Btw, I don’t include our Treasury Secretary in this group.)
    You can see the change even in our popular culture.
    On television the most intelligent pundit (by far) and one of the most popular is a brilliant, funny woman–who also happens to be a lesbian.
    Three years ago, would this have seemed possible?
    I’m not feeling arrogant–just very, very happy that this country seems to be turning around.

  35. Nate, I’m not sure why you single out the poor as being most likely to abuse the system. We are in this economy mess specifically because the very rich abused the system. People are people and some are good and decent and some are not, regardless of their economic situation. I happen to think that healthcare is a basic right, just like security,only the foes are different. I don’t think a three bedroom house is a basic right, but a roof over one’s head is. If you can guarantee that poor people are not going to be drafted next time we have a major war, I would agree to reconsider healthcare for them, but we all know who gets drafted and who gets to stay home and go to college.
    Most poor people, given a choice, will not elect to be impoverished. Some people work 2 or 3 jobs at minimum wages and still cannot afford to take the kid to a doctor. That is plain wrong. An equitable arrangement in any society is for one to contribute according to his/her abilities and receive according to his/her needs. That in my opinion is the purpose of having a state instead of each individual fending for himself and let Darwin’s theories be applied.
    Deron, I totally agree that having 5 babies on Medicaid is irresponsible and we should work to prevent that from occurring. However, throwing mom in jail, as Nate suggests is not my cup of tea. Education comes to mind, but that will take time and it seems like people have no patience for underprivileged errors in judgment caused by lack of education and social skills. Wall Street, greed based errors seem to fare better for some reason.
    I’ll stop now, since tcoyote is right about brevity…

  36. Just a process comment. I think these rambling posts are abusive of the medium.
    They are like napalm. They burn up oxygen and stifle debate and the lively exchange of views. They have a funny way of either ending the threads or degenerating into shouting matches. This is the Internet. Brevity is a virtue. Edit, compress, weed out the dross, THEN post, please. . .

  37. Maggie – I’m not sure Americans are calling for more government involvement in their lives. They just want the bad stuff to go away. I’m sensing a bit of arrogance from you that I haven’t seen before. That is a danger of having the same party in control of the executive and legislative branches. Much of the checks and balances are gone. I think many Democrats that were angered by the arrogance of the Bush administration are now arrogant themselves. The divisiveness is concerning.
    Margalit – I’m not suggesting we have the government regulate reproduction. I’m suggesting that it is blatantly irresponsible both personally and socially to think that one’s fellow citizens are ok with paying for someone having 5 children. It’s a window into the soul of our current society. My question for you is: Are you ok with a woman having 5 children on Medicaid and do you think it is a wise use of healthcare dollars?
    Why are the core values of social responsbility (Liberals) and personal responsibility (Conservatives) becoming increasingly at odds and mutually exclusive over the years?

