Is it meant to be reassuring that, nine years into the fight, it isn't news that the enemy is stronger that it was when the fight began? 

I don't think so, and the attempt to make it seems so points up how ludicrous the entire operation has become.

"Have the American people outlived their usefulness to the rich minority in the United States? A number of trends suggest that the answer may be yes.

"In every industrial democracy since the end of World War II, there has been a social contract between the few and the many. In return for receiving a disproportionate amount of the gains from economic growth in a capitalist economy, the rich paid a disproportionate percentage of the taxes needed for public goods and a safety net for the majority.

"In North America and Europe, the economic elite agreed to this bargain because they needed ordinary people as consumers and soldiers. Without mass consumption, the factories in which the rich invested would grind to a halt. Without universal conscription in the world wars, and selective conscription during the Cold War, the U.S. and its allies might have failed to defeat totalitarian empires that would have created a world order hostile to a market economy.

"Globalization has eliminated the first reason for the rich to continue supporting this bargain at the nation-state level, while the privatization of the military threatens the other rationale."

Click here to read the full article

I believe this to be the most important and difficult issue we face. We have given over control of our country to a class of people that is no longer invested in the well-being of the country. 

Thanks to Michael Lind for writing this, and to Salon for publishing it. 

Thank you, barth. I was afraid people weren't going to notice, what with all the shock and awe over General Mac Crystal (is that why he's so skinny?) running that Afghanika Corps HQ over there.

The Baptists are onto something. The prayer field surrounding Little Rock is getting bigger every day. There's a twenty-foot-high and seventy-foot long billboard at each end of town now, on I-30, with nothing but the simple word "JESUS" on each one, in block letters big enough to read from five miles away. That says it all. That way, you know right when you're entering Jesus, and right when you're exiting Jesus. It's like Jesus is Lord over Little Rock and he want's you to know it, too.

I go through there sometimes because it's in my home state, Arkansas. You can feel it. It's like a hum or something. And I'll say this. Ever since they started the Baptist construction boom, Mexico has been getting farther away from Little Rock. Receding. You don't even read much about it in the Arkansas Democrat-Gazette any more, that's how effective it is.

They can keep their Mexican Drug War down there anyway. We got Ozark Electric Green and anybody can cook up a batch of Crystal in their own kitchen, like that old fieldstone house around the corner from me... But that's another story.

What we're doing wrong in Afghanistan is so easy to figure out. Who knew Rolling Stone would get it first?

You got to give those people something to look forward to, a hope of things to come. Not in this life, of course. Steeples are a good start. Better than domes because they stick up higher and, you know, look tall and firm, not all soft and round.

Wednesday Bible studies would be a good way to start. You could do that before you even finished any churches, and pretty soon all those people would be dropping a little something in the hat for the building fund. Before you know it, this war would be paying for itself, just like the one in Iraq.

You could throw in some pot luck dinners. When I was a kid we'd have an all-day-singing-and-dinner-on-the-ground with somebody talking about John the Revelator to stir up more interest and raise a little money. I bet that would wow them. Rock of Ages. Church in the Wildwood. A Closer Walk With Thee. Softly and Tenderly. Blest Be the Tie. The Doxology. (Okay, I let it slip. I grew up Methodist. Anybody catch the clue?)

You get this force field effect when you build the churches. A ring of them makes a bigger field. Inside the ring all the missionaries are safe to operate. Like one ring, you know, to bind them. Then they can do their job.

Just build Baptist churches all over there. (Methodist churches would be okay but I don't think they'd be as potent.) You got to get the steeple height right, though. The altitudes of the steeples need to be 7/6ths higher than the altitude of any dome or round-shaped object occurring within a perimeter defined by how far Sampson could fling a Philistine from the top of the steeple. Pretty far. You might wonder about 7/6ths but that's easy, too. Seven because that's the number of spiritual perfection (He rested on the Seventh day, remember?), and six because that's the number of man (see, the Serpent was created on the Sixth day), so everyone knows that Spiritual Perfection is higher than Man.

Once the power ring gets going, and the missionaries do their work, it makes it safe for the politicians. I worry that they don't properly understand politicians over in Afghanistan. But we've got two right here in Arkansas that can get the job done for them.

First there's Mark Pryor. He's a Senator, like his Daddy before him. Little Mark (we love him down here) carries a Bible when he makes campaign commercials, and he's got the right attitude on science and all. It's like when Bill Maher asked him about evolution he said "The scientific community is a little divided on that."

