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Health Care Outlook Not Improving

 Sen. Max Baucus (D-Mon) released his much-anticipated healthcare proposal Wednesday morning.

Sen. Max Baucus (D-Mon) released his much-anticipated healthcare proposal Wednesday morning.

The next big test for a health care bill in 2009 (notice that I did not call it health care reform) will come in Senate Finance.

The
final vote in that committee will tell us a lot about whether the
Democrats have any chance for 60 votes in the full Senate. So far, it
does not look good.I have the greatest respect for Senators
Baucus and Grassley and their good faith efforts to find a bipartisan
health care solution. But I also think their efforts were fatally
flawed from the beginning.I think the problem is that Baucus
and Grassley were trying to bridge the wide chasm between liberal and
conservative ideas. Finding the fine balance necessary has created an
unwieldy compromise—no one is happy. Most striking, the compromise
reached between cost and premium subsidies has yielded an $880 billion
bill that requires middle class people to buy health insurance they will in no way will be able to afford. On top of that, the policies have big deductibles and out-of-pocket costs.

As
I have said on my blog before, we cannot do something as big as
health care reform without bipartisanship. The American people will
never be comfortable with one side’s proposals so long as the other
side is taking shots.Any successful health care effort will need political cover from at least some respected members of the minority party.This
health care effort has occurred on one side of the political spectrum.
Grassley and Baucus tried to bridge a wide chasm between the
conservative side and the liberal side and were only able to build a
rickety bridge across it that, it would appear, Grassley can’t even
sign onto.To get this done, we will need to build a consensus
on health care from the middle and then build out. We need to start
with the things everyone can agree on and then push simultaneously as
far right and left as we can go and still hold a consensus.I know I have said this a few dozen times before on this blog, but Wyden-Bennett is an example of that middle-out model.You might respond that Wyden-Bennett is off the table.Have you noticed the growing number of times that name keeps coming up?

Robert Laszweski has been a fixture in Washington health policy
circles for the better part of three decades. He currently serves as
the president of Health Policy and Strategy Associates of Alexandria,
Virginia. Before forming HPSA in 1992, Robert served as the COO, Group
Markets, for the Liberty Mutual Insurance Company. You can read more of
his thoughtful analysis of healthcare industry trends at The Health
Policy and Marketplace Blog
, where this post first appeared.

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58 replies »

  1. There are those of us who have nothing to gain politically or business-wise. That would Not be Most of who is working on the healthcare failure.
    This appears why we are getting solutions prior to understanding the problem– and it’s Cause.
    This is not working, and can’t work again. Isn’t it obvious this is how we got to our existing failure.
    No one wants to hear that those working on this problem argue over solutions that would benefit themselves or their deals. Its about Image, big business, politics.
    It only appears intelligence failing. It’s just intelligence applied wrongly, with a little too much SELF in it.
    The cause is quite simple and laid out plainly at:
    (http://HealthcareHurts.blogspot.com)

  2. Social security is going to be bankrupt soon and they say Medicare costs will make it too expensive to run as well. Everyone is going to pay more money for less healthcare. You can believe whomever you want but this is just another money grab by your federal government so they can shift the money to whatever programs they think it needs to go to. Nevermind if you happen to be one of the people who needs medical treatment. How long are you going to keep letting your government take away your liberties?

  3. I must say that I’m terrified by the idea of forcing everyone to buy insurance at the point of a gun. Let’s not sugar coat it, if you choose not to buy health insurance in MA and don’t pay the fines, you will ultimatly face an officer with a gun.
    As a healthcare provider I see the duplicty and outright lies of the insurance industry everyday. Having health insurance no longer means having access to healthcare. All it means is that some faceless company somewhere is spending your money on quarterly executive bonuses. Meanwhile your’re left scrambling to pay for a non-covered service because you didn’t have an attorney review the policy before you signed on the dotted line.

  4. Jacob Hacker is not an economist, he is a political scientist, a very astute and knowledgeable one at that, but still not a professional economist. Read Uwe Reinhardt’s works, professional or for the layman, or Robert Evans’ (Canadian) or Victor Fuchs’ or those by many others, for good analysis.
    Mr. Laszewski consistently and regrettably writes drivel on this topic, reflecting unfortunately the apparent need to keep income flowing from his advisory practice that evidently caters to private insurers.
    On the topic of the most basic analysis, take a look at Prof. Reinhardt’s analysis of WellPoint’s income statement published in the NYTimes http://economix.blogs.nytimes.com/2009/09/25/how-much-money-do-insurance-companies-make-a-primer/#more-33027 Nothing complex there.
    To simply the analysis much more. The ratio of the excess of revenue to benefits costs divided by revenue ranges from about 22% to 26% for the three years shown. Subtracting the 5% or so that Medicare incurs for administration leaves about 19% of “wasted” or “valueless spending”.
    Applying that to the $1 trillion per year financed by private insurance yields the reasonably accurate figure of $200 billion yearly in valueless spending simply because private insurers exist and are allowed to insert themselves as intermediaries in the flow of funds. They exist because laws passed by Congress mainly since WWII have permitted them to exist, but for no fundamental economic reason.
    The residents of the USA collectively bear this waste of resources with essentially no say on it, despite the obvious fact that Congress – which has created the legislation – is nominally supposed to represent those people, at least the citizens among them.

