The NY Times never called so I guess they’re never going to publish my letter about Karen Ignagni, the head of AHIP, in response to her letter the other day to the Times about Krugman’s column. I referred to it in my post on Friday. So what did she say and why was I so miffed?

Well let’s just say that if I had made so many factual mistakes in an essay in the third grade I’d still be standing in the corner wearing the pointy white hat with the big D on it. Here’s her letter with my comments cut into it:

In making a case for a one-size-fits-all health care system, Paul Krugman ("A Private Obsession," column, April 29) ignores the private sector’s progress in adding value to our health care system and stretching consumers’ health care dollars.

It is of course a joke to suggest that Krugman’s calling for a one size fits all system–which is code for government-provided (socialized) medicine. He explicitly criticized the UK system for being that, even while acknowledging that it was better for the poorer Brit than ours was for the poorer American  The vast majority of single payer systems (including the UK!) have a safety valve private care delivery sector, and in some of them (e.g. France, Germany, Japan) it’s much bigger than the government-run system. And by the way, some data on our government-run system, you know the one that’s good enough to our brave service men and women, suggests that it’s pretty damn good compared to private HMOs. But let’s ignore that and focus on the other end of the sentence, the part about how the "private sector is stretching consumers health care dollars".  OK, so in 1997-8 or thereabouts AAHP (Ignagni’s then employer, and forerunner of AHIP) put out a press release extolling a brilliant in-house study claiming that managed care plans had saved the economy billions of dollars in comparison to what people would have spent on health care had the rate of premium increases in the mid-1990s been the same as it was in the late 1980s–when they were going up three times the rate of inflation. That was such a crappy piece of "research" that I wrote a special article for my corporate clients explaining why, and suggesting that they never allow this kind of stuff to get out with their name attached to it. Of course we never saw the corresponding article published in 2004 or 2005 when those same health plans which had supposedly been so great at taming health care inflation completely capitulated, and the "consumer" saw their prices going through the roof. I suspect their researchers are still working on it. But it’s good to know that, for Ignagni, apparently the last 5-6 years of double digit health inflation has seen the private sector "adding value"! I guess if you’re a senior exec at  health plan, it does seem that value has indeed been added — mostly to your bank account of course. But there’s more:

During the 1990’s, Americans decisively rejected a single-payer system. They were concerned about the rationing of care, endless delays and lack of access to state-of-the-art procedures experienced in countries with government-run systems. That’s why residents of these nations go to great lengths to gain access to American health care, and why their leaders are reaching out for disease management, care coordination and other private-sector initiatives.

Next we come to the most blatant lie in the whole brief letter. Apparently Americans rejected single-payer in the 1990s. This is complete rubbish and Ignagni knows it. Ignagni claims that Americans were offered a single payer proposal in the 1990s. They were not — the Clinton plan explicitly kept a role for large private health plans. The political gambit of the Clinton’s was to ensure that they didn’t have total enmity from the private health plan sector. They were sufficiently successful that several members of the AAHP — the "large insurer" association which Ignagni then headed — initially supported the Clinton plan. Did she forget?  Well maybe selective amnesia has reared its head, as the HIAA (the small insurer association that merged with AAHP to form AHIP a few years back) was of course violently opposed to the Clinton plan. HIAA was opposed because the plan would have put most Americans into large purchasing groups and would have effectively banned risk-shifting and medical underwriting — the only way small (and many large) plans make any money.  It was HIAA that came up with the "Harry and Louise" ads which sowed FUD amongst wavering Democratic politicians with an astro-turf campaign run by PR agency Porter Novelli. But the rejection of the Clinton plan was caused by a bunch of factors, mostly connected to the fast improving economy and the  scandal mess the Clintons were getting themselves into over Whitewater, Travel-gate, Vince Foster, and Bob Dole refusing to let the moderate Republicans meet with Hillary about health care. Single payer had precious little to do with it, even if many Americans had a clue what it meant, which most didn’t (and still don’t).

And of course the issue about foreigners (i.e. Canadians) rushing down here for health are has been conclusively proved to be complete rubbish by the UBC/Michigan team that used actual data and actual research to look into it, and then published it in the leading academic journal in health policy — an approach that AHIP hasn’t exactly been known to much concern itself with. Meanwhile Ignagni continues:

Mr. Krugman’s government-versus-private juxtaposition minimizes the complexities of reforming health care and overlooks the vibrant public-private partnerships that millions of Americans count on. For example, Medicare and Medicaid patients who opt for private-sector plans are getting better care at lower costs than their counterparts in the government-only side of the program.

