TW: A piece from Business Week which frames some of the moral and financial dilemmas posed by illness without veering too far into the political weeds which dominate any further rational debate these days.
How much care is too much? If it is not too much care for one, what about for others? Who pays? If not you, should the well be endless, if so does it ever stop?
And then there are the providers with all of their convoluted motivations...
http://www.businessweek.com/magazine/content/10_11/b4170032321836.htm
Showing posts with label Health Care policy. Show all posts
Showing posts with label Health Care policy. Show all posts
Tuesday, March 16, 2010
Tuesday, March 2, 2010
Pre-existing Conditions Come In Many Forms
From Marginal Revolution:
"...[Nicole] Kidman injured her knee during the filming of Moulin Rouge in Australia in 2000, resulting in a $3 million insurance loss, and then quit Panic Room in 2001, leading to the insurer having to pay some $7 million for the replacement actress (Jodie Foster). As a result, her public and critical acclaim notwithstanding, Miramax was initially unable to get insurance on her for its film Cold Mountain, which had a budget approaching $100 million. From the perspective of the insurer, Fireman's Fund, she was a definite risk. As an insurance executive noted in an email, "...the fact remains that the doctor we sent her to for her examination noted swelling in the knee." The executive goes on: "The other major fact that can't be changed is our paying three claims for this actress's knees over the years."
To get the necessary policy from Fireman's Fund, Kidman agreed to put $1 million of her own salary in an escrow account that would be forfeited if she failed to maintain the production schedule, and she agreed to use a stunt double for all scenes that the insurer considered potentially threatening to her knee. In addition, the co-producer, Lakeshore Entertainment, added another $500,000 to the escrow account...Having made the all-important move from borderline uninsurable to borderline insurable, she could make movies again. No matter how great their acting skills and box office drawing power, stars cannot get lead roles if they are uninsurable. Great acting skills and box office drawing may make the star, but insurance is what it takes to make the movie..."
http://www.marginalrevolution.com/marginalrevolution/2010/02/something-is-wrong-when-nicole-kidman-cant-get-insurance.html
"...[Nicole] Kidman injured her knee during the filming of Moulin Rouge in Australia in 2000, resulting in a $3 million insurance loss, and then quit Panic Room in 2001, leading to the insurer having to pay some $7 million for the replacement actress (Jodie Foster). As a result, her public and critical acclaim notwithstanding, Miramax was initially unable to get insurance on her for its film Cold Mountain, which had a budget approaching $100 million. From the perspective of the insurer, Fireman's Fund, she was a definite risk. As an insurance executive noted in an email, "...the fact remains that the doctor we sent her to for her examination noted swelling in the knee." The executive goes on: "The other major fact that can't be changed is our paying three claims for this actress's knees over the years."
To get the necessary policy from Fireman's Fund, Kidman agreed to put $1 million of her own salary in an escrow account that would be forfeited if she failed to maintain the production schedule, and she agreed to use a stunt double for all scenes that the insurer considered potentially threatening to her knee. In addition, the co-producer, Lakeshore Entertainment, added another $500,000 to the escrow account...Having made the all-important move from borderline uninsurable to borderline insurable, she could make movies again. No matter how great their acting skills and box office drawing power, stars cannot get lead roles if they are uninsurable. Great acting skills and box office drawing may make the star, but insurance is what it takes to make the movie..."
http://www.marginalrevolution.com/marginalrevolution/2010/02/something-is-wrong-when-nicole-kidman-cant-get-insurance.html
Wednesday, February 10, 2010
Getting Past Cheap Slogans
TW: Folks seem confused by health care reform. When confused many fall back on the simple- "keep government out!", "I like my current plan" etc. But here again Suroweicki frames some of the challenges with the allegedly simple sloganeering. In the process Suroweicki happens to make the pro-reform in one of the more straightforward approaches I have seen.
From Jim Suroweicki at New Yorker:
"...American politicians—as well as American voters—have a confused, and often contradictory, set of beliefs about how health insurance should work. The wayward, patchwork plan that we seem likely to end up with is probably a good reflection of the wayward, patchwork opinions that most legislators have on the subject.
Consider the Genetic Information Nondiscrimination Act, which went into effect in November. The law prohibits health insurers from using genetic information to set rates or deny coverage. At the moment, genetic testing for disease is still relatively crude and uncommon. That will change in the future. People who know that they are much more likely to get sick, and therefore much more likely to run up huge medical bills, will be able to get insurance at the same price as those with less risky genetic profiles. Everyone, it turns out, supports this: the bill passed unanimously in the Senate, and nearly so in the House.
Politicians on both sides of the aisle overwhelmingly believe, likewise, that insurance companies should be prohibited from taking preëxisting conditions into account when setting prices or extending coverage. Both the House and the Senate reform bills include language banning this. Even Republicans have been vehement on the subject: Senator Tom Coburn, of Oklahoma, has said that “everyone agrees” that we need to eliminate the use of preëxisting conditions, while Senator Chuck Grassley, of Iowa, declared that insurers have to be barred from “charging higher premiums to people who are sick.” The insurance companies themselves have accepted that the only factors they’ll be allowed to take into account in setting prices will be age, region, and whether or not someone smokes. The general consensus, then, is that even if you’re already sick, and guaranteed to run up huge medical bills in the future, you should be able to get health insurance at the same price as someone your age who’s perfectly healthy. Economists have a name for this: “community rating.” And the fact that it has such strong backing in Washington is heartening. Americans, and American politicians, have decided that people should have guaranteed access to insurance, and that they shouldn’t have to worry about losing it just because they get laid off or fall ill.
So where’s the contradiction? Well, Congress’s support for community rating and universal access doesn’t fit well with its insistence that health-care reform must rely on private insurance companies. After all, measuring risk, and setting prices accordingly, is the raison d’être of a health-insurance company. The way individual insurance works now, risk and price are linked. If you’re a triathlete with no history of cancer in your family, you’re a reasonably good risk, and so you can get an affordable policy that will protect you against unforeseen disaster; if you’re overweight with high blood pressure and a history of heart problems, your risk of becoming seriously ill is substantial, and therefore private insurers will either charge you high premiums or not offer you coverage at all. This kind of risk evaluation—what’s called “medical underwriting”—is fundamental to the insurance business. But it is precisely what all the new reform plans will ban. Congress is effectively making private insurers unnecessary, yet continuing to insist that we can’t do without them.
The truth is that we could do just fine without them: an insurance system with community rating and universal access has no need of private insurers. In fact, the U.S. already has such a system: it’s known as Medicare. In most areas, it’s true, private companies do a better job of managing costs and providing services than the government does. But not when it comes to health care: over the past decade, Medicare’s spending has risen more slowly than that of private insurers. A single-payer system also has the advantage of spreading risk across the biggest patient pool possible. So if you want to make health insurance available to everyone, regardless of risk, the most sensible solution would be to expand Medicare to everyone. That’s not going to happen. The fear of government-run health care, the power of vested interests, and the difficulty of completely overhauling the system have made the single-payer solution a bridge too far for Washington, and for much of the public as well. (Support for a single-payer system hovers around fifty per cent.) That’s why the current reform plans rely instead on a mishmash of regulations, national exchanges, and subsidies. Instead of replacing private insurance companies, the proposed reforms would, in theory, turn them into something like public utilities. That’s how it works in the Netherlands and Switzerland, with reasonably good results.
One could recoil in disgust at the inefficiency and incoherence of the process—at the fact that private insurers will continue to make billions a year providing services the government has shown, via Medicare, that it can provide on its own. But, messy as the reform plans are, they can still dramatically transform the system for the good. Reform would guarantee that tens of millions of people who don’t have insurance will get it, and that people who have insurance now won’t have to worry about losing it. And, by writing community rating and universal access into law, Congress will effectively be committing itself to the idea that health care, regardless of risk, is a right. If a little incoherence is the price of that deal, it’s worth paying."
http://www.newyorker.com/talk/financial/2010/01/04/100104ta_talk_surowiecki
From Jim Suroweicki at New Yorker:
"...American politicians—as well as American voters—have a confused, and often contradictory, set of beliefs about how health insurance should work. The wayward, patchwork plan that we seem likely to end up with is probably a good reflection of the wayward, patchwork opinions that most legislators have on the subject.
Consider the Genetic Information Nondiscrimination Act, which went into effect in November. The law prohibits health insurers from using genetic information to set rates or deny coverage. At the moment, genetic testing for disease is still relatively crude and uncommon. That will change in the future. People who know that they are much more likely to get sick, and therefore much more likely to run up huge medical bills, will be able to get insurance at the same price as those with less risky genetic profiles. Everyone, it turns out, supports this: the bill passed unanimously in the Senate, and nearly so in the House.
Politicians on both sides of the aisle overwhelmingly believe, likewise, that insurance companies should be prohibited from taking preëxisting conditions into account when setting prices or extending coverage. Both the House and the Senate reform bills include language banning this. Even Republicans have been vehement on the subject: Senator Tom Coburn, of Oklahoma, has said that “everyone agrees” that we need to eliminate the use of preëxisting conditions, while Senator Chuck Grassley, of Iowa, declared that insurers have to be barred from “charging higher premiums to people who are sick.” The insurance companies themselves have accepted that the only factors they’ll be allowed to take into account in setting prices will be age, region, and whether or not someone smokes. The general consensus, then, is that even if you’re already sick, and guaranteed to run up huge medical bills in the future, you should be able to get health insurance at the same price as someone your age who’s perfectly healthy. Economists have a name for this: “community rating.” And the fact that it has such strong backing in Washington is heartening. Americans, and American politicians, have decided that people should have guaranteed access to insurance, and that they shouldn’t have to worry about losing it just because they get laid off or fall ill.
So where’s the contradiction? Well, Congress’s support for community rating and universal access doesn’t fit well with its insistence that health-care reform must rely on private insurance companies. After all, measuring risk, and setting prices accordingly, is the raison d’être of a health-insurance company. The way individual insurance works now, risk and price are linked. If you’re a triathlete with no history of cancer in your family, you’re a reasonably good risk, and so you can get an affordable policy that will protect you against unforeseen disaster; if you’re overweight with high blood pressure and a history of heart problems, your risk of becoming seriously ill is substantial, and therefore private insurers will either charge you high premiums or not offer you coverage at all. This kind of risk evaluation—what’s called “medical underwriting”—is fundamental to the insurance business. But it is precisely what all the new reform plans will ban. Congress is effectively making private insurers unnecessary, yet continuing to insist that we can’t do without them.
