OP-ED

The President’s Proposal

You might be wondering why I haven’t written about the President’s Health care bill. The reason is that I have very little to say.

This, I realize, is unusual. But the truth is that the president’s proposal is very similar to the Senate bill—which is not a surprise.

Nevertheless, I am very glad to see the proposal. I was worried that the White House had put reform on the back burner.

Will it pass? As always, I’m trying to be optimistic. But I think that everything depends on whether the White House decides to twist arms. The president will have to persuade House liberals that this is a good first step—and that we can worry about improving the plan over the next three years.

I would still like to see a public option, and I hope that, in the end, the federal government will wind up overseeing the state-based exchanges. But the legislation doesn’t goes into effect until 2014; that gives us more than enough time to improve on it.

The President also will need to keep an eye on Senate moderates. I would favor sending Joe Lieberman on a special mission to South Korea. A relative who is stationed there tells me that the demilitarized zone is particularly bleak this time of year.

There is no need to worry about the Republicans. They can be counted on to vote against any reform bill that even attempts substantive reform. Universal coverage is not their top priority, and they definitely don’t want to pay for it.

As for the details: I’m glad to see higher subsidies for those who earn less than $44,000 or more than $66,000—though I think that subsidies for a family of four earning less than $66,000 are still too low. I prefer the numbers in the House bill (See a table comparing the president’s proposal to the House and Senate bills here http://www.whitehouse.gov/sites/default/files/summary-presidents-proposal.pdf. But the subsidies can be revised when we see just how much insurance is going to cost in 2014.

I’m delighted to see that insurers are required to pay a larger percentage of medical expenses; as regular readers know I think that high co-pays and deductibles serve as a barrier to needed care. But I would hope to see co-pays limited to 10% of medical costs for all families earning less than, say $100,000 , not just for families of four earning less than $33,000. See second table here http://www.whitehouse.gov/sites/default/files/summary-presidents-proposal.pdf , But again, these numbers can be amended .

I’m glad to see a tax on unearned (investment ) income to help pay for the bill. That money will help fund the $11 billion that the president promises for community centers over five years—more than the $ 8.5 billion that the Senate offered. This is an excellent investment; community centers have already shown that they can serve as medical homes.

When it comes to penalties for those who choose not to buy insurance, I’m afraid they are still too low. As Igor Volsky points out over at the Wonk Room, the president’s plan “may make it easier for younger Americans to opt out,” and we need those young, healthy citizens in the pool if we want insurance to be affordable for everyone. Volsky lays out the differences among the Senate, House and President’s plans in a clear, concise chart http://wonkroom.thinkprogress.org/2010/02/22/obama-health-plan/

Finally, since I can’t read President Obama’s mind, I’m not going to bet how this will turn out. I’m just glad that the White House hasn’t given up.

Maggie Mahar is an award winning journalist and author. A frequent contributor to THCB, her work has appeared in the New York Times, Barron’s and Institutional Investor. She is the author of “Money-Driven Medicine: The Real Reason Why Healthcare Costs So Much,” an examination of the economic forces driving the health care system. A fellow at the Century Foundation, Maggie is also the author the increasingly influential HealthBeat blog, one of our favorite health care reads, where this piece first appeared.

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60 replies »

  1. how is this a free country, if one has to prostitute oneself to corporate america to obtain health care for one’s family. that enforced dependence is frankly a form of slavery. what has become of the american dream. and i’m not talking about people who want to follow festivals selling tie-dyed t-shirts. there are plenty of potential small businesspeople who would be able to support themselves with their enterprise if they didn’t have to make sure they have two million dollars in the bank in case of a health emergency in the family, and because they have an aging parent. you simply are not ‘free’ if being self-employed is not an option. i’m frankly astounded that conservatives — many of whose parents made started out as small businesspeople raising families — are not raising cain about this.
    anyone who thinks it’s reasonable to expect people to *choose* between doing what they want to do for a living and insuring their family is no less than a sociopath and no more than a corporate whore him- or herself who wants to drag the rest of this country down with them.