  38. “You touch a general problem that comes with any kind of social wellfare, and that is abuse.”
    Knowing such programs are prone to abuse why do people insist on enlarging them in ways that only benefit those wishing to abuse it?
    First dollar coverage only benefits those wishing to consume more healthcare then they need. It’s inefficient to pay taxes or premiums to someone else to pay minor bills. You can’t critique the inefficiency of the current system then turn around and propose no or low out of pocket robust insurance for everyone.
    Unemployment only benefits those who don’t want to work. Millions of people find another job while working 8 hours a day. If someone can’t find work and needs income the intelligent thing to do would be to pay them to work, not “search for a job”. Can we ever have to many crossing guards? Is it ever a bad thing to sort recyclables out of the trash?
    Why do we have millions of welfare moms collecting money because they can’t work due to the need to watch their kids? Am I the only one that ask why they can’t take turns watching each others kids while they work 4 days a week?
    Public Housing was a complete disaster, welfare has been a disaster, public healthcare is bankrupting us, how many more GENERATIONS of people do we need to kill and doom to a life of economic slavery before we realize social welfare doesn’t work? It never has and it never will.
    Margalit, what sort of free health insurance/care do you think you can give to the poor they won’t abuse? What exactly do we owe the poor? Is everyone living in this country legally or not entitled to no out of pocket healthcare, 3 bed 2 bath house, free utilities, guaranteed pension, and a monthly stipend for food and other misc expenses? Our poor already live better then the middle class of most countries. As we have given more and more handouts to them their number has swelled. Is it beyond the realm of belief that if you make poverty to comfortable people will choose to live it instead of working?
    “but you are OK with government regulating reproduction based on annual income? How would that work exactly?”
    If you can’t feed, cloth, house, and educate a child and you keep bringing them into the world it is child abuse. We already have laws against abusing children, we need to start locking parents up for life that don’t live up to their obligations.
    “A great many doctors see the advantages of a new, improved Medicare in the form of “Medicare for all”
    Poll time, would anyone out there like a boss that pays you almost anything you ask for regardless of the quality or quantity of work you did? What a shock that providers like a fraud prone system with no safeguards to protect the taxpayer from fraud and abuse. I think for the sake of the planet we would all like a unicorm to fly to work, that doesn’t mean I would vote to ban cars hoping Unicorns would come true. We can’t afford Medicare for those that have it, Medicare for all is not even an option.
    “Many doctors and hosptials understand how useful it would be to have comparative effectivness information”
    We ignore all the comparative effectivness knowledge we have now, just imagine how much more we could ignore if we spent a few billion on it. Everyone knows how to treat a cold, has that made any difference in the prescribing of antibiotics? If we can’t wean the public off ineffective care for something that obvious what is any amount of comparative effectivness going to do? Allow me to answer, its billons more politicians can dole out to those lavishing them with campaign contributions. More money for their allies in the academic and provider world. Won’t save a penny of premium just raise taxes for more politicking.
    “and ideology (on the part of conservatives)”
    And Democrats and their fellow progressives are following a path of? Logic and sound reasoning? It’s Liberal Dogma that created the unaffordable healthcare monstrosity we have. From Medicare to Ted Kennedy’s obsession with HMOs, to our endless mandates liberal ideology and propaganda is the problem.
    “This will pave the way for the structural refroms and cost-containtment we need in order to be able to afford universal coverage.”
    It says so right here on the brochure. The salesman promised us! It’s been awhile so allow me to share some of my faviorte progressive propaganda in regards to healthcare/insurance;
    Ted Kennedy;
    “As the author of the first HMO bill ever to pass the Senate, I find this spreading support for HMOs truly gratifying. Just a few years ago, proponents of health maintenance organizations faced bitter opposition from organized medicine. And just a few years ago, congressional advocates of HMOs faced an administration which was long on HMO rhetoric, but very short on action.”
