Universal Health Care—Not As Easy As It Looks
For the past year, progressives have begun to talk about health care reform as if it is inevitable. After all, the polls show that the majority of taxpayers, employers and even most doctors want to see a major change. What’s stopping us?
I’m no longer as optimistic as I was six months ago. Recently, I spoke at a Massachusetts Medical Society Forum where what I heard about the Massachusetts plan made my heart sink. While everyone in Massachusetts wants health care reform, no one wants to pay for it. Those who are receiving state subsidies to buy insurance are enthusiastic. But uninsured citizens earning more than 300% of the poverty level are expected to purchase their own insurance. The state hoped that 228,000 of its uninsured citizens would sign up; as of last month, just 15,000 had enrolled. Many have decided that they would rather pay the penalty than buy health insurance.
At the forum, Robert Blendon, professor of health policy and political analysis at Harvard’s Kennedy School of Government, talked about what Massachusetts’ experience might mean for the national health care debate: “Massachusetts is the canary in the coal mine,” Blendon, who is also a professor at Harvard’s School of Public Health, declared bluntly. “If it’s not breathing in 2009, people won’t go in that mine.” If the Massachusetts plan unravels, he suggested, Washington’s politicians will say “If they can’t do it in a liberal state like Massachusetts, how can we do it here?"
I wrote about his speech on my blog (www.healthbeatblog.org). (See Oct. 19 post.) I’m not writing off Massachusetts; the leadership backing reform is strong. But it won’t be easy. And Massachusetts is a very liberal state. If it faces a tough road to reform, what does that mean for the rest of the nation?
Last week, I decided to ask Blendon some follow-up questions: Just what would it take, politically, to achieve national health care reform sometime in the next two to four years? How many seats would reformers have to capture in Congress? Is this likely?
Some observers say that if a reform-minded president hopes to succeed, he or she will have to ram a plan through Congress sometime in 2009. But health care is complicated; wouldn’t it make more sense for a new administration to take its time and explain what it is doing to the public, while trying to create a sustainable, affordable, high quality health care system?
Finally, what are the biggest barriers to reform? If major change proves impossible, what more modest back-up plans should a new president have in mind? What other health care legislation could he or she hope to pass?
I went to Blendon with these questions because he has had extensive experience plumbing the Mind of the American Public while conducting polls for the Washington Post, the Henry J. Kaiser Family Foundation and Harvard. And what he has learned is that, beneath the seemingly uniform surface of the polls, “the public’s views on health care issues are often more complex and conflicted” than they appear.
Moreover, while some people have immersed themselves in the intricacies of health care policy, and others are well-versed in the intrigue of American politics, Blendon knows both--as his cross-appointment at the Kennedy School and the School of Public Health suggests. And when I heard him talk in Massachusetts, I was persuaded, even though what he was saying was not what I wanted to hear.
Blendon understands “the political process.” And he knows that it is not rational. Democracy is messy. Success depends on winning hearts as well as minds; an emotional appeal can trump the most logical argument. And unlike the legal process, there is no guarantee that the political process will resolve disputes or end in agreement.
When I talked to him this week, Blendon began by elaborating on why he believes that in 2009, any new administration will face a “poisonous” political climate, making compromise on health care difficult.
“Whether we decide to stick it out in Iraq, or whether we pull the troops out—which I think we will—we’re going to go through a very painful period, like the period that followed Vietnam. Rather than returning to domestic politics,” Blendon predicts that the country will be mired in a debate about “who lost the war. Whoever wins the White House, there will be a huge split in this country about how the war ended.”
In the best-case scenario this could lead to a search for an issue that we can agree on. Couldn’t healthcare be that issue? Maybe. “But if the debate over SCHIP is any model,” Blendon warns, “it shows that it is not easy to find compromises on these issues.”
If Democrats win the White House, they are committed to doing “something large,” Blendon observes. But even if they win, he says, they won’t have much time to forge a grand compromise. In an ideal world, reformers would spend the first year of a new administration studying the problem, educating the public, and forging alliances that lobbyists wouldn’t be able to fracture. In the past I have written about going slow, and doing it right.
But Blendon is convincing when he argues that “there is no relationship between how you would think, analytically, about health care reform and how the political process works. That first year you’ll have six to eight months to get something done. By the second year, legislators start to worry about getting re-elected” (which makes them exceedingly risk-adverse.)
During that six-to–eight-month window, a wily president should meet with the leaders of the major committees, Blendon advises, to see if, behind the scenes, they can begin to strike a bargain. “Reformers need to ask ‘what are the points that are absolutely critical to various interest groups if we want them to find reform acceptable?’ You want many people to feel that they have had a major say. Then they should develop a very general plan.”
“This is what Mitt Romney did when he forged a plan for Massachusetts,” Blendon points out. “This is what Johnson did with Medicare. Of course, Johnson had the advantage of having grown up in the Congress. He had a sense of everyone there, and what was most important to them. And Johnson was pragmatic.
”Reformers should forget about finding a perfect solution," Blendon warns. “The very best plan for reform would be polarizing. Every interest group would oppose it, and it would never pass. What reformers need to do is to decide which groups they can bargain with. In Massachusetts they decided they could make a deal with the insurers. But reformers will need to work quietly behind the scenes,” he argues, finding concessions they can live with—or fix later. In other words, the operation needs to be covert, and it needs to be quick.
The critical issue will be how many seats progressives are able to win in Congress, he adds. “If Democrats took a dozen seats in the Senate and 20 in the House, that could give them a Johnson-like landslide,” says Blendon, referring to the historic plurality Johnson enjoyed in 1964. “It would be very difficult,” he adds. “Possible, but very difficult.”
Meanwhile, reformers need to remember that, beneath the polls saying that everyone wants a change, “the public’s view is more complicated. Middle-income people with insurance are risk adverse,” says Blendon. “Legislators need to be very careful about how they try to re-arrange coverage for the middle-class. Even if these people say they are dissatisfied with the present system, they think they have a lot to lose—especially if they haven’t been seriously sick and tried to actually use their insurance.”
Blendon is convinced that if a Democrat wins the presidency, he or she will attempt major reform. But, if that first strategy fails, a new president will need a back-up plan. Offering subsidies to states willing to experiment with reform could be a fall-back. “In the short term, if six states could show that it can be done, that might be a way to push the idea forward,” he suggests, “while at the federal level, Congress could vote to cover more kids under SCHIP and Medicaid.”
Looking for a second opinion, I asked American Prospect co-editor Paul Starr to comment on Blendon’s suggestions. In an e-mail, Starr wrote: “Blendon’s assessment of the prospects for reform seem basically right to me. If we could contrive to get universal coverage for kids out of an enlarged SCHIP, that would be a morally and politically significant step, which the new administration could legitimately claim as an accomplishment by 2010.”
Author of The Social Transformation of American Medicine, Starr understands what is wrong with our corporate health care system. And he remembers the last attempt at reform: “What has to be avoided is making a big proposal and coming up with nothing as in 1994.," he warns. "That would be demoralizing and humiliating for any Democrat; it would be crushing for Hillary. Which is why Republicans will do all they can to try to ensure that happens.”
That is my greatest fear.
Make no mistake I’m not giving up on national reform: I’m still hoping progressives may sweep Congress. But if they don’t, it could be easier to forge compromises at the state level where, as Blendon points out, the political pressure is “more diffuse. State legislatures are less politically polarized. They’re more pragmatic. In Washington, you have a huge set of ideological barriers.”
