New Momentum to Fix Health Care in America
Some people were surprised to learn today that I participated in a news conference with the CEOs of several major corporations – including Wal-Mart, with whom our union has major differences. We announced the formation of Better Health Care Together, a new partnership committed to building the momentum and political will we need to bring health care to every man, woman and child in America by 2012.
To some, it may seem like I took a risk, but it’s nothing compared to risks millions of people in our country are forced to take everyday because of our broken health care system.
Three years ago I led a march for quality affordable health care across the Golden Gate Bridge with 10,000 concerned Americans, including a woman named Lisa Scott. Lisa is a single mom. She worked every day of her life. Her 16 year old daughter Janelle was having respiratory problems, and the doctor sent her for an x-ray. But because Lisa still owed several hundred dollars from a previous illness, the x-ray was postponed and the doctor said they would just monitor her progress. Three days later Janelle died. She died in the richest country on earth, even though her mom worked every day. She died simply because she was too poor to afford health care.
This is not the America any of us want.
So I stood today with corporate CEOs, civic leaders, and another union for Lisa, and because I love this country. I am ready to do anything in my power to find real solutions to make quality, affordable, health care available to everyone.
And I stood up for America’s and our children’s future. Health care is no longer just a moral crisis, it’s an economic crisis as well. Our country is living through the most profound, most significant and most transformative economic revolution in human history. This is not our fathers and grandfathers economy.
More people went to work today in retail than manufacturing. Our economy is no longer national but international. And the truth is, we are not going to drive into the future looking in the rear view mirror. We need new 21st century ideas and partnerships if America is going to thrive in today’s global economy.
It is time to admit that the employer-based health care system is dead, a relic of the industrial economy. America cannot compete in the new global economy when we are the only industrialized nation on earth that puts the price of healthcare on the cost of our products.That is a major drag on American business competitiveness and job creation. American business by 2008 will pay more for health care than they will make in profits. That is untenable.
But the good news is that the solution is no longer a matter of policy, but of politics and leadership. Today the winds of change are blowing. Unlike 1993, when health care reform failed, forces from every corner of America are coming together and looking for answers. Governors of both political parties are showing leadership, as are presidential candidates, the insurance industry, the Business Roundtable and AARP.
The idea that it is time, in fact it is long overdue, for America to come together and ensure that everyone has quality, affordable health care by 2012 has gained wide acceptance everywhere. Everywhere, that is, but Washington, D.C.
And that’s why I chose to join today with several major corporations, some of whom I don’t always agree with, and some of whom I have been strongly critical -- and will continue to be. But I believe this partnership of unlikely allies sends a powerful message and offers even greater hope that we can finally stop talking about health care and do something about it.
We can’t keep tinkering, hoping that incremental change will fix our broken health care system. We need fundamental change, meaning new thinking, leadership, new partnerships, and some risk taking, and compromising.
That’s what we all owe our country. And what united us today at the announcement is our shared belief that it will be a far greater America when we finally get health care for all.
Team USA needs new a health care plan if we are going to compete in a global economy, and if we are going to help make the dreams of our children come true.
America’s future is not a matter of chance. It is a matter of choice.
Basing national coverage on employers is clearly dead. At the conference, was there any sentiment on single-payor versus multiple-payor consumer-directed, mandatory enrollment?
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Howard
*equal opportunity offense to both extremes*
February 7, 2007 4:32 PM | Reply | Permalink
Single-payer may be equally dead, Howard. First, there's the sticker shock of the cost of it. Second, insurance is still considered a purview of the states -- each having their own insurance commissioners, etc... Add to that the various private insurance companies with lots of lobbying dollars. This is going to be the biggest political battle since the Civil Rights movement. Get a dream, folks.
February 7, 2007 5:47 PM | Reply | Permalink
I totally agree that employer based healthcare isn't adequate.
One thing I'd caution about, though -- if single payer is a nonstarter, as some say it is, that means that people will still have to buy their own insurance, either from the government or from a private insurer. In that case, I think the premiums should still be paid out of pretax dollars.
Now, I know that doesn't do much for the working poor. I think it's ludicrous to think that people who can't afford something in the first place benefit from a tax deduction when they do. But, it is important to the broader middle class, who can afford health insurance, but could also use some help or benefit.
