« More Desperation from the Right | Robert Reich's Blog | Why Wall Street Reform is Stuck in Reverse »
Why Obama Has to do What Letterman Did: Refuse to Pay Hush Money
Last January, as I understand it, the White House promised Big Pharma, big insurance, and the American Medical Association the moral equivalent of what Joel Halderman allegedly demanded of David Letterman: hush money. The groups agreed to stay silent or even be supportive of healthcare reform, as long as they were paid off.
But now that it's time to collect, the bill is larger than the White House expected, and it's going to fall like an avalanche on middle class Americans in coming years. That could mean an ugly 2012 election (read Sarah Palin).
So the President has to do what Letterman did: Refuse to pay.
Big Pharma is on the road to getting its deal: not only 25 to 30 million more paying customers, but also a continued ban on Medicare using its bargaining clout to reduce drug prices, a bar on genetic drug manufacturers introducing similar biologic drugs until the originals have been on the market at least twelve years, and no public insurance option to negotiate low drug prices. (Big Pharma did agree to $80 billion of cost cuts over the next ten years, to be sure, but its hush money payoffs far exceeded that sum.)
Big insurance is well on the way to getting what it wants: 25 to 30 million more paying customers (many of them young and healthy), a requirement that almost all businesses "pay or play," and no competition from a public option.
Doctors (that is, the American Medical Association) are on the way to getting what they want: Instead of a temporary patch on scheduled decreases in Medicare reimbursements to them, a permanent fix that would change the reimbursement formula altogether and reward them $240 billion over the next ten years.
But when they all get paid off, who will do the paying? Middle-class Americans who are already in a financial squeeze -- whose wages are lower, adjusted for inflation, than they were thirty years ago, and whose jobs are disappearing. They'll face still higher premiums, co-payments, and deductibles; and they'll pay higher drug prices, Medicare premiums, and taxes to cover the rest.
That's because these payoffs make it next to impossible to contain the wildly escalating costs of health care. And 25 to 30 million additional Americans will be covered.
The only thing in the emerging bills that's related to cost containment is a proposed excise tax on so-called "Cadillac" insurance plans, priced over a certain threshold amount (the threshold is now up for grabs). But because the costs of health care are likely to rise faster than inflation, whatever the threshold, the middle class will get socked again.
So Obama has to forcefully weigh in with Nancy Pelosi and Harry Reid as the two try to cobble together passable bills for each chamber -- demanding real cost containment.
The three big means of containing costs: (1) A true public option (better yet, one that allows anyone now holding private insurance to opt into; (2) authority for Medicare to negotiate low drug prices; and (3) lower Medicare reimbursement rates to doctors (in other words, no "doctor fix").
In addition, the so-called "medical exchanges" in the emerging bills (as well as the public option, which hopefully will be included) should give preference to pre-paid heathcare plans, like Kaiser Permanente, whose doctors are on salary and have every incentive to keep people healthy rather than charge for more services and tests.
But if Obama doesn't weigh in forcefully and say "no" to the hush money for Big Pharma, big insurance, and the AMA, America's middle class will get walloped. And if the walloping starts before 2012, Sarah Palin or some other right wing-nut populist will wallop Obama. And after she or he wallops Obama, America will get walloped even worse.
But now that it's time to collect, the bill is larger than the White House expected, and it's going to fall like an avalanche on middle class Americans in coming years. That could mean an ugly 2012 election (read Sarah Palin).
So the President has to do what Letterman did: Refuse to pay.
Big Pharma is on the road to getting its deal: not only 25 to 30 million more paying customers, but also a continued ban on Medicare using its bargaining clout to reduce drug prices, a bar on genetic drug manufacturers introducing similar biologic drugs until the originals have been on the market at least twelve years, and no public insurance option to negotiate low drug prices. (Big Pharma did agree to $80 billion of cost cuts over the next ten years, to be sure, but its hush money payoffs far exceeded that sum.)
Big insurance is well on the way to getting what it wants: 25 to 30 million more paying customers (many of them young and healthy), a requirement that almost all businesses "pay or play," and no competition from a public option.
Doctors (that is, the American Medical Association) are on the way to getting what they want: Instead of a temporary patch on scheduled decreases in Medicare reimbursements to them, a permanent fix that would change the reimbursement formula altogether and reward them $240 billion over the next ten years.
But when they all get paid off, who will do the paying? Middle-class Americans who are already in a financial squeeze -- whose wages are lower, adjusted for inflation, than they were thirty years ago, and whose jobs are disappearing. They'll face still higher premiums, co-payments, and deductibles; and they'll pay higher drug prices, Medicare premiums, and taxes to cover the rest.
That's because these payoffs make it next to impossible to contain the wildly escalating costs of health care. And 25 to 30 million additional Americans will be covered.
The only thing in the emerging bills that's related to cost containment is a proposed excise tax on so-called "Cadillac" insurance plans, priced over a certain threshold amount (the threshold is now up for grabs). But because the costs of health care are likely to rise faster than inflation, whatever the threshold, the middle class will get socked again.
So Obama has to forcefully weigh in with Nancy Pelosi and Harry Reid as the two try to cobble together passable bills for each chamber -- demanding real cost containment.
The three big means of containing costs: (1) A true public option (better yet, one that allows anyone now holding private insurance to opt into; (2) authority for Medicare to negotiate low drug prices; and (3) lower Medicare reimbursement rates to doctors (in other words, no "doctor fix").
In addition, the so-called "medical exchanges" in the emerging bills (as well as the public option, which hopefully will be included) should give preference to pre-paid heathcare plans, like Kaiser Permanente, whose doctors are on salary and have every incentive to keep people healthy rather than charge for more services and tests.
