OP-ED

Good Intentions Aren’t Enough with Health Care Reform

Sarah-palinFormer Alaska Governor Sarah Palin’s widely publicized comments on death panels and  rationing this August were among the opening shots of an unprecedented national fight over health care reform. At the time, few sober analysts would have predicted that Palin’s criticisms would gain traction. Yet, they found a receptive audience among conservative opponents of the Obama administration’s health care reform plans, triggering an ugly battle between supporters of reform and right wing opponents.This weekend, Gov. Palin returned to the healthcare debate with another post to her official Facebook page that touches on the talking points you’re likely to hear in the months to come from Republican critics of the Obama administration’s health care reform efforts.  In the spirit of debate we are republishing the post in its entirety. — John Irvine

Now that the Senate Finance Committee has approved its health care bill, it’s a good time to step back and  take a look at the long term consequences should its provisions be enacted into law.

The bill prohibits insurance companies from refusing coverage to people with pre-existing conditions and from charging sick people higher premiums. [1] It attempts to offset the costs this will impose on insurance companies by requiring everyone to purchase coverage, which in theory would expand the pool of paying policy holders.

However, the maximum fine for those who refuse to purchase health insurance is $750. [2] Even factoring in government subsidies, the cost of purchasing a plan is much more than $750. The result: many people, especially the young and healthy, will simply not buy coverage, choosing to pay the fine instead. They’ll wait until they’re sick to buy health insurance, confident in the knowledge that insurance companies can’t deny them coverage. Such a scenario is a perfect storm for increasing the cost of health care and creating an unsustainable mandate program.

Those driving this plan no doubt have good intentions, but good intentions aren’t enough. There were good intentions behind the drive to increase home ownership for lower-income Americans, but forcing financial institutions to give loans to people who couldn’t afford them had terrible unintended consequences. We all felt those consequences during the financial collapse last year. Unintended consequences always result from top-down big government plans like the current health care proposals, and we can’t afford to ignore that fact again.

Supposedly the Senate Finance bill will be paid for by cutting Medicare by nearly half a trillion dollars and by taxing the so-called “Cadillac” health care plans enjoyed by many union members. The plan will also impose heavy taxes on insurers, pharmaceutical companies, medical device companies, and clinical labs. [3] The result of all of these taxes is clear. As Douglas Holtz-Eakin noted in the Wall Street Journal, these new taxes “will be passed on to consumers by either directly raising insurance premiums, or by fueling higher health-care costs that inevitably lead to higher premiums.” [4] Unfortunately, it will lead to lower wages too, as employees will have to sacrifice a greater percentage of their paychecks to cover these higher premiums. [5] In other words, if the Democrats succeed in overhauling health care, we’ll all bear the costs. The Senate Finance bill is effectively a middle class tax increase, and as Holtz-Eakin points out, according to the Joint Committee on Taxation those making less than $200,000 will be hit hardest. [6] With our country’s debt and deficits growing at an alarming rate, many of us can’t help but wonder how we can afford a new trillion dollar entitlement program. The president has promised that he won’t sign a health care bill if it “adds even one dime to our deficit over the next decade.” [7] But his administration also promised that his nearly trillion dollar stimulus plan would keep the unemployment rate below 8%. [8] Last month, our unemployment rate was 9.8%, the highest it’s been in 26 years. [9] At first the current administration promised that the stimulus would save or create 3 to 4 million jobs. [10] Then they declared that it created 1 million jobs, but the stimulus reports released this week showed that a mere 30,083 jobs have been created, while nearly 3.4 million jobs have been lost since the stimulus was passed. [11] Should we believe the administration’s claims about health care when their promises have proven so unreliable about the stimulus?

In January 2008, presidential candidate Obama promised not to negotiate behind closed doors with health care lobbyists. In fact, he committed to “broadcasting those negotiations on C-SPAN so that the American people can see what the choices are. Because part of what we have to do is enlist the American people in this process. And overcoming the special interests and the lobbyists…” [12] However, last February, after serving only a few weeks in office, President Obama met privately at the White House with health care industry executives and lobbyists. [13]

Yesterday, POLITICO reported that aides to President Obama and Democrat Senator Max Baucus met with corporate lobbyists in April to help “set in motion a multimillion-dollar advertising campaign, primarily financed by industry groups, that has played a key role in bolstering public support for health care reform.” [14] Needless to say, their negotiations were not broadcast on C-SPAN for the American people to see.

Presidential candidate Obama also promised that he would not “sign any nonemergency bill without giving the American public an opportunity to review and comment on the White House Web site for five days.” [15] PolitiFact reports that this promise has already been broken three times by the current administration. [16] We can only hope that it won’t be broken again with health care reform.

All of this certainly gives the appearance of politics-as-usual in Washington with no change in sight.

Americans want health care reform because we want affordable health care. We don’t need subsidies or a public option. We don’t need a nationalized health care industry. We need to reduce health care costs. But the Senate Finance plan will dramatically increase those costs, all the while ignoring common sense cost-saving measures like tort reform.

Though a Congressional Budget Office report confirmed that reforming medical malpractice and liability laws could save as much as $54 billion over the next ten years, tort reform is nowhere to be found in the Senate Finance bill. [17]

Here’s a novel idea. Instead of working contrary to the free market, let’s embrace the free market. Instead of going to war with certain private sector companies, let’s embrace real private-sector competition and allow consumers to purchase plans across state lines. Instead of taxing the so-called “Cadillac” plans that people get through their employers, let’s give individuals who purchase their own health care the same tax benefits we currently give employer-provided health care recipients. Instead of crippling Medicare, let’s reform it by providing recipients with vouchers so that they can purchase their own coverage.

Now is the time to make your voices heard before it’s too late. If we don’t fight for the market-oriented, patient-centered, and result-driven reform plan that we deserve, we’ll be left with the disastrous unintended consequences of the plans currently being cooked up in Washington.

– Sarah Palin

[1] See http://tinyurl.com/yjs3mgf
[2] See http://tinyurl.com/yfuw3k3
[3] See http://tinyurl.com/yfxq8ca
[4] See http://tinyurl.com/ykefsk6
[5] See http://tinyurl.com/ygf42fj
[6] See http://tinyurl.com/ykefsk6
[7] See http://tinyurl.com/lkvgsp
[8] See http://tinyurl.com/nx4nh6
[9] See ibid.
[10] See http://tinyurl.com/yhhr56v
[11] See ibid.
[12] See http://tinyurl.com/yhzhkvg and http://tinyurl.com/lhyr9o
[13] See http://tinyurl.com/yksd6h3
[14] See http://tinyurl.com/yl9gg27
[15] See http://tinyurl.com/yknpxd6
[16] See http://tinyurl.com/d2k5hb
[17] See http://tinyurl.com/yf8qmfh

This post originally appeared on Sarah Palin’s official Facebook page.

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  3. Caribou Barbie (Shara Palin) Has become the Image of the Party of No.Turning back time to ownership of humans(slavery), women as mere property and the masses as indentured servants. Just Like O’sama Bin Laden is the face on the War on Terror.She is Cute, comes in several poses and matching outfits. She, like all Barbies loves MR Ken. Who still is a Bachelor. Why that is so? The GOP needs Caribou Barbie to be distraction from the Ugliness that engulfs the party. I think Ken and Barbie who were only plastic Figures. Need to stay out of Health Insurance Debate.
    I also feel that Health Insurance companies are Unnecessary and any Doctor worth his weight needs NO GUIDANCE by insurance.The reason Medicare is so unappealing is the returns are smaller.However, the demographic that uses Medicare frequents providers on more frequently.
    The Bottom line; Its Just the Money!!!!
    I wonder; if other services like Auto Mechanics,Electricians, Heating and Air were set up the same way,requiring insurance as a prerequisite to provide Services.Would it only be a privilege of affordability or a basic right?

