Will Business Force Reform Back To The Drawing Board?

Brian KlepperUntil now, non-health care business has been noticeably absent from the health care reform proceedings , and quiet about the bills’ impacts on their management of employee benefits, on cost, and on the larger issues of global competitiveness. Where have the voices been of the powerful business leaders who will pick up much of the tab?

They’ve finally surfaced, and now we’ll see whether they have the will to bring reform back on track. They certainly have the strength. The question is whether this salvo by the business mainstream could force Democrats to reconsider and revise the content and structure of their proposals.

On October 29th, a powerful collaborative of major employer organizations sent a letter to Speaker Pelosi and Republican Leader Boehner asserting that the House legislation “falls short of the bipartisan goal of controlling costs and jeopardizes employer-sponsored coverage which now serves more than 160 million Americans.” The same group sent a similar letter to Senate President Reid earlier that week.

It is important to note that the collaborative – the group includes the American Benefits Council, the Corporate Health Care Coalition, the ERISA Industry Committee, the U.S. Chamber of Commerce, the National Association of Manufacturers, the National Association of Wholesaler-Distributors, the National Coalition on Benefits, the National Retail Federation, the Retail Industry Leaders Association, the Business Roundtable and the National Business Group on Health – represents the mainstream of American business. In general, these associations’ member firms have sponsored employee health coverage for decades, and understand the linkages between health, productivity, cost and competitiveness. Their very real stake in the outcome, their long term sponsorship and their sheer collective clout enable them to enter and change the terms of the discussion.

Then, Tuesday, Employee Benefit News published a list of 10 specific items prepared by National Business Group on Health President Helen Darling, a longstanding progressive voice in health benefits, that “should concern plan sponsors that provide health care benefits to their workers.” The bill, she said:

  1. Lacks meaningful ways to control health care costs;
  2. Takes us down the road to even worse deficits and crushing national debt by not getting more savings from the health system and making the coverage more affordable;
  3. Does not support strong evidence-based medicine or a way to make certain that we don’t pay for treatments that are not effective;
  4. Does not establish a strong independent Commission that could help Congress make the politically hard, but obvious, good decisions to eliminate wasteful and harmful treatments and spending;
  5. Does nothing to correct medical liability problems and related costly defensive medical practices;
  6. Doesn’t expand employers’ ability to help employees to actively engage in wellness activities or achieve health goals;
  7. Undermines ERISA and opens ERISA plans to unacceptable burdens;
  8. Raises serious questions about the public plan and how it would operate;
  9. Could require an employer who provides comprehensive benefits to still be subject to an 8% payroll tax if employees decline employer coverage because it costs more 12% of the employee’s income; and
  10. Contains an outrageous requirement that would require employers still offering retiree medical coverage to continue it indefinitely, thereby hurting employers who have maintained retiree benefits in good faith.

Non-health care businesses comprise about six-sevenths of the economy – meaning they have six times the heft and influence of the health care industry – and financially sponsor coverage for more than half of Americans. Year after year, employers have borne the lion’s share of onerous health care cost increases, 4 times general inflation over the last decade. Endless reports have described how health care, business’ largest and most unpredictable benefit cost, has sapped America’s global competitiveness and placed its employers at a severe disadvantage. An equal torrent of words has been spent on health care’s excessive waste, at least 30% of our $2.6 trillion expenditure, or north of $800 billion annually. Even so, most business leaders are loathe to simply give up the health system they currently sponsor, its flaws notwithstanding, unless they can be confident the alternative can result in lower cost, improved quality, and an equally or more productive workforce.

Keep in mind that, at this point, health care reform has been a series of power plays between Congress and the health care industry (meaning the professionals, firms and associations representing health care’s four major sectors: the supply chain, HIT, care delivery and insurance/finance).

Until now, the health care industry – those who seek dollars – has dominated, lobbying Congress and contributing enormous sums to election campaign coffers to make sure that the legislation doesn’t impede health care profiteering and sends new funds their way. Meanwhile it has held its breath, apparently hoping that other interests with clout won’t notice. As the bills come down to the wire, the air waves have NOT burned with cautionary and righteously indignant health care industry messages opposing them. That’s because organizations in the health industry are reasonably certain they’ve won. They have been sitting tight until the deals are done.

And with good reason. As they stand now, the reform bills are very generous to the health care industry, facilitating, through mandate and/or subsidy, millions of new customers but, as we’ve recently pointed out, doing pathetically little to rectify the health care crisis’ structural drivers. For example, the health plan sector can raise rates without restraint, and a significant chunk of Medicare dollars will be transferred to private sector control. The biotech industry gets a 12 year moratorium on generic competition. With only token progress away from fee-for-service reimbursement and toward primary care re-empowerment, the system will continue to make specialist excesses lucrative. The American Medical Association (AMA) and Medical Group Management Association (MGMA) couldn’t be more enthusiastic, though both are now campaigning for H.R. 3961, which would eliminate the 21.2% drop in Medicare physician reimbursements scheduled to go into effect January 1, 2010. There are many more examples.

Commercial purchasers have waited to see how all this would play out. But now they’re stirring, and not a moment too soon. Non-health care business leaders finally appear to be mobilizing against the weak cost control provisions of the current proposals.

What is needed now is an orchestrated, mobilized, highly visible campaign effort that features the faces and voices of well-known American CEOs, and that leverages the full force of business’ leadership across industries, not just for their own interests, but for those of all Americans. The places to start are in the structural areas we and others have recently discussed: primary care, fee-for-service reimbursement and cost/quality performance transparency. Properly implemented, reforms in these approaches throughout health care could have profoundly positive impacts on both cost and quality, empowering the market to make health care far more affordable for businesses and working families.

It is possible that the entire health care reform process just changed tone and direction. If it did not, then we’re no worse off than before. But if it did, then the ramifications for how American policy works – not just for health care but for all our issues – could have just entered a new and profoundly important paradigm.

Brian Klepper and David C. Kibbe write together on health care market dynamics, health IT, innovation and policy.

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  2. A journey of a thousand miles begins with one step. Let’s talk about the first step. This first step should address healthcare cost which is pushing us over the edge. Why has the concept of state Medical Public Service Commissions (PSC’s) not surfaced? We have seen in areas where there is a competition problem that PSC’s can do a good job. Let’s turn the problem of healthcare costs over to state PSC’s.
    In so doing there are numerous hidden benefits that you would not expect at first blush as follows:
    1. PSC’s will determine the basic cost of each Medical Charge Code used by providers to bill insurance. If the current medical charge code manual is not specific enough for some procedures, new medical charge codes can be added to help narrow these costs. Then these determined costs will be adjusted for inflation annually until reviewed again and a new cost basis set. In addition, the PSC will calculate a market adjusted mark-up percent for fair and reasonable provider profits for the coming year. The provider mark-up percentage will be determined by a new market ‘check and balance ‘ mechanism unavailable until now. More on this later.
    2. Because some Zip Codes have inherently higher costs than rural areas, the co-pays may vary by Zip Codes to offset these cost differentials so the Medical Charge Code cost basis can be leveled across the state. These office visit co-pays would be standard across all insurers in a Zip Code and paid by the patient. These co-pays should not deter patients from seeing their doctor.
    3. The PSC eliminates provider networks and provider service contracts. Thus, competition between providers is increased because insurance no longer delivers a pool of patients. Patients can go anywhere in the state and use their insurance because all insurers pay the same for identical services as set by the PSC.
    4. Insurers now compete solely on the price of their policies because the doctors/hospitals are no longer tied to their networks. All insurance is accepted by the doctors/hospitals because they all pay the same PSC rates.
    5. The elected State Insurance Commissioner may increase insurer competition quickly, if needed, by soliciting outside insurers to come into the state and compete. There are no network or provider service contract requirements.
    6. The PSC can greatly reduce the over prescribing of medical services by the way the provider mark-up (profit) percentage is determined. It can tie the profitability of the providers to the profitability of the insurers. If the profitability of the insurers decline because of the overuse of medical services, then the mark-up percentage for the providers is reduced on every Medical Charge Code. The providers will then think twice about how they prescribe healthcare because it now directly affects their profits. This one feature alone will cut healthcare costs significantly.
    7. Tying the provider mark-up to the net profit margins that private insurers earn in the state creates a healthy ‘check and balance ‘ mechanism. If provider costs go up, profits of both go down. If profits go up above what the average state business earns, the State Insurance Commissioner can intervene and license new outside insurers to compete and lower premiums, if necessary. But both the insurers and providers have a right to earn a reasonable profit, so the elected State Insurance Commissioner will only increase insurer competition when it becomes necessary to reduce average insurer profits for the benefit of the public when these profits noticeably exceed what other state businesses earn.
    Note: If insurer profits surge due to the more efficient delivery of healthcare, then the insurer can invoke a mechanism to reduce gross profits with offsetting insurance policy premium reductions. This results in a lower net profit for the insurers which the PSC will use to determine the provider mark-up percentage for the coming year. Thus by lowering premiums, the insurer gains a direct cost reduction for the coming year from a lower provider mark-up percentage. This allows the insurers and providers to earn fair and reasonable profits and policyholders to pay lower premiums. If the insurer refuses to lower excessive gross profits, then the State Insurance Commissioner may intervene and policyholders may react by dropping the insurer for a new one during the end-of -year sign-up period while retaining their same doctors/hospitals.
    8. The PSC does not make healthcare decisions and does not affect the doctor-patient relationship. The full time job of the state Medical PSC is determining the cost of Medical Charge Codes. The PSC will standardize these codes to make filing claims easier for doctors/hospitals.
    The state Medical PSC concept has amazing potential. Not only does it break the bond between doctors/hospitals and insurance companies, but it relies on a ‘check and balance ‘ system to spread the wealth among providers, insurers and policyholders. Without a doubt, this approach has never been seen before and will position the American Healthcare system to control costs as healthcare is expanded by Washington. Congress does not know about this brilliant idea. Please write/call your representatives and tell them that we must have state Medical PSC’s.