The truth is that we could do just fine without them: an insurance system with community rating and universal access has no need of private insurers. In fact, the U.S. already has such a system: it’s known as Medicare. In most areas, it’s true, private companies do a better job of managing costs and providing services than the government does. But not when it comes to health care: over the past decade, Medicare’s spending has risen more slowly than that of private insurers. A single-payer system also has the advantage of spreading risk across the biggest patient pool possible. So if you want to make health insurance available to everyone, regardless of risk, the most sensible solution would be to expand Medicare to everyone. That’s not going to happen. The fear of government-run health care, the power of vested interests, and the difficulty of completely overhauling the system have made the single-payer solution a bridge too far for Washington, and for much of the public as well. (Support for a single-payer system hovers around fifty per cent.) That’s why the current reform plans rely instead on a mishmash of regulations, national exchanges, and subsidies. Instead of replacing private insurance companies, the proposed reforms would, in theory, turn them into something like public utilities. That’s how it works in the Netherlands and Switzerland, with reasonably good results.
One could recoil in disgust at the inefficiency and incoherence of the process—at the fact that private insurers will continue to make billions a year providing services the government has shown, via Medicare, that it can provide on its own. But, messy as the reform plans are, they can still dramatically transform the system for the good. Reform would guarantee that tens of millions of people who don’t have insurance will get it, and that people who have insurance now won’t have to worry about losing it. And, by writing community rating and universal access into law, Congress will effectively be committing itself to the idea that health care, regardless of risk, is a right. If a little incoherence is the price of that deal, it’s worth paying."
http://www.newyorker.com/talk/financial/2010/01/04/100104ta_talk_surowiecki
Friday, January 29, 2010
What Can I Say
TW:...about my fellow Americans who are so freaking irresponsible as to allege support for democracy when blatantly not educating themselves sufficiently to participate effectively. These vacuums of ignorance about what is going on are rife for demagougery and manipulation. This is not a partisan issue it is an issue of an informed populace participating in order to urge their elected officials to act upon challenges.
From Taegan Goddard:
"A new Pew Research poll found that just 32% of Americans know the health care reform bill before Congress received no support from Republican Senators.
In addition, just 26% know that 60 votes are needed to break a filibuster in the Senate."
From Taegan Goddard:
"A new Pew Research poll found that just 32% of Americans know the health care reform bill before Congress received no support from Republican Senators.
In addition, just 26% know that 60 votes are needed to break a filibuster in the Senate."
Tuesday, January 26, 2010
It Gets Harder If You Actually Try To Solve Something
TW: McArdle is a conservative but a thoughtful one. She has actually suggested an alternative approach to reform. It sounds interesting on first blush but once exposed to the scrutiny all alternatives must eventually face (much different than just saying NO!!!) begins to unravel and raises more questions than it answers. But at least she is trying as opposed to most in the Republican party. We have real problems, we need solutions.
From Economist:
"MEGAN MCARDLE has a plan:
'Raise the Medicare tax by half a percentage point, and eliminate the tax-deductibiity of health insurance benefits for people making more than $150K a year in household income, $100K for singles. Then make the federal government the insurer of last resort. Any medical expenses more than 15% or 20% of household income, get picked up by Uncle Sam.
I think this is a reasonablish plan. It would be interesting to see how the CBO would score it. But here's the problem: having Uncle Sam pick up all medical expenses over 15% or 20% of household income wouldn't just be extremely expensive, it would essentially mean single-payer government catastrophic health insurance for everyone.
Why's that? Well, catastrophic illness always costs more than 20% of a household's income, apart from the very rich. There aren't that many people in the country who earn five times as much each year as radiation therapy costs. Obviously, what Ms McArdle means is that the government would pick up the tab over and above whatever your private insurance covers. But that means the obvious incentive for private insurers is to make sure they never cover any medical expenses above 20% of your income. They'll try to shift all of those expenses to the government. And since you'll know the government is picking up the tab anyway, you won't care. In fact, it will become impossible for private insurers to offer policies that cover expenses running higher than 20% of your income. You would have no interest in paying the extra premiums to buy such a policy; your care will already be covered by government.
The effect on policies and premiums could be complicated, and without more details it's hard to say exactly what happens. (Do premiums count as "health expenses" towards that 20% of income? What about if your company pays part or all of the premium?) But the general effect will be to have insurance cover very little of the kinds of costs associated with catastrophic care, so that the costs quickly mount to 20% of the patient's income and everything new is shifted onto the taxpayer. And you'll have no private insurer who covers the cost of procedures or drugs that in and of themselves cost more than $25,000 or so, since the federal government will pick up most or all of the tab for almost all patients. If you could buy a policy that was $1,000 a year cheaper but didn't cover cancer or transplants, but you knew the maximum cost to you of such treatments would be just 20% of your income anyway, you'd buy the cheaper policy. So private catastrophic insurance will all but vanish.
Once that happens, every harm which Ms McArdle and conservative-leaning critics have claimed would result from single-payer insurance will ensue. The taxpayer will be paying for almost every cancer patient in the country. That means the government will likely regulate how cancer is treated: what treatments are warranted and reimbursable under what circumstances. (Did someone say "death panels"?) The government will decide how much to pay for expensive drugs, and will negotiate the prices of, for example, biologics like some kind of MedPAC on steroids. Market pricing for biologics, transplants, and other expensive drugs and procedures will largely cease to exist, since the government will be the only buyer.
I frankly don't have a problem with this. I think America would be much better off with single-payer health insurance than with the system it has now. So I say, great, creative idea. Of course it'll never get anywhere, since unions and big business will never allow the elimination of tax deductibility for health insurance for people making more than $150,000 a year. And the insurance companies will kill it too, since it would incentivise large numbers of people and businesses to drop out of the private insurance market entirely and just rely on the government's 20% maximum guarantee. Still, if conservatives did widely embrace such a plan, it would serve the important function of protecting them against accusations that they don't have a plan."
http://www.economist.com/blogs/democracyinamerica/2010/01/libertarian_health_care_proposal_single-payer
From Economist:
"MEGAN MCARDLE has a plan:
'Raise the Medicare tax by half a percentage point, and eliminate the tax-deductibiity of health insurance benefits for people making more than $150K a year in household income, $100K for singles. Then make the federal government the insurer of last resort. Any medical expenses more than 15% or 20% of household income, get picked up by Uncle Sam.
I think this is a reasonablish plan. It would be interesting to see how the CBO would score it. But here's the problem: having Uncle Sam pick up all medical expenses over 15% or 20% of household income wouldn't just be extremely expensive, it would essentially mean single-payer government catastrophic health insurance for everyone.
Why's that? Well, catastrophic illness always costs more than 20% of a household's income, apart from the very rich. There aren't that many people in the country who earn five times as much each year as radiation therapy costs. Obviously, what Ms McArdle means is that the government would pick up the tab over and above whatever your private insurance covers. But that means the obvious incentive for private insurers is to make sure they never cover any medical expenses above 20% of your income. They'll try to shift all of those expenses to the government. And since you'll know the government is picking up the tab anyway, you won't care. In fact, it will become impossible for private insurers to offer policies that cover expenses running higher than 20% of your income. You would have no interest in paying the extra premiums to buy such a policy; your care will already be covered by government.
The effect on policies and premiums could be complicated, and without more details it's hard to say exactly what happens. (Do premiums count as "health expenses" towards that 20% of income? What about if your company pays part or all of the premium?) But the general effect will be to have insurance cover very little of the kinds of costs associated with catastrophic care, so that the costs quickly mount to 20% of the patient's income and everything new is shifted onto the taxpayer. And you'll have no private insurer who covers the cost of procedures or drugs that in and of themselves cost more than $25,000 or so, since the federal government will pick up most or all of the tab for almost all patients. If you could buy a policy that was $1,000 a year cheaper but didn't cover cancer or transplants, but you knew the maximum cost to you of such treatments would be just 20% of your income anyway, you'd buy the cheaper policy. So private catastrophic insurance will all but vanish.
Once that happens, every harm which Ms McArdle and conservative-leaning critics have claimed would result from single-payer insurance will ensue. The taxpayer will be paying for almost every cancer patient in the country. That means the government will likely regulate how cancer is treated: what treatments are warranted and reimbursable under what circumstances. (Did someone say "death panels"?) The government will decide how much to pay for expensive drugs, and will negotiate the prices of, for example, biologics like some kind of MedPAC on steroids. Market pricing for biologics, transplants, and other expensive drugs and procedures will largely cease to exist, since the government will be the only buyer.
I frankly don't have a problem with this. I think America would be much better off with single-payer health insurance than with the system it has now. So I say, great, creative idea. Of course it'll never get anywhere, since unions and big business will never allow the elimination of tax deductibility for health insurance for people making more than $150,000 a year. And the insurance companies will kill it too, since it would incentivise large numbers of people and businesses to drop out of the private insurance market entirely and just rely on the government's 20% maximum guarantee. Still, if conservatives did widely embrace such a plan, it would serve the important function of protecting them against accusations that they don't have a plan."
http://www.economist.com/blogs/democracyinamerica/2010/01/libertarian_health_care_proposal_single-payer
Monday, January 25, 2010
Yes Its Messy, Just Like Life
TW: The opponents of health care reform have very effectively used the messiness of the process to bolster their opposition. No alternatives presented merely use picking away at the ugly process in order to derail reform. Another approach is particularly insidious, the piecemeal BS as in "we will use the 'free-market' bits without the big government bits'. I have tried to explain moral hazard, adverse selection etc. This stuff all fits together or it does not fit at all.
One of the drawbacks is its yearning for simplicity powered by emotion. A perfect opportunity for an opposing party to demagogue its way back to power by manipulating the emotions.
