Yet Clinton understands, better that practically any candidate, that we must rein in health spending. I look forward to seeing the details of her plan.

Maggie-

THANKS!

All the serious candidates are talking about the imperative of health care cost control. This of course freightens citizens who come from a "more is always better" mentality.This mentality backfires badly in medicine.

Prevention- both individual and institutional- will free up $ for those who have non-preventable conditions which we have obligation to treat.

I hope Hillary can combine her interest in childhood education with her health care reform plan. Believe me they are related. She knows that.

I'm looking for courage from her.

Dr. Rick Lippin
http://medicalcrises.blogspot.com

All of this knowledgeable and concerned commentary leaves out one basic fact. When insurance companies provide medical insurance, 20-30% or more of the dollars go into overhead and not into paying for health care.

In California, where I live, Arnold proposed that 85% of insurance go into premiums and the insurance companies fought it.

Cut out the insurance companies, go to Medicare for
All. Medicare spends 3% on overhead. It seems like a simple solution.

Why a flat tax? Why not force higher income peoplt to pay a progressively higher pecent of their income for their health care?

Education is also supported by taxes and young couples with kids don't pay more taxes than old grandparents. This and social security simply imply that health care should be a government provided service. This also shows the inappropriateness of cut throat insurance companies as providers of a basic services.

If health insurance is to be provided through inefficient and greedy to the extreme insurance companies, why not have our fighting forces run solely by private companies? I can see one advantage in the latter, they wont go to war; it's too expensive.

Dr. Rick, mandates have nothing to do with cost control, and will do nothing about prevention. I agree with you about prevention helping to contain costs, but cost control is not the problem; private profits is the problem.

Something has to be affordable, and cost control is an issue, only if you have to pay for it.

Efficiency of production, and cost control, are different things.

I write software, I use software; I don't buy software. Any kind of software I need or want is inherently affordable and usually readily available - because it's free, and freely shared. Any kind of software I need or want, I can write myself if I can't find it. And it's easier for me to give it away than to sell it, I've found from long experience. Selling software doesn't work for the typical software developer; it has only worked for the rare exception of a developer who is also a first-class capitalist; few of us are both of those things.

Selling health insurance doesn't work either, albeit for different reasons.

Lots of people do just fine without having to pay directly for software; the basic model works great. And the model has been applied to health care, everywhere in the industrialized world but the US, and it works great there, too. It can control costs; but more important, it improves efficiency, judging from the empirical evidence of these examples, not just the psychological speculations of religiously blinded capitalists.

But don't software developers have to get paid? Yes, for something, but not for direct software sales; the two are different issues. Well more than 90% of the world's software is not developed for sale at all, and its developers. if paid at all, are paid for their time, not for their work product, nor do they receive any sales revenue from that work product. So we software developers, clever folks that we are, finally got a clue that we'd do better sharing our work product amongst ourselves, than having to be cheated and limited by someone else's perverse notion of private property.

If the government just funded software developers, we'd not all make as much as Bill Gates has, but we don't anyway. But the world wouldn't be locked into the monopoly it's locked into now, where software is concerned. The problem isn't so much how we'd get paid, as why Mr. Gates' monopoly gets paid so much for so little, and thus manages to prevent so much of the world from using all this free software that's around, and that could be even better, if more were able to use it and contribute to it more freely. Financial costs can be illusions; psychological; not real at all. Real costs are entirely different things.

Prevention, cost control, and mandates, if they're related, are only related from a capitalist's perspective. But not from mine.

I didn't expect much from Clinton, but this sounds like something the GOP would propose to co-opt real universal health care. There is no reason for such a system except as yet another cave to the Norquist-level loonies who think taxes are the devil's work. I hope the early reports have it wrong. If not I'm going to have a hard time voting Dem in the general election, should primary voters repeat the "electability" mistake.

Innovation in the system of education itself is not the appropriate measure of its quality.

Innovation by those it educates, well, that's another thing, and it's more to the point.

