Universal Care Saves Lives...

TW: On a day when a douche bag like Joe Lieberman is getting the publicity he so slavishily craves by screwing over his former party, it is good to re-visit yet again why health care reform is important. What does it mean in terms of lives saved if uninsureds are integrated into our deeply flawed system?

From Ezra Klein at WaPo:
"...The Institute of Medicine developed a detailed methodology for projecting the lives lost due to lack of insurance...We're very comfortable talking about the financial cost of health-care reform. We're less comfortable talking about the human benefits. But the fact that health insurance saves lives isn't controversial. A 2003 study examining cancer records from Kentucky found that uninsured women with breast cancer were 44 percent likelier to die than their insured counterparts. And that was after controlling for demographics, stage of diagnosis and initial treatment. A 2007 study found that the uninsured were 24 percent to 56 percent likelier to die of stroke, depending on the type. That study, too, controlled for all the relevant variables...

All this is intuitive. The uninsured are less likely to seek early care. They are less likely to get good care. They are less likely to return for follow-up care. They are less likely to be able to afford the maintenance of chronic conditions. At its most basic level, that's what this is all about. That's why people have been fighting for universal health care for almost a century now. That's why this matters, and why the basics of the bill -- subsidized access to health-care insurance -- are so terribly important. This is life and, well, death. Lots of it, in fact.

...Medicare saved lives. Medicaid saved lives. The health-care coverage that costs the average worker more than $13,000 saves lives. That's why we shoulder these expenses. And health-care reform will save lives, too. That's why we're doing it..."
http://voices.washingtonpost.com/ezra-klein/2009/12/the_150000_life_health-care_pl.html

Some Health Care Cost Containment Measures

TW: Ezra Klein from WaPo has aggregated some key thinkers' thoughts on health care delivery cost containment. These are the nitty gritty details of legislation which, after all of the hyperbolic "debate" re death panels etc., could actually make differences. Is your congressperson working on these details or merely demagoging? These are also the type details media do not cover for the simple reason if they did no one would watch. Below are some snapshots:

" '...Medicare has to lead the way in moving away from a system that rewards low value, high cost services and undercompensates for time spent with patients to help manage or even prevent illness. Provisions in the Finance bill encourage innovation -- not just by creating a Center for that purpose -- but by empowering it to broadly experiment with new payment mechanisms, requiring their evaluation, and authorizing their broader implementation.
But equally important...are the provisions in both the House and Senate bills to authorize changes in the existing payment system to re-price services that are just plain over-priced. Until we stop paying too much for the wrong kind of service, we won't get providers to deliver the right kind of service. Getting the current payments right, then, is as important to change as putting new kinds of payments in place...'
--Judy Feder is...dean of the Georgetown Public Policy Institute, and a health-care policy expert at the Center for American Progress.

'Successful cost control requires two strategies: (1) aggressive government bargaining to constrain prices and utilization, and (2) the development of new care models that provide more efficient care. For now, the first strategy seems out of reach. Democrats choose to blame insurance and pharmaceutical lobbies. In truth, the opposition is broader.

I am becoming more optimistic about the second strategy. I don’t know whether accountable care organizations or primary care medical homes really save money...

I’m also struck that these efforts enjoy wide support among partisans who normally disagree. As a partisan myself, I have no trouble identifying friends and enemies in the fight over universal coverage. When I ponder delivery reform, I find the white hats and black hats more difficult to place. However liberal and conservative experts might disagree over the public option, both want to shift resources from specialty to primary care. Both want Medicare purchasing through competitive bidding. Both want medical care to be explicitly guided by comparative effectiveness research...'
--Harold Pollack is a professor at the Univ. of Chicago, a faculty chair of the university's Center for Health Administration Studies

'Baucus...has a little noticed but very important provision to establish a Chronic Care Management Innovation Center at CMS. The Center, funded at $1 billion per year, would experiment with different ways to encourage evidence-based, coordinated care. Reforms that improve quality and reduce costs could be expanded nationally without further legislation.
Improved chronic care management is a key part of necessary reform. It is what will turn the dream of prevention into a reality, improving health and saving money. Further, the idea of experimentation is exactly right. We don’t know all the steps to take in reform. But we have a number of ideas. Those ideas should be tested, refined, and then expanded or dropped as appropriate. The chronic care management center is a model for how payment reform might work as a whole'
--David Cutler is Dean of the Social Sciences...Professor of Applied Economics at Harvard University...He was also one of the Obama campaign's most influential health-care policy advisers.