  4. The Republican party got us into the heath care mess by blocking govt alternative….
    The single Payer health care does not cost a whole lot. Small business and individuals who want to could buy into the plan and it would break the monopoly on health care…
    The GNC or Republican party has a long history of lying and Sara Palin on on the lying band wagon.
    They lied about Iraq, weapons of mass destruction.
    They lied about it being a big mistake…
    Cost 1 trillion and counting.
    The lied and are lying about health care.
    Cost 15 trillion.
    Evidence: Blue/Cross holds monopolies in multiple states…. These blood sucking liars and their allies are funding Fox News and right winger Glen Beck who is right out of the 1950’s McCarthy Scare.
    Which is better the present corporate take over of health care where you have absolutely no say or government takeover where you have some say?
    Fact: In all of the so called Socialized Health care countries they could vote out socialized health care in one day and no country is doing that including Glen Becks “communist Australia, Canada and ofcourse Communist New Zealand and don’t forget Communist Great Britian.”
    Fact: In all of these countries the same drugs that you pay for here are ten times cheaper there.
    Fact: There are more doctors and nurses which drastically brings the costs of
    health care down while make their health care system 5 times better than ours because Doctors go to medical school there for free.
    (Life expectancy much higher and there they have the H1N1 vaccine for all, here
    you have to wait in line and we are getting the rationed heath vaccines.
    Fact: The ave wait time in the ER in the USA is 6 hours.
    Fact: the Ave wait time om the ER in France is less than one hour.
    Fact: Cancer patients are given “Standard medical treatments at the so called best hosptials in the world while the most effective treatments are barred from
    the USA by Big Pharma and it’s Cohort The FDA to insure Big Phama get it’s the biggest profit.
    Fact: Diabetics will become the no 1. killer in the USA while Burger King and Big Mac keep their junk food profits going.
    Dimitri

  5. Governor Palin got one thing right, in her article on “Good Intentions,” when she said that “good intentions are not enough.” The problem with pending healthcare-reform legislation, like so many reform initiatives that have preceded it, is that it is not really healthcare-reform legislation, it is “health insurance” reform legislation.
    Until we are willing to admit that the problem with the American healthcare system is health insurance, we will continue to add new layers of complexity to a system that is already convoluted.
    Think about it for a moment. If our objective is to provide universal access to healthcare, what value do health insurance, managed care, Medicaid, and Medicare add? Don’t these entities exist to restrict access to care to only those individuals who are covered? Don’t these entities exist to limit care to only those services that are covered by an individual’s specific policy?
    If we are serious in our desire to make healthcare available to all Americans, we must eliminate the middlemen and then apply a little American ingenuity to reconstruct the system to do what we need it to do. The Reconstruct Healthcare Blog unveils a uniquely American solution to our healthcare dilemma while keeping government out of the healthcare-delivery business.

  6. all plans that are funded through tax dollars should be prohibited from charging back private health plans. Congress should acknowledge the commitment they made to the beneficiaries of these programs and provide the funds necessary to pay for the promised services. This was the standard many years ago when private health plans had COB restrictions against paying for services provided to beneficiaries of government plans.

  7. Well the health care debate is alive and kicking.
    I am not sure the question about Ms. Palin’s daughter’s health care provider was ever answered and I don’t know for certain who paid for the expenses. However, my (very educated) guess is that the taxpayers did. Remember, Mrs. Palin’s husband is an Alaska Native. This entitles him and his children to “free” care from the Alaska Native Medical Center, part of the Indian Health Service. Now I suppose she could have also been covered under the State of Alaska’s health care program Mrs. Palin would have been covered under as Governor or the health insurance plan available to Mr. Palin as a BP Alaska employee.
    What is important to realize about the Palin family is that, even though Mrs. Palin quit her job and Mr. Palin quit his job, unlike most Americans, Ms. Palin’s children and husband were guaranteed free coverage under the Indian Health System. Which, by the way like the VA, Medicare and Medicaid charges back services provided to beneficiaries to private health plans. Therefore the Palin’s may still be mired a sink hole of “coordination of benefits” paperwork if the daughter was covered under both private and public plans. I would however doubt that their family is on the hook for paying those expenses out of pocket as most other American families would have been.
    This being said, most of the comments on this site (along with Mrs. Palin) are still not dealing with the real issue here. The real issue is: who and how will health care be paid for. As long as our society guarantees that everyone, no matter their ability to pay, will be provided health care services, there will be a mechanism for paying for that care. Reason also tells us that the answer to the question of who pays is “the citizens of the US.”
    So, we can waste time and energy arguing about secret meetings, who pays for Mrs. Palin’s grandchild’s health care or other irrelevant issues or we can cut through the “blue smoke and mirrors” (thanks Jimmy Breslin) and talk about the real issue; how do we structure a plan that is cost effective and provides quality care to all comers. Unfortunately, like the brouhaha about Mrs. Palin’s comments on “Death Panels”, we are easily sidetracked. There are some truths that must be faced in this debate. They are:
    1. The cost of providing health care services to residents in the US will come from the pockets of those same residents; be it through taxes, health insurance premiums or direct pay for services.
    2. Care will be rationed. Whether that is through an insurance company using formularies for prescription drugs or putting exclusions and limits on what they will pay for or a government agency “cutting reimbursements” nobody will get unlimited care unless they can pay out of their own pocket (another form of rationing.)
    What we do know about our current system is that it is inefficient because of COB, especially between government programs the private sector plans. These provisions make privately funded plans the payor of last resort. In my opinion, this is a tax on private plans (which are paid for out of the wages of employers and employees) and shifts the costs of government plans to the private sector. The same goes for “cost savings” plans which lower reimbursement for publicly funded plans such as Medicare and Tri Care. Providers who take these patients pass on unreimbursed expenses to (can you guess?) privately funded health insurance plans whose premiums go up as a result or people with or without health insurance who pay cash for services.
    So, let’s get the debate back on track. Here is my first suggestion; all plans that are funded through tax dollars should be prohibited from charging back private health plans. Congress should acknowledge the commitment they made to the beneficiaries of these programs and provide the funds necessary to pay for the promised services. This was the standard many years ago when private health plans had COB restrictions against paying for services provided to beneficiaries of government plans. In my opinion bringing back this provision would go a long way to eliminating much of the cost shifting from government to private insurers. Second, it would free up funds now being paid for claims administrators and allow it to be used for providing services to sick people.
    So, can we debate the real issues here or are we to continue the name calling and accusations of unethical behavior by public officials? Let’s hope we can get back on track a solve the quagmire we in the US call a “health care system.” We owe it to future generations to fix this mess.

  8. Good intentions or not matters little, what we need is common sense and forthrightness in attacking the real problem and in the process being honest with the American people. None of that is happening now.
    What we are going to get is a good solution for the wrong problem with the creation of an even bigger problem down the road. About the time Medicare crashes, we will learn about the problem we have created with a new public option.
    And, the American people will learn what it really takes to control health care costs (as will the medical profession so willing to jump on board with the current version of problem solving.
    Here is an assessment you may want to take a look at.
    http://quinnscommentary.com/category/healthcarehealthcare-reform/

  9. With all the increased awareness of ghost-authoring practices in the medical community, I’m really surprised that THCB ran an article that was clearly not authored by Sarah Palin. When that is added to my general disapproval of this cookie-cutter, GOP-message-laden post (that provides no new information for anyone truly keeping up with the issue), THCB has just gone down a serious notch in my estimation.

  10. I don’t think you can ever rely on an aultristic system, efficency is maintained by personal responsibility.
    productivity is measured by the person paying for it. If some person perceives benefit from hiring someone to dig a hole and fill it up repeatidly then the person doing the work is being productive. You might disagree with the value of a hole being dug and filled but you can’t deny the person doing the work was productive. They dug and filled a hole.
    While you are a good doctor that pratices in the best interest of your patient many doctors do not. You can’t build a system predicated on all doctors being honest. If you build a system based on the assumption doctors will pratice in their best interest you greatly reduce the inefficency of those that do not, a properly designed system wouldn’t impeed an honest doctor but would a dishonest one.
    Maximum ROI can only be achieved with a strong paying consumer. We have tried strong providers, strong insurance companies, and strong government and none of them lasted more then a decade or so.
    Isn’t a mechanis suppose to fix cars? Attorney’s represent their clients, Politicians represent the voters, you can’t rely on what other people are suppose to do.
    Margalit that was the way I feel it should work, not saying that is how it does work.

  11. Nate:
    I’m a capitalist as well. But as a physician my role is to recommend that which is best for the patient, not that which is best for me. I routinely recommend a course of action that is not in my economic best interest.
    **I also don’t see a difference between paying for beneficial treatment or paying for voodo medicine, we pay either way. **
    Then you don’t see the difference between productive labor vs paying someone to dig a hole and then fill it up and there is little i can do to open your eyes. The point is to get maximum health care bang for the buck. Paying for ineffective treatment is not going to do it. But I suspect you know that and are simply being “provocative”.

  12. Wow, Nate! Wow! I have no idea where to start, so I won’t even try.
    I think you just illustrated why medicine is not, cannot, will not ever be the same as any other business.
    I am 100% certain that no self respecting physician practices this way, other than maybe some folks in places like McAllen….

