How Soon Can We Expect National Health Reform?
In the past, we have debated how soon Americans will be ready for national health reform. Many observers believe that we’ll only get reform when more people are uninsured—specifically when more middle-class and upper-middle-class families find themselves “going naked.”
Meanwhile, a new Commonwealth Fund Report shows that while two-thirds of low-income adults (earning less than 200 percent of the federal poverty threshold) were uninsured or underinsured in 2006, just 17 percent of those earning more than 200 percent of the federal poverty level (FPL) were either underinsured or uninsured at some point during the year.
In other words, the people with political clout are pretty well covered.
The report, which counts middle-class people as “underinsured” if they had to spend more than 10 percent of their income out of pocket on medical expenses, observes that employers are continuing to back away from offering health benefits: “Between 2000 and 2005, the proportion of workers receiving employer-provided health insurance declined from 74.2 percent to 70.5 percent. But again “middle- and lower-wage workers,” suffered most, with “the largest decreases” hitting this group.
The fact that 83 percent of those earning more than 200 percent of the FPL are well insured explains why polls show 80 percent of Americans saying they are happy with their health insurance—and, by and large, don’t want to see it changed. This is why they are afraid of single payer plans; they don’t want to be forced into something new.Of course, their insurance may not be as good as they think it is, but as long as they don’t become seriously ill, they won’t know that there are gaps in their coverage. And most of the time, most middle and upper-middle-class people are not seriously ill.
Meanwhile, low-income workers don’t have enough political power to push Congress to stand up to the lobbyists who will fight national health reform tooth and nail.
Here, then, is the crucial question: how many middle-class and upper-middle-class Americans will join the ranks of the uninsured or seriously underinsured between now and 2009? If you believe, as I do, that we’re heading into a serious recession, a fair number could lose their benefits. But will it be enough to reach a tipping point?
This is why I think that the next president should have a back-up plan for his or her first term. True national health reform will have powerful enemies. For, as defined by the progressive candidates with the most detailed plans (Clinton and Edwards), creating a sustainable, affordable, high quality health care system for all will require:
· tightly regulating private insurers while forcing them to compete, on a level playing field, with public sector insurance (something like Medicare for all), and then letting Americans choose whether they want to keep private insurance or sign up for the government plan
· negotiating significantly lower prices with drug-makers and device-makers, and insisting that they prove their products are better than existing products before bringing them to market
· creating an independent “Center for Comparative Effectiveness Research” which does head-to-head comparisons of tests, treatments and products in order to determine which are most effective
· and finally, providing subsidies so that low-income and middle-income Americans can afford comprehensive insurance policies.
If the votes aren’t there to accomplish this goal, too much compromise could be disastrous.
This is the problem with Obama’s approach to health care. He thinks he can sit down with the for-profit companies that have a financial stake in preserving the status quo, and persuade them to give up a fair share of their profits.
That won’t happen. Drug-makers and device-makers will not willingly slash prices. For years, their shareholders have enjoyed double-digit earnings growth and companies that don’t deliver will watch their share price plummet. The executives sitting at the table with Obama own millions of those shares.
Meanwhile, the best-paid specialists are not going to be happy about proposals that we cut into their income stream by eliminating the kickbacks (in the form of consulting fees) that they receive from drug and device makers--while raising the fees that we pay for primary care. Yet that’s what we need to do.
Our nation’s healthcare bill is spiraling by more than six percent a year—two or three times as fast as incomes are growing. The reason it is climbing so fast is because we pay too much for everything, and because we do too many unnecessary, and often unproven tests and procedures.
Private insurers are only part of the problem. Even if we eliminated the private insurance industry and moved to single payor tomorrow, the amount that we pay private insurers to cover their advertising, marketing, exorbitant executive salaries, underwriting, and other administrative costs plus profits for their shareholders represents only 4 ½ percent of our national health care bill. In other words, just one year of rising health care prices would wipe out the savings that we would realize by moving to single payor. (Granted, we would also cut administrative costs for doctors and hospitals that would no longer have to fill out thirty different forms for thirty different insurers, but as the price of healthcare continues to skyrocket even that savings would disappear very quickly.)
The bottom line is that unless legislators are willing to stand up to the lobbyists and put a brake on health care spending, we simply won’t have enough money to subsidize universal coverage. We’ll end up where Massachusetts is today: offering insurance that is too expensive for many—and/or fails to provide adequate coverage.
There is no point in pretending we have national health insurance if we let insurers sell “Swiss Cheese” policies (filled with holes) to the middle class. And if we don’t rein in the cost of over-priced drug, devices and treatments, tax-payers will not be able to afford the subsidies that low-income and middle-income Americans will need in order to buy full coverage.
This is what has happened in Massachusetts—which I’ve written about here and here on www.healthbeatblog.org. And Massachusetts is much wealthier than many states.
This is why I think the next president should have a back-up plan for his or her first term. If he or she doesn’t have the votes for full reform, overhauling Medicare would be an outstanding first step, paving the way for national health insurance in his or her second term.
We need a good model for national health insurance and Medicare could serve as a prototype—if we cut the waste.
Right now Medicare is too expensive because it’s paying for so many unnecessary, unproven and over-priced tests, drugs and treatments. Even though Medicare keeps hiking co-pays and deductibles, it’s headed for serious financial trouble.
But there is a blueprint for reform. The Medicare Payment Advisory Commission (MedPac), an independent committee composed of intelligent, well-informed people, has made excellent suggestions which include: pursuing comparative effectiveness research; encouraging primary care by raising fees for family doctors and other generalists; lowering fees for some specialists; moving away from paying health care providers “fee-for-service” (which encourages overtreatment) and refusing to cover products and services unless we have medical evidence that they are effective. (See www.medpac.gov ).
Both Clinton and Edwards have incorporated many of their recommendations into their health care proposals. If either one is elected I suspect that, at the very least, they will begin trying to implement some of these suggestions as they lay the groundwork for full scale national health reform.
Make no mistake: I’m not giving up on national health reform in the next president’s first term. Everything will depend on how many votes a reform-minded president has in Congress—which in turn will depend on how many voters are pushing, and pushing hard, for change. But I'm afraid that things will get better only if, first, they get worse.
They are in another sense, however, even than the administrative costs. They're not easily moved to results-based rather than procedure-based criteria for what to pay. One thing I'm getting from Sicko is that they come up with preposterous reasons for denying procedures that have nothing to do with needs or outcomes. They don't make more money by taking care of people. The providers are procedure based, in that more procedures give them more money, and the insurer is procedure based, in that fewer procedures give them more money. Neither really gets us better bang for the buck.
Another thing I get from the movie is people's surprise when they discover they're underinsured. I read the same thing about plan choices under Medicare drug coverage, and one could draw a similar message in spades from the subprime mortgage crisis: people can easily be snowed into lousy decisions. The private sector just doesn't have any incentive to allow efficient markets.
John
http://www.haberarts.com/
December 21, 2007 9:46 AM | Reply | Permalink
December 21, 2007 2:09 PM | Reply | Permalink
I like Moore's films and liked Sicko (which I reviewed on theheatlhcareblog.com)
But he is not always right about the insurers. You may remember the very appealing man who was dying of cancer; his wife was trying to get the insurer to agree to another treatment.The truth is that it would have done him no good. The type of cancer he had is fatal and he was in the late stages. She was asking for futile care.
Sometimes insurers are right when they say no . But I would much rather see non-profit public sector insurers setting guidelines for what should and shouldn't be covered.
You're right, many people are surprised when they try to use their insurance--and find out what isn't covered.
December 22, 2007 11:26 AM | Reply | Permalink
Maggie,
You claim:
Can you back that up and provide some evidence?
To me that sounds like a complete distortion of his position. I know it's a popular meme coming out of the Hillary campaign, but a quote or some substance would be nice.
What I read in the Obama plan is that in the first round of legislation he'll allow everybody to buy into a government plan, basically Medicare, and expand mandates for children and the poor to receive subsidized HCI, basically expand Medicaid. Also, that he will regulate the private insurance industry to end cherry picking, externalization, and improve paperwork/records compatibility.
So, in the first round of legislation he'll cover many of the uninsured like the poor and children, and allow many people who want to buy into Gov HCI, to do so. Certainly millions will drop ridiculously over priced HMOs and PPO's for his program, myself included, and then be the best possible sales people for it.
In fact, Hillary's plan also does those things, and so does Edward's, so it seems to be pretty universally accepted that's a good plan. Do you have a criticism of the above?
The main difference is that Obama's plan doesn't require mandates for the general public from the beginning.
His strategy is to cover the children and poor first, and let people who choose to buy in, to do so. And then as the program builds momentum and popularity, to have more people buy into the Gov plan, which will also squeeze private insurers into a more supplemental care based business model, just out of their own economic self interst as thier market shrinks by competition with the Gov plan. He's also made clear he plans follow up rounds of legislation, to keep the ball rolling towards universal care, which he's stated is the goal during his Presidency.
Which makes far more sense politically in my opinion. People don't like mandates, especially not with new plans that aren't yet known by the public. Also, many people won't like being force d to buy from many of the lousy private companies,nor will they like being forced to buy into a new program. That seems likely to cause massive pushback, and play right into Republican memes on "big government" and "paternalism" and such.
Could you please address those actual issues, rather than making general slurs against candidates. Do you support mandates? What are your predictions for political outcomes and viability of mandates? I think it's important people be on the record about that, for future reference.
Also, unless I'm misreading your recent posts, you're in favor of some pro-nonprofit private insurers, that you've praised many times. Companies which are non-profit, but still have many of the other deficiencies of small insurers, such as rather large compensation packages for executives, non-standardized paperwork and record keeping, advertising budgets, lobbying and undue policy influence and the ability to fund think tanks and pundits, and so on down a long list. Things which MEdicare for example cuts out, and which are greatly reduced or non-existant on other Single Payer system elsewhere globally. Correct?
Could you explain your support for them and how that fits into a goal of Universal Care which is cost efficient, not relative to our atrocious national average of inefficiency, but relative to other countries that actually have efficient Universal Care and Single Payer systems.
Lastly, unless I'm also misreading your take on Massachusets, aren't you basically proposing something along those lines?
And isn't it true Mass, since passing mandates, has had massive political pushback? That there has been tens of thousands of waivers issued, and that rates have actually gone up considerably from private insurers.
How is that going to work nationally, when it's already having trouble in a liberal North Eastern state?
Rather than just claiming Obama is naive or such, how about getting to the actual differences in their proposals, which are a lot the same, and basically differ on the issue of mandates.
PS, as I've made clear in other posts, I'm for eventually arriving at Universal, Single Payer system for a fairly high ceiling of base coverage. Private companies could perhaps bid competitively to run front offices for a de facto Single Payer system, so long as thier margins were low and anti-competative practices highly regulated. But, private insurance, profit or non-profit, will never be close to as efficient as a Single Payer system at providing base care, or providing preventative care, which is a national health issue as important as national security to our wellbeing. Privates should primarily be in the business of supplemental, selling second and third MRI at whatever price the market will bear.
And I think mandating from the beginning is very foolish politically, and am totally against it. Single Payer and Universal will win out on merits, so long as the execution isn't foolishly aggressive and crammed down people's throats. We should never mandate someone buy crappy private HC insurance as busted as our system is becasue they'll just raise rates.
December 22, 2007 1:39 PM | Reply | Permalink
December 22, 2007 2:53 PM | Reply | Permalink
Kozmik -- This is not a "slur" against Obama. And I get my info about Obama from Obama's people not Hillary's people. When Obama came out with his plan, the chief of staff in his Cogressional office called me to talk about it. Then she set me up in an interview with David Cutler, his chief health care adviser, that day. I've interviewed Cutler a couple of times before. Let me add that I would be happy to see any one of the 3 Democratic candidates win the election.
But Clinton and Edwards have much more detailed plans. (Have you read them?) Obama's plan is less detailed, so it's hard to tell how similar his plan is to their plans. But the broad outlines are very much alike--except that, as you point out, he is not going to require people to sign up for insurance—at least not at the beginning.
