Olympia Snowe, Abortion, and the Public Option

It's been some time since I posted here, and I must admit much of it is out of frustration. It's bad enough that Congressional Republicans practice obstructionist politics, but Max Baucus seems set on being a one-man show, developing his own healthcare bill that does not include a public option, just because. And now, big surprise, Republicans are trying to eliminate coverage for abortions from any plan that is part of the pool from which uninsureds and small business will purchase coverage.

Orrin Hatch's proposed amendment denying abortion coverage was defeated in the Senate Finance Committee by a vote of 10-13. Abortion is legal, so I wish these folks would get over it. Frankly, I think it's absurd that Medicaid does not cover abortions, meaning those who need it most must figure out a way to pay out of their own pockets. Proponents of healthcare reform have danced around the issue by saying that only amounts attributable to individual premiums can be used to fund abortions. Of course, that's impossible to do administratively, but honestly, saying women have the right to seek an abortion while at the same time allowing state and federal laws to make it all but impossible, is like saying every accused has a right to a fair trial only if your state doesn't want to build a courthouse and hire judges they have the right to just put you in jail. Expect more screaming and yelling from the nut jobs on the right, but this time I really hope the Dems will treat this as the non-starter it is.

In other interesting news, it turns out according to a Poll by Democracy Corps the majority of Senator Snowe's constituents in Maine support the public option. I can't help but think Ms. Snowe, like Mr. Baucus, just enjoys having her name in the news and being courted by both sides. Both want to come up with that "compromise" plan that will mesh both sides of the aisle. The American people long ago realized that was a pipe dream, and that there's no value in compromise for compromise sake. It's becoming more and more obvious that Congressional Republicans represent no one but themselves. So if Ms. Snowe wants to break from the pack and represent the people who voted for her, she's going to have to warm to the public option.

Finally, my favorite amendment comes from Senator Charles Grassly who proposed that members of Congress should have to purchase their medical coverage from the same pool they establish for uninsured Americans.

“My interest in having members of Congress participate in the exchange is consistent with my long-held view that Congress should live under the same laws it passes for the rest of the country.”

Short of the public option, I think that's the best idea they've come up with yet.

Senate Finance Committee Dems Rebuff Republican Attempt to Delay Vote

House Democratic leaders are looking to blend the three House Healthcare Reform bills together by next week, though Speaker Nancy Pelosi prefers to postpone a vote until the Senate Finance Committee does before bring their bill to the House floor.

In the meantime, a Republican member of the Senate Finance Committee, Jim Bunning of Kentucky, sought to delay the SFC's vote until the bill was put into "actual legislative language" as opposed to the "plain English" version, and the Congressional Budget Office had made its final estimate of cost. Olympia Snowe (R-Maine), whom the Dems are courting as the possible only Republican vote, agreed that she wanted to know the final numbers as well.

The request didn't fly as Dems pointed out that Republican committee members had, in the past, voted on plain English versions of legislation and based on general but not final CBO estimates, in particular the Medicare prescription drug plan and the Bush tax cuts. No wondering why the Republicans pushed those through without final estimates. I can't say I blame Democrats for doing the same. We can't cut back on this bill anymore anyway.

Information from CQ Politics Sept. 23, 2009 Midday Update.

Baucus v Snowe

As noted in the sidebar, Senator Baucus wants to send his healthcare bill to the Senate floor by the end of the week. However, Olympia Snowe wants more time. Senator Snowe is under fire from an ad by MoveOn. Org and other members of the coalition fighting for a public option.

Will Ferrell Adds a Little Humor on Behalf of MoveOn.Org

Will Ferrell stands up for the real healthcare victims.

Employer Paid Heathcare at $30,000?

Here are some sobering statistics from Drew Altman at the Kaiser Family Foundation. In 2009 average healthcare premiums for family coverage will hit $13,375. I already knew that since that's what I would pay if my daughter hadn't graduated to a separate policy. (Come to think of it, that is what I pay since she can't afford to pay her own premiums.) But here's something I didn't know. If premiums continue to rise at only the relatively modest rates they have over the last five years, by 2019, the average family premium will reach $24, 180. If prices rise at the average rate they have over the last 10 years, family premiums will average $30,803.

Let's add some perspective in addition to what Mr. Altman notes. According to the US Census Bureau the real median household income for 2008 was
$50, 303. So let's say in 2008 the average family premium was $12,500, since that's what I was paying. That amounts to nearly 1/4 of the median family income. What is even more frightening in terms of healthcare costs is that between 2007 and 2008 real household median income declined by 3.6%.

These are household statistics, not individual income statistics. So what this says is that by 2019, healthcare costs for employers could amount to more than the cost of hiring another employee. Is it any wonder that, already, many companies that provide medical benefits are hiring more part-time, and consequently ineligible, employees?

In my second post on this blog, "It's Your Problem Too" I noted the many ways the currently insured can find themselves unexpectedly uninsured. So what do you think will happen to your employer provided healthcare when costs go that high?

Under most of the current bills, employers will be penalized for dropping coverage, but with costs like that it may be worth it to just pay the tax. That's why we need cost containment as well as universal coverage, and that's where the hard part comes in.

As Altman points out, cost containment has been cut back or eliminated from most bills. This same issue has arisen every time any attempt has been made toward healthcare reform since the '80s. Somewhere along the line we, as consumers, bought into the idea––as we did with housing and cars––that more has to be better and side-effects be damned. But the side-effects of too much healthcare, like the side-effects of too much oil consumption, can be detrimental to your health as well as your wallet.

Statistics show there is no correlation between the greater number of tests and procedures Americans undergo as opposed to other nations, and better health. As I've pointed out in more than one post, our overall health outcomes are not the same as countries with more streamlined healthcare delivery, they are actually worse.

Opponents of healthcare reform since the first Clinton attempt have used the word "rationing" as a scare tactic. Rationing in today's political lexicon connotes something necessary being withheld. In reality we are talking about elimination of wasteful spending on unnecessary services that could harm your overall health.

Let's take as an example the proliferation of CT scans and MRIs. In this blog post by Judith Graham of the Chicago Tribune on the need for data sharing to cut down on unnecessary testing, a physician points out how too many of these imaging tests can be harmful.

There’s the rub. If the physician had access to the [original] MRI, he wouldn’t need to order three CT scans that expose the young woman to radiation and potential complications associated with the chemicals used to produce color contrast in the scans, Anastos said. The MRI would have been enough to determine whether the tumor was benign.

Another post at KevinMD points out:

The problem is that these scans are so sensitive, incidental findings are often found. In many cases, they may not be the true cause of the symptoms, and worse, can necessitate more invasive testing that can have serious side effects.

I can personally attest to the back pain issue he mentions later in the article. The first time I experienced a pain down my right thigh, I went to my PCP who sent me for an MRI and then to an orthopedist, who had me return regularly for appointments where he'd do no more than ask me to bend this way and that. One day, I noticed the pain subsiding and canceled my next appointment. Two years ago, suffering from more severe pain that I traced to a new exercise I had added to my regimen, I considered seeing my PCP again. Treatment had changed by then, and I figured he'd send me for physical therapy. Instead I went online first and read exactly what Dr. Kevin said, wait six weeks and, in the meantime, stretch your hamstrings whenever possible. I continued my exercise regimen but eliminated anything I could feel in the back area. In six weeks it was gone, and I had saved my insurance company thousands of dollars while saving myself the dangers of another MRI.

This isn't rationing. It's good practice that benefits everyone. Changing healthcare delivery is also the only way we can make healthcare affordable to all, but it will never happen if opponents whip up a frenzy of fear and politicians continue to pander to the uninformed.

Baucus Plan Falls Short––No Surprise

The Baucus plan for healthcare reform––more accurately the Senate Finance Committee plan–-has been unveiled. It puts me in mind of the much awaited Iraq Study Group report a few years ago. Everyone, including the President and Congress, took a holiday from voicing any Iraq policy until the report came out. As though it would actually turn up something new that everyone didn't already know.

The Baucus plan comes in as far less expensive than the House plan––$774 billion over ten years vs. 1.042 trillion over the same period.