Perhaps Ms Ignagni doesn’t hold much truck with those Canadians and their biased use of data.  However, there’s a minor research organization called the General Accounting Office attached to a place called the US Congress that AHIP may have passing familiarity with, so perhaps we should introduce some of their research at this point. The GAO has twice in the past decade looked into the subject of the "Medicare and Medicaid patients who opt for private-sector plans (and) are getting better care at lower costs" and found that while those seniors in Medicare HMOs may indeed have been having lower costs than their colleagues in the standard Medicare program (because they were covered for their drugs) the actual costs to the overall Medicare system — that is to you and me the taxpayer — went up because Medicare was overpaying the HMOs. The HMOs were of course recruiting healthier than average seniors, pocketing an amount close to average cost for a Medicare recipient, and the taxpayer was making up the difference. Funnily enough as soon as those payments were cut to closer to what the seniors were actually costing the plans, the private sector bailed out of Medicare as fast as it could. Only now after huge bribes payments for private plans to recruit seniors were put into the MMA to buy AHIP’s member plans’ support is the number of Medicare recipients in private plans starting to tick up again. GAO by the way isn’t exactly brimming with optimism that the new PPOs, introduced as part of the MMA, are going to save any money either. But undettered Ignagni continues: 

Americans deserve a real health care debate and real solutions, starting with evidence-based medicine, medical liability reform and the information they need to make better decisions. That’s a more complex but ultimately more productive path to reform. (Karen Ignagni,  President and Chief Executive, America’s Health Insurance Plans, Washington, April 29, 2005)

It is indeed nice to know that we deserve a real debate, not some phony scare tactics cooked up by, say, members of the HIAA which never got close to discussing an actual "solution" in 1994 when they had their chance to be constructive. And frankly given the huge amount of cash that her members and their executives have been pulling down the last few years, why would any of them be interested in "reform"? I guess that given it’s a debate about health care in the US, we can’t  expect many actually correct facts to be brought up, but surely there should be some kind of special award to Karen Ignagni for getting so many wrong in so few words!

Coda: One thing I didn’t know about Ms. Ignagni before googling her is that she used to work for the AFL-CIO. Well at least she knows how to pick a winner!

So for the final post on the theme of the uninsured and how messed up our health system is, I turn to the pages of the New York Times which shows that the taxpayer (or as Don Johnson calls us — the "market customer"!) is trying to get WalMart to not dump the cost of its employees’ benefits onto the public.  Maryland just passed a bill aimed at Walmart and supported by Giant stores, a local grocery chain which does cover its workers’ health care costs, insisting on better benefits coverage from Walmart and employers like it. In California a not-dissimilar ballot initiative just failed last time and will come again this fall probably. While I’m not in favor of an employer mandate (or for that matter employers being involved in health insurance at all) it’s clear that Walmart benefits from being stingy to its employees while its competitors such as Safeway and Costco which pay better wages and give better health benefits make less money.

And as everyone joins in a race to the bottom, the number of jobs that have health insurance attached dwindles, and the number of those uninsured or falling on to the taxpayer’s plate increases. For those without insurance and not poor enough for Medicaid, the individual market beckons like a Siren attracting a ship onto the rocks. The individual market sucks, and for many  examples of how, see the comments to this recent post.

Part of the reason the individual market is such a mess is the the aggressive underwriting behaviors of the plans reprensented by Karen Ignagni at AHIP.  She has a letter in the NY Times today attacking Krugman’s column in which he opposed private health care.  It’s an incredible piece.  She manages to make more straight factual errors in three paragraphs than I would have thought possible. It’s so bad that that I actually wrote a letter pointing them out to the Times. If they don’t publish it I’ll do a longer version here next week. But her overall point is that what’s important is to debate some more…..anything than to solve the problem.

Cover the uninsured week continues (mostly by chance here at THCB), as I don’t hold much hope in changing anyone’s mind in our current political impasse and imbecility. You might want to check out the huge number of comments to yesterday’s post — particularly one from Don Johnson that veers close to Lord of the Flies territory in terms of "you’re poor, sick and stupid?  Well you should have got educated and gotten rich". However, I don’t really have the stomach to tear into the conservatives on this issue any more.  They’re at once morally wrong, economically illogical, and seem to have mythical interpretations of the facts. On the other hand, The Industry Veteran does have the stomach for it:

Your colloquy with Don Johnson reminds us that for conservatives, the chimera of the market is an article of religious faith.  Never mind that what they call a
market lacks many of the necessary elements required for labeling some activity
a market. As long as their perfervid perceptual grid can label a phenomenon as
non-government and afford someone the opportunity to make a pile of dough,
conservatives will slap the sacrosanct market label on it.  Now if substantial
government activity, such as buying, selling and deciding who else can
participate proves necessary to the existence of this putative market, that
doesn’t bother these Thomist marketers.  Whatever they deign as a market is
virtue, the rest is sin.