But Obama, like everyone else who has studied the issue realizes that if you want insurers to cover sick people, you will ultimately have to have everyone in the program. I’ll get to that in a minute
First, on Obama’s willingness to compromise – he’s made that clear “Temperamentally, I'm someone who tries to seek common ground," he said recently.. "I tend not to demonize people who don't agree with me, but try to find areas overlap”http://www.concordmonitor.com/apps/pbcs.dll/article?AID=/20071222/FRONTPAGE/712220314.
On the health care issue, he has repeatedly said that he wants to get everyone with a financial stake—insurers, drug-makers, etc. “around a big table” to discuss the issues.
Many people favor this idea. As the Huffington Post reported recently: “Obama advocates getting all sides (consumers, doctors, hospitals, drug companies, health insurance companies, hospitals) together around a ‘big table,’ and hammering out a satisfactory universal health care program; Edwards attacks big business and says they have to be defeated to get anything done. “The media makes Obama look like the good guy--he advocates a new, non-confrontational type of politics that can work on our underlying agreement that health care needs repair, whereas Edwards' "harsh anti-corporate rhetoric would make it difficult to work with the business community to forge change." http://www.huffingtonpost.com/michael-schwartz/paul-krugman-hits-the-nai_b_77409.html
The question, then, is not whether Obama favors sitting down and trying to compromise, but whether that’s a good idea. ( And the fight is not between Obama and Clinton, but Obama and Edwards. Edwards is the one who has called for confrontation rather than compromise.)
Ezra Klein thinks Obama’s position may make more sense than Edward’s “fight like hell” rhetoric: “Obama, as far as I can tell, is hoping that his immense personal charisma and persuasive capabilities will help him gather the stakeholders and power players in a room, dazzle them with smart restatements of their positions, and then elicit agreement on his priorities. That doesn't seem terribly likely to me, but it's at least a plan...I can't figure out what the Edwards plan is. How do you fight like hell to change the power balance in the system? What's the pressure point? [I don’t mean to suggest that Ezra backs Edwards plan—he thinks it “doesn’t seem terribly likely that it will work,” but at least it’s a plan.]
Paul Krugman on the other hand: denounces Obama’s stance: “"Anyone who thinks that the next president can achieve real change without bitter confrontation is living in a fantasy world.”
Matt Stoller agrees with Krugman. In Newsweek, Jonathan Alter argues for Obama’s compromising position.
The big difference between Obama and the others comes on the question of mandates—and even then it more a question of style than substance. http://www.healthbeatblog.org/edwards/index.html As I’ve explained on my blog, Obama doesn’t want to force anyone to sign up for insurance—unless he has to.Click here http://www.healthbeatblog.org/edwards/index.html and you’ll find the post where I quote David Cutler, Obama’s health care adviser saying:
“If there are free riders [people who don’t sign up but expect to receive care if they’re in an accident], Obama is open to mandates. . . . He hasn’t ruled anything out. It’s a matter of priorities. The fact is the policy differences on the mandate issue aren’t that large at all. Sen. Obama believes they’re an option down the road, if other approaches don’t work.” \In that post, I also explain why you have to have everyone insured if you want national health reform to work. “Here, I’ve decided to try to spell out, as clearly as possible, why we need a mandate. Very simply, it addresses a serious defect in our health care system: under existing rules, you don’t have to buy insurance, but you can be priced out of the insurance system if you are sick.
Mandates address one of the most serious inequities in our current system. Today, laws in many states, including California, allow insurance companies to refuse to cover anyone applying for an individual policy who suffers from a “pre-existing condition”--including common conditions such as asthma or pregnancy. As a result, if a person loses her group coverage—either because she changes jobs or because her employer no longer offers health benefits—and then discovers that she’s pregnant, she may find that she is uninsurable.
Moreover, even if you manage to secure coverage, in many states the insurer can jack up your premiums if you become sick and actually begin using your policy. A small business also may find itself penalized if one or more of its employees become seriously ill; in some cases employers have had to cancel insurance for the entire group because they couldn’t afford spiraling premiums.
In addition, the Los Angeles Times reports (see a 1/08/07 story by Lisa Girion, available by subscription) that in states like California private insurers can –and do—refuse to insure entire categories of workers who they deem “too risky” to cover, including roofers, pro athletes, dockworkers, migrant workers and firefighters , even if they are in good health and can afford coverage.
The LA Times looked at confidential underwriting guidelines of three health plans: Blue Shield of California, PacifiCare Health Systems Inc. and Health Net Inc. which all said that “actuarially speaking,” certain workers pose too big a risk.
A last resort for people turned away by the private market is a state's high-risk pool, in which the state assumes the financial risk while paying private insurers to administer coverage. But in California, enrollees must lay out as much as one-third of their income on monthly premiums that cost up to $796 (see 12/21/06 story by Lisa Girion, also in the L.A. Times). Meanwhile, annual benefits are capped at just $75,000. If your child is diagnosed with cancer, it’s likely that you’ll run through that $75,000 in less than six months. Then what do you do?
In each case, insurers are penalizing people for being sick, or because it seems likely that they might be injured. Those who most need insurance are excluded.
It is one thing to raise car insurance premiums if a driver has a series of accidents (suggesting that he might well be a reckless driver). But most people become sick through no fault of their own, No matter how careful we are, unless we die in an accident, each of us is going to become seriously ill at some point in our lives. We just don’t know when. This is why we all need insurance.
To prevent insurers from shunning the sick, some states, including New York, have passed “community rating laws” which say that insurers must charge everyone in a given community the same price for the same policy, regardless of age or health status. Moreover, insurers are not allowed to hike rates because a business or an individual has made claims.
In states like New York, where community rating applies, no one is left out in the cold. If an individual wants to apply for a new insurance policy, he does not have to report pre-existing conditions. But he does have to show that he was already insured with another carrier; you cannot just wait until you’re diagnosed and then decide you want coverage.
Insurance in New York is much more expensive than it is in California because the pool includes sick people who would have been excluded in California. (The percent of premiums that insurers pay out to provide care is roughly the same in both states. Insurers don’t make higher profits in New York. If anything, they prefer to operate in states like California where they can hope to avoid patients suffering from serious, debilitating diseases).
If you are young and healthy, you might prefer to live in a state like California, where insurance is cheaper—assuming you don’t mind living in a state where your mother can’t get insurance because she has had breast cancer and your best friend can’t afford insurance because she’s a diabetic.
Progressives believe-- rightly, I think-- that most of us don’t want to live in such a society. So the three leading Democratic candidates, including Obama, are calling for community rating. Their proposals for reform offer citizens a choice between public sector insurance (that would be much like Medicare) and private sector insurance, and under their plans, both public and private insurers would abide by community rating, insuring everyone in the community, young or old, sick or healthy, at the same price.
And to make sure that everyone can afford the price, the government would offer subsidies, based on income. Thus, only upper-income twenty-somethings would wind up paying the full price. The subsidies are key. As The American Prospect’s Paul Starr points out:
“The secret power of the mandate is that it is as much a mandate on government as it is on individuals. It is a mandate on government to make coverage available and affordable. For it would be patently unacceptable to demand that people have coverage and then provide no practical way for many people to get it.”
But the government (i.e. taxpayers) will be able to afford those subsidies only if the healthy and wealthy participate in the pool.
Why Insuring Everyone Means That Everyone Must Be Insured
If we want community rating ,Edwards and Clinton publicly acknowledge that we also must mandate that everyone sign up. Otherwise, no one would buy insurance until they were sick or elderly; then they would enroll, secure in the knowledge that insurers had to cover them, and couldn’t charge them more.
Meanwhile, the insurance pool would be comprised mainly of people who are expensive to insure, and premiums would skyrocket.
Put simply, mandates are the flip side of community rating. If you want to say insurance must cover everyone—even if they are suffering from a slow, progressive disease like Parkinson’s—then you have to insist that everyone gets into the pool. This is the only way we can afford universal coverage.
If you think about it, this is precisely what Medicare does: no one over 65 is excluded, but everyone—even the young and healthy-- must pay the same percentage of their paycheck in Medicare taxes.
In the end, Harvard economist David Cutler, Obama’s health care adviser, agrees that for national health reform to work, we will need to bring everyone in under the tent. But he says that, rather than forcing people to buy insurance, Obama believes “a better approach is to do everything possible to make it affordable and available. When it is, almost everyone will have it.
Will everyone sign up? Many young people look in the mirror and feel immortal. Meanwhile, young libertarians just don’t believe that they have a responsibility to help cover others. In Massachusetts, where the mandate has no teeth, over 200,000 of the Commonwealth’s uninsured have refused to sign up. Roughly one-fifth of those who refused earn more than $50,000 a year; many are under 35, but choose not to buy coverage even although under the Massachusetts plan, a 27-year-old can buy insurance for as little as $176 a month.
The problem with Masschusetts is first, that while they have mandates, the mandates are very soft. You pay only a relatively small fine if you don’t sign up. (Under Edwards and Clinton’s plans, you would be automatically enrolled if you don’t sign up.) So many young people decided not to sign up.
Also, Massachusetts does not have pure community rating. While insurers cannot penalize people for being sick, they can penalize them for being old. In Mass. ( in contrast to N.Y.) insurers can charge a 57-year-old twice as much as a 27-year old for the same policy. The state decided to let insurers continue to do this in order to make insurance cheap for young people. But young people are still refusing to sign up.
And many older people honestly cannot afford the insurance. Meanwhile because the young people didn’t sign up, there isn’t enough money in the pool to subsidize these older people. Thus, Massachusetts has had to “exempt” something like 10 percent of the population from the mandate, telling these older people that they don’t have to sign up for insurance. Yet, they are the people who need insurance most.
Cutler’s idealism is sincere. He, like Obama, would prefer to soft-sell reform, and no doubt Obama believes that if insurance is cheap enough, young healthy people will voluntarily sign up. I’m not so sure.
Finally, Obama has never spelled out how he will make insurance cheaper. Here Edwards and Clinton provide more detail, and their rhetoric is much tougher. I'm not sure if Obama plans to curtail wasteful care, tell people that we can't cover drugs and procedures unless there is medical evidence showing that they are effective. Will he insist drug maker and device-makers provide deep discounts? Will he agree that Medicare is pay many specialists too much fee-for-service? Will he tell communities that already have enough hospital beds that they can't build new wings?
People like Paul Krugman and Ezra Klein have suggested that at the end, health care just isn’t a priority for Obama. He might put other issues first.
I just don’t know. But I would say that I agree that the notion that if you just sit down with the corporate interests , they’ll be willing to make significant sacrifices isn’t just hopeful—it’s unrealistic.
December 23, 2007 11:38 AM | Reply | Permalink
Again, do you have some evidence Obama just plans to sit down with the corporations, and sing kumbaya or such? As is a popular meme out of the Hillary camp, which you're reinforcing without substance. If you have evidence, by all means, let's hear it.
That's another bogus claim. As I'll post down thread, Obama's plan has plenty of detail.
Regardless, it's a silly argument to begin with. Presidents don't legislate and the details of any plan are going to shift somewhat in the legislative process. What's important are the main initiatives in plans, which Obama has laid out.
So you concede, their plans are basically identical on principles and implementations, with the exception of mandates.
Obama mandates for children only from the beginning, Hillary mandates for everyone.
Yes, all candidates agree universal care is the goal and important to producing efficient health care. Again, the question is how to get there, not the goal. and the only major difference is the question of mandates, and whether they're political viable.
December 23, 2007 11:46 PM | Reply | Permalink
And from there you claim he's "naive" or that he'd compromise principles? Because he'd like to find common ground where possible, and is against mindless demonization.
Just more political garbage and slander.
I've asked several times now, and the best you have yet to do is quote other pundits also echoing the Hillary camp slander they also can't substantiate. That's called the media/pundit echo chamber.