But if Obama doesn't weigh in forcefully and say "no" to the hush money for Big Pharma, big insurance, and the AMA, America's middle class will get walloped. And if the walloping starts before 2012, Sarah Palin or some other right wing-nut populist will wallop Obama. And after she or he wallops Obama, America will get walloped even worse.
Advertisement
"A true public option (better yet, one that allows anyone now holding private insurance to opt into..."
This isn't a "better yet" idea, it's essential. I should have, from day one, the right to tell United Health Group to go jump in a lake. If I don't have that right, than United has no incentive to offer me anything to convince me to stay. Right now the insurers say "Your employer picked us, so you have to either live with it or go try to buy on your own." The insurers are in no way competing for my individual business. A true public option open to any American that wants it changes that dynamic considerably.
But it's not even on the table! Instead we have a mandate that amounts to a subsidy of the private insurance industry. The insurers are getting what any business would want -- a law requiring people to buy their product.
Truly sickening.
October 18, 2009 12:47 PM | Reply | Permalink
Yes, yes and yes.
A public option isn't an option and won't do anything to chance the behavior of the system if you can't opt for it unless you're uninsured.
October 18, 2009 2:14 PM | Reply | Permalink
Corporate interest triumphs over will of the people/the right thing.
Get used to it folks. The SCOTUS already decided that money=free speech and will most likely determine corporations=humans this term.
Don't struggle as they put on the chains, it's all in the name of sacred "stability".
October 18, 2009 3:56 PM | Reply | Permalink
I'd say he needs to get out of the business of hush money to banks and financial corps as well. The huge, quiet bailouts aren't doing us any favors.
October 18, 2009 4:46 PM | Reply | Permalink
The premise that the deal was cut is in error. Nothing in writing--no teeth and only speculation...
There is no bipartisenship--the Baucus bill! is without cost controls, competition, or accountiblilty for the insurance companies!
Why are people ignoring the fact that there are 5 bills in congress...not just the HC Baucus/Conrad pandering one...Think Obama is letting Congress and Corps show their cards before lowering the hammmer. This man is cunning and ruthless. No one can deny --Congress did not do their job and the insurance companies are greedy- now!
October 18, 2009 8:29 PM | Reply | Permalink
And what evidence do you offer that Obama will ride to the rescue?
This is not the first time Reich talked of these Obama deals with the devils. The White House has already admitted to the deal with Big Pharma.
And the deal with the insurance industry sure looks real: Obama and the White House have done nothing but praise Baucus, Snowe and the Baucus bill and pointedly not praised Sens. Brown, Harkin, Rockefeller, et all, who have championed a strong Public Option. Plus they constantly say (as several top WH aides did again on the sunday talk shows) the PO isn't essential.
The fix has been in just as Reich has been saying. What the WH didn't expect, I think, is the strong grassroots and Democratic base agitation for a PO, so they are scrambling now to find some fake sop -- trigger, coops -- that they can dress up as a PO.
Plus this whole dustup over the 60-vote filibuster is cover, as well, I think, for them to excuse themselves from fulfilling their campaign pledge and getting a real public option. If the WH really wanted to put on the screws, they could probably get the 5-8 conservative Dems who oppose the PO to at least vote with their party and overcome a GOP filibuster and then pass a bill with a PO by majority vote.
On that point, MSNBC had an interesting story last week pointing out that in the history of Senate filibuster votes, majority party members have never sided with the opposing party on party-line votes. Though I suppose if any party was going to do it, it would be the Dems.
October 20, 2009 12:27 AM | Reply | Permalink
What did people expect? Obama has never been for a public option or mandated health care.
October 19, 2009 5:20 PM | Reply | Permalink
What you don't say is that, unless Obama reneges on his promise, all those tea party "wingnuts" were right.
Of course, you do say it. You just can't bring yourself to be honest and say the last part of the sentence.
October 18, 2009 12:48 PM | Reply | Permalink
Well the tea baggers certainly had most things wrong -- death panels, etc -- but the public reaction, if this Baucus bill giveaway to the insurance and drug industries is basically the final product, is not too far off from what spider is saying. When people are forced to buy from the insurance industry racket and prices keep going up, the average American is quite likley to rebel by voting in the GOP Taliban again. The details of this reform are too far complicated for the average American to understand. All they will know is that they are paying through the nose and they are mad.
October 20, 2009 12:42 AM | Reply | Permalink
"And if the walloping starts before 2012, Sarah Palin or some other right-wingnut populist will wallop Obama, and then will wallop America."
So be it, then.
October 18, 2009 12:50 PM | Reply | Permalink
"That could mean an ugly 2012 election (read Sarah Palin)."
Surely that couldn't be their strategy?
"Vote Republican extremists back into office or we raise your healthcare costs?"
Spider, you should write your own stuff, if you have an opinion, trying to co-opt someone else to make your stale Rushcult talking points sounds like whining in the wind.
Get a blog.
October 18, 2009 12:53 PM | Reply | Permalink
You've got the cause and effect backwards.
It is: "Raise health insurance costs and the voters will vote the Democrats out of office no matter who is running against them - even Republican extreemists."
.
October 20, 2009 9:37 AM | Reply | Permalink
exactly
October 20, 2009 11:53 AM | Reply | Permalink
Progressives should make their list of populist demands like those outlined by Reich and present Reid and the Administration with a simple choice:
public option open to all, Medicare negotiating authority, lower Medicare rates for doctors, preference given to 'pre-paid' healthcare plans OR no vote on cloture.
