OP-ED

The Oxymoron Columnist

MerrillCharles Krauthammer’s columns in the Washington Post are like the Wall Street Journal editorial page, must-reading for anyone who wants to keep up with the illogical fulminations and small-minded cruelties of what passes for intellectual discourse on the right. The intellectual bankruptcy of today’s offering shows not only why health care reform should pass, but why it will.

After scolding President Obama for continuing to push for reform despite “electoral rebukes” in Massachusetts, New Jersey and Virginia, he complains that the cost-savings in the bill are “ridiculously insignificant.” Dismissing the popular support of the insurance industry reforms that would protect most Americans from the worst predations of the health care insurance marketplace, he goes on to describe the 30 million Americans who would get health coverage as unworthy recipients of taxpayer largesse. The half trillion dollars in Medicare “cuts,” he writes, are “not to keep Medicare solvent but to pay for the ice cream, steak and flowers.”

He concludes by citing Warren Buffett as calling on the president to “start over and get it right” with a bill that focuses exclusively on cutting health care costs.

The man who ran as a post-partisan is determined to remake a sixth of the U.S. economy despite the absence of support from a single Republican in either house.”

Actually, one Louisiana Republican did vote for the bill. But that little untruth isn’t the real problem with his formulation. How can a bill whose cost-cutting is insigificant “remake a sixth of the U.S. economy”?

It can’t, and it doesn’t. Whether the bill will actually bend the upward trajectory of health care costs by a trillion dollars in its second decade, as administration officials Peter Orszag and Nancy-Ann DeParle argue in a separate op-ed in today’s Post, will be determined in large part by the success of the payment reforms that are contained in the legislation. There is a serious likelihood that the bundled payments and accountable care organizations cited by Orszag and DeParle will fail because of the monopolistic powers that hospitals and physicians have in the health care economy, and the powerful hold they have as special interests over majorities in both political parties on Capitol Hill to keep it that way (for more on that, see “Unchecked Provider Clout in California Foreshadows Challenges to Health Care Reform” by Robert Berenson of the Urban Institute and Paul Ginsburg and Nicole Kemper of the Center for Studying Health System Change on the Health Affairs website).

But challenging “Obamacare” on those serious concerns — a worthy exercise — is something that Krauthammer can’t be bothered with. That would require knowing something about or at least thinking logically about the nation’s complex health care system and how its powerful special interests interact. Instead, what we get from the troglodytes on the right are ad nominem attacks mixed with slapdash cruelty for the less fortunate (health insurance as steak and ice cream, indeed).

The Post op-ed page is badly in need of a house-cleaning.

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65 replies »

  1. What a bunch of scummy little hypocrites, sitting there frothering at the mouth over their imagined victimization by supposed freeloaders, meaning anyone who doesn’t have health insurance. One would never suspect that these self-righteous ones are the beneficiaries of the most costly freeby in the tax code, namely the exemption from the income tax for their beloved health insurance, which costs the government over $246 billion a year in lost revenue. The “freeloaders” have to make up for this lost revenue, while paying the bills for their own health costs with income which is fully taxed. Then in regard people who have no money, their “solution” is a gigantic tax-funded subsidy, not to pay for their health care, but merely to pay an insurance company. What a bunch of geniuses!

  2. Bev – It’s an interesting article and perspective. I’ll offer the following comments.
    1. How would the situation have been handled in Canada or Western Europe?
    2. To what extent is our protocol driven by our litigation system and environment?
    3. In this particular instance, if the patient’s information were on an easily accessible electronic registry, or a Medic Alert necklace or bracelet or on a card in the patient’s wallet, the staff would have been able to quickly learn of the DNR and DNI orders.
    4. With respect to the doctor describing what he would want for himself, I wonder if he would be prepared to pay for such care out of pocket if he could afford to if that money could otherwise be used to fund his grandchild’s college education or for some other very worthwhile purpose. People are very quick to make claims on (finite) taxpayer (Medicare) resources and feel entitled to do so.
    Separately, regarding treating cancer specifically, I think it is very unfortunate that oncologists and surgeons often frame the choices available to the patient in terms of fighting vs. giving up. They implicitly make the patient and family feel brave and courageous if they choose to fight but weak and cowardly if they want to give up. They are often quick to try to enroll you in a clinical trial without fully explaining what you’re signing up for in terms of risks and side effects and general quality of life. Sometimes they resist or oppose making a palliative care consultation available to the patient and family even when the hospital has a good palliative care program. They also happen to get paid more if they do more. The bias, especially at the famous cancer centers, is toward very aggressive treatment. More honesty and balance in their treatment approach would not only be helpful but would probably also be more cost-effective.

  3. Barry;
    I didn’t respond to your question about dr’s and resuscitation efforts because there is no one opinion and the opinions are strongly held. However, here is another one, in the Washington Post so you can read it this time, which offers another viewpoint.Would I agree with that? Hard question. My own dad died slowly of cancer but was incoherent from brain involvement so that decision was somewhat easier.
    http://www.washingtonpost.com/wp-dyn/content/article/2010/03/08/AR2010030802432_2.html?hpid=sec-health

  4. Barry, my first choice would be to increase the penalty so there is no significant advantage to not buying coverage. I don’t know how to deal with the underground economy, or how to collect penalties from them. That’s where a VAT would be ideal, but it’s not going to happen. I would suspect though, that this is a minority that evades every other duty as well.
    Yes, Nate, some people will cheat the system if they can. They do now. However imposing the death penalty for cheating on your taxes would qualify as cruel and unusual punishment in my opinion.

  5. “according to their ability.”
    This has never been accomplished before, without accomplishing this you can’t have a sustainable system. As long as people can cheat the system and get away with it they will. Dieing becuase you didn’t buy insurance when you could is the only effective way to force people to pay according to their ability.