If logical rigor has nothing to do with what
they call a market, and if they remain untroubled by the fact that US health
care possesses the shortcomings of markets and non-markets, it is only fair to
ask what is the sine qua non whose presence calls forth the blessed
appellation of "market" upon some shabby activity. I maintain that for America’s
medievally fixated conservatives, profit-making is this indispensable quality.
If the system in question is one that most observers might call communism,
organized crime or government-managed capitalism, that matters not a fig to Mr.
Johnson and his erstwhile colleagues at the Wall Street Journal‘s
editorial page.  Henrik Hertzberg recently referred to the Journal as
the church newsletter of the non-evangelical right wing and Mr. Johnson is at
least a deacon in that deranged parish. Profit-making provides their road to
eternal salvation.

Now profit-making is the caloric of this pre-modern
thought process.  It is an ethereal fluid whose presence and quantity can be
judged only by the enlightened clergy. This means if friends of Mr. Johnson and
his fellow seers judge that profits in some system flow to people who lack their
favor (e.g., commissars or made men) while remaining beyond the reach of people
in whom Johnson sees the divine light (e.g., Pfizer, Amgen or Medco), then the
activity loses its market designation.  Even if the divinely inspired Pfizer and
Amgen possess many of the same compelling powers as the netherworld government,
their presence hallows the activity into market status.

As people with a
religiously closed mind, Johnson and his compatriots are beyond the reach of
rational argument.  Evidence and logic cannot persuade them.  They transvalue
values to make good into evil, sin into virtue.  Quite frankly, I don’t think
they justify the time or effort required to rebut their nonsense.

So there’s been lots of back and forth in both THCB and Don Johnson’s BusinessWord about the uninsurance issue. Take a look at my comments alone to understand some of the issues involved.  And randomly enough it’s "Cover the Uninsured Week".  The irony of Orrin Hatch, a crypto-fascist from the wonderful state of Utah, being one of the Senators kicking off the week is just too delicious to forgo a mention. But the real issue and the reason to care is that, if you don’t have access to health insurance, your care and your health will be worse. In fact CDC data show that millions of uninsured adults forgo needed treatment for chronic health conditions. And of course who pays when they do show up for the treatment they need when these conditions have got worse? They do with their pain and those of us who are taxpayers or insured pay with our money.

Meanwhile Don fails to answer my question about what’s the difference between subsidies for the uninsured and more taxation, other than saying that universal insurance would not answer the question for the poor and the uninsured!!  That’s just ridiculous and is patently untrue.  If health care was free at the point of use, people wouldn’t not get it for cost reasons nor would they be beholden to huge debts because of it — those are by far the two worst symptoms of uninsurance. But he does raise the real politik situation when he says that:

What is the greater good here, take care of the 93% of Americans who
are insured today or the 7% who are uninsured for a year or more? I
think I know how the insured and their representatives in Congress will
vote.

And that’s the problem. So long as the majority (actually only 80%)
perceive their plight to be divorced from the minority, and no one
gives a tinkers cuss about the poorer 20%, we end up with what we
have.  Of course in reality we’re all mostly getting a worse deal than
we perceive and we’d be better off financially in a universal system that had built in cost constraints. So we are not seeing a "greater good". But then again hiding information from us is what the system’s all
about.

So yesterday I poked a little at Don Johnson from the Businessword in an article called What’s wrong about Don Johnson? Like the sporting gent he is, Don has replied in kind. So please go over there and read it first, then come back.

As is his right (after all I had called him mean) Don was somewhat feisty in his post.  I’m not going to get into the rights and wrongs of invading Iraq, other than to point out that it showed that we could as a nation come up with $100bn a year  if we felt it was important. I’m not ever going to comment on Don’s lack of understanding about what it means to be left-wing–after all he didn’t have the benefit of a Cambridge education on the subject and I did! I’m not even going to say much about his desire to get all those uninsured immigrants out of the country, although for a guy who runs a parenting magazine I assume Don knows something about parents employing cheap labor as nannies– but suffice it to say that the illegal immigrants are not flooding over the border to get cheap health care (although the Canadians are seeing that phenomenon to a minor extent). I’m not even going to ask Don to explain how the government by definitively regulating the price and purchase quantity of something in a particular way when pressured into it by a strong lobbying group (in this case raising doctors fees under Medicare) is creating a "market" when the determination of price and quantity by buyers and sellers without the interference of a third party is the hallmark of a market, as understood by generations of free-market conservatives who railed at government interference from FDR’s time onwards.

Instead I’m going to pose a simple question for Don to answer. He claims the problem is that a relatively small number of people (some 7% of the population) are uninsured for a full year or more.  That is roughly true.  But what Don doesn’t mention is that over 80 million people or more than 25% of the population are uninsured for up to 4 months in a two year period. Furthermore, once you are uninsured, if you have a chronic health condition becoming insured again is very hard and very expensive. But let’s ignore all that and let’s ignore the hordes of Latin Americans overrunning our country and stealing those $4 an hour jobs from the Americans queuing up to pick vegetables and work in meat packing plants.