My Summary Thoughts On Health Care (cont.): Is the Public Option Necessary?

TW: Necessary for what would be the relevant follow-up question. Necessary for universal care to be attained, absolutely not. One can have universal care strictly using existing public programs and private insurance. Necessary for cost controls. There are numerous means by which to control costs. The public option is one of them but by no means the only one. Necessary to keep the left-wing of the Democratic party happy. Definitely as many on the left have decided this is their Waterloo (to quote Mr. Kos from Daily Kos for example).

To many progressives the public option has come to embody more than perhaps its actual substance. It symbolizes for them, corporate interests and their lobbyists losing for once amidst the tumult of the legislative process. There are also more substantive arguments in favor of the public option, Paul Krugman as usual articulates them more succinctly than most:

"...[One] the huge overhead of the private insurers, much of which involves marketing and attempts to cherry-pick clients — and even with community rating, some of that will still go on. A public plan would probably be able to attract clients with much less of that. [TW: reducing OH cuts real costs from the health care system]

Second, a public plan would probably provide the only real competition in many markets...."
[TW: many states have very poor competition amongst the private insurers]
http://krugman.blogs.nytimes.com/2009/09/08/why-the-public-option-matters/

TW: I agree with Krugman on these two points. But there are also two primary rebuttals relative to the public option:

One, the public option would, if not immediately in time, receive public subsidies rather than merely be a low cost conduit by which folks could pool their insurance risks. Should subsidies emerge private insurers would be at a disadvantage. This is one of the features some conservatives latch onto in order to extrapolate the complete takeover of health care by "government".

Two is the politics. For better or worse, rightly or wrongly folks fear "government". There may not be enough votes to include a public (aka government) option in the reform bill. This is somewhat circular and certainly a political calculation incorporating the actual benefits and risks of the public option.

As I said earlier I am an incrementalist, I have yet to see any progressive define why a health care bill without the public option is worse than no health care reform bill. Or for that matter why it is crucial to the bill. The public option would not be a magic bullet to control costs or seal universal coverage. The former will require multiple efforts, legislation and initiatives; the latter will be attained without it.

So do I believe the best bill would include the public option? Yes. Would it make it better? Yes, but then I can think of a dozen things that would make the current bill better.

ps as far as this "trigger" thing goes, it is a B.S. way for folks to back down from the public option without appearing to totally cave. I understand why folks do such things but it is not a meaningful measure. But again if it makes folks feel better and vote for actual reform so much the better.

My Summary Thoughts On Health Care: Focus On Universal Care

TW: Things have calmed down somewhat on the health care front. Legislation of some sort will get done. I side with those in the incrementalist camp. Something is better than nothing and something will nudge the can down the road. When pondering what I support, I tend to get twisted reconciling what I would do if working in a vacuum versus what I view as politically feasible. Rather than getting hung up gaming the politics I will just enumerate some themes after having spent much time pondering the challenges.

I am netting out on making sure universal coverage (or something close) is created, nothing more, nothing less for now. Health care reform must ultimately include measures to "bend the cost curve", "ration health care spending", etc. etc., but few of those measures will be enacted into this current bill. This makes some sense. Universal care and costs measures are related but separate issues. As cost pressures increase, more and more folks will succumb to the donut hole which exists in American health care. If universal care is not enacted, the hole will gradually enlarge and become a de facto default source of rationing (even more so than it already is) within our system.

This piece from Time a couple of weeks ago struck a chord:
"Patrick Gilbert, an uninsured lumber company worker in upstate New York, is in a predicament that President Barack Obama and congressional Democrats believe they can solve. Gilbert and his wife have two children, but he says that on his family's $50,000 annual income, he can't afford the $600 monthly premiums for his employer's coverage.

"If I could find some reasonable insurance for about $100 a month, then I would do that," says Gilbert, 38, a lymphoma survivor who lives near Lake Placid. "Something reasonable, not with high deductibles. Something fair."

The House's health overhaul proposal would allow Gilbert to obtain family coverage for $250 a month, with the government picking up the rest of the premium costs. While that subsidy would make insurance more affordable for Gilbert, he could still be stuck with huge medical bills if he or his family members got seriously ill. In the worst case scenario, Gilbert could end up paying $4,400 in co-insurance and deductibles on top of $3,000 in annual premiums — adding up to 15 percent of his family's income."