  3. Employers provide insurance in a effort to recruit New Employees and compete with other Business’s. They select policies based on Premium Dollars and functionality. Recently my insurance company raised premiums 30 %. The choice for the employer was either accept the increase in premiums or increase from $500.per person to $1,000.00 per person deductibles and the cost of emergency room Visits from $100.00 to $250.00 among other changes. This is a Business decision based on the law of averages. Business decisions often clash with personal Needs.
    I have read some of the post above and I can tell you that employers continue to pass on the majority of the expense to the Employee. They are setting on the sidelines because they don’t want to upset the broker who offers insurance and for some ,it is the cost of Doing Business.
    I have seen young opinionated individuals claim to know it all about Health Care. What they know won’t fill a recipe card.The problem is we have spoiled our children to the degree of being selfish,uncaring,and mutually self absorbed to understand the problems or the plight of neighbors and friends that are denied Health Insurance.More importantly they don’t care and they feel that it is their duty to block change. This Behavior is destructive and needs to be changed. Spare the rod;spoil the child.

  4. we all know we need more Competition. nobody is making this point. lets try the free stuff first. its free. if it doesnt work then we can change our stratagy as needed. my idea is to get the consumer in the game. lets say i need an mri and the insurance companys and the goverment will pay 1200 dollars. if we offered the consumer a rebate of half the amount we can save back to the consumer they will call around and find the best price. people will all the sudden care what it cost and try to find the best deal. it will force hospitals to post prices or hire more staff to take all the phone calls. so lets say i found one for 600.00 the goverment would save 300 dollars and i would make 300. its a win win. goverment saves money and i make money.

  5. Hospital Cost shifting is what targets patients and leaves them vulnerable for unsubstantiated Expenses that are intended to make up for the uninsured. The Facts are that Health Care has priced themselves out of a fair Market value. Ever increasingly setting themselves up for failure or Non- Payment for services.They are just Too expensive and Health Insurance contracts are not paying there fair share.Insurance Manipulates and inflates the Cost of Services and often leave not only the individual but the institutions saddled with excessive Debt.
    Its unbelievable that Providers would allow Insurance to dictate to their Members. Its embarrassing that providers would sign a non Competition Clause that virtually enslaves them to the whims of insurance. Counter productive clauses such as these only limit and constrain Improvements.
    Contractual agreements such as these Superficially Drive up Cost, employ wasteful duplication, and unnecessary procedures. Can We do better? Yes! However it will take a miracle to change minds of those who are comfortable with the Status Quo.

  6. I am amazed that we don’t see costs being contained through these reforms. The federal and state governments will lower their rates,patients will continue to have free care in the emergency room,insurers will not give hospital higher rates. Cost shifting has stopped at the door of hospitals. They will close,merge or more likely change into primary care centers,wellness centers,free standing asu,medical homes,retail clinics. This radical change was the intent of health care reform.Insurers and pharmaceutical companies will pay a little bit more into the system but will survive and grow. Hospitals have attempted to push back on how health care should be delivered through lobbyists and politicians. The Trojan horse has entered through reform and now it is time to adapt.

  7. I commend this excellent review of the failure of HR 3962 and the Senate plan to be economically sustainable. Nancy Sebelius’ optimistic estimate of the cost of health care in 2020 is 23.3% of the GNP versus 23.2% with the status quo. Helen Darling’s 10 salient cost issues are well taken. Klepper and Kibbe are right that the place to begin is “primary care, fee-for-service reimbursement and cost/quality performance transparency.”
    Consider “Physician Managed Care”, an imperfect health care reform plan but better than the Democrats’ efforts: http://doctormanagedcare.com/PMC/Book.pdf
    Physician Managed Care will describe a new comprehensive plan that promises to shift up to $10 trillion over 10 years in medical system waste to valuable health services for patients. Patient care would be administered through competing private “accountable care organizations” (ACOs), with patient health risk adjusted global budgets. Patients would choose their ACOs and change if they are unsatisfied. Primary care physicians (PCPs) would coordinate all care, offering additional services such as same day appointments, 24-hour phone consultations, and non-urgent questions answered by email (i.e., similar to how “direct practice” PCPs now operate). ACOs could consist of local networks of physicians (PCPs and specialists), groups of PCPs, or fully integrated health systems (i.e., HMOs like Kaiser Permanente and the Mayo Clinic). ACO health care professionals would provide care to members, or the ACO would contract for patient services as needed with independent specialists, hospitals, and other health services providers.
    Physician Managed Care funding would be from both the federal government (73%) and individuals (27%)—patient premiums ($200 per month per adult and $50 per month per child) and out-of-pocket payments for uncovered tests and treatments. Low income people would receive subsidies for premiums.
    With Physician Managed Care after 2011, all increases in health care spending would be in the private component of costs (i.e., insurance premiums, out-of-pocket spending, and charitable giving). The federal government contribution would remain frozen at the 2011 level ($1.7 trillion). Assuming that free market forces driving efficiency eliminate inflation in private costs, the percentage of the GDP would be back in line with that of developed countries all over the world by 2020 (12.6%,). Even with a 10% per year increase in private health care spending, national health expenditures would remain at the current level of about 18.0%. Compared with the status quo national health expenditure projections or the Democrats’ HR 3962 plan, Physician Managed Care would save the country $4 – $10 trillion by 2020. Consider this proposed method of bending the health care inflation curve in relationship to the projected $9+ trillion federal deficit by 2019.

  8. Everyone is so damn afraid to chip in a little more so that the rest of the country can be healthier. It’s not socialism. It’s democracy. It’s called sharing. We learned it when we were in preschool. It’s time we put our basic rules of morality into practice. This may not be a perfect bill, but it’s an improvement. If you’ve got something better, naysayers, let’s see it.

  9. Barry,
    The problem with health care costs is that there are objective factors outside the control of either government or private industry that push costs up. I am not at all convinced that the main reason for cost escalation is the fact that government is involved in regulation.
    I do agree that good intentions are never enough and should be tempered by reality, but I also believe that good intentions should be the starting point in all endeavors.
    I think almost everything you listed up there is fairly common sense. I do take exception with high deductible plans, since the difference in premiums between those and the regular plans is, in my experience, not that large and the net effect is that folks just take more risk and ultimately pay more for health care, while insurers pay less. I don’t think the public can absorb any further increases in health care expenditure. If a $5000 deductible plan would have $5000 lower premium, that would work, but that is not the case.

  10. Margalit,
    I would like to address the issue of lack of trust in government as it relates to healthcare. Nate, in past posts, spoke of the history of Medicare, Medicaid, public housing, public education and other government programs that either did not live up to their promise or cost far more than initially projected or both.
    Historically, when the left proposes programs like these, they tell us that their motive is a fairer and more just society and they claim the moral high ground based primarily on their noble intentions and supposed concern for the less fortunate. The problem, from my perspective, is that when programs don’t work like inner city public education and public housing, the left never admits failure. Instead, they claim we need “more resources.” We commit more resources and we get more failure and higher taxes and/or larger deficits to cover the bill. They also underestimate the extent to which individuals will game the system to claim benefits, usually by hiding income so they can minimize or eliminate tax payments while qualifying for subsidies and other benefits to which they are not legitimately entitled. I’m reminded of a quote that I think is attributed to the writer, James Joyce. He said: “The force of idealism is lost when it fails to recognize the reality of things.” Good intentions alone won’t get the job done.
    Two large sectors of our economy that have seen costs increase well in excess of general inflation for decades now are healthcare and education. In both cases, government plays an outsized role as both a payer and a regulator. The current direction of health reform would give the federal government and even larger role than it has now. In light of its record across a wide range of entitlement programs, more government involvement is likely to make matters worse, not better. This is especially true, I believe, with respect to the so-called public insurance option. At the same time, the status quo is unsustainable and unacceptable.
    So, what’s my alternative you may fairly ask? If it were up to me, I think the following reforms would go a long way toward righting the system:
    1. Eliminate the tax preference for employer provided health insurance and raise salaries by the amount employers are currently paying for health insurance. Reduce income and/or payroll tax rates sufficiently to ensure that the federal government does not collect any more in taxes than it does now. The standard deduction and Earned Income Tax Credit (EITC) could also be raised to protect the working poor.
    2. Reform the medical tort system. Replace juries with special health courts with the expertise to resolve medical disputes objectively and fairly. Provide doctors and hospitals with safe harbor protection from lawsuits if they follow established evidence based care guidelines.
    3. Take steps to root out fraud more aggressively. Any doctor or other provider who has the power and authority to perform or order a service, test or procedure and bill a payer for it should have a biometric ID card that includes a picture and a unique numerical identifier.
    4. Increase the use of living wills and advance directives and establish registries so the information is available to doctors and hospitals when needed. This should cut down on futile and often unwanted end of life care.
    5. Invest in electronic medical records to reduce duplicate testing and adverse drug interactions, especially in hospitals.
    6. Move away from the fee for service payment model toward bundled payments and partial or full capitation to the extent feasible.
    7. Develop robust, user friendly price and quality transparency tools to help referring doctors send patients to the most cost-effective providers.
    8. Encourage the use of high deductible insurance that would pay all costs for covered services once the (high) deductible is satisfied.
    Over time, I’m confident that these strategies could bend the medical cost growth curve significantly without a public insurance option and without smothering the insurance industry in overregulation. If we can, in fact, bend the cost curve, we can much more easily afford to provide subsidies to lower income people to help them purchase health insurance.

  11. Margalit, basic education is a social need and crucial to the evolution of all of society. I have no problem contributing to your 12 children’s primary education. You can buy whatever you want with your food stamps, they don’t go that far if you want to blow it all on Russian caviar that’s up to you. In your examples, there are LIMITS. If Yellowstone blows their entire budget covering one lodge in 24k gold plating, but the rest of the park becomes a polluted cesspool, society would make some changes. I’d rathar pay for executions than pay to feed and house convicted murders for life. So yes indeed, let’s make up our mind regarding principle. To quote MLK, morality can’t be legislated but behavior can be regulated. “The human condition” we can’t afford to provide all things to all people, Margalit.