From Economist:
"TWO sausage metaphors spring to mind when thinking about the health-care bill and its future. First was the familiar "legislative sausage machine" that stuffed the casing with such wonders as the Cornhusker giveaway, the union bribe and so forth. The second, now, would be "salami tactics", also known as "pass the popular bits": the idea that thin slices of the bill could be sent through Congress, to see what makes it through.
The problem, says Richard Kirsch of Health Care for America Now, is that
'The public wants to stop insurance companies from denying coverage for pre-existing conditions. You can't do that without a mandate; you can't do a mandate without subsidizing coverage; you can't subsidize coverage without Medicare savings and new revenues. The public wants to end medical bankruptcies—but to do that you need to provide affordable coverage to people and you need to mandate decent insurance benefits and put a ban on annual and lifetime caps. Doing all that requires setting up exchanges and subsidizing coverage.'
Put another way, the whole of the bill is a lot more than the sum of its parts; the unhealthy, fattening parts might make it through but not the lean meat. This strategy combines the worst of political timidity and policy failure, and the Democrats don't want to be known as the sausage party."
http://www.economist.com/blogs/democracyinamerica/2010/01/nickname_you_dont_want
One of the drawbacks is its yearning for simplicity powered by emotion. A perfect opportunity for an opposing party to demagogue its way back to power by manipulating the emotions.
From Economist:
"TWO sausage metaphors spring to mind when thinking about the health-care bill and its future. First was the familiar "legislative sausage machine" that stuffed the casing with such wonders as the Cornhusker giveaway, the union bribe and so forth. The second, now, would be "salami tactics", also known as "pass the popular bits": the idea that thin slices of the bill could be sent through Congress, to see what makes it through.
The problem, says Richard Kirsch of Health Care for America Now, is that
'The public wants to stop insurance companies from denying coverage for pre-existing conditions. You can't do that without a mandate; you can't do a mandate without subsidizing coverage; you can't subsidize coverage without Medicare savings and new revenues. The public wants to end medical bankruptcies—but to do that you need to provide affordable coverage to people and you need to mandate decent insurance benefits and put a ban on annual and lifetime caps. Doing all that requires setting up exchanges and subsidizing coverage.'
Put another way, the whole of the bill is a lot more than the sum of its parts; the unhealthy, fattening parts might make it through but not the lean meat. This strategy combines the worst of political timidity and policy failure, and the Democrats don't want to be known as the sausage party."
http://www.economist.com/blogs/democracyinamerica/2010/01/nickname_you_dont_want
If the Danes Can Do It....
From NYT:
"...You see how easy it is for me?” Mr. Danstrup said, sitting at his desk while video chatting with his nurse at Frederiksberg University Hospital, a mile away. “Instead of wasting the day at the hospital?”
He clipped an electronic pulse reader to his finger. It logged his reading and sent it to his doctor. Mr. Danstrup can also look up his personal health record online. His prescriptions are paperless — his doctors enters them electronically, and any pharmacy in the country can pull them up. Any time he wants to get in touch with his primary care doctor, he sends an e-mail message.
All of this is possible because Mr. Danstrup lives in Denmark, a country that began embracing electronic health records and other health care information technology a decade ago. Today, virtually all primary care physicians and nearly half of the hospitals use electronic records, and officials are trying to encourage more “telemedicine” projects like the one started at Frederiksberg by Dr. Klaus Phanareth, a physician there.
Several studies, including one to be published later this month by the Commonwealth Fund, conclude that the Danish information system is the most efficient in the world, saving doctors an average of 50 minutes a day in administrative work. And a 2008 report from the Healthcare Information and Management Systems Society estimated that electronic record keeping saved Denmark’s health system as much as $120 million a year.
Now policy makers in the United States are studying Denmark’s system to see whether its successes can be replicated as part of the overhaul of the health system making its way through Congress. Dr. David Blumenthal, a professor of health care policy at Harvard Medical School who was named by President Obama as national coordinator of health information technology, has said the United States is “well behind” Denmark and its Scandinavian neighbors, Sweden and Norway, in the use of electronic health records.
Denmark’s success has much to do with the its small size, its homogeneous population and its regulated health care system — on all counts, very different from the United States. As in much of Europe, health care in Denmark is financed by taxes, and most services are free.
...Kurt Nielsen, the hospital’s director, says that while the doctors are not particularly adept at information technology, they have gradually embraced it. And it helps that the staff was involved in developing the innovations.
“My staff at the hospital is very, very satisfied,” he said. “We build these systems in an incremental way, and seek their input throughout.”
...Culturally, Danes are also different. Mr. Larsen, of Denmark’s health information agency, says his countrymen have few objections to the national patient registry — perhaps because they have different priorities from Americans when it comes to medical privacy.
“As long you are a healthy man, you fear for your privacy,” he said. “It is when you are sick that you wish people knew what your problem was.” ...”
http://www.nytimes.com/2010/01/12/health/12denmark.html?scp=1&sq=sindya%20bhanoo&st=cse
"...You see how easy it is for me?” Mr. Danstrup said, sitting at his desk while video chatting with his nurse at Frederiksberg University Hospital, a mile away. “Instead of wasting the day at the hospital?”
He clipped an electronic pulse reader to his finger. It logged his reading and sent it to his doctor. Mr. Danstrup can also look up his personal health record online. His prescriptions are paperless — his doctors enters them electronically, and any pharmacy in the country can pull them up. Any time he wants to get in touch with his primary care doctor, he sends an e-mail message.
All of this is possible because Mr. Danstrup lives in Denmark, a country that began embracing electronic health records and other health care information technology a decade ago. Today, virtually all primary care physicians and nearly half of the hospitals use electronic records, and officials are trying to encourage more “telemedicine” projects like the one started at Frederiksberg by Dr. Klaus Phanareth, a physician there.
Several studies, including one to be published later this month by the Commonwealth Fund, conclude that the Danish information system is the most efficient in the world, saving doctors an average of 50 minutes a day in administrative work. And a 2008 report from the Healthcare Information and Management Systems Society estimated that electronic record keeping saved Denmark’s health system as much as $120 million a year.
Now policy makers in the United States are studying Denmark’s system to see whether its successes can be replicated as part of the overhaul of the health system making its way through Congress. Dr. David Blumenthal, a professor of health care policy at Harvard Medical School who was named by President Obama as national coordinator of health information technology, has said the United States is “well behind” Denmark and its Scandinavian neighbors, Sweden and Norway, in the use of electronic health records.
Denmark’s success has much to do with the its small size, its homogeneous population and its regulated health care system — on all counts, very different from the United States. As in much of Europe, health care in Denmark is financed by taxes, and most services are free.
...Kurt Nielsen, the hospital’s director, says that while the doctors are not particularly adept at information technology, they have gradually embraced it. And it helps that the staff was involved in developing the innovations.
“My staff at the hospital is very, very satisfied,” he said. “We build these systems in an incremental way, and seek their input throughout.”
...Culturally, Danes are also different. Mr. Larsen, of Denmark’s health information agency, says his countrymen have few objections to the national patient registry — perhaps because they have different priorities from Americans when it comes to medical privacy.
“As long you are a healthy man, you fear for your privacy,” he said. “It is when you are sick that you wish people knew what your problem was.” ...”
http://www.nytimes.com/2010/01/12/health/12denmark.html?scp=1&sq=sindya%20bhanoo&st=cse
Thursday, January 7, 2010
Not So Efficient
TW: Gelman is a stats guru. This presentation frames a fundamental challenge we as a nation face- inefficient health care delivery. One can criticize the reform effort but to claim the status quo is viable and the "best" system in the world is laughable.
http://www.fivethirtyeight.com/2010/01/healthcare-spending-and-life-expectancy.html
http://www.fivethirtyeight.com/2010/01/healthcare-spending-and-life-expectancy.html
Thursday, December 17, 2009
The Health Care Reform Will Address Cost Containment
TW: Atul Gawande reports on health care for New Yorker and has put together excellent stuff which we have highlighted before. He is out with a new piece focused on the cost containment measures in the proposed health care reform pending in Congress. The fundamental point is the bill attempts a plethora of approaches integrating cutting edge thinking on the topic. As I have said repeatedly, one person's health care cost is another's revenue. One person's frivolous test is another's reassuring procedure. Containing costs is complex at least the bill attempts to address the issue unlike those who merely sit back demagogue merrily along towards their next election.
From Atul Gawande at New Yorker as summarized by Ezra Klein:
"Pick up the Senate health-care bill -- yes, all 2,074 pages -- and leaf through it. Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be.
The bill tests, for instance, a number of ways that federal insurers could pay for care. Medicare and Medicaid currently pay clinicians the same amount regardless of results. But there is a pilot program to increase payments for doctors who deliver high-quality care at lower cost, while reducing payments for those who deliver low-quality care at higher cost. There’s a program that would pay bonuses to hospitals that improve patient results after heart failure, pneumonia, and surgery. There’s a program that would impose financial penalties on institutions with high rates of infections transmitted by health-care workers. Still another would test a system of penalties and rewards scaled to the quality of home health and rehabilitation care.
Other experiments try moving medicine away from fee-for-service payment altogether. A bundled-payment provision would pay medical teams just one thirty-day fee for all the outpatient and inpatient services related to, say, an operation. This would give clinicians an incentive to work together to smooth care and reduce complications. One pilot would go even further, encouraging clinicians to band together into “Accountable Care Organizations” that take responsibility for all their patients’ needs, including prevention -- so that fewer patients need operations in the first place. These groups would be permitted to keep part of the savings they generate, as long as they meet quality and service thresholds.
...Which of these programs will work? We can’t know. That’s why the Congressional Budget Office doesn’t credit any of them with substantial savings. The package relies on taxes and short-term payment cuts to providers in order to pay for subsidies. But, in the end, it contains a test of almost every approach that leading health-care experts have suggested. (The only one missing is malpractice reform. This is where the Republicans could be helpful.) None of this is as satisfying as a master plan. But there can’t be a master plan."
http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?currentPage=all#ixzz0ZlZtZebl
From Atul Gawande at New Yorker as summarized by Ezra Klein:
"Pick up the Senate health-care bill -- yes, all 2,074 pages -- and leaf through it. Almost half of it is devoted to programs that would test various ways to curb costs and increase quality. The bill is a hodgepodge. And it should be.