    “HMOs have proven themselves again and again to be effective and efficient mechanisms for delivering health care of the highest quality. HMOs cut hospital utilization by an average of 20 to 25 percent compared to the fee-for-service sector. They cut the total cost of health care by anywhere from 10 to 30 percent. And they accomplish these savings without compromising the quality of care they provide their members.”
    John Kennedy;
    “We’re not asking for anybody to hand this out, we are asking for a chance for the people who will receive the benefit to earn their way-the same principle established under the Social Security system in the 30s.”
    Does anyone want to claim Medicare beneficiaries come close to funding their own care? If this was true Medicare would be a sustainable system supporting itself not redirecting cost to the private system.
    Johnson;
    “And I’ve never seen one have too much health benefits. So when they come in to me and say we’ve got to have $400 million more so we can take care of some doctors bills, I’m for it on health. I’m pretty much for it on education. I’m for it anywhere it’s practicable. . . . My inclination would be . . . that it ought to retroactive as far back as you can get . . . because none of them ever get enough. That they are entitled to it.”
    So progressives can you still say you have never seen one have too much health benefits? It’s seems the entire problem today is too much health benefits. How many times do you have to make this mistake before you learn?
    “We’ve just got to say that by God you can’t treat grandma this way. She’s entitled to it and we promised it to her.”
    I was promised SS when I hit 65, oops that’s gone. Haven’t we had enough broken promises from Democrats? For 43+ years Democrats have been making us promises in regards to Healthcare and Insurance and have broken almost everyone.
    Johnson: Does he charge what he wants to?
    Cohen: No, he can’t quite charge what he wants to because this has been put in a separate fund and what the Secretary of HEW would have to do is make some kind of agreement with somebody like Blue Shield, let’s say, and it would be their responsibility . . . that they would regulate the fees paid to the doctor. What he tried to do was make sure the government wasn’t regulating the fees directly. . . the bill provides that the doctor can only charge the reasonable charges, but this intermediary, the Blue Shield, would have to do all the policing so that the government wouldn’t have its long hand . . .
    Ya that worked out great! We got no policing and the long hand.
    I love this telling footnote, the phrase generational theft has been thrown around a lot lately;
    “Poverty among the elderly was at 35.2% in 1959, down to 24.6% by 1970, and stood at only 10.2% in 2000. This huge reduction in poverty among the elderly is generally believed to be due to a combination of Social Security cash benefits and Medicare coverage. Whereas, the elderly used to have the highest rate of poverty among age cohorts, today children do, and the elderly are the most prosperous cohort.”
    Nothing like sticking the kids that can’t vote and haven’t even had an opportunity in life to save and make sound decisions.
    Government has been trying to cram this down our throats for 70+ years, the only way they can succeed is to destroy the system we have in place.
    “Opinion polls indicated strong public opposition, with 76.3 percent of the public in a 1942 Fortune poll saying that the government should not provide free medical care (Cantril 1951: 440).”
    “Having developed the 1943 bill for Senator Wagner, the Social Security Board in 1944 specifically recommended to Congress that compulsory national health insurance be made part of the Social Security system.”
    “Moreover, while retaining control of Congress, Democrats suffered net losses in the House and Senate. Wilbur Cohen and Isidore Falk, key Social Security Administration (SSA) officials instrumental in the push for Social Security and government health insurance since the early days, came to believe that universal compulsory health insurance could not be passed. With this realization came the idea of restricting their proposal to the elderly, an idea first suggested by Dr. Thomas Parran of the Public Health Service in 1937”
    “Recrafting the proposal as compulsory federal health insurance for the aged thus reflected a deliberate decision to use an incremental strategy, initially targeting the group of recipients who would evoke the greatest sympathy with the public. However, despite this foot-in-the-door approach, resistance continued.”