Mark is on the side of all those scientists who have done the research to prove that the earth is just a bit over 6,000 years old. But best of all, when Bill Maher said he was worried that there are people running this country who really believe in a talking snake (like in the Garden of Eden), Mark reassured him with "You don't have to pass an IQ test to be in the Senate." What a wit! See, that's what we need more of.

So Mark gets it and he could go to Afghanistan first and prepare a place there in that ring of newly-constructed Baptist churches for Blanche Lincoln.

Blanche, for those who don't know her, is a little gal from over at Helena. Cute as a bug when she showed up and said she'd like to be a politician, too! She's a little long in the tooth, now, of course, but still smart as a whip! She's another Senator. She could go over there and help Mark out. Mark would concentrate on the important stuff like building private schools and getting the government to give people vouchers to pay the tuition, while Blanche could be helping out with the health care so everybody has a better life. Blanche has friends in insurance companies that would know just what to do. And she's got good friends at Walmart too, so pretty soon all those Afghans could be buying anything they want straight from China.

Well, this is getting to be too long. I really just wanted to say thanks to barth for reminding everyone that the Rolling Stone *hearts* Baptist churches.

Want to know what the end of the world is like? Want to meet someone who hasn't had the fight knocked out of her?

• Watch and listen.

Update: just as I was posting this I went back to check the link. Guess what? It disappeared!

So I changed the link to the one above. Don't be surprised if it, too, is gone by the time you try to connect to it. (I read somewhere that it's a PBS video that they don't want shared.)

Fortunately, someone else taped the same thing. You can see it here, in two parts:

• Part One

• Part Two

With Senator Reid's announcement, we appear to be putting the finishing touches on dividing the health insurance risk pool in two:

• The high-risk public pool of elderly, unemployed or underpaid, chronically ill and dying individuals, along with children of low-income families, and
• The low-risk private pool of relatively healthy, employed and decently paid individuals.

The health care costs of the high-risk public pool are paid for with public funds. The health care costs of the low-risk private pool are paid for with private funds.

Here's the makeup of the high-risk public pool, broadly speaking:

• Medicare covers everyone over 65 along with end-stage renal disease patients, totalling about 35-40 million.
• Medicaid covers about 50 million low-income individuals, mostly children, pregnant women, elderly (dual eligible) or disabled. Among those covered by Medicaid are people whose very expensive chronic illnesses have caused them to "spend down" their assets to the point where they no longer have the ability to pay for health care.
• The limited public option, restricted to those qualified to participate in the insurance exchange and estimated to cover about 10 million people. The exchange risk pool will be a grab bag, including some self-employed, some employed by small companies, some unemployed and underemployed, some chronically ill with assets too high to qualify for Medicaid, and so on.

The high-risk public pool will cover 90-100 million Americans. The low-risk private pool will cover 180-200 million Americans. 10 or 20 million will remain uninsured and continue to drain the public and charitable side of the system.

Private health plans will operate in both the low-risk and high-risk pools. Public plans are forbidden to operate in the low-risk pool.

What we have here is reverse cherry-picking. Private insurors may no longer be able to deny coverage for pre-existing conditions, or cancel coverage when you need it most, but they are rewarded by a system that provides no public-sector competition in the lucrative low-risk private pool, and will drive more and more of the highest cost patients into the high-risk public pool.

There is only one risk pool that makes any sense, and that is "everone." Absent a public option that is available to everyone (the "E" in Medicare E) there remain too many ways for private insurors to game the system, skimming the more profitable portions of the pie while avoiding competition where it could truly make a difference.

Rejoice that the Senate can say "public option." Now it's time to be sure the words mean something.

Wall Street mover/shaker now accepting offers:

Creative financier. Talented rainmaker. Innovative lender.

Recent Achievement Example: accepted $1.2 trillion from Federal Reserve, non-recourse, at 0.0001% annual interest rate. Invested in T-bills at 4%. No risk, remarkable spread. Infinite ROI a/c zero capital requirement. Returns $48 billion annually. How's that for creative financing?

Reason for leaving present position? Kenneth Feinberg says I can't have my 10% of $48 billion earned commission. #@&*! government thinks it can do my job, just let them try it.

Currently vacationing in the Seychelles. Interested parties may apply by leaving a message on my cell phone. Phone messages that do not clearly specify the compensation package will not be returned. All offers will be considered on a first come, first served basis. Do not leave multiple messages, because that's needy.

