The Trigger Fight As A Template For Obama's First Term | 78 comments
expanding Medicare is all we need -- not a "public insurance option" -- or any insurance -- (4.00 / 2)
and that requires only budgeting it.

that they won't do this is the whole problem -- and no part of this "reform" is any kind of solution -- with a "trigger" or without.

they don't even really want to expand actual healthcare at all.

I'm mixed (4.00 / 6)
On the one hand, the virulent opposition of private insurance suggests to me that a strong public plan might indeed by a real crack in the insurance-based system, which could lead to its downfall.

On the other hand, I find the arguments against a public-private mix compelling. These, for example, from PNHP"

1 - It foregoes at least 84% of the administrative savings available through single payer. The public plan option would do nothing to streamline the administrative tasks (and costs) of hospitals, physicians offices, and nursing homes, which would still contend with multiple payers, and hence still need the complex cost tracking and billing apparatus that drives administrative costs. These unnecessary provider administrative costs account for the vast majority of bureaucratic waste. Hence, even 95% of Americans who are currently privately insured were to join the public plan (and it had overhead costs at current Medicare levels), the savings on insurance overhead would amount to only 16% of the roughly $400 billion annually achievable through single payer - not enough to make reform affordable.

2 - A quarter century of experience with public/private competition in the Medicare program demonstrates that the private plans will not allow a level playing field. Despite strict regulation, private insurers have successfully cherry picked healthier seniors, and have exploited regional health spending differences to their advantage. They have progressively undermined the public plan - which started as the single payer for seniors and has now become a funding mechanism for HMOs - and a place to dump the unprofitably ill. A public plan option does not lead toward single payer, but toward the segregation of patients; with profitable ones in private plans and unprofitable ones in the public plan.

http://www.pnhp.org/facts/sing...

If the second point proves to be accurate, this plan could actually undermine the single-payer cause.

Let me put this way: I wish the defining piece of progressive legislation were more definitely progressive.


[ Parent | ]
these are serious issues, and there is absolutely no doubt that single (0.00 / 0)
payer would be far and away a better solution.  

i'd love to see people who actually knew about these issues talk about how the public plan might relate to the problem of cherry-picking.  it seems to me that, even if this were an issue, we would at least A) have many more people insured, and B) have a better set of conditions against which the private insurers had to compete for 'healthy' insurees.

also, a random thought: why is it that the left can't buy off people like baucus.  what if a coalition of people on the left promised to raise the same amount of money he has raised from the insurance companies in exchange for his support of single payer?  go down the line with the senators, and then organize massive mobilizations, and what would prevent us from having single payer?  

[ Parent | ]
I really don't know (4.00 / 3)
What makes sense to me is a tiered system, modeled a bit after the French system (said to be the best in the world), where there is a national health insurance, which can be supplemented by private insurance and a willingness to pay more.  Perhaps, the best strategy is to start with a relatively small public option that just covers the basics and emergency treatment while leaving a decent chunk of health care as still the province of private insurance, but using that foothold to widen the scope of a public plan slice by slice, year after year in an incremental fashion.  Take the Dean strategy of getting everyone emotionally invested in the system first, then fixing the system.

I wouldn't be inclined towards the position of Canada's New Democratic Party, which broke with the Liberal Party and forced a vote of no confidence over a stated desire to ban private health care completely.


Things You Don't Talk About in Polite Company: Religion, Politics, the Occasional Intersection of Both

[ Parent | ]
This is good too (4.00 / 1)
And all this needs to be a concern of the media and not which dress Michelle is wearing to what this week. No wonder the whole country is obsessed with trivia and women are focused on clothes and makeup unstead of competence and excellence in some career field. The expertise young girls devote to hair and makeup (animal grooming to ward off anxiety) could be displaced to so much better things.
[ Parent | ]
Chronic conditions (0.00 / 0)
and end of life care account for most of the current costs. Are these "basics" ?. Presumably, ER visits would be reduced somewhat under the new plan because with health insurance no one would be using the ERs as primary providers as is currently the case.

As for "fixing" a system. Somethings are more difficult to undo once they are done. I suppose that if it were possible to remove the trigger at some future date, one might give the idea another look. I admit that I'm not the one to do so.


"It sounds wrong...
     ...but its right."

[ Parent | ]
That's something I would leave to the experts (4.00 / 1)
I'm not a health care expert.  I'm just suggesting that you can draw a line somewhere and that people who know more than me have a better idea of where that line can be draw.  If you look at the Canadian system, there are some things that get treated faster than in the US and some things that get treated slower.  The standard example is that you can wait months for elective surgery such as hip replacements due to health care rationing.  

I actually support the concept of health care rationing, but I would be willing to accept the idea of supplemental private health insurance to cover such areas.  Does that mean that wealthier people will have better health care than poor people?  Absolutely.  Do I think that is a problem?  Not as long as everyone has a certain minimum level of health care.

But wherever you draw the line, create a public option for that part of health needs.  Tell the insurance companies that they can cater to needs in the other share without government competition.  Then, you start stripping away parts of their space, slice by slice, based on what the public wants.