    “When Rep. Albert Ullman (D., Ore.) cited allegations that the “public is somehow being hoodwinked” and “being misled” and asked HEW’s Wilbur Cohen about the degree to which the public misunderstood the program, Cohen stated that “we do recognize this problem and I think it has been complicated by the use of the term ‘medicare’ which is an erroneous term when applied to this program” (U.S. House Hearings 1965: 104). Although government officials sometimes expressed dismay about this public misimpression, the misinformation nonetheless fueled support for passage of a bill they strongly supported.”
    At least back then Democrats where honest about hoodwinking the public.
    “However, data submitted for the record from a 1960 University of Michigan study showed that “87 percent of all spending units headed by persons aged 65 or older” had assets whose median value matched asset ownership of people aged 45-64 and exceeded the asset ownership of people under age 45 (U.S. House Hearings 1963-64: 242-43). While HEW Secretary Celebrezze waxed eloquent about the necessity to furnish protection “as a right and in a way which fully safeguards the dignity and independence of our older people,” Rep. Curtis questioned whether it was appropriate to “change the basic system” when 80 to 85 percent of the aged were able to take care of themselves under the existing system, recommending instead that we “direct our attention to the problems of the 15 percent, rather than this compulsory program that would cover everybody”
    Even back then Democrats where more worried about getting their hands on the money and power then actually helping those that needed it.
    I could go on forever but what should be clear is lies and propaganda have paced the way for reform, it’s never been about doing the right thing or helping those that need it. Today is just another battle in the 70+ year war of Democrats trying to destroy healthcare anyway they can.
    Maggie and those like here will tell any story they have to in order to fool the public in supporting their failed ideology. If they really believe in paying for quality not quantity what has stopped them from amending Medicare to prove it. When diagnostic testing cost exploded they didn’t test for quality or implement utilization review they cut cost for all test. Liberals have never delivered on any of their promises, we have exposed 70 years of lies.
    “But those providers are in the minority, particlarly in the more enlightened regions of the country where hospitals and doctors practice more efficient medicine (the Northwest and parts of the MidWest, Northern New England,Northern California.) And, even on the East Coast and the West Coast, there are many elightened doctors”
    To caught up in her idelogical rant Maggie apparently has never checked out a site such as;
    http://www.cbo.gov/ftpdocs/89xx/doc8972/MainText.3.1.shtml
    Those regions Maggie claims practice more efficient medicine have the highest per capita spending according to the CBO. Maybe that is what this debate comes down to, those of us in the middle of the country who define efficient as spending the least amount possible for the best results versus Maggie and those on the left who define efficient has taxing as much as possible to spend as much as possible on their opinion of good care.
    “When it comes to the economy, the president is not the captain of the ship. He can not “jawbone” the stock market into rising; he cannot make the deficit disappear. He cannot tell the Chinese what to do with their currency.”
    That is the exact opposite of what Obama promised if we voted for him. He said he has all the answers and would solve all these issues if elected. Now that he is in not only can he not deliver on anything he campaigned on he can’t even give a coherent speech any longer.
    “We have a president, a budget director, a FDA commissioner, an assistant FDA commissioner, and a CBO that understand the need to squeeze the waste out of our money-driven health care system.”
    By switching to government managed plans that have THE HIGHEST level of waste of any plans in the country. The only thing more shocking then Maggie claiming this is people actually fall for it. Medicare and Medicaid have the worst record on waste so to cut waste we should expand them.
    “That’s the difference between government and for-profit corporations: corporations are supposed to look out for their shareholders; governments are suppposed to look out for the public good.”
    Just like how Congress looked out for us with the housing crisis. Just how government looked out for us with the TARP money and AIG bonuses. There are things government is suppose to do, defend our borders, look out for us, then there is reality of what they really do. Maggie wants us to ignore the repeated failures for government to do what it is supposed to do and trust it as long as it is looking to invade our lives and our wallets.
    Is it to much to ask for government to fulfill it’s existing promises before it goes making and breaking new ones?

