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 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.

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.

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.

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

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.

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."

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.

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.

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.

Reforming Healthcare: Can We Afford To Do It? Can We Afford Not To?

Twenty-some years ago a young couple, John and Mary, bought a house cheap knowing it needed certain repairs. They both had good incomes. Their investments were growing by the hour, so it seemed like a good plan. Only, they kept finding excuses not to spend money on the things that needed doing. In good times they didn't want to take large sums out of the market. In bad times they wanted to leave the money there until they made up their losses. Then there were so many other "smaller" expenses that ate up their income, like the flat screen TV they had to buy when it looked like the old set just possibly might go on the blink right before John's big Super Bowl party, and Mary's iPhone that was such a bargain, being a laptop and a phone in one, though she still replaced her old laptop when it crashed.

Twenty years later the chickens have come home to roost, almost literally as crows are entering through the gaping holes in their roof. The rusted out hot water heater not only doesn't heat water, it flooded their basement. The leaky dishwasher they figured they could live with as long as it washed the dishes, rotted a hole through the floor, and the windows they'd always meant to replace allowed water to seep into the walls, nurturing a spreading mold. Not only are the costs and damage worse than twenty years ago, now Mary lost her job and John will probably lose his. Their investments have tanked, and their 401(k) isn't even worth breaking into. John and Mary have no choice but to take a loan, and now...that health problem John's been putting off going to the doctor about just sent him to the ER requiring life-saving surgery.

John and Mary's predicament is very much like the situation the US finds itself in right now. For over twenty years–-and that includes the Clinton years––we've been told the best way to keep our economy going is to spend our money on consumer goods rather than taxes. That's a fun notion anyone would want to believe, even those of us with niggling doubts about just how all that money spent at the mall would trickle into the public sector, and certainly no sensible politician would go up against another one touting that dream of a free lunch. Only now our infrastructure is crumbling, libraries are closing, Medicare and Social Security are in danger, our air traffic control equipment is outdated––you name it and it needs fixing––right in the middle of an economic crisis some economists term the worst since the great depression. With the federal deficit exceeding $1 trillion without even making a dent in these burgeoning needs, many Americans understandably wonder whether now is the best time to tackle healthcare reform with an extremely expensive public option.

First, let's get the facts straight here. I happened to be watching one of those moderated he said/she said debates about healthcare reform on the Lehrer News Hour when news broke that the CBO had estimated the cost of H.R. 3200, the America’s Affordable Health Choices Act of 2009 would cost just over $1 trillion over the next 10 years. Everyone was suddenly struck dumb as, while to you and me 1$ trillion sounds like a lot of money, for the government, spreading that cost over 10 years isn't that big a deal, and everyone discussing it knew that. Since then, the $1 trillion figure has been bandied about quite a bit, without adding the time frame. When I write these posts, I try to go to the source rather than quoting articles about articles about the source, so I went to the CBO site, and as of the point I decided I was spending way more time than this short post warranted, I hadn't read a figure that exceeded a few hundred billion. If anyone wants to, or has, read the whole thing and wants to point it out to me, I'd be much obliged.

The second estimate picked up by the let's start a tempest in a teacup media was something to the effect that, without cost containment measures, a public plan would be unsustainable. Here again, I went to the actual CBO letter. From what I can gather, and it is pretty arcane, that came from projections beyond the next ten years, the accuracy for which the CBO will not vouch (that's a little convoluted), because projections beyond 10 years are even harder than 10 year projections. However, I assume all the hoopla is based on this point,

"As long as overall spending for health care continued to expand as a share of the economy, people’s share of insurance costs would continue to rise faster than their income, or the government’s subsidy costs would continue to rise faster than the tax base, or both."

Again, if anyone can find anything more specific that the media was referring to, I'd like to read it.

So what we have so far, as I see it, is that healthcare reform is doable and it can be affordable, but not without cost containment, and I'm betting not without tax increases either. That's something many of us have known all along. Only we've been trying to impose cost containment on our healthcare for more than 30 years and it's never stuck. As to increased taxes, well, you all know what a lead balloon that one is.