The bill tests, for instance, a number of ways that federal insurers could pay for care. Medicare and Medicaid currently pay clinicians the same amount regardless of results. But there is a pilot program to increase payments for doctors who deliver high-quality care at lower cost, while reducing payments for those who deliver low-quality care at higher cost. There’s a program that would pay bonuses to hospitals that improve patient results after heart failure, pneumonia, and surgery. There’s a program that would impose financial penalties on institutions with high rates of infections transmitted by health-care workers. Still another would test a system of penalties and rewards scaled to the quality of home health and rehabilitation care.
Other experiments try moving medicine away from fee-for-service payment altogether. A bundled-payment provision would pay medical teams just one thirty-day fee for all the outpatient and inpatient services related to, say, an operation. This would give clinicians an incentive to work together to smooth care and reduce complications. One pilot would go even further, encouraging clinicians to band together into “Accountable Care Organizations” that take responsibility for all their patients’ needs, including prevention -- so that fewer patients need operations in the first place. These groups would be permitted to keep part of the savings they generate, as long as they meet quality and service thresholds.
...Which of these programs will work? We can’t know. That’s why the Congressional Budget Office doesn’t credit any of them with substantial savings. The package relies on taxes and short-term payment cuts to providers in order to pay for subsidies. But, in the end, it contains a test of almost every approach that leading health-care experts have suggested. (The only one missing is malpractice reform. This is where the Republicans could be helpful.) None of this is as satisfying as a master plan. But there can’t be a master plan."
http://www.newyorker.com/reporting/2009/12/14/091214fa_fact_gawande?currentPage=all#ixzz0ZlZtZebl
Wednesday, December 16, 2009
Health Care Pragmatism
TW: One of the reason I like Silver so much is his pragmatism (Ezra Klein is similiar). Without pragmatism nothing gets done in politics, which is the Republican strategy of 24/7 opposition can be effective if getting nothing done is the goal. Some liberal Dems are getting seriously agitated that their dreams of a "pure" health care (and many others) bill is not emerging. It is all about the votes, either you have them or you do not.
From Nate Silver at 538.com:
"1. Over the medium term, how many other opportunities will exist to provide in excess of $100 billion per year in public subsidies to poor and sick people?
2. Would a bill that contained $50 billion in additional subsidies for people making less than 250% of poverty be acceptable?
3. Where is the evidence that the plan, as constructed, would substantially increase insurance industry profit margins, particularly when it is funded in part via a tax on insurers?
4. Why are some of the same people who are criticizing the bill's lack of cost control also criticizing the inclusion of the excise tax, which is one of the few cost control mechanisms to have survived the process?
5. Why are some of the same people who are criticizing the bill's lack of cost control also criticizing the inclusion of the individual mandate, which is key to controlling premiums in the individual market?
6. Would concerns about the political downside to the individual mandate in fact substantially be altered if a public plan were included among the choices? Might not the Republican talking point become: "forcing you to buy government-run insurance?"
7. Roughly how many people would in fact meet ALL of the following criteria: (i) in the individual insurance market, and not eligible for Medicaid or Medicare; (ii) consider the insurance to be a bad deal, even after substantial government subsidies; (iii) are not knowingly gaming the system by waiting to buy insurance until they become sick; (iv) are not exempt from the individual mandate penalty because of low income status or other exemptions carved out by the bill?
8. How many years is it likely to be before Democrats again have (i) at least as many non-Blue Dog seats in the Congress as they do now, and (ii) a President in the White House who would not veto an ambitious health care bill?
9. If the idea is to wait for a complete meltdown of the health care system, how likely is it that our country will respond to such a crisis in a rational fashion? How have we tended to respond to such crises in the past?
10. Where is the evidence that the public option is particularly important to base voters and/or swing voters (rather than activists), as compared with other aspects of health care reform?
11. Would base voters be less likely to turn out in 2010 if no health care plan is passed at all, rather than a reasonable plan without a public option?
12. What is the approximate likelihood that a plan passed through reconciliation would be better, on balance, from a policy perspective, than a bill passed through regular order but without a public option?
13. What is the likely extent of political fallout that might result from an attempt to use the reconciliation process?
14. How certain is it that a plan passed through reconciliation would in fact receive 51 votes (when some Democrats would might have objections to the use of the process)?
15. Are there any compromises or concessions not having to do with the provision of publicly-run health programs that could still be achieved through progressive pressure?
16. What are the chances that improvements can be made around the margins of the plan -- possibly including a public option -- between 2011 and the bill's implementation in 2014?
17. What are the potential upsides and downsides to using the 2010 midterms as a referendum on the public option, with the goal of achieving a 'mandate' for a public option that could be inserted via reconciliation?
18. Was the public option ever an attainable near-term political goal?
19. How many of the arguments that you might be making against the bill would you still be making if a public option were included (but in fact have little to do with the public option)?
20. How many of the arguments that you might be making against the bill are being made out of anger, frustration, or a desire to ring Joe Lieberman by his scruffy, no-good, backstabbing neck?"
http://www.fivethirtyeight.com/2009/12/20-questions-for-bill-killers.html
From Nate Silver at 538.com:
"1. Over the medium term, how many other opportunities will exist to provide in excess of $100 billion per year in public subsidies to poor and sick people?
2. Would a bill that contained $50 billion in additional subsidies for people making less than 250% of poverty be acceptable?
3. Where is the evidence that the plan, as constructed, would substantially increase insurance industry profit margins, particularly when it is funded in part via a tax on insurers?
4. Why are some of the same people who are criticizing the bill's lack of cost control also criticizing the inclusion of the excise tax, which is one of the few cost control mechanisms to have survived the process?
5. Why are some of the same people who are criticizing the bill's lack of cost control also criticizing the inclusion of the individual mandate, which is key to controlling premiums in the individual market?
6. Would concerns about the political downside to the individual mandate in fact substantially be altered if a public plan were included among the choices? Might not the Republican talking point become: "forcing you to buy government-run insurance?"
7. Roughly how many people would in fact meet ALL of the following criteria: (i) in the individual insurance market, and not eligible for Medicaid or Medicare; (ii) consider the insurance to be a bad deal, even after substantial government subsidies; (iii) are not knowingly gaming the system by waiting to buy insurance until they become sick; (iv) are not exempt from the individual mandate penalty because of low income status or other exemptions carved out by the bill?
8. How many years is it likely to be before Democrats again have (i) at least as many non-Blue Dog seats in the Congress as they do now, and (ii) a President in the White House who would not veto an ambitious health care bill?
9. If the idea is to wait for a complete meltdown of the health care system, how likely is it that our country will respond to such a crisis in a rational fashion? How have we tended to respond to such crises in the past?
10. Where is the evidence that the public option is particularly important to base voters and/or swing voters (rather than activists), as compared with other aspects of health care reform?
11. Would base voters be less likely to turn out in 2010 if no health care plan is passed at all, rather than a reasonable plan without a public option?
12. What is the approximate likelihood that a plan passed through reconciliation would be better, on balance, from a policy perspective, than a bill passed through regular order but without a public option?
13. What is the likely extent of political fallout that might result from an attempt to use the reconciliation process?
14. How certain is it that a plan passed through reconciliation would in fact receive 51 votes (when some Democrats would might have objections to the use of the process)?
15. Are there any compromises or concessions not having to do with the provision of publicly-run health programs that could still be achieved through progressive pressure?
16. What are the chances that improvements can be made around the margins of the plan -- possibly including a public option -- between 2011 and the bill's implementation in 2014?
17. What are the potential upsides and downsides to using the 2010 midterms as a referendum on the public option, with the goal of achieving a 'mandate' for a public option that could be inserted via reconciliation?
18. Was the public option ever an attainable near-term political goal?
19. How many of the arguments that you might be making against the bill would you still be making if a public option were included (but in fact have little to do with the public option)?
20. How many of the arguments that you might be making against the bill are being made out of anger, frustration, or a desire to ring Joe Lieberman by his scruffy, no-good, backstabbing neck?"
http://www.fivethirtyeight.com/2009/12/20-questions-for-bill-killers.html
Thursday, December 10, 2009
Cleveland Clinic As a Model For Reform
TW: This Newsweek piece examines the Cleveland Clinic as a possible symbol of what our health care system could like. Extrapolating top-end clinics like Mayo and Cleveland is not linear but certain characteristics: the team approach, non-volume based provider compensation (e.g. a doc does not make money every time she prescribes a scan or treatment), heavy use of integrated data systems etc. are likely relevant.
I did not clip it, so read it instead.
http://www.newsweek.com/id/224585
I did not clip it, so read it instead.
http://www.newsweek.com/id/224585
Monday, December 7, 2009
A Real Problem Seeking Solution
TW: I still think many folks believe health care reform is focused on providing more health care to the poor. It is not. It is focused on those working and middle class folks who for various reasons struggle to obtain care. Amongst other attributes, universal care would facilitate labor market participation by those currently likely to drop out due to health reasons. More importantly how would the nattering nabobs of health care reform negativity address the situation outlined below.
From Economist describing a Nic Kristof story from NYT:
"...what it's like to have a brain disease in America when you don't have health insurance. John Brodniak, a sawmill worker from Mr Kristof's hometown in Oregon, was diagnosed this spring with an abnormal growth of blood vessels in the brain which periodically leaks, causing him intense pain, blackouts, and memory loss. He was 23.
'With John unable to work, he lost his job — and his insurance coverage. [His wife] Esther had insurance for herself and for her two children (from a previous marriage) through her job building manufactured homes. But she couldn’t add John to her plan because of his pre-existing condition.
Without insurance, John has been unable to get surgery or even help managing the pain. When he collapses or suffers particularly excruciating headaches, Esther rushes him to the emergency room of one hospital or another, but an E.R. can’t do much for him. One hospital has told them not to come back unless he gets insurance, they say.
Esther used up her family leave time to look after her new husband. “Then I went back to work, and he fell several times,” she said. “I told my boss that I had to quit. Taking care of John was more important than building someone else’s house.”
That meant that the couple had no income—and no insurance for anyone in the family, including the children. Neighbors have helped, and a community program has paid the rent so that they are not homeless. But bills are piling up, and John and Esther don’t know how they will cope.