After you read it, you may be moved to help BlueAmerica encourage the good Senator from Arkansas, and others like her, to support real health care reform. Maybe we can remind her that the path she, Mark Pryor and Mike Ross are pursuing is pretty much responsible for Arkansas being ranked 48th among the states in health care.

--

Moderator: Hello and welcome to Senator Lincoln's Health Care chat. The Senator is looking through the initial submissions now and she'll post the first question and answer shortly.

In the meantime, you can use the chat box at the bottom of screen to submit your own question. Please be sure to include your first name and your city so we can identify you.

Thanks for being a part of this. We'll be underway shortly!

5:03
Moderator: First question was submitted in advance by email from Larry:

Given the very dismal records of the government in managing social security, medicare, medicaid, welfare, and just about every other government-run program, please explain to me why any of us should believe that the government is going to be any more effective at running health care?

5:06
Sen. Blanche Lincoln:
Larry, I understand there are many areas where government must perform better. However, at least three of the programs you mentioned, Social Security, Medicare and Medicaid are the most successful social programs in the world.

Without Social Security, millions of elderly Americans would have lacked the basic necessities in their later years. It covers virtually everyone and is fully portable from one job to another. And, it's remarkably efficient. Less than one percent of annual income is used for administration.

We need to build on the success of Social Security, Medicare and Medicaid to ensure the fiscal solvency of these programs for generations.

5:09
Moderator: Next question was submitted by Blake over email in advance.

As a doc in the Delta area, hi unemployment, few industries, I am so tired of seeing patients who wait til the last minute to come for what turns out to be either a TERMINAL diagnosis, or ADVANCED disease diagnosis, with subsequent shortened life span. WE MUST HAVE reforms! Insurance for all so NO ONE is afraid they CAN'T afford to come to the doctor or get expensive tests or Xrays, or can't afford the drive to the specialists that in our case our greater than 1 hour away! The "Medicare" for all seems good, but the insurance industry also must change.

5:11
Sen. Blanche Lincoln:
You make a strong case for why we can't afford to do nothing about health care. Health care delivery in much of our rural state is challenging and expensive.

Consumer health care costs in Arkansas are rising five to six times faster than wages. I am supporting reforms that force the insurance industry to accept customers with pre-existing conditions and prevent those companies from dropping you when you get sick.

5:11
Sen. Blanche Lincoln:
I want medical decisions back in the hands of patients and doctors, not government bureaucrats and now insurance bureaucrats that routinely deny coverage for pre-existing conditions.

5:16
[Comment From Ray and Judy ]
We are terribly disappointed that you have caved in to the insurance industry and failed to support the public option for health care. It may very well affect our vote for you in the next election.

5:27
Sen. Blanche Lincoln:
Sorry for the delay. We had a little technical difficulty. This is the first time we've tried something like this.

Unfortunately the insurance companies opposed the bill I supported in the Finance Committee. There are many ways to provide greater options and choices to indivudals, including non-profits, a state plan, and a co-op plan.

5:28
[Comment From Nathan - Rogers ]
As long as hospitals and insurance company executive are paid based on the profits their comapnies make, how can we expect the focus to be on the patient without a public option?

5:29
Sen. Blanche Lincoln:
We're changing that by changing the rules for insurance.

They can no longer deny you based on pre-existing conditions. They can no longer drop you when you become ill. They can no longer charge you more based on your gender.

And thanks to my amendment in the Finance Committee, taxpayers will no longer subsidize enormous excutive compensation.

5:31
[Comment From David Loenneke ]
Senator, I know your schedule is terribly busy, but would you commit to holding several meetings in person around the state to discuss health care reform? It is obviously a topic of great importance to the American people.

5:34
Sen. Blanche Lincoln:
You are exactly right. It is critically important to the American people and our economy.

I have had legislation in Congress every year since 2004 to reform small business health care access. I held public hearings in April and again in early September around the state and through avenues like this online chat and our website.

I will continue to reach out to hear your concerns. I know how importan this is to all Arkansans.

5:35
[Comment From Jesse Barr, Winslow, AR ]
Changing the rules will not work! The insurance companies will stall and obfuscate and pay any fines as a cost of doing business! Competition is the ONLY way to make the insurance corporations change their behavior!