Moreover, when Congress passes legislation, it must, by law, provide a ten-year forecast of how it will fund the new law. In Massachusetts, they only had to show how they would pay for it over two years.
Still, a state solution is at best a short-term solution. And since states cannot run a deficit, funding will remain an enormous problem. Blendon reports that in California, reform is currently “stalled” on the question of how to pay for it.
In Massachusetts, he is more hopeful that the state may be able to overcome resistance. “But it will take time. You need targeted advertising. Young adults don’t think they need insurance: ads should remind them that they could be in a car accident. And you need moral suasion. You need signs in doctor’s offices saying, ‘by this date, you are supposed to have coverage.' I’m optimistic primarily because of the quality of the leadership in Massachusetts backing the plan,” Blendon adds.
If we don’t get national health reform in 2009, will progressive leadership emerge in, say, five other states ready and able to show that reform can work—without simply letting the lobbyists run the show? Time will tell.
Comments (125)
3 times poverty income isn't a lot of money so I don't blame people for risking the penalty and not signing up. There's no moral argument to be made against these people, either. They rightly think that the law shouldn't be telling them to fork money over to United Healthcare and they're kind of right.
The Mass. plan fails by forcing people to hand their money over to big, inefficient corporations. You've got to get rid of them to realize any savings and you need one big risk pool, too.
Of course, as soon as we go there, the middle class who get insurance from their jobs and either like that insurance genuinely or naively (probably a mix of both) get nervous.
Which is one thing I like about Hillary's proposal -- though it keeps private insurers in the game, it forces them to compete with a government plan that might eventually put them out of business. That's something only the federal government can do. We've got to trick the private insurers into marching into a slaughter.
thosethingswesay.blogspot.com
November 12, 2007 11:27 AM | Reply | Permalink
I'm with atrios. Send everybody a membership card. Let them use it.
If you want to phase it in, then start with everybody under 18. Raise taxes to cover the additional costs. The tax increases will be offset by reductions in premiums to people with kids.
Then drop Medicare eligibility to 50 years old, require everyone to buy some kind of insurance and float a federal catastrophic insurance plan with 2000 and 5000 dollar deductibles. Allow everyone to participate in the federal employees plan through direct enrollment.
The only thing that makes this complicated is that the participation of the insurance companies IS the heart of the difficulty, but politicians see some need to(read "get contributions to") protect them.
That's bad public policy. The insurance companies are the problem.
November 12, 2007 11:52 AM | Reply | Permalink
You certainly may be correct that the time is not right. But I think the idea that this is going to happen by some grand compromise is just plain wrong. Did the New Deal happen with a grand compromise? What we need is a reform movement with a real passion to elect politicians who are genuine reformers and genuinely progressive. We need people as zealous for universal health care (and other progressives ideas) as the neocons are for war or the evengelicals are for social issues. Do those folks start with the idea of compromise?!
Instead we have a national establishment that is risk averse to the point of paranoia and selects candidates who believe their role is to begin by surrendering each point to the opposition.
November 12, 2007 12:20 PM | Reply | Permalink
If we give up on the best plans before we even start the negotiating process we are left with plans like that in MA. It's failure is more of a failure of educating folks to push for the best. Cause third or fourth best will still be hard to empliment and maintain and they will not give the cost savings and sense of we are all in this together that the best plans offer.
November 12, 2007 12:30 PM | Reply | Permalink
It is not just the campeign contrabutions that come from the insurance industry that make it important. It is a large employer. The people employed by providers to fill out insurance paperwork is also high. Any plan that makes all these people loose their jobs will not be politicaly viable.
November 12, 2007 1:06 PM | Reply | Permalink
How long as it been since anyone bothered about the loss of manufacturing jobs? I can't count the number of times some blogger (and usually a "progressive" blogger) has told me all those union stiffs are a bunch of dinosaurs who better get over it and get on with it and stop whining.
November 12, 2007 1:06 PM | Reply | Permalink
Lesson could also be another we've heard before, that some things just can't be achieved at the state level, without enough compromises and limits that too many costs fall on government (which gets only the hardest cases), which in turn has less flexibility in budgeting. Indeed, the only thing I've really admired about the Clinton or Edwards plan is the idea Krugman has expounded that a public option will beat out the others and it'll just morph into a more secure plan. But in the meantime it could just crash instead unless private competition is ruthlessly regulated.
John
http://www.haberarts.com/
November 12, 2007 1:11 PM | Reply | Permalink
Vincente Navarro has said for years, that the greatest barrier to health care reform are big employers - insurance benefits are a form of employee control. How many people take jobs or stay in jobs because of the health care benefits provided?
November 12, 2007 1:24 PM | Reply | Permalink
It's so difficult and complex that only European countries are smart enough to do it. Is that what you're saying? The reason the MA plan runs into trouble is because it's not single payer. Corporate healthcare doesn't work. From what I understand the MA plan just forces people to participate in a system that's already broken.
November 12, 2007 2:45 PM | Reply | Permalink
Destor 23, Jay Acroyd, Bluebell, Dale JHaber, Larry Greater,BevD--
It's good to hear your voices.
Destor 23 and JHaber, I too very much like the fact that Hillary's plan (and Edwards) would force for-profit insurers to compete with a public program--supposedly on a level playing field.
That's the catch. As JHaber says, insurers would have to be tightly regulated, offering the same price to everyone regardless of whether they're sick or old, offering only comprehensive insurance--no Swiss cheese plans or catastrophic plans--otherwise older, sicker people will all sign up for the public plan and it will go under.
But Blendon is pointing out that unless progressives manage an exceptional (read historic) sweep in Congress, they won't have the votes to get regulation of the for-profit insurance industry. And keep in mind that these days, many Democrats are not that progressive.
The New Democrats of the 1990s went after the upper-middle-class suburban vote. And that vote brought many moderates to Congress who know that their constituents are worried about losing any of what they have. Bob Blendon says its the middle-class that is worried about losing something; here I disagree with him. I'd say it's the upper-middle class.
I don't think that most truly middle-class people (as defined by median joint income of $52,000 per household) are feeling that happy or secure with what they have. But many upper-middle-class people (defined as families with joint income of, say $70,000 to $110,000) do have pretty good insurance (or at least think they do.)
They are afraid of real health care reform. They don't want to see the system cut waste so that we can afford to insure everyone. They don't want Medicare (or private insurers) to tell them that it they want a second MRI , a "cutting edge" $10 million procedure that has never been proven to be effective , or a drug they saw advertised on TV, they'll have to pay for it themselves.
(Drug-makers advertise on TV when they can't sell the product directly to doctors because there is not enough evidence that it works. Did you ever notice how when a film isn't doing well at the box office, you start seeing a lot of ads on TV? Same phenomena. The companies only spends the big bucks for TV ads because they have to.)
And these moderate Democrats are backed by the for-profit insruance industry. Think Connecticut and the initials J.L.
Blue-bell--I, too, am very frustrated with how risk-adverse our legislators seem. But I should say that I borrowed the phrase "grand compromise" from Paul Wellstone, the late, very left and very honest Senator killed in a plane crash. I recently corresponded with a woman who knew Wellstone very well and talked to him about healthcare a few weeks before he died. He also thought that change should come at the state level. (Then again, he came from a progressive state.)
