Category: health care Page 33 of 35

A heated argument is going on about the right health insurance model between those those who believe in a public option and those who believe in single payer.

Or perhaps I should say between those who are willing to take what they can get: public option; vs. those who want to hold out for what they consider the best option: single payer.

By way of reconciling what differences can be reconciled, let me ask a question of each side.

A Question for Public Option Advocates

Do you want to eventually have a single payer or a comprehensive system like the French have?  If not, why not?

A Question for Single Payer Advocates

Are you willing to fight for a public option which could eventually lead to single payer or a comprehensive system like the French one? If not, why not?

At this point what I’m seeing is both sides retreating into moralistic screaming.

The public option folks are saying: “It is better to save some lives than none, and if you single payer purists don’t support a public option which will save even a few lives, you’re responsible for those deaths.”

The single payer people are saying: “The public option is so watered down that all it will do is discredit real public reform, aka single payer.  You public option folks are settling for so little that the few lives you might save are outweighed by all the lives you won’t save and the damage to the chance at real comprehensive health care reform.”

Both sides are assuming the other side is operating in bad faith.  The public option folks assume the single payer folks just want to be pure rather than saving lives, the single payer that the public option folks are just sell-outs shilling for a bad bill.

But what I’m seeing, as someone with a foot in each camp, is that both sides are (mostly) sincere.

Now there is one group that can’t be reconciled.  People who want a public option so weak it either won’t survive, or can’t be used as the basis for a comprehensive system.  The usual suspects like Insurance company executives, for example.  But also some people in the Obama administration, such as Health Secretary Katherine Sibelius, the health secretary, who said that the plan would be drafted specifically so that it could never become single payer.

But for everyone else, for those acting in good faith, there should be some common ground from which we can work together. Let’s start by recognizing that the battle over public option vs single payer is a distraction away from what we could accomplish if we worked together.

United we stand a chance.  Divided, we will lose our chance at health care reform.

The most devastating critique I’ve read of the current public option comes from Kip Sullivan. What makes it devastating is that although he’s a single payer advocate, instead of attacking it from the point of view of single payer, he takes it on on its own terms—comparing the House bill’s version of the public option to the one originally proposed by Hacker:

• The PO had to be pre-populated with tens of millions of people, that is, it had to begin like Medicare did representing a large pool of people the day it commenced operations (Hacker proposed shifting all or most uninsured people as well as Medicaid and SCHIP enrollees into his public program);
• Subsidies to individuals to buy insurance would be substantial, and only PO enrollees could get subsidies (people who chose to buy insurance from insurance companies could not get subsidies);
• The PO and its subsidies had to be available to all nonelderly Americans (not just the uninsured and employees of small employers);
• The PO had to be given authority to use Medicare’s provider reimbursement rates; and
• The insurance industry had to be required to offer the same minimum level of benefits the PO had to offer.

What would this mean in effect?  123 million people enrolled, the ability to set premiums substantially below those of private insurers and the ability pay hospitals and doctors less than private insurers, leading to massive cost savings.

But of the five conditions, only  one is met in the new plan: requiring the insurance industry to offer the same plan.  Not a single other requirement of the original public option plan is met.  Not one.  As Sullivan points out, the public plan starts without a single enrollee and has to hire sales staff, negotiate contracts and so on, all while being required to pay back its start up costs within 10 years.

What advantage do you have over the private insurers that means you will be able to out compete them?  The only one I can think of is that you don’t have to make a profit, but that’s only half true, because of the requirement to pay back within 10 years, you effectively do have to turn a profit.

Go read the entire thing.  Sullivans’ argument is, in my opinion, strong enough as to be devastating.  I’ll be discussing this more next week, as promised, but Sullivan has said most of what I wanted to say and said it better than I would have. His argument about why the CBO scoring of only 9 million enrollees is either correct, or even overstates the case is of particular interest.

Yesterday Brett asked why I’ve become negative on health care reform when so many other bloggers aren’t.

