31 January 2007

Damaged Care

Laura Dern as Dr. Linda Peeno and the real thing

I took the evening off and watched Damaged Care — a 2002 HBO film about Dr. Linda Peeno (Why not Pinot?), whose job was to deny coverage to sick patients at Humana and another HMO. Her conscience finally wouldn't allow her to do it anymore, and she became an outspoken critic of the HMO model.
Slow start, but a fairly painless way to learn about how HMOs work their magic.
I was sad to see Kaiser, which I've always thought of as the sole good guy in the gang, portrayed as no better than the rest. And it wasn't in the instance cited in the film, where a Kaiser advice nurse told a mom that there was no need for an ambulance for her critically-ill baby, that she could find directions on her own in the rain to a hospital 50 miles away.

Insurance breaks the bank

Marcia Angell, former editor of the New England Journal of Medicine, says in a guest edit in the Boston Globe that we can't fix the system with band-aides. She says the states' reforms haven't come close to fixing the problem.
Though well-intentioned, plans like [Massachusetts'] all have the same fatal flaw: They offer no workable mechanism to control costs, mainly because they leave the private insurance industry in place. Yet, soaring costs are the fundamental problem ; lack of coverage follows from that. Already the Massachusetts Connector is having difficulty holding premiums down to the levels forecast when the plan was enacted. Even if they are held down at the start, there is little to stop insurers from raising them afterward , shrinking benefits, or both. It will take a large and costly bureaucracy to ride herd on all the ways to game this system. Perhaps the biggest risk is that failure will give universal care a bad name, just as the failure of the Clinton plan did 13 years ago. (That plan, too, made the mistake of giving the private insurance industry a central role.)

30 January 2007

208 goes for principles

The Colorado Blue Ribbon Commission for Health Care Reform met today as part of a two-day retreat.

Their goal was to put their cards on the table, so that everyone understood where the others stood on reform, and to begin adopting principles to guide them in choosing a proposal and understanding their common values.

Of course, everyone already knew how Linda Gorman felt. She’s the libertarian from the Independence Institute, who has spoken out against comprehensive reform — the commission’s mandate from the Colorado Legislature.

Dan Stenerson, president and CEO of Shalom Park, a long-term care facility, suggested these “buckets” for organizing principles:
• Healthcare that would be universally available for anyone who lives in Colorado
• Measuring accountability
• Client-managed

“Client-managed” became “client-centered” at Steven Summer’s request. Summer is executive director of the Colorado Hospital Association.

Dr. Elinor Christianson, president of Health Care for All Colorado, suggested to the group that they vote on the Institute of Medicine guidelines and the Colorado Medical Society guidelines, both of which were drawn up after months of consideration.

The Colorado guidelines are:

1. Coverage - Health care coverage for Coloradans should be universal, continuous, portable and mandatory.

2. Benefits – An essential benefits package should be uniform, with the option to obtain additional benefits.

3. Delivery system – The system must ensure choice of physician and preserve patient/physician relationships. The system must focus on providing care that is safe, timely, efficient, effective, patient-centered and equitable.

4. Administration and governance –The system must be simple, transparent, accountable, efficient and effective in order to reduce administrative costs and maximize funding for patient care. The system should be overseen by a governing body that includes regulatory agencies, payers, consumers and care givers and is accountable to the citizens.

5. Financing – Health care coverage should be equitable, affordable and sustainable. The financing strategy should strive for simplicity, transparency and efficiency. It should emphasize personal responsibility as well as societal obligations, due to the limited nature of resources available for health care.

The IOM guidelines are:

1. Health care coverage should be universal.
2. Health care coverage should be continuous.
3. Health care coverage should be affordable to individuals and families.
4. The health insurance strategy should be affordable and sustainable for society.
5. Health care coverage should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient centered, and equitable.

Commissioners heard from Martha King of the National Conference of State Legislatures, who warned them that what they were doing was difficult, and could be sabotaged by a single ideologue. To succeed, members needed to all buy into their common mission.

King also said they needed to constantly remember that it’s legislators who would adopt or not adopt their proposal, and that those legislators would be obsessed with gauging how it would play in Paonia (a small, Western Colorado town).

She argued that everyone needs to give a little and also to check their egos and ideology at the door.

Two commission members today shared family stories. Barbara Yondorf, senior program officer at the Rose Community Foundation, said that her daughter, adopted at age six from a troubled family, had succeeded despite the odds arrayed against her. Other children in her daughter’s situation, Yondorf said, might not have been so successful. Those children should not be condemned for not making the choices that a privileged child would have made.

Christy Blakely, director of Family Values in Colorado, an advocacy group for families with children with special needs, said that she was finally able to sleep on the night that her daughter had been awarded government services.

Despite their similar frustrations with the system, Yondorf and Blakely had different view on plans with high deductibles. Yondorf thought once people chose those plans they should stay with them, understanding that they’d made their choice.

Blakely said that some of her hardest conversations were with parents with high deductibles that left them unable to care for their children.
Commissioner Grant Jones, executive director of Denver’s Black Church Initiative, also spoke about family, saying he felt education and outreach should be a key part of any reform — something his “Uncle Sherman” could relate to. “My eyes glaze over on some of this content,” he admitted.

Commissioners talked about whether they were interested in pursuing deciding which populations would be eligible for a subsidy in a program like Massachusetts, or covering everyone.

The concept of universal coverage was not dismissed out of hand. Bill Lindsay, chair of the commission (and president, Benefits Group, Lockton Companies of Colorado, Inc.) said at one point that What Dr. Rocky White, a single-payer advocate in Western Colorado, had done was interesting, but….

Is that “but” inevitable?

Lindsay also said, however, that he didn’t personally understand “how you move ahead with equity if you don’t have more people in the system” — meaning larger risk pools.

Lisa Esgar, senior director of Operations & Finance, Department of Health Care 
Policy & Financing, State of Colorado, spoke about the waste in the system. “How far do we want to go?” she asked. “Medicaid, poor programs pasted on top of one another over the years. Do we look at financing? Restructuring? The low-hanging fruit is poor organization.”

Esgar recently traveled to Europe as part of a Marshall Memorial Fellowship group, looking at government systems there.
She told me that she had been impressed with European healthcare.
Perhaps she’ll share her experiences with the commission.

David Rivera, Colorado’s outgoing commissioner of insurance, as usual had nothing to say.

A commissioner who is an advocate for the disabled said he believed that healthcare is a right; that payer sources should be merged; that efficiencies should be improved; and that he hoped to see both better utilization and consumers be in control.

“We cannot continue with the current three-tiered system,” he said, listing the tiers as being the system for people with good private coverage; people with Medicare or Medicaid; and people with nothing.

One of Gorman’s only comments of the day was to say that her frame was very different. She believes that the focus for reform should be on individual incentives, not the system. She finds it unreasonable that Colorado insurance companies are legally able to give better rates to people who haven’t submitted a claim in the past year. She flatly said that preventive care doesn’t work. Maybe vaccines, but nothing else. She used the cost of colon screening here — which seems a favorite of conservatives to prove this point. She said that she hears other commissioners promoting myths.

Carrie Besnette, vice president of The Daniels Fund, took issue with that later prompting Gorman to say that her background is academic, where people stand in a room and yell at each other until someone wins their point.

Gorman was absent for much of the afternoon.

Other presenters were Lori Weigel of Public Opinion Strategies, and Leo Tokar of Kaiser Permanente. Both had so much to say that I’ll cover their presentations in other posts later this week.

After dinner, Kathleen Stoll, director of policy for Families USA, and Nina Owcharenk, senior policy analyst at the Heritage Foundation, spoke about their joint work on forging consensus on a comprehensive reform plan adopted by sixteen groups, including their organizations, AARP, and Kaiser.

It’s a plan I think is unsustainable because it doesn’t reform the private insurance model that has served the United States so poorly.

And if you’re in favor of single-payer, that’s key.

But it’s an achievement, nonetheless, and the two women advised this commission on how they could also reach a consensus.

Another endorsement

The Minneapolis Star-Tribune has endorsed single-payer healthcare system for the United States. After describing the program in Massachusetts and the proposed program in California as exciting, the editorial board writes that "the closer you look at these ambitious plans, the more you see they are mere patchworks."
They say it's time to think about just making the leap to single-payer.
This radical notion would seem unthinkable, except that every other civilized nation already has thought about it and embraced it -- from conservative societies such as Japan and Australia to nanny states such as Germany and France. Every one of them covers more people, produces better medical outcomes, wastes less revenue on overhead and marketing, and spends less money than the United States.