October 18, 2009 1:10 PM | Reply | Permalink
But the insurance industry won't support that!
Oh, wait... not supposed to matter. The industry is supposed to obey laws, not make them.
October 18, 2009 1:27 PM | Reply | Permalink
Who says they're not supposed to make them? Do you live in America, on planet earth? Special interests ALWAYS have a say in making the laws which affect them.
Think it through. Do you really want the laws made the ignoramouses who've no real knowledge or experience of what they're supposed to regulate? Do you think there are good substitutes for that knowledge and experience? How would you stop people from acting on matters which affect their livelihoods?
It can't be any other way.
October 18, 2009 6:59 PM | Reply | Permalink
I find it disappointing that Robert Reich, whom I once admired, continues to dogmatize on a subject that he seems to know little about. He is simply wrong in where he places his emphasis on the issues of cost containment and the remedies for excessive costs.
This is not because some of the excessive costs he mentions are fictional, but rather because they are not the most important ones, nor are the fixes he proposes the most important remedies. Medicare managers have already negotiated drug price reductions, and more would be desirable, but as long as the entire system for new drug development remains in place, the future savings will be small. A public option would also reduce costs, but not dramatically. More important, it would do nothing by itself to halt the unsustainable trajectory of rising healthcare costs, which do not reside primarily within the insurance sector. The tax on "cadillac" insurance plans, as well as proposed Medicare reimbursement reductions, are also small steps, with the latter a more complex issue than Reich realizes.
Where he is particularly misguided, however, is in implying that the proposed bills do not address the more important source of cost excess - duplicate or unnecessary facilities, tests, procedures, and specialty referrals within the healthcare system itself, driven by a fee for service paradigm that rewards excess. Reducing Medicare reimbursements without restructuring the system is likely to cause pain without much gain. Fortunately, the proposed bills do make a start at restructuring - increased incentives to engage in primary care vis-a-vis specialization, increased incentives for preventive medicine, penalties for hospitals with excessive readmission rates, pilot programs for alternative payment mechanisms that include various forms of bundled payments as well as integrated care through accountable care organizations, and comparative effectiveness research to identify interventions that work vs those that don't or are harmful. The proposals only take a baby step in that direction, but at least they correctly identify the main sources of cost excess, rather than attributing it to insurers or to failure to negotiate drug prices adequately.
To summarize, Reich has identified small problems that deserve to be rectified, and is engaging in rhetorical overkill in denouncing the lack of what he sees as adequate attention to these, while ignoring the much larger source of excessive costs that truly deserve attention they have not yet received. For more on the major problems related to excesses within healthcare that increase costs without improving care, the work of the Dartmouth group is worth reviewing:
http://dartmed.dartmouth.edu/spring07/html/atlas.php
October 18, 2009 1:48 PM | Reply | Permalink
You're on the right track, but still pretty far off. Our entire culture militates against real reform.
Where, for example, is insistence that medical education be subsidized so that doctors don't come out of 10 years of medical education $200,000 or more in debt? Where is insistance that obese people take responsibility for their condition? Ditto smokers, alcoholics, drug addicts. Where is insistence that health care for the retired by rationed so that the young are not overburdened?
Statistics that strike me every time I hear them are
The healthiest 50% of the population uses only 3% of medical care costs. The sickest 15% uses 75% of the costs. People over 55 use 50% of the costs, over 65 33% of the costs.
All that has to change. The young and healthy can't be expected to provide unlimited subsidies for the old and sick.
October 18, 2009 2:26 PM | Reply | Permalink
Are you by any chance a black widow?
October 18, 2009 2:31 PM | Reply | Permalink
Spider thanks for summarizing the GOP plan. Don't get sick and don't get old. If you do just die.
October 18, 2009 2:35 PM | Reply | Permalink
Bar the part about helping pay for medical education. That would be helping the undeserving...Can't see a Rethug advocating that.
October 18, 2009 8:59 PM | Reply | Permalink
"Where is insistence that health care for the retired by rationed...?"
The old Republican "death panels" approach to health care.
October 20, 2009 9:43 AM | Reply | Permalink
Where is insistence that health care for the retired by rationed so that the young are not overburdened?
If you mean "rationed" in the sense or denying coverage to provide effective treatments for the elderly, that is a view I find objectionable. No other society has found a need to do that in order to control costs, and as a practical matter, it would prove unacceptable within American society as well. Equally important, it's unnecessary, as the link I cited above to the Dartmouth studies will demonstrate. What we need to do is eliminate services that increase costs without improving health. If we do that, we won't need to worry about overburdening the young. The other industrialized democracies have already accomplished this task, and have kept their costs at about half of ours, while achieving health outcomes that are not merely no worse than ours, but actually better. These outcomes include longer life expectancy, demonstrating that we don't need to cut short the lives of elderly Americans in order to control costs.
October 18, 2009 2:37 PM | Reply | Permalink
What we need to do is eliminate services that increase costs without improving health.
You don't know what services can be eliminated as unnecessary for improving health. Was that MRI unnecessary, that CTScan, that lab procedure? All you know is that their use is influenced by who pays. What is clear is that health care and health are two very different things.
No other society has found a need to do that in order to control costs
No other society has been able to control costs. The French system - probably the best in the world - has been forced into passing on those increases to citizens in the form of ever more necessary and expensive private "supplemental" insurance.
You really ought to make more of an effort to become current, instead of just repeating the same old stale talking points.
As for the rest of you - CVille Dem and NobleCommentDecider - no one is stopping you from spending more of your own money to help others. Your own money. Not someone else's.