  2. Thank you for the many comments.
    On malpractice, take a look at Texas: caps on torts has not capped over-treatment (or over-spending.)
    Dan M: Thanks for the kind words.
    I don’t think we’ll end up with incremental compromises. On the Sunday morning shows (this morning) the REpublicans made it pretty clear that they are not intersested in compromise. Mitch McConnell stated that no Republican would vote for reform– even if the Democrats offered to add tort reform to the bill.
    The Republicans don’t want to cover 30 million people.
    Peter–I agree with much of what you say. But if we don’t embrace this first step toward reform, we won’t get anything for at least 3, probably 7 years. By that time, universal coverage will be unaffordable–whether by single-payer or some other means.
    Single payer savings just aren’t as great as some say. The Commonweaelth fund estimates that a government plan would cost a family about $2,000 less than a private sector plan: $11,000 instead of $13,000 in today’s dollars. That’s probably about right. Note that most other developed countries do NOT have single-payer– only Canada and the UK. And they pay much less than we do, while receiving care that is, on balance, better.
    If we vote for the current plan, a few years from now I’m pretty confident that we will have a public option. If that proves a huge success, we might gradually move to single-payer. That’s the only way we’ll get there–and I still would prefer a hybrid private/public plan with non-profit insurers competing with the government plan.
    What would you do if Jed Bush–or one of Bush’s daughters–is elected president at some point in the future– and the conservatives re-take Congress? Imagine what they would do to a government health care plan. . .And you would have no other options. (This is what happened in the UK when Margaret Thatcher took over.)
    To really put a lid on health care inflation, we have to stop overpaying for products and healht care services, and we need to stop paying for unncessary tests and procedures while also greatly reducing the number of medical errors that add to costs. That’s all in the Senate and House bills–under Medicare reforms.
    Medicare is already cutting fees for diagnostic testing and cardiologists–beginning this year.
    Medicare reform is already beginning and if we have reform legislation, it will pave the way for rational cost-saving throughout the system.
    Bottom line: Barry wrote: “We also need an electorate willing to reward politicians with re-election if they cast votes that require short term pain and sacrifice (higher taxes or less than unlimited end of life care, for example) from us in exchange for a more cost-effective, affordable and sustainable healthcare system over the long term.”
    I really think everyone should think about this. We’re at a point of no return. Either we begin to try to cover everyone and control spending (which means letting Medicare lead the way by cutting reimbursements and raising co-pays for UNnecessary and Unproven tests and procedures) — or in another 9 years, health care premiums will double.
    That means that the middle class and most of the upper-middle class will not be able to afford insurance–or much health care.
    No doubt some low-cost providers will pop up to help us out (probably primarily foreign-born foreign-trained physicians who now take care of our poor). But it will be very, very hard to find a low-cost hospital. Or affordable surgery.
    We wil wind up with a sharply tiered health care system–much like the systems in some developing countries–where only the very wealthy will receive care.
    I imagine the government will try to continue to take care of the elderly- after all, they have paid into Medicare for so many years. But as Medicare adds to the deficit, our economy will suffer.
    If we actually choose that path (I don’t believe that we will) we will wind up a second-tier economic power with third-world health care.

  3. Dear Maggie, I can not agree more with You.
    I believe that we, the people who are getting screw up by previous 20 or more years by republicans governing, we must be more vocal and instead paying attention to pools, start writing about OUR needs and ideas on HEALTH CARE !!!
    Whe we have (in this big country) just few big Health Insurances III. Maybe it is time to start looking for health care insurances in different directions. If Blue Cross is rising their members 39% , why not change provider???? why stay with dthose who are killing their own Members, by charging so much and giving so little??? We have thousands doctors who will do their job for less and help all of US with smmaller payments.Maybe it is start to turn back from corrupted doctors and look for those who truly want to help those who need them. Another thing is “ILLEGALLS WHO GET FREE RIDE ON ALMOST ANYTHING.cALIFORNIA PROBLEM IS AESPECJALY, BECAUSE JUST THAT!!!! It is time to get in office a new blood, and get those with experience-corrupted OUT from office and vote for TERM LIMITS on Congres and Senat. How people in a such old age are running OUR COUNTRY. Some are complaining that we can not put in office someone with no experience, well!!! most in Congres are with more then 15 years of, and what they are doing??? screwing US on everything.They have a lot of experience doing just that!!!

  4. “We need to replace it with some people with integrity who can actually accept the job and act for “We the people.””
    We also need an electorate willing to reward politicians with re-election if they cast votes that require short term pain and sacrifice (higher taxes or less than unlimited end of life care, for example) from us in exchange for a more cost-effective, affordable and sustainable healthcare system over the long term. When I ask my favorite health reform question, what’s your contribution, “we the people” need to offer a credible answer.

  5. As an analogy, Congress is much like Phineas Gage, the famous case of the pre-frontal cortex injury in the 1800s where he lost executive function of the brain, but could still express right vs wrong. However, any decisions he made were made absolutely and only for immediate self-gratification and not based on any future outcomes potentials. As a sitting TBI Congress, we will not rehabilitate it. We need to replace it with some people with integrity who can actually accept the job and act for “We the people.” I doubt it matters much which party. We just need honest, straight-spoken people with functional frontal lobes.

  6. “there will be disappointment (38%) and anger (20%) aimed at both parties. This will surely translate into repercussions come November….”
    Which third party will they be able to vote for then?

  7. What poll are you looking at Nate? The one I saw was from Kaiser and they did ask very specific questions, not just “do you want reform?”.
    To Peter’s point, that is true, Kaiser did not attach a price tag to anything, so maybe if they did, folks would have replied differently.
    What the Kaiser poll shows very clearly is that if Dems fail to pass reform, along the current lines, there will be disappointment (38%) and anger (20%) aimed at both parties. This will surely translate into repercussions come November….

  8. Margalit, how did this lil tidbit fail to get mentioned?
    “. An overwhelming majority of Americans, 73%, prefer that Congress either start from scratch (48%) or stop work completely on health care reform (25%). Obama’s Health Plan contains essentially the same policies as the bill passed by the Senate, with the addition of price controls for health insurance premiums.
    CNN buries the lede in its article accompanying the release of its findings, never mentioning that an overwhelming majority (73%) of the American public disapprove of passing a bill similar to the one before Congress, including four in ten Democrats who want the President and Congress to start over. CNN does manage to state that “nearly three quarters” of Americans want some kind of reform, including in that figure the 48% who want Congress to start over in that grouping in a somewhat dishonest fashion…”

  9. And step down extra hard on the hopelessly ill littering the sidewalk.
    For all your grandiose talk, none of you are up to the battle with the medical establishment effective cost controls would require.

  10. great there goes even that chance at a smile….you will stop at nothing to ruin insurance companies will you? Just for that I’m going to go deny some claims for no reason but I am having a bad day.

