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POLITICS/POLICY: Social mobilty, and its impact on health care politics

This is taken direct from Ezra Klein’s piece on “Brave New Economy, With Such Immobility In It” and it goes to the heart of why insecurity over health benefits will be the political issue of the next ten years.

The Center for American Progress just released a comprehensive study of economic mobility and income volatility. And, according to its data, Andy’s right about the American lack of fatalism, the belief in opportunity and mobility. When asked if people get rewarded for their effort, 61 percent of Americans agreed, versus 49 percent of Canadians, 33 percent of the British, and 23 percent of the French (weirdly, the Philippines win this one, with 63 percent agreeing). But of all these societies (save the Philippines), America is one of the least mobile, which is to say the least dependent on hard work rather than social station. In Denmark, the relationship between your parent’s income and yours is 15% percent or so. In Canada, it’s 19% percent. In France, it’s 41 percent. And in America, it’s 47 percent. The only country more hidebound and hierarchal is Andy’s native England (50 percent), also the country most closely approximating the American economic model.As it is, if you’re born in the lowest income quintile, you have a 1 percent chance of reaching the top 5 percent. If you’re born rich, you’ve a 22 percent shot at remaining there. For the middle class, hard work and productivity have begun to count far less. In 2003 and 2004, years when the GDP saw strong growth, the median household was no more upwardly mobile than in 1990-91, during a deep recession. Think about that for a second: inequality has reached such a height that the average household is actually worse off during today’s expansion than yesterday’s recession.There’s been a serious increase in downward mobility, too, with only 13 percent of families seeing $20,000 (in real terms) loss during the 1990-91 recession, while nearly 17 percent experienced such a drop during the 2003-04 expansion. Households in the top 10 percent have, by contrast, seen a reduction in downward mobility during the same period. And while it used to be the case that you could combat stagnation through hard work, even that’s dying out. Households where the adults worked more than 40 hours a week were able, during 1990-91 and 1997-98 able to translate their labor into upward mobility. Now, the correlation has disappeared.

Now overlay over that the findings from Commonwealth (which I wrote about over at Spot-on yesterday) that health insurance from employers is declining fastest amongst those in the third and fourth lowest income quintiles, and that those earning between $20K and $40K—who are probably pretty much the same people—have seen their likelihood of being uninsured at some point in the last year go from 28% to 41%. Add to that picture the fact that the top 10% of Americans have seen their share of national income increase in the past twenty years, while everyone else has suffered a relative (and in many cases a real) decline in income.

So adding it all up, despite a rise in the number of high income households, if you don’t start off that way you’re much less likely to trade up in class or income. You’re going to be making relatively less money than your parents were. And the rising cost of health care is going to manifest itself in your greater likelihood to lose insurance coverage.

This has to keep playing itself out for a while longer before it has any real political effects. But unless these underlying trends reverse, by definition, the politics of redistribution will come up. And because of its crucial and emotional nature, they’ll come up first in health care. Of course we have to get that pesky Iraq situation taken care of first.

 

OFF-TOPIC: Henry doesn’t deserve to be player of the year in England

Those of you who don’t like soccer can skip this!

Proving that English football writers know nothing, they’ve voted Thierry Henry FWA player of year for third time in a season when Arsenal have been rubbish and he’s been notable by his absence from most of their toughest games. Arsenal have ridden a very easy draw in the European Champions league final (avoiding Barcelona, Chelsea and AC Milan, the three best teams in Europe). In the knock-out phase they got Juventus in a real form rut and Real Madrid in a dreadful state, and only just scraped past them. They got kicked out of the FA cup at Bolton in a game in which Henry was totally absent while being on the pitch, and have struggled to come 5th in the league. While he’s a great player and deserved the award before, he did not this season.

Any one of John Terry, Joe Cole or William Gallas (Chelsea’s best players as they dominated the league again) is much more deserving. Wayne Rooney had a great season while his Man Utd teammates imitated doormats around him, and, and even Stevie Gerrard, inexplicably given the PFA award (the one the footballers vote for) had a better year than Henry.

I guess reputations count on; but the Premier league table doesn’t lie, and the luck of the draw in the Champions league will run out on the Gunners when Barcelona stuff them in Paris next month. Perhaps if Henry reproduces his best form in the World Cup  Germany this summer, and the French team holds together behind him, then the World Player of the year award next December might be justified. But that’s based on the calendar year. Over the 2005–6 season, it’s not Henry’s year.

 

HEALTH PLANS: It’s blood on the streets today; but is the ride over?

Here’s the news from my FierceHealthcare newsletter on insurers’ stock prices today

Today’s earnings announcements from health plans and insurers don’t look too bad. WellPoint reported a 20 percent surge in profits yesterday, a gain that the company attributes to an increase in membership and decreased medical costs. Aetna also posted good earnings, with first quarter profits up 3.2 percent, but reported a first quarter medical cost ratio of 79.4 percent in its main commercial business. That was up from 77.9 percent a year earlier. Meanwhile, PBM Express Scripts had first quarter earnings of $104.7 million compared with $85.3 million for the same period a year ago.

Wall Street wasn’t having any of it. Aetna’s stock was down over 20 percent today as the company’s CEO Jack Rowe hands over the reins to Ron Williams and CFO Alan Bennett makes plans to retire in 2007. Express Scripts stock is down nearly 10 percent, and the rest of the health plan and PBM sector is down heavily too.