I'm sorry to say it, but yes, there was a lot of compromise involved in the New Deal. In particular, FDR compromised with Southern Governors and legislators who insisted that the New Deal be segregated. In the WPA white workers and black workers did not work side by side. FDR didn't want to lose Southern Democrats. For the same reason, FDR refused to support an anti-lynching bill.
Some thirty years later LBJ decided that he was willing to lose the Southern Democrats in order to support civil rights legilsation. But of course LBJ made many, many other compromises along the way. Blendon's point is that you have to decide which group you are willing to compromise with.
When it came to Medicare, LBJ decided to compromise with hosptials and doctors and essentially cut them a blank check. (I tell the story in my most recent post on www.healthbeatblog.org about national health reform. )
BevD--I agree that, for certain wealthy corporations, health benefits represent "golden handcuffs." Though that is not as true as it once was. Even at the wealthiest corporations, health benefits are not what they once were. (Unless the company is unionized. )
Jay Ackroyd-- Your suggestions are interesting. I particualry like rolling Medicare back to age 50 and letting people buy Medicare (with help from their employers if the employer now helps them buy private insurance.) But conservatives realize that this would open the door to "single-payor" healthcare. Many moderates (including Democrats) are against single-payor because the people who voted them into office do not want to find themselves in the same boat as everyone else. They would prefer to be in a tiered system because they are wealthy enough to feel confident that they would be on the top tier.
Larry Greater--You are right--, Congress is not going to vote to eliminate the private insurance industry. One reason is jobs. Another is campaign contributions.
Finally Dale wrote: "If we give up on the best plans before we even start the negotiating process we are left with plans like that in MA. It's failure is more of a failure of educating folks to push for the best. " Dale, that's what my heart says. And I've been saying that for a long time. But listening to Blendon, I realize that you also have to count the votes in Congress. AS I said in the post, I'm not giving up on major reform. And I'm holding out hope for a Progressive sweep in Congress.
But I now think that the new Democratic president should also have a fall-back plan. Paul Starr is right--if he/she tries for something major --and fails--he/she will lose much of his/her political capital And Republicans will try to lay the trap.
November 12, 2007 2:49 PM | Reply | Permalink
Naggie, nice to see you, too. I have been looking at Health Beat, although not as regularly as I should, just not commenting.
John
http://www.haberarts.com/
November 12, 2007 3:15 PM | Reply | Permalink
One path to universal health care is always ignored. That is to make Medicare a universal program, covering everyone. Medicare does not cover 100% of the medical expenses, especially not in high cost of living states, so it leaves an opening for the insurance companies to make money with supplemental insurance. That is an advantage.
Once we get universal Medicare coverage, we can start increasing the value of that coverage until supplemental insurance is only needed for plastic surgery, weight reduction, and other elective procedures. But, that still leaves a corner for insurance companies to make some money.
I don't see why this is not a workable method to arrive at our goal.
Hoppy in Sacramento
November 12, 2007 3:24 PM | Reply | Permalink
Here's a possible strategy for Democrats when it comes to health care problems in the US: ignore them. At a certain point, health care in the US will become so expensive that a majority of voters won't be able to afford it. THEN you'll see an opportunity for reform!
All you have to know about the plan in Massachusetts is that Romney backed it. It's just another way to shovel cash at health insurers, a state-wide analog to Bush's phony prescription drug "benefit."
November 12, 2007 3:58 PM | Reply | Permalink
Maggie,
Thank you for your response.
I agree with the distinction you make between the upper middle class interests and middle classs interests. Democrats need to do a better job of directing messages at both. In Minnesota, Republicans have lost ground in several upper middle class communities including Rochester home of Mayo Clinic. They've lost because of quality of life issues on health and education. Upper middle class voters are generally highly educated. You can appeal to them on the importance of a quality health infrastructure. I don't care how rich they are in Texas, when George Sr. wanted his hip replaced he came to Minnesota.
But I disagree with you on insurance. President Reagan and President Bush came to MN because of the Mayo Clinic. They didn't come because it's the home of United HealthCare and the obscene compensation given to their insurance CEO's. And if you are an upper middle class Minnesotan you know you're a short drive from the best and you also know that the only thing blocking the road is your insurance company making you go through hoops before you get it. When BCBS decides to do a "tiered" system on hospitals and conveniently places all the children's hospitals and Mayo in the tier they don't routinely provide, upper middle class folks can figure that game out too.
Democrats need to work harder and get more confident at making common sense arguments. When our bridge fell in the river (due to lack of attention to public instrastructure) at least the people who fell in were within about a mile of a level 1 trauma center. In one case, it was an 8th month pregnant woman suffering a severe brain injury. Both she and her child are alive because of it. Yet many of those injured found that their insurance was insufficient to cover weeks of hospitalization and months without income.
And what does right wing radio do? Vilify the victims who were guilty of doing nothing other than driving home from work on a public highway. How dare they mention that their insurance was insufficient! But that kind of argument only sells to the know nothings. To others, you can appeal to the common good. Democrats should stop being afraid to do that.
November 12, 2007 4:38 PM | Reply | Permalink
Right, I agree with that part as being the core problem. Efficiency and preventative care isn't increased. So you have the same dilemma with a lousy short-term cost/risk/benefit scenario for poor people, which prevents any overall longterm increase in efficiency. And because the system is still so inefficient it's impossible to allow wealthier people to help subsidize HC for poorer people, and enjoy secondary benefits such as increased community prosperity, at the same cost as they're already paying. Which then results in a long term lack of preventative care and long term inefficiency which hurts everyone.
The problem with the Massachusetts system is the botched way they implemented it which has all the problems and none of the benefits.
November 12, 2007 4:49 PM | Reply | Permalink
And it will be more than offset by an increase in preventative care to avoid the most costly medical expenses, as well as the increased risk pool, reduced buck passing and paperwork by insurance companies.
The conversation needs to be about the overall economic and cultural costs to a society of the uninsured and unhealthy, who avoid preventative care, post natal care, regular checkups and nutritional health for children and adults, and so on, until they're stricken by serious illness and chronic poor health, becoming an economic and cultural burden to everyone.
It may not cynically be in the short term interest of a small business or poor individual to pay for health care for themself or employees, figuring that the overall system won't improve and they'll just have more bills.
But it's in the interest of all businesses to collectively insure everyone, to improve the entire system by improving preventative care, which then lowers medical bills, and improves public health and the health of their employees and neighbors for secondary benefits to the culture and economy.
If we really want a "Shining City on a Hill" and a "rising tide to float all boats" then universal HC is the way to do it. Tens of millions of uninsured, a lack of preventative care for adults and children, rampant obesity, chronic illness, and expensive medical procedures after disease has set in, those are hurting all of us directly through higher insurance premiums and corporate bureaucratic waste and cost externalization, as well as indirectly through the many costs to our society and national achievement.
November 12, 2007 5:38 PM | Reply | Permalink
Maggie,
I'm sorry to see that you seem to have become stuck a false dilemma and are contradicting so much of what you've said before. Particularly you seem to have embraced recently the notion that wealthier people are going to lose if they help subsidize the poorer people's health care. That's a misconception that needs to be overcome, not reinforced or taken as insurmountable.
Again, if this is falsely portrayed as class warfare, then sure it will fail.