Reality check: There is a long history of principled leadership combined with bipartisan outreach to produce good and long lasting legislation. There are always Republicans who will break from their party and cross the isle given a chance, for issues they personally care about. It always helps to have a stamp of bipartisan approval. McCain and torture, a growing demand for environmentalism, and HCI reform in the Republican party, are examples.
It's especially hypocritical hearing that attack on Obama from a Clinton supporter. How Rovian.
Who is known for unprincipled triangulation? Who has repeatedly produced the worst of both worlds in legislation, like NAFTA, deregulation, and other Clinton policy fiascos.
December 23, 2007 11:58 PM | Reply | Permalink
.> And from there you claim he's "naive" or
> that he'd compromise principles? Because he'd
> like to find common ground where possible, and
> is against mindless demonization.
The last 20 years have been one long exercise in perfecting the techniques of driving one's political opponent from the field using orchestrated howling, Rovian judo, and the power of massive concentrations of money and political influence. The only way to achieve substantial progressive change would be with strong, powerful campaign of leadership using the bully pulpit to overcome the influence of concentrated money. If you say you are going to start by sitting down to negotiate a compromise you have already lost - the nominally Democratic 2006 Congress has demonstrated this in spades this year.
.
To put it another way: what TV/cable network does Obama own that he can use to unrelentingly pump his message? The entrenched intrests in the health care arena own one that has a substantial market share and they aren't afraid to use it.
.
sPh
December 24, 2007 8:57 AM | Reply | Permalink
Who is saying that? Certainly not Obama. And the fact is that Obama's campaign is doing quite well in primary staes and in Iowa, despite having so many power brokers like the Clintons, and the pundits against him.
As Obama is fond of saying, yes repeating lies works, but so does repeating the truth.
Was Obama on WALMART's board? Did Obama botch HC reform once already? Did Obama legislate NAFTA? Vote for the Iraq war? Deregulate energy markets in the 90's to bring about the creation of ENRON? Deregulate banking and accounting practices? I could go on. There's no shortage of the "mistakes" Bill claims give them such great experience. Who is the power couple in Democratic politics known for capitulating to Republicans and their own corporate interests? One has to wonder how the Clintons are so adept at passing legislation which is pro-corporate, and yet so inept at passing pro-consumer and pro-middle class legislation.
The fact is Obama has said he's going to regulate private HCI, and force them to compete with a Gov program similar to Medicare/Medicaid which is many times more efficient and less wasteful. He's also going to allow Medicare to negotiate large drug purchases and allow safe drugs to be imported from other countries who already do negotiated buys. Frankly, that's the HCI companies worst nightmare.
And he's smart enough to do this without mandates for adults, which are totally unnecessary, and would just be a poison pill to reform, giving ammunition to political opposition.
December 24, 2007 1:35 PM | Reply | Permalink
Another distorted reading of Obama's plan and red herring.
Most people who can afford insurance already have it, on their own or through work, and will continue to under Obama's plan including incentives, tax policy, and more cost efficient options. Those who can't afford it will be subsidized under his plan. Children will be mandated. Many will take advantage of superior value in the Gov plan.
So that's the vast majority of uninsured people getting insured right there, by politically popular means, without a mandate.
The deliberate holdouts are a tiny fraction of the population and problem, and can be dealt with later via mandates, if necessary, once there is popular support for a real and existing program, with the kinks worked out.
December 24, 2007 12:45 AM | Reply | Permalink
You write: "Most people who can afford insurance already have it."
This is not true. According to the Center for Disease Control., 27% of people 25-34 have no insurnace. In a story on "The Young Invincibiles," New York Magzine profiles college-educated relatively comfortable yougn people who have jobs that offers insurance, but don't take it.
As I mentioned in my post, insurance is much more expensive in New York than, say, in California because insurers are required to cover everyone (community rating) ---as they would be under Obama's plan.
This is one reason so many young, relatively affluent New Yorkers don't have insurance--and why nationwide, many wouldn't sign up under Obama's plan. Because he, like the other candidates, is insisting that insurers cover everyone, sick or healthy, young or old, at the same price, young healthy people will be paying quite a bit more than they now pay in California.
This is ncessary in m order to make insurance affordable for the sick and elderly, but many young, healthy people won't like it. Look at Massachusetts.
December 24, 2007 11:17 AM | Reply | Permalink
So, Mahar is saying that the uninsured 27% of people in the 25-34 age demographic, are affluent "Young Invincibles" as profiled in NY Magazine? Mahar has said some rather incredulous things, but an anecdote of one young and educated professional couple in NY Magazine is nowhere close to a serious opinion.
Btw, it remains a fact 85% of Americans are insured, albeit it grossly inflated rates. And that over 15% of Americans are barely getting by and at or near the poverty line. Figure it out.
Here's another theory of the uninsured, one based in reality: they're too poor to afford medical insurance.
The median household income is only about $50K.
The poorest quintile are unemployed and working people, household income ranging down around $0 to $18K. The second quintile is from $18K to $35K. Meaning, about 40% of American households earn under $35K, and about "27%" of people are down in the $0 to $25K household income range.
Insurance premiums for a small family can easily be a few to several hundred dollars a month, even higher if they have any "preexisting medical conditions." Meaning, $3600 up to $6000 or more a year. Most of which goes to subsidize the care of older people and HCI waste.
How can the poorest young people afford that without subsidy? It's impossible. These people are already desperate to try and get ahead, afford college and such, and have no choice but to hope they don't get a serious illness, or hope for charity if they do.
***
For Mahar to ignore the economic realities of the poorest young working people, and conclude that the uninsured are just a bunch of feckless affluent idiots, based on a NY Mag anecdotal puff piece, is just utterly delusional.
It smacks of the sort of Clinton and PK economics which brought us polices like NAFTA and erosions of consumer protections and the working class in the first place. I guess Hillary's policies make perfect sense, if one lives in a bubble and is surrounded by insurance lobbyists and affluent pundits.
December 24, 2007 4:05 PM | Reply | Permalink
It's outrageous a pundit has the gall to suggest that the majority of young uninsured people are feckless affluent idiots, while bemoaning her children may not inherit her Manhattan condo.
The fact is 85% of the country is insured. 40% of the country have a household income from $0 to $35K. The two bottom quintiles can't afford our outrageous medical costs, or can only barely afford it by cutting elsewhere in already stretched budgets.
Those two facts show how much people value medical insurance, even when they can barely afford it, while being robbed by wasteful insurance companies making record profits while lobbying government to disallow them buying into Medicare/Medicaid, of their own volition, from their own government. Truly amazing.
Even more amazing is Mahar's suggestion that the real reason for the uninsured is they're just a bunch of young and feckless affluent professionals. It's just so beyond the beyond, so totally out of touch with reality, I'm having trouble imagining how that aspect of Mahar's "expertise" got past what I hope are more informed and reasonable people at TPMC.
It's also becoming clear why Mahar always praises private insurance companies and claims they should be a big part of the solution, several times in this thread, while attacking Obama as supposedly naive for wanting to negotiate with the insurance companies, something he's never said, and downplaying his emphasis on cost controls and regulating the insurance industry.
I was a Mahar supporter when she was making sense. I'm beginning to think it was just another bait and switch.
December 24, 2007 10:20 PM | Reply | Permalink
You write: "Most people who can afford insurance already have it."
This is not true. According to the Center for Disease Control., 27% of people 25-34 have no insurnace. In a story on "The Young Invincibiles," New York Magzine profiles college-educated relatively comfortable yougn people who have jobs that offers insurance, but don't take it.
As I mentioned in my post, insurance is much more expensive in New York than, say, in California because insurers are required to cover everyone (community rating) ---as they would be under Obama's plan.
This is one reason so many young, relatively affluent New Yorkers don't have insurance--and why nationwide, many wouldn't sign up under Obama's plan. Because he, like the other candidates, is insisting that insurers cover everyone, sick or healthy, young or old, at the same price, young healthy people will be paying quite a bit more than they now pay in California.
This is ncessary in m order to make insurance affordable for the sick and elderly, but many young, healthy people won't like it. Look at Massachusetts.
December 24, 2007 11:17 AM | Reply | Permalink
That is another bogus argument and has several flawed assumptions and half truths. In reality, just the opposite is true.
1) The young see value in insurance, even with our present system ripping them off. It's indisputable that the vast majority of young people who can afford insurance buy it for preventative care and catastrophic coverage. especially young families need medical, but really everyone does. The first question every poor family asks their children about a new job is "did you get medical?"
2) The young are already paying far too much, more than many can afford. Much of that goes to waste for the enormous profits, overhead, and inefficiency of the private insurance industry.
3) Pitting the young against the old, as our present system does, is just flat wrong. If costs were controlled, young and old could benefit from medical insurance which they both value for different reasons.
4) Legislating flat rates won't hurt the young, so long as legislation firstly improves cost efficiency by regulating private companies, and by allowing Medicare/Medicaid to compete with them for customers based on efficiency and value.
5) Obama has made lowering costs and improving value his #1 priority. He wants to improve the system to drive down costs, and put in place subsidies where needed, before forcing people into it. Which is vital for pragmatic political reasons.
6) Under the insurance reforms in Obama's plan, both the elderly and young will have a better value and lowered costs due to increased regulation of private insurance, negotiated drug buys, and other legislation to drive down HCI costs and end predatory practices. Most importantly is the option to buy into a far more efficient Medicare program. Again, it's all about increasing value for all consumers to make insurance affordable.
7) In fact, mandates do not lower costs, but raise them. In Massachusets mandates were passed with Republican support, while mandates to improve value and lower costs were hobbled, and the result has been to allow insurance companies to inflate rates for a captive market. Which has also generated a great deal of public outrage and blowback against reform. That's a likely outcome for a Hillary plan and would be a classic Clinton bait and switch as well.
8) Obama's plan will end predatory practices from privates, and allow the Gov plan to compete on value with them. For the first time Americans will actually have a choice to buy medical which is not based on an industry of collusion and predation. Where does that leave the private insurers? In a lot of red ink. Which is the surest way to reveal the truth about medical insurance, and change public opinion towards an appreciation for public services when they can out-compete a rotten industry on value and service. And that's how we'll get real Universal Coverage and increased value from Single Payer: by winning the public opinion.
9) A mandate from day one is unnecessary, heavy handed, and perhaps even walking into a Republican trap. It will have great political costs, at great risk of total failure, and at best a small benefit. At worst, mandates could derail HC reform altogether. We could very well get the mandates to buy, and few to none of the reforms, subsidies, or effective implementation of the Gov Plan. Which would perversely result in helping the private insurers jack rates up further, and make reform politically unpopular, just as the Clintons did in the 90's, killing reform for over a decade.
December 25, 2007 8:12 AM | Reply | Permalink
Again Mahar falls back on unsubstantiated smears and lies, echoing Hillary's attack memes.
Exerpts From Obama's web site, highlighting some specifics about lowering costs and regulating the HCI industry:
* Guaranteed eligibility. No American will be turned away from any insurance plan because of illness or pre-existing conditions.
* Comprehensive benefits. The benefit package will be similar to the Federal Employees Health Benefits Program (FEHBP), and cover all essential medical services, including preventive, maternity and mental health care.
* Affordable premiums, co-pays and deductibles.
* Subsidies. Individuals who do not qualify for Medicaid or SCHIP but still need assistance will receive an income-related federal subsidy to buy into the new public plan or purchase a private health care plan.
* Simplifying paperwork and reining in health costs.
* Easy enrollment. The new public plan will be simple to enroll in and provide ready access to coverage.
* Portability and choice. Participants in the new public plan and the National Health Insurance Exchange (see below) will be able to move from job to job without changing their health care coverage.
* Quality and efficiency. Participating insurance companies will be required to collect and report data to ensure that standards for quality, health information technology and administration are being met.
...
