No pretending... I support single payer
Before addressing Jonathan's points, I will not pretend that those reading these posts do not understand the single payer model, as advanced by Physicians for a National Health Program. Simply, single payer national health insurance would automatically include absolutely everyone, would cover all reasonable, beneficial health care services and products, would be financed through an equitably-funded universal risk pool, and would introduce economic mechanisms to slow the rate of cost escalation and improve quality by reducing administrative waste and by realigning incentives to reinforce the primary care infrastructure and reduce detrimental high-tech excesses.
Those participating in this dialogue generally agree that reform should be targeted to achieve most of these goals (universal, comprehensive, equitable funding, efficiency, higher quality, etc.), but there is disagreement on the model of social insurance that we should try to achieve, and on the political feasibility of each approach.
We at PNHP believe that reform should be based on optimal policies (those in the single payer model), and that political feasibility should be established by fully informing politicians and the public about the implications of all policy options (admittedly, a monumental task, but not one from which we should shirk merely because it requires a major, concerted effort).
Now my comments will be limited to Jon's points (policies) with which I differ.
That a single payer system would "set prices" is a problem? The most effective cost containment measure of the managed care revolution was the setting of prices by the private health plans, and we are still living with that. No matter what system of social insurance we end up with, we will have some form of price setting. Do private plans really do that better? In their book, "Medicare Prospective Payment and the Shaping of U.S. Health Care," Rick Mayes and Robert Berenson make the point that "contrary to conventional wisdom and whole libraries of books and articles that point to managed care as the biggest 'change agent' in American medicine in the last twenty years - the private sector neither initiated this battle nor provided the critical innovation that transformed health care in the United States. Instead, it was Medicare’s transition to a prospective payment system (PPS) that triggered and repeatedly intensified the economic restructuring of the U.S. health care system." And, "Medicare payment reforms have empowered the federal government, making it similar to health care systems in other Western countries."
And efficiency? Jon asks if the government would allocate its dollars to maximize the public interest. As a financing mechanism, Medicare is certainly much more efficient administratively than private plans. And as far as allocating dollars within the health care system, Mayes and Berensen demonstrate that Medicare is far more efficient in determining where those dollars should be spent. Medicare financing requires continual refinement (e.g., SGR), but that is further evidence that the government can be efficient in health care financing.
And choice? Yes, we agree that single payer would provide greater choice of health care providers than the health plans with their restrictive provider lists. But choice of financial exposure? Jon concedes that allowing the healthy to opt out shifts the financial burden back onto the sick. But that is what you are doing when you allow healthy individuals to choose their level of financial exposure. You are allowing them to opt out of paying their equitable share into the social insurance risk pool.
And establish a floor of coverage? What floor? Basement? The floor just short of the concierge level? Specifically, what level of coverage would a government floor provide? Would it cover an elective hip replacement in an individual who is disabled due to advanced osteoarthritis? Or would it simply cover a walker or wheelchair? Once you decide that elective services of this nature should be covered, you really are supporting a floor that includes all reasonable beneficial services. It is true that a taxpayer supported system really shouldn't fund vanity cosmetic surgeries or penthouse hospital suites, nor should it fund a two million dollar cancer chemotherapy program that provides an additional three weeks of poor quality life.
And private insurers gaming the system? As long as they control the risk pools, they will game them. A universal risk pool would be the most efficient, though other nations use social insurance mechanisms such as sickness funds or post-experience fund transfers based on favorable or adverse selection. Insurers are now very busy shifting risk to patients, providers and purchasers, trying to limit their function to being primarily vendors of very expensive administrative services. The record shows that they're profoundly inefficient at that as well.
Though we all share concerns about those whose jobs would disappear, that can hardly be used as a reason to perpetuate this profoundly wasteful, private bureaucracy that actually has a detrimental impact on our health care delivery system. The single payer model includes transitional costs for job placement, retraining and other measures to ease the transition. "Transitional" is vastly superior to "perpetual" when it comes to the spending of taxpayer funds. And the disruption would be limited primarily to the insurance system as the improvements in the health care delivery system would be evolutionary rather than revolutionary.
For now I'll defer comments on political feasibility, perhaps responding later to Jacob Hacker.
This sounds like we might have significant differences, but actually we agree on almost everything - certainly on the general principle of health care justice. And the goals of Matthew Holt are so close to ours that I won't have to send my son to beat him up, even if he doesn't get some of the details right. In fact, maybe Matthew will join my son and me when we attend Jonathan's book event at Cody's in Berkeley next Thursday. We won't beat up on him, but we might have a comment or two.
(To explain the insider joking, our son, Steven, has offices near Matthew Holt's in San Francisco. Steven is a member of the business community who happens to be very supportive of health care justice. He doesn't beat up anyone, but he is co-founder of Riverbed, Inc.)