I was educated in public schools. I have a Ph.D. in computer science. I have written, and still do write, every kind of software you or anyone else uses, from lowest level firmware to device drivers to OS kernels to communications protocols to database engines to window managers to GUI applications to ... Hopefully, you get the idea.

I know the most intimate details of the innovations that are now part of your daily modern life. Do you?

I have innovated, put simply. And I was educated in public schools.

So were most of those who have innovated, in scientific and other disciplines, not only in the US, but in all countries on this planet.

Maybe you think a socialized educational system doesn't work. Maybe it just didn't work for you. Don't just extrapolate from your nose, look past it for real evidence.

I mostly agree with you, Howard, but you're off my point, which didn't make so explicity, I suppose.

I'm also largely self-taught as well. But I'm not at all entirely self-taught, and not privately taught for the most part (I graduated from 1 private university, but 2 public ones). And I've done as much as anyone I know who was privately taught. I know plenty of folks, for example, who attended private primary and secondary schools.

But like you, and most other literate adults in most countries of the world, I attended public schools.

Educational effectiveness, and metrics for it, are a tough issue. But anyone who would suppose that education is not a good enough thing that society shouldn't try to educate everyone, at public expense, i.e., that societies would be better off leaving individuals to be entirely self or privately educated, if at all, is not a rational person, in my opinion. That person would effectively have us less well educated, by and large, than we are, despite the rational idea that the more broadly educated a society is, the better it is as a society.

So I'm not about the details here, nor is someone who would suggest that public education isn't at all effective. I'm about the big picture, and the truth of that big picture really should be more obvious than some would suggest.

Hillary has taken more money from the insurance companies than any other Presidential candidate, Democrat or Republican. Of course she will not cut out the insurance companies.

We are in agreement, I believe, that it is a social good that every citizen be educated to his or her full potential. Unfortunately, with pop solutions such as NCLB, many of our public K-12 schools, especially the ones with the least home support, are using increasingly less effective methods.

Let me tell a tale or two from high school, which may illustrate some dangers of overcentralized control. Just as there were strong differences among high schools I attended, I want there to be opportunity for healthcare providers, using evidence-based medicine, to use different approaches. "Socialized medicine", as opposed to socialized medical finance, offers a danger of overcontrol.

I spent one year in a high school in Towson, MD, and the other three years in one in West Orange, NJ. Both had excellent reputations, but the former, which I attended as a junior, had a principal who believed that students could feel positive about just about every day at school.

My grades were poor in New Jersey and excellent in Maryland, not all the schools' fault -- family issues and such. Now, in the New Jersey school, "gym" consisted of the non-varsity being divided into teams, given a ball appropriate to the season, and told to go amuse themselves while the "coach" socialized with the "team".

In Maryland, the physical education teacher -- note my differing terminology -- started the term by saying he was making a commitment to each of us. He would change the activities fairly frequently, and his commitment was to find at least one athletic activity at which each of us would be proficient and enjoy. He also promised to improve our physical condition. That was the only good grade I ever got in physical education, and the only time I remember being cheered, by my peers, for an athletic performance.

In New Jersey, there was extreme rigidity on having one's notes graded, not being able to make up missed quizzes, etc. New Jersey had some weird graduation rules, and I barely made it not because of a lack of knowledge of history, but because of missed history quizzes.

After being in college a bit, I visited my history teacher, who was the department chairman. After all, he had graded me harshly, and I thought he might enjoy learning that with an assortment of advanced placement tests, I had, while nearly failing his course, managed to get 12 semester hours of college credit in history. Actually, I placed out of my entire first year.

So returning to the big picture, the key policy element is universal coverage and universal funding of healthcare. That doesn't mean centralized direction of healthcare, although there certainly need to be centers of excellence, and best practice guidelines (as opposed to rigid protocols).

--
Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

Sure, Public education works great for people who can efford to live near good schools.
American education system as well as American health care system TODAY leave poor behind.

Yeah, but Hillary's plan is like being REQUIRED to pay for private school for your own kids and also pay for public education for the poor.

She's going to coerce everyone even those only marginally able to afford health insurance to buy it and then she's going to tell them that they also get to pay the premiums for the poor. How willing do you think they're going to be to pay the premiums for the poor? Instead, they're more likely to say "if I have to pay, they have to pay" even if they can't afford to pay.