Paul Krugman outlines the problems better than I can, but the biggest and most important issue–-and the one probably responsible for the lower price tag––is the replacement of a public option with those useless non-profit insurance cooperatives that will never happen.

Pelosi Says House Bill WILL Include a Public Opton

House Speaker Nancy Pelosi says the bill the House will send to the President this fall will include the Public Option.

Read more...

Public Option: Yes We Can

Add your name now.

Note: There are a lot of petitions going around, and you may think if you've signed one, you've signed them all. Up until now most have exhorted Congress to pass some form of healthcare reform. Another went to President Obama urging him to give his strong suppport to the Public Option. This one is different. This petition tells Congress that we the voting public demand the Public Option be part of any healthcare reform package.


In the latest news from Democracy for American, Howard Dean says they've polled Congress and tally 218 House and 51 Senate Democratic votes for the Public Option. He goes on to explain why 51 (and not 60) Senate votes is enough for passage. There's also a new CBS News Poll that shows a vast majority of Americans (77%) believe a Public Option is important to reform.

Add your name to the petition.

US Chamber Plans to Butcher Financial Overhaul

This Monday President Obama will deliver a speech on Wall Street, one day prior to the first anniversary of the Lehman Brothers bankruptcy filing, with the purpose of jump-starting plans for a financial overhaul. Part of the plan is to establish a federal Consumer Financial Protection Agency. Get ready, taking a page from the Healthcare Reform opponents' handbook, the U.S Chamber of Commerce is planning a campaign to fire up the little guy. Only this time, they may have gotten, shall we say the wrong end of the cleaver?

According to a September 8 article in the Wall Street Journal, the Chamber spent $2 million on an ad that shows a picture of a butcher and the caption, "Virtually every business that extends credit to American consumers would be affected -- even the local butcher and the credit he extends to his customers."

The local butcher? Who the heck are they after with this one anyway? Do these guys spend so much time on Wall Street that they believe the Main Street the media keeps referring to really exists outside of Disney World?

About the only place you find a local butcher these days is in those gentrified city neighborhoods where customers pay through the teeth so they can walk to their shopping from high-end condos and tote home specially ordered cuts in eco-friendly reusable shopping bags. All the credit extended is on a plastic card. Somehow I don't think that's the demographic the Chamber is trying to reach.

But here's the really funny part. When you think of a time when the local butcher did extend credit to cash-strapped families, what does it bring to mind? Like maybe the Great Depression? So is that the best image for the Chamber's anti-financial reform message?

I guess they figure they're too big to fail.

Obama's Speech to Congress: Did It Do the Trick?

Many of us were hoping for one of those rousing campaign speeches by Barack Obama, sending us onward and forward for healthcare reform, and over all, I think he did a good job at appealing to our better angels. It's about time an American president pointed out that there are things only the government can do, and that you can't expect businesses to regulate themselves. Just a few short months ago, everybody was on board with that and ready to hang bank CEOs in effigy. I've always known Americans had short memories, but over the past few decades we've fallen into collective Alzheimer's. Which is why I don't get all the fretting from the Blue Dogs. By the next election most of their constituents won't even remember there was a healthcare debate, let alone how their members of Congress voted on it.

The president came out a little stronger on the public option than members of his administration were hinting he would. I have to believe it had something to do with all those petitions from Progressive organizations.

To my progressive friends, I would remind you that for decades, the driving idea behind reform has been to end insurance company abuses and make coverage affordable for those without it. The public option is only a means to that end – and we should remain open to other ideas that accomplish our ultimate goal.

Can't disagree with that. I just don't know what other means there would be. Certainly not silly ideas like coops, but maybe Senator Baucus will be so tickled at having been singled out for his payment plan, that he'll drop that non-starter.

Here's my question, though. If it's true, as members of the Obama administration have been saying lately, that the public option is such a small part of reform that it could be jettisoned for the sake of compromise, then why do the private insurers take it so seriously? If people like House Minority Leader John Boehner believe so strongly that the government can't run anything, then why are they saying a public option would drive private insurers out of business? Of course, I should know better than to look for logic in any of this.

It's not time to quit yet. Click on these sites to learn what you can do to support the public option.

Pledge to donate a symbolic minimum of $3.26 to members of Congress who support the public option.

Call the White House: 202-456-1111

Call Your Representative in Congress: 202-224-3121

Call Your Senators: 202-224-3121

Then go to Senator Russ Feingold's site to let him know you called.

Call your own Representative.

Baucus Plan: The War of the Pages

Senate Finance Chairman Max Baucus added yet another healthcare reform proposal to the already headache inducing pile. This one, it was pointed out more than once in the news coverage, is only 28 pages.

I don't get it. All through August America's town halls echoed with numbers––page numbers––and echoed is the perfect word, because most of them were just picking up something they heard from someone else. What is this new system that rates bills by numbers of pages, inflated numbers to boot. HR 3200 comes in at only 328 pages. When Senators, Representatives, bloggers, and screaming talk show hosts talk about 1000 pages, they are including all the different proposals. By that count, Senator Baucus just made it 1028. So does that count as simplification or complication?

A complication, definitely. First, the proposal can afford to be short because the main part of it, regulations on private insurers requiring things like guaranteed issue and no denial for pre-existing conditions, is already covered at length in HR 3200. The main thrust of the Baucus proposal is in two areas: Expansion of Medicaid to those without insurance making 133% of the poverty level, and funding to establish healthcare cooperatives. This combination has the additional benefit of appearing to cost $100 billion less than HR3200

This proposal is a sop to those seeking a public option. Here's why they add nothing, and possibly detract from HR 3200.

Expanding Medicaid instead of a public option appears to save money, because Medicaid is only partly funded by the federal government. The rest is funded by the individual states. They also administer the plan under broad government guidelines. I can't imagine that states, many of which are struggling under their own huge budget deficits, will be very keen on this one. As you can see from the report linked to above, overall spending on Medicaid nearly doubled between 1998 and 2003. It spends more than Medicare, which is a government run plan, and the variations in administration make it less efficient. If we're looking to expand an existing plan rather than start a new one, we'd be better gradually lowering the eligibility age for Medicare.

With regard to healthcare cooperatives, I'm not clear whether this refers to medical cooperatives or insurance coops. I covered both in an earlier post and I see nothing wrong with adding some incentives into the bill for those so inclined to try something like this, but both types are difficult to get off the ground and would require more than just money. To provide guidance for start-ups as well as compliance monitoring would, no doubt, require another government agency.

While I haven't seen a lot of detail about Baucus' idea for funding his proposal, what I've read so far sounds reasonable. I don't think any Democrat is against trying to save more money if it doesn't cut back on the number of people covered.

One of the major problems I see with the so-called compromise proposals is that shorter, in the long run, does not mean less complicated. Somewhere along the line it became the mantra of health reform––on both sides––that people want choice. Really? Did you ever try to assist a senior in choosing a Medicare Prescription Drug Plan? It makes choosing a cell phone plan seem easy. As a Benefits Manager, it was my experience that individuals felt overwhelmed by choices in healthcare coverage and would often call may office hoping we could just tell them which plan to enroll in.

That's one reason why I don't see coops of either type getting off the ground. Even on entering an already established coop, individuals will gamble on whether the cost savings today will be there five years later, or whether additional cost equates to more or better care, or whether a lump sum outlay will get as good a return as it would in a standard investment.

Whether 28 pages or 328 or 1028, it's time to stop coming up with so-called compromise proposals that do nothing but complicate the issue even more.

We Can't Afford to Wait Video by Moveon & R.E.M.

Bill Moyers: Obama's Moment

If you missed Bill Moyers Journal on PBS last Friday, take a moment to listen to Obama's Moment. Moyer urges the president to take a strong role in pushing for the public option.

It's one thing for average Josephines like me to say what Obama should do, but I've never held any political office let alone a high one. Moyers, on the other hand, was a major adviser to Lyndon Johnson who took part in everything from drafting bills to messages to Congress. In short, he knows a thing or two about rallying lawmakers. I've always admired Moyers' bold and intelligent editorials. I'm often moved by his words. I hope the president is as well.

Public Option or Bust?