TW: Gilbert's dilemma is real but exposes the utterly unrealistic expectations of some. There is no insurance plan for a family of four (inc. a lymphoma survivor no less) that costs $100 per month. Gilbert could probably pay $100 per month for the rest of his life and not re-pay the treatment he received for the original lymphoma much less cover himself and the rest of his family goinig forward.

Health care is expensive and getting more expensive as technology permits life to be extended and in many cases quality greatly improved. Thirty years ago, Gilbert's lifetime health care expenses might have been greatly lower because he would have been killed by the lymphoma.

So what does one do with the Gilbert families in America? The status quo is to leave them dangling hoping for good health, perhaps hoping for some charity or waiting in long queues whilst clogging our acute care facilities where they must be treated by law?

Health care is becoming more and more expensive for many reasons including the fact that it can do more and more. Yet folks incomes are not increasing fast enough to keep up with the health care increases. Our society has a choice: figure out how to systematically provide health care for all or systematically reconcile to the notion that many working poor and increasing numbers of middle class folks will suffer from inferior health care and in some cases die. Right now we have a messed up hybrid which is failing increasing numbers of folks. Not the poor so much (Medicaid) and certainly not the elderly (Medicare) but many stuck in between.

Universal care will be expensive, very expensive but ignoring this growing donut hole is just wrong. Will tough choices be necessary on the cost side? YES!...but lets get universal health care done then maybe the Republicans will get serious about working together to address costs because right now they would prefer the donut hole continue and grow rather than work on cost solutions.

On a related note this is a useful link from WaPo outlining key health care reform issues:
http://www.washingtonpost.com/wp-srv/special/politics/8-questions/index.html

The Case For Universal Care

TW: This piece makes a case for universal care. I do not necessarily agree with this piece entirely, but I strongly favor universal care. Will do a little fisking.

From Avia Orenstein in the Bloomington Herald:
"I attended the Sept. 2 town hall forum on health care, and I was distressed to hear a young woman ask: “Why should hard-working people like me be required to pay for someone else’s health care?”...as Rep. Baron Hill replied, we do in fact already pay for others’ health care.......her question seemed fueled by misinformation and mean-spiritedness as well. As was readily apparent from the moving stories offered at the town meeting, “hard-working” people are not being served by the current system. Although some people at the forum yelled out “get a job,” certainly they, too, must recognize that the working poor (those who serve us at chain stores or restaurants, for instance) are trapped in an untenable system in which health insurance is simply not affordable.

Joining the working poor are people who work for small business, people who have lost their jobs in this tough economy and people with pre-existing conditions. Was the questioner really willing to accuse someone with a congenital condition of being lazy? I can only hope she was merely misinformed."

[TW: Here in rests a challenge with the current debate. The original question implies several things but one is that universal care is at least partially if not primarily about care for unemployeds and the poor. It is not. Poor folks have Medicaid, those over 65 yrs old Medicare both of which involve others partially or wholly paying for their care. If folks do not like re-distribution, then attack Medicaid and Medicare . This current debate is about creating a structure by which health care is available for the working poor, the lower-middle class and those who end up launched from private insurance due to recission or pre-existing conditions. Universal care is about making the American workforce more mobile where portable health care benefits are real, where folks can move jobs without fear of losing legacy health care benefits despite pre-existing conditions.]

"...I assume that the questioner would not be heartless enough to have us turn away a critically ill individual at the emergency room; under our current system, this approach for treating preventable illnesses and conditions ends up costing everyone significantly more than the preventive care available under universal health insurance.

No bubble is vast enough to insulate ourselves from the effects of others’ lack of health care. Our economy and our well being depend upon a healthy work force. We need our baristas to have paid sick days, or, when forced to work, they’ll sneeze the foam from our frothy drinks.

If our kids’ teachers aren’t compensated with good health coverage, our children’s education will suffer hand-in-hand with every teacher who is ill. Facing an H1N1 outbreak, we don’t want fellow citizens to choose between paying rent and getting medical treatment. In short, we are simply too interconnected not to ensure the cost of others’ health care...."