What's the alternative? Compare it to other public services, where there may be multiple tiers. Take fire service. IIRC, there are 9 or 10 levels of rating for fire departments, with adjustments for housing density and such. The basic level of building fire insurance is based on department rating.

Putting in smoke detectors gets you a better rating for the building. Putting in a sprinkler system gets a lot better rating. In like manner, there can be a basic level of coverage, perhaps with adjustments for verifiable preventive behavior. In the Federal plan, there's a Catholic option, similar to most plans but that has a little lower premium because it won't cover abortion, sterilization, or contraception. I don't know if it covers what the Church considers heroic and futile end-of-life care.

In residential areas, it is impractical to have subscription-based fire service, because if a building with no coverage burns, it can easily set the adjacent covered ones on fire.

Perhaps an even better example is public health. There tends to be more public health expenditure for tuberculosis control in poor areas, because that's the highest incidence of this contagious disease.
--
Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

A good base to work an estimate from might be what Medicare costs are for coverage if you aren't on a Medigap or Medicare Plus and you haven't paid into the system long enough. Of course, that is an elderly group. But it shows your guess to be low. Current Medicare coverage premium value is $503.50 per month!

It's $410 per month for Part A (inpatient hospitalization) to those who haven't paid into the system long enough. For this charge, just like everyone on Medicare, you still have to pay a $992 deductible for the first 60 days of hospital, and much more after 60 days!

Plus it's $93.50 per month for Part B (eligible physician services, outpatient hospital services, certain home health services, durable medical equipment.) I believe everyone on Medicare has to pay this somehow, if not charged directly, someone else is "paying" it, like the plan you are on. This has plenty of deductibles and/or co-pays, too.

Source, more info.: Medicare Premiums for 2007 at the offiical Medicare site.

Of course, that is an elderly group.

As Yossarian said to the Doc, "That's some "Of  course" that "Of course." 

the new Clinton plan will mandate that everyone buy insurance

PEOPLE--GO SEE "SICKO"

Please.

Michael Moore makes it crystal clear at the beginning of the movie that he will not cover uninsured people in the film, he will only include PEOPLE WITH HEALTH INSURANCE.

And then he exposes the whole HOUSE OF HORRORS that the health insurance industry has brought the American people.

They have people on their staffs whose ONLY JOB is to find a reason, any reason, to DENY medical claims. One woman was denied because she had not reported a previous YEAST INFECTION.

The principal mission of health insurance companies is to DENY CLAIMS so as to INCREASE THEIR PROFITS.

This whole plan of Clinton's is BOGUS.

HRC has been given $1,472,151 by the HEALTHCARE INDUSTRY since 2000.
http://www.opensecrets.org/politicians/allindus.asp?CID=n00000019

Rx for huge government subsidies to the insurance industry:

"the new Clinton plan will mandate that everyone buy insurance, with the federal government providing subsidies for those who cannot afford the premiums."

What is the point of having insurance companies involved anyway? What do they do? Their only role would be in collecting premiums and denying claims as much as possible, since they are "for profit" operations, with stockholders' interests held above those of the insured.

Michael Moore's "Sicko" makes clear the inherent flaws of using private insurance companies. If private insurance companies are involved, there will have to be regulation and oversight of the service providers and of the insurance companies.

The only thing that makes economic sense is a single payer plan in which the government itself collects taxes and pays the claims; there will also have to be oversight of the service providers if the government pays the claims.

Why is it that government provided health care plans work in Canada, Europe, even Cuba, and they cannot work here?

Hillary's plan is "DOA".

Edwards puts out a health care plan that might actually address the situation. Within the week, Kucinich declares that Edwards did not quite go far enough. Three days later, Obama puts out a watered down version of Edwards plan and the media goes wild proclaiming accolades. Over three months later THE Great and Glorious Clinton grants us the grace of the Clintonian plan and I am supposed to fall over myself and sacrifice goats or something to the Clinton?