  5. Oh please. Republicans won’t sign on to Wyden-Bennet anymore. At what point do you acknowledge that the Republicans aren’t going to back ANY health care reform this year?

  6. have I just not noticed it before or are economist suddenly the witch doctors of healthcare? Besides politicians and journalist I have never seen a speciaility of people blab more on something they have no understanding of. And worse yet been given so much creditability. They obviously don’t teach these clowns in school the economics doesn’t exist in a bubble free of all other reality.

  7. Gary O contrary to your assertion and the drabble written by Hacker who obviously has never negotiated a hospital contract your both clueless. It doesn’t matter if you are the only insurance company in town, if there is hospital monopoly or duopoly you have no power. He’s an economist, who cares what he says, he doesn’t have any experience or education in the matter. If he told you one surgery was cheaper then another would you let him do your operation?
    Hospitals have all the power unless there are enough health systems in the area to play them against each other. If the insurance company can’t reach an agreement with the hospital the hospital is not forced to sign anything, they can then charge all patients covered by that insurer full price. It only takes a remedial education to see who dictates terms in this situation. There are very few areas, I can think of only 1-2, where the insurance companies can dictate pricing to hospitals by threatening to move admissions.
    Hospitals have done a brilliant job at castrating insurance companies. Even if they don’t have common ownership they create systems and alignments, this means where insurance companies use to be able to bully some small independent facility now that facility is “partnered” with the major hospital in town and they negotiate together. You can’t pick off the weak to create leverage against the strong. The other thing they did was bring the rural and suburban facilities into their systems. Usually these are the only facility in that town so you are forced to work with the entire system on their terms or you have no coverage outside the metro area.

  8. Actuary,
    First, I pointed out that there is concentration in the health insurance market to show that the large carriers will naturally fight to maintain their dominance and that Senator Baucus and his senior aide who is helping draft the Finance Committee bill have deep ties to that industry.
    Secondly, and somewhat aside from the first point but in answer to your point about hospital concentration, the insurers have used their concentration to increase their own profits without using their weight to tamp down hospital costs. I’m sure you have read economist Jacob Hacker’s The Case for Public Plan Choice in National Health Reform: Key to Cost Control and Quality Coverage, which, inter alia, discusses concentration in both industries:

    The consolidation of the private insurance market over the last two decades was widely expected to bring down costs. (In 16 states, the dominant carrier accounts for at least 50 percent of private enrollment; in 36 states, the top three carriers account for at least 65 percent of the market.33) Yet it obviously has not. Instead, private plans are passing on rising costs to individuals while increasing their profitability. The reasons for this are multiple, and they go to the heart of the argument for a public plan alongside private plans.
    First, the hospital market has grown increasingly concentrated, giving providers considerable market power of their own in negotiations with insurers. In areas where hospital concentration has proceeded farthest, the evidence suggests, hospital prices and profitability are higher without commensurate increases in service quality.34 Second, private insurers appear to have largely acquiesced to these price increases. [Emphasis added.] As John Holahan and Linda Blumberg explain, “Dominant insurers do not seem to use their market power to drive hard bargains with providers . . . . Competition in insurance markets is often about getting the lowest risk enrollees as opposed to competing on price and the efficient delivery of care.”35 Both of these trends provide strong reason for doubting that private insurance payments are the appropriate standard for public payments. (p. 8)

    Contrary to your assertion, the concentration argument is not “phony.”