  13. rbar careful judgineg the entireity of ones knowlwedge by a couple hundred post.
    Asking for unnecessary tests and treatments is choosing the more costly option. Each treatment is a decision on its own, by choosing to have a test that is not needed or repetitive is more costly then choosing to forgo said treatment.
    I disagree with limiting people to what is clearly beneficial, I think more of our health is mental then medicine prefers to admit. Placebo’s do cure the perception of a condition, the perception of a condition can cost just as much or more then the actual condition. If rubbing cow urine on your hand relieves your arthritis and stops you from getting an Humira Rx then please apply generously. Not to mention there has been more then one case of medicine being wrong. Heard thinking can be dangerous, heard treating deadly.
    I also don’t see a difference between paying for beneficial treatment or paying for voodo medicine, we pay either way. If our systems where properly structured people would rarely get reimbursement from insurance, they would pay medical bills in lieu of premiums.
    From 20 years of paying doctors claim there is nothing I will ever be able to do to stop providers from delivering unnecessary care, only the patient can say no to a treatment so that responsibility must lie with them, I can educate and enform them but in the end they need to make the decision. Peter/Phillips don’t take that as an absolute and point out the couple exceptions where I can in fact deny treatment.
    Andrew I’m capitilist, if there is a more expensive option you would be a terrible businessman to not offer it. As a for profit effort your job is to sell your service, withholding your service becuase you don’t think it is worth it I disagree with. If some rich person wants to pay $100 per aspirin becuase they are hand pressed you should gladly take his money and reduce the cost of aspirin for average joes. A functioning economy requires the redistribution of wealth, I rather the wealthy spend their money then it be redistributed by a tax man. By selling designer cures health care companies can invest in research or subsidizing cheaper and new cures. If they are greddy bastards and keep all the extra money for profit that to is fine as that trickles down to mutual fund owners where are predomintly average people’s retirement accounts.

  14. Nate,
    Apart from all the invectives (you are clearly distinguished in that category), I notice that you have only a pale idea of medical waste/overutilization. Most of it is not conscientously choosing a more costly option, but docs ordering unnecessary tests and treatments, often asked for, explicitely or between the lines, by the patient. I too would agree that a patient should be able to get the unnecessary MRI for migraines if he/she is willing to pay for it (or for supplementary insurance), but for the covered majority, there has to be a principle: you get what is proven to be clearly beneficial (or thought to be beneficial by experts), but for everything else, you have to pay.

  15. Nate
    **Personally I don’t think doctors should be making any judegments about the cost aspects of care.**
    It depends. If two treatment options are equivalent in outcome (generic ACEI vs branded ACEI for HTN or CHF) why should I not choose the less expensive one without offering the more expensive option to the patient. Where I agree with you is if the outcome is not equivalent and the difference in cost is large. It is not for me to judge whether a small benefit is “worth it”. Example: Plavix vs aspirin in patients with chronic CAD (not post PCI). The is an 8.7% relative risk reduction with plavix vs. aspirin over 5 years. So if the 5 year risk of MI, CVA or death is 20% on aspirin it is about 18% on Plavix. Is that absolute reduction of 2% over 5 years worth $1800 per year? That’s not for me to decide. If you earn $500,000/year you would probably pay it. If that $1800/year was the difference in being able to pay the mortgage or not, you probably wouldn’t pay it. In cases like this I will often inform the patient of the data and the cost and let them decide. The are several problems with this though. 1) It is VERY time consuming. 2) Many patients lack the statistical sophistication/education to really understand what I am telling them. They are therefore incapable of making an informed decision. 3) Much more commonly in medicine the difference in outcome between two different therapies is not really known. We may have reasons why we believe or think option A is better, but there is no data to support or thought one way or the other.

  16. MD as Hell:
    We need to acknowledge that there is actually a very low percentage of discretionary spending in the budget. Lowering the tax rate on the very wealthiest of Americans in 2001 resulted in going from a ~$500B budget surplus to a ~$1T deficit. We need to raise the upper marginal tax rate and reinstate the estate tax. The very wealthiest currently pay a smaller percentage of their income in taxes than those of us (that includes you and me, bub) in the middle. Paris Hilton needs to pay her fair share. In all likelihood, those of us at the upper end of the middle (that does include you and me) need to make a slightly higher contribution to Social Security withholding.

  17. Margalit Gur-Arie
    **Medicare is offering a 2% incentive to physicians for using electronic prescribing software,…**
    The response rate to this in particular, and the incentives to switch to EMR in general, is so low because the cost of implementation is greater than the incentive given. And though it does show options, it (and Medicare) do absolutely nothing to push toward cheaper but equivalent alternatives. Private insurance companies do. That was, and remains, my point. When people like Ram Duriseti assert that insurance companies bring nothing to the table, I feel compelled to respond.
    **What baffles me is that while stating that medicine cannot be reduced to a cookbook, you are perfectly OK with accepting intervention from a variety of cookbooks …**
    I am not and never said that I was. I am however OK with being asked to justify why I chose a $700/year drug as opposed to a $50/year drug. After all, I am spending their money. The ticklish part comes if/when they disagree with me and still refuse to cover the drug despite my explanation. Has happened twice in my career and one was ultimately reversed upon further appeal up the ladder. In the other the patient paid out of pocket for the more expensive drug. Again though, my point was that unlike Medicare, private insurance companies do make an effort to keep down the costs of healthcare in ways that do not adversely impact quality. Some insurance companies mail out letters reminding women to get mammograms. Does the federal govt (Medicare) do something as simple as that? No. So when people tell me that Medicare is “more efficient” than private payors, all I can do is laugh. I mean, they don’t have to collect the premium, they provide no disease management, they make no effort to question costly drug prescriptions or imaging studies. All they do is write a (small) check, one that is, in effect subsidized by private payors. But I digress.
    **Those cookbooks are solely based on cost analysis.**
    And outcome. And that’s all that should count: cost and outcome.
    **Do you get a call when you don’t order the MRI, and maybe you should have?**
    Errors of omission are always much more difficult to track. I don’t know of anyone capable of doing a decent job with that. It only comes under scrutiny when someone has a bad outcome through inaction.
    **Lastly, I don’t think that asking physicians to be more aware of the power they have on influencing health care costs is tantamount to full risk HMOs. **
    No, and perhaps I responded too strongly to that. It’s just that the current system is designed to reward overuse. The more I do the more I am paid. Full risk HMOs failed because they still linked compensation to consumption, or lack thereof. Until physician income is tied to outcome (a difficult and tricky thing to do) instead of utilization, there will be no significant change in physician behavior.

  18. J Bean,
    We are no longer loaning money to ourselves. Soon we will be owned by our creditors. We will have to stop sometime. Now is good.

  19. A blog by a disgraced clown like this and 54 comments to boot?( I am stupid enough to be #55)
    This is surely one of Matt’s jokes?- right?
    If not-THCB- You have hit a new low for you
    Dr. Rick Lippin
    Southampton,Pa

  20. Medical transcription: Medical care is labor intensive and labor costs make up the bulk of the (non-administrative!!) costs. The average annual household income in India is $550 (US) while the average annual household income in the US is $55000. It’s actually kind of surprising that the US cost of medical care is only 10 times the cost of Indian care. That would imply that Indian care is relatively expensive.
    MD as Hell: The US is not “bankrupt”. The US has a GDP that is only slightly smaller than the entire European Union. The national deficit has been proportionally higher in the past without any problem. There is one political party that makes a big fuss about “financial responsiblity” … whenever they are out of power (they borrow and spend like drunken sailors when they are in power).
    Numbers taken out of context are meaningless.

  21. Dr. Weinstein broaches an interesting point. Right or wrong the physician/patient relationship is a holy one. I have to think a large part of maintaining this close working relatoinship is being able to use the insurance company as a fall guy. If a doctor discusses your options with you and it is the insurance company that says to try step therapy first or wait two weeks for an MRI they take the blame and provider remains the trust buddy. If you start asking doctors to factor cost into their treatments then patients will start to blame them, is this the road we want to go down?
    Personally I don’t think doctors should be making any judegments about the cost aspects of care. With only minor offense intended have you ever seen how poorly they run businesses? A doctor should make the patient aware of all treatment options in an unbias manner. It is then the responsibility of the patient, with consideration to what his insurance will reimburse, to decide which route they want to go. If the patient wants the expensive drug and is willing to pay the difference then the insurance company and doctor have no right to interfer.

  22. Dr. Weinstein,
    Medicare is offering a 2% incentive to physicians for using electronic prescribing software, which other than sending scripts to pharmacies, also displays formularies and generic alternatives at the point of prescribing. This is benefiting commercial payers more than Medicare and they are not providing any financial support for this endeavor. CMS will be requiring reporting on the generic utilization as part of meaningful use. Not to absolve Medicare, but I would say that Medicare will be pitching in from a more selfless angle than most private payors.
    What baffles me is that while stating that medicine cannot be reduced to a cookbook, you are perfectly OK with accepting intervention from a variety of cookbooks written with questionable purpose in mind, otherwise you would get a call when prescribing antibiotics for colds, which should be in everybody’s cookbook. However antibiotics are too cheap to warrant a phone call. Those cookbooks are solely based on cost analysis. Do you get a call when you don’t order the MRI, and maybe you should have?
    Lastly, I don’t think that asking physicians to be more aware of the power they have on influencing health care costs is tantamount to full risk HMOs.