I thought this President thingy was about . . . What is that word Clinton is devoid of . . . Oh yeah . . . Leadership. The window for this conversation passed three months ago.

Hoppy,
Under your plan HMO's could still deny reimbursement, correct? Or will they be required to pay all claims.

Well, I'll salute you, hoppy.

Many of the issues involved in administering a single payer plan would be either the same, or would benefit enormously, from tapping the expertise of people now working for private insurance companies.

For that matter, there is a great deal of expertise and knowledge among people who now run private insurance companies that could and should be brought to bear in setting up and administering at the government policy level a single payer plan.

davai,
You're wrong because it doesn't matter if 50 million people have health insurance or 100 million do--the insurance companies thrive on denying payment for medical claims, and the best way they've found to deny claims is through pre-existing conditions, of which they use hundreds.

A question about these purchase mandates... how are they enforced? If somebody refuses to buy a policy, are their wages garnished and are they just put into a plan? Are they fined? Denied medical care? Tossed in jail? I've just never gotten a good picture about how this works.

thosethingswesay.blogspot.com

If healthy and younger people are able to opt out of the system the system will collapse as only ill, the most costly, choose the system. Turning health care insurance, not healthcare, into a welfare entitltement is to doom it to failure.

This is what happened to Social Security. State workers were able to opt out of it and then in order to shore it up states had to participate in social security. Democrats need to be slow in ridding the nation of insurance companies and insurance agents who helped defeat previous efforts and health insurance reform, and provide a lot of jobs. The goal should be a long term expansion of Medicare so that like Social Security Medicare is a universal social insurance program.

Daniel A. Greenbaum

JohnOneOne

Yes Micrsoft has monoploistic practices as does AMA and state medical license boards.

But Microsoft just lost case this AM and AMA lost to chiropractic many years ago.

Giv Ed Rendell of PA "Rx for Pennsylvania" gives much more autonomy to nurse practitioners, physician assistants and midvives etc.

I am for putting ALL Health Care providers on a salary with incentives to keep patients healthy.

Dr. Rick Lippin
http://medicalcrises.blogspot.com

There's a whole other thread in the role of mid-level providers. Add pharmacists to the list as well. when I think of the average retail pharmacist, I can only be amazed that someone with (now) six years of training does mostly low-level technician functions. Seeing the difference with clinical pharmacists in institutions, where their knowledge is really used, is a striking difference.

Indeed, one area where pharmacists are being used in a striking manner is in some group medical practices, where the pharmaceutical salespeople ("detail men") no longer can call directly on the physicians. Instead, they are seen by the pharmacist, who reviews their latest and greatest, and then has scheduled briefings with the physicians to alert them to true advances, me-too drugs, drug warnings, and drug economics. In all fairness, some pharmaceutical reps do provide substantive information, including relevant peer-reviewed materials, and some know the very delicate balance between pushing a drug for an off-label indication, and, when the clinician brings up that indication, doesn't flog their drug but helps acquire information from research.

One thing troubles me, Rick, and that may be a function of my own personality. Physicians vary all over the place in the way they deal with knowledgeable patients, not just patients that focus on healthy lifestyle but that have the knowledge to, say, be involved in a drug choice. Over time, that rarely is a problem for me. I have found, however, nurse practitioners more resistant to my suggestions. At NIH Clinical Center, for example, the physicians deal with the subspecialty research issue of the patient in a study, while an NP handles the rest of continuing inpatient care. I've had NPs be very resistant to a diabetes control regimen that works for me, not even on issues such as drugs, but when I get the most informative blood glucose measurements timed in relation to meals and insulin injection.

I agree totally with your focus on prevention and patient responsibility. There needs to be some changes among professionals to deal with patients that take that responsibility.

Of course, when I talk about patient knowledge, I mean real knowledge in a proper context. Several direct-to-consumer prescription ads I've seen over the last few days, I'm sure, caused my blood pressure to skyrocket. It was amazing how they stayed just inside the line of outright lies, and managed to suggest that a potent drug, still with very valid uses, was something to "ask your doctor". In reality, the drugs had significant risks, and were things for one's doctor to prescribe only after several others had failed.