– read the article about WellPoint from the Los Angeles Times– see this Houston Chronicle article about Aetna’s stock slide – read this article from MarketWatch for more about Express Scripts

So is this finally it?  Have the plans been found out? Will we see MLRs head back into the mid-80 percents?  Should we all have shorted UNH and AET in January. Well I myself have believed that health plans have been overvalued forever….but if I’d gone short when I started saying that a few years back (like in this April 2004 column), I’d be living in a cardboard box under a freeway now. Look at what’s happened to their stock since then (the bottom orangel line is the S&P 500). Even with their recent declines they’re all up at least 50% since then and Humana is close to being up 200%:

Hi

 

HEALTH PLANS: Blue Cross of California looks like its hand was in cookie jar

There’s more from the LA Times about the Blue Cross of California case where benefits were retroactively denied. For some reason, although the case has been sealed, the Times was able to report on testimony of four BC employees.

A California Blue Cross employee testified in secret last year that the state’s largest health-plan company routinely canceled policies of sick members after looking for inconsistencies — not fraud — in their applications. Experts say, however, that state law allows only deliberate omissions or misstatements as grounds for canceling health coverage.

Given that the lawyers obviously combed through these cases, and found people like the woman denied coverage for obstetric care 2 years into her policy, this starts smelling worse and worse for Wellpoint. Health insurers are in a very vulnerable position right now. Their profits are sky-high, and far more of the premium is sticking with them than their cleints or the genreal public understands—medical loss ratios are down in the low 70s. Not to mention certain executives with their multi-million or billion dollar pay outs.

Wellpoint would be well advised to do what they can to make this case disappear very quickly. Otherwise they might start realizing that they’re in an election year and health insurers are only just above the oil and tobacco guys in the popularity stakes.

POLICY: Meanwhile, remember love story

Over at The Plank, more confirmation that “being a loony libertarian/conservative in health policy means never having to acknowledge facts that disagree with you”. After all, when you can get Fraser and PRI to send you lies for free, why bother looking at OECD, or other commie institutions like the Wall Street Journal which understand reality.

More from Ezra

POLICY/PHARMA/TECH/PHYSICIANS: The Industry Veteran thinks Uwe and McLellan are missing the point

It’s been a while since we heard from The Industry Veteran, but the dialogue between Mark McClellan and Uwe Reinhardt I reported on at WHCC last week did raise his hackles. I love Uwe’s analysis and think McLellan is very sensible (though suffering from obvious political restraints). But the Veteran didn’t exactly see it that way. Here’s his sense of what ‘s wrong with health care and how to fix it.

The dialogue you reported between Mark McClellan and Uwe Reinhardt was hugely disappointing as both appeared more intent on glad-handing each other than identifying culprits in the health care system. I offer the following as a useful rule of thumb for THCB readers: whenever someone says more IT represents a principal solution to a better health care system, the red light should flash on one’s shit detector.As uncle Marcus Aurelius advised, let’s return to first principles. Assuming THCB wishes to address the big issues and not turn into a blog for techie nerds, the problems of health care cost, quality and access in the U.S. result from some basic factors. The first of these is that there are too many middle men extracting too much profit (or, in Marshallian terms, too much economic rent) from the system. Among these, third-party payers are both pernicious and dispensable. Most analysts euphemistically classify payers and the efforts of other sectors to deal with them as “administrative costs.” It seems I’ve been seeing these administrative costs pegged at 25-30% of the health care bill for the past twenty years. Since Bush’s millenarian-oil junta has been running the country, I would guess that figure to be substantially higher because payments to providers have been tapering while premiums keep escalating. Given that the administrative costs for Medicare are approximately 2%, it appears self-evident that the current system, based on employers and insurance companies, should appeal only to Reagan-Bush types who consider the proper role of government to be one of handmaiden to business.Within the provider segment, specialist physicians are another extortionist bunch. There is simply no defensible reason for every mother’s doctor-son to expect an annual income between a quarter-million dollars and $650,000. Do I hear in the background, diminuendo, the arachnid voices of techie wonks crying for tactical proposals in lieu of venting and ideology? Sink your incisors into these. (1) Use relative value reimbursement scales to promote a systematic de-skilling. (2) Increase the labor supply in the medical specialties with U.S. citizens who graduate from foreign medical schools. (3) Feminize the medical profession by elevating nurse practitioners and using staff-model and other arrangements that permit 9-to-5 shift work.Manufacturers, particularly in pharmaceuticals, are due their reproach as parasitic middle men. The European countries routinely use reference pricing to help keep them in line and health care’s Iron Triangle of cost-access-quality does not appear worse there than here. In fact the WHO rates U.S. health care as thirty-something in world while France receives the number one spot.Now you’re probably correct, Matthew, in pointing out that the public opinion polls on health care have to show a larger percentage of people expressing a vehement discontent with the system over a sustained period before substantive change can occur. To foster that attitude, I humbly advise interested parties to hammer away at the big issues instead of creating diversions and wasting time with minor tributaries such as IT. I believe there is sufficient greed to expose, enough contradictions to raise and tragedies to highlight, all of which can help prepare the public mood. The drama that can affect public attention, however, seldom resides in the IT department

POLICY: Leif Haase on Many Roads to Rome?

I’m on the east coast, and have been pottering around meeting various people learning a little. One of the most interesting was Leif Wellington Haase who is the health policy guru at the Century Foundation. Over a very nice lunch (Thanks Leif!) he explained to me that the Foundation, which used to be more liberal social club than active policy shop, is very much shedding that image. It’s now putting together a task force that will under-pin a rational debate over what future universal coverage looks like. Rational is code here for distinguishing itself from the HSA fantasists who don’t believe in the rationale for universal coverage

Leif’s proposal, which is not a million miles from the Fuchs/Ezekiel proposal, is summarized here. It’s intended to be a call to action to everyone to get involved in the debate before we end up in the healthcare equivalent Brazil or Cambodia (take your pick). How that fits into the wider rational debate in the universal coverage world, Leif explains here — Universal Coverage: Many Roads to Rome?

…And he’s yet another person telling me to write a book <sigh>

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