October 18, 2009 2:57 PM | Reply | Permalink
Spider - The link I provided above demonstrates that it is possible to identify excessive interventions that increase cost without improving health. MRIs and CT scans are salient examples of procedures utilized in vast excess in some regions without any beneficial effect on health outcomes. As a physician, I'm familiar with their excessive use - e.g., a CT scan in the primary workup of uncomplicated headache, and other examples are almost endless.
Because of advances in technology, all nations are experiencing cost pressures, but the other democracies have been able to contain them at lower levels than we do, while improving rather sacrificing health quality. If we emulated them, we would be much better off. None of these nations has avoided cost rises, but it is incorrect to state they have been unable to control costs. The fact that their costs are about half of ours, even as they rise everywhere, testifies to their ability to exert control.
You mention the French system, which is often touted as an example of excellent healthcare, and I agree. The underlying principle there, and everywhere else in the world of civilized democracies, is universality - everyone is mandated for coverage, either via the tax system or through required purchase of insurance. It is our failure to achieve that universality here that accounts for our poor health showing relative to other nations.
October 18, 2009 3:47 PM | Reply | Permalink
I don't object to emulating the French system...but I don't minimize the difficulty of adapting our very different culture to it.
You still minimize the inability of other systems to control costs. Those systems started out with half our costs and they remain at about the same percentage. Since our costs have risen explosively it doesn't take a genius to figure our that theirs have too.
There's certainly plenty of evidence that many common procedures do not improve health. The geographical differences in frequency of use are certainly a good example. You can also point to certain egregious, individual examples. You might even be able to do something about standardizing procedures throughout the country.
But, again, in any particular case there will always be disagreements among doctors among what was or was not necessary.
And, on a much larger scale, there's quite a bit of evidence that much of medicine is totally useless or even counterproductive. These days I hardly meet an adult who isn't on a prescription of some kind (a drug addict in other words) and I have yet to meet anyone who can, with assurance, point to the personal benefit of psychotherapy (an exageration, of course, but barely).
October 18, 2009 4:03 PM | Reply | Permalink
I hate to break your bubble but the young and healthy get old and sick a lot sooner they they'd ever imagine.
October 18, 2009 3:26 PM | Reply | Permalink
You're not breaking my bubble. I'm old...and it happened a lot sooner than I wanted. That's for sure.
I've taken very good care of myself, and I evidently have very good genes, so I have yet to suffer the worst of life's indignities.
But I have decided that when that time comes I won't attempt to prolong my life with every expensive procedure that someone else can afford (or not afford). Whether I will have the courage of my convictions remains to be seen.
October 18, 2009 3:34 PM | Reply | Permalink
My 88 year-old mother would agree but if it were only that simple. She just fell and broke her upper arm, a break that could not be fixed without surgery and a type of break that is rare for a young person. So do you put her on opiods for the rest of her life and get her a room at a nursing home or do you do the surgery so she won't be in pain and has chance to continue living independently (and cheaply). A lot of the stuff done for the elderly is to enable them to live more independently and without pain.
Still, we had to battle Fred's metric driven heartless healthcare system to get her a few days of PT and OT to get her on the road to recovery.
Lord save us from a system based on metrics in total disregard for the person in the bed, young or old.
If it were up to me, I'd fire every care denier and hire a nurse to replace them. As far as I can tell the only people who give a damn in the entire system are nurses.
As for those inexpensive young people, if her surgeon wasn't so obsessed with sports medicine and hanging out at high school football games he might have had more than 5 minutes to spend with her.
October 18, 2009 3:44 PM | Reply | Permalink
No one is talking about denying your mother surgery on her broken arm. Be reasonable.
Also stop fantasizing about the supposed purity of nurses. They're as screwed up as everyone else.
October 18, 2009 4:07 PM | Reply | Permalink
Bluebell? Care to comment? Were the physicians talking about refusing to do surgery on your mom?
October 18, 2009 4:40 PM | Reply | Permalink
Oh, the physician was happy to do the surgery. No doubt he collects from Medicare on that. The heartless beancounting "social worker" wanted to kick her out after 2 days and deny her any skilled care. The nurses and all of her family could figure out she needed a week or so of some skilled PT and OT because being old she has balance issues (that's why she fell) and needed a bit of transition before she went home. But shoulders and arms do not fall under the appropriate metric of the beancounters. Had it been a hip or a heart bypass, the skilled rehab care would not have been questioned. No common sense. No primary care physician even shows up. The surgeon gets his five minutes interrupted by the "social worker" and heads for the hills. Fortunately for mom I am as mean as the beancounters. Who said all this experience ranting was not good practice for the real world.
October 18, 2009 4:52 PM | Reply | Permalink
Now you've got me really curious. Who pays the social worker? I wonder how she ended up having control (or thinking she had control) over medical care issues.
(And yes, it's weird that the primary care doctor doesn't end up even being involved in these decisions--the idea that there's a strong doctor-patient relationship doesn't really fly once you've been through a few situations like this.)
October 18, 2009 5:24 PM | Reply | Permalink
I wish I knew. You'd think she'd work for the hospital. Maybe Medicare is cracking down. I wish they'd focus on what the patient needs first and then figure out who is going to pay for what instead of looking the body part up in a book like an auto part. I swear you get more TLC from the guy doing an oil change and he spends more time with you than your surgeon -- and that is literally true.
October 18, 2009 5:49 PM | Reply | Permalink
How do you think that surgeon will believe when 47 million or so new patients are screaming for his attention?
October 18, 2009 6:07 PM | Reply | Permalink
So you are for rationing care then? Maybe we could retrain all those ivy educated Wall Street schmucks to do something useful.