  12. Lisa,
    Is it shortsightedness or deliberate obfuscation when people ask about paying for other people’s health care?
    Are you OK paying for my 12 children’s education even if you have no kids?
    Are you OK paying for my food stamps? Should you pay for Russian caviar as part of my food stamps? How about fresh salmon steaks?
    Are you OK paying for maintenance of Yellowstone park even though you never go camping?
    Are you OK paying beef subsidies while being vegan?
    Are you OK paying for my Medicaid care?
    How about foster care for all those 12 children when I decide to change my diet to alcohol and coke exclusively?
    Are you OK paying for my bus to work even if you own three cars? How about paying for interstate highways if you never left the county you were born in?
    Are you OK with paying part of the brand new baseball park downtown even if you never watched a game in your life?
    Are you OK paying to help hurricane victims even if you will never experience one yourself?
    Are you OK paying for executions even if you think they are nothing but government sponsored murder?
    My definition of illness is the human condition.
    First, let’s make up our mind regarding the principle. Are we a socially responsible society whose success is measured by the collective well being of all it’s members, or are we a collection of isolated individuals measuring personal success only? Are we a forest or are we a bunch of trees?
    So make a decision, either way. We can quibble about the details later.

  13. Margalit, what do you define as illness? Health care should be a social service, indeed, but who is going to define health care? Needs or wants? Should I be taxed to pay for your invitro fertilzation? We can’t provide all things to all people, we can’t afford to. Already there’s a backlash to the evidence mammographies are over-used.

  14. Nate,
    This is not as simple as government is/is not to be trusted. Government is not a monolithic, static entity. It is composed of people, with different beliefs and different levels of integrity and mental capacity at different times. I’m not sure that it makes sense to debate whether we do or do not trust government in general. In theory, we should trust the notion of democratic governance. Reality is that some governments have been more trustworthy than others.
    I am not trying to evade the issue at hand, and I do understand the distrust. If you scroll a billion comments back, you will see that I am not at all happy with the way government functions right now either.
    The main difference between us, I think, is that your solution is to eliminate government intervention, so we are on our own and may the best man win. I think governments are very valuable social tools and we should work towards ensuring trustworthy governments, even if we disagree with the currently elected flavor, and this goes much beyond just health care reform.
    I totally agree that illness does not lend itself very well to “insurance”, hence my contention that health care should be a social service, financed by taxation and administered as such.

  15. “I would be the first one to admit that Medicare is a mess.”
    Margailt would you also admit Medicare is not what the people wanted and Congress lied to the public about what it would do and what it would cost? You made some strong claims that government should be trusted, you don’t understand why people don’t trust it and it only gives the people what the majority want….I disproved all that and you glossed over it and moved on. You held some presumptions that were very wrong, do you still beleive as you did when you typed that stuff or do you know understand the distrust?

  16. Barry, you’re a lucid & thoughtful contributor here. While you’re on a roll, why not explain for Margalit the reasons why “illness” is a matter frequently poorly suited for insurance in the 1st place, whether the “insurer” is the government or a private entity? Surely you’d agree that anyone who has spent any time in the health insurance business and has had to endure various bodies’ credentialing/continuing ed requirements has a grasp of those principles. Further, it’s an issue the public would benefit from understanding more thoroughly.
    Be sure to include plenty of examples featuring behavioral health, back pain, etc cases.
    Nate, you should join in, too. Your “history of the Medicare fraud perpetrated by Congress in 1965” was comedy gold. Keep that stuff coming!

  17. “I never understood the lack of coverage for long term care like nursing homes, or that insane doughnut hole.”
    Margalit – To provide long term care as part of Medicare would be prohibitively expensive. LTC is basically custodial care mostly for the frail elderly who can no longer perform some or all of the normal activities of daily living (ADL’s). Medicaid alone already spends more than $100 billion annually for LTC for the poor and billions more for home healthcare. If it were suddenly covered by Medicare, people would come out of the woodwork by the hundreds of thousands to claim benefits that are currently being provided by family members, albeit often at considerable financial and emotional sacrifice. It’s just not affordable to cover it. My wife and I purchased long term care insurance about eight years ago. The daily benefit started at $150 and includes inflation protection. We pay a bit less than $3,600 per year for a policy to cover both of us for life after we pay out of pocket for several months first. Most people cannot afford that.
    The Part D donut hole is the result of politics. Lawmakers wanted to keep the 10 year cost to $400 billion but they wanted to sprinkle benefits over as many seniors as possible in order to maximize the number of elderly voters who perceived Part D as a “good value” relative to premiums paid. They could have easily designed a benefit with a higher initial deductible of, say, $500 or $600 instead of $250 and there would have been no need for the donut hole. However, that wouldn’t have satisfied their political objectives.
    Regarding special interests, economists tell us that the single biggest thing we could do to bend the medical cost growth curve would be to eliminate the tax preference for employer health benefits and lower income and, perhaps, payroll taxes instead so the Treasury doesn’t collect any more net revenue than it does now. The biggest opponent of this idea: labor unions, a key Democratic constituency. Sensible tort reform that took medical disputes out of the hands of juries in favor of health costs could, over time, significantly reduce defensive medicine. The biggest opponent: trial lawyers, a key Democratic constituency. Instead of just bashing insurers, drug companies and other corporate interests, the left would enhance its health reform credibility if it were prepared to take on its own special interests. I won’t hold my breath waiting.
    Finally, those of us who staunchly oppose a public insurance option do so, in part, because we think the government simply cannot be trusted to sustain true level playing field competition with private insurers even if it starts out that way. Nate’s comments regarding the history of Medicare suggest that such lack of trust is well founded.

  18. Nate, I would be the first one to admit that Medicare is a mess. The logic of paying for some stuff, but not the other is a bit perplexing, to say the least. I never understood the lack of coverage for long term care like nursing homes, or that insane doughnut hole.
    I also don’t agree with the way Medicare pays physicians.
    However, I still think that what LBJ did was a good thing. The problem is that they (we) didn’t follow through. A program so big and so important should have been evaluated and reevaluated constantly. Things that were not there initially should have been added. Others should have been removed.
    Healthcare has changed dramatically in the last 44 years and Medicare was not properly changed to reflect that. There were no routine organ transplants in LBJ’s days. There were very few life saving treatments that cost tens of thousands of dollars on an outpatient base. You can’t just say that all seniors need is hospital insurance. What is financially catastrophic today didn’t even exist in 1965, not to mention that folks didn’t live as long.
    I’m not going to presume that I know what should have been done along the years, but one thing I’m certain of. We are not collecting enough taxes to cover all these new and improved treatments.
    I also think that Medicare is doomed to be unaffordable as long as the pool is split between old and sick on one side and young and healthy on the other. I’m sure you can disprove this somehow 🙂
    The point here is that government is not some static disconnected agency removed from ourselves. If we have governments that are dishonest and are not acting in the public good (and we do), we should fix that problem first. There will never be anything sound passed in a government that is representing special interests instead of voters. The current bill is a perfect example.
    My only hope is that by rattling and disturbing the status quo, which is unsustainable, we will be able to affect positive change in the future. I am fully aware that the chances for that are nil if we don’t reform campaign finance and everything else that allows dishonest people to sit in government.

  19. so lets review the facts;
    Public wanted a bill with limited government government intervention
    Public wanted catostropihic protection
    Public got a bill that excluded catostrophic protection
    Public got a bill that started a time of termendous government involvement.
    Margalit history seems to show the exact opposit of what you claimed, they “hoodwinked” the public then passed the exact opposit of what they wanted, and you ask why we don’t trust them? Is this enough reason for us not to trust them or is it OK to lie to the public as long as you know its in their best interest?
    Think how different the world would be today if they had passed just a catostrophic plan 44 years ago. No 34 trillion in unfunded liabilities, no 45 billion a year lost to fraud, we would still be able to afford basic care without relying on insurance or givernment handouts.
    Just once I would like anyone on the left to respond to these facts. I post these and it goes silent, the left refuses to discuss history when it conflicts with their dogma.
    These are actual quotes from senators refuting your claims which raises the questions where did you get your information you based those claims on in the first place?

  20. Since they apparently don’t teach history in our schools any more and our media can’t be bother to report the facts here is a brief extract of Medicare and how it came to be. Let me know if your opinion has changed after reading this Margalit.
    “The gulf between what the public thought and what was actually in the bill was enormous. The most pressing rationale for compulsory health insurance continually put forward by government officials and echoed by the public was the specter that responsible older people could be ruined financially by catastrophic illness.”
    “During the 1965 Senate Finance Committee hearings, Chairman Russell Long (D., La.) asked HEW Secretary Anthony Celebrezze, whose department had written the bill, “Why do you leave out the real catastrophes, the catastrophic illnesses?” (U.S. Senate Hearings 1965: 182). When Celebrezze replied that it was “not intended for those that are going to stay in institutions year-in and year-out,” Senator Long countered: “Well, in arguing for your plan you say let’s not strip poor old grandma of the last dress she has and of her home and what little resources she has and you bring us a plan that does exactly that unless she gets well in 60 days.”
    “Long added that “Almost everybody I know of who comes in and says we ought to have medicare picks out the very kind of cases that you and I are talking about where a person is sick for a lot longer than 60 days and needs a lot more hospitalization” (U.S. Senate Hearings 1965: 184). [14] Yet the very element that government officials continued to cite to win public support for Medicare was deliberately omitted from the administration’s bills.”
    “When Rep. Albert Ullman (D., Ore.) cited allegations that the “public is somehow being hoodwinked” and “being misled” and asked HEW’s Wilbur Cohen about the degree to which the public misunderstood the program, Cohen stated that “we do recognize this problem and I think it has been complicated by the use of the term ‘medicare’ which is an erroneous term when applied to this program”
    “A central rationale offered to the public for the bills that became Medicare was that they would enable people to “avoid dependence” in old age. In fact it was a bogus rationale that served as a key form of transaction-cost augmentation used to secure the bill’s passage. That this rationale was not believed by the bills’ authors in HEW is clearly indicated by Celebrezze’s acknowledgments above regarding the omission of coverage for catastrophic illness. Nonetheless, government officials’ repeated assertions that Medicare would “avoid dependence” made it more difficult for voters to understand that dependence in old age would not be forestalled by these measures, thereby diminishing resistance to the bills.”