As noted in my last post and various articles, there is much question whether President Obama will draw a line in the sand for the public option. Most indicators say, no. The thinking on this, I would imagine, is going one of two ways. Appease the conservatives so sometime later on they will concede on something the administration wants––though I can't believe Obama is that naive––or half a loaf is better than none.

Half a loaf is better if the bread is fresh, but what if it's stale? Without a public option what we have is a utopia for private insurers where everyone is mandated to have coverage. They never had any quibble with that part of the reform package, but what incentive is there for them to keep costs down? And if people worry about healthcare rationing under a public plan, what do they think will happen when insurers are forced to community rate and cover pre-existing conditions? They will cut back on services in order to continue making huge profits, but they are not likely to do that in conjunction with oversight panels working toward the best care at the best price.

Maine Senator Olympia Snowe has a put forward a compromise option where the public plan would kick in in any state where private insurers don't reduce costs to a level set by the Department of Health and Human Services. A complaint I've heard over and over is that the House reform bill is too complicated. This would make it more complicated. One of the criteria for rate-setting is location. What private insurers can charge will differ not just from state to state, but within the state, as will the allowable costs of healthcare providers. These trigger points not only need to be set, they will need to be monitored, and I assure you, private insurers will start squawking immediately that limits are too restrictive. Then, as soon as we have a Republican Congress again, the limits will be raised or done away with. Or, conservative governors will say the federal government has no right to impose a public option on their state.

The only way to force private insurers to lower costs is to have a public option that acts as the pace car. It has to be the final line in the sand.

So the question remains, what if the bill can't pass without it? Politically I think it's better for the bill not to pass at all than to pass without the public option. Congress is mistaken if they think their constituents will let reform die this time. Unlike the Clinton years, too many have been following this for too long, pouring their money and their time into the effort to get this done. Many are from the Obama campaign who picked up where they left off after the election. They've been at this for nearly three years and they don't believe in lost causes.Should reform not pass this time these folks (or should I say we) will take to the streets and demand it. We should start by demanding single payer. Next to that HR3200 will look like heaven to conservatives, and we'll be d---ed sure to get real reform passed this time.

Obama and the Public Option

The latest news says Obama will not insist on the public option when he addresses the joint session of Congress on September 9. If you support the public option, especially if you voted for Obama or were an active member of his campaign, you can sign a petition to let him know.

The message not making it through to the administration is much of the support he is losing is among those who want Obama to take a stronger, not a weaker stand on reform. There are many, both among the general public and in Congress, who feel the current bill is already a huge compromise. Now he apparently is considering a betrayal of those in the House who stand by the public option. Where will that leave him next time he needs their support?

Why would a president want to prove he can stare down his own party? Does he really think the Republicans will have a sudden epiphany and take his side the next time around? Did he learn nothing from the Clinton administration? President Clinton supported a number of traditionally Conservative measures like NAFTA and Welfare Reform. He backed off gun control and made little efforts for abortion rights. He came out against big government, and what did he get for it? Impeached.

Healthcare Cost Containment Part IV: Insurance Companies

Interspersed with posts about what is happening now, I have been posting a several part history of healthcare cost containment efforts and how it has essentially amounted to creating one straw villain after another in our attempts to find a quick fix. Part I dealt with the focus on Doctors overcharging insurance companies. Part II dealt with blaming the consumer. Part III dealt with malpractice suits.

In this final post on cost containment in what may be the waning days of this blog, since Congress may soon be making its decision, I'm not going to cover the current situation. We all know how insurance companies make a profit off not covering people, and regulating them may be the only thing opponents and proponents of reform agree on. This post will be about the time from about the late 1980s through the Clinton health reform plan when the insurance companies were being accused of coming between doctor and patient.

First, a little review. In Part I I noted how, by the late 1970s medical specialties were growing and most doctors were choosing these specialties over general practice. At that time the idea of the family doctor was disappearing. It was not unusual for individuals to have no real relationship with any one physician and to go directly to a specialist with a problem. Someone with a simple earache might go directly to an ear nose and throat specialist. Or someone who had suffered a heart attack, having no family doctor, after release from the hospital might use his cardiologist as his primary care physician.

After all the criticism of managed care, this may sound like Eden, but there were some big problems.

1. Paying a specialist for illnesses that could be easily treated by a GP was not cost-effective.
2. Specialists up on the newest methods were more likely to over-treat a problem like performing back surgery when physical therapy would have been less costly and as effective.
   
3. Patients were often forced to self-diagnose in order to choose which specialist to see.

It was in the early 80s, when employers first got serious about cutting medical costs, that it became common to offer a managed care plan. At the time these were usually HMOs, offered as perhaps a lower cost option, but not as the only plan as has become more common in recent years. HMOs were cheaper for a variety of reasons, but the one we'll look at for these purposes is the managed care approach. Participants in HMOs had to choose a primary care physician (PCP) from a list of HMO participating physicians. The PCP served as a gatekeeper of sorts. He/she was your first stop for any non-emergency illness. Whenever possible, the PCP would treat the problem. When necessary, the PCP would refer the patient to a specialist or surgeon who also participated in the HMO.

Unlike the traditional indemnity plan where patients had to meet a deductible plus a 20% copay, with HMOs the patient usually paid one small copay per doctor visit, say $15 or $25, often something larger for specialists, and maybe a fee for tests, after that everything was covered at 100%, at least from the patient's point of view. That's because they weren't responsible for anything over reasonable charges allowed the physician.

As time went on more and more employers began offering HMOs and PPOs exclusively, and insureds, used to seeing any specialist they wanted, and physicians used to working autonomously, started complaining that insurance companies were discouraging physicians from referrals to specialists as well as insisting that physicians see more patients than they could spend necessary time on. Indeed there were incentives for physicians to limit time with patients and referrals as HMOs paid contracting doctor's a certain amount per patient and the additional cost of referrals cut into everyone's profits.

While it was a shock to the system, reports of denied care were largely sensational and anecdotal. A system-wide study would have been helpful, but to my knowledge this wasn't done, but the hue and cry soon caused HMOs and PPOs to be more lenient about referrals, and instead to make profits on higher premiums, less adverse selection, and dropping people likely to accrue high costs.

However, insurance companies aren't the only ones profiting from your healthcare dollars today. Physicians who buy into imaging machines and out-patient surgical centers, for-profit hospitals, and drug companies all have a profit motive for providing more and more care at higher prices. Whether you call it managed care or rationing, without some oversight of the system, everyone will just continue to milk it for all they can get. This won't be the first time our "more is better" mentality will come back to bite us, but this time it's your life and not just your lifestyle that's at stake.

I agree that no for-profit industry should be in charge of decisions regarding your healthcare, but a nonprofit government agency that includes healthcare as well as financial professionals, that makes recommendations based on outcomes studies, can and should. No one wants to put a pillow over Grandma's face no matter how cost-effective, but when Grandma's heart is in failure and all her systems are breaking down, do we need to x-ray her swollen big toe? And it's not just end of life where we spend too much. Other countries with universal coverage spend less on healthcare, perform fewer procedures, and have healthier populations than we do.

By now it should be obvious, the clue to reforming healthcare isn't reigning in the providers or the consumers or the lawyers or the insurance companies. It's all of the above. What many don't realize in their support of the current status quo, is that the status quo is at the breaking point. Very soon all employers, large and small, will be dropping healthcare coverage or moving to countries where they can produce a product at a lower cost. Then none of us will have coverage.

Think about it.

Compare Healthcare Proposals

The woman I was collecting signatures with today clued me into this link comparing all the major and minor proposals. The major ones covered are the two Senate proposals and the general guidelines provided by President Obama. In addition there are other proposals that, to my mind, are head and shoulders above HR 3200 or any of the major proposals. They are essentially single payer. The amazing thing to me is these plans haven't gotten a second glance, and yet, of all the proposals they appear to be the only ones with the potential to contain costs, and a clear-cut method for paying for them. Some would require individual buy-ins, others simply impose an across the board tax.

Reading HR3200 Part I: The Missing 587 Pages

Yesterday I visited the website of my Congressman Jim Gerlach (R-PA) and found this:

"Looking for something to read in addition to a dog-eared paperback novel in the waning days of summer?"

I clicked "Read More Story." I'm not looking for something to read. I'm actually behind on my reading due to all this blogging and collecting signatures, but I was game.