Apropos of salary, I had one endocrinologist that had been part of a general internal medicine group, and under time pressures so they could live with the reimbursements they got. He changed into a solo practice (endocrinology only), where he could see patients for the amount of time he felt appropriate, and also could be a community faculty member for students and residents seeing patients with him in a office environment. He tells me he makes a lot less money, but is much happier.

--
Howard

*equal opportunity offense to both extremes*

"Those who cannot remember the past are condemned to repeat it" [George Santayana]

There aren't the votes in Congress for real medical care because Hillary isn't the only one getting big bucks (our money) from the "health-care" industry. Any congress-critter voting for single-source funded healthcare can look forward to an empty envelope.

If insurance companies are the heart of the problem with health care, why is their "expertise" of interest?

I think the unstated issue is that there is not the political will to liquidate the insurance companies. If they are treated like regulated monopolies, does it really matter that much if the state actually takes over their ownership?

If one wanted to truly figure out how much Hillary is pandering to health insurance contributors vs. how much intention she has to work towards an eventual single payer system, it would behoove reporters/investigators to see what she has changed from her opinions in the past and then confront her on it, ask her why she has changed, what is the reason, where is the intent headed. Given that all the major candidates are talking an evolutionary process rather than enacting single payor tomorrow, it would probably be a helpful thing to do.

wikipeda has a good entry, where it quotes her with footnotes:

In 2005, referring to her previous efforts at health care reform, Hillary Clinton said "I learned some valuable lessons about the legislative process, the importance of bipartisan cooperation and the wisdom of taking small steps to get a big job done."[19] Again in 2007, she reflected on her role in 1993-1994: "I think that both the process and the plan were flawed. We were trying to do something that was very hard to do, and we made a lot of mistakes."[24]

For a cover article of The New York Times Magazine, April 18, 2004, she wrote "Now Can We Talk About Health Care?" (That's a permanent free access link rather than the subscription one wikipedia has.) How does what she said there differ from what she is proposing now? Why has she decided on the plan she has? Ask her, please.

After all, this women has the entire complicated health care system in this country in her head probably like few other people. She's a valuable resource if one could just get her to be honest about her eventual intent. What is she actually telling the health insurance industry about its future? Is she leveling with them as well? One would think at least health insurance workers would want to know.

The obvious way to reduce costs is to get rid of the middleman (insurance companies) that generate costs simply so they can make a profit.  How many people in doctor's offices do nothing all day except

1.  Find out what hoops they, and the patient must jump through to get care paid for

2.  Fill out hundreds of forms, fax them in

3.  Re-fill them out when the insurance company rejects them over a minor clerical mistake

4.  Explain and re-explain to patients the ins and outs of their insurance companies' demands

Remember, the only way an insurance company makes money is to charge more than they pay, and they do that by refusing to pay for care, or by jacking up rates (oh, and not covering people who really need it)

What do insurance companies provide that is beneficial?  Absolutely NOTHING!  They are simply gate-keepers who suck money from people -- they do nothing that is constructive.

My own insurance company just sent me a flyer about some changes to prescription coverage.  I didn't read the whole thing because it was 6 pages long and I knew it wouldn't matter anyway, because they have me over a barrel.  One thing did catch my eye:

They will not cover the cost of any medications that promote reduction of smoking!

Yes, your health care dollars are at work -- for insurance executives only!

Jan

Lotta good people working in a bad system. Many know it is rotten but have families to feed and bills to pay just like the rest of us. I believe many would jump at the chance to make a different, far more humane system work to serve the broad public good, for the simple reason that most people don't get up every morning to go to work rubbing their hands together and rejoicing at how they can help deny care to some poor soul, for the greater profitability of the company.

The people who work for private insurance companies administering claims know a lot about administering claims, which will be part of any single-payer financing system. For the most part, it's not the people working for private health insurers who are the problem--and I hope fellow single payer advocates won't demonize them.