October 18, 2009 6:44 PM | Reply | Permalink
I am for rationing health care then. And now, because it is done now, not just here but everywhere.
October 18, 2009 6:49 PM | Reply | Permalink
Well, it's not really weird that the primary care physician doesn's show up (unless you're looking at it from the patient's point of view).
PCPs stay away from the hospital. The specialists don't want them there and the PCP's offices are already stuffed with people waiting for the assembly-line 3 minute once-over and prescription of antibiotics and pain-killers they expect to receive.
So no one coordinates care for folks like your mother. Instead, she gets a parade of specialists who barely acknowledge each other's existence. And a social worker with the social skills of a Brown Shirt.
Recognizing this, the medical schools and residency hospitals have created a new cash cow specialization. An MD or DO, with the proper training and residency, can become a "Hospitalist." A glorified case manager. In other words, another stranger in the hospital to shepherd the already strange herd of specialists.
The hospitalist is still not your PCP, however. But that's okay. You only get to see your PCP for 3 minutes at a time, a few times a year, anyway. It's not like he/she knows who you are, so what's one more stranger?
October 18, 2009 9:17 PM | Reply | Permalink
"...folks like your mother..."
Apologies, should read "folks like bluebell's mother."
October 18, 2009 9:19 PM | Reply | Permalink
No worries, I knew what you meant...
October 18, 2009 9:53 PM | Reply | Permalink
...if her surgeon wasn't so obsessed with sports medicine and hanging out at high school football games he might have had more than 5 minutes to spend with her...
Ah, you're just beginning to catch on to the "money driven medicine" thing. Most certainly he sees himself making more money there, and not treating people like your mom.
Hospital nurses, on the other hand, are on salaries or hourly pay. (Not that my experiences agree with your own, I don't find all of them are angels of mercy--some are saints and deserve medals--but there are also plenty of them that are so fed up with hours, or especially, workload, that they don't seem to give a damn.)
Enough experiences like this, maybe you'll eventually start to see that there is no magic coming in a public plan that still is organized around fee-for-service like Medicare is, and then tries to negotiate those individual fee payments hard downward. There will just be more fleeing to where the money is, even perhaps only providing out-of-pocket, no insurance accepted service, if they have made a big enough name for themselves in some popular field (sports medicine, plastic surgery, etc.) and can swing a big enough practice from that.
It's probably a necessary step in the slo motion reform of our system, that we go through that, because too many consumers still believe they should be making all the choices and that drives where the providers go (not to mention things like what kind of drug development is promoted.) But no one should be expecting magic ponies from a fee-for-service system that negotiates those fees hard downward, until we get reform of how doctors and similar providers are paid, not to mention how they are trained and how much it costs them to get that training.
Things like this available on line do not bode well:
http://www.aapsonline.org/medicare/optout.htm
Don't get me wrong. If she had some rare heart dysfunction with which some fancy heart surgeon could make a name for himself at the next heart conference, that heart surgeon might do it, take the Medicare payment gladly, and be really interested in her case and spend a lot of time on it. Because the P.R. from a success could get him higher paying patients. It's all about low prestige and low pay for ordinary wholistic care, and in the end, for those who are smart at loooking out for number 1, it's a business, no longer a profession.
October 18, 2009 8:32 PM | Reply | Permalink
I figure you tend to progress towards the goal you set. Until the goal becomes health CARE, the system can't be fixed.
October 19, 2009 6:03 PM | Reply | Permalink
When that time comes, how will the people caring for you know you've made that decision?
October 18, 2009 4:37 PM | Reply | Permalink
You tell them if you're still a conscious, sentient being. If you're not, the situation is obvious.
October 18, 2009 4:44 PM | Reply | Permalink
While the situation may be obvious to you, it's not so obvious to the health care providers who are currently obligated to keep you (rather expensively) alive in a variety of situations that you might find pretty undignified. I asked the question to find out if you have a health care directive, otherwise known as a living will.
October 18, 2009 4:51 PM | Reply | Permalink
No living will. They're not very effective anyway if you're not there to enforce them. What has to be changed are those laws which force health care workers to keep vegetables alive as long as the money holds out. Good luck with that. The religious lunatics will fight you tooth and nail. Probably much of the Left will too.
October 18, 2009 5:37 PM | Reply | Permalink
I'm afraid I totally disagree. Changing those laws goes into denial of care and death panel territory.
The problem is that dying is a messy business. "Allowing" someone to die is not as easy as you'd think. You hardly ever end up with somebody who's totally brain dead and it's just a question of unplugging the life machine and waiting ten minutes for the inevitable. You've got to make decisions about food, water, medicine, respirators, opiates. And there are a lot of degrees of "vegetable" so you would have to be way more specific about what you mean by that.
Without people's specific wishes written down and somebody designated to enforce them, the default is always going to be to do all we can to keep people alive. That's just the way it is, because at some points it's hard to tell the difference between letting someone die and actually killing them. Nobody wants to be stuck with that, and no way should you leave that decision to somebody else if you have an opinion about it.
And "changing the laws about keeping vegetables alive" ain't gonna happen in the near future. Nor should it.
October 18, 2009 6:21 PM | Reply | Permalink
You missed the last part of the sentence
as long as the money holds out
Once it does, morality flies out the window as well. Economic triage goes on all the time. Go to an emergency room and the first thing they do is find out whether you can pay. If you can't....
It doesn't work that way in Western Europe - yet. But it will as the economic pressures intensify.
October 18, 2009 6:35 PM | Reply | Permalink
Actually, it's easier than you think to let them die. Simply refuse to admit them or refuse further care. Nobody is "entitled" to your services.