It turns out Congressman Gerlach made copies of HR 3200 America's Affordable Health Choices Act of 2009 available in his offices and certain libraries throughout his district.

The Congressman notes:

"This 1,017-page tome may not be as exciting as the titles topping the New York Times Best Sellers List, but the public deserves a chance to read the legislation before Congress votes this fall,” Gerlach said. “That’s why I believe it’s important to make copies of the bill available throughout communities in the 6th District."

Something told me he wasn't really expecting anyone to read the darn thing, let alone understand it. That's why he mentioned the number of pages and "gave away" the ending.

"I hate to spoil the ending for readers. However, the plan House Democrat leadership proposes would allow the federal government, rather than doctors and patients, to make more decisions about treatments ranging from knee-replacement surgery to chemotherapy for cancer patients. The plan also will impose higher taxes and burdensome mandates on small business owners, family farmers and other job creators as they attempt to shrug off the effects of the worst recession in more than two decades. That’s why I oppose this attempt to usher in an era of government-controlled health care that the Congressional Budget Office, the nonpartisan researchers for Congress, concluded would fail to stem the rising cost of health care and balloon our national debt to staggering levels."

Well I decided to call the Congressman's bluff and his office, which is just a few miles from my house, to see about getting a copy of this thing. As noted here many times, I worked in benefits. I had to read and understand ERISA and various other arcane acts of Congress and amendments to the Internal Revenue Code so it didn't daunt me. Unfortunately, I would not have been able to take the copy away with me, which I knew I would want to do since I was sure it would refer to other laws I'd want to check out online, like Medicare. However, as the person who answered the phone helpfully pointed out, the Congressman's page included a link where I could read it online.

I'm about halfway through, and it is going quite well. I'm pretty impressed, and I will keep you posted on what I learn. However, I'm a little confused because the bill I'm reading is only 328 pages! Congressman Gerlach (and he isn't the only one) says it's over 1000 pages. It has been implied by some that the bill is so long and arcane as to cover up what they are really trying to do––which in and of itself is stupid because length leads to precision not the other way around. So what's the deal? If I add on the committee markups (all the specific amendments by House members who want to add things like Autism Awareness,etc) I get another 72 pages. If I include the CBO estimates they add on, say 20 pages. That comes to a total of about 430.

So where are the missing 587 pages that would add up to 1017? Beats me. In between my reading of the bill, which really isn't so bad when you consider about a third of it is tables of contents and about another third is boilerplate stuff, I will have to take a ride over to the Congressman's office and compare his version to the on online.

I'll keep you posted.

Senator Edward Kennedy: What More Fitting Memorial Than Passing Healtchare Reform

For all those whose cares have been our concern, the work goes on, the cause endures, the hope still lives and the dream shall never die.

Education and Healthcare Reform were two issues Senator Edward Kennedy felt and fought strongly about. Had his health not prevented him from adding his booming voice to this campaign, I wonder if it might not be going differently at this point. Some people are just too venerable to shout down.

Senator Kennedy could be the last vestige of an era in this country that will never return. The era ushered in by Franklin Roosevelt when it was taken for granted that those with money and power had a reponsibility toward those who had neither. Ending poverty was so entrenched in the American psyche that even Republican presidents like Richard Nixon accepted it as part of their legacy. That, of course, came to an abrupt end with Ronald Reagan and every president––Republican or Democrat––since. (Clinton presided over Welfare Reform that created a new class in our country, the working poor.)

Senator Kennedy summoned all his strength to appear at the last Democratic Convention. Though terminally ill, he was obviously energized by the Obama campaign as were other formerly prosaic speakers like John Kerry. Sadly, that energy seems to be waning, replaced by the old "appease the enemies of big government so I can get re-elected" strategy.

Senator Kennedy's death doesn't need to be an end. It can be a beginning. What could be a more fitting memorial to the man than reviving the moral argument for Healthcare Reform and putting behind it all the energy then candidate Obama used to raise the hopes of minorities, young people, and us Progressive Democrats who never thought our party would rise to its former glory. Or the President and Congress could pay the usual lip service then stop mentioning Senator Kennedy's name lest it push the Conservatives (for whom Kennedy was a huge pain in the you-know-what) farther away.

Kennedy believed Obama could usher in a new era, or more correctly, revive an older, better one. Maybe we should change that campaign cry to "I hope he can."

Healthcare Cost Containment Part III: Tort Reform Is Not Healthcare Reform

Interspersed with posts about what is happening now, I have been posting a several part history of healthcare cost containment efforts and how it has essentially amounted to creating one straw villain after another in our attempts to find a quick fix. Part I dealt with the focus on Doctors overcharging insurance companies. Part II dealt with blaming the consumer.

As frightening as it is to think of doctors making mistakes with impunity, we find something distasteful about making money off those mistakes. It is like putting a price, or worse, getting rich off the death or injury of a loved one. There is also a sense that by expecting doctors to perform these risky procedures it's a bit unfair to "punish" them when something goes wrong. After all, we all make mistakes at work, only our mistakes usually aren't life and death matters. And now, these frivolous lawsuits for "every little thing" are driving up our healthcare costs and in my state of Pennsylvania, so they claim, driving doctors out of business.

It sounds to many of us like the payouts on some of these malpractice suits are ludicrous, and we are often told that the bigger the payout the more the lawyer gets out of it. Law, especially litigation, is not my field so whether these payouts are "ludicrous" and whether most malpractice suits are "frivolous," I don't know. I do know that in a country where it so easy to end up without coverage for your medical costs, we are putting the cart before the horse when we ask people not to sue over an illness or injury caused by their physician or hospital that could end up costing them millions of dollars in healthcare costs.

If you suffer an illness or injury due to malpractice that forces you to leave your job, you are without coverage just like anyone else. You also now have a pre-existing condition. If you are able to hold onto your medical coverage, your costs could very likely exceed the lifetime cap and you could end up paying the rest out of pocket. All because your doctor made a mistake.

The American College of Obstetrics and Gynecology estimates that "obstetricians can expect an average of 2.53 medical malpractice lawsuits to be filed against them during their career." We always need to be careful with such statistics. That doesn't mean that every obstetrician will be sued at least twice in his career. Two or three could be sued 100 times and it would skew the average. Be that as it may, I have read that doctors who deliver babies are at far more risk of being sued and many have stopped doing it.

In the article I link to in the above paragraph they imply that the reason for so many suits is that everyone wants a healthy baby and normal delivery. When this can't happen we want answers, in other words, people sue out of anger and perhaps grief. Knowing intimately a family with a child who was severely brain damaged at birth I can give you another reason. Raising a severely disabled child can be difficult and expensive. Just the red tape of getting necessary services usually requires one parent to stay home full-time. Both those injured at birth and in later years by malpractice may have to purchase a new home that is more accessible, and even then it will require certain renovations. Special vans will be required for transportation, and while most of us assume our financial obligations to our children will end at some point when they go out on their own, these parents' physical and financial obligation never ends, not even at their death, when they must have some plan in place for the child's continued care.

Of the two people I know who filed a major lawsuit, one for malpractice and one due to an accident caused by an uninsured motorist, neither did it to get rich––and neither of them did get rich. They sued as a last resort to pay the bills. While I can't quote statistics, I'd bet that more often than not, whether it's a man who fell from his ladder while painting or a woman given the wrong medication in the hospital, the story behind the story, the story that will not be reported on CNN or Fox News or screamed about on the blogs, is that these people had medical bills they couldn't pay and suing to get someone else to pay was their only choice.

Certainly all the malpractice suits have had a detrimental effect on our healthcare. Some question how much they actually add to cost, but they have caused doctors and hospitals to cover their mistakes. If we recognize that mistakes will happen, it would behoove us to encourage healthcare providers to come forward with their mistakes as a way to eliminate them. However, until we live in a society where the victims will not be punished by huge costs, tort reform before healthcare reform is putting the cart before the horse.

Paul Krugman: All the President's Zombies

Krugman hits the nail on the head.

The Republicans have had a strategy over the past 30 year to push the moderates out of their party, while the Democrats' strategy has been to take them in.