  6. Margalit – While I outlined the potential appeal to conservatives of Paul Starr’s suggested approach and indicated how I would deal with those who refused to buy insurance (essentially as we do now), my own preference is for a mandate to buy but offer a financial hardship exemption if the cheapest policy in the market exceeds 10% of income for middle income people and a lower percentage farther down the income distribution.
    The problem with the bill as proposed is that the mandate is way too weak. It would be verified through the income tax system but many people who earn their income in the underground economy don’t file tax returns or pay income taxes. For those who do, way too many young healthy people will rationally opt to pay the penalty safe in the knowledge that if their health deteriorates, they can enter the health insurance market and buy a policy at standard rates. This is the problem in a nutshell. The insurance pools will not have enough young and healthy people which are likely to drive premiums even higher than they are now in the majority of states that currently use medical underwriting.
    My alternative to Starr’s approach for people who pay the penalty rather than buy a policy while they are healthy but want health insurance when they get sick is to charge them for the premiums they would have had to pay during the time they didn’t buy up to a maximum of five years. They can pay it out over time but they will be on the hook for the money.

  7. Barry, since it is immoral to just let somebody die for no reason really, and since it is unfair to ask what you call responsible people to perpetually pay for bad decisions made by others, I would suggest that the only solution is to mandate that everybody contributes to health care costs, according to their ability.
    Is this being a nanny? To a certain degree, it is. I am having a hard time imagining that this seemingly more conservative country would be willing to stand by and watch people dying en masse. Therefore mandating coverage is a means of protecting the propertied from the foolishness of others. Rather conservative, I’d say.

  8. “You mean all those people lucky enough to have their employer buy it for them, or the ones lucky enough to have the government pay for treatment through Medicaid, Medicare and the VA?”
    Peter – Add in about 18 million people who buy insurance in the individual market including 800,000 in CA alone. Throw in millions more who pay a very significant percentage (sometimes up to 50%) of their small employer’s costs to buy in the small group market. Then add many millions of Medicare beneficiaries who spend $200 or more per month to buy a Medi-gap policy. Even in high cost Massachusetts, young people can buy a bronze level health insurance policy for less than $150 per month.

  9. Bev – I’m interested in your professional medical opinion as to the extent to which the treatment patterns described in the articles happen because doctors think this is what they should be doing independent of patient and family demands and expectations and that the hospital and doctors are paid more if they do more. How significant a factor are family members’ demands and expectations to “do everything?” Also, I wonder if doctors could do a better job of explaining to families that while they are doing a lot TO the patient, they are doing little or nothing FOR the patient. Is that really what you want and do you think your loved one would want this if he or she could tell us?

  10. Sorry, I meant to add that the high costs are not dollar costs alone. Families seem to want everything done and this is the result. Are we treating these people, or torturing them? (I could be snide and say ask Dick Cheney, but that’s another subject….. (:)

  11. Barry;
    Unfortunately the impact is entirely lost when not reading the entire articles. These articles are often on subjects of public interest and concern and it irritates the dickens out of me that they remain subscription only (there is no abstract even). I just wrote a nasty letter to the NEJM.
    I will concentrate on the second one, “Failing to Thrive” – briefly, it concerns two cases reviewed by a medical resident – one, her own grandmother who was demented and seemed to be having a stroke; the family (most of whom were physicians) debated whether to take her to an ER or not. They finally did, nothing specific was found, and after a few days she returned to baseline and was discharged, still alive and demented a year later. The second case was a 90 year old admitted from a nursing home for failure to thrive (in the resident’s words, defined as “half-dead without evidence of something objectively treatable”). The attending agreed that there was no acute disease they could treat at the time, but they couldn’t send him back because “We haven’t done anything to fix him.”
    After choking on his applesauce and nearly dying from the subsequent pneumonia and various side effects from his antibiotics, a dilemma arose over whether to insert a feeding tube due to his chronic aspiration (choking).
    Again I quote, “among patients who are dying of chronic disease and hence have stopped eating, feeding tubes neither prolong life nor prevent aspiration.” However, a feeding tube was offered to the family, inserted, and immediately malfunctioned. Several more days were required to get the patient back to his original state, except now with a feeding tube. “Mr. T’s hospitalization…found him half-dead at the beginning, half-dead at the end, and much sicker in the middle….”
    “We see the same patients repeatedly, back and forth from their nursing homes, infested with bedsores, colonized by resistant organisms….we torture them with our needles and catheters, and they scream.”
    I wish you could have read the entire articles, but you get the general idea. Wonder why costs are so high?

  12. “All those honest and responsible people who bought insurance..”
    You mean all those people lucky enough to have their employer buy it for them, or the ones lucky enough to have the government pay for treatment through Medicaid, Medicare and the VA?

  13. Margalit and Peter,
    My suggested approach to treating those who refused to buy insurance is essentially the same way we deal with the uninsured now. If you show up at an ER, under EMTALA, they have to treat you until you’re stabilized even if you can’t pay. They don’t have to renew drug prescriptions, provide kidney dialysis or a course of cancer treatment. If providers are willing to treat those conditions without getting paid, that is, of course, their prerogative but they don’t have to and usually won’t.
    Under Margalit’s view, we would, in effect, say that while we would have preferred that you bought insurance, we will treat you for free or for whatever modest amount you can pay no matter how irresponsible you were or how foolishly you spent your money that could have been used to buy health insurance which you could have afforded with your income. All those honest and responsible people who bought insurance will now bear an additional burden to cover the cost of your stupidity and irresponsibility. Alternatively, you’re suggesting that we shouldn’t impose pre-existing condition restrictions and you can just wait until you get sick to sign up for insurance. We know that won’t work. We’re not going to have a taxpayer funded system, single payer or otherwise, anytime soon. At best, we will build on the employer based system we have and try to fix the dysfunctional individual market. That’s the reality like it or not and is probably the best we can do.