Of course, it’s dangerous to speak for other bloggers, but I think the calculus which many are operating under is that if you get a bill with some sort of public option, and some sort of subsidies, some lives will be saved.  Something, in other words, is better than nothing. I also think that people need to believe.  Many bloggers worked really really hard to elect Obama, to get a House and Senate majority, and the that it can’t deliver on something so fundamentally important as making sure every American has the health care they need is something they just don’t want to believe.

Also most other bloggers are not fundamentally econobloggers and econobloggers who don’t buy the “TARP saved the universe” disillusionment started much earlier than for most other bloggers.   For me it started at TARP time when Obama pushed through Paulson’s highway robbery act  Then Obama hired Geithner and Summers as his key economic people.  So I started down the path of “no hope” a lot earlier than most bloggers.

I use the stimulus bill as my model for looking at healthcare.  As with the stimulus bill I think that the House draft bill is the high point.  I think this is the best bill we are going to see.  I think the Senate bill will be worse (Daniel reported last night, as I was writing, that the Senate bill probably won’t have a public option) and that it may well be worse than nothing even if a weak public option is in the bill. In particularly Medicare and Medicaid are being hit to pay for this, people will have deductibles on “non preventative” care (and maybe preventative by the time it gets through) and so on.  The Massachussets experience, which is the closest parallel, has not been good.

There is a counterargument, I made part of it the first day I wrote at OpenLeft.  The public option could drive out private insurance or at least drive costs lower.  Getting people into the system turns them into real patients and suddenly there are doctors and so on who don’t want to lose them, and that gives them a constituency, and above all, you do save some lives and help some people and isn’t that better than nothing?

I’m not a single payor purist, though I think the fact single payer isn’t even on the table is a terrible indictment of the system—however, I’ll settle for a good public option, or even a non-sucky one.  But I’m becoming convinced that any public option will either be too compromised, or non existent, and at that point, all that happens is you have slashes to Medicare and Medicaid, forced purchase of bad insurance, and through those purchases more money being pumped into the system.

Is forcing people to buy insurance the real goal?  The best way to make money, bar none, is to have government force people to buy your product.  It’s a wet dream for any industry, so if it’s going to be done, it has to be done right—it has to be very highly regulated and controlled with rates of return set like utilities.

Will it be?

(Addendum: Before I ride off into the sunset next thursday, I’ll see if I can pull together a post on what is required for a good public option.  One of the reasons I favor single payor is that it has many fewer moving parts. It’s easier to do single payor right than it is to do a public option right.  Not least because there are many different working models of single payer and variations.  Getting the public option right is very complicated.)

He who has the gold, makes the rules

The numbers on how much various medical interests have spent on influencing Congress and the Presidency make clear why health care reform keeps getting watered down:

..the data so far suggest that the second quarter has a good chance of reaching a new high for the health-care lobby. The industry already set records from January to March, when health-care firms and their lobbyists spent money at the rate of $1.4 million a day.

Impressive…  Is anyone on the side of good reform spending that type of money?

Of course they aren’t.  Healthcare in the US costs 5% more of GDP than it should.  That’s a lot of money, and there are a lot of people getting rich off that money.  They’ll do whatever they have to in order to keep the flow coming.  When you’re talking 692 billion dollars (give or take), well, what’s 1.2 million a day to keep the cash flow coming?

The fundamental truth of America’s Congress is that its first and most important function, when you take the time to look at the bills it passes, is to take money from rich special interests and then pass bills which favor them.  The same, I’m afraid, is true of the presidency.  Most of the 15 trillion given, loaned and guaranteed during the financial crisis was to the financial sector, and most of that was given by the Federal Reserve, which if it answers to anyone (questionable) answers to the President.  But even when Congress got into play it’s noticeable that they gave 700 billion for TARP but are now insisting that health reform be “decifit neutral”.  Likewise no one seems to mind giving lots of money to the military.