One thing that's good about employer-based insurance, at least if the employer is large, is that the pooling of workers helps keeps the premiums down because the risk is spread out. If we move to a system where people have to buy on their own, premiums might go up. A tax deduction for the purchaser might take some of the sting off.
thosethingswesay.blogspot.com
February 7, 2007 5:45 PM | Reply | Permalink
Hey, Des, what do you think about this: the Fed guarantees and provides catastrophic coverage only. This would mean if your bills exceeded 50K in a year, the Fed steps in as a re-insurer and picks up at least half of the tab. This should relieve a lot of pressure on the employer model, because you can have one or two very sick people in a group and they push everybody's rates up -- even though the group as a whole is relatively healthy. As long as insurers know they don't have that huge potential risk out there -- they could reduce their overall premiums. So, you would actually get the insurance companies behind a federal program, because it's in their interests. It also straddles the line between single-payer and employer.
John Kerry proposed something like this in his campaign, but he just tossed it out as an idea -- not a real plan with numbers behind it.
February 7, 2007 6:50 PM | Reply | Permalink
The main problem with catastrophic-only coverage is that it fails to cover preventative care. And since the road to catastrophe is often lack of prevention, it seems penny-wise and pound-foolish.
February 8, 2007 8:42 AM | Reply | Permalink
Though you might be able to cheaply by preventative care insurance under this scheme. I'm not sure, though. I guess a lot of complaints from the right are that people overuse doctors because they don't feel they're paying for the visits. They basically want to price people out of preventative care (skip the check-up, save $100).
Maybe keeping an insurance system with the add-on of a federal government resuinsurer would make the whole thing cheaper?
thosethingswesay.blogspot.com
February 8, 2007 11:49 AM | Reply | Permalink
One area in which much preventive care [and chronic disease maintenance; the difference is blurry] cost can be lowered is by better use of mid-level practitioner such as advanced practice nurses, physicians' assistants, and other evolving categories. A well-trained mid-level practitioner can do a history, physical, and screening tests well enough to know when to refer abnormalities to primary care physicians, or, indeed, directly to a specialist.
There is a lot of controversy, incidentally, over the actual value of the classical annual physical exam, although not screening lab tests. Periodic physical exams, sometimes quite frequent, are appropriate with many chronic diseases.
Once the physician has established an appropriate monitoring and treatment plan, perhaps on recommendations from mid-level providers, the patient can have routine monitoring by the mid-level practitioner. Obviously, there has to be discretion. Someone, for example, with cardiac valvular disease needs to have a very experienced ear at the stethoscope, and this will usually mean a cardiologist -- although it can be a midlevel practitioner that subspecializes in cardiology, depending on the complexity of the case.
I can't say that I have been totally pleased with every mid-level practitioner with whom I've worked. As someone working in the health sciences and having complex chronic diseases, I've had good and bad experiences. There are times where my having detailed knowledge is threatening; there are times where the practitioner is absolutely delighted to do that.
Sometimes, there's a bit of gaming: while I like my new primary care physician and his general approach to diabetes, some of his dietary recommendations, to put it mildly, do not make sense to me. He insisted I see a dietitian who is also a certified diabetes educator. Just on the phone, I was able to establish that I was not questioning him based on random knowledge but on science, and, while I have my first visit today or Monday, I think we will have the leisure to put together a sensible plan. As is so classic when a manager won't listen to an employee but to a consultant saying the same thing, she and I have agreed that where we agree but the physician doesn't, she may be able to get across points that he is resisting.
Ideally, and I recognize this is an option available to few, I like to develop relationships with my primary physician such that I can call or email him with absolutely all the information needed to decide on a change or new medication, a lab test to decide what to do next, or a referral. This takes an awful lot of trust, and effective acceptance as a peer. My general comment is while I'm not a physician, I play one on medical computers. This has led to some *gulp* situations in an office emergency when the physician pressed me into service as an assistant. They were at least procedures I understood and had watched before, and there really wasn't an alternative other than a risky ambulance run...when an incision is popping open, it needs attention NOW.
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Howard
*equal opportunity offense to both extremes*
February 8, 2007 12:11 PM | Reply | Permalink
not necessarily, ned. you would still have your traditional plan at work with the office co-pays and wellness visits, but one would expect lower rates for that, since the insurance company doesn't have as much potential catastrophic risk. The states could weigh in here on the other side to help pay for preventive care, under the blanket of a federal catastrophic plan.
February 8, 2007 3:56 PM | Reply | Permalink
In the present employer-paid system, there is a strong disincentive for preventive and even aggressive chronic maintenance care, to the detriment of national healthcare expenditures but to the advantage of benefits managers/insurers.
Here's the problem. With the exception of some organizations that indeed regard a healthy workforce as good as them, it is the goal of the employer to minimize his overhead cost for health coverage. In like manner, the benefits managers bid for that business by keeping their costs low. Competition being what it is, a certain number of employers will change plans every year or so.