5:37
Sen. Blanche Lincoln:
I share your views. Providing competition and choice is the best way to make insurance companies change their behavior and be more competitive. It is also the best way to provide more affordable choices for people. Changing the rules is the first step towards forcing the competition.

5:39
[Comment From Shannon, Little Rock ]
Did the bill you supported in the Finance Committee have a public option?

5:40
Sen. Blanche Lincoln:
It had a co-op plan that was run by its members, was completely solvent, met all of the rating and minimum standard rules, and any profits made had to go back into the co-op to be applied toward bringing down costs of premiums.

5:41
[Comment From Matt - Springdale ]
How can a private business compete with the gov't on an even playing field? The gov't doesn't have to make a profit. The feds can keep racking up more debt while they put regular insurance companies out of business.

5:42
Sen. Blanche Lincoln:
You make a good point. So far the public options offered have put government in the role of either subsidizing plans or running them. And please note that the finance committee bill was deficit neutral.

5:44
[Comment From hershey from fayetteville ]
senator, please get this right - don't give our seat to the republicans

5:45
Sen. Blanche Lincoln:
My first concern is about how health insurance reform will affect the people of Arkansas. I know that I will be accountable at the next election, but this issue is not about politics. It's about people, it's about our country, and it's about our state.

5:47
[Comment From Judith and Les, Randolph ]
Under current rates....too many Arkansans will be left without insurance forever. There are too many low level minimum wage earners....where do they fit in without a Public Option?

5:49
Sen. Blanche Lincoln:
In the bill I supported last week, we worked hard to provide meaningful subsidies for low income families, to create exchange pools similar to federal employees like myself where small business and the self-employed can choose from multiple options just as I do.

We also provided meaningful tax credits for small business to help with their employees.

5:51
[Comment From Barbara, Heber Springs ]
Is there some way small companies can 'piggy back' on to large corportations insurance policies, or be 'adopted' by them. If a large corp. had 1,000 employees covered, could the small company 'join' it and make it a corporation with best prices that now has 1025 people?

5:52
Sen. Blanche Lincoln:
Under our bill there is no need to because we create an exchange pool that allows small businesses to combine themselves to have the same negotiating power that major corporations do.

5:54
[Comment From Kevin ]
Judith response ...put them on Medicaid -- most probably qualify, but the admin forms, and eligibility is horribly confusing!!!

5:56
Sen. Blanche Lincoln: Kevin is right. We have 500,000 Arkansans who are uninsured, approx 77,000 are children and 2/3rds of them are eligible for ARKids First.

A large portion of the uninsured in Arkansas are eligible for Medicade.

I advocate automatic enrollment and allowing them to opt-out if they choose to go to the exchange. It's crazy to try to create new programs for individuals who already fit into programs that work.

5:58
[Comment From "Doc" - Fayetteville ]
It seems to me that you are more inclined to keep insurance companies in the health care business than you are to see people provided health care... Please comment. Do insurance companies NEED to sell health care policies to survive?

5:59
Sen. Blanche Lincoln: We already have an employer based, private health care system. We are trying to make it more affordable for everyone. We can't just throw it all out and start over, but we can make it more efficient and more affordable for everyone.

6:05
[Comment From Stan Wilson ]
Again why are you opposed to a public option or everyone having the same health care options that you have?

6:05
Sen. Blanche Lincoln: That is exactly what I am for.

I am for expanding health care options for everyone just like the options that I and 8 million other federal employees have. Today the state of Arkansas has one or two options for customers. My goal is to expand that to dozens of choices.

6:06
Sen. Blanche Lincoln:
That's all the time we have for today. Thanks so much to everyone who participated. I'm so grateful to know that so many Arkansans are engaging in this critical national debate.
Talk to you all again real soon.

6:07
Moderator: We received hundreds of comments from folks across Arkansas, and the Senator couldn't answer each of you directly. We'll be doing events like this again in the near future. We'll be sure to let you know.

Thanks again.

Most of the excess [in health care costs] resides within healthcare itself, in the form of duplicate or unnecessary facilities, test, procedures, and specialty referrals driven by a fee for service paradigm that rewards excess.

and PseudoCyAnts asks a very good question:

any decent study citations to go along with this? it has the feel of conventional wisdom, which far too often is in error.

Since Pseudo's question isn't answered, I thought it might be worth starting a new thread.

We can agree there is some level of waste, duplication and even fraud, and that it should be contained as much as possible. The question is whether waste and duplication on the part of providers actually do account, as Fred avers, for "most of the exceess" in health care costs.