  11. Geewiz –
    My only concern with scrapping and starting over is that I can’t see a way we end up anywhere different than where we are today. There are firm ideological differences with little inclination to compromise. If we’re going to be in the same place a year later why waste the year?
    David Brooks had a nice piece in yesterday’s New York Times discussing the calamities of educated, thoughtful healthcare strategy colliding with politics. The result is the House and Senate bills we see before us.
    I predict we’ll see compromise in small, incremental reforms so that both sides can claim victory. Coverage won’t be substantially expanded and costs will not be reasonably controlled. The administration will have to get on to other things (the economy and security) and we’ll bop along dumbly for another 4-5 years until Medicare’s appetite for the Federal budget becomes so extreme that we have to either dramatically raise taxes or cut spending on popular programs (like Medicare, Social Security and Defense).
    Then we’ll have to try to re-engineer the rudder on the Titanic at moments before iceberg impact.

  12. “Now Peter that isn’t fair at all the Republican plan passing would make me smile for at minimum a week or two.”
    A week, really.
    GOP Plan:
    Sec. 103. No annual or lifetime spending caps.
    without—
    10 (2) cutting Medicare benefits for seniors;
    I believe two things you oppose.

  13. Then why not, as has been suggested, scrap it and start over? There is obviously no rush if Obama and team are talking 2014 anyway. Would be nice to have a plan the CBO can price (they say there is not enough info in the President’s plan to price it) so that the plan actually improves care and reduces costs.

  14. It’s hard to see a point in congress anymore I agree. All they do is fight with each other. All these plans are getting us nowhere. As a current nursing student it is really frightening to think where we will be in 5-10 years and how I will have to be dealing with patients.

  15. Thereby the desire to scrap it and start with a whole new and hopefully functional, cost-saving, humanitarian plan.

  16. what is reform?
    Without first defining what it is how do people know if they want it? It’s like asking do you want to be successful, of course most people do, until you define success that doesn’t mean anything though.
    Conservitives want reform as well, they just don’t want liberal reform that is sure to fail. This is a perfect example of the dishonesty in your argument. You ask a generic and meaningless question then use that as proof people support your bill. BS, no one wants your reform except the far left of the country which is less then 20%.
    If you asked who wants government rationed care 80% of Americans would say no, that is a far more honest poll question then who wants reform.
    Now Peter that isn’t fair at all the Republican plan passing would make me smile for at minimum a week or two. Isn’t that enough of a reason right there to pass it?

  17. Margalit, Nate has a point. The public can always agree to changes they think will not cost them anything. They didn’t like the Democratic Plan because they perceived it to cost them something, while the Republican plan won’t cost them anything (at least up front) it also won’t do anything.

  18. I believe the desired reform is NOT what is being carried to the four yard line right now. Reform would mean fixing a lot of the portability and cost issues, not a 2000-page tome that gives any government more power and authority over us. I’d love some reforms if they are functional and sensible. The trouble is, I see little or no sense in Congress anymore – just arrogance.

  19. “Perhaps Peter would like to identify a state in which negigence, proximate cause and damages are not required elements of proof in a malpractice action.”
    My point, if you missed it, was I have not seen any proof that tort “reform” has led to reduced utilization. Maybe you could provide some.
    But if all three elements are present then I guess it’s one of those non-frivolous cases isn’t it.
    “There’s no rhyme nor reason to it”
    To what, 2 wrongs? If we are told that the cost of insurance is simply the cost of care outside the insurer’s control plus a measly 5%, how would outside insurance companies, looking at the same actuarial figures be able to offer the same benefits for less? If they could offer it for significantly less then is there more beef in the profit than we are led to believe? The monopoly, present here in NC as BCBS, is a political monopoly where no health legislation passes unless it gets the thumbs up from BCBS. They ran a political campaign, despite their non-profit status, against the Democratic health “reform” package. People in NC don’t trust BCBS and were able to stop it from getting “For Profit” status, but the victories are few.
    “You will note that Peter has precious little to say about how the President’s Proposal will reduce provider costs or generate adequate funding for existing liabilities.”
    achone, you haven’t been paying attention. I ended up opposing the Democrtic Plan because it did not address system costs. I am also an advocate of single-pay, which would control provider cost inputs (your bane), control user utilization and require NO insurance companies so we could save that modest 5%. It would also reduce paperwork and marketing costs and ensure all providers would get paid, no cost shifting and a mandate. The resulting reduced cost of healthcare would fund reduced liabilities. Not surprisingly it would allow state to state portability and release employers from the burden of providing healthcare coverage, a boost for small businesses. But I can only lead the horse to water.

  20. It is not meaningless in the debased political environment in which health care reform is being debated. It means that the majority still wants to see reform and it means that reelection considerations need to be “slightly” different than what conservatives are peddling in the media.
    It is very likely that Dems will lose seats in November no matter what they do with healthcare. It is very likely that Dems will lose a hell of a lot more seats than anticipated if they drop the reform ball on the four yard line.

  21. “Well, well, well…. Guess what? Folks still want health care reform and they will be disappointed if it doesn’t pass.”
    Little girls still want ponies and guys want to date super models. Ask them if they want to wake up to feed them every day, walk them, and comb them every day for the next 15 years or lose weight, learn another language, and do what ever it is to attract a super model and the interest plummets.
    It is a meaningless poll and even less meaningful to comment on it, it says nothing! Now ask if they would be willing to have their taxes double for guaranteed coverage, or would they accept rationing, etc etc and then you have something to talk about. The left doesn’t want to do that though becuse it kills their narritive. People don’t want the reform the left proposes so you pimp generic polls.