Interesting set of priorities.  Politicians seem to always be telling us how “protecting Americans” is their most important duty.  Which is how they justify spending money on a military which doesn’t seem to protect Americans from anything noticeable.  And by protecting I assume they mean “save American lives.”  This is odd, because health reform, properly done, would save those lives than anything else except massive reform of the way Ameiricans eat. But, unlike with the military, there isn’t a health-reform complex pushing to save American lives that is nearly as strong as the one pushing to keep the gravy train going.  So suddenly, saving American lives isn’t a priority.

This is a story I had missed.  It seems that insurance companies determined rates for “out of network” medical services by looking at an independent database run by a company called Ingenix, United Health Group.

But the way the database “independently” determined the going rate was by having insurance companies enter data on how much the rate was for given services.  And for a decade they systematically entered prices which were lower than the actual prices being charged by doctors.

The result was that patients would get a larger bill than expected, the insurance companies would redeem the doctors for less than expected, and often the gap would never be made up.  A win for insurance companies, a loss for patients and doctors.

Companies involved, include (but I’m not sure if are limited to):

United, WellPoint, Aetna, Cigna, GHI/HIP, Capital District Physicians’ Health Plan, Independent Health, Excellus, MVP Health Care, HealthNow and Guardian Life Insurance Co

They have all “settled” with NY Attorney General Andrew Cuomo’s office and promised to use a new, more transparent database as soon as one is available.  They have given 100 million to make the new database.  And, of course, none have admitted they did anything wrong.

Bottom line on this is that the amount of money they saved (ripped off) is almost certainly more than their “settlements”.  So the entire scheme has been worth it, especially since no one went to jail.  Just another cost of doing business.

This is how large american corporations operate.  Law breaking and immoral behaviour is simply a cost-benefit matter.  If the money saved by doing something illegal is more than the cost of doing something illegal (including legal costs), too many of them will do it.

I would suggest that the only things which would really get executives to stop doing these sorts of things are to either treat them as criminal matters (and send CEOs to jail) or to treat them as what they are: clear collusive action to use an oligopoly position to control prices, and break them up.  But the second is no longer possible after the Supreme Court ruled that actions which suggest collusion cannot be taken as evidence of collusion, overturning prior precdent.

And, of course, senior executives rarely go to jail for screwing ordinary people, let alone committing massive fraud (or half Wall Street would be heading for the hoosegow) so real criminal charges certainly won’t happen.

I wonder what other scams the insurance companies are running we don’t know about?  What other ways they are fixing the books?  Only a fool would bet they aren’t.

Lying about healthcare, indeed fear-mongering about healthcare, has ramped up as insurance companies attempt to keep their profits.  Those profits are created by a system where the US spends 5% more of its economy on healthcare in exchange for the worst results of anywestern nation.  To insurance company executives, their profits, their executive salaries, and their bonuses, are not just worth lying for, but also worth killing for—or at least letting people die.

The Shona Holmes Healthcare Hitjob

Case in point: Shona Holmes is the current poster girl for the liars slandering Canadian health care in an attempt to discredit reform.  Ms. Holmes alleges she was horribly endangered by Canada’s healthcare system:

Both CNN and McConnell made a big deal out of Shona Holmes, an Ontario woman who claims she was forced by Ontario’s health system to go to the United States for life-saving surgery for a brain tumour. She claims that in 2005 delays in access to treatment at home made it necessary to go to the Mayo Clinic in Arizona and pay $97,000 for her care.

Her story sounds bad, doesn’t it?  Except, of course, it’s a lie:

On the Mayo Clinic’s website, Shona Holmes is a success story. But it’s somewhat different story than all the headlines might have implied. Holmes’ “brain tumour” was actually a Rathke’s Cleft Cyst on her pituitary gland. To quote an American source, the John Wayne Cancer Center, “Rathke’s Cleft Cysts are not true tumors or neoplasms; instead they are benign cysts.”