The Christian Science Monitor recently ran an op/ed by Dr. Arthur Gerson, former dean of the University of Virginia School of Medicine. Here's a quote:

Our current healthcare spending is approximately $2.1 trillion (that's up from $1.3 trillion noninflation adjusted in 2000). We waste an estimated one-third – or about $700 billion – on unnecessary procedures, unnecessary visits to the doctor, overpriced pharmaceuticals, bloated insurance companies, and the most inefficient paper billing systems imaginable.

Dr. Gerson doesn't quote his source, unfortunately, but if it's a good source our search for waste and duplication must extend well beyond health care providers, to include "overpriced pharmaceuticals, bloated insurance companies" and more.

Information published by The Commonwealth Fund, one of the go-to NGOs when it comes to health care research and quality advocacy, provides some support for looking beyond just the providers. You may find this Web page interesting. It contains a series of charts entitled, "Universal Health Insurance: Why It Is Essential to Achieving a High Performance Health System and Why Design Matters Charts."

One chart here, entitled "Health Expenditure Growth 2000–2005 for Selected Categories of Expenditures," shows growth in the following cost categories [if I knew how to do it, I'd reproduce the chart]:

• 12.0% – Program administration and net cost of private health insurance
• 10.7% – Prescription drugs
• 8.6% – Hospital care
• 7.9% – Physician & clinical services
• 6.1% – Nursing home & home health
• 8.6% – Total

Another Commonwealth page of interest here is entitled "Overuse and Duplication/Waste Charts." (click for Web reference).

Beyond waste and duplication, and perhaps even more costly, is our inefficiency in treating chronic diseases. The fragmentation of our health care system, with it's competing interest groups and agendas, causes a lot of this inefficiency.

The CDC makes a very plain statement about this (click for Web reference):

Chronic diseases – such as heart disease, stroke, cancer, and diabetes – are among the most prevalent, costly, and preventable of all health problems.

According to the CDC (click for Web reference):

• Chronic diseases account for 70% of all deaths in the United States.
• The medical care costs of people with chronic diseases account for more than 75% of the nation’s $2 trillion medical care costs.
• Chronic diseases account for one-third of the years of potential life lost before age 65.

If chronic diseases account for 75% of health care costs, and attendent suffering, we might want to look at what's driving those costs and whether there's a way to bring them under control. We might especially want to know if there could be a connection between providing better care and controlling costs.

Insurance companies, acting rationally as we expect for-profit corporations to do, control their own costs of chronic disease by refusing coverage, refusing treatment, and recision. The diseases don't go away, though, and the costs get dumped on non-profit hospitals and Medicaid. In other words, the excess cost of refusing intelligent treatment for chronic diseases is passed on to you and me. Meanwhile, there is more suffering than there needs to be.

One of the Commonwealth charts (see links, above) is entitled "Adults Without Insurance Are Less Likely To Be Able To Manage Chronic Conditions." The chart illustrates the following:

• Uninsured patients are three times more likely to skip their medications due to cost than are insured patients.
• Uninsured patients are 2.2 times more likely to be hospitalized or visit the ER than are insured patients.

Another chart, with a very long name, shows that putting caps on drug reimbursements increases the number of more adverse consequences suffered by patients, off-setting the savings in prescription costs.

The Robert Wood Johnson Foundation is another NGO that focuses a good bit of attention on chronic care (click for Web reference). Here's a quote from RWJ:

[Deficiencies in current management of chronic diseases] include:

• Rushed practitioners not following established practice guidelines
• Lack of care coordination
• Lack of active follow-up to ensure the best outcomes
• Patients inadequately trained to manage their illnesses
  

Overcoming these deficiencies will require nothing less than a transformation of health care, from a system that is essentially reactive - responding mainly when a person is sick - to one that is proactive and focused on keeping a person as healthy as possible.

Transforming complex systems, like health care, is not easy to do. Organizing the energies and agendas of doctors, hospitals, nurses, technicians, patients, consultants private insurors, Medicare, Medicaid, and innumerable other interest groups requires more than just research and advocacy. It requires leadership than can transcend the inevitable internecine squabbling. That's why I believe that single-payer universal coverage is the best way to achieve the transformation RWJ advocates.

But back to our discussion. There's no doubt that controlling waste and duplication will help save costs and, done correctly, improve outcomes. But we need to keep our eye on the prize. Affordable, high-quality health care for everyone.