  14. “If he shows up at the hospital emergency room complaining of chest pains and having a heart attack or is seriously injured in an accident, we treat him as we would now, write it off as uncompensated care to the extent that he can’t pay and build it into the price charged to others.
    If he is diagnosed with cancer, we don’t treat him except to provide comfort care.”
    Interesting, so he should have known better for cancer, but not for a heart attack or car accident? And who gets to “write it off”, the hospital? And what about his family, do they get to suffer from his failure or inability to pay? I wonder what the societal costs are for single mothers and orphaned children?

  15. Bev — Unfortunately, both links require a subscription. Perhaps you could briefly summarize the key points made in the articles.

  16. I would bet an organ or two if the laws were changed and people knew they wouldn’t get free care that the 80-90% of the uninsured that are uninsured by choice would change their mind and either enroll in coverage they are already eligbile for or by the coverage they could afford. Same goes for financial liability, if we would force people able to pay to actually honor their liabilities they would take them more seriously. That would include no cable tv, cell phones, smoking or other indulgences the supposed poor enjoy so commonly.

  17. “It’s a fundamental difference in philosophy.”
    Yes, I agree. I could never accept a system that allows a young man to die because he foolishly chose to buy video games rather than health insurance. I cannot bring myself to take the definition of personal responsibility to this level.
    I think, Barry, that this is the most fundamental difference between liberal and conservative philosophies. Everything else is marginal and negotiable.

  18. There is one possible alternative to dealing with bills generated by the uninsured if we are going to continue to treat them as we do now. That is, their bills could become financial obligations of the individual and the spouse, if any, that could not be dischargeable in bankruptcy. We would not try to collect them beyond the family’s reasonable ability to pay while the patient and spouse were alive but they would become financial claims against their estates after their deaths. Expenses incurred by uninsured children would also, of course, be financial obligations of the family.
    Separately, I think there is a lot of gold to be mined on the cost side of healthcare by aggressively going after three of my favorite areas – fraud, defensive medicine, which requires tort reform, and end of life care which requires changes in how good sound medical practice is defined and applied as well as more reasonable patient expectations. End of life care, by the way, mainly involves cancer care in the hospital setting and Alzheimer’s and dementia in the nursing home setting.

  19. “Do we make him pay the ultimate price for his mistake? That was my question above.”
    My answer is: it depends.
    If he shows up at the hospital emergency room complaining of chest pains and having a heart attack or is seriously injured in an accident, we treat him as we would now, write it off as uncompensated care to the extent that he can’t pay and build it into the price charged to others.
    If he is diagnosed with cancer, we don’t treat him except to provide comfort care. If he can self-pay or find a charity to pay on his behalf, fine. If a drug company, hospital and oncologist wants to enroll him in a clinical trial and cover all costs as part of their research budget, great. Aside from comfort care, I would not provide care at taxpayer expense.
    If he needs kidney dialysis, a kidney transplant or other organ transplant, he’s out of luck again, unless he can self-pay or find a charity to pay on his behalf.
    In summary, I would treat events that happened suddenly and could be immediately life threatening if not treated. I would also at least provide comfort care including pain medication in all circumstances.
    The bottom line is that I trust people to act in their own best interests and, for adults; I am willing to let them suffer significant adverse consequences if they make poor decisions. Liberals seem to think that government knows best and we all need government to act as our nanny and be there to bail us out every time we screw up. It not only costs an enormous amount of money to do that but it makes people less inclined to take and accept responsibility for their own actions and choices and makes them more dependent on government. It’s a fundamental difference in philosophy.

  20. Barry, for those getting insurance through an employer, we are not exactly Germany. We have no minimum requirements, unless the states have them, and there are plenty of policies with lifetime maximum and even yearly maximum, not to mention the high deductibles that keep getting higher.
    What if a young 25 years old decided not to take his employer’s insurance and then he got sick and decided he made a mistake and he need insurance (well, it’s not insurance at this point). He of course cannot pass the insurer “tests” and can’t afford the high risk pools, so what happens now? Do we make him pay the ultimate price for his mistake? That was my question above.
    Nate, I understand that your answer was affirmative.

  21. Margalit – I think I’ve said before that if we were starting with a clean sheet of paper, my preference would also be a taxpayer financed voucher approach though I would want the taxes to be dedicated and highly transparent as opposed to general income taxes. Both Germany and France use payroll taxes, both in the 13%-15% range but the tax does not apply to all wages but is capped at some reasonable level, similar to our Social Security payroll tax. As I’ve also said before, we would need to integrate payroll and income taxes to achieve fairness between wage earners and those who earn most of their income from non-wage sources like dividends, interest, capital gains, rent, royalties, etc. However, as a practical matter, we are likely to be limited to building on what we have.
    Right now, we have a hybrid system. For those with good employer coverage, in effect, we’re Germany. For those on Medicare we’re Canada without the severe wait times and with a significant role for private insurers via Medicare Advantage, though seniors are having increasing difficulty finding doctors who will accept them as patients, at least in some markets. The same is true for the poor on Medicaid only more so. For those who get their care through the VA, we’re the UK’s NHS. The people who fall through the cracks are the unemployed and those who work for small businesses who don’t offer health insurance because they can’t afford it. Even today, 99% of employers with 200 or more employees still offer health insurance to their employees.
    Separately, to amplify my prior comment about employer health insurance, you can get it at a later time after you join the company if you had what’s called a change in life circumstances. This includes being enrolled in your spouse’s plan but your spouse either loses his or her job or the employer no longer offers health insurance or you were previously on your parent’s insurance but you no longer qualify for it due to age.

  22. “Are we really prepared to take this approach to its logical conclusion?”
    close to half the country already has a negative tax bill, they are paid just for being alive, it seems the left in order to avoid the horror of one person suffering for their own poor decisions is willing to inslave first the top 2% of the population then up to the 49% not lucky enough to get their free ride before the cut off. Where exactly is the logical conclusion of your wealth and labor redistribution?