  9. Gary O. To get back on track, I agree with Rob MDs post of Sept 16, 12:34 except in 4. strike “insurance plans” because insurance plans attempt to keep costs down … if anyone disagrees with any of his proposals, why?
    So I guess you aren’t lying, you (like many who haven’t been involved in this area for 20 years) just need to read some respected journals regarding the economics of health care instead of relying on some windbag politicians (redundant, I know).
    You state:
    “In only three state markets do the largest three plans control less than 50 percent of the total enrollment, and in only fourteen do the largest three plans control less than 65 percent.” I won’t hold my breath that you will be doing any retracting.”
    Large market share concentrated in a few insurers is NOT correlated with higher cost. However, large market share concentrated in hospitals IS associated with higher costs.
    The concentration argument is a phony: Only three grocery chains control over 50% of the market where I live, and only 3 or 4 auto makers control over 50% of the market in most of the US, and like health insurers, they are all very low margin businesses (in auto, negative margin).
    Do you have any idea how little the profits of health insurers impact overall costs? Also, do you know that there are many health insurers that are not investor owned? This includes BCBS of Alabama (with its 90% market share), a state below the national average for health care costs.

  10. So you think dieing people should be denied the right to cash in their life insurance early becuase it nauseates you?
    This must mean you are also morally opposed to reverse mortgages that also are contingent on the death of the home owner.
    Is there any limit to how much you will impose your personal feelings on others? tens of thousands of ieing people felt they where a good deal for their sitution. Hundreds of thousands made the personal decision that a reverse mortgage was in their best interest.
    Why is the left so opposed to letting people live their lives the way they want? Do you have to control everything?
    It’s administered like any other loan by the way. In its simple explanation that all this is, they loan you $x and you pay it back with the proceeds of your life insurance policy. Let me quess you find the whole concept of loans and charging interest offensive also? After the insurance companies should we get rid of the banks and credit unions?

  11. Let me amuse you, Nate.
    I find it nauseating that a whole bunch of investors would buy securities that do better when people are dying faster. How do you track that investment? By watching live stats of the death ratios? Maybe a forecast of near death percentages? And you sit there watching the computer screen wishing that they freaking die faster because you need to sell some securities today?
    Here is an idea. Maybe the health insurance companies should buy a bunch of these securities and deny/postpone treatment to the dying folks so their investment value goes up. Endless possibilities here, don’t you think?

  12. “life insurance is really a savings mechanism”
    No it is not, life insurance is really a risk transfer to protect your family, business partner, or other interested party from your unexpected death.
    Just like life insurance protects from the unknown time of a known event, death, true health insurnace protects from the unknown timing of getting injured or ill, that is why it doesn’t work when people wait till they are injured or ill to buy it.
    Please amuse me and tell me why securitization of Viaticals is a joke. Your starting to act like Peter running on and bashing things you don’t understand. Let me give you a quick education and you tell me which part of this bothers you so.
    Terminally ill person has a life insurance policy for 1 million. They would like to have access to that money before they die, maybe to pay bills or to enable them to spend more time with family. They sell the policy to an investor who pays them a portion of the face value depending on how much longer they will live. This has been done for decades, there are few companies buying them though and the payouts could be better. Lack of competition drives pricing down.
    Enter Wall Street who has unlimited money to invest. Their are also thousands of investors. They now want to compete for the right to buy these peoples policies. They will pool them together and spread the risk of any one person living longer. When risk goes down the payout to the dieing person goes up. Between the increased competiton of investors looking to buy the same policies, less risk, and standard pratices those about to die will now have more options and receive a greater payout.
    So Peter, er I mean Margalit, what about this rubs you the wrong way? You don’t think dieing people should get more money before they pass away or you don’t like capitalism at all?
    Other Peter,
    typical drabble, there is a difference between offering a social service to a small percentage of the population, food stamps, and being a communist, central planning and control over all food and it’s rationing. I highly doubt you understand it nor are capable of grasping it. Just know there is one.

  13. I have the greatest respect for Senators Baucus and Grassley and their good faith efforts to find a bipartisan health care solution.
    “Good faith?!?”
    What planet did you write this from, Robert?

  14. “Everyone dies so why is life insurance not a social service?”
    Why would you need a social service if you’re dead?
    “Everyone gets sick why is disability insurance not a social service?”
    If we could run our healthcare system away from a profit-off-the-sick system at 1/2 the cost like other industrial nations do and eliminate co-pays and deductibles for serious illness then people may be able to afford disabililty insurance or not need it at all.
    “Everyone gets hungry, want to make that a social Service?”
    Actually it is, they’re called food banks and food stamps. You don’t see many insurance execs at food banks.
    “Place to stay…”
    Actually that’s a social service too Nate; housing assistance for the poor.
    “Lets discuss the governments success in delivery of social services”
    Let’s discuss the corporate sector’s success in delivery of social services. If we could get corporate (and wealthy) America to stop demanding tax breaks, subsidies and bailouts that take money out of local communities then we could spend that money delivering better social services.