[TW: This is the argument that universal care will push folks away from more expensive forms of acute care and also introduce less expensive preventative care. This is true if not compelling to most as the cost is somewhat clear and the benefit far more nebulous. The argument that unhealthy folks create negative externalities is also relevant if also not particularly compelling for the same reason. Providing universal care will cost money to claim otherwise is wrong, perhaps not as much as some claim but it will cost something.]

"There is a greater issue here that transcends economics and enlightened self-interest. Health care, like food, shelter, education, free speech and the ability to marry, is a basic human right.
Since the beginning of human existence, we have relied on one another for companionship and help. No person is an island, and no person deserves to be cast away on one, especially someone who is sick and in need of care.

A key expression of our humanity is that we care about those outside our own narrowly drawn circle of friends and family. We don’t owe each other luxurious vacations, and I accept that some hard-working people in our capitalistic society will earn much less than their more financially successful fellow citizens.

But there are certain basic decencies that our humanity demands. Caring for the weak and sick among us is one of them; it’s nothing less than a moral
imperative..."

[TW: Health care as a right? Enumerating new rights gets many folks up in arms for good reason. I do not see such an enumeration as a necessity for universal care. It is the "right" thing to do without being a "right".

Americans are when push comes to shove and given our considerable wealth not willing to let folks suffer and perish without systematically strong health care (I think...).

Americans sense health care is different than other products and services and should be available to all at some level. Right now we have a system with a donut hole of sorts. The wealthy, the poor, the elderly and most in the middle get care but there is a significant and growing group of folks in the middle who do not. Those within this donut hole may get acute care and some charitable care but they do not get systematic care at levels equivalent to those outside the donut hole. Do we have challenges paying for universal care? Absolutely, but they are by no means insurmountable. Our health care costs challenges exist with or without universal care, closing the donut hole is a step in addressing those challenges systematically.

Finally, to me those who oppose universal care for those in the donut hole should if they are intellectually consistent oppose care for the poor and elderly as well.]

Some More Views On Health Care: The Politics

TW:
The Politics:
1) The Republicans clearly perceive opposition to almost any Obama led health care reform as an electoral winner. We have posted on this previously. To a certain extent from a purely Machiavellian view it is logical. Cutting Obama off at his knees versus helping him attain a huge legislative goal is not a difficult choice. So far the strategy has worked, Obama's poll numbers are down from high levels. What is the end game though?

We now have the RNC chair, Mr. Mike "Buffoon" Steele issuing senior bill of rights which would enshrine Medicare cost growth at extraordinary rates into perpetuity. Expanding the wedge between those over 65 and those under. As an aside I actually think at this point Steele's buffoonery is very intentional and quite effective. He can be the carrier for whatever pandering the Republicans need presently. In a couple of years he can be tossed aside never to be heard from again.

Should the Republicans re-gain electoral strength then what? The Dems would cry uncle and say lets toss out all of their own views on universal care etc? The Republicans have done a fine job of irresponsibly opposing whilst providing nearly no viable alternatives to a growing problem that will not go away.

2) Universal care and cost containment have become nearly hopelessly conflated. The two are very different concepts. Most Americans I believe sympathize with the need for universal care, they may be unclear on how to pay for it, but they empathize with the need for it. They understand or at least sense many of the inequities in our system. However, the Republicans have done two things well. Accuse the Dems of expanding government recklessly and accuse the Dems of trying to pay for universal care on the backs of Medicare reductions for seniors.

3) Seniors have the best health care deal in America. Their funding is open-ended and with minimal shared costs, no issues with pre-existing conditions, insurance rescissions etc. They sense not irrationally that there is only one way for their care to go in a new system -down- either through increased cost sharing or new limitations.

4) Those under 65 sense they are bearing increased risks and facing escalating cost sharing but a bird in hand still beats one in the bush. This cost escalation is relentless but still generally an ever growing drip, drip rather than a cold slap in the face sufficient to motivate comfort with a new system.

5) Many folks have discomfort with "bigger government". Some have a visceral discomfort, others a more subtle discomfort. Few though can articulate how to "reform" health care without "bigger government", but again the bird in hand.

6) Overlaying all of this are the entrenched interests of health care providers, insurers, unions, suppliers, state and local governments, you name it, they have skin in the game.

The solutions post tomorrow...

