Refuse the mandate. Civil disobedience is the answer, if they try.

Synch I like your leadership on this issue. It's phenomenal what the power of one voice can do.

http://www.youtube.com/watch?v=fVq_fdtIVbE

Sorry Fred.

No Mandate unless the insurance companies are restrained from profiting off of a basic plan. They should not be rewarded or encouraged to impliment business plans that profit from basic healthcare. This logic would contribute toward your overall concern about costs. Its a mess, I know, but insurance companies profiting off a mandate makes it much much worse...I'm talking people in the street worse.

First, I appreciate the thoughtful, temperate responses to my comments above. Where I disagree, however, is with the implication by others that the public option is central to reform (see the link in my first comments above). If it were, it would make sense to hold the mandate, which I believe is in fact central, hostage to the passage of a public option.

I won't rehash all the evidence, which again can be found in my earlier blog, but I'll impose a couple of repetitions on readers here.

First, cost control. The message is simple - this is not an insurance industry issue, but a healthcare industry issue. Despite some suggestions by others, insurance industry costs are reasonably well contained, the containment is not likely to change with or without a public option, and squeezing insurers would reduce costs only slightly. If a public option were implemented in the manner currently proposed, a family with an annual premium of $!3,000 might see it drop to about $11,500 - not meaningless, but not dramatic either - and rates would continue to rise at rapidly over time in either case. Insurance industry profits have consistently run at about 3-4 percent (less than 2 percent of total healthcare costs), their overhead has been about 11 percent of their budgets (about 5 percent of total healthcare costs), and their medical loss ratios (the fraction of a premium dollar spent on medical services has consistently run at about 85 percent. That figure is in fact written into proposed legislation, and so the fear that private insurers are about to embark on wild profiteering is unfounded.

Insurance inequities. This is by far the most devastating consequence of current insurer practices - not excessive profiteering. Given the excessive costs charged by healthcare providers, insurers attempt to keep premiums affordable by excluding high risk individuals - those who are ill and those with significant pre-existing conditions - in some cases, the latter can buy individual policies but at unaffordable dicriminatory rates. This is what the current proposal will fix, and this is what will transform the system from one that unfairly singles out millions of individuals whom nature has penalized with illness to imposel the additional penalty of uninsurability.

However, it is impossible to require insurers to accept high risk individuals if low risk individuals can opt out of the system (until they get sick and become high risk). That would transform a system that is now unaffordable for some into one unaffordable by practically everyone, because average premiums would rise to reflect the much greater average risk.

In my fervently held view, holding the millions of Americans who are currently deprived of affordable coverage hostage to political demands for a public option of only modest benefit is terribly unfair to those millions. No other nation would contemplate such an approach, and none has - every other nation, in one way or another, mandates universal coverage in order to guarantee appropriate risk sharing, and therefore universal affordability.

Without a mandate, there will be essentially no reform passed, because no-one in Congress will impose skyrocketing premium charges on the selectively high risk population who would be the ones left insured. Absent a mandate, reform of the terrible inequities that now prevail is dead. It is why right wing activists are pressing hard to defeat a mandate, including attempts within state legislatures to exempt individual states - attempts that will probably prove unconstitutional.

The issue of affordability for those mandated to acquire insurance has been raised. Current proposals will subsidize, in whole or part, premiums for low income families, and in rare cases, exempt individuals from a mandate. Those who can afford insurance but refuse it will be required to pay a tax penalty to help defray the costs of subsidies for those who can't afford premiums. If there is to be debate or demands on the proposed reforms, it should be to make sure that insurance is affordable for all, not that it is optional for all.

Because high costs are primarily a healthcare system problem rather than an insurance problem, remedying them will not be quick or easy - the system is much too chaotic and complicated. The reform proposals make a start, and should be passed for that reason. Medicare will be a crucial player, because it possesses the leverage to pressure providers to become more efficient in providing value for money received. It has not yet begun to apply that leverage effectively, but proposed changes will help. Given the numbers involved, it will have far more power to drive down costs than a public option. Desirable as the latter might be, it would only play a bit part in the story that will play out over coming decade.

Finally, although a public option in its original form is very unlikely, some type of non-profit presence with some type of public input may well emerge. I would welcome that, but the focus must remain on passing a reform package that results in near universal, affordable coverage. That remains within reach, regardless of the fate of a public option or some facsimile.

Fred I could be wrong here but I suspect that obsession with a public option is connected to the prospect of mandating individuals to help corporations profit from healthcare reform.