  22. Perhaps Peter would like to identify a state in which negigence, proximate cause and damages are not required elements of proof in a malpractice action.
    I believe there has been some talk of standardizing health insurance forms. One minute these guys are complaining about insurers exploiting their state “monopolies” to gouge the public, and the next about their eagerness to sell substandard insurance across state lines. There’s no rhyme nor reason to it: just a ritual “talking points” dance.
    You will note that Peter has precious little to say about how the President’s Proposal will reduce provider costs or generate adequate funding for existing liabilities. It’s all about funding for new entitlements. “Comparative Effectiveness”: I’m sure those doctors in McAllen are already quaking in their designer boots.

  23. I’d add to the above that an Electronic Medical Record is critical. In the ER we still see people pop in with some complaint, saying they need a workup, only to later find out they have had 3 CT Scans and 4 MRIs for exactly the same issue in the last 2-months. A big part of stopping abuse is knowing what the patient’s are doing before they get to us.

  24. “but that doesn’t cut costs, it just cuts benefits.”
    Actually, portability can cut costs because it does increase competition rather than locking in selected few companies to a single state. And, where it has been used (eg: Texas) it maintained benefits at exactly the same level. It just allowed people to move from Waco to Lubbock without losing coverage.
    “Medicare needs to do more on fraud but that would mean more employees and changes to how it’s obligated by statute to pay within 30 days and probably a more rigorous provider approval process.”
    If structured correctly, the gains in recovery for fraud would easily pay for the employees, plus generate more funds. Having worked with a fraud and abuse unit, I can attest that all one needs to do to cover costs plus generate profit is set up a correct screening approach so time is spent on where the money is.
    Related to tort reform, 1/3rd of medical costs are still done to cover risk, without actual need for the tests, etc. One state’s action won’t solve it. There needs to be a system with a knowledgeable Layperson, a Healthcare expert, and a Judge to review merit. Once the medical establishment trusts that system, costs for “cover my ___” medicine will drop, but not until then.
    And as for Medicare Funds…
    The media has reported for decades that the funds are “raided” by the Congress for other projects, and I have never heard a single congress person say, “We never did that.”
    Think insurance is expensive now? Wait until it is Free. The Congress will take most funds targeted for coverage and use it on other, unrelated projects. Until Congress is changed and we get some people with honesty and integrity, we won’t be able to afford anything.

  25. “If people want reform, then they need to establish portability between and within states,”
    With one national plan from one insurance company? I’m assuming that means insurance companies able to do business across state lines. How would that cut system costs? For sure it would allow insurance companies to offer bare bones plans in a race to the price bottom, but that doesn’t cut costs, it just cuts benefits.
    “investigate and manage fraud,”
    I agree that Medicare needs to do more on fraud but that would mean more employees and changes to how it’s obligated by statute to pay within 30 days and probably a more rigorous provider approval process. I think there’d be opposition (lobbying) from providers for these measures.
    “do tort reform and set up expert panels to judge actual merit of the 90% rate of inappropriate law suits against docs and hospitals,”
    Ah yes, unless you’re one of the plaintiffs. Many states already have malpractice legislation. Florida for instance does where you must prove 1.negligence
    2.proximate (immediate) cause AND 3.damages. Failure to prove any one of these elements, and your case dies. Miami-Dade is at the top of the most expensive places in the U.S. to get medical care, can you prove a connection to malpractice awards and medical utilization/costs?
    Here’s the situation in Virginia:
    http://legalmedicine.blogspot.com/2009/11/end-of-frivolous-lawsuits.html
    “limit futile care (which eats up tons of end-of-life Medicare dollars)”
    I think you’re right on this one, but writing the rules is difficult – remember “Death Panels”.
    “educate docs to actualy present reality to end-of-life patients and their families,”
    Actually part of the ‘Obama” plan addressed living wills and end of life issues in an attempt to have the patient control this and not their emotional family or the docs.
    “and … by the way … the benefits for Medicare won’t be there for me if the Govermnet keeps robbing the Medicare funds to protect brown tree snakes, pay foreign coiuntries to be our “friends,” and fund some questionable so-called arts.”
    I don’t think Medicare funds pay for those things, but you don’t think the government should fund this:
    http://www.fort.usgs.gov/Resources/Education/BTS/
    Actually if all medical costs keep rising the way they have been then I doubt you’ll be able to afford anything, even private insurance.

  26. Not impressed with the Republical plan either. If people want reform, then they need to establish portability between and within states, investigate and manage fraud, do tort reform and set up expert panels to judge actual merit of the 90% rate of inappropriate law suits against docs and hospitals, limit futile care (which eats up tons of end-of-life Medicare dollars), educate docs to actualy present reality to end-of-life patients and their families, and … by the way … the benefits for Medicare won’t be there for me if the Govermnet keeps robbing the Medicare funds to protect brown tree snakes, pay foreign coiuntries to be our “friends,” and fund some questionable so-called arts.