29 January 2007

Governor Rendell says yes

We should all take notes on ho this man asked Pennsylvania Governor Rendell about single-payer. He was friendly, funny and wanted a yes-or-no answer. The Pennsylvania Healthcare Solutions Coalition did a good job with this.

Injustice's apologists

There's a column at the Guardian's comment is free section about the U.S. healthcare system. The author, Sasha Abramsky, mixed up a few quibbling points. Bill Clinton, for instance, didn't try to institute a "single-payer" system. Bill and Hillary kept the private insurers in an amazingly complicated loop. Abramsky also writes, "While leaving the delivery of healthcare in private hands," Massachusetts and Schwarzenegger's California proposal "aim to subsidise the purchase of insurance for those too poor to pay."

To me, that implies that other reform proposals, in particular single-payer proposals, would not leave the delivery of healthcare in private hands.

That's wrong. All the single-payer advocates I'm aware of want healthcare delivery to remain in private hands — as it is everywhere except Great Britain. It's the financing that should be publicly administered — as it is everywhere in the industrialized world except the United States.

Doctors and hospitals would still compete.

My friend whose doctor is in sole practice would still choose him (and she'd still wait, I assume, for an extra day because she got Strep on his day off) and I'd still choose Kaiser.

The difference is that our taxes would pay for it instead of our premiums. The difference would be that instead of up to a third being taken off the top for administrative expenses, it would be about 3 percent.

The main problem with Abramsky's column was with the commenter who regurgitated the same nonsense Denver talk show host Mike Rosen wrote up a couple weeks ago in "No Crisis of the Uninsured" for the Rocky Mountain News.

For these two (and who knows how many others living in the right-wing echo chamber of weapons of mass destruction, no global warming, the "gay agenda," Bush's competence and other myths of the new millenium), the peer-reviewed and generally accepted count for the uninsured (about 47 million), based mainly on Census figures, aren't good enough. Back in 2003, the GAO decided that they would count differently, and that the uninsured were actually "only" 30 million. Some research assistant wrote this up for the Heritage Foundation in 2004. Expect the right-wing to glom onto this.

Did anyone refute this back then? Rosen's explanation was pretty eye-watering.
The ploy is to pretend that a rotating aggregate or a snapshot is the same thing as a permanent population. Fifty-nine million is the aggregate number of those who at some time during the year, even if only for a day, were without health insurance. This is a meaningless statistic.
Forty-six million is the snapshot figure, the average number who have no insurance on a given day.

I've seen that explained far differently, although I don't have sources at hand.

Reassuringly, Rosen writes that the average family that loses its insurance during the year will become insured again within five and a half months.

So! Not to worry! Just put off that diabetes, that heart attack, that appendicitis.

What a way to run a country.

Watch out for these numbers. They're not likely to convince many, but they're being tested for their ability to cloud the water. We should have evidence on hand to refute them.

Rosen begins his piece by writing:
If your goal is to lay a political foundation for socialized medicine in this country, what better way to do it than to create the public impression that we have a vast army of people - even better: children - who are permanently unable to obtain health insurance.

And if your goal is to perpetuate an unjust system, what better way to do it than to twist numbers to convince enough people that there is no problem?

This line worked better 10 years ago, when there was less of a problem because healthcare costs were half of what they are now.

This tactic isn't likely to work today. Americans aren't worried about healthcare because of propaganda. They're worried because they've been personally hurt by the system, or know someone who has been. Physicians haven't been won over in large numbers because progressives have twisted the facts. They've come over because they've anguished over not being able to do the right thing for their patients, trapped in a system rigged for profit, not care.

Take action on Iraq

On Thursday, MoveOn wants to send 1 million messages to Congress. They'll deliver petition signatures from hundreds of thousands of Americans all over the nation who are opposed to escalation in Iraq. Then, volunteers will call our senators all day to let them know that the people expect Congress to check this imperial president's bloody missteps.

Go to MoveOn to volunteer on Thursday. Tell them that our tax dollars should be used to build healthcare and other goods, rather than sending our young men and women to fight in a misbegotten, unjust war with no hope of success.

28 January 2007

Hillary's plan

The NYT article on Hillary Clinton's healthcare plan is already a week old and behind their firewall, but here's part of what it says:

Mrs. Clinton’s proposed legislation would renew the Children’s Health Insurance Program, which provides money to states to cover children under 18 whose families earn too much money to qualify for Medicaid. The 10-year-old program, which now covers four million children, is to expire this fall. Rep. John Dingell (D-MI) plans to introduce a similar bill.

Mrs. Clinton’s legislation would raise the income eligibility limit so that more children could enroll. In New York a family of four earning $75,000 would qualify. The bill would allow any family, as well as employers, to buy insurance.

Members of the senator’s staff said they were still working out the cost of the proposal. About 8.3 million Americans under 18 do not have health care, but about 70 percent of them are already eligible for Medicaid or for the program Mrs. Clinton seeks to expand.

This is pretty much what she said yesterday to a campaign crowd in Iowa. The news reports focused on what she did and didn't say about Iraq. Here's the most striking part of what she did and didn't say about healthcare:

In discussing the need for a consensus, Sen. Clinton said that all the players needed to come together — families, hospitals, doctors, people of faith, employers — and find a solution to the mess. Missing from her list were insurers. I don't think she would do that accidentally.

Has she heard the voices who say she would have been better off simply pushing for a single-payer system back in 1994 when they had the chance? Does she feel burned by the insurance industry? She should — she bent over backwards to include them in the Clinton Health Plan, and they turned on her. Greed will out.

At the same time, that's a lot of money for a pragmatic centrist (aka conservative) like Sen. Clinton to turn her back on. She might have simply left out "insurance companies" as a message: "Send more money asap and I'll mention you next time." Is that too cynical a suspicion?

The Democratic candidates have to know that the insurance industry and their allies, beginning with Big Pharma, will bring out their big guns in the 2008 election. That fire power could be used against targeted Democratic primary candidates, but then could be turned against the winning Dem in the general election. Or a clever Democratic candidate might strike a bargain with the for-profit healthcare industry that would admit some change — a little change, in order to stave off true reform. For instance, a candidate might push a plan that would cover more children at mostly taxpayer cost. That would be better for the industry than the system's collapse following a total Republican give-away to them — or so a savvy "centrist" might argue.

Or maybe the Republican candidate will be able to make that case, and shut the Dems out in the cold, in which case the industry's money would be used against the Democratic front-runner, not necessarily the candidate promising single-payer. How would you use those millions, if you were the strategist for the health insurance industry?

All of this angling and strategizing doesn't get the job accomplished, which is to pass single-payer. This might be a situation where the Democratic party should simply come out for single-payer. It's a policy so completely in line with our values, that it will be counter-productive to continue to sound so similar to Republicans, and so accommodating to an industry that has betrayed its public trust as a corporate member of the community.

Then again, Clinton, Obama, and Edwards are all politicians who are playing to win. That makes it up to us. To paraphrase William Lloyd Garrison, it's up to them to see which way the wind is blowing, and it's up to us to raise the wind.

Arrgh. Pirates

Yeah, yeah, it's not going to convince anyone not already convinced. Arrgh.

Still, with this video at the Foundation for Taxpayer and Consumer Rights, the Austin Lounge Lizards expose the health insurance industry's motto:

If you can’t afford to pay my ransom this is what I’ll say;
Yo ho, yo ho, go ahead and die —
I’ve got my share and I don’t care.

27 January 2007

Portland's ice the best

If you haven't seen this YouTube video of Portland's icy streets, take a look. An SUV sliding for half a block sideways?
Friends tell me it was by the Multnomah Athletic Club, and that after they parked the firetrucks to keep traffic out, cars crashed into the firetruck. Those crazy Portland drivers.


What sets off our hearts?

I've been in tears several times over the past couple days, thinking about Paul.

I just now opened iTunes and, in a fit of decision paralysis, scrolled and clicked without looking for the first song.

"Heartbreaker" by Led Zeppelin.

One of Paul's songs, which I've been avoiding for months, because it hurts to hear it.

Tracy Chapman helps:

I've seen and met angels wearing the disguise
Of ordinary people leading ordinary lives
Filled with love, compassion, forgiveness and sacrifice

I have also met angels in disguise, and we all know and/or know of saints. I'm thankful for that.
But it's not enough, is it?
I want us to all be together again.
I want there to be a heaven.

26 January 2007

Risk pool explanation

A Philadelphia Inquirer columnist, Andrew Cassel, gives his readers a good explanation of risk pools, something I was struggling to explain the other night. He writes that, “insuring people in large groups can be more efficient because risks are spread out. In effect, healthy individuals subsidize sick ones.
"Ideally, the same thing happens when people buy insurance on their own. Insurers balance the risks by signing up many individuals, expecting that only some will need health services at any given time.