Trying to parse this without drastically reforming, nee damn near eliminating the profit incentive from basic healthcare insurance is a tough sell. I'm also not sure we're attributing costs accurately when we measure just their profit and administrative costs. What of the additional costs to providers who have to expend time and energy getting paid by insurers who by definition seek not to pay?

It's not just profit, which is easily manipulated by increasing "costs" including obscene executive salaries. One in every $700 of health care costs in the US went to ONE MAN, the CEO of United Health. There are also many other costs that we pay for in private insurance that have no benefit for actual health care: sales, marketing, underwriting, lobbying, palatial offices, jets and cars, the entire claims denial departments, etc. Further, the insurance companies are lousy at negotiating with providers (or not actually trying). Medicare pays doctors 19% less and hospitals 25% less than private insurers, yet 97% of doctors and nearly all hospitals accept new Medicare patients, the same rate of private insurance patients they accept.

By the insurance industry's own analysis, their overhead + profit is 16.7%, while Medicare's (also by their own analysis)is 3.3%. The cost savings of a Medicare-for-all option is thus 33% to 39% less than private insurance. That's even including the 13% waste and fraud in Medicare. The absolute lowest hanging fruit for cost savings on total health care costs is the elimination of private for-profit insurance. Nothing else proposed even comes close. All other cost savings are negligible (0.5% for tort reform for example).

The next round of cost savings is not even possible in this country at this time. When even covering a discussion of "living wills" and such is decried as "death panels" there is no way we can address the fact that end of life care costs far too much as a % of total health care cost. We have a lot of growing up to do before we can discuss savings through limits of care (rationing! death panels!).

Finally, it seems to me there is an internal inconsistency in your position. For-profit insurers can only eke out a piddling 3-4% profit (oh and a piddling $700 MILLION for one CEO) by denying care, dropping customers and refusing anyone they consider high risk (pre-existing conditions for example). So how can they survive without those strategies? How much more will it cost us if these are outlawed? Private insurers are losing 14,000 customers A DAY. How long can they sustain that? The problem with waiting is that if these companies fail, we will "need" to bail them out. ("If we don't, millions of Americans will be without coverage.") ONLY if there is a public option can we say "sorry, folks. We're plumb bail-outed out."

What the somewhat conflicting and generally highly informed and insightful comments in this thread have done for me, is to reinforce my ORIGINAL instinct: Other developed societies have dealt with this enormously complex issue in the broadly similar ways they have (ie, primary basic government funding, with varied lesser mixtures of private or public supplements) for a REASON.

That reason would appear to have less to do with the notion that they are all "socialists", and rather MORE to do with the fact that they are genuinely interested in trying to manage the intricate Health Care needs of their populations in a manner that is compassionate, straightforward, realistic, and rational at the same time.

I have said in here before that one of these days, that's where WE will be - not because we are revoluntionaries or radicals, but because that is where good Yankee common sense will eventually take us. I see the public option as an overall good first step on the long road to good sense, but I ALSO agree with those who say it is not enough by itself to assure real reform. 'Real reform' is going to eventually be a single-payer type system, or some as yet unknown, uniquely American variation thereof.

In the meanwhile, tinkering and patching at the margins should not do much harm, and MIGHT even do a little good. Either way, it's something we just have to get out of our system. Until it is proven by practical experience that tinkering won't work, it seems to be the best we can do at the current level of political energy.

Fred, I have to disagree with many of your points. You claimed that Medicare cost has increased at the same rate as private health insurance (PHI). According to CBO, over the 17 year period Medicare +202%, PHI 246%. But PHI avoids high risk patients and those over 65. If they can't handily beat the increases in Medicare with their cherry picked low risk patients, what makes you think that banning the cherry picking won't cause their rates to skyrocket? Indeed, I would argue that there is no way PHI can affordably cover all those they currently refuse to. In fact, as this article points out, just comparing the core demographics of each system shows that health spending by 19-64 demographic (what PHI caters to) always costs less than the 65+ demographic and the cost increase should be lower as well. No surprise there I hope.
http://healthaffairs.org/blog/2009/06/05/dangerous-confusion-on-medicare-cost-control/
The article also points out that if we adjust the denominator in the cost per patient number to reflect the graying of our population, the PHI number is actually 270%.(assuming population of 19-64 year olds with PHI declined 6% during that time)

It's important to remember that the population served by Medicare is completely unattractive to PHI companies. They KNOW they can't compete with Medicare and don't want these high risk patients. There IS no for-profit solution for the elderly, and I believe the same applies to the other "undesireables" with health problems or risks. PHI only maintains its costs by avoiding risk. Forcing them to cover the riskier populations will cost us dearly. We need a public option. If PHI can beat it, fine. I'll bet they can't.