The doctors warn that pressure from the growth could lead a major blood vessel nearby to burst, killing him. “They tell me I’m a time bomb,” John said.'
When Ted Kennedy died in August, a number of right-wing commentators made the absurd suggestion that creating a universal health-insurance system in America was risky because, in such a system, the 77-year-old Mr Kennedy might not have been eligible for the high-quality care he received for a possibly inoperable brain tumour in the final year of his life. John Brodniak is a young, healthy man dying of an operable brain growth because America's current insurance system will not cover him.
Mr Brodniak's story is not without its complications: he has qualified for an Oregon Medicaid programme, but no hospital in the area will accept its low reimbursement rates for the treatment he needs. The health-reform plan currently moving through Congress would remedy such situations by requiring private insurance plans to accept people like Mr Brodniak, regardless of pre-existing conditions, and providing subsidies for those too poor to afford private plans. But the main point is that the idea that people might be refused urgent, life-saving medical care for fiscal reasons isn't some kind of future dystopia. It's the way things are right now. If we call that a "death panel", we're all sitting on it, and John Brodniak is waiting for our verdict."
http://www.economist.com/blogs/democracyinamerica/2009/11/we_have_met_the_death_panel
From Economist describing a Nic Kristof story from NYT:
"...what it's like to have a brain disease in America when you don't have health insurance. John Brodniak, a sawmill worker from Mr Kristof's hometown in Oregon, was diagnosed this spring with an abnormal growth of blood vessels in the brain which periodically leaks, causing him intense pain, blackouts, and memory loss. He was 23.
'With John unable to work, he lost his job — and his insurance coverage. [His wife] Esther had insurance for herself and for her two children (from a previous marriage) through her job building manufactured homes. But she couldn’t add John to her plan because of his pre-existing condition.
Without insurance, John has been unable to get surgery or even help managing the pain. When he collapses or suffers particularly excruciating headaches, Esther rushes him to the emergency room of one hospital or another, but an E.R. can’t do much for him. One hospital has told them not to come back unless he gets insurance, they say.
Esther used up her family leave time to look after her new husband. “Then I went back to work, and he fell several times,” she said. “I told my boss that I had to quit. Taking care of John was more important than building someone else’s house.”
That meant that the couple had no income—and no insurance for anyone in the family, including the children. Neighbors have helped, and a community program has paid the rent so that they are not homeless. But bills are piling up, and John and Esther don’t know how they will cope.
The doctors warn that pressure from the growth could lead a major blood vessel nearby to burst, killing him. “They tell me I’m a time bomb,” John said.'
When Ted Kennedy died in August, a number of right-wing commentators made the absurd suggestion that creating a universal health-insurance system in America was risky because, in such a system, the 77-year-old Mr Kennedy might not have been eligible for the high-quality care he received for a possibly inoperable brain tumour in the final year of his life. John Brodniak is a young, healthy man dying of an operable brain growth because America's current insurance system will not cover him.
Mr Brodniak's story is not without its complications: he has qualified for an Oregon Medicaid programme, but no hospital in the area will accept its low reimbursement rates for the treatment he needs. The health-reform plan currently moving through Congress would remedy such situations by requiring private insurance plans to accept people like Mr Brodniak, regardless of pre-existing conditions, and providing subsidies for those too poor to afford private plans. But the main point is that the idea that people might be refused urgent, life-saving medical care for fiscal reasons isn't some kind of future dystopia. It's the way things are right now. If we call that a "death panel", we're all sitting on it, and John Brodniak is waiting for our verdict."
http://www.economist.com/blogs/democracyinamerica/2009/11/we_have_met_the_death_panel
Tuesday, December 1, 2009
The Impact Of 24/7 Disinformation
(question was whether one knew what the "public option" was)
TW: I am not going to repeat for the tenth time what the public option is. In a democracy if folks are too lazy or so biased as to open their minds to knowledge regarding core legislative issues then we deserve the dysfunctional governance folks bitch about regularly yet consistently refuse to put in the time to correct.
Wednesday, November 25, 2009
Dealing With End Of Life
TW: Have posted on this several times. No doubt end of life is a challenging ethical dilemma. It is interesting that most discussion is framed on the elderly when in fact most of the same issues are relevant for everyone including premies, infants, children and middle-aged folks for that matter.
The challenge boils down to we have finite resources how do we manage them. When life and death is the topic such simplistic framing seems inadequate but without framing there is no basis upon which to address the challenge.
From Economist:
"IN RESPONSE to a post of mine from Friday, commenter MaverEcon made an insightful point: "Whenever people talk about death, it's all about platitudes. We're unwilling to have serious and respectful debates on the topic." The unseriousness is exemplified by those who toss around terms like "death panels" and "rationing" in an effort to close off debate on how end-of-life care should be managed. In reality, though, that is where the debate should begin.
In September, Lexington devoted his column to Americans' fear of death, noting
'Health reformers always smash up against two unpalatable truths. We are all going to die. And the demand for interventions that might postpone that day far outstrips the supply. No politician would be caught dead admitting this, of course: most promise that all will receive whatever is medically necessary. But what does that mean?'
For one thing, it means that Medicare spent $50 billion last year to care for patients in the last two months of their lives. As "60 Minutes" pointed out on Sunday, "that's more than the budget of the Department of Homeland Security or the Department of Education." It means we give liver transplants to the terminally ill, defibrillators to those with untreatable cancer. It means we use lots of money and resources, as if we have an endless supply of both, in order to briefly delay the reaper, or avoid looking him in the eye.
As a nation, perhaps that is how we want to spend our money. That's fine (if foolish). But we have so far reached that conclusion without having an honest debate over the benefits and costs. As others have pointed out, we condemn "rationing" as if we don't already do it. For example, instead of buying some of those defibrillators and paying for some of those transplants, we could computerise America's medical records. At this time, someone holding up a placard might accuse me of "killing grandma". In reality, though, my decision would save many more grandmas—a study found that between 2002 and 2004 nearly a quarter of Medicaid beneficiaries died due to safety incidents, many of which were likely preventable with better record keeping. But improving record keeping doesn't quite have the emotional appeal of caring for the elderly. So we give grandma her procedure, whatever it may be, while ignoring the fact that more money spent in one place means less money spent in another. Ignoring that every excessive procedure comes with a cost, in terms of the nation's overall health.
If nothing else, let's debate this (with Godwin's law in mind). I'm not arguing for a "Boomsday" scenario where we start enticing the elderly to end their lives early. But I do think we should become acquainted with the reaper before he comes for us. Not only will it allow us to have more honest discussions about how we use our limited resources (by the way, feel free to use your own money to pay for any care you want), but it will also lead to more dignified deaths. I know that sounds odd, but so does this statistic presented by "60 Minutes": "A vast majority of Americans say they want to die at home, but 75% die in a hospital or a nursing home." That is because we and our loved ones often do not consider death before it is upon us. That was the idea behind the so-called "death panels"—to make dying more dignified, not to bring it on more quickly. As a nation, we've so far dealt with that topic in a very immature way.
Any debate dealing with decisions about death will stir certain emotions. We should not ignore those feelings, but we should also not let them cloud our good judgment. There was a moving seen during the "60 Minutes" report where a doctor asked an elderly patient suffering from liver and kidney failure about one end-of-life scenario:
"Either way you decide, we will honor your choice, and that's the truth," [Dr Ira] Byock reassured [Charlie] Haggart. "Should we do CPR if your heart were to suddenly stop?"
"Yes," he replied.
"You'd be okay with being in the ICU again?" Byock asked.
"Yes," Haggart said.
"I know it's an awkward conversation," Byock said.
"It beats second place," Haggart joked, laughing.
The doctor thought Mr Haggart was condemning himself to a "bad death", suffering on machines with little to no chance of recovery. In this case, though, the goal wasn't to change Mr Haggart's decision. It was to make sure it was an informed one. But would it be wrong for me to point out that his ICU care would've cost up to $10,000 a day? That same money could pay for a year's worth of care for a person with type-2 diabetes. Let the debate begin."
The challenge boils down to we have finite resources how do we manage them. When life and death is the topic such simplistic framing seems inadequate but without framing there is no basis upon which to address the challenge.
From Economist:
"IN RESPONSE to a post of mine from Friday, commenter MaverEcon made an insightful point: "Whenever people talk about death, it's all about platitudes. We're unwilling to have serious and respectful debates on the topic." The unseriousness is exemplified by those who toss around terms like "death panels" and "rationing" in an effort to close off debate on how end-of-life care should be managed. In reality, though, that is where the debate should begin.
In September, Lexington devoted his column to Americans' fear of death, noting
'Health reformers always smash up against two unpalatable truths. We are all going to die. And the demand for interventions that might postpone that day far outstrips the supply. No politician would be caught dead admitting this, of course: most promise that all will receive whatever is medically necessary. But what does that mean?'
For one thing, it means that Medicare spent $50 billion last year to care for patients in the last two months of their lives. As "60 Minutes" pointed out on Sunday, "that's more than the budget of the Department of Homeland Security or the Department of Education." It means we give liver transplants to the terminally ill, defibrillators to those with untreatable cancer. It means we use lots of money and resources, as if we have an endless supply of both, in order to briefly delay the reaper, or avoid looking him in the eye.
As a nation, perhaps that is how we want to spend our money. That's fine (if foolish). But we have so far reached that conclusion without having an honest debate over the benefits and costs. As others have pointed out, we condemn "rationing" as if we don't already do it. For example, instead of buying some of those defibrillators and paying for some of those transplants, we could computerise America's medical records. At this time, someone holding up a placard might accuse me of "killing grandma". In reality, though, my decision would save many more grandmas—a study found that between 2002 and 2004 nearly a quarter of Medicaid beneficiaries died due to safety incidents, many of which were likely preventable with better record keeping. But improving record keeping doesn't quite have the emotional appeal of caring for the elderly. So we give grandma her procedure, whatever it may be, while ignoring the fact that more money spent in one place means less money spent in another. Ignoring that every excessive procedure comes with a cost, in terms of the nation's overall health.