Instead given the current state of the market for the individual in which family insurance can run up to $1000 a month for those without health conditions, how does Don propose to enable (and force) poorer families and sicker individuals to buy insurance without giving them a subsidy (i.e. taxing someone else)? And how is that taxation different than what I suggest we need to get to universal (and compulsory) health insurance?

Krugman’s series on health care continues in the NY Times and no doubt Don Johnson (over at BusinessWord) will be fulminating over this too. Don got a little offended when I called his stance mean. Don is a sensible guy and understands health care well, even if we disagree on on policy and politics.  So what do I mean by "mean".  Let’s ignore the fact that Don thinks that moderate social democrats like Krugman and Uwe Rhienhardt are the hard left — any observer of real politics would be giggling at that one.  I mean have they seriously suggested nationalizing health care delivery? No. Let alone nationalizing steel, autos, oil, and even agriculture.  (Yup, Don, that’s what the "hard left" from Lenin to Bevin did.  By his standards FDR was a Bolshevik).  But let’s look at Don’s opinion:

"I guess it’s ‘mean" to advocate regulated free markets that:
1. Help us have the lowest unemployment levels and lowest income taxes.
2. Give people who take the time to become educated, find rewarding jobs and seek out health care providers they like the freedom to spend their money on health care, if they think that’s important.
3. Try to minimize the role of centralized governmental planners who’ve never successfully created a health care system that cares for everyone in the country and makes everyone happy.
4. Give everyone incentives to earn the money needed to buy the best health care they can afford.
5. Not force wage earners to pay for the health care of strangers who could buy their own insurance if the politicians weren’t so good at giving everyone else’s money away in exchange for votes of the unthinking left."

The problem with this rhetoric is threefold. First, even if one accepts that we have "regulated free markets" in the rest of the economy and all those commies in Europe, Canada and Japan don’t, no one can seriously maintain that health care is a regulated free market like, say, buying groceries. It fails all of Adam Smith’s sniff tests for being in a state of perfect competition, and any serious student of the subject only has to read another Princeton hard lefty Paul Starr to know that the combination of vigorously pursued professional hegemony and third-party payment has left us with a system run by providers of various types, mostly for their own benefit.  So health care isn’t a regulated free market and people aren’t in a position to "spend their money on health care, if they think that’s important" the way any rational economist would understand–even if the vast majority of people didn’t have third party payment to cover that spending — which they do.

Second, Mark Pauly, a health care economist who is in Don’s camp wrote a hysterical piece in Health Affairs a few years back suggesting the reason we were so inefficient in our health care spending and spent so much on it, was that we were so efficient in the rest of the economy —  and could therefore afford to act like drunken sailors when it came to health care. I never understood why just because we had (apparently) lots of money to spare because we are a rich and productive nation, we should spend it all on a very inefficient health care system rather than, say, on Frappuchinos, education for first graders, or invading foreign countries which don’t have anything to do with us. There is no rational connection between the overall economy and how we choose to allocate resources to health care.  How we allocate resources to health care, and how much we allocate, is largely a political question. It’s directly political (in the 50% that the government pays for) and indirectly political in how (in order of importance) the government treats the taxation of health benefits, how it controls the industry’s pricing and capital spending, how it encourages its citizens to allocate their resources, and how it allows lawyers to persuade doctors (and doctors to persuade doctors, and drug companies to persuade doctors) that more care rather than less care is better. What any of that has to do with overall productivity in the economy escapes me. Finally while it may be a nice idea that health care is a luxury good that consumers will buy on the margin in preference to other luxury goods, that is not how we’re buying it yet and won’t be for quite some time.

But the third issue is where I call Don mean. Politically we have a straight choice.  We know that the costs of the health care system fall disproportionately on the poor and the sick.  And we also know that access to health insurance coverage is lower among those groups. Suggesting that people could voluntarily buy health insurance but just aren’t doing so is in my opinion total BS, and appears to be backed up the the opinions of America’s employees who are desperate to maintain their health benefits from their employers. Further we know that those without health insurance struggle mightily with the costs of care, and many more of them are in trouble than their equivalents in other countries where their access to coverage is subsidized by those people paying those high taxes that Don obsesses about (something else that needs to be refuted in another post).

You may recall that in the last couple of years we’ve had the ability give big tax cuts to the rich, and to spend nearly $100bn a year invading Iraq. The money that went on either of those political initiatives would have easily covered expanding health insurance coverage for those at the bottom end of the social ladder. In general you’re either for this or you’re against it.  And I think that, knowing the consequences of not having insurance on the health and wealth of those without it, to take the "against" position is mean.