That the real problem. People think there's such a thing as "free" medical care. There isn't. All those professionals who design and manufacture the machines, research and test the drugs, build and maintain the facilities, diagnose the problems and administer the care must be trained. There aren't that many good ones no matter how good the training. And they must be paid. More often than not, paid extremely well.
So there are only two important questions. Who pays? And how much can he, she, they afford? No money? No workee.
October 18, 2009 6:45 PM | Reply | Permalink
So let me get this straight. You want care until you run out of money. And at that point you want us to look in your pockets for an envelope containing a dollar to cover the cost of wheeling you down the hall and dumping you in front of the hospital to die?
Remember to enclose an extra dollar if you want to keep the gown.
Seriously, dude. That just makes no sense.
October 18, 2009 8:07 PM | Reply | Permalink
I'm just describing how the world works. If you can't pay somebody else must. If they can't or won't you don't get care...or anything else.
October 18, 2009 10:46 PM | Reply | Permalink
Fred, I know you really believe what you say, but there are many of us who are not stupid, who disagree with you. Reich is one, and I am another. Not to be rude, but I don't think you have the right to accuse anyone else of "rhetorical overkill."
See bloodnok's comment below. Who, in Italy, the UK, Spain, or Japan makes 7 figure salaries to run their healthcare? How many bureaucrats do they have compared to our multi-layered, and paper-strewn system? How much do the health-care providers in those countries spend on advertisement? Do they even HAVE health-care lobbyists (think of the multi-millions that have been thrown at Washington in the past year)?
And finally, in those countries, does anyone LOSE coverage for any reason at all? Do health-care costs bankrupt any of their citizens?
I cannot comprehend your argument that duplication of tests, unnecessary procedures, etc are the problem, and THEREFORE we should only address those issues! Why not have affordable coverage (which will only happen with a Public Option - the insurance industry promised us that last week); AND STILL TACKLE the money-wasting issues you so correctly bring up?
Does it have to be either-or? Why not do all the things that will make the system better?
October 18, 2009 2:30 PM | Reply | Permalink
Please see my above comment and the attached link, Cville, which already attempt to address some of your points. I favor insurance reform and a public option, but what I was pointing out is that insurance reform alone (including a public option), without restructuring of the healthcare system, would result in only a small cost savings, and would do nothing to alter the unsustainable cost trajectory that American healthcare is on - a trajectory that if not altered, will bankrupt both the privately insured component and the existing public option that we call Medicare. Bureaucracy within Medicare is minimal, but Medicare costs are rising at almost the same rate as in the private sector. As you say, we have to work on all aspects of the problem, but we would be deceiving ourselves if we expected major cost savings without tackling the issue of excesses within healthcare.
To summarize these conclusions, insurance reform will rectify major inequities in access, but only correct a small fraction of the cost problem. To fix the latter adequately will require restructuring of healthcare itself, and that requirement has not received the attention it deserves.
October 18, 2009 3:32 PM | Reply | Permalink
Ok Fred, I am going to try to put what you're saying into simple English. It won't be perfect, but work with me here. Here goes:
Reich (along with many others) is focused on things that will make Health Care more fair, get more people insured and into the system, and have some impact on costs.
But if you really want to lower the nation's total health care bill (and not raise it astronomically) you are going to have to provide different types of services, in a different way, so that you can get roughly the same level of overall effectiveness at the same or lower per-person cost.
The list:
1. People need to spend more time with their primary care doctors (or god forbid, nurses!) figuring out together and treating what is going on with their health, rather than being referred to specialists who have never seen them before for expensive batteries of tests.
1.a. This means we will need more primary care docs and nurses, who have more power to diagnose and treat. So: subsidies for med school GPs, more focus on Physician Assistants, Nurse Practitioners, and health care providers who are not MD specialists in general.
1.b. Evidence-based medicine and good adherence to health care algorithms (basically flow charts by another name).
2. Preventive medicine. Figure out what really works, how to get people to do it. And then reimburse for it.
3. Penalties for hospitals with excessive readmission rates. Well, yeah.
4. "pilot programs for alternative payment mechanisms that include various forms of bundled payments" Are you talking about capitation? I couldn't make sense of this.
5. "as well as integrated care through accountable care organizations." Put organizations in charge of the health of a group of people and then hold them accountable for making them healthier.
6. "Comparative effectiveness research to identify interventions that work vs those that don't or are harmful." Studies conducted by/paid for by somebody other than drug companies, and constant re-examination of established practices to see if there's a better or more effective treatment. Bonus points if the treatment is cheaper or less invasive.
7. "The proposals only take a baby step in that direction, but at least they correctly identify the main sources of cost excess, rather than attributing it to insurers or to failure to negotiate drug prices adequately."
Giving everybody access to care isn't going to magically make care a lot cheaper, although it will have some effect. Broadly speaking, we need to get people into rooms talking with other people about how to improve their health rather than in front of expensive machines for short-term, expensive interventions that don't have lasting, positive impact.
October 18, 2009 4:08 PM | Reply | Permalink
Thanks, Erica. I wasn't referring to capitation when I mentioned bundled payment mechanisms. Capitation (a fixed payment per patient without regard to illness burden or services) certainly tends to keep costs down, but discourages necessary treatments as well as unnecessary ones. By "bundling", I was referring to lumped payments for a set of multiple services, sometimes involving multiple providers acting in a coordinated fashion, designed to meet all the healthcare needs of a patient in a particular circumstance, and monitored to ensure satisfactory outcomes. The idea is to say, "Do everything necessary to give this person good care for his/her current problem, and we'll pay you an amount appropriate for that problem" - see
http://www.nationaljournal.com/njonline/hc_20090721_3407.php
Accountable care organizations (ACOs) might in some cases operate via a bundling system, but in other cases might utilize fee for service, but again in a coordinated fashion to ensure that every provider understands what the others are doing, and all work together to do what's needed and avoid duplication or unnecessary interventions.