  15. Gary those stats are very misleading. TO start with 50% + of all people with employer based coverage are covered by a self funded plan. In that case the insurance company is actually the employer. That fact alone disroves their claim. If you are discussing provider network monoply power it is a valid fact, if your discussing insurance company monoply power not so much.
    Margait,
    Everyone dies so why is life insurance not a social service?
    Everyone gets sick why is disability insurance not a social service?
    Everyone gets hungry, want to make that a social Service?
    Place to stay…etc etc I could go on for other.
    Lets discuss the governments success in delivery of social services….I rather keep my health care private thank you.

  16. Oh, this is so perfect….
    Nate, Actuary, you are just convincing me more than ever that health care should be totally and completely devoid of “insurance”.
    Insurance is for stuff that may or may not happen – house burning down, car crashes, share holders bringing a law suit….
    There is no “maybe” in health care. Everybody will be needing it, some more, some less. It’s a social service and it should be treated as such.
    A public “option” is not nearly enough…..

  17. Actuary,
    Need to call you out about your assertion that I “either have no clue or [am] deliberately lying – particularly about health insurance companies.” You failed to offer any refutation to any of my assertions, including that about high market concentration in the health insurance industry.
    Yesterday, Factcheck.org issued a Retraction of its September 10 criticism of the President’s characterization of market concentration. Factcheck.org found more than one study to show that President Obama had “understated” in his speech to Congress that in many U.S. states the health insurance market is controlled by just a few companies. The retraction also pointed to a study that found that the “top three firms typically dominate each market. … In only three state markets do the largest three plans control less than 50 percent of the total enrollment, and in only fourteen do the largest three plans control less than 65 percent.” I won’t hold my breath that you will be doing any retracting.
    Thought you might want to add Senators Wyden and Bennett to your list of “liars.” Senator Wyden was interviewed today by Dylan Ratigan. Video. Partial transcript:

    Ratigan: Why are people in Washington, D.C. so terrified to unleash the natural forces of competition in health insurance as we have unleashed it in every other major industry to tremendous success for this country.
    Wyden: Ultimately the status quo caucus led by the powerful insurance interests don’t want this kind of competition. They are slicing a fat hog and I had a chance, with Senator Bennett of Utah, to be with the President yesterday. And in effect what we were saying is “Look, you can’t change the American health system, you can’t hold insurance companies accountable, you can’t protect taxpayers, you can’t get premiums down, without choice and competition.

    Yah, yah, I know he was try to sell their own bill, which would end employer-based insurance, but the fact remains that those two senators also recognize that we are sorely missing viable competition in the health insurance marketplace and that our corporate masters will fight tooth and nail to continue their domination.
    What motivates you defend such outrageous anti-American conduct while our own people are suffering? Oh, I think I know.

  18. Look how well it worked when we removed the financial penalty for women on welfare to have kids, now they want to do the same thing with insurance.
    If they are going to force health insurance to be gender nutural then I want a refund on my auto insurance which has always been 2x or more higher then a females.
    while I am up here on my soap box I also want free admission and $1 drinks before 12.
    Peter you might want to look up what an actuary is before you run at your mouth, who am I kidding run at your mouth and I will correct you. The science of determing risk for various classes of people has nothing to do with profit. When they calcualte mortality tables do you think they skew them so they can charge people more?
    profit is a function of the load built into the rate which has nothing to do with expected claims. When you underwrite you calcualte your expected claims plus trend then add fixed cost, profit, and any other loads.

  19. “Actuary, you are proof that applying insurance mindset should have nothing to do with providing healthcare. Healthcare is not about “if” something will happen, it is about “when” something will happen”
    Peter, insurance is about the “if”, as in, if I have a costly illness, my insurance will protect me (and my family,if applicable)from financial ruin.
    The math is to try to have everyone (actually only truly applies to individual insurance) pay an amount of premium based on their expected claim cost. Even then, State Insurance regs do allow some protection against overaggressive insurers.

  20. Actuary, you are proof that applying insurance mindset should have nothing to do with providing healthcare. Healthcare is not about “if” something will happen, it is about “when” something will happen. I know that actuaries would love to apply all sorts of pool dividing math, descrimination and research to maximize premium profits, but healthcare should not be about dividing the pool, it should be about including everyone in the pool and then finding ways to make the pool less costly.
    Med Insurance, I won’t disagree about obesity, but how would you get “big government” to act to solve obesity?

  21. This country will never have affordable healthcare until it starts to deal with the real problems behind the skyrocketing healthcare costs. 40% of Americans are obese, the obese population spends 77% more on drugs than people of normal weight!
    Compare this to Japan where the obesity rate is 3%!!