  23. “I think we all know that it will take time to reduce fraud and waste and it has to be done judiciously,”
    Actually no, I could eliminate half of it overnight. Getting rid of the quick mandatory payments so questionable claims could be audited would fix a major chunk of the problem and not adversly effect anyone. FYI if a provider gets their Medicare ID and next week bills for 10 million question it. An ounce of common sense would save billions without effecting one legitmate claim.
    Long term have the adjusters build relationships with the members and when someone calls in and says the Medicare EOB they just recieved was for services they didn’t get actually listen and do something about it, currently they are either ignored or if the patient is persistant enough added to a stack to review three years later.
    Logical reform liberals refuse to discuss.
    “stuff like that is why I prefer universal coverage financed by taxes (VAT or income).”
    Margalit what is the difference between VAT or Income fraud and ignoring the mandate, in both cases people are abusing the system and undermining it.
    If our current tax system alreadys loses 100s of billions to non payment is your logic to just keep raising the rate on those honest people who do pay until you collect enough? You have managed to find a cure worse then the illness. Most uninsured are capable of getting insurance and choose not to, you want to further burden the honest people. and you expect this to actually save money.

  24. Barry, stuff like that is why I prefer universal coverage financed by taxes (VAT or income). I understand that it is not politically feasible to pass legislation to that effect in the current economy, but at some point, we should do just that.
    The problem with the “young and healthy” or other misguided people being excused from contributing to the health care pot, is that once they get sick and are left with no options they can afford, I would find it morally impossible to turn around and say “too bad, you had your chance…”. Are we really prepared to take this approach to its logical conclusion?

  25. “So if the addition of millions of uninsured to the system is accompanied by effective waste & fraud reduction, the total cost of health care should not increase that much. If that assumption holds true, why would insurance premiums sky rocket?”
    Margalit – If we don’t make much progress on fraud reduction, even with new tools, in the short term, premiums will continue to skyrocket due to increasing provider contract reimbursement rates, especially from hospitals and large physician groups with significant local market power, higher drug prices, especially for specialty cancer drugs, increased utilization, and increasing numbers of healthy people declining coverage or buying policies with much higher deductibles. All of these reasons were mentioned by Wellpoint CEO, Angela Braly, in her testimony before the House Energy and Commerce Committee. The individual mandate in the bill is very weak and millions of rational healthy people are likely to opt to pay the penalty rather than buy insurance.
    In NY and NJ, individual insurance is community rated and very expensive. There is no mandate to buy coverage, but to purchase an individual insurance market policy, you have to prove that you had coverage before which expired no more than 63 days earlier. That is, if you have more than a 63 day gap in coverage, insurers don’t have to sell you a policy. Due to high costs, there are very few young healthy people in these pools willing to pay $600 or more per month per person for decent coverage.
    A few days ago, Paul Starr, author of the Pulitzer Prize winning book, “The Social Transformation of American Medicine,” in a WSJ op-ed piece, suggested that people be excused from the mandate to buy coverage, but if they decline to buy, insurers will not have to sell it to them later if they want it then unless they can pass an underwriting screen and they will be subject to pre-existing condition limitations. This assumes they do not qualify for an income based exemption which they would be eligible for if the cheapest policy in the market exceeds some reasonable percentage of their income – like 10% or so for middle income people. I think this is a reasonable approach and should satisfy freedom loving conservatives who object to heavy handed government requiring people to buy something they don’t want and don’t think they need. This, by the way, is how most employer plans work. If you sign up for the insurance when you first join the company, you’re in the pool with no pre-existing condition limitations. If you decline but then want it later if your health deteriorates, you have to provide evidence of insurability by successfully passing an underwriting screen.

  26. Nate, if I remember correctly, during the “Healthcare Summit”, Dr. Coburn delivered a long speech regarding waste and fraud control that the Republicans would want to see and that according to him, would fix all our problems “tomorrow”. With the exception of “undercover patients” (??!!), it seems that everything he mentioned was already there and now they added “under cover” operations as well.
    I think we all know that it will take time to reduce fraud and waste and it has to be done judiciously, or the same folks that want to see costs cut, will start screaming about “death panels” and “throwing grandma under the bus”….
    And no, cutting costs by letting the “bums” and “undeserving” go without care, is not an option, in my opinion.

  27. “I don’t have a crystal ball, so all I can do is assume that the provisions in the bill will be executed.”
    This is interesting logic and a great example of what allows liberals to be liberal. We have 45 years of history of bills not turning out like they were suppose to, i.e. Medicare cost 10 or 100 times what it was projected and this exact scenerio has played out at least 10 times. Yet you naively believe this time it will work out just like they intend.
    Why do you think the rosiest of pictures will play out when it never has in the past? Isn’t it extremly risky to be taking these chances with assumtions no one beieves will come true?
    “accompanied by effective waste & fraud reduction”
    What provision are you talking about? There is no waste and fraud reduction proposed let alone effective waste & fraud reduction. This is the biggest complaint Republicans have about the bill, you throw millions of people into a flawed system without doing anything to fix the system. If you would just fix the system you wouldn’t need the subisides and everything else.

  28. “If this bill does pass with guarantee issue and all the other “improvements” you can expect insurance to sky rocket at least 50% in a couple years…”
    Nate, I don’t have a crystal ball, so all I can do is assume that the provisions in the bill will be executed. So if the addition of millions of uninsured to the system is accompanied by effective waste & fraud reduction, the total cost of health care should not increase that much. If that assumption holds true, why would insurance premiums sky rocket?

