Here We Go Again – Again


Last Friday morning, delirious, wasted, bone tired, driving home from the Emergency Room at 8AM in my beat-up little truck with only one speaker working. Amid all of us awash in the blogosphere thank the stars for NPR and professional journalism.  Steve Inskeep, from Morning Edition was interviewing Angela Braly, CEO of Wellpoint.  Perfect! Wellpoint is the largest health insurer in the U.S. in terms of covered lives. Also, Wellpoint, the former non-profit Blue Cross of California converted into a very profitable for-profit corporation, represents the epitome of for-profit medicine.

Mind you I’ve already thrown in the towel.  Any meaningful reform seems well past doomed. Harold and Louise are already back channeled through Newt and Sarah, and fringe lunatics are getting airtime, calling Obama a Nazi because they cannot understand the difference between National Socialism and Medicare. It would be comedy writ large if not for the gullibility of the American electorate. Oh well, here we go again.

The trouble is that our problems are so deep and fundamental that any sort of government driven health reform is destined to have limited impact despite the best intentions.  That’s what was so painful and profound about Inskeep’s interview with Braly.1 If we are going to even start to move this mountain we are going to have to foster change from within the system. That change is going to have to come from all of us as a society and as patients, families, health care providers, health care organizations, and influential health care managers and executives.

Newt and Sarah know the game they are playing – they’re politicians.  Their party is out of power and they are using opposition to health care reform to rebuild their base by any means necessary. Braly and her compatriots are a whole different animal.  They know exactly what is at stake.  Listening to the interview you might wonder how this ditzy soccer mom every got recruited to run a major corporation.  It’s uncanny.  She does not answer a single question.  What she does do, however, is illustrate what will essentially kill not only health reform but also real change.  What Braly does is deflect responsibility to everyone else in the system and not once acknowledge that not only do we have a problem but that we all share the responsibility for getting here – Wellpoint, Braly, and every one of us in health care included.

Braly’s no fool.  She is the third highest paid health insurance executive having been compensated $9,844,212 in 2008 by Wellpoint.2 Only Ed Hanway, CEO of CIGNA, and Ron Williams, CEO of Aetna, were paid more.  Wellpoint’s profit in the last fiscal year was close to 4% as even Braly admits, which is equal to or greater than the entire administrative cost of the Medicare program.  Inskeep calls Braly on virtually every statement she makes but as a pro, Inskeep just lets her dig herself in deeper.

I think I fainted.  I crawled out of the car and went in to go to sleep with it all blaring in my head.  My patient with gallstones diagnosed a month ago now with elevated LFTs and awaiting an ultrasound wanting to know if she could just go out a get a carne asada burrito and then come back for the test.  The Alzheimer’s patient who could not walk or feed himself or recognize anyone who fell out of bed and broke his hip and needed a hip replacement not only because he was full code, but because it is the only humane thing to do.  The health information systems we struggle with feigning silence when we know they are archaic and are killing our efficiency.  The practice variation and flaunting of evidence every one of us is guilty of as physicians.  The elderly couple with the husband with pneumonia who has to be admitted to the ICU with the wife pleading with us that the hospital copay will ruin them this month. The healthy forty year old female executive demanding a bone density test because she ‘paid for her insurance.’  The 340 pound 53 year old diabetic back again with an ischemic leg status post three resuscitations this year alone and over $125,000 in fully covered medical expenses now headed towards $175, 000.

Ms. BRALY: Our profit is in the 3-4 percent range – I think this year, around 4 percent. When you look, though, across health care, there are profit margins in a number of sectors around health care that are three, four, five times ours. If you look at biotech margins or pharmaceutical companies or device manufacturers, they’re three, four, five, six times the margin in the health insurance business. And the irony of that is it is our job to get to the efficiency of health care.

INSKEEP: There might be another irony there, as well, because if it’s your job to make things efficient and the cost of doing business keeps going up year after year after year, doubling in five years, as the president says, somebody might suggest you’re not doing a very good job.

The key is that none of us is doing a very good job but it’s too easy to point fingers and deflect blame.  I’m a pessimist about health care reform because I think the blocking and tackling have finally begun in earnest. I’m optimistic, however, about what we can and should still do even if we end up again with the status quo.