If nothing else, let's debate this (with Godwin's law in mind). I'm not arguing for a "Boomsday" scenario where we start enticing the elderly to end their lives early. But I do think we should become acquainted with the reaper before he comes for us. Not only will it allow us to have more honest discussions about how we use our limited resources (by the way, feel free to use your own money to pay for any care you want), but it will also lead to more dignified deaths. I know that sounds odd, but so does this statistic presented by "60 Minutes": "A vast majority of Americans say they want to die at home, but 75% die in a hospital or a nursing home." That is because we and our loved ones often do not consider death before it is upon us. That was the idea behind the so-called "death panels"—to make dying more dignified, not to bring it on more quickly. As a nation, we've so far dealt with that topic in a very immature way.
Any debate dealing with decisions about death will stir certain emotions. We should not ignore those feelings, but we should also not let them cloud our good judgment. There was a moving seen during the "60 Minutes" report where a doctor asked an elderly patient suffering from liver and kidney failure about one end-of-life scenario:
"Either way you decide, we will honor your choice, and that's the truth," [Dr Ira] Byock reassured [Charlie] Haggart. "Should we do CPR if your heart were to suddenly stop?"
"Yes," he replied.
"You'd be okay with being in the ICU again?" Byock asked.
"Yes," Haggart said.
"I know it's an awkward conversation," Byock said.
"It beats second place," Haggart joked, laughing.
The doctor thought Mr Haggart was condemning himself to a "bad death", suffering on machines with little to no chance of recovery. In this case, though, the goal wasn't to change Mr Haggart's decision. It was to make sure it was an informed one. But would it be wrong for me to point out that his ICU care would've cost up to $10,000 a day? That same money could pay for a year's worth of care for a person with type-2 diabetes. Let the debate begin."
Tuesday, November 17, 2009
Hypocrisy
TW: Klein hits all the notes. Read the list of folks who voted for the Medicare Prescription Benefit, almost everyone of them has at some point this year pontificated about deficit spending blah, blah, blah. What makes my teeth itch is that folks cannot wrap their collective heads around the notion that deficits should be addressed when times are good, NOT when times are bad. None of these hypocrites lifted a finger during the W. Bush administration as national security spending exploded, medicare increased unabated and tax cuts for the wealthy were doled out like luxury candy.
Yet as Obama seeks to address a gaping hole in American society, the lack of universal coverage, a problem that is growing as more and more folks are squeezed out of coverage; all we hear from the hypocrites is blaaaah, guvmint is taking over, baaaaah.
From Ezra Klein at WaPo:
Quoting Matt Yglesias-
'John Breaux and Bill Frist have an op-ed in Politico whose exoteric message is that Congress should use the 2003 Medicare bill as a model for bipartisan health reform. The esoteric message is a reminder that the easiest way to get a bipartisan deal passed is to just have bipartisan agreement not to pay for it at all. That was the secret to the 2003 bill. First you take something a bloc of voters want — in this case prescription drugs — then you figure out a way to provide it in a manner that’s very good for the interests of stakeholders in the business community. Easy as pie.'
It is insane that the people who voted for the deficit-financed, $700 billion Medicare Prescription Drug Benefit are allowed to scream about fiscal rectitude this year. Just amazing. The occasional defense I've heard is that 2003 wasn't the middle of the most severe recession in memory. That's a defense in much the same way that poking yourself in both eyes so you can't see your assailant is a defense. Deficit spending makes more sense during recessions, not less. Deficit spending is also cheaper during recessions, as interest rates are lower because investors want to buy treasuries.
By the way, for those keeping score, the senators who voted for Medicare Part D and are still in the Senate are:
Lamar Alexander, Max Baucus, Bob Bennett, Kit Bond, Jim Bunning, Tom Carper, Saxby Chambliss, Thad Cochran, Susan Collins, Kent Conrad, John Cornyn, Mike Crapo, Byron Dorgan, Mike Enzi, Dianne Feinstein, Chuck Grassley, Orrin Hatch, Kay Bailey Hutchinson, James Inhofe, Jon Kyl, Mary Landrieu, Blanche Lincoln, Dick Lugar, Mitch McConnell, Lisa Murkowski, Ben Nelson, Pat Roberts, Pete Sessions, Richard Shelby, Olympia Snowe, Arlen Specter, George Voinovich and Ron Wyden. Lieberman did not vote.
None of these people have any authority to complain about the spending in health-care reform. When the CBO scored Medicare Part D, it concludes that the bill "would increase mandatory outlays by $407 billion for fiscal years 2004 to 2013 and would raise federal revenues by $7 billion over that period." In other words, it was a vote to add about $400 billion to the deficit in the first 10 years, and trillions more in the decades after that.
The health-care reform bills currently under consideration in both the Senate and the House actually cut money from the deficit, but they are being criticized as fiscally irresponsible by many of the people who voted for Medicare Part D. It's like watching arsonists calling the fire department reckless."
http://voices.washingtonpost.com/ezra-klein/2009/11/the_lessons_of_medicare_part_d.html
Yet as Obama seeks to address a gaping hole in American society, the lack of universal coverage, a problem that is growing as more and more folks are squeezed out of coverage; all we hear from the hypocrites is blaaaah, guvmint is taking over, baaaaah.
From Ezra Klein at WaPo:
Quoting Matt Yglesias-
'John Breaux and Bill Frist have an op-ed in Politico whose exoteric message is that Congress should use the 2003 Medicare bill as a model for bipartisan health reform. The esoteric message is a reminder that the easiest way to get a bipartisan deal passed is to just have bipartisan agreement not to pay for it at all. That was the secret to the 2003 bill. First you take something a bloc of voters want — in this case prescription drugs — then you figure out a way to provide it in a manner that’s very good for the interests of stakeholders in the business community. Easy as pie.'
It is insane that the people who voted for the deficit-financed, $700 billion Medicare Prescription Drug Benefit are allowed to scream about fiscal rectitude this year. Just amazing. The occasional defense I've heard is that 2003 wasn't the middle of the most severe recession in memory. That's a defense in much the same way that poking yourself in both eyes so you can't see your assailant is a defense. Deficit spending makes more sense during recessions, not less. Deficit spending is also cheaper during recessions, as interest rates are lower because investors want to buy treasuries.
By the way, for those keeping score, the senators who voted for Medicare Part D and are still in the Senate are:
Lamar Alexander, Max Baucus, Bob Bennett, Kit Bond, Jim Bunning, Tom Carper, Saxby Chambliss, Thad Cochran, Susan Collins, Kent Conrad, John Cornyn, Mike Crapo, Byron Dorgan, Mike Enzi, Dianne Feinstein, Chuck Grassley, Orrin Hatch, Kay Bailey Hutchinson, James Inhofe, Jon Kyl, Mary Landrieu, Blanche Lincoln, Dick Lugar, Mitch McConnell, Lisa Murkowski, Ben Nelson, Pat Roberts, Pete Sessions, Richard Shelby, Olympia Snowe, Arlen Specter, George Voinovich and Ron Wyden. Lieberman did not vote.
None of these people have any authority to complain about the spending in health-care reform. When the CBO scored Medicare Part D, it concludes that the bill "would increase mandatory outlays by $407 billion for fiscal years 2004 to 2013 and would raise federal revenues by $7 billion over that period." In other words, it was a vote to add about $400 billion to the deficit in the first 10 years, and trillions more in the decades after that.
The health-care reform bills currently under consideration in both the Senate and the House actually cut money from the deficit, but they are being criticized as fiscally irresponsible by many of the people who voted for Medicare Part D. It's like watching arsonists calling the fire department reckless."
http://voices.washingtonpost.com/ezra-klein/2009/11/the_lessons_of_medicare_part_d.html
Saturday, November 7, 2009
Big Week For the Catholic Oligarchy
TW: Conservative Catholic dogma had a big week. First they were by far the largest funder against gay marriage in Maine and prevailed in their quest to stop the "evil" of gay marriage. And now they (along with their allies from the Southern Baptists amongst others) wield their power to help keep abortion funding out of the public option. It is a free country so they have every right to do so. Does not mean I have to like it. If one is wealthy, like in so many other ways, one has many choices. If one is amidst the working poor and middle class, one succumbs to the whims of others.
From Ezra Klein:
"The final compromises before a bill comes to the floor are never very pretty. This one, however, is worse than I anticipated. Opposition from anti-abortion Democrats, driven in large part by aggressive activism from the Catholic Church, forced Democratic leadership to allow a vote on Bart Stupak's amendment limiting elective abortion coverage from both private and public insurers on the exchange. It reads:
The amendment will prohibit federal funds for abortion services in the public option. It also prohibits individuals who receive affordability credits from purchasing a plan that provides elective abortions. However, it allows individuals, both who receive affordability credits and who do not, to separately purchase with their own funds plans that cover elective abortions. It also clarifies that private plans may still offer elective abortions.
Because of the limits placed on the exchanges, most of the participants will have some form of premium credit or affordable subsidy. That means most will be ineligible for abortion coverage. The idea that people are going to go out and purchase separate "abortion plans" is both cruel and laughable. If this amendment passes, it will mean that virtually all women with insurance through the exchange who find themselves in the unwanted and unexpected position of needing to terminate a pregnancy will not have coverage for the procedure.
Abortion coverage will not be outlawed in this country. It will simply be tiered, reserved for those rich enough to afford insurance themselves or lucky enough to receive from their employers.
The amendment is expected to pass with relative ease. Republicans will join with anti-choice Democrats to push it over the finish line. Once the amendment passes, the bill is cleared for a vote, and all parties expect that vote to succeed. Today looks likely to end with a historic, and important, vote. A vote that is a first step towards helping more than 30 million people secure health-care coverage, and making sure hundreds of millions are better protected from the vagaries of the insurance industry. But Stupak's amendment is a bitter start. It is, however, not the end. Even if it muscles into the House bill, it will also have to pass in the Senate, and then survive conference, before it becomes law."
From Ezra Klein:
"The final compromises before a bill comes to the floor are never very pretty. This one, however, is worse than I anticipated. Opposition from anti-abortion Democrats, driven in large part by aggressive activism from the Catholic Church, forced Democratic leadership to allow a vote on Bart Stupak's amendment limiting elective abortion coverage from both private and public insurers on the exchange. It reads:
The amendment will prohibit federal funds for abortion services in the public option. It also prohibits individuals who receive affordability credits from purchasing a plan that provides elective abortions. However, it allows individuals, both who receive affordability credits and who do not, to separately purchase with their own funds plans that cover elective abortions. It also clarifies that private plans may still offer elective abortions.