Next, a short history of healthcare cost containment efforts and why they haven't worked. You can find the history of taxes on your own.

Healthcare Coverage: Debunking some of the myths

Last week in The Inquirer, columnist Susan Estrich, who, while I despise labeling, would probably call herself liberal, came out against Obama's healthcare reform. The title of the piece was Don't risk your benefits. A known liberal columnist coming out against healthcare reform can hold a lot of sway, so as my first post I'd like to discuss some of her points and explain where I think she got it wrong.

Your benefits are not at risk–-at least not through a reform plan
Let's start with the title of the article. I find it strange that, over the last couple of decades since the advent of HMOs and PPOs, all the news seemed to be about patient disatisfaction with insurance plans that put obstacles between them and their healthcare providers. Now, suddenly, we are told most people are satisfied with their coverage and won't give it up for love or money. Well, the good news is, if people really are satisfied with their plans, they are free to keep them. I don't know how many different ways it can be said before people stop buying into the misinformation put out there by reform opponents. There is no plan in the House or the Senate or recommended by the Obama administration that would require anyone to involuntarily give up their current health coverage. Period.

Lest you think this blog will simply be an apology for the Obama plan, this is a good place to point out that I have strong doubts a competitive market system with the addition of a public plan is nearly enough to solve our current healthcare problems. I believe anything less than an entire system overhaul with more centralized control, what some might call single payer or, yes, socialized medicine, is required. More on that in other posts, but for now, suffice it to say, the prospects of that happening in the near future are nil. So this sudden love affair everyone seems to have adopted with their favorite insurance company can continue without interruption––at least the government won't interrupt it, whether your insurer or your employer interrupts it is another matter.

The best healthcare in the world
The US ranks 27th in the world for life expectancy. Our infant mortality rate is higher than the other industrialized nations. According to a study funded by the Commonwealth Fund of 14 Western European countries plus Canada, Australia, New Zealand and Japan, the US is now dead last (and by a wide margin) in reducing its "amenable mortality rate," that is, the number of deaths per 100,000 "from certain causes before age 75 that are potentially preventable with timely and effective health care." At one point we ranked fairly well on the scale, but while everyone has improved somewhat since the 1990s, the other countries have been improving at much higher rates.

I could continue listing statistics. The point is, opponents of healthcare can't continue hiding behind the myth that our system is too good to be tampered with. All the countries outranking us have some form of universal healthcare coverage, but it isn't only the uninsured and the underinsured whose health is suffering. In his book Prescription for Real Healthcare Reform in which he lays out the basics of the Obama plan, Dr. Howard Dean claims that the US "wastes as much as $700 billion a year on tests and treatments that cannot be shown to improve health." Dean notes that the Obama plan calls for establishment of an independent institute to research and review comparative effectiveness of treatments. (1)

The government coming between you and your doctor
Ms. Estrich seems to enjoy a good professional relationship with her doctor and fears a system where government will intervene in that relationship. I don't know what kind of coverage she has, but most of us already have insurance companies intervening between us and our doctors and they do it with profits in mind. Many physicians support healthcare reform. The AMA supports reform that will bring affordable healthcare to everyone, but pretty much under the system we now have. I'm not sure how that's going to happen. Other large groups of physicians support more systemic reform and the Physicians for a National Health Program are lobbying for single payer. However, they favor public coverage with private choice. I'm not sure I favor that much either.


These represent just the tip of the iceberg when it comes to the misunderstandings and misinformation flying around regarding healthcare reform. I have nothing against a spirited debate, but it has to be more than a rationale for the status quo by those who feel they, personally, have nothing to gain from a change, and it has to have some basis in fact rather than conjecture.

If you agree or disagree, I would love to read your comments. Please, keep it civil, try not to resort to name-calling, and try to focus your comments on this specific post. If you wish to discuss another aspect, chances are I'll cover it at some point, and if I don't, you can contact me. Maybe we can arrange a guest post.


Next: What you stand to lose from the status quo

(1)Dean, Howard, MD. 2009. Prescription for Real Healthcare Reform. Vermont: Chelsea Green Publishing Company.