If on the other hand it's correctly described as a system which will increase overall efficiency, to allow more people to have healthcare, and most importantly preventative care, for the same cost or less than affluent people are already paying, and with all the added secondary benefits to society and especially families and children, then it can and should succeed.
And of course major political change is necessary for a major political change. But this is also a rational, moral and economic change with great benefits to everyone throughout society, and long overdue. It's less radical than either the New Deal or the Reaganomics.
That's also disappointing to hear you reinforcing that meme. There does not need to be a loss of jobs. In fact, there will be a shift in jobs from many unhealthy corporate bureaucratic type jobs whose main purpose is to externalize costs and maximize rent, towards job creation in more healthy economic growth areas including services like healthcare and nursing jobs, recreation, and so on.
The large number of unpleasant, unappreciated, and low paid clerk type jobs, often in hostile environment such as insurance deniers and debt collectors, are an unfortunate product of our present system of wasteful, counter productive, and frankly "evil" medical insurance, and the economic and cultural viscous spiral it's contributing to.
We could be redirecting those resources to large numbers of quality jobs, in life improving services, and benefiting by a net economic growth tied to a net improvement in public health, a virtuous circle.
While the ceiling is virtually limitless, the bottom draws near.
That is another false premise. They're already paying for it themselves, either out of pocket, or through high premiums, and know that. Furthermore, there is nothing about universal single payer insurance to prevent them from continuing to buy pro-rated supplemental insurance for second MRI, as they do in other developed nations, at or below the premium they're already paying in a less efficient system.
November 12, 2007 5:39 PM | Reply | Permalink
Only thing I would quibble with is this bit:
Bob Blendon says its the middle-class that is worried about losing something; here I disagree with him. I'd say it's the upper-middle class.
I don't think that most truly middle-class people (as defined by median joint income of $52,000 per household) are feeling that happy or secure with what they have.
Purely anecdotal, but thinking of a few family members in that income range, their health insurance is extremely important to them, and it's taken some wrangling to secure it.
They might not feel that happy or secure with what they have, but I would say they are very, very skeptical that the government could provide them with something better.
A plan that they feel threatens what they already have in return for something that experts claim will be better -- doesn't matter if the case is made via reasoned arguments, emotional stories, statistics, or yodeling -- will not sway them.
November 12, 2007 5:49 PM | Reply | Permalink
Re: The people employed by providers to fill out insurance paperwork is also high. Any plan that makes all these people loose their jobs will not be politicaly viable.
The insurance companies can switch from actually issuing policies to simply administering them. This is already a very profitable business. The people who actually do the real work at insurance companies (niot the marketing people or the excessive numbers of executives) will still be employed (though maybe not by their current employer) as the work they do still will need to be done.
November 12, 2007 5:57 PM | Reply | Permalink
Re: Which is one thing I like about Hillary's proposal -- though it keeps private insurers in the game, it forces them to compete with a government plan that might eventually put them out of business.
I don't see that happening (private insurers going out of business) for the same reason public schools, though free, have not put private schools out of business.
November 12, 2007 5:57 PM | Reply | Permalink
But for many large employers the cost of those benefits is getting to be unsupportable and there are other ways to keep and attract employees: higher wages, better retirement plans, more flexible schedules etc.
November 12, 2007 6:04 PM | Reply | Permalink
Re: They don't want Medicare (or private insurers) to tell them that it they want a second MRI , a "cutting edge" $10 million procedure that has never been proven to be effective , or a drug they saw advertised on TV, they'll have to pay for it themselves.
Private insurance plans, even "very good" ones already have quite a track record of telling people "No" and I very much doubt that the upper middle class, or even the upper class, is spared this response. However people with money can afford to pay for a lot of things on their own if the insurer balks. And that is where you have to be careful. The 1993 plan forbade people to pay out of pocket for covered (but denied) services. Any new plan must allow this "security blanket" option, as well as the option to purchase private coverage.
November 12, 2007 6:06 PM | Reply | Permalink
It's not always clear-cut what should be elective. There is quite a bit of new data, of which the specialists are trying to make sense, of the relationships among obesity, diabetes, and relatively newly identified classes of hormone-like substances. One of these hormones appears to be generated in a part of the intestine that is remove in a particular weight-reduction surgery, not the most common form.
Preliminary data indicates that losing that piece of intestine causes loss of a secretion, which appears to cure type II diabetes. This is all very preliminary.
There are new classes of drugs for diabetes that, in simple terms, don't either reduce insulin resistance (the mechanism of Type II diabetes), cause the secretion of more insulin to overcome the resistance, or simply add more insulin. Instead, they seem to regularize a variety of metabolic features that are contributing to the diabetic pathologies, and also frequently cause a reasonable limit in the desire to eat, and may have even other mechanisms by which they induce weight loss. I have a new study sitting in my in-box that I haven't read yet, but deals with interaction of multiple receptors that seem to affect not only insulin resistance, but dyslipidemia (think (wince at term) "bad cholesterol."
The data are not at all conclusive, but should an operation that reduces weight, but also seems to cure -- not control -- diabetes be elective?
You may well be making the distinction between cosmetic and reconstructive plastic surgery. Breast reconstruction after mastectomy or lumpectomy is increasingly a standard of care. Plastic surgeons are usually the experts on wound healing, scarring, etc. There are cases, however, where a psychiatric disorder objectively seems related to some aspect of appearance. Which of these should be elective?
No, a cuter nose doesn't count. Some years ago, in an attempt to help some breathing problems, I had nose surgery that involved breaking the nose to get access at some of the more distant areas. The surgeon can put the nose back together as it was, or, without any real effort, reshape it. It was hard to get approval from the insurer, who was intent on it being a cosmetic procedure, until I got a supervisor and said "Look. I may have a big nose, but it's my nose. I want it put back the way it was before the surgery. Can we get this thing moving?"
Alas, the procedure did not particularly help the breathing problem. It's done under a local anesthetic, but I will testify that listening to a surgeon hammering on your nose until it goes *crunch*, although painless, is not my idea of a recreational medical procedure.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
November 12, 2007 6:08 PM | Reply | Permalink
.> The 1993 plan forbade people to pay out of
> pocket for covered (but denied) services.
Can you give us a pointer to that section? My understanding is that the The New Republic article "No Exit" claimed that to be the case but the claim was false.
sPh
November 12, 2007 6:21 PM | Reply | Permalink
They're not going out of business. They would be in the business of supplemental care packages to meet any need at any price according to market demands, and perhaps on the customer service side of providing a fairly high ceiling of universal base coverage.
Which is how other developed countries do it, cognizant of how and where market competition functions best.
November 12, 2007 7:19 PM | Reply | Permalink
That's a bogus meme. Those jobs stink, are anti-growth, inherently inefficient to the consumer, and easily offshored.
They'll be offset by more and higher quality, economic pro-growth jobs, such as medical technicians and clerks actually providing health care rather than denying it, which are also more domestically rooted physically in doctor's offices.
November 12, 2007 7:28 PM | Reply | Permalink
A good point.
How people choose to spend the benefits of a more efficient single payer system, should be up to them. If they want to buy more supplemental insurance, or remodel the kitchen, it's up to them.
And if they choose more medical insurance for second MRI or such, the medical insurance industry will be happy to sell it to them.
November 12, 2007 7:35 PM | Reply | Permalink
Sure, and lack of exercise, driving, and fatty foods in huge quantities has nothing to do with it.