2. National Health Insurance Exchange. ... The Exchange will act as a watchdog group and help reform the private insurance market by creating rules and standards for participating insurance plans to ensure fairness and to make individual coverage more affordable and accessible. Insurers would have to issue every applicant a policy, and charge fair and stable premiums. The Exchange will require benefits comparable to those offered in the new public plan. Insurers would be required to justify an above-average premium increase. The Exchange would evaluate plans and provide information about differences between them.
3. Employer Contribution. Employers that do not offer or make a meaningful contribution to the cost of quality health coverage for their employees will be required to contribute a percentage of payroll toward the costs of the national plan. Small employers that meet certain revenue thresholds will be exempt.
4. Mandatory Coverage of Children. Obama will require that all children have health care coverage. Obama will expand the number of options for young adults to get coverage, including by allowing young people up to age 25 to continue coverage through their parents' plans.
5. Expansion of Medicaid and SCHIP. Obama will expand eligibility for Medicaid and the State Children's Health Insurance Program.
6. Flexibility for State Plans. Obama's plan allows states to continue innovating on health care reform. Due to federal inaction, some states have taken the lead in health care reform. The obama plan builds on these efforts and does not replace what states are doing. States can continue to experiment, provided they meet the minimum standards of the national plan.
****
Modernizing the U.S. Health Care System to Lower Costs and Improve Quality
****
Achieving universal coverage has long been a goal of Democratic presidential hopefuls. But Obama's emphasis on cost savings is bound to appeal to people who have insurance but still have seen their costs skyrocket...
. . .
On Tuesday in iowa city, U.S. Sen. Barack Obama of illinois, a democrat, announced his [health care plan] . . . One aspect is particularly noteworthy: it includes limits on the profits of private-sector health-care businesses. He believes that's the right move for consumers, but it risks offending some powerful interests. He did it anyway. That tells voters something important about him.
- Editorial, Des Moines Register, 6/1/07
. . .
The Obama plan will lower costs and improve efficiency in the health care system by: (1) offering federal reinsurance to employers to help ensure that unexpected or catastrophic illnesses do not make health insurance unaffordable or out of reach for businesses and their employees; (2) ensuring that patients receive and providers deliver the best possible care; (3) adopting state-of-the-art health information technology systems; (4) reforming our market structure to ensure fairness and increase competition.
****
There is plenty more detail available on Obama's site. Maybe Mahar should read it and address real issues, not just Hillary talking points. It's rather obnoxious to regurgitate such unsubstantial slander, and insulting to readers to presume we're so ignorant of Obama's plan.
From the beginning it's been Hillary's strategy, and those of her surrogates, to slander Obama and try and define him early.
Maybe they should reevaluate that strategy is doing. Take a look at Hillary's national poll numbers dropping like a rock while she loses Iowa and New Hampshire to Obama whose national numbers are going up like a rocket.
December 24, 2007 1:12 AM | Reply | Permalink
Kozmik-
I'd note only that there is nothing specific here that would reduce our nation's health care bill, and many things that would increase health care spending.
For example federal reinsurance to employers reduces the employers' costs --but requires yet more tax dollars.
You quote the DesMoines register saying Obama would limit profits for private-sector health care businesses. What exactly did Obama say? Where are the numbers?
Clinton and Edwards both talk about esblishign an indepdennt body to comparative the effectiveness of various treatments, drugs, devices and surgeries-- and then cover only those that are effective. This is how you save money.
Obama doesn't talk about saying "no" to anything.
December 24, 2007 11:02 AM | Reply | Permalink
Re: In a story on "The Young Invincibiles," New York Magzine profiles college-educated relatively comfortable yougn people who have jobs that offers insurance, but don't take it.
Presumably they are working at jobs where the insurance is crappy and they are expected to pay the lion's share of the premium. I've never known anyone working at a job where the benefits were employer-paid (or required only a token copay on the premiums) who turned down health insurance, unlesst hey were covered under a spouse's plan that was a better deal. There's no reason to, since the premiums, including the employee's portion, is fully deductible and very few employers will give you the cash outright if you do turn down coverage.
Re: As I mentioned in my post, insurance is much more expensive in New York than, say, in California because insurers are required to cover everyone (community rating) ---as they would be under Obama's plan.
Even in California insurers are required to cover almost everyone courtesy of 1996's HIPAA law. Once you have insurance you cannot be turned down as long as you do not let the coverage lapse longer than 62 days and if you are going from job to job you will be covererd under group rates which are also community rated (within the group).
December 24, 2007 1:26 PM | Reply | Permalink
Kozmik-
I'd note only that there is nothing specific here that would reduce our nation's health care bill, and many things that would increase health care spending.
For example federal reinsurance to employers reduces the employers' costs --but requires yet more tax dollars.
You quote the DesMoines register saying Obama would limit profits for private-sector health care businesses. What exactly did Obama say? Where are the numbers?
Clinton and Edwards both talk about esblishign an indepdennt body to comparative the effectiveness of various treatments, drugs, devices and surgeries-- and then cover only those that are effective. This is how you save money.
Obama doesn't talk about saying "no" to anything.
December 24, 2007 11:03 AM | Reply | Permalink
Oh baloney.
Allowing Medicare to compete with private insurers wouldn't lower costs? Regulating the insurance industry to cut waste and fully disclose costs and practices wouldn't drive down costs? Negotiated drug buys won't lower costs? None of Obama's other policies will lower costs?
You should tell Hillary becasue her plan, that you've presumably read, says the same things since since cribbing from Obama and Edwards.
Private insurance wastes $.30 on the dollar in administrative costs. Additionally they have a vested interest in enabling Big Pharma to make drugs more expensive, becasue insurance profits are tied to overall outlays. Drug companies waste about $.60 on the dollar on administrative costs, profit, direct marketing and sales, and of course lobbying. Much of what medical care we do get from the insurance industry, goes right into the drug industry. All told, it's over half waste.
Medicare is 98% efficient, with only $.02 dollar going to overhead. Negotiated drug buys would additionally allow them to get a better value from the $.98 on the dollar.
The two biggest savings in national HC costs can be found in 1) decreased private insurance waste and competition with an unshackled Medicare/Medicaid which is allowed to bring value to consumers by negotiated buys, scale, and standardization. 2) a resulting increase in preventative care.
Has Mahar even read Obama's plan? Apparently not, or she would know that's also in his plan, and is frankly a staple in any HCI reform package. But hey, don't let facts get in the way of blind patronage. Don't feel obligated by intellectual honesty to represent the various plans fairly, or even read them.
Showing true colors. Now I see why Mahar keeps praising private insurance companies.
Blaming health costs on excessive care is a Republican and private insurance meme, designed to downplay the private sector waste, downplay regulation, and downplay predatory practices part in driving up costs.
Waste and overhead creates far more cost inflation than experimental or unnecessary care. In fact, even getting necessary care is difficult for many people becasue private insurers have entire divisions dedicated to denying care and litigating against claims. Claim denial is a major source of revenue.
Such pandering to the insurance industry and two-faced politics also dovetails perfectly with the Clintons, DLC, and Third Way, who are pro-corporate at heart. Always campaigning on populist bait, and then switching in office.
Mahar isn't even discussing HC reform anymore. Just shilling for Hillary.
December 25, 2007 8:30 AM | Reply | Permalink
You're right, PK does merit special mention. Let's look at his actual record of policy endorsements, predictive utility, and draw some conclusions from that.
PK backed NAFTA 110% and called critics naive then too. PK has been a sucker for deregulation, and was even on the ENRON payroll for $40K for "consulting" at a time when ENRON was known to be paying many pundits for favorable press. Let's not forget that the ENRON we came to know was created due to deregulation passed during the 90's, often with Clinton backing.
Whenever the Clintons, DLC, and Third Way types are about to make a policy blunder, there is PK the loyalist cheer leading and attacking critics. In fact, PK was expected to get a high ranking position in the Clinton admin in 1992, but was determined to be more valuable for press endorsements, a role he continues to this day.
Regardless, if Obama wins the Dem primaries and then the Presidency, which is becoming ever more likely, PK will be singing his praises by 2009 at the latest, and probably by inauguration or earlier, as is his function.
December 24, 2007 1:35 AM | Reply | Permalink
We've already agreed Universal Care is the goal.
You're again dodging the question of political viability in the first round of legislation.
Again, do you deny the fiasco that mandates have been in Massachusetts, a liberal NE state? Is it reasonable to expect such mandates to be more or less popular nationwide? Do you deny that insurance rates in Mass have sky rocketed since the mandate, becasue they now have a captive customer base!
That's just empty rhetoric. Obama is the only candidate laying out realistic goals, short term and long term, and has a serious plan to get there. Others are just pandering to constituency groups with slogans and writing checks they can't cash. In fact, the Clintons have a quite a record of pandering to the base during campaigns, and failing to deliver in office. They're the masters of bait and switch.
December 24, 2007 1:42 AM | Reply | Permalink
Good, after the ad homs and appeals to the echo chamber of party authority and pundits, we're finally getting to the real policy difference.
A viable mandate brings in the holdouts. A mandate can't be implemented without the support of a super majority.
Prior to mandating, there must be an established and popular Gov program as one option, with millions of happy customers to recommend it. It can't be mandated before it's even established and the kinks worked out. There must also be a great deal of private insurance regulation and reform to ensure nobody is forced by a Gov mandate into a lousy private HMO or PPO.
Presently there is great support for reform, which is a fantastic opportunity. But, that could quickly change for the negative and backfire if poorly implemented, just as it did in the 90's under the Clintons.
December 24, 2007 1:47 PM | Reply | Permalink
December 22, 2007 2:15 PM | Reply | Permalink
There goes the endorsement of private sector "non-profit" insurance again. Does Mahar need to make any disclosures about how much she's being influenced by the opinions of private insurance companies?
Let's be honest about "non-profits" shall we? They aren't exactly altruistic organizations. They still have very large executive compensation packages and still function the same as for-profit insurance companies in most ways. They still have a financial interest in preserving their market share which isn't necessarily coupled with providing quality care to the insured. They still rely on big marketing budgets, still lobby Washington in their interest, are still against regulation, still have a huge amount of overhead compared with single payer systems in other countries, and are still inefficient and have a vested interest in hiding that fact from the public.
Most of the inefficiency of private insurance companies is not the profit, but the waste, and non-profits are only marginally less wasteful.
Private insurance wastes $.30 of every dollar on overhead, including executive compensation, marketing, litigation and cost externalization by denying care and forcing people out of plans.
Medicare and other single payer systems are almost 100% efficient. Medicare gets $.98 of every dollar to health care, having only 2% overhead. Which is typical of single payer systems in other developed nations.
December 24, 2007 9:51 PM | Reply | Permalink
Maggie, inspired by recent reading, I wrote this to put on your old post before I saw this new post, so please excuse if it veers away from your particulars. Please don't feel you have to respond, I just wanted to share some thoughts.
Perhaps I am prejudiced by the fact that I have had a lot of recent family experience with this, but I can't get over thinking about the "high tech" factor as so important, that intensive care medicine that is covered by premium insurance plans that people have now is one major reason that, as you said in your last mpost, "many Americans are nervous about health insurance."
It's the "rationing" thing. If they have such coverage through an employer, they are afraid that the government getting more involved will end up in them losing access to that, that most plans will offer what the government does and it will be only for the wealthy who can pay a lot more out of pocket. And I am willing to bet that those who don't have such insurance don't begrudge those who do taking advantage of it, rather, but rather, they look at it as they would like to have it for themselves, too, that it's only right. It's not like class jealousy about having a fancy house or car, they want both rich and poor to have it.
This is a problem faced by all nations as the baby boom gets older. If everyone gets access to the high tech care, costs are going to skyrocket.
I know you have commented on this before and that your standard statement is that most of thatt money is going to end of life care, and you intimate that people will just have to get used to the idea of hospice rather than radical attempts at the end to stave off death. But do you have stats to back that up?