Now, put yourself in the position of the insurer, knowing the reality of churn. You might spend a good deal on optimal preventive or maintenance care, but that avoids future disease and its costs. With churn, the money you spend might wind up saving money on the insurer a year or two away, when the patient doesn't get sick. You've lost the benefit.
Now, if all insurers covered comparable preventive and maintenance care, they'd average out on the avoided costs. If, however, an insurer can low-bid assuming cuts in preventive and maintenance care, he wins.
If you are familiar with game theory, this has a flavor of the Prisoner's Dilemma: if everyone stays a stand-up guy and doesn't turn in any of the mob, you all win. The first one to turn state's evidence, however, wins big at the expense of the other.
Of course, the Mob might put out a contract on him. Now, think about that...are a Mob contract and no preventive medicine sort of comparable?
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Howard
*equal opportunity offense to both extremes*
February 8, 2007 4:08 PM | Reply | Permalink
A little extreme I think. Insurance companies are aware of the benefits of wellness care. Most companies over 100 employees still have a plan with an office co-pay ($30 or so) and wellness benefit money, usually equal to one month's premium annually. So, the wellness money is there. However, you are correct, one person with a liver transplant can burn them, and they slap the company with a 50% increase the next year.
Back to my post above, that's where a catastrophic plan would max out the insurance company risk at $ 50,000 for that employee (as opposed to at least $ 250,000 for the transplant). The government plan would then kick in and pay the majority of the rest. Even the insurance companies would be on board with a plan like that, because they basically get a non-profit re-insurance partner in the federal government.
I'm thinking practically here. Most people on this site want a universal plan, but I don't see how it's doable at the moment, especially with Medicare in such poor fiscal health. We're already facing massive spending increases to keep that program solvent.
February 8, 2007 6:29 PM | Reply | Permalink
Again, you are talking medium to large business.
I don't think Medicare's financial health is the issue as much as the death struggle (more accurate term than it might seem) that the insurers and pharma may put up. Are you assuming a single payor Medicare ramp-up, or are you considering multi-payor CDHP, possibly with vouchers for Medicare and uninsured/poor? To some extent, that's what Massachusetts is doing.
Would there be universal coverage, or do you have a way of dealing with the unfunded mandate of EMTALA for uninsured critical patients?
I would also want to see outcome metrics on insurers and real efficiency figures, and pickle cost shifting in formaldehyde.
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Howard
*equal opportunity offense to both extremes*
February 8, 2007 6:34 PM | Reply | Permalink
i'm speaking in broad terms -- there is a lot to consider, but mostly leave other programs at the fed/state level alone. We're going to have to decide if we want a European-style system of health care with the taxes to go with it. France has a payroll tax almost 100% of each employee's salary. This is how they pay even for elective surgery like breast implants (maybe a necessity in France). I don't think the country is ready for that. With razor-thin margins in Congress -- neither party is going to get too radical. MA could be a good model to follow nationally. It'll be interesting to see how it affects health care in that state.
February 8, 2007 9:21 PM | Reply | Permalink
Why leave programs alone? Are you familiar with the problem of EMTALA, the legitimate problem it was meant to solve, the way it is abused, and the unfunded mandate it creates causing massive cost shifting in trauma centers?
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Howard
*equal opportunity offense to both extremes*
February 8, 2007 9:43 PM | Reply | Permalink
You perhaps mean that 100% of a French employee's salary is taxable, but tax rates are 40% max for income tax, with a couple precent added for social levies (such as Social Security).
February 9, 2007 8:28 AM | Reply | Permalink
I guess I misunderstood you to be suggesting that the feds *only* guarantee catastrophic coverage, not that the feds' guarantee of catastrophic coverage be in addition to what we have right now. But I'm not sure why you think there is a role for the federal government in the catastrophic market and not in the market for preventative care, and that the latter should be left to the states? I understand that it's the catastrophic coverage that breaks the bank for businesses and insurance companies, but on the other hand, there is a market for catastrophic care, and the insurance companies can make it work if they want to. But one of the things we need in this country is *more* coverage of preventative care, and leaving it to a state by state decision will, I think, make such coverage very politically vulnerable. it's still a lot of money that's required, and it just makes it easier for the states to say, oh well, we can't afford quite as much of this right now, we'll try to make it up later. I'm afraid state coverage of preventative care would be a very attractive target for the budget knives.