The funny thing is that my intestine starts secreting hormones to create fatty tissue whenever I eat a lot and don't exercise, and the opposite is also true. Which has become especially apparent since tracking in a spreadsheet my weight, body fat and muscle mass, exercise habits and motivation levels, and nutrition.
Regardless, more efficient HC Insurance will allow more people to be healthier, and those who aren't to still get the medical attention they need at more efficient costs.
November 12, 2007 7:39 PM | Reply | Permalink
Maggie
As you know I remain optimistic. Why?
Amost 15 years has passed since Hillary botched her and Bill's 93-94 run at reform. In the 15 years things have gotten MUCH worse.We are paying more and getting less and the waste and corruption has become increasingly transparant to the payers- citizens,big business and federal and state governments.
Note above I said big business (except of course the $2 trillion dollar health care-woops disease care- business) That is very important because they own congress right now.
This issue has ripened despite the constipated and fearful federal politicians.
US citizens in large numbers are fed up especially with big insurance companies who immorally make profits by denying healthcare and who make even the well insured jump through excessive hoops.
We remain an international embarassment as you know.
Be Well,
Dr. Rick Lippin
http://medicalcrises.blogspot.com
November 12, 2007 7:42 PM | Reply | Permalink
One of the reasons we haven't seen any progress on health care (to name just one critical public issue among many) is that the folks who "know" have been in charge. All the reformist "experts" and gurus are so closely wedded to the system that exists that they can't get anything done of any real significance because they don't even consider those actions that would produce real reform. Why? Because it would create too much controversey and conflict, etc... In other words, the battle will be very difficult and no one wants to risk their own position so the greedy interests remain in control ad infinitum.
It is increasingly clear that no compromise with the predatory health insurance companies will serve the public well or be anything but more and more costly to our people as time goes on and the present malignant system remains in place. The ONLY reform that is going to be worth doing and that can produce results for all Americans is throwing the insurance companies on the scrap heap of history. Socialize health care and do it in one fell swoop. If you don't take that approach you'll never get anything done. Make Medicare universal and expand it to take care of all medical problems. Let the insurance companies "compete" with that and let's see how long they last eh?
The very idea of "compromise" or striking a "grand bargain" is preposterous given that the nation is going to be relying on the Democratic Party for reform. Any such "bargain" or "compromise" undertaken by Democrats will mean only that the little people will get screwed even worse. Congressional Democrats seem to think that the word "compromise" means they must "capitulate". Collectively, there isn't one stiff spine amongst them. As a group, they are so utterly compromised they fail at even the most simple tasks where clear, obvious actions need to be taken and this occurs even when the public is lopsidedly in favor of their position! It is appalling. They have demonstrated this over and over and over again throughout this year.
It's hard to overstate the ineffectiveness of the Democrats on all issues at this point in history. It is not, however, difficult to see why they are so ineffective. One cannot reform a system that one is completely beholden to. You don't bite the hand that feeds you in politics and the dirty truth is that our Democratic members of Congress are, by and large, owned by the corporate interests they say they are willing to fight. Bah! They haven't invented an interest evil enough that the Democrats will fail to bow and scrape for.
The entire system is rigged in favor of everyone who has power, privelege and money which excludes about 90% of the American public. If we took the enormous sums paid out by employers and employees alike (as well as those paying for their health insurance on their own) and applied that massive sum to one, unified and uniform health care system, we would not need to be forcing anyone to pay "more" than they currently pay and we would be providing health care for all.
The Massachusetts Plan was doomed to fail from day one. Who in their right mind, acting rationally in an economic sense, is going to fork over huge sums to be insured if they aren't wealthy and aren't sick right now? It would be economic suicide. These compromises are just not viable. Only a radical departure from the for profit health care system we now have will ever meet the needs of the citizenry at an acceptable cost.
Until the time when we have a President with the guts to say that it's time to shut down the rapacious insurance industry, stop treating health care as another profit center for investors and focus on keeping Americans healthy we will never see any meaningful or worthwhile reform of the health care system in the United States. This will require that the Democrats do what they have been afraid to do now for about 35 years which is to go after the corporations and other greedy interests and fight for the average American man and woman and their families. I'm not going to hold my breath and I wouldn't recommend anyone else do so either.
November 12, 2007 9:04 PM | Reply | Permalink
But uninsured citizens earning more than 300% of the poverty level are expected to purchase their own insurance. The state hoped that 228,000 of its uninsured citizens would sign up; as of last month, just 15,000 had enrolled.
No; the state didn't hope. Doubtless, the state was told/advised of that estimate by experts who are either clueless or liars.
What voters will likely ask themselves makes the experts advising Clinton and Edwards any wiser or any more trustworthy?
November 12, 2007 9:52 PM | Reply | Permalink
I don't think that 70K is upper middle class.
In anycase, so called upper middle class doesn't want to pay more in taxes and get less health care benefits. They can't really afford "to pay for it themselves".
November 12, 2007 10:43 PM | Reply | Permalink
You really don't know much about health insurance jobs. Even in a pure single payor system, you're going need people to process the claims, determine authorizations and precerts, to answer phone calls and emails, maintain the software and IT systems, audit the financials, etc. You would not need adversting (although some community outreach would still be necessary) and you wouldn't need a lot of executive staff. Most health care payor jobs are necessary and they're not going to be lost (but could be shifted of course)
November 13, 2007 3:31 AM | Reply | Permalink
Right, which is why the support for a single payer might trend the other way. My question, though, is since your benefits package is part of your wages, which is how they cost it, then who is going to get the excess? Employers claim that their average contribution to an employee's health care is @7800.00 with the employee paying @3500. then who benefits from the lower payments?
November 13, 2007 6:04 AM | Reply | Permalink
They did not loose their jobs in one fell swoop. The loss of manufacturing jobs has been a death by 1000 cuts.
November 13, 2007 7:56 AM | Reply | Permalink
If health care is provide for “free” by the government, the labor costs go down for companies offering health care as a benefit. That savings would naturally be distributed as lower prices, higher profits, and or higher wages based on market forces, just as other cost savings are. I suspect that companies will have to pay higher taxes to pay for the free government health care so there would not be a lot of savings.
November 13, 2007 7:57 AM | Reply | Permalink
I am in favor of a single payer system. I think socialized medicine would be an even better program. If all was right with the world my job would not exist. I was simply poining out a concern that law makers will have to deal with. This is not a simple problem. There are as many people working at doctors offices trying to get claims paid as there are at insurance companies trying to deny them. Any healthcare reform that does not drasticly reduce these positions will not be saving the kinds of money that the system must in order to bring costs down. That level of job loss will efect the economy in ways that legislators must take into consideration.
November 13, 2007 8:02 AM | Reply | Permalink
Maggie,
Your post is framed within the context of health care reform not being inevitable within the next two to four years. I would just like to point out that if you go just beyond that time frame that there is one important difference between the Federal government situation politically and that of Massachusetts. The biggest generation in our history is set then to start accessing Medicare, while at the same time more and more big employers are loath to keep their retirees within their health care groups to give them gap coverage. This sets a different political and budgetary dynamic for the Federal government than for the one in Massachusetts. It would be interesting if as you investigate more on what the Clinton/Edwards plans entail and what they considered in creating their plans, how much they considered this dynamic and how they think it will play out.
November 13, 2007 8:53 AM | Reply | Permalink
What if they could chose from a much bigger pool of providers by switching to a government plan?