Because I don't buy that. Both personal experience and this recent article suggest to me that this problem it isn't quite that black and white. My highlighting:
from "The Checklist" by Atul Gawande, The New Yorker, December 10, 2007
Here's what I see: it's not as simple as "end of life." A lot of people as they age are ending up getting very expensive care that extends their life by something like a decade or more. It's because it is becoming technologically possible to do so. Beyond that, there is also a lot more being done for young people with serious illness. I could point out the success of any p.r. campaign to "save little Jill or Johnny with rare x disease" how supportive the general public is that everyone should get maximum care.
This will affect any health care system, the U.S.'s current, any universal, any socialized, any single payer. Politicians need to be honest about this: sny kind of health insurance that includes state of the art against disaster and the bad luck of severe illness will become more and more expensive as time goes on. Preventive care can help, but it can only do so much, there is lady luck to contend with as well, some people still get seriously sick and some still have accidents, and those people will cost the rest of the insured a lot of money, more and more all the time as technology develops. Everyone has to decide, what do people want to deny to everyone and allow only for those who can afford it? Do you deny 1 year of life, 10 years of life, what? As the above story makes clear, if we want to spend fortunes on high tech, we can do more than just "waste money on end of life." As he says in the article, the survival rate of the I.C.U. is not meager. I think most people know this, because they often know of someone whose life was saved by high tech care, and I think implying that it is not the case makes them distrust what government would do.
Of course, they don't trust "the HMO's" on this either. They all know stories about denial of care.
I think that the best possible strategy is to be straightforward about this situation, especially with the huge boomer generation getting to the age where they are going to be accessing more of this kind of care. To sell any health insurance reform, one has to say: insurance is going to get more expensive whether we reform or not. Most private insurance companies are going to "ration." That the government will also have tto "ration," but we can do more and better with the same money and cover everyone, because of preventive care for everyone, because it's non[profit and because of the savings on bureaucracy. But it will still be the case that not everything can be covered, and those with the wherewithal are going to be able to buy more life-saving services.
I just don't think one can sell reform without this kind of honesty, it's why people are nervous. There has to be a mechanism judging what's covered and what's not that's at least as respected as our court system, that's seen to be rrelatively "fair" enough to the majority that rule of law is supported. Then they'll be willing to pay their "tax" for it with a minimum of kvetch, though there will always be a lot.
Medicare is a good model, it's seen as relatively fair as to access of all kinds, even though current payments do rule out the very best institutions and doctors. So there is hope that people will accept limits, limits like Medicare has. But they have to know straight out: covering everyone to the limits that Medicare does for seniors now, it's going to get even more expensive. The people running Medicare kknow this, that it's going to get a lot more expensive or cuts in coverage are going to have to be made. And people who can afford more coverage will get better care, be honest about that, that's the way it is now, and there will always still be an "unfairness" problem to some extent.
I think most Americans want reform, but they won't buy reform until someone who is seen as leveling truthfully is promoting it, someone they can trust. They don't want to see it go from bad to worse, and the access of the huge boomer generation (with an entitlement chip thanks maybe to Dr. Spock :-)) to late in life care is going to test that. Most of them trust Social Security itself, so it's not impossible. And with Social Security, there is little resentment about everyone getting nearly the same amount, even though for many it is basic subsistence level and the rich don't need their payments.
P.S. As much as we all like to disparage the pharma industy (I certainly do,) one does have to mention in this regard that high tech drugs are good at keeping people away from needing high tech institutions, labor and machines which are far more expensive. And that is something to keep in mind when reforming pharma and access to it.
December 21, 2007 10:20 AM | Reply | Permalink
Re: A lot of people as they age are ending up getting very expensive care that extends their life by something like a decade or more.
I’m not sure that that kind of care is particularly expensive. Generally it involves things like antibiotics to cure pneumonia and various drug therapies for cancer, etc. Yes, some of those drugs are expensive, but we are still not talking about 100K worth of expensive in most cases. Moreover single payor, and other universal systems, manage to provide decent late life care without busting the bank as evidenced by the fact that those nations have life expectancies equal or superior to our own: they are not pulling plugs on people ten years or even two years early. It remains the fact that it’s the last six months, not the last ten years, of life that are the source of the bulk of most people’s health care expenses. And there’s already a fairly decent public consensus (see: Terri Schiavo) that people should not be kept alive indefinitely when they are in hopeless straits; most people do not want to be hooked to machines for a few more months of painful, empty life.
Now if you’re going to get into science fiction scenarios where we develop rejuvenation treatments that allow people to live decades or centuries more, then, yes, we need to have a serious talk about that. But today’s technology is a far cry still from that. We have achieved our higher life expectancies almost wholly by making death at younger ages rare, not by slowing the aging process.
December 21, 2007 2:31 PM | Reply | Permalink
It's rarely that simple. I seem to have most of the heart disease and other genetics that killed my father at 42, and had him gasping in his mid-thirties (I'm sure smoking didn't help). It turns out that he gave me good and bad genetics; aggressively managing the heart disease for about 10 years (by NIH mostly) caused a reversal of a good deal of the damage. Apparently, I have a genetic predisposition that will recollateralize my heart (essentially enlarge blood vessels to do an auto-bypass), if I was kept alive long enough. He wasn't alive long enough for that second mechanism to take over.
As far as the 100K costs, some drugs can suppress enough other problems that they are cost-effective, assuming no lifetime cap. The "disease-modifying antirheumatic drugs" (DMARD) are a good case in point -- these are not primarily painkillers, but suppress or reverse the destructive inflammation. There is a fairly wide range of DMARDs, and it isn't always clear which class will work in a given patient, and also be safe for them. It's a bit amusing that gold salts are among the older DMARDs, but they are a good deal cheaper (simplifying, about $17 versus $800 per dose) than the monoclonal antibodies against TNF-alpha. The latter also have to be given more often than gold, but may be safer and much more effective.
When you start balancing the cost of DMARDs against physical therapy, prosthetics, surgery and rehab, however, the expensive ones may turn out to be cost-effective -- and that's before considering the cost of disability and loss of income.
Right now, it looks like a typical human lifetime, with obvious variation, for a person kept in good health is 85-90. Getting beyond that, without the right genetics, is hard.
Not that we are anywhere close, but there is more than science fiction in describing strategies for extreme longevity. We aren't close, but, in principle, nanomachines that could adjust telomere genes could turn off the programmed cell death mechanism, apoptosis. Apoptosis is strongly protective against many cancers, but it may also be the cause of degenerative diseases. If it could be turned off for non-cancerous cells, significant life extension is theoretically possible.
Fair is fair, though. Michael deBakey did get an aneurysm fixed at age 98 (IIRC), and, after a year of rehab, he's back to the active practice of medicine (I don't know if he's still operating, but certainly teaching). I think it's a fair rule that anyone who invents a procedure or drug should be able to get it at any age.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
December 21, 2007 3:19 PM | Reply | Permalink
Re: Not that we are anywhere close, but there is more than science fiction in describing strategies for extreme longevity.
"Science fiction" is not meant as a derogatory comment. After all, nuclear power and space flight were once in the realm of science fiction.
What I mean by it is that we are talking about something possible, but probably not anytime in the near future.
December 22, 2007 4:29 PM | Reply | Permalink
Art Appriasor--
Just one comment: the most expensive, aggressive ICU care is not what accoutns for 86% of patients surviving ICU. In fact, the least expensive, less agressive ICU care is as good--and often better.
Mattehw HOlt (of the heatlh care blog) describes what the researchers have discovered over more than two decades of research:
"The Dartmouth crowd looked at care in the intensive care units of Americas best 100 hospitals as ranked by the venerable (but useless) poll in US News & World Report. The answer? Very sick patients in some academic medical centers (New York University, Cedars-Sinai in LA) were getting up to four times the service (e.g. procedures, tests, physician visits, etc) as similar patients as were others (Mass General, Mayo Clinic). And, as you've guessed by now, there was no perceivable benefit to patients or improvements in outcome. In fact probably the reverse. "
So more hi-tech, very expensive care is not what baby-boomers will need. They will need more competent care--i.e. using checklists.
See comment right below this one on how people in other developed countires live, on average, longer than we do while spending an average of half of what we do on health care. They spend less in part because they do fewer high-tech procedures
December 22, 2007 11:32 AM | Reply | Permalink
That each Democratic presidential primary candidate, because he or she cannot be seen as ceding the progressive ground to an opponent, has proposed some form of universal health care policy should in no way be viewed as that candidate's promise to expend political capital on getting the proposal enacted post-election.
Tiny little nibbles around the edges are about all we should expect.
December 21, 2007 10:24 AM | Reply | Permalink
I think Edwards would expend political capital. In fact, he might try to move ahead too quickly and too aggressively-- and fail to get what he wants while spending political capital he can't afford to lose. (This is not a knock on him; I'm just basing this on what he has said, and his passion about poverty.)
Hillary, I think is likely to proceed more cautiously (given her past experience) but I think she is determined ot get national heatlh reform, though it could take her two terms to do it.
Obama does not seem as committed to reform. And his chief advisor on health care, David Cutler, is about the only health care economist in the country who doesn't think our health care is over-priced. Cutler thinks we're getting a good bang for our buck.
December 22, 2007 11:36 AM | Reply | Permalink
But isn't Hillary for mandates? Aren't mandates the most poltically risky and aggressive issue at stake?
Aside from that difference, what big difference is there between Hillary's and Obama's plans?
December 22, 2007 1:11 PM | Reply | Permalink
Kozmik--
See my long reply to you above. Mandates aren't really an "issue"--they are necessary, if everyone doesn't sign up voluntarily.
If the young and healthy don't get into the pool with the old and sick, no one will be able to affordnational health insurance-not the government (i.e., not taxpayers) not employers, not individuals.
In other developed countries, where everyone is covered, everyone is required to have insurance, for just that reason.
So it's not an issue, because there is not debate on this among people who have studied health care systems. Obama can pretend that the young and healthy will "do the right thing" and sign up on their own. And he may sincerely believe this. No doubt he would do the right thing. But most people aren't Obama. -
December 23, 2007 11:44 AM | Reply | Permalink
Sorry, but that is just baloney. I'd like to see Mahar try and actually substantiate that.
Here on some facts and numbers on the insured which disagree with Mahar:
1) We don't have Hillary style mandates today.
2) About 15% of America is uninsured. Most of them can't afford it but would like insurance. The poor will be covered by subsidy under Obama's plan, and all children will be covered as well. Meaning, the vast majority of that 15% will get insured under Obama's plan, without any adult mandates.
3) The other 85% of Americans are already insured, and will continue to be, without a mandate. Their problem is lowering costs, which will be accomplished by regulating private companies, and forcing them to compete with something like Medicare/Medicaid, and eventually by large numbers of people migrating to the Gov plan as it has superior potential for base coverage efficiency, better than any private can ever provide.
4) Lowering costs for the insured 85% will offset costs for the other 15% and subsidy for the poorer end of the 85%.
5) Very close to universal coverage can be accomplished with no mandate, with much greater popular support, and with much less political blowback. And it's always possible to mandate later to take care of hold outs, the last few percent.
A mandate from the beginning accomplishes almost nothing, at huge political cost and risk to the entire reform process and Democratic/progressive control of it. It's vulnerable to SNAFUs and public frustration, and libertarian/market ideological attacks, at the very time when the reforms are least established and most vulnerable.
Mandates not an issue? Get real. The mandates Hillary wants from the beginning are a huge risk for nothing.
And back into the echo chamber.
If mandates are so unquestionably great, you should be able to provide some numbers to show why, not just abstract theories and hand waving. Deal with the facts and stop falling back on ad homs and logical fallacies like appeals to authority whenever you don't have an answer.
December 24, 2007 2:39 AM | Reply | Permalink
. 3) The other 85% of Americans are already
> insured, and will continue to be, without a
> mandate.
Can you justify this statement? During the last 10 years I have gone from working for Megacorp to a succession of medium-sized and now small corporations. 10 years ago they provided decent health plans - not as top shelf as Megacorp once did, but livable. Today the smaller companies are groaning under the costs of health plans, are cutting them every year, and are considering dropping them as soon as they can figure out a way to do so. And like many people my age in my profession I am being pushed every week to convert to independent contractor status. Tried pricing an individual health insurance plan for middle-age parents with children?