"But there's a catch. In a competitive market, some insurers can focus on attracting people more likely to stay healthy - say, by offering lower rates to the young and affluent.
"That makes it harder or more expensive for those with higher risks to obtain coverage - a phenomenon economists call 'adverse selection.'"

Just one problem here. "Some" insurers try to screen out less healthy potential customers? "Some" insurers?

Cassel continues (before he was so rudely interrupted), "So if the current tax incentive goes away, what then?
"One alternative, of course, would be to put all Americans into one big insurance pool. That's the basis of the so-called single-payer idea: Have the government insure everyone, as Medicare does now for people over 65."

Of course.

Why no single-payer?

Try this rant by Joe DeRayond on Counterpunch out for size:
"The health care system of the United States is hostage to the enormous profits distributed to insurance companies, hospital corporations, and drug purveyors. They swarm over the Congress, plying the legislative system with money, "expertise", and favors. Congressmen leave their seats to take jobs with pharmaceutical companies, as did Jim Greenwood of Bucks County, Pennsylvania, and Billy Tauzin of the 3rd District of Louisiana."
That would probably do it.

The problem, not the solution

This is the first specific I’ve heard about the Massachusetts’ plan working out exactly as predicted. Members of a panel charged with implementing Massachusetts’ healthcare plan this week told some insurers to offer more affordable premiums.
Then-Gov. Mitt Romney had promised that the plans Massachusetts’ citizens are mandated to buy would be affordable, the least expensive being about $200 a month.
Try $340 to $380 a month.
Just as single-payer realists warned, “universal health care achieved through the requirement to buy private insurance will lead to bloated premiums and bare-bones coverage for middle-income residents who can only afford the minimum plans.”
Steffie Woolhandler, co-founder of Physicians for a National Health Program and a physician, said, "We should not let these board members get away with telling us that they’re surprised [about the costs for the minimum plans].”
The executive director of Mass-Care, a single-payer advocacy group, says making a low-cost but effective private-insurance plan is impossible.
"’I call it a ‘Marie Antoinette’ policy,’ Woolhandler said. ‘Private insurance is the problem, not the solution.’”

Connecticut looks at reform

It looks like Connecticut’s Democrats will unveil a plan in a couple weeks that would expand health insurance programs, covering Connecticut’s 400,000 uninsured and also raise Medicare and Medicaid rates for doctors and dentists. The plan would cost $450 million but could bring new federal funds to the state to cover about half of that. The plan would do this by first expanding eligibility to an existing program that provides coverage to low-income children and adults. That could cover an additional 140,000.
But the Ds also want to assemble a “panel to come up with ways to cover the remaining 260,000 uninsured - typically younger adults with no children who don't qualify for state assistance programs and don't receive insurance coverage from their employers.”
They would “consider ideas ranging from mandated health coverage by employers to a statewide single-payer system.”

Reich is for single-payer

Robert Reich, Secretary of Labor from 1993 to 1997, one-handedly applauds Bush's healthcare plan, which I called the Catastrophic Bush Health Plan. Reich likes it because it would decouple employment and healthcare, which would indeed be a good thing. He doesn't mention that Bush's plan would throw people into the individual insurance market, the least efficient, most discriminatory, most costly healthcare system in the world. A lot of people would die before things got so bad that we kicked the bums out and instituted a single-payer system. But single-payer is what Reich is for, noting that if it's good enough for Congress it should be good enough for you and me.

"Note I said single payer, not single provider. Americans want to keep their choice of doctor and hospital. But a single payer – either through Medicare or the federal employee’s health insurance program – would avoid the current insanity by which private insurers spend hundreds of millions of dollars a year advertising and marketing to younger and healthier beneficiaries, and seeking to discourage older and riskier ones, or people with pre-existing medical conditions. America now has the only health-insurance system in the world designed to avoid sick people."

The 208 Commission's great notion

Grant Jones, executive director of Denver’s Black Church Initiative and a member of the Colorado Blue Ribbon Commission for Health Care Reform, says the commissioners should “embrace the notion that what we’re setting out to do is a big idea. All the commissioners need to communicate that this is big…”

But isn't that true only if the commissioners are ready to embrace more than just the notion? Don't they need to embrace real change — as every other industrialized country in the world has done?

Jones sits on the commission's communications committee, which met this morning.

The public is welcome at all commission meetings, which are listed on the commission's website. The communications committee is especially receptive to public input.

When a woman in the public seating suggested this morning that the commission use their website to collect people’s stories about their healthcare experiences, commissioner Julia Greene, director of health systems in Colorado for the Service Employees International Union (SEIU), enthusiastically embraced the idea.

Most of the commission’s communication’s committee also agreed, saying such a collection of stories could provide a powerful testimony to the need to comprehensively reform our healthcare system.

While one commissioner did say they’d get so many stories the website would become unmanageable, the suggestion resulted in a palpable change of direction. Consider that earlier another commissioner, Clarke Becker, executive director of the Colorado Rural Development Council, had said that the Colorado legislature understands that the commission can’t spend all their time listening to people’s stories — the commission would never get anything done if they took the time for that.

Both statements say something about the mess that our free-market, profit-based healthcare is in.

Becker spoke about meeting with the Colorado legislature. Rep. Anne McGihon (co-sponsor of Senate Bill 208 that created the commission) is reportedly not comfortable with the commission’s plan to piece together various proposals.

It sounds as though, however, that Joan Fitz-Gerald, Senate president, and Andrew Romanoff, Speaker of the House, may not have a problem with the commission patching together a variety of band-aide solutions to the present system and calling it comprehensive reform.

Commissioners are losing sleep over fast-approaching deadlines and their final deadline of November 30 to present a proposal for comprehensive reform to the legislature. Both the governor and Senate and House leaders have agreed to wait on the commission's report before proposing healthcare bills that would change the landscape.

One commissioner said party leaders in the legislature were already having “great difficulty in controlling some of their members from proposing major healthcare proposals in this session.”

The commission will issue its solicitation for proposals to comprehensively reform Colorado’s healthcare system on February 22.

The proposals are due back on April 6. By May, the commission will choose the best three to five to send to an independent evaluating firm, which will do modeling on them to figure out their real effect on healthcare and the economy. They’ll also begin more vigorous outreach at that point to get public input.

The evaluating firms all say they’ll need six months to do the modeling.
More immediately, the commission will meet Jan. 30 and 31 for a retreat to which the public is invited. Details are on their website.

They’ll agree on the criteria with which they’ll judge the proposals at that retreat. Then the criteria go up on the website, with invitations for public comment.

He who shall not be named

The Colorado Blue Ribbon Commission for Health Care Reform has a commissioner who shall not be named. He is obviously a public figure — serving on this public commission, after all; being listed as president of the Colorado Alliance for Health and Independence; identified elsewhere as a former board member of the Colorado Cross Disability Coalition and currently lobbying for them at the state legislature; and identified as being with the Governor's Advisory Council on Disability in a staff summary of a meeting of the House Committee on Transportation and Energy — but he says he’s not, and claims he won’t speak to the press. So. Accommodating his wishes, he shall not be named.

Legally he is a “public figure” because he engages in actions that generate publicity. As for his right to privacy, the Associated Press Libel guidelines state: “When a person becomes involved in a news event, voluntarily or involuntarily, he forfeits the right to privacy. Similarly a person somehow involved in a matter of legitimate public interest, even if not a bona fide spot news event, normally can be written about safely."

Those guidelines are conservative, meant to help journalists avoid lawsuits.

It seems as though he’d be a better advocate for his causes by working with the press, doesn’t it?

This reminds me of the days after Princess Di's death, when people became soooo hostile to reporters. It was miserable. I'd be there trying to do my job — write up St. Charles' spaghetti dinner, for instance — and people would snarl at me.

I wasn't chasing celebrities for crying out loud, or doing investigative reporting on whether the liturgy committee was trying to sneak inclusive language into the intentions at Mass. It was rather basically free public relations for the parish.

Most Americans do not understand that there must be a free and unfettered press for a democracy to work. You cannot have a democracy without a free press. Period.

It's too bad that newspapers and magazines can sell tons more papers when they push the rules regarding celebrity privacy. But who is buying? Is it just the pusher who's guilty, or do the buyers have some responsibility?

I've never been a paparazzi, never had that kind of ethics, chutzpah or the money that rewards it.

But it's too bad that it's rewarded. Maybe instead of feeling hostile to the press — especially the majority of reporters and photogs who are just doing their jobs, and wouldn't even considered trying for that topless shot of Jena Bush — maybe we should work on reforming our celebrity, wealth-worshiping values — that reward that.