  23. Margalit Gur-Arie :
    I was writing more in the abstract but using first person grammar. but to address your comments:
    **why are you writing that expensive brand name prescription in the first place? **
    There are many reasons why I might. Example: 15% of patients will cough on an ACE-I so I may prescribe an equally effective ARB that doesn’t cause cough to a patient that has a high incidence of side effects to any prescription I give them. I am trying to avoid a call back from the patient (which costs me time) and avoid the patient from experiencing a side effect. Is that worth an extra $40/month? Well, it depends on whose pocket it comes out of. In fact I do try to prescribe generics when appropriate but the fact is we spend billions unnecessarily on branded drugs and my point was that insurance companies, unlike Medicare, make an effort to curtail this.
    **Same type of question for the MRI – why don’t you decide to wait if you know it’s the appropriate thing to do?**
    Again, there are many reasons why I might do this. First, you naively assume that all primary care physicians know all the appropriate algorhythms for all presenting problems. Perhaps in an ideal universe but not here on earth. And the less certitude one has as to the correct thing to to, the more likely one is to order (unnecessary) studies and make (unnecessary) referrals. Sad but true and unlikely to change anytime soon. Second, many patients come in with certain expectations. When they come in with a cold they want antibiotics. When their back hurts they want an imaging study. Now, I can (and often do) spend 15-20 minutes educating them as to why waiting is the better course of action. If I am lucky, they undrstand and agree. If I am less lucky (as is often the case) they still want the antibiotics or the MRI and I can either order it or I can refuse, alienating and possibly losing the patient. The fact is, there isn’t enough time in a day to explain the logic behind every decision to every patient. You have to pick your battles. But once again, the point was that the insurance companies attempt to limit unnecessary studies (and then they are the bad guys in the eyes of the patient, not me)while Medicare doesn’t.
    **BTW, some nice CDS software would accomplish the same thing **
    This assumes that medicine can be reduced to cookbook recipes and further, that all the third party payors use the same cookbook. Not the case.
    **The argument now is for patients to take personal responsibility for their lifestyle and habits, thus reducing chronic disease rates and health care costs as a result.
    Is it not reasonable to ask physicians to do the same?**
    This was the idea behind a full risk HMO. The result was a strong economic incentive to under treat.

  24. Palin is a socialist, a smear she attempts to pin on others.
    Palin’s death panel stunt was full blown socialism, a defense of Medicare waste and fraud for health care providers, hidden behind a ridiculous claim that reductions in this spending were related to effective health care and shortened lives.
    Palin supports the very socialism she claims to despise, by opposing reform in order to support continued subsidies to providers and insurers, particularly the government regulations, and absence of other regulations, that keep them in power, shielded from transparency and consumer access, in order to earn hundreds of billions more than necessary to provide effective health care.
    Palin does not support free markets, free choice or less taxes. Palin supports the status quo, by claiming falsely, that market competition could work where it has repeatdly demonstrated failure. Simply allowing consumers to shop across state lines fixes little or nothing given the massive failures involved.
    Palin supports the continued redistribution of wealth from consumers to insurers and providers driven heavily by market failure and government power, walling and sealing it off in its current form for current beneficiaries regardless of obvious failures, to continue until it brings down the economy with unsustainable costs.
    Palin’s socialist smears are twisted in the phony attempt to paint herself as a free marketer, even getting it wrong on the housing market failure. Private lenders opposed interference from government lenders that prevented them from overselling houses even more than they did, not the other way around.
    Now Palin compares mandates and incentives of proposed health care reform, to demonstrate their failure, after supporting mandates and incentives of Medicare, to demonstrate their success.
    For Palin, it just depends on which form of socialism funnels the most money to insurers and providers.

  25. Dr. Weinstein, just curious, why are you writing that expensive brand name prescription in the first place? If you have any sort of prescribing software in your office, then you should see a list of alternative generics right there, or maybe just don’t check the DAW box.
    Same type of question for the MRI – why don’t you decide to wait if you know it’s the appropriate thing to do?
    The argument now is for patients to take personal responsibility for their lifestyle and habits, thus reducing chronic disease rates and health care costs as a result.
    Is it not reasonable to ask physicians to do the same?
    Are you sure this is something you want the payer to do for you?
    BTW, some nice CDS software would accomplish the same thing and would not be dependent on which pharma manufacturer payed which PBM to put their brand name drug on its preferred formulary.

  26. **I challenge anyone to explain exactly what value the health insurance oligopoly brings to the process of delivering health care.**
    As a practicing physician I am no fan of insurance companies but let me give you some examples of the “value” they bring to the table:
    1) When I prescribe an expensive branded drug I will often get a call back asking, in one form or another, to either justify the use of the drug or to prescribe a generic.
    2) When I ask for an MRI to assess lower back pain I will often get a call back and if the patient hasn’t failed a few weeks of conservative therapy, or if the patient doesn’t have any worrisome neurological findings, I’ll be told (appropriately) to wait.
    3) The insurance companies provide disease management services designed to enhance compliance, keep closer tabs on the patient and, to be sure, decrease the liklihood of hospitalization.
    4) They track compliance with proven benefit therapy (ie, beta blockers post MI) much more aggressively than Medicare.
    These are just a few of the examples of the sort of things that insurance companies do that both lower cost and improve the quality of care. The motivation may be profit (apparently an evil thing according to the posters here) but the result is lower cost and higher quality. Medicare, with the exception of a feeble attempt at #4, do NONE of these things. It simply writes a (small) check.
    As an aside, we (meaning Congress) could have outlawed the exclusion of pre-existing disease from insurability 20 years ago if we wanted to. And we could have put an annual cap on out of pocket expenses as well. Congress could have passed these laws whenever they wanted to, and never have (a result, of course, would be higher premiums for everyone). So don’t demonize the insurance companies for playing by the rules. Demonize Congress for writing the rules that we have.
    Insurance companies deserve plenty of criticism but they should not be everyone’s convenient whipping boy.

  27. This entire blog is getting to be very boring. Everyone continues to ignore the fact we as a country are bankrupt. Go ahead and pass reform. There will never be any funds for it long term. When it collapses under its own weight, cash won’t be any good. Credit cards and debit cards will be a joke. Better start hoarding antibiotics now. I wouldn’t worry about statins. Might was a few truck loads of steroids. Maybe some diuretics and antihypertensives. Lots of aspirin. Narcotics if you can score some. Some Plavix. Insulin if you think you will need it. Some local anesthetics will be comforting and a lot of super glue might come in handy. Guard then closely, for the looters will want to take them from you. You will be on your own. Hopefully you will know what to do with them. No doctor will be available. Maybe you can find a malpractice attorney who knows how not to use them. You can work backwards from there. Good luck.

  28. Margalit why stop at healthcare? No blues aren’t charitable, either are non profit hospitals, neither are most churches, and too many charities carry a political motive. Maybe you didn’t believe me when I said it so I’ll say it again clearer. I think the entire concept of tax exempt non profit should be stricken from the tax code. I don’t think it is a legal right of the federal government to say Mr. Smith has to pay taxes and Mr. Jones does not. Over time the abuse of non profit status has reached a level where they should all be cancelled.
    MG lets destruct your comments;
    “generally pointless” – I would disagree that people could learn more facts quicker from one of my post then listing to an hour of 30 second sound bites on the news. I have often stated no one should believe anything I or anyone else says but take my comments, do their own research, then develop their own beliefs, something you don’t get from journalist today.
    “rants/mocks/debases anyone who brings up an alternative viewpoint.” – This is completely dishonest statement, I have just as many civil discussions with people as those where I tear someone down. Further you will never see me tear into someone who didn’t first attack someone else. I am very happy to have a civil debate with anyone, but if they are going to come out the gate belittling Palin for example or right wing this or that or generally attacking someone else with talking points or usually outright misstatement of facts then yes I will attack them, don’t start a fight if you don’t want to get hit in the face.
    “Nate is never wrong” – of this I am very proud but would correct you, I am seldom wrong. Just a few weeks ago when discussing CalChoice with Robert, I think it was him, I was wrong on the organizing law in a co-op discussion. You mean this as an insult to me but it actually reflects very poorly on you. Why am I seldom wrong? Because I study my ass off before I speak. I know this concept is completely foreign to a number of THCB readers, Peter, Phillip, Maggie, etc but wouldn’t the world be a much better place if people actually took 5 minutes to research something before they started debating based on lies or misinformation? Lets go back a few months, was anything really served when the lefties kept claiming insurance companies had 30-40% margins and Medicare cost 1/10th to administer? People need to take more pride in their opinion and the first step is having an informed opinion. People should be ashamed to be wrong, with the internet so readily available an error in fact usually proves laziness.
    “any solution involving more gov’t oversight or regulation is automatically.” – I assume you meant wrong? Which once again you are…wrong. I’m not opposed to fair, honest, and transparent regulation, I have given countless examples of regulation I support. You make this claim because I oppose the regulation you want, this is a dishonest argument on your part. The left employees this tactic tirelessly. For example if I oppose 3200 I oppose all reform and support the status quo, completely dishonest but a simple defensive move for a liberal with no argument. I would be more then happy to discuss needed regulation, keep in mind, unlike 95% of the people on here I actually deal with the day to day workings of these regulations. How many other people here know the administrative and legal burdens of Medicare secondary payor, COBRA, HIPAA, etc. What sounds like a nice feel good regulation to a lefty that doesn’t deal with it I know to be an administrative nightmare that prevents small employers from offering insurance. I want smarter regulation that doesn’t drive up the cost because politicians are to stupid to draft a bill clearly.
    “conveniently comes up with weak excuses/explains or the inevitable shortcomings that appear. “ – if your done attacking my style and prose why don’t you engage me in a substantive debate?
    I like medical transcription’s idea. Instead of one huge sweeping bill that isn’t going to fix anything and will make everything worse I rather see annual bills fixing specific problems. While we start the studies we can attack the fraud and waste in Medicare and Medicaid and price transparency. Then when a specific and defined problem is studied we can debate and address just it. I know this is not how they make sausage in Washington but I think we can all agree we are tired of sausage healthcare. Further I bet the majority of reforms would have 80%+ support, does anyone not want fraud reform in Medicare? They keep telling us billions are just sitting there to be saved lets save it. There are hundreds of other ideas we all support, lets pass those first then fight over the remaining later.
    “So now it’s underfunding that is the problem, I thought Republicans were concerned about too much government spending.”
    Peter your stupidity never stops. MG when someone starts a comment like this they deserve nothing but scorn and derision. If we are going to make promises to someone we need to either fulfill those promises or cancel them. So Peter how much are native american’s allotted for healthcare? I assume you looked this up before your started commenting, do you feel that amount is sufficient? I assume you also know the legal status of Native American’s is quit different then African Americans right? I actually disagree with the concept of sovern lands the way it is currently administered. I think this compromised approach where they are free but aren’t has done far more harm to them then making a firm decision, they are either free and a different nation or they are US American and live under our rules. This political non solution either needs to be funded as promised or done away with. Not that I expect you to grasp the complexity of conservative thought. It’s hard when MSNBC doesn’t tell you what to think isn’t it?