February 9, 2007 8:02 AM | Reply | Permalink
Assuming single payor doesn't fly, consumer-driven health plans seem the only reasonable alternative. Medicare/Medicaid is imperfect, in that it is worse than the biggest private company on telling providers not only to take its reimbursement or leave it, but forbidding providers to deal with Medicare-covered patients, perhaps that have long seen them, on a self-pay basis. Medicare is as guilty as any large benefits manager of reaping the benefits of cost shifting.
One of the needs of a long-term solution is a preferably independent audit organization that looks at the real costs of care, with due regard to unneeded or inefficient care. In universal coverage, the reimbursements have to cover fair actual cost of the providers. I freely admit there are inefficiencies that can be improved upon, sometimes by finding a way to handle the cost of entry into a more efficient mechanism.
Given a requirement (with religious exemptions) for universal enrollment, the working poor, and indeed Medicare, could be covered by vouchers into a CDHP choice system.
Your point about large employers spreading risk doesn't hold when the entire population takes the risk. Small business often is priced out of coverage, because insurers underwrite not on medically valid population statistics, but on experience with that employer. A small business with one employee with catastrophic costs, or employees with chronic conditions, soon is priced out of the market. In my direct experience, if I joined a small company that wanted to hire me, they were told their premiums would double, and the policy would not be renewed.
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Howard
*equal opportunity offense to both extremes*
February 7, 2007 6:59 PM | Reply | Permalink
Re: In that case, I think the premiums should still be paid out of pretax dollars.
My own idea is that premiums (at least for the major med part of the insurance) ought to be set not as a constant dollar amount, but as fraction of income so that companies would offer plans on the market pegged at, say, %5 percent or whatever figure they found they needed to stay afloat. The premiums could simply be deducted from payroll in most cases. And for sure we woudl have to demand strict community rating, that is, risk spread across the entire group of suscribers.
Re: This would mean if your bills exceeded 50K in a year, the Fed steps in as a re-insurer and picks up at least half of the tab.
50K is considerably more than most people in this country make. 10K would be more like it. Or maybe a sliding threshhold dependent on income.
February 7, 2007 7:00 PM | Reply | Permalink
The point was it cost less to insure up to only 50K.
February 7, 2007 7:16 PM | Reply | Permalink
At some point in the past the nation (and other civilised states) decided clean water and effective urban sanitation was beneficial even to the wealthy, since it reduced their risk of disease if poor people weren't sick. In practice it was made a right, not a privilege, to have clean water.
A similar decision could be made regarding health care. Since a healthier population would make the rich richer, (as well as safer from disease) than the tax cost of providing care, I don't see overwhelming obstacles to single-payer. Admittedly the cost balance is supposition on my part, but I feel it reasonable.
Unlike driving a car, in which case it is possible to go an entire lifetime without a need for catastrophic payout, all of us will get old and need care. All of us will benefit from some attention in the middle years to prevent costlier illness in later years. How can this be insured? Only draconian defining of non-covered events allows a profit. Or never covering anyone of advanced years.
Since the companies are already cherry-picking the healthy population to extort, we are already paying the tab for advanced-age health care. What's to lose with single-payer? Only the insurance companies. Everyone else does fine.
February 7, 2007 7:17 PM | Reply | Permalink
I long to see the Democratic Party declare that good health care is an entitlement for all residents of this country. And, I long equally for the Democratic Party to declare that we, who are so adamant about not allowing non-citizens into our country, need to pay our membership dues for the privilege of being citizens - and that is what taxes are. We need to be solidly on the side that says we get great benefit from our tax dollars, and are proud to be participating in that great deal.
Hoppy in Sacramento
February 7, 2007 8:19 PM | Reply | Permalink
Tom, good post. I suspect the insurance companies would be involved as they are with Medicare, even though Medicare is seen as single-payor -- you can actually get your supplementals from a variety of companies -- the key is they all offer the same benefit, unlike non-Medicare private coverage.
However, we are seeing a rationing of Medicare already in the form of doctors limiting the # of Medicare patients they see. If you're retired and your old doctor retires, it's not easy to find a replacement that wants another Medicare patient. Would we see the same thing with a national plan? If you've visited Canada, you are aware that their care is rationed (by our definition). You can wait up to 6 weeks for an MRI in some parts of the country. That would never be considered acceptable here, but you can see where a national system could set up the same scenario.
February 8, 2007 4:08 PM | Reply | Permalink
The scare tactic phrase is "rationed medical care" but we already have rationed medical care from private plans, too.
Publicly provided care must limit itself to reasonable interventions, and make some decisions like placing a low priority on a transplant for a 90-yr-old. And there will always be tussles over what should be provided.
But is is both more humane and honest to have that out with everyone's input, not have it decided by an insurer's back office.