Things You Don't Talk About in Polite Company: Religion, Politics, the Occasional Intersection of Both

[ Parent | ]
OK (0.00 / 0)
I know something about the need to reorient the emphases of our current healthcare system away from emergency and intervention and toward prevention and risk awareness. Many friends are physicians and I work in the research division of a hospital. This is a topic within the community because many health care workers want to provide this kind of care, but have problems because the system (read hospital and insurance suppliers, even big pharma)actively pushes them away from it.

I can see how the hospitals and insurance can work it out,maybe, but big pharma will always be the hold-out. You see, their product lines are favored by the interventionist methodology and they lose out under the prevention regimen. Witness Medicare Part D and the Bush Administration for examples of their power. I've always considered the insurance companies as viable negotiating partners because they will follow the money. Readjust the profit motives in more positive directions and they should go along. Physicians are, on the whole and in my experience, mostly interested in taking care of their patients. If the average salary of the MD is reduced in the new mechanism, those that would leave the field won't be very much missed, I suspect. Big Pharma's incentives are trickier to rejigger. I'd settle for negotiating much lower costs for routine, high-volume drugs and helping them to set up an independent Institute to oversee clinical trials of new drugs and support on-going Comparison Trials (easily and ideally tied in to the proposed eHealth Histories) to determine best practices. The former is the bait that Pharma would like to nibble, and the latter a demon they'd hope to banish. Therein, may lie the nub a a negotiation.  

"It sounds wrong...
     ...but its right."

[ Parent | ]
The "high administrative costs" is a red herring (4.00 / 9)
It's not about clerks, administrators, computers, etc., being that expensive. They're not, at least if managed well (which most successful corporations seem to be quite good at). It's about two completely other things. One, the high salaries and bonuses paid to their top execs, which can be in the tens and sometimes hundreds of millions. And two, the huge amount of money spent on marketing, underwriting and claims denial, all intended to attract only the most profitable (i.e. healthy and affluent) of members, and deny coverage to everyone else. Both of these have nothing to do with peoples' health or a well-run health care system, and everything to do with profits. They're a big reason for why the private system is so expensive, and doesn't serve tens of millions of people who are un or underinsured.

Done right, a true public option would have none of these, since it would be run by the government, or by a strictly regulated public utility-like non-profit corporation that would be mandated to offer decent and affordable plans to EVERYONE, and subsidize whose who could not afford them. Right off the bat it would be far cheaper to run than anything the private sector could offer, and over time would siphon off millions of their members to the point where it effectively became a single-payer system. THAT is why they fear and oppose it.

The liberal soul shall be made fat. He who waters shall be watered also himself. (Proverbs 11:25)

[ Parent | ]
single payer is ideal - a public option is realistic (0.00 / 0)
     I had not heard of points (1) and (2). But, unfortunately, they may both be correct. And item #2 has a lot of insidious implications.
    One of Obama's traits is that he wants to be the anti-Bush when it comes to compromise. Bush was quite happy to say (paraphrased for satire) "According to Katherine Harris, I got at least 50.1% of the vote... I will now rule with absolute power and not give a damn about those who did not vote for me." Obama does not want to come off as a partisan extremist. And every dittohead like Joe the Plumber will already say that if one penny of tax money is spent to save the life of a poor child, it is "socialism".
    So, regardless of the cost savings, even Obama does not want force a better, more-efficient single-payer system upon the fools like Joe the Plumber who want to overpay for bad service from the insurance companies. Add to that the fact that the insurance companies are fanatically opposed to single payer, and you will see why it will be politically difficult to pass HR 676, even though it is the most moral and most economically efficient plan.
    But even if a public/private arrangement is the best we can hope for in the short run, and even if it MIGHT pave the way for eventual single-payer... it sounds like the insurance industry would just rig the system, and push the poor and sick into the public program, while enrolling as many healthy and wealthy people as possible into their for-pay health plans.
    What this means is that we have a long fight ahead of us. But if Chris Bowers is correct, this is a fight that we MUST win, if we want to get ANYTHING progressive done this year. After we get a public option out there, we can expect to fight the insurance co.'s for several years... trench warfare, one inch of progress at a time. (Our next move, after getting the public option now, will be to put more Progressives in the House and Senate in 2010, and then push for more progress towards an eventual single-payer system, like HR 676.)

1 Corinthians 13:1 (KJV) - "Though I speak with the tongues of men and of angels, and have not charity, I am become as sounding brass, or a tinkling cymbal."/ GOP = Greedy Old Privatizers or Greedy Old Privateers?
[ Parent | ]
Medicare for all yes (4.00 / 2)
The VA hospitals are all in place. At least until they decide to dismantle them as the bulk of vets are old and dying off.
[ Parent | ]
True enough (4.00 / 1)
The hospitals and clinics will be hurting for patients in the near future, but it would require a significant change in the mission. I can see alot of opposition from the vets and the employees (I work in the VA). It would be a tough argument to make. Its tough to ask this population of citizens to sacrifice any more for their fellow Americans. The truth of the matter is that the VA often fails to meet the needs of the vets and care is very uneven across the system. Aside from appropriating more funds, this idea has many significant political hurdles.