October 18, 2009 4:31 PM | Reply | Permalink
"This is not because some of the excessive costs he mentions are fictional, but rather because they are not the most important ones,"
In your opinion perhaps. Reich has a different viewpoint Fred. He's in a position to be a lot more knowledgeable about the issues in DC than you or I. His perspective is simply not one you share.
He is discussing this issue on a plane you don't consider as important as your own. Fair enough, but he understands the action in DC, he's been there at the highest levels. He knows what he's talking about.
October 18, 2009 11:21 PM | Reply | Permalink
Bob Somerby has the correct formulation; from the OECD data on healthcare spending:
Total spending on health care, per person, 2007
United States: $7290
United Kingdom: $2992
Italy: $2686
Spain: $2671
Japan: $2581 (2006)
Just focus on those numbers, folks, & get really mad about your so-called "best healthcare system in the world" ...
October 18, 2009 1:55 PM | Reply | Permalink
Here's something else to think about
Suppose we successfully reformed our system so that we were able to deliver the same level of care at half the cost; $3500 per person per year.
What a success! Yippee!
But that still leaves 40,000,000 uninsured because they can't pay for it. Someone must come up with that $3500 per year per person or 140 BILLION per year! Who? Well, let's say only the rich. Who are the rich? Let's say those who make more than half a million a year. How many of those are there? Probably around a million. So to pay for the uninsured each rich earner must cough up 140,000 dollars a year in extra taxes!
It'll never happen.
Even though this is only a seat of the pants calculation - subject to quite large error - you can see the magnitude of the problem and why cost control is so important.
October 18, 2009 8:05 PM | Reply | Permalink
I certainly agree that cost control is important. However, some of your assumptions are wrong. Among the 45 million uninsured are many who can pay the full premiums themselves, and millions more who can afford part of them and need only partial subsidies. Only a small minority would need full subsidization, because many of those in the very low income bracket are already covered by Medicaid. The calculations have already been done, and demonstrate that a combination of taxes and cost savings extracted from Medicare Advantage and other sources will provide sufficient revenue for reasonable levels of subsidization.
October 18, 2009 9:09 PM | Reply | Permalink
I should qualify the above by stating that some of the very poor are Medicaid eligible but not yet receiving Medicaid benefits. The main point stands - taxes and cost savings are calculated to yield enough revenue for a reasonable level of subsidization. It's not as though the staff officials who drafted these proposals didn't do their arithmetic.
October 18, 2009 9:12 PM | Reply | Permalink
Yeah? Well, if its all covered what is Reich yapping about? Why do we have this thread?
October 18, 2009 10:52 PM | Reply | Permalink
Going back to my rough calculations.
Lets suppose that only 10,000,000 or the equivalent need a full subsidy. Divide by 4. But we haven't reduced per capita per annum costs by half and have no plan to do so. Multiply by 2. And we have no realistic plan to keep future costs from exploding. Multiply by 2 again.
You get the idea. The rich cannot pay for this. You can see why Reich is sure the middle class are going to get dinged. Seriously dinged.
October 18, 2009 10:59 PM | Reply | Permalink
Far fewer than 10 million would need a full subsidy. However, the main point is that the math has already been done to calculate how many billions in subsidy funds will be necessary to provide affordable insurance premiusm to those who can't afford the full cost, and the proposed legislation comes up with the required amounts. Part of the money comes from cost savings, particularly in the Medicare Advantage Program, and part comes from new taxes, but it's all accounted for.
Some of us believe the subsidies should be greater, particularly in the Senate Finance Committee version of the legislation, but they are not terrible, and it's a good start.
October 18, 2009 11:27 PM | Reply | Permalink
So I repeat. If it all works out what is Reich talking about?
October 18, 2009 11:44 PM | Reply | Permalink
(This began as a reply to one of Fred's posts, above, but now I don't know which one to attach it to!)
Fred,
Most people agree that we must restructure health care, and most professionals agree about the need to reduce waste, promote evidence-based medicine, implement health information technology, encourage primary care, etc. In other words, there's pretty good agreement about what needs to be done, and pretty good agreement with the Dartmouth thesis that less care is often better care.
The fight comes over money. That's where politics gets involved, and when money and politics are involved, heroic efforts may be required to change things for the better.
Here's where we stand with the health care reforms that are currently on the table: absent a vigorous public plan, one that is available to every family regardless of employment status, there is little hope that what we are doing is heroic enough to restructure health care. The distortion field of for-profit health insurance, technology and pharmaceutical industries, combined with the political power of local constituencies in places like Miami that overspend on health care, and the natural inertia of the system, are just too strong.
Maggie Mahar, the journalist whose outstanding work in popularizing the Dartmouth studies you cite, has an excellent blog, Health Beat. The following is a quote from her most recent post [emphasis mine].
Waste and duplication add a lot of cost without adding value, but what lies at the heart of waste and duplication? What is it that drives the cost upward?
Uwe Rheinhardt, the Princeton health care economist, lays it at the foot of innovation. Here's Mahar again, in her white paper "The Agenda: Getting Better Value From Medicare."
The focus on waste and duplication is much too narrow. Until we change the nature of the medical-industrial complex there is little hope of bending the cost curve while improving health outcomes for Americans. Many physicians and NGOs are trying to change the culture of health care from inside, but they need the help of powerful outside forces to make it happen.