Because of the limits placed on the exchanges, most of the participants will have some form of premium credit or affordable subsidy. That means most will be ineligible for abortion coverage. The idea that people are going to go out and purchase separate "abortion plans" is both cruel and laughable. If this amendment passes, it will mean that virtually all women with insurance through the exchange who find themselves in the unwanted and unexpected position of needing to terminate a pregnancy will not have coverage for the procedure.
Abortion coverage will not be outlawed in this country. It will simply be tiered, reserved for those rich enough to afford insurance themselves or lucky enough to receive from their employers.
The amendment is expected to pass with relative ease. Republicans will join with anti-choice Democrats to push it over the finish line. Once the amendment passes, the bill is cleared for a vote, and all parties expect that vote to succeed. Today looks likely to end with a historic, and important, vote. A vote that is a first step towards helping more than 30 million people secure health-care coverage, and making sure hundreds of millions are better protected from the vagaries of the insurance industry. But Stupak's amendment is a bitter start. It is, however, not the end. Even if it muscles into the House bill, it will also have to pass in the Senate, and then survive conference, before it becomes law."
Thursday, November 5, 2009
Republican Happy Horse Dung On Healthcare
TW: I have been pounding the table since Obama took office about folks needing to participate in solutions rather than just bitching. The Republicans have adopted an electoral strategy of nearly blind opposition. I am passionate about health care reform and in particular universal care. The Republicans have stated repeatedly that they would offer alternatives, the latest is cynical schmutz. It practically ignores universal care whilst trumpeting tired old saws about limiting medical malpractice liability and allegedly cutting costs for the "average" folk.
Their plan would cover 5% of the folks currently without care, "save" $5 billion a year in malpractive liability and maybe (assuming all of their own highly dubious projections were accurate) save the "average" folk a small fraction of the massive increases everyone faces in medical costs over the coming years. Things like mandating coverage for folks with pre-existing conditions etc. ignored.
This is a lame ploy to claim they are trying when they are most definitely not. Their entire bill amounts to about $6 billion a year. We spend that every two weeks in Iraq. This is a multi-trillion issue for those with serious intentions not hollow populist rhetoric.
From Politico:
The House Republicans health care plan only provides coverage to 3 million uninsured Americans, about 33 million less than the Democrats bill, according to the Congressional Budget Office.
"The GOP alternative, which has no chance of becoming law, would leave about 52 million Americans without coverage.
Republicans sought to lower premiums for the most Americans possible while covering far fewer uninsured Americans because they wanted to keep the costs down. They also chose not to end insurance industry practices that discriminate against the sick or the most expensive to insure in order to keep premiums low.
And it looks like they achieved that goal, according to the CBO; the Republican legislation would cost $61 billion over the next 10 years - nearly $1 trillion less than the Democrats' bill - and cut the deficit by $68 billion over its first decade.
The Republicans also save nearly $50 billion over the next decade by creating new restrictions in medical liability lawsuits.
But perhaps the most important number the GOP will are tout are those that show the plan would lower insurance premiums for many Americans. CBO estimates that the average premiums for small group plans, which includes companies with roughly fewer than 50 employees, would decrease by 7 to 10 percent by 2016. Premiums in the individual market would decline by 5 to 8 percent. While employees with bigger companies would only see a slight decrease..."
http://www.politico.com/livepulse/1109/Republicans_only_cover_3_million_uninsured.html
From Ezra Klein at WaPo:
"...CBO begins with the baseline estimate that 17 percent of legal, non-elderly residents won't have health-care insurance in 2010. In 2019, after 10 years of the Republican plan, CBO estimates that ...17 percent of legal, non-elderly residents won't have health-care insurance. The Republican alternative will have helped 3 million people secure coverage, which is barely keeping up with population growth. Compare that to the Democratic bill, which covers 36 million more people and cuts the uninsured population to 4 percent. But maybe, you say, the Republican bill does a really good job cutting costs. According to CBO, the GOP's alternative will shave $68 billion off the deficit in the next 10 years. The Democrats, CBO says, will slice $104 billion off the deficit.
The Democratic bill, in other words, covers 12 times as many people and saves $36 billion more than the Republican plan. And amazingly, the Democratic bill has already been through three committees and a merger process. It's already been shown to interest groups and advocacy organizations and industry stakeholders. It's already made its compromises with reality. It's already been through the legislative sausage grinder..."
Their plan would cover 5% of the folks currently without care, "save" $5 billion a year in malpractive liability and maybe (assuming all of their own highly dubious projections were accurate) save the "average" folk a small fraction of the massive increases everyone faces in medical costs over the coming years. Things like mandating coverage for folks with pre-existing conditions etc. ignored.
This is a lame ploy to claim they are trying when they are most definitely not. Their entire bill amounts to about $6 billion a year. We spend that every two weeks in Iraq. This is a multi-trillion issue for those with serious intentions not hollow populist rhetoric.
From Politico:
The House Republicans health care plan only provides coverage to 3 million uninsured Americans, about 33 million less than the Democrats bill, according to the Congressional Budget Office.
"The GOP alternative, which has no chance of becoming law, would leave about 52 million Americans without coverage.
Republicans sought to lower premiums for the most Americans possible while covering far fewer uninsured Americans because they wanted to keep the costs down. They also chose not to end insurance industry practices that discriminate against the sick or the most expensive to insure in order to keep premiums low.
And it looks like they achieved that goal, according to the CBO; the Republican legislation would cost $61 billion over the next 10 years - nearly $1 trillion less than the Democrats' bill - and cut the deficit by $68 billion over its first decade.
The Republicans also save nearly $50 billion over the next decade by creating new restrictions in medical liability lawsuits.
But perhaps the most important number the GOP will are tout are those that show the plan would lower insurance premiums for many Americans. CBO estimates that the average premiums for small group plans, which includes companies with roughly fewer than 50 employees, would decrease by 7 to 10 percent by 2016. Premiums in the individual market would decline by 5 to 8 percent. While employees with bigger companies would only see a slight decrease..."
http://www.politico.com/livepulse/1109/Republicans_only_cover_3_million_uninsured.html
From Ezra Klein at WaPo:
"...CBO begins with the baseline estimate that 17 percent of legal, non-elderly residents won't have health-care insurance in 2010. In 2019, after 10 years of the Republican plan, CBO estimates that ...17 percent of legal, non-elderly residents won't have health-care insurance. The Republican alternative will have helped 3 million people secure coverage, which is barely keeping up with population growth. Compare that to the Democratic bill, which covers 36 million more people and cuts the uninsured population to 4 percent. But maybe, you say, the Republican bill does a really good job cutting costs. According to CBO, the GOP's alternative will shave $68 billion off the deficit in the next 10 years. The Democrats, CBO says, will slice $104 billion off the deficit.
The Democratic bill, in other words, covers 12 times as many people and saves $36 billion more than the Republican plan. And amazingly, the Democratic bill has already been through three committees and a merger process. It's already been shown to interest groups and advocacy organizations and industry stakeholders. It's already made its compromises with reality. It's already been through the legislative sausage grinder..."
Wednesday, November 4, 2009
We Pay Much More PER UNIT Of Health Care
TW: These charts have been all over the blogosphere, but they are pretty important so in case you missed them. The theme is obvious we do not necessarily consume more health care than others but we sure do pay a lot more per unit of care than folks in other countries. The reasons are complex and for other posts but something we should keep in mind (and yes tort reform would help, a little, but that is not anywhere near the whole answer).
From Ezra Klein at WaPo:
"There is a simple explanation for why American health care costs so much more than health care in any other country: because we pay so much more for each unit of care. As Halvorson explained, and academics and consultancies have repeatedly confirmed, if you leave everything else the same -- the volume of procedures, the days we spend in the hospital, the number of surgeries we need -- but plug in the prices Canadians pay, our health-care spending falls by about 50 percent."
http://voices.washingtonpost.com/ezra-klein/2009/11/an_insurance_industry_ceo_expl.html
TW: This shows how the blogosphere for better or worse becomes circular.
From Economist:
"...Incidentally, I found that salaries chart on a Mark Perry post at Wall Street Pit, but he got it from a Greg Mankiw post, but he got it from a Derek Thompson post at the Atlantic, and he in turn got it from...an old Ezra Klein post. Something to beware of, out on the internets: the trail of "corroborating evidence" often looks like the information flows Dick Cheney set up to make it look like several sources had corroborated information on WMD in Iraq. Not that the figures here aren't accurate: this New York Times article confirms American doctors typically make two to three times as much as doctors in other industrialised countries."
http://www.economist.com/blogs/democracyinamerica/2009/11/americas_health_care_bargain.cfm
From Ezra Klein at WaPo:
"There is a simple explanation for why American health care costs so much more than health care in any other country: because we pay so much more for each unit of care. As Halvorson explained, and academics and consultancies have repeatedly confirmed, if you leave everything else the same -- the volume of procedures, the days we spend in the hospital, the number of surgeries we need -- but plug in the prices Canadians pay, our health-care spending falls by about 50 percent."
http://voices.washingtonpost.com/ezra-klein/2009/11/an_insurance_industry_ceo_expl.html
TW: This shows how the blogosphere for better or worse becomes circular.
From Economist:
"...Incidentally, I found that salaries chart on a Mark Perry post at Wall Street Pit, but he got it from a Greg Mankiw post, but he got it from a Derek Thompson post at the Atlantic, and he in turn got it from...an old Ezra Klein post. Something to beware of, out on the internets: the trail of "corroborating evidence" often looks like the information flows Dick Cheney set up to make it look like several sources had corroborated information on WMD in Iraq. Not that the figures here aren't accurate: this New York Times article confirms American doctors typically make two to three times as much as doctors in other industrialised countries."
http://www.economist.com/blogs/democracyinamerica/2009/11/americas_health_care_bargain.cfm
Saturday, October 24, 2009
Circular Health Care Logic
TW: Klein does a simple example to focus on some of the circular logic inherent in some of the conservative opposition to health care reform.