I think the scenario you describe in your anecdote is one of the main things that killed Hillary's first plan. But since then, I think a lot more people like those in your anecdote have had the experience of their employers changing their plans when the employer got a better deal from another insurer, thereby forcing people to constantly change doctors, not to mention co-pays, prescriptions, ways of getting services, locations of clinics, etc. That's a major deal for anyone that actually uses their insurance, i.e., has a chronic illness like diabetes, changing plans and providers all the time. My own anecdotes tell me that it's increasingly common for this to happen.
November 13, 2007 9:05 AM | Reply | Permalink
if we can send several hundred soliders to Iraq for a surge we can certainly do the same in health care.
To boldly go...
November 13, 2007 9:15 AM | Reply | Permalink
Many hospitals, and some physicians, compete by offering extra-cost amenities, which are not directly related to care. These might still be an area for the market, although it would not absorb the totality of a displaced insurance industry providing primary coverage.
For example, it is quite common for hospitals to provide a meal tray, at cost, to a visitor to a patient, allowing them to spend more time together. Within medical constraints on diet, both patients and visitors sometimes can order a higher-quality meal; these are often "gourmet" frozen dinners but considerably better than basic hospital food.
Another service can be on the borderline between amenity and actual care. Especially in pediatric hospitals, the room may contain a recliner that converts to a bed, allowing a parent to stay constantly with a sick child. If agreed-to by medical and nursing staff as appropriate, family or friends may, at the request of the patient, stay with them, much as would a private-duty nurse.
In a number of cultures, it is quite customary for members of the family to stay with the patient, and often to provide basic assistance with eating, bedpans, etc., as well as psychological support. This really helps when the nursing staff is overworked. I've done this a number of times, being diplomatic to the nurses (yes, I can be diplomatic) and being seen as a help rather than a hindrance. Once I've gotten to know the staff, I've very informally done more skilled things that otherwise would have given more work to the nurses, and improved patient care, such as unscrambling a tangled IV line or suction drain -- I don't recommend this unless you truly know what you are doing.
I agree, kozmik, that we need to take good examples from other industrialized countries; the German system has excellent features rarely discussed here. I don't want to rule out, however, support to the patient that is most common in less developed countries. Volunteer/family support is not unique to LDC's; it's close to the norm in Italy, which has excellent medical care.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
November 13, 2007 9:17 AM | Reply | Permalink
as an activist, I certainly agree but wars are ended when soldiers no longer want to fight-- that's why I think the military spends money on things like predator drones that mechanically kill.
at some point, I think universal care will come about because anything else would just be too complicated. at some point, I just believe that the boomers will break down the barrier and common sense will prevail.
To boldly go...
November 13, 2007 9:19 AM | Reply | Permalink
First, thank you all for your comments.
At the moment, I don't have time to reply to them point by point, person by person--but I will, probably this evening.
In the meantime, I'd like to make one point about my own beliefs, and then throw out some information. I STILL FAVOR UNIVERSAL HEALTHCARE. I WOULD LIKE TO SEE MEDICARE FOR ALL. AT THE VERY LEAST I WOULD LIKE TO SEE MEDICARE FOR ALL COMPETING WITH INSURERS ON A LEVEL PLAYING FIELD. AND, AS I"VE ALWAYS SAID THE ONLY WAY TO AFFORD MEDICARE FOR ALL IS TO CUT WASTE--i.e. OVERTREATMENT. ONE OUT OF THREE HEALTHCARE DOLLARS ARE WASTED ON UNNECESSARY TESTS AND TREATMENTS, OVERPRICED DRUGS ETC.
MANY PEOPLE WILL SEE CUTTING THAT WASTE AS "RATIONING." IT WILL TAKE A LONG TIME TO DO ALL OF THE RESEARCH NEEDED TO FIGURE OUT WHAT IS EFFECTIVE CARE AND WHAT ISN"T. AT THE OUTSET MEDICARE FOR ALL WILL REQUIRE A SIGNIFICANT TAX HIKE AND PEOPLE UNDER 65 WILL HAVE TO PAY FOR MEDICARE--IT WON'T BE FREE. THIS IS WHY IT MAY BE VERY DIFFICULT TO GET MEDICARE FOR ALL THROUGH CONGRESS DURING THE NEXT PRESIDENT"S FIRST TERM UNLESS PROGRESSIVES REALLY SWEEP THE ELECTIONS.
I don't like that fact, but we need to face it and think about it.
Next two points of information. First, many of you seem to think the insurers are the main problem--or that people in Mass. aren't buying the insurance because they don't want to give money to companies that pay their executives millions. As I said in the original post MOST HEALTH INSURERS IN MASS ARE NON-PROFITS. These are not for-profit corporations that are beholden to shareholders. Some of them are Very Good. This is not the big problem in Mass.
Secondly, on what most Americans, middle-class or upper-middle class want. It is, as Blendon says, very complicated.
Recently Ezra Klein (who many of you know as a left, progressive blogger) wrote about these polls:
"Kaiser, ABC, and USA Today just released a pretty expansive poll documenting the country's opinions on health care. The nickel version is that your countrymen are mostly liberal, deeply confused, and more likely to loathe the status quo than clearly conceptualize potential alternatives. Respondents said it was the third most important issue in the country, behind Iraq and the economy, but before immigration, gas prices, or terrorism. That's probably because opinions towards the system are so overwhelmingly negative: 80 percent are dissatisfied with the cost of health care in the country, and 54 percent are dissatisfied with the quality. So the system starts out with few friends.
"From there, things get more complicated. Nearly 90 percent are satisfied with the quality of care they received. Nearly 60 percent are satisfied with their costs. In other words, Americans believe everyone else's health care system costs too much and delivers too little [NOTE: in other words they think that other people's care should be rationed--but not their own. Polls show that people don't trust doctors in general, but they believe their doctor is very good and that they should have anything and everything he recommends.--MM] .
Ezra continues: " Meanwhile, a full 25 percent reported that they or someone in their household had problems paying for medical bill in the last 12 months, and 28 percent put off medical treatment due to cost. Of that 28 percent, 70 percent admitted that the delayed treatment was "serious." And remember, this is all in the last year."
MM: How can they say their own care is very good if they put off treatment due to cost, and sometimes the delay was serious? This is not rational, but most of us are not rational at least some of the time. And Americans like to feel that they are basically okay. (This is why so many working-class people describe themselves as middle-class.) They don't want to think that they or their family members are in danger of dying or becoming really sick if they don't get care. The don't want to think that their doctor might be greedy, or overtreating them. This is too scary. So they trust their doctor--while distrusting doctors generally. And they really don't want the health care that they get to change--
Ezra goes on to describe what the polls show about how people think the system should be fixed:
"Letting individuals shop around for the best prices they can get garners wide support, with 80 percent judging it some level of effective. Suggest far higher deductibles and low risk insulation, however, and watch that drop. 56 percent would prefer "a universal coverage program...like Medicare that is government run and financed by taxpayers" to the current system, but that number plummets if you ask about higher taxes, limited choice, or rationing. 70 percent support an employer mandate while a mere plurality support tax breaks for low-income workers (despite the fact that high income workers currently enjoy a massive tax break through employer deductions).