The Public Option: The Backdoor Approach

This is a great article by Mark Trahant on two successful public health agencies most of us didn't even know existed. Maybe the administration needs to be a bit more cagey. Drop the Public Option and quietly expand the existing ones.

Healthcare Reform: What it is and what it isn't

This post isn't going to be a refutation of those silly lies about healthcare reform like it includes death panels or is the first step on a slippery slope to Communism. The people who buy into that, or say they do, have another whole agenda that has nothing to do with healthcare, and I doubt they'd read anything that didn't feed their venom anyway.

This post is for those who think they do support healthcare reform, but might not quite understand what's going on. Talking to some supporters I'm reminded of the time a group of pre-schoolers was arguing in my back seat about whether an absent classmate was "selfish." (They said "shell fish" but I knew what they meant.) With great pride I heard my daughter take the lone position jumping to the child's defense. At home later, after beaming at the praise I lavished on her for standing up for her friend, she asked me, "Mommy, what does shell fish mean anyway?"

While I'm thrilled every time someone signs a petition or contacts a senator in support of healthcare reform, on another level it bothers me that they might be doing it simply because the plan would mean another win for Barack Obama and not because of what the plan means for America. I believe there is no more room for knee-jerk Liberals than there is for knee-jerk Conservatives when it comes to participating in Democracy. So here, in a nutshell, are some of the aspects President Obama covered in his press conference the day it was overshadowed by the last question about the arrest of Henry Lewis Gates. All of this information comes from Howard Dean's Prescription for Real Healthcare Reform and President Obama's address to members of Organizing for America on Thursday August 21 (see below).

Employer Based Coverage
The proposed program would make essentially no changes in the system we now have where most Americans are covered under contracts through their employer with private companies. The only difference would be regulation of insurance companies so that they could not deny claims for pre-existing conditions, they could not rescind coverage once you've been accepted––meaning you couldn't be dropped when you needed it most––and all insurance would have to be community rated (everyone pays the same price regardless of past illness) rather than experience rated. There will be no lifetime or annual maximums on coverage, where covered individuals reach their maximum and then become responsible for all their costs.

Public Options
You'll notice this sub-topic is plural. That's because we already have public options that will remain in place. The best known and the one that covers the most people is Medicare that covers individuals over age 65. We also have Medicaid for low-income families and the SCHIP program to provide medical coverage for uninsured children. To these existing programs would be added another option, a pool of public and private insurers individuals can choose from. Those who buy from this pool will receive a subsidy from the government.

Cost containment measures
To my mind this is probably one of the weakest areas of the proposed program. It is why I preferred single payer, because it would have allowed for a total overhaul of our entire healthcare system. We need to reform, not only the way doctor's are reimbursed, but everything from the cost of a medical education (or how much of it students must shoulder), to how doctors do business and charge insurers, to limiting and covering individuals for mistakes made by thier doctors. If we are going to put more people into the system, we need more general practitioners. We already don't have enough, so we would need to incentivize medical students to go into less lucrative general practice. We also need to change the healthcare delivery system with one MRI machine, cancer center, heart surgery center, for every so many people

As I said in another post, as frustrating as it is to some of us, that overhaul simply isn't going to happen this time around. Obama promises some plans for cost containment, like covering more "wellness" and "prevention" care. I thought that was already in most plans, but I'm thinking of standard HMOs and PPOs. It stands to reason that if insureds have a high deductible they are waiting to go to the doctor until they are sick and require treatment, so that may bring modest savings. Pooling together small businesses may give them more bargaining power. Howard Dean talks about effectiveness studies, but the results would need teeth. Improving records sharing through information technology would certainly save a bit, and, of course, bringing more, probably younger people into the group should reduce costs as well. The largest percentage of our healthcare dollars are spent on end of life care. Much of it, I think, against the better judgement of doctors, patients, and families. It's just that right now, everyone is afraid to tell the other person what they are thinking for fear of the blowback. Covering a consultation for end of life care could actually save big bucks in the end.

What Healthcare Reform is not
I think there is a misconception among both opponents and supporters that the government will be taking a major roll in providing healthcare. Unfortunately, from my point of veiw, it will not. The idea that we'll be waiting in line at healthcare clinics to see the physician assigned to us by the government and only receive government sanctioned care, as opponents believe, couldn't be more off base. That the government will provide everyone with some form of healthcare, as some supporters believe, is wrong as well. You'll still pay for your coverage if you are uninsured. Only, the hope is that you will pay affordable costs for better quality coverage.

Medicare recipients seem concerned that healthcare will be funded through Medicare cuts. Where that came from I'm not sure. However, as a society I do believe at some point we must confront what Richard Dooling calls Health Care's Generation Gap where the elderly are often over-treated while children and their parents don't get the care they need.

There is much this reform bill is not, most of it what people like me would have liked it to be. But, in the words of Walter Cronkite, "that's the way it is."

Rumors of the Death of the Public Option Are Greatly Exaggerated

To hear the news you'd think the public option is dead in the water, but according to Democracy for America, it isnt. The house will need at least 218 votes to pass a healthcare reform bill and 64 Democrats have said they will not vote for a plan without a public option. That would leave only 198 Democrats, not enough to pass any kind of reform bill. While I've noted that the Congress would rather err on the side of doing nothing, they also don't want to appear to do nothing. They'd prefer passing a bill that kind of fades out like an old fifties pop song, but they know passing nothing will lead to death by a thousand cuts come election time. So the public option looks like the only alternative.

So, is the public option really so important? I agree with Howard Dean that reform without a public option is not real reform. It will just be another attempt at reform that sputters and dies. Think about it. Some are floating the idea of medical cooperatives, similar to Kaiser Permanente. In these cases doctors and other healthcare providers work for the coop as opposed to contracting with it as they do with HMOs and PPOs. Often these coops are contained within single buildings or several buildings throughout the area they cover. I think this is an excellent idea for providing low-cost healthcare. I really do, and if these coops had started organizing 30 years ago when President Carter proposed healthcare reform, they might have taken root by now. As it is, I can't imagine it is going to be very easy to incentivize enough healthcare providers in enough places to challenge private insurance companies soon enough to bring any relief to those of us chafing under the costs.

The other idea is health insurance coops. This, as best I can tell, is where the consumers, or the insureds, own the company, kind of like the venerable Green Tree that sold perpetual fire and homeowners. However as this article points out, they are difficult to start, difficult to keep going, and even harder to gain any real bargaining power.

In other words, these are smoke screens, exactly the kind of programs that will be rolled out with great fanfare as the Dems celebrate victory. Maybe even some money will be put behind them, but they won't get off the ground, and even if a few do, they will be the first budget items cut if/when another Republican administration comes in.

The real reason we need a public option is that it is the only way to make reform permanent. I'm old enough to remember the outcry against Medicare. Plenty of people then, including Ronald Reagan who was still just an actor, warned that it was a step toward Communism. Now that we have it, people can't think of living without it. Yes, Medicare has its funding problems, mainly because there was no way to predict how healthcare costs would rise and how different healthcare delivery to the elderly would become, and how long people would live. However, now that it is a fixture we continually find solutions to keep it going. We don't scrap it because without it tens of thousand of elderly would be bankrupted by their medical costs.

While Dean says it's a go, I do see signs of Obama caving. So much has been made of this being his Waterloo, that he may be finding it politically expedient to call whatever Congress passes a success. I think it's time to bring out the threats, like the Republicans did to Arlen Specter. The Dems need to get with the program, or as Dean warned, the Dems will put up more progressive primary candidates to run against everyone who voted against reform.

I hope and pray Howard Dean is right and the public option is not really dead. If it is, we are too.

Healthcare Cost Containment: A Short History Part II-It's the Consumer

Part II in my series on the villains of Heathcare Cost Containment. Part I was about the doctors.


By the early 1980s we were into the Reagan era––the era of individual responsibility. Just as the poor were responsible for being poor and needing only to be kicked off Welfare to end poverty for good, so healthcare consumers were seen as responsible for rising costs. Spoiled by employer-paid healthcare they had no notion of the expenses employers racked up on their behalf. Force them to shoulder a share of the costs and they'd pretty quickly turn into savvy consumers shopping for the best deal.