25 January 2007

Slamdance now and then

Paul, me, and Curtis at Slamdance, 2003

Paul and Curtis' film, The Real Old Testament, was an audience favorite at Slamdance in January 2003.

The Slamdance folks in Los Angeles were good to us after Paul died, coming over to Curtis' and just being good friends to him. Before too.

Sounds like they had a good run this year.

They got extra print attention too, with a number of outlets describing a melee outside a screening in Park City — something about a documentary, "Children of God," about a group of missionaries in Mexico who have been accused of pedophilia and child abuse. The group's leader committed suicide during filming of the film according to Variety.

Starr's dialectics

Dialectic is one of the classical three liberal arts that Western culture inherited from the Greeks. It means the exchange of a thesis countered by an antithesis. Take for example:

"Healthcare is a human right in civilized societies, because healthcare is sometimes needed for life itself. " vs

"Health care is just another consumer item, like a Lexis, for those who can afford it."

Thesis and antithesis. Philosophers or the guys at the corner bar pick it apart and come up with some kind of synthesis that is closer to the truth than the originals.

How about: "Although more money will always buy more of it, healthcare is a human right and should be universally accessible."

Now the conversation has changed direction, and we can go on to the next level — unless there are libertarians or other obstructionists in the room, at which point we're back to "is too," "is not," "is too."

Dialectics got a bad rap because most of us learned about it in school in terms of Marxian Dialectics and communism. It was something about class struggle and things getting so bad people will revolt — according to Wikipedia, "a framework for development in which contradiction plays the central role as the source of development." In other words, things getting so bad people will revolt.

Paul Starr, who wote The Social Transformation of American Medicine, the 1983 Pulitzer Prize winning history of how American healthcare system has evolved over the last two centuries, thinks that things have to get worse in American healthcare before the people will revolt. Or at least the contradictions and true costs must become more apparent to people before we'll demand a single-payer or some other universal healthcare system. He's in favor of Bush's plan for that reason.

He writes in Bad Plan, Necessary Step in the American Prospect that it would be better to go ahead and get employers out of the health insurance business, because they've hidden the true cost of healthcare. The middle class doesn't understand how much their employers and the government spend on their health insurance. Starr sees the conservatives behind Bush's plan believing: "that it would lead Americans to accept lower insurance coverage and higher out-of-pocket costs and, therefore, would slow overall cost increases. I think they have misjudged the public reaction. Clarifying the full cost of private health insurance is going to make Americans much more likely to support a public alternative."

"In a world where health costs have been submerged, liberals have been at a huge political disadvantage. In the world conservatives want to create, liberals would have a much better shot."

That may be so, and if it is, we have a problem. How many progressives have the stomach to knowingly go along with a disasterous plan because it will make things better in the long run? It's like sending men to their certain deaths in a battle, knowing that the sacrifice will, probably, help win the war. Actually it would be even trickier, because it would need to be done in the political arena instead of on a comparatively straightforward battlefield.

We face the same problem, albeit less starkly, with state proposals like the one in California that may help more people, yet at an unsustainable cost. Do we support them because they may save lives next year? Or do we stand against them, because they're unaffordable and inefficient, and may give a talking point to ideologues who will say, "You see? We can't afford universal healthcare."

As long as private insurance is in the picture they're right, we can't afford it. Every other industrialized country, however, shows how very affordable universal healthcare can be if done right.

Starr is, by the way, Professor of Sociology and Public Affairs, and Stuart Professor of Communications and Public Affairs, at Princeton University; and co-founder and co-editor of the American Prospect.

Endorsing single-payer

How many newspapers have endorsed single-payer healthcare?

This is from today's St. Louis Post-Dispatch's editorial on Bush's state of the union:

"The president showed an admirable willingness to address the nation's growing health insurance crisis. But his diagnosis of what has caused the problem is wrong, thus his prescription to fix it is wrong, too....

"That leveling would be accomplished not by improving coverage for people buying insurance on their own, but by making it more expensive for companies to provide adequate insurance to their workers. That's a step in the wrong direction. The right direction is toward a single-payer national health care plan."

The irrelevant president

Joe Conason writes that, regarding Bush, we’ve heard it all before, and that his speech was irrelevant.

"At no time in recent years, for instance, has there been such broad consensus, in the business community as well as the labor movement, and among citizens of all political persuasions, that we must reform the American health-care system to contain costs and provide universal coverage...

"Yet the health-care schemes floated by the president and his aides would achieve little except to damage the present system of employer coverage without building a viable replacement. That is why the advocates of universal care will scarcely bother to deconstruct the Bush plan, which was dead on arrival."

I'd just add that quality is the third suffering element of U.S. healthcare, in addition to out-of-control costs and unjust access.

24 January 2007

Commonwealth & Bush

Karen Davis, president of the Commonwealth Fund, has a column explaining why the Catastrophic Bush health plan won't help the people who need it most — the low-wage uninsured without the discretionary income to buy insurance. That group is the majority of the uninsured. Davis says the biggest winners with the catastrophic Bush plan would be those now buying insurance through the individual market. Forty percent of that group make more than $50,000 a year. Lower-income families and the uninsured would not be helped.

Here's the breakdown of the uninsured and taxes:
• 55% are in the 0% tax bracket
• 16% are in the 10% tax bracket
• 23% are in the 15% tax bracket
• 5% are in the 27% tax bracket
• 1% are in the 30-39% tax bracket

"Moreover," writes Davis, "the plan could cause employers to drop their health benefits, especially in parts of the country where premiums are highest, in industries that disproportionately cover older workers, and in the small business sector."

Which is probably the point.

Bush's fault — and ours

How many Europeans are cursing Bush and and United States for our gluttonous energy appetite as they are whipped by this latest storm?

Sure, it's weather not climate. But when weather lasts long enough it becomes climate, and the science is clear about climate change. Know that the world is blaming us collectively, not just Bush. On climate change, on the Iraq fiasco, on our balking at working with other nations in joint poverty reduction efforts, on family planning. After 2000, in both France and the Philippines, people seemed more aware than Americans were that Bush was an illegitimate president who had stolen the election and endangered democracy. Since 2004, the world no longer sounds so forgiving.

Europeans — perhaps because their press is less controlled by big business? — have a far better understanding of global climate change, and the U.S.'s obstruction against finding a solution.

The United States needs to act fast and take a leadership role on reducing greenhouse gas emissions — both for the sake of our children and grandchildren, for the polar bears, and for our nation's deservedly tanked reputation.

I'd sure prefer being proud of my country.

23 January 2007

Isn't that nice for you?

At times Nancy Pelosi applauded Bush’s State of the Union words on healthcare. At other applause breaks, she politely rested, a look on her face like that of the Southern lady who answered, “Well isn’t that nice for you?” when the boorish guest said something outlandish.

After all, Bush is nothing if not boorish, and what he proposed on healthcare was outlandish.

That was predictable.

What’s not predictable is what will happen now. Will we all be distracted, as we were in 2005, when Bush rolled out privatizing Social Security?

Congress should ignore Bush’s plan this time. Both he and it are irrelevant when it comes to finding solutions to this country’s problems.

The plan would allow a federal tax deduction of $7,500 for individuals and $15,000 for families who buy health insurance, on their own or through an employer. People who buy more expensive plans would pay income taxes on the excess.

Healthcare policy wonks across America are scratching their heads over the plan giving those deduction amounts ($7,500 or $15,000) to everyone who buys a policy even if it costs far less.

So younger, healthy workers who buy a rock-bottom policy — the equivalent of a liability-only auto policy — will get a tax windfall. Older, less healthy workers pay more.

Evidently the deduction amount will increase over time, but it wouldn’t be pegged to actual changes in healthcare costs.

The plan would also allow states more “flexibility” with their citizens’ share of Medicare and Medicaid dollars

The Treasury Department says that Bush’s plan could bring health insurance to 5 million more Americans, fewer than one in nine of the uninsured.

No word on what it will do to the quality of coverage.

Like the Social Security “reform,” the plan is intended as a diversion from the Iraq fiasco as much as a real policy proposal.

They’re also hoping to divorce employers from the budget-busting business of covering employees — something that has sapped our global competitiveness because of the inefficiencies of our system.

We'll still have the most inefficient system in the industrialized world, with healthcare eating up 16 percent of our GDP and rising fast.

Compare that to countries with universal health coverage, either through a single-payer system or something close to it where healthcare costs are an average of 11 percent of GDP and rising less quickly.

This plan would instead reduce the healthcare people get for our dollars.