February 8, 2007 4:18 PM | Reply | Permalink
How is waiting 6 weeks for an elective MRI not acceptable here? I'm familiar with a fair number of insurers that preapprove MRIs and only reimburse with certain providers. The provider, in turn, if that insurer doesn't reimburse well, may not accept more than a certain number of appointments with that insurance.
Canada is far more complex than it seems. Remember, actual coverage is set at the provincial (state-equivalent) level, not nationally. What is set nationally is the number of medical school and residency slots.
From friends' experience, Ontario seems better than BC, although my Ontario friends are in Toronto and Ottawa, and my BC friends in Kamloops, a smaller area (but 2nd or 3rd biggest in BC). Even in BC, it was possible to get a MRI for an orthopedic emergency in a quite reasonable time.
Provincial reimbursement is not on number of procedures, but on capitation -- each imaging center gets a fixed amount of money. They rarely give out all the possible appointments, because they do save some slots for true emergencies. Ironically, a loophole some have found is that while capitation applies to people, there's no rule against fee-for-service for veterinary patients. Your lower case cat may be able to get a CT (CAT scan is old terminology) scan faster than you can. Some facilities don't like sharing between humans and not, but it goes the other way as well: certainly in the US, there are an increasing number of arrangements where a patient too obese to fit in a human MRI scanner is sent to a veterinary referral center, where the patient goes into a horse MRI.
Apropos of the training slots, Canada both is much better at assisting in medical education expense, but imposes a system where 50% or more of graduating medical students get primary care residencies. Canada sets specialty residencies based on perceived demand for the specialty.
In the US, each specialty board approves the number of residencies and fellowships in that specialty, with no real assessment of need. Since US medical students tend to graduate with crushing debt, they have strong incentives to go into the better-paying specialties.
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Howard
*equal opportunity offense to both extremes*
February 8, 2007 4:31 PM | Reply | Permalink
One thing that never gets mentioned when everyone trots out the comparisons to other nations like Canada is they have a massive trade surplus with us. So, indirectly, we are subsidizing their national health care every time we fill up a tank of gas. When your economy generates more dollars than it exports, you can afford more generous benefits. The same goes for most European countries that have surplus trade with the US.
February 8, 2007 6:36 PM | Reply | Permalink
Re: When your economy generates more dollars than it exports, you can afford more generous benefits.
I don't see that froeign trade has anything to do with it. We donlt import healthcare services (with minor exceptions). It's almost completely a domestic enterprise. And the US GDP is certainly large enough to afford decent benefits for everyone.
February 8, 2007 7:16 PM | Reply | Permalink
by that i mean the increase in the overall budget you have to work with. Canada's tax receipts get a huge boost from oil sold to the US.
February 8, 2007 8:05 PM | Reply | Permalink
Canadian benefits are more constant per person than in the US, but they deliver services more cheaply than we do. Another dimension is that they are a generally less litigious society, and do not have the malpractice and defensive medicine we do. While they have the same range of tests we do, they constantly review to tell if the expense of the test really adds to treatment.
For example, certainly in the past but less so since some of the Canadian research, if you came into a US ER with an injured ankle, you'd get it X-rayed, for $70 or so in test charges plus possibly a fee for the radiologist. Canada went through the clinical evidence, and came up with a series of tests to be done during physical examination called the Ottawa Ankle Criteria. They take a few minutes. If you pass the criteria, it is about as certain as can be that your ankle isn't broken, so an X-ray is not needed to align the bones. If it's not broken, you can safely put it in a soft cast or splint, much faster than a hard cast. How is this more generous benefits?
A friend of mine, by no means wealthy, developed myleodysplastic syndrome, the blood disease that killed Carl Sagan. She was never in a position where she had to worry if she would have to find the coverage for the treatment that might save her life (and did--she beat it completely). I will agree that Canada did have better disability coverage.
Essentially, Canada has made the decision that people will not die of diseases that have a reasonable chance of cure, just because they don't have coverage. If they can't be cured, there are decent hospice and pain management programs.
Averaged, they spend less per person on healthcare than we do. Generous? Subsidized by the US?
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Howard
*equal opportunity offense to both extremes*
February 8, 2007 9:41 PM | Reply | Permalink
generous in terms of federal dollars spent on healthcare relative to national budget
February 10, 2007 11:38 AM | Reply | Permalink
Given that the amount spent per capita is larger than ours, I don't see this as generous. I see ours as inefficient.
This is not unique to Canada. The US per capita expenditure is still greater than healthier industrialized countries with mixed public-private multipayor systems.