  27. “Look at how well Congress has handled Medicare and Social Security. Funds come in, are looted and go elsewhere, and the programs face bankruptcy.”
    Geewiz, not sure if you know but the GOP “Plan” explicity says no cuts to Medicare and also calls for abandonment of Comparitive Effectiveness. How would you ensure that Medicare benefits are there for you when you need them? Would you want all the healthcare you want when you are over 65, or would you support some controls on benefits?
    You might also want to read this on SS:
    http://www.ppionline.org/ppi_ci.cfm?knlgAreaID=450020&subsecID=900194&contentID=254807

  28. So it is okay to take people’s money, give it to a bureaucracy managed by a Congress who cannot control their own lust for power and money, and see what happens? Look at how well Congress has handled Medicare and Social Security. Funds come in, are looted and go elsewhere, and the programs face bankruptcy. What makes anyone think the future of healthcare taxes will face any different pathway?

  29. Maggie –
    Thank you for taking the time to consider my point of view and having the intellectual honesty to state what you believe in.
    I have been disappointed that the conversation around this important issue has remained far too rhetorical, as if human beings in America weren’t involved.
    When things like comparative effectiveness research, individual mandates and individual caps all get demonized as a “massive governmental takeover” of the system, the conversation ignores that people face bankruptcy and access (i.e., rationing) issues to preserve the right to “whatever we want, whenever we want” for many.
    If we decide as a nation that largely preserving the status quo is OK, fine. But the opposition shouldn’t get away with a polyanna approach that acts as if there aren’t real consequences for not addressing major problems that require significant changes to fix.
    Mr. Grassley, look straight into the camera and say, “I think it’s more acceptable to limit access to care, thereby increasing the burden of illness and chronic disease, on a small portion of our population, than requiring all Americans to be insured, even through the private sector.” Then, at least, you’re being as honest as Ms. Mahar
    Again, I appreciate you having the fortitude to state your opinions on the personal, human impacts of the decisions we face. Too often the discussion seems like a conversation about some abstract, collective idea in which individual, personal impacts either don’t exist or don’t matter.
    We shall see.

  30. Mark maybe you can define your meaning of better job then? They are better at controling cost only because they have the power of law. That allows them to control their cost not the actual incured cost. Congress dictates they are reducing reimbursements by 100 billion. Most people don’t consider that controling. Further it only works becuase there is a private system to absorb those cost.
    I wont rehas it here but you are 100% on your overhead claim and have no idea what you are talking about. Your 5% versus 25-30% has no validity at all.
    “(which does not provide any coverage for the poor).”
    Again Mark no clue what you are saying, you lack even a basic understnading of the market. Who do you think runs most Medicaid programs? What do you call SCHIP, those are all private insurance plans paid with subsidies. Have you ever heard of the working poor? Millions of whom have insurance.
    You didn’t get a single fact right in your entire post.

  31. I should have specified the differences between Medicare and Medicaid when I said they are doing a better job than private insurance.
    Medicare does a better job of controlling costs than private insurance (consistently lower year on year cost increases). It also has much lower overhead (5% vs the 25-30% for private insurance). Most people are happy with the service and the coverage.
    Medicaid, OTOH, as has been pointed out is a state run program, not a federal program and the results vary quite a bit from one state to the next (this is a good argument for a federal program). It is successful as a safety net program providing some health services to the poor that private insurance will not cover at all (due to affordability or per-existing conditions). It should cover more people for more health problems but that is a matter of funding and management. I think it is fair to say that even with its faults Medicaid does a better job than private insurance (which does not provide any coverage for the poor).

  32. bev M.D. you were further ahead when you ignored me, businessweek was wrong, the study they used to write the story was wrong, as documented by countless people including ABC. The Harvard “researcher” is a single payor advocate and hack scientist who doesn’t know how to set up a study.
    Let me repeat sice you seem to have missed it;
    Moreover, Harvard’s definition of “medical” expenses includes situations that aren’t necessarily medical in common parlance, e.g., a gambling problem, or the death of a family member. If your main wage-earning spouse gets hit by a bus and dies, and you have to file, that’s included as a “medical bankruptcy.”
    would you like to apologise or just go back to not commenting?

  33. Hello Nate;
    Re medical costs as a primary driver of bankruptcy, see this quote from Business Week:
    “Medical problems caused 62% of all personal bankruptcies filed in the U.S. in 2007, according to a study by Harvard researchers. And in a finding that surprised even the researchers, 78% of those filers had medical insurance at the start of their illness, including 60.3% who had private coverage, not Medicare or Medicaid.”
    http://www.businessweek.com/bwdaily/dnflash/content/jun2009/db2009064_666715.htm
    Now perhaps that has been eclipsed for just this year by job losses, but neither you nor the original commenter specified a given year. For at least 2007, he was correct and you were not.
    I wouldn’t have bothered to play Gotcha if you didn’t do the same to others. Get your own facts straight.

  34. This Obama outline – I can’t really call it a bill nor can the CBO score it – is not bipartisan. It is hyperpartisan. Why not challenge the Republicans by putting Real Tort Reform in the Bill along with some other of their ideas. Perhaps the Chinese menu style compromise – One from Column A, One from Column B. I know the public would welcome such a show of real compromise. Reid’s compromising with Pelosi is not bipartisan.

  35. I’ll take it, archon. There must be some oversight on what providers charge, particularly hospitals. It won’t hurt to break up those big hospital conglomerates either, particularly the ones that are right next to each other.