The logical reform is to move people from thousands of employer-based risk pools into one, single-payer pool, eliminating the insurance middleman, thereby lowering costs and protecting everyone. This plan would end employer-based insurance by instead dividing us into 300 million individual insurance droplets. Costs will rise and we’ll end up with less healthcare.

How much leverage, after all, will each of us have against premium increases and coverage decreases once we’re completely on our own?

In a perfect conservative think-tank world, the Catastrophic Bush Health Plan might instead play out like this:

Health insurance will become more like home or auto insurance, something for catastrophic events. Sure, you could file for that broken leg but your premiums would skyrocket. And don’t even think about insurance paying for doctor’s check-ups, calls to the advice nurse, physical therapy, or medication. That would be health coverage, not insurance.

Your premiums, which you will pay, not your employer, will, however, cover your catastrophic $250,000 treatment for cancer. (Unless you happened to buy a plan that didn’t cover that. But never mind.)

In this conservative la-la land, costs will go down because people will get less treatment. We’ve been over-utilizing our medical resources because a third party has been paying for them.

No doubt a lot of medical providers will go out of business since they’ll have fewer patients. Oddly enough, that aspect of this paradigm doesn’t get much play from conservative bloggers, pundits or think tanks.

They do like to talk about how costs will also go down because there will be more transparency.

(Never mind that oversight could bring transparency far more easily in a single-payer system.)

You would get a cost printout before treatment for that broken leg, for instance. After learning that the cast alone is costing you $450, you could opt to just stay in bed.

Once the plaster-makers understood that people were refusing to pay their outrageous cast costs, they would lower prices to something more reasonable.

(Never mind those “wink-winks” here between conservatives selling this plan and the businesses providing casts and other medical equipment. The prospect of earning fewer dollars AND selling fewer units isn’t usually a draw at the Chamber of Commerce. Never mind.)

(Also never mind that single-payer healthcare systems negotiating with plaster manufacturers — and pharmaceutical companies — actually have a track record of bringing prices down. In this worldview, that is seen as unfair.)

We’ll all be out there haggling on our own with doctors, nurses, hospitals and all the rest for the best prices we can get.

(Never mind that patients can choose any doctor they want in single-payer systems.)

There’s no incentive for the common good in the plan — no incentive for people to pay that extra $100 for a cancer screening that pays off for public health when millions of people are screened, but feels more like a matter of luck or hypochondria when it’s just you.

If over-utilization is part of rising health costs, bet that speculative screening would be among the first to fall.

There’s also no regulation to guarantee a minimum of coverage or cap profit-taking.
There will have to be an expensive reinsurance addendum for this plan, to cover people who couldn’t get insurance.

The clear winners?

Insurance companies, who could keep raising rates, knowing that the states would cover their firefighters.

The losers?

American families.

Write your legislators and tell them to ignore this catastrophic plan, and get on with the business of solving America’s problems.

SOTU & Pelosi

The best part of 2007's State of the Union speech is already past. It was the standing ovation for Rep. Nancy Pelosi (D-CA), the first woman to serve as speaker of the house. It truly was an emotional moment.
And now, to see her there instead of Dennis Hastert — what a relief on the eyes and to the heart.

Support our troops

In Portland (aka Little Beirut) on Sunday, my daughter Kira bought a thrift-store tee shirt with a map of Iraq next to a map of Michigan, with “Operation Iraqi Freedom” emblazoned across. She wore it to work, and got such strange looks that she ended up putting on a sweatshirt over it. People just didn’t know what to say. Did it mean she was a Bush supporter? Was it meant in irony?
Then at the neighborhood pub last night, a guy at the end of the bar asked her if that was a “support our troops” band on the shirt's arm.
It was, she said.
He thanked her.
He’d recently gotten out of the hospital, and was scheduled to return for his fourth tour of duty next month.
He’d been injured when the Humvee he’d been in hit an IED. He was the only survivor.
He told her that few of the troops still have confidence in either Bush or any rationale for being there.
Kira bought him a beer and asked what she could do.
Send socks and baby powder, he told her. The guys are always short on socks and baby powder.
This war sucks.

Buried since Christmas

The neighbor's car

Curiouser and curiouser

Three years ago Britain began transfusing plasma (the liquid part of blood) exclusively from male blood donors. They're still using blood donated by women to make other blood products, but not to transfuse into accident victims and those in surgical trouble. And now the U.S. is following suit. It looks like antibodies from some women’s blood is the cause of complications from transfusions. Note where the original life-saving research was done: in single-payer, under-funded Britain.
“Curiouser and curiouser!” Cried Alice (she was so much surprised, that for the moment she quite forgot how to speak good English). ...

22 January 2007

Real research vs. PR

Paul, Missy and Curtis

The health stories on the local news tonight were a Belgian heart study on endurance athletes at risk for ventricular arrhythmia and a British study on dogs being a better choice for keeping people healthy. Maybe because you have to walk ‘em.

Notice that those two studies weren’t in the U.S.

Fearmongers against healthcare reform spreads the lie that the free market alone can bring health advances. Not true: governments, including our government, are the major research funders for basic science. Big Pharma’s part in new meds is mostly confined to copying their competitors’ top sellers. So we now have lots of “purple pill” options, lots of erectile dysfunction cures of the pharmaceutical variety.

This 2003 Health Affairs page says that pharmaceutical companies now spend more than government: $30 billion to $20 billion.

A problem with that number is that Pharma counts “opportunity cost” as part of their research total. That means they add in what their $10 million or $100 million for research could have made in a bull market and then add that to the total.
John Mack has a good explanation of how this works on the Pharma Marketing Blog:

Assuming it takes my son only 4 years to complete his undergraduate study at Penn State, I will have spent over $100,000 on tuition, room, board, books, wine-in-a-box, transportation, etc. …
But wait! I forgot my lost opportunity to invest that $100,000 in the next best thing (whatever that is). I could have made another $100,000 with a better investment. So, I will really be spending $200,000 on my investment in my son's degree. I'll have to factor that in on my next IRS return!
But wait! Suppose my son, God forbid!, quit college in his junior year and never earned his BS degree? Did I actually spend $200,000 on his failed attempt? I mean, could I go around to my friends and relatives and say, it was a $200,000 failure?

That’s what Pharma does.

By that bookkeeping, the government still spends more money on research: $40 billion to $30 billion in 2003.

And what does Pharma spend their $30 billion on?

Merrill Goozner in The $800 Million Pill writes that after reviewing the 127 new drugs approved between 1989 and 1993, Dr. David Kessler, head of the FDA from 1990 to 1997 said,

“only a minority offered a clear clinical advantage over existing therapies. Many of the others are considered me-too drugs because they are so similar to brand-name drugs already on the market...”
"In 2002, just seven of seventeen new drugs were rated a priority by the FDA, which indicated they represented a legitimate medical advance..."

Some of the new drugs are dangerous.

“The diabetes drug Rezulin gained fast-track approval status in 1997 even though an FDA examiner warned that it might cause heart and liver damage. A Pulitzer Prize winning series in the Los Angeles Times later revealed that Rezulin caused at least thirty-three deaths and was kept on the market by Warner-Lambert despite there being at least nine other drugs for the condition. (The Rezulin case highlighted on the of the enduring truths about me-too drugs: Users of the new molecule were exposed to greater safety risks than consumers using tried-and-true drugs already on the market. Every one of the thirteen drugs withdrawn from the market for safety reasons during the 1990s failed to meet a medical need that wasn’t already served by a number of drugs already on the market…”

Pharma is offering fewer real advances as they concentrate on profits, but governments continue to fund research on real science, vaccines and preventatives — even dogs — even though there’s no profit in it. Just public health.

Scan detects selfishness

Medical News Today reports that scientists have found a part of the brain that reacts differently in selfish and altruistic people.

They define altruism as "as a tendency for people to put the welfare of others above their own. And what this research suggests is that altruism stems from being able to tune into the intention and actions of others which then leads to thinking along the lines of 'perhaps I had better treat them like I would want to be treated.'"

That empathetic ability may confer survival advantages, with altruism being a side effect.

For the opposing view, here's Ayn Rand:

"Doctors are not servants of their patients, they are traders like everyone else in a free society and they should bear that title proudly considering the crucial importance of the services they offer."

21 January 2007

Pipes rails on Arnold

Sally Pipes, one of the most mean-spirited voices in the healthcare debate, decries Arnold's plan in the National Review. Basically, she doesn't like it. She writes:

"The result: Employers will be paying higher taxes, employees earning lower wages, Medicaid will be subsidizing more people, and 10 to 20 percent of Californians will still be officially counted as uninsured. Next stop: single-payer health care for America."

Don't Be Silly!