  22. Actuary, would you also like ethnic discrimination to separate costs?
    I am just pointing out that women will now be charged more at ages 60-64 to “correct” this supposed “wrong”.
    Most other insurances (car, life, annuity)use gender as a rating variable, and rightly so.

  23. The Republicans have no interest in cooperating. They are doing everything they can to make sure that Obama does not get a legislative victory so that they can portray him as an ineffective leader. So this has little to do with compromise between opposing views on health care. Any credible individual that has read anything about this issue knows that the cost of our health care system is a severe crisis. The Republicans are scared that Obama will sign good legislation that he initiated so they are doing everything they can to destroy the effort to do something that would actually benefit this country. Good going Republicans…I don’t know how you guys sleep at night.

  24. “Let us all individually self ensure or re-insure for those benefits not covered and make it a personal accountability.”
    Would that include end-of-life care RobMD?
    “Let physicians with patients and families determine if an aggressive therapy is appropriate for their age and disease burden…”
    Would that also apply if patients didn’t self insure for end-of-life care?
    “Let the profession and oversight third parties respond to professional abusers.”
    Would the third parties include trial lawyers and their clients?
    Actuary, would you also like ethnic discrimination to separate costs?

  25. I truly believe that these new bailout and healthcare plans are designed to make my head explode. That would silence at least one American’s concern and voice of opposition.
    Now on top of the announcement that charges for the existing Medicare plan will be raised, thereby reducing the SSN payment, Sen. Baucus wants to reduce Medicare/Medicaid and force me to pay for more insurance as I enter retirement age.
    After paying the maximum SSN tax since 1974, being told I was paying for my “secure” future, he thinks this would be a fair arrangement.
    Before I will ever take any new plans seriously, I have one issue:
    “When you replace my retirement and healthcare options, will you and all the hundreds of thousands of Federal employees join me in the same exact new plan? Or will you continue to separate yourselves from the vast majority of hardworking Americans and continue to belong to your private ‘Cadillac’ plan, funded yet again by my tax dollars?”

  26. Here is my movie critic-sytle rating of these posts.
    Rob MD — very knowledgable, has obviuosly thought about this and proposed some excellent solutions. Many of these have been out there and Obama and the dems have disingenuosly said “bring me your ideas” but they won’t listen, parhaps because they are bought and paid for by the trial lawyers.
    His response is in itself worthy of its’ own blog.
    Nate — knowledgable and fiesty,as always. Will probably start his own “CO-OP” to keep insurers “honest”.
    Peter, Greg , Gary O. – three ideologues who either have no clue or they are deliberately lying – particularly about health insurance companies. They are the “birthers” of the left wing.
    _______________________________________________________
    Just one part of this “debate” that shows the dems are completely clueless. The health care bills all disallow “gender discrimination” and insurers will have to charge men and women the same rate.
    This is all done because women have supposedly been wronged, even though rates are based on claim costs (something Peter, et.al. does not seem to understand).
    One problem, in the 60-64 age group, men currently pay between 10-15% more than women, so now women will be charged more at these ages.

  27. Nate brings up many good points & counterpoints but he also refuses to acknowledge the irrefutable downside to have incredibly high OOP expenditures for health care (e.g., people skipping treatment, increased self-medicating, etc) or the fact that infrastructure, information on quality and pricing, and others things really needed to make a high-deductible plan potentially really work as advocated don’t remotely exist in the US (nor really any country in the world).

  28. Clearly y’all have not been intimate with high cost claims payers are seeing today. $1-2M dollars per hospitlalization is not uncommon. Consider the 30M to treat 8 premature babies in California. Only the very wealthy will be able to override “worthiness” rationing as seen in England-but is even more difficult with our cost model of health care delivery. Americans do not want subjective Qaly metrics applied to a more vital aging society. They would rather have it all and for free (human nature), but if having to ration desire it to be blind to social value. Let us all individually self ensure or re-insure for those benefits not covered and make it a personal accountability. We cannot have infinite wishes fulfilled in a finite world–trying to do so will drive us into third world status.
    As Qaly leads one to the conclusion that a dog may have more society value than a human being with age and disease, I want off this planet. As seen in Germany who promulgated Qaly to the extremes, it can lead to a very sad day for humans indeed.
    Let physicians with patients and families determine if an aggressive therapy is appropriate for their age and disease burden–not some arbitrary rule that can be abused. Let the profession and oversight third parties respond to professional abusers.