  39. John Ballard- thanks for metioning the guest post –“Doctor’s Orders” on http://www.healthbeatblog.org written by
    recently a retired doctor.
    His outstanding post, and the many comments that followed illustrate that not evenyone is as blindly and narrowly self-interested as the authors seem to think.
    They write: “Doctors and hospitals . . . don’t want big, powerful insurers.” A great many doctors see the advantages of a new, improved Medicare in the form of “Medicare for all”–and they like insurers like Kaiser.
    A great many enlightened hospital administrators see the advantages of “bundled payments” that pay doctors and the hospital for an episode of care, paying more for good outcomes, less for poor outcomes.
    Many doctors and hosptials understand how useful it would be to have comparative effectivness information, organized in one place, and treatment guidelines for patients fitting a particular profile. .
    The authors demonstrate their cynicism when they write: ” Ideology, self-interest, and rhetoric will shape the health reform debate. A sneak preview of this process was embedded in the recent stimulus package. $1.1 billion was added for comparative effectiveness research. Many policy wonks agree that we need better information on what works and what doesn’t in health care, but disagree on the details of what to study and how to use the information.”
    The fact is that the bill did pass, with the $1.1 billion intact. Rhetoric and self-interest (on the part of drug and device lobbyists) and ideology (on the part of conservatives) did Not carry the day. This never would have passed a year ago. Things Have Changed.
    And among those who count– the 16 members of the – new comparative effecitveness panel there is broad agreement. Merrill Goozner describes the panel that the Institute of Medicine has appointed on Gooznews here
    http://www.gooznews.com/archives/001350.html
    Go to his post and you will note that the device-makers and drug-makers have not been given a seat at the table (those who profit from overpriced and ineffective drugs and devices should have chance to testify, but not to vote.)
    You’ll see that, with the understandable exception of Alzheimer’s, advocates for particular diseases (cancer, heart disease etc.) are not on the panel. The insurers represented are enlightened non-profits (and two of the three also are providers.)
    Medicare will be using this comparative effectiveness research– as well as existing research– to begin steering patients and doctors toward more effective, less ccstly treatments. Medicare will also be using this reserach (implicitly) while adjusting its fee schedule.
    This will pave the way for the structural refroms and cost-containtment we need in order to be able to afford universal coverage.
    Most involved in healthcare, from the White House Budget director to dcotors like Christine Cassel, head of the American Board of Internal medicine (who is on the panel) and Dartmouth’s Jim Weinstein (also on the panel) understand what needs to be done: measure what works and what doesn’t; pay providers for quality, not quantity; put a lid on health care spending and lift quality. They understand, that lower spending and higher quality go hand in hand.
    There are, of course, those who feed at the trough and would like to see the healthcare industry grow: this includes device-makers, drug-makers, for-profit insurers and even some doctors and hospital CEOs who are blinded by self-interest.
    But those providers are in the minority, particlarly in the more enlightened regions of the country where hospitals and doctors practice more efficient medicine
    (the Northwest and parts of the MidWest, Northern New England,Northern California.) And, even on the East Coast and the West Coast, there are many elightened
    doctors (particularly younger doctors and women doctors) as well as hospital administrators.
    The authors don’t seem to realize it, but the world is changing.
    And that change will accelerate because of the change that is taking place in our economy.
    It is clear that the U.S is entering a recession/depression that may rival the Great Depression of the 1930s.
    And, contrary to the conventional wisdom, there is not much the administration can do about this except to try to help those who are hit hardest– the poor, the unemployed and the working poor.
    When it comes to the economy, the president is not the captain of the ship. He can not “jawbone” the stock market into rising; he cannot make the deficit disappear. He cannot tell the Chinese what to do with their currency.
    We live in a global economy, and what happens to our economy depends, to a large degree, on the kindness of stragers. If foreign buying of our debt slows significantly, we are in a world of trouble.
    The Chinese have already signaled that they are concerned. IF they decide our deficit it too high, we will have to raise interest rates to coax foreigners to continue purchasing our Treasuries. . . Meanwhile, the dollar will sink further.
    Even if that doesn’t happen,unemployement is likely to go well over 10% in the next year or so. We’re in for a long, steep recession/depression–it will take time to work off the excesses of the long Gilded Age that has its roots in the 1980s.
    Against this background, everything changes.
    Americans already are calling for more govenrment
    regulation –and more government involvement in their lives.
    It is no longer just “the left” that looks at for-profit corporations with suspicion.
    Americans realize that for-profit corporations put their profits–and their shareholders–first. This is their job. Along the way, exectuives routinely line their pockets.
    We can no longer afford this–particuarly not when it comes to healthcare.
    We have a president, a budget director, a FDA commissioner, an assistant FDA commissioner, and a CBO
    that understand the need to squeeze the waste out of our money-driven health care system.
    And, after 8 years of bad government, the public recognizes good government when it sees it.
    Public trust in this administration—and public distrust of corporate America– is key. This is a whole
    new ball game. Think 1980– except this revolution will take us in the opposite direction.
    Obama won.
    He’s going to redistribute income–downward– using the money to invest in the public good.
    That’s the difference between government and for-profit corporations: corporations are supposed to look out for their shareholders; governments are suppposed to look out for the public good.