Together with the data — the overwhelming data that shows that our system is the most expensive and yet the only one in the industrialized world that doesn't cover all our citizens — this may the strongest argument for a single-payer system.
We are the only people in the industrialized world who pay out the nose for the privilege of playing roulette with our children's health.
Sure, Americans aren't followers. But is it really American to stubbornly stay the course with a deadly, incompetent plan, just digging ourselves in deeper and deeper?
My apologies. That was poorly argued.
Just because we also did it in Iraq doesn't make it American.
(Thanks, Dave, for the graphic.)

Healthcare rationing?

Americans have been desensitized to the idea of healthcare rationing here in the United States. Healthcare rationing means some leftist whining we already have rationing because poor (and increasing numbers of middle class) people already don’t have healthcare. Right?
Wrong. That’s just the beginning. Ask Dr. Clark Huff, a Denver dermatologist who will tell you about having to call the insurer whenever a patient needs a wart removed.
Once they get around to taking his call, someone with, probably, a high school degree will give him the go-ahead. Or not.
How do they decide? And how about when it's melanoma? My guess is that the Saturday special doesn't cover that either, at least until you've reached that $10,000 deductible. Which wouldn't be a problem if you'd been socking away your savings into a Health Savings Account, as George and Laura have no doubt been doing.
Scratch that. They're covered by our tax dollars, something that would be inappropriate for you or me, but works out just fine for the Bushes.
Dr. Huff is now a member of Physicians for a National Health Plan and Health Care for All Colorado — speaking out against our current rationing system and in favor of rationality.
Health rationality.

Snowy Denver

It used to be that it would snow in Denver — mostly in November or April, and then melt off within a few days.
We've had snow on the ground for weeks now. It's snowing again.
And although this is admittedly weather, not climate, it fits in with global climate chaos, which comes with global warming.

20 January 2007

The despised Andrew Sullivan

Ezra Klein notes that arrogant conservative Andrew Sullivan, who currently blogs at Time, is going to The Atlantic Monthly.

Klein writes that it was bad enough that Time carried him, but The Atlantic? How could they?

Well, for one thing, The Atlantic isn't progressive. If Sullivan was going to Harpers, now that would be news.

Source Watch, a project of the Center for Media and Democracy, says The Atlantic "registers increasingly as a neocon dominated periodical."

The 1999 article that The Atlantic ran on how the earth could sustain 100 billion people — what was the worry about a measly 6 billion? — was the one that did it for me. That's not publishing the other side of the story. That's publishing a rank lie. Max Singer, a senior fellow at the Hudson Institute, wrote that humanity's population future would be a matter of fashion:

"Fashions in families might keep changing, so that world fertility bounced above and below replacement rate. If each bounce took only a few decades or generations, world population would stay within a reasonably narrow range-although probably with a long-term trend in one direction or the other.

"The values that influence decisions about having children seem, however, to change slowly and to be very widespread. If the average fertility rate were to take a long time to move from well below to well above replacement rate and back again, trends in world population could go a long way before they reversed themselves. The result would be big swings in world population-perhaps down to one or two billion and then up to 20 or 40 billion."

To think that the earth could sustain 40 billion humans is beyond conservative and into crazy. And here's the last line: "What we have learned from the dramatic changes of the past few centuries is that regardless of the size of the world population at any time, people's personal decisions about how many children they want can make the world population go anywhere-to zero or to 100 billion or more."

He's more worried about a birth dearth, by the way, than overpopulation.

Eric Alterman in The Nation reminds us that The Atlantic's late editor Michael Kelly, a "belligerent right-winger... proceeded to add a bunch of Weekly Standard writers to its antiliberal stable."

How about The Atlantic columnist and anti-feminist Caitlin Flanagan, who delights in pitting stay-at-home moms against those who work for a paycheck?

Christopher Hitchens also regularly writes for The Atlantic. He's a similar character, although Hitchens went from usually left to the right when he vehemently supported the invasion of Iraq. Sullivan has always called himself a conservative.

Both men are arrogant, brilliant writers — they no doubt see themselves as the intellectual heirs of William Buckley. All three men are infuriatingly wrong some to much of the time, but they're still a pleasure to read and listen to. Andrew Sullivan was also intellectually honest about the Bush administration's incompetence before the 2004 elections.

I'd rather see Sullivan at The Atlantic than Flanagan.

19 January 2007

Crowd for single-payer

It took a lot to get Dr. Cory Carroll out from behind his stethoscope and into activism. But the stories about going without healthcare that he heard from patients, one after another, finally wouldn’t let him rest.

Dr. Carroll joined the Physicians for a National Health Plan, perhaps the most visible and active group behind American healthcare reform, and now speaks to groups in addition to treating patients.

Dr. Carroll was one of four panelists last night at Health Care for All Colorado’s education and action meeting at the Foothills Unitarian Church in Fort Collins, Colo. There he was preaching to the choir for the most part, but he’s spoken to crowds unconvinced about single-payer healthcare, and even crowds unconvinced that there’s a problem.

Like the one at a recent Insurance Underwriters’ convention, for instance.

More than 100 people heard Dr. Carroll; Alexandra Bernasek, a professor of economics at Colorado State University; Nicki Carter, a family nurse practitioner; and Dr. Mark Wallace, vice-chair of Colorado’s Blue Ribbon Commission for Health Care Reform (the 208 Commission).

Dr. Wallace recalled that in his school years, professors warned that American healthcare costs were approaching 12 percent of the gross domestic product. That wasn’t sustainable, the professors said.

Healthcare now consumes 16 percent.

In years past, physicians have been sanguine about the U.S. healthcare system. “But now when I sit with my colleagues, they’re willing to say it’s broken,” Dr. Wallace said.

It’s difficult to ignore the hard data. Even some non-industrialized nations are seeing better outcomes than are found in the United States. There’s also a general understanding that the system needs to be more fair.

“There’s increasing agreement that the system is broken,” said Dr. Wallace.
He told the crowd that we hadn’t come to this impasse because of a lack of technical expertise. So why hasn’t there been a successful reform model in the United States? Something that other reformers in other states could point to, and say let’s do it like that?

“There’s been a lack of political will,” he said.

Dr. Wallace urged the group to talk to their neighbors about the issue, adding that there were folks on his cul-de-sac who doubtless didn’t think there was a problem with U.S. healthcare. “They’re covered,” he said. “They’re doing fine.”

He said that the 208 Commissioners had been charged to find a practical plan that would comprehensively reform healthcare in Colorado. That meant, he said, expanding healthcare services and reducing healthcare costs for Coloradoans.

The commission has thus far worked on bylaws and created its committee structures.

There are committees for:
1) proposals, to solicit plans for change,
2) communications, to tell the public what’s happening, and build consensus for the top plan,
3) operations, dealing with timelines and business, and
4) evaluation, finding a firm to evaluate the proposals.

Dr. Wallace said that the commission wants the proposal they finally choose to be credible. “I ask that we remember that this will come back to politics,” he said.

Newly elected state Rep. John Kefalas, D-Fort Collins, and state Rep. Randy Fischer, D-Fort Collins, attended the forum, as did Betsey Markey, Sen. Ken Salazar’s (D-CO) regional director for the North Central Colorado area.

Kefalas said that passage of reform depended upon how it was framed, that businesses and individuals had to see that it was in their economic interests to fix it.

Questions for the panel began with a man wondering why no one had addressed the biggest determinant of health: lifestyle.

Dr. Carroll agreed with him that lifestyle is key, and described our system as “ill-care” rather than healthcare. He said that there’s no reason a single-payer system wouldn’t pay for evidence-based medicine like acupuncture.

A woman worried over the administrators and insurance workers who would be jobless in a single-payer system

Bernasek, the economics professor, told the woman that there’s no reason single-payer reform wouldn’t include retraining those workers. She also said that saving jobs isn’t a good reason to preserve inefficiency.

“But how many people would lose their jobs?” the woman asked.

“Not as many as are uninsured,” called out another audience member.

A man stood to angrily say that HCAC should set up an intentional process to move the politics, since it wasn’t going to happen on its own.

Eliza Carney of HCAC urged him to volunteer.

Another question came from a man who said he was uninsured. He asked if there were any studies showing that business benefits from a single-payer system.

Bernasek answered that there were, and then shared that a college classmate is a chief economist at Ford Motors. He has admited to her that his stand against single-payer is based on ideology, and that Ford would be better off if this country had a single-payer system.

“The fear is that if we go down this road there will be other incursions on the free market,” Bernasek said.

She told the group that the country she had been raised in, Australia, funds its single-payer healthcare system through a 1.5 percent income tax. That comes to far less than what people pay under the current chaotic U.S. system.