In that vein and with Matthew’s and the team at The Health Care Blog’s permission I am going to start a series of blogs called ‘Nuts and Bolts’ to talk about the incremental things we need to do no matter what happens in Washington. We need incremental changes throughout the health care ecosystem and while some need policy changes, others just need personal changes from each of us. The first installment will not be about ‘Death Panels,’ or policy, it will be about how critical it is for each of us to make our own decisions about our own lives and our own sense of death.  It will be called ‘Nuts and Bolts – Advance Directives.’ Then we can go from there.

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17 replies »

  1. Rick, Thank you for writing a thoughtful and action oriented article. I applaud your focus on nuts and bolts approach to reform, the idea of accountability and change from within the healthcare arena and viewing reform as a long term process. Most importantly I know you have skin in the game and see reform through the real world. And finally thank you for being an optimist. I recently wrote a Letter to my friends which i have posted on to help the lay person become involved. I look forward to your nuts & bolts blog. An appreciative reader, Oakleigh

  2. I meant all political funding Nate. Left, right, up and down under. This is not a partisan issue.
    Tim, I’m sorry, but I don’t quite understand your argument. Conservatives are regarding government as corrupt, but are still trying their hardest to become part of this corruption. What does that make them exactly? Better equipped to navigate the waters?

  3. “is to outlaw election campaign contributions from businesses”
    compared to Unions who only have the nations good at heart? How about Soros, now there is a stand up guy. I disagree with Margalit most of the time but I can’t believe she would be so openly politicial to try and cut of conservative funding while leaving the liberal funding base in place. I sincerly hope she meant all politicial funding and vote buying. Including Obama’s foreign credit card donars.

  4. MD as HELL,
    Government doesn’t have to collect money from us, taxpayers, to appease special interests. It creates a legislative and regulatory environment that can favor one group of businesses over others.
    What Margalit proposes, if I understand her correctly, is to outlaw election campaign contributions from businesses, who almost always expect a certain ROI on that money.

  5. “…people view elected government as a clunky, inefficient, corrupt institution that is not to be trusted to act in the best interests of the people it represents.”
    Congratulations. You just articulated perfectly the worldview of the founders of this country, and it remains the baseline conservative world-view, and it is our worldview despite what those in power say they intend to do at any given time. Which — though you might disagree with us in substance — is behind the resistance to healthcare reform, not some desire to protect industry profits, like the left likes to say in their knee-jerk demonization exercise.
    You say Obama has not done what he said he would do? Really? Really? We call that “government”; when we point out the probability of that continuing to occur as it has since the dawn of time, you call that “misinformation”. You think it is a recurrent aberration, which can be fixed if we just get the people with pure hearts into power. We think it is the human condition.
    “Misinformation”? No, a difference of opinion about that “power corrupts” thingy. The difference between us and you is that we’re not trying to talk about what is in this bill or that one; we don’t trust the people who are writing them or the people who will administer them or their heirs. So “death panels”, for example, was never intended to reflect the language of some bill or other; it was intended to express an opinion about what a certain government power is likely to become in the hands of future regulators. Disagree if you like, but it is lack of insight to project cynicism onto Palin for saying it. She was not lying, she was extrapolating your observations about the tendency of politicians to transmogrify their promises into something else. She has consciously assimilated the mood of your post into her political worldview, where you are likely to… recover.

  6. Margalit,
    The people never expected direct benefits from the country when it was hatched, because they were getting rid of an overbearing, oveertaxing monarchy that did not have their interests at heart. Now too many people want the government to be the babysitter, the equalizer and the provider. It cannot work that way.
    Special interests were nonexistant when the government had no power to grant favor upon special interests. Let’s quit giving the government money they should not have. Then you can vote again.