So, in sum: The health care system sucks, but nearly every American's health care is great. That would suggest the opportunities for reform are minor, unless directed at the loathed elements (like insurance or Pharma). Folks don't like the high costs and fear they'll soon be overtaken by bills, but they blame all manner of minor and moderate contributors for the problem, not their own health choices, overtreatment, or new technologies. Universal care is heavily desired, but only if it doesn't cost anything or demand any sacrifices. In other words, the appetite for reform outpaces the realism of would-be reformers. The tradeoffs of the current system seem poorly understood, and attitudes towards its desirability are contradictory. Not a whole lot of hope in here for anyone," Ezra concludes.
Let me add that when Ezra says that people blame "minor and moderate contributors for the problem" that includes for-profit insurers. I don't think for-profit insurers do the system much good, but the fact is that if you look at the whole $2.2 trillion that we spend on healthcare, private insuraerstakes just 4.4% of the total to cover their administrative costs, obscene executive salaries, advertising , lobbying and profits. In other words, if I were czarina and I waved a wand and made the whole insurance industry disappear, we'd save just 4.4%. And it would be a one-time saving. (Their share of the pie isn't growing that quickly. What's growing quicly is the share taken by drug-makers, device-makers, specialists and hopsitals, due to the high cost of medical technology--technology that everyone wants for himself and his family, but isn't so sure that other Americans need . . )
Let me be blunt: the big problem is that many Americans are . . . well . . .selfish. Americans have always prided themselves on their individualism and independence--which can be very good. The dark of this is that we lack a coillective vision. Start talking about "the common good" and many people rolls their eyes. "What are you, a missionary?" they say.
Many Americans are primarily concerned about themselves and their own families. They are mucy less willing to pay higher taxes to help improve quality of care and access for others. They are, as Oleeb says, reluctant to buy health insurance if they're not sick and don't expect to become sick. i(Oleeb wrote, "who in their right mind, acting rationally in an economic sense, is going to fork over huge sums to be insured if they aren't wealthy and aren't sick right now? " The answer to that, is that the whole idea of insurance is based on the notion of paying into the pool when you don't need it (or don't know if you will need it) so that the money will be there for someone else who is unfortunate enough to get sick. IF everyone does that, then when you are sick, there will be a safety net for you, too. That's collective thinking.)
Someone who earns $75,000 refuses to acknowledge that he or she is upper-middle class. (When JOINT medican income for a household is $52,000--i.e. half of the households in the country earn less than that.) But the person earning $72,000 says he can't afford to contribute to the insurance pool.
In European countries there a much stronger sense of solidarity, which is why European are willling to pay much higher income taxes than we do to provide social safety nets for everyone in the country. (This is particularly true of Europeans over the age of 40. Younger Europeans have become more American in their attitudes, putting more emphasis on the individual, less emphasis on family and solidarity, though this varies by country.)
The French have a very good health care system because they believe that nothing is too good for another Frenchman. Unfortunately, Americans don't feel that way about each other. We are divided not just ideologically, but by race, religion (or lack of religion), class and even ethnic groups (through inter-marriage among ethnic groups has softened some of the prejudice there.)
In Europe there is certaintly prejudice against new immigratnts (though they're not taling about building walls around their countries), but otherwise people in a given country identify with each other. The middle-class is larger, the gaps (in terms of wealth and income) dividing the poor from the middle-class and the middle-class from the rich are much smaller. This used to be the case in the U.S. in the 1950s--but of course only for white people. And back then there was a lot of distrust of other ethnic groups--Italians, Irish, Jewish people etc.
What the experience in Massachusetts tells me is that yes, most people think everyone should have health care--but they are not willing to pay for it--even though the least expensive plans are pretty affordable--$300 a month. This is not pocket change. But it buys you a plan that includes prescription drugs and that has no limit, either annually or over the course of your lifetime. (This is very important if you have cancer.) And many middle-class people don't pay the full $300 a month. Thanks to subsidies from the state, a couple earning up to 300 percent of the poverty, or $41,070, could pay as little as $210 a month, or $2,520 a year. $2,520 a year to insure two people--that's not bad.
Massachusetts is unique in having so many non-profit insurers and they worked with the reformers to come up with affordable, comprehensive insurance packages.
November 13, 2007 10:19 AM | Reply | Permalink
This is an informative and thoughtful post but I want to point out one area of confusion that needs to be corrected.
You write "How can they say their own care is very good if they put off treatment due to cost, and sometimes the delay was serious?"
I think you have blurred your "they"s. The numbers you've quoted actually are:
1) you write [or quote]: "Nearly 60 percent are satisfied with their costs" - that's one group of "they";
and
2) 28% of those polled put off treatment due to cost -that's a second and likely completely different "they".
That only adds up to 88%. So both statements can be true with no one contradicting himself or herself.
You also speak in terms of nearly 90% being satisfied with their care but 70% of the 28% having put off treatment due to cost saying the delay was serious. That leaves a slight overlap - 10% by my count (70% of 28% being about 20%, subtracted from 100% leaves 80% vs. 90%). That could be explained in part by (a) compounding the individual margins of error on each question, plus (b) I don't know what the "nearly"s add up to and (c) for some of the respondents, even though they put off care, when they got the care, perhaps they were satisfied with it under the circumstances at the time the care was delivered. (C) depends on how the question was framed, how the respondent understood it and whether those both are the same as your interpretation of the question and the answer.
So, bottom line, I don't think the answers are all that puzzling or contradictory.
November 13, 2007 11:19 AM | Reply | Permalink
You wrote:
"Many Americans are primarily concerned about themselves and their own families. They are mucy less willing to pay higher taxes to help improve quality of care and access for others. They are, as Oleeb says, reluctant to buy health insurance if they're not sick and don't expect to become sick. i(Oleeb wrote, "who in their right mind, acting rationally in an economic sense, is going to fork over huge sums to be insured if they aren't wealthy and aren't sick right now? " The answer to that, is that the whole idea of insurance is based on the notion of paying into the pool when you don't need it (or don't know if you will need it) so that the money will be there for someone else who is unfortunate enough to get sick. IF everyone does that, then when you are sick, there will be a safety net for you, too. That's collective thinking.)"
I certainly agree with you on how and why an insurance pool is supposed to work. However, my point on this was that the people who have to pay because they don't have any insurance otherwise don't have enough money to pay to play, as it were, and if given any choice at all will not pay. Who can blame them? Everyone knows they will be sick sometime, but those who aren't affluent make choices like this daily in order to survive and I'm not talking about people who are indigent here. The average person in the category I'm talking about doesn't have any "extra" money for anything let alone a hefty monthly sum for health insurance. The only way to resolve this is if everyone pays into the same system. The idea that we can graft on to the existing system another one that serves those who don't otherwise have insurance just won't work because those folks we're talking about can't afford it which is what the whole problem is to begin with.
Everyone needs to be in one big pool and it needs to be financed through taxation. That way everyone who pays something (employers and employees alike no longer pay as they have, but pay the same amount in taxes so it isn't an additional burden). Choice (in terms of participation) will NEVER be an acceptable means of reliable funding for any public program. Can you imagine if income taxes were not mandatory how many people would opt in so they could use the roads, sewers, and so on? Why anyone thinks that will work for healthcare is beyond me. And again, I'm referring to a system where you really are creating a patchwork quilt of insurers that are public and/or private with varying degrees of coverage and so on. It just makes no sense to do it that way in my opinion.