Dr. Wallace said he’d spoken at Colorado’s Club 20 that morning. That’s a generally conservative organization representing Western Colorado business interests. The group’s conversation led them to the realization that healthcare doesn’t operate like an open market.

“What happens when a competitor opens in an open market?” Dr. Wallace asked. “The price goes down. What happens when a new hospital opens in a community? You all here know about this. Prices go up.”

He said that the Club 20 members’ fear concerned who would set prices under a single-payer system.

Dr. Carroll, who was an engineer before he was a physician, said that he’s a person who likes data, and that the data from working, single-payer systems in other countries proves inescapably damning of the U.S. model.

“It’s a no-brainer,” he said. “Why the hell are we paying more to get less?” he asked.

The last comment came from a man who said that America’s future was a bleak one. Executives and politicians, he said, would have healthcare and the rest wouldn’t.

18 January 2007

Arnoldcare debate continues

“Arnold-Care” might be a good, moderate solution since it’s bracketed by criticism from the Left and from the Right.

Then again, it may just be a rationalizing, unsustainable plan with little to recommend it, especially after further compromises are made.

The California Nurses Association has certainly launched a non-stop war against it. Curious, considering fondness that organization has for Governor Schwarzenegger. Their president has flamed several editorial pages with salvos against the plan. As has Rose Ann DeMoro, the association’s executive director, and Zenei Cortez, their vice president.

Cortez writes “Why insurers love the new health plan” in the San Francisco Bay Guardian.

“Gov. Arnold Schwarzenegger's much-trumpeted health plan is the most ambitious overhaul of the state's healthcare system since ... well, since SB 840, the far simpler, more universal, more comprehensive, single-payer health plan sponsored by Sen. Sheila Kuehl, which the governor vetoed last September,” she writes.

“If you're one of the 6.5 million Californians without health coverage, get ready to find a lot of hands in your pocket.”

DeMoro, at Tom Paine, writes: “With ever-escalating premiums, it’s a safe bet that the average family not eligible for the low-income subsidies will opt for the bare bones plan which, Schwarzenegger has recommended, would specify deductibles of up to $10,000.”

In another analysis, Daniel Weintraub of the Sacramento Bee writes that the individual mandate plan is more realistic than a single-payer — although the only reason he gives is because Schwarzenegger believes a single-payer would limit choice and innovation, and cause waits and rationing. He doesn’t give any evidence for that.
He does note that it’s an unknown whether numbers of employers might discontinue healthcare coverage, and thus send a huge group of individuals into the state risk pool.

“That wouldn’t necessarily be a bad thing. Health insurance and the economy would both be more stable if employers stopped being the middlemen in health care."

Is he talking about a round-about way of reaching single-payer?

"Economic theory says that employers, to recruit good workers, would substitute higher wages for the health care premiums they pay today if they stopped providing insurance as a fringe benefit. But the transition could be rough and uneven. And most people probably wouldn’t trust that it would happen.

“For that reason, the individual mandate is going to be a tough sell for the governor. Skeptics on the right see it as big government. On the left, they see it as a way to shift the burden from employers to workers. But without it, Schwarzenegger’s plan falls apart. He can’t compromise on that point and still pass a law that promises universal coverage.”

Weintraub lost me at the end. Without cost-shifting to the employee, the plan falls apart? And without it he can’t pass a plan that promises universal coverage?

How about the single-payer plan that he vetoed last year?

In the Oakland Tribune, Josh Richmond wrote that at the Martin Luther King breakfast in San Francisco, Gov. Schwarzenegger came to the podium on crutches as an audience member shouted, "Healthcare for people, not insurance companies!"

Richmond also got some heartening quotes from California Democrats, who get it that single-payer can be a winning issue.

“San Francisco Labor Council Executive Director Tim Paulson told the crowd nothing short of a single-payer system will do, and Assemblyman Mark Leno, D-San Francisco, warned the audience to beware of any healthcare reform that costs up to a quarter of a worker's paycheck. ‘That's the governor's plan,’ said Leno, who once again is co-sponsoring single-payer universal healthcare legislation.

“Freshman Assemblyman Sandre Swanson, D-Oakland, seated at a front table, praised the governor for putting the issue on a front burner, but said ‘those of us on the left who believe healthcare should be a right: It's our responsibility to push our perspective, our agenda. ... The devil's in the details, so let the debate begin.’”

To Be of Use, by Marge Piercy

"To Be of Use," by Marge Piercy, is a good poem for when you're feeling used up.

The people I love the best
jump into work head first
without dallying in the shallows
and swim off with sure strokes almost out of sight.
They seem to become natives of that element,
the black sleek heads of seals
bouncing like half submerged balls.

I love people who harness themselves, an ox to a heavy cart,
who pull like water buffalo, with massive patience,
who strain in the mud and the muck to move things forward,
who do what has to be done, again and again.

I want to be with people who submerge
in the task, who go into the fields to harvest
and work in a row and pass the bags along,
who stand in the line and haul in their places,
who are not parlor generals and field deserters
but move in a common rhythm
when the food must come in or the fire be put out.

The work of the world is common as mud.
Botched, it smears the hands, crumbles to dust.
But the thing worth doing well done
has a shape that satisfies, clean and evident.
Greek amphoras for wine or oil,
Hopi vases that held corn, are put in museums
but you know they were made to be used.
The pitcher cries for water to carry
and a person for work that is real.

"To be of use" by Marge Piercy © 1973, 1982.
From CIRCLES ON THE WATER © 1982 by Alfred A. Knopf, Inc. and Middlemarsh, Inc.

17 January 2007

Round-up: State plans

Dean Olsen, staff writer for the Springfield Register, writes that Illinois Democratic Governor Roy Blagojevich’s spokesperson emailed this: "We don't think a uniform single-payer system would really address the complex needs of our population."

“[I]f the Chicago Democrat follows the example set by a handful of other states, Illinoisans should expect a plan that would expand subsidized health coverage for poor and middle-class residents, require uninsured individuals to buy coverage and penalize employers that don't provide it," writes Olsen

“That's also the type of plan that a state task force is expected to recommend to the governor when it meets Thursday in Chicago. The plan would cost the state $3 billion per year.“

Olsen writes that the latest economic recovery hasn't reduced the number of uninsured, 46.6 million people nationwide, because health-care costs are rising faster than inflation, and new jobs are in the service sector, which doesn’t offer good health benefits.

He gives a helpful outline of Maine’s, Massachusetts’ and Vermont’s healthcare plans:

Massachusetts Commonwealth Care (being phased in):

• Anyone who can afford insurance must buy it
• Employers must make "fair and reasonable" contributions toward employee health coverage or be assessed up to $295 per worker
• An authority to improve availability and affordability of coverage
• Subsidies for low-income people
• Insurance reforms to reduce premiums and create new options.
• Funded by state, federal, employer and individual contributions

Unanswered questions include whether there's enough money to finance the plan and whether requiring people to buy health insurance actually lead to universal coverage.

Vermont Catamount Health (begins in October):

• A new insurance product meant to be affordable and comprehensive
• Subsidies for low-income uninsured citizens with incomes up to three times the federal poverty level
• employer assessments of $365 per uninsured worker
• Funded by an increase in the tobacco tax, federal matching funds, enrollee premiums and employer assessments

Maine's Dirigo Health Plan (enacted in 2003):

• Relies on voluntary measures
• A health-insurance product available to small businesses, the self-employed and others without access to employer-based insurance
• Discounted premiums and reduced deductibles and other out-of-pocket costs for people earning up to three times the federal poverty levels
• Funded by individuals and employers, state general funds and federal Medicaid matching funds

Enrollment in Dirigo has been capped at 12,000 because of a shortage of money.

Free Market Faith

Chris Voccio, publisher of the Tribune-Democrat in Johnstown, Penn., declares in this 16 Jan. opinion piece that the “idea that health care is a ‘right’ is absurd,” and that the “very last thing we should do is move to a single-payer system. Health care prices would rise even faster.”

Voccio also believes that “We have the greatest health care in the world, but our prices are rising too fast.”

His solution? “[W]e should move in the opposite direction, farther away from the third-party- payer system and closer to the free-market approach that has done such a great job keeping the prices of computers in check.”

Voccio is divorced from reality. It is, after all, the free market that has led to high prices in healthcare. A similar delusion is behind one of the many comments on a healthcare reform story from the State-Journal Register in Springfield, Ill.:

“All control over healthcare, and payment for it, is done today thru lawmaking known as mandating and that IS all controlled by democrats here. You cannot honestly say today that it isn't. If lawmakers had stayed out of it, the market would have decided if the purchase of insurance was worth it or not. Now that this system is in danger of collapse, some think mandating it, and everything about it, will solve the problems.”