That's why a vigorous public option is critically important.
October 18, 2009 5:15 PM | Reply | Permalink
Red - I agree with much of what you say, but I think your last sentence is a non sequitur. That's not because I oppose a public option - I favor it - but because it will have relatively little leverage in restructuring the system compared with the far more powerful public option that already exists, Medicare. Some of the restructuring is already proposed in the reform measures, particularly within the Medicare population, but on a small scale, and much more will be necessary over the coming decade. If Medicare can make these reforms stick, and thereby achieve good or better outcomes at lower cost, the providers who do this will be sought after by private insurers or by public plan administrators alike, and the reforms will spread to the non-Medicare population. A public option as currently proposed, with its limited subscriber base, would have much less ability to pressure providers.
At the risk of belaboring the point, reforms of all elements of healthcare are needed, but we already have the wherewithal (Medicare) to push the healthcare system to start implementing them, and we have proposed legislation to help Medicare do this. A public option would be gravy, but it's not the main meal.
I don't think you've said this, but others seem to believe that whether proposed legislation is "good" or "bad" depends on whether it includes the public option. That's terribly misguided in my view, when one looks at the contributions to healthcare problems from various components of the system. Even without the public option, proposed insurance reforms will be a very good achievement. With or without it, proposed changes in healthcare itself will be a good beginning, but only a beginning. What is "bad" about some of the proposals (mainly Baucus) is a weak mandate and inadequate subsidies, but the House bill, HR3200, and the Senate HELP Committee bill do better in this regard, and I hope their stronger mandate and greater subsidies will show up in the final legislation.
October 18, 2009 6:29 PM | Reply | Permalink
Excellent observations about Medicare. If we had world enough, and time, then trying to gradually bend the system by making improvements in Medicare and hoping they trickle down to other segments of health care would be alright with me. We've been trying that for quite a while now.
The argument for a vigorous public option is about two things.
I expect you're right that the public option, as currently conceived, will be pretty weak, so that's why I always use an adjective like "strong" or "vigorous" in front of the phrase. To be vigorous, the public option will need to offer very good coverage to anyone and everyone, even those whose employers offer a private health benefit package.
It will be less expensive (see the quote from Mahar's blog, above) and it should be able to attract a significant subscriber base. If it does, it will add considerable leverage to that which is already available through Medicare.
I think we're beyond the time when Medicare demonstration projects can be counted on to make the changes we need, as quickly as we need them. Much of what needs to be done is already known, yet the industry doesn't do it. Protecting against hospital acquired infections, and administering aspirin for myocardial infarction, are just two examples. We need to get it done, now, and I do believe, like Mahar, that a vigorous public option is an important part of the recipe for getting it done.
The argument shouldn't be about whether or not pretty good things can be accomplished without a public option. We have an historic opportunity, one that may not recur for decades. Now is the time to insist on the best damn health care reform we can get.
October 18, 2009 8:58 PM | Reply | Permalink
Now is the time to insist on the best damn health care reform we can get.
Yup!
Carpe diem.
(As in Andrew Marvell's "To His Coy Mistress")
October 18, 2009 9:17 PM | Reply | Permalink
Thus, though we cannot make our sun
Stand still, yet we will make him run.
October 19, 2009 1:45 AM | Reply | Permalink
More than a few of us have been saying for a long, long time now that passing a bad bill is worse than passing no bill at all. If the price of "any bill" is that we have to allow the parasites to continue to feed off the rest of America then the price is far too high.
It is far, far better to kill a bad bill now and come back with Medicare for All with a vengeance next January. If Obama continues to cling to his naive fantasy of bipartisanship and cutting deals with the parasites then leave him behind and expose him for the DLC he would have to be if he insists on maintaining the very poor course he has put us on this year.
October 18, 2009 5:20 PM | Reply | Permalink
There will be no public option (unless it consists of one of the compromise ideas being floated around, i.e. each state deciding, etc) and Sarah Palin will NOT get the GOP nomination should she run for president in 2012.
Those are safe bets.
October 19, 2009 1:12 PM | Reply | Permalink
But Mr. Reich -
Isn't Obama paying hush money in the form of insurance premiums for federal employees?
Isn't Obama paying hush money to overseas contractors (war profiteers) even though its been shown time and time again that they've bilked billions (if not a trillion) making money on the deaths of middle easterners and U.S. soldiers?
Isn't Obama paying hush money by exempting oversight to 8000 out of 8200 banks but still giving their depositors protection under FDIC?
Isn't Medicare Prescription coverage hush money to Big Pharma?
President Obama needs to take the Republican's advice and impose a spending freeze until healthcare reform, contracting oversight and banking regulations are passed.
If he announced this Friday that the U.S. Treasury would no longer disburse payments until the appropriate reforms were passed and enforced, there would be sweeping reform drafted by the people who want that money by Monday @ 8 a.m.
Political power and majorities are a dog and pony show made for tv - he should be voting the taxpayers pocketbook. I know that's what I voted for.
October 19, 2009 6:17 PM | Reply | Permalink
Let me get this straight: If Letterman is a sexual preditor, which he is if he takes avantage of his possition to get sex from his interns (students), And you say you want the President to act like Letterman?
Well if you think of our economy as the letterman soundstage, and the: Banks , Stock investment companys, realestate loan companys, Car manifactur companys as interns. Well President Stupidly is Boinking everythings in sight, just like letterman.
The simularity is our Atorneys General is very experienced at this type of case, ie President Clinton and Monica Lewinsky.
October 19, 2009 9:36 PM | Reply | Permalink