  29. Peter are you ever embarrased of your self?
    I attack you for claiming Republicans only had two ideas on cost cutting and mention what 4-5 of them are, your responce is to link to an article from commerace commity, are you a secert congressman who post here under the name Peter? What does any of this have to do with your comment that;
    “Their only other tepid adventure into cost cutting is to harness the competitive spirit of the American insurance industry to be able to offer us less price”
    Are you claiming this link represents every Republican idea?
    To your other joke of a retort, wow TNR is the bible of political debate now? Couldn’t find anything on Hunnington? I’ll keep it simple, Dems had 60 votes, they could have passed anything they wanted….oh wait no they couldn’t becuase even the dems didn’t want single payor, to spend the moneyto insure everyone, or their name near what was being proposed. Doh there went that argument Peter, Dems blocked Dems dream bill, Republican ideas were never on the table and Obama never talked with them until he failed and needed plan B

  30. “I guess we would still need something for non citizens and those who select to pay a penalty instead of buying insurance, but it wouldn’t be as big of a problem.”
    of the 48 million uninsured today around 20 million are already eligibile for free insurance and turn it down, do you think paying a $700 fine instead of $4000 premium insurance is going to get the majority of those to insure? 10 million or so of the 48 are illegal, Obama wants to make them all legal but until then they still won’t have insurance.
    If this bill does pass with guarantee issue and all the other “improvements” you can expect insurance to sky rocket at least 50% in a couple years how many more uninsured will that add?
    Is the penalty linked to average premium? Not that I read, that makes to much sense, so a few years from now when single cost is $6000 even more people will elect to pay the penalty instead of buying insurance.
    Guarantee you 4 years from now more people will be insured then if they had passed no bill. Considerably more poeople will be uninsured if they would address cost instead.

  31. “Unreasonably demanding patients, entrepreneurial and/or defensive physicians, fee for service reimbursement and our tort system work together in creating the perfect storm.”
    Exactly right, although the last two points really just elaborate on “entrepreneurial and/or defensive physicians.”
    And don’t forget to add fraud to the mix. Deceptive business practices need to be broken out from entrepreneurism. Fraud exists by the tens if not hundreds of billions. I subscribe to a weekly industry newsletter that gives that weeks’ awards in fraud cases for Medicare and Medicaid. Every week several new hospital systems, long term care facilities, device manufacturers, pharma companies, insurers, etc., are forced to pay millions of dollars. Often the individual penalties go into the tens of millions, occasionally hundreds of millions. Every week. And that’s only for the ones who are caught and the case goes as far as an award of damages (often things are tricky to prove even when everyone knows the system was being gamed). And that’s only for public programs. Private insurance may be better at policing fraud and abuse, but it is a long, long way from perfect.

  32. I am, I guess, rather at the other end of the ideological spectrum from MDhell, but I know what he’s talking about:
    “Medicare patients have a key to the printing press.”
    There is plenty of patient driven abuse; there are families who want all kinds of futile medical attention to their moribund and/or severely demented loved ones. I spent overtime yesterday with a very nice old lady who I recently diagnosed with a common chronic, very treatable condition who had a myriad of questions which I patiently answered for a 2nd time (that was basically her 2nd 50 minute visit within a month) but is going to see my subspecialist faculty colleague in the summer because her friend asked around for the highest degree of expertise in town.
    But a large part of the force on the lever of the printing press are entrepreneurial physicians themselves. Many patients see medical services – prescriptions, tests – as some kind of indulgence, and many of our colleagues comply, motivated by the urge to please and/or the urge to make money. I have never crunched the numbers, but I heard often enough that within the hospital, medicare is a reasonable payor … and in the office, even a relatively poorly paid (compared to private insurance) procedure is a money maker. Unreasonably demanding patients, entrepreneurial and/or defensive physicians, fee for service reimbursement and our tort system work together in creating the perfect storm.

  33. MD as HELL, wouldn’t EMTALA be completely redundant if everybody had insurance? I guess we would still need something for non citizens and those who select to pay a penalty instead of buying insurance, but it wouldn’t be as big of a problem. And no, I would not like a return to openly dumping patients.
    I agree with you that one of the problems is too much treatment, but it’s not the only problem and I’m not sure if it’s the biggest problem.
    Balance billing is not something I like because it presents ample opportunity to take advantage of patients. What would be the purpose of negotiating contracts with payers if you just turn around and balance bill the patient? Not to mention that the patient has no idea what the price is and what portion will be covered by the payer.
    Terry, I’m glad MD as HELL mentioned it, if you don’t see how tax payers are paying for uninsured care, look up EMTALA. All the uncompensated care costs are partially shifted to private insurers resulting in higher premiums, and partly written off or counted as charity, which results in lower tax collection from hospitals. Any way you want to look at it, your right to not buy insurance, becomes my obligation to pay for the care you will need, unless of course you are very rich, or prefer to go without health care and let the chips fall where they may. Most uninsured are neither.

  34. “And regarding the freedom to choose not to buy insurance, do I have the freedom to not pay ER bills for the uninsured by choice? This is not freedom. It is plain stealing from tax payers.”
    Margalit, I can assure you that no one is stealing from the tax payer except the citizen who presently is told by the government they can have it all when they want it, and they do not have to pay for it. (EMTALA).
    If you are worried about the tax payer, then why do you want them to be forced to pay for insurance?
    Just cancel EMTALA and quit paying for BS that patients who are anxious want to have but would not seek if they had to pay for it themselves.
    Medicare patients have a key to the printing press. The lock must be changed. There must be limits. The only way to do that is to change the standard of care in court s docs can test less and treat less, coupled with the end to no out of pocket costs to the patient for anything and everything.
    Docs being free to balance bill that which Medicare did not cover would be good, but the politics of Medicare have never allowed that. It has always been easier to screw the doc who votes than piss off the more plentiful patients who vote.

  35. The Democrats are corrupt, but not stupid. Only suckers work for the public interest, or at least that’s the strong impression I get from watching this nightmare effort at Health Care reform. The backroom deals to buy votes, the special interest groups like big labor that get a better deal than the rest of us. The hand writing is on the wall for the future of health care if Obamacare passes and government gains control over all the health care dollar. In order get any decent health care you will either have to be in the DC in crowd, like big labor, or pay a bribe to the corrupt powers to be in DC or you are out of luck. Maybe that is why Obama and Pelosi are so intent on passing Obamacare against the will of the American people. Obama and Pelosi want to be first in line to get all the money coming their way from the taxes that are being paid the first four year of the bill since thee are no services being provided. What a piggy bank that will be. If a private company charged you for four years without providing any service or product they would be prosecuted and put in jail. I think that the Dems in the US House needs to look out for themselves and VOTE NO on this monster of a bill and not follow the pied piper Obama like rats being led to their slaughter.