I'll offer the following analogy. I bet a lot of folks here agree that Paul Bremer made a huge mistake with his de-Baathification initiative. He painted a broad brush and failed to realize that many joined the party because it was required for their job while privately detesting it and everything it stood far. He made enemies out of many people who he need not have, people who instead of contributing to destabilizing the country in the aftermath might have been able to help do the opposite.

Here's another little trick of theirs:  They will cover certain screening tests, such as mammograms and colonoscopies after a certain age.  Once you have breast cancer or colon cancer, those tests are no longer considered "screening."  They are then "diagnostic," which comes under a different type of coverage with a much higher co-pay.

Makes me wish I believed in hell because it would give me great pleasure to imagine these insurance creeps burning up with Dick, George, and the rest of them!

Jan

Verily, Hoppy.

Politician's approach to the HEALTH CARE needs of the people is to make it all about increasing income for the insurance companies, not about addressing problems with the actual CARE.
The problems with Health Care is not even being discussed.
EX:
*** the Insurance Cartel's recent huge rip off of Medicare drug program.
**** huge price markups of drugs
*** lack of emphasizes on Wellness programs
( insurance rarely covers those costs).
ad nauseum.
Timing of the Insurance benefit plan co-incides nicely with the wave of baby boomers who are more likely to need more medical service.

Well, if you don't get car insurance, you get a huge fine, and your car can be taken away until you get it.  I don't hear too many people complaining about that.  Why?  Because if only half the people had car insurance -- and you did, but got slammed by someone who didn't, it would be YOUR insurance that would have to pay.  The common good sounds alot easier to understand when it is as simple as car insurance.

  For those who work it should come out of the paycheck, and employers would hopefully still contribute (the premiums should be less in a universal pool anyway).

But for those who manage to get away with avoiding having insurance, and later on seek to opt-in (once they are sick or injured) the premiums should be very high for them, as it is for seniors who delayed getting the Medicare Part B for their medications.

Jan

Are you against a progressive income tax for the same reasons?

Howard, Cville Dem, Davai Blue Bell

First, Davai quoted Howard describing how in the German system "Instead, the German system looks at costs by provider on a statistical basis (quarterly, IIRC), and audits the high-cost outliers" and asks a very logical question:

"Why don't  Medicare and insurance companies do this today?
Seems like easy hanging fruits."

The answer: lobbyists and campagin contributions. High-cost providers are  often very powerful providers. They make campaign contributions to Congressmen who, in turn, are reluctant to audit the outliers. You would think for-profit insurance companies would be willing to do it. But they have gotten so much bad publicity whenever they try to cut costs that they would rather just pay the high-cost providers and pass the extra cost on to us in the form of higher premiums.

Howard --what you have to say about pharmacists is very interesting. You're right, we could make much better use of them. And your description of the German plan serves as a reminder that other  countries have plans that are so much more rational.

Cville Dem (and others). I too would like to see the middlemen disappear. But if Medicare (or a Medciare-like public sector non-profit) insurer) is allowed to compete with for-profit insurers, I think the for-profit insurers will lose a huge amount of business and ultimatley the majority will wither away. See my post from this afternoon updating Hillary's plan. She would let people choose between the Medicare-like plan and private sector insurers.

Davai-- As Bluebell points out the heatlh of public schools depends on whether the parents in the community have financial resources and power. White flight did great damage to our public schools by taking many middle-class and upper-middle-class students (and parents) out of urban school systems. Meanwhile we foolishly (and very unfairly) let property taxes fund public schools. This means that schools in wealthy suburbs will get adequate funding, while schools in ghettos won't. My daughter has taught  first grade in a school in the Bronx for several years. She has to buy all of the supplies for the kids (paper, pencils, crayons etc.) plus bulletin boards and a rug for the classroom, paying for these things out of her own pocket. Often, she doesn't have  math books. And she buys dozens of books for the kids to read.

Her school also has mice and the occasional rat. The physical plant is horribly run down. None of the windows open--and they haven't been cleaned in years. I could go on . . .

Can  you imagine how hard it is to attract the best teachers and administrators to such schools? 

For a really good solution to the public school crisis, I highly recommend reading Richard Kahlenberg's work here