Don McCanne-
I read your post carefully and admire PNPH.
But I did not see the word PREVENTION- not even once- in your post.
Do you and PNHP have a position on prevention? Because to me it is a glaring ommission in your post?
Be Well,
Dr. Rick Lippin
Southampton, Pa
http://medicalcrises.blogspot.com
April 12, 2007 4:44 PM | Reply | Permalink
Prevention is paramount, for sure. I think PNHP would agree, right Don? It definately came up at a Boston forum this evening "Universal health care: paving the way toward a healthy society" with 5 panelists, followed by a great speech from the nat'l AMSA president, Jay Bhatt. A PNHP doc gave a great presentation (of course!:) on the panel and there seemed to be near-unanimity in the room of about 50 folks that SP financing was what we have to work toward in the U.S.to ever get quality universal healthcare.
Folks also agreed that the insurance industry is a primary obstacle in the way. What didn't get discussed was corporate america's control of our political processes--a crucial ingrediant to understanding how we'll ever win this fight and what it will take, etc.
Then at the end of the event a strange thing happened. I wonder if it has to do with asking people if they will go beyond agreeing that a SP plan is better, to asking if they will speak up in a setting that isn't full of allies and point the finger at the insurance industry as being the problem. Has anyone else had challenges in this way and how do you deal with it?
A community agency speaker on the panel who talked about "going to all the meetings of the new MA health reform board" and said that the new law does some good things and some not good things and that she was continuing to be a regular player in working on the law's implementation. During the forum she also said the insurance industry is the problem and that profit-driven motives are a big problem. The MA reform plan is built on the insurance industry! And she got offended when I asked if she is speaking up at all these meetings about these issues, because as it turns out she's not and doesn't think it's her place or necessary to do so.
How can we get people to understand that being willing to accept crap reform like the MA plan (yes, it extended coverage to those in poverty but we didn't have to create a mandate on everyone else to help some of the poor, did we?!!) and to be willing, even eager, to spend significant time and effort working to make the MA plan "the best it can be" is in effect a betrayal of doing what's right and instead perpetuates doing what is so very wrong? Or is this over-reaching?
It's a strange time indeed to be a universal hc activist in this state. There's a new NPR affiliate MA Health reform blog at http://blogs.wbur.org/commonhealth/
that seems more a tool of the insurance industry than a real blog... Lemme' know what you think if any TPM readers check it out. Thanks.
April 12, 2007 6:27 PM | Reply | Permalink
Dr. Lippin,
Everyone agrees with you that prevention is far better than management of preventable disorders. No contest.
But keep in mind that we are discussing a much more limited topic - financing of the health care delivery system. Prevention is a much more broad societal issue that involves not only our health care system, but also numerous government agencies, communities, schools, the private sector, etc. Our governmental public health services play a major role in protecting and improving the health of the community.
We support reinforcement of our primary care infrastructure, which is far better suited to apply preventive practices to the patient community. Preventive interventions and early management of chronic disease are particularly suitable services for a primary care medical home staffed by health care professionals (as opposed to disease-management administrative arms of private insurers). Studies of Barbara Starfield and others have demonstrated that a strong primary care base provides higher quality care at lower costs. It also helps to reduce inappropriate use of detrimental high-tech excesses, while enabling more appropriate access to beneficial, specialized high-tech services.
But a very large part of prevention takes place outside of the health care environment. Community design that encourages exercise is a role of local government authorities and the private sector that builds the communities. Healthy food can be promoted by government policies combined with responsible production by the food industry - from the farms to retail sales and food services. Schools can adopt programs designed to educate children on better health habits. The entertainment industry can increase its efforts to set better examples for healthy behavior. Transportation safety from highway design to vehicle design is important. Preventive interventions in the work environment are important. The list is endless.
Even if all of us do our best, illness and injury will still occur. So we do need a health care delivery system that can provide early interventions when possible, but that also will need to be there to provide medical management when illnesses or injuries do occur. It is the equitable and adeqate financing of this narrower component that single payer is all about.
April 12, 2007 7:08 PM | Reply | Permalink
Excellent.
It's also worth mentioning that high health care costs are a tremendous drain on the whole economy.
Increasing medical cost efficiency will unburden the economy: resulting in economic growth, and more jobs.
It's not a zero sum game.
April 12, 2007 7:44 PM | Reply | Permalink
That most certainly CAN be used to perpetuate the system -- by people who would lose their jobs, and many more people who could be induced to fear losing their jobs, and immensely more people who might fear competing with all tehse people to keep their jobs at their accustomed wage levels.
Like trade liberaliztion, SP could make a lot of people worse off, even as it makes the economy in the aggregate better off.