From Ezra Klein at WaPo:
"Imagine a world in which there are only 10 people. All of them want to buy health care. But some of them are sicker, or older, than others. Two of the 10 people cost $10 to cover. Two of them cost $2. And everyone else costs $5.
Like in our own world, insurers are pretty good at discriminating against the sick. They deny the two bad risks coverage. Average premiums are thus only $4.25 a person. That's not too bad.
But it is a bit cruel. After all, the people who need insurance most are locked out of the system. Recognizing the inequity, the 10 residents of our imaginary land elect Schmarack Schmobama president, in part because he's run on a platform of universal health care. He comes into office and passes a law saying insurers have to offer care to everybody at a similar price, and there will be subsidies to help those who can't afford the cost. What happens to premiums?
Well, as Michael Gerson says in his column today, they go up. With the two $10 risks included in the total, average premiums are now $4.40. The subsidies help people who can't shoulder the expense, but that's not quite the point. As Gerson writes, health-care reform has made "the average insurance plan more expensive." This is the first reason, he says, that "non-Maine Republicans object to the Senate Finance bill."
But the average insurance premium is now more expensive because insurers can't discriminate against the sick, and they can't discriminate as much against the old. Most of us -- even those of us in the middle class -- eventually become sick, and eventually become old. Our insurance plan might be more expensive now, and so we consider ourselves losers, but we won't be locked out later, which would have been losing on a whole other scale. Whether we come out ahead in a single year may well be different than whether we come out ahead over time. After all, insurance itself is a hedge against catastrophic bad luck. On some level, so too is this bill.
Moreover, this is emphatically not why non-Maine Republicans object to the bill, or at least it wasn't at one point. Republicans have bent over backwards to proclaim their openness to insurance market reforms. Sen. Mike Enzi, for instance, told AARP that, "I support fundamental changes that would prevent insurance companies from denying access to anyone needing health insurance coverage." If everyone can access coverage, then the risk pool will become more expensive because the bad risks will no longer be locked out. Enzi, in other words, supports the fundamental change that raises average premiums.
Conversely, the pieces of the bill that have driven the most partisan bickering have been the elements that would drop the cost of average premiums. You may or may not like the public plan, but the Congressional Budget Office and many other analysts have said it will lead to lower premiums for consumers. The individual mandate has sparked a fair amount of Republican opposition, but its purpose is to pull healthy customers into the pool so average premiums remain low. The level of subsidies has created some controversy, but it will offset the premiums costs for most consumers.
Republicans have adopted the insurance industry's talking point that health-care reform will "make the average insurance plan more expensive." The problem is, most of them support, or have previously supported, the elements of the plan that drive that increase. And most of them oppose both the insurance industry's ideas for mitigating the problem (a much stronger individual mandate) and the elements of the Democratic bills that would drive down premium costs..."
http://voices.washingtonpost.com/ezra-klein/2009/10/is_this_why_republicans_cant_s.html
From Ezra Klein at WaPo:
"Imagine a world in which there are only 10 people. All of them want to buy health care. But some of them are sicker, or older, than others. Two of the 10 people cost $10 to cover. Two of them cost $2. And everyone else costs $5.
Like in our own world, insurers are pretty good at discriminating against the sick. They deny the two bad risks coverage. Average premiums are thus only $4.25 a person. That's not too bad.
But it is a bit cruel. After all, the people who need insurance most are locked out of the system. Recognizing the inequity, the 10 residents of our imaginary land elect Schmarack Schmobama president, in part because he's run on a platform of universal health care. He comes into office and passes a law saying insurers have to offer care to everybody at a similar price, and there will be subsidies to help those who can't afford the cost. What happens to premiums?
Well, as Michael Gerson says in his column today, they go up. With the two $10 risks included in the total, average premiums are now $4.40. The subsidies help people who can't shoulder the expense, but that's not quite the point. As Gerson writes, health-care reform has made "the average insurance plan more expensive." This is the first reason, he says, that "non-Maine Republicans object to the Senate Finance bill."
But the average insurance premium is now more expensive because insurers can't discriminate against the sick, and they can't discriminate as much against the old. Most of us -- even those of us in the middle class -- eventually become sick, and eventually become old. Our insurance plan might be more expensive now, and so we consider ourselves losers, but we won't be locked out later, which would have been losing on a whole other scale. Whether we come out ahead in a single year may well be different than whether we come out ahead over time. After all, insurance itself is a hedge against catastrophic bad luck. On some level, so too is this bill.
Moreover, this is emphatically not why non-Maine Republicans object to the bill, or at least it wasn't at one point. Republicans have bent over backwards to proclaim their openness to insurance market reforms. Sen. Mike Enzi, for instance, told AARP that, "I support fundamental changes that would prevent insurance companies from denying access to anyone needing health insurance coverage." If everyone can access coverage, then the risk pool will become more expensive because the bad risks will no longer be locked out. Enzi, in other words, supports the fundamental change that raises average premiums.
Conversely, the pieces of the bill that have driven the most partisan bickering have been the elements that would drop the cost of average premiums. You may or may not like the public plan, but the Congressional Budget Office and many other analysts have said it will lead to lower premiums for consumers. The individual mandate has sparked a fair amount of Republican opposition, but its purpose is to pull healthy customers into the pool so average premiums remain low. The level of subsidies has created some controversy, but it will offset the premiums costs for most consumers.
Republicans have adopted the insurance industry's talking point that health-care reform will "make the average insurance plan more expensive." The problem is, most of them support, or have previously supported, the elements of the plan that drive that increase. And most of them oppose both the insurance industry's ideas for mitigating the problem (a much stronger individual mandate) and the elements of the Democratic bills that would drive down premium costs..."
http://voices.washingtonpost.com/ezra-klein/2009/10/is_this_why_republicans_cant_s.html
Friday, October 9, 2009
A Public Option...Option
TW: Tom Carper (Dem. Senator Delaware) has proposed a public compromise which would create a federal public insurance option but allow individual states to opt in or out. So if you live a CA, NY, IL you would probably have an actual public insurance option if you live in MS, TX etc. probably not at least initially. I like the proposal, it provides some state level experimentation which many conservatives like. If the public option works to control costs it would likely thrive and expand, if not then vice versa.
From Nate Silver at 538.com:
"Some of the usual suspects are out this morning with criticism of Tom Carper's compromise proposal to insert a robust public option into the Democrats' health care bill, but allow states to opt out of it by legislative or popular action...But this compromise is leaps and bounds better than most of the others that have been floated...
...1) If the public option is indeed popular -- and the preponderance of public polling suggests that it is -- we should expect the solid majority of states to elect to retain it. Perhaps some Republican governors or legislatures would seek to override the popular will in their states -- but they would do so at their own peril (and at Democrats' gain).
2) Behavioral economics further suggests that default preferences are extremely powerful. Making the public option the default would probably lead to much greater adaptation than requiring states to "opt in".
3) If the public option indeed reduces the costs of insurance -- and most of the evidence suggests that it will -- than the states that opt out of it will have a pretty compelling reason to opt back in. Say that Kansas opts out of the public option and Missouri keeps it. If a Kansan realizes that his friend across the border is buying the same quality health insurance for $300 less per month, he's going to vote restore the public plan in a referendum or demand that his legislator does the same in Topeka.
4) Even in states that do opt out of the public option, the fact that voters could presumably elect later to restore it creates an extremely credible threat to the private insurance industry that will itself help to create price competition.
5) The ability to negotiate at Medicare or Medicare-plus-X-percent rates really is what makes the public option so powerful. It's not just having "another option". Although creating an additional competitor would certainly be valuable, as health insurance is a virtual monopoly or duopoly commodity in some regions, you could achieve that goal through a variety of other means such as co-ops or exchanges, some of which are already in the health care bill. Rather, it's the ability of the government to potentially provide more efficient (i.e. cheaper) delivery of health insurance than private industry because of its advantages of scale that distinguishes the public option from something like co-ops. As a general rule, then, compromises that allow the government to take advantage of its size and negotiate at Medicare-type rates should be preferred strongly to those that would neuter it.
6) If the policy wonks are wrong about the public option reducing health care costs -- I don't think they will be, but they could be -- this creates a relatively pain-free way to remove it."
From Nate Silver at 538.com:
"Some of the usual suspects are out this morning with criticism of Tom Carper's compromise proposal to insert a robust public option into the Democrats' health care bill, but allow states to opt out of it by legislative or popular action...But this compromise is leaps and bounds better than most of the others that have been floated...
...1) If the public option is indeed popular -- and the preponderance of public polling suggests that it is -- we should expect the solid majority of states to elect to retain it. Perhaps some Republican governors or legislatures would seek to override the popular will in their states -- but they would do so at their own peril (and at Democrats' gain).
2) Behavioral economics further suggests that default preferences are extremely powerful. Making the public option the default would probably lead to much greater adaptation than requiring states to "opt in".
3) If the public option indeed reduces the costs of insurance -- and most of the evidence suggests that it will -- than the states that opt out of it will have a pretty compelling reason to opt back in. Say that Kansas opts out of the public option and Missouri keeps it. If a Kansan realizes that his friend across the border is buying the same quality health insurance for $300 less per month, he's going to vote restore the public plan in a referendum or demand that his legislator does the same in Topeka.
4) Even in states that do opt out of the public option, the fact that voters could presumably elect later to restore it creates an extremely credible threat to the private insurance industry that will itself help to create price competition.
5) The ability to negotiate at Medicare or Medicare-plus-X-percent rates really is what makes the public option so powerful. It's not just having "another option". Although creating an additional competitor would certainly be valuable, as health insurance is a virtual monopoly or duopoly commodity in some regions, you could achieve that goal through a variety of other means such as co-ops or exchanges, some of which are already in the health care bill. Rather, it's the ability of the government to potentially provide more efficient (i.e. cheaper) delivery of health insurance than private industry because of its advantages of scale that distinguishes the public option from something like co-ops. As a general rule, then, compromises that allow the government to take advantage of its size and negotiate at Medicare-type rates should be preferred strongly to those that would neuter it.
6) If the policy wonks are wrong about the public option reducing health care costs -- I don't think they will be, but they could be -- this creates a relatively pain-free way to remove it."
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