When you say "national budget", are you simply saying we really do spend more, but, since it's kept out of obvious taxes by the employer-based system, it's hidden. A multipayor consumer-driven health plan with mandatory enrollment need not all come out of general revenues. There would need to be government expenditures to cover the presently uncovered, but the efficiencies returned on the cost of coverage might well make up for that.
Have you also thought about the effect of the lack of coverage on national security, effects ranging from increased difficulty in wiping out reservoirs of infection, to catastrophic expenses caused by lack of maintenance for chronic diseases, and even to detection of covert bioterrorism?
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Howard
*equal opportunity offense to both extremes*
February 10, 2007 3:58 PM | Reply | Permalink
we've had universal coverage in my state for years now, and all the promises of reduced costs due to blanket coverage never came true. In fact, the costs of the state-sponsored plan mushroomed beyond anyone's worst-case scenarios. Premiums for private insurance also rose in accordance with the national average. There was no savings to the middle class. I don't trust any politician using this argument.
The other unintended consequence was the health care plan had suddenly become a civil right for everyone on the plan. Any politician trying to make reforms was promptly sued by advocacy groups for violating their civil rights. I can see this happening on a national level and the same scenario playing out.
February 11, 2007 10:36 PM | Reply | Permalink
Not knowing your state, I can't comment specifically. For example, I don't know how it deals with cost shifting, including from the unfunded mandate of EMTALA, the partial reimbursements from Medicare/Medicaid, and the market leverage of the larger insurers. Realistic implementation of universal coverage has to deal both with malpractice and with known sources of medical errors.
Was private insurance employer-driven or consumer-driven? If employer-driven, was it subject to outside review, as has worked to improve European coverage?
What preventive and maintenance care is part of the universal coverage? Has your state examined the problem of ER overuse and the reasons for it, some of which are subtle, such as after-hours accessibility and public transportation?
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Howard
*equal opportunity offense to both extremes*
February 11, 2007 10:44 PM | Reply | Permalink
Here is a link to the state web page for TennCare:
http://tennessee.gov/humanserv/adfam/afs_med.htm
I don't know all the specific answers to your questions, but the costs grew so fast the current governor had to boot tens of thousands of folks off the plan to keep it solvent. Even so, there are now lawsuits pending to put these people back on the plan by advocacy groups.
It's a cautionary tale about jumping into a universal plan with both feet. A major change to coverage like this should be rolled out slowly, fine-tuned and carefully studied, before it's made available to everyone.
February 13, 2007 6:22 PM | Reply | Permalink
I don't think you have heard me suggest a national jump, and not to single-payor. My inclination is to try things on a state-by-state basis, definitely trying consumer-driven health plans (CDHP).
Let's be clear about TennCare. It is not a universal coverage program, but a program for the uninsured. An economically rational universal coverage program sets up floor coverage for all. If it's CDHP, multiple providers or benefit managers bid; the uninsured-Medicaid are paid for by vouchers and get basic care, but quite a few other people will opt for basic care and allow economies of scale. In general, a program purely for the uninsured or those who cannot pay for market-rate coverage has a sicker patient pool and higher costs.
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Howard
*equal opportunity offense to both extremes*
February 13, 2007 6:31 PM | Reply | Permalink
Tenncare is not just for the uninsured or uninsurable. It was originally designed for those who "could not afford" health insurance as well. We had 1 in 5 residents on it at one time. The goal was to make sure everyone in the state had some type of coverage, (making coverage universal) but it was not a single-payor universal -- you are correct. It's structured more like an HMO.
I think if they had just stuck with the uninsurable, it would have worked. Those people need some place to go. You cannot allow private companies to turn them down and not offer an alternative. Yes, they are the sickest, but the percentage of people who are truly uninsurable is relatively low.
February 14, 2007 10:58 AM | Reply | Permalink
The singular of anecdote not being data, I shall proceed to offer my own case. After layoffs from a major company, and most jobs in my field turning contract, I was again in search of coverage. I've done extensive consulting work for a company in the Nashville area, but I telecommuted for Virginia. At one point, I was on employee status, but still had (over $500 per month) COBRA.
They are a small business. When my COBRA ran out, the CEO suggested, and I agreed, to going back onto employee status to get coverage. This, incidentally, is a company in healthcare, very familiar with the issues. They were told by their insurance agent that if I went on the policy, with a history of coronary artery disease and diabetes, their premiums would immediately double and their policy would not be renewed. We agreed that my coming on board was not realistic.
In Virginia, the only provider I could get even to offer a policy was an HMO, with a premium of over $1000 per month and still major preexisting disease exclusions.