  40. Deron, what do you mean by “Why should one woman be allowed to have 5 children using Medicaid $$?”?
    You are concerned about the size of government as it pertains to providing healthcare, but you are OK with government regulating reproduction based on annual income? How would that work exactly?
    rbar, I also don’t quite understand what “generalized bare bones health coverage” is. Are we suggesting poor health care for the poor?
    Somehow I think we can do better, if we can muster the determination to ignore all the entrenched special interests in this industry.

  41. I don’t believe that health care transformation can wait for a more “safe time” political or otherwise. We are beyond waiting for better times. If we are going to have a fight about it then now is the time. There are no longer any “safe options.” We can all, collectively, think of millions of reasons why it won’t work, but that is a self defeatist attitude and not a good one to have when we are losing the war on a daily basis. Time is not on our side.

  42. You touch a general problem that comes with any kind of social wellfare, and that is abuse. Society can tweak the system and curb it as much as possible, but can never eradicate it completely. As long as people are driving cars, there will be always some amount of incompetent or intoxicated driving, and the DMV and police are fighting that … but car traffic will not be abolished since it is, in that example, the greater good.
    I think I know what you are talking about – I see a substantial minority of people on medicaid or medicare who draw benefits for a rather fictional disability and do doctor shopping for very nonessential medical needs (e.g. pain syndromes that are obviously not impairing) and sometimes even – subconsciously – as a hobby/entertainment. I think the only way to curb this without throwing worker’s protection and SS overboard would to make disability payments temporary and subject to regular nonadversarial scrutiny, like a commercial driver’s license is subject to nonadversarial scrutiny.
    I think that a generalized bare bones health coverage is what we owe every member of our society, and that is the greater good outweighing the abuse problem.

  43. rbar – I was thinking more along the lines of US 2009 vs. US 1787. One thing about our Constitution that is both good and bad is the fact that it makes some very general points. Promoting the general welfare and ensuring domestic tranquility are very important functions of government, but how far do we want to take that?
    The crises in the U.S. healthcare and financial systems are colossal screw ups on the part of all of us. We cannot and should not lose sight of that. Insurance companies, specialist physicians, and greedy CEOs are simply the convenient scapegoats, when in fact it’s all of us.
    One thing we should all be able agree on is the fact that government today is more expansive today than it was in 1999, which was more expansive than 1989, etc. Every now and then, we should take a step back from our normal discussions and ask ourselves why that is. Giving government control over the healthcare system or any other system for that matter will not eliminate greed and selfishness. It will just cause those things to manifest themselves in different ways and different places. Healthcare does not exist in a vaccum. It is simply a subset of society. The core problems in healthcare are not unique to healthcare, but sometimes I think all of us, including myself, make it seem like they are.
    I could go on for days with this, but I don’t want to monopolize this particular thread. Let me just end with one last point. I think the Medicaid system is a necessary part of our society, but it has gotten so large and is so fraught with abuse. In theory, it should be in place to help those that have fallen on hard times or othwerwise cannot provide for themselves because of factors beyond their control. For some, it has become a way of life. I won’t take everyone’s time with a ton of examples, but let me give you the most blatant one. Why should one woman be allowed to have 5 children using Medicaid $$? For those that argue that it is that woman’s right, I will counter that you are taking the “promote the general welfare” concept to a level beyond the original intent of the Founders.

  44. Yes, many fractions would have to give in: the pharmaceutical companies which is one of the most profitable industries … the physicians (esp. interventionnalists) who are (except for financial sector professionals) the highest paid large professional group … insurance companies because the business model of competing entities heavy in admin. costs is not reasonable … and the trial lawyers, because defensive medicine is a real cost factor. And let’s not forget that patients have to adjust too – health care will become unaffordable if you expect huge work ups for minor problems, or exhausting all medical possibilities for a medical problem in an ailing 88 year old with dementia. I would agree that a true insurance with high deductible is a logical choice – but we know that barriers to care reduce both needed and unneeded care.
    I frankly don’t think the situation is desperate enough at this point. Once health care expenses go beyond 20% of the GDP or the number of uninsured doubles, people might be ready for a real overhaul.
    The only thing I’d realistically hope for at this point would be a good public plan that will, if done right, easily outperform its private competitors, grow immensely and come close to single payer.
    Deron, you wrote:
    “There is an inverse relationship between the size of government and the level of morality, and personal and social responsibility of the citizenry.” … what exactly do you have in mind? US vs. Soviet Union, Netherlands vs. Sweden, Somalia vs. Venezuela? Just curious.

  45. Senate Finance Committee Chairman Max Baucus and member Senator Chuck Grassley ruled single-payer off the table. However, a MAJORITY of Americans want single-payer reform.
    Why?
    Sen. Baucus has received more campaign contributions from health insurance and pharmaceutical companies over the past four years than any other Democrat in Congress.