  21. A majority of Americans never supported Medicare in anything close to the form it passed. Even Democrats at that time said the public was hoodwinked. America wanted catostrophic protection and they got the exact opposit. I can send you countless links tha will explain the history of Medicare to you, or read the congressional records from that time, America was never behind what the Democrats passed. Americans don’t support the bills presently offered yet they are all that can be passed.
    Why do you trust government in regards to healthcare when it has lied to you every time it passed a bill?
    Would you call in the army if you had a spider in your tube? That is a simple life issue that people rightly should be expected to handle on their own. Healthcare was the same way until the government got involved. It wasn’t until the government passed Medicare that people couldn’t afford an office visit. You see the same thing in education, before the government “helped” fund education you could put yourself through a great school working part time. Now that the government “has made it affordable” most people can’t afford it and surely not on a part time job income. I did three years slinging food, I couldn’t imagine a kid being able to do that today the way price has appreaciated. Our government has waged a war on the pubic and it is past time we start fighting back.
    Maggie nice try but I tested your claim on multiple occasions by cleaning up the comment and removing any personal reference and just linking concise facts and links to the truth and you still deleted them. Any time you where corrected you deleted the comment now matter how passive and gentle it was.

  22. “The government did nothing but represent the majority of its constituents.” The very definition of democracy

  23. Nate, let me start from the bottom up.
    If I were a conquered Native American, I would not trust the occupying government and if I were a victim of discrimination in the past, I would not trust the people that did that to me. The government did nothing but represent the majority of its constituents. We (or our parents and grandparents) are all at fault.
    As to the failed Medicare and Medicaid, let’s apply the same logic you applied to wars. Why do a “half assed” job? It is of course bound to fail. Having the old and sick and poor all by themselves in some weird pool is bound to get expensive.
    I say, let’s commit all troops here and have universal care funded by taxation for everyone (note I didn’t say public plan).
    I think what you are saying is that we shouldn’t commit any troops at all.
    The question is whether we need to win this war, or is it better to just stay home and be happy without the possible spoils of victory.
    Or maybe the advantages of victory don’t justify the expected casualties. I think they do.

  24. Lisa–
    Since you keep bringing this up (though it has nothing to do with this post) I’m sorry I had to delete your comment about your husband’s injuries. It was graphic in a way that at last one reader found disturbing, and as I explained in my e-mail to you, I though it was too personal for the blog.
    After you explained about your husband’s treatment I also deleted my comment pointing out that insurers don’t always pay the cost of treatments for burns–but it took me a while to figure out how to delete that portion of my comment without deleting my responses to other readers.
    None of this belongs on THCB’s thread, of coures, but since you brought it up twice, I thought I should explain.
    (If anyone’s wondering, all of this came up on HealthBeat after I talked about in vitro fertilization (IVF) in an Op-ed in the Washington Post yesterday and mentioned that in many developed countries national healht insurance covers IVF, and that in the U.S. 12 states mandate that insurers cover it.
    Lisa objected to the idea that, as she put it: “I should go to work every day and pay a portion of my salary (and/or my employer contribute a portion of their profits) into a fund so Jane Doe can get an embryo emblanted in her uterus? Really?”
    (For those who are interested, when insurers cover IVF we actually save money because women are less likely to wind up having sextuplets–with all of the accompanying, expensive complications. When insuerers are covering IVF, women are far more likely to have only or two embryos are implanted at a time. )
    Nate, your comments have been deleted on HealthBeat because, as a matter of policy, we don’t allow expletive language or crude personal attacks on the blog. But I do think that a “Nate filter” is a terrific idea!
    Matthew, — sorry to have HealthBeat disagreements dragged onto your blog.

  25. Matt, got a great monetization idea for you, sell a Nate filter for something like $0.05 per post. Kick me back one to two cents and you will be rolling in the dough.

  26. When I would correct factual errors on Maggie’s site she would delete my comments as well. She would never try to argue or back up her point just delete any dissent. Not must more you can say when someone wields editorial power like that.
    I love my conversations with Margalit and always look forward to her response and opinion. I much rather exchange some harsh words with her now as we work to a good solution then be trading shots with her in a civil war. I don’t think I have ever exceeded anything acceptable in English legislative chambers. By American standards of discourse it might be harsh but PC civility hasn’t exactly lead us down the road we desire.
    I think we are doomed to repeat history if we never admit the source of the mistakes. We won the battles of Vietnam but lost the war because we fought it with to much political concern. Somalia we again worried more about the political perception then winning and suffered loses we never should have. Here we are once again with Iraq and Afganistan more worried about the perception instead of doing the job right. You never fight a war half assed, you either commit all our troops to win or you send none of them. A mistake we have made countless times.
    Specifically in regards to healthcare majority of politicians can’t even admit Medicare is insolvent by any other measure. We have not had a true accounting of Medicare and Medicaid cost and liability in 30+ years. If we have yet to even define the problem how can we avoid repeating it?
    I don’t think you can point to a single sustainable program of social welfare. Not only has everyone passed in this country been designed as a ponzi scheme but their failure has been built upon and extrapolated to worsen their damage and hasten their demise. The three pillars of liberalism, Social Security, Medicare, and Medicaid are all unsustainable as admitted by the agencies that over see them. This was not the execution of the programs but their design that was contingent upon continual growth. No civilization in history has had continual growth, none of these three programs made any allowance or a flattening of population and income growth.
    Why do you support a first step backwards? I don’t understand the logic of supporting a bill we know is flawed, will increase premiums, and drastically explode our deficits. Where is the positive in this? CMS came out today and said the house bill does nothing to control inflation except the reduction in provider reimbursements which might or might not happen.
    I don’t see a single good provision in this bill. This bill is exactly like the last 44 years of reform from Congress. It has been 44 years when will we start learning and doing things better? How many failures do you allow Congress before you entertain the idea that maybe reform doesn’t need to come from Congress? Are you opening to even considering the notion Congress is responsible for the problems?
    No specific provision creates death panels. No specific provision allows the government to take away your SS benefits but they do. No specific provision in original Medicare allowed the government to dictate pricing to providers but a couple years later they did. The entire point of the argument is once you hand over control to the government you have no control and they will do as they like. Once every senior was in Medicare providers didn’t have a choice but to accept their payment mandates. Once you contributed to SS your entire life you don’t have a choice but to take their Medicare.
    In these specific examples do you see no reason at all to mistrust the government expanding on promises they already broke? My question back is why should any of us trust them after they already lied to us multiple times over 44 years?
    Look further back in our history, if you where Native American would you trust the government? If you where a Tuskagee Airmen would you trust the government? If you where a 20 something making your first substantial contributions to SS would you trust your SS statement of benefits to come?

  27. Maggie, I noticed you kept your false statements about my husband’s medical procedures on your website, yet you deleted my post correcting you. Just what in the heck kind of organization is the Century Foundation, anyway?

  28. I’ve actually learned quite a bit from Nate’s comments. His TPA work gives him a real world perspective on the health insurance market as well as the preferences of small group employers and their employees. While I’m not a fan of Association Health Plans, I think his comments regarding tort reform and Medicare / Medicaid fraud are on target. I think it would be helpful if he toned down the rhetoric though. Even if I think a commenter is an idiot, I don’t think it adds any value to the discussion to say so. Civility is a good thing that we should all try to sustain especially when we disagree. At any rate, keep the comments coming, Nate.

  29. Maggie,
    I know Nate’s style of writing is a bit “different” than most. However, one cannot just ignore opinions and sometimes facts that diverge from one’s entrenched beliefs. Opinions and beliefs should be constantly tested by evaluating opposite points of view, otherwise they turn into dogmas. Reality is that Nate is a representative of a way of thought and a belief system that is quite prevalent in our society. Ignoring it just because the presentation is a bit rough would place us in a very dangerous position.
    I don’t start a conversation presuming I am always right. I like debating issues because I hope to learn something new and be forced to reexamine my own thoughts. I think the ability to listen and seriously consider what other people have to say is as much part of the democratic process as the ability to voice your own preferences.
    I can do without the vitriol, but I can also see beyond it and constructively use the content to expand and refine my own thoughts. I actually like reading Nate’s posts and hunting for useful information in them.

  30. Maggie, are you describing Nate, or yourself? You made false statements about my husband on your blog, because you and I disagreed on the definition of medical “wants” vs medical “needs.” You personally attacked me and the state I live in as a defense to your opinion. You made it personal and put misinformation on your blog and tried to dress it up as fact. You have called me names like “callous” and “cruel” because I don’t agree with every opinion you have, and decided you no longer wish to speak to me because I don’t personally want to be ordered to pay for the wants and desires of others. I’m quite shocked by your behavior in this regard, Maggie and your credibility factor has taken a nosedive.

  31. Margait–
    Bev M.D. has suggested that when reading threads on THCB, it may make sense to just skip over Nate’s comments.
    I’m inclined to agree. Life is short. Nate’s vitriolic
    comments can easily suck all of us in.. But responding is probably pointless. We’re just wasting our time and energy.
    Nate doesn’t change his point of view. Nate is pretty committed to being Nate.
    I’ve argued with him occasionally. I’ve read other people arguing with him many times. To no effect.
    If you don’t read his comments, you won’t feel compelled to resond to his mis-statements, misinfromation and personal attacks.

  32. Nate,
    Smart people are not doomed to repeat history. They learn from past mistakes. The mistake was not in the principle, it was as usual in the execution. I think we are capable of learning and doing things better in the future.
    I agree that the bill as it currently stands is lacking. It’s just a first step, hopefully.
    I am not aware of any specific provisions in the bill that require creation of death panels. Your speculations in this regard stem from a general belief that government cannot be trusted. My belief is that government is (or should be) all our voices pulled together.
    I often wonder where the complete mistrust of government is coming from. Folks on the right side of the aisle usually point to the founders of this country as being opposed to “social” government. I have no idea what that opinion is based on other than distortion of history. They were opposing foreign government. They created their own government to replace the foreign one and it was as big and as hell bent on taxing as the foreign one, but it was ours.
    Here is how John Adams viewed government:
    “…Government is nothing more than the combined force of society, or the united power of the multitude, for the peace, order, safety, good and happiness of the people….”
    Surely he was not a Marxist-communist-murderous-liberal….