  29. Nate,
    You are an idiot.
    Palin did nothing to fix healthcare in her state and in fact some have argued she made things worse. Why would anyone want to listen to Palin when she has no record on healthcare in her own state?
    Not sure what Native Americans and their healthcare coverage has to do with anything? If natives are covered by govt insurance than that makes the very low average insurance coverage ranking in Alaska even worse. If you got, as you say 16% of the population already covered, to get to such a low insurance coverage, the other non-natives must been even less covered than the numbers show.
    Why is it that Republican states always seem to have the worse statistics when it comes to insurance coverage? I guess because of people like you really do not care about the uninsured.
    Great you are genius Hawaii, has a slightly higher insurance market concentration. It is ridiculous that in many states there is essentially zero competition. That is the bigger point and in Alaska it is about the most market concentration of any state in the Union. Hard for Palin to preach free market, when her own state is a duopoly. What did she do to break up the duopoly and promote competition, as she is currently preaching is the solution to all our healthcare problems? Nothing.

  30. Mandating the purchase of health insurance without providing a public option would be a travesty for the people and boon for health insurance companies. It is unconscionable for a country such as ours not to provide a public OPTION for people to buy into. This is not socialism. This is not a free government handout. We need a public option in this country!

  31. “Would you like to discuss the woeful federal funding of the Indian Insurance Trust?”
    So now it’s underfunding that is the problem, I thought Republicans were concerned about too much government spending. Actually the problem with native healthcare is largely cultural as they experience many more problems with poverty, diabetes, heart disease, alcoholism, drug abuse, depression, suicide, crime, and obesity than do other ethnic groups, other than Afican Americans. Is it now argued by Republicans that we should spend more on Afican American healthcare because they experience a larger degree of the same health issues than whites? These are the issues that Republicans would argue are personal choices and can be cured by exercising personal responsibility, not spending more money. Providing Native healthcare also means trying to recruit trained healthcare professionals to rural and remote areas, the same problem as rural white america.
    My wife worked at the Alaska Native Medical Center for 5 years when it was Federally funded and administered, and she can attest to the great level of care natives received at that facility, despite trying to care for a large unhealthy and self destructive population. I have been to Barrow Alaska and seen their medical transport jet and helicopter which is on standby 24/7 to take residents (largely native) to Anchorage for treatment. Routingly natives were transported (free of charge) from rural Alaska to Anchorage for treatment.
    If there is a failure it is a failure of Natives to adapt to the loss (destroyed by white guys) of their traditional culture and take advantage of the federal programs offered to them to help them succeed. But many natives, as with many poor whites, will not/can not leave their destructive and failed communities and families to better their lives.

  32. Having a discussion with Nate is generally pointless. He is bright and makes some very valid points but he rants/mocks/debases anyone who brings up an alternative viewpoint. Also, Nate is never wrong and any solution involving more gov’t oversight or regulation is automatically.
    It is basically like having a conversation with the most rabid “free-market economist” who magically believes in the power of the “free market” under all circumstances and conveniently comes up with weak excuses/explains or the inevitable shortcomings that appear.

  33. Nate, why always go to extremes? I said healthcare non-profit, not all non-profit.
    Do you really think that the Blues and all their subsidiaries are truly charitable organizations? How about all those big hospitals that seem to be single handedly supporting the entire construction business?

  34. Lets run with what Margalit said and do away with tax exempt organizations altogther. strip mall churches, political organizations, charities that pay more in executive salaries then most of us will ever make. Family foundations. They all need whiped away, equal protection, we all pay taxes.

  35. I’m interested, as someone new to this debate, over the statistics Ms. Palin quotes from Douglas Holtz-Eakin. Will the burden of the reform bill as it now stands be passed primarily onto the middle class? What are some possible solutions to this?

  36. Actuary, I was not suggesting that health care should be free. Taxation is just fine with me, or any other means to collect a fair share from everybody.
    3% profit sounds low, but what does it really mean? 3% after paying exorbitant salaries to executives, after investment in infrastructure, after marketing and lobbying expenses, etc.
    I think the part that angers me most is that some of these insurers have special taxation benefits while they spend millions in persuading elected officials to disregard their fiduciary responsibilities to the voters back home. Yep, we’re paying for that too….
    This entire non-profit status in healthcare needs to be reexamined, for hospitals too. Even 501(m) is too much.

  37. Here is what was reported in 2006 about a similar Republican proposal for association health plans:

    The ranking Democrat on the Senate HELP committee, Edward M. Kennedy of Massachusetts, however, renewed his criticism following the president’s speech.
    “In the guise of helping small businesses afford health insurance for their workers, the Republican plan is a blank check for the insurance industry and a bad deal for patients, resulting in higher premiums and lower benefits,” he said.

    We know where deregulation of the finance and insurance industries has gotten us. No thanks. Fooled not.

  38. just thinking of the irony, United Healthcare would probably lose 50% plus of their small group business if AHPs passed. Lewin, owned by UHC, does a study that completly defies logic, and claims AHPs will increase the uninsured population. Normally the lefty clowns immediatly discount anything lewin says because it is owned by big evil. In this case you don’t only bite it hook line and sinker you add to the fantasy and claim AHPs help insruance companies. What a twisted argument Gary.

  39. Phillip just solved the healthcare crisis, it has all been explained. Apparently our market is comprised of 118% where as other countries are only made up of 100%. This 18% multiplier will soon be proven to be responsible for 128% of our higher cost. Actually Phillip this is even funnier then I thought, you managed to hit stupid then fall a few more levels. Giving you the benefit of the doubt, maybe they printed it wrong, maybe you mistyped, I opened the link. Alabama is 83%, you need to follow the different colored lines across, that is why they are there. So back to Palin and how stupid she is, you where saying….
    What’s up with Hawaii, Rhode Island, and Vermont by the way, not to mention MA has it’s issues.
    Just read your correction so you get a pass on the above, luckily for those mocking you there is another screw up, Hawaii at 98% would be higher then 95% unless you removed them from the Union. Rhode Island at 95% would be a tie.
    Since your not very bright let me interrupt your Republican bashing to point out that a large percentage of Alaskan’s are native American and their insurance is supposed to be supplied by the federal government, they are basically outside the control of the State and Palin in some insurance aspects. Since you can’t use the internet I looked it up for you, they make up 16% of the population. Would you like to discuss the woeful federal funding of the Indian Insurance Trust? Are you having one of those days Phillip where you wish you had just kept quite?
    I was going to try to be non-invective and avoid the trifles nut your to big an idiot for me to do that.
    Sorry quoting far left morons like commonwealth fund and Lewin is not an argument. When they learn how to spell insurance I’ll care about their opinion.
    Next dummy you apparently don’t understand what an Association is, one of the main benefits of AHP bills was to bypass insurance companies. Far from being a tool for insurance companies to game the system it is a method for small employers to exit the system altogether like large employers do. Have I mentioned what an idiot you are? It’s called ERISA, they use to be called MEWAs. Unions do it all day and call it Taft Hartley, are they gaming the system? Let me take this time to again point out what a tool you are.
    The 283,000 number is a joke, I’m an ameba in the insurance world and I alone would have tens of thousands of lives, I’m doing a quasi AHP now with 1000 lives.
    Further still the goal of AHP was not to cover the uninsured it was to make small group insurance affordable for small businesses. Learn what your talking about before you question other peoples decency.
    lol quoting Lewin and commonwealth as sources, ya well my pet rock said your full of S&*# and he is twice as smart as the three of you.