To turn to the general, universal has to be that -- universal, and premiums defined for the population as a whole, not individual or small group experience. This can be, and has, been done with multi-payor, but either essentially consumer-driven (see the Federal Employees Health Plans) or heavily government regulated (see Germany).
Health "insurance" is different than other kinds of insurance. People are not insuring only against a catastrophic event, as with home fire insurance. Instead, the insurer will definitely pay out over a year for virtually every insured. Premiums (and subsidies/vouchers) need to reflect actual cost, without huge profit margins or administrative overhead. Cost-shifting is a cancer in the system, and I include the cost-shifting of Medicare/Medicaid. Most industrialized countries do subsidize from tax revenue, where we shuffle it around, subsidize from the sick, and create unfunded mandates like EMTALA. Don't get me wrong; EMTALA addresses a real need, but it is being used by people other than the true emergency patients it was designed to cover. Further, especially in large cities, there are lots of true emergencies for uninsured people. People with bad health from drug abuse, and then multiple gunshot wounds, tend not to be under a group policy from their gang. Right now, providers cost-shift onto the insured and self-pay patients. Is it logical to have only the sick pay for the uninsured that must be treated?
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Howard
*equal opportunity offense to both extremes*
February 14, 2007 11:22 AM | Reply | Permalink
Howard, i hope this info is not too late, but Blue Cross has Guaranteed Issue products for people coming off of COBRA. Granted, they are a little more expensive, but not as bad as you might think -- especially if you're looking for single coverage. You can't be turned down for any reason.
February 14, 2007 1:10 PM | Reply | Permalink
Isn't that for Tennessee residents only, rather than employees of Tennesee companies? It was Blue Cross that quoted the doubling of the small business premium and nonrenewal of the premium.
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Howard
*equal opportunity offense to both extremes*
February 14, 2007 1:22 PM | Reply | Permalink
i'm not an expert there, so you'd have to call BC in your state. I know they offer it here, so one would assume the same policy would be available in other states.
February 14, 2007 5:43 PM | Reply | Permalink
On the one hand, I'm the first to suggest that we need to see different programs in different states, in search of solutions -- and it may well be that not one size fits all.
That being said, there's the problem of what sometimes is termed "patient burden" or words along those lines. I've worked with some bioethicists who term the effort of getting into what may be a very useful clinical trial, or multiple trials, "research burden". By either name, it is the effort, and knowledge, needed by the patient to make the system work for them.
A while back, for a few cheerful months, I thought I was going to be getting a very large income, until fraud was discovered. Even at the high income end, with high-deductible catastrophic care tied to a Medical Savings Account, it still was an enormous effort to find what coverage was available -- or, as it turned out, not available in Virginia.
I'm intimately familiar with the language of medicine, with quite a few aspects of healthcare finance, and with law. It was rough for me even to get the information. What will it be like for someone without much education, language skills, or the basic methodology of how to research something?
--
Howard
*equal opportunity offense to both extremes*
February 14, 2007 6:43 PM | Reply | Permalink
[Duplicate. Sorry.]
February 14, 2007 1:22 PM | Reply | Permalink
There are just some things that it is appropriate for governments to do. The fact that this is so has been obscured over the past 40 years by a wave of Libertarian blather about the efficiency of markets.
Every other industrialized country has some sort of national health care system. What this does is two-fold. First it turns health care into a basic right and second it eliminates profit from a vital service.
Currently the US is still privatizing public services as the recent wave of selling of public roads and lottery systems illustrates, so fixing things is an uphill battle.
The solution is so obvious that no politician will discuss it (and Andy Stern is acting as a politician here, not a union leader). The solution is a government-administered national health insurance program. We already have two: the Veterans Administration and Medicare. Without the private insurance industry in the middle costs would drop by 30%. With the addition of government control over drug prices costs would drop even further.
These savings would cover all the assumed additional costs that a national health system would create. There is little chance of such a system being put in place if even progressive leaders like Stern trim their sails.
--- Policies not Politics
Daily Landscape
February 8, 2007 9:24 AM | Reply | Permalink
It is true every other country has national health care. It is not true that every other country has single-payor. It is true that in the countries where insurance is multi-payor, public-private, the private insurers, and often the pharmaceutical companies, are heavily government regulated.
The motivation for multi-payor, one version of which is the consumer-directed health plan (CDHP), is not just a libertarian fantasy. In a reasonable CDHP, there are often alternative approaches, of which medical outcomes analysis has not determined one is necessarily best. For example, there is conflicting data over health maintenance organizations (HMO) versus preferred provider organizations (PPO). Within each of these is the differing approach of staff, group and network models for providing professional services, as well as systems with and without a primary care provider as gatekeeper to all specialized services.