.
It is not in any way clear to me that the current work-based health plan system will last another 5 years (and it is already substantially worse than it was even in 2000). When it collapses most of the people you describe will be dumped out on their own.
.
sPh
December 24, 2007 8:51 AM | Reply | Permalink
There are 300 million people in America, and about 45 million uninsured at any given moment. 85% are insured. 15% uninsured. That data is widely available.
It's not always the same 15%. People in vulnerable income brackets are often losing and then regaining medical periodically. More instability in the lower 40%, but even median households can be vulnerable to financial disruptions.
20% of households earn $0-18.5K, while the next quintile earn $18.5K to $35K. The median household is about $55K.
And yet, we still have 85% insured.
The claim that people who can afford medical won't buy it, is totally contrary to reality. The facts show that even people who can barely afford it will buy in if they at all can. And people who can afford medical have it almost universally already.
Actually, it's clear it won't last, and that no system can bring medical to working Americans at or below median income, and the top half will be paying ever larger rates, unless costs are brought under control. Employers are dropping medical as costs are increasing at double digit rates.
If rates are reasonable, people will buy in voluntarily. If rates aren't reduced, and even worse if they keep climbing, then we'll see even more people uninsured, mandate or no mandate.
December 27, 2007 5:23 PM | Reply | Permalink
Twice the poverty level isn't very much. You're still under median income, I think. So I'm going to guess that a lot of workers who are at twice the poverty level are at the beginning of their careers. They're young and healthy and that's why they're pretty much happy with whatever insurance coverage they've got.
It does look like entry level salary with benefits is what we're talking about here.
thosethingswesay.blogspot.com
December 21, 2007 10:44 AM | Reply | Permalink
Destor 23--
I looked this up and it turns out that while a large share of people earning under twice the federal poverty level are relatively young, they are not young singles.
Most are familes, with two parents, and if I recall correctly, 70% have children. So these are peope who need health insurance--for good pre-natal care, post-natal care,--even if the whole family is very healthy. And poorer families often are not very healthy.
Many people in this group will earn minimum wage--or not much above minimum wage--for all of their working lives.
For people on the lowest fifth of the income ladder there is very little upward mobility.
December 23, 2007 11:50 AM | Reply | Permalink
Which one is the real Mahar?
A) That the vast majority of even young people, even those of modest income, value medical greatly for the reasons Mahar listed above, and absolutely will buy in, especially if given an affordable option.
B) That a majority or even significant fraction young people are "invincible" and feckless and don't value medical, and won't buy in, which as Mahar claims elsewhere justifies the political risk of Hillary's mandates, which may pass in lieu of cost control reforms.
Mahar can't have it both ways.
All the evidence, and common sense, supports A. Which agrees with Obama's plan to focus on lowering costs and ending predatory practices first, and that people already do buy medical and will increasingly do so if rates are more affordable. and that mandates are always possible latter to bring in stragglers, but that priorities should focus on reducing costs first.
December 27, 2007 12:25 PM | Reply | Permalink
John and Art Appraisor--
Thanks for your comments. I'm on deadline right now, but will get back to you later this afternoon.
In the meantime, Art Appraisor (and j haber too), let me urge you to read the piece that I wrote about "Checklist" --the Atul Gawande story that Art Appraisor is quoting. I wrote about it on my blog (www.healthbeatblog.org) here on my blog see http://www.healthbeatblog.org/2007/12/pilots-use-chec.html
(J Haber--you'll be happy to hear that HealthBeat ischanging to the typeface TPM cafe uses (same size and face) after the first of the year!.
What I'd point out is that,if you read Checklist, you realize that we can save many many lives with low tech care. It's called taking a pencil, a piece of paper and making a list. The list includes things like "wash your hands." It saves many many lives.
But unfortuantely, there's no profit in checklists---so we don't pursuethis strategy. I really don't think pushing the envelope for more high-tech care for more people is the answer. Some people may live longer in the future if they can afford the ultimate in hi-tech care. But do you really want to live to 105?
We already use more high-tech medicine than other developed countires, and we're no healthier. We don't live longer.
Particualry when we have no cures for (and are not even close to cures for) Alzheimers, Parkinson's, etc. Many people are going to outlive their midns. This does not seem to me, progress.
I think we want to concentrate on keeping people as healthy as possible while they are alive--not extending life. If we're going to spend dollars on hi-tech care, it really should be reserved for the young--people who haven't yet had a chance to have a full life.
This is what many countries in Europe do. You don't get an organ transplant when you're 85. Anyway, I'll be back later . . .
December 21, 2007 10:55 AM | Reply | Permalink
My personal opinion, you should leave this theme out of your arguments, that's one thing I was thinking of in my comment above. I think its not a good seller politically. I think many people know that few get organ transplants at 85 under most insurance NOW unless they can come up with out of pocket. So it strikes as dishonest, because most 85 year olds don't get them now, and makes people worry whether you really mean a 65 year old. (I think it scares people when you keep stressing this, as in: first they came after the 85 year olds, then the 75 year olds... :-))
Totally anecdotally, I have the impression that end-of-life care of 80 and 90-year olds is not the whole picture of high tech costs. That a substantial amount of those heart surgeries et. al. are people in their 60's. And it isn't all prevention, some people seem to have the bad luck to inherit organs that only seem to last six decades. Now you know, boomers are going to be becoming that when you start this fight. Doncha think there's a problem there? They wanna know, is this scheme gonna cover us in our 60's and 70's like Mom and Dad got covered or are you going to take it away? If not, they might want to keep the employer-provided private, thank you very much but no thanks.
It's just political reality, I think.
If I am wrong that it's people in their 60's that are costing a lot of money, then I think you should stress this constantly as a point of honesty. Otherwise, it's not a strong selling point to push the 85-year-old thing, because few of them are getting organ transplants now, and we still have the costs. The example in Gawande's article of Anthony DeFillipo was 48, a limo driver who started to hemmorrhage after hernia and gall bladder surgery. His sister was asked and she said "do everything possible." He had complications up the kazoo, was in several weeks, the time span is not clear. He went home handicapped, and we don't know whether he's happy to be alive or not. His sister wanted him alive, thought. Gawande says most people in his situation do not make it. So, and this is the important point, if most people do not make it, wouldn't a single payer/authorizer say no? That is what most people in their 40's wouldn't cotton to, don't you see? Why pay health insurance taxes if you aren't they aren't going to pay to save me when I am 48 and have the bad luck he did? Or the other argument, why do the rich 48-year old CEO's get this and the limo drivers don't?
Those are more of the kind of examples I saw in the ICU over three months, not 85 year olds....but 40's, 50's, 60's. Who gets all the bypasses, I don't think it's all 85-year olds.
Yes prevention, is the selling point for the young folks. But not the boomers, don't you see? I think you are right to stress it, for the selling to the younger generation. But it's getting too late for prevention to save as much with the boomers as one could. The sellers will have to point out the mistake of that, and warn that there will be a big hump of expenses (or denial of care and need for supplemental insurance that the poor won't get.)
This is why I like the transitional plans of Clinton and Edwards. I think it's a way to get over that hump with people learning for themselves from the boomer experiences what the problems are.
But yes, getting everyone preventive care, nearly forcing it, is going to help keep costs down SO that AFTER the boomer generation, more high tech care can be provided for the unlucky trauma, congential or accidental few.
And YES YES YES, it's so obvious in Gawande's article that I don't feel the need to even mention: the benefits of the government running a lot more things, having those checklists, and all the other things that are not being provided by our patchwork system et. al. That's a real good selling point, a real good one, maybe DeFillippo would have been out of ICU in one day, or may not have even had the initial surgical complications. There's big money savings there, not to mention saving anguish and suffering all around. That sort of thing works well with an incremental introduction if the government is smart enought to do it right and then crow about it. (I do remember when the EPA was widely considered controversial..not so any more...not many Americans wish to go back to choking on filth like China.)
December 21, 2007 11:43 AM | Reply | Permalink
The uninsured are those who can't afford the costs of insurance or those who choose not to take on those costs, the latter group composed of those who have decided that the benefits of having insurance don't justify the costs. Before we push for universal coverage, we've got to get the costs under greater control. Best practices, better IT, drug and device negotiations, etc. -- all put into effect by the biggest insurers -- Medicare and Medicaid.
Cost control should be job number one, and a Democratic Congress with a Democratic President should be able to accomplish it.
December 21, 2007 12:05 PM | Reply | Permalink
You put down some good words here, I think this is part of what I am realizing or trying to say. If you're not selling "state of the art," many are not going to like to be forced to buy it. And getting costs under control would include making the need for "state of the art" more rare in occurence, so you could indeed probably offer more of "state of the art" more affordably. The amazing thing is that one doesn't often hear much complaining about Medicare as it currently makes do, even though it does has many limits, not the least of which is it's more limited on the preventive front and less limited on the catastrophic front (though there are limits on that too,) and many of the more fancy schmancy providers won't take it alone. I think people like that they are being covered for high tech intervention with it now, that they aren't complaining that they have pay for their own physicals. Perhaps that just the way it is, protection from catastrophe is what people expect from "insurance."
December 21, 2007 12:41 PM | Reply | Permalink
I'm like John Cleese. Whenever I think about health care, its availability or its costs, my brain hurts.
Maybe the first thing we should do is stop subsidizing Medicare (currently, its reimbursement schedules are kept artificially low). But if we raise fees, what do we do about the fact that Miami performs three times as many open heart surgeries per capita as does Minneapolis and achieves no better outcomes? Do we tell Miamians that they're overusing the system?
I have the feeling that requiring Medicare to be financially rational and then, taking that program's cost out of the discussion might allow us to get a handle on the question of what universal coverage would cost. And being upfront about costs is the first step in getting majority support for universal health care coverage.
December 21, 2007 12:59 PM | Reply | Permalink
In these graphs from Gawande's article, sounds like Pronovost might agree with you:
It's sort of like building an infrastructure for universal health care?
December 21, 2007 1:02 PM | Reply | Permalink
,sorry-- repeats comment above..
December 22, 2007 11:46 AM | Reply | Permalink
repeats above
December 22, 2007 11:47 AM | Reply | Permalink
Elllen-Since a greater supply of specialists and hospital beds is driving more expensive and aggressive (but no higher quality) care in Miami, ultimately, we need to reduce the number of specialists and beds (through attrition and through not allowing more hospitals to be built in places that already have enough beds.
Medicare is also talking about sending private letters to docs and hospitals that are using far more resourcces than the average provider--letting them know that they are outliers. And then ultimatley, if they continue to be outliers without being able to prove they have sicker patients, Medicare would cut their fees.
Finally, yep, at some point, someone has to break it to the folks in Miami that all of this extra care really isn't doing them any good, and in some cases is doing them harm. Eventually this will happen--more and more newspaper stories about the Dartmouth reserach in places like the New York Times.
Someone from Forbes called me last week--wants to interview me about the reserach for a Forbes story.
Eventually, it's a story you will see everywhere.
Not yet rated. Not yet rated.December 22, 2007 11:49 AM | Reply | Permalink
repeats.
December 22, 2007 11:50 AM | Reply | Permalink
repeats
December 22, 2007 11:51 AM | Reply | Permalink
Ellen--
I agree completely.
Though perhaps cost control and reform could be done together . . .
December 22, 2007 11:56 AM | Reply | Permalink
P.S. From Gawande's article. Surgical ICU, Sinai-Grace Hospital, inner city Detroit, only three sound like the 85-year old category, but all certainly sound expensive. In the good old days of affordable medicine, they probably should all be dead. Though other kinds of prevention might have helped most of them, preventive medicine could only have possibly helped two of the mentioned:
December 21, 2007 12:28 PM | Reply | Permalink
Re: They wanna know, is this scheme gonna cover us in our 60's and 70's like Mom and Dad got covered or are you going to take it away? If not, they might want to keep the employer-provided private, thank you very much but no thanks.