Accordingly we (yes, I cringe to admit, I was in on the design of such a plan) increased deductibles, though only to about $150, and by then that would be met with just a couple of doctor visits. A few employers required employees to pay a small part of their premiums each month. We also instituted some changes in plan design. Just like now, it seemed a good idea to focus more on prevention, so plans began covering routine medical exams and vaccines at 100%. Prior to that, believe it or not, some plans didn't cover routine physicals at all. We also covered second opinions with regard to surgeries at 100% and a third opinion if someone wanted "the best out of three." The idea was not to deny necessary surgeries but cut down on unnecessary and/or over-performed surgeries. Notice, this was an incentive, not a requirement and the anecdotal evidence at least is that it never caught on. Few patients wanted to go up against their doctors in asking for a second opinion, and when they did, physicians rarely broke ranks, so insurers ended up paying twice for the same prognosis and paying for the surgery anyway. There were also minor incentives for more out-patient procedures.

Just like now there was a great hue and cry against these changes as consumers and their physicians predicted people dying in the streets. Seems people are always more concerned about being under-treated than over-treated. This was also when the HMO offering became a popular option, though only as a second choice. More on HMOs and Managed Care in another post.

Yet again, the measures taken had little if any effect on containing costs. However, the possibly unintended consequence of causing consumers to participate more in healthcare choices, along with some studies being publicized in the press, was that patients began eying their doctors' decisions with a bit more skepticism. Maybe that young mom didn't need the hysterectomy that sent her hormones into a nosedive and deprived her of a third child. Maybe little Joey didn't really require that scary tonsillectomy. And then there were those disquieting rumors of doctors making mistakes––big mistakes––that cost lives and were swept under the rug like recent stories of pedophile priests.

Popular culture often provides a good indicator of political trends. Like Denzel Washington battling the evil insurance companies a couple of decades later in John Q. , the feel-good movie of 1982 was The Verdict in which down-and-out lawyer Paul Newman redeems himself with an early malpractice suit against a physician who, through routine error, sent a young woman into a permanent coma, financially ruined her next of kin, and caused a competent nurse to lose the job she loved because she knew too much. The climax that brings to mind the movie Babe, had audiences cheering as the jury foreman asks if it's possible to award more damages than the original suit requested. Don't believe me? Rent it.

Today many think the easiest and best way to solve our healthcare woes is tort reform. Would you say we Americans are a fickle lot?

There Is Still Hope of Reform: Maybe Quite a Bit

I spent Saturday collecting signatures in support of President Obama's plan for healthcare reform at a local farmer's market. We collected over 150 signatures in just three hours. We probably would have collected even more, but it was broiling hot and we couldn't set up our table in the shade, because we would be soliciting within the market, so we left about 45 minutes before closing.

Not only did we collect a lot of signatures, the people who signed were vehemently in favor, not just tepid. When I'd ask people if they wanted to sign, they'd often reply "Absolutely" after which I was always expecting a "not" that didn't come. Some people politely refused, and some few didn't even know what it was about, but I'd say 80% of the people I asked, signed.

There were a handful of vehement opponents. One fellow volunteer ran into a woman who argued for several minutes, but as often happens, her points were broad ones about too much government etc. etc. Nothing specific to healthcare reform, and she and her husband were pretty obviously Medicare recipients. Which I always find kind of odd. They will tell you what a mess Medicare is, but I don't see anyone saying they are willing to give it up.

Of course, I expected that my venue at a farmer's market might be a little more cushy than others. Frequenters of farmer's markets tend to be more liberal, but the point is, those people are out there, even if we aren't seeing them on TV, and the volunteer who was there last week said they didn't do nearly as well, which may show that all that anger is really moving people in the opposite direction. Supporters who took reform for granted are realizing they need to stand up to get noticed. Based on their zip code, the signatures will go directly to their senators and representatives. So now they don't need to sit through raucous meetings where their representative won't get to speak anyway.

Besides the numbers there were other things I found gratifying about my experience. Watching TV I had begun to believe most Americans were stupid. I didn't think these shouters were stupid because they disagreed with my point of view but because of their reasons. Things like death panels and calling the reforms socialized medicine or saying this is a step toward Communism had no connection, not only to the real bills before Congress, but to the real world. Yesterday, many of the supporters gave me real and solid reasons for their support, not just tag lines spewed by the administration.

Many of those signing my petition worked in healthcare. We had two physicians and several nurses and medical social workers. We also had a two men retired from the marketing side of the medical insurance industry.

I also appreciated those people who were undecided and asked reasonable and cogent questions. None of them signed my petition based on our discussion, but I knew they were weighing the facts not the hype. If they were the only people standing in the way of reform, at least I'd find it easier to accept.

But there was one very disconcerting moment when one young woman said she was glad to hear they were at least doing away with the "death counseling" for old people. "Of course, you know what that really is?" I asked (knowing she didn't). "If a person over 65, at any time, voluntarily wanted to be counseled about care options at the end of life, the doctor would be paid for that hour or whatever he spent with that person." Her reply was, "but to have it decided by a committee." I only hope she saw my look of utter disbelief before I told her, "there was never anything in the bill about committees. What I explained is all there was to it."

I don't know if I got through before her baby's fussing caught her attention. One step forward, two steps back.


If you want to help collect signatures or other things to help reform along, check out this site, but while it was set up by the many people behind the Obama campaign, remember, this is not about Barack Obama. Whether you were an avid or tepid supporter of his campaign, or voted for John McCain or voted for no one at all, this is about healthcare reform for all Americans, not just Democrats.

Interview with Howard Dean: There will be primaries

Frankly, I wish Obama had made Howard Dean healthcare czar. This guy knows the lay of the land, and he knows how to get things done.

O judgment! thou art fled to brutish beasts, And men have lost their reason

Several years ago I read an excellent two volume biography of Adolf Hitler by John Toland. Late into the night I read how pre-war Nazi thugs infiltrated union meetings and other leftist organizations, starting shouting matches that would turn into brawls where they would bring out their clubs and chains. We often wonder how a phemenon like Nazi Germany could have occurred in the modern age, but I realized then how much power unreasonable people can weild and how they can drive reasonable people underground making them afraid to express their opinions.

What I mean by "unreasonable people" is people who react out of all proportion to the situation or issue at hand and often against their own best interests, similar to the way some today are reacting to healthcare reform. So far, violence has broken out only in a few instances, however reasonable people understand that when unreasonable people take control, there is always the threat of violence, and at the very least, reasonable people will be forced into stressful angry situations with little chance of being heard or making a difference. So reasonable people go underground, and, at worst, give up, so that the decision makers think they don't exist and the unreasonable people get their way.

Not to be too abstruse, let me provide an example. At the beginning of this century (that still feels strange), I decided to put a pro-choice sticker on my car. At the time I saw a lot of pro-life stickers, and I wanted to proclaim where I stood. The result of taking that stand was that many friends and neighbors with whom I never discussed the issue took the time to voice their support. I kept the sticker for two years until my daughter got her driver's license and I read (and saw) that anti-abortion activists were posting photos online of license plates on cars parked at abortion clinics. I knew I had taken a slight risk placing that sticker on my car (several people called me "brave"). The question was did I want to place my daughter, who would be driving my car to her after school job, at risk. As a reasonable person, I weighed those risks and removed the sticker. I made a similar "reasonable" decision about protesting at Planned Parenthood clinics. As a mother with responsibilities to my family, I weighed the value of possibly putting my life at risk and decided against it.

That's not to say unreasonable people think healthcare reform is worth dying or killing for. They don't think at all, they just react, usually after being whipped into a frenzy by otherwise reasonable people who find them useful.

While Hitler's mental health has been brought into question, everyone around him wasn't crazy. They were intelligent people, possibly idealogues, , and like many, probably greedy for power and money, who saw in that little man the very useful ability to whip up anger and hatred amongst the unreasonable people.

Of course, the great benefit of using unreasonable people to do your bidding is that you can always deny responsibility if it goes too far. You can also, with a wink and a nod, scold them for their actions. At the same time when the unreasonable people are knocking themselves out fighting against their own best interests, you can step in and reap the profits and tell them you are doing it for them. And they are so unreasonable as to believe it.