  29. Replacing a good idea of a public insurance option with a few non-profit co-operatives that would be expected to compete with a cartel of giant for-profit insurance companies is ludacris.
    There is a tremendous consolidation in the health insurance industry over the past 15 years. A cartel of very large for-profit insurance companies dominates the industry.
    One out of every three Americans is enrolled in some kind of plan offered by just seven of those large companies. And almost all metropolitan areas in the country and states that are more rural than urban are now dominated by just two or three insurers.
    To be sure, health insurers take every opportunity to badmouth co-ops, saying they are a backdoor to socialized medicine. They would love to have a bill that creates co-ops that won’t work instead of a public option plan.
    Don’t forget the Blue Cross/Blue Shield movement, sharing some of the characteristics of cooperatives, eventually became more and more like their for-profit competitors. Many of the largest Blue plans became for-profit and those that didn’t are largely indistinguishable from private, for-profit insurers; skyrocketing rates, high-deductibles and co-pay plans.
    America has granted insurance companies the right to create bottlenecks in the financing of health care in order to extract profits out of the suffering of ordinary people, without providing any actual health care whatsoever.

  30. Nate–in 1969 I paid my own college tuition with money from a summer job–$520 a semester. Likewise, healthcare bills in ’65 are a far cry from 2009. Half of a bill then is a heck of a lot less than a 20% co-payment now. If we don’t change what we pay for, and how we pay for it, we will go bankrupt irrespective of the system’s structure. Single vs. multi, private vs. public is not what will win this game.

  31. Rob MD, I don’t see how you separate rationing based on “worthiness” from rationing based on economics.
    People that can afford to, will override the QALY rationing and pay for treatment even when they are judged “unworthy”. The poor will be the only ones subject to “worthiness” evaluations.
    So we’re back to economic rationing, but with a method to the madness.

  32. This new bill doesn’t look to bad. Forces people to buy insurance but doesn’t impede to badly on the markets methods to deliver it. From what I haev read still very poorly written as it leaves way to much open for interuptation by staffers later.

  33. “On top of that, the policies have big deductibles and out-of-pocket costs.”
    Why is this bad? In 1965 American’s paid for half of all their care out of pocket. No or low deductibles and low OOP doesn’t save money, it just inefficiently moves it from one pocket to the next. Either through insurance premiums or taxes you still need to pay the bill. Insurance and taxes add a minimum 20% to the cost, there is no logical reason to have low deductibles and OOP.
    “Why do we need bi-partisan when 70% of the public want what the Progressive Democrats want?”
    Because 70% never wanted what progressive democrats propose. While 70% might like a free government plan paid for by other people Progressive Democrats have no ability to deliver that. What PD can deliver is another Medicare which is unsustainable and bankrupting our systems.
    “I think that would do it and it would be a better world with less corruption now present in our current system”
    Rob is right about the waste and corruption, I lost track of the new regulatory requirements in the new bill, the last things we need is another agency to ask approval from.
    “It does not attempt to determine medical care by “worthiness” but by medical need which recognizes healthcare as a scarce resource.”
    Peter that is how the left sells single payor, what Rob outlines is how it really works. It would be nice if the public is told the truth unlike the way the left passed Medicare.
    “bare-bones, high-deductible policies”
    OH NO Greg you mean to tell us insurance policies might actually look like insurance. That can’t turn out good.

  34. I have the greatest respect for Senators Baucus and Grassley and their good faith efforts to find a bipartisan health care solution. But I also think their efforts were fatally flawed from the beginning.

  35. ” Just allocate more money and pay more subsidies at higher incomes.”
    Dan, I didn’t think this process was about more tax dollars to patch a broke and overly expensive and corrupt system. Simply not sustainable.

  36. Senator Baucus’ Insurance Industry Profit Protection and Enhancement bill is an absolute gift to the health insurance industry. Wendell Potter’s Congressional testimony stated that the Baucus plan would create a government-subsidized monopoly for the purchase of bare-bones, high-deductible policies that would truly benefit Big Insurance. No wonder there was a chorus of disapproval from both the left and the right. Potter saw for-profit insurers hijacking our healthcare system, and paid Senator Baucus to do it for them.