  40. No way I’m even reading her post. She is not qualified to speak on any issue and the “death panels” rant disqualified her from opening her mouth at all.
    But I admire your cojones for printing it, my friend Matthew.

  41. Nate, have you no decency? We are talking about reform and you counter with invective and trifles, as if pounding your fist on the table will win the argument. Your answer to solving the acknowledged health care crisis is “the right has been proposing AHPs for over 15 years to address the cost for small business….” That is not comprehensive reform. It’s worse; it’s just a a method for insurance companies to increase the number of ways they can game the system – the only racket they know. This is from the Commonwealth Fund’s report using the Lewin Group’s analysis for the latest proposed AHPs:

    Representative Sam Johnson’s (R–Texas) “Small Business Health Fairness Act of 2007” (H.R. 241)/ Representative Vern Buchanan’s (R–Fla.) “Small Business Growth Act of 2007” (H.R. 1012)/ Representative Howard McKeon’s (R–Calif.) “Working Families Wage and Access to Health Care Act” (H.R. 324):
    Permits trade, industry, professional, or other similar associations to form association health plans, which could provide health benefits to employees of businesses that are members of the associations.
    Estimates of Coverage and Costs in 2010 (Rep. Johnson’s bill)
    Number of uninsured covered (283,000)
    Remaining uninsured 49.2 million
    Total health spending ($0.4 billion)
    Federal $0.2 billion
    State and local $0.7 billion
    Employers ($1.6 billion)
    Household $0.2 billion
    Findings:
    Rep. Johnson and Sen. Durbin’s bills are focused on the affordability issues facing small companies that buy insurance in the small-group market. By allowing small businesses to effectively bypass state insurance regulations, the Johnson bill makes small-group coverage more affordable for companies with a young and healthy workforce but less affordable for those with an older or less healthy workforce, which would result in a net loss of coverage of 283,000 people.

    The reason for the net increase in the number of uninsured, is that the bill would enable AHPs to avoid state insurance regulations by selling policies across state lines. Firms with younger, more healthy employees in states with community ratings would purchase policies in unregulated states, such as Delaware, causing the rates for employers with older, less healthy employees to become more unaffordable – the proverbial death spiral. And, all this with very little to show for a reduction in total national health care costs.

  42. Actually in my last comment above I meant to say that Alaska is a duopoly, in fact the two top firms have 95% of the market, and has the highest market concentration of health insurance companies of any state in the Union.
    Premera Blue Cross has 60% of the Alaskan market and Aetna has 35% for 95% of the market divided between only two firms. Sure Palin argues for a “free market”, as she does and is her only solution in this piece, but she does not even have it in her own state, where she did nothing, but actually restrict competition (see my post above).
    As usual she talks a good game, but at the end of the day she sticks to the corporate line or is a hypocrite, like a good little Republican.

  43. I wonder who is actually writing these things for Sarah Palin. Do you think she even has a clue about the healthcare issues? Must be all that reading she is doing now that she has retired.
    It is too bad that she retired from “running” Alaska, as her own Alaska system is broke and in fact the state legislator has passed laws which reduce the competition in the state.
    “Last year the legislature (Alaksan) passed HB511 that broadened the field of medical services that require CON approval. The legislation was introduced under the guise of closing loopholes. But the reality is the legislation was politically motivated to squash the growth of competing providers like imaging centers. One Republican Senator even admitted on the senate floor that the bill did little more than protect monopolies before he voted for passage.
    And when asked if the administration or the legislature had done any research to evaluate the economic impacts by limiting competition, the answer was no. Not the answer we should accept when government is exercising a heavy hand on private industry.”
    See:
    http://www.andrewhalcro.com/policy_makers_heal_our_health_care
    So hard to listen to Palin preach on healthcare when she did nothing in her own state and in fact made the cost problem worse by restricting competition.
    Alaska is essentially a duopoly with Premera Blue Cross having 83% and Aetna having 35% of the market.
    http://www.americanprogress.org/issues/2009/06/pdf/health_competitiveness.pdf
    Give all the oil funds and funding for healthcare in Alaska, the state is only ranked 34 overall in state healthcare rankings. However, the state is 48th worse in health insurance coverage. Reasonable healthcare, but hardly anyone in Alaksa has health insurance. Healthcare is a big problem in Alaska and Palin did absolutely nothing to fix it, and in fact it can be argued that she made it worse.
    See:
    http://www.commonwealthfund.org/Charts-and-Maps/State-Scorecard-2009/DataByState/State.aspx?state=AK

  44. So many fools to mock I don’t know which to start with. Ann RN, I hope you studied harder for your nursing degree then you did for this post. Overwhelming majority of our healthplans are not profit driven, off the top of my head I would guess under 20% of American’s are covered by a profit driven insurance product. Self Funded plans, Medicare, Medicaid, and blues just to name a few are all not profit driven.
    Your proposing another Medicare program, which along with Medicaid are the only reason we have a crisis, to be blunt that is just stupid.
    To claim low down payment loans didn’t have a higher default rate then other loans is just plain political ignorance. She never said it single handedily caused it but no educated person disagrees it was a factor.
    “majority support for a non-profit public insurance plan in national reform.”
    Care to back this up with any proof? When explained their options America is strongly against a public option, when offered pie in the sky free insurance yes it has support. Some of us are to smart to vote for pie in the sky dreams with no chance of reality.
    LOL just saw where your from Ann, so some clown from MA is going to tell us how to fix healthcare. You have the most expensive system in the world, you have managed to screw up healthcare more then any other place in existence, no thanks I’ll pass on anything and everything you suggest.
    Something about the name Ann, Ann Neumann what’s your excuse for being stupid? Are you also a nurse from MA? “private companies have over-treated, over-medicated, and over-tested us for decades to their own financial benefit” Actually most of your large hospitals and providers are not private companies they are public. 50 million uninsured, where did you pull that out of, I hope not where I am thinking. Back that number up? What does 30 million people CHOOSING to be uninsured have to do with this debate? And finally tort reform and its possible effect on defensive medicine has not been debunked by anyone ever. Buying across state lines is also a valid, al be it clumsy way of circumventing mandates which in some states account for over 20% of premium so it to is legit.
    Evan, are you not bothered that the current plan is 100% resulted from bad reform? If they had never done Medicare, COBRA, HMO Act etc we would never have had the problems we do today. And you can go to gop.gov or something like that and see their plan and just search for any of my post and you will see the proper way to fix what liberals broke.
    MarkS it’s not losing the lawsuit that kills you it is getting sued. If your going to mock someone else for not making sense you should first at least grasp the basics. Google defensive medicine and read up. Then write Sarah a nice apology for speaking out like you did.
    Peter calling someone an idiot, that’s worth a chuckle, I laugh to picture the person intellectually inferior to Peter.
    The point that sticks out is why is the left so afraid of discussion and debate? Not one of the lunnies attacked any of her points with an argument just personal attacks and her and unsupported claims that she is wring, at least add a per Obermann or Bill Mahar now and then kids.
    Gary O your logic is in a death spiral, would a moment of silence help? Since you can’t be bothered to learn before putting your foot in your mouth the right has been proposing AHPs for over 15 years to address the cost for small business, this has been blocked every year by Democrats protecting their union overloards. That sir makes you the fool.
    Great post Actuary, it should be pounded into the forehead of more then a few commentors.

  45. Obviously somebody is feeding Palin her facts, but then again, somebody is also feeding Obama “facts”. The current plans simply do not address costs.
    Quick Calculation: If the insurance industry gets 2 million “customers” who average $10,000 in claims,(i.e., those with preexisting conditions)and can only collect $6,000 in annual premiums, that 8 billion shortfall will have to be made up by charging the other 40 million people with individual insurance an extra $600/yr (or about an extra 10%).
    If the industry was getting the “young invincibles” at even $3,000 a year this could offset the losses, but since the “mandate” is now laughable, the people who already have insurance will be paying more.
    Instead of the “windfall profits tax” that Commisar Pelosi proposes, there should be a “windfall loss credit” that will allow insurance companies to absorb the pre-existing waiver.
    I believe the health insurance industry made about 3% of premium in profits in 2008, or as Obama would say, the industry is “wildly profitable”.
    By the way, Margalit, a very important part of education (college, and grad school) is definitely not “free”. … and the property taxes to finance the “free” education for K-12 are overwhelming.