    According to the Consumer Watchdog study, Baucus has received $413,000 since 2005 from insurance and drug companies, third behind Sens. John McCain and Mitch McConnell.
    The Center for Responsive Politics found that during 2003-2008, Max Baucus received $590,185 from the insurance industry and $524,813 from the pharmaceutical/health product industry. Sen. Grassley received $376,893 from insurance companies and $244,722 from the pharmaceutical / health product industry. Grassley’s second largest donor is Blue Cross/ Blue Shield.
    Baucus is now pressuring the Congressional Budget Office (CBO) to favorably judge his health plan as financially sound–even though it is not. The CBO issued a series of recent studies which have found that most savings claimed, in the effort to keep private-for-profit insurance companies in the mix, do not exist.
    Alternatively, a single-payer system would save more than $350 billion per year
    SINGLE-PAYER SHOULD BE GIVEN A FULL AND FAIR HEARING BY THE SENATE FINANCE COMMITTEE

    http://www.opensecrets.org/races/indus.php?cycle=2008&id=MTS2

  46. Cost containment vs. expanding coverage? A very important piece of health care reform should be a mandate for all with sufficient income to purchase health insurance. We need to have everyone in the system in order to control the costs. Health care costs will not be affordable in a health care system where mainly the chronically ill people are the ones signing up. Expanding coverage will help contain costs. http://www.BenefitStudio.com

  47. Just came “into the room” so to speak and find the Germans and Allies in the same old trenches.
    IMO there are more conflicting special interests in health care than in any other 5 industries put together.
    Nobody seems to want to take a completely fresh look at what should be a simple service industry w/customer and provider. Everyone else in the “primary conversation” wastes energy and money and leaves the customer and provider outside the decision process.
    All the voices in healthcare have been here too long… and are digging deeper into their trench or foxhole.
    What if everyone had a means to reimburse their provider for their health care services by themselves? Think about all the special interest voices that would go away. Don’t need insurance, don’t need government, and don’t need employers in the conversation. Just need customer and provider.
    See how quiet things become. If you care to listen I’ll tell you how we do it.

  48. “Speed is vital and a prolonged debate causes support for health reform proposals to decline as critics tear them apart.”
    Considering how fast the administration has moved so far, I think they understand this reality. Ready. Set. GO!
    It’s like snatching off a band-aid. Get it over asap and pick up the spilled milk later.
    ===================
    Changing topic somewhat, I highly recommend a guest post at Magie Mahar’s blog by a recently-retired physician. Somewhat longish and dry, but rich with content. Comments thread is even longer, but the author’s comments there are also worth reading, especially his insights and descriptions of the Mayo Clinic and its satellite operations.
    http://www.healthbeatblog.com/2009/03/a-guest-post-what-the-doctor-ordered.html

  49. There is an inverse relationship between the size of government and the level of morality, and personal and social responsibility of the citizenry. If the size of government continues to increase over time, what does that say about our society as a whole? What kind of wakeup call is it going to take before we stop and say “Damn, we need to stop screwing up or we will all be government employees”?

  50. Even though their lobbyists are still in town both Big PhRMA and Big Insurance are on the ropes. US Vox populi is thorougly fed up with them.
    This reality and the economic imperative to achieve reform will drive successful reform in 2009-2010
    The stars have finally alligned.
    Dr. Rick Lippin
    Southamtoon,Pa

  51. “Speed is vital and a prolonged debate causes support for health reform proposals to decline as critics tear them apart. And this debate will be about politics, not just policy. If a major bill passes, it will increase the popularity of the president and help the Democrats in the next election.”
    Both TARP and stimulus bill passed very quickly, with the ink still wet on the largely unread pages. Neither bill has done much to improve the popularity of those associated with them. Details overlooked in the rush to final passage (AIG bonuses, anyone?) are now coming back to haunt these who pushed them through. There are reasons why legislation goes though a careful and deliberate process, as it is simply less painful to fix a law before it passes. One circumvents these process and input safety mechanisms at one’s own peril.

  52. Great summary explaining why nothing of great import is likely to happen until Obama’s 2d term when re-election is not an issue. Major changes in our healthcare system will unfortunately require an unimaginable amount of political will, and an expense of political capital that will be unrecoverable in the short term–hence a second-term project if it is to be meaningful. While eliminating Medicare Advantage is a start, it is not a big deal overall, and even that will be tough at this stage.

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