  36. I’m sure it’s occurred to some of you that, by using private insurance as a loss transferring mechanism, you will be forcing, in many instances, the less affluent into helping the more affluent to stave off bankruptcy.
    If you can create a federal agency to exercise oversight of insurer rating, why can’t you create one to exercise oversight of provider rates? That’s what you would have done under “single payer,” no? The seeds sprinkled on the ground may or may not produce effective mechanisms. Does anyone really believe abuses result from earnest ignorance of “best practices”? Why not take the bull by the horns and create an agency to which payers can appeal questionable charges? (I’ll credit Margalit with this, whether she wants it or not.)
    Some interesting language from the Proposal: “The President’s Proposal modifies these statutory provisions that currently limit random medical review and place statutory limitations on the application of Medicare prepayment review.” Who knew?

  37. On the bankruptcy question, I have to admit I am skeptical of the Harvard study. The primary authors are long time proponents of a single payor system, and their research usually ends up supporting that position. I gather even they have backtracked somewhat on their findings, from medical expenses “causing” to “being one of the causes” in bankruptcy. Another study (from AEI, who I’m sure has their own agenda)is similarly (but more factually) skeptical: http://www.american.com/archive/2009/august/the-medical-bankruptcy-myth
    Like most things, the “truth” is probably in the middle – the impact of medical expenses on bankruptcy rates is perhaps not as bad as some claim, but it certainly can’t be ignored.
    Of course, I’d be interested to see how many of the bankruptcies were caused by people already on public programs (e.g., seniors who end up in the nursing home)….the Obama proposal won’t change that.

  38. Maggie – thanks for your comments. I was lumping Medicare & Medicaid together because Mark was, and agree they are very different (as my comments noted).
    Three things in response to your response:
    First, I think it is difficult to get a real read on Medicare cost control versus private insurance, for several reasons. One is that Medicare has the huge advantage of essentially dictating prices, which not only helps “control” their cost increases but also pushes those costs onto private insurance payers. The second is that private insurers themselves vary in their cost control effectiveness, both between carriers and between market segments within a carrier. E.g., inflation for large employers is very commonly several points lower than for smaller employers (and not out of any antipathy for smaller employers!). Reasons for this are not entirely clear, but hypotheses include more stable risk pools and more ability to carry out more effective cost management programs.
    Second, Medicare’s design is essentially rooted in 1960’s Blue Cross(Part A) and Blue Shield (Part B) designs, which have all but disappeared from the private market. Most notably, that design did not include major medical coverage, which addresses more catastrophic events. So, yes, private insurance does have “holes,” but ones more aimed at deliberate cost-sharing.
    Third, I would be interested in seeing the basis for your statement “Most people on Medicare are happier with Medicare than they were with the insurance they received from their employer.” I don’t know that I’ve seen such data, and interpreting such data would be compounded because employer coverage varies so widely. One reason that Medicare HMOs (now Medicare Advantage) came about was that people in HMOs and other private plans wanted an equivalent type of coverage, especially for preventive care. One would also have to distinguish satisfaction with traditional Medicare from Medicare Advantage, as the latter looks very much like private coverage, and to tease out if how much they were contributing versus how much they pay for Medicare impacts satisfaction. It’s all possible to do — I just haven’t seen the studies.
    Thanks.

  39. This is what passes for science with Maggie and the left, remember this when you read anything they say;
    “A good part of the problem is definitional. The Harvard report claims to measure the extent to which medical costs are “the cause” of bankruptcies. In reality its survey asked if these costs were “a reason” – potentially one of many – for such bankruptcies.
    Beyond those who gave medical costs as “a reason,” the Harvard researchers chose to add in any bankruptcy filers who had at least $1,000 in unreimbursed medical expenses in the previous two years. Given deductibles and copays, that’s a heck of a lot of people.
    Moreover, Harvard’s definition of “medical” expenses includes situations that aren’t necessarily medical in common parlance, e.g., a gambling problem, or the death of a family member. If your main wage-earning spouse gets hit by a bus and dies, and you have to file, that’s included as a “medical bankruptcy.”
    When I asked the lead author, Dr. David Himmelstein, about his definitions of medical bankruptcy back in 2005, he said, “It’s a judgment call,” and added that any death, for example, “to our mind is a medical event.”

  40. Ms.Margalit,
    A penny saved is a twopence earned.
    Variant: A penny saved is a penny earned.
    Saving is another form of earning. – Ben Franklin
    Just because Ms. Mahar and you do not consider investment income as earnings, does not make it so. Just ask the IRS.
    64 out of 300+ million Americans voted for Obama, fewer for the other jokers. 22% does not make a majority and this country operates under a representative republic not a true democracy.
    Tangetial points, but since Ms. Mahar, who I could argue knows even less about the healthcare system (or earnings) than Obama is given permission to post here, I guess it’s ok to go a bit off subject. Thanks for listening. LD