Conservative members of Congress–-at least some of them––are far too intelligent to really believe Obama is acting like a Nazi or that these minor reforms to our healthcare coverage will lead even to socialized medicine let alone a socialist government. They know there is nothing in these bills that supports killing granny or euthenizing Downs Syndrome babies, but they are not above resorting to such nonsense to whip up the unreasonable crowds to do their bidding, which is to simply bring Obama down and get back the power they had come to believe they had a lock on.

The people yelling (the term protest is not accurate) at these town hall meetings do not look to me like CEOs of major companies who could pay more taxes if the Bush tax cuts are repealed. Nor can they all be employed by private insurance. They are the people who would benefit most by healthcare reform and have absolutely nothing to gain if it doesn't go through. Yet the conservatives have whipped them into thinking healthcare reform is just another a raw deal for the little guy. They believe it and so the unreasonable people go to these meetings, shouting down those who are trying to inform them, while reasonable people make the reasonable decision to stay home, since there is nothing to gain by being there.

The sad thing is, in the end, the unreasonable people will have lost and so will the reasonable people. The only winners will be the manipulators.

It's truly frightening.

Twitter Crashes: Brits tired of US Pols bashing NHS

The Brits are twittering back. It seems they are tired of US ads and blogs that give their National Health Service a black eye. Click on the title to read the article.

Single Payer Advocates: Why You Should Support ObamaCare

The problem with polls, or at least the way they are usually reported in the media is that they require a yes or no answer. With regard to healthcare reform, many of the contacts I've made through meetings and organizations don't support any of the current reform options, because they don't believe they go far enough. Many feel that a single payer plan is the only way to truly reform the system.

Until a few weeks ago, I was one of them, and I continue to prefer single payer and remain appalled that it was never even considered as an option. A single payer system involves more than the government simply picking up the tab for healthcare. At its best it would be an overhaul that would lead to an integrated system of healthcare delivery with oversight by a cabinet office or government agency. I still fear that anything less will not contain run away healthcare inflation or ensure delivery to under-served communities. Without cost containment and without the requisite number of doctors (particularly General Practioners) and hospitals to serve all those new insureds, I see a strong possibility for failure.

So it may sound odd that I am exhorting supporters of single payer to get on board with the Obama plan. The reason is what I stated in the beginning of this post. This is being cast both by opponents and our famously no-nuance media as a "for us" or "agin us" issue. If health reform goes down this time, no one is going to re-visit it and push for single payer. Congress will be only too glad to let this drop, hiding behind the excuse that the American people once again decided they weren't ready for change.

Real healthcare reform isn't one of those feel-good issues everyone can get behind, like just telling insurers to cover everybody. Real reform is complicated and requires major concessions from everyone involved (including consumers). Even a half-way measure like a public option means facing contentious issues like denying certain services and reconsidering end-of-life expenditures. Members of Congress today see their job more as a popularity contest and with Americans having notoriously short memories, they'd rather err on the side of doing nothing––which voters will soon forget––than facing the merest chance of a failure that could still be hanging over their heads at re-election time.

While I have my fears that the simple addition of a public option won't be enough, there's still the possibility it could turn into the opponents' greatest nightmare–– a success that will lead to even more changes. If, with the public plan, premiums are lowered and outcomes improved, individuals as well as businesses will vote with their premium dollars and we may achieve single payer by evolution rather than revolution. Once all the dust settles and citizens take the public option for granted as they do Medicare and no member of Congress worth his/her salt would threaten it, maybe it ccould be used as a platform for the next step.

If the public option fails now or eight years from now, it means the end of major healthcare reform, but if we let it fail now, we'll never know if it could have worked or at least served as a stepping stone. That is why it is extremely important for those who prefer single payer to step up and support the public option. Call your senators and representatives, show up at rallies, attend town hall meetings, and make your voice heard. If you are asked in a poll or on the street if you support the president's healthcare reform plan, say yes instead of no.

Don't let the perfect become the enemy of the possibly good.

Healthcare Cost Containment: A Short History Part I––The Doctors

When it comes to current events, Americans lack a sense of history. In the past 30 years I've seen run away healthcare inflation blamed first on the doctors, then on consumers, then lawyers, and then on the insurance industry, as though there can exist only one villain at a time, and forgetting that the prior set of issues were never remedied before we moved on to the next set. I'm now realizing that my career in medical benefits followed the trajectory of cost containment efforts. So here's a little bit of history on what brought us to this point.

In his book, Dr. Howard Dean makes the interesting point that most of the existing healthcare systems of the industrialized nations hearken back to the situations they found themselves in post-WW II. The UK, for example, had no remaining healthcare infrastructure while citizens were in dire need of medical care. The government had no choice but to take over the healthcare system, which they have since continued, not just out of tradition but because they made it work. In the US employers began offering healthcare coverage as a free benefit when wage controls prevented salary increases. Unfortunately for us, what seemed like a good idea at the time has turned into a failure.

When I began working as a medical claims examiner in the late 70s, first with New York Life and then John Hancock, the system that had been in place for some 30-plus years was just beginning to show signs of unraveling. With the exception of Blue Cross-Blue Shield, most employer healthcare products at the time were sold by life insurance companies. As they were not big money-makers they were bundled with more lucrative group life insurance plans.

Back then there were generally only two types of plans. One was straight "Major Medical," a plan with a deductible (standardly $100). After meeting that deductible (which sounds ludicrously low, but remember with lower costs it could take quite some time to meet), the insurer paid 80% of the charge, the insured, 20%. The second type of plan was a mix of "Basic" and "Major Med." Under these plans basic flat fees were paid for certain services according a schedule. E.g. an office visit might qualify for $15. Charges over that amount then fell into the Major Med portion subject to deductibles and coinsurance. Attesting to the vast changes in medical care in just three decades, we actually had a schedule listing a fee for just about every medical service, test, or procedure offered at the time. We rarely received a claim for anything not on the schedule, and the majority of services and procedures recurred so frequently that we were able to memorize the payments. The most important thing to note here, however, is that while the payments might be divided between insurer and insured, the provider always received 100% of the charge, usually without question.

Toward the end of the 70s, several factors came together causing insurance companies and the Carter administration to start looking for ways to contain medical costs.

• A new generation of doctors didn't know what it was to charge patients directly or wonder if they could pay. With faceless insurance companies picking up the tab, there was no reason for providers––doctors or hospitals––not to pad the bills a little here and there.
• With the growing use of antibiotics, development of vaccines, and new drugs and procedures being discovered every day, the public began to see doctors and hospitals as a way to a cure rather than pronouncers of imminent death. Consumers visited their doctors more regularly, underwent more surgeries, and became more demanding of services.
• New developments led to an explosion of new specialities, and more and more young med students began choosing the more lucrative and generally less demanding specialties (and in fairness, they were probably more mentally challenging as well), over general practice.

Employers' cheap added benefit was quickly turning into a very expensive one and they began leaning on insurance companies to do something about it. Thus were born the first "reasonable and customary" restrictions, complicated formulas imposed on charges––usually physicians' charges––to determine if they were too high. The problem was, it didn't have teeth. Only Blue Cross-Blue Shield required doctors to accept the reasonable and customary fee for assigned benefits (benefits paid directly rather than reimbursed to the patient), and many physicians began pulling out of the Blues because of it. Most insurers would simply send statements to the doctor and patient stating what charges were excluded.

I suppose the notion was that the insured would get wise to the physicians and call them out on it. Only, in those days arguing with doctors was like arguing with the Pope. They were considered infallible and they were not beyond excommunication. So patients usually picked up the charge after giving poor claims examiners like myself an earful. Or else the doctor would send some twenty-five page medical report to dazzle us with detail and get us to to reconsider, which, more often than not, is what occurred.

And that, my children, is how the first feeble attempts at healthcare cost containment failed. It is also why a favor a managed care or at least an outcomes-based component of any new reform plan.

Part II will be about the healthcare consumer as villain. However, in between I may not be able to resist focusing on some of the wild lies out there meant to scare people off reform.