  33. All I can say Margalit is you must have never studied the history of healthcare in this country. When the panel is in place it’s to late, people will be dead. That is like when Liberals passed public housing saying lets just build these tall prisons of poverty lock up the minorities and assume everything will work out, why speculate on what could go wrong locking up thousands of people with little to no employment and high substance abuse rates.
    We didn’t speculate enough when Ted Kennedy tried to force us all into HMOs. When Medicare promised that physicians would be paid a fair rate we didn’t speculate what would happen if congress repealed that portion of the law. When Congress passed COBRA in the 12th hour we didn’t speculate what 15 years of lawsuits from poorly written legislation would do.
    It’s this character flaw that separates liberals and communist from the rest of humanity, your ability to ignore insurmountable evidence of impending consequences and charge ahead completely sold on the theory you want to believe. Reality never pierces your dogma. Just like Stalin and Mao killed millions believing their philosophy irrefutable you don’t care how many are killed by your reform. Everyone just needs to shut up and accept their fate under your experiment.
    If not now when is the time to question death panels? After 100 have been murdered? 10,000 killed early? 1,000,000 Americans purged by another failed progressive agenda?
    You say;
    “I find it ridiculous to discuss death panels as if we have no other choices. There is so much money wasted in the system that can be recovered with no moral dilemmas,”
    Why has the liberal agenda never included any of these. Yes there are hundreds of simple, beneficial, and highly bi partisan measures that we could pass that would save far more then Maggie’s panels….NONE OF THEM ARE IN THE BILL!
    Your party wrote the bill and advocates for death panels then you try to dismiss them as speculation and preach we should pass substance, then write a bill with substance. Remove government from the day to day operation of our healthcare system and we won’t worry about government denying us our healthcare system day to day.
    “What is to stop Medicare or Medicaid from instituting death panels today?”
    Absolutely nothing, just like there was noting to stop the federal government from taking away our Social Security if we dare try to opt out of Medicare. I’m not 65 and I buy my own insurance, so I will be damned if I let the government take over my freedom like they have those over 65 and poor. I’m going to speculate, I’m going to point out the liberal lies, and I’ll do everything I can to stop the left from killing more people with their failed liberalism ideology.

  34. Nate,
    The death panels discussion is nothing but pure speculation. It could happen with or without health care reform. What is to stop Medicare or Medicaid from instituting death panels today? Most folks on these programs have no other options.
    I find it ridiculous to discuss death panels as if we have no other choices. There is so much money wasted in the system that can be recovered with no moral dilemmas, so why make assumptions and create “what if” scenarios that are not at all likely to occur unless this entire country goes bankrupt. I think a better strategy would be to concentrate on steps to make sure that we never face such scarce resources.
    That said, there really is a lot of unnecessary and most important unwanted care administered at the end of life. People should have the freedom to decide when and how they want to die. And I think this goes farther than just advanced directives regarding withholding of treatment in certain situations.

  35. Margalit, didn’t mean to imply you specifically support the QALYs Maggie is pushing but I think you will admit you have a progressive ideology towards Health Care reform. The Liverpool Panel is just one manifestation of an ideology that has failed in every major initiative it has ever undertaken and destroyed millions of lives along the way. While you may not specifically agree with this one you consistently support 100s of others that have the same effect and likely outcome as the Death Panels liberals swear don’t exist.
    Let’s look back to your comments of 8/25/09
    “The sheer fact that the “death panel, palliative care” discussion is even taking place now is a brilliant Republican PR move.”
    “We all know this death thing has absolutely nothing to do with health insurance reform,”
    Under the guise of healthcare reform Daschel and Maggie and countless other progressives are proposing panels exactly like those that lead to the Liverpool panels. How can you claim the bill Liberals are trying to cram down America’s throat that explicitly opens the door to UK type death panels has nothing to do with insurance reform? If it is in the bill then it has everything to do with insurance reform.
    In your opinion is preventing death panels merely PR to you, something we shouldn’t worry about let alone discuss? You found it necessary to dismiss them when there is a clear link to death panels and liberal reform bills, why should we ignore those links?
    I don’t believe either you or rbar want to kill seniors for cost savings but you’re complicit in your denial that the current reform bills open those doors. Your hands will be even more stained by not only ignoring the possibility but attacking and discrediting those that do raise it.
    Do a google search on THCB and see how many times the loyal lefties dismissed the argument and attached those that said it was something that should be addressed. Just read the comments on the Palin post, I’ll challenge any of the lefties on here to argue how Maggie’s comments and the actual UK Death Panel are impossible here.
    Maggie isn’t alone, look at bev M.D.s comment on them. you can find countless examples of the left trying to stifle honest debate and concern to cover up the evil aspects of their bill. This is how Medicare was passed and look at the mess it turned into.

  36. There is a lot of expensive end of life care provided in this country that patients don’t even want. It is provided because of fear litigation if it isn’t and it happens to be well reimbursed if it is. I think there is plenty that we could do to increase the percentage of the population that has a living will from its present 25%-30%. For example, it could be offered (not required) as part of the process of signing up for Medicare. Patients who fill out physician paperwork on their first visit could be asked if they have a living will. If they don’t, doctors could encourage them to execute one. If they do, perhaps they could be asked to provide a copy so it can be included as part of the record. Insurance cards could have a little box indicating whether the member has a living will or not. As either a taxpayer or a privately insured individual, I have no problem paying for palliative care consults in end of life situations so patients and family members can understand the options available to them and the quality of life implications of each. I don’t think it needs to be done every five years. Once people think about it, they know what their values are and can figure out what they want and don’t want under most circumstances – advanced dementia or Alzheimer’s, late stage cancer, ESRD, etc. The key is to make one’s wishes known in advance to both providers and family members and to ensure that the relevant documents are included as part of the record or are readily accessible when needed.
    As for QALY metrics, I think they have a legitimate role to play in determining payment policy – whether we will pay for drug X or procedure Y or test Z or not, regardless of the patient’s age.

  37. Nate, I have to run, but seeing your latest comment, I am compelled to make a quick reply.
    If you check my previous posts on this forum, you will find that I have expressed nothing but reprehension to QALYs and institutionalized protocols for deciding end of life measures.
    As much as you are tempted to deal with only black and white, most of us are immersed in the many shadows of gray.

  38. This is what Maggie and the other progressives have in mind to control the cost of healthcare;
    A grandfather who beat cancer was wrongly told the disease had returned and left to die at a hospice which pioneered a controversial ‘death pathway’.
    Doctors said there was nothing more they could do for 76-year- old Jack Jones, and his family claim he was denied food, water and medication except painkillers.
    He died within two weeks. But tests after his death found that his cancer had not come back and he was in fact suffering from pneumonia brought on by a chest infection.
    Is this your answer to the cost issue rbar, kill any senior that gets pneumonia? Is this the compassion you say we are missing Margalit?
    When will the public wake up and see progressives and liberals for the monsters they are? Public housing, welfare, millions and millions of lives destroyed and yet they keep preaching the same failed ideology. This is communism light, what liberals have done is no different then Stalin and Moa just less succesful. If not tempered by Americans that love freedom and what this country once stood for we would be no different then the dead masses of Asia and the Soviet Empire.

  39. A quick lesson for rbar and lefties that don’t think death panels are a legitimate concern.
    Whack jobs like Maggie are the ones currently writing the legislation and if passed would write the more important guidelines and implement the bill. So when Maggie and other nuts say stuff like this;
    “all of the cost savings cannot be spelled out in the legislation. Nor should it be. We don’t want Congressmen deciding where to cut. These decisions should be made by physicains and medical experts on the Independent Panel that both Obama and Jay Rockefeller have proposed should oversee Medicare spending.”
    Now take a quick trip over the pond for a history lesson on The Liverpool Care Pathway;
    “Rosemary Munkenbeck says her father Eric Troake, who entered hospital after suffering a stroke, had fluid and drugs withdrawn and she claims doctors wanted to put him on morphine until he passed away under a scheme for dying patients called the Liverpool Care Pathway (LCP).”
    “Last week The Daily Telegraph reported a warning from experts that some patients with terminal illnesses were being wrongly put on the NHS scheme and allowed to die prematurely if they ticked “the right boxes”.”
    “The pathway scheme was developed to improve the care of patients in their dying hours and ensure that they were not being “overmedicalised”.”
    ” When a patient is put on the pathway the medical team looks for signs that they are approaching their final hours, which can include loss of consciousness or difficulty swallowing medication.
    But doctors last week warned semi-consciousness and confusion are a side effect of painkillers such as morphine if patients are also dehydrated.”
    “The LCP has been gradually adopted nationwide and more than 300 hospitals, 130 hospitals and 560 care homes in England use the system.”
    The last part is important, LCP was drawn up by a panel of experts like what Maggie proposes, this was never put to the public for their opinion or voted on, it was deemed in the best interest of the system.
    That boys and girls of the left is why INTELIGENT people are discussing death panels. You can start lining up to the right to apologize for all your ignorant rhetoric about how the bill doesn’t have a section creating death panels and the right was trying to scare people.

  40. What a shock a clueless rambling from Maggie devoid of any actual accurate or factual statements.
    “No public option means no competition for the country’s for-profit insurers.”
    The current non profit insurers, who control over 50% of the market by the way, suddenly aren’t competition? Please do explain this Maggie, or are you unaware that the majority of Americans are covered by non profit insurers?
    “No employer mandate–these businesses don’t want to contribute to paying for care.”
    Yet for some reason, even with no mandate currently, the majority of them do, again Maggie do you not know how to do basic research?
    “Finally, they are wrong to suggset that the House biil is inadequate. It will help millions of Americans, and it will contain costs.”
    Because Maggie said so and that’s all you need to worry about. Medicare will cost a couple billion, oops blew that, HMOs will save healthcare, money and lives, oops blew that one. Liberals and other people that think like Maggie have never once been right in their lives about healthcare but this time will be different. If I was artistic I would spoof the apple commercial about Windows 7, I would have all the broken promises of Democrats in regards to Healthcare over the past 44 years and string them together, at the end we can have Maggie promising it will work, really it will this time.
    When someone like Maggie can’t get a single fact strait shouldn’t we be worried about any plan she is supporting?