Don't hand-wave this obstacle away. You can get away with it in policy analysis fantasy camp, only to get reality-checked when you start playing keepsies.
April 12, 2007 8:01 PM | Reply | Permalink
You want to argue for perpetuating waste as welfare? Go ahead. Knock yourself out. Under present circumstances, that's a total loser.
For every one person fearing job loss due to medical efficiency increase, there's going to be several hoping to keep their job due to medical efficiency increase.
Besides, there isn't going to be any hardship resulting from fixing medical insurance. That's a bogus myth, a Big Lie. The type argument big insurance hopes to scare people with.
The economy will improve as a direct result of improving medical cost efficiency. Instead of wasting money into yachts and bureaucracy, we'll be creating jobs in services that improve quality of life, which then further spurs more growth.
Well be getting off the downward spiral and onto the upwards spiral.
The hardship is NOW. Things are going to get better when insurance is fixed to be less wasteful, and we get this yolk off our collective necks.
NOW is when high medical costs are putting tens of thousands of people out of work and burdening the economy, creating more poverty, and that directly leads to medical hardship.
NOW is when people are literally dying because they can't afford medical care.
You can't justify perpetuating waste. It's a lose/lose scenario. In the end everybody loses if it's not fixed.
The Soviets tried that with endless tractor factories, unwilling to adjust the economy to be more efficient. Look where the children of those factory workers are now. Maybe prostitutes and junkies.
By comparison look at Japan, SKorea, and Western Europe. Healthy, efficient, economies. They make most of our high tech consumer products, have higher job stability and quality of life, lots of labor, as well as professional workforce. They take more vacations, have higher productivity per hour, and they have lower health care costs due to single payer systems.
You want to argue for perpetuating waste as welfare? Go ahead. Knock yourself out.
April 12, 2007 8:26 PM | Reply | Permalink
Would someone else like to help kozmik understand what I actually wrote? I have less than zero patience with this form of less than zero response.
April 12, 2007 9:56 PM | Reply | Permalink
Since you have reading comprehension issues, let me help you:
April 13, 2007 12:45 AM | Reply | Permalink
You're calling my response lacking? Listen hypocrite, you have yet to substantiate any paranoid claim you've made.
You're claiming a backlash or fear of dislocated people outweighing the damage high medical costs are already doing. ABSURD!
Even even more ridiculous considering more efficient health care will actually promote job creation and a healthier economy!
The fact is: many people are already being dislocated because of high health care costs. That's only going to continue under the present system.
There are already more people at risk of losing jobs and seeing industries go bankrupt because of high health care costs, than the entire medical insurance industry employs. It's not health care workers in imminent danger, it's everybody else.
The math is against your argument, completely opposite in fact.
You're regurgitating one of the lamest Rt Wing talking points. Validating it either flags you as a Rt Winger or a self defeating paranoid.
Like I said, you're so wrong you think it's right.
April 13, 2007 12:53 AM | Reply | Permalink
Don- I really appreaciate your thoughtful response - but my blockquote of your words above is precisely the problem with this TPM Cafe dialogue.
Going on ad nauseum about how to finance an economically unsustainable "disease care" system is not addressing the fundamental dilemma of how to engage in compassionate and ethical cost reduction. This in the huge elephant in the room with us which this dialogue is not seeing?
My vision is a modified HR 676 with much more emphasis on both individual and institutional prevention
I would like to help PNHP achieve this
I am not about either blaming victims or proposing denying needed care to the ill.
Be Well and thanks again
Dr. Rick Lippin
Southampton, Pa
htpp://medicalcrises.blogspot
April 13, 2007 6:38 AM | Reply | Permalink
To RonK and kozmik - Maybe you 2 can agree to meet on the common ground you seem to share: concern about people who need gainful employment and the health of our entire ecomomy.
I agree with koxmik's perspective on this issue. I've worked "in the trenches" in all kinds of healthcare settings, in hospitals, health centers, detoxes, and home care nursing for 30 years, the past 15 of them as a master's prepared registered nurse.
We can make universal healthcare work. In fact the hardest part of getting from here to there is overcoming the big money corporate stranglehold on our public policy making process and its very unhealthy control of our political processes. Here in Massachusetts, as in most states, we've got horror stories to tell about this and we all know the probelm is much much worse on the national level. Our MA citizen's healthcare constitutional amendment is but one glaring example. See http://www.healthcareformass.org
With a transition to universal coverage using SP financing many if not most of the displaced workers can be taken care of by being offered positions, and new training as needed, to have gainful employment within the new healthcare system. And they'll actually get to do jobs that help people!!
We need folks who can organize health promotion sessions, do community outreach, triage calls coming in to healthcare facilities (when's the last time you called a doctor's office or clinic and actually had a caring human being directly answer the phone?!). All kinds of new jobs will be needed for the new focus on HEALTH rather than the current focus on treatment of disease.