There’s no doubt Holmes had a problem that needed treatment, and she was given appointments with the appropriate specialists in Ontario. She chose not to wait the few months to see them. But it’s a far cry from the life-or-death picture portrayed by Holmes on the TV ads or by McConnell in his attacks.

In other words, her condition was not immediately life threatening, and it was prioritized accordingly.  But Holmes didn’t want to wait behind people who needed care more than she did, so she went the US where she could pay out of pocket to jump to the head of the line.

Healthcare Triage: US vs Canada

Here’s the deal: both the US and Canada prioritize patients, and both engage in health care rationing.  In Canada health care is prioritized by how urgently a patient requires treatment.  In America, to a much greater extent, access to medical care is prioritized by how much money the patient has.  Someone in the US who was sicker than Ms. Holmes was forced to wait longer for treatment because Holmes was rich enough to pay $97,000.

A Personal Perspective on Canadian Healthcare

I should add that I have firsthand experience with how the Canadian system prioritizes treatment.  In 1993, at the age of 25, I became very ill with ulcerative colitis.  I was hospitalized, and put on very expensive drugs.  About a week after being hospitalized, the nurse watching me called in my doctors on a Sunday because I was deteriorating so fast—pain killers were no longer having any effect (i.e., high doses of morphine were not working), I wouldn’t let anyone touch me, and I was becoming delirious.  At about midnight, they wheeled me into the operating chamber and took out my large intestine.  While they were digging around, they found out I had appendicitis, and they took that out too.  It would have burst within 2 days, and in my weakened state, it would have killed me.

Unfortunately, one of the treatments for ulcerative colitis involves immune suppressing drugs.  My immune system basically shut down, my liver almost shut down, and I spent almost another 3 months in the hospital, riddled with extremely painful and crippling infections and other problems.  At one point I was on 9 drugs; one of them was an antibiotic so expensive that only a single doctor in the hospital could approve it.  My gastroenterologist called the treatment the equivalent of “pouring gold dust into your veins.” I wasted away, my weight dropping below 90 lbs.  I often joke that I was old young: I’ve used a walker, crutches and cane.

The Universal Healthcare Bottom Line

The ultimate point of my story is simple: I got the care I needed, when I needed it, and I never paid a single red cent.

Which is good, because I couldn’t have afforded to pay.  I was young and had very little money.  The kind of care I received, even back then, would have cost hundreds of thousands of dollars in the US.

If I  had lived in the US, my parents would have faced a choice between paying for my incredibly expensive treatment, or watching me die.  They were both old, and it would have wiped out their savings entirely and thrown them into bankruptcy, and frankly, I don’t know how they could have supported themselves.  My life, at that cost, would have had too high a price.  I wonder how many Americans have had to make that calculation.

But I survived, and neither I, nor my parents, was bankrupted.  In similar circumstances I doubt all of those things would be true for an American 25-year-old trying to survive the same medical condition in America’s health care industry.

Healthcare Rationing, American-style

I have had two American friends die in the last 5 years who would have survived if they had had fully covered health care. (Note I didn’t say health insurance, that’s not what people need.  They need health care.)

One of them died of the flu.  He didn’t seek treatment because of the cost of his insurance co-payment, and he was found dead.

Another had a heart condition, but didn’t know it, because she didn’t have health care, because she couldn’t afford it.  If she’d had health care, she would probably still be alive.

Both of those people are dead because of people like Holmes, and the people behind her.  My two friends are dead because insurance company executives want to keep their obscene salaries, and force Americans to pay more for health care than they should.

So What’s the Healthcare Reform Fight Really About?

Billions of dollars are at stake in the battle for American healthcare reform.  That’s the sort of money executives, and their lobbyists, and their bought-and-paid-for politicians are willing to kill for: to let you, or your friends, or your family suffer and die. Think of your dead friends and relatives as collateral damage in the fight for health industry profits; that’s how the insurance executives see them.