  37. There are problems with the Baucus plan, but not that it “requires middle class people to buy health insurance they will in no way will be able to afford”.
    The following is from page 7 of the plan summary on the Senate Finance site [http://finance.senate.gov/press/Bpress/2009press/prb091609.pdf%5D.
    “Exemptions from the penalty will be made for individuals where the full premium of the lowest cost option available to them (net of subsidies and employer contribution, if any) exceeds ten percent of their adjusted gross income (AGI)”
    What this means is that those facing premiums above 10% of income would *not* be required to purchase health insurance. Their problem instead is that they may not be able to *afford* insurance. This is a major reason why the CBO coverage estimates for legal, nonelderly residents under the Baucus plan is only 94% [http://www.cbo.gov/ftpdocs/105xx/doc10572/09-16-Proposal_SFC_Chairman.pdf, page 5].
    The good news is that no structural changes to the plan are needed to fix this problem. Just allocate more money and pay more subsidies at higher incomes. The bad news is that maintaining deficit-neutrality means additional revenue-raisers or compensating cuts.
    There’s a long way to go in this process, and I would be surprised if there weren’t *some* increase in subsidies to reflect the more progressive policy preferences reflected in the other bills and in the majority of the Democratic caucus.
    But after we work as hard as we can to get as much as we can, we probably have to accept the reality that we won’t end up with a true universal-coverage bill this year. It’s just too expensive in the current political/economic environment.
    If so, we’ll need to work for additional funding for the final increment of coverage in the future — hopefully in better economic times. That’s an approach Ted Kennedy would understand.

  38. Robert Laszewski- You are again underestimating the power of personality of our new young President (on a recent roll) and the extensive e-network of people who voted for him.
    You may have been inside the beltway a bit too long? (Your bio above says “fixture”)
    I believe the Dems are prepared to go with reconciliation process. The moment has arrived.
    Dr. Rick Lippin
    Southampton,Pa

  39. @Darrell M:

    If you are an American, you would never allow the feds to control health care in any shape or form.

    So, you would rather allow the insurance companies to continue their stranglehold on the entire health care industry? Ninety-four percent of the health insurance markets are currently controlled by a few companies. If you are an American, you would recognize that our federal government is the only agency that can effectively force them to compete, to become less wasteful and to make a system that works for everyone. (Think T. Roosevelt who took on the railroads, Standard Oil, and the food processing industry.) We need a bill that will give us a real choice of health insurance plans so that if you are not treated right by your insurance company, if costs keep going up or if quality keeps going down, you will be able to vote with your pocket book.

  40. RobMD, I did not separate by age. My wife is a neonatal nurse who knows about costs and outcomes. This system can give you a functioning child but the larger system will not help to give the 24/7 care support needed or the life care and support needed by these preemies who can have life long health problems and the support for families who provide the care, of which many get divorced because of the strain. My mother (a Canadian citizen) was a resident in a government assisted old age home there which included full government paid for healthcare. NOT ONCE was her care compromised or her life subjected to “worthiness” evaluation. We did however have a living will for her which did aid in her own directed end-of-life care. The so-called “assisted euthanasia” charge is false and presumes that a person should not determine their own end-of-life depending on their suffering. Nothing in single-pay trades dollars for life, but there needs to be in any system a way to evaluate how scarce dollars are spent. You would be in awe at the compassionate government supported treatment of the aged in Canada, and probably Europe as well.

  41. If anyone believes that the politicians can put together a bill that can address the shortcomings of the current system, you’re in for a big surprise. In any event, to hand over such a big part of our economy and something that has a huge effect on all of us is just completely insane. Republican, Democrat or Independent; it does not matter, you should cherish our Constitution for the mere fact that it limits the powers of the federal government. If you are an American, you would never allow the feds to control health care in any shape or form. It’s all about power over the people in the end. A nice straightforward bill that addresses those without health insurance would be nice, but without throwing everybody into the mix to pay for it, it just want happen.

  42. Peter–I specified government single payer. So far, when it is the government (as in Europe), all depend on rationing based on society value of the person (e.g. age limits on ERSD, assisted euthanasia promoted, etc). The savings of either a single payer or a free market model would be used to assist in insuring the working poor (the true uninsured) while reducing the yearly trend lines on the cost of care. Peter, you should know that even that the majority of healthcare spend it on the aged, disease ridden, that the trend is mostly attributable to the application of unnecessary technology to the lower aged, medically inappropriate ranks (Imaging, Rx, etc).
    Rationing in all models must occur in that we have a population with infinite needs (and physicians willing to serve) and realistically have finite resources. I prefer one done on pure economics. If cuts need to occur, then cut all ages, i.e., remove a benefit from all. If one needs that benefit, they will have to be accountible to self insure. I have seen your model, and it does not attend to the fundamental drivers of our cost inflation or alignment of incentives nor clean up the corrupt self referral business.
    We must not delay on educating Americans on the correct concept of rationing while avoiding the issues embedded in Qaly as feared by our Seniors who’s generation we owe so much–fought the Wars and paid the most for our social programs.