Comments on Insurers Have Hill Defenders

Just a few comments on the article I posted in my sidebar about Hill Defenders of Insurance Companies. Sen. Nelson wants his colleagues to "tone down the rhetoric," but Susan Collins' warning "that creating a public, government-run insurance program to compete with private insurers could disrupt state-regulated insurance markets" sounds to me like as good an example of empty rhetoric as I've ever heard. What exactly does that mean? Disrupt in what way? And is disruption necessarily a bad thing? If investigators disrupt a terrorist plot, that's a good thing, right? That is the type of language often used by politicians to stir up fear by hinting that reeling in the profits of a certain industry will have a dangerous rippling effect through the entire community. Conspicuous in their absence are any specifics. Something like saying, "these lawsuits will completely disrupt the tobacco industry in this country."

"All four say Congress would need to include provisions to ensure that the government program would not have an advantage over private insurers." Say-wha? A plan with affordable premiums that does not deny coverage for pre-existing conditions and has lower administrative costs couldn't help but compete with private insurers. Do we really need a public plan that doesn't meet those criteria?

“I’m always surprised when I hear some of my colleagues describe the public plan as being needed to keep the insurance companies honest . . . when insurance carriers are regulated in every state in the nation,” Collins said. They are a heavily regulated industry.” But obviously still not regulated enough. The problem is provisions vary from state to state and most states still allow private insurers to get away with all or part of what I mention above. To her credit, Susan Collins' state of Maine has moved in the right direction in some areas as requiring individual policies " be written on a guaranteed issue basis, meaning insurance carriers are not permitted to deny you coverage due to unfavorable current or past health history." Looking at the website, however, I don't see anything that would prevent an insurer from finding an excuse to drop individuals suffering a major illness.

It doesn't really matter, though, whether Maine has that provision or not. Probably the best regulated and most efficient running health system in the country is the system created under Dr. Howard Dean when he was governor of Vermont. Only we can't all move to Vermont. That's why we need regulations that go beyond state borders and a public option anyone is free to choose.

Watch out for those who call themselve "moderates" who claim to be looking for a compromise and accuse reform proponents of being too "partisan." One public health plan competing against all the existing private plans is a compromise. It is not single payer or socialized medicine. Without a public plan there can be no reform, just some regulations that, like regulations on the financial industry that went into effect following the Great Depression can be repealed or ignored whenever the political tide changes.

Healthcare Reform: It's Your Problem Too

I promised my next post would be a history of cost containment efforts, but in response to what I'm hearing on the news and reading in my e-mails (I've been having trouble with comments here and my blog was blocked for a while, but I hope it is all fixed now), there are an awful lot of people out there who think healthcare reform is for "the other guy/gal" and that there's nothing in it for them but higher taxes. I noted in my blog description that reform is really about "good old American 'what's in it for me' thinking for both the uninsured and the currently insured who could find themselves uninsured at any moment."

I hate resorting to the same hyperbole that has recently framed this discussion, but get real people. Opponents of healthcare reform are using scare tactics to warn off the people––you the middle class––who will benefit most from reform. This isn't about the poor, they get Medicaid, and the wealthy have their gold-plated plans. It's about you and me, from the lower to the upper end of the middle class who are suffering, and if reform doesn't pass, the only winners will be the insurance companies, the politicians they keep in their pockets, and the high income people who have fine healthcare and now won't have to pay an additional penny in taxes so you can have yours. And if you think it's bad now, wait until these companies see no more obstacles in their way.

Or maybe you don't think it's bad. Maybe you are buying into the myth that we have the greatest healthcare system in the world. Well, I hope you are sitting down.

According to a report by Families USA 86.7 million people or 33% of the population under 65 went without health insurance for some or all of the the two year period of 2007-2008.
You've heard a lot about the 48 million uninsured, but they are the "chronically" uninsured. This higher figure includes those individuals who probably didn't think they had anything to worry about. People with employer-paid healthcare plans who lost their jobs. Divorced spouses who now have to pay full cost if they want to continue on the ex-spouse's plan or for whom the COBRA extensions have run out. Employees of small businesses where a spike in premiums left them no choice but to drop their coverage. Employees of large or small businesses that began requiring them to pick up part or all of their heathcare premiums, who, unable to afford it, had to drop their coverage all together.

25% of all uninsured under 65 during that two-year period remained uninsured for 24 months
Twenty-four months is a long time to keep your fingers crossed and hope you won't get sick, especially when dealing with the added stresses of looking for a job, trying to put food on the table, meet your rent or mortgage payments, probably doing more of your own home repairs––climbing ladders, doing electrical work. The mean cost of a hospital stay in the state of Nebraska (home of Mike Snider) is $21,865. That's just the hospital stay. It doesn't include things like rehab, special equipment––wheelchairs, crutches––medications following a hospitalization or for any ailment you might have already had like high blood pressure or even chronic sinus infections. Statistics vary, but from what I can find, the average cost of a visit to a doctor's office runs anywhere from $60 to a few hundred dollars. According to Blue Cross Blue Shield, the average cost of an ER visit (which is where most of the uninsured must go, because doctors don't take people who can't pay––though ERs don't always take them either), is $383.


The percentage of uninsured was highest among 19 to 24-year-olds and 25 to 44-year-olds
Let's say it looks like you're going to make it to Medicare age without going uninsured. Do you have kids? The standard health insurance plan covers children up to age 18 or up to age 23, if they are full-time students. So if you have a kid ready to graduate, chances are they will go uninsured for a good part of their lives. Sure, kids often don't see the long-term value in something like health coverage and turn it down even if they can afford it, but it is often too expensive to afford on the low salaries many young people receive (it costs $165 per month for my daughter), and fewer and fewer employers of young adults provide coverage. Many young people work in jobs that employ them just under the number of hours to be considered full-time. It pays businesses from restaurants to universities (many are now hiring large numbers of adjunct professors) to hire more part-time workers than fewer full-time workers who would be eligible for benefits. It's every parent's fear that a child will have an accident or suffer a major illness, but in this case the fear is two-fold. Most parents would want to help an uninsured child with healthcare expenses, and it could wipe them out.

These statistics showing how easy it is for the average person to end up uninsured at some point in their lives go on and on. You can read them yourselves. What many people don't realize, because it has become such a way of life in this country, is how we are held hostage every day by our current system.

Do you think you'd be more appreciated at Company Y than your current Company X? You'd better not have a pre-existing condition. Employer group plans have to accept everyone, but depending on state regulations, the new insurance plan can exclude coverage for pre-existing conditions for anywhere from three to twelve months. That means, if you have high blood pressure, they would exclude your meds, your doctor visits, and probably your heart attack if it could be shown as connected (which of course it could).

Do you want to indulge that entrepreneurial spirit American politicians so often praise? Be prepared to go uninsured if you have a pre-existing condition or pay higher premiums because of it. A few years ago, when my husband and I were looking for less expensive alternatives to our $1200/month plan, we expected a rate increase for his high blood pressure. We didn't think our daughter's mild dermatitis for which she used an antibiotic cream three years before would add to it as well.

Think your current premiums for individual coverage are too high and you want to look around?
If you've been in your current plan for several years, you'd better stick with it. When you see those people testifying before Congress about losing coverage the day before cancer surgery, you may think the company has a right to flag "fraudulent applications." If you haven't completed an application for individual insurance recently, you may not know that they ask you to list the exact date you sought treatment any time during the past 10 years. That includes colds, flu, sinus infections, prescriptions for seasonal allergies. No one keeps that information. So you fudge it or skip it. The interesting part is, the company doesn't investigate your application immediately. You could go on for years paying monthly premiums and being reimbursed for the usual minor costs. Then, bam, just when you need it most, they terminate your coverage because you didn't mention the time you visited your doctor for poison ivy in 1999.

Are you a divorcee who has met the new love of your life? He'd better have good coverage.
If you are covered under the COBRA provisions of your ex-spouse's plan, they end if you re-marry. If the new spouse doesn't have a plan, or you don't think you'd qualify, you'd better stay single. Often divorced spouses with serious health problems will take health coverage as their settlement. Because of the expense, they rarely get anything else, and, again, forget re-marrying.

We cannot go on calling ourselves the greatest country in the world when we are slaves to our healthcare carriers and when one illness could wipe out a lifetime of savings for hard working people.

Don't fall for their lies this time. It is too important and the opportunity won't come along again.