  46. Sarah Palin is the face of the Republican Party. Her opinion piece reflects her party’s profound dilemma: they tacitly acknowledge the Democratic Party and the American people are way in front of them in recognizing the need for health care reform. They also know that health care will not reform itself (also the title of Kaiser Permanente CEO George Halvorson’s newest book).
    How do you appear to be for reform, which everyone knows means government intervention, without putting the spotlight on your policy failures and glaring philosophical inconsistencies? Talk about a death spiral.

  47. despite all the talk, WHERE IS THE PRESIDENTS HEALTH CARE BILL…. All he does is TALK.
    Meanwhile the foes of Healthcare Reforem, line the pockets of our Rep and Senators to the tune of 1.6 Million dollars a day
    Where is the transpanancy
    Jim

  48. I keep asking the question, “what is our other option?”
    If we don’t go ahead with the current proposals in Congress, what are we looking at? We all are in agreement that the status quo will bankrupt the country and remove any semblance of affordability in our current situation, but what is our other option.
    As much as I may not agree with the current Republican leaders, if they would provide a detailed plan for changing healthcare, I’d listen.
    But until then, I’d take bad reform over no reform any day, especially given that the bad reform we are looking at now may be great in light of what else we are faced with.

  49. I wasn’t being snarky. It seemed like a perfect parody of right-wing talking points complete with arguments for selling insurance across state lines.
    Now that I see that it was reprinted, things make a bit more sense. I have to admit that I chuckled at the thought of Palin sending in her submission to M. Holt.

  50. There are a couple of viable discussion points in her post. I’m just glad you didn’t send us to her website to read it. And I am wondering if she has read it yet.
    However, my first thought was that it must be slow day for healthcare news. . .

  51. TO be fair, by running this THCB is partly poking a hornets nest because we enjoy that sort of thing, and partly noticing that the last time Palin inserted herself in the debate it had quite an impact.
    However, this time her criticisms have some grounding in reality–as I wrote about in my “When AHIP needs the public option”
    Her solutions are of course, just the same old Shaddeg bill talking points which we know won’t work

  52. Palin’s objective is not to suggest working ideas for health care reform. Her objective is to end reform.
    If it were the former she would have left the debunked Republican talking points about Tort Reform and buying across state lines go; she would have acknowledge that private companies have over-treated, over-medicated, and over-tested us for decades to their own financial benefit, without government oversight or regulation. Meanwhile we remain 37th in the world on health care.
    This facebook article, bound to be spread across the internet, is not a furthering of the debate, this is an un-credible, mis-informed, politically motivated distraction. 50 million uninsured Americans. Calling them “entitled” should be denounced as unacceptable and an illegitimate contribution to discourse.

  53. Good grief, who wrote this post for Palin? The content of the post’s message is indeed the focus for a blog, but cannot be entirely divorced from the supposed messenger. I’m a nurse who’s worked in hospitals (oncology) outpatient, and homecare (visiting nurses) for 15 years. I’ve also been studying health policy and been active as a health reform advocate for 20 years and I’ll tell you that Palin’s post is hoohey.
    What this country needs is a non-profit national health insurance program, NOT a bogus market-based profit-driven hodgepodge of lousy overpriced insurance products. That’s what we have now and as a result tens of thousands of patients die prematurely each year! These people–who are our family members, co-workers, and neighbors–die prematurely after living sicker lives with more suffering.
    What we have now is a “market-oriented” system. It puts corporate profit and personal fortune-making before patient’s healthcare needs. This approach is horribly dysfunctional and should be outlawed because it hurts people while simultaneously ripping them off. Hopefully these widespread practices will stop when reform is enacted.
    RE “Palin’s” post: “There were good intentions behind the drive to increase home ownership for lower-income Americans, but forcing financial institutions to give loans to people who couldn’t afford them had terrible unintended consequences.”
    — BOGUS argument that blames the victims of Wall Street’s unbridled greed; GMAFB. Who’s funding Palin these days?
    and
    “Now is the time to make your voices heard before it’s too late. If we don’t fight for the market-oriented, patient-centered, and result-driven reform plan that we deserve, we’ll be left with the disastrous unintended consequences of the plans…”
    — Yes, now’s the time to make your voice heard but “Palin” gets it wrong on what we must tell Congress to enact. It’s “the market” that’s an inherently flawed model for healthcare; it is failing us terribly in both clinical outcomes and financial efficiency outcomes. Nurses, doctors, sick patients and their families know it and that’s why there’s majority support for a non-profit public insurance plan in national reform.
    Call Obama and your members of Congress and give them this message that nurses, doctors and patients are delivering. Us this toll-free number 1-866-279-5474:
    “We need a public plan option with affordable premiums, that pays hospitals and doctors Medicare rates plus 5% and includes Medicare providers – and all of us want to have that choice in 2010! Put that up for a vote and we’ll support you!
    The bill must include the state single payer [improved Medicare-For-All] option, proposed by Rep. Dennis Kucinich.”
    — Thank you. Ann Malone, RN, MSN, Boston MA

  54. While, it is difficult to take a policy piece by former Gov. Palin with any degree of seriousness after the campaign she ran, one has to give her credit for taking responsibility for her own health by staying fit.
    I speak as a physician and a computational statistician who specializes in the computational modeling for complex decision processes. Here’s the cold hard truth: there is blind acceptance, and falsehood on both sides of this debate. Shocking.
    I challenge anyone to explain exactly what value the health insurance oligopoly brings to the process of delivering health care. I don’t see them as evil, but I see them in the same light as tax accountants: an industry that has popped up because of failures elsewhere in the system. It is true that regulation does not free them to force greater price discrimination from consumers. The problem is that a world without that regulation would lead to claims denials for people afflicted by the vagaries of fate through no fault of their own (e.g., trauma, severe infection, cancer, inherited illness). Put aside the issue of morality. Such a business without regulation would be akin to predatory lending. Anyone on this blog pontificating about deregulation has no idea what they are talking about until they are seriously ill, dealing with the stress and income loss, while having family members argue with insurance companies. I’m not saying it’s wrong, but we don’t have rationed care now? Anyone who contends this is either appallingly disingenuous or shockingly ignorant.
    On the other side of the debate, we have the viewpoint that increasing greater access to a scarce resource while hiding the costs will generate a better outcome. Without creating provisions for personal responsibility and responsible resource consumption, I do not see how there can be any cost controls. Savings at the level of efficiency can be achieved only by parsing large amounts of discrete and relatively homogenized data sets and enforcing spending decisions based upon those results. One has to be believe in the central limit theorem and not superstition to trust that such policy decisions will work at the population level (with the occasional individual failure — no such thing as a 100%). A true fiscal conservative would emphasize the importance of this and tell the truth: if you are on the public dime, you cannot everything you want all of the time. Most importantly, most health care dollars are spent on the treatment of chronic and preventable disease. This is the kind of disease that arises with poor health maintenance. Health maintenance is much more about health habits than it is about a having access to a primary care physician to tell you that you need to exercise and lose weight. Does somebody on this blog think that the latter is a big mystery to the average patient? We need to get a handle on technology utilization. This is NOT a uniquely American affliction which is why over the last decade, the USA was only 7th in terms of per capita PERCENTAGE increases in health care expenditures.
    So, let’s come back to the author. Don’t attack the messenger? Spare me. When the messenger puts themselves out as a political operative and yet cannot articulate a policy that is consistent with self-proclaimed core principles, they open themselves to personal critique. The former Gov. Palin, like other Modern Repubicans, had an opportunity to bring adulthood and responsible governance to the table. Instead, they brought, once again, polemic and God-talk. As a former Republican, I would have appreciated seeing the bill injected with a hefty dose of personal responsibility. Instead, what we got were political talking points about “death panels”, “Marxist socialist fascist non-citizen muslims”, and other such infantile and unfathomably stupid critiques.
    Matthew, I’m glad you are giving a voice to all sides of the debate. For those who are upset that this is a blog for “people in the know” and for “serious discussion”, the policy debate is not just about intellectual masturbation. Real solutions require convincing the political class on all sides of the debate. If people “in the know” look down their noses at political hacks, then substance will never infuse policy because, right or wrong, the political hacks wield power.