Now that’s amazingly incoherent. I’m not positive what this person was trying to say, but my guess is that the attempted remark comes from a closed loop argument that will be used against healthcare reform.

The Right is already arguing that the free market will solve the healthcare crisis. That’s an old and trusty standby. For the argument to work, however, people need to also believe that the free market is blameless in the current crisis. If it were even partially at fault then the market would not be a perfect solution after all. In fact, that might even justify regulation. And once you head down that slippery slope…

What Is It with Canadians & Knee Surgery?

Jesse Thiessan, a transplanted Canadian, writes “Caring Is Creepy” for the Portland State University’s paper The Vanguard.

The headline writer got the head from her lede:

“Like the creepy guy who falls asleep next to you on the late-night bus, the breakdown of our health care system is getting harder and harder to ignore.”

Even student journalists rarely write the headlines that go over their stories. It's not Thiessan's fault.

Like most other critics of the Canadian National Health System, Thiessan targets knee surgery waits to show that Canada isn’t perfect. Leaving me wondering: What is it with knee surgery in Canada? Why do so many Canadians need knee surgery? And why doesn’t the Canadian National Health System deal with it?

Thiessan has this nice connection:

The United States ranks lowest in the G8 for the amount of health care paid by the government (44.6 percent). Yet paradoxically, we rank highest for the percentage of government revenue that goes towards health care (17.6 percent). In other words, we shell out the most tax dollars for the least amount of care.

How do anti-single-payer folks explain that — even to themselves?

Thiessan’s solution is a two-tier system:

“All developed nations-with the exception of the United States and my maple-syrup-swilling homeland-have some variation of a universal health care system along with a private system, akin to our system of private/public schooling.”

Fair enough.

Former Oregon Governor John Kitzhaber’s group, the Archimedes Project, takes as one of its assumptions for reform that:

Those with more disposable income will always be able to purchase
more health care than those who depend solely on public resources.

I doubt that will assuage the fears of people who want to be afraid of single-payer or universal healthcare.

Obama's Plan

James Pethokoukis at U.S. News and World Report gives a “Sneak Preview of Obamanomics.”
He says Obama would ask “experts to design a basic, high-quality plan and then allow anyone to purchase this model government plan or a comparable rival plan though private insurers. In other words, no government-run single-payer health plan. He would also require the healthcare industry to completely digitize all its records to cut costs and errors.”

Better than Schwarzenegger’s.

Arizona Dem Has a Plan

Arizona State House Minority Leader Phil Lopes, (D-Tucson) has a health plan for Arizona. It would make Arizona “the employer” to provide citizens with a benefit package similar to that of state employees.

Sounds like single-payer to me.

Lopes would cover everyone except people already on Medicare, Medicaid, and active and retired military, who get federal insurance. People over 55 who have already retired would pay a premium.

Mexico would pay the state for medical care for their citizens living in Arizona.

Cape Care Moves Forward

Cape Care is a non-profit, single-payer plan that would be funded by a tax to residents of Cape Cod, Mass., municipalities that have voted it in. It was supported by town meetings in 11 towns and voted down in three others.

The Harwich Oracle reports that it “would eliminate the role of insurance companies and take a form much like schools and public safety...

"Based on the population Cape Care would work with and the potential savings of buying medicine in bulk and eliminating insurance company profits, the coalition said it’s feasible that health care could be provided for everyone. The state estimates there are 14,000 uninsured Barnstable County residents.

Cape Care member Doug Marshall of Sandwich says that Sandwich is now spending 16 percent of the town budget, and that in five or six years they'll spend 20 to 22 percent of their entire budget on health care.

This is an exciting plan. Can the insurance industry stop reform even at the town hall level? There’s more information at the Cape Care website.

On Mount Whitney

Paul's best friend Robin just sent this along.

As my friend Bob Pfohman would say, "We were happier then."

Except then comes my mother, who would say, "Act happy, dammit!"

And she's right. We do have to act happy. We owe it to each other.

So cheers. Here's to life and the future. As the poem says,

Do not stand at my grave and weep
I am not there; I do not sleep.
I am a thousand winds that blow,
I am the diamond glints on snow,
I am the sun on ripened grain,
I am the gentle autumn rain.
When you awaken in the morning's hush,
I am the swift uplifting rush
Of quiet birds in circled flight.
I am the soft stars that shine at night.
Do not stand at my grave and cry,
I am not there; I did not die.

Commonwealth's 7 Steps

Considering that the United States spends far more money per capita than any other country in the world on healthcare, it’s fair to take those extra resources into account when grading. If we spent what Morocco spends, for instance, our patient outcomes would garner an ‘A’ grade.
We might even get a ‘B’ for coverage — after all, Medicare keeps a lot of Americans healthy.
In regard to cost containment, the idea falls apart. We have no cost-containment; our system is completely unsustainable.
Even with all that being the case, we could do better, even without the reform that is so obviously needed.
Commonwealth Fund President Karen Davis has written up seven suggestions, with examples, for “Achieving the Best Health System in the World.”
Or at least scrabbling up from a failing grade.
She urges that we:

1. Extend Health Insurance to All

Example: State of Maine

This isn’t her best example. Dirigo Health has stumbled getting people enrolled. The goal was to cover all of the roughly 130,000 uninsured Maine residents by 2009, but so far fewer than 20,000 have signed up, according to the New York Times. Enrollment had to be capped because of a shortage of money.
Davis writes that “increased federal financing are likely to be needed to extend these approaches to states with higher rates of uninsured and more limited ability to fund coverage from local sources.”
In fact, we may need to consider selling California off to fund our insatiable system. That should pay for it for possibly a decade. Maybe more.
Wouldn't Belgium, Canada, France, Great Britain, Germany, Japan, Spain — geez, any of the other industrialized countries in the world — have been a better example?

2. Pursue Excellence in Provision of Safe, Effective, and Efficient Care

Example: University of Colorado Health Sciences Center
Here Davis is pushing the “use of evidence-based medicine, promoting effective chronic care management techniques, prioritizing patient safety, and ensuring care coordination across sites of care, especially when transitioning from the hospital to other settings.”
All these things seem self-evident; but true to form, libertarian think tanker Linda Gorman and insurance man Allan Jensen spoke out against them at a recent Colorado Health Care Reform (208) Commission meeting. According to them, evidence-based medicine is actually very problematic. Of course. Same as evolution. Just a theory.

3. Organize the Care System to Ensure Coordinated and Accessible Care for All

Example: Mount Sinai School of Medicine EXPORT Center
Providers should address system failures and target improving healthcare delivery to underserved populations.
Hard to accomplish with an inchoate, fragmented non-system, but a good goal.

4. Develop the Workforce to Foster Patient-Centered and Primary Care

Example: Denmark
“The U.S. is strikingly different from other industrialized countries in one important respect: its relative under-investment in patient-centered primary care. The U.S. has a much lower fraction of primary care physicians, and much better financial rewards for specialty care. A review of the literature indicates that better access to primary care lowers total cost and improves outcomes.
“In Denmark, which has the highest public satisfaction with health care of any country in Europe, primary care is much more accessible than in the U.S. A blend of capitation and fee-for-service payments to generalist physicians in Denmark assures that everyone has a primary care physician or "medical home," and generalist physicians typically provide services quickly, often in same-day appointments.”
I don’t know what Denmark’s percentage of GPs is, but in France, in 2002, 53.3 percent of physicians were in general/family practice. Compare that to 22.5 percent of U.S. doctors in general or family practice.

5. Increase Transparency and Reward Quality and Efficiency

Examples: Massachusetts Health Quality Partners Increase Transparency and New York State
“Public reporting of information on the performance of health plans and providers can spur improvements in quality and efficiency, by helping consumers make more informed decisions and by stimulating providers and plans to be more accountable for their results.”

6. Expand the Use of Information Technology and Exchange

Example: Rhode Island Information Exchange
“The Rhode Island Health Information Exchange (HIE) initiative is a public–private effort to allow providers, with their patients' permission, to electronically access important patient health information from a variety of sources.”

7. Encourage Leadership and Collaboration among Public and Private Stakeholders

Example: Puget Sound Health Alliance
The alliance “is an independent non-profit organization composed of employers, physicians, hospitals, consumers, health plans and other interested parties. The group's aim is to improve care and continuity by developing guidelines for providers, self-management and decision-making tools for patients and consumers, evaluations and reports on quality, and a collaborative approach to quality improvement.”

These are improvements that need to take place in most countries. It’s notable that European countries are far ahead of the U.S. in all of these points.