  41. “If you google “bankruptcy and cause” you’ll find dozens of citations saying the same thing–based on reseraching bankruptcy files.”
    Ya and if I google Global Warming and glaciers it would tell me they would be melted in 50 years in India. If I googled sea levels it would tell me that whiny little country was already underwater.
    “”Medical problems caused 62% of all personal bankruptcies filed in the U.S.”
    Junk science, was never true, and been discredited endlessly and beyound reproach.Just becuase left wing wack jobs keep quoting it doesn’t change the fact it is wrong.
    What is with you people on the left that you can’t do even basic reserach?
    http://blogs.abcnews.com/thenumbers/2009/03/medical-bankrup.html
    President Obama’s kicking off his health care reform today in the worst possible way: with a mischaracterization of data.
    “The cost of health care now causes a bankruptcy in America every thirty seconds,” Obama said at the opening of his White House forum on health care reform. The problem: That claim, based on a 2001 survey, is simply unsupportable.
    The figure comes from a 2005 Harvard University study saying that 54 percent of bankruptcies in 2001 were caused by health expenses. We reviewed it internally and knocked it down at the time; an academic reviewer did the same in 2006. Recalculating Harvard’s own data, he came up with a far lower figure – 17 percent.
    A more recent study by another group, approaching it another way, indicates that in 2007 about eight-tenths of one percent of Americans lived in families that filed for bankruptcy as a result of medical costs. That rings a little less loudly than “one every 30 seconds.”
    This is why you people should have no voice in running this country, if you can’teven get basic facts right why should we trust any ideas you have? You have no base on which to build your ideas as everything you think you know is factually wrong

  42. Nate, Mark, Kim, Margait & Wendell, Dan
    Nate: You’re mistaken. “Medical problems caused 62% of all personal bankruptcies filed in the U.S. in 2007, according to a study by Harvard researchers. And in a finding that surprised even the researchers, 78% of those filers had medical insurance at the start of their illness” From Business Week, June 2009.
    If you google “bankruptcy and cause” you’ll find dozens of citations saying the same thing–based on reseraching bankruptcy files.
    How much should we spend on end-of-life care? That’s tricky because in many cases, we don’t know which patients are going to die. In some cases (cancer for instance) doctors may have a pretty good idea of how much time a patient has left. In other cases (heart attacks, etc.) some patients will recover, go home
    and resume their lives–other’s won’t. As palliative care specailist Diane Meier points out, often you just don’t know who is going to walk out of the ICU. In those cases, of course you want to do everything possible in hopes of saving the life of a person who may live another 20 years.
    But you don’t know which ones will make it– so you have to do whatever you can do for all of them.
    Mark–Thank you. I agree about Medicare– but Medicaid is another story. Medicaid isn’t a federal program; the states have much discretion. And in many states, no matter how poor you are, you don’t qualify for Medicaid unless you have children. States are also free to cut certain services; these days, many states are talking about doing away with hospice care for Medicaid patients. This is both cruel and foolish. Many patients will die in pain, and they will die in a hospital–which is far more expensive than hospice care.
    Medicare, on the other hand is a good, if not perfect program. See my comment to Kim.
    Kim– See my comment above to Mark. You can’t lump Medicare and Medicaid together.
    When it comes to reining in health care inflation Medicare has done a better job than private insurers. Since 2000, health care costs under Medicare have not been rising as quickly as they have for private insurers. That said, there is still to much waste under Medicare–too many unncessary tests and procedures, too many over-priced drugs and devices.
    It’s true that Medicare doesn’t cover everything. Most people want a Medigap policy to fill in the cracks.
    But most private insurance policies also have holes . .
    Most people on Medicare are happier with Medicare than they were with the insurance they received from their
    employer.
    Still, Medicare needs to reform what it pays for and how it pays for it to reward high quality, efficient, evidnece based medicine. There are many proposals in the SEnate and House bills that would do just that.
    Margait & Wendell– Thank you.
    Dan–1) No, I don’t think we want people to go bankrupt simply because they are sick. . This is why the reform legislation caps how much a family can be asked to pay out of pocket in a given year. The cap is set on a sliding scale–depending on your income– but even the wealthiest family would not be expected to pay more than $10,000 in medical bills in a given year.
    2) At this point in time, the $2.6 trillion that we spend on health care is enough to provide evidence-based care to all Americans. We don’t have to ration. But we do need to eliminate wasteful, unncessary and unproven tests and treatments, and very often less expensive drugs and devices will provide the same benefit as newer, more expensive products.
    If we do need to ration, the rationing should be based on medical evidence measuring benefits and risks and asking is this treatment providing enough benefit to justify the price?
    The president has already set up a panel of disinterested medical experts who will be sifting through comparative effectiveness reserach. Ultimately I expect that they will be issuing guidelines (not rules) to help steer doctors toward the most effective care for patients who meet a particular medical profile.
    3) No, we shouldn’t try to guarantee everything that someone wants (or thinks he wants). Patietns are not medical experts, and too often they are sold a bill of goods. Nor can we guarantee that sociey will pay for everything that a doctor recoommends. Physicians are faillible; some fall in love with a medical technology and refuse to see its limitations. Others are money-driven and put profits ahead of patients.
    This is why we need guidelines regarding what counts as effective, necessary care.
    We also must refuse to over-pay for that care. For instance, the government really shoudl begin negotiatiing for discoutns on drugs and devices. Drug companies are now enjoying 18% profit margins. The rest of society just cannot afford to keep over-paying for drugs.

  43. “The medical debt causing these bankruptcies isn’t overwhelming in many circumstances. Statistics available in 2003 are as follows: about 20% of bankruptcy filings involve a medical debt of less than $1,000; about 40% involve a medical debt of less than $5,000; and 13% of bankruptcy filings involve a medical debt of over $10,000.”
    More recent studies disporve this myth even more convinceingly. Very few people file BK becuase of medical bills.