  41. Brian, Michael M. Margait
    Brian– You write that CEOs should lead us forward: “What is needed now is an orchestrated, mobilized, highly visible campaign effort that features the faces and voices of well-known American CEOs, and that leverages the full force of business’ leadership across industries.”
    You seem a bit out of touch with how mainstream America views this nation’s CEOs. The 1980s are over. The days of the CEO as celeb have passed.
    As unemployement rises and the economy falters, American have been losing faith in our “business leadership.”
    Matthew characterization of the natoin’s employers as “confused, cranky, aimless and spineless” seems closer to the mark.
    People realize that, throughout the Bush administration, big business has been robbing the country, profiteering on a pointless war while failing to pay middle-income Americans a fair wage. Wages have stagnated while the cost of the necessities of life– fuel, food, education, health care have climbed.
    As for the Chamber of Commerce . . . Bloomberg News reports: “The group has led the charge against President Barack Obama’s proposal for an agency intended to shield consumers from lending abuses. It also has opposed the White House stance on energy development and combating climate change.”
    Bloomberg quotes Obama: “Predictably, a lot of the banks and big financial firms don’t like the idea of a consumer agency very much,” Obama said Oct. 9. “In fact, the U.S. Chamber of Commerce is spending millions on an ad campaign to kill it.”
    Do you really think that mainstream Americans want this anti-consumer group involved in shaping health care reform?
    As Matthew says, it would be better if employers got out of the benefit business. I agree.
    And the current legislation, which includes a public plan, would let that happen over time. Within 3 years, employees working in firms with up to 100 employees would be able go into the Exchange, along with the self-employed. and pick the public plan. That plan will have the clout to lower costs and raise quality. I’ve anayzed how many people will be eligible for the plan and who they are here on http://www.healthbeatblog.com (the most recent post)
    When you suggest that the reform legislaiton will not contain heath care spending, you ignore the enormous savings that can be realized as first Medicare and then the public plan use financial carrots and sticks to steer both physicians and patients toward more effective, higher quality, and affordable care.
    You ignore that Medicare is already leading the way–planning to cut fees for MRIs and CT-scans by up to 38% next year, and to cut cariologists’ fees by 6% while raises fees for primary care by 4% and for nurse practioners by 3%. (Congress has just 60 days to oppose or these changes for physicians or they automatically go into effect Jan. 1)
    This is just the first in a series of cuts and increases in the physicians’ fee schedule that we can expect to see over hte next 3 years as Medicare very carefully adjusts fees with an eye to what provides the greatest benefit for the patient. Medicare alreadyhas announced that it plans serious cuts in oncologists’ fees.
    You also ignore the provision in the House legislation that would allow Medicare to negotiate discounts on drugs.
    You ignore the provision that insists that insurers pay out 85% of the premiums they collect in reimbursments for medical care.
    You ignore the hugesavings that will come when those who now buy their own insurance in the individual market (7% of the population or 21 million people) join the exchange, and autormatically become eligible for group rates. According to MIT economist Jonathan Gruber, under the Senate Finance Committee’s reform plan, those who move from the individual market to the Exchange’s group market will enjoy savings or as much as $8500 for (per family).
    Brian, you pretend that the 21% across the board cut in
    physicians fees is a real possiblity. Surely you know that President Obama made it clear that it would never happen at the beginning of the year when he did NOT include the savings from that cut in his budget.
    Year after year, Bush included the savings in his budgets–and year after year, Congress did not make these crude, across the board cuts. But the accounting fiction helped make Bush’s budgets look better.
    The Medicare Payment Advisory Commission, White House Budget director Peter Orszag and President Obama all understand that we need to reduce Medicare spending carefully–using a scalpel not an axe.
    Ih that way, over the next three years, Medicare will be setting the stage way for an affordable public plan.
    The House legilsation has a large section on Medicare reforms, and makes it clear that the public plan will incorporate those reforms.
    Michael M. writes: “please note that they say nothing about cost controls being used to pay for universal coverage. In fact, the most vocal of the groups signing this letter, the US Chamber of Commerce, has opposed even moderate market-driven attempts to expand coverage as ‘socialism.’ This is very true.
    Margait points out: “Forcing the bill back to the drawing board at this point will guarantee that nothing is passed and the status quo is maintained, which is the goal of those they represent, with an added bonus of hurting the Democrats in the process, and ensuring ‘better’ results in the coming elections.
    So if you are trying to chronicle the events, this is just the latest salvo from the Republican right wing, big business, big money lobby.”
    She’s absolutely right. This is just an attempt to delay, and undermine healthcare reform.
    The legislation is far from perfect, but it’s a good start. We then have 3 years to refine and strengthen it before beginning to roll out universal coverage in 2013.
    Anyone who though that we could overhaul a $2.6 trillion industry with a single piece of legislation was dreaming.
    Finally, all of the cost savings cannot be spelled out in the legislation. Nor should it be. We don’t want Congressmen deciding where to cut. These decisions should be made by physicains and medical experts on the
    Independent Panel that both Obama and Jay Rockefeller have proposed should oversee Medicare spending.
    The Comparative Effectiveiness panel (made up mainly of physicains) and already appointed by the Institute of Medicine can provide help.

  42. What does this business group really object to?
    Politico.com explains: “They have concerns with the employer mandate, public option and required minimum benefits package, among others.”
    In other words they woullike to keep the broken system we have where insurers can sell “Swiss cheese” insurance, filled with holes (no minimum benefit package.) Of course people don’t usually discover those holes until they get sick and fall through them.
    No public option means no competition for the country’s for-profit insurers. Let them run our heatlh care system–and continue to put profits ahead of patients.
    No employer mandate–these businesses don’t want to contribute to paying for care.
    Finally, they are wrong to suggset that the House biil is inadequate. It will help millions of Americans, and it will contain costs. Please see this post on Healthbeat (www.healthbeatblog.org) “Looking at the Glass Half-Full” http://www.healthbeatblog.com/2009/11/heath-care-reform-looking-at-the-glass-halffull-.html
    and part 2 of the post here http://www.healthbeatblog.com/2009/11/reform-looking-at-the-glass-halffull-part-2.html

  43. Margalit have you been diagnosed with multiple personality disorder? I have identified at least two, one is an educated person capable of debate the second one is an uneducated rube strait off the commune detached completely from reality. It’s like you where educated by Marxist overlord in the hills somewhere and never interacted with society.
    First yes employers do sponsor healthcare, over 50% of every American with group insurance is in an ERISA plan where they have no insurance carrier. If there is no insurance carrier and the person has insurance who exactly do you claim is sponsoring it?
    If they pay less for insurance they do pay more in wages and this is proven in countless studies and real world cases. Business that have lower insurance cost in a specific industry frequently pay higher wages. An increase in insurance cost reduces future raises, seldom do you see deflation in wages. Two companies with unequal benefit cost will not pay the same wages resulting in 100% pass through in savings to the employer. Those benefit savings are used to pay higher wages to recruit better employees form the firms that have not controlled their benefit cost.
    No mention of the polls a week ago? Why is that? Obama tricks the independents into voting for him then breaks every promise he made so they leave him in droves. You being the far lefty commune drop out ignore the present and all the evidence independents do not support his legislation and instead use 12 month stale opinions as a public mandate. Doesn’t fly. No public opinion poll has ever supported the bill proposed by the house. The people want reform but not the reform they have been offered and this is proven every time they poll people on specifics and not general opinion.
    Google will love to hear they have been cast with the Republicans now, as will the heavily democratic hedge funds and banking sector. Not to mention Hollywood, maybe they can make some right leaning propaganda now. Which big business exactly are you referring to? I know you have a flare for overstatements and generalizations but this is even further out there.
    Your President is modern day aristocracy.
    “The current legislation does the same for about 5.8/6 of the population”
    That is incorrect rbar, the current legislation claims to do such, never once in the history of HC legislation has it actually accomplished what it claimed like it said it would. What makes you think this will be the first time it actually does? Isn’t that a foolish gamble considering the 100% historical failure rate?
    What is unreasonable about the death panel argument? NHIS has death panels, have you never heard of the Liverpool panels? It came about the same way and out of the same type of legislative environment as what the left is pushing here. Just because you miss the obvious doesn’t make it an invalid argument. Why don’t you and I have a debate about the threat of government taking away peoples social security benefits if they opt out of Medicare? This will be a theoretical debate as no such law in the country says the government can do anything close to this. In case you don’t catch the sarcasm this is a reality now. When lefties try dismissing the death panel concerns it is an argument made out of ignorance not fact. Current legislation being proposed opens the door to death panels just like it happened in England.
    “I spent over $6000 for health “insurance” in the past 12 months. Used once for an office visit for a total out of pocket cost of just under $400.”
    108days this isn’t a problem with insurance your just a bad consumer. You can’t hold the system at fault because you refuse to use it properly, well actually with current tort law you can but that’s a different problem. If you don’t use HC services buy an HSA and bank the savings. In the time you wasting posting about your dislike of the system you could have actually done something about it and solved the problem.
    “People are getting harmed or killed and the solution to that problem is to remove any recourse for accountability?”
    15 million med mal cases pales in comparison to the number of straw men you are killing. No one has ever proposed removing recourse, they want to eliminate med mal turning into a lottery. In how many of those cases does the plaintiff prevail? By leaving out that fact you cover up the problem, bogus lawsuits.
    Matt, why would business support a terrible bill like Wyden/Bennet? You don’t seem to grasp how the US tax system works, business will still be paying for healthcare regardless if it is the current system or something new congress passes. Business knows what its cost is under the current system and has some level of control over it. A poorly written bill could double their cost and remove any ability they have to control it. Now if an employer needs to reduce cost or attract employees it can do so within weeks or a couple months. Once government takes over healthcare and sets their tax rates at 1.5 to 2 times what they currently spend on insurance they have no ability to reduce cost at all. I know you don’t like business, capitalism, or freedom but you have to make a more honest argument then you have been.
    As to the argument business has been silent what should they have done? They have attended protest, they try to get their opinion out there, but when they media is pushing a narrative and doesn’t want to publish your side what options are you left with. I have never once had a journalist respond to any of my efforts to make my voice or the voice of my hundreds of business clients heard. Our side of the story conflicts with what they want to say so they ignore it. So that leaves us to spend a fortune on TV ads and kick backs to politicians, in case you haven’t noticed the economy ain’t all that great right now, many businesses are barely keeping their doors open and don’t have money to spend on politics right now.
    “When we have to trust the benevolence (or business savvy) of those who employ our labor to keep us healthy for the duration of our labor, and with no recourse, we can’t but acknowledge that something was lost.”
    Again Margalit join the rest of society and come out of your cave. NOTHING was lost. The American worker gave away control over their health. Employers didn’t want to offer no deductible co-pay plans that dictate how people are treated. That was a congressional law passed by the near sighted and incompetent party you support that is now again trying to fix the systems they broke. It was dictated by the public that demanded lower and lower out of pocket expense lacking the basic math skills to see how inefficient such a system was. If given the option employers would have kept the scheduled reimbursement plans that only became involved after a person had treatment that the initially did 40 years ago. To say the public lost is ignorance of history. The public traded away their control for a perceived simplicity that wasn’t there and now they have buyers remorse. To further disprove your ridiculous argument look at the back lash to employers raising deductibles, if the public wants to control their health they first must take responsibility for it. Until they step up and do so you can’t argue anything was lost or taken from them. They received EXACTLY what they ask for and now they have buyers’ remorse.
    “That would violate private insurance industry contracts with their providers – it’s the insurance industry that restricts transparency.”
    Peter your still an idiot. With 2-3 minutes effort I can find the contract between almost any provider and insurance company. Many are already public record and most are freely published. Most carriers now allow you to look up allowables on their website. The information is there it just hasn’t been aggregated and distributed, mainly for lack of return, how would someone get paid for doing such work? Who educated you with this crap?