Of course it will not be an easy task, but none of this easy. But it will be the right thing to do.
April 13, 2007 8:58 AM | Reply | Permalink
Ann -- I thoroughly support SP and believe it will be a major net plus for the US economy. kozmik's acid-laced misrepresentation of my view does not furnish any basis for discussion.
We'll find other occasions to discuss your view -- that neither realistic nor unrealistic fear of personal economic harm will present obstacles that require political problem-solving to make SP a reality.
April 13, 2007 10:09 AM | Reply | Permalink
“With a transition to universal coverage using SP financing many if not most of the displaced workers can be taken care of by being offered positions, and new training as needed, to have gainful employment within the new healthcare system. And they'll actually get to do jobs that help people!!”
How will SP achieve the large cost savings promised if the same number of people are employed?
April 13, 2007 10:27 AM | Reply | Permalink
PS- Don
Sorry-I gotta to get something off my chest.
Did you really have to end your good post with a plug for your son's for profit company?
Rick Lippin
April 13, 2007 1:23 PM | Reply | Permalink
(This entry is off topic, so most readers should skip past it.)
Well, no, I didn't. I just felt uncomfortable leaving unanswered Matthew's insider humor about my son beating up on him. Besides dispelling any thought that he might have pugilistic tendencies, I used that opportunity to address another point that has been mentioned frequently in the reform debate - we need the support of the business community. Thus I stated that he "is a member of the business community who happens to be very supportive of health care justice." I certainly didn't need to mention his company, but that I did so was not promotional. Most readers of these pages wouldn't understand what his technological products are anyway.
April 13, 2007 2:47 PM | Reply | Permalink
IMO, the ideal "destination" system is not only universal, it's non-intercessionary.
That is, your connection to health care finance is not threaded through assignment to a family unit (in transition, non-unique, or in dispute for some share of the population at any given time), an employer (likewise), or a political jurisdiction (likewise, in our mobile work culture).
Else, some of us will be caught in unnecessary policy cracks, selection fights, eligibility waiting periods, hand-off inefficiencies and stale paper, and some of us will avoid making logical life changes for fear of losing a good deal or falling into paperwork purgatory.
Unwinding these traditional attributions will take some doing, but should be an item of evaluation in any strategic plan, incremental or otherwise.
April 13, 2007 4:32 PM | Reply | Permalink
You're arguing that SP can be blocked because a few "sob stories" will derail it. Whether or not you claim to be pro-SP, that's a wet blanket, and a regular Rt Wing talking point. You can say you're pro-SP, but if you take a big crap all over it, people might have cause to wonder.
Secondly, your "worry" isn't even valid. It's totally backwards. Increasing health care efficiency will create jobs in large numbers and raise wages. The #1 complaint employers have is that health care is a huge burden that's literally putting companies out of business. How you claim to be pro-SP and not know this... is a mystery.
As I've already pointed out several times, there are already far more "sob stories" as you would call them resulting from high health care costs. People denied coverage. People losing their jobs and homes. People dying.
They already vastly outnumber any possible downside to improving the efficiency of health care.
It just boggles the mind. Again your "concern" is either paranoid and really misinformed, or regurgitating the memes Rt Wingers are trying to spread. Either way, it's just bogus and totally contrary to the facts.
You may as well argue Marie Antoinette is making a powerful argument for cake and will thusly outwit the masses seeking bread. That's not how the story goes.
April 13, 2007 6:33 PM | Reply | Permalink
I think that was already answered several times.
Much of the cost of medical care is just waste that could be eliminated with no loss of medical care jobs.
Drug prices for example, which are enormous and growing at about 12% a year, are almost all waste. You could cut their costs and lose no nursing and such jobs, and improve the quality of drugs on the market. Right now the incentive is for Big Pharma is to patent and market the most expensive and bogus drugs they can, basically sell snake oil. Big Pharma spends practically nothing on manufacturing and researching useful new drugs. What they do is patent redundant and expensive drugs to support Wall Street expectations and a huge marketing operation. Large buys and a more rigorous drug approval process would end that snake-oil game, and saving a LOT of money that presently just goes to Wall Street, no jobs.
The first thing to happen is that lowered medical costs from efficiency gains, and an increase in care quality once bogus procedures and harmful drugs are removed, will spur economic growth and create jobs. For example, a lot of families barely able to afford health care will be able to start affording good childcare.
It's a win/win, which is why every other developed nation has SP healthcare. It's just better, in every way.
April 13, 2007 7:01 PM | Reply | Permalink
Thanks Don,
Good luck and good health to you and your son.
Rick Lippin
April 14, 2007 9:17 AM | Reply | Permalink