There is no question that there should be objective national statistics on the outcomes of these varied means of delivering care, and, if some emerge as superior, others may be dropped.
Another aspect is the availability of pure self-pay outside the system. This is forbidden for Medicare patients, and in the Clinton CDHP model. This is more where markets have had a benefit, as in demonstrating the utility of the free-standing surgical center, originally for cosmetic surgery -- and also identifying where such centers are a very bad idea.
Any or all of the models I have discussed, except self-pay, can be organized on a not-for-profit basis, so the profit aspect of privatization does not necessarily apply.
--
Howard
*equal opportunity offense to both extremes*
February 8, 2007 9:37 AM | Reply | Permalink
HowardB: "I like to develop relationships with my primary physician such that I can call or email him." That truly would be ideal in lowering costs and ensuring preventative care. For now, it's not so easy, when reimbursement depends both on office visits and on not taking more time with patients than necessary.
I appreciate Howard's knowledgeable talk about alternatives. They're helping me put off concluding too quickly about single payer and other options, as well as not freaking out every time a Democratic candidate hints at one or the other. Of course, any plan will have to take into account the uninsured, and I appreciate Andy's focusing on that better than Nathan has.
John
http://www.haberarts.com/
February 8, 2007 2:04 PM | Reply | Permalink
With CDHP, for the uninsured, and possibly something to examine to reduce the administrative cost of Medicare, one option might be for various consumer cooperatives to bid for tax-based vouchers to provide these services.
The nature of reimbursement is tough for phone and email. Some programs are experimenting with it, but there's an enormous liability aspect unless the clinician is very, very sure that the patient is giving all relevant information.
Relationships such as I have are tough, although they actually can save time IF the patient can communicate efficiently. In my work with information systems directly supporting physicians, one of the utterly essential requirements is that they appear to think and talk like physicians.
I've been involved with some nurse bioethicists dealing with the impact of the Internet on increasing patient knowledge. There are several levels of problems, the worst being patients that get information from junk science sites or go in demanding an advertised prescription drug without knowing the nuances of its use (or alternatives to it). The next worst is where someone studies seriously, but just may not have enough background to draw inferences from what is not just vocabulary, but a way of writing. Next, let's assume you have someone with a PhD in a biological science and who thoroughly understands the vocabulary and concepts. Unless they also have clinical exposure, they may not know how to communicate efficiently, and in a manner that automatically flips a physician into peer communication mode.
Have you ever seen the paramedics bringing in patients on the show ER? The fast burst of numbers and diagnostic terms is a good example of efficient communication among professionals. In medical training, a senior will often ask a junior "give me the bullet", where one of the skills being developed is to decide what is utterly essential and convey that.
Another aspect is that clinician communication is very high-context; there is much assumed information never explicitly said. For example, I am pleased with my new internist being more aggressive with my diabetes. He has prescribed a drug that my previous endocrinologist was reluctant to prescribe, because it can cause water retention dangerous in patients with heart disease. I'm seeing him about every 2 weeks to adjust things. At my last visit, my blood sugar was much improved, but I had gained substantial weight. Most diabetes drugs can cause weight gain by improving sugar intake, but this can also add water weight. He started to go into diet, and I told him quickly my appetite was depressed, but "check lower extremity edema (a sign of water retention". As I had noticed, several physical tests confirmed that.
Now, I notice that I've lost an inch or two from my waist, but gained weight. My sugars are better; he increased the new drug. If I were just to call him rather than go in next week, I'd say "waist decreasing, sugars improving, still edema. Why don't you bump the Avandia (diabetes drug) by 2mg, increase Lasix (diuretic to get rid of retained water) to 40mg, and get lytes (blood electrolytes, to see if the Lasix is causing me to lose too much potassium) in about a week." He's going off for surgery himself, so I'd say "relax, your PA and I can manage the fluid and electrolyte balance. The diabetic improvement is worth some experimenting and I'm not showing cardiac functional impairment."
This is not meant to show off, but to give an example of the staying on the same wavelength that I've found necessary before a doctor gets comfortable with my just calling in a suggestion. Now, at least, we are at the level face-to-face where we are discussing the alternatives, he's not simplifying language, and we are getting comfortable throwing out not fully formed ideas.
Think back to some of the other public policy discussions where science is involved. How widely can we spread this knowledge? I'm just not convince the Internet will be the medical education resource many hope, because too much background is needed for real cooperative health management.
--
Howard
*equal opportunity offense to both extremes*
February 8, 2007 3:29 PM | Reply | Permalink