  44. “A very simple bill that required that all providers post their prices in advance, hold them for a reasonable period of time and charge all (non-government) patients the same amount would immediately begin to reduce the cost of services.”
    That would violate private insurance industry contracts with their providers – it’s the insurance industry that restricts transparency.
    “What is illegal under FEDERAL LAW is for me to tell anyone what I ACCEPT from each payor.
    It is bad business when the feds tell you what to do.”
    Who do you think got the Feds to create that law – the private insurance industry.
    “My group of 10 docs and 8 PAs needs 2 coders and 6 insurance clerks, which the patient pays for indirectly, just to file claims. The patient has yet to even see a bill, at this point. I would love to eliminate the overhead (although I have good people working for me).”
    Well if you want less overhead then a single-pay system with one payer and one set of rules is the most efficient system.
    “The United States has the most bureaucratic health care system in the world. Over 31% of every health care dollar goes to paperwork, overhead, CEO salaries, profits, etc. Because the U.S. does not have a unified system that serves everyone, and instead has thousands of different insurance plans, each with its own marketing, paperwork, enrollment, premiums, and rules and regulations, our insurance system is both extremely complex and fragmented.
    The Medicare program operates with just 3% overhead, compared to 15% to 25% overhead at a typical HMO. Provincial single-payer plans in Canada have an overhead of about 1%.
    It is not necessary to have a huge bureaucracy to decide who gets care and who doesn’t when everyone is covered and has the same comprehensive benefits. With a universal health care system we would be able to cut our bureaucratic burden in half and save over $300 billion annually.”
    “8. 8.Raises serious questions about the public plan and how it would operate;”
    They needn’t worry, the public plan has been effectively neutered by policians in favor of the insurance industry.
    Margarlit hits the nail on the head with her take on this perverted process that will take us just as fast into bankruptcy as doing nothing. While we’re all struggling to claw our way out of national debt the profit takers and lobby paid politicians will be long gone on their tropical island sipping their margaritas. Bernie Madoff was small time compared to what’s going on in healthcare.

  45. Given the importance of an improved healthcare system from the standpoint of American competitiveness, America’s businesses must absolutely become immersed in the debate over how to cut costs and stay healthy. The fact remains that we can’t stay globally competitive – or afford quality healthcare for all – or grow our economy – without fundamentally changing our healthcare paradigm for the 21st century. Each of us has a stake in this dialogue, and each of us has a responsibility to engage in more responsible healthcare choices. Hopefully the business community’s letters to our nation’s decision-makers can help get everyone on board with the need for sustainable, long-term change.

  46. Too late to the game? Employers are the game. Whatever has happened previously was a in sandbox in their backyard. If you don’t want to play their game , then a whole lot of people are going to be former employees.
    Afterall, health insurance premiums are just employee compensation retained to buy insurance at an advantage over what the individual could do for himself. Nothing more. Insurance and (the real biggie) pensions are all employer based for the mutual advantage of employer and employee. As soon as there is no advantage to the employer, whether through burdensome paperwork, more red tape, or a down economy where they are learning to do more with fewer people, then there is no need for the employer to employ people like in the good old days.
    Bye bye, economy.
    Have a huge decrease in demand and spending in one-sixth of the economy through “reform”, bye bye, jobs.
    Borrow from China to pay for the unfunded Medicare liability or stiff the recipients of the yet-to-be-incurred never-to-be-PROVIDED healthcare, bye bye Medicare.
    Tax young people in the guise of health insurance to try to avoid the above, bye bye Nancy and Harry.
    Let’s require employers to hire people they do not need. Oops, we do that already through unions. No wonder card check is so important to the dems.
    Lock up in jail people who refuse to buy insurance?
    Sig Heil!

  47. As you said, the health care debate thus far has not been about providing quality, low-cost health care to as many Americans as possible. It has been a power struggle between Republicans and Democrats, with the American public caught in the middle. I don’t think anyone agrees that health care is perfect, but it’s impossible to disagree with the fact that something needs to be done to fix it and bring costs down. That’s clear.

  48. Thanks for the great article. I’m somewhat surprised I haven’t seen this development more widely reported by mainstream media. Regardless of our distrust for big evil corporate America or trust of our political party’s elected government officials, I’m happy to see the largest payer weigh in with a collective voice. Removing argument of who should pay in the future, it is informative to see the reaction from those who are the biggest payer NOW.
    I personally like the employer-based system because it aligns the incentives of the economy and a social need. Sure us employees pay for it indirectly, but at least we’re not given a choice to spend those dollars elsewhere (and it’s tax free). If you left it up to individual choice what to do with our income, it wouldn’t be spent on health insurance or wellness for that matter. Notice what happened to people’s retirement saving when pensions fell out of style and people were given 401k’s? Have you seen how much the average employee has saved for retirement under that system? (spoiler alert: retirement is the next health reform-level crisis coming.)

  49. Margalit,
    If you look back through the body of my writings, you’ll find that you’ve just summarized – and quite nicely, I thought – my most pressing concerns about the current status American governance.
    That said, my solution is try to provoke and persuade those in power to use that power in ways that works to our mutual advantage. You might think of this as the strategy of the powerless.
    BTW, I’m not a journalist, but an analyst and commentator, but thanks for the attaboy.

  50. Brian,
    I admire your ability to record and relate events in a dispassionate manner. I however, am not a journalist and lack the ability to suppress my concerns, particularly the ones relating to the “bigger picture”.
    Whether a public plan is a good thing or not is debatable, of course. Whether the current bill is satisfactory or disastrous, is very debatable.
    What is not debatable is the fact that if you lift your sights from the immediate health reform debate, and look at the horizon, you will realize that our political system no longer functions as designed.
    When we have to rely on powerful, unelected and unrepresentative interest groups to provide checks-and-balances to this, and future policy debates, something is amiss.
    When the best we can hope for, as private individuals, is that these clashing powerful interests will maintain stability of our system because the power centers are no longer with individuals and communities, something has gone terribly wrong.
    When we have to trust the benevolence (or business savvy) of those who employ our labor to keep us healthy for the duration of our labor, and with no recourse, we can’t but acknowledge that something was lost.
    And when we realize that these changes are, most likely, neither static, nor reversible, and when we extrapolate them into a not so distant future, there is a definite shortage of reasons for optimism.

  51. Margalit,
    I don’t believe this is a fair or an accurate perspective. First, these business groups are not in any way monolithic in their views.
    The Chamber of Commerce is perhaps the most anti-reform and unrepresentative of all these groups. Contrary to their image as representative of mid-sized and small businesses around the country, the US Chamber is an association of very large firms, many of them in HC. This was the group, for example, that spearheaded the Employers Coalition on Medicare – under the direction of then CoC Director of Health Policy Kate Sullivan Hare, later the HC lobbyist for Wal-Mart – which orchestrated the Medicare D heist at highly inflated cost to the benefit of the Fortunes, the drug firms and the health plans.
    But many of the others are firms that, for better or worse, have provided solid benefits for many years. They do it out not out of altruism, but from enlightened self-interest, of course. It is clear that healthy employees are more productive, and that good health benefits are mandatory for meaningful recruitment/retention. And, yes, its true, that the cost for benefits comes at the expense of wage growth. In other countries, the unrestrained cost growth would come at the expense of higher taxes. I’ll leave it to you to argue whether this is the fault of the purchasers who pay more or the industry that benefits when it costs more.
    I’m not arguing that this is the best arrangement, or that they’ve been as effective as they might have been. Simply that this is what is.
    What is important is that SOMETHING has transpired to suddenly precipitate focused collaboration among a diverse and historically uncollaborative group of firms. In my experience, most (not all) businesses don’t see benefits management as a strategic opportunity to extract additional value from the hides of their employees. I don’t ascribe malevolence to it. The firms I’m familiar with understand benefits as a necessary obligation that must be dealt with.
    I see the effort David and I described as very positive. Until now, the health care industry’s sway over the process – and the enormous benefit they would have gained from it – was effectively unchallenged. There has been no check-and-balance. This is very poor legislation that, yes, provides benefit to some, but at very great cost across a system that is already creaking with excess.
    At the very least, business’ ability to potentially change the nature of the discussion is monumental, not only for its impact on this legislation, but for the precedent it sets on important policy discussion of all types.
    While its great to have ideals, please keep in mind that there is no center of power for individual points of view. The best we can hope for at the moment, poor as it may be, is for some powerful interests to counter-balance others, for the sake of keeping the environment stable. The rest of us are simply hoping for some degree of fairness in the outcome. There’s not a lot of that in the legislative bills as they are currently constituted.