  43. “I believe either a single payer governmental run plan with its attendant care/service rationing on a human value (wothiness)basis”
    RobMD, you have a distorted view of single-pay, of which I am an advocate. It does not attempt to determine medical care by “worthiness” but by medical need which recognizes healthcare as a scarce resource. Worthiness would require determination of a person’s benefit to society in order to get NEEDED medical care, of which single-pay does not determine. Single-pay does not care if you’re rich or poor, smart or dumb. Tell me how an uninsured who requires a transplant and must pay an upfront fee of upwards of $100,000 does not apply “worthiness” to medical care.

  44. I think the problem is that Baucus and Grassley were trying to bridge the wide chasm between liberal and conservative ideas.

    Give me a break. Baucus advocated no “liberal” ideas at the table; Baucus carries water for the health insurance companies. It has flooded his campaign coffers and continued to shovel it his way at the same time he was supposedly trying “to find a bipartisan health care solution.” (See WaPo article “Industry Cash Flowed to Drafters of Reform: Key Senator Baucus Is a Leading Recipient” ) His senior aide who directs the Finance Committee health staff in writing the bill was the VP for Public Policy and External Affairs at Wellpoint before rejoining Baucus in 2008 in time to help author the bill. (See “The Wellpoint/Liz Fowler Plan”.) Insurance companies profit from denying care. We need an alternative plan that will take care of people.

  45. The crazy thing is the Grasserly (certainly no moderate
    Republican senator along the lines of Snowe or more recently Chafee) is now being considered “too liberal” in Iowa and likely is going to have a tough primary campaign next time around.
    He knows healthcare issues inside & out and likely would have been a guy who could have found some sensible compromises but has to look tough for his conservative base on the healthcare reform bill.

  46. I believe Peter and others are correct in that no fundamental operational or financial model change seems on the agenda–it is pure insurance reform without moving us towards a more affordable model.
    However, not being an ideologue, I believe either a single payer governmental run plan with its attendant care/service rationing on a human value (wothiness)basis OR a free market solution with rationing on a purely economic basis can work. Today we have neither.
    I prefer the later and so do the American people in particular the Seniors who in America are not willing to disadvantaged by age and disease burden (since our Seniors have paid more into Medicare than anyother generation and in general Americans do not embrace Qaly yet).
    To achieve optimal competition with today’s entrenched stakeholders, the following would have to be at least achieved:(the objective is to align incentives, reduce unnecessary cost, and optimize free market dynamics)
    1. National Tort reform , e.g. California’s Micra (actually reduces direct and indirect unnecessary costs and removes excuse to order defensive high cost testing-allows us to hold providers accountable for non evidenced based testing, Rx, etc)
    2. Allow cross state lines insurance sales–this seems to me also unconstitutional at its core
    3. Repeal the Certificate of Need (CON) which is now used as a “License to Steal” in many states by hospital systems).
    4. Deconsolidate all provider groups (especially hospitals and insurance plans) to minimize leveraged negotiations as exists now which is highly inflationary
    5. Enforce Stark laws and go further where no physician or family can have any interest in any ancillary or in office testing. Allow them to be professionals only
    6. Plan a “re-birth” of Primary care to achieve 75%/25% ratio of PCPs/other specials by numbers. Non PCP drive the unnecessary testing (high cost imaging) and PCPs should be held accountable for practicing to their limit of training, experience, and comfort. All of this will take a re-allocation of the pot of money now for physicians to attract PCPs to take pride and value again their position/mission in the health delivery system. Specialty training slots would have to be highly regulated to enable this.
    7. Outlaw DTCA which is bad medicine and drives unnecessary costs to consumers. Same with Pharma detailing and grants to physicians except for issues re: academic (real) research.
    8. Enhance public awareness campaign re: evils of technology inappropriately applied–must change publics embrace on diagnostics.
    I think that would do it and it would be a better world with less corruption now present in our current system

  47. ” requires middle class people to buy health insurance they will in no way will be able to afford”
    Isn’t that what we have now with no reform? And why is the Wyden-Bennett Bill going to be any different?
    http://www.cbpp.org/cms/?fa=view&id=674 It also provides subsidies to people unable to afford insurance but it does not cut healthcare costs, it only attempts to cut insurance costs – is that really where our leaders think costs are driven? Once people really wanting reform realize that the fight is not about insurance reform, it’s about healthcare reform, can we then discuss cutting rising and unaffordable costs. Actuarial risk spreading will not get us better healthcare at a better price. As I have said before, trying to maintain the private healthcare insurance industry is an impedimant to reform, and Americans can expect many more years of rising costs that outpace their ability to afford care.

  48. Why do we need bi-partisan when 70% of the public want what the Progressive Democrats want? I really don’t understand. And I don’t think Senators Baucus or Grassley have a good faith bone in their bodies, they are bought and paid for.

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