  44. 1. Is it OK for medical expenses to be the number 1 cause of personal bankruptcy in America?
    No it is not, thankfully it isn’t. Medical expenses isn’t even in the top two and off the top of my head don’t think it is top 5. Don’t remember the order but divorce and lose of employement are 1 & 2.
    2. Is economic rationing (that is, the ability to get something determined by one’s ability to pay) the preferred form of rationing of health services, over supply-side rationing or regulatory/governmental rationing? You have to pick one.
    Actually you don’t. You can have a guaranteed basic level of care that every citizen is entitled to that is far less then what most American’s currently feel entitled to and people would live long productive lifes. Most people when presented with the question honestly would have no problem excluding drastic end of life measures that cost hundreds of thousands for 1-3 additional months from people that can’t pay for it.
    fundamental elements of this conversation.
    Even more fundamental is getting the basic facts strait and putting an end to the propoganda like medical bills are a major contributor to BK, its complete garbage and has no truth at all.

  45. And what is “truth”? The man who made himself infamous for posing that question had supped with the philosophers. He had been around the metaphysical block a time or two. He realized that “truth” is a pit of uncertainty and ambiguity. As a conservative, one of my articles of faith is fallibility of the intellect. In accord with that principle, I always assume the capacity of independent thought in those who have clambered up on the opposite side of the pit. They do not often reciprocate.

  46. The “fruits of the economy” are currently sporting a big minus sign in the very front, and I agree, we should allocate more “fruits” to “those who so tiresomely boast of their “productivity” and “creativity”” in bringing about the current crop of “fruits”, particularly the big orchards owners.

  47. But surely we’re not going to stop with health care equalization. The collective conscience of humanity urgently demands a more equitable distribution of the fruits of the economy. The proper role of those who so tiresomely boast of their “productivity” and “creativity” is that of worker bees to the societal hive. This petrified, patriarchic system of wealth distribution is an ongoing affront to the truly caring and committed, and must give way to a culture of sharing.

  48. Just saw an interesting bumper sticker on a Chevy pickup, opposite a “1st CAV DIV” sticker: “1984 WAS AN INSTRUCTION MANUAL.”

  49. Mark — it’s hard to see the basis for saying “The Federal Government has done a much better job with Medicare and Medicaid that the insurance industry has with private insurance.” Better in terms of what? Medicare’s design is so limited that most Medicare beneficiaries have additional coverage to address the many holes in coverage. Don’t even get me started on how widely variable Medicaid benefits are state-by-state, or how poor some of those benefits are. Both programs arbitrarily limit provider payments, to the point providers are bailing or limiting new patients. And, of course, Medicaid is breaking the state’s fiscal backs and Medicare is a vast unfunded liability that goes into the abyss that is the federal deficit.
    Both programs do serve crucial populations that, as a society, we need to protect, and both deserve some credit for innovations along the way. But neither is exactly a shining example of what one would ideally want. All the forms of financing — public & private — in our health system are metaphorically living in glass houses, so we should all be careful with our stones.

  50. I might be a simple man but to me this conversation boils down to three questions that we have to honestly answer as a society. I’m not judgmental about people’s feelings, I just want honest statements so we can acknowledge them as a nation and move on.
    1. Is it OK for medical expenses to be the number 1 cause of personal bankruptcy in America? If so, we should develop a bankruptcy and personal credit system for healthcare to accommodate it.
    2. Is economic rationing (that is, the ability to get something determined by one’s ability to pay) the preferred form of rationing of health services, over supply-side rationing or regulatory/governmental rationing? You have to pick one.
    3. Is unlimited growth in total national health expenditures acceptable to maintain the guarantee to everything a person wants at someone else’s expense? Again, it’s OK to choose that as long as you acknowledge the consequence of that choice (that is, the economy’s ability to do things beyond finance healthcare services).
    While those seem like leading questions, they are fundamental elements of this conversation. Other nations have decided to answer these questions. We don’t like their answers, and that’s fine. We are just being polyannas if we pretend we don’t have to make choices with consequences.

  51. louisdous, I think there are two assumption in your comment that may be slightly inaccurate.
    First, money does not always reside with those that “worked for it”. There are millions of hard working folks that don’t have enough money for health care these days. Hard work does not equal to financial security any longer, but that is an altogether different tragedy.
    Second, the ability of the current government to twist arms, or pass legislation, is not due to the “power of the gun”, it is due to the power of Democracy. A majority of Americans voted for this government and is now expecting it to deliver on the promises they made. If America indeed changed its mind, which I seriously doubt in spite of the shrieking conservative fringes, there will be new elections in the fall and that would be the Democratic way to affect changes to policy direction.

  52. Good to hear from you, Maggie. I think I agree with you on most of your points. I do hope that the president has a strong commitment to getting this done. I have to say that I have not been impressed with his leadership.
    The Federal Government has done a much better job with Medicare and Medicaid that the insurance industry has with private insurance. This can be made better still with the cost control and quality measures in the bill.
    We should commit to universal care and raise taxes to pay the cost. We can start by reversing the tax cuts that the rich received under Bush.

  53. Ms. Mahar, You are absolutely correct. You have very little to say. Except, raise taxes, especially on the young or the productive folks who saved and invested money. Let’s re-phrase that to take money from those that worked for it and give it to those who did not work for it, or simply reward not working for money.
    Aside from bashing anybody else or because they have the power of the gun (or can twist arms), can you give me one reason why you believe it is a good idea to have the federal government taking the lead on putting in a self admitted bad plan of reform and trust them to make it better later? Has the federal government honestly ever done anything better than the free market?
    Please recall it is the president that could not get his own party to agree on a plan. Thanks for listening. LD

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