  52. OK, so what exactly is on Ms. Darling’s list?
    40% of the items (6,7,9,10) are employer specific financial concerns.
    20% of the items (2,8) are unsubstantiated Republican rhetoric that we’ve been hearing every day for the last few months.
    The remaining 40% of the items are well known problems that have been raised by both left and right ad nauseum.
    (they must have very good PR since the order of the item is anything but random)
    So, basically they are saying that the bill has the potential to hurt their profit margins, it is not a complete solution, which we all know, and for good measure, there’s a couple of scary “deficit-public plan concerns” sprinkled in.
    Forcing the bill back to the drawing board at this point will guarantee that nothing is passed and the status quo is maintained, which is the goal of those they represent, with an added bonus of hurting the Democrats in the process, and ensuring “better” results in the coming elections.
    So if you are trying to chronicle the events, this is just the latest salvo from the Republican right wing, big business, big money lobby, including insurers. It may be partially disguised in sheep clothing, but these are the same wolves we know and love.
    This is not a new effort either (see The Campaign for Responsible Health Reform). The US Chamber of Commerce spent almost $35MM on lobbying in just the last quarter. It worked pretty well, I must say, and now is the time for the final assault.

  53. And where were they when the leadership of the Republican party, the party of business, said their main goal was to defeat Obama? Where were they during the important part of the political process, the committee process, urging Republicans and Democrats alike to make the cost controls stronger because the business community would provide political cover?
    Finally, please note that they say nothing about cost controls being used to pay for universal coverage. In fact, the most vocal of the groups signing this letter, the US Chamber of Commerce, has opposed even moderate market-driven attempts to expand coverage as “socialism.”
    This is CYA politics — they did nothing to make the legislation better, but are covering their rears with their constituents about the final result.

  54. Colleagues: Thank you for your good comments. Matthew, I don’t think religion enters into it at all! 😉 Brian and I are realists, agnostics for the most part, and also chroniclers of this new national dialogue, this debate in which all voices with a stake in health care for our nation ought to speak out and be heard.
    You can’t simply dismiss employers — or any other interested and involved group — by saying they’re idiots, which is what you seem to be doing. While we agree with your point that the non-health care industry and employers have been confused, and we’re frustrated by how late their entry into the debate comes, it is still worthwhile recognizing this new chess piece on the board. And applauding it, however late in the game.
    Personally speaking, I don’t think this game has reached even its half time. There is a lot more action going to occur, and the 10 points Ms. Darling wrote about are some of the reasons this is so.
    Kind regards, dCK

  55. Matthew,
    I don’t disagree. As a group, employers have squandered opportunity after opportunity to leverage their collective strength in ways that might have easily made HC better and less expensive. The harsh truth is that Marriott has focused its lobbying efforts on hospitality, Microsoft on IT, and Southwest Air on transportation rules. Rarely have the special interests cross lines and lobbied in the common interest, as a check and balance on the open-field-running power of a specific special interest.
    But that’s the opportunity that presents itself now. Perhaps this collective action has been precipitated by the magnitude and visibility of the threat. Whatever works.
    As always, I’m less interested in what ought to be than in how we cope with and try to impact what is. So my focus on the employers is not because I believe employer-sponsored coverage is the best approach, but because its the configuration we have. Right now, the employers are the best shot we have at getting a modicum of rational reform.
    I feel the same way about the public option. As I’ve written here before, I’m agnostic about it. We have 40 years of Medicare’s performance as a public option that shows its cost growth tracking nearly identically with commercial health plan cost growth. The commercial plans spend money on marketing and medical management approaches, while Medicare is induced by lobbying to spend money on things of marginal or no value. This doesn’t mean that the public option can’t be a better approach. It means that it can’t be a better approach until we fix special interest influence over our system.

  56. Too little, way way too late.
    And worse, the employers have said nothing about the biggest issue–that they pay for health care for their employees with pre-tax dollars.
    Brian. Glad you still have the religion you had when we first me but it was said best by Bobby Leitman & Ian Morrison 15 years ago. Employers are confused, cranky, aimless and spineless.
    The only hope is for them to get out of the business of health benefits. Wyden/Bennet gave them a chance to do that.
    And where was their support for that? I rest my case

  57. RBAR “when cost explosion and deficits will require drastic action.” We’re already there with regard to cost explosion. You say 5/6 of the population is “covered”? Our coverage sucks! And coverage for what? I spent over $6000 for health “insurance” in the past 12 months. Used once for an office visit for a total out of pocket cost of just under $400. Total insurance contribution $38. And why aren’t we talking about the fifteen million injuries to patients per year? Everybody wants to talk about “tort reform.” Are there 15 million med mal lawsuits filed annually? People are getting harmed or killed and the solution to that problem is to remove any recourse for accountability? To correct what went wrong so it doesn’t happen again? Fix what’s broken before you tell my red white and blue behind I have to pay for this mess.

  58. The death panels and illegal alien nonsense was the only coverage given by the Obama-media, rbar. The arguments were always there.
    I want what 108DAYS wants: a simple bill which I will pay and go on from there. It does not need to be a bill that supports a massive EHR and a massive cadre of clerks and bean counters. Just give me an honest bill and get out of my way.
    I want to be able to deliver care with the same simplicity. After 28 years there are few challenges in medicine. It gets easier. What gets harder is turning my work into money.
    My group of 10 docs and 8 PAs needs 2 coders and 6 insurance clerks, which the patient pays for indirectly, just to file claims. The patient has yet to even see a bill, at this point. I would love to eliminate the overhead (although I have good people working for me).
    Lynn wants transparency in pricing so all are charged the same. Well, it already is that way. What is illegal under FEDERAL LAW is for me to tell anyone what I ACCEPT from each payor.
    It is bad business when the feds tell you what to do.

  59. Even though I make my living in the medico-industrial complex, I have to largely agree with the above list.
    So far, we put enormous ressources into the pockets of the insurance- and pharmaceutic industries, 500 K earning docs, superfluous procedures, senseless end of life care, fancy giant hospitals with valet parking … and only covered 5/6 of the population.
    The current legislation does the same for about 5.8/6 of the population … the only hope I have is that the public option (which is far from certain to be realized) will be the secret threat, to be converted into medicare for all (or for the willing) at a later date … when cost explosion and deficits will require drastic action.
    The conservative opposition did rarely use these reasonable business arguments … just “death panels” and “illegal alien” nonsense. Shame on them.

  60. I’m a citizen of this country. I don’t want my employer to have anything to do with the health care of me or my family. I don’t want to be ordered by the federal government to purchase insurance. I want to be able to take my kid to the doctor if he’s sick, pay the bill, and have no harm done. The health care industry needs to clean up its act. This debate has turned into a “how to finance this industry” debate. Fix what’s broken, first.

  61. With utmost sincere respect for both Brian and David:
    Fabulous!! So now the remainder of the lobbying power is throwing its weight into the debate. I guess two wrongs may be be perceived as a right.
    I think the only legitimate stakeholders have made their opinion heard, both at the polls a year ago and in numerous public opinion surveys conducted ever since. The citizens of this country want universal care and a public plan option, but that has been soundly defeated by the healthcare “industry” lobby. The measly little that is left in the House bill will probably get further diminished in the Senate.
    Now come the other Wall Street driven interests with lofty statements like number 6 above and “concerns” about the public plan. Large employers are, and always have been, unmistakeably aligned with Republican agendas. These are not knights in shining armors raising in defense of people’s welfare. It’s, of course, all about the money.
    I am not sure that I would go so far as to say that employers “sponsor” health care. What employers pay to insurers is in lieu of wages to the employee. It’s not charity. It’s payment for services rendered. If they have to pay more to insurers, they will pay less to the employees. If they pay less for insurance, they will NOT pay more to employees. Employers are not to be confused with spokespeople for employees.
    This is almost like watching a badly made movie where giant transformers are battling each other and carelessly trampling little people in the process.
    Forcing the reform bills into oblivion is not a novel desire. We had death panels and outlandish insurance industry forecasts and town hall lunatics. Now comes the voice of reason, calling from private golf courses, gilded boardrooms and finely appointed mansions.
    I wish the President would heed this call and stand up and deliver one of those Kennedy style blistering speeches, shaming (yes, shaming) this modern day aristocracy and defending whatever shreds of democracy we have left.

  62. I’ve been wondering why America’s employers have been laying down for this, they should be up in arms. While I don’t agree with everything on their top 10 list, overall they’re very sound arguements.

  63. Brian and David have said it well, however perhaps all are trying to accomplish too much too quickly. If the focus was on controlling the cost, and if successful, then access issues would become much easier to resolve.
    Only through transparency of the cost, can the cost be addressed. A very simple bill that required that all providers post their prices in advance, hold them for a reasonable period of time and charge all (non-government) patients the same amount would immediately begin to reduce the cost of services.
    When you have prices for identical services and identical outcomes varying by a multiple of 6 or 8, only competition will bring that in line.
    This one action, would, in a matter of a few months begin to signficantly reduce the costs nationwide.
    Sound to simple? Well it is and fixing the problem can start with very simple solutions.

  64. This is the single best blog entry of the thousands that I have read in the past year! This tells it like it is. Why the CEO and business population has been so silent is likely explained but the lack of detail that has been coming out of Congress or the Administration. Finally with the Pelosi bill there is something that we can study and comment upon.
    That the study period yields these vast shortcomings has been predicated by many including the conservative pundits but the lack of transparency until now is stunning. This lack of transparency is apparently being continued by Harry Reid and his colleagues by shutting out the American public from his private “debate” and this is a lousy use of the term – debate.
    We can only hope that the work of Ms. Darling is seen by many and heeded by lawmakers as this IS the real story here.

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