  36. “Republicans think that blaming this on the lawyers is the easy, and PC thing to do”
    Where as Peter blames it on the insurance companies cause all his cool friends tell him to.
    “Their only other tepid adventure into cost cutting is to harness the competitive spirit of the American insurance industry to be able to offer us less price”
    Peter can’t read obviously cause if he did he would also mention AHPs they proposed for 15 years. He would also mention reducing mandates, and he would also mention attacking fraud, unfortunetly Peter can’t read and count so he only mentions two of them.
    “it’s nice to have a discussion of health care and how we can create a system that provides for everyone in this country. The trouble I have with your comments — and Krauthammer’s column — is that I don’t think either of you are interested in doing that.”
    Then your not looking close enough Dennis, I think everyone should have great healthcare, it shouldn’t be free and given to people that don’t work for it and it sholdn’t be provided by the government with borrow money that can’t be paid back. I would bet at the end of the day our only difference in opinion is the right deals from reality and the left thinks you can tax more and borrow money forever. You can’t pay for SS, you can’t pay for Medicare, and you can’t pay for Medicaid, how many more empty promises are you going to make?
    “so the only current and indefinite means of making that market operate to the benefit of consumers (patients) is administrative and regulatory.”
    Can you provide any examples of this every working over any length of time? It seems history has shown on numerous occasion this ideology leads to highly inefficient and expensive failures not long term sustainable nirvona like the left dreams of.
    “I do have to give Republicans credit for demanding a bi-partisan bill while refusing to negotiate.”
    Where exactly is your head buried Margalit? Obama refused to even meet with republoicans for his first year. The right tried to communoicate with him and he ignored all efforts to talk. He holds one BS fake conference and you think he is open minded. Get back in touch with reality.

  37. No one is being “forced” to pay for some one else’s Emergency Room Services. If so I never got the bill for Joe Blow’s ER visit. I just do not know where the left comes up with this nonsense. However, if Obamacare passes, I will be FORCED to buy insurance that the government dictates I buy including stuff I do not want or need. Right now I have a choice; of what type of insurance I want to buy and I can also choose not to buy any insurance. As to the argument ER visits unfairly spread higher Health Care Cost to everyone, that is also a bunch of BS. Just look at what is happening in Massachusetts where the model of Obamacare has been implemented. fyi, overall Health Care Costs have gone up to the point they are higher than anywhere else in the nation. So what is the solution to the rising costs? You guessed it. Government rationing of health care services because that is the only thing government can do to bring costs down. So if you like standing in line, in vain, waiting for that expensive surgery or cancer treatment you need to save your life I am sure you will just love Obamacare.

  38. As one for whom the WaPo is my daily newspaper, I am subjected to “Dr.” Krauthammer every day. Every single day he picks out something about Obama to yammer about. When, recently, he had a column on something else (and that column wasn’t any good either), there were several comments asking sarcastically what was wrong with him because he wasn’t bashing Obama today.
    He hardly qualifies as a “pundit.” Ranter is more like it. I don’t read him anymore. These guys’ worst insult is to be ignored.

  39. The fact that the people on these posts thinks it is ok to cut old people off at the knees when it comes to their health care while at the same time giving Unions tax breaks that no one else will get is just plain despicable if not evil. According to Richard Foster, the chief actuary for the Centers for Medicare and Medicaid Services, the Medicare cuts in the Senate HCR Bill will effectively destroy Medicare services for Seniors due to the fact physicians and hospitals will be forced to drop Medicare patients because the Medicare reimbursement rates will be lower than the cost of providing their care. Mr. Foster adds that other planned Medicare cuts would damage doctors and hospitals: “Over time, a sustained reduction in payment updates, based on productivity expectations that are difficult to attain, would cause Medicare payment rates to grow more slowly than, and in a way that was unrelated to, the providers’ costs of furnishing services to beneficiaries.” ref. http://online.wsj.com/article/SB10001424052748703652104574652563562216036.html?mod=WSJ_Opinion_AboveLEFTTop#articleTabs=article

  40. Interesting to see how much shriller conservative voices have gotten lately….
    For the Constitutional purists out there, how is it perfectly fine to impose tort reform legislation on the States, but it’s not OK to mandate individual coverage?
    And regarding the freedom to choose not to buy insurance, do I have the freedom to not pay ER bills for the uninsured by choice? This is not freedom. It is plain stealing from tax payers. I thought the conservative insurance lobby here would be the first to celebrate individual mandates, but instead it seems that the solution is to grant me my freedom from paying the ER bills and just let the uninsured drop dead in the street. I guess it could be a cost effective option and costs must come first.
    Is it just me or are we overusing the “free” word, like in saying free market when we really mean unregulated market, which is synonymous to predatory market as far as consumers are concerned, and very cozy for “freely” colluding sellers?
    I do have to give Republicans credit for demanding a bi-partisan bill while refusing to negotiate. It’s a brilliant strategy for keeping things exactly as they are now. And I do agree that it’s all about political power. It’s not about health care. It’s about making this particular President fail, no matter what the consequences to the country.
    And if by any chance this bill gets “shoved down our throat” through the unheard of mechanism of a plain majority vote, there are elections coming up and you don’t have to vote for Obama this time… 🙂

  41. Re: The Oxymoron Columnist, by Merrill Goozner
    Mr. Goozner, as a Columbia School of Journalism graduate and ex-college professor
    You no doubt possess impeccable progressive credentials.
    You come armed with self-righteous elitist essentials,
    You may know more about health care than Krauthammer,
    Who learned his health care in the Harvard Medical School slammer
    You have a great passion
    For unlimited compassion
    When that compassion uses other people’s money,
    And when it comes from the Federal Easter bunny.
    Your blog rant has shown,
    Your liberalism in full groan
    You can show your intellectual arrogance
    By framing it as a national moral advance
    You can call Dr. Krauthammer whatever you want
    You can descend into a long condescending taunt
    But please admit, 75 percent of Americans reject what Obama is proposing
    That, not Krauthammer’s oxymorons, is why Obamacare is decomposing
    You may regard Krauthammer as your philosophical inferior
    But three of four Americans regard his views as superior.
    That’s the essence of American Democracy,
    We’re not yet an autocratic aristocracy.