  55. “However, the maximum fine for those who refuse to purchase health insurance is $750. [2] Even factoring in government subsidies, the cost of purchasing a plan is much more than $750. The result: many people, especially the young and healthy, will simply not buy coverage, choosing to pay the fine instead.”
    Sarah, you spew out a great deal of political jargon and can obfuscate facts with the best of them, but this is a legitimate concern. The simple answer is to tax the rich to cover these costs. The better answer is to cut health care costs in half so that our costs are in line with the rest of the worlds.
    The bills before congress do not get at the systemic root cause of our health care problems. They only treats the symptoms. As long as we pay doctors, hospitals and big pharma for USE of their products and services we will have problems with our health care system because the profit motive lines up with more health care not better health care.
    In a capitalistic society, better health care only comes when it is rewarded with more money. Aligning the profit motive with desireable behavior can be implemented, but it requires a transformation in thinking.
    There is no line between healthy and sick. There is simply better health, we all can learn to be healthier. The pursuit of better health lasts a lifetime. Our health care system can support us everyday of our lives. When doctors, hospitals and pharma get paid in advance to ACCESS (not use) their products and services the profit motive is aligned with better health care. Systemically the invisible hand of capitalism will correct every problem that currently exists with health care.
    Treat the cause not the symptoms and you will fix health care.

  56. Is this post about politics, money, health care, insurance, medicine, macroeconomics, the recovery, business, jobs creation or tax policy? I can’t make heads or tails of it. Throw stuff at the wall and see what sticks. What a mess. No wonder the legislative process is compared with making sausage.
    I keep looking for constructive alternatives and MarkS found what few were advanced. Vouchers and tax manipulations are indeed more of what we already have. “Unintended consequences” of “the free market’s…real private-sector competition” are already here in the form of a forty-year old train wreck. The incestuous, symbiotic, conflict-of-interest infested, bribe-fueled, loophole-finding, back-scratching corruption of many of our elected representatives bears little or no resemblance to the mission or spirit of real health care.
    Fools rush in where angels fear to tread.
    ==========================
    My only observation is about tort reform. The president tossed that one out in his speech to Congress. He knows, as we all do, that actual malpractice settlements amount to a minuscule fraction of costs, so letting opponents have that one gives up very little.
    But he also knows that the FEAR of malpractice suits is a really big cost driver. And what no one says openly is that that same fear of malpractice gives the insurance industry all the excuse needed to keep those premiums waaay into the profit-making territory. I’m no insider, but malpractice premiums must be one of the insurance industry’s most productive cash cows.
    There must be a way to craft legislation (progressive amounts, three strikes?) that rids health care of bad doctors without kneecapping malpractice settlements altogether.

  57. You cannot eliminate tests done by doctors and I don’t believe that is way to get more money. In today’s day and age we can’t just have guessing games on patients. U need proveable tests done to prove someone has a disease or sickness. We’d be back in barbaric days if docs just guessed. A doc guessed on me without a swab test and I developed rheumatic fever because he didn’t diagnose strep throat and didn’t use test. I suffered for over 5 yrs going to hospital and doctor over it! Tests are necessary. This doc was from Armenia and said it was polyps. What a lark.

  58. >>Wonder who “ghosted” this for Citizen Palin? I’m also curious who paid for the prenatal care and delivery of her grandchild? Alaska Medicaid or Alaska State Employee Health Plan perhaps? Just curious if she has every availed herself of a public insurance plan or been uninsured. If she were ever truly at the mercy of our healthcare marketplace. I might find her just a little more credible.<<
    You're attacking the messenger, not debating the message. As for your last comment, where is Congress' credibility? Or do you agree that there's none there either?

  59. Abby, Peter and E don’t seem to want to hear any arguments other than their own. I may not agree with Gov Palin on a variety of issues, but telling her, or anyone you disagree with, to essentially shut up is a sad trend in American politics. Address the validity of her arguments and please take your mean-spirited comments to HuffPo. Thanks for posting Gov Palin’s entry Tom.

  60. Wonder who “ghosted” this for Citizen Palin? I’m also curious who paid for the prenatal care and delivery of her grandchild? Alaska Medicaid or Alaska State Employee Health Plan perhaps? Just curious if she has every availed herself of a public insurance plan or been uninsured. If she were ever truly at the mercy of our healthcare marketplace. I might find her just a little more credible.

  61. I enjoyed it. Debates involve multiple sides of an issue and it is good to see this blog is not doomed to become an echo chamber of the same opinions posted repeatedly by a handful of authors. Somehow folks will survive a differing view — from a different author — being placed in front of them to consider.

  62. I can’t believe we have let this debate include someone so removed from the reality of this debate. Honestly, this was once a forum for educated and impassioned bloggers to make their case, now it has included the side-show of American politics.
    Disgraced Gov. Palin (R-Alaska) has no business discussing this topic or being in this forum.
    If we run out of bloggers for a day, why not just post a request for readers to opine? This is not a right-wing vs. left-wing comment, but rather one that is committed to ensuring that we have a couple of outlets (since mainstream media is failing us) where rational and educated information can be reviewed.
    A shame that I wasted 12 minutes on Gov. Palin today, time I’ll never get back.

  63. > Congratulations, Mr. Holt, your blog
    > has officially jumped the shark.
    > This is a joke, right? A spoof of some sort?
    No, it is a public forum.
    t

  64. “There were good intentions behind the drive to increase home ownership for lower-income Americans, but forcing financial institutions to give loans to people who couldn’t afford them had terrible unintended consequences.”
    Again Ms. Palin shows a complete lack of knowledge about issues. She simple mouths the mantra necessary to attract her reich wing supporters and divert discussion about the facts. She continues to voice inaccuracies that the financial meltddown was a failure of too much government and not a failure of too less regulation of the “free” market. That she still holds ANY public credibility is a due to our failed corporate 4th estate that sells personality over substance, and again shows she’s not any smarter than a 5th grader.
    I will not even attempt to debate an idiot and corporate shill who despite that 95% of the healthcare market is private and that insurance simply passes costs along, attempts to convince us that more deregualtion of the insurance market will make a dent in unaffordable care.

  65. “We don’t want subsidies…” just tax subsidies.
    “We don’t want government handouts…” just government vouchers.
    “We don’t want government interference in medicine…” just government interference in patient’s rights to receive compensation for malpractice. (BTW, $54 billion over 10 years is 0.0027 of current costs…)
    Sarah, you’re still not making sense.

  66. “health care is, or rather should be, a social service, just like education.”
    Wow Margilt, you are aware how much of a failure our public education system is correct? Many schools have sub 50% graduation rates, that is your model for HC reform? I’ll assume after further thought you want to take that comment back.
    “provide affordable, quality health care to every American in this country.”
    THis is best accomplished in a free market system mostly free of government intervention. It worked great until 1965 when the government started fixing it.

  67. Im a registered nurse with 20 years experience managing a surgeons private practice. One of biggest money saving mechanisms that could be put into place: Concerning medicare recepients- stop the over utilization of procedures, test, and Dr. visits. Doctors are paid by CPT codes for procedures and office visits. They know how to get more money from medicare and the other insurance companies using certain CPT codes. For example a dermatologist who does a biopsy on a skin lesion will get a lot more payment than just “freezing” it off. A well trained dermatologist can diagnose many skin lesions by simply looking at the lesion (but if he performs a biopsy, he gets paid a lot more) This is just one example of over utilization by doctors.
    Tort reform is a MUST if cost are ever to be brought down. Doctor’s malpractice insurance premiums are a very large percentage of his overhead. (Which the insurance companies wind up paying for)

  68. “However, the maximum fine for those who refuse to purchase health insurance is $750. [2] Even factoring in government subsidies, the cost of purchasing a plan is much more than $750.”
    The costs are the problem. Until prices are strongly regulated, and health insurance companies eliminated, there can’t be true reform. Tort reform would lend itself to providers being held even less responsible than they are now, if you can imagine that. I will never purchase health insurance, and will not contribute to the companies CEO salaries. If I’m going to pay, I want to pay for health care.
    You want market-driven health care? Abolish the insurance companies now. Anyone wanting health care must pay for it, period. The alternative is socialized medicine.
    This editorial does not scare me at all. That is because even though the proposed reform is not a solution, it will force the dismantling of the current system. What actually is scary is that this single issue may have the capacity to drive the USA to full socialism, when socialized health care is perfectly possible in a capitalistic system. The refusal to cooperate for the good of all of us, by those opposing reform and protecting certain interests, is going to bring out some real ugliness.

  69. I’m afraid that we are mixing terms here. There are two kinds of costs: there is the cost of health care and there is the cost of healthcare insurance.
    If and when people wait to buy insurance until they get sick, the cost of insurance will indeed rise. The cost of the actual care will not be affected by this behavior.
    So which cost are we trying to reduce here? and why?
    Here is another novel idea, or maybe not so novel, health care is, or rather should be, a social service, just like education. So let’s just stop toying around with insurance schemes and reforms and concentrate on what is really important: provide affordable, quality health care to every American in this country.
    Get big corporations, Wall Street and all other greedy predators out of our health care system. There is enough money poured into the system by all of us to provide better care than any other nation on earth. We just need to realign providers interests and reallocate some of the resources towards real quality of care.
    This is not about free markets, investments or profits. This is about human decency, compassion and social responsibility.

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