November 13, 2007 11:53 AM | Reply | Permalink
This part of your post is worth selecting out & quoting:
This gets at why I have recently been converted from someone who once thought single payer instituted all at once was best to something incremental or transitional moving towards single payer. That, along with the "rationing" problem you describe. If private plans have to compete with a government program for a while, everyone will learn from experience that with the high tech & new treatments constantly developing, that BOTH will have to "ration." If single payer was instituted soon, especially with the demands of the huge aging baby boom, the single payer would get all the blame for the "rationing." People have to have time to figure out that everyone except the very wealthy cannot in the future get every treatment WHETHER private or government!
The countries that have universal government care are struggling with the very same problem--costs and demands are going to go up up up. It is better that people see for a while and understand the problem, that all insurers will be "rationing," both private and government. Transitional also gives the government plan(s) time to work out the glitches and, ahem, to "steal" the best that the private plans come up with, if they manage to come up with anything popular at manageable cost, that is. They will be more supportive of a single payer after learning from hard experience.
In addition, those medical care professionals who are truly pro-single-payer and fed up with the private cos. can put their money where their mouth is to speed the transition along and opt only to take patients with government plans.
It seems that Massachusetts tell us that the hardest hump to get over, as we see with SCHIP, will be the first step, the idea of mandating coverage for all and get the money to pay for those that cannot make the premiums. I will point out, though, that we managed somehow to transition to expecting all drivers of automobiles to be insured when once that was not the case. Almost everyone now accepts "no insurance, no drive."
November 13, 2007 12:20 PM | Reply | Permalink
As promised, I will go back and respond to earlier comments this evening.
But here, let me quickly try to clear up a couple of questions in the three most recent posts and underline one comment:
Art Appraisor-- thanks for highlighting that section, and for your comment. I'd urge Everyone to read it-it's a good summary ifand important part of my long post. And you are absolutely right--if single payer were instituted tomorrow, people would blame the government when it began to cut waste, screaming that the govt was "rationing" care. If a govt program is competing with private insurers, private insuers will follow the govt lead in cutting waste, and people will see that whether heatlh care is delivered through the private sector or through the public sector, we can't afford unlimited, wasteful care.
Mt57: 90 percent said they were satisfied with the quality of their care. 28 percent of that same group said they had to delay treatment because of cost, and it caused problems --so how could they be happy with quality fo care they received? That's the contradiction.
Oleeb wrote: "My point on this was that the people who have to pay because they don't have any insurance otherwise don't have enough money to pay to play, as it were, and if given any choice at all will not pay. Who can blame them?"
-I'm not sure if you read my whole post. As I explained, "Thanks to subsidies from the state, a couple earning up to 300 percent of the poverty level or $41,070, could pay as little as $210 a month, or $2,520 a year. $2,520 a year to insure two people--that's not bad.
A family of four earning less than $60,000 is eligible for a subsidy. Above $60,000 they are not. Households earning $65,000 or $70,000 are not swimming in money, but they are earning $12,000 to $17,000 more than the average (median) household. If they can afford cable TV, they can afford a few thousand a year for health insurance. And if they have children and subscribe to cable, but don't have insurance for themselves and their kids--and expect other people to pick up the cost when they are sick--I would say they are irresponsible.
Once again, everyone thinks that they can't afford to pay for national health insurance --that someone richer than they should pay for it. If you earn $60,000 you think people earning over $80,000 should pay for it; if you earn $80,000 you still think you're "middle-class" and that people earning over $100,000 should pay for it . . (At the Mass conference one of the speakers said that he talked to one person who said it wasn't fair to raise taxes to pay for healthcare, that "The goverenment" should pay for it. He didn't explain who he thought the government was.)
I agree with you that raising taxes to cover the cost would, in many ways seem easier than mandating insurance---and then hoping peole will sign up. The problem is that this country is on the brink of a financial crisis (thanks to the last 8 years of largely unproductive government spending.) It's going to be very hard to get a large tax hike through Congress--particularly because just rolling back Bush's tax cuts for the affluent won't do it. The middle-class will have to pay higher taxes too--at a time when the price of oil, food, education, healthcare and imported goods is going to be rising.
As Ezra implies, national health insurance will require some financial "sacrifice" from at least the top half of the income ladder (households over $52,000 joint.) This is what no one wants to hear--and very few people in Congres want to vote for (though they may, if the progressives have a solid majority . . .)
November 13, 2007 12:37 PM | Reply | Permalink
Right now my DirecTV bill is $74/month. According to CareFirst, my local BC/BS provider, the cheapest individual policy would set me back $600/month.
So if I lose the TV and somehow find an extra $526 a month, problem solved!
Guess I should move to Massachusetts, apparently the land of cheap health care and sticker-shock cable rates.
November 13, 2007 1:56 PM | Reply | Permalink
I think there is a tendency among Congressional Democrats today to think that they can only move on legislation that people already agree with. They throw up their hands and say, we don't have the votes before the votes have been counted or the bills even debated.
The perfect example of this is the Cheney impeachment drive. They say, it can't be done because you'll never convince enough Republicans to sign on. But the process of investigation would drive public sentiment toward impeachment, as Cheney's crimes are ritually exposed on the 6 o'clock news every night.
Democrats have to be willing to do the hard work of standing up to people, and especially to right wing propagandists, and say, everything you ever thought about health care is wrong - and here's why. My own misconceptions were destroyed several years ago, and it's a liberating moment. I've shared it with other people and seen their eyes open, seen them begin to realize the enormity of the lies they've been led to believe.
The perfect model is what happened with Social Security reform. After the 2004 election, "everybody" knew Social Security was about to go bankrupt. "Something" had to be done. If they'd taken a vote in Congress on November 11, 2004, our Social Security would now be invested in a worthless pile of defunct mortgages. The debate over Social Security changed perceptions, and once people learned that, contrary to nearly everything they'd ever been told by the media, Social Security wasn't in deep trouble after all. They told the Congresspeople to keep their hands off Social Security, and at the end of the day, Congress agreed - Democrat AND Republican. Don't forget this happened before 2006 and before Bush jumped the shark in New Orleans.
It sounds to me that the Mass. plan was devised by just the very sort of pragmatists who were all for rewriting Social Security, people who surrender before the fight begins, because fighting is hard work and so messy and makes people uncomfortable at their cocktail parties.
November 13, 2007 1:56 PM | Reply | Permalink
I suspect that in many cases doctors are overly cautious. It's the movement of the art of medicine to the science of medicine. Even for the most minor complaint, a doctor will order a battery of expensive tests in order to confirm what they already suspect.
At the same time, many doctors use tests to substitute listening to patients. They pop in for two minutes, order some tests, and hurry off to see other patients while the tests are run. Then they pop back in and write a prescription.
On the other hand, you have doctors who treat every patient as a hypochondriac trying to get a scrip for oxycontin, who, because they've already eliminated the patient as a reliable witness to the symptoms, rely solely on tests to determine a cause of illness, as though they are coroners trying to determine a cause of death.
Last Thanksgiving, I came down with pneumonia. The first doctor I saw, at a minor emergency clinic, was of the third type. She completely missed the pneumonia and told me I had a sinus infection.
Three days later, deathly ill, I visited my family doctor, who immediately suspected pneumonia and ordered a chest x-ray. He wanted me to come back after finishing the antibiotic for a follow-up x-ray, which I did. But at that appointment, he wanted me to follow-up two weeks later with yet another chest x-ray, "just in case," and even if I