Since most people retire in their 60s I doubt keeping employer-based health insurance will be a big cause for people in that particular age range. Keeping Medicare in something like its current form is and will be.
By the way, there are many surgeries and some non-surgical procedures (e.g., bone marrow transplants, which are non-surgical for the recipient) that are not done for people of advanced age simply bcause they are unlikely to survive it. That is going to remain a check on what is done for people in that age range for the foreseeable future.
December 21, 2007 2:48 PM | Reply | Permalink
You're right-- the fact that older people are less likely to survive some prcedures will keep a check on what we do.
December 22, 2007 11:58 AM | Reply | Permalink
art appaiser--
You're entirely right. Normally I wouldn't say "no transplants for 85-year-olds --at least not in a post. I'm more casual when commenting, just writing stream of conscious. But it definitely could set off the "first they come for the 85-year-olds" meme!
In terms of where the money is going now-and where we are going to be spending money on boomers, you can't really generalize form the individual cases you see. You need epidemiological data. When you look at that, you find that
"10 percent of Americans are responsible for 70 percent of the U.S. health care bill, and most of them are suffering from one of five chronic diseas: diabetes, congestive heart failure, coronary artery disease, asthma and depression. (*This ifrom George Halverson's newest book--he's CEO of Kaiser Permanente.) Note that cancer, and other acute, dramatic diseases aren't even on the list. The most expensive diseases are the "chronic" ones that last a long time.
These diseases can be expensive because if they are not monitored properly, they can quickly lead to avoidable hospitalizations—and, in the case of diabetes, avoidable amputations. One of the most pressing questions health care reformers face today is this: How can we better manage these very expensive diseases—and how can the patient participate in self-management?
You're right it's too late for preventive care for most of the boomers, but it's not too late for chronic disease management.
And this is something, like insisting on checklists, that govt could do. Private insurers and employers are often reluctnant to spend money on long-term chronic disease management because five years down the road , the patient will have changed jobs or have switched insurance. He'll be someone else's problem. But for taxpayers, that person is going to our problem as long as he lives. . .
December 23, 2007 12:03 PM | Reply | Permalink
I would quibble that it is just in time for this boomer to quit tobacco, rather than too late. Among other new medications Chantix is amazing.
Another thing which is never too late is building and maintaining muscle mass. This seems the best way to get the most mileage out of aging joints.
And of course why should there be any cutoff age for good diet?
BTW, my example of a hip replacement was not intended to be equivalent to a transplant. It is much less expensive and of course is off-the-shelf hardware these days.
My mother is working full time, in excellent health, and likely to live another ten years. Had she known her hip was degrading she would have loved a prophylactic replacement years ago. And she does not have high-priced health insurance, being self-employed. She is in the Kaiser Permanente system in Maryland, which took over from the health provider of my youth, Group Health Association of Washington, D. C.
December 23, 2007 12:47 PM | Reply | Permalink
tom Wright--
How does she like Kaiser in Maryland?
December 23, 2007 12:52 PM | Reply | Permalink
Few complaints, mostly good.
December 23, 2007 2:35 PM | Reply | Permalink
Tom Wright--
Good. Reserachers I respect (at DArtmouth and elsewhere) view Kaiser in Northern California as the "gold standard" for very competent, comprehensive care. In other words, the kind of care we would like in a nat'l health care system.
It may not be the Mayo Clinic, (then again, the Mayo Clnic probaby doesn't live up to the reputation of the Mayo Clinic) l and, because Kaiser is huge, you can always find examples of mistakes.. But in Northern Califronia, both patients and doctors are extremely loyal to Kaiser, and overall outcomes are very good.
Some people say Kaiser can only work in the Northwest--I'm glad to hear it's working in Maryland. And am certainly glad it's working for your mother.
December 23, 2007 3:58 PM | Reply | Permalink
I am wondering if the inclusion of asthma in the list (rather than emphysema and related conditions) is not an error. I have asthma (albeit rather mildly) and my expenses consist of occasional office visits and three prescriptions. Those costs are not going to break any baks.
December 23, 2007 3:45 PM | Reply | Permalink
JPF 311--
No, I don't think asthma is a mistake. For one, Halverson's book is extremely well documented.
Also, children with asthma wind up in ERs late at night pretty frequently. If we had better programs teaching them and their parents how to manage the disease, this wouldn't happen. Ideally, these programs wouild be in the public schools. But in most communities, it's not happening. And if your child can't catch her breath, what do you do? You head for the ER
Also asthma is a particular problem for kids in inner cities where air quality in the buildings where they live is very poor.
December 23, 2007 3:51 PM | Reply | Permalink
From a coldly rational cost standpoint, asthma is one of those diseases that will cost the least when it is managed aggressively. Some years back, there was a fundamentally new way of looking at the disease: it is a disease of inflammation, rather than a disease of bronchoconstriction (i.e., difficulty in getting air into the lungs).
By using drugs that prevent (e.g., cromolyns) or minimize (e.g., corticosteroids) the inflammation, the bronchocostriction, which are the quality of life and the immediate threat to life aspects, doesn't happen, or happens rarely. Corticosteroids taken orally can have severe side effects, but one of the breakthrough concepts was that inhaled corticosteroids mostly stay in the lungs and don't go other places.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
December 23, 2007 4:05 PM | Reply | Permalink
Howard--
I agree-completely.
But children need to be trained to use inhalers. We're not doing that. .
December 23, 2007 7:10 PM | Reply | Permalink
If you think they will be hard to train, consider my mildly asthmatic cat. Believe it or not, there is an inhaler for cats, similar to the cones used for anesthesia (i.e., over the head and stops against front paws), and some cats will tolerate it. OTOH, systemic corticosteroids seem to have fewer side effects in cats than humans, so if things worsen, I may have to inject him.
On the human side, there is a cost benefit to hypoallergenic bedding, air cleaners, etc., but, AFAIK, even HMOs that are prevention-oriented won't cover them.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
December 27, 2007 1:12 PM | Reply | Permalink
This whole issue of questionable procedures dictating costs is a Red Herring.
The fraction of procedures which are controversial, are a tiny percentage of actual medical insurance costs.
Furthermore, private insurers have a level of overhead which are higher, by over an order of magnitude, than programs such as Medicare and Medicaid.
Any care, whether it's the most basic care like knitting 100 broken legs of 20 year olds, or most controversial organ transplant at 85, the biggest problem is still the overhead and waste.
December 27, 2007 12:24 PM | Reply | Permalink
Alzheimer's is a huge concern for the baby boomers, and that is only one of the disabilities of old age. I am concerned that nobody is even talking about long-term care for the elderly. Most of this is not high-tech at all, but the accumulated expense is very high. Clearly, nobody is talking about long-term care because there is total pessimism on the subject. The numbers of baby boomers needing long-term care will overwhelm the system. Blogs are a great place to overindulge in hyperbole, but I think it would be difficult to exaggerate the seriousness of this problem.
December 21, 2007 12:01 PM | Reply | Permalink
I agree about long-term care, though here is what I think will happen:
Middle-class and upper-middle-class boomers will wind up spending their assets on long-term care and leave much less to their children.
For instance, in my case, my husband and I have an apartment in Manhattan. If one of us lives to be old enough to need long-term care, that person would sell the apt and use the money plus whatever savings we had left to go into an assisted living center. In exchange for most or all of your assets, more and more centers will agree to take care of you for the rest of your life. (Some people will die the next year, and their assets will cover those who live another 12 years.)
Twenty or thrity years ago, I probably would have left the apt. to my children. These days, given the cost of health care, this seems less likely. But they'll be perfectly happy as long as I'm well cared for (and don't move in with them!)
But what about all of the people who don't have a home to sell?Many will wind up on Medicaid, in nursing homes,. The problem is that the nursing homes could become very crowded. And they are going to need to be regulated much more tightly. Today, too many elderly people are not well taken care of.
Also, in my generation, I suspect some elderly people will move in with each other to help each other out.. One person will still be able to drive, the other can cook, etc. (Women are probably more likely to do this. I have one close friend who brings it up from time to time, and in fact, I would be happy to live with her.)
Finally, families will pitch in and help out.
December 22, 2007 12:07 PM | Reply | Permalink
Maggie,
Please read carefully what you wrote:
Is this how you want to bring prices down, by discouraging competition and by price control? It’s contrary to how the progress was achieved in US and in the world for the last several hundreds years.
December 21, 2007 1:11 PM | Reply | Permalink
Davai-
Actually the way progress in health care has been achieved in the rest of the developed world is by governments regulating prices and spending. That's how they manage to cover all of their citizens--with as good or better outcomes as we achieve here..
Did you know that, in in this country, if an uninsured child goes to a hospital following an auto accident, or other common type of childhood acccident, he or she is TWICE AS LIKELY TO DIE as an insured child?
Sure, we have competition--lots and lots of competition. I'd rather have live children.
December 22, 2007 12:12 PM | Reply | Permalink
Maggie,
I'm not talking about health care in general, but about medical devices specifically.
We have lots and lots of competition among producers all kind of devices, cars, computers, electronic gadgets, and so on, and as the result of such fierce competition we see a remarkable progress. Somehow for medical devices you suggest a different route for progress, price control and limit to competition. I don't see how this is going to work.
It's very disturbing stats. Do you have any explanations for that?
December 22, 2007 1:51 PM | Reply | Permalink
Davai--
UInfortunately, while the competition is fierce in the device industry (because there is a lot of money involved) we're not making that much progress in terms of quality.
New devices are often no better than the less expensive ones they replaced and in many cases they are much riskier.
Look at all of the stories about souped-up defibrillators, coated stents, over-priced artificial knees that are supposedly "made especaily for women"--just a lot of hype, and a lot of hazard. Why do you think device-makers have to pay doctors millions in consulting fees in order to get them to hype their products? If these products were so good, the pay-offs wouldnt' be needed.
The device industry is more corrupt than the drug industry--and people on Wall Street know this. I've written about it at length in my book "Money-Driven Medicine" (which you can get for just a few dollars on Amazon.com. Don't mean to be promoting the book-- I won't make a penny on the sale. But if you're interested in the topic, it's very affordable, has an excellent index, and so makes a good reference book.
As for the stat on uninsured chldren--the research was done by Families USA and it was reported on ABC News here http://abcnews.go.com/WN/Health/story?id=3240851&page=1: There is a lot of evidence that uninsured and poor people just get less attention in ERs and in hospitals in general. There are also less likely to be demanding than wealthier people--less likely to rush up to the desk and say "You must do something at once!." They are more accustomed to terrible things happening, more depressed, less confident about their rights, and less articulate in communicating their needs.
When my daughter was 2 1/2 she suddenly went into a coma--for no apparent reason. (We later speculated that she had picked up one of my mother's blood pressure pills from the floor). By the time we got her to a nearby hospital she was completely knocked out and I was frantic. The admitting nurse wanted me to fill out insurance forms before she would call a doctor.
After about a minute and a half, she gave up that idea and got the doctor.
I was not shy about insisting on my daughter's right to be seen immediatley. (She was there for about 19 hours before she finally came out of the coma. I kept trying to talk to her--to get her to respond. Finally, I said "knock, knock, and very, very faintly, she said "who's there?"
They never figured out what sent her into the coma.
If I were poorer and less well-educated I might well not have been as forceful about getting her seen immediately..
Finally the uninsured and preumably poorer child may be in poorer health to begin with and so have less stamina. In addition, studies show that there can be an element of racism involved.
December 23, 2007 12:21 PM | Reply | Permalink
First, thanks to everyone for interpreting my comment at all! In starting,"They are," I hadn't meant it quite so in medias res. I was going first to paste from Maggie's post the referent, "Private insurers are only part of the problem." Glad it made sense halfway anyhow. I look forward to hearing more.