"It sounds wrong...
     ...but its right."
[ Parent | ]
Be careful what you ask for (4.00 / 5)
I can easily see them adopting this path, but in name only. I.e. turning Medicare Advantage, which is basically minimally regulated government-subsidized private insurance, into "Medicare for all", and then renaming it so people don't realize that it's lipstick on a pig. Even if this leads to more people being covered, it won't lower costs or improve health care. It'll just be yet another corporate giveaway sold as "progress". And they'll have the world's best salesman pushing it for them. Yes he can!

The liberal soul shall be made fat. He who waters shall be watered also himself. (Proverbs 11:25)
[ Parent | ]
Maybe... (4.00 / 1)
But, then a lot of hospitals will close...

Medicare simply doesn't pay doctors enough....

When thy dole out 32 cents for a b-12 shot, not a lot of facilities will survive.

Medicare for all sounds great on the surface, but there needs to be other fundamental changes for it to work, otherwise, the unintended consequences could be disastrous...

It's not just as simple as extending medicare to more people...  a total revamp of funding and reimbursement would also be necessary...

REID: Voting against us was never part of our arrangement!
SPECTER: I am altering the deal! Pray I don't alter it any further!
REID: This deal keeps getting worse all the time!

[ Parent | ]
France (4.00 / 2)
Although as others have pointed out, France uses a tiered system where the single-payer portion is fairly minimal but people still can buy private insurance for additional coverage.  Given that France is considered to have the best health care according to studies, that might not be a bad place to end up.
[ Parent | ]
That is essentially Medicare in the states, too.... (4.00 / 1)
Medicare parts A & B & D have lots of gaps in coverage... Part B has no out of pocket limit, and part D has the donut hole.  Many people enroll in Medicare Advantage Part C which fills most of the holes for almost no fee... or people get medigap plans on top of regular medicare.  Many retiree medical plans are standard major medical, but only pay second after medicare.

Medicare for all would not eliminate the insurance companies... it would allow them to market and sell profitable niche products to nearly everyone...  It really is a program that would work for insurers, but they'd lose  a lot of control.

In business, money is second to power and control, and that's what this health reform fight is really about.

REID: Voting against us was never part of our arrangement!
SPECTER: I am altering the deal! Pray I don't alter it any further!
REID: This deal keeps getting worse all the time!

[ Parent | ]
Wealth redistribution (4.00 / 1)
Very highly paid docs will have to take a hit, so that others can still have a job. In fact, this has already been happening in some practices. Physicians of various specialties form joint practice (like law firms) and all payments go through the firm from which all pull a salary (some bonuses, too). Main effect is to make it financially feasible for some to work as an up-dated version of the town doctor. Develop long-term relationships with the patients, make house-calls, and provide the impetus for preventative care, that kind of thing. The supplement comes from the surgeons and other in-demand specialists.

"It sounds wrong...
     ...but its right."
[ Parent | ]
Redistribution? (0.00 / 0)
This isn't about taking money people already have and giving it to someone else. It's whether a set of government rules that allow some people to make great sums of money will be changed in a way that achieves our purposes better (ensuring health care for all) that will allow some people to make great sums of money that are somewhat smaller than they were previously.  

Who are the best keepers of the people's liberties? The people themselves. The sacred trust can be no where so safe as in the hands most interested in preserving it.
James Madison
[ Parent | ]
If the new system is going to support all the docs (4.00 / 1)
in the current system, there will have to be some redistribution within the doctor community, or maybe some will leave their practice. A finer grain of problem than you detail, its part of the issue. One I'm a bit more in tune with because I work with MDs and in a very clinically oriented institution.

Under the current system, preventative care is not incentivized and, hopefully, whatever system results from this round of reform will change that situation. Lack of incentive means low compensation. Even so, few physicians live below the poverty line.

"It sounds wrong...
     ...but its right."

[ Parent | ]
Medicare is NOT the answer (0.00 / 0)
Expanding Medicare might be a way to get a foot in the door, so to speak, for UHC, but Medicare is a relatively poor program that can best be described as better than nothing.

Medicaid is a bit better, but its payment system to providers is crap.  Try finding a doctor or dentist that will take more than a few Medicaid patients at a time, its a money loser (a cardiac specialist told me he made roughly $7-$8 an hour per Medicaid patient, in a state with a minimum wage of $8.55/hr).

Of all the systems that we already have and I have had experience with, the VA system (in a properly run hospital, which is hit or miss) is the best format I can think of.  All services provide based on need, regardless of cost.  Private insurance is billed for service with no deductible or unpaid portion passed on to the patient.  If no private insurance, patient is billed based on income level.  Federal VA system subsidizes the rest.

I think expanding the VA system to include non-vets (which could require it to be transfered to another Department), opening Medicare to everyone and loosening the requirements for qualifying to Medicaid is a good start to covering more people.  

Starting from scratch, though, is probably the best thing to do for a good system.

[ Parent | ]
The Trigger Fight As A Template For Obama's First Term | 78 comments
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