Some Views On Health Care After All These Months

TW: Some things I have learned on health care several months into the debate yet many weeks if not months from the end of it. Mostly what I have learned is how little I know. Our system is a cockeyed hybrid of legacy systems which provides sometimes world class, sometimes mediocre and sometimes no care very expensively. Some background thoughts:

The consumer buckets:
1) Government funded health care programs are open-ended pits with insufficient cost controls. These programs included Medicare, Medicaid, the VA, and a slew of public service employee and retiree plans. If Americans think these pits can continue to be funded in their current forms, I believe they are seriously wrong. These programs as currently structured with little patient participation in payment are recipes for ever escalating consumption of health care. If a product is essentially free, the demand for any product will be extreme. Btw, these programs have made millions of lives better, longer and more worthwhile.
2) Private funded health care programs are stealthily eroding the compensation of current employees. Most employees being only partially if at all aware of the problem. Much like bucket #1, with the connection severed between consumers and providers via insurance demand is escalating with no end in sight.
3) Those not covered by 1 and 2 above are increasingly left dangling. Those who argue "they can go to the emergency room" or "charity will take care of them", are wrong. I do not trust the level of care provided by emergency rooms and charity and it is not at all clear to me why folks under the age of 65 should receive poorer care than those above or for that matter those working at a job with strong insurance.

The growth in this bucket will increase folks staying in jobs they do not like or even perform well in but which provide strong health care not necessarily because their current job's plan is cheap but because they would struggle to find coverage elsewhere due to age or illness. As health care costs escalate discrimination against the unhealthy be they obese, smokers, or merely older or inheritors of some bad genes will increase. In a truly free health care market only the healthiest thrive, unfortunately one's health is governed not only by controlled factors but many uncontrolled factors as well.

Providers:
4) Insurance companies inherently benefit from lower costs and higher fees and premiums, just like all other businesses. These natural incentives are, in the absence of onerous, regulation bound to grow #3. But getting angry with insurance companies does not address the real challenges with health care. There are good, ethical providers and probably some less so but again that is nothing new or unusual. Understand though, insurance companies behave as rapacious capitalists (like most other industries). They attempt regulatory capture, they seek to restrict competition etc. In a heavily regulated industry their opportunities will be tremendous to exercise their rapaciousness.
5) Doctors/hospitals/drug makers/equipment makers etc.. Our system rewards usage more than productivity. Productivity in some ways is anathema to health care. These providers behaving rationally will optimize their revenues which means more and more costs. This does not make them bad folks, it means they are rational, normal folks like the rest of us. Rapacious capitalism married up with 3rd party payers is a recipe for fiscal disaster.
6) As medical technology advances many new and very expensive treatment options are being developed. Fifty years ago it would have been hard to spend a $1.0MM on a premee or cancer patient or heart attack victim or car accident victim. Today it is easy. Extending length and quality of life has costs, costs which we gladly bear. But how to balance them relative to other needs, to our fiscal limitations? These are challenging questions which most of us would prefer to avoid but ultimately we cannot.
7) Read up on international health care, Americans tend (like others but more so) we have the best of everything, we do not.

Some thoughts on the politics and solutions will follow on some new posts.

Health Care Reform In Perspective

TW: The very tedious, vacuous and frustrating process by which health care reform is being contemplated can be depressing. I still think a bill will get done, it will be deeply flawed my only hope is that it will be better than nothing despite the powerful interests aligned against most of it. There are very legitimate conservative arguments which should be integrated into the bill but for the most part the Republicans are chosen to focus on fear mongering without raising them as suggestions. To suggest actually actionable measures would be to create an environment of bi-partisanship which they clearly wish to avoid in favor of cutting Obama's knees out from under him and set the stage for a 2010 comeback.

Putting all of this to the side, Begala makes some good points about where this reform effort compares to the 1930's effort to pass social security.

From Paul Begala in the WaPo:
"I think my fellow progressives ought to give Max Baucus and other members of the Senate Finance Committee a little breathing room as they labor to produce a health-care bill that can garner enough votes to pass the Senate.

Progressive politics is, in my view, a movement, not a monument. We cannot achieve perfection in this life, and if that is our goal we will always be frustrated. The right has far more modest goals: At every turn, its members seek to advance their power and protect privilege. I've never seen the Republican right oppose a tax cut for the rich because it wasn't generous enough; I've never seen them oppose a set of loopholes for corporate lobbyists because one industry or another wasn't included. The left, on the other hand, too often prefers a glorious defeat to an incremental victory.