  42. “Warren Buffett as calling on the president to “start over and get it right””
    I have tried reading Mr. Krauthammer’s column in the past, but that experience once or twice was enough, so I will use Mr. Goozner’s references to the column. The reference to Mr. Buffett’s comments is misleading. Mr. Buffett in fact states that were he in Congress he would vote for a reconciled bill.
    Mr. Buffett, presumably like many others with adequate knowledge of the USA’s and other healthcare systems – note the comment from the Canadian resident or citizen above (isn’t the word “Canuck”, rather than “Canuckian” by the way?) – along with knowledge of the operation of participants in markets outside of healthcare would prefer to see much more fundamental change to the healthcare system. Change such as the example Mr. Goozner cites of addressing the lack of economy of most provider entities, notably specialists and many hospitals which have a strong hand in price-setting, if not outright monopolists.
    That is the sense of “start over” from Mr. Buffett.
    The allegations from those in this weblog such as the ubiquitous Nate and smooth-writing ruler41 that supporters of the enactment of a reconciled bill are in some way against competitive markets or something similar is laughable.
    I would certainly prefer to see medical service delivery entities operate under the competitive conditions of any small business in other industries that does in fact operate in a highly competitive market. The mechanism of competition would work wonders for wringing out the best service and quality providers which operate the most efficiently, often but not always at lowest cost.
    Unfortunately the market for medical services does not operate under competitive conditions as a whole, so the only current and indefinite means of making that market operate to the benefit of consumers (patients) is administrative and regulatory. Myths to the contrary only perpetuate an abysmally functioning system.

  43. To shrill that the most cost-effective means of assisting the uninsured is to fund for them private insurance through companies repeatedly denounced as corrupt is not simply unintelligent. It is the waging of a rabid ideolgical war bent on victory at any cost.

  44. Nate, it’s nice to have a discussion of health care and how we can create a system that provides for everyone in this country. The trouble I have with your comments — and Krauthammer’s column — is that I don’t think either of you are interested in doing that.

  45. Mr. Goozner,
    In a post about how illogical the Right-wing is, you pen this sentence:
    How can a bill whose cost-cutting is insigificant (sic) “remake a sixth of the U.S. economy”?
    I keep studying it; I;ve tried squinting my eyes and turning my head sideways. I’m certain it’s just my conservative logic that won’t let me see past the major premise of the sentence, which apparently is: “cost-cutting is the only tool by which an economic sector could be re-made via legislation.”
    Maybe you could diagram the syllogism for us troglodytes.

  46. Hal,
    It may surprise you to learn that neither doctors nor hospitals are legally able to conspire together to fix prices. Under existing anti-trust law.

  47. I suggest those that find the concept of “health reform” to be withing the purview of Congress read the Constitution.
    The bankruptcy of thought of our nation lies solely on the left, whose feckless nonsense pollutes 90% of the broadcast media, but get no ratings. Only can the left decide that society is bettered by forcing me by law to purchase a good a may not want such as health insurance?
    Is larger gov’t involvement and expenditure really indicated in healthcare? Why? What will gov’t do that free citizens cannot?
    When overpriced FP and IntMed docs stop preventing reasonable acceptance of mid-levels in our system, I will begin to believe MD’s have some worthwhile knowledge.
    Here’s my one sentence health reform: NP’s (and other midlevels) get 100% of the reimbursement of MD’s. Think about it…it would work. When’s the last time you refused the services of a CRNA vs. an MDA?

  48. Addressing the bigger issue of provider clout in negotiating rates, I think eventually we may be forced to actually apply anti-trust law against the cartel-pricing.
    No other economic group in America is legally permitted to conspire together to fix prices.
    Why should doctors/hospitals be an exception to common-sense law?

  49. I won’t add to Mr. Goozner’s well worded rebuke of Charles Krauthammer’s healthcare yellow journalism, it would be too easy and the length of the post too long. I will ask everyone, if Obama WAS concentrating on “cost control” would he be better off politically in this fight – I say no, maybe even worse, because that would truly and correctly affect 1/6th of the nation’s economy.
    Cost cutting is the only way to bring coverage to more people and the only way to save coverage for those who already have it. But nobody wants their costs (and incomes) cut, just the other guy’s. Republicans think that blaming this on the lawyers is the easy, and PC thing to do because, you know; we all hate lawyers – until we need one. Their only other tepid adventure into cost cutting is to harness the competitive spirit of the American insurance industry to be able to offer us less price – but, they’re careful not to say, for less coverage. They even state in their GOP Health Plan; “without — (2) cutting Medicare benefits for seniors,” yet they scream that Medicare will go bankrupt if the Democrats don’t do anything. Americans WON’T do anything to control costs, except deny more millions of other Americans healthcare coverage, until their own paid-for-by-someone-else coverage is threatened even more than it is now. I wonder when the strain of reduced coverage, higher co-pays, higher shared premiums and higher deductibles of their present insurance will prompt them to say, we need, what Warren Buffet called, “Plan C”. Which political party will voters then turn to for rescue to risk at-the-polls annihilation thanks to all the Krauthammer-like jerks the mob loves to cheer on, who don’t understand their journalistic obligation for rational truth telling about a national problem only getting worse, and with NO solution in sight.

