Public Option: Yes We Can

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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.

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.

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.

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.

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.

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.