...No self-respecting liberal today would support Franklin Roosevelt's original Social Security Act. It excluded agricultural workers -- a huge part of the economy in 1935, and one in which Latinos have traditionally worked. It excluded domestic workers, which included countless African Americans and immigrants. It did not cover the self-employed, or state and local government employees, or railroad employees, or federal employees or employees of nonprofits. It didn't even cover the clergy. FDR's Social Security Act did not have benefits for dependents or survivors. It did not have a cost-of-living increase. If you became disabled and couldn't work, you got nothing from Social Security.

If that version of Social Security were introduced today, progressives like me would call it cramped, parsimonious, mean-spirited and even racist. Perhaps it was all those things. But it was also a start. And for 74 years we have built on that start. We added more people to the winner's circle: farm workers and domestic workers and government workers. We extended benefits to the children of working men and women who died. We granted benefits to the disabled. We mandated annual cost-of-living adjustments. And today Social Security is the bedrock of our progressive vision of the common good.

Health care may follow that same trajectory. It would be a bitter disappointment if health reform did not include a public option. A public plan that keeps the insurance companies honest is, I believe, the right policy and the right politics. I believe subsidies should extend to as many Americans as need help and that the hard-earned health benefits of middle-class Americans should not be taxed. I believe insurer abuses like the preexisting-condition rule should be outlawed. The question is not whether I or other progressives will support a health-reform bill that includes everything we want but, rather, whether we will support a bill that doesn't..."

Core Health Care Issues: Why Not Keep the Status Quo?

TW: A bit sarcastic but I think u get the idea. The status quo has numerous faults and regardless of whether you think you personally benefit from the status quo, its finances are unsustainable. The challenge is the bad parts are hidden to many if one is well-insured and the economics are merely corrosively bad rather than explosively obvious.

From Jon Alter at Newsweek:
"Go ahead, shoot me. I like the status quo on health care in the United States. I've got health insurance and I don't give a damn about the 47 million suckers who don't. Obama and Congress must be stopped. No bill! I'm better off the way things are.I'm with that woman who wrote the president complaining about "socialized medicine" and added: "Now keep your hands off my Medicare." That's the spirit!

Why should I be entitled to the same insurance that members of Congress get? Blue Dogs need a lot of medical attention to treat their blueness. I'm just a regular guy and definitely deserve less.

I had cancer a few years ago. I like the fact that if I lose my job, I won't be able to get any insurance because of my illness. It reminds me of my homeowners' insurance, which gets canceled after a break-in. I like the choice I'd face if, God forbid, the cancer recurs—sell my house to pay for the hundreds of thousands of dollars in treatment, or die. That's what you call a "post-existing condition."

I like the absence of catastrophic insurance today. It meant that my health-insurance plan (one of the better ones, by the way) only covered about 75 percent of the cost of my cutting-edge treatment. That's as it should be—face cancer and shell out huge amounts of money at the same time. Nice.

I like the "lifetime limits" that many policies have today. Missed the fine print on that one, did you? It means that after you exceed a certain amount of reimbursement, you don't get anything more from the insurance company. That's fair.

Speaking of fair, it seems fair to me that cost-cutting bureaucrats at the insurance companies—not doctors—decide what's reimbursable. After all, the insurance companies know best.

Yes, the insurance company status quo rocks. I learned recently about something called the "loading fees" of insurance companies. That's how much of every health-care dollar gets spent by insurance companies on things other than the medical care—paperwork, marketing, profits, etc. According to a University of Minnesota study, up to 47 percent of all the money going into the health-insurance system is consumed in "loading fees." Even good insurance companies spend close to 30 percent on nonmedical stuff. Sweet.

The good news is that the $8,000 a year per family that Americans pay for their employer-based health insurance is heading up! According to the Council of Economic Advisers, it will hit $25,000 per family by 2025. The sourpusses who want health-care reform say that's "unsustainable." Au contraire.

And how could the supporters of these reform bills believe in anything as stupid as a "public option"? Do they really believe that the health-insurance cartel deserves a little competition to keep them honest? Back in the day, they had a word for competition. A bad word. They called it capitalism. FedEx versus the U.S. Postal Service, CNN versus PBS—just because it's government-backed doesn't mean you can't compete against it. If they believed in capitalism, the insurance companies would join the fray and compete. "