  50. Thank you Louisdous…. Thank you!!! I thought I had wondered into a nightmare world until I read your great post.
    Freedom!!!

  51. Talk about ignorance and illogical fulminations.
    “Actually, one Louisiana Republican did vote for the bill. But that little untruth isn’t the real problem with his formulation.”
    Seeing as how these are new proposals being offered up it is correct that no republican supports what is now being voted on. Thanks for pointing out what a real untruth looks like.
    “Krauthammer is a physician who should at least understand and acknowledge the suffering of the 45 million without insurance”
    Dennis seeing as how 40 million of those CHOOSE to be uninsured what suffering are you talking about? Except that of your strained logic and argument. If there really was suffering like you claim the 20 million already eligible for free benefits would take the time to enroll and those making 75,000+ a year would go buy a policy. Is that another lefty untruth I see?
    “without once recognizing the fact of how the every other advanced nation manages to cover everyone, stay healthy, and keep costs under better control than America.”
    More left BS, every country you claim has cost under control is rushing headlong into financial collapse just as quick, and quicker, then we are. None of the systems you lust after are sustainable.
    “Unfortunately, in the United States, it’s the free market in health insurance which has created the overpriced, uncomprehensible, and unworkable system most Americans have to suffer with.”
    Only a left could call healthcare a free market when 50% of it is already paid for by government. Do you even know what the term free market means Dennis?

  52. I don’t have a dog (in this fight or at all). But if Ben Franklin was alive today, I’m pretty sure he’d track down Mr. Goozner and kick the crap out of him for even thinking about comparing himself to him.
    Mr. Goozner, I have a bit of logic for you. If you lie, you are a liar.
    Since I read your OpEd OpEd first, I had to read Mr.Krauthammer’s piece twice and double check the link to confirm it was in fact, the same article you were referring to because you so mischaracterized it.
    Mr. Krauthammer’s never even refers to the 30 million whatevers Mr. Goozner talks about.
    The refrence to “ridiculously insignificant” was the tort reform demonstration studies, not to any cost savings or bending of cost curves.
    Not only are you a liar, you are ignorant. You accuse Mr. Krauthamer of ad nominem attacks (at no one) while you are the one that actully engages in ad hominen attacks against him (troglodyte).
    And by the way, the 30 million already have coverage. Since you can not distinguish between covered and insured, it is clear you are the one “That would require knowing something about or at least thinking logically about the nation’s complex health care system…”
    Thanks for listening. LD

  53. Krauthammer is indeed required reading to understand the emerging lunacy (some might say it’s already here) of the right wing in America. His phony analogy of “free ice cream, steak and flowers” struck me as particularly bizarre turn void of any real substance.
    In a great irony, Krauthammer is a physician who should at least understand and acknowledge the suffering of the 45 million without insurance plus millions more with substandard insurance. Yet he delves into talk of cost, cost, cost without once recognizing the fact of how the every other advanced nation manages to cover everyone, stay healthy, and keep costs under better control than America. Like almost every other right-winger in the debate, he cannot conceive of a world beyond his ideological blinder that the free market always works best. Unfortunately, in the United States, it’s the free market in health insurance which has created the overpriced, uncomprehensible, and unworkable system most Americans have to suffer with. That is the only reason the US is where it is today.

  54. MERRILL GOOZNER’s blog is an example of what is sick about today’s attempt at serious discourse. He lives in one of the iron-clad castles of ideology that those on the Left and the Right hide in and defend, mindlessly. Where has free thinking gone? Goozner’s world is just the obverse side of the Rush Limbaugh coin: Republican BAD!
    Also, anyone worth his or her salt in helthcare communications knows that the current healthcare mud-wrestling show is not about reforming the system, it’s about political power.

  55. For those of you who are not adepts in the mysteries of nonlinear logic, let me explain what Mr. Goozner is driving at here. Mr. Krauthammer proposes that, although everyone would be in favor of free ice cream, steak and flowers, they would balk if these goodies came at the expense of cuts to Medicare, “not to keep Medicare solvent but to pay for the ice cream, steak and flowers.” Thus, in his sneering, patrician, “let them eat cake” disdain, Mr. Krauthammer is saying that expanded health coverage is as frivolous as ice cream, steak and flowers. See? He also makes a great fuss over the failure to reduce costs. Typical RW bs.
    I do believe forums like this have saved many a dog a kick in the ribs.

  56. Straw man argument! A classic fallacy! And whatever other self righteous terms the new skeptical movement throws at someone when they disasgree and need to act like snarky know-it-alls!!!

  57. From the perspective of an outsider (Canuckian), the highly polarized, partisan political system of the USA is an endless source of amusement, when it doesn’t make you cry.
    Arguably the most powerful and advanced nation currently on this earth (though I do wonder if that lofty categorization has slipped in the past few years), the USA’s political system seems more like a Punch and Judy act or a Capulet vs Mongague fued than a system/process geared towards the benefit of it’s citizens.
    Healthcare especially seems to bring out the worst on both sides, and soon both Romeo and Juliet will be lifeless corpses if the trend is not reversed.
    And the citizens’ needs? What citizens? Oh….you mean the people that actually pay for this dysfunctional and often corrupt system?
    There are some bright spots of course….Dr. Lawrence Lessig’s efforts to revamp the lobbyist approach come to mind.
    Anyway….an observation from an “outsider” for what it’s worth.

  58. I concur with Mr. Goozner, The allegations from Republican members of Congress and the various elements – including many writers such as Mr. Krauthammer – on the extreme right-wing of politics are reprehensibly outrageous.
    Paul Krugman, who chimes in frequently on healthcare related issues, has a relevant column in today’s (March 5, 2010) NYTimes on the separate worlds that the Republican politicians and others of the extreme right-wing occupy versus Democratic politicians and the mainstream of USA polity – the 70-80% of the population that is not extreme rightist. There is no near-term bridging of any policy gap between those separate worlds.

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