  7. Margalit,
    To me, the current state of healthcare reform reflects the fact that even though most of us agree on the general objectives, like covering the uninsured, improving quality and cost containment, we half-heartedly admit the need to make or accept certain changes at the personal level. It is like until both coasts go under rising water, and tornadoes become well too common in all parts of the country, we will eventually decide to get more eco-friendly and actually do something about the environment.
    There are quite a few bills going through House and Senate committees. The Kaiser Foundation website – – provides a tool to compare them. I assume you are talking about H.R. 3200. IMHO, it suffers from
    • lack of clarity as to what the healthcare industry has to transform into in order to better serve the needs of individual patients and the nation as a whole
    • lack of understanding that reform is a process, not a single step
    Actually, the administration has made a conscious decision to stay clear from the legislative process, I believe, for two reasons: to avoid the fate of the Clinton’s bill of 1994, prepared without any real involvement of Congress, and to maintain their “non-partisan” image. That did not work, though. The bill is being linked to Obama anyway, at least, this is how many Americans see it, and he himself has to defend it to get something passed by the end of the year.
    As for money in politics, yes, it still plays a huge role in every election campaign. I hope the Internet will gradually level the playfield, allowing new ideas and their bearers to become more visible to the public. In some respect, the last year’s presidential race showed that traditional media is losing ground to new media.

  8. I thought I could use html tags to bold the quotes. Hard to know what’s mine and what is quoted without that.

  9. Dr Wonderful, what planet are you on? “fully exempt from all anti-trust laws?” You seem to have no idea that big health insurers sometimes have to divest parts of their acquisitions, or fail to make acquisitions at all due to anti-trust concerns. See two recent cases with United:
    In December 2005, the company received final regulatory approval for its $9.2 billion purchase of PacifiCare Health Systems. It agreed to divest parts of PacifiCare’s commercial health insurance business in Tucson, Arizona and Boulder, Colorado to satisfy antitrust regulator concerns, and also agreed to end its network access agreement with Blue Shield of California. (from wikipedia)
    The Department of Justice announced today that it will require UnitedHealth Group Inc. (United) and Sierra Health Services Inc. (Sierra) to divest assets relating to Uniteds Medicare Advantage business in the Las Vegas area in order to proceed with Uniteds acquisition of Sierra. (PRNewswire)
    Maybe you once read that the Feds don’t have uniform blanket jurisdiction over anti-trust matters regarding insurance. That is true. The states have priority. Their anti-trust laws apply first, and only if a state fails to regulate some insurance area or activity, or fails to do so in a reasonable manner, do the Feds step in. But, obviously, that does not remotely mean that there are no anti-trust laws in health insurance. Also, the McCarran-Ferguson Act, which may have set you off, does not only apply to health insurance, but the “business of insurance” more generally:
    The McCarran-Ferguson Act was passed in 1945 and provides that the antitrust laws, including the Sherman Act, the Clayton Act, and the Federal Trade Commission Act, shall apply to the “business of insurance” to the extent it is not regulated by a state, and shall also apply to boycotts, coercion and intimidation. As construed by the courts. As interpreted by the courts, the law exempts the business of insurance from government and private antitrust liability, unless the conduct is unregulated by a state or goes beyond otherwise actionable restraints of trade to constitute boycotts, coercion or intimidation.
    It’s fine to argue that insurance shouldn’t be treated differently than other industries. It is not fine, in fact it’s embarrassing, for you to argue that health insurance remaings “the only industry in America that is fully exempt from all anti-trust laws.”

  10. Where is the health insurance and pharma blog where members are posting their ideas for cost-cutting reform plans? I would suspect it doesn’t exist.
    Let’s be real, our politicians have done a great job leading the public to believe that the ‘income incentive’ problem with health care costs sits with the ‘greedy test-ordering’ specialists and ‘inefficient’ primary care docs. There is very little mention of the growing profit percentages of the industrial health care complex. Simply put, their job is to make money with health care dollars, so whatever reform plan will work, it will have to rein-in this expression of capitalism. I would agree that competition in the form of laxed insurance regs, easing of antitrust, and competition with the government and drug pricing would all work well, but as Margalit states, the REAL reform requires a total overhaul of our campaign and political system. As long as special interest funding exists as it does today, there is no way we (ie the heatlh care providers) will ‘compete’ with pharma/insurance/hospitals.
    I too am discouraged.
    Post your plans at:

  11. What a great post!!! And how sad….
    I lost all hope:
    I started out in January this year wishing that President Truman would be able to observe our times somehow, because health care would be fixed in a few short months. We elected a charismatic President committed to the cause, gave him a mandate to make the needed changes and topped it off with a majority in both houses. Failure was not a consideration in my mind.
    So what happened? Why are we here today? Do the people really not want affordable care for all? Is this the Republican political machine trying to discredit a Democratic President with an eye to future political gains? Maybe, but that wouldn’t explain the terrible “blunders” made by the administration; the convoluted lengthy bills, the lack of one unified message, the strange statements released with pharma and insurers and hospital lobyists and the general involvement of these folks in everything.
    So after banging my head on every wall in the house and several desks (just kidding), I realized that all of us here on THCB and elsewhere are debating the symptoms, not the root cause disease.
    Failure to pass a decent healthcare reform bill is a symptom of our gravely ill political system.
    You just need to read a few of the recent THCB threads to understand that people view elected government as a clunky, inefficient, corrupt institution that is not to be trusted to act in the best interests of the people it represents.
    So whose interests does it represent? Personal aggrandizing interests of those elected and those appointed by them? Maybe, but that would not be enough to explain why health care cannot be reformed.
    It’s actually rather simple: “elected” officials represent the interests of those who enabled them to become “elected”, and it wasn’t the American people. It was corporate America. Corporate America is funding our “democratic election process” and therefore dictating its outcomes. We the people have no real voice or ability to influence the state of our nation.
    I voted for every democratic president since Bill Clinton and for some that never made it to the White House. I voted for Barack Obama thinking that he would be the one to buck the lobbying trend (he said he would). What a grand exercise in futility!
    What these people do once the campaign is over is an insult to every American that bothered to cast a vote.
    Unless we change our campaign funding laws and put an end to the selling of our politicians to the highest bidder, I will not vote again.

  12. Is is so sad that no one can see the massive pink elephant in the room. This pre-produced and manipulated campaign against resonable health insurance reform is clearly the work of the health care industry.
    One thing they are terrified of is actually having to compete like any other industry. As it stands now, there is no competition and they want to keep it what way. They’ve actually become a dormant insdustry just laying there while rivers of money flow passively to them. It’s actually very unhealthy for the country.
    How can this be? Well, it’s because they remain the only industry in America that is fully exempt from all anti-trust laws. Yes, that’s right. By law they are allowed to work togetehr, collude, and price fix. That is non-competitive to say the least. It also allows them to pull together and falsely inflate premiums and, oh my gosh, always refuse to show any real claims loss data to justfiy it.
    You really want to reform health insurance? Repeal their anti-trust exemption immediately and force them to actually compete against one another.

  13. Rick:
    As a health policy wonk, I must admit that my crystal ball shattered a few weeks ago as a result of an overdose of cognitive dissonance coming from both sides of the aisle and stakeholders of all type/sorts.
    What I am certain of is that with a few sentences, you have refocused us all on a critical-to-healthcare-reform strategy and tactic: “If we are going to even start to move this mountain we are going to have to foster change from within the system. That change is going to have to come from all of us as a society and as patients, families, health care providers, health care organizations, and influential health care managers and executives.”
    Thanks, I needed the nudge!

  14. Rick, there is already a website titled, “health care nuts and bolts” that is dedicated exactly to what you are proposing. The url is I created this site about six months ago to discuss the mechanics of medical cost management without the name calling we see in so much of the health care discussion. I am calling for guest posts at
    We do need a revolution as Dr. Kibbe states but first we need to get a discussion going. I have been trying to discuss “nuts and bolts” in this site for many months but unfortunately the political or self interest keeps popping up. There are too many angry people who would rather cast aspersions or name call, and not enough who want to really address the “nuts and bolts”. I, for one, strongly support your effort.
    Health care reform will ultimately depend on a bottom up approach since without realistic methods for controlling costs there can be no real reform.

  15. Rick: Really wonderful and poignant post. I, too, heard the Braly interview on NPR, and thought: if people in positions of power are going to continue to be this self-serving and protective of their medical profiteering, it will take a revolution to change the system. Thank you for dissecting her 1984-speak. Regards, dCK

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