Second, I did indeed read that article from The New Yorker. I think I might have quoted the most suitable lefty fodder in some other thread, where he says that the uninsured rate in the neighborhood of an inner city hospital translates into near bankruptcy for the hospital and, in turn, to worse care there. So there's another reason to be concerned about insurance, even apart from those who don't have it. But that's not really pertinent here.
Third, Maggie and ArtA both raise the concern of those satisfied now. To some extent, it may involve shifting the debate from benefit to risk, as in (was it?) Hacker's book that while lots are doing ok, more are aware now that they could pass through the minority that aren't, and they might have passed through in the past. This makes sense when insurance is itself about risk.
Part, though, lies in Art's thoughtful way of putting it: most who have care have it through work and are scared of losing that: maybe, we could reason, this will allow employers to forgo responsibility. (By the same token, that can generate support now for reform from some businesses feeling the crunch.) Thus, I suppose one has to confront that in particular, with assurances that coverage will remain in place or affordable but also more portable. Anyhow, know it's tough!
John
http://www.haberarts.com/
December 21, 2007 1:52 PM | Reply | Permalink
Although at any given time most middle class (above) people have very good insurance, given today's volatile job market a lot of those peopel are likely to experience being uninsured for at least small stretches of time, especially since COBRA is increasingly unaffordable even for well-paid people. So I do expect we will have a good consensus that there needs to be a backup (and (affordable) insurance of last resort for people without other coverage, possibly by allowing the unisured to buy into a retooled Medicaid (but not Medicare) at rates prorated to their income. So I think it's quick possible to get to universal coverage by this picemeal approach, but not to single payor which you correctly note will be resisted by people who are satisfied with their coverage.
December 21, 2007 2:20 PM | Reply | Permalink
I agree wtih everything you say--expect the idea of making the back-up insurance something like Medicaid.
As terms of survival rates and outcomes patients on Medicaid do almost as badly as people who have no insurance. This is because the fees that Medicaid pays hospitals and doctors are so low--much much lower than what Medicare pays for the same servcies.
As a result, many docs won't take Medicaid patients. At many academic medical centers, there are two clinics: one for insured patients, one for patients on Medicaid. The Medicaid patients are seen by doctors-in-training--if they can get an appointment.
This goes back to the mid-sixties when Medicare and Medicaid legislation was passed (in one package.) Southern Democratic Congressmen refused to vote for the bill if Medicaid patients were going to receive equal care, and if the doctors who treated them received equal fees. These legislators knew that, in their states, many of the poor were black, and they were not willing to vote for or pay for equal care for blacks.
They also didn't want black people in"white hospitals" or being treated by white doctors.
At some point in the early 1960s, even a hopsital like Johns Hopkins (in Baltimore) was segregated, with black and white patients on different floors, getting very different care.
So the poor care under Medicaid can be traced back to racism--not something we want to duplicate.
December 22, 2007 12:19 PM | Reply | Permalink
Maggie,
I was not advocating Medicaid coverage however I do think that (or something like it) is what we will get for universal coverage. That way the insurance companies will get to keep their lucrative middle and upper class business while the lower income folks will be shunted off onto a cheap and rather chintzy public program, and while low wage employers like Walmart will happily dump their workers on it, anyone with any money or bargaining power won't go for it. Hence, no rush to the public program as many people here seem to expect. Public health insurance would be rather like public transportation: people will resort to it if necessary but only in serious need. Still, even that would be a vast improvement over the moral and financial disaster we currently have.
December 22, 2007 4:33 PM | Reply | Permalink
JPF 311--
I don't think either Clinton or Edwards would settle for a public program that is like Medicaid. If you look at ther plans and their speeches, they are talking about something much more like Medicare (plus the things that young people need.)
(I just don't know as much about Edward's plan because it's less detailed.)
Both Clinton and Edwards aware of the legacy of racism that goes with Medicaid. Also, Medicaid is a state program (like SCHIP) which leaves states with the option of fully funding it or not. Which means that Medicaid in a poor state like Mississippi or a state that refuses to take care of its poor like Florida or Texas, is really bottom-of-the-barrel care.
A national insurance program won't leave it to the states to decide whether or not to offer comprehensive insurance.
Finally, everyone realizes that if the public sector plan draws only low-income people it will be very, very expensive for taxpayers--because low-income people are sicker and need more care due to poorer diet, lack of exercise (too exhausted after work, too dangerous to exercise outdoors at twilight , can't afford a gym), environmental factors, lack of education, depression and the self-medication (drugs, alcohol) that accompanies despression.
So it will be very important to the government to make the public sector plan attractive to middle-class and upper-middle-class people . Most probably won't sign up immediatley, but over time, if they see that it is indeed like Medicare, they'll swtich.
December 23, 2007 12:35 PM | Reply | Permalink
Hi-
First, let me say I'm very, very impressed by this thread and the way you are talking to each other.
This is what interactive blogging should be all about.
(As a former English professor I always think of a blog as a college seminar. In a really good seminar, people start talking to each other across the table --saying very interesting, intelligent things--and not just talking to whoever is running to the seminar.)
You've raised a great many provocative points, and I want to weigh in. But frankly, there's too much meat here for me to address it this evening. Long day finishing up a report at the Foundation where I work (about the Best and Worst Health Care News of 2007), children home for the holidays, etc.
But tomorrow I will have time to sit down, think about what you have said, and respond. And I'm hoping that many of you will have a chance to come back and keep the conversation going at odd moments over the next week . . .
And that others will join in!.
December 21, 2007 3:26 PM | Reply | Permalink
I pounced on the New Yorker article and drew a conclusion that many public-good issues hide inside the health care process, and that they are the sort of problem best addressed in civic policy. When a general practice or condition affects many people roughly equally it is wholly appropriate to use government to establish safe procedures and conditions.
Whether one ends up in an ICU is another story, but even that is by itself not a economic disaster. It is a long stretch of continuing care, or a heroic rebuilding, that adds up to ruinous costs. But most of us will not face accidents in mid or early life that require a life of care. Society should be able to easily afford taking care of the rare disaster.
And the nursing-home catastrophe of end-stage life can in many cases be avoided through doing simple (if difficult) things like quitting tobacco, exercising adequately, and so on. Still, for many, and maybe most of us, some period or other will be expensive. To a great extent the difficulty in matching insurance to that is because of rapidly changing practices. For now fiat systems have the advantage from the individual's perspective because they can absorb inequities.
The rapid change is caused to a great extent by the commerce of health. Most of the improvements would arrive anyway, but likely a bit more slowly and with less societal and economic dislocation in a national-health setup. Worth noting that private enterprise only succeeds when it offers what people already want. And if it is known what people want, society does not have to wait until someone figures out how to make a profit at it.
It would be better if we had certainty of a limited lifetime. Then we could as a society decide what efforts should be generally available. Unfortunately, we have no certainty of that, and some suspicion that life extension is not only possible but likely, at some cost. I expect, but don't enjoy the prospect of, more versions of apartheid that will reflect genetics and longevity. A wide-open private sector will lead to a class of literal immortals, and they will end up controlling tremendous wealth, The only defense is a strong national-health system that discourages exotic private medicine. Let them go to Switzerland--if we allow it here it will rip society apart.
December 21, 2007 5:26 PM | Reply | Permalink
Re: And the nursing-home catastrophe of end-stage life can in many cases be avoided through doing simple (if difficult) things like quitting tobacco, exercising adequately, and so on.
I'm not sure that's true. The people who suffer the consequences of smoking, overeating, lack of exercize etc are the people who generally die younger and don't end up sitting in nursing homes for years. And there's nothing (as far as we know) you can do to prevent Alzheimer's, Parkinson's, or the degenerative frailty that comes with extreme old age.
December 21, 2007 7:08 PM | Reply | Permalink
Backwards.
Healthier people tend to be more like Holmes "One-Hoss Shay" that work fine until they simply fall apart.
Smoking leads with almost complete certainty to emphysema and oxygen need, often in someone's early sixties.
Overeating correlates with diabetes, which involves lots of care challenges due to cirulation damage.
Lack of exercise correlates with joint problems and subsequent replacement and therapy.
Alzheimer's is a conundrum still, but best evidence so far implies exercising the brain may help some to hold it at bay. My mother is working full time as a private music teacher, walks three miles a day, at age 84, and finally needed a hip replaced due to arthritis, (not a fall). She monitored her bone density to prevent joint collapse.
We all die. But we can be more healthy until then. BTW, note that I only said "in many cases."
December 22, 2007 11:43 AM | Reply | Permalink
See, Maggie's previous language about 85-year olds would make me presume that she would be against this kind of expensive replacement surgery for a person of such an age. That she should just get "comfort care," i.e., pain medication to deal with it, for the condition, that something like having a hip replaced should not be for people at the far end of life expectancy. Plus that complications could ensue. Since that's what I thought, others may think it too, whether or not Maggie thinks that in a case like this. That's why I think it's important politically how you approach this subject. It's one of the main fears of big "socialized medicine" bogeyman. Opposition can really play games with those fears.
December 22, 2007 3:20 PM | Reply | Permalink
Why are you saying "bogeyman"?
Is the fear totally baseless?
December 22, 2007 3:34 PM | Reply | Permalink
p.s. It's actually an excellent example of the problem I was thinking about. Boomers who have jogged and gone to the gym and tried to take care of themselves are not going to like the idea of hip replacements or other joint replacement from wear and tear or arthritis being limited to those of more youthful age ranges when they reach their 70's and 80's. A hip replacement is a perfect example of what I think of as "high tech" medicine. It was not a run of the mill thing only a short while ago. People just suffered with the lower quality of life, and went downhill quicker because they couldn't exercise anymore. Now we have continual development of the ability to improve old age, but these things are expensive.
December 22, 2007 3:58 PM | Reply | Permalink
There are some aspects of cost containment that may be unappetizing, but quite realistic. My pacemaker is made in three subassemblies: the leads into the heart, a connector block, and the electronics with wired-in battery. That connector block, if someone took it out of my chest after I didn't need it any longer, is reusable. A implanted pacemaker-defibrillator is more likely to be reusable.
Some joint replacements can be removed, overhauled, and reused. The economics would have to be examined, as it may not be cost-effective to rebuild the bearing surface. Still, there are a lot of spare parts in coffins.
There are also things that are learned over time about reducing the late-in-life care. For example, I had a cardiac bypass quite young in life. All the grafts came from the (surplus) saphenous vein in my leg, and the surgeon, using the best practice of the time, did not use the left internal mammary artery as a graft.
The rationale is that saphenous vein grafts tend to clog after 8-10 years, and needed reoperation, and he wanted to save the artery for later. We now know that if you use the artery in the first place, it's unlikely to clog and need reoperation.
--
Howard
*equal opportunity offense to both extremes*
"Those who cannot remember the past are condemned to repeat it" [George Santayana]
December 22, 2007 5:57 PM | Reply | Permalink
btw, it should soon be possible and commercially viable to grow pretty good arteries in the lab using technology derived from stem cell research and scaffolds.
I wonder how long it'll be before growing superior arteries, than are resistant to wear and clogging.
December 22, 2007 7:20 PM | Reply | Permalink
Do you have any figures showing cost savings from reusing hip and knee joints?
I find it extremely far fetched that anyone would go through what it takes to salvage a lump of machined titanium. About as likely as a regular medical practice of salvaging gold fillings, which is actually far easier.
Titanium is used becasue bone and tissue bonds with it at the molecular level. It's used for dental implants, joints, and other applications for that reason.
Meaning that the titanium part would have to be harvested in an expensive and gory operation, and then cleaned to avoid any contamination, immune response, and so on. Then it would probably have to be resurfaced, which could change the dimensions. Then it would have to be rebuilt with the wearing parts, which is a lot of the cost of building a new one. I'll bet it's actually a lot more expensive, and medically and legally risky, to harvest most artificial parts.
Regardless, even if that was possible, the vast majority of costs are related to the individual application, such as surgrey, pre and post-op care, and the assembly of custom parts and fittings.